Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
PROOF OF INSURANCE (2020) CLOSED'R'' DATE (MM/DD/YY"
CERTIFICATE OF LIABILITY INSURANCE 08/19/2019
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(iss) 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($).
... ., . „ .,
PRODUCER CONTACT .,.,..
pH0 E FAX
MARSH RISK &INSURANCE SERVICES TT"
345 CALIFORNIA STREET, SUITE 1300 �Af�bla.E>H _._.._21ju <UPI'
CALIFORNIA LICENSE NO. 0437153 E MA L
SAN FRANCISCO, CA 94104 App
Attn: sanfrancisco.certs@marsh corn
CN 101346861-STND-GAWU-19-20
INSURER(_S) AFFORDING COVERAGE NAIC N
INSURER A: Travelers Property mCasualt Com anY Of America 25674
INSURED
THE MOST WORSHIPFUL GRAND LODGE OF FREE INSURERS:
.
AND ACCEPTED MASONS OF THE STATE OF CALIFORNIA INSURER C
ATTN: KHALIL SWEIDY INSURER D
1111 CALIFORNIA STREET "
SAN FRANCISCO, CA 94108 INSURER E;
INSURER F;
COVERAGES CERTIFICATE NUMBER: SEA -003626586-02 REVISION NUMBER: 8
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 'AID CLAIMS.
INSR TYPEOFINSURANCE_...................._..l•°PbUCYEFF POLIC'YEXP............
LTR ��f POLICY NUMBER fMMIDDrYYYY) I'MWODNYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY 16602NO38269TIL19 04/01/2019 04/0112020 EACH OCCURRENCE Is 1,000,000
`T9WWWTO RENTED ......-�
CLAIMS -MADE 1E OCCUR _i,9fiEm@u(AS,;LLm� wrtrwwemca $..._ 1,000,000
GEN'tAGGR'EG'A'T'E LIMITAPPLIES PER:
.e•...._� POLICY 0, PECOT- LOC
OTHER,
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
UMBRELLA LIAR
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
OCCUR
EXCESS LIAR V u CLAIMS -MADE
DEI
D I RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y 1 N
ANYPROPR IETORIPARTN ERIEXEC UT I VE
OFFICER/MEMBE R EXCLUDED? NIH
(Mandatory in NH) I E.L. DISEASE - EA EMPLOYEEI, $
If yes, describe under q
DESCRIPTION OF OPERATIONS below I E.L. DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule. maybe attached if mora space is required)
Re: EI Segundo Masonic Center Association: Twisted Tales event, October 3 - 31, 2019. EI Segundo Teen Center, 405 E. Grand Avenue, EI Segundo.
MED EXP (Any one person)
$ 5'000
PERSONAL& ADV INJURY
$ 1,000,000
...........
GENERAL AGGREGATE
$ 2,000,000
_.....
,.LO YCTS-COMP/OPAGG
S 2,000,000
The City of EI Segundo, The EI Segundo Rotary, and each party's parent, owners, partners, subsidiaries, affiliates, agents, successors and assigns as now exist or are hereafter constituted, and all of their employees
directors, officers, shareholders, members, managers and representatives are included as additional insured where required by written contract. This insurance is primary and non-contribulory over any existing
insurance and limited to liability arising out of the operations of the named insured subject to policy terms and conditions.
CERTIFICATE HOLDER
City of EI Segundo
Attn: City Clerk
350 Main Street
EI Segundo, CA 90245
ACORD 25 (2016/03)
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.
AUTHORIZED REPRESENTATIVE
of Marah Risk & Insurance Services
Mary Lou Cutaiaf�—o�n�-
fN 1988-2016 ACORD CORPORATION, All rights reserved.
The ACORD name and logo are registered marks of ACORD
COMBINED'SING�tF L�IrdIL $'
Ea accGdanll
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
pRO�ERiYOAMAGE $
..,.,, .., ..,.
$
EACH OCCURRENCE $
AGGREGATE $
I
STAR,TLITE ERS
E.L. EACH ACCIDENT s
The City of EI Segundo, The EI Segundo Rotary, and each party's parent, owners, partners, subsidiaries, affiliates, agents, successors and assigns as now exist or are hereafter constituted, and all of their employees
directors, officers, shareholders, members, managers and representatives are included as additional insured where required by written contract. This insurance is primary and non-contribulory over any existing
insurance and limited to liability arising out of the operations of the named insured subject to policy terms and conditions.
CERTIFICATE HOLDER
City of EI Segundo
Attn: City Clerk
350 Main Street
EI Segundo, CA 90245
ACORD 25 (2016/03)
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.
