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PROOF OF INSURANCE (2020) CLOSED0 DATE(MMIDD/YYYY) . CC111I "L3 CERTIFICATE OF LIABILITY INSURANCEI 05123/2019 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). PRODUCER CONTACT US Centralized Services rsh USA Inc. NAME! 701 Market Street, Suite 1100 .11Gdd' NE 866-966-4664 „.....Apo) St Louis, MO 63101 _WAI At ,C. ,En,DmAfi� s: q I ....w...... Attn: ATT CertRequest@marsh.com Re ues� , sD� IT mmIT COm NA INSURERS AFFOR mals IC # NSU,, ER A : Old R .any COVERAG..... .. _"........ E CN103150778-GAW CRT -19 20 X X SCha .........„mmmmm I a Republic Insurance Company 24147 INSUREDINSURERCingular Wifeless PCS, LLC INSURER B One AT&T Plaza INSURER C: 208 South Akard Street, INSURER D: Room 1830.06 Dallas, TX 75202 „!•NSu,REfj E: INSURER F: COVERAGES CERTIFICATE NUMBER:CHI-007309896-19 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. ................................. TYPE OF INSURANCE.-................................ ..-......... POLICY NUMBER AM FD ................._._.........................._....... LTR ,r�D p O Dry' �.. INSR A t�L, Gt1-IR .................�� r� 'LILY EFF POLICY EXP LIMITS M Yvan IMMIDDdYY'YYI .. A X COMMERCIAL GENERAL LIABILITY MWZY 31363619 06/01/2019 06101/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE �� OCCUR _PF FMISS (Ea occurrence), 1,000,000 crurre $ ......... MED EXP (Any one person)N/A . ........... ...-_ __ PERSONAL & ADV INJURY $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: FA#12992945; GSM ID: NI -0515; Address: 400 Lomita St., EI Segundo, CA 90245; CountyL Los Angeles. City of EI Segundo, its officials and employees is/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. This insurance is primary with respect to the interest of the Additional Insured and any other insurance maintained by Additional Insured is excess and non-contributory with this insurance. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE i of Marsh USA Inc. I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 0,000,000 .............. X POLICY D JECTpRO. D LOC PRODUCTS - COMP/OP AGG OTHER A AUTOMOBILE LIABILITY MWTB31363519 A X ANY AUTO MWZX 31363719 (MI) $ 1,000,000. .............. OWNED SCHEDULED ..LIM.nm�.......... AUTOS ONLY AUTOS 0610112019 0610112020 HIRED r— NON -OWNED $ AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) DA41hfiA PRE PROPERTY UMBRELLALIAB OCCUR EXCESS LIAB MADE DED RETENTION $ A WORKERS COMPENSATION MWC31363819 EACH OCCURRENCE .................,.........$ AND EMPLOYERS' LIABILITY Y I N ANYPROPRI ETORIPARTNE R/EXECUTIVE OFFICER/MEMBER EXCLUDED? t`I N/A $ (Mandatory in NH) 06/01/2020 II X I I I OTH- If yes, descrrbe under DESCRIPTION OF OPERATIONS below A Excess Workers' Compensation / MWXS 31363919 (OH, WA) $1,000,000 ............................... Employers' Liability See Second Page DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: FA#12992945; GSM ID: NI -0515; Address: 400 Lomita St., EI Segundo, CA 90245; CountyL Los Angeles. City of EI Segundo, its officials and employees is/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. This insurance is primary with respect to the interest of the Additional Insured and any other insurance maintained by Additional Insured is excess and non-contributory with this insurance. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE i of Marsh USA Inc. I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD GENERAL AGGREGATE $ 0,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 06/0112019 06/0112020 COMBINED SINGLE $ 1,000,000. ..LIM.nm�.......... 0610112019 0610112020 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) DA41hfiA PRE PROPERTY Pold_._A EACH OCCURRENCE .................,.........$ ...........,... AGGREGATE $ 0610112019 06/01/2020 II X I I I OTH- STATUTE ER E L. EACH ACCIDENT $1,000,000 ............................... ELL DISEASE - EA EMPLOYEE $ 1,000,000 E L DISEASE - POLICY LIMIT $ 1,000,000 0610112019 0610112020 EL Each Accident/ EL Disease 1,000,000 EL Disease -Policy Limit 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: FA#12992945; GSM ID: NI -0515; Address: 400 Lomita St., EI Segundo, CA 90245; CountyL Los Angeles. City of EI Segundo, its officials and employees is/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. This insurance is primary with respect to the interest of the Additional Insured and any other insurance maintained by Additional Insured is excess and non-contributory with this insurance. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE i of Marsh USA Inc. I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN103150778 LOC #: St. Louis C ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED Marsh USA Inc. New Cingular Wireless PCS, LLC One AT&T Plaza POLICY NUMBER 208 South Akard Street, 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 Page 2 of 2 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IL 10 (12106) QLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED WHERE REQUIRED UNDER CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Paragraph 2. of SECTION II - WHO IS AN INSURED is amended to include any person or organization for whom you have agreed under contract or agreement to provide insurance. However, the insurance provided shall not exceed the scope of coverage or limits of this policy. Notwithstanding the foregoing sentence, in no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement. Where required by contract, we will consider our policy to be primary under any other insurance maintained by the additional insured for injury or damage covered by this endorsement and that their policy will be noncontributing with this insurance. GL 739 006a 0609 MVVZY 313636 19 AT&T Inc. 06/01/2019 - 06/01/2020 IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the following: A. In the event this policy is cancelled for any permissible reason, other than for nonpayment of premium, we shall endeavor to provide advance written notice of cancellation to certificate holders set out in the schedule on file with the Company, after notifying the first Named Insured of such cancellation. Notice of cancellation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancellation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancellation date, nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. PIL 029 10 10 M\NT6 313635 19 AT&T Inc. 06101!2019 - 06/01/2020 IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY NOTICE OF CANCELATION TO CERTIFICATE HOLDERS This endorsement modifies the notice of cancelation of insurance provided hereunder by adding the following: A In the event this policy is canceled for any permissible reason, other than for nonpayment of premium, we shall endeavor to provide advance written notice of cancelation to certificate holders set out in the schedule on file with the Company, after notifying the Insured first named in item 1 of the Information Page of such cancelation. Notice of cancelation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancelation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancelation date, nor negate cancelation of the policy. All other terms and conditions of this policy remain unchanged. PC 010 10 10 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313 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