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
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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 WVDADDL
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
AUTOS ONLY AUTOS NON-OWNED OWNED SCHEDULED
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 EMPLOYEEE.L. EACH ACCIDENT EROTH- STATUTE PER
(MM/DD/YYYY) LIMITS POLICY EXP(MM/DD/YYYY) POLICY EFFLTR TYPE OF INSURANCE POLICY NUMBER 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)
© 1988-2016 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
Willis Towers Watson Insurance Services West, Inc.
c/o 26 Century Blvd
P.O. Box 305191
Nashville, TN 372305191 USA
The Salvation Army - Division 17
30840 Hawthorne Blvd., Bldg D
Rancho Palos Verdes, CA 90275
Division/Location: 17-100 Redondo Beach Corps
CA-Business Auto is fully Self-Insured per the attached State Certificate.
SEE ATTACHED
City of Redondo Beach
415 Diamond Street
Redondo Beach, CA 90277 10/04/2023 1-877-945-7378 1-888-467-2378 [email protected] Greenwich Insurance Company 22322 XL Specialty Insurance Company 37885 W30551387 A 2,000,000 1,000,000 Self Insured Retention: 0
$1,000,000 2,000,000 6,000,000 6,000,000 Y Y RGE3001798 10/01/2023 10/01/2024 A Excess Auto Liability - CA Y RAE500021813 10/01/2023 10/01/2024 Any Auto / CSL Self-Insd Retention SR ID: 24764335 BATCH: 3155938 $2,000,000 $3,000,000 Willis Towers Watson Certificate Center Page 1 of 2 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:
The Salvation Army - Division 17
30840 Hawthorne Blvd., Bldg D
Rancho Palos Verdes, CA 90275
Contract agreement for HUD Community Development Block Grant (CDBG) funding.
The Salvation Army Redondo Beach Corps Community Center Program Title: Meals on Wheels Program The term of this Agreement shall commence on July 1, 2022 and end June 30, 2023.
The City, its officers, elected and appointed officials, employees, and volunteers are included as Additional Insureds as respects to General Liability and Auto Liability as required by written contract or agreement.
General Liability policy shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insureds as required by written contract or agreement.
Waiver of Subrogation applies in favor of The City, its elected and appointed officials, officers, employees, volunteers, attorneys, and agents (collectively “Indemnitees”) with respects to General Liability as required by written contract or agreement.
INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAIC#: 37885 POLICY NUMBER: RWE500047508 EFF DATE: 10/01/2023 EXP DATE: 10/01/2024 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:
Excess Workers Compensation E.L. Each Accident $1,000,000 CA EL Each Employee $1,000,000
Retention: $1,000,000
ADDITIONAL REMARKS:
Excess Workers Compensation Policy No. RWE500047508 provides coverage in the state of CA CA-Workers Compensation is fully Self-Insured per the attached State Certificate 2 2
Willis Towers Watson Insurance Services West, Inc. See Page 1 See Page 1 See Page 1 See Page 1 25 Certificate of Liability Insurance SR ID: 24764335 BATCH: 3155938 CERT: W30551387
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
OFFICE OF SELF-INSURANCE PLANS
11050 Olson Drive, Suite 230
Rancho Cordova,CA 95670
Phone No. (916) 464-7000
FAX (916) 464-7007
TO WHOM IT MAY CONCERN:
This certifies that Certificate of Consent to Self-Insure No. 0566 was issued by the Director of Industrial Relations to:
CERTIFICATION OF SELF-INSURANCE OF WORKERS' COMPENSATION The Salvation Army
under the provisions of Section 3700, Labor Code of California with an effective date of November 15, 1933. The certificate is currently in full force and effective.
Dated at Sacramento, California
This day the 20th of April 2017
Lyn Asio Booz, Chief
ORIG: Craig Nicles
Director Of Claims Management
The Salvation Army
180 East Ocean Boulevard, 10th Floor
Long Beach, Ca 90802
Edmund G. Brown Jr., Governor
COMMERCIAL GENERAL LIABILITY
CG 20 26 12 19
POLICY NUMBER: RGE3001798
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 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):
Any person or organization where required by written contract provided that such contract was executed prior to loss.
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 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;
whichever is less.
This endorsement shall not increase the
applicable limits of insurance.
ENDORSEMENT #
by Greenwich Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY INSURANCE CLAUSE ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS COVERAGE PART
It is agreed that to the extent that insurance is afforded to any Additional Insured under this policy, this insurance shall apply as primary and not contributing with any insurance carried by such Additional Insured, as required by written contract.
All other terms and conditions of this policy remain unchanged.
XIL 424 0605
©, 2005, XL America, Inc.
Policy No. RGE3001798 issued to The Salvation Army
This endorsement, effective 12:01 a.m., October 1, 2023 forms a part of POLICY NUMBER: RAE500021813 COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Named Insured: THE SALVATION ARMY
Endorsement Effective Date: October 1, 2023
SCHEDULE
Name Of Person(s) Or Organization(s):
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision
contained in Paragraph A.1. of Section II – Covered
Autos Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms and Paragraph D.2. of
Section I – Covered Autos Coverages of the Auto
Dealers Coverage Form.
Where required by written contract executed prior to loss