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PROOF OF INSURANCE (2021) CLOSEDA� ® CERTIFICATE OF LIABILITY INSURANCE I DAT7/2��2o20YY) 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 IOA Insurance Services I CONTACT NAME: Betty Tran 130 Vantis, Suite 250 I PHO, N . Ext): 949-297-5962 FAX Aliso Viejo, CA 92656 I E-MAIL fA/c. No): 949 297-5960 ADDRESS: betty.tran@ioausa.com INSURER(S) AFFORDING COVERAGE NAIC # www.ioausa.com CA License #OE67768 I INSURERA: RLI Insurance Company 13056 INSURED Omnis Consulting, Inc. 405 S. State College Blvd., Suite 204 Brea CA 92821 I INSURER B: INSURER C: INSURER D: I INSURER E: I INSURER F: COVERAGES CERTIFICATE NUMBER: 56717804 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER IMM/DD/YYYYI IMM/DD/YYYYI A / COMMERCIAL GENERAL LIABILITY `/ `/ PSB0002339 7/22/2020 7/22/2021 EACHOCCURRENCE $2,000,000 CLAIMS -MADE 1✓ OCCUR Scheduled Al Endt DAMAGE PREMISES To(Ea RENTED TE encel $1,000,000 Prim/NonCon #PPB3130212 MED EXP (Any one person) $ 10,000 Wvr Subr Professional Services 2,000,000 of performed by the Insured PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: are Excluded GENERAL AGGREGATE $4,000,000 POLICY ECT LOC PRODUCTS-COMP/OPAGG $4,000,000 OTHER: $ A AUTOMOBILE LIABILITY✓ ✓ PSA0001537 7/22/2020 7/22/2021 Eaa acccidentSINGLE LIMIT $1,000,000 1000000 ✓ ANY AUTO Designated Insured Endt BODILY INJURY (Per person) $ OWNEDSCHEDULED #CA20481013; Prim/NonCon BODILY INJURY $ AUTOS ONLY AUTOS and Blkt Wvr of Subr (Per accident) PROPEDAMAGE $ ✓ AUTOS ONLY ✓ AUTHIRED OS ONLDY included on pg 2 of Form (Per accident) Prim/NonCon ,/ Wvr of Subr #PPA3000313 $ A UMBRELLALIAB OCCUR PSE0003846 7/22/2020 7/22/2021 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS -MADE Excludes Professional AGGREGATE $2,000,000 Liability DED RETENTION $ $ A WORKERS COMPENSATION ✓ PSW0002073 7/22/2020 7/22/2021 AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE Waiver of Subrogation ,/ SPER TATUTE EORH E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A Endt #WC0403060484 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1.000.000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 A Professional Liability RDP0040525 7/22/2020 7/22/2021 $1,000,000 Each Claim Claims -Made $2,000,000 Annual 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 provisions. CERTIFICATE HOLDER * Per ACORD Additional Remarks Schedule City of EI Segundo Department of Public Works - Engineering Division 350 Main Street EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE a� (AVC) Alicia K. Igram © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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. ACORD 25 (2016/03) 56919804 1 7/20-21 GL, AUTO, EXCESS, WC & PL I Noel Zemla 1 7/27/2020 9:20:57 AM (PDT) I Page 1 of 6 AGENCY CUSTOMER ID: LOC #: ACOOR " ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED IOA Insurance Services Omnis Consulting, Inc. 405 S. State 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 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 56919804 1 7/20-21 GL, AUTO, EXCESS, WC & PL I Noel Zemla 1 7/27/2020 9:20:57 AM (PDT) I Page 2 of 6 Policy NumberP8B0002339 Named Insured: OmnioConsulting, Inc. RLI Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Schedule Name ofPeraon(s)orOrgan ization(s): City of El Segundo 1' SECTION |U C. Who Is An |mmmned 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' |nthe performance ofyour ongoing operations; b. In connection with premises owned byorrented toyou; or c. In connection with ''your work" and included within the ''productoomp|ebsd operations hazard". 2. The insurance provided tothe additional insured by this endorsement is limited as follows: a' This insurance does not apply tothe rendering of or failure to render any "professional b. This endorsement does not increase any of the limits of insurance stated in D. Liability And Medical Expenses Limits mfInsurance. 3' The following iaadded toSECTION U|U H'2. Other Umsmxmmoe — COMMON POLICY CONDITIONS (BUT APPLICABLE ONLY TO SECTION U| — 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 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 asa named insunad, and we will not share with that other inouranoe, provided that: a' The "bodily injury" or "property damage" for which coverage is sought occurs after you have entered into that contract oragreement; 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 oragreement. 4. The following iaadded toSECTION III hL2Transfer of Rights of Recovery Against Others to Um — COMMON POLICY CONDITIONS (BUT APPLICABLE TO SECUONU—PROPERTY AND SECTION 11 — LIABILITY) We waive any hgNo 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 beha|f, under a contract or agreement with that person or organization. We waive these rights only vvhena 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, orthe "personal and advertising injury" offense iacommitted. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED' Page 1 of 1 S6717804 1 7/20-21 GL, ^nTO, EXCESS, wc & PL | Noel uemla 1 7p7p020 9:20:57 AM (PDT) | 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: 7/22/2020 SCHEDULE Name Of Person(s) Or Organ ization(s): City of El Segundo 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.I. of Section 11 — 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 @ Insurance Services Office, Inc., 2011 56717804 1 7/20-21 GL, AUTO, EXCESS, WC & PL I Noel Zemla 1 7/27/2020 9:20:57 AM (PDT) I Page 4 of 6 Page 1 of 1 This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM A. Broad Form Named Insured The following is added to the SECTION 11 — COVERED AUTOS LIABILITY COVERAGE, Para- graph A.1. 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 11 — COVERED AUTOS LIABILITY COVERAGE, Para- graph A.I. 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 11 — COVERED AUTOS LIABILITY COVERAGE, Para- graph A.1. 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, 5. 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 "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 11 — 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 11 — COVERED AUTOS LIABILITY COVERAGE, Exclusion B.5. 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"; Page 2 of 5 56919804 1 7/20-21 GL, AUTO, EXCESS, WC & PL ( Noel Zemla 1 7/27/2020 9:20:57 AM (PDT) ( Page 5 of 6 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 El 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 7/22/2020 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. 56717804 1 7/20-21 GL, AUTO, EXCESS, WC & PL I Noel Zemla 1 7/27/2020 9:20:57 AM (PDT) I Page 6 of 6