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PROOF OF INSURANCE (2021) CLOSED
AC" 08//1717/22020020 Y) CERTIFICATE OF LIABILITY INSURANCE V DATE /— �F I 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 CONTACT Aimee Guesno NAME: Cornerstone Specialty Insurance Services, Inc PHONE. (714) 731-7700 FAX (714) 731-7/SU P Y IARC. No. Ext1. (AfC„ Not, 14252 Culver Drive. A299 E-MAIL. aimee@cornerstonespecialty com ADDRESS: INSURER(S)AFFORDING COVERAGE Irvine CA 92604 INSURERA: RLI Insurance Company INSURED INSURER B: Arch Insurance Company J.C. CHANG &ASSOCIATES, INC I INSURERC: 385 Van Ness Avenue, Ste, 208 I INSURER D 1 I INSURER E: Torrance CA 90501 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 20/21 COVERAGES 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 MAYBE 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 ADDL'S'UBW POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD_ WVD , POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR $ 1,000,000 X ADDT'L INSURED/ PRIMARY $ 10,000 A BLNKT WVR OF SUBRO Y PSB0001179 08/16/2020 08/16/2021 PERSONAL&ADV INJURY $ INCLUDED GEN'ILAG'GREGATE� LIMIT APPLIES PER: $ 4,000,000 POLICY PR 1:1 LOC O'THER $ AUTOMOBILE LIABILITY ANYAUTO $ 4,000,000 NAIC # A OWNED SCHEDULED PSA0001762 AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB X OCCUR A X EXCESS LIAB CLAIMS -MADE I PSE0001604 DED -I_I" 1 RE TEN; ON $ 0 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PRO PRI ETOR/PARTNER/EXECUTIVE N/A PSW000210' AOFFICER/MEMBER EXCLUDED? � (Mandatory in NH) If yes. describe under DESCRIPTION OF OPERATIONS below tJAP/IA'ty'ETO Iik:tJ I ECa _IPRF::MI'�i£:S IEa occaerrer�cetl MED EXP (Any one person) GENERAL AGGREGATE PRODUCTS-COMP/OPAGG COP�1BXNf�,:D;)gI~l�GLE L,dMIIT 4E�a accadenll BODILY INJURY (Per person) 08/16/2020 08116/2021 V BODILY INJURY (Per accident) PROPERTY DAMAGEiP'eu acr'udra'191 VUninsured/Underinsured EACH OCCURRENCE 08/16/2020 08/16/2020 08/16/2021 I AGGREGATE 11 X1 STATUTE 08/16/2021 IY EL EACH ACCIDENT ed within the policy period $ 1,000,000 $ $ $ 1,000,000 $ 1,000,000 IIII $ i nnn nnn N$ O"fH- ER E L DISEASE - EA EMPLOYEE E L DISEASE -POLICY LIMIT ®""' Each Claim Professional Liability B Claims Made PAAEP0029003 08/16/2020 [08/16/2021 Annual Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 107, Additional Remarks Schedule, maybe attached if more space is required) City of EI Segundo, its officials, and employees are Additional Insured for General Liability but only if required by written contract with the Named Insured prior to an occurrence and as per attached endorsement, Coverage is subject to all policy terms and conditions *30 days notice of cancellation, except for 10 days notice for non-payment of premium. For Professional Liability coverage, the aggregate limit is the total insurance available for all covered claims report $5,000,000 $ 1,000,000 $ 1,000,000 $ 1,000,000 $3,000,000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo -Public Works ACCORDANCE WITH THE POLICY PROVISIONS. i 350 Main Street ' - AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 \y�(/{A„a dw- 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Policy Number: PSB0001179 RLI Insurance Company Named Insured: J.C. Chang & Associates, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. RLIPack® FOR PROFESSIONALS BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM - SECTION II — LIABILITY 1. C. WHO IS AN INSURED is amended to include as an additional insured any person or organization that you agree in a contract or agreement requiring insurance to include as an additional insured on this policy, 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 on any basis to any person or organization for which coverage as an additional insured specifically is added by another endorsement to this policy. b. This insurance does not apply to the rendering of or failure to render any "professional services". c. 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 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 ONLY TO 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. PPB 304 02 12 Page 1 of 1 Policy Number: PSA0001762 PPA 300 03 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided un the following: BUSINESS AUTO COVERAGE FORM I. Blanket Additional Insured II. Blanket Waiver Of Subrogation The following is added to the SECTION II — COVERED AUTOS LIABILITY COVERAGE, Paragraph 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. The following is added to the SECTION IV — BUSINESS 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. PPA 300 03 13 Page 1 of 1 4. Loss Payment— Physical Damage Coverages At our option, we may: a. Pay for, repair or replace damaged or stolen property; b. Return the stolen property, at our expense. We will pay for any damage that results to the "auto" from the theft; or c. Take all or any part of the damaged or stolen property at an agreed or appraised value. If we pay for the "loss", our payment will include the applicable sales tax for the damaged or stolen property. 