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PROOF OF INSURANCE (2019) CLOSED CERTDATEtaaw0mrn CERTIFICATE OF LIABILITY INSURANCE I 03d271201 8 `��.`,... .... ., .. ,,..„ 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 Olt PRO'DUCE'R,AND THE CERTIFICATE HOLDER. IMPORTANT'. If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. It SU,BROC TION IS WAIVED, suibjoa to' the terms and conditions of the policy,certain policies may require an endorsement. A statement on this osrdficate does not confer rights to the cartifi'-caste,holder In flaui of such andorsamenl(a), IIA 202 300 Hlacox Inc.dlbla/Hiacox Insurance Agency In CA P a E� tI81i' PRODUCER IA Oe cy �. ( 4� .7 .� ��... __6w(��Ilrl•. 520 Madison Avenue pp ronlac hisroxxom 32nd Floor l �aWlsPtsl,AF r(tp4No COVERAoaNAIL:• New York )_NY 10022 weunERA: Hlscox insurance CompaqInc _ 10200„ slsuRED slsuluw<TT 5: Koester Environmental Compliance Services WWI ft c_....�w........ ,...................w........,..,..... 7 Glenn wwREao....................................wwww...w............ __._.... u ae: Irvine CA 92820 wsursutP: COVERAGES CERTIFICATE NUMBER: REVI'SIO'N 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 )ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 'OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS. �n tOEfi TYPE OF MURANCE 120M.WIL nauCY A ...... _.11. uuyT' Ag LWI a I�II C p dA oENE LIAaa ITY EACH OCCURRENCE S 1,000.0m CLAIMS-MADE FROCCUR RSP, iM9.P ".( P, a&rr unlr'R 6 b0,000 � CGL Is on BOP Fane MED EXP(Any Ona s> 1 s 5, w� 000 A Y UDC-1559408-BOP-18 03/2412018 03/24/2019 PERSONAL a ADV INJURY s S/T Each Occ. CTECM A4014C,WE LIMIT APPUES PER: GENERAL AGGREGATE S 2,000,000 PRO L J . .+�I_"ITL&;.Y I �JECT LOC Ta-COMP/ AGO S S/T Gen �9 O'T 11r:R, S AUTOMDaNAL1Aa1LITY C,{'71M1YCNFO SINOILh UMI'I' S (Ea aYual��ur41 ANY AUTO BODILY INJURY Mw peramI S .. �." SCHEDULED AUTOS ` ALL OWNED A ' AUTOS H Auros UDC-1559408-BOP-18 03!2412018 03/24/2019 BODILY INJURY(P ) S NON-OWNED PZ PER TDAMAGE UTOa AUTos k � tHOPILLALW OCCUR EACH OCCURRENCE S EJTCESS LIAII P C AGGREGATE S YIN $ DED I R R OrH- S WORTtER'aC NRAINTON �. . PER AT1,,ITF................I I,t a NYPRC rrRrPARTL :�G:C�'..0 S"Y'ME (". N/A E L.EACH ACCIDENT S NHI YMlarlgaa aYwa Moa DISEASE.- Y .... aEM�LO E&„S 0 SC;T'KION OF OT ER�.ATIONS WOO E...,.......E If LIMIT,S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddlNond Ramwka Schedule,may be aaadrad N more apace N n4Mred) City of EL Segundo,Its Officers,Officials,Employees,Agents and Volunteers is an additional Insured i CERTIFICATE HOLDER CANCELLATION City of ELSegundo,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 W(PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE 1988-2014 ACORD CORPORATION, Ali rights reserved. ACORD 25(2014101) The ACORD name and logo aro registered marks of ACORD HISHISCOX Hlscox Insurance Company Inc. Policy Number: UDC-1559406-BOP-18 Named Insured: Koester Environmental Compliance Services Endorsement Number: 16 Endorsement Effective: March 24, 2018 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL I - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s)Or Organization($): City Of EI Segundo, its officers,officers,otNcials,employeas,agents and volunteers 350 Main Street EI Segundo,CA 90245 Information required to complete this Schedule, if not shown above,will be shown In the Declarations 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 Paye 1 of 1 POM1049CO00079428-007/048-'MP-AO164 ISEL13 PERSONAL AUTOMOBILE Oft To Renew Dedarsdon effei POLICY DECLARATION Doe 6,2017 -31-1 ztllzie�1111 F- " --- Your oDivora" expi Doc 08,2017, al 12,,01 A.M, Payment oi to premium nawm yaw pai for me Perm vlxwn.Ir ymir payment s twit mk*vad bolic"09a 00,2017 ft Offorlo Rai wfll be nW1 and ftd, YANIRA M KOESTER WAWANESA INSURANCE 7 GLENN STREET 9050 FRIARS RD STIE 101 IRVINE CA 926M SAN DIEGO CA 92108-5865 Telephone: 1-800-640-2920 Policy Number Ai Number Pi Period 12:01 A.M.standard Orris at the address of the 11625950 2555551-1 From Dec 6,2017 to Jun 8,2018 Named Insured as stated herein Named Inure Phone Number.94"594463 Your 6 month premium for three(3)vehicle(*)Its $779.84. Refer to the breakdown of premiums