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PROOF OF INSURANCE (2014) CLOSEDDATE (MM/DDNYYY) AC "'"R CERTIFICATE OF LIABILITY INSURANCE /2013 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 endorsemen4 s PRODUCER CON NAME Sri FACT Dealey, Renton & Associates PHONE FAX 199 S Los Robles Ave Ste 540 MAIL PJC, No : Pasadena, CA 91101 A30RESS: Oinsd r 626 844 -3070 INSURER(S) AFFORDING COVERAGE _ NAIC. #-------- INSURED KOA Corporation 1100 Corporate Center Dr #201 Monterey Park, CA 91754 323 - 260 -4703 INSURER B INSURER C : E,. COVERAGES CERTIFICATE NUMBER: 1A791144n 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. .................... .. _ _._ .............. fNSR ADDLSUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR POLICY NUMBER MMIDD /YYYY MM /DDIYYYY _ ....... ____ .... _................................................................................ LIMITS B GENERAL LIABILITY Y Y 5802075LB40 /13/2013 /13/2014 EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES ,Ea Ocurrenre $1,000,000 CLAIMS -MADE OCCUR MED EXP (Any one person) $10 000 PERSONAL BADVINJURY $1,000,000 GE.. GEN'L AGGREGATE. LIMIT APPLIES PER PRODUCTS COMP /OP AGG .. _.._... -._.. ........ j $2,000,000 POLICY X 2 LOC $ A AUTOMOBILE LIABILITY Y BA2A439568 /13/2013 /13/2014 a_or COMBINED, -V 000200 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS X PROPERTY e accident) nDAMAGE $ X NON-OWNED HIRED AUTOS AUTOS A X I UMBRELLA LIAB X OCCUR Y Y CUP6464YO33 /13/2013 /13/2014- EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $4,000,000 DED X RETENTION $0 $ C WORKERS COMPENSATION y VVZP81013908 /19/2013 /19/2014 X WC S "r'A'TU- )( O'T'H- AND EMPLOYERS' LIABILITY Y/ N ssilx.LiiLT.S....... .. ........... .............................._ ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? N/A E L EACH ACCIDENT _ "" $1,000,000 " " " "— " " " " " " " " " " " " " " "" �- (Mandatory in NH) E L DISEASE EA EMPLOYEE $1,000,000 describe 11nder .,. _,....,_,__ DESCRIPTION OF OPERATIONS below E.L, DISEASE - POLICY LIMIT $1.000,000 D Professional Liability 23631684008 /13/2013 /13/2014 $2,000,000 Per Claim Claims Made Form $2,000,000 Annual Aggr DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) General Liability excludes claims arising out of the performance of professional services. Umbrella Policy is follow -form to underlying GL /AUTO /Employers Liability policies RE: All operations -- The City of El Segundo, its officers, officials, employees, agents, representatives adn certified volunteers are named as additional insured as respects general & auto liability for claims arising from the operations of the named insured. City of El Segundo*, Public Works Dept. � , !►� Att n F n I R' r c1"a11111A_\I Lei e5'1! 191'.1: 7111111IILIR14 VAt0la►ra]0PrPWil11111i►l11111rd IIIA I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. . oza ive a 350 Main Street L%�\ AUTHORIZED REPRESENTATIVE El Segundo CA 90245 Sri AW ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6802075L840 COMMERICAL GENERAL LIABILITY ISSUE DATE: 10 /1/2013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE NAME OF PERSON(S) OR ORGANIZATION(S): City of E1 Segundo *, Public Works Dept. Attn: Floriza Rivera 350 Main Street E1 Segundo CA 90245 PROJECT /LOCATION OF COVERED OPERATIONS: *completed to read: The City of E1 Segundo, its officers, officials, employees, agents, representatives adn certified volunteers -- Re: All Operations PROVISIONS A The following is added to WHO IS AN INSURED (Section II): The person or organization shown in the Sched- ule above is an additional insured on this Cover- age Part, but only with respect to liability for bod- ily injury", 'property damage" or 'personal injury caused, in whole or in part, by your acts or omis- sions or the acts or omissions of those acting on your behalf: a, In the performance of your ongoing oper- ations; In connection with premises owned by or rented to you; or 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 person or organization has assumed liability in a contract or agreement. CG D3 82 09 07 The insurance . provided to such additional insured is limited as follows: d. This insurance does not apply to the render- ing of or failure to render any "professional services ". 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 Declarations for this Coverage Part, whichever are less. This endorsement does not increase the limits of insurance stated in the LIMITS OF 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, for the addi- tional insured shown in the Schedule, the insur- ance provided to that additional insured under this ' ,q © 2007 The Travelers Companies, Inc. Includes the copyrighted material of Insurance Services Office Inc., with its permission Page 1 COMMERICAL GENERAL LIABILITY Coverage 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 additional 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; after you have entered into that "contract or agreement requiring insurance" for such additional insured. But this insurance 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 the additional insured is also an additional insured under any other insurance. C. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): We waive any rights of recovery we may have against the additional insured shown in the Schedule above because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" on or for the project, or at the location, shown in the Schedule above, performed by you, or on your behalf, under a "contract or agreement requiring insurance" with that additional insured. We waive these rights only where you have agreed to do so as part of the "contract or agreement requiring insurance" with that additional insured entered into by you before, and in effect when, the "bodily injury" or "property damage" occurs, or the "personal 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 under which you are required to include the person or organization shown in the Schedule 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 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. CG D3 82 09 07 Page 2 © 2007 The Travelers Companies, Inc. Includes the copyrighted material of Insurance Services Office Inc., with its permission POLICY #: BA2A439568 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following; BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions ofthe Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 10/1/2013 Countersigned By: Named Insured: KOA Corporation 11todIALU Authorized Representative) SCHEDULE Name of Person(s) Or Organization(s): *completed to read: The City of E1 Segundo, its officers, officials, employees, agents, representatives adn certified volunteers -- Re: All Operations (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 �N Copyright, Insurance Services Office, Inc., 1998 Workers' Compensation and Employers' Liability Insurance Policy Waiver of Our Right to Recover From Others Endorsement - California WC 04 03 06 If the following information is not complete, refer to the appropriate Schedule attached to the policy. i Insured:KOA Corporation Policy Number WZP81013908 , Producer: Dealey, Renton & Associates Effective Date 10 / 1 / 2 013 Schedule Person or Organization Job Description City of El Segundo *, Public Works Dept. *completed to read: The City of El Attn: Floriza Rivera Segundo, its officers, officials, 350 Main Street employees, agents, representatives adn El Segundo CA 90245 certified volunteers -- Re: All Operations Additional Premium % We have the right to recover our payments from any- one 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.) Authorized Representative WC040306 You must maintain payroll records accurately segre- gating the remuneration of your employees while en- gaged in the work described in the Schedule. The additional premium for this endorsement shall be the percentage, as shown in the Schedule applicable to this endorsement, of the California workers' compensation premium otherwise due on such remuneration.