AUTHORIZED REPRESENTATIVE
of Marah Risk & Insurance Services
Mary Lou Cutaiaf�—o�n�-
fN 1988-2016 ACORD CORPORATION, All rights reserved.
The ACORD name and logo are registered marks of ACORD
A
AGENCY
MARSH RISK & INSURANCE SERVICES
POLICY NUMBER
CARRIER
AGENCY CUSTOMER ID: CNIO1346861
LOC #: San Francisco
ADDITIONAL REMARKS SCHEDULE Page 2 of 2
NAMED INSURED
THE MOST WORSHIPFUL GRAND LODGE OF FREE
AND ACCEPTED MASONS OF THE STATE OF CALIFORNIA
ATTN: KHALIL SWEIDY
I 111 CALIFORNIA STREET
SAN FRANCISCO, CA 94108
NAIL CODE
(I, I EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: ?5 FORM TITLE: Certificate of Liabillty Insurance
I
I Waiver of subrogation is applicable where required by wdttBn contract and subject to policy terms and conditions
ACORD 101 (2008101) © 2008 ACORO CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - PERSONS OR
ORGANISATIONS FOR BODILY INJURY OR PROPERTY
DAMAGE AS REQUIRED BY WRITTEN
CONTRACT OR AGREEMENT
ENT
This endorsement modifies insurance provided under the follaMng:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The following is added to SECTION II — WHO IS AN
INSURED:
Any person or organization that is not otherwise an
insured under this Coverage Part and that you have
agreed in a written contract or agreement to Include
as an additional Insured on this Coverage Part is an
Insured, but only:
a. With respect to liability for "bodily injury' or
"property damage" that occurs subsequent to the
signing of that contract or agreement; and
b. If the "bodily injury" or "property damage" is
caused, in whole or in part; by your acts or
omissions in the performance of "your wank" to
which that contract or agreement applies or the
ads or omissions of any person or organization
performing operations on your behalf.
The Insurance provided to such additional insured is
subject to the following provisions:
a. The limits of insurance provided to such
additional insured will be the minimum limits that
you agreed to provide in the written contract or d,
agreement, or the limits shown In the
Declarations, whichever are less.
b. This insurance does not apply to any person or
organization for whom you have purchased an
Owners and Contractors Protective policy.
c. The insurance provided to such additional insured
does not apply to:
(1) Any "bodily injury" or "property damage"
arising out of the providing, or failure to
provide, any professional architectural,
engineering or surveying services, Including:
(a) The preparing, approving, or falling to
prepare or approve maps, shop drawings,
opinions, reports, surveys, field orders or
change orders, or the preparing,
approving, or failing to prepare or
approve, drawings and specifications;
and
(b) Supervisory, inspection, architectural or
engineering activities.
(2) Any "bodily Injury' or "property damage"
caused by "your work" and included in the
"products -completed operations hazard"
unless the written contract or agreement
specifically requires you to provide such
coverage for that additional insured during the
policy period.
If the written contract or agreement does not
require that the insurance provided under this
Coverage Part apply on a primary basis, or a
primary and non-contributory basis, then this
Insurance is excess over any valid and collectible
other insurance, whether primary, excess,
contingent or on any other basis, that is available
to the additional insured for a loss we cover,
CG D1 "0215 0 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
Includes copyrighted material from Insurance Services Office, Inc. with its permission.
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
XTENC ENDORSEMENT FOR SERVICE INDUSTRIES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for
any Injury, damage or medical expenses described in any of the provisions of this endorsement may be
excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions
do not apply to the extent that coverage is excluded or limited by such an endorsement_ Tile following listing is a
general coverage description only. Read all the provisions of this endorsement and the rest of your policy
carefully to determine rights, duties, and what is and is not covered.
A. Who Is An Insured — Unnamed Subsidiaries
B. Who Is An insured — Employees And Volunteer
Workers — Bodily Injury To Co -Employees And
Co -Volunteer Workers
C. Who Is An Insured — Newly Acquired Or Formed
Limited Liability Companies
D. Blanket Additional Insured — Broad Form
Vendors
E. Blanket Additional Insured — Controlling Interest
F. Blanket Additional Insured — Mortgagees,
Assignees, Successors Or Receivers
PROVISIONS
A. WHO IS AN INSURED — UNNAMED
SUBSIDIARIES
The following is added to SECTION II — WHO IS
AN INSURED:
Any of your subsidiaries, other than a partnership
or joint venture, that is not shown as a Named
Insured in the Declarations Is a Named Insured
if:
a. You are the sole owner of, or maintain an
ownership interest of more than 50% in, such
subsidiary on the first day of the policy
period; and
b. Such subsidiary is not an insured under
similar other insurance.
G. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Premises
H. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Operations
I. Blanket Additional Insured — Grantors Of
Franchises
J. Incidental Medical Malpractice
K. Blanket Waiver Of Subrogation
b. After the date, if any, during the policy period
that you no longer maintain an ownership
interest of more than 50% in such subsidiary.
For purposes of Paragraph 1. of Section II — Who
Is An Insured, each such subsidiary will be
deemed to be designated in the Declarations as:
a. A limited liability company;
b. An organization other than a partnership,
joint venture or limited liability company; or
c. A trust;
as indicated in its name or the docurrtents that
govem its structure.
B. WHO IS AN INSURED — EMPLOYEES AND
VOLUNTEER WORKERS — BODILY INJURY
TO CO -EMPLOYEES AND CO VOLUNTEER
WORKERS
No such subsidiary is an insured for "bodily The following is added to Paragraph 2.a.(1) of
SECTION II — WHO IS AN INSURED:
injury' or "property damage" that occurred, or
"personal and advertising injury" caused by an Paragraphs (1)(a), (b) and (c) above do not
offense committed: apply to "bodily injury" to a co -"employee" while
a. Before you maintained an ownership interest in the course of the co -"employee's" employment
of more than 50% in such subsidiary; or by you or performing duties "related to the
conduct of your business, or to bodily injuryto
CG D4 67 0219 ® 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 5
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL GENERAL LIABILITY
your other "volunteer workers" wtile performing
duties related to the conduct of your business.
C. WHO IS AN INSURED - NEWLY ACQUIRED
OR FORMED LIMITED LIABILITY COMPANIES
The following replaces Paragraph 3. of
SECTION II - WHO IS AN INSURED:
3. Any organization you newly acquire or form,
other than a partnership or joint venture, and
of which you are the sole owner or in which
you maintain an ownership interest of more
than 50%, will qualify as a Named Insured if
there is no other similar insurance available
to that organization_ However
a. Coverage under this provision is
afforded only:
(1) Until the 180th day after you acquire
or form the organization or the end
of the policy period, whichever is
earlier, if you do not report such
organization in writing to us within
180 days after you acquire or form it;
or
(2) Until the end of the policy period,
when that date is later than 180 days
after you acquire or form such
organization, if you report such
organization in writing to us within
180 days after you acquire or form it;
b. Coverage A does not apply to "bodily
injury" or "property damage" that
occurred before you acquired or formed
the organization; and
c. Coverage B does not apply to "personal
and advertising injury" arising out of an
offense committed before you acquired
or formed the organization.
For the purposes of Paragraph 1. of Section
II - Who Is An Insured, each such
organization will be deemed to be
designated in the Declarations as:
a. A limited liability company;
b. An organization, other than a
partnership, joint venture or limited
liability company; or
C. A trust;
as indicated in its name or the documents
that govern its structure,
D. BLANKET ADDITIONAL INSURED - BROAD
FORM VENDORS
The following is added to SECTION II - WHO IS
AN INSURED:
Any person or organization that is a vendor and
that you have agreed in a written contract or
agreernerlt to include as an additional insured on
this Coverage Part is an insured, but only with
respect to liability for "bodily injury" or "property
damage" that:
a. Occurs subsequent to the signing of that
contract or agreement; and
b. Arises out of "your products" that are
distributed or sold in the regular course of
such vendor's business.
The insurance provided to such vendor is subject
to the following provisions:
a. The limits of insurance provided to such
vendor will be the minimum limits that you
agreed to provide in the written contract or
agreement, or the limits shown in the
Declarations, whicheverare less.
b. The insurance provided to such vendor does
not apply to:
(1) Any express warranty not authorized by
you or any distribution or sale for a
purpose not authorized by you;
(2) Any change in "your products" made by
such vendor;
(3) Repackaging, unless 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;
(4) Any failure to make such inspections,
adjustments, tests or servicing as
vendors agree to perform or normally
undertake to perform in the regular
course of business, in connection with
the distribution or sale of "your
products";
(5) Demonstration, installation, servicing or
repair operations, except such
operations performed at such vendor's
premises in connection with the sale of
"your products"; or
Page 2 of 5 0 2017 The Travelers Indemnity Company. All rights reserved. CG D4 67 02 18
Includes copyrighted material of insurance Services office. Inc. with its permission
(6) 'Your products" that, 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 on behalf of such
vendor.
