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PROOF OF INSURANCE (2019) CLOSED DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/4/2018 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). CONTACT' PRODUCER ICA Insurance Services NAME, BgUyTran 130 Vantis, Suite 250 PHONE FAX Aliso Viejo, CA 92656 INC, C,No,Exit L949.297.5962 q,mdo.NO 949-297-5960 AtL ADDRESS,, betty trari, aoausa.coni INSURER(S)AFFORDING COVERAGE NAIC# www ioausa,com CA License#OE67768 INSURER A: RLI Insurance,Company 13056 INSURED INSURER B: Lund and Associates Engineering, Inc. 23138 Galva Avenue wsuRElxc: Torrance CA 90505 INSURER D INSURER E: INSURER F: ... ... COVERAGES CERTIFICATE NUMBER; 44760319 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 INSR WUD POLICY NUMBER fMMlOOlXYVYI RMMdDO7Y'YYY'b A n' COMMERCIAL GENERAL LIABILITY ✓ ✓ PSB0007910 10/1/2018 10/1/2019 EACH OCCURRENCE s2000000 Scheduled Al Endt DAMAGE 70 RE=NTED I S1,000000 CLAIMS-MADE ,/ OCCUR „PREMI5FS(Ea occurrPnce) #PPB3130212 ✓ Primary/Non-Contributory MED EXP(Any one person) $10,000 Professional Services ✓ Waiver of Subrogation performed by the Insured PERSONAL S ADV INJURY s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: are Excluded GENERAL AGGREGATE $4,000,000 POLICY ✓ PRO- JECT „✓ 00,000 LOC PRODUCTS-COMP/OPAGG S4.O, M"f'HEIR 6 A AUTOMOBILE LIABILITY PSB0007910 10/1/2018 10/1/2019 0O"^"B"NFnSINGI•"F'LCMIT 000,00 62,0 „CEI Arl"Vdorlt) ., 0 ANY AUTO Included in General BODILY INJURY(Per person) $ OWNED SCHEDULED Liability BODILY INJURY(Peraccidenl) $ AUTOS ONLY AUTOS ...,, HIRED NON-OWNED PROPERTY DAMAGE $ ✓ AUTOS ONLY AUTOS ONLY 4Pepr+l'M''�'�dC ron;p $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED... RETENTIONS $„ WORKERS COMPENSATION OTH- 1 AND EMPLOYERS'LIABILITY Y/N I FCr(.('I L ER ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT 5 OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E L DISEASE EA EMPLOYEE'. S If yes,describe under DESCRIPTION OF OPERATIONS below E L,DISEASE-POLICY LIMIT $ A Professional Liability RDP0034054 10/1/2018 10/1/2019 $1,000,000 Each Claim Claims-Made $2,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is an Additional Insured with respect to General Liability(GL),but only when required by written contract with the Insured prior to an ocCurrence as per Endorsement noted above.GL includes Separation of Insureds and Contractual Liability'per limitations in the BusinessOwners' Coverage form. Coverage is sub)ecl to all policy terms,cond'It'iwis,Limitations and exclusions.30 Day Notice of Cancellation/10 Days for Non-Payment in accordance with:policy provisions, CERTIFICATE HOLDER CANCELLATION PW 18-20:California Street Storm Design Cit Qj EG Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE ✓. (AVC)Alicia K. Igram ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 44760319 1 10/18-19 GL/PL Tracy Lund i 10/4/2018 3:52:59 PV, (PDT) i Page 1 of 2 Policy Number:PSB0007910 RLI Insurance Company Named Insured:Lund and Associates Engineering, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. RLIPack° FOR PROFESSIONALS SCHEDULED ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM—SECTION II— LIABILITY Schedule Name of Person(s) or Organization(s) City of EI Segundo 1. SECTION II C. Who Is An Insured is amended to primary basis, or a primary and non-contributory include as an additional insured the person or basis, this insurance is primary to other insurance organization shown in the schedule above, but only that is available to such additional insured which with respect to liability for "bodily injury", "property covers such additional insured as a named insured, damage" or "personal and advertising injury" and we will not share with that other insurance, caused in whole or in part by you or those acting on provided that: your behalf: a. The "bodily injury" or "property damage" for a. In the performance of your ongoing operations; which coverage is sought occurs after you have b. In connection with premises owned by or rented entered into that contract or agreement; or to you; or b. The "personal and advertising injury" for which c. In connection with "your work" and included coverage is sought arises out of an offense within the "product-completed operations committed after you have entered into that hazard". contract or agreement. 2. The insurance provided to the additional insured by 4. The following is added to SECTION III K.2 Transfer this endorsement is limited as follows: of Rights of Recovery Against Others to Us — COMMON POLICY CONDITIONS (BUT a. This insurance does not apply to the rendering APPLICABLE TO SECTION I — PROPERTY AND of or failure to render any "professional SECTION II— LIABILITY) services" We waive any rights of recovery we may have b. This endorsement does not increase any of the against any person or organization because of limits of insurance stated in D. Liability And payments we make for "bodily injury", "property Medical Expenses Limits of Insurance. damage" or "personal and advertising injury" arising 3. The following is added to SECTION III H.2. Other out of "your work" performed by you, or on your Insurance — COMMON POLICY CONDITIONS behalf, under a contract or agreement with that (BUT APPLICABLE ONLY TO SECTION II — person or organization. We waive these rights only LIABILITY) where you have agreed to do so as part of a contract or agreement with such person or However, if you specifically agree in a contract or organization entered into by you before the "bodily agreement that the insurance provided to an injury" or"property damage" occurs, or the "personal additional insured under this policy must apply on a and advertising injury" offense is committed. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. Page 1 of 1 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION ........................ .......... ____"_. ................. ..w,...,..............W._................. .............,..... p�p li WARNING: FAILURE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINALPENALTIES CIVILAND I ), IN ADDITIONIPROVIDED FOR IN LABOR CODE § , . I affirm under penalty of perjury under the laws of California one of the following declarations: I (� 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 EI Segundo. Policy No. U 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 EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent ._.....— Phone# CZJ I 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 those provisiorm or the agreement ill automatically become void. Signature of Applicant Date5�/g p-1 Reviewed by: 1