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PROOF OF INSURANCE (2020 - 2021) CLOSEDKOSMAAS-01 (�1 .4� 12v CERTIFICATE OF LIABILITY INSURANCE GATEINIMIM� I 012212019 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the p'o'licy, certain policies may require an endorsement, A statement on this ca'rtificals does not confer rights lo'the certificate holder in lieu of such endorsement(s). PRODUCER CT Brett,,, r Cleanse # OC38891 � A R Sternberg . . _.. _._ LyyddY Martin Company PMIONE .."""."°�_ __ FAX 20300 Ventura Blvd. Suite 340 JArC.No, �I y (310) 478.2625 317 � ArC,Irol.. Woodland Hills, CA 913641K6*tt I^�1dldymartin.C'om �_._......_ iNs'U. RE'rtga aFfe Coa Ltd __.._.�..,.._+ JO s - INSURER A.Sentirtellnu p ..._.(4r! 100'0 ...,..........._.._ KOamont a Associates, Inc. 1NsuR o N M1aREA a a POba: Kosmont Companies 1601 N. Sepulveda Blvd. 0382 Manhattan Beach„ CA 90268 Y L$URIR C : _ M. INSURER O: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CER'T'IFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUED TO TH't: INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT T'O WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBER HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. "iHSRp R TYPE OF INSURANCE b1%, LA -W-Ki POLICY NVNWCR PCLICY EFF d POLICY EXP,u LIMITS LX X y Ian a Erd afmcr6l a 1 tOliQlpOii(I' A . X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR �( d72SBABC384'2' 6/27/2019 6!27/2020 1,0010„000 I MF.1) Ex'P #"v area aarsanl S 10,000 _qXF IG'REs ..TE LIMIT APPLIES PER, POLICY ._, ❑ LOC A AUTOMOBILE LIABILITY ANY X OM O SCHEDULED AUT”" ONLY I AUTOS WNEp ,A- AUTOS ONLY Fx-,� AUT ONLY A. X UMBRELLA UAB X � OCCUR EXCESSUTAS CLAIMS -MADE DED II OX k RE'TpE7NTIT,IION.$' 10,000 pNrx E'EMPB. Y"EiR.S" UABtLITY Y I N ANY CPER 5'ov''RA, ExCTuDED? U1'IYE ,I � coo orY n I) 1 _J �S d Vice CRpIPTION OF OPERATIONS Wow PERS MdALdsAiS^N'&NJL.'4Is .. .,4--2,000,000 1w�wltl��lifiti .....,,..�..... cNRAc A�ery7, $ 2,000,040 PRDDUCTS^aaP}ryPAGS s-- 2,000,000' rt Erf 51Dt£ii E'UMIT S 1,444,440 �72SBABO3942 6/27/2019 6/2712024 q 1Y SODILY INJURY (Por gC u''dory 5 d PpCPERTrS)AMrAOE r's6; Pdrn%) Ili N t '$ 1 X X 172SHASC3942 6127/2019 6/2712020 H V RENc4 3.004,000 31000,000, $ ��O NIA „,LH�4.IEN' S ._•.....,�.,. � .E4_F!SASE.....F�'?•�,�.°��±~a.�..'�,....._, . E L D ^ ICY t IMIT S DESCH"ON OF OPERATIONS I LOCATIONS I VEHICLESACOR0101, Addition/ Rawnerks Schedule, Int, W aaechad It More space to required) The City, its oMcisls, a'nd employees ere n'ameil 'additional !routed per written Contract - the Insurance Is primary and non-contributory -see attached Business Liability Form CERTIFICATE HOLDER I City of EI Segundo Planning a Building Safety Dept 330 Main Street El Segundo 80248-3813 AUr40RIYEOREPRESENTATIVE 0 1988-2015 ACORD CORPORATION. All rights reserved. The ACORO name and logo are registered marks of ACORD I ACORD 25 (2016103) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", "volunteer workers", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). b. Real Estate Manager Any person (other than your "employee" or "volunteer worker"), or any organization while acting as your real estate manager. c. Temporary Custodians Of Your Property Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of that property; and (2) Until your legal representative has been appointed. d. Legal Representative If You Die Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this insurance. e. Unnamed Subsidiary Any subsidiary and subsidiary thereof, of yours which is a legally incorporated entity of which you own a financial interest of more than 50% of the voting stock on the effective date of this Coverage Part. The insurance afforded herein for any subsidiary not shown in the Declarations as a named insured does not apply to injury or damage with respect to which an insured under this insurance is also an insured under another policy or would be an insured under such policy but for its termination or upon the exhaustion of its limits of insurance. 3. Newly Acquired Or Formed Organization Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain financial interest of more than 50% of the voting stock, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; and Form SS 00 08 04 06 BUSINESS LIABILITY COVERAGE FORM b. Coverage under this provision does not apply to: (1) "Bodily injury" or "property damage" that occurred; or (2) "Personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. 