Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
PROOF OF INSURANCE (2020 - 2020) CLOSEDACOPREF CERTIFICATE OF LIABILITY( INSURANCE 1 DATE iMMtQD/YYYY)
512912019
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
Altex Risk Solutions, Inc. (CB) PttoNE , S00 8Cr7_0390 noy..,630-378-2,508.__
_ Services �...
2850 Golf Road, 5th Floor Christen -8 Brothers 1-1-1
Rolling Meadows IL 60008-4050 aoDss:
tNSURER(S) AFFORDING COVERAGE NA{C #
�
.II3 oRED CHMBRO-14
thers of the Christian Schools &Affiliates
LOG #1177028 DAUGHTERS OF CHARITY OF SVOP
1205 Windham 'Parkway
Romeoville IL 60446-1679
._INSURERA:Pennsylvania Manufacturers Assoc .....Inss Co 12262
eINSURER BB mOld Republic Insurance Company 241„47
INSURER C :
INSURER D
INSURER E
_11.INSURER F,
COVERAGES CERTIFICATE NUMBER: 890063064 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE I3E,EN 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 WD CLAIMS-
I T R Y TYPE OF INSURANCE ADDL j ....... � i+MIDD EFF POLICYEXP � EACH OLt U 3REN^,F S
LTR COMMERCIAL GENERAL LIABILITY iM 821900 0998922 NUMBER 6115120x019 t r 6115/2020 LIMITS 4,000,000
ME
� DAMAGerfQ RENTLD
CLAIMS -MADE L_.I OCCUR REMISFS,(Fso+x••,rrmocr.�SsIncluded
D t,xP IAny one pemon)
PERSONAL & ADV INJURY $Incl e .......•.
,all.NLAGGREDATFLf%IiTAPPLIES PER: j GENERAL AGGREGATE SNIA
_.... -I
LOC
-OP Incuded
CT,nS
BGGPC1�3CY
f
,V OTHER
AUTOMOBILE LIABILITY Y MWTB21543
...PR�O�DU,
6115/2019 6/15/2020 COMBINED SINGLE f$1,000,00D
y
...
ANY AUTO
BODILY INJURY (Per person) S
OWNED i SCHEDULED
ry,
Y
BODS INJURY (Par accident) S
AUTOS ONLY B AUTOS
HIRED NON -OWNED
r .
E , S
Y„�„_ AUTOS ONLY i� X„ AUTOS ONLY
Ptkrt a
5
UMBLLA
� OCCUR
OCCURRENCE 5...... .,...
_.... EXCESS LIAB�
CLAIMS -MADE
["AGGREGATE
UED RETENTIONS
S
WORKERS COMPENSATION
I STATUTE E,,,,,H-
I 8
ANDEMPLO
YIN
.
ANYPR.OPPJFTOF�PAP'TNERFCXECUT{VE
CCIDENT $ _................ •...•••••••..
OFFGtMJMEM8EREX0L1UDCD? NIA
(Mantl®tory in NH)
M
E.LDISEASE EMPLOYEE "
If es, describe under
DESCRIPTION OF OPERATIONS below
Y LIMIT S
L DISEASE - POLICY
E.L.
DESCRIPTION OF OPERATIONS t LOCATIONS] VEHICLES (ACORD 191, Additional Ramaria; Schedult, may be aattacti It more apace is M quirad)
Only the General Liability CoverageWilli apply on a Primacy and Nora -Contributory basis (.per attached endorsement) if required by fully executed written
contract. Certificate Holder is added as Additional Insured (per attached endorsement) for General Liability and Automobile liability coverages Solely, strictly and
specifically with regards to:
Consultant Services for the Community Development Block Grant Program for Home Delivered Meals.
