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PROOF OF INSURANCE (2023 - 2023) CLOSED/1119-"it" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDn'YYY) 11 /25/2022 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 Halidee Callejas NAME: MOC Insurance Services PHONE (415) 957-0600 FAAJXNo), License No. 0589960 E-MAIL hcallejas@mocins.com ADDRESS: 101 Montgomery St., Ste, 800 INSURER(S) AFFORDING COVERAGE NAIC # San Francisco CA 94104 INSURERA: Massachusetts Bay Insurance 22306 INSURED INSURER B : Allmerica Financial Benefit 41840 Keyser Marston Associates, Inc. INSURER C : Hanover Insurance Company 22292 1299 4th Sreet Suite 408 INSURER D : INSURER E : San Rafael CA 94901 1INSURER F : COVERAGES CERTIFICATE NUMBER: 2022-2023 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 MAYBE 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 IN WVD POLICY NUMBER POLICY E F MMIDD/YYYY. M MMIDDM(YY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE x OCCUR PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 A Y ZDFA49104908 12/01/2022 12/01/2023 GEN'LAGGREGATE LIMITAPPLIES PER PRO POLICY IRON LOC GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ Included OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS Y AWFA490049 12/01/2022 12/01/2023 BODILY INJURY (Per accident) $ +X HIRED HxNON-OWNED ONLY AUTOS ONLY PROPERTY DAMA "EAUTOS PeraccidenlXColl Uninsured Motorist $ 1,000,000 $500 Comp $1,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4,000,000 C EXCESS LIAB CLAIMS -MADE Y UHFA49117108 12/01/2022 12/01/2023 AGGREGATE $ 4,000,000 DED I X RETENTIION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER EL EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under .DESCRIPTION OF OPERATION&belt:: E,L DISEAS PC'LICY LIMIT S C Pr ofessional Liability Retention $25,000 LHFD42616505 12/01/2022 12/01/2023 Each Wrongful Act Aggregate Limit $t,000,000 $2,000,000 Retro Date: 11/11/1976 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 officers, officials and employees are Additional Insured as respects their interest appears per written contract. Insurance is primary and non-contributory. 30 day notice of cancellation/10 day for non-payment of premium. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE ElSegundo CA 90245-3813 I�w ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: C R" ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED MOC Insurance Services Keyser Marston Associates, Inc. POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance: Notes EXCESS PROFESSIONAL LIABILITY COVERAGE POLICY NUMBER: MPX3021922 POLICY TERM: 12/1/2022 - 12/1/2023 CARRIER: AMBRIDGE GLOBAL SPECIALTY USA AM BEST RATING: A XV LIMITS: $1,000,000 PER CLAIM $1,000,000 PER AGGREGATE RETROACTIVE DATE: 12/1/2020 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: ZDFA49104908 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) or Organizations : Location(s) of Covered Operations ............................. The City of El Segundo, its officers, officials and employees It is understood and agreed that this insurance is primary, and any other insurance maintained by the Additional Insured shall be excess only and not contributing with this insurance in regards to all operations as pertains to the named insured. Information ie wired to com letewthis Schedule, if not shown above, will be shown in the Declarations, A. Section II — Who Is An Insured is amended to B 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(s) desig- nated above. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment 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 in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 20 10 07 04 C ISO Properties, Inc., 2004 Page 1 of 1 Keyser Marston Associates, Inc Policy No® AWFA490049 BUSINESS AUTO COVERAGE FOR Various provisions in this policy restrict coverage. Read the entire policy carefully to determine rights, duties and what is and is not covered. Throughout this policy the words "you" and "your" refer to the Named Insured shown in the Declarations. The words "we", "us" and "our" refer to the Company pro- viding this insurance. Other words and phrases that appear in quotation marks have special meaning. Refer to Section V — Definitions. COMMERCIAL AUTO CA 00 01 03 06 SECTION I — COVERED AUTOS Item Two of the Declarations shows the "autos" that are covered "autos" for each of your coverages. The following numerical symbols describe the "autos" that may be covered "autos". The symbols entered next to a coverage on the Declarations designate the only "autos" that are covered "autos". A. Description Of Covered Auto Designation Symbols Symbol Description Of Covered Auto Designation Symbols 1 An "Auto" 2 Owned "Autos" Only those "autos" you own (and for Liability Coverage any "trailers" you don't own Only while attached to power units you own). This includes those "autos" you acquire ownership of after the policy begins. 