4. Operator Of Mobile Equipment With respect to "mobile equipment" registered in your name under any motor vehicle registration law, any person is an insured while driving such equipment along a public highway with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the equipment, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to: a. "Bodily injury" to a co "employee" of the person driving the equipment; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. S. Operator of Nonowned Watercraft With respect to watercraft you do not own that is less than 51 feet long and is not being used to cavy persons for a charge, any person is an insured while operating such watercraft with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the watercraft, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to-- a. o: a. "Bodily injury" to a co -"employee" of the person operating the watercraft; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 6: AddltIdiiv ' W6urefwi: °Wfieni ",R@4611redr sy, iWrltttwrti'Cdntrs4 :�1Wt"Won AirverrWnt 'Or, Pennit, :Thei.persori(s)_�or,:orgeni2etion(a�a�Idatttifiedt'In. Para§raph!,*6'i:,throdWfs:,bbl ares dddilddiali, Intiuredii+`;wharf, Yd ihave *Ome ., Inii"eG:wriltten' Page 11 of 24 BUSINESS LIABILITY COVERAGE FORM cdntrad, wrMen, dgm��orbecause: nym' (e) Any failure to make such 1%ftk,'Idsued� ^by, m -state :cW �litical'. inspections, adjustments, tests or 'SuWW0DSIdn` NhatdUdh orsdn*or citgan*sifibn' servicing as the vendor has bbl-iddw&-eib 6n: Ad8itibnall.AnWied on Vwwr agreed to make or normally ,06111cy!, provided thbJm]0rKordamage monurm undertakes to make in the usual mubmequmny,txthe: execution of, the contractor course of buoinaos, in connection agreement, 6r..ft.iwmuahce,m�,t,wpennit. with the distribution or om|e of the A Obmm6ft mrbamilmWn, IS. tn additional products: pirbvIsimm mm|� for. that' (f)l Demonstration, inotoUmUnn. bY, the, 'contract.- servicing or repair uperaUono, '~=^—~—'—�~' ~--- exceptsuch opo��onspo�nmod or the vendor's premises in However, nosuch person ororganization |aan connection w�� 1ba m�� of dho additional insured under this provision if such product; person or organization is included as an (Q) Products which, after distribution additional insured by an endorsement issued oroo|e�yyuu.hmvoboun|obo|ed byuoand made opa�oYthis Cuvomgepm�. including all persons or organizations added or no|obm|mU or used as n as additional insureds under the specific container, part o,ingredient o[any mddiUnmo| insured uowusgw grants in Gsmiun other thing or substance by or for p.—Optional Additional Insured Coverages. the vendor; or a' Vendors (h) "Bodily injury" or "property dommWmy arising out of the sole Any pemon(o)o,mganizatiom(o)(referred to negligence ofthe vendor for its below as vendor), but only with respect to own acts uromissions urthose uf "bodily injury" ur"property damage" arising its employees or anyone a|oe out of "your products" which are distributed acting on its behalf. However, this o,sold inthe regular course of thevenuneo exclusion does not apply to: business and only if this Coverage Part "bodily (i> The exceptions contained in provides coverage for injury" or Subparagraphs (d)orU0,mr ^pnmpnny damage" included within the ^products -completed operations hszend^ (ii) Such inspections, adjustments, (1) The insurance afforded to the vendor tests orservicing aothe vendor is subject to the following additional hos agreed uomake nrnormally exclusions:undonmkeo�m�m|ntxeuomg course of business. in This insurance does not apply to: connection with the distribution (a) "Bodily injury" or "property orsale ofthe products. damage" for which the vendor is (2) This insurance does not apply to any oU|ig�ted to pay damages by insured person o, organization from reason of the assumption of whom you have acquired such products, liability inacontract oragreement. or any ingredient, part orcontainer, This exclusion does not apply to entering into, accompanying or liability for damages that the containing such products. vendor would have inthe absence �. �ws�wms��uipmnamt ofthe contract n,agreement; (b) Any oxpnuoo warranty 11) Any person or organizationfrom 'with lease but only ' . with roopemmtheir ooui|i�h,,'bodi|y (c) Any physical or chemical change injury", "property damage" o, in the product made intentionally ^pemmno| and advertising injury" bythe vendor; oouoed, in wmp|o or in part, by your (d) RepochoQing, except when maintonanoe, operation or use of unpacked solely for the purpose of equipment |woned to you by such !nopection, demonotramnn, teoUnB, person ororganization. or the substitution of parts under instructions from the monufactune,, and then repackaged in the original container: Page 12 of 24 Form SS 0008 04 05 (6) When You Are Added As An Additional Insured To