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PROOF OF INSURANCE (2021 - 2021) CLOSED
® DATE (MM/DD/YYYY) AC"R" CERTIFICATE OF LIABILITY INSURANCE 6/19/2021 6/ 11 /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 Lockton Insurance Brokers, LLC CONTACT NAME: 777 S. Figueroa Street, 52nd FL PHONE FAX C1 License #0F 15767 Male Ezt : vc No Los Angeles C1 90017 ADDRESS: (213) 689-0065 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Atlantic Specialty Insurance Company 27154 INSURED Prosum, Inc. INSURER B : H1scoX Insurance Company, Inc. 10200 1302737 2201 hark Pl., Ste. 102 INSURER C : Federal Insurance Company 20281 E1 Segundo C1 90245 INSURER D : INSURER E INSURER F COVERAGES PROSU01 CERTIFICATE NUMBER: 2911178 REVISION NUMBER: XXXXXXX 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 LTR POLICY NUMBER MM DD YYYY MMDD Y YY LIMITS LT A X COMMERCIAL GENERAL LIABILITY Y N 7110082470014 6/19/2020 6/19/2021 EACH OCCURRENCE $ 1,000,000 DAMAGE TCLAIMS-MADE � OCCUR PREM SESOEa occur ENIEence $ 1. 000 000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑PRO JECT ❑ LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY N N 7110082470014 6/19/2020 6/19/2021 COMBINED SINGLE LIMIT $ Ea accident 1. 000 000 X ANY AUTO BODILY INJURY (Per person) $ XXXXXXX OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS XXXXXXX HIRED NON -OWNED PROPERTY DAMAGE $ XXXXXXX AUTOS ONLY AUTOS ONLY Per accident Comp/Coll Lied $ 1,000 A X UMBRELLA LAB X OCCUR N N 7110082470014 6/19/2020 6/19/2021 EACH OCCURRENCE $ 7,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 7,000,000 DED I I RETENTION $ $ XXXXXXX A WORKERS COMPENSATION Y 4060321310011 12/31/2020 12/31/2021 X STATUTE OERH AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑Y N/A A (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 B Ober N N MPL227318520 6/19/2020 6/19/2021 S5,000,000 Each Wrongful Act Technology Prof Liab S5,000,000 Lim/S25K Ret. C 3rd Party Crime 82429026 6/19/2020 6/19/2021 S3,000,000 Lim/SI OK Ret. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City, its officers, officials, employees, agents, and volunteers are an Additional Insured to the extent provided by the policy language or endorsement issued or approved by the insurance carrier. Waiver of Subrogation applies to the worker's compensation. 30 Lay Notice of Cancellation applies per attached endorsement. 2911178 City of El Segundo City Clerk SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:dnlllliStratiVe Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street, Room 5 ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo CA 90245 AUTHORIZED REPRE ENTA VS O 1088-2016—ACMD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Attachment Code: D452802 Certificate ID: 2911178 POLICY NUMBER: 7110082470014 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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 Name Of Additional Insured Person(s) Location(s) Of Covered Operations: Or Organ ization(s): Project #1906006 Benchmark Contractors, Inc. 3330 Ocean Park Brick & Machine Blvd. Santa Monica, CA 90405, Lot 9735, LLC, 9735 Washington Blvd, Owner's Members, Managers, Partners, Clarett Culver City, CA 90232 West Development, LLC, DLJ Real Estate Capital Partners, Any Lenders With An Interest In Project and Their Parents, Affiliates and Subsidiaries, Employees, and Agents 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work including materials parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 Attachment Code: D529981 Certificate ID: 2911178 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attached clause" need be completed only when this endorsement is issued subsequent to This endorsement, effective on12/31/2020 at 12:01 A.M. standard time, forms a part of (DATE) Policy No.4060321310011 Endorsement No. of the Atlantic Specialty Insurance Company (NAME OF INSURANCE COMPANY) issued to PROSUM, INC. Premium (if any) $ Authorized Representative 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 additional premium for this endorsement shall be 2.00 % of the California workers' compensation premium otherwise due on such remuneration. Schedule PPrsnn or nrnani7atinn Joh DPscrintinn WC 252 (04 84) Copyright 1984, OneBeacon Insurance Group LLC E-INSURED Attachment Code: D566344 Certificate ID: 2911178 POLICY CHANGE 1 Effective 6/19/2020, this endorsement forms a part of Policy No. 7110082470014 (At the time stated in the policy) issued to PROSUM, INC. (See ASC 00 11 01 98, Schedule 2) ATTN: AMIT BHATIA 2201 PARK PL STE 102 EL SEGUNDO, CA 90245-5167 Producer: LOCKTON INSURANCE BROKERS, LLC by Atlantic Specialty Insurance Company In Accordance with this Policy Change Your Premium is Revised as follows: No Change in Premium This Policy Change Amends the Following Policy Provisions: Common Policy Declarations, 4 VIL 100 10 98 Add Form(s): VIL 229 06 12 NOTICE OF CANCELLATION TO DESIGNATED CERTIFICATE HOLDER 3 5-41-0030 07/09/2019 EBC CPW PR 0.984 ASC 00 10 01 98 E-INSURED POLICY CHANGE Page 1 of 1 Attachment Code: D566344 Certificate ID: 2911178 Policy Number: 7110082470014 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Notice of Cancellation to Designated Certificate Holder A. If we cancel this policy for any reason other than nonpayment of premium, we will endeavor to provide notice of such cancellation to the certificate holder(s) at the address(s) shown in the schedule below when notice of cancellation is sent to the first Named Insured. In no event will the timing of notice to a certificate holder exceed the timing of notice to the first Named Insured. B. Our failure to provide notice of cancellation to a certificate holder scheduled below will not amend or extend the effective policy cancellation date or negate policy cancellation. Notice of cancellation is provided solely as a courtesy for the convenience of the first Named Insured and does not constitute a prerequisite to effective policy cancellation or confer any rights whatsoever on the certificate holder(s) scheduled below. SCHEDULE Name of Certificate Holder and Address CITY OF EL SEGUNDO CITY CLERK ATTN: ADMINISTRATIVE SERVICES 350 MAIN ST ROOM 5 EL SEGUNDO, CA 90245-3813 REFERENCE #2911178 RE: 30 DAY NOTICE OF CANCELLATION VIL 229 06 12 Copyright 2012, OneBeacon Insurance Group LLC Page 1 of 1 E-INSURED Attachment Code: D566104 Certificate ID: 2911178 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY NOTICE OF CANCELATION TO DESIGNATED PERSON OR ORGANIZATION Schedule Person or Organization CITY OF EL SEGUNDO CITY CLERK REFERENCE 2911178 ATTN ADMINISTRATIVE SERVICES 350 MAIN STREET, ROOM 5 EL SEGUNDO CA 90245 10 days' notice for cancelation for nonpayment of premium 30 days' notice for cancelation for any other reason The following is added to PART SIX — CONDITIONS: If we cancel this policy, we will notify the Person or Organization shown in the Schedule above the number of days shown in the Schedule before cancelation. Notice to such Person or Organization will not be earlier than to the first named insured. We will not provide notice to such Person or Organization for cancelation for nonpayment of premium if no entry for the number of days' notice appears in the Schedule above. Our failure to provide notice to such Person or Organization will not extend the policy cancelation date or negate cancelation of the policy. 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 06/25/2019 Policy No. 4060321310011 Endorsement No. 6 Insured PROSUM, INC. Premium $ Insurance Company Atlantic Specialty Insurance Company Countersigned By WC 99 06 18 B (03 16) Contains copyrighted material of NCCI, Inc., used with its permission. Page 1 of 1 Copyright 2016, OneBeacon Insurance Group LLC E-INSURED