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PROOF OF INSURANCE (2020 - 2021) CLOSED' ® DATE (MMIDDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE September 5. 2015 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 ADDIITIONAL INSURED, the policy(les) 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 CONTACT NAME' Hiscox Inc d/b/a/ Hiscox Insurance Agency in CA PHONE(888)202-3007 FAX IArC, No„ Exq;._/AFC, Nol� 520 Madison Avenue E.MAI'L tact hiscox com 32nd Floor AODRFss., con@o New York, NY 10022 _-_ ___ _ INSURER(S) AFFORDING COVERAGE NAIC# Hiscox Insurance Company Inc 10200 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSL0MNCE 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 INTSRR AobL SUBR POLICY NUMBER POLICY EFF' POLICY EXP TYPE OF INSURANCE BE'R II'ArAIDDFYYYYI IIIAIIAIODnd'YYY: LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X ; OCCUR X CGL is on BOP Form A Y Y GEN L AGGREGATE LIMIT APPLIES PER X POLICY PRO- JECT 67 HER INSURER A . INSURED INSURER B : JWA Urban Consultants Inc 609 Deep Valley Dr #200 Rolling Hills Estates CA 90274 INSURER INS'URE'R D OWNED INSURER E: AUTOS ONLY INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSL0MNCE 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 INTSRR AobL SUBR POLICY NUMBER POLICY EFF' POLICY EXP TYPE OF INSURANCE BE'R II'ArAIDDFYYYYI IIIAIIAIODnd'YYY: LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X ; OCCUR X CGL is on BOP Form A Y Y GEN L AGGREGATE LIMIT APPLIES PER X POLICY PRO- JECT 67 HER S- 2.000.00- AUTOMOBILE LIABILITY 100.00117 ANY AUTO S OWNED SCHEDULED AUTOS ONLY AUT,.'4 _ A H'RED X NON OV0 NE'D X -! AUTOS ONLY ! AU TSS ONLY UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DED RETEN1101a $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORlPARTNER/EXECUTIVE OrF,0ERI'P,AE!"WIEREXCi, UDE D1' (Maridalrrry in NH�I IR Je4, describe undef' D SCRIPT'11;1!1W OF ORER,'f7; IONS Y7Yd1Cr,t EACH OCCURRENCE S- 2.000.00- --- 100.00117 pewE9uR E'E: %Ec cccurrenceT__ S MED EXP (Any one perscnl S_ 5.000 UDC -4264569 -BOP -19 09/05/2019 09105/2020 PERSONAL S, ADV INJURY s S/TEach Occ. GENERAL AGGREGATE S 2,000.000 PRODUCTS - COMP/OP AGG s S/T Gen Agg. C010BIIQED SINGLE LIMIT S Ea ace dent) BODILY INJURY (Per person) S BODILY INJURY (Per accident) S UDC -4264569 -BOP -19 09/05/2019 09105/2020 PROPERTY DAMAGE Leer amdent) e'. EACH OCCURRENCE S AGGREGATE S_ 5 PER E L EACH ACCIDENT EL DISEASE -EAENIPbC"a"^ 5 E i, 'Cf!SEASE • I''01:ICY LINO! 7 $, DESCRIPTION OF OPERATIONS I LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mare space is required) The City of EI Segundo, its elected or appointed officials, officers, employees, or volunteers are additional insureds The Hiscox Business Owner's Policy 1s Primary and endorsed with a Waiver of Subrogation in favor of The City of EI Segundo, its elected or appointed officials, officers, employees, or volunteers, subject to the policy's terms and conditions CERTIFICATE HOLDER CANCELLATION The City of EI Segundo Attn Greg McClain, Planning Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main SL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ! ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 40 iSCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC -4264569 -BOP -19 JWA Urban Consultants Inc 17 September 5, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MODIFIED WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following BUSINESSOWNERS COVERAGE FORM The following is added to Subparagraph 2. in Paragraph K. Transfer Of Rights Of Recovery Against Others To Us of Section III - COMMON POLICY CONDITIONS (APPLICABLE TO SECTION I - PROPERTY AND SECTION 11 LIABILITY): You may waive your rights against another party so long as you do so in writing prior to: (i) an offense arising out of your business that caused a "personal and advertising injury"„ or (ii) an "occurrence" that caused "bodily injury" or "property damage". BOP E5213 CW (03110) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 Policy Number: UDC -4264569 -BOP -19 Named Insured: JWA Urban Consultants Inc Endorsement Number: 18 Endorsement Effective: September 5, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA - FIRED AUTO AND NON -OWNED AUTO LIABILITY This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Coverage Additional Premium A. Hired Auto Liability $175.00 B. Non -owned Auto Liability $ 0.00 1I, Information required to complete this Schedule, if not shown above, will be shown in the Declarations A. Throughout this endorsement the term spouse means: Spouse or a registered domestic partner under California law. B. Insurance is provided only for those coverages for which a specific premium charge is shown in the Declarations or in the Schedule. 