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PROOF OF INSURANCE (2019) CLOSED DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/26/2016 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 2 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). d ONCT PRODUCER M,AAMME� 9 Aon Risk Services South, Inc, PHONE FAX Atlanta GA Office (A/C.No.Ext): (866) 283-7122 V ( No). (800) 363-0105 113550 Lenox Road NE E-MAIL W O suite 1700 ADDRESS:,,, 2 Atlanta GA 30326 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Trans Pacific Ins CO 41238 ZOLL Medical Corporation INSURER B: Tokio Marine America Insurance Company 10945 and subsidiaries -.........� 269 Mill Road INSURER C: The Travelers Indemnity Co. 25658 ..............� . .................... Chelmsford MA 01824-4105 USA INSURER D: Federal Insurance Company 20281 ............... INSURER E: Mitsui Sumitomo Insurance USA Inc. 22551 ...�..... .. .m_._ .......... . ,.......... INSURER F: COVERAGES CERTIFICATE NUMBER: 570071941492 REVISION NUMBER: pp THIS IS TO CERTIFY THAT THE(POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DCCUMEN°i°'wi,r'H 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 CLAIIMS. Limits shown are as requested INSR ADDL'SUBR� POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE MSD WVD POLICY NUMBER IMMIDWYYYY) �qMMMDfYYYY' A X COMMERCIAL GENERAL LIABILITY CLLb4097bUU1 U//U1/LU145 U7/U1/1U19' EACH OCCURRENCE $1,000,000 DAMAGE fO RFN'I ED $1,000,000 V CLAIMS II X II OCCUR PREMISES(Ea occurrence) �.........:......._. u - _....... MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,0001 CD GEN'LAGGREGATE LIMITAPPLIES PER. GENERAL AGGREGATE $2,000,00 OTHER: � ❑ 1 2019 COMBINED SINGLE LIMIT o X POLICY PRO LOC PRODUCTS-COMP/OPAGG Excluded_ JECT 0 (Ea argicip—ntl $1,000,000 r` B CA6409761 O1 07/01/2018 07/0 / " AUTOMOBILE LIABILITY --- BODILY INJURY(Per person) O X ANYAUTO ...•.•.•.... .....•.•.� Z OWNED SCHEDULED BODILY INJURY(Per accident) SII r AUTOS ONLY AUTOS """"""" .•.•.•.._.. .._... PROPERTY DAMAGE V HIRED AUTOS NON-OWNED (Per accident) ._._•... ONLY _,........ AUTOS ONLY N E X UMBRELLA EXCESS LGRELIAB II IOCCUR MADE EXS5200217 07/01/2018 07/01/2019EACH O 1 AGCCURRENCE $25,000,000 GATE $25,000,000 C WORKERS ORKS SCOMPPBEINSYTIONAND _ UB53319473 07/01/2018 07/01/2019 X I STATUTE w IORTH• ...•DED' JRETENTION Y('N m...• ANY PROPRIETOR/PARTNER/EXECUTIVE �'',q,q E L EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? F NIA '�"""••••••••••"" - (Mandatory in NH) II�JII E L,DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under _.LI DESCRIPTION ION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1.000,000 D Products Liab 36019266 07/O1/2b18 07/01/2019'Prod/Comp Ops/Agg $5„000,'000 Y Retro Date 10/1/2004 uProd/comp Ops/occ $5,000,000 VIII Deductible $200,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) p�l Products Liability - claims made coverage. RE: Premises/operations. City of E1 Segundo is included as Additional Insured in accordance with the policy provisions of the General Liability policy. A Waiver of Subrogation is granted in favor of City of E1 Segundo in accordance with the policy provisions of the workers' Compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE , EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of El Segundo AUTHORIZED REPRESENTATIVE �^ Attn: Carol Lynn Anderson I� a 350 Main Street A cfJex 117611 El Segundo CA 92045-3813 USA . AI� ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000057723 LOC#: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk services South, Inc. ZOLL Medical corporation POLICY NUMBER y see certificate Number: 570071941492 CARRIER NAIC CODE see certificate Number: 570071941492 I EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY ININSD SVD EFFECTIVE F SEXPIONRTYPE OF INSURANCE WPOLICY NUMBER DTEDATELIMITS (MMIDD/YYYI� (MMIDDIYYYY) EXCESS LIABILITY D 79882432 07/01/2018107/01/2019 Aggregate $5,000,000 Ex Products Liab Each $5,000,000 Occurrence II u I ACORD 101(2008101) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER:CLL64097 60-01 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED 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): ANY PERSON OR ORGANIZATION WHEN YOU AND SUCH PERSON (S)OR ORGANIZATIONS) HAVE AGREED IN WRITING IN A CONTRACT OR AGREEMENT THAT SUCH PERSON OR ORGANIZATION BE NAMED AS AN ADDITIONAL INSURED ON THIS POLICY PROVIDED THE CONTRACT OR AGREEMENT WAS EXECUTED PRIOR TO THE "BODILY INJURY", "PROPERTY DAMAGE" OR "PERSONAL AND ADVERTISING INJURY". 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 is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for"bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the Declarations. insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is 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 26 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 Insured Copy T A ELER J" WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 00 03 13 (00)-001 POLICY NUMBER: UB-5J319473-18-12-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. Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual. DATE OF ISSUE: 07-18-18 ST ASSIGN: PAGE 1 OF