6. Transfer Of Rights Of Recovery Against Others To Us If any person or organization to or for whom we make payment under this Coverage Form has rights to recover damages from another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident" or "loss" to impair them. B. General Conditions 1. Bankruptcy Bankruptcy or insolvency of the "insured" or the "insured's" estate will not relieve us of any obligations under this Coverage Form. 2. Concealment, Misrepresentation Or Fraud This Coverage Form is void in any case of fraud by you at any time as it relates to this Coverage Form. It is also void if you or any other "insured", at any time, intentionally conceals or misrepresents a material fact concerning: a. This Coverage Form; b. The covered "auto"; c. Your interest in the covered "auto'; or d. A claim under this Coverage Form. 3. Liberalization If we revise this Coverage Form to provide more coverage without additional premium charge, your policy will automatically provide the additional coverage as of the day the revision is effective In your state. 4. No Benefit To Ballee -- Physical Damage Coverages We will not recognize any assignment or grant any coverage for the benefit of any person or organization holding, storing or transporting property for a fee regardless of any other provision of this Coverage Form. 6. Other Insurance a. For any covered "auto" you own, this Coverage Form provides primary Insurance. For any covered "auto" you don't own, the Insurance provided by this Coverage Form is excess over any other collectible insurance. However, while a covered "auto" which is a "trailer" is connected to another vehicle, the Covered Autos Liability Coverage this Coverage Form provides for the "trailer" is: (1) Excess while it is connected to a motor vehicle you do not own; or (2) Primary while it is connected to a covered "auto" you own. b. For Hired Auto Physical Damage Coverage, any covered "auto" you lease, hire, rent or borrow is deemed to be a covered "auto" you own. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". c. Regardless of the provisions of Paragraph a. above, this Coverage Form's Covered Autos Liability Coverage is primary for any liability assumed under an "insured contract". d. When this Coverage Form and any other Coverage Form or policy covers on the same basis, either excess or primary, we will pay only our share. Our share is the proportion that the Limit of Insurance of our Coverage Form bears to the total of the limits of all the Coverage Forms and policies covering on the same basis. 6. Premium Audit a. The estimated premium for this Coverage Form is based on the exposures you told us you would have when this policy began. We will compute the final premium due when we determine your actual exposures. The estimated total premium will be credited against the final premium due and the first Named Insured will be billed for the balance, if any. The due date for the final premium or retrospective premium is the date shown as the due date on the bill. If the estimated total premium exceeds the final premium due, the first Named Insured will get a refund. b. If this policy is issued for more than one year, the premium for this Coverage Form will be computed annually based on our rates or premiums in effect at the beginning of each year of the policy. CA 00 01 1013 © Insurance Services Office, Inc., 2011 Page 9 of 12 POLICY NUMBER: PSA0001762 COMMERCIAL AUTO PPA 300 03 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. RLIPack® BUSINESS AUTO ENHANCEMENT SCHEDULE OF COVERAGES ADDRESSED BY THIS ENDORSEMENT D. Blanket Waiver Of Subrogation The following is added to the SECTION IV — BUSINESS 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. PPA 300 03 11 Page 1 of 1 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) 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 % of the California workers' compensation premium otherwise due on such remuneration. Person or Organization All persons or organizations that are party to a contract that requires you to obtain this agreement, provided you executed the contract before a loss Schedule Job Description Job 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 08-16-2020 Policy No. PSW0002101 Endorsement No. Insured J.C. Chang & Associates, Inc. Insurance Company RLI Insurance Company