3 Owned Private Only the private passenger "autos" you own. This includes those private passenger Passenger "autos" you acquire ownership of after the policy begins. "Autos" Only 4 Owned "Autos" Only those "autos" you own that are not of the private passenger type (and for Li - Other Than Pri- ability Coverage any "trailers" you don't own while attached to power units you vate Passenger own). This includes those "autos" not of the private passenger type you acquire "Autos" Only ownership of after the policy begins. 5 Owned "Autos" Only those "autos" you own that are required to have No -Fault benefits in the state Subject To No- where they are licensed or principally garaged. This includes those "autos" you ac- Fault quire ownership of after the policy begins provided they are required to have No - Fault benefits in the state where they are licensed or principally garaged. 6 Owned "Autos" Only those "autos" you own that because of the law in the state where they are li- Subject To A censed or principally garaged are required to have and cannot reject Uninsured Compulsory Un- Motorists Coverage. This includes those "autos" you acquire ownership of after the insured Motor- policy begins provided they are subject to the same state uninsured motorists re- ists Law guirement. 7 Specifically De- Only those "autos" described in Item Three of the Declarations for which a pre- scribed "Autos" mium charge is shown (and for Liability Coverage any "trailers" you don't own while attached to any power unit described in Item Three). 8 Hired "Autos" Only those "autos" you lease, hire, rent or borrow. This does not include any "auto" Only you lease, hire, rent, or borrow from any of your "employees", partners (if you are a partnership), members (if you are a limited liability company) or members of their households. 9 Nonowned Only those "autos" you do not own, lease, hire, rent or borrow that are used in con - "Autos" Only nection with your business. This includes "autos" owned by your "employees", part- ners (if you are a partnership), members (if you are a limited liability company), or members of their households but only while used in your business or your personal affairs. CA 00 01 03 06 © ISO Properties, Inc., 2005 Page 1 of 12 0 19 Mobile Equip- Only those "autos" that are land vehicles and that would qualify under the definition ment Subject To of "mobile equipment" under this policy if they were not subject to a compulsory or Compulsory Or financial responsibility law or other motor vehicle insurance law where they are li- Financial Re- censed or principally garaged. sponsibility Or Other Motor Ve- hicle Insurance Law Only B. Owned Autos You Acquire After The Policy Begins 1. If Symbols 1, 2, 3, 4, 5, 6 or 19 are entered next to a coverage in Item Two of the Declara- tions, then you have coverage for "autos" that you acquire of the type described for the re- mainder of the policy period. 2. But, if Symbol 7 is entered next to a coverage in Item Two of the Declarations, an "auto" you acquire will be a covered "auto" for that cover- age only if: a. We already cover all "autos" that you own for that coverage or it replaces an "auto" you previously owned that had that cover- age; and b. You tell us within 30 days after you acquire it that you want us to cover it for that cover- age. C. Certain Trailers, Mobile Equipment And Temporary Substitute Autos If Liability Coverage is provided by this Coverage Form, the following types of vehicles are also cov- ered "autos" for Liability Coverage: 1. "Trailers" with a load capacity of 2,000 pounds or less designed primarily for travel on public roads. 2. "Mobile equipment' while being carried or towed by a covered "auto". 