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PROOF OF INSURANCE (2018 - 2019) CLOSED a I DATE(MM/DD/YYYY)
"R" CERTIFICATE OF LIABILITY INSURANCEliki 3/9/2018
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 have ADDITIONAL INSURED provisions or 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: Alison Olsen
Dealey, Renton &Associates PHONE FAx
P. O. Box 12675 I(A/C,No.Ext): 510-465-3090 (A/C,No):510-452-2193
Oakland, CA 94604-2675 I E-MAIL @ y
E-MAILADDRESS: Insurance.Certificates Deale renton.com
License#0020739 I INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: Travelers Property Casualty Co ofAmeri 25674
INSURED KOACORPOR INSURER B:American Automobile Ins. Co. 21849
KOA Corporation
1100 Corporate Center Dr#201 I INSURER C:XL Specialty Insurance Co. 37885
Monterey Park, CA 91754 I INSURER D:
323-260-4703 I INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:694458566 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER (MM/DD/YWY) IMM/DD/YWY)
A X COMMERCIAL GENERAL LIABILITY Y Y 6808H966428 3/13/2018 3/13/2019 EACH OCCURRENCE $2,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $1,000,000
X Contractual Liab MED EXP(Any one person) $10,000
X XCU Included PERSONAL&ADV INJURY $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000
POLICY � JjRO-
ECT El LOC PRODUCTS-COMP/OP AGG $4,000,000
OTHER: $
A AUTOMOBILE LIABILITY Y Y BA2A439568 3/13/2018 3/13/2019 COMBINED SINGLE LIMIT $
(Ea accident) 1.000.000
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTBODILY INJURY(Per accident) $
OS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
A X UMBRELLA LAB X OCCUR CUP6464YO33 3/13/2018 3/13/2019 EACH OCCURRENCE $5,000,000
EXCESS LAB CLAIMS-MADE AGGREGATE $5,000,000
DED I X I RETENTION$0 $
B WORKERS COMPENSATION Y WZP81042082 9/19/2017 9/19/2018 X SPER TATUTE OERH
AND EMPLOYERS'LIABILITY Y/N
ANYPROPRIETOR/PARTNER/EXECUTIVEF—] NIA
E.L.EACH ACCIDENT $1,000,000
D
OFFICER/MEMBER EXCLUDE
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
C Professional Liability DPR9922841 3/13/2018 3/13/2019 $2,000,000 per Claim
$2,000,000 Annual Aggregate
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
AM Best's Rating on all policies above:A/XII or greater. Umbrella Policy is follow-form to underlying Policies: GL/Auto Liability/Employers Liability.
KOA Job No./Name: JB71264 EI Segundo Parking Improvements Cost Study
City of EI Segundo, its officials,and employees are named as Additional Insured as respects General and Auto Liability as required per written contract or
agreement. General Liability is Primary/Non-Contributory per policy form wording. Insurance coverage includes Waiver of Subrogation per the attached.
CERTIFICATE HOLDER CANCELLATION 30 Day Notice of Cancellation
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
Planning &Building Safety Dept.
Attn: Gregg McClain, Planning Manager AUTHORIZED REPRESENTATIVE
350 Main Street
EI Segundo CA 90245-3813 q
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Policy Number: BA2A439568 COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - PRIMARY AND
NON-CONTRIBUTORY WITH OTHER INSURANCE
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
PROVISIONS 2. The following is added to Paragraph B.5., Other
1. The following is added to Paragraph A.1.c., Who Insurance of SECTION IV — BUSINESS AUTO
Is An Insured, of SECTION II — COVERED CONDITIONS:
AUTOS LIABILITY COVERAGE: Regardless of the provisions of paragraph a. and
This includes any person or organization who you paragraph d. of this part 5. Other Insurance, this
are required under a written contract or insurance is primary to and non-contributory with
agreement between you and that person or applicable other insurance under which an
organization, that is signed by you before the additional insured person or organization is the
"bodily injury" or "property damage" occurs and first named insured when the written contract or
that is in effect during the policy period, to name agreement between you and that person or
as an additional insured for Covered Autos organization, that is signed by you before the
Liability Coverage, but only for damages to which "bodily injury" or "property damage" occurs and
this insurance applies and only to the extent of that is in effect during the policy period, requires
that person's or organization's liability for the this insurance to be primary and non-contributory.
conduct of another"insured".
