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PROOF OF INSURANCE (2018) CLOSED 0 DATE(MMIDDIYYYY) AC" '"R " CERTIFICATE OF LIABILITY INSURANCE I 05/05/2017 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 CONTACT NAME: Hiscox Inc.d/b/a/Hiscox Insurance Agency in CA PHONE 888 202-3007 (A/x / � Ix>ttl� FAX, Yaw); E MA D p s, contact @�hiiscox.com 520 Madison Avenue AD A,F'FOR�DING,COVERAGE' NAIC# 32nd Floor ...........Im� � sufzE„R($) New York,NY 10022 INSURERA: Hiscox Insurance Company Inc 10200 INSURED INSURER B: Koester Environmental Compliance Services INSU,RERC: 7 Glenn INSURER D; INSURER E Irvine CA 92620 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ISR� TYPE OF INSURANCE I1N bC ICY EXP I '...] ! POLICY NUMBER .(MM DDfYYYY) IMM ODIYYYYLV LT LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ( $ 1,000,000 ----- --- II�/ OAMAGE"r0 d2ENt Lr7 CLAIMS-MADE U X I OCCUR PREMISES,tEa ocourrenoe) $ 50,000 X CGL is on BOP Form MED EXP(Any one person) ( $ 5,000 A Y UDC-1559406-BOP-17 03/24/2017 03/24/2018 PERSONAL a ADV INJURY $ SIT Each Occ. _GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ($ 2,000,000 X POLICY E PFi("O- LOC PRODUCTS $ SIT Gen.A JEI 9g_ - - OTHER $ AUTOMOBILE LIABILITY 'CO'MIMNED'SINGLE LIMIT $ ..---- (Ea accRdent), ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS AUTOS UDC-1559406-BOP-17 03/24/2017 03/24/2018 BODILY INJURY(Per accident) $ 'fir _ X HIREDAUTOS IX NON-OWNED PROR RTYDA'MAGE X AUTOS (Por-acociont't $ UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS AGGREGATE �$ -MADE DIED I I RETENTION$ S WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN J STATUTE t ER, ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBEREXCLUE F NIA ....... (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101 Additional Remarks Schedule may be attached if more ace is required) ( � � Y P 9 ) City of EL Segundo,Its Officers,Officials,Employees,Agents and Volunteers is an additional insured CERTIFICATE HOLDER CANCELLATION City of EL Segundo,Its Officers,Officials, Employees,Agents and Volunteers 350 Main St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EL Segundo,CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD "t HI SCOX Hiscox Insurance Company Inc. Policy Number: UDC-1559406-BOP-17 Named Insured: Koester Environmental Compliance Services Endorsement Number: 16 Endorsement Effective: March 24, 2017 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): City Of El Segundo, its officers, officers,officia Is,ern ployess,agents and volunteers 350 Main Street El Segundo,CA 90245 Information required to complete this Schedule, if not shown above,will be shown in the Declarations. ITITITITITITITITITITITITITITITITITITITIT 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 01 06 © ISO Properties, Inc., 2004 Page 1 of 1 Am SCX Hiscox Insurance Company Inc. Policy Number: UDC-1559406-BOP-17 Named Insured: Koester Environmental Compliance Services Endorsement Number: 17 Endorsement Effective: May 04, 2017 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA - H�I ED AUTO AND NON-OWNED AUTO LIABILITY This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Coverage Additional Premium A. Hired Auto Liability $ 133.00 B. Non-owned Auto Liability $ 0.00 Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Throughout this endorsement the term spouse C. For insurance provided by this endorsement only: means: 1. The exclusions under Paragraph B.1. Appli- Spouse or a registered domestic partner under cable To Business Liability Coverage in California law. Section II— Liability, other than Exclusions a., B. Insurance is provided only for those coverages for b., d., f. and i. and the Nuclear Energy Liability which a specific premium charge is shown in the Exclusion, are deleted and replaced by the fol- Declarations or in the Schedule. lowing: 1. Hired Auto Liability a. "Bodily injury"to: The insurance provided under Paragraph A.1. (1) An "employee" of the insured arising out Business Liability in Section II — Liability of and in the course of: applies to "bodily injury" or "property damage" (a) Employment by the insured;or arising out of the maintenance or use of a (b) Performing duties related to the "hired auto" by you or your "employees" in the conduct of the insured's business;or course of your business. (2) The spouse, child, parent, brother or 2. Non-owned Auto Liability sister of that "employee" as a conse- The insurance provided under Paragraph A.1. quence of Paragraph (1)above. Business Liability in Section II — Liability This exclusion applies: applies to "bodily injury" or "property damage" arising out of the use of any "non-owned auto" (1) Whether the insured may be liable as an in your business by any person. employer or in any other capacity;and BP 06 86 01 10 ©Insurance Services Office, Inc., 2009 Page 1 of 2 (2) To any obligation to share damages with b. Any partner or"executive officer"for any or repay someone else who must pay "auto" owned by such partner or officer damages because of injury. or a member of his or her household; This exclusion does not apply to: c. Any person while employed in or other- (1) Liability assumed by the insured under wise engaged in duties in connection an"insured