3. Any "auto" you do not own while used with the permission of its owner as a temporary substi- tute for a covered "auto" you own that is out of service because of its: a. Breakdown; b. Repair; c. Servicing; d. "Loss"; or e. Destruction. SECTION II — LIABILITY COVERAGE A. Coverage We will pay all sums an "insured" legally must pay as damages because of "bodily injury" or "property damage" to which this insurance applies, caused by an "accident' and resulting from the ownership, maintenance or use of a covered "auto". We will also pay all sums an "insured" legally must pay as a "covered pollution cost or expense" to which this insurance applies, caused by an "acci- dent' and resulting from the ownership, mainte- nance or use of covered "autos". However, we will only pay for the "covered pollution cost or ex- pense" if there is either "bodily injury" or "property damage" to which this insurance applies that is caused by the same "accident". We have the right and duty to defend any "insured" against a "suit' asking for such damages or a "covered pollution cost or expense". However, we have no duty to defend any "insured" against a "suit" seeking damages for "bodily injury" or "prop- erty damage" or a "covered pollution cost or ex- pense" to which this insurance does not apply. We may investigate and settle any claim or "suit' as we consider appropriate. Our duty to defend or settle ends when the Liability Coverage Limit of Insur- ance has been exhausted by payment of judg- ments or settlements, 1. Who Is An Insured The following are "insureds": a. You for any covered "auto". b. Anyone else while using with your permis- sion a covered "auto" you own, hire or bor- row except: (1) The owner or anyone else from whom you hire or borrow a covered "auto". This exception does not apply if the covered "auto" is a "trailer" connected to a cov- ered "auto" you own. Page 2 of 12 © ISO Properties, Inc., 2005 CA 00 01 03 06 0 (2) Your "employee" if the covered "auto" is owned by that "employee" or a member of his or her household. (3) Someone using a covered "auto" while he or she is working in a business of selling, servicing, repairing, parking or storing "autos" unless that business is yours. (4) Anyone other than your "employees", partners (if you are a partnership), members (if you are a limited liability company), or a lessee or borrower or any of their "employees", while moving property to or from a covered "auto". (5) A partner (if you are a partnership), or a member (if you are a limited liability company) for a covered "auto" owned by him or her or a member of his or her household. c. Anyone liable for the conduct of an "in- sured" described above but only to the ex- tent of that liability. 2. Coverage Extensions a. Supplementary Payments We will pay for the "insured": (1) All expenses we incur. (2) Up to $2,000 for cost of bail bonds (in- cluding bonds for related traffic law vio- lations) required because of an "acci- dent" we cover. We do not have to fur- nish these bonds. (3) The cost of bonds to release attach- ments in any "suit" against the "insured" we defend, but only for bond amounts within our Limit of Insurance. (4) All reasonable expenses incurred by the "insured" at`our request, including actual loss of earnings up to $250 a day be- cause of time off from work. (5) All costs taxed against the "insured" in any "suit" against the "insured" we de- fend. (6) All interest on the full amount of any judgment that accrues after entry of the judgment in any "suit" against the "in- sured" we defend, but our duty to pay in- terest ends when we have paid, offered to pay or deposited in court the part of the judgment that is within our Limit of Insurance. These payments will not reduce the Limit of Insurance. b. Out -Of -State Coverage Extensions While a covered "auto" is away from the state where it is licensed we will: (1) Increase the Limit of Insurance for Li- ability Coverage to meet the limits speci- fied by a compulsory or financial re- sponsibility law of the jurisdiction where the covered "auto" is being used. This extension does not apply to the limit or limits specified by any law governing motor carriers of passengers or prop- erty. (2) Provide the minimum amounts and types of other coverages, such as no- fault, required of out-of-state vehicles by the jurisdiction where the covered "auto" is being used. We will not pay anyone more than once for the same elements of loss because of these extensions. B. Exclusions This insurance does not apply to any of the follow- ing: 1. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the "in- sured". 2. Contractual Liability assumed under any contract or agree- ment. But this exclusion does not apply to liability for damages: a. Assumed in a contract or agreement that is an "insured contract" provided the "bodily in- jury" or "property damage" occurs subse- quent to the execution of the contract or agreement; or b. That the "insured" would have in the ab- sence of the contract or agreement. 