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PROOF OF INSURANCE (2021 - 2021) CLOSEDKOSM&AS-01 BSTE'R'NRE RG CERTIFICATE OF LIABILITY INSURANCE DATE10/1/(11/20YYYY)20 . 0 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 License # OC36891 NRaAlw'"cT...Brett R Sternberg t.PHONE n,,,,,,, yy Martin Company FAX 6 2� erduggo' Way (A+ N�, EXb tt 0I dd marti .0 (AIC. Nv(: mmmmmmm Ste. 105 #414 P y illo8 'Ss. y 7> ymair 31, om 7 Camarillo, CA 93012 . ---...............................m,mWnl,�pRE:R! IAFFORDING COVERAGE ................_...,.,.,,,,,,, NALC p.................... INSURER A Sentinel Insurance Como.arlyA t t'd'' 110.00 INSURED. INSURER.B : ...................... .... ............................. Kosmont & Associates, Inc. INSURER.0 : Dba: Kosmont Companies 1601 N. Sepulveda Blvd. #382 INSURER D Manhattan Beach, CA 90266 INSURER_ INSURER F: COVERAGES CERTIFICATE NUMBER.: 24 R'EV'ISION NU'M'BER: _............. 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 ADDL ER IA X COMMETYPE RCIAL-TROG ..........................1�.S.R.�'.�d POLICY EFF POLICYEXPt LIMITS INSURANCE I n POLICY NUMB IMM/DDlYYYYr--lMMlDO,l7YYY 1,000,000 RAL CLAIMS -MADE X IoccuR X X 72SBABC3942 6/27/2020 6/27/2021DAMAGE TO RENTED ny 1,000,000 10,000 -- ....................... I L. MEP, EXP(Any one PersonaPERSONAL ...$........ ................... 1,000,000 GEN "L AGGRE GENERAL GGREGA P AGGADV I NJ URY $, 2,000,000 X POLICY 2,000 00 _ J LIMIT APPLIES PER. GENERAL AGGREGATE $ 0 .d�,AT;pE L PET .............. LOC S, OTHER $ _.'L'I.............. A Nen SINGLE � �LIMN i 1,000,000 AUTOMOB ILE LIABILITY ,(�,a eccudendW S (Fa ac .- .. �... ANY AUTO 72SBABC3942 6/27/2020 6/27/2021 BODILY INJURY ,(Pe„r oe„r„san,,,,,,,,,,, S OWNED AIUTOS ONLY SCHEDULED AUTOS „BODILY INJURY (Peraccident) „ 5,,,,,,,,,,,, _ X A1. �S ONLY . X '�r, C� AUIX 1�i CJI r''I Pyr "c: gtgllA A�GE ........$ p$ ........... A X UMBRELLA LIAB 4 X OCCUR 'I EACH OCCURRENCE$ 3,000,00 1. 0 EXCESS V X X CLAIMS-MADE10,0 72SBABC3942 6/27/2020 612712021 AGGREG „ _3 � ATE ....... 3 0000 DED X A RETENTION $ 0 0� $ COMPENSATION WORKERS OTH^ STq TUTS I � ER AND EMPLOY ERS' LIABILITY M,P_N AANN, PROPRIETOR/PARTNER/EXECUTIVE In CH,ACCIDENT $ NIA NH) EXCLUDEDv � .2Z.11teidmt E,L....DIS.E;ASE..-,EA,EMPLOYEE $_ If yes, describe under DESCRIPTION OF OPERATIONS below L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS P VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached It more space is required The l City, its off'icial's„ and employees are Included as additional insured per written contract as respects to Genera' Liability -the insurance is primary and non-contributory - see attached Business Liability Form CERTIFICATE,, HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Segundo Planning 8 Building Safe Det THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 9 9 tY P ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo 90245-3813 .-•• m.... AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD (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 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. 5. 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 carry 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. '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. Additional Insureds When Required By WrHten. 'Contract, Written Agreement Or Permit The person(s) or • organization(s)Identified in Paragraphs a. through f. below are, additional insureds when you have agreed; in a written Form SS 00 08 04 05 Page 11 of 24 BUSINESS LIABILITY COVERAGE FORM ,contract. writtenagreement, or because of a (e) Any failure to make such permit "Issued' by a state or political inspections, adjustments, tests or subdivision.