PROOF OF INSURANCE (2019) CLOSED A O 061041/20182018 CERTIFICATE OF LIABILITY INSURANCE DATE /YYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT US NAMr. 866-966-4664 SBNICeS
7101sMarket Street,Suite 1100 PHONE/ Q Ext); FAX No):
Attn:ATT.CertRe uest marsh com /#bbt,CSS; Att CertRequest@marsh.com
St Louis,MO 63101 E•
Q @
INSURER(S)AFFORDING COVERAGE NAIC#
018566-GAW-CRT-18-19 X X SCha INSURER A:Old Republic Insurance Company 24147
INSURED INSURER B:
New Lingular Wireless PCS,LLC
One AT&T Plaza INSURER C:
208 South Akard Street, INSURER D:
Room 1830,06
Dallas,TX 75202 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: CHI-007309896-15 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR. 'ADDL'SUBfx ... .�,tP'OLICY EFF POLICY'EXP
LTR TYPE OF INSURANCE POLICY NUMBERP
INSD WVD M'ODIY'YYYI (MMIDDNYYVI LIMITS
AX COMMERCIAL GENERAL LIABILITY MWZY313636 06/01/2018 06/01/2019 EACH OCCURRENCE $ 1,000,000
DAMAOr Ys Rs Nl r`b
CLAIMS-MADE I X OCCUR PREMISES [a oi:!Lwmm ) $ 1,000,000
MED EXP(Any one person) $ N/A
PERSONAL&ADV INJURY R
Y $ 1,000,000
GE LAGGREGATELIMITAPPLIES GENERAL AGGREGATE $ 10,000,000
X
PR)
POLICY I JE,Ct LOC PRODUCTS COMP/OPAGG S 1,000,000
OTHER $
- -_ BiiNE'D SINGsI E I IMI B
A AUTOMOBILE LIABILITY MW'f6313635 0610112018 06/01/2019 COM
( ) BODILY INJURY A X ANY AUTO MWZX 313637 MI 0610112018 06/01/2019 Ea asci (Per person) $
$ 1,000,000
INJURY(
OWNED SCHEDULED BODILY INJURY Per accident) $
AUTOS ONLY AUTOS
AUTOS ONLY AUTOS ONLY ac
(I+a r r.1!1 y DJaMA4'71.,
HIRED NON-OWNED 'M'ROP"�ERfYt) $
$
UMBRELLA LIAB I OCCUR EACH OCCURRENCE $
EXCESS LIAB I CLAIMS-MADE ( AGGREGATE $
DED Y RETENTION$ $
A WORKERS COMPENSATION MWG31363800 06/01/2018 06/01/2019 X (STATLITF 0TH-
OFFIC PRIETOR/PART ER/E ECUTIVE N E EACH ACCIDENT FR
AND EMPLOYERS'LIABILITY YIN
I I .. ?,000,000
NIA $
(MandatorynNH) EL DISEASE-EA EMPLOYEE S 1,000,000
_ yes,describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S 1,000,000
A Excess Workers'Compensation/ MWXS 313639 (OH,WA) 06/01/2018 06/01/2019 EL Each Accident/EL Disease 1,000,000
Employers'Liability See Second Page EL Disease-Policy Limit 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
Re:FA#12992945;GSM ID:NL0515;Address:400 Lomita St.,EI Segundo,CA 90245;CountyL Los Angeles.
City of EI Segundo,its officials and employees is/are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the
Certificate Holder and the Insured, This insurance is primary with respect to the interest of the Additional Insured and any other insurance maintained by Additional Insured is excess and non-contributorywith this
insurance Waiver of Subrogation is provided for Workers'Compensation,as required by written contract and allowable bylaw
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn:Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo,CA 90245
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
I Manashi Mukherjee ��L0.uoo►.:
@ 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 018566
LOC#: St. Louis
ADDITIONAL REMARKS SCHEDULE Page 2 of 2
AGENCY NAMED INSURED
Marsh USA Inc. New Singular Wireless PCS.LLC
...........-................. One AT&T Plaza
POLICY NUMBER 208 South Akard Street,
Room 1830.06
CARRIER----............ NAIC CODE Dallas,TX 75202
.......................". ----"---.-
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE; Certificate of LiabRity Insurance
..................... ---------- .......................................................................................................................
................
Excess Workers'Compensation-MWXS 313639(OH-WA)
Self-Insured Retentions
OH&WA-$500,000,000(except Terrorism)
OH&WA-$600,000,000 Terrorism
...............
Excess Automobile Liability-MWZX 313637(Ml)
Combined Single Limit-$1,000,000
Self-Insured Retention-$1,000.000
ACORD 101 (2008/01) 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
IL 10 (12100) OLD REPUBLIC INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
BLANKET ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART/FORM
It is agreed that SECTION II -WHO IS AN INSURED, is amended b include any person or organization
to whom you have agreed to provide insurance in the absence of a written contract or agreement, and to
whom you have issued a Certificate of Insurance.
The insurance provided by the policy through this endorsement shall not exceed either the scope of
coverage or the Limits of Insurance shown on the Certificate of Insurance and shall be limited to "bodily
injury", "property damage", or "personal and advertising injury" caused solely by the insured and its
"employees".
Additional insured status afforded b the Certificate Holder(s) is limited to the ongoing operations of the
insured and its"employees".
In addition, coverage shall not extend to "bodily injury", "property damage", or "personal and advertising
injury", arising out of the acts or omissions or the negligence of the Certificate Holder, and its employees.
GL 739 045 0612
MVYZY313836 AT&T kw. 0"1/9018.0"1/2019
IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS
This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the
following:
A. In the event this policy is cancelled for any permissible reason, other than for nonpayment of
premium, we shall endeavor to provide advance written notice of cancellation to certificate
holders set out in the schedule on file with the Company, after notifying the first Named Insured of
such cancellation. Notice of cancellation to certificate holders may be made by any commercially
reasonable means, including mail, electronic mail, facsimile transmission or courier service,
B. This advance written notification of a cancellation of coverage is intended as a courtesy only. Our
failure to provide such advance written notification will not extend the policy cancellation date, nor
negate cancellation of the policy.
All other terms and conditions of this policy remain unchanged.
PIL 02910 10
Mwzr 313asa arar Inc. oaninata•060112019
I L 10 (12106) OLD REPUBLIC INSURANCE CONI PANY
WORKERS'COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
NOTICE OF CANCELATION TO CERTIFICATE HOLDERS
This endorsement modifies the notice of cancelation of insurance provided hereunder by adding the
following:
A In the event this policy is canceled for any permissible reason, other than for nonpayment of
premium, we shall endeavor to provide advance written notice of cancelation to certificate holders
set out in the schedule on file with the Company, after notifying the Insured first named in item 1
of the Information Page of such cancelation. Notice of cancelation to certificate holders may be
made by any commercially reasonable means, including mail, electronic mail, facsimile
transmission or courier service.
EL This advance written notification of a cancelation of coverage is intended as a courtesy only. Our
failure 10 provide such advance written notification will not extend the policy cancelation date, nor
negate cancelation of the policy.
All other terms and conditions of this policy remain unchanged.
PC 010 10 10
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
POLICY NUMBER: HWC 313638 00
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
SCHEDULE
WHERE REQUIRED BY WRITTEN CONTRACT
DATE OF ISSUE: 06-01-18
Q 1983 National Council on Compensation Insurance.