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PROOF OF INSURANCE (2024) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 06/27/2024 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 be endorsed. If SUBROGATIONIS 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: HUB INTERNATIONAL NORTHWEST LLC PHONE (541) 207-1370 FAx 52701682 (A/C, No, Ext): (A/C, No): PO BOX 3018 E-MAIL ADDRESS: BOTHELL WA98041 INSURER(S) AFFORDING COVERAGE NAIC# .......................... INSURERA: Hartford Underwriters Insurance Company 30104 ....... INSURED INSURER B ; HAZADAPT, INC. - INSURER C 3200 SE MIDVALE DR FL 102 CORVALLIS OR 97333-3142 INSURER D:. 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 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 POLICY EXP CLAIMS. LIMITS INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF TVivo NS [JMM./� Y'y"w' COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED $1,000,000 Cq. MM -MADE. OCCUR PREMISES c grrence X General Liability MED EXP (Any one person) $10,000'' A X 52 SBM AZ1 BZJ 07/24/2023 07/24/2024 _ _PERSONAL & ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO"' ❑ LOC PRODUCTS - COMP/OP AGG $4,000,000 JEC'T OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY a ci en ANY AUTO BODILY INJURY (Per person) BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS HIRED NON -OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) _._ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS - AGGREGATE MADE DED RETENTION $ WORKERS COMPENSATION PER •OTH- AND EMPLOYERS' LIABILITY STATUTE F E.L. EACH ACCIDENT ANY YIN PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? . E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT DES IPTION OF OPERATIONS below.... _W A Employment Practices Liability I 52 SBM AZ1 BZJ 07/24/2023 07/24/2024 Each Claim Limit $25,000 Insurance Annual Aggregate Limit $25,000 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SL3032 attached to this policy. CERTIFICATE HOLDER. CANCELLATION City of Elsegundo California SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE __F ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) 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. I affirm under penalty of perjury under the laws of California one of the following declarations L_) 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. C_) 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 # ( x) I 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 Signature y comp ant " p ions or the agreement will automatically become void. immediate)lom I with those i Date Appl 07/02/2024 Print Name Virginia Ida Agreement for: Dated:. Reviewed by: I, Virginia Katz, as CEO of HazAdapt, a duly incorporated C-corporation, hereby declare and certify the following: 1. Workers' Compensation Insurance Waiver: HazAdapt is self-employed with no employees. As per state statutes, Workers' Compensation Insurance is not required for HazAdapt due to the absence of employees. Therefore, we request a waiver for the requirement of Workers' Compensation Insurance and provide this statement in lieu of such coverage. 2. Auto Liability Insurance Waiver: HazAdapt does not own or operate company -owned vehicles in the conduct of its business operations. Additionally, HazAdapt's business activities do not involve the use of personal vehicles for operational purposes. Given these circumstances, we request a waiver for the requirement of Auto Liability Insurance. I certify that the information provided here is accurate and true to the best of my knowledge. HazAdapt commits to notifying the City of El Segundo immediately should any changes occur that might affect the status of insurance requirements as detailed above. Signed: Virginia Katz HazAdapt, Inc. Founder, CEO Date: July 1, 2024