ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT NAME: PHONE FAX
(A/C, No, Ext): (A/C, No): E-MAIL ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS - COMP/OP AGG OTHER: $ COMBINED SINGLE LIMIT
(Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $
$ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $
If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT INSURER(S) AFFORDING COVERAGE NAIC #
COMMERCIAL GENERAL LIABILITY
Y / N
N / A
(Mandatory in NH)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
$
$
$
$
$
The ACORD name and logo are registered marks of ACORD
12/23/2022
License # 0757776
(310) 568-5986
18058
St. Paul's United Methodist Church
2600 Nelson Ave.
Redondo Beach, CA 90278
A 1,000,000
X .PHPK2498727 1/1/2023 1/1/2024 1,000,000
15,000
1,000,000
3,000,000
3,000,000
The City of Redondo Beach, its agents, officers, elected and appointed officials, employees & volunteers are additional insured on the general liability policy, per form #PI-RO-012 (10/16), with respects to liability arising out of work or operations performed by on behalf of the named insured for "Project Needs".
City of Redondo Beach
Recreation & Community Service Dept
1922 Artesia Blvd
Redondo Beach, CA 90278
STPAULS-14 GGUTIERREZ1
HUB International Insurance Services Inc.
600 Corporate Pointe
Suite 600
Culver City, CA 90230
Lizet Hernandez
[email protected]
Philadelphia Indemnity Insurance Company
X
X
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
PI-RO-012 (10/16) Page 1 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
GENERAL LIABILITY DELUXE ENDORSEMENT:
RELIGIOUS ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposure are provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits of Insurance and additional coverage provided by this endorsement. For complete details on specific coverages, consult the policy contract wording.
Coverage Applicable Limit of Insurance Page #
Damage to Premises Rented to You $300,000 2
Expected or Intended Injury-Property Damage included 2
Non-Owned Watercraft Less than 58 feet 2
Medical Payments $15,000 2
Medical Payments – Extended Reporting Period 3 years 3
Athletic Activities Included for Non-Organized
Activities
3 Covered Injury Reimbursement Included 3
Wage Loss included 3
Supplementary Payments – Bail Bonds $2,500 4
Supplementary Payment – Loss of Earnings $500 per day 4 Employee Indemnification Defense Coverage for Employee $25,000 4 Additional Insured-Medical Directors and Administrators Included 4 Additional Insured – Managers and Supervisors included 4 Additional Insured – Organization and Subsidiary Included 4 Additional Insured – Funding Source Included 4
Additional Insured – Managers or Lessors of Premises included 4 Duties in the Event of Occurrence, Claim or Suit Included 5 Unintentional Failure to Disclose Hazards Included 5
Liberalization Included 5
Bodily Injury – includes Mental Anguish Included 5
Personal and Advertising Injury – includes Abuse of
Process, Discrimination
Included 5
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
PI-RO-012 (10/16) Page 2 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
A. Damage to Premises Rented to You
If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word “fire” is changed to “fire, lightning, explosion, smoke, or leakage from automatic fire protective systems” where it appears in:
1. The last paragraph of SECTION I - COVERAGES. COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY after the Exclusions;
2. Paragraph 6 of SECTION III - LIMITS OF INSURANCE;
3. Paragraph b.(1)(b) of 4. Other Insurance in SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS; and
4. Paragraph 9.a. “Insured contract” in SECTION V - DEFINITIONS.
The Damage To Premises Rented To You Limit section of the Declarations is amended to the greater of:
1.) $300,000; or
2.) The amount shown in the Declarations as the Damage to Premises Rented to You Limit.
This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof.
B. Extended “Property Damage”
SECTION I - COVERAGES. COVERAGE A, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY 2. Exclusions a. is deleted and replaced by the following:
a. Expected or Intended Injury
“Bodily Injury” or “Property Damage” expected or intended from the standpoint of the insured.
This exclusion does not apply to “bodily injury” or “property damage” resulting from the use of reasonable force to protect persons or property.
C. Non-Owned Watercraft
SECTION I - COVERAGES. COVERAGE A, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY 2. Exclusions, paragraph g. (2) is amended to read as follows:
(2) A watercraft you do not own that is:
(a) Less than 58 feet long; and
(b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingent.
D. Medical Payments - Limit Increased to $15,000, Extended Reporting Period
If COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part:
1. The Medical Expense Limit is changed subject to all of the terms of SECTION III - LIMITS OF INSURANCE to the greater of:
a. $15,000; or
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
PI-RO-012 (10/16) Page 3 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission. b. The Medical Expense Limit shown in the Declarations of this Coverage Part.
2. COVERAGE C MEDICAL PAYMENTS. 1. Insuring Agreement a., provided that: (2) is amended to read:
(2) The expenses are incurred and reported to us within three years of the date of the accident;
E. Athletic Activities
COVERAGE C MEDICAL PAYMENTS. 2. Exclusions. e. Athletic Activities is deleted and replaced with the following:
e. Athletic Activities-to a person injured while taking part in athletics.
F. Covered Injury Reimbursement
When a covered injury to a claimant results in loss of life within one year from the date of the accident, we will pay $5,000 to the following:
1. the parent or guardian if the deceased was a minor;
2. the surviving spouse, if any; or
3. a person authorized by law or legally entitled to receive such payment.
