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PROOF OF INSURANCE (2019 - 2019) CLOSED Client#:294228 IXPCOR
ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY)
8/29/2018
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 ADDITIO1.NAL INSURED pro11 v 11 i 11 si1.o 1.ns 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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
USIInsuraceSvicesLLC Vyq�"'o,.Xt�484351-4600 I c,N 10537-497,4
H, o.....
6
1787 SentryPkwyW. Veva 16 E-MAIL
Suite 300 INSURER S)AFFORDING COVERAGE NAIC
Blue Bell PA 19422 (....o.......................................... #
Associated Industries Ins.Co.,Inc. ........................................................................ 123140
INSURER A: _
INSUREDStarStone.Nati
INSURER B: National Insurance Company '25496
IXP Corporation INSURER C:Travelers Commercial Insurance Company
136137
Princeton Forrestal Village, INsuRRD:NationalunionFirelnsPlnsbar9l,P................................... _....__......................_..
A 19445
103 Main Street Suite 100 INSURR.E......L,be.............u,r, ......__1._.......... ._.
rly Insurance Underwriters,Inc. 19917
Princeton,NJ 08540
INSURER F t
COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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.
SUBR POLICY
POLICY
AR COMMERCIAL NS LWVD AES1035691 04 08/31/2018108/31/2019IEACH OCCURRENCE LIMITS$1,000,0„
POLICYNCE NUMBER MM/DD/VY F)
I p T 00
............L............ CLAIMS-MADE 41 OCCUR ,PREr lO,21I�S�iEaFc�acc�rD,e„irace,).. .$,100,000
1 MED EXP(Any one person) $0
............I ........................... . 1 PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: 1 GENERAL AGGREGATE $2,000,000
PRO- PRODUCTS-COMP/OP AGG,.,, Z-
._.....� POLICY I,,,,,,X„ 000 OOO
JECT LOC R................?
OTHER:
$
A AUTOMOBILE AES103569104 08/31/2018 08/31/2019GOMRnNFD)RIP�Lp LIMIT1,0
00,00
0
�-�a� �d�rm ---_11-1111- ........_.._
ANY AUTO BODILY INJURY(Per person) $
IOWNED SCHEDULED
BODILY INJURY(Per accident) $
AUTOS ONLY X X P,r
1. AUTOS ONLY AUTOS
HIRED AUOTOS ONLY p�Pc den4ERTY�DAMAGE
...............�,...........$........................ ....
...,.-,,...., $
B EX............LLA.................. .i. occuR 59184D183ALI 08/31/2018 08/31/2019(EACH OCCURRENCE $5 —
CESS IAB AIMS MADE AGGREGATE $5,000,000�OOO,UU
UMBRELLA LIAB
x
_X QED XI RETENTIO)N$O L
C WORKERS COMPENSATION ... .................. .................................................UB003K766849 01/01/2018 01/01/2019... .....P�Eh.. ....
AN000EMPLOYERS LIABILITY YIN PTAT ACCIDENT .FR 1,000,
❑ �OTH
OF
(Mandatory In NH) EXCLUDED? N/A E.L.DISEASE-EA EM„ $ �OOOr f)0
6°'ERAA�¢MBERYEXCLNER/EXECUTIVE E L EACH PLOYEE $ p .
If yes,describe under
DESCRIPTION OF OPERATIONS b,el,ow,
_ I E L,DISEASE-POLICY LIMIT $1,000,000
D Professional Liab 18336672 08/31/2018 08/31/2019 $5,000,000
E Excess Liab- E04NAAS4JW006 08/31/2018108/31/2019 Excess$5,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Liability policies will be endorsed to name CITY,its officials,and employees as additional insureds
under said insurance coverage and to state that such insurance will be deemed primary such that any other
insurance that may be carried by CITY will be excess thereto.Such endorsement must be reflected on ISO
Form No.CG 20 10 11 85 or 88,or equivalent.For purposes of this Agreement,equivalent insurance includes
Form CG 2010 04 13 and CG 20 37 04 13.
CERTIFICATE HOLDER CANCELLATION
EI Segundo Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
g P THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attention: Jaime Bermudez, Lieutenant ACCORDANCE WITH THE POLICY PROVISIONS.
348 Main St.
EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE
©1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S23762116/M23761305 AXYZP
POLICY NUMBER:AES1035691 04 COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL II SU 'ED - OWNERS, LESSEES O
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s)Of Covered Operations
All persons or organizations where required by
written contract with the Named Insured
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the following additional
organization(s) shown in the Schedule, but only exclusions apply:
with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or
damage' or "personal and advertising injury' "property damage"occurring after:
caused, in whole or in part, by:
1. All work, including materials, parts or
1. Your acts or omissions;or equipment furnished in connection with such
2. The acts or omissions of those acting on your work, on the project (other than service,
behalf; maintenance or repairs) to be performed by or
in the performance of your ongoing operations for on behalf of the additional insured(s) at the
the additional insured(s) at the location(s) location of the covered operations has been
designated above. completed;or
However: 2. That portion of "your work" out of which the
injury or damage arises has been put to its
1. The insurance afforded to such additional
intended use by any person or organization
insured only applies to the extent permitted by other than another contractor or subcontractor
law; and engaged in performing operations for a
2. If coverage provided to the additional insured is principal as a part of the same project.
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 2
This page has been left blank intentionally.
�" Vi�L �I WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 00 03 13(00)- 001
POLICY NUMBER: UB-3x766849-18-43-G
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 any one not named in the Schedule.
SCHEDULE
DESIGNATED PERSON:
DESIGNATED ORGANIZATION:
ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED
BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS
WAIVER.
DATE OF ISSUE: 12-15-17 ST ASSIGN: PAGE 1 OF