Loading...
PROOF OF INSURANCE (2019 - 2020) CLOSEDQ&w DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/31/20191, 6/28/2019 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 Lockton Insurance Brokers, LLC CONTACT .............. ___.... .............................. _.__ 777 S. Figueroa Street 52nd Fl. PHONE V FAX IAIC.I" Q .F la ......... ...... ................ CAxc. Nnl. CA License #OF15767 E•MA1 Los Angeles CA 90017 _!APP915.9."""' I INSUR R(S) AFFORDING 1 : ^ E. ............. ,COVERAGE.................................................. .Nv...0 ( ) 689-0065 .. INSURER A: AtniSP..c....vsurance ComQv715 ........ INSURER Prosum, Inc. RB.Hl200 1302737 a Coany' 2201 Park Pl., Ste. 102 INSURER C: Federal eral Insurance Company ...... ....... .0281 El Segundo CA 90245 INSURER D INSURER E : INSURER F: COVERAGES PROS1301 CERTIFICATE NUMBER: 2911178 REVISION NUMBER: X.XXXXXX 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. LICYEFF OLICYEXP VLTR .YYYYYYY COMMERCIAL GENERAL LIABILITY ITIT IN S1 POLICY NUMBER IMUBR M DD/YYYYI INPINMMMYYYY'1 EACH OCCURRENCE _SRL A X Y N 7110082470013 6/19/2019 6/19/2020 tlAtw96F._r E _—..... ., 000,000 OCCUR PREMISES (Ea occorrerr�c�p.... ­-- CLAIMS-MADE 1� I u $ 1 000,000 (Any pe 10 000 MED EXP An one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: ......� POLICY PRO ( I J'ECT LOC O"1HER: A AUTOMOBILE LIABILITY N N 7110082470013 I X ANY AUTO __.. OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A X UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS -MADE p RET... i DED II ENTNTION $ WORKERS COMPENSATION A AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? �r (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below B Cyber Technology Prof Liab C 3rd Party Crime N N 7110082470013 Y 4060321310009 NIA N N MPL227318519 82429026 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED. The City, its officers, officials, crnployces, agents, and volunteers are an Additional Insured to the extent provided by the policy language or endorsement issued or approved by the insurance ,carrier. Waiver of Subrogation applies to the worker's compensation. 30 Day Notice of Cancellation applies per attached endorsement. CERTIFICATE HOLDER 2911178 City of El Segundo City Clerk Attn: Administrative Services 350 Main Street, Room 5 El Segundo CA 90245 CANCELLATION See Attachments 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 REPR r .. RATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD PERSONAL & ADV INJURY $ 1,000,000 GENERAL .AGGREGATE $ 2,000,000 PRODUCTS ..-.....COMP/OP AGG $$ 2,000.00.0 6/19/2019 6/19/2020 cOMBI_DSINGLE LIMIT _jEao d n1I.........$ 1,000a00.0 ................ ........_. BODILY INJURY (Per person) $ XXXXXXX __ ..............w........,..... BODILY INJURY (...., Per i en , $. XX�'LXXXX................. PROPERTY DAMIAGEacc........ ((?mr acobdenf f .....Im$..... XXXXXXX Comn/Coll Ded $ 1,000 6/19/2019 6/19/2020 EACH OCCURRENCE ,OQOQ00 AGGREGATE OO OOO $ 7,Q . XXXXXXX ( EIRH �. 12/31/2018 12/31/2019 ....X...l..PER LTE E„L EACH,ACOIDENT $ E.L.DISEASE -ITEAmEMPLOYEE $ 1,00,Q.,QQ0 ................_ E.L. DISEASE - POLICY LIMIT $ 1.000,000 6/19/2019 6/19/2020 $5,000,000 Each Wrongful Act $5,000,000 Lim/$25K Ret. 6/19/2019 6/19/2020 $5,000,000 Lim/$10K Ret. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED. The City, its officers, officials, crnployces, agents, and volunteers are an Additional Insured to the extent provided by the policy language or endorsement issued or approved by the insurance ,carrier. Waiver of Subrogation applies to the worker's compensation. 30 Day Notice of Cancellation applies per attached endorsement. CERTIFICATE HOLDER 2911178 City of El Segundo City Clerk Attn: Administrative Services 350 Main Street, Room 5 El Segundo CA 90245 CANCELLATION See Attachments 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 REPR r .. RATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 7110082470013 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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): The City, its officers, officials, employees, agents, and volunteers. Location(s) Of Covered Operations: See Description of Operations section on attached Certificate of Insurance 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", "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 of the the additional insured(s) at the location(s) designated above. CG 20 10 07 04 Attachment Code: D452802 Certificate ID: 2911178 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. © ISO Properties, Inc., 2004 Page 1 of 1 Attachment Code: D566104 Certificate ID: 2911178 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY NOTICE OF CANCELATION TO DESIGNATED PERSON OR ORGANIZATION Schedule Person or Organization CITY OF EL SEGUNDO CITY CLERK REFERENCE 2911178 ATTN ADMINISTRATIVE SERVICES 350 MAIN STREET, ROOM 5 EL SEGUNDO CA 90245 10 days' notice for cancelation for nonpayment of premium 30 days' notice for cancelation for any other reason The following is added to PART SIX — CONDITIONS: If we cancel this policy, we will notify the Person or Organization shown in the Schedule above the number of days shown in the Schedule before cancelation. Notice to such Person or Organization will not be earlier than to the first named insured. We will not provide notice to such Person or Organization for cancelation for nonpayment of premium if no entry for the number of days' notice appears in the Schedule above. Our failure to provide notice to such Person or Organization will not extend the policy cancelation date or negate cancelation of the policy. 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 06/25/2019 Policy No. 4060321310009 Endorsement No. 6 Insured PROSUM, INC. Premium $ Insurance Company Atlantic Specialty Insurance Company Countersigned By WC 99 0618 B (03 16) Contains copyrighted material of NCCI, Inc., used with its permission. Page 1 of 1 Copyright 2016, OneBeacon Insurance Group LLC E -INSURED Attachment Code: D529981 Certificate ID: 2911178 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attached clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on 12/31/2018 (Date) at 12:01 A.M. standard time, forms a part of Policy No. 4060321310009 Endorsement No. of the Atlantic Specialty Insurance Company (Name of Insurance Company) Issued to PROSUM, INC. Premium (if any) $ 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 int he 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 2.0 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description BLANKET PER SCHEDULE ON FILE WITH COMPANY WC 252 (04 84) Copyright 1984, OneBeacon Insurance Group LLC E -INSURED