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PROOF OF INSURANCE (2020) CLOSED0 DATE (MM/DD/YYYY) AC"6R" CERTIFICATE OF LIABILITY INSURANCE llI� 1 2119/2020 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 COEiN''ACT IOA Insurance Services CA n _,,,,,,,,,,,,,,,,,,,,,,,,(W Donn s,quiv l,_,_, FAX 130 Vantis, Suite 250 Aliso Viejo, CA 92656 Mn). (949)297-5962 rAlc" N°': AIL OOREss: donna.eswivefftoausa"com www.ioausa.com CA License #OE67768 INSURED Ornnis Consulting, Inc. 405 S. State College Blvd., Suite 204 Brea CA 9213211 INSURER(S) AFFORDING COVERAGE NAIC # ,., .............................. _. INSURER A: RLI Insurance Comp any..m 13056 INSURER B INSURER C t INSURER D! INSURER E: I INSURER F; COVERAGES CERTIFICATE NUMBER: 54187661 REVISION NUMBER: 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 3ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH DOLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE.OF........................................................................................... x5 POOCY EFF POLICY EXP INSURANCE I POLICY NUMBER I'MMIDDIYYYY) (MM/DD/YYYY) LIMITS A I/" COMMERCIAL GENERAL LIABILITY ,/ / PSB0002339 7/22/2019 7/22/2020 EACHOCCURRENCE $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is an Additional Insured with respect to General Liability (GL) and Automobile Liability but only when required by written contract with the Insured prior to an occurrence as per Endorsements noted above. GL includes Separation of Insureds and Contractual Liability per limitations in the BusinessOwners' Coverage form. A Workers' Compensation Waiver of Subrogation as noted above is included for the person or organization named in the Schedule that are parties to a contract requiring this Endorsement, provided that contract is executed before the loss. Coverage is subject to all policy terms, conditions, limitations and exclusions. 30 Day Notice of Cancellation/10 Days for Non -Payment in accordance with policy provisigns. CERTIFICATE HOLDER CANCELLATION " Per ACORD Additional Remarks Schedule SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN De artrnent of Public Works - Engineering Division ACCORDANCE WITH THE POLICY PROVISIONS. 3511 Main Street EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE p, (AVC) Alicia K. Igram ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 54187661 1 7/19-20 GL, AUTO, EXCESS, WC & PL I (AVC) Donna Esquivel 1 2/19/2020 3:17:03 PM (PST) I Page 1 of 6 CLAIMS -MADE OCCUR Scheduled Al Endt ,MED, EXP AnY one person) #PPB3130212 ✓ Prim/NonCon Professional Services 7" Wvr of Subr performed by the Insured GEN'L AGGREGATE LIMIT APPLIES PER: are Excluded POLICY PRO - JECT LOC $ 7/22/2019 OTHER OTHER: � $ 1,000 000 A AUTOMOBILE LIABILITY PSA0001537 ANY AUTO Designated Insured Endt . OWNED SCHEDULED #CA20481013; Prim/NonCon „ AUTOS ONLY AUTOS and Blkt Wvr of Subr HIRED NON -OWNED $ 7/22/2019 r� AUTOS ONLY .' AUTOS ONLY included on pg 2 of Form Prim/NonCon V Wvr of Subr #PPA3000313 A UMBRELLA LIAB OCCUR 1_� PSE0003846 / EXCESS LIAB CLAIMS-MADE Excludes Professional "jLiability ryPERY ................... DED I, RETENTION $ ✓.OTH E.L. EACH ACCID .. ...........w ENr.,..STATUTE .......... A WORKERS COMPENSATION �/ PSWO002073 AND EMPLOYERS' LIABILITY YIN Waiver of Subrogation 7/22/2019 ANYPROPRIETORJPARTN ER'IEX'ECUTIVE OFFICERWEMSEREXCLUDED? Y N/A Endt #WC0403060484 (Mlandatory In NH) dcscnbe under Uas, SCRIPTION OF OPERATIONS b0ow A Professional Liability RDP0033360 Claims -Made DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is an Additional Insured with respect to General Liability (GL) and Automobile Liability but only when required by written contract with the Insured prior to an occurrence as per Endorsements noted above. GL includes Separation of Insureds and Contractual Liability per limitations in the BusinessOwners' Coverage form. A Workers' Compensation Waiver of Subrogation as noted above is included for the person or organization named in the Schedule that are parties to a contract requiring this Endorsement, provided that contract is executed before the loss. Coverage is subject to all policy terms, conditions, limitations and exclusions. 30 Day Notice of Cancellation/10 Days for Non -Payment in accordance with policy provisigns. CERTIFICATE HOLDER CANCELLATION " Per ACORD Additional Remarks Schedule SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN De artrnent of Public Works - Engineering Division ACCORDANCE WITH THE POLICY PROVISIONS. 3511 Main Street EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE p, (AVC) Alicia K. Igram ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 54187661 1 7/19-20 GL, AUTO, EXCESS, WC & PL I (AVC) Donna Esquivel 1 2/19/2020 3:17:03 PM (PST) I Page 1 of 6 DAMAGE TO RENTED PRE:MIS_F.j&(ruxLLrgnceJ $1,000,000 ,MED, EXP AnY one person) $10,000 INJURYPERSONAL & ADV 9 GENERAL AGGREGATE $4,0�00,000 PRODUCTS - COMP/OP AGG . I_............................................