Loading...
PROOF OF INSURANCE (2017) CLOSEDa F ­DATE (MMIDDNYYY) AC"RV CERTIFICATE OF LIABILITY INSURANCE 1 07/0712016 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(les) 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). _U6WT_ACT_ PRODUCER Kmk-, PHONE Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA (888) 202-3007 520 Madison Avenue contact §hisc E-MAIL oxxom 32nd Floor 1,14SURK9,M_ �FF0111DI (G COVERAGE NAIC # New York, NY 10022 INSURERA� Hiscox Insurance Coq)p ny nc 10200 INSURED INSIIRFR R Koester Environmental Compliance Services INSURER C 7 Glenn Irvine CA 92620 1 URERF. A^ ^C0Y1CI&­ATI= kI11RAD=D- THIS I'll 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. __MwDO1YYyY) OLCY'FF P&'a�'5C 1147SR LSUBRJ­ .•..... . .... •__V_ C y LIMITS LTR TYPE OF INSURANCE I KiF.1D,]LSv.UrNn1 POLICY NUMBER tM"Q2nMn LTR ,X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 .......... . . CLAIMS-MADE X OCCUR _RRE�M , ES Ep qvwmm. ..PA $ 50,000 X CGL is on BOP Form MED EXP Ljtny_qpe person) 5,000 A Y UDC-1559406-BOP-16 03/24/2016 03/24/2017 PERSONAL & ADV INJURY $ S/T Each Occ. _GEN'_LAGGRE_GATELIMITAP_P LIES PER: GENERAL AGGREGATE .................. ... .. . . $ 2,000,000 POLICY D PRO- JECT F-1 LOC I PRODUCTS - COMP /OP AGG ... . . ....... . ..... $ S/T Gen. Agg. . .. .. . .......... $ OT14ER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANY AUTO A ALL OWNED SCHEDULED UDC-1559406-BOP-16 03/24/2016 03/24/2017 BODILY INJURY Per accident) $ AUTOS AUTOS U NON-OWNED PROPERTY DAMAGE $ AUTOS X HIRED A AUTOS . . ...... $ UMBRELLA LIAB OCCUR EACH OCCURRENCE .......... EXCESS LIAR AGGREGATE $ DE. ERETENTION $ $ WORKERS COMPENSATION 0TH �A "ER AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUI I V E I OFFICER/MEMBEREXCLUDED? Li NIA E.L. EACH ACCIDENT $ (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional f<emarKS scneauie, May De 211MCM10 IT more space Is roquireu) City of EL Segundo is listed as add itional insured HOLDER ............... City of EL Segundo 314 Main St EL Segundo, CA 90245 ACORD 25 (2014/01) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Vito HSCOX Policy Number: UDC - 1559406 - BOP -16 Named Insured: Koester Environmental Compliance Services Endorsement Number: 20 Endorsement Effective: August 03, 2016 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Oraan City Of EI Segundo, its officers, officers, officials, employess,agents and volunteers 350 Main Street El Segundo,CA 90245 Information reauired to comDlete this Schedule. if not shown above. will be shown in The following is added to Paragraph C. Who Is An Insured in Section II — Liability: 3. Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omis- sions or the acts or omissions of those acting on your behalf in the performance of your ongoing operations or in connection with your premises owned by or rented to you. _/ BP 04 48 0106 © ISO Properties, Inc., 2004 Page 1 of 1 Policy Number: UDC - 1559406 - BOP -16 Named Insured: Koester Environmental Compliance Services Endorsement Number: 21 Endorsement Effective: August 03, 2016 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA D O LIABILITY AUTO This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM A. Hired Auto Liability B. Non -owned Auto Liability SCHEDULE $ 133.00 $ 0.00 Additional Premium Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Throughout this endorsement the term spouse means: Spouse or a registered domestic partner under California law. B. Insurance is provided only for those coverages for which a specific premium charge is shown in the Declarations or in the Schedule. 1. Hired Auto Liability The insurance provided under Paragraph A.I. Business Liability in Section II — Liability applies to "bodily injury" or "property damage" arising out of the maintenance or use of a "hired auto" by you or your "employees" in the course of your business. 2. Non -owned Auto Liability The insurance provided under Paragraph A.I. Business Liability in Section II — Liability applies to "bodily injury" or "property damage" arising out of the use of any "non -owned auto" in your business by any person. C. For insurance provided by this endorsement only: 1. The exclusions under Paragraph B.I. Appli- cable To Business Liability Coverage in Section II — Liability, other than Exclusions a., b., d., f. and i. and the Nuclear Energy Liability Exclusion, are deleted and replaced by the fol- lowing: a. "Bodily injury" to: (1) An "employee" of the insured arising out of and in the course of: (a) Employment by the insured; or (b) Performing duties related to the conduct of the insured's business; or (2) The spouse, child, parent, brother or sister of that "employee" as a conse- quence of Paragraph (1) above. This exclusion applies: (1) Whether the insured may be liable as an employer or in any other capacity; and BP 06 86 01 10 0 Insurance Services Office, Inc., 2009 Page 1 of 2 (2) To any obligation to share damages with or repay someone else who must pay damages because of injury. This exclusion does not apply to: (1) Liability assumed by the insured under an "insured contract'; or (2) "Bodily injury" arising out of and in the course of domestic employment by the insured unless benefits for such injury are in whole or in part either payable or required to be provided under any work- ers' compensation law. b. "Property damage" to: (1) Property owned or being transported by, or rented or loaned to the insured; or (2) Property in the care, custody or control of the insured. 