CERTIFICATE HOLDER
I
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Cit of I Segundo Its Official and Employees ACCORDANCE WITH THE POLICY PROVISIONS,
Oflic€; of Oily Clerk,
350 Main Street AUTHORI REPRESENTATIVE
EI Segundo CA 90245-3813
USA
v
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
PENNSYLVANIA MANUFACTURERS'
ASSOCIATION INSURANCE COMPANY
Attaching to and forming part of Policy No. 821900 0998922
Named Insured: THE RELIGIOUS AND CHARITABLE RISK POOLING TRUST OF THE BROTHERS OF THE
CHRISTIAN SCHOOLS AND AFFILIATES
Effective date of this endorsement is June 15, 2019
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED
SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under SECTION 11 INSURING AGREEMENT C, GENERAL LIABILITY
COVERAGE defined within the Coverage Agreement
SECTION 1: Schedule
Fill, arne of Additional Insured Persons(s) or ' Designated Location(s) Of Covered Operations:
Organization (s):
ANY PERSON OR ORGANIZATION WHEN YOU HAVE
AGREED IN A WRITTEN CONTRACT FOR THAT PERSON OR
ORGANIZATION TO BE ADDED AS AN ADDITIONAL
INSURED ON YOUR POLICY.
If no entry appears above, information required to complete this endorsement will be shown in the Certificate, of Coverage
as applicable to this endorsement.
Section 11 Insuring Agreement C -Name of Insured Amended
X Who Is An Insured defined in the General Insurance Agreement is amended to include as an Additional Insured
the, person(s) or organization(s ' � shown in the Schedule above, but only with respect to liability in the performance of
the Named insured's ongoing operations for the Additional insured(s) at the Location(s) designated in the Suhedule
above for "bodily injury" or "property damage", caused in whole or in part, by the Named Insureds acts or omissions
which takes place after the execution of a written agreement with the Additional Insured(s).
BFor the coverage provided by this endorsement: the following paragraph is added to Section IV —General
Conditions, Section 11, Insuring Agreement C -General Liability.
This insurance is primary insurance as respects to this coverage to the adclitior4 insured person or organization,
wherethe written contract or vtoni1en agreement rpquires that this insurance be primary and noncontributory. In :.hat
event. we %vill not seek conlribution from any other insurance policy available to the additional Insured on which the
additionat insured person or organization is a Named Insured.
C. Who Is An Insured is also amended to include as an additional insured the person(s) or orgar0zaflonj's) shown in
thea Schedule, with: respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by the
"Named Insured's work" at the location designated and described in the schedule of lhis andorsernent performed for
that additional insured and included in the "Producls-completed cper,ations hazard".
The most we will pay is the amount of insurance required by the written contract or the amount of applicable limits of
insurance under this policy: whichever is less.
This Insurance does not apply to any claims or suits seeking damages, including defense, arising out of, directly or
indirectly, from any actual or alleged participation in any act of sexual misconduct, sexual harassment, sexual molestation,
sexual abuse or any claim sexual in nature, physical or mental, of any person.
Except as amended in this endorsement, this insurance is subject to all coverage terms, clauses and conditions in the
policy to which this endorsement is attached and only applies to the extent permitted by law.
IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
SCHEDULE
Name of Person(s) or Organization(s):
All persons or organizations as required by contract or agreement
With respect to COVERED AUTOS LIABILITY COVERAGE, Who Is An insured is changed with the
addition of the following:
Each person or organization shown in the Schedule for whom you are doing work is an "insured". But
only for "bodily injury" or "property damage" that results from the ownership, maintenance or use of a
covered "auto" by:
1. You;
2. an "employee" of yours; or
3. anyone who drives a covered "auto" with your permission or with the permission of one of your
"employees".
However, the insurance afforded to the person or organization shown in the Schedule shall not exceed
the scope of coverage and/or limits of this policy. Not withstanding the foregoing sentence, in no event
shall the insurance provided by this policy exceed the scope of coverage and/or limits required by the
contract or agreement.