�.._.,.,......,.,.,.,.._,.,.....,_.a, ^ $4, 00 000,0 $ 7/22/2019 7/22/2020 COMBINED SINGLE LIMIT IEa aicc'ldanl) � $ 1,000 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) I $ ROPERTY DAMAGE I $ P44r accident) �,P I $ 7/22/2019 7/22/2020 EACH OCCURRENCE $2,000,000 AGGREGATE $2,000,000 7/22/2019 7/22/2020 ryPERY ................... ✓.OTH E.L. EACH ACCID .. ...........w ENr.,..STATUTE .......... ,,,$, 9,,000,000 E.L. DISEASE - EA EMPLOYEE $ J 110, 0Q0 E.L. DISEASE -POLICY LIMIT $ 1.000,000 7/22/2019 7/22/2020 $1,000,000 Each Claim $2,000,000 Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is an Additional Insured with respect to General Liability (GL) and Automobile Liability but only when required by written contract with the Insured prior to an occurrence as per Endorsements noted above. GL includes Separation of Insureds and Contractual Liability per limitations in the BusinessOwners' Coverage form. A Workers' Compensation Waiver of Subrogation as noted above is included for the person or organization named in the Schedule that are parties to a contract requiring this Endorsement, provided that contract is executed before the loss. Coverage is subject to all policy terms, conditions, limitations and exclusions. 30 Day Notice of Cancellation/10 Days for Non -Payment in accordance with policy provisigns. CERTIFICATE HOLDER CANCELLATION " Per ACORD Additional Remarks Schedule SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN De artrnent of Public Works - Engineering Division ACCORDANCE WITH THE POLICY PROVISIONS. 3511 Main Street EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE p, (AVC) Alicia K. Igram ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 54187661 1 7/19-20 GL, AUTO, EXCESS, WC & PL I (AVC) Donna Esquivel 1 2/19/2020 3:17:03 PM (PST) I Page 1 of 6 AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED IOA Insurance Services Omnis Consulting, Inc. 405 S, Stale College Blvd.„ Suite 204 POLICY NUMBER Brea CA 92821 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (03/16) HOLDER: City of EI Segundo ADDRESS: Department of Public Works - Engineering Division 350 Main Street EI Segundo CA 90245 Project Reference includes: Construction Support and As -Built Plans for Water Improvements on Indiana Street, Project PW 18-07; Water Main Improvement on Cedar Street and Walnut Avenue, Project PW 18-10; and Fiber Optic Vault Lid Replacements, Project PW 19-08 I ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 54187661 17/19-20 GL, AUTO, EXCESS, WC & PL i (AVC) Donna EaquiVel 1 2/19/2020 3:17:03 PM (PST) i Page 2 of 6 Policy Number: PSB0002339 RLI Insurance Company Named Insured: omnis Consulting, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, RLIPack° FOR PROFESSIONALS SCHEDULED ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM — SECTION II — LIABILITY Schedule Name of Person(s) or Organization(s): City of EI Segundo 1. SECTION II C. Who Is An Insured is amended to include as an additional insured the person or organization shown in the schedule above, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by you or those acting on your behalf: a. In the performance of your ongoing operations; b. In connection with premises owned by or rented to you; or c. In connection with "your work" and included within the "product -completed operations hazard". 2. The insurance provided to the additional insured by this endorsement is limited as follows: a. This insurance does not apply to the rendering of or failure to render any "professional services". b. This endorsement does not increase any of the limits of insurance stated in D. Liability And Medical Expenses Limits of Insurance. 3. The following is added to SECTION III H.2. Other Insurance — COMMON POLICY CONDITIONS (BUT APPLICABLE ONLY TO SECTION II — LIABILITY) However, if you specifically agree in a contract or agreement that the insurance provided to an additional insured under this policy must apply on a "_�ZQI I-V primary basis, or a primary and non-contributory basis, this insurance is primary to other insurance that is available to such additional insured which covers such additional insured as a named insured, and we will not share with that other insurance, provided that: a. The "bodily injury" or "property damage" for which coverage is sought occurs after you have entered into that contract or agreement; or b. The "personal and advertising injury" for which coverage is sought arises out of an offense committed after you have entered into that contract or agreement. 4. The following is added to SECTION III K.2 Transfer of Rights of Recovery Against Others to Us — COMMON POLICY CONDITIONS (BUT APPLICABLE TO SECTION I — PROPERTY AND SECTION II — LIABILITY) We waive any rights of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal and advertising injury" arising out of "your work" performed by you, or on your behalf, under a contract or agreement with that person or organization. We waive these rights only where you have agreed to do so as part of a contract or agreement with such person or organization entered into by you before the "bodily injury" or "property damage" occurs, or the "personal and advertising injury" offense is committed. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. Page 1 of 1 54187661 1 7/19-20 GL, AUTO, EXCESS, WC & PL I (AVC) Donna Esquivel 1 2/19/2020 3:17:03 PM (PST) I Page 3 of 6 POLICY NUMBER: PSA0001537 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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: Omnis Consulting, Inc. Endorsement Effective Date: 7/22/2019 SCHEDULE Name Of Person(s) Or Organization(s): City of EI Segundo Information required to complete this Schedule, if not shown above, will be shown in the Declarations. i 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. CA 20 48 10 13 C Insurance Services Office, Inc., 2011 Page 1 of 1 54187661 1 7/19-20 GL, AUTO, EXCESS, WC & PL I (AVC) Donna Esquivel 1 2/19/2020 3:17:03 PM (PST) I Page 4 of 6 This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM A. Broad Form Named Insured The following is added to the SECTION II — COVERED AUTOS LIABILITY COVERAGE, Para- graph A.I. Who Is An Insured Provision: Any business entity newly acquired or formed by you during the policy period, provided you own fifty percent (50%) or more of the business entity and the business entity is not separately insured for Bus- iness Auto Coverage. Coverage is extended up to a maximum of one hundred eighty (180) days following the acquisition or formation of the business entity. This provision does not apply to any person or organization for which coverage is excluded by endorsement. B. Employees As Insureds The following is added to the SECTION II — COVERED AUTOS LIABILITY COVERAGE, Para- graph A.1. Who Is An Insured Provision: Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. C. Blanket Additional Insured The following is added to the SECTION II — COVERED AUTOS LIABILITY COVERAGE, Para- graph A.I. Who Is An Insured Provision: Any person or organization that you are required to include as an additional insured on this coverage form in a contract or agreement that is executed by you before the "bodily injury" or "property damage" occurs is an "insured" for liability coverage, but only for damages to which this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in SECTION II — COVERED AUTOS LIABILITY COVERAGE. The insurance provided to the additional insured will be on a primary and non-contributory basis to the additional insured's own business auto coverage if you are required to do so in a contract or agreement that is executed by you before the "bodily injury" or "property damage" occurs. D. Blanket Waiver Of Subrogation The following is added to the SECTION IV — BUSI- NESS AUTO CONDITIONS, A. Loss Conditions, S. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against any person or organization to the extent required of you by a contract executed prior to any "accident" or PPA 300 03 13 "loss", provided that the "accident" or "loss" arises out of the operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract. E. Employee Hired Autos 1. The following is added to the SECTION II — COVERED AUTOS LIABILITY COVERAGE, Paragraph A.1. Who Is An Insured Provision: An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. 2. Changes In General Conditions: Paragraph 5.b. of the Other Insurance Con- dition in the BUSINESS AUTO CONDITIONS is deleted and replaced with the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow; and (2) Any covered "auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". F. Fellow Employee Coverage SECTION II — COVERED AUTOS LIABILITY COVERAGE, Exclusion B.S. does not apply if you have workers compensation insurance in -force covering all of your employees. G. Auto Loan Lease Gap Coverage SECTION III — PHYSICAL DAMAGE COVERAGE, C. Limit Of Insurance, is amended by the addition of the following: In the event of a total "loss" to a covered "auto" shown in the Schedule of Declarations, we will pay any unpaid amount due on the lease or loan for a covered "auto", less: 1. The amount paid under the PHYSICAL DAMAGE COVERAGE section of the policy; and 2. Any: a. Overdue lease/loan payments at the time of the "loss"; 54187661 1 7/15-20 GL, AUTO, EXCESS, WC & PL I (AVC) Donna Esquivel 1 2/19/2020 3:17:03 PM (PST) I Page 5 of 6 Page 2 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) 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 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 % of the California workers' compensation premium otherwise due on such remuneration. Person or Organization City of EI Segundo Schedule Job Description Jobs performed for any person or organization that you have agreed with in a written contract to provide this agreement. 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 7/22/2019 Policy No.PSW0002073 Endorsement No. Insured Insurance Company Omnis Consulting, Inc. RLI Insurance Company Countersigned By 01998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. 54167661 1 7/19-20 GL, AUTO, EXCESS, WC & PL I (AVC) Donna Esquivel 12/19/2020 3:17:03 PM (PST) I Page 6 of 6