SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A :
NAIC #
NAME:
CONTACT
(A/C, No):
FAX
E-MAIL
ADDRESS:
PRODUCER
(A/C, No, Ext):
PHONE
INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
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).
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.
OTHER:
(Per accident)
(Ea accident)
$
$
N / A
SUBR
WVD
ADDL
INSD
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. $ $
$
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOSAUTOS ONLY
NON-OWNED
SCHEDULEDOWNED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below
If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
$
$
$
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-
STATUTE
PER
LIMITS(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
$
OCCUR
CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE
DAMAGE TO RENTED
$PREMISES (Ea occurrence)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT LOC
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
4/7/2023
Arthur J. Gallagher Risk Management Services, LLC
500 N. Brand Boulevard
Suite 100
Glendale CA 91203
Michelle Gonzalez
818-539-8630
[email protected]
License#: 0D69293
Nonprofits' Insurance Alliance of CA
10023
WAYMAKE-01
Service American Indemnity Company
39152
Waymakers
1221 E. Dyer Road, Suite 120
Santa Ana CA 92705
685571032
A
X
1,000,000
X
500,000
X
Deductible: None
20,000
1,000,000
3,000,000
X
Y
2022-12069
10/1/2022
10/1/2023
3,000,000
A
1,000,000
X
X
X
Y
2022-12069
10/1/2022
10/1/2023
Comp/Collsion Ded
500/$500
A
X
10,000,000
2022-12069-UMB
10/1/2022
10/1/2023
10,000,000
X
0 B
X
Y
SATIS0352402
10/1/2022
10/1/2023
1,000,000
1,000,000
1,000,000
A
A
Fiduciary
Professional Liab.
Deductible: None
2022-12069-DO-NPO
2022-12069
10/1/2022
10/1/2022
10/1/2023
10/1/2023
Limit/Aggregate/Ret
Per Claim
Aggregate
$1M/$1M/$5,000
$1,000,000
$3,000,000
Nonprofits' Insurance Alliance of CA - A.M. Best #: 011845 Policy: Improper Sexual Conduct
Policy#: 2022-12069
Policy term: 10/1/2022 to 10/1/2023
Carrier: Nonprofits' Insurance Alliance of CA
Per Claim: $1,000,000, Aggregate: $1,000,000
Deductible: None
See Attached...
City of Huntington Beach
2000 Main Street
Huntington Beach CA 92648
ACORD 101 (2008/01)
The ACORD name and logo are registered marks of ACORD
© 2008 ACORD CORPORATION. All rights reserved.
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE:
ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY CUSTOMER ID:
LOC #:
AGENCY
CARRIER NAIC CODE
POLICY NUMBER
NAMED INSURED
EFFECTIVE DATE:
WAYMAKE-01
1 1
Arthur J. Gallagher Risk Management Services, LLC
Waymakers
1221 E. Dyer Road, Suite 120
Santa Ana CA 92705
25 CERTIFICATE OF LIABILITY INSURANCE
Policy: Cyber Liability
Policy#: ESL0239533957
Policy term: 10/1/2022 to 10/1/2023
Carrier: Underwriters at Lloyd's, London
Aggregate Limit: $2,000,000
City, its officers, elected or appointed officials, employees, agents, and volunteers named additional insured on General Liability and Auto Liability with respect to the operations of the named insured. Such insurance is Primary and Non-Contributory. Waiver of Subrogation on Workers Compensation applies in favor of certificate holder. Written notice shall be provided at least ten (10) days in advance of cancellation for non-payment of premium and thirty (30) days in advance for any other cancellation or policy change.
POLICY NUMBER: 2022-12069
Named Insured: Waymakers
COMMERCIAL GENERAL LIABILITY
CG 20 26 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
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): City of Huntington Beach, its officers, elected or appointed officials, employees, agents, and volunteers
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 your acts or
omissions or the acts or omissions of those acting
on your behalf:
1. In the performance of your ongoing operations;
or
2. In connection with your premises owned by or
rented to you.
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 Ill - 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.
CG 20 26 12 19 © Insurance Services Office, Inc., 2012 Page 1 of 1 1-□1 NONPROFITS
INSURANCE
- ALLIANCE OF CALIFORNIA
A Head for Insurance. A Heart for Nonprofits. POLICY NUMBER: 2022-12069 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
PRIMARY AND NON-CONTRIBUTORY
ENDORSEMENT FOR PUBLIC ENTITIES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:City of Huntington Beach, its officers, elected or appointed officials, employees, agents, and volunteers
A. Section II - WHO IS AN INSURED is amended to include:
4. Any public entity as an additional insured, and the officers, officials, employees, agents and/or volunteers of that public entity, as applicable, who may be named in the Schedule above, when you have agreed in a written contract or written agreement presently in effect or becoming effective during the term of this policy, that such public entity and/or its officers, officials, employees, agents and/or volunteers be added as an additional insured(s) on your policy, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:
a. Your negligent acts or omissions; or
b. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing operations.
No such public entity or individual is an additional insured for liability arising out of the sole negligence by that public entity or its designated individuals. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization.
B. Section Ill - LIMITS OF INSURANCE is amended to include:
8. The limits of insurance applicable to the public entity and applicable individuals identified as an additional insured(s) pursuant to Provision A.4. above, are those specified in the written contract between you and that public entity, or the limits available under this policy, whichever are less. These limits are part of and not in addition to the limits of insurance under this policy.
C. With respect to the insurance provided to the additional insured(s), Condition 4. Other Insurance of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following:
4. Other Insurance
a. Primary Insurance
This insurance is primary if you have agreed in a written contract or written agreement:
(1) That this insurance be primary. If other insurance is also primary, we will share with all that other insurance as described in c. below; or
NIAC-E61 02 19 Page 1 of 2
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84)
WC 04 03 06
(Ed. 4-84)
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Endorsement No.Endorsement Effective Date: Policy No.
Carrier Name / Code:
Policy Effective Date: to Premium $
Insured:
DBA:
Countersigned by
Page of
Job Description
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 per- form 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 NA % of the California workers' compensation premium otherwise due on such remuneration.
Schedule
Person or Organization
SATIS0352402
Service American Indemnity Company
Waymakers
10/01/2022
10/01/2022 10/01/2023
1 1
Specific Waiver is $200 Flat Charge
City of Huntington Beach
2000 Main St
Huntington Beach CA 92648-2702
DOO:
RE: Light of Love Event - December 4, 2022 City of Huntington Beach, its officers, elected or appointed officials, employees, agents, and volunteers named additional insured on General Liability and Auto Liability with respect to the operations of the named insured. Waiver of Subrogation on Workers Compensation applies in favor of certificate holder.
POLICY CHANGE
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMPANY:
(12069)
POLICY NUMBER:
NAMED INSURED:
POLICY CHANGE EFFECTIVE:
COVERAGE PART AFFECTED:
POLICY CHANGE#: Page 13
Nonprofits Insurance Alliance of California
2022-12069
Waymakers
10/1/2022
BUSINESS AUTO
The following additional insured(s)/loss payee(s) is/are hereby added to read:
Veh # Additional Insured - NIAC-A1
ALL
VIN #
City of Huntington Beach
2000 Main St.
Huntington Beach, CA 92648
All other terms, limits and conditions remain the same.
ADDITIONAL PREMIUM:
RETURN PREMIUM:
TOTAL PREMIUM: $0
$0
$0
11/17/2021