Loading...
PROOF OF INSURANCE (2022 - 2023) CLOSEDKOSM&AS-01 BSTERNBERG `1111 " CERTIFICATE OF LIABILITY INSURANCE ' DATE(MYYY) s/2o/2022022 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 Lyddy Martin Company 5 21 Verdugo Way CONTACT Brett R Sternberg NAME: PHONE FAX (A/C, No, Ext): (310) 478-2625 317 1 (A/C, No): E-MAIL brett@lyddymartin.com Ste. 105 #414 Camarillo, CA 93012 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Sentinel Insurance Company, Ltd 11000 INSURED INSURER B : INSURER C : Kosmont & Associates, Inc. Dba: Kosmont Companies 1601 N. Sepulveda Blvd. #382 INSURER D: INSURER E: Manhattan Beach, CA 90266 INSURER F : COVERAGES CERTIFICATE NUMBER: 12 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X X 72SBABC3942 6/27/2022 6/27/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence 1,000,000 $ MED EXP (Any oneperson) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JJECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY 72SBABC3942 6/27/2022 6/27/2023 COMBINED SINGLE LIMIT Ea accident 1,000,000 $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ X PROPERTY DAMAGE Per accident) ccident $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE X X 72SBABC3942 6/27/2022 6/27/2023 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 DED I X I RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City, its officials, and employees are included as additional insured perwritten contract as respects to General Liability -the insurance is primary and noncontributory -see attached Business Liability Form CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo Planning & Building Safety Dept y g g g y P THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo 90245-3813 I I AUTHORIZED REPRESENTATIVE I 4!�� 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 rare, 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 liabil!iity 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 Custodlians 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, dl. Legal Repr6sentative If You Die Your legal representative if you die, but only with respect to duties as Such, That representative will! have all your rigt-its and duties, under this insurance. 30MM��" 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 whicl--n an insured under this insurance is also an insured under another policy or would be an insured Linder 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 quality as a Narried Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the T80th day after you acquire or form the organization or the end of the policy period, whichever is earlier; and b. Coverage under this provision does not apply to: (1) "Bodily injury" or "property damage" that occurred; or (2) ""Personal and advertising injury" an I sing out of an offense committed before you acquired or formed the organization, ff= With respect to "mobfle equipment" registered in your name under any motor vehlcle 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. "Itodily in ury" to a co-"empl�oyee"' of the J person driving the equipment; or bl"Prop!erty 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, 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-"emplioyee" 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 tfie employer of any person who is an insured Linder this provision, ;fit"holl""Iflson,($"Y"�iorl���i R dowww*ft, Woo, Form SS 00 08 04 05 Page, 11 of 24 (e) Any failure to make such y � " inspections, adjustments„ teats or ttb �� icfi ,.Ipild tt,,,r> rltffoli`iyrr° servicing as the vendor has / " /� ,`6601 )�f� .�� ". " - agreed to make or normally f ; ,;, undertakes to make in the usual course of business, in connection with the distribution or sale of the ti products; Nz Demonstration,, installation, riddIOV servicing or repair operations, #mom f tit tatf except such operations performed However, no such person or organizationis an at the vendor's premises in, additional iinsured under this provision if such connection with the sale of the person or organizations is included as arm product; additional insured by an endorsement issued O (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, partor ingredient of any additional insured coverage grants in Section other thing or substance by or for R _ Optional Additional insured Coverages, the vendor„ or a. Vendors (h) "Bodily injury"" or ""property Any persons) or organization(s) (referred to damage" arising out of the sole below as vendor), but: only avittm respect to negligence of the vendor for its "bodily injury"" or "property darnage" arising own acts or omissions or those of out of ""your products" which are distributed its employees or anyone else or sold l in i the regular course of the vendors acting acting on its behalf. However, this business and only if ' this Coverage "art does not apply to:. 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". (ri) 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, inconnection with the distribution (a) "Bodily injury"' or "'property or sale of the products. damage" for which the vendor is () This insurance does not apply to any obligated to pay darnages by insured! person or organization from reason of the assumption of horn you have acquired such products„ liability in a contract or agreerrment or any ingredient" part or container, This exclusions does not apply to entering into, accompanying or liability for damages that the containing such products, vendor wivoulld have in the absence of the contract or agreement; ta. Lessors Of Equipment (b) Any express warranty (1) Any persons or organization from unauthorized by you, vwhons you lease equipment„ but only (c) Any physical or chemical) change with respect to their liability for "bodily „� ""propedky "' in the product Trade intentionally injury", damage or ) ""personal and advertising injury" by the vendor; caused, in whole or in part, by your (dl) Repackaging, except when maintenance, operation or use of unpacked solely for the purpose of equipment ieased to you