1. Hired Auto Liability The insurance provided under Paragraph A.1. Business Liability in Section II — Liability applies to "bodily injury" or "property damage" arising out of the maintenance or use of a "hired auto" by you or your "employees" in the course of your business. 2. Non -owned Auto Liability The insurance provided under Paragraph A.I. Business Liability in Section II — Liability applies to "bodily injury" or "property damage" arising out of the use of any "non -owned auto" in your business by any person. C. For insurance provided by this endorsement only: 1. The exclusions under Paragraph B.1. Appli- cable To Business Liability Coverage in Section II — Liability, other than Exclusions a., b., d., f. and i, and the Nuclear Energy Liability Exclusion, are deleted and replaced by the fol- lowing: a. "Bodily injury" to: (1) An "employee" of the insured arising out of and in the course of: (a) Employment by the insured; or (b) Performing duties related to the conduct of the insured's business; or (2) The spouse, child, parent, brother or sister of that "employee" as a conse- quence of Paragraph (1) above. This exclusion applies: (1) Whether the insured may be liable as an employer or in any other capacity; and BP 06 86 01 10 0 Insurance Services Office, Inc., 2009 Page 1 of 2 (2) To any obligation to share damages with or repay someone else who must pay damages because of injury. This exclusion does not apply to: (1) Liability assumed by the insured under an "insured contract"; or (2) "Bodily injury" arising out of and in the course of domestic employment by the insured unless benefits for such injury are in whole or in part either payable or required to be provided under any work- ers' compensation law. b. "Property damage" to: (1) Property owned or being transported by, or rented or loaned to the insured; or (2) Property in the care, custody or control of the insured. 2. Paragraph C. Who Is An Insured in Section II — Liability is replaced by the following: 1. Each of the following is an insured under this endorsement to the extent set forth be- low: a. You; b. Any other person using a "hired auto" with your permission; c. For a "non -owned auto": (1) Any partner or "executive officer" of yours; or (2) Any "employee" of yours; but only while such "non -owned auto" is being used in your business; and d. Any other person or organization, but only for their liability because of acts or omissions of an insured under a., b. or c. above. 2. None of the following is an insured: Any person engaged in the business of his or her employer for "bodily injury" to any co -"employee" of such person in- jured in the course of employment, or to the spouse, child, parent, brother or sis- ter of that co -"employee" as a conse- quence of such "bodily injury", or for any obligation to share damages with or re- pay someone else who must pay dam- ages because of the injury; b. Any partner or "executive officer" for any "auto" owned by such partner or officer or a member of his or her household; c. Any person while employed in or other- wise engaged in duties in connection with an "auto business", other than an "auto business" you operate; d. The owner or lessee (of whom you are a sublessee) of a "hired auto" or the owner of a "non -owned auto" or any agent or "employee" of any such owner or lessee; or e. Any person or organization for the con- duct of any current or past partnership or joint venture that is not shown as a Named Insured in the Declarations. D. For the purposes of this endorsement only, Para- graph H. Other Insurance in Section III — Com- mon Policy Conditions is replaced by the follow- ing: This insurance is excess over any primary insur- ance covering the "hired auto" or "non -owned auto". E. The following additional definitions apply: 1. "Auto business" means the business or occu- pation of selling, repairing, servicing, storing or parking "autos". 2. "Hired auto" means any "auto" you lease, hire, rent or borrow. This does not include any "auto" you lease, hire, rent or borrow from any of your "employees", your partners or your "ex- ecutive officers" or members of their house- holds. 