PROOF OF INSURANCE (2018) CLOSED CERTIFICATE OF LIABILITY INSURANCE DATE(M"�°°",IYY'
9/30/2018 1 9/22/2017
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 Lockton Companies NAME CT .... ... ...., ..., „,,,,
Farmington CT 06032 76 Batterson Park E-Md .. Fv.No.........
HON').8,.. d6tl:................................ ^ ld_................................
Al
860-678-4000 s __w__.
INSURER(S)AFFORDING COVERAGE NAIC#
lnurance Cozorattn 42404
' R B
INSURED Galls LLC Liberty Mutual Fire Insurance Company ,,,.,,, 23035
RA
1345090 R c XT
1340 Ron KY 40505 INSURERD:The ussell Cave Road Special,ty_ln$.tgan e Company . 3788
Lexington
Ohio Casualty Insurance Company 24074
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 121'04450 REVISION NUMBER: XXXXXXX
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 'ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH 'OLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
ILICY&0 POLICY UP
LTR .... TYPE OF INSURANCE.... .. N'9 ` POLICY NUMBER IMM DDIYYYY)..(MMIDDfYYYY)
LIMITS
ACOMMERCIAL GENERAL LIABILITY Y N TB7-Z11-261104-037 9/30/2017 9/30/2018 EACH
...� I ECHOECLAIMS-MADE ^ X OCCUR ATC pEN e
PRMS $ rTence) ,E 309xOQ00
M.E4..EXP(Any one person) $ 10.000.......... ...........................
PERSONAL&ADV INJURY $ 1,000,000
GAT E LIMIT APPLIES PER: GENERAL AGGREGATE 2 JECT LOC PRODUCTS-COMP/OPAGG S 2xOOO O09,#.00
GEN'L AGGREGATE b
... PO�LiCY PRO- .00 ......
OTHER: $
B AUTOMOBILE LIABILITY N N AS2-Z11-261104-027 9/30/2017 9/30/2018 COMBINED SINGLE LIMIT
(Eeapddor
$ x
1 Q,QQxQ.. . ......................
ANY AUTO BODILY INJURY(Per person) E XXXXXXX
AO OS ONLY AUT BODILY INJURY(Per accident) $ XXX
-. XXXX
HIRED AUTOS ONLY (Por oraCll4nq)___ $..XXXXXXX......,,,
AUTOS ONLY NON-OWNED PROPERTY DAMAGE
X C:OITD:51,00( X COil:'1»1,000 $ XXXXXXX
UMBRELLA LIAB COCCUR
LAIMS-MADE N N US00080358LI17A 9/30/2017 9/30/2018 AEACH GGREGATE RENCE b 10,000,000
C X.., EX CESS IJA9 000x000„ _
X... DEDRETENTIONS 10,000 E.... �. .
XXXXXXX
WORKERS YIN N -X ER H-
B AND EMPLOYERS'LIABILITY WC2-Z11-261104-017 9/30/2017 9/30/2018 STA UTE____....ER. ....................................,,,,,,,,,,,,,,,..,,.,,,,,
ANY PROPRIEfOR/PARTNER/EXECUTIVE NIA E L EACH ACCIDENT $ 1,x000,,0„00
OFFICE(Mandatory In
ube un OPERATIONS below EMBER EXCLUDED? I N E L.DISEASE-POLICY LIMIT S 1 derxO,0,Q00
1
D 1.000.000
D Excess Umbrella N N ECO(18)58276018 9/30/2017 9/30/2018 Limit:$15,000,000;XS$10,000,000
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,AddMonal Remarks Schedule,may be attached If more space Is required)
Re:El Segundo Police Department Services Arcclnent,The City of El Segundo,its officials and employees are included as Additional Insured on the General
Liability as required by written contract.Such insuraricc is primary and noncontributory.
CERTIFICATE HOLDER CANCELLATION
12104450
City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Office of the City Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo CA 90245 AUTHORMED
REPRESENTATIVE/
®1988-201 ACOkD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Policy Number TB7-Z11-261104-037
Issued by Liberty Insurance Corp.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL GENERAL LIABILITY
ADDITIONAL INSURED ENHANCEMENT FOR WHOLESALERS
This endorsement modes insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Index of modified items:
Item 1. Blanket Additional Insured Where Required By Written Agreement
Lessors of Leased Equipment
Managers or Lessors of Premises
Mortgagees,Assignees or Receivers
Grantor of Franchise
Vendors
Any Person or Organization
Item 2. Blanket Additional Insured—Grantor Of Permits
Item 3. Other Insurance Amendment
Item 1. Blanket Additional Insured Where Required By Written Agreement
Paragraph 2. of Section II—Who Is An Insured is amended to add the following:
Additional Insured by Written Agreement
The following are insureds under the policy when you have agreed in a written agreement to provide them coverage
as additional insureds under your policy.
1. Lessors of Leased Equipment The person(s) or organization(s) from whom you lease equipment, but only
with respect to liability for "bodily injury", "property damage" or "personal and advertising injury' caused, in
whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or
organization(s).
This insurance does not apply to any"occurrence"which takes place after the equipment lease expires.
2. Managers or Lessors of Premises: Any manager(s) or lessor(s) of premises leased to you in which the
written lease agreement obligates you to procure additional insured coverage.
The coverage afforded to the additional insured is limited to liability in connection with the ownership,
maintenance or use of the premises leased to you and caused, in whole or in part, by some negligent act(s) or
omission(s) of you, your "employees", your agents or your subcontractors. There is no coverage for the
additional insured for liability arising out of the sole negligence of the additional insured or those acting on
behalf of the additional insured,except as provided below.
If the written agreement obligates you to procure additional insured coverage for the additional insured's sole
negligence, then the coverage for the additional insured shall conform to the agreement, but only if the
applicable law would allow you to indemnify the additional insured for liability arising out of the additional
insured's sole negligence.
LC 20 60 0117 C 2016 Liberty Mutual Insurance Page 1 of 4
Includes copyrighted material of Insurance Services Office, Inc.,with its permission.
This insurance does not apply to:
a. Any"occurrence'which takes place after you cease to be a tenant in that premises or to lease that land:
b. Structural alterations, new construction or demolition operations performed by or on behalf of that manager
or lessor,or
c. Any premises for which coverage is excluded by endorsement.
3. Mortgagees, Assignees or Receivers: Any person(s) or organization(s) with respect to their liability as
mortgagee, assignee or receiver and arising out of your ownership, maintenance or use of the premises.
This insurance does not apply to structural alterations, new construction and demolition operations performed
by or on behalf of such person(s)or organization(s).
4. Grantor of Franchise: Any person(s) or organization(s) but only with respect to their liability as grantor of a
franchise to you.
5. Vendors: Any person(s) or organization(s) that distributes or sells "your products" in the regular course of their
business, hereafter referred to as vendors, but only with respect to"bodily injury' or "property damage" arising
out of"your products" which are distributed or sold in the regular course of the vendor's business,subject to the
following additional exclusions:
a. The insurance afforded the vendor does not apply to:
(1) "Bodily injury' or"property damage" for which the vendor is obligated to pay damages by reason of the
assumption of liability in a contract or agreement. This exclusion does not apply to the liability for
damages that the vendor would have in the absence of the contract or agreement;
(2) Any express warranty unauthorized by you:
(3) Any physical or chemical change in the product made intentionally by the vendor;
(4) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or
the substitution of parts under instructions from the manufacturer, and then repackaged in the original
container;
(5) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make
or normally undertakes to make in the usual course of business, in connection with the distribution or
sale of the products;
(6) Demonstration, installation, servicing or repair operations, except such operations performed at the
vendor's premises in connection with the sale of the product;
(7) Products which,after distribution or sale by you, have been labeled or relabeled or used as a container,
part or ingredient of any other thing or substance by or for the vendor;or
(8) "Bodily injury' or"property damage" arising out of the sole negligence of the vendor for its own acts or
omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does
not apply to:
(a) The exceptions contained in Paragraphs(4)or(6)above;or
(b) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally
undertakes to make in the usual course of business, in connection with the distribution or sale of
the products.
b. This insurance does not apply to any insured, person or organization, from whom you have acquired such
products,or any ingredient, part or container,entering into, accompanying or containing such products.
LC 20 60 0117 ®2016 Liberty Mutual Insurance Page 2 of 4
Includes copyrighted material of Insurance Services Office,Inc.,with its permission.
