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PROOF OF INSURANCE (2023) CLOSED0 DATE (MMIDDIYYYY) AC6REP CERTIFICATE OF LIABILITY INSURANCE 01/20/2023 �Ill 1 THIS CERTIFICATE IS ISSUED AS 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 CONW4CT Tina Cowie PHONE N,- EKt�� (714) 731-7700 (714}73i-7750 Cornerstone Specialty Insurance Services, Inc —INS qol). 14252 Culver Drive, A299 C MAIL ADDRESS, tina@cornerstonespecialty.com . . . ........ INSURERSp AFFORDING COVERAGE NAIC# Irvine CA 92604 INSURERA: Travelers Indemnity Co of Conn ........... 25682 ....... . . . . . . . . . . . . ............ . INSURED INSURER 8 : Travelers Property Casualty Co .............. 25674 — JASON ADDISON SMITH CONSULTING SERVICES, INC, . ............ INSURER C: Travelers Casualty & Surety Co ofAmerica ....... ....... 31194 DBA: JAS PACIFIC _INS.IJRER D: . .... ............ P.O..Box 2002 INSURER E: Upland CA 91786 1 N S URER F: COVERAGES CERTIFICATE NUMBER: 22/23 COVERAGES 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. TN -SR LTR .. .................... TYPE OF INSURANCE =1 INS OR ....... . . POLICY NUMBER . . . . ....... . .... P�� mr LI Yr ..LM MI A`M HAP LOY Ky P� _�DPM(YL LIMITS . ....... X� ............. __ COMMERCIAL GENERAL LIABILITY . .......... EACH OCCURRENCE s 2,000.000 —17 —1 CLAIMS -MADE FxOCCUR _EREWSES Ma UcWre-lce�, s ... 1,000,000 X� ADDITIONAL INSURED JyED I . XID (Any one person) s 5,000 A — X — -------------- - --- BLNKTWVROFSUBRO Y Y 680-1 H359042 08/08/2022 08/08/2023 PERSONAL &ADV INJURY 2,000,000 GE:N'LAGGREGATE I M11 APPLIES F'ER: GENERAL AGGREGATE s 4.000,000 POLICY X JECT __1 PRO- F-1 LOG PRODUCTS - COMP/Op AGG S 4,000.000 OTHCR . ................ . . ......... . AUTOMOBILE LIABILITY ... . . . . . . . . . ................ T,0 iEs IT aoc,dei)l�5 . . ............. - $ 1,000,000 X ANYAU10 BODIRY INJURY (P ei person)mmITITIT s A SCHEDULED Y Y BA-DS426316 08/08/2022 08/08/2023 BODILYlNJURY (Pei accident) S /0,,WN1..r.1 TGS 0NI..y HIRED AUTOS NON OWqED 7-R-5ITERTir _DAWME - --------- S AI ) ros OINI Y q ALI OS ONLY jilei acridenn ... ...... . . . . . .... s — X — ---- - UMBRELLA LLAB X ...... OCCUR .. ..... .... . . . . . ....... . . ........... ........................ . . .......... . EACH OCCURRENCE . .......... 5 5,000,000 B JEXCESS LAB CLAIMS -MADE Y Y CUP-34297370 08/08/2022 08/08/2023 .......... AGGREGATE $ 5,000,000 X DED RI ENTI s 0 S ........... WORKERS COMPENSATION . . . ........... . . ..... TH- =XITTIR I" A III.ITIT ER AND EMPLOYERS' LIABILITY YIN s 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?ILA NIA Y UB-81<37343A 08/08/2022 08/08/2023 _L- _L��tA CCIDENT ­, (Mandatory in NH) E L )iSF,.ASE.. EA EMPLOYEE 1,000,000 S . ..... If yes, describe under DESCRIPTION OF OPERATIONS below ............ E 1. DISEASE D01 ICY I MIT S 1,000 000 Each Claim $2,000,000 C Professional Liability 107296206 08/08/2022 08/08/2023 Annual Aggregate J $2,000,000 Claims Made . . ...... ----- - I . . ............ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is Additional Insured for General Liability but only if required by written contract with the Named Insured prior to an occurrence and as per attached endorsement Coverage is subject to all policy terms and conditions, *30 days notice of cancellation, except for 10 days notice for non-payment of premium For Professional Liability coverage, the aggregate limit is the total insurance available for all covered claims reported within the policy period CERTWWCATE HOLDER 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 .1 J�� @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 680-11­1359042 NAMED INSURED: Jason Addison Smith Consulting Services, Inc. dba JAS Pacific POLICY PERIOD: 8/8/2022 to 8/8/2023 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided underthe following; COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Coverage Part, but: a. Only with respect to liability for "bodily injury", "property damage" or "personal injury"; and b. If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies, or in connection with premises owned by or rented to you. The person or organization does not qualify as an additional insured: c. With respect to the independent acts or omissions of such person or organization; or d. For "bodily injury", "property damage" or "personal injury" for which such person or organization has assumed liability in a contract or agreement. The insurance provided to such additional insured is limited as follows: e. This insurance does not apply on any basis to any person or organization for which coverage as an additional insured specifically is added by another endorsement to this Coverage Part. f. This insurance does not apply to the rendering of or failure to render any "professional services". g. In the event that the Limits of Insurance of the Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the insurance provided to the additional insured shall be limited to the limits of liability required by that "written contract requiring insurance". This endorsement does not increase the limits of insurance described in Section III — Limits Of Insurance. h. This insurance does not apply to "bodily injury" or "property damage" caused by "your work" and included in the "products - completed operations hazard" unless the "written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured applies only to such "bodily injury" or "property damage" that occurs before the end of the period of time for which the "written contract requiring insurance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 2. The following is added to Paragraph 4.a. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: The insurance provided to the additional insured is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover. However, if you specifically agree in the "written contract requiring insurance" that this insurance provided to the additional insured under this Coverage Part must apply on a primary basis or a primary and non-contributory basis, this insurance is primary to other insurance available to the additional insured which covers that person or organizations as a named insured for such loss, and we will not share with the other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal injury" for which coverage is sought arises out of an offense committed; after you have signed that "written contract requiring insurance". But this insurance provided to the additional insured still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the additional insured when that person or organization is an additional insured under any other insurance. CG D3 81 09 15 © 2015 The Travelers Indemnity Company, All rights reserved, Page 1 of 2 Includes the copyrighted material of Insurance Services Office, Inc„ with its permission COMMERCIAL GENERAL LIABILITY 3. The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: We waive any right of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" performed by you, or on your behalf, done under a "written contract requiring insurance" with that person or organization. We waive this right only where you have agreed to do so as part of the "written contract requiring insurance" with such person or organization signed by you before, and in effect when, the "bodily injury" or "property damage" occurs, or the "personal injury" offense is committed. 4. The following definition is added to the DEFINITIONS Section: "Written contract requiring insurance" means that part of any written contract under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs and the "personal injury" is caused by an offense committed: a. After you have signed that written contract; b. While that part of the written contract is in effect; and c. Before the end of the policy period. Page 2 of 2 © 2015 The Travelers Indemnity Company, All rights reserved CG D3 81 09 15 Includes the copyrighted material of Insurance Services Office, Inc,, with its permission Jason Addison Smith Consulting Services, Inc. POLICY# BA-OS426316 Effective: 8/8/2022 to 8/8/2023 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ rr CAREFULLY. BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE - This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. BROAD FORM NAMED INSURED B. BLANKET ADDITIONAL INSURED C. EMPLOYEE HIRED AUTO D. EMPLOYEES AS INSURED E SUPPLEMENTARY PAYMENTS - INCREASED LIMITS F. HIRED AUTO - LIMITED WORLDWIDE COV- ERAGE - INDEMNITY BASIS G. WAIVER OF DEDUCTIBLE - GLASS PROVISIONS A. BROAD FORM NAMED INSURED The following is added to Paragraph A.1., Who Is An Insured, of SECTION II - COVERED AUTOS LIABILITY COVERAGE: Any organization you newly acquire or form dur- ing the policy period over which you maintain 50% or more ownership interest and that is not separately insured for Business Auto Coverage. Coverage under this provision is afforded only un- til the 180th day after you acquire or form the or- ganization or the end of the policy period, which- ever is earlier. B. BLANKET ADDITIONAL INSURED The following is added to Paragraph c. in A.1., Who Is An Insured, of SECTION II - COVERED AUTOS LIABILITY COVERAGE: Any person or organization who is required under a written contract or agreement between you and that person or organization, that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to be named as an addi- tional insured is an "insured" for Covered Autos Liability Coverage, but only for damages to which H. HIRED AUTO PHYSICAL DAMAGE - LOSS OF USE - INCREASED LIMIT I. PHYSICAL DAMAGE - TRANSPORTATION EXPENSES - INCREASED LIMIT J. PERSONAL PROPERTY K AIRBAGS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS M. BLANKET WAIVER OF SUBROGATION N. UNINTENTIONAL ERRORS OR OMISSIONS this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section II. C. EMPLOYEE HIRED AUTO 1. The following is added to Paragraph A.1., Who Is An Insured, of SECTION II - COV- ERED AUTOS LIABILITY COVERAGE: An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in an "employee's" name, with your permission, while performing duties related to the conduct of your busi- ness. 2. The following replaces Paragraph b. in B.5., Other Insurance, of SECTION IV - BUSI NESS AUTO CONDITIONS: b. For Hired Auto Physical Damage Cover- age, the following are deemed to be cov- ered "autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow; and (2) Any covered "auto" hired or rented by your "employee" under a contract in an "employee's" name, with your CA T3 53 0215 b 2015 The Travelers Indemnity Company All rights reserved Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc with its permission, COMMERCIAL AUTO permisslon, while performing duties (a) With respect to any claim made or "suit" related to the conduct of your busi- brought outside the United States of ness. America, the territories and possessions However, any "auto" that is leased, hired, of the United States of America, Puerto rented or borrowed with a driver Is not a Rico and Canada: covered "auto". (i) You must arrange to defend the "in- D. EMPLOYEES AS INSURED sured" against, and investigate or set - tle any such claim or "suit" and keep The following is added to Paragraph A.1., Who Is us of all proceedings and ac- An Insured, of SECTION II - COVERED AUTOS An tions. LIABILITY COVERAGE: (ii) Neither you nor any other involved Any "employee" of yours is an "insured" while us- "insured" will make any settlement ing a covered "auto" you don't mm, hire or borrow without our consent in your business or your personal affairs. (iii) We may, at our discretion, participate E SUPPLEMENTARY PAYMENTS - INCREASED rt defending the "insured" against, or LIMITS in the settlement of, any claim or 1. The following replaces Paragraph A.2.a.(2), "suit". of SECTION II - COVERED AUTOS LIABIL- (iv) We will reimburse the "insured" for ITY COVERAGE: sums that the "insured" legally must (2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily cluding bonds for related traffic law viola- injury" or "property damage" to which tions) required because of an "accident" this insurance applies, that the "in- vue cover. We do not have to fumish sured" pays with our consent, but these bonds. only Lp to the limit described in Para- 2 The following replaces Paragraph A.2.a.(4), graph C., Limits Of Insurance, of of SECTION II - COVERED AUTOS LIABIL- SECTION II - COVERED AUTOS ITY COVERAGE: LIABILITY COVERAGE. (4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for "insured" at our request, including actual the reasonable expenses incurred loss of earnings up to $500 a day be- with our consent for your investiga- cause of time off from work. tion of such claims and your defense the "insured" against any such F. HIRED AUTO - LIMITED WORLDWIDE COV- s "suit", but only r.p to and included " ERAGE - INDEMNITY BASIS within the limit described in Para - The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of graph 8.7., Policy Period, Coverage Territory, SECTION I _ COVERED AUTOS of SECTION IV - BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in nONS: addition to such limit. Our duty to (5) Anywhere n the world, except any country or make such payments ends when vie jurisdiction while any trade sanction, em- have used r.p the applicable limit of bargo, or similar regulation imposed br the insurance in payments for damages, United States of America applies to and pro- settlements or defense expenses. hibits the transaction .of business with or (b) This insurance is excess over any valid within such country or jurisdiction, for Cov- and collectible other insurance available ered Autos Liability Coverage for any covered to the "insured" whether pdmary, excess, "auto" that you lease, hire, rent or borrow contingent or o-t any other basis. without a driver for a period of 30 days or less (c) This insurance is not a substitute for re - and that is not an "auto" you lease, hire, rent quired or compulsory insurance n any or borrow from any of your "employees", country outside the United States, its ter - partners (if you are a partnership), members ritodes and possessions, Puerto Rico and (if you are a limited liability company) or Canada. members of their households. Page 2 of 4 O 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 0215 Includes copyrighted material of Insurance Services Office, Inc with its permission. You agree to maintain all required or compulsory insurance h any such coun- try Lp to the minimum limits required by local law. Your failure to comply with compulsory insurance requirements will not invalidate the coverage afforded by this policy, but we will only be liable to the same extent we would have been liable had you complied with the compulsory in- surance requirements. (d) It is understood that we are rot an admit- ted or authorized insurer outside the United States of America, its territories and possessions, Puerto Rico and Can- ada. We assume no