3. "Non -owned auto" means any "auto" you do not own, lease, hire, rent or borrow which is used in connection with your business. This in- cludes "autos" owned by your "employees", your partners or your "executive officers", or members of their households, but only while used in your business or your personal affairs Page 2 of 2 0 Insurance Services Office, Inc., 2009 BP 06 86 01 10 ACCIII DATE�(M® IDD 1YYY).. CERTIFICATE OF LIABILITY INSURANCE 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,AN0 THE CERTIFICATE HOLDER. r �......................... ........................... 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 r t)f� le hold pr in lieu' of such endorse I. PRODUCFR DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACCORD 101, Additional Remarks Schedule, if more space is required) 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 DI I: _ .. AUTHORIZED REPRESENTATIV ,I E .................... _........ _,,,, ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. Allrights reserved. The ACORD name and logo are registered marks of ACORD nl I, y AFFORDING COVERAGE NAIC # IN$URERS — �.r. ................... ........_._....,..,... ............... ..................................... uNSIJR_ER.�.........rr�� ............. �....�........._� HFinp;hir.e rrtsucance Company ...................... INSURED........................... INSURER B: MI7",. { i ' L;) „I I' i, 1 I' '; „ ',' I' _.......... ......................... _.....,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,., .............. i,) t •,.,. •..t �,,v',; INSURER C: __..................... _,._........ .............................................. .............- ; I`4;;, r ,i 11�„k t.;"�,' ^., , „ 6t ''11 )" , �,; INSURER D: INSURER E: w..._.__,.,........."......................... .,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.........,.......................................�..... 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 ........------. TYPE OF INSURA ..m LTR ._ ......................... ........��..........NCE................... AULrL NSRD............ Suis'it..................,,m POLICY NUMBER WVD . _F.-.....,.... ..MMIDDy.. Im.............�MMloorvYvvl .......................... I POL m._EPF POLICY EXP LIMITS GENERAL LIABILITY EACH OCGURANCE '--^ DAMAGE TO fENTE..D ...... .._._,.,.,.,.,M... COMMERCIAL. GENERAL. LIABILITY PREMISES (Ea ur,^curancO C,'I_AIMS MADE OCCUR MED EXP tAny one person) DOES NOT APPLY PERSONAL 8 AND INJURY - GENERAL. AGGREGATE GENT. AGGREGATE LIMIT APPLIES PER. PRODUCTS COMP/OP AG;G �.�..... ......... �...........ILO p POLICY 1PROJECT .„��. .......... ..�........_ TY F;UTOM 0 0u_r LIABILITY . ...........................................................�....,cri ...'_ c;denutu 3IIv�.r..r. I.IMI tra a t;C.iderrlt ANY AUTO BODILY INJURY ,Per person) A.J.. OWNED SCHEDULED ._ AUTOSv AUN-0WUNED DOES NOT APPLY, BODILY INJURY (Per accident) r^Taurr.�ta ...........................�. I r I.rFlNitnut tr'er HIRED AUTO' NA, accde it rrno .. ...... ..a................. UMBRELLA LIAB �I ......w....................................__.....�. OCCRANGE EACH ...........................................,_AGH ......... ® EXCESS LIAR .,LAIM MADE CLAIMS DOES NOT APPLY FGATJ GRrU<�S'TAT��4....����.�. ...... .... fIC}N 5 � .................� ... ...._..,.,.,. ...... .................�... ,....._..�_..... WORKERS COMPENSATION ........____............ ........................- OTHER IABIION AND EMPLOYERS'LIABILITY LIMITS TORY. L..... ANY PROPRIETOR/PARTNER/EXECUTIVE E I.. EACH AGGII:)ErJT OFFICE/MEMBER EXCLUDED? YIN NIA DOES NOT APPLY ...."....Uiti.-onF..........................................mmm r. - EA (Mandatory In NH) r ry LJ EMPI.� YEE ................ ....................._. It yes, describe under DESCRIPTION OF Prai I E L. DISEASE LIMIT OPERATIONS below .,, ..ICY --111111 _-----.... ....... Per Occurrence r 000...... gg ^4 Annual Ar re ate 1, 000, DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACCORD 101, Additional Remarks Schedule, if more space is required) 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 DI I: _ .. AUTHORIZED REPRESENTATIV ,I E .................... _........ _,,,, ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. Allrights reserved. The ACORD name and logo are registered marks of ACORD CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. U I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # (_V) I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must 9 p �- me y Date � immediately comply with those provisions o aoree nt will automatically become void. Signature of Applicant Name J AZoK Agreement for: JVW�,1v1 t V 14TOI- , l h -t- — lV Dated: Reviewed by: