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PROOF OF INSURANCE (2020) CLOSEDcollo® CERTIFICATE OF LIABILITY INSURANCE �I DAT D"YYY' 09/17/2019 712 0 7/201 1 9 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 Marsh USA, Inc NAME' PHONE. FAX Two Alliance Center dGlc, No, Exl) (Arc, Nog' 3560 Lenox Road, Suite 2400 EMAIL Atlanta, GA 30326 ADDRESS Attn: Atlanta CertReq UeSt@marsh Com I Fax: 212-948-4321 INSURERI',S) AFFORDING COVERAGE NAIC # CNI02326389-RI-GAUWX-19-20 INSURERA I,y,arls6,),v..aslurarlr:e .EI uparYl' 35378 INSUREDINSURERIndustries, Inc INSURER S Tr,�vt.iWs PrrpaEtl;y 25674 (,a,r,.leliy I; rrgrlgy c�P, I,+'olr.ric;gt, 2414 W 12th Street INSURER C ,ttq r Ptoperl'y And ruasua4y °1r..,Cr:, 20699 Suite 2 INSURER D: T'11(; "l" oreP t5 IfrodSrl°Ilyrp'y d'.r:JrurC)#"'I,1 v,IP "ruvrl rrr;Ia 25666 Tempe, AZ 85281 INSURER E I,�Ktiorlal I,Jmp,) Fiie wm,, t;; ?if Pillsxbu qgP"A 19445 INSURER F '1 hF, I"!h'arter Caf. Eiai, ("rh 25f5 15 COVERAGES CERTIFICATE NUMBER: ATL -004980931-01 REVISION NUMBER: 1 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, INSR TYPE OF INSURANCE ADDL SUSR POLICY EFF POLICY EXP LIMITS LTR INM WVD POLICY NUMBER �YM&uDDWYY'YY1 IMtAiDDNYY'YI A X COMMERCIAL GENERAL LIABILITY MKLV2PBC000367 08/01/2019 08/01/2020 EACH OCCURRENCE s 2,000,000 —_1 CLAIMS -MADE X OCCUR DAMAGE 10 HLr-1l E: 13 Pb T'E'%.tlSES (E,e occi.,rrerr,re,p 5 X SIR $10,000 Per Occ MED EXP f,Aftyr clm p4Vsr,1I',, $ EXCLUDED PERSONAL & ADV INJURY S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $ 4,000,000 POLICY LXJ jE LOC PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY AGGREGATE S 10,000.000 B AUTOMOBILE LIABILITY TJ-CAP-9D897065TIL-19 08/01/2019 08/01/2020 OMBINEDtPgGLE LIMP' (En tircidloni), 1,000,000 X ANY AUTO BODILY INJURY (Per person) '5 OWNED SCHEDULED BODILY INJURY (Per accident) 5 AUTOS ONLY AUTOS HIRED NON -OWNED ORS(: PE.R7Y'' DAMAr.E' S AUTOS ONLY AUTOS ONLY ,;Prr acz,:ierrl'g S 1- yr UMBRELLA LIAB ,T';, OCCUR XOOG71549501001 08/01/2019 08/01/2020 EACH OCCURRENCE S 10,000,000 EXCESS LAB CLAIMS -MADE AGGREGATE S 10,000,000 DED X RETENTION S '7!r, rlflPy $ F WORKERS COMPENSATION UB -2N106953 -19-51-R Wr"n,2019 08/01/2020 X PE��•IE I•rE �roI AND EMPLOYERS' LIABILITY D UB -2N 159031-19-51-K 08101/2019 08/01/2020 'S 1000.000 AN PIER M MBEREXCLUDEE ECUTIVE rfl)•N NIA B (Mandatory in NH) UB -7J602089 -19-14-G 08/01/2019 08/01/2020 E L EACH ACCIDENTAL KYLE A' . EA =rw^ s 1,000,000 If yes, ca'esh','ag! tundur I.:tESCRIPTQN ;:)F OPERA I'5ONS bulow (See Additional Page) E L DISEASE - POLICY LIMIT S 1,006,666 E Excess Umbrella BE 016159343 08101/2019 08/01/2020 Each Occurrence 15,000,000 Aggregate 15,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE:2019 Maintenance Roll Coat: Hilltop Park 300 Maryland St — Job #19-26881; George Gordon Clubhouse Playground (3) 300 E Pine Ave, - Job #19-27500, Sycamore Park 1230 E Sycamore - Job #19-27501; Kansas Park 400 Kansas St - Job #19-27502 The City of EI Segundo, its officers, officials, employees, and agents are listed as additional insured in regards to services performed by the Insured, on a primary and non-contributory basis on the General Liability (via CG 2010 & CG 2037) and Automobile Liability (via CA T4 37) policies, when required by written contract A Waiver of Subrogation applies in favor of the additional insureds on the Workers Compensation policy, when required by written contract r CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 401 Sheldon Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2016 ACORD CORPORATION. All rights reserved„ ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102326389 LOC #: Atlanta ACC)RV ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY NA1161EID MINSUIRIED Marsh ()SA, Ix Roberh.;a)ri ndw;trip,,,�, li)(,, W 'l Mi SweE,,I POLICY NUMBER 2 I orrqx,,A/ W,28 1 NAIC CODE CARRIER .............................. . . . .. . ... . . . . ....... EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance ............... ............. UB -2.N IN3953 19-51 N (/V, FL, OR VVI� U I i 2NVi9013i.19-51 K (AIK AL COC A IA 11. IN KS, KY MD NN MN N/10 MNC, N I) NI: NV NY O� 10 K PA IIII'SC IN)X XJFVA WA VVY) UI; t,.1601089 19 14-G (AZ GA CC' CJ I LGA IF) 11 IN kS V10 RAI MN N40 MFNC NI I NM NV NY OkOR FAc rN fXWV) ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD INSURED: PLAYCORE HOLDINGS, INC. EFFECTIVE DATES: 08-01-2019 - 08-01-2020 POLICY NUMBER: MKLV2PBC000367 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE - 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) Blanket as required by written contract Location(s) Of Covered Operations As per written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. 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 oragreement to provide for such additional insured. 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. CG 20 10 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With 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 C Insurance Services Office, Inc., 2012 CG 20 10 0413 INSURED: PLAYCORE HOLDINGS, INC EFFECTIVE DATES: 08-01-2019 - 08-01-2020 POLICY NUMBER: MKLV2PBC000367 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Blanket as required by writeen contract All Locations Information required to complete this Schedule. if not shown above, will be shown in the Declarations. 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" 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". 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 is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contractor agreement, the most wewill pay on behalf of the additional insured is the amount of insurance.- 1. nsurance: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. CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 iNSURED NAME: F°N.AYG."Q)Gtn:4:;it1)UR. INC ITFECTiVI: DA7F; 08/01 /M 1910 08/01/ 020 POLICY IVtJNIHER: F.r...f'f4.Y..9D897i)65...T[1....1 } COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following; BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following is added to Paragraph c. in A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE in the BUSINESS AUTO COVERAGE FORM and Paragraph e. in A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE in the MOTOR CARRIER COVERAGE FORM, whichever Coverage Form is part of your policy: This includes any person or organization who you are required under a written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to name as an additional insured for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured". CA T4 37 02 16 © 2016 The Travelers Indemnity Company All rights reserved Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission Account Name: Playcore Group Inc. Effective Date: 08-01-19 to 08-01-20 M1 4 M,003652]i WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A) — POLICY NUMBER: UB -2N159031 -19-51-X WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED,`"? BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium Insurance Company Countersigned by DATE OF ISSUE: - - ST ASSIGN: Page 1 of 1