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PROOF OF INSURANCE (2021 - 2021) CLOSED(MWDDNYYY A,CC' CERTIFICATE OF LIABILITY INSURANCE ' DATE 9/24/2020 ) 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 1 NAMEACt Dealey, Renton & AssociatesPHONE FAX 790 E Colorado Blvd #460 P_ Ngo 510-465-3090 I (Arc. New Pasadena, CA 91101 RDDRESS: Certificates(Dealevrenton.com INSURER(S) AFFORD License #0020739 AFFORDING COVERAGE � NAICM INSURER A: XL Specialty Insurance Co. 37885 INSURED KOACORPOR INSURERS: Travelers Property Casualty Company of America 25674 INUA Corporation 1'100 Corporate Center Drive #201 Monterey Park, CA 91754 (323) 260-4703 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:191870568 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. 'LTR TYPE OF INSURANCE AODL SUBR POLICY EFF POLICY EXP .._ LIMITS /NSD—WVD POUgYNUMBER IM,MIODIYYYYI ( ryIYO'2=y_ N B X I COMMERCIAL GENERAL LIABILITY Y Y 6808H966428 3/13/2020 3/1312021 EACH OCCURRENCE $_2,000,000 17 .TAGE TO RENIIED CLAIMS -MADE 1K OCCUR PREMISES Ea oEs+. rr nr S 1,000,000 X Conbadual Uab MED EXP (Any one person) $10,000 X XCU Included I PERSONAL & ADV INJURY S 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 54,000.000 POLICY JE 7 I a " I, T LOC PRODUCTS -COMPIOPAGG S4,000,000 OTHER: S B AUTOMOBILE LIABILITY Y Y BA2A439566 3/13/2020 3113/2021 Ilia ac6donn151NGLE LIMA $1,000,000 X ANY AUTO BODILY INJURY (Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) S XHIRED NON -OWNED N PROPERTY DAMAGE $ AUTOS ONLYAUTOS ONLY deer accidenil $ B X UMBRELLA LIAR I x I OCCUR CUP6464Y033 3/13/2020 3/13/2021 EACH OCCURRENCE $ 5,000,000 EXCESS LIAR I�--j CLAIMS -MADE AGGREGATE $ 5,000,000 I X 1I _ � DED RETENTION $ n $ B WORKERS COMPENSATION Y U821-459350 9/19/2020 9/19/2021 X PER AND EMPLOYERS' UABIUTY Y / N TE ERH - - - AN''APROF'RIET'ORiPARTNERfEXECUTIVE E.L EACH ACCIDENT $1,000,000 OFFICEFUMCMBER'EXCLUDEDv NIA (Mandatory len NH) Ek DISEASE - EA EMPLOYEE $1,000,000 YFyye's. d'eacribe UndaT -"-"-""..""1 0' .SCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 1.000,000 A Professional Liability DPR9957134 3113/2020 3/13/2021 Per Claim 2,000,000 Annual Aggregate 4,000,000 Pollution Liability Included DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) AM Best's Rating on all policies above: A1XI'I or greater. Umbrella Liability policy is foil'ow-form to its underlying Policies: General Liability/Auto LiabilitylEmploy'ers Llabllity. KOA .Nob No./Name; MC06084 / EI Segundo -CM'& Insp Pavement Rehab PW20-'01-FY119/20 City of El Seundo, its offrcials, and employees are named as Additional Insured as respects General and Auto Liability as required per written contract or agreement, General Liability is Primary/Non-Contributory per policy form wording. CERT'I'FICATE HOLDER Cit++y of EI Segundo Putrlic Works Department 350 Main Street EI Segundo CA 90245 ACORD 25 (2016/03) CANCELLATION'' 30 Day Notice of 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. AU'THORQED REPRESENTAIWE 444,11-k ©1988-2015 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 68081-1966428 COMMERCIAL GENERAL LIABILITY ISSUED DATE: 9/24/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Any person or organization that you agree in a written contract to include as an additional insured on this Coverage Part for "bodily injury" or "property damage" included in the "products - completed operations hazard", provided that such contract was signed and executed by you before, and is in effect when, the bodily injury or property damage occurs. Location And Description Of Completed Operations Any project to which an applicable contract described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional in- sured and included in the "products -completed opera- tions hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER 6806H966428 COMMERCIAL GENERAL LIABILITY ISSUED DATE: 9/24/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Names of Additional Insured Person(s) or Organization(s): Any person or organization that you agree in a written contract, on this Coverage Part, provided that such written contract was signed and executed by you before, and is in effect when the "bodily injury" or "property damage" occurs or the "personal injury" or "advertising injury" offense is committed. Location of Covered Operations: Any project to which an applicable written contract with the described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) A. Section II — Who Is An Insured is amended to in- This insurance does not apply to "bodily injury" or clude as an additional insured the person(s) or "property damage" occurring, or "personal injury" organization(s) shown in the Schedule, but only or "advertising injury" arising out of an offense with respect to liability for "bodily injury", "property committed, after: damage", "personal injury" or "advertising injury" 1. All work, including materials, parts or equip - caused, in whole or in part, by: ment furnished in connection with such work, 1. Your acts or omissions; or on the project (other than service, mainte- 2. The acts or omissions of those acting on your nance or repairs) to be performed by or on behalf; behalf of the additional insured(s) at the loca- tion of the covered operations has been com- in the performance of your ongoing operations for pleted; or the additional insured(s) at the location(s) desig- nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in - B. With respect to the insurance afforded to these tended use by any person or organization additional insureds, the following additional exclu- other than another contractor or subcontrac- sions apply: for engaged in performing operations for a principal as a part of the same project. CG D3 6103 05 Copyright 2005 The St. Paul Travelers Companies, Inc. