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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.