6. Any Person or Organization Other Than a Joint Venture: Any person(s) or organization(s) (other than a joint
venture of which you are a member) for whom you are obligated to procure additional insured coverage, but
only with respect to liability for"bodily injury', "property damage" or"personal and advertising injury' caused, in
whole or in part,by your act(s)or omission(s)or the act(s)or omission(s)of those acting on your behalf:
a. In the performance of your ongoing operations; or
b. In connection with premises owned by or rented to you.
This insurance does not apply to:
a. Any person(s)or organization(s)more specifically covered in Paragraphs 1 through 5 above;
b. Any construction, renovation, demolition or installation operations performed by or on behalf of you, or
those operating on your behalf; or
c. Any person(s) or organization(s) whose profession, business or occupation is that of an architect, surveyor
or engineer with respect to liability arising out of the rendering of, or failure to render, any professional
architectural,engineering or surveying services, including:
(1) The preparing, approving or failing to prepare or approve, maps, drawings, opinions, reports, surveys,
field orders, change orders, designs and specifications; or
(2) Supervisory,inspection,architectural or engineering activities.
This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the
supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which
caused the"bodily injury' or "property damage", or the offense which caused the"personal and advertising
injury', involved the rendering of or failure to render any professional services by or on behalf of you, or
those operating on your behalf.
The insurance afforded to any person(s)or organization(s)as an insured under this Item 1:
1. Applies to the extent permitted by law;
2. Applies only to the scope of coverage and the minimum limits of insurance required by the written agreement,
but in no event exceeds either the scope of coverage or the limits of insurance provided by this policy;
3. Does not apply to any person(s) or organization(s) for any "bodily injury', "property damage" or "personal and
advertising injury' if any other additional insured endorsement attached to this policy applies to such person(s)
or organization(s)with regard to the"bodily injury', "property damage"or"personal and advertising injury
4. Applies only if the "bodily injury' or "property damage" occurs, or the offense giving rise to the "personal and
advertising injury'is committed,subsequent to the execution of the written agreement;and
5. Applies only if the written agreement is in effect at the time the"bodily injury' or"property damage" occurs, or at
the time the offense giving rise to the"personal and advertising injury'is committed.
Item 2. Blanket Additional Insured—Grantor Of Permits
Paragraph 2.of Section II-Who Is An Insured is amended to add the following:
Any state, municipality or political subdivision that has issued you a permit in connection with any operations
performed by you or on your behalf, or in connection with premises you own, rent or control, and to which this
insurance applies, but only to the extent that you are required to provide additional insured status to the state,
municipality or political subdivision as a condition of receiving and maintaining the permit. Such state, municipality
or political subdivision that has issued you a permit is an insured only with respect to their liability as grantor of such
permit to you.
LC 20 60 0117 0 2016 Liberty Mutual Insurance Page 3 of 4
Includes copyrighted material of Insurance Services Office,Inc.,with its permission.
However,with respect to the state, municipality or political subdivision:
1. Coverage will be no broader than required;and
2. Limits of insurance will not exceed the minimum limits of insurance required as a condition for receiving or
maintaining the permit;
but neither the scope of coverage nor the limits of insurance will exceed those provided by this policy.
This insurance does not apply to:
1. "Bodily injury', "property damage" or "personal and advertising injury' arising out of operations performed for
the state, municipality or political subdivision;
2. Any "bodily injury' or "property damage" included within the "products-completed operations hazard", except
when required by written agreement initiated prior to loss;or
3. "Bodily injury', "property damage" or"personal and advertising injury', unless negligently caused, in whole or in
part, by you or those acting on your behalf.
Item 3. Other Insurance Amendment
If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any
other basis for any person(s) or organization(s) that qualifies as an additional insured on this policy, this policy will
apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV—
Commercial General Liability Conditions will not apply. Where the applicable written agreement does not specify on
what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV —
Commercial General Liability Conditions will apply. However, this insurance is excess over any other insurance
available to the additional insured for which it is also covered as an additional insured by attachment of an
endorsement to another policy providing coverage for the same"occurrence",claim or"suit".
LC 20 60 01 17 m 2016 Liberty Mutual Insurance Page 4 of 4
Includes copyrighted material of Insurance Services Office, Inc.,with its permission.
W-9Fortrr Request for Taxpayer Give Form to the
(:Wv.NoivernlW2017) Identification Numiber and Certification requester.Do not
=.1111=r IN,Go to wwwdirs.goirlFormIND for lirwilruclillons and the briiiiat Information. send to the IRS.
