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PROOF OF INSURANCE (2019 - 2020) CLOSED
Page 1 of 2 A 0, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/2018 12/26i2D1a 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ... „_ CONTACT JLAME- PHONE ...• .._.• .•..............................•.•.•.. Willis of Pennsylvania, Inc. FAX 1-888-467-2378 1-877.... 378 I IAfC,• " Century 1. �S.R...F,!Ur......................................�.._. Nm'...................................... UL A KESS; certificates@willis.cam Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAICN ..... .. •.......,�.•.•., NSURERA: Tokio Marine America Insurance Company 10945 INSURED INSURER B: Travelers Casualty and Surety Company 19038 Kyocera Document Solutions West LLC ••••••••••••••••••••••-••...........••• •ITIT ITIT••mmIT•�m��mm 14101 Alton Parkway INSURER C: Travelers Property Casualty Company of Ame 25674 Irvine, CA 92618 USA INSURER D: I INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W9670670 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 IERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 3OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS VLTR TYPE OF INSURANCE INI;V y$d.IOR P POLtlCY EE' POLICY EXP' ry INs� ,YL POLICY NUMBER tiONVOWYYYY) tMMPDOIYYYYt l' LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 OCCUR t'fih"P�i�i'G EACH OCCURRENCE $ CLAIMS-MADE E"TO„KF14TEDm'".•.•. 1,000,000 PREMISES(Es occurrence) $ A I MED EXP(Any one oerson) $ 5,000 y y CLL6407345-04 04/01/2018 04/01/2019 1,000,000 w_ PERSONAL 8 ADV INJURY $ G'E`ryNI AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE $ 2,000,000 POLICY❑PRO O LOI 1,000,000JECT OTHER $ AUTOMOBILE LIABILITY ...... ComfiINEDi SINGLE LIMIT $ 1,000,000 _(Ea accldamn X ANY AUTO BODILY INJURY(Per person) $ ........... •.•.......•.•.•.•...•...•.•.•.•.•.•.•.•.•.•.•.•.•. A OWNED SCHEDULED CA640732604 04/01/2018 04/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY . AUTOS _ HIRED NON-OWNED PROPE'R7•YDAMAGE ..........-.5..•...... .................................. ,........... AUTOS ONLY ......... AUTOS ONLY ,,,hPcr)ucdctrt).(BL)........................................................................ $ •. A . X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 ............ _ ,,.,�.„..,-.,.-......�................•.•.........•................„_.. EXCESS LIAB CLAIMS-MADE CU6407347-04 04/01/2018 04/01/2019 AGGREGATE $ 5,000,000 .. •.•.•.•.•.•.•.•. ......... DEQ I X I RETENTION$10,000 $ WORKERS COMPENSATION IIS7AR.TUTE ORH AND EMPLOYERS'LIABILITY X f-_�- ----------•••------•�--••••�— B ANYPROPRIETOR/PARTNERIEXECUTIVE Y 1 N EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? No N/A UB-3F96054-7-19 01/01/2019 01/01/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under •_. 1,000,000 DESCRIPTION OF OPERATIONS below El DISEASE-POLICY LIMIT $ C Workers Compensation 6 UB-3F9BO68-8-19 01/01/2019 01/01/2020 E.L. Each Accident $1,000,000 Employers Liability EL Disease -Pol Limit$1,000,000 Per Statute EL Disease - Ea Emp. $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached H more space is required) SCOPE OF WORK: Copier Sales, Leasing & Maintenance. City of E1 Segundo with whom the Insured has agreed in written contract, agreement or permit is included as an Additional Insured with respect to liability arising out of the Insured's operations, personal property leased to the insured, premises owned or rented by, or temporarily occupied by the insured with permission of the owner. 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 E1 Segundo AUTHORIZED REPRESENTATIVE Attn: City Clerk 350 Main Street E1 Segundo, CA 90245-3813 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR iD: 17301619 BATCH: 1001357 AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 (AGENCY NAMED INSURED Willis of Pennsylvania, Inc. Kyocera Document Solutions West LLC 14101 Alton Parkway POLICY NUMBER Irvine, CA 92616 USA See Page 1 CARRIER I NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE:See Page 1 ADDI'TION'AL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance If required in the written contract, agreement or permit, the Insured waives any right of recovery (where permitted by law) that they may have against City of E1 Segundo because of payments that may be made for injury or damage. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 17301619 BATCH: 1001357 CERT: W9670670 Commercial General Liability This endorsement changes policy CLL640734 5-04 to which it is attached and is effective 04/01/2018 at 12:01 a.m. standard time at the Insured's mailing address. Issued to: KYOCERA DOCUMENT SOLUTIONS Issued by: TNUS Insurance Company Producer: WILLIS OF OHIO, INC. THIS ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT CAREFULLY. THE GENERAL LIABILITY ENHANCED COV RAGE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. ADDITIONAL INSURED—VENDORs when required by contract or agreement If an amount is shown in the Declarations for the Products-Completed Operations Aggregate Limit, Section II- Who Is An Insured is amended to include as an additional insured your"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: 1. The insurance afforded the"vendor" does not apply to: a. "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 liability for damages that the"vendor"would have in the absence of the contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the"vendor"; d. 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; e. 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; GL7 04 00103 13 ®Tokio Marine Management, Inc.,2012 Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Insured Copy f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. 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 h. '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: (1) The exceptions contained in Sub-paragraphs d. orf.; or (2) 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. 2. 