Coverage under this provision does not apply to:
a. Any person or organization from whom you
have acquired "your products", or any
ingredient, part or container entering into,
accompanying or containing such products;
or
b. Any vendor for which coverage as an
additional insured specifically is scheduled
by endorsement.
E. BLANKET ADDITIONAL INSURED —
CONTROLLING INTEREST
1. The following is added to SECTION II —
WHO IS AN INSURED:
Any person or organization that has financial
control of you is an insured with respect to
liability for "bodily injury", "property damage"
or "personal and advertising injury" that
arises out of:
a. Such financial control; or
b. Such person's or organization's
ownership, maintenance or use of
premises leased to or occupied by you.
The insurance provided to such person or
organization does not apply to structural
alterations, new construction or demolition
operations performed by or on behalf of such
person or organization.
2. The following is added to Paragraph 4. of
SECTION II — WHO IS AN INSURED:
This paragraph does not apply to any
premises owner, manager or lessor that has
financial control of you.
F. BLANKET ADDITIONAL INSURED —
MORTGAGEES, ASSIGNEES, SUCCESSORS
OR RECEIVERS
The following is added to SECTION 11— WHO IS
AN INSURED:
Any person or organization that is a mortgagee,
assignee, successor or receiver and that you
have agreed in a written contract or agreement
to include as an additional insured on this
Coverage Part is an insured, but only with
respect to its liability as mortgagee, assignee,
successor or receiver for "bodily injury", "property
damage" or "personal and advertising injury"
that:
"COMMERCIAL GENERAL LIABILITY
a. Is "bodily injury" or "property damage" that
occurs, or is "personal and advertising injury"
caused by an offense that is committed,
subsequent to the signing of that contract or
agreement; and
b. Arises out of the ownership, maintenance or
use of the premises for which that
mortgagee, assignee, successor or receiver
is required under that contract or agreement
to be included as an additional insured on
this Coverage Part.
The insurance provided to such mortgagee,
assignee, successor or receiver is subject to the
following provisions:
a. The limits of insurance provided to such
mortgagee, assignee, successor or receiver
will be the minimum limits that you agreed to
provide in the written contract or agreement,
or the limits shown in the Declarations,
whichever are less.
b. The insurance provided to such person or
organization does not apply to:
(1) Any "bodily injury" or "property damage"
that occurs, or any "personal and
advertising injury" caused by an offense
that is committed, after such contract or
agreement is no longer in effect; or
(2) Any "bodily injury", "property damage" or
"personal and advertising injury" arising
out of any structural alterations, new
construction or demolition operations
performed by or on behalf of such
mortgagee, assignee, successor or
receiver.
G. BLANKET ADDITIONAL INSURED —
GOVERNMENTAL ENTITIES — PERMITS OR
AUTHORIZATIONS RELATING TO PREMISES
The following is added to SECTION II — WHO IS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to premises owned
or occupied by, or rented or loaned to, you and
that you are required by any ordinance, law,
building code or written contract or agreement to
include as an additional insured on this
Coverage Part is an insured, but only with
respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
arising out of the existence, ownership, use,
maintenance, repair, construction, erection or
removal of any of the following for which that
governmental entity has issued such permit or
authorization: advertising signs, awnings,
CG D4 67 0219 0 2017 The Travelers Indemnity Company, All rights reserved. Page 3 of 5
Includes copyrighted material of Insurance Services Office, Inc. with its permission
COMMERCIAL GENERAL LIABILITY
canopies, cellar entrances, coal holes,
driveways, manholes, marquees, hoist away
openings, sidewalk vaults, elevators, street
banners or decorations.
H. BLANKET ADDITIONAL INSURED —
GOVERNMENTAL ENTITIES — PERMITS OR
AUTHORIZATIONS RELATING TO
OPERATIONS
The following is added to SECTION II — WHO IS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to operations
performed by you or on your behalf and that you
are required by any ordinance, law, building code
or written contract or agreement to include as an
additional insured on this Coverage Part is an
insured, but only with respect to liability for
"bodily injury", "property damage" or "personal
and advertising injury" arising out of such
operations.
The insurance provided to such governmental
entity does not apply to:
a. Any "bodily Injury", "property damage" or
"personal and advertising injury" arising out
of operations performed for the
governmental entity; or
b. Any "bodily injury" or "property damage"
included in the "products -completed
operations hazard".
1. BLANKET ADDITIONAL INSURED —
GRANTORS OF FRANCHISES
The following is added to SECTION 11— WHO IS
AN INSURED:
Any person or organization that grants a
franchise to you is an insured, but oriy with
respect to liability for 'bodily injury', "property
darnage" or "personal and advertising injury"
arising out of your operations in the franchise
granted by that person or organization.