I Name Jos shown,on your incorfie,lax rsturyi).Name is required on this tine:do not leave this fine blank.
Galls Parent Holdings,LLC
2 Business n*m0duagaided antily name,if different from above
Galls,LLC
3 Check appropriate box for federal lax classification of the person whose name Is entered on line 1.Check only one of the 4 Exernipti.;;(ood"apply only to
4M lolrowirilii seven boxes. cwOn enfities,now Individuals;see
a instructions on pace 3):
0 a n Individuallsote pwiarkrjo;or L1 C Corporation El S Corporation 13 Partnership ❑TrusVestitte
C sirvaia-rnambor LLC Exempt payee code Of any)
U.lt.d fibility corn pony.Enter the tax classification(CSC corporation,S=S corporation,P-Partnerstap)► Is
0 Note,,Check the appropriate box dor the line above for the tax Wassiflicallon of the sienft-mendw owner. 00 not check Exemption from FATCA reporting
LLC it the LLC Is classified as a 3angW Member LLC that is,disregarded from the owner unless the owner of the LLC is code Of any)
another LLC that is not disregarded'beanIII's owner lot U,$,ledwal lax purposes.Otherwise,a sIngle-marober LLC Viat
is Mareflarded from the ownershouid check the appropriate box tor the tax ciassificafion of its owner,
Other
Other(see instructions)10. 00MAOM to Motaft ffAkVakwd oubW V*U.S)
5 Address(riumbar,West,and apt or suite no.)See instructions, Requester's name and address(optionaD
P.O.Box 71628
6 Chy,stais,and ZIP code
Chicago,IL 60694-1628
1 List account numbef(s)here(013iioww—)
K� 'Taxpayer Identification NUMber(TIN)
Enter your TIN In the appropriate box.The TIN provided must match the name given on line I to avoid $octal$000MY number
backup withholding.For Individuals,this Is generally your social security number(SSN),However,fare
resident allan,sale proprietor,or disregarded entity,see the Instructions for Part 1.later,For
entities,it IS your employer Identification number(FII).It you do not have a number',see Hc -LJ-1 LH-LJ
TIN,inter. or
Note:If the account is In more than one name,see the Instructions for line 1.Also see What Name and �Employer Identification number
Number To Give the Requester for guidelines on whose number to enter. F8'J 2
11MM Certification
Under penalties of perjury,I certify that:
1.The number shown on this form Is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2.1 am not subject to backup wiliftholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup Withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding,and
3,1 am a,U.S,citizen or other U.S,person(defined below),arid,
4,The FATCA code(s)entered on this form(if any)Indicating that I am,exempt from FATCA reporting is correct.
Certification Instructions.You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all Interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(MA,and goneralty,payments,
other than Interest and dividends,you we not required to skin the Wilicatlon,but you must provide your correct TIN.Sea the Instructions for Part 11,Won
Sign Sigrawtvirs,at
Here I U.S,pereen b, Date b-
General Instructions •Form I 099-01V(dividends,Including those from stocks or mutual
Section references are to the Internal Revenue Code unless otherwise funds)
noted. *Form 1099-MISC(various types of Income,prizes,awards,or gross
proceeds)
Future developments,For the latest Information about developments *Form 1099-B(stock or mutual fund sales and certain other
related to Form n W-9 and its Instructions,such as legislations enacted transactions by brokers)
after they were published,go to wwwJmgov1FormW9, Forrn'1099-S(procueds from real estate transactions)
Purpose of Form :Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 rectuoster)who is required to file an 6 Form 1098(home mortgage Interest).1098-t-(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
Identification number(TIN)which may be your social security number *Form 1099-C(canceled debt
(SSN),individual taxpayer identification number(ITIN),adoption a Form 1099-A(acquisition or abandonment of secured property)
taxpayer Identification number(ATIN),or employer Identification nurnbor
(Eft to report on an Information return the annount.paid to you,or other Use Form W-9 only If you am a U.S.parson(Including a resident
amount reponabia on an,information return,Examples of Information alien),to provide your correct TIN.
returns Include,but are not Ilmlled to,tha following. It you do not return Form W-9 to the requester with a 17N,you might
Form 1099-INT(Interest earned or paid} be subject to backup withholaYng.See What Is backup withholding,
later,
Cat No,102SIX Form W-9(Rev.11-2017)