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. NAMED INSURED: KOA Corporation COMMERCIAL GENERAL LIABILITY COVERAGE ADDITIONAL COVERAGES BY WRITTEN CONTRACT OR AGREEMENT This is a summary of the coverages provided under the following forms (complete forms available): Excerpt from COMMERCIAL GENERAL LIABILITY COVERAGE (FORM #CG T1 00 02 19) SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS 4. OTHER INSURANCE - d. PRIMARY AND NON-CONTRIBUTORY INSURANCE IF REQUIRED BY WRITTEN CONTRACT. - If you specifically agree in a written contract or agreement that the insurance afforded to an insured under this Coverage Part must apply on a primary basis, or a primary and non-contributory basis, this insurance isry to other insurance that is available to such insured which covers such Insured as a named In= and we will not share with, that other insurance, provided that: (I) The "bodily injury" or "property damage" for which coverage is sought occurs; and The "personal and advertising injury" for which coverage is sought is caused by an offense that is committed; subsequent to the signing of that contract or agreement by you. Excerpt from XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS AND SURVEYORS (FORM #CG D3 79 02 19) PROVISION M. - BLANKET WAIVER OF SUBROGATION - WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT: If the insured has agreed in written contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of. a. "Bodily injury" or "'property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the signing of that contract or agreement. Page 1 POLICY NUMBER: BA2A439568 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • A Z44 11FA I I INRE a FA -.1 A, 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 modi- fied 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 pro- vided in the Coverage Form. SCHEDULE Name Of Person(s) Or Organ ization(s): ANY PERSON OR ORGANIZATION THAT YOU ARE REQUIRED TO INCLUDE AS ADDITIONAL INSURED ON THE COVERAGE FORM IN A WRITTEN CONTRACT OR AGREEMENT THAT IS SIGNED AND EXECUTED BY YOU BEFORE THE BODILY INJURY OR PROPERTY DAMAGE OCCURS AND THAT IS IN EFFECT DURING THE POLICY PERIOD. 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 provi- sion contained in Paragraph A.I. of Section 11 — Cov- ered 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 0 Insurance Services Office, Inc., 2011 Page 1 of 1 Policy No. BA2A439568 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PRIMARY AND NON -CONTRIBUTORY WITH OTHER INSURANCE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM PROVISIONS 1. The following is added to Paragraph A.1.c., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: This includes any person or organization who you are required under a written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to name as an additional insured for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured". 2. The following is added to Paragraph B.5., Other Insurance of SECTION IV — BUSINESS AUTO CONDITIONS: Regardless of the provisions of paragraph a. and paragraph d. of this part 5. Other Insurance, this insurance is primary to and non-contributory with applicable other insurance under which an additional insured person or organization is the first named insured when the written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, requires this insurance to be primary and non-contributory. CA T4 74 02 16 © 2016 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy # BA2A439568 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following replaces Paragraph A.S., Transfer of required of you by a written contract executed Rights Of Recovery Against Others To Us, of the prior to any "accident" or "loss", provided that the CONDITIONS Section: "accident" or "loss" arises out of the operations S. Transfer Of Rights Of Recovery Against Oth- contemplated by such contract. The waiver ap,- ers To Us plies only to the person or organization desigi- We waive any right of recovery we may have nated in such contract. against any person or organization to the extent CA T3 40 02 15 0 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of I Includes copyrighted material of Insurance Services Office, Inc. with its permission. Aftk WORKERS COMPENSATION TRAVELERS J AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 99 03 76 ( A) - 001 POLICY NUMBER: UB -2L459350-19-47-0 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be 2.00 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR ALL LOCATIONS WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. 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 Policy No. Endorsement No. Insured Premium Insurance Company Countersigned by ST ASSIGN: Page 1 of i