by such inspection, demonstration, testing" person or ort'anizatloni, or the substitution of parts Lander instructions from the manufacturer, and therm repackaged in the original container; Page 1,2 of 24 Form SS 00 08 0405 22M��rw. (6) When You Are Added As An Additional! Insuaredl To Other Insurance That is other insurance available to, you covering liability for darnages 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 organizafloni who is an, additional insured under thiis, 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 4isurance be primary, If other insurance is also primary, we will share with all that other insurance by the method described in c. below. (b)'PKrh6ry,-,AnJ,& Non-Cotitributory, To 'Othor, 1nisuronce When R6qtArI SyC6rttradt If Vou, have aigrood in a written C o'tr6,r j n 't, wriae-n, agiraernotit , or ,permit, thatthis insurance', Is primary, and nori4contributor y, with (he additional insuried's own !insurance, this Insur6nee Is primary 4nd', we w1it snot seek whotribution 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 wwilli be entitled to the insured's rights against all!, those other insurers, 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 Linder all that other insurance, We wilt share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance prculsion and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. 3MLMZ�* M! Form SS 00 08 04 05 Pagie 17 of 24 AC R" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 6i3i2021 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: Rick Powell Rick Powell Insurance Agency, LLCPHONE ,A/C, No, Ext : 818 861-7440 (A/CNo) (760) 804-9710 ADDRESS: rick@insurance4ca.com 3500 West Olive Ave. Suite 300 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : HISCOX INS CO INC 10200 Burbank CA 91505 INSURED INSURER B : INSURER C : Kosmont & Associates, Inc. dba Kosmont Companies INSURER D : 1601 N Sepulveda Blvd #382 INSURER E : INSURER F : Manhattan Beach CA 90266 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ETT- CLAIMS-MADE ❑ OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 11F<U11EF< I Y DAMAGE$ (Per accident) UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ ORKERS COMPENSATION ND EMPLOYERS' LIABILITY Y / N - STATUTE I ER E.L. EACH ACCIDENT $ NY PROPRIETOR/PARTNER/EXECUTIVE FFICER/MEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYEE $ Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ Per Claim $2,000,000 A Errors and Omissions y MPL1425837.21 03/15/2021 03/15/2022 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo Planning & Building Safety Dept ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo CA 90245 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 'a [ DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE Acct#: 1171322 10/01 /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 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 Companies, LLC PHONE ETM .1t➢: X, N.. CONTACT 3657 Briarpark Dr., Suite 700 888 826 8365 E-MAIL Houston, TX 77042 ADDRESS INSURED KOSMONT & ASSOCIATES, INC. 1230 ROSECRANS AVE STE 630 MANHATTAN BEACH, CA 90266-2499 INSURER B : INSURER D INSURER E : INSURER F : -- -INSURER(S)AFFORDING COVERAGE ------------------------------- Ace ... American Insurance Co. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: NAIC # 22667 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'St1BR ,..... POLICY FFF POLICY EXP...... G I --- -......... --- ---......... LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY CO EACH $ _ �......�... �OCCURRENCE CJFINIA �...t� r��ivw�, CLAIMS MADE OCCUR PREM!SES (Ea occyr„renre) '......,,,� one person) � ............... J PERSONAL L & ADV INJURY -.$ ................-.. $ GEy ER: GENERAL AGGREGATE $ POGCYEGATEPLEIMOITTAPPLIESPOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY K"OMBINED'SN LE LIMIT EP 0-A01114-------------- ____.-------- .._______. $ ANY AUTO BODILY INJURY (Per person) $ .�_ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED IHOPERTYOAMAGE ''.., $ .. HIRED AUTOS ........'. AUTOS (Per au rpT(rut), , ,.. ., $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR MS MADE AGGREG ATE........... ....... DED RETENTION $ .........$ .................. $ WORKERS COMPENSATION PER OTH X I $TATIJTE ER AND EMPLOYERS' LIABILITY N YIN ,,, „ ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? �' N/A X C70055077 10/01/2021 10/01/2022 ,,,a .,°-�— (Mandatory in NH) E L DISEASE EA EMPLOYE $ 1 000-000 If yes, describe under ............... ...:.,.. ... , ..: ........ ,,,,, ...,........,,... DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 9 000,000 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 CITY OF EL SEGUNDO ATTENTION: GREGG MCCLAIN, PLANNING MANAGER 350 MAIN STREET EL SEGUNDO, CA 90245 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. AUTHORIZED REPRESENTATIVE 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. Policy Number 19001 Crescent Springs Drive Symbol: RWC Number: C70055077 Kingwood, TX 77339 Policy Period Effective Date of Endorsement 10/01 /2021 TO 10/01 /2022 10/01 /2021 Issued By (Name of Insurance Company) Ace American Insurance Co. Insert the poky number, The remainder of the information is to be completed onI when this endorsement is issued subsequent to the preparafion of the policy. 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 El 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 �a u'tfionze epresen a ive WC 99 03 22 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 F(7 Number Policy Period Effective Date of Endorsement _ITITIT� 77 10/01/2021 TOm1m0/01/2022___ �_ 10/01/2021 Issued By (Name of Insurance Company) Ace American Insurance Co. V erY 1k e f aticy n' un ber. The remainder of the information is to be co -� pld4sd�rtanl� when this, endorsement is uvSapeCd sarbsaq.u¢snq to the prwpis�aCion zaR�. 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-Ma it Address Physical.Address C ITY OFWWEL SEGUNDO 355Main street Et 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