3. Workers' Compensation Any obligation for which the "insured" or the "insured's" insurer may be held liable under any workers' compensation, disability benefits or unemployment compensation law or any similar law. 4. Employee Indemnification And Employer's Liability "Bodily injury" to: a. An "employee" of the "insured" arising out of and in the course of: (1) Employment by the "insured"; or CA 00 01 03 06 © ISO Properties, Inc., 2005 Page 3 of 12 0 .0 Q CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) ....._ OF THIS F CERTIFICATE TE DOES NOT AFFIRMATIVELY ISSUED TTER INFORMATION VELY AMEND, EXTEND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN C THE ISSUING I SUR R(S), AUTHORIZY THE ED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the olic _•"•�•_... - p y(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 Marsh Affinity NAME Marsh Affinity a division of Marsh USA Inc. PHONE AX (AdC Na Erl);800-743-8130N PO Box 14404 Des Moines, IA 50306-9686 DDtESS: INSURER($) AFFORDING COVERAGE _ NAIC # •- - - •-••. - ."" INSURED "� "" _ .-."""" NNSURE'R A : AIU Insurance Cornpany 19399 ADP TotalSource DE IV, Inc. INS1JRER B 5800 Windward Parkway INSURER C: Alpharetta, GA 30005 INSURER D : Keyser Marston Associates, Inc. N'IV'S�URE•I E : 1299 Fourth St. Ste 408 INSURER F: San Rafael, CA 94901 ------- . __ .....�a.�.-........ _ d OVERAGES 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 CERTIFICATE MAY BE ISSUED OR MAY TO WHICH THIS 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'. '.,. .—_—_•..."......�....._- lNSR LTR TYPEOFINSURANCE ADOu sU'BR _.._. _ ..... ._....._.. ..._.._. INSD w�VO POLICY NUMBER YEFF) .... .......�..... (POLI (POLIi�P, LIMITS MM_DDNYYY 141MFODdYYYY) COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE rO REN9FD $ 6� IwIANS Ca accura"-- MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO ❑ LOC GENERAL AGGREGATE $ �. JECT PRODUCTS COMP/OP AGG $ .......... ....... --iOTHER: AUTOMOBILE LIABILITY COMBIN'Ek7 SING& E' G.gf 6GT ANY AUTO LEe ac rcN3n1 OWNED SCHEDULED BODILY INJURY (Per person) $ AUTOS ONLY AUTOS Y INJURY Y (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY _ $ pPP1rOaoYnDAEACroE UMBRELLA LIAB W OCCUR $ EACH OCCURRENCE $ EXCESSLIAB CLAIMS -MADE -"""" -- �" AGGREGATE $ DE RETENTION $ $ .... WORKERS COMPENSATION AND EMPLOYERS LIABILITY Y/N A ANVPRa� r Isa aruPARtNEREwE UIWE OIFRCERWEMBEP EXCLUDED? XI TRIAI� TE X WC 053418316 CA 07/01/2022 07/01/2023 E-L EACH ACCIDENT $ 2 000 000 IWrarrdalory In NH) _..". Y yes„ de5eri4e Gender E,L.. DISEASE- EA EMPLOYEE $ 2,000,000 DESCRIPTION N OF OPERATIONS below ......�...... ...... ..-. """""_ E.L, DISEASE - POLICY LIMIT $ 2,000,000 ( cN�ad IP p LN ) ._.... re s ace is re" All worksitelemployees wo k n0 for KEYYSERIMARSTON ASSOCIA'O �INC 9ASSOCIATES,lunder lADP , paid TOTALSOURC,E, INC s aymIf, are covered bowel SUBROGATION IN FAVOR OF CERTIFICATE HOLDER AS RESPECTS OF JOB PERFORMED BY KEYSER rl WRITT NIIV O OF MARSTON� ASSOCIATES, INC. AS REQUIV"REDItBY CERTIFICATE E HOLDER _ CANCELLATION �._ City of El Segundo Attn: Risk Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ✓o hcc ACORD 25 (20116/O8) __ _....... .. � 0 1988-2015 ACORD COIRPORATION. All rights res...... erved', The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 43 03 06 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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 work described in the Schedule. The additional premium for this endorsement shall be _% of the California workers' compensation premium otherwise due on such remuneration. Schedule WAIVER OF SUBROGATION IN FAVOR OF SAN BERNARDINO COUNTY AND ITS OFFICERS, EMPLOYEES, AGENTS, VOLUNTEERS, CONTRACTORS, AND SUBCONTRACTORS. AS RESPECTS OF JOB PERFORMED BY KEYSER MARSTON ASSOCIATES, INC. AS REQUIRED BY WRITTEN CONTRACT. Person or Organization City of El Segundo Attn: Risk Manager 350 Main Street El Segundo, CA 90245 Job Description Notes: 1. This endorsement may be used to waive the company's right of subrogation against named third parties who may be responsible for an injury.. 2. The sentence in ( ) is optional with the company. It limits the endorsement to apply to specific jobs of the insured, and only to the extent that the insured is required to obtain 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 07/01/2022 Policy No. WC 053418316 CA Endorsement No. Insured ADP TotalSource DE IV, Inc. 5800 Windward Parkway Alpharetta, GA 30005 UC/F: Keyser Marston Associates, Inc. 1299 Fourth St. Ste 408 San Rafael, CA 94901 Insurance Company AIU Insurance Company Countersigned by ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001.