responsibility for the furnishing of certificates of insurance, or for compliance h any way with the laws of other countries relating to insurance. G WAIVER OF DEDUCTIBLE - GLASS The following is added to Paragraph D., Deducti- ble, of SECTION III - PHYSICAL DAMAGE COVERAGE: No deductible for a covered "auto" will apply to glass damage if the glass is repaired rather than replaced. H. HIRED AUTO PHYSICAL DAMAGE - LOSS OF USE - INCREASED LIMIT The following replaces the last sentence of Para- graph AA.b., Loss Of Use Expenses, of SEC- nON III - PHYSICAL DAMAGE COVERAGE: However, the most we will pay for any expenses for loss of use is $65 per day, to a maximum of $750 for any one "accident". PHYSICAL DAMAGE - TRANSPORTATION EXPENSES - INCREASED LIMIT The following replaces the first sentence in Para- graph A.4.a., Transportation Expenses, of SECTION III - PHYSICAL DAMAGE COVER- AGE: We will pay up to $50 per day to a maximum of $1,500 for temporary transportation expense in- curred by you because of the total theft of a cov- ered "auto" of the private passenger type. J. PERSONAL PROPERTY The following is added to Paragraph AA., Cover- age Extensions, of SECTION III - PHYSICAL DAMAGE COVERAGE: Personal Property We will pay up to $400 for "loss" to wearing ap- parel and other personal property which is: (1) Owned by an "insured'; and COMMERCIAL AUTO (2) In or cn your covered "auto". This coverage applies only h the event of a total theft of your covered "auto fib deductibles apply to this Personal Property coverage. K AIRBAGS The following is added to Paragraph 13.3., Exclu- sions, of SECTION III - PHYSICAL DOGE COVERAGE: Exclusion 3.a. does not apply to "loss" to one or more airbags h a covered "auto" you mn that in- flate due to a cause other than a cause of "loss" set forth h Paragraphs A.1.b. and A.1.c., but only: a If that "auto" is a covered "auto" for Compre- hensive Coverage under this policy; b. The airbags are not covered under any war- ranty; and c. The airbags were not intentionally inflated. We will pay up to a maximum of $1,000 for any one "loss". L NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS The following s added to Paragraph A,2.a., of SECTION IV - BUSINESS AUTO CONDITIONS: Your duty to give us or our authorized representa- tive_ prompt notice of the "accident" or "loss" ap- plies only when the "accident" or "loss" is known to: (a) You (if you are an individual); (b) A partner (if you are a partnership); (c) A member (if you are a limited liability com- pany); (d) An executive officer, director or insurance manager (if you are a corporation or other or- ganization); or (e) Any "employee" authorized by you to give no- tice of the "accident" or "loss". M BLANKET WAIVER OF SUBROGATION The following replaces Paragraph A.5., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV - BUSINESS AUTO CONDI- TIONS: 5, Transfer Of Rights Of Recovery Against Others To Us V\L- waive any right of recovery we may have against any person or organization to the ex- tent required of you by a written contract signed and executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of operations contemplated by CA T3 53 0215 © 2015 The Travelers Indemnity Company, All rights reserved, Page 3 of 4 Includes oopyrighled material of Insurance Services Office, Inc with its permission. COMMERCIAL AUTO such contract. The waiver applies only to the The unintentional an1ss1on of, or unintentional person or organization designated n such error in, any information given by you shall not contract. prejudice your rights under this insurance. How- N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right m col - The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of cealment, Misrepresentation, Or Fraud, of cancellation or non -renewal. SECTION IV - BUSINESS AUTO CONDITIONS: Page 4 of 4 © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 0215 Includes copyrighted material of Insurance Services Office, Inc. with its permission, NAMED • It: Jason AddisonConsulting Inc. POLICY i • i' 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 underthe 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 8.5., 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 740216 U 2016 The Travelers Indemnity Company, All rights reserved, Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc, with its permission. 0 TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A)- ooi POLICY NUMBER: UB-8K37343A 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. oo % of the California workers' compensation pre- mium. Person or Organization ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. Schedule ENGINEERS Job Description 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 W preparation of the policy.) Endorsement Effective 8/8/22 Policy No. UB-8K37343A Endorsement No. Insured Jason Addison Smith Consulting Services Inc. Premium Insurance Company Countersigned DATE OF ISSUE: 08-01-22 ST ASSIGN: Page 1 of 1