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PROOF OF INSURANCE (2019) CLOSED
� ,pp � DATEO(6 6/DOD7/YYYY) - CERTIFICATE OF LIABILITY INSURANCE 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 d SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this 2D certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 'p AME, NAon Risk ew York serNY vices Northeast, Inc, PHONE (85FAX ............. � 6) 283-7122 (800) 363-0105 d AVr�,Nor, Exrcy. V'PAlru',,No eV„ _..�. V 199 Water Street E-MAIL O New York, NY 10038-3551 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: National Union Fire Ins CO Of Pittsburgh 19445 cellco Partnership dba Verizon wireless INSURER B: 1095 Avenue of the Americas — New York NY 10036 USA INSURER C: INSURER D: "I.... ........ ..._......_ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570071966463 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF(INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAKED ABOVE.FOR THE POLICY PEMOD INDICATED,NOTW'ITHSTANDI'NG ANY REQUIREMENT,'TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO 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:POLI'CIE'S LIMITS SHOWN MAY HAVE BEEN RE'DUC'ED BY PAID CLAIMS. Limits shown are as requested YNS'k ADY]U' UBR F"'MADDI'EFF P() EACH OCCURRENCE LTR (NSD WVo PMOILIC YYYY POLICY E F A ,X I COMMERCIAL GENERAL LIABILITY GL4b11607 POLICY NUMBER Ob/30/GUI LIMITS $2,000,000 : CLAIMS-MADE OCCUR �p'R'LMq'S;F,SO&ZE tsI"I Y-''D $Z,000,000 A An B .. -MED EXP(Any one person) PERSONAL&ADV INJURY $2,000,000 m ...._e ```GE'ryry��N'L GENERAL AGGREGATE $2,000,000 AGGREGATE LIMITAPPLIES PER: � POLICY F-]PRO- LOC ,PRODUCTS-COMP/OP AGG $2,000,OOO JECT r OTHER: o AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT LO _,(Ea accldentl ANY AUTO BODILY INJURY(Per person) C OWNED SCHEDULED BODILY INJURY(Per accident) w AUTOS ONLY AUTOS . .............. PROPERTYDAMAGE HIRED AUTOS NON-OWNED V .......,.-._ ONLY AUTOS ONLY Wer accident) w 0) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE ........................ DED RTETCNIJON ANY PROPRIETOR/PARTNERI EXECUTIVE YIN ..._.... , EL EACH ATE CRH WORKERS COMPENSATION AND V PER STATU .� CCI.DENT OFFICERIMEMBER EXCLUDED? NIA - ----"""""'""""" (Mandatory in NH) E L DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ice" IRE: Site Name: Posa Park, Site Address: 400 Lomita Street, El Segundo, CA. City of E1 Segundo is included as Additional Z, Insured with respect to the General Liability policy where required by written contract. .w CERTIFICATE HOLDER CANCELLATION inP ., 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: City Clerk Sack wayt, City Manager 350 Main Street (� i % �Ol�e/rd�Jlna El Segundo CA 90245 USA e�sa�s ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACS® DATE((6MM/DDD1(YYYY) CERTIFICATE OF LIABILITY INSURANCE 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(les)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). PRODUCER (CONTACTp NAME': Aon Risk Services Northeast, Inc. PHONE — ............. ._.,_.___. FAX .._., New York NY Office I(A/C.No.Ext): (866) 283-7122 I (A/C.No.): (800) 363-0105 d 13 199 water Street E-MAI ADDRESS: 7E)New York NY 10038-3551 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: National Union Fire Ins Co of Pittsburgh 19445 ................. LOS Angeles SMSA LP INSURER B: American Home Assurance Co. 19380 dba Verizon wireless .- ......"" 1095 Avenue of the Americas INSURER C: New Hampshire Insurance Company 23841 New York NY 10036 USA INSURER D: Illinois National Insurance Co 23817 INSURER E: ................... NI INSURER F: COVERAGES CERTIFICATE NUMBER: niuut' 845774 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED"T°O'THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT'WW'9THSTA'NDINO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT'WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 'ISSU'ED 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. Limits shown are as requested INSR A00t.5USR POLICY EFF POLICY 6?(Y II LTR TYPE OF INSURANCE IN�SID WVO POLICY NUMBER ((,M,�MIDDIYYYYI IMMIODWY°YYY'p LIMITS A X COMMERCIAL GENERAL LIABILITY GL4611bU/ 96/30/2018-)b EACH OCCURRENCE $1,000,000 _ ..- 1 CLAIMS-MADE X OCCUR DAMAGE TO REN a $1,000,000 PREMISES(Ea occurrence,)„m,m,,,, , X XCU Coverage is Included MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 $1,000,000 N ;EN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATEW POLICY E PRO- JECT LOC IPRODUCTS-COMP/OPAGG $1,000,000 . . ......._......................... O OTHER: 1 r ACA 461-15-19 06/30/2018 06/30/2010 COMBINED SINGLE LIMIT LO AOS AUTOMOBILE LIABILITY IEa accident) $1,000,00o X ANYAUTO CA 461-15-20 06/30/2018 06/30/2019 BODILY INJURY Per person) O OWNED """"'"""SCHEDULED MA BODILY INJURY(Per accident) d A AUTOS ONLY AUTOS CA 461-15-21 06/30/2018 06/30/2019 HIRED AUTOS NON-OWNED PROPERTY DAMAGE ONLY AUTOS ONLY VA (Per accident) . w= A See Next Page 06/30/2018 06/30/20191 t Gf , UMBRELLA LIAB OCCUR OCCURRENCEEACH EXCESS LIAB CLAIMS-MADE AGGREGATE ........,. IIIII 1DED 1 RETENTION V C WORKERS COMPENSATION AND wCU14590551 06/30/2018 06/30/2010 ,STATUTE IEORH EMPLOYERS'LIABILITY X ............. .-.... _ ... B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN EL EACH ACCIDENT $1,0_00,000 OFFICER/MEMBER EXCLUDED? N] N/A WC014590550 06/30/2018 06/30/2019 W..w.............. (Mandatory in NH) ••• CA E .DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under E L DISEASE-POLICY LIMIT $1,00 1.0,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) " RE: Cell Site: Posa Park, Location Code: 160970, Address: 400 Lomita Street, El Segundo, CA 90245, 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 350 Main Street w El Segundo CA 90245 USA e 'a� 4�Z � r�r ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000027366 LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Aon Risk services Northeast, Inc. LOS Angeles SMSA LP POLICY NUMBER See Certificate Number: 570071845274 CARRIER MAIC CODE see certificate Number: 570071845274 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 ADDTHON.M, 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 FNSR ADDL SURR EFFECTIVE EXPIRATION LTR TYPE OF INSURANCE rNSD WVD POLICY NUMBER DATE DATE LIMITS (MMIDDNYYY) (MMfODIVYYY) AUTOMOBILE LIABILITY A ICA 774-22-65 06/30/2018 „06/30/2019 NH - Primary A CA 774-22-66 06/30/2018 06/30/2019 NH - Excess WORKERS COMPENSATION D N/A WC014590552 06/30/2018 06/30/2019 FL C N/A WC014590553 06/30/2018 06/30/2019 ME C N/A WcO14590549 06/30/2018 06/30/2019 111,NY,TX,VA C N/A wc014590554 06/30/2018 06/30/2019 MA,ND,OH,WA,WI,WY ACORD 101(2008101) 02006 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD