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PROOF OF INSURANCE (2015) CLOSEDC CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DDNYYY) 'iwwa.. 10/3/2014 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 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 NTA1C Tina Cowie NAME,__ Cornerstone Specialty Insurance Services, Inc. PHONE (714) 731 -7700 Ne: (714)731 -7750 14252 Culver Drive, A299 AODR ss ,tina @corn+erstonespecialty.com Irvine CA 92604 INSURERA:Travelers Property Casualt Co 5674 INSURED JASON ADDISON SMITH ............. ___..- . ... CONSULTING ........................... INSURER B :Travelers Indemnit Co of Conn 5682 SERVICES, INC. DBA: JAS PACIFIC INSURER C; Continental Casualt C2yp4ny 0443 P.O. BOX 2002 '.. INRIIRFRn Upland CA 91786 1 INSURER F COVERAGES CERTIFICATE NUMBER -14/15 ALL COVERAGES REVISION NUMBFR! 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. ....... - _..... ILTR TYPE OF INSURANCE POLICY NUMBER. (MMIDDIYYY POLICY EXP LIMITS YY MNII't3fiIYYYY GENERAL LIABILITY EACH OCCURRENCE $ $ 1,000,000 _ E lhRi \lliil�fG \��a�J��Ja:l r W I g SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 4 mm THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN b ACCORDANCE WITH THE POLICY PROVISIONS. City of E1 Segundo t10 350 Main Street - El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Tina Cowie /TCOWIE ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. INSn25l7ninn51 n1 Tha &newn n2ma 2nrl Innn era ranicfararl marlrc of A!`(1Rr1 POLICY NUMBER: 680- 7384P218 COMMERCIAL GENERAL LIABILITY NAMED INSURED: Jason Addison Smith Consulting POLICY PERIOD: 8/8/2014 to Services, Inc. dba JAS Pacific, Inc. 8/8/2015 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) a� This endorsement modifies insurance provided under the following: ' � / COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to WHO IS AN INSURED (Section II): Any person or organization that you agree in a "contract or agreement requiring insurance" to in- clude as an additional insured on this Coverage Part, but only with respect to liability for "bodily in- jury", "property damage" or "personal injury" caused, in whole or in part, by your ads or omis- sions or the acts or omissions of those acting on your behalf: a. In the performance of your ongoing opera- tions; b. In connection with premises owped by or rented to you; or l/ c. In connection with "your work" and included within the "products- completed operations hazard ". Such person or organization does not qualify as an additional insured for "bodily injury", "property damage" or "personal injury" for which that per- son or organization has assumed liability in a con- tract or agreement. INSURANCE (Section III) for this Coverage Part. B. The following is added to Paragraph a. of 4. Other Insurance in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): However, if you specifically agree in a "contract or agreement requiring insurance" that the insurance provided to an additional insured under this Cov- erage Part must apply on a primary basis, or a primary and non - contributory basis, this insurance is primary to other insurance that is available to such additional insured which covers such addi- tional insured as a named insured, 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; The insurance provided to such additional insured is limited as follows: d. This insurance does not apply on any basis to any person or organization for which cover- C. age as an additional insured specifically is added by another endorsement to this Cover- age Part. e. This insurance does not apply to the render- ing of or failure to render any "professional services ". f. The limits of insurance afforded to the addi- tional insured shall be the limits which you agreed in that "contract or agreement requir- ing insurance" to provide for that additional insured, or the limits shown in the Declara- tions for this Coverage Part, whichever are less. This endorsement does not increase the limits of insurance stated in the LIMITS OF after you have entered into that "contract or agreement requiring insurance ". But this insur- ance still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the insured when the insured is an additional insured under any other insurance. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us in COMMERCIAL GENERAL LIABILITY CON- DITIONS (Section IV): We waive any rights 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, under a "contract or agreement requiring insurance" with that person or organization. We waive these rights only where you have agreed to do so as part of the "contract or agreement requiring insur- ance" with such person or organization entered into by you before, and in effect when, the "bodily Page 1 of 2 © The Travelers Companies, Inc. CG D3 891 09 07 Includes the copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY injury" or "property damage" occurs, or the "per- sonal injury" offense is committed. D. The following definition is added to DEFINITIONS (Section V): "Contract or agreement requiring insurance" means that part of any contract or agreement un- der which you are required to include a person or organization as an additional insured on this Cov- erage Part, provided that the "bodily injury" and "property damage" occurs, and the "personal in- jury" is caused by an offense committed: a. After you have entered into that contract or agreement; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 © The Travelers Companies, Inc. CG D3 891 09 07 Includes the copyrighted material of Insurance Services Office, Inc. with its permission. �::-1011 IICY IN DUI BIER: BA-0C906515 1INSUIREID- Jason. Addison Smith Consulting Services, Inc. dba JAS Pacific EFFECTIVE DAT& 8H8/2014 to 8/8/2015 COMMII AUTO BLANKET ADDITIONAL INSURED ThII& endorsement modifies Insurance provided under the foHnMnq,: BUSNESS AUTO COVEIMGE FORM �00 1"OR rAIRRiER CA)VERAGE FORM TRIUCKERS CXNERAGE FOfRM With mqmd to coymagia provk1ed b, EhIs endorw. rnenf, the pronwirans of the GoveriKle Fonin ajiqAy unkiss, itnodffied by 1he andorsemerd. The folkywing is addeld to (tw Bection 10 LjoliArly CoNeirfragle, i"Iniagraph A.A. Who Is Ain Inawned Pio- vlsbw AnV person or orpriiraqion 1h at yr)rj aue mquilreid 10 0GAIC10 2S Fick1fliuml inGUMd on the Coverage 1�;orm In a written conlract or agownenil that Is su gnod and enculad by ytim beftw's Him "IlitwJily irn, ry" w "pn'4uirly darviage (=Airs iYA thag Us in offect dudng itio poky poiNod n9 an "inswod'" for t isbUy Coviowlje, I onty for damages Or) which Ks inwance applies and only Gun Me extent that iI tx oigainization rjualfifies as airi 'linsurled' uriclier the Who U s Arii irijurad proviollon wrilained in seq;bon IN CAT4 37 08 OS 0, 20018 Ulm fine 11%'p 1 011 INSURED: Jason Addison Smith Consulting Services, Inc. dba JAS Pacific, Inc. TRAVELERS POLICY DATES: 8/8/2014 to 8/8/2015 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 (00) - 001 POLICY NUMBER: UB- 3642T261 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. 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 3 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS OR ORGANIZATIONS THAT ARE PARTIES TO A CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT, PROVIDED YO EXECUTED THE CONTRACT BEF E THE LOSS.