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. For the purposes of this coverage, "vendor" means any vendor when you and such vendor have agreed in writing in a contract or agreement, which was executed prior to the time the"bodily injury" or "property damage"" occurred, that such vendor be added as an additional insured on your insurance policy. 2. ADDITIONAL INSURED—permissive users of mobile equipment Section II —Who Is An Insured is amended to include as an insured any person while using with your permission "mobile equipment" you own,hire or borrow except the owner or anyone else from whom you hire or borrow that "mobile equipment" provided the "bodily injury" and "property damage" occurred: 1. On premises you own or rent; or 2 On ways next to premises you own or rent. The additional insured insurance provided by this paragraph is excess over any other valid and collectible property or similar type insurance available to the insured, including any deductible amounts. 3. PRIMARY AND NONCONTRIBUTORY—OTHER INSURANCE CONDITION The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1)The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. GL7 04 00103 13 ®Tokio Marine Management, Inc., 2012 Page 2 of 4 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. Insured Copy 4. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US—Broad FORM The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against a person or organization, if you are required to do so under a written contract, agreement or permit, because of payments we make for injury or damage. However, the injury or damage must occur subsequent to the execution of the contract, agreement or permit. 5. WORLDWIDE COVERAGE TERRITORY A. The following is added to Section IV-Conditions: Expanded Coverage Territory 1. If a "suit" is brought in a part of-the"coverage territory" that is outside the United States of America (including its territories and possessions), Puerto Rico or Canada, and we are prevented by law, or otherwise,from defending the insured,the insured will initiate a defense of the "suit". We will reimburse the insured, under Supplementary Payments, for any reasonable and necessary expenses incurred for the defense of a"suit"seeking damages to which this insurance applies,that we would have paid had we been able to exercise our right and duty to defend. If the insured becomes legally obligated to pay sums because of damages to which this insurance applies in a part of the "coverage territory" that is outside the United States of America (including its territories and possessions), Puerto Rico or Canada, and we are prevented by law, or otherwise, from paying such sums on the insured's behalf, we will reimburse the insured for such sums. 2. All payments or reimbursements we make for damages because of judgments or settlements will be made in U.S. currency at the prevailing exchange rate at the time the insured became legally obligated to pay such sums. All payments or reimbursements we make for expenses under Supplementary Payments will be made in U.S. currency at the prevailing exchange rate at the time the expenses were incurred. 3. Any disputes between you and us as to whether there is coverage under this policy must be filed in the courts of the United States of America (including its territories and possessions), Puerto Rico or Canada. 4. The insured must fully maintain any coverage required by law, regulation or other governmental authority during the policy period, except for reduction of the aggregate limits due to payments of claims,judgments or settlements. Failure to maintain such coverage required by law,regulation or other governmental authority will not invalidate this insurance. However, this insurance will apply as if the required coverage by law,regulation or other governmental authority was in full effect. B. Subparagraphs c.(3)and(d)of Condition 2., Duties In The Event Of Occurrence,Offense,Claim Or Suit of Section IV—Conditions are replaced with the following: c. You and any other involved insured must: (3) Cooperate with us in the investigation or settlement of the "suit" when not prevented by law, or otherwise to do so; and d. No insured will,except: (1) To initiate a defense of the "suit" as described in Paragraph A.I.above; or (2) At that insured's own cost, GL7 04 00103 13 ©Tokio Marine Management, Inc., 2012 Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. Insured copy voluntarily make a payment,assume any obligation, or incur any expense,other than for first aid,without our consent. C. With respect to coverage afforded by this endorsement,the following is added to Paragraph 4.b. under the Conditions section: 4. Other Insurance b. Excess Insurance This insurance is excess over: (3) Any of the other insurance, whether primary, excess, contingent or on any other basis: (a) If the insured's liability to pay damages is determined in a "suit" brought outside the United States of America (including its territories and possessions), Puerto Rico or Canada, or in a settlement we agree to; or (b) That is coverage required by law, regulation or other governmental authority in a part of the "coverage territory" that is outside the United States of America (including its territories and possessions), Puerto Rico or Canada. D. Paragraph 4.of the Definitions Section is replaced by the following: 4. "Coverage territory" means anywhere in the world with the exception of any country or jurisdiction which is subject to trade or other economic sanction or embargo by the United States of America. i GL7 04 001 0313 ©Tokio Marine Management, Inc., 2012 Page 4 of 4 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Insured Copy TRAY '1' WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 99 03 76( A)— 001 POLICY NUMBER: (YJUB-3F98068-8-19) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be 02.00 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER, INCLUDING KASHIWA FUDOSAN AMERICA, INC., METRO PROPERTIES, LLC TAK DEVELOPMENT, INC RIVERROCK REAL ESTATE GROUP, INC. 395/400 OYSTER POINT BOULEVARD SOUTH SAN FRANCISCO, CA 94080 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium Insurance Company Countersigned by DATE OF ISSUE: 01-15-19 ST ASSIGN: Page 1 of 1