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PROOF OF INSURANCE (2017) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MMI °DIYYYr) 8/5/2016 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 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 endorsemont(s). NTM r PRODUCER ,,,,�,,.,, Tina Cowie Cornerstone Specialty Insurance Services, Inc. 14252 Culver Drive, A299 Irvine CA 92604 . _ - -- INSURED JASON ADDISON SMITH CONSULTING SERVICES, INC., DBA: JAS PACIFIC P.O. Box 2002 Upland CA 91786 1INSURER COVERAGES CERTIFICATE NUMBER:16 /17 COVERAGES (714)731-7700 .. � EAX (7i 50 _ (APP No,; 4) 731-7750 tina @cornerstonespecialty.com . ... __. E(..SLFFO-_ RDING COVERAGE _ l NAIL Travelers Propert y Casua lty Co # 25674 _ (:Travelers Indemnity Co of Conn 25682 .. ". ". " .... .. . _ .-Continental Casualtv Commanv 20443 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, INSR ......... ............ . ". .. ... ...... A'OiSL�BilY6i3 .., ,,,,..... .. "...POLICY EFF POLICY EXP -_.,.. LIMITS YI TYPE OF INSURANCE LTR. POLICY NUMBER MMIDD X '... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 000 $ 1,000,000 A I CLAIMS -MADE X OCCUR DAMAGE °i`�l5 iTLNYEIi PREMISES -(F.a cccu",nre) ....... ,m.m. ............ $.,.,_ 300 000 X ADDITIONAL INSURED 680- 7364P218 8/8/2016 6/8/2017 MED EXP (Any one person) ---- $ 5,000 ... X ... BLNRT WVR OF SUBRO ................. ....._ .. ... PERSONAL &ADVINJURY _._ ..... $ 1,,000 000 ....,............ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ... R PRO- JECT LOC POLICY (, X � � ... ----- PRODUCTS COMP /OPAGG .. ... $ 2,000,000 OTHER : AUTOMOBILE LIABILITY OM %N n.. SINME 9..f I ,tEa accLC -1 , $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ B .. ALL OWNED SCHEDULED BA- OC906515 ''.. 8/8/2016 8/8/2017 ........ BODILY INJURY (Per accident) -------- $ AUTOS AUTOS NED "PR6PtOtY DAMAGE $ . HIRED AUTOS '... AUTOS „(Per rywc aden,l) $ UMBRELLA LIAR X EACH OCCURRENCE $ 5,000,000 A Ix [OCCUR CLAIMS MADE EXCESS LIAB .. ... ......... i AGGREGATE ,,,,, ,,,®, $ 5 000 r.... 000,000 DED ( RETENTION $ (CUP- 3429T370 8/8/2016 8/8/2017 $ WORKERS COMPENSATION OT '.....,,,,,X � STA7,U,TE � AND EMPLOYERS' LIABILITY YIN ,,,FRH Ea";4YEIVi. CIDA 0 A ' . P tMandat rV IMB �RICXCLIUDECY7 NIA XJUB- 3642T261 8/8/2016 6/8/2017 ®,,;,,,,,, ,� .... ......,., E DISEASE EMPLOYE $.. 1,000 000 f.. 0 yyes, describe urger DF�.':'.SCRIPT'IION OF OPERATIONS below E L DISEASE POLICY LIMIT $ 1,0001000 C Professional Liability AEH114007309 8/8/2016 8/8/2017 Each Claim $2,000,000 Claims Made Annual Aggregate $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is Additional Insured for General Liability but only if required by written contract with the Named Insured prior to an occurrence and as per attached endorsement. Coverage is subject to all policy terms and conditions. *30 days notice of cancellation, except for 10 days notice for non - payment of premium. For Professional Liability coverage, the aggregate limit is the total insurance available for all covered claims reported within the policy period. ........ CATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Tina Cow.i.e/TCOWI.E, ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS0251gmanrn POLICY NUMBER: 680 - 738412218 COMMERCIAL GENERAL LIABILITY NAMED INSURED: Jason Addison Smith Consulting POLICY PERIOD: 8/8/2016 to Services, Inc. dba JAS Pacific, Inc. 8/8/2017 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) 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 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 per- son or organization has assumed liability in a con- tract or agreement. 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- 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 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; 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. C. 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 0 The Travelers Companies, Inc. CG D3 89109 07 Includes the copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY injury" or "property damage" occurs, or the "per- erage Part, provided that the "bodily injury" and sonal injury" offense is committed. "property damage" occurs„ and the "personal in- D. The following definition is added to DEFINITIONS jury" is caused by an offense committed (Section V): a. After you have entered into that contract or "Contract or agreement requiring insurance" agreement; means that part of any contract or agreement un- b. While that part of the contract or agreement is der which you are required to include a person or in effect; and organization as an additional insured on this Cov- c. Before the end of the policy period. Page 2 of 2 ® The Travelers Companies, Inc. CG D3 89109 07 Includes the copyrighted material of Insurance Services Office, Inc, with its permission. POLICY NUMBER: BA- OC906515 INSURED: Jason Addison Smith Consulting Services, Inc. dba JAS Pacific EFFECTIVE DATE: 8//8/2016 to 8/8/2017 CA T4 37 08 08 2.DD9'Rw'TercroveWv r4n niais, Inc Page I of 1 INSURED: Jason Addison Smith Consulting Services, Inc. dba JAS Pacific, Inc. .fl a POLICY DATES: 8/8/2016 to 8/8/2017 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 YOU EXECUTED THE CONTRACT BEFORE THE LOSS.