contract"; or with an "auto business", other than an (2) "Bodily injury" arising out of and in the "auto business"you operate; course of domestic employment by the d. The owner or lessee(of whom you are a insured unless benefits for such injury sublessee) of a "hired auto" or the are in whole or in part either payable or owner of a "non-owned auto" or any required to be provided under any work- agent or "employee" of any such owner ers'compensation law. or lessee; or b. "Property damage"to: e. Any person or organization for the con- duct of any current or past partnership (1) Property owned or being transported by, or joint venture that is not shown as a or rented or loaned to the insured; or Named Insured in the Declarations. (2) Property in the care, custody or control D. For the purposes of this endorsement only, Para- of the insured. graph H. Other Insurance in Section III — Com- 2. Paragraph C.Who Is An Insured in Section II mon Policy Conditions is replaced by the follow- -Liability is replaced by the following: ing: 1. Each of the following is an insured under This insurance is excess over any primary insur- this endorsement to the extent set forth be- ance covering the "hired auto" or "non-owned low: auto". a. You; E. The following additional definitions apply: b. Any other person using a "hired auto" 1. "Auto business" means the business or occu- with your permission; pation of selling, repairing, servicing, storing or c. For a"non-owned auto": parking "autos". (1) Any partner or "executive officer" of 2. "Hired auto" means any "auto" you lease, hire, rent or borrow. This does not include any yours; or "auto" you lease, hire, rent or borrow from any (2) Any"employee"of yours; of your"employees", your partners or your"ex- but only while such "non-owned auto" is ecutive officers" or members of their house- being used in your business; and holds. d. Any other person or organization, but 3. "Non-owned auto" means any "auto" you do only for their liability because of acts or not own, lease, hire, rent or borrow which is omissions of an insured under a., b. or used in connection with your business. This in- c.above. cludes "autos" owned by your "employees", 2. None of the following is an insured: your partners or your "executive officers", or members of their households, but only while a. Any person engaged in the business of used in your business or your personal affairs. 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; Page 2 of 2 ©Insurance Services Office, Inc., 2009 BP 06 86 01 10 DATE(MM/DD/YYYY) C'C>RV CERTIFICATE OF LIABILITY INSURANCE 1l I 04/15/2017 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 'CONTACT Hiscox Inc.d/b/a/Hiscox Insurance Agency In CA PHO ONE x (888)202- 3007 ) IAA/C f); ,No):, 520 Madison Avenue ADDRESS contact�a hiscox.com 32nd Floor INSURER(S)AFFORDINGCOV,ERAGE NAIC# New York,NY 10022 INSURERA: Hiscox Insurance Company Inc 10200 INSURED INSURER B Koester Environmental Compliance Services INSURER C: 7 Glenn INSURER D! INSURER E Irvine CA 92620 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 RAID CLAIMS INSR hCAbbL.S,U:OR' POLICY MMDDXVLTR PE OF INSURANCE INSQ n POLICY NUMBER 1M 1 ( IYVY ) LIMITS COMMER N LIABILITY _ EACH OCCURRENCE $ DAMAGE"Y'G REN"/'EIS -- ----_I;CLAIMS-MADE ( OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY E PRO 0 LOC PRODUCTS-COMP/OP AGG $ JEaf),'°) 07 hHlr R $ n AUTOMOBILE LIABILITY COMQINECa SIt4Ca,E I.NMIT $ (Ea 000dGnt) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS IHIRED AUTOS NON-OWNED PI'('PERlYOAMAGE, $ I AUTOS (Per accklent) II $ UMBRELLA LAB OCCUR EACH OCCURRENCE S EXCESS LIAB I CLAIMS-MADE AGGREGATE $ rr DED I � RETENTION$ ( S WORKERS COMPENSATION PER AR.T(.ITE FIR, OIH- AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) EL DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ Professional Liability Each Claim: $ 1„000,000 A UDC 1559406 EO 17 03/24/2017 03/24/2018 Aggregate: $ 1,000„000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION 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. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i 9 CITY OF EL SEGUNDO WORKERS'CO PENSATION DECLARATION F 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 ($100,0100), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE §3706, INTEREST,AND ATTORNEY'S FEES. y t I I affirm under penalty of perjury under the laws of Califomia one of the following declarations: (�1 have and will maintain is certificate of corss+ent of sett-insure for workers'compensation,issued by the Director of lndustrial Relations as provided for by Labor Code§3700 for the performance of the work setforth the agreement with the City of B Segundo, Policy No. I have and will maintain workers'compensation 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 carver and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# (9 1 certify that, in the performance of the work set forth in the agreement with the City of EI 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 1 must immediately comply with y!`e" WSW 7- e7<-r rTM a, ement%mill automatically become void. � .. Signature of Applicant �"a� (� .. Date f� Agreement for. 6s n � (orn��.can Dated: . .�. ,o,..... ....... Reviewed by. I I � 4 b