CA T4 74 02 16 6 2016 The Travelers Indemnity Company.All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc.with its permission.
Policy# BA2A439568
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF SUBROGATION
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
The following replaces Paragraph A.5., Transfer of required of you by a written contract executed
Rights Of Recovery Against Others To Us, of the prior to any "accident" or "loss", provided that the
CONDITIONS Section: "accident" or "loss" arises out of the operations
5. Transfer Of Rights Of Recovery Against Oth- contemplated by such contract. The waiver ap-
ers To Us plies only to the person or organization desig-
We waive any right of recovery we may have nated in such contract.
against any person or organization to the extent
CA T3 40 02 15 ©2015 The Travelers Indemnity Company.All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc.with its permission.
Workers' Compensation and Employers' Liability Insurance Policy
Waiver of Our Right to Recover From Others Endorsement - California
WC 04 03 06
rl'tlae foll''owirag information is not coni piece, refer to the :'rpfar^alar i:'rte ticlte'clrrle attached to tire. policy.
1117saulre'al KOA Corporation 1"011icv Nuurrulte'r° WZP81042082
Producer Dealey Renton&Associates l-ftectk e Date 09/19/2017
selreatcrl'e
Person or Or°gur izatiora Job Descrip,atir.rra
ALL PERSONS OR ORGANIZATIONS THAT ARE PARTIE TO A CONTRACT THAT REQUIRED
YOU TO OBTAIN THIS AGREEMENT,PROVIDED YOU EXECUTED THE CONTRACT BEFORE
THE LOSS
ri,cictitiorrual pr•erariurrra %,
We lltaa' c the a°ig hr to ince er ourr payments l''roilu Cally. You must uraaaiurtaairu 1myrol'l records aaccuraale'l'y° segrc.-
ortc li,:abic for ill inrjUl'y° ecrVer°ecl by this policy. 'uy"e t,��il'1 gating, the of your errrl?loyecs Mhil'c ert-
not etrfoll-ce our right against tl'le p°rersazrt Ol' cuu"gryaaruizaation aa�".ecl ill lite �ucrrlw described in tiv� ticlv�claulc .
uraartrecl in rlte schedule, (This alg l'cellleurt applies only The aacicliti01101 1.r°erouirarrr tot- tluiis eurclaarseurrearl shall be
to t'hc exlerrt that you lacrl'onn work under au writtcra rlre percentage, was slrowill ill the schedule .app"blieaabl'e to
contract that a°e'cpauir°es you to obtain tlris alg li-cerurerrl dais eruela.urse'rtrena't. of rlre ('aalifolruri.a t orkers' c'cuuripcir'-
l'roila tis.,) satiorr parcuruiuurr7 otherwise clauc on lurch rcraatrnerrutiorr.
Ths r'a1a-m C%V'18Ka :7W a9a@;9ctivd to Change F13lors4',8'I'wm Mici yssued :I Ilei- 010 1)ot04y 14 451"181'.4'➢7
cruc, ol`the Firculau's F'uud hmrimce 4"ou palsies .os �Iawcd ira rlw 11(oi,i
Wu;au�tau;3!ua3<t..u'�t
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER:6808H966428 ISSUE DATE:3/9/2018
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SCHEDULED ADDITIONAL INSURED
(ARCHITECTS, ENGINEERS AND SURVEYORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
NAME OF PERSONS OR ORGANIZATIONS:
City of EI Segundo
Planning & Building Safety Dept.
Attn: Gregg McClain, Planning Manager
EI Segundo CA 90245-3813
PROJECT/LOCATION OF COVERED OPERATIONS:
KOA Job No./Name: JB71264 EI Segundo Parking Improvements Cost Study-- City of EI Segundo, its officials,
and employees
PROVISIONS
1. The following is added to SECTION II - WHO IS The insurance provided to such additional insured
AN INSURED: is limited as follows:
The person or organization shown in the Sched- e. This insurance does not apply to the render-
ule above is an additional insured on this Cover- ing of or failure to render any "professional
age Part, but: services".
a. Only with respect to liability for "bodily injury", f. In the event that the Limits of Insurance of the
"property damage" or"personal injury"; and Coverage Part shown in the Declarations ex-
b. If, and only to the extent that, the injury or ceed the limits of liability required by the "writ-
damage is caused by acts or omissions of ten contract requiring insurance", the insur-
you or your subcontractor in the performance ance provided to the additional insured shall
of "your work" to which the "written contract be limited to the limits of liability required by
requiring insurance applies, or in connection
that "written contract requiring insurance".