If a written contract or agreement e>asts between
you and such additional insured, the limits of
insurance provided to such insured will be the
minimum limits that you agreed to provide in the
written contract or agreement, or the limits
shown in the Declarations, whichever are less.
J. INCIDENTAL MEDICAL MALPRACTICE
medical services", first aid or "Good
Samaritan services" to a person, unless
you are in the business or occupation of
providing professional health care
services.
2. The following replaces the last paragraph of
Paragraph 2.a.(1) of SECTION it — WHO IS
AN INSURED:
Unless you are in the business or occupation
of providing professional health care
services, Paragraphs (1)(a), (b), (c) and (d)
above do not apply to "bodily injury' arising
out of providing or failing to provide:
(a) "Incidental medical services" by any of
your "employees" who is a nurse, nurse
assistant, emergency medical
technician, paramedic, athletic trainer,
audiologist, dietician, nutritionist,
occupational therapist or occupational
therapy assistant, physical therapist or
speech-language pathologist; or
(b) First aid or "Good Samaritan services"
by any of your "employees" or "volunteer
workers", other than an employed or
volunteer doctor. Any such "employees"
or "volunteer workers" providing or failing
to provide first aid or "Good Samaritan
services" during their work hours for you
will be deemed to be acting within the
scope of their employment by you or
performing duties related to the conduct
of your business.
3. The following replaces the last sentence of
Paragraph 5. of SECTION III — LIMITS OF
INSURANCE:
For the purposes of deterrrining the
applicable Each Occurrence Unit, all related
acts or omissions committed in providing or
failing to provide "incidental medical
services", first aid or "Good Samaritan
services" to any one person will be deemed
to be one "occr arena
4. The following exclusion is added to
Paragraph 2., Exclusions, of SECTION I —
COVERAGES — COVERAGE A — BODILY
INJURY AND PROPERTY DAMAGE
LIABILITY:
Sale Of Pharmaceuticals
1. The following replaces Paragraph b. of the "Bodily injury" or "property damage" arising
definition of "occurrence" in the out of the violation of a penal statute or
DEFINITIONS Section: ordinance relating to the sale of
pharmaceuticals committed by, or with the
b. An act or omission committed in knowledge or consent of, the insured,
providing or failing to provide "incidental
Page 4 of 5 0 2017 The Travelers Indemnity Company. All rights reserved. CG D4 67 02 19
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
S. The following is added to the DEFINITIONS
Section:
"Incidental medical services" means:
a. Medical, surgical, dental, laboratory, x-
ray or nursing service or treatment,
advice or instruction, or the related
furnishing of food or beverages; or
b. The furnishing or dispensing of drugs or
medical, dental, or surgical supplies or
appliances.
6. The following is added to Paragraph 4.b.,
Excess Insurance, of SECTION IV —
COMMERCIAL GENERAL LIABILITY
CONDITIONS:
This Insurance is excess over any valid and
collectible other insurance, whether primary,
excess, contingent or on any other basis,
that is available to any of your 'employees"
for "bodily injury" that arises out of providing
or failing to provide "'Incidental medical
services" to any person to the extent not
COMMERCIAL GENERAL LIABILITY
subject to Paragraph 2.a.(1) of Section 11 —
Who Is An Insured.
K. BLANKET WAIVER OF SUBROGATION
The following is added to Paragraph 8., Transfer
Of Rights Of Recovery Against Others To Us.
of SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS:
If the insured has agreed in a contract or
agreement to waive that insured's right of
recovery against any person or organization, we
waive our right of recovery against such person
or organization, but only for payments we rnake
because of.
a. "Bodily injury" or "property damage" that
occurs; or
b. "Personal and advertising injury" caused by
an offense that is committed;
subsequent to the execution of the contract or
agreement.
CG D4 67 0219 0 2017 The Travelers Indemnity Company. All rights reserved. Page 5 of 5
Includes copyrighted material of Insurance services Office, Inc. with its permission.
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL. FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement
with the City of EI Segundo.
Policy No.
I have and will maintain workers' compensation insurance as required by Labor Code § 3700 far the performance
of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone #
I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
mpioy any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become subject to orkers' compensation provisions of Labor Code § 3700 1 must
immediately comply with thus Isio the reernent will automatically become void.
Signature of Applicant Date 6l2r��o�g
Print Name ''' �� ". AIWd
f� ;
Agreement for: a -�" ;. tom'
Dated:
Reviewed by: ,,