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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