- that such person or organization servicing as the vendor has be added as an additional' insured on your agreed to make or normally policy; provided the injuryor damage occurs undertakes to make in the usual subsequent to the execution of the contract or course of business, in connection agreement, or the issuance of the permit. with the distribution or sale of the A person or ' organization is an additional products; insured' under this provision only for that (f) Demonstration, installation, period. of time required by the contract, servicing or repair operations, agreement or permit. except such operations performed However, no such person or organization is an at the vendor's premises inconnection additional insured under this provision if such with the sale of the person or organization is included as an product additional insured by an endorsement issued (g) Products which, after distribution by us and made a part of this Coverage Part, or sale by you, have been labeled including all persons or organizations added or relabeled or used as a as additional insureds under the specific container, part or ingredient of any additional insured coverage grants in Section other thing or substance by or for F. — Optional Additional Insured Coverages. the vendor; or a. Vendors (h) "Bodily injury" or "property Any person(s) or organization(s) (referred to damage" arising out of the sole Wow as vendor), but only with respect to negligence of the vendor for itsown "bodily injury" or "property damage" arising acts or omissions or those of out of "your products" which are distributed its employees or anyone else acting on its behalf. However, this ev or sold in the regular course of the vendor's exclusion does not apply business and only if this Coverage Part provides coverage for "bodily injury" or (i) The exceptions contained in "property damage" included within the Subparagraphs (d) or (f); or "products -completed operations hazard". (ii) Such inspections, adjustments, (1) The insurance afforded to the vendor tests or servicing as the vendor is subject to the following additional has agreed to make or normally exclusions: undertakes to make in the usual This insurance does not apply to: course of business, in connection with the distribution (a) "Bodily injury" or "property or sale of the products. damage" for which the vendor is (2) This insurance does not apply to any obligated to pay damages by insured person or organization from reason of the assumption of whom you have acquired such products, liability in a contract or agreement. or any ingredient, part or container, This exclusion does not apply to entering into, accompanying or liability for damages that the containing such products. vendor would have in the absence of the contract or agreement; b. Lessors Of Equipment (b) Any express warranty (1) Any person or organization from unauthorized by you; whom you lease equipment; but only with respect to their liability for "bodily (c) Any physical or chemical change injury", "property damage" or in the product made intentionally "personal and advertising injury" by the vendor; caused, in whole or in part, by your (d) Repackaging, except when maintenance, operation or use of unpacked solely for the purpose of equipment leased to you by such inspection, demonstration, testing, person or organization. or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; Page 12 of 24 Form SS 00 08 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 insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. 8. 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: Waiver Of Rights Of Recovery (Waiver Of Subrogation) If the insured has waived any rights of recovery against any person or or�,eur�iiw�ation".ftrtr ell poi' �i e�''^u^yment, including Supplementary Payments, we have made under this Coverage Part, we also waive that right, provided the insured waived their rights of recovery against such person or organization in a contract, agreement or permit that was executed prior to the injury or damage. Form SS 00 08 04 05 Page 17 of 24 `1 CERTIFICATE OF LIABILITY INSURANCE DATE 1 03//18/218/2022D0 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 k.. ..... ME: Rick Powell Rick Powell Insurance Agency, Llc PHONE 818 861-7440 FAX 760 804-9710 I=, No, E.,y ( ) (AIC, No): ( ) EMAIL rick@insurance4ca.com 3500 West Olive Ave, Suite 300 ADDRESS; ._ Burbank, CA 91505 INSURER(S) AFFORDING COVERAGE NAIC # Phone (818) 861-7440 Fax (760) 604-9710 INSURER A: HISCOX INSURANCE COMPANY INC. 10200 INSURED INSURER B Kosmont & Associates, Inc, dba Kosmont Companies INSURER C: 1601 N Sepulveda Blvd #382 INSURER D: INSURER E: Manhattan BeachCA 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 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. ADDLSUBR WSR 11 P!!, OF I. 1,71.. ......, INSURANCE N)'gSR.!W,!yD .... V u„V,n':',"'u „G 1, MBER POLICY E�F POLI LIMITS XP !16Md«t!'D9�..._ J, hutNtidtl,pd`M"�'YY) .,, . _ -- — - 4uuNwll PCIALGENEF!,0IIIlrhfl ll'I"V^ EACH OCCURRENCE $ II II P u, Ud:JMS^MADE P Of:)d',Y, U DAMAGE TO RENTED PREMISES (Ea occurrence) $ ❑ MED EXP (Any one person) $ El PERSONAL 8, AOV IN.JU„ Y„ „ S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S ❑ POLICY ❑ I17PCOl ❑ LOC PRODUCTS - COMPIOP AGG S ❑ OTHER S LI MIT AUTOMOBILE LIABILITY cO aacrlIont)SINGLE 5....,,,,.... _ . ❑ ANY AUTO BODILY INJURY (Per person) $ ❑ALL OWNED SCHEDULED ❑ BODILY INJURY (Per accident) $ AUTOS AUTOS El HIRED AUTOS ❑ NON -OWNED PROPERTY DAMAGE $ a"!dent) AUTOSQPoa ❑ ❑ $ I❑ UMBRELLA LIAB -]OCCUR EACH OCCURRENCE S EXCESS LIAB AW CL S-MAOE AGGREGATE S r❑ _ _ .. . DED ❑ RETENTION$ $ WORKERS COMPENSATION PER H_ ❑ STATUTE ❑ ER AND EMPLOYERS' LIABILITY Y I N ANY PROF111E'10RlPAR7N'ERIEXECUTIVE S CEA .S ... . . M, FOC1.IRIMEIMBER EXCLUDED? NIA (M'a'ndatory in NH) E.L DISEASE EMP1 LOYEE If yes, describe under E.L. DISEASE- POLICY LIMIT $ 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, it 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 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE - erved. ©1988-2014 ACORD CORPORATION. All rights res ACORD 25 (2014101) QF The ACORD name and logo are registered marks of ACORD DATE (MM/DD/YYYY) AC"RLY CERTIFICATE OF LIABILITY INSURANCE Acct#: 1171322 I 10/01/2020 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 NAME, Lockton Companies, LLC PHONE FAX 3657 Briarpark Dr., Suite 700 No,_6xt), 888-828 -8365 (MC No): Houston, TX 77042 ik,DPRESS; INSURED KOSMONT & ASSOCIATES, INC. 1230 ROSECRANS AVE STE 630 MANHATTAN BEACH, CA 90266-2499 INSURER(S) AFFORDING COVERAGE INSURER A: Ace American Insurance Co. INSURER B: INSURER INSURER D: INSURER E a INSURER F: NAIC If 22667 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. ILTR Nin isuBR' POLICY EFF � TYPE OF INSURANCE �WYJ j WVD POLICY NUMBER tMDDI"YYYY1 (�MJDOrYYYP LIMITS COMMERCIALAL LIABILITY CLAIMS -MADE OCCUR oNTED PREMISES nc�:) i,�„ MED EXP (Any one person) $ PERSONAL & ADV INJURY IE GEAGGREGATE„ N'L AGGREGATE LIM17 APPLIES PER: GENERAL u PRO, ❑ POLICY�I JEC,1 LOC I LJ I P AG PRODUCTS - COMP OG I $ OTHER $ AUTOMOBILE LIABILITY '', COMBINED SINGLE LIMBI (Ea accident) $ ANY AUTO BODILY INJURY person) $ ALL OWNED SCHEDULED (Per BODILY INJURY Per accident)$ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (F cu rlccodent) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE IG EXCESS LI AB CLAIMS -MADE, AGGREGATE $ DED RETENTION $ �� $ RKERS COMPENSATION PER OTH- X STATUTE ER EMPPROLOYERS'LIABILITY AND EMPLOYERS' LIABILITY /' N�� ANDD /EXECUTIVE ”" �Y ELI EACH ACCIDENT $ 1,000A00 A N / A OFFICER/MEMBER EXCLUDED? X 068709179 10/01/2020 10/01/2021 ....... (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 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 ©1988-2014 ACORD CORPORATION. All rights 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. L/C/F KOSMONT & ASSOCIATES, INC, 19001 Crescent Springs Drive Kingwood, TX 77339 Policy Symbol Policy Number Policy Period Effective Date of Endorsement ma........ C687Q91.7Q 10/01•/2020 TO 10/01/2021 1„0/0,1/2020 Issued By (Name of Insurance Company) Ace American Insurance Co. ................. Vnaseit'Itre polir„y nuonherThr remainder of the infcrmation is to ttm comphAed only M^aPwean twu5, endorsemeN is issued nutrseyuentl to Ole prepzm3tuon 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 shall 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. ................. SCHEDULE Name of Certificate Holder E -Mail Address Physical Address CCF' 6F EL. SEGUND6 350 Main Street EI Segundo, CA 90245 All other terms and conditions of the Policy remain unchanged Authorized Representative Acct#: 1171322 ALL -32688 (01/11) Page 1 of 1 Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number Insperity, Inc. L/C/F KOSMONT & ASSOCIATES, INC Policy Number 19001 Crescent Springs Drive Symbol: RWC Number: C68709179 Kingwood, TX 77339 Policy Period Effective Date of Endorsement 10/01/2020 TO 10/01/2021 10/01/2020 Issued By (Name of Insurance Company) Ace American Insurance Co. Insert the poky number The remainder of the information is to be completed oniv when this endorsement is issued subsequent to the preparation of the polmy 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 ( 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 WC 99 03 22