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PROOF OF INSURANCE (2021 - 2022) CLOSED
0 DATE (MM/DDNYYY) AC40RV CERTIFICATE OF LIABILITY INSURANCE 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 �ON E (888) 202-3007 N) 2'9xt); ...C .... 520 Madison Avenue EMAIL contact@hiscox.com 32nd Floor ADDfEs. AFFOHiscox Insurance Company Inc'10 New York, NY 10022 INSURERS RDING .#. iumioGo e , ..........CO.VERAGE NAIC ..... 200 INSURED6W .e.e.m....... ..................�..�........�.....,,,,,�..,.— Urban ConsultantsInc..I,NSURER..C.� ,�De ..... .....-.m,,,....... _...._......... p alley Dr __w..._..................�..A,m. Rolling Hills Estates, CA 90274 iNsugeR D: INSURER F : ,. w..,.,..+�e. nirW^. RFVICIAN NIIMRFR• 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. _,. _ .. �.... __..............�ww ....__.... __, __ .... .... TILT R TYPE OF INSURANCE ADDL SfVD POLICY NU POLICY IEFP POLICY EXP LIMITS LTR NUMBER MMd'DDsYYYY MMIDD/YYYV. LIMITS _ X GENERAL LIABILITY EACH RE T`CE $ 000000 -COMMERCIAL OCCUREMISES CLAIMS -MADE X.... R PlEa..P.P9WQnpe .�.... , 100,000 $ 00 000 .......,.,.. ........ X ___ CGL is on BOP Form mMED EXP (Any one person �.......��......,,m,......... $ 5,000 ................. q Y Y UDC-4264569-BOP-20 09/05/2020 09/05/2021 PERSONAL & ADV INJURY $ S/T Each Occ. GEN k AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE .w..NE _. 2000,000 PHI POLICY JFCT LOC PRODUCTS - COMP/OPAGG $ S/T Gen. Agg $ 01 HER COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY . .a aIdenlB �..... ..�........... ANY AUTO BODILY INJURY (Per person) $ . OWNED SCHEDULED BODILY INJURY (Per accident) $ A AUTOS ONLY . AUTOS I NON -OWNED UDC-4264569-BOP-20 09/05/2020 09/05/2021 �"Ffi4�PERT�"�y,aMAGE $ X X AUTOS ONLY ros ONLY Au Par rosst Lk ............. _ ....._. $ UMBRELLA LIAB7_1OCCUR EACH OCCURRENCE...... $ .......... EXCESS LIAB CLAIMS -MADE '-- ..............M..., ,.._ AGGREGATE $..... DED RETENTION $ $ WORKERS COMPENSATION PER OTH- STAT4,ITE F,�,R AND Y / N ANYPROPRI TOR/PARTR/NEE/XECUTIVE E.L EACH ACCIDENT , $ m mmmmmm OFFICER/MEMBEREXCLUDED? (Mandatory in NH) N / A SEASE-EA E.L. DI EMPLOYEE $ ......... IF yes, describe under . DESCRIPTION OF OPERATIONS below E.L. 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 El 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 El Segundo, its elected or appointed officials, officers, employees, or volunteers, subject to the po licy terms and conditions. The City of El Segundo, Attn: Greg McClain, Planning Manager 350 Main St El 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 r' IJ 19BU-2015 AGURD GURPURA I IUN. All rlgnts reserves. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD VA016 H I JCO Policy Number: Named Insured: Endorsement Number: Endorsement Effective: U DC-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 FIGHTS OF RECOVERY AGAINST OTHERS TO CIS 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) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. AM H I SCOX. 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. a It El � 1, Isaallull will I This endorsement modifies insurance provided under the following BUSINESSOWNERS COVERAGE FORM SCHEDULE Additional Premium A. Hired Auto Liability 1I $175.00 B. Non -owned Auto Liability 1I $ 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 ACCO F_5;A�TE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE05/20/2021 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 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 PRODUCER CONTACT Karen Bronson NAE Cor Risk Solutions PHONE FAX wo.N°•at) ` 312-637-8755 wo.N°, 180 N Stetson Ave Suite 4500 _ Chicago, IL 60601 no Ress: kbronson@corrisks olutions.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: New Hampshire Insurance Company 23841 INSURED INSURER B: JWA Urban Consultants, Inc. INSURER C: PO Box 9493 Marina del Rey, CA 90295 INSURERD: 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 CONTRACTOR 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 LTR TYPE OF INSURANCE ADD'L INSRD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURANCE COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurance) MED EXP (Any one person) DOES NOT APPLY PERSONAL & AND INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC AUTOMOBILE LIABILITY UUMBINEU SINGLE LIMI I (Ea accident) BODILY INJURY (Per person) ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS DOES NOT APPLY BODILY INJURY (Per accident) PRUPRRI Y UAMAGE (perAIITnS accident) HIRED AUTOS NON -OWNED UMBRELLA LAB OCCUR EACH OCCURANCE AGGREGATE EXCESS LAB CLAIMS MADE DOES NOT APPLY DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC STATUS TORY LIMIT OTHER E.L. EACH ACCIDENT ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE/MEMBER EXCLUDED? Y/N (Mandatory in NH) N/A DOES NOT APPLY - EA E.L. EMPLOYEE EMPLOY EE If yes, describe under DESCRIPTION OF ❑ OPERATIONS below E.L. DISEASE -POLICY LIMIT A Professional Liability 0649095328- 03/23/21 03/23/22 Per Occurrence: $1,000,000 Annual Aggregate: $1 0 0 0 0 0 0 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACCORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE City of El Segundo THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Development Services Department AUTHORIZED REPRESENTATIVE 350 Main Street E1 Segundo, CA 90245 ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. Allrights 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 El 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 El 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 El 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 11reement will automatically become void. Signature of Applicant Date Print Name Agreement for: VVw 4 Q' "1 S, l h-.?— — Dated: q ::Aq Reviewed by: