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PROOF OF INSURANCE (2020) CLOSEDDATE (MM/DDN"Y) AR" CERTIFICATE OF LIABILITY INSURANCE 1 05/23/2019 1114� 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). 701 Market Street, Suite 1100 1Ad Centralized alined Services tic. Marsh USA Inc. NAME: I PH� ��.Ext1�........8.6...96 -0664 � St. PRODUCER Louis MO Street, S E-MAIL AttCertR 1„ u h com Attn: ATT.CertRe ues marsh.com t 1 Xmars q � AD INSURER 5�.......... S AFF NG COVERAGE NAIC # CN103150778-GAW-CRT-19-20 X SCha X INSURER A: Old Republic Insurance„Company 24147 INSURED INSURER B New Lingular Wireless PCS, LLC �._........-............................................................... .......-__.. One AT&T Plaza NsuR.ER.q......... — - ...-... ... ......... ...... —_ .......................... 208 South Akard INSURER 0: Room 1830.06 Dallas, TX 75202 INSURER E INSURER F; COVERAGES CERTIFICATE NUMBER: CHI -007317234-19 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 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. .......................��,”AbTOL Sfflak 06CiC_.EF'—'—OLI—YE— xp NSA TYPE OF INSURANCE POLICY NUMBER fMM1DDfYYYYI IMMIDD/YYYYI LIMITSLTR NSD A X COMMERCIAL GENERAL LIABILITY MWZY 31363619 06/01/2019 06/01/2020 EACH OCCURRENCE $ 5,000,000 t�afulA� i�hrJYEU CLAIMS -MADE �� OCCUR PREMISES (Fa occurrencet_„ ,,,,,,,,,,, 1,000,000 Any one person) $ NIA PERSONMED AL & ADV INJURY $ 5...._..... __ 5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: LAD095/FA#10086765/ 348 E. Main Street, EI Segundo, CA 90245 City of EI Segundo (Landlord), its officials, and employees are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law CERTIFICATE HOLDER • City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Deputy City Clerk I; City Clerk's Office — Mona F. Shilling THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. _ Vt GL%A1P. 1u - I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 POLICYPRO ❑ LOC tlECT PRODUCTS - COMP/OP AGG C1NER A, AUTOMOBILE LIABILITY MWf631363519 A X ANY AUTO MWZX 31363719 (MI) $ 5,000,000 OWNED SCHEDULED tgAae',ul wn.R). AUTOS ONLY AUTOS 06/01/2019 06/0112020 HIRED NON -OWNED $ AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) $ UMBRELLA LIAB OCCUR I PROPERTY DANkFi(a EXCESS LIAB CLAIMS -MADE .............. DED I I RETENTION $ ... A WORKERS COMPENSATION MWC 31363819 AND EMPLOYERS' LIABILITY Y I N EACH OCCURRENCE ANYPROPRI ETOR/PARTNE R/EXECUTIVE OFFICER/MEMBER EXCLUDED? N NIA $ (Mandatory in NH) If yes, describe under 06/0112020 XIPER orH- DESCRIPTION OF OPERATIONS below A Excess Workers' Compensation I MWXS 31363919 (OH, WA) Employers' Liability See Second Page DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: LAD095/FA#10086765/ 348 E. Main Street, EI Segundo, CA 90245 City of EI Segundo (Landlord), its officials, and employees are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law CERTIFICATE HOLDER • City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Deputy City Clerk I; City Clerk's Office — Mona F. Shilling THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. _ Vt GL%A1P. 1u - I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD GENERAL AGGREGATE $ 10,000,000 PRODUCTS - COMP/OP AGG $ 0 $ 06/0112019 06/0112020 COMBINED SINGLE LIMIT $ 5,000,000 tgAae',ul wn.R). 06/01/2019 06/0112020 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DANkFi(a mer aa;cnd'r-nf,t......_........... ... EACH OCCURRENCE AGGREGATE $ 06IU112019 06/0112020 XIPER orH- ..1.,STATIJTE....., ER E L EACH ACCIDENT $ 5,000,000 .................................... DISEASE ..-EA EMPLOYEE $ 5,000,000 ,E,L".. E L DISEASE - POLICY LIMIT $ 5,000,000 06/0112019 06/0112020 EL Each Accident/ EL Disease 1,000,000' EL Disease -Policy Limit 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: LAD095/FA#10086765/ 348 E. Main Street, EI Segundo, CA 90245 City of EI Segundo (Landlord), its officials, and employees are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law CERTIFICATE HOLDER • City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Deputy City Clerk I; City Clerk's Office — Mona F. Shilling THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. _ Vt GL%A1P. 1u - I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN103150778 LOC #: St. Louis ACC?Ra ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. New Cingular Wireless PCS, LLC _,,,,,,,,,,,,,,,,,,,,. One AT&T Plaza POLICY NUMBER 208 South Akard Room 1830.06 Dallas, TX 75202 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Excess Workers' Compensation -MWXS 31363919 (OH -WA) Self Insured Retentions OH & WA - $500,000,000 (except Terrorism) OH & WA - $600,000,000 Terrorism Excess Automobile Liability - MWZX MWZX 31363719 (MI) Combined Single Limit - $1,000,000 Self Insured Retention - $1,000,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS - COMPLETED TED OPE TIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizatiori All Persons or Organizations as Required by Written Contract or Agreement. In no event shall the insurance provided exceed the scope of coverage or limits as required by said contract or agreement. Location And Description Of Completed Operations The Locations as Specified in the Written Contracts or Agreements. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". CG 20 37 07 04 O ISO Properties, Inc., 2004 Page 1 of 1 MWZY 313635 19 AT&T Inc. 06/01/2019 - 06/01/2020 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR 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) All Persons or Organizations as Required by Written Contract or Agreement. In no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement, I Location(s) Of Covered Operations The Locations as Specified in the Written Contracts or Agreements. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 10 04 13 i A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional 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. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or ..property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. 11Uith respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 � Insurance Services Office, Inc., 2012 CG 20 10 04 13 MWZY 313636 19 AT&T Inc. 06/01/2019 - 06/01/2020 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 POLICY NUMBER: MWC 313638 19 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 anyone not named in the Schedule. SCHEDULE WHERE REQUIRED BY WRITTEN CONTRACT DATE OF ISSUE: 06-01-19 1983National Council on Cotnpansakoon Insurance.