below. Description of Owned Vehicle(s) Vehicle'IdsntllllqW Vehicle on Number -1 Premium pariVehlicis 2 2014 Tesla ir Maks. 74 POR 914 4742917018 11211 MODEL8 BASEIMODEL 8 5YJSA1 HI OEFP47488 329.87 PERFORMANCE 3 2016--Chevrolet TAHOE LTZ 1 GNSCCKCGGR326438 32111.97 Insurance Is provided only with respect to the coveragelsi for which a Premium Is stated,si to all conditions of the policy. Coverage and Limits of Liability Premiums,par Vehicle($) See Polley br Cove"D@Wls pp2 i i 3 Bodily Injury Liability $100,000 pair pa,rSon/$300,000 each oommum 40-30 54.02 87.60 Property Damage Liability $100,000:each oom nos 29.97 89.21 55.95 -Medical Payments $5,000 each person 2.62 13.74 12.60 Comprshei'— SaDO deductIble 6.57 19.73 18.78 Collision OW deduodbile 32.60 105.71 102.44 Roadside Assistance 3.77 Rental Expense $25 day/$750 max each covered lose 10.46 17.155 UnInsured/Underinsured Motorists Protection $100,000 per persont$300,000 esch occurrence 10.71 30-68 26.05 Uninsured Motorists Collision Dedued6il -- Waiver 1.33 1.33 1.33 Total Premium per Vehicle 124.007 329.87 3RL97 Nm 08,2017 0&,40 CT 'Winwanees Insurance"'Is a trademark of Wawanasa General Insurance Company aDACE WMIDWYYYY) ACCMV CERTIFICATE OF LIABILITY INSURANCE 04103/2o18 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 eerdflcsto holder Is an ADDITIONAL INSURED,the polley(lea)must be endorsed, H SUBROGATION 18 WANED,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 lieu of such endomemont(i). certificate holder I .. .. _ .. .. ... T .,..w» PRODU cHlscox Inc.d/b/a/Hlscox Insurance Agency In CA CONTACT -... ___.____. 3007 520 Madison Avenue 1D . a 02W' oDI11aCthdaaxax,cDrD .. 32nd Floor _.. .. INsuRE �.,_......... .. New York,NY 10022 Ftl' DNo cove'1IAae NAID s ran . . INsuRsaA: Hkrcox Insurance Company Inc 1020.0. .,,,.... INSURE ...-_ ..... .... Koester Environmental Compliance Services mauRElr c, 7 Glenn Irvine,CA 92620 n+puReu�we NSURE'RF= 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 IOLICIES,LIMITS SHOWN MAY HAVE D BY PAID CLAIMS. TYMY �R Lam COMMBRCU OF IN8U ALLUla1LRY E BEEN RED" F "ihOLiff -P EACH OCCURRENCE CLAI E 0 OCCUR 8... .I!J.. „ . ........ _PERSONAL.,, ... . GEN't AGGREGATE LIM'II1AMMS _GENERAL MOREGATE f A OUTOtrgalLELlAa1LITY EAMSINE08ING1.8 LIM11 5 _.................._-.. ANY AUTO j BODILY INJURY(Per WWI f ALL OWNED FOULED BODILY INJURYti... HIRED AUTOS AUT09 (D?mr 1'a vI NON.a;'WN'ED AROPEN,'7 .IT....,..GE (Per saldrRl.S UMBRELLALIAB OCCUR EACH OCCURRENCE f Excess I" AGGREGATE i .ia.. . ... .,19N . N1ER'S O i CLAIMSMADE WOA AND EMPLOYEAD A tILITY IiR:4A71V1!' Y PER. PEAT G1. „I. IH• ...........�„�......�., 0 Lu1TNEW E.L.DISEASE R ANYPRC�'N IEreCYki'dF� OD D dCEOW MBCREXCLUMD'� NIA LEACH AC _. _� ......................."..... .. IrNsrvdstzwy In N14I PL i IlEaSaC dosaPOworo QD�ERAT40NT�u�Icnw E.L DISPOLICY uw,,,.... ,.... ...................... .........,,._ „mow CY L1W f A Professional Liability N UDC-155940E1.EO-1S 03/24/20/8 03/24/2019 Each Claim;$1.000,000 Aggregate:$1,000,000 DESCRIPTION OF OPERATIONS I LOCATMN I IVEHICLEs(ACORD 101,AddNleml R~s SahsduN,aW,bs Nhdwd N maf-F—1-M411nd) . CE'RTI'FICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESMOND POLICIES BE CANCELLED BEFORE 350 Main Street THE UPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN EI Segundo CA 80245 ACCORDANCE WITH THE POLICY PROVISIONS. ,.... . REIRVAIIINYATIVE 151off, 11 »,, (01944-2014ACORI)CORPORATION, All rig his rsse'rvad. ACORD 25(2014101) The ACORD name and logo arra 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 dectarations: (_)I have and will maintain a certificate of consent or 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 EI Segundo. Policy No, _.... _� _._...._ C_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 forthe performance of the work for which the agreement with the City of EI Segundo is executed. My workers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# 111 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 1 must ig y Apart �rvi�roope�r � rr�er�t will automatically become void. immediate) corn with it s Q Signature of Applicant Date 9 ,�(7 �tX �l Gulp l is n S ce 2 a,s Agreement for. _� ��.�n Dated: Reviewed by: ... 1 V