2. Paragraph C. Who Is An Insured in Section II — Liability is replaced by the following: 1. Each of the following is an insured under this endorsement to the extent set forth be- low: a. You; b. Any other person using a "hired auto" with your permission; c. For a "non -owned auto ": (1) Any partner or "executive officer" of yours; or (2) Any "employee" of yours; but only while such "non -owned auto" is being used in your business; and d. Any other person or organization, but only for their liability because of acts or omissions of an insured under a., b. or c. above. 2. None of the following is an insured: a. Any person engaged in the business of his or her employer for "bodily injury" to any co- "employee" of such person in- jured in the course of employment, or to the spouse, child, parent, brother or sis- ter of that co-"employee" as a conse- quence of such "bodily injury", or for any obligation to share damages with or re- pay someone else who must pay dam- ages because of the injury; b. Any partner or "executive officer" for any "auto" owned by such partner or officer or a member of his or her household; c. Any person while employed in or other- wise engaged in duties in connection with an "auto business ", other than an "auto business" you operate; d. The owner or lessee (of whom you are a sublessee) of a "hired auto" or the owner of a "non -owned auto" or any agent or "employee" of any such owner or lessee; or e. Any person or organization for the con- duct of any current or past partnership or joint venture that is not shown as a Named Insured in the Declarations. D. For the purposes of this endorsement only, Para- graph H. Other Insurance in Section III — Com- mon Policy Conditions is replaced by the follow- ing: This insurance is excess over any primary insur- ance covering the "hired auto" or "non -owned auto ". E. The following additional definitions apply: 1. "Auto business" means the business or occu- pation of selling, repairing, servicing, storing or parking "autos ". 2. "Hired auto" means any "auto" you lease, hire, rent or borrow. This does not include any "auto" you lease, hire, rent or borrow from any of your "employees ", your partners or your "ex- ecutive officers" or members of their house- holds. 3. "Non -owned auto" means any "auto" you do not own, lease, hire, rent or borrow which is used in connection with your business. This in- cludes "autos" owned by your "employees ", your partners or your "executive officers ", or members of their households, but only while used in your business or your personal affairs. Page 2 of 2 0 Insurance Services Office, Inc., 2009 BP 06 86 01 10 RV CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/Y`/YY) 07/07/2016 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 SU'BROGAT'ION 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 Hiscox Inc. d /b /a/ Hiscox Insurance Agency in CA PH �y® 0888mm202 3007 520 Madison Avenue MAmL �rntsct t11coX Dom x+ a. �.... ._ � ... . 32nd Floor .. mIN SURER (S AFFORDING COVERAGE _ m NAIC# ..m. New York, NY 10022 INSURER A Hiscox Insurance Company Inc 10200 .....,......_... . __............r_ INSURED INSURER B 7 Glenn Environmental Compliance Services INSyRtR�9 Irvine CA 92620 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 1 U I Ht INSUKtU NAMtU ACUVt rUK I Ht rUULr rtKIUU 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. DDL INSd R' POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER M /DD M D IYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 111REMISE§Jgpoc ' vi IAA T(Y CLAIMS -MADE OCCUR currence $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY f] PRO LOC u JECT AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS UMBRELLALIAB OCCUR EXCESS LIAB CLAIMS -MADE DE.D RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECU I IVE 0... N/A OFFICER/MEMBEREXCLUDED7 (Mandatory In NH) If ves. describe under I Professional Liability A Y D EXE.LAny one erson $ PERSONAL & ADV INJURY $ LAGGREGATE $ GENERA.....�m_�_ ..- �..,. . PRODUCTS - COMP /OP AGG $ COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY N .nt (Per accident) $ PROPERTY DAMAGE $ EACH OCCURRENCE $ AGGREGATE _.. . ..........-- ...........$ f'E OTii- FL E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ Each Claim UDC - 1559406 -EO -16 03/24/2016 103/24/2017 Aggregate: DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of EL Segundo is listed as add itional insured TE HOLDER City of EL Segundo 314 Main St EL Segundo, CA 90245 ACORD 25 (2014101) $ 1,000,000 $ 1,000,000 !C " SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. 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: (_) 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. �I (__) I have and will maintain workers' oompensation 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 rvry now Policy Number Expiration Date Name of Agent Phone # ( 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 I must immediately comply with t e'" ovisio r ,he a ement will automatically become void. 1 Signature of Applicant w Date m��.. r - � Agreement for. °� G 1 ( !� Dated: , T) Reviewed by: mo� u KOESTER ENVIRONMENTAL COMPLIANCE SERVICES 7 Glenn, Irvine, CA 92620 July 7, 2016 City of El Segundo 314 Main Street El Segundo, CA 90245 Attention: Fire Chief 949- 516 -8036 This letter is to request to have the Workers Compensation insurance requirement waived. Koester Environmental Compliance Services does not have any other employees beside myself. This will remain the case for the duration of the contract with the City of El Segundo. Should you have any questions, or need additional information regarding the above mentioned, please contact me at 949 -516 -8036. Sincerely, Steve Koester