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PROOF OF INSURANCE (2021 - 2021) CLOSEDI DATE (MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE RANCE 09/28/2020 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 CONTACT Hiscox Inc. d/b/a/ Hiscox Insurance Agency In CA PHONE .E t) (888) ( AX ..IT 202-3007 AIC, No): 520 Madison Avenue EwMAIL contact@hiscox.com 32nd Floor .........�����... �,�RODUCTS-COMP/OPAGG ...$5,X. Gen. Agg,, IRER(SI AFFORDING COVERAGE N New York, NY 10022 ,,,,,,,,,,,,, OTHER, - INSURER A; Hiscox Insurance Company Inc10200 00 —....................................... _........... .................. _........_ „ INSURED INSURER B : .............. _....._..... JWA Urban Consultants Inc .............. 609 Deep Valley Dr #200 iNsuRER c Rolling Hills Estates, CA 90274 INSURER D OWNED SCHEDULED INSURER E —__ .......... ............. .•.•..... ....._-...............• $ 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 jPOLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR ........... .. TYPE OF INSURANCE ...............•�.dW, . 1XIDn POLICY NUMBER ,.....P�WP1�T01 OIDDNYYYd fMM DD EXP .p'........ .......................m..m,m.. M'VV1 LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 ...........__ . -- V D .,.... DAMAGE cu�CLAIMS-MADE occuR �s (Ea9�r,ce,) $ 100,000 X CGL is on BOP FormM $ 5,000 ,......E,D EXP (Any one person��.................m,m,.................................._ A ............ Y Y UDC -4264569 -BOP -20 09/05/2020 09/05/2021 PERSONAL &ADV INJURY $ S/T Each Occ. LIMITAPPLIES PER GENERALAGGREGATE s 2,000,000 GI-LAG�GFtE nA rv......�... PRO- II PCPLICN LOC .........�����... �,�RODUCTS-COMP/OPAGG ...$5,X. Gen. Agg,, .1 .IEC;•'Y' OTHER, - .. �.���� COM BIKED 5ING,.E (LIMIT AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED DILY (Per accident) $ AUTOS ONLY AUTOS A HIRED X NON -OWNED UDC -4264569 -BOP -20 09/05/2020 09/05/2021BOOPEiCyAMAGE $ XPpr AUTOS ONLY AUTOS ONLY �6P INJURY efaat,�... ..... ...... ....................m. UMBRELLA LIAB ' OCCUR ( EACH OCCURRENCE $ EXCESS LI BCLAIMS-MADE AGGREGATE $ ...•••mm.. DED RETENTION $�....... WORKERS COMPENSATION §PE.. AT TE R.._............ L_J .•.•.....,m,..•....• Y / N AONYPRO RIETO ANYPROPRIETOR/PARTNER/EXECUTIVE „w,,,• _LEACH ACCIDENTTH $ OFFICER/MEMBER � N / A (Mandatory in NH) E.L.�.. DISEASE - EA EMPLOYEE, _. _ L:........�.................... $ If yes, describe under DESCRIPTION OF OPERATIONS below ELL. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of EI Segundo, its elected or appointed officials, officers, employees, or volunteers are Additional Insureds per policy terms and conditions. The Hiscox Business Owner Po licy is Primary and is 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 po licy terms and conditions. CERTIFICATE HOLDER CANCELLATION The City of EI Segundo, Attn: Greg McClain, Planning Manager 350 Main St EI Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Policy Number: Named Insured: Endorsement Number: Endorsement Effective: UDC -4264569 -BOP -20 JWA Urban Consultants Inc 14 September 5, 2020 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MODIFIED WAIVER OF TRANSFER OF SIGHTS 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 II 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 (03/10) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 Policy Number: UDC -4264569 -BOP -20 Named Insured: JWA Urban Consultants Inc Endorsement Number: 19 Endorsement Effective: September 5, 2020 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA - HIRED A1TO_AAD_ft'0_A_-041,1,A'M 4UTO 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 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.I. 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.1. 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 C 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: a. 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 DATE TE F LIABILITY INSURANCE 05/0112020 ....., ._... THIS CERTIFICATE IS ISSUEDASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ATE 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 PRQD�10ERa..A.N.h..THE CERTIFI. ATE MOLDER.,_................................._....�� ..w...w ww. 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 S r i, irate holder in lieu of such endorsement(s). 'AROnUCFR "I,r INSURERS) AFFORDING COVERAGE NAIC # IN 5VH,,'1Pn'; A I''„' 4Y I�p:':,, ':1, Ill. n,d; n1:o�1 glc'i 9r •.l''r a INSURED INSURER B: INSURER Cr INSURER D: INSURER E: q INSURER F: COVERAGES CERTIFICATE _NUM' BE ........... R: 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 AUU'L ISUkSK POLICY NUMBER POLICY EFF POLICY EXP p LIMITS LTR ... INSRD IWVD .�,. IMPA010 YYI tAMIDDIYYYYI V Llr I: .I VVI11, IYryll GENERAL LIABILITY I. 7ltrrydl„I"';f:;l 1 1 u1V V.......1..M I'Y'd _. ...,_ .I�. _ .......... DOES NOT APPLY mm' I k "dRl: ".,I\ 1,r III I\.rcl l o'd I"'A II 1 1 141, FIJI l; 'v II II",I, IJI''f 71'�,4„f' ..... Y .... __.�...... ,',„u 1YI1n x111.11 VL'V',ill tll'r' of I, V,'sll"I�,ru lu!rnl ,11�uivi I III'I IIS, k'4, IYHO, u l '', 1 VII"Y��I,II I✓111'V''I Wim. ..II,.I I..., II.! ...... .����� l DOES NOT APPLY II II111 rf�IC,,;J1 rr Iouu r r I'�II I it 11 L' ' /\II'I'I,?'„t "v ti� Y 1 ........... .. ,.,.,... , ........... ...,. �UMBREL EXCESS LA LIAB LIAB �I,I,a'.II\al arc;,l'.;II. DOES NOT APPLY AGGREGATE �DED �RI: 'fl1:I`ll1DI"1!1 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECITIVE DIFFICOMEMBER I:.XCLUDED? NIA DOES NOT APPLY r. I. ul r.�wr_ cR (Mai idatary in NH) I 4, EMPLOYEE II Vas, deS XOP_ unuer DE;:iC;RIP rIC71U OF q ”' ITIT OPERA[IUNSbelow Y',,:I.. IYIV',ril':.,I!+;.i'; V'"I,!IIV,'' Al n I n„I,jI41 t ,rl,', DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACCORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION r:Hi 1[ 11,1) �,F YIff ;,%R,A1! I11 r'IPIIMI (:IIS I'„ I 'IIIC;"Ill1) 1111 0H IC I"'I%!1111^RI"II,)11 U'I II AUTHORIZED REPRESENTATIVE ACORD 25 (2010105) ©1998-2010 ACORD CORPORATION. Allfights 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: U 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. (_) 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 # ZI 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 immediately comply with those provisions o agreement will automatically become void. Signature of Applicant A&K"� Date Print Name Agreement for: JVVA- Vl ,�Y m.1471rll-,S , l K.c. — Aror4 t,—a" Dated: Reviewed by:