G. Wage Loss
We will pay “wage loss” as described below to an injured person if the injured person is also eligible for payment under COVERAGE C MEDICAL PAYMENTS, subject to the additional terms below. a. Exclusions
1. arising out of any actual or alleged act of “sexual misconduct or sexual molestation”; including damages on account of any negligent hiring or transfer of, failure to supervise or failure to dismiss any employee or volunteer worker alleged to have committed any act of “sexual misconduct or sexual molestation”.
2. for any “wage loss” that is not documented or which is speculative in nature.
3. for time away from work by an injured person unless required by a physician, or for time away from work after a physician has given approval for the injured person to return to work. b. Limit of Insurance
1. We will pay two-thirds of the “wage loss” sustained by an injured person. In the event that another policy, program or plan pays a portion of the “wage loss” but less than two-thirds of the “wage loss” then we will pay the difference between that portion and two-thirds of the “wage loss”.
2. The most we will pay under this coverage extension is $5,000. c. Conditions
1. Proof of “wage loss” must be provided in writing by the employer of the person sustaining the “wage loss”. If a person to whom coverage applies under this extension is self-employed, then such person must provide tax returns and other necessary records to document their “wage loss”.
d. Definition
1. “Wage loss” means loss of actual gross income, but only to the extent that such income was being paid on the date that “bodily injury” caused by an accident occurred. “Wage loss” does not include potential income that may have been received from overtime hours, on-call pay, or similar types of compensation. “Wage loss” also does not include compensation for Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
PI-RO-012 (10/16) Page 4 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission. paid sick leave, short-term disability days, long-term disability days, or family leave that was used as a result of the “bodily injury”.
H. Supplementary Payments
In the SUPPLEMENTARY PAYMENTS - COVERAGE A AND B provision:
1. The limit for the cost of bail bonds is changed from $250 to $2,500; and
2. The limit for loss of earnings is changed from $250 a day to $500 a day.
I. Employee Indemnification Defense Coverage
Under SUPPLEMENTARY PAYMENTS - COVERAGES A AND B the following is added:
3. We will pay, on your behalf, defense costs incurred by an “employee” in a criminal proceeding.
The most we will pay for any “employee” who is alleged to be directly involved in a criminal proceeding is $25,000 regardless of the numbers of employees, claims or “suits” brought or persons or organizations making claims or bringing “suits”.
J. SECTION II - WHO IS AN INSURED is amended as follows:
1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Coverage part, paragraph 3.a is changed to read:
a. Coverage under this provision is afforded until the end of the policy period.
2. Each of the following is also an insured:
a. Medical Directors and Administrators - Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. Such duties do not include the furnishing or failure to furnish professional services of any physician or psychiatrist in the treatment of a patient.
b. Managers and Supervisors - If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors.
c. Organization and Subsidiary - Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage part. However, coverage does not apply to any organization or subsidiary not named in the Declarations as Named Insured, if they are also insured under another similar policy, but for its termination or the exhaustion of its limits of insurance.
d. Funding Source - Any person or organization with respect to their liability arising out of:
1) Their financial control of you; or
2) Premises they own, maintain or control while you lease or occupy these premises.
This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. e. Managers or Lessors of Premises - Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased to you subject to the following additional exclusions:
This insurance does not apply to:
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
PI-RO-012 (10/16) Page 5 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission. 1) Any “occurrence” which takes place after you cease to be a tenant in that premises. 2) Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization.
K. Duties in the Event of Occurrence, Claim or Suit
1. The requirement in Condition 2. a. of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS that you must see to it that we are notified as soon as practicable of an “occurrence” or an offense, applies only when the “occurrence” or offense is known to:
a. You, if you are an individual;
b. A partner, if you are a partnership; or
c. An executive officer or insurance manager, if you are a corporation.
2. The requirement in Condition 2.b. that you must see to it that we receive notice of a claim or “suit” as soon as practicable will not be considered breached unless the breach occurs after such claim or “suit” is known to:
a. You, if you are an individual;
b. A partner, if you are a partnership; or
c. An executive officer or insurance manager, if you are a corporation.
L. Unintentional Failure To Disclose Hazards
It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure.
M. Liberalization
If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coverage to all endorsement holders as of the day the revision is effective in your state.
SECTION V - DEFINITIONS
N. Bodily Injury - Mental Anguish
The definition of 3. “Bodily Injury” is changed to read:
“Bodily Injury”:
a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these; and
b. Except for mental anguish, includes death resulting from the foregoing (item a. above) at any time.
O. Personal and Advertising Injury – Abuse of Process, Discrimination
If COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is not otherwise excluded from this Coverage Part, the definition of “Personal and Advertising Injury” is amended as follows:
1. Item 14 b. is revised to read:
a. Malicious prosecution or abuse of process:
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
PI-RO-012 (10/16) Page 6 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
2. Adding the following:
a. “Personal and advertising injury” also means discrimination based on race, color, religion, sex, age or national origin, except when:
1. Done intentionally by or at the direction of, or with the knowledge or consent of:
a. Any insured; or
b. Any executive officer, director, stockholder, partner or member of the insured; or
2. Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an insured; or
3. Directly or indirectly related to the sale, rental, lease or sublease or prospective sales, rental, lease or sub-lease of any room, dwelling or premises by or at the direction of any insured; or
4. Insurance for such discrimination is prohibited by or held in violation of law, public policy, legislation, court decision or administrative ruling.
The above does not apply to fines or penalties imposed because of discrimination. b. “Personal and Advertising Injury” does not mean discrimination based on gender identity, gender expression or sexual orientation.