Other Insurance That is other insurance available to you covering liability for damages arising out of the premises or operations, or products and completed operations, for which you have been added as an additional insured by that Insurance; or (7) When You Add Others As An Additional Insured To This Insurance That is other insurance available to an additional insured. However, the following provisions apply to other insurance available to any person or organization who is an additional insured under this Coverage Part: (a) Primary Insurance When Required By Contract This. insurance is primary if you have agreed in a written contract, written agreement or permit that this insurance be primary. If other insurance is also primary, we will share with all that other insurance by the method described in c. below. (b) Primary And Non -Contributory To Other Insurance When Required By Contract If you have agreed in a written contract, written agreement or permit that this insurance is primary and non-contributory with the additional insured's own insurance, this insurance is primary and we will not seek contribution from that other insurance. Paragraphs (a) and (b) do not apply to other insurance to which the additional insured . has been added as an additional insured. When this insurance is excess, we will have no duty under this Coverage Part to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. BUSINESS LIABILITY COVERAGE FORM When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of; (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (2) The total of all deductible and self- insured amounts under all that other insurance. We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part c. Method Of Sharing If all the other insurance permits contribution by equal shares, we will follow this method also. Under this approach, each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurers share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. B. Transfer Of Rights Of Recovery Against Others To Us a. Transfer Of Rights Of Recovery If the insured has rights to recover all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. This condition does not apply to Medical Expenses Coverage. b. Wstvar Of Rights; Of Recovery�(WalVer Of Sutiiogstlon) If the Insured has, waived any ;tights of. recovery against, any :person or ottnit�orr'!1str,',etl: gr`'plNif �'e��niri including Supplementary' Payments, *& have made underrthis ,CoVe"t Part. -wee also watve-that right; provldedthbalinsured waived -their rights of recovery,' agalhst, such •person or, organlzation in a': adribact, agreement or permit 'that was executed prior to the injury or -damage. Form SS 00 08 04 05 Page 17 of 24 CERTIFICATE OF LI03//18/218/202200 LIABILITY INSURANCE DATE 1 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 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 CONTACT Rick Powell NAME: Rick Powell Insurance Agency, Llc PHONE 818 861-7440 FAX (760) 804-9710 (AIC, No, Ext): ( ) (A/C, No): E-MAILcom 3500 West Olive Ave, Suite 300 IADDRES,5,r E-MAILrick@insurance4ca.com Insuranceca. Burbank, CA 91505 INSURER(S) AFFORDING COVERAGE NAIC # Phone (818) 861-7440 Fax (760) 804-9710 INSURER A: HISCOX INSURANCE COMPANY INC. 10200 INSURED INSURER B Kosmont & Associates, Inc, dba Kosmont Companies 1601 N Sepulveda Blvd #382 INSURER C: INSURER D: INSURER E: Manhattan Beach CA 90266 INSURER F ; COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. LTR„ TYPE OF INSURANCE (N$R wVD POLICY NUMBER (M MIDDYfYEYFYYy IMMIDDIY POLICY EXP LIMITS L� COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ F-1CLAIMS-MADE❑ OCCUR DAMAGE PREM SESO(Ea occurrence) $ ❑ MED EXP (Any one person) $ ❑ PERSONAL & ADV INJURY S, GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S ❑ POLICY ❑ JPICT� ❑ LOC PRODUCTS - COMP/OP AGG S ❑ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea uiccudewP 5 ❑ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED ❑ BODILY INJURY (Per accident) $ AALL UTOS AUTOS NON -OWNED F]HIRED AUTOS ❑yy AUTOS P11 PERTY DAMAGE (Per accident) $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE S Ew.7I EXCESS LIAB ❑ CLAIMS -MADE AGGREGATE $ El DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑ STATUTE ❑ PER OTH AND EMPLOYERS' LIABILITY Y I N ANY PROPR'IETORIIPARTNER/EXECUTIVE NIA E L EACH ACCIDENT S OFFICER)M'EMBEREXCLUDED? � IMandatory in NH) E L DISEASE - EA EMPLOYEE $ If yes, describe under E L DISEASE -POLICY LIMIT g DESCRIPTION OF OPERATIONS below A Errors & Omissions Coverage Y MPL1425837.20 03/15/2020 03/15/2021 $2,000,000/$2,000,000 Per Claim/Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EI Segundo Planning & Building Safety Dept THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) QF The ACORD name and logo are registered marks of ACORD A16�C R� DATE /01 /2019 Y) CERTIFICATE OF LIABILITY INSURANCE 2 � 10/01/2019 �' Acctfl 117132 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 the certificate holder in lieu of such endorsement(s). RODUCLocktoncCo ponies, LLC PHONE rights to CONTACT PRODUCER 3657 Brlarpark Dr., Suite 700 1A.. FW; ase-e28•a365 � A Net: E -MAI(„ Houston, TX 77042 S'S: IN RER A ; Ace American AFFORDING COVERAGE NAIC k Insurance Co. 22667 ............_ INSURED P y RE Ins aril ,Inc. UC/F KOSMONT & ASSOCIATES, INC. INSURER C 19001 Crescent Springs Drive INSURER D: Kingwood, TX 77339 SURER E; ry INSURER F COVERAGES CERTIFICATE NUMBER: 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 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. INSH TYPE OF INSURANCE � �g ^FN W POLICY NUMf EA (MMf(�DryEFF) IM DY IVMVI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR PREh1i6E50E0 $ 6AMB'hI`aE"r(F.d)..4.�,n.IILf�E�V.i _ MED EXP (Any one person) $ PERSONAL & ADV INJURY GEN'L AGGR'E'GATE LIMIT APPLIES PER: .. $ GENERAL AGGREGATE $ PRO. LOC PRODUCTS - COMP/OP AGG $ POLICY [:�] JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE V„bMrT $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED — SCHEDULED BODILY INJURY (Peraccidenl) $ AUTOS AUTOS NO OWNED PROPER"YOAMAGE $ HIRED AUTOS AUTOS _JPgLv idenll ......... i $ UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS -MADE DED fi . II RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY V B N ANY A OFFICEWMEMERIEXICLUDED? ECUT'IVE � N / A X (Mandaloryin NH) IIyos, ft'xriba Under D¢„.S,,CRgPTI'�ON OF OPFRATIQNS fWInvr EACH OCCURRENCE $ AGGREGATE $ X PER CITH- , SEATI,JTE ER E.L- EACH ACCIDENT $ 1,000,000 C66712679 10/01/2019 10/01/2020 — .L. DISEASE - EA EMPLOYEE $ 1,000,000 E L, DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) WAIVER OF SUBROGATION IN FAVOR OF CITY OF EL SEGUNDO WHEN REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF EL SEGUNDO AUTHORIZED REPRESENTATIVE ATTENTION: GREGG MCCLAIN, PLANNING MANAGER 350 MAIN STREET EL SEGUNDO, CA 90245 19$8-2'014 ACORD...._.CO.._.... ' RPORATION. All r4fits reserved, ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number Insperity, Inc, UC/F KOSMONT & ASSOCIATES, INC. Policy Number 19001 Crescent Springs Drive Symbol: RWC Number: C66712679 Kingwood, TX 77339 od Effective Date of Endorsement 10/01/2019 TO 10/01/2020 l(Name Isslued Byicy of Insurance Company) Ace ican Insurance Co. Insert therpol cy number. The remainder of the Information is to be completed cnty when this endorsement is issued subsequent to the preparation of the po x. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. (X) Specific Waiver Name of person or organization: CITY OF EL SEGUNDO 350 Main Street EI Segundo, CA 90245 ( ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be INCLUDED percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: INCLUDED AZZ6�M7 11� AUthonzea Kepresentative WC 99 03 22 Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Nornber Insperity, Inc. IJC/F KOSMONT &ASSOCIATES, INC. 19001 Crescent Springs Drive Kingwood, TX 77339 Policy Symbol I Policy Number Palley Period -Effective Date of Endorsement 12679 110101/2019 TO 10/01J2020 CI 10/01/2019 Issued By (Name of Insurance Company) Ace American Insurance Co. Insert the pohey number The remainder of the linformalmn is to be completed only when This andorsomenj 15 issiwed so 0 1 sequenj to the peeparatlon of the policy, NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below (the "Schedule"). You or your representative must provide us with both the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule. B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. C. The notice referenced in this, endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation, to the person(s) or organization(s) shown in the Schedule shalil impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. E. We may arrange with your representative to send such notice in the event of any such cancellation. F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and physical address of the persons or organizations listed in the Schedule. G. This endorsement does not apply in the event that you cancel the Policy. Name of Certificate Holder CITY OF EL SEGUNDO All other terms and conditions of the Policy remain unchanged. Acct#: 1171322 SCHEDULE I!E-MailAddress I Physical Address 350 Main Street EI Segundo, CA 90245 4 Authorized Representative ALL -32688 (01111) Page 1 of 1