PCA 001 10 13
.�1+�" CERTIFICATE OF LIABILITY INSURANCE DATE{FAM/DDIYYtYj
_ 1 11/25/2018
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 po'licy(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 NO"INE
E: CT CtlriSlia..n Breathers Services
Artex Risk Solutions, Inc. CB PHt"'
a Nit; 53'0-378-2508
2850 Golf Road, 5th Floor t N 800407-0300
Rollin Meadows IL 60008-4050 A aL
9 RESS: _,,..........
_,mr«la/RER s, A''t"oRDaNa COVERAGE � NAIC p ...,,.....
'.................
...... ,. - .. suReRe:OldReCuabllr InslrrancB..... .Company 2a1�M _
I Brothers of the Christian Schools & Affiliates _ IN "....
�.�
INSURED CHRIBRC-14
Loc #1177028 DOC POW ST VINCENT SENIOR CITIZEN NTR aassuatE,Rc
1205 Windham Barkway INSURER D: .,,,,.._.............
Romeoville IL 60446-1679INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1949040129 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 AW 9WVD POLICY NUMBER............ (MOLICCYErr !BFPO ICOi ................. .�..,...........
INSR LIMITS
LTR ;
,COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE �, S
.T.✓. -` -^-I "11AMAGE T O Ftt^ N tEO
II CLAIMS -MADE ..� OCCUR PREM'I'S'E'S Ma;tcu r ncn! .,,1 '$ .................„_,,,_,.,_
_
9EN'L AGGREGATE LIMIT APPLIES PER:
...� POLICY „..� PJEGRO- ❑LOC
_ry II T
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY ,, AUTOS
HIRED NON -OWNED
AUTOS ONLY V� AUTOS ONLY
UMBRELLALIABI OCCUR
MED EXP (Army wao'ua,pe�rson)$
INJURY
2ENERALAGGRE6ATI
I S......"
PRODUCTS -COMPIOPAGGIT
S
u5
COMBINED SINGLELlMrr
f $
_& ..1"IZdrm+rl
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident) $
PEiT'Y DAh9
EACH OCCURRENCE
$
I DED � RETENTION
$ CLAIMS -MADE � AGGREGATE
'WORKERS
EXCESS LIAR
E LIABILITY YIN Y MWG365399M{CA} 1t9J2619 1/912620 IE.L�EACHLITE ACCIDENT H $ 0l}„6p0 ..,.,....
APER }
AND EMPLOYERS'
LIABILITY
. I ROPRIFTC?-lr7rARTNEM'EXECUTIVE
AN N.,, N 1 A I _
a""1•ndat /ry in N14)� �kCLU'DED'�J � E.L DISEASE- EA EMP LIMIT �...� �. dYCDLI
(Mandatory m NH) I E._. -
If yes, deec;ibe under
DESCRIPTION OF OPERATIONS below T $ 1,0D0,
_I I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 161, Additional Remarks Schedule, may bwr attRehad If more space is required)
Wavier of Subrogmion, per the attached endorsement, (where allowed by law) is provided Lender the Work'er's Compensation coverage when required by fully
executed written contract.
Evidence of Coverage
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DAIS THEREOF, NOTICE WILL BE DELIVERED IN
Cityof El Segundo, its officials and employees I ACCORDANCE WITH THE POLICY PROVISIONS.
Office of the City Clerk
350 Main St AUTHORIZ REPRESENTATIVE
El Segundo CA 90245
I
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed. 04.84)
POLICY NUMBER: MWC 305311 04
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -
CALIFORNIA
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.)
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 0 % of the California workers' compensation premium
otherwise due on such remuneration.
SCHEDULE
PERSON OR ORGANIZATION JOB DESCRIPTION
ALL PERSONS OR
ORGANIZATIONS WHERE
REQUIRED BY WRITTEN
CONTRACT
DATE OF ISSUE: D1-01-19
@1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.
From the WCIRB's California Workers' Compensation Insurance Forms Manual@ 1999.