with premises owned by or rented to you. This endorsement does not increase the lim-
its of insurance described in Section III - Lim-
The person or organization does not qualify as an its Of Insurance.
additional insured:
g. This insurance does not apply to "bodily inju-
c. With respect to the independent acts or orris- ry" or "property damage" caused by "your
sions of such person or organizatioor work" and included in the "products-
d. For "bodily injury", "property damage" or "per- completed operations hazard" unless the
sonal injury" for which such person or organi- "written contract requiring insurance" specifi-
zation has assumed liability in a contract or cally requires you to provide such coverage
agreement. for that additional insured, and then the insur-
ance provided to that additional insured ap-
CG D3 82 09 15 ©2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 2
Includes the copyrighted material of Insurance Services Office, Inc., with its permission
COMMERCIAL GENERAL LIABILITY
plies only to such "bodily injury" or "property 3. The following is added to Paragraph 8., Transfer
damage"that occurs before the end of the pe- Of Rights Of Recovery Against Others To Us,
riod of time for which the "written contract re- of SECTION IV - COMMERCIAL GENERAL LI-
quiring insurance" requires you to provide ABILITY CONDITIONS:
such coverage or the end of the policy period, We waive any right of recovery we may have
whichever is earlier. against the additional insured shown in the
2. The following is added to Paragraph 4.a. of SEC- Schedule above because of payments we make
TION IV - COMMERCIAL GENERAL LIABILITY for "bodily injury", "property damage" or "personal
CONDITIONS: injury" arising out of"your work" on or for the pro-
The insurance provided to the additional insured ject, or at the location, shown in the Schedule
shown in the Schedule above is excess over any above, performed by you or on your behalf, done
valid and collectible other insurance, whether under a "written contract requiring insurance"with
primary, excess, contingent or on any other basis, that person or organization. We waive this right
that is available to the additional insured for a loss only where you have agreed to do so as part of
we cover. However, if you specifically agree in the the "written contract requiring insurance" with
"written contract requiring insurance" that this in- such person or organization signed by you be-
surance provided to the additional insured under fore, and in effect when, the "bodily injury" or
this Coverage Part must apply on a primary basis "property damage" occurs, or the "personal injury"
or a primary and non-contributory basis, this in- offense is committed.
surance is primary to other insurance available to 4. The following definition is added to the DEFINI-
the additional insured which covers that person or TIONS Section:
organization as a named insured for such loss, "Written contract requiring insurance" means that
and we will not share with the other insurance, part of any written contract with the person or or-
provided that: ganizations shown in the Schedule above, under
(1) The "bodily injury" or "property damage" for which you are required to include that person or
which coverage is sought occurs; and organization as an additional insured on this Cov-
(2) The "personal injury" for which coverage is erage Part, provided that the "bodily injury" and
sought arises out of an offense committed; "property damage" occurs and the "personal inju-
after you have signed that "written contract requir-
ry" is caused by an offense committed:
ing insurance". But this insurance provided to the a. After you have signed that written contract;
additional insured still is excess over valid and b. While that part of the written contract is in ef-
collectible other insurance, whether primary, ex- fect; and
cess, contingent or on any other basis, that is c. Before the end of the policy period.
available to the additional insured when that per-
son or organization is an additional insured under
any other insurance.
Page 2 of 2 0 2015 The Travelers Indemnity Company. AIII rights reserved_ CG D3 82 09 15
Includes the copyrighted material of Insurance Services Office, Inc_,with its permission
POLICY NUMBER: BA2A439568 COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage
under the Who Is An Insured provision 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.
Named Insured: KOA Corporation
Endorsement Effective Date:3/13/2018
SCHEDULE
Name Of Person(s) Or Organization(s): KOA Job No./Name: JB71264 EI Segundo Parking Improvements
Cost Study-- City of EI Segundo, its officials, and employees
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies
as an "insured" under the Who Is An Insured
provision contained in Paragraph A.1. of Section II —
Covered Autos Liability Coverage in the Business
Auto and Motor Carrier Coverage Forms and
Paragraph D.2. of Section I — Covered Autos
Coverages of the Auto Dealers Coverage Form.
CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1