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PROOF OF INSURANCE (2019) CLOSED C CERTIFICATE OF LIABILITY INSURANCE I ®ATE`M 07/199/2018/2016 THIS CERTIFICATE IS ISSUED ASA 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. R 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 Tina Cowie NAME: rW. -- '- ............. FAX �1PAH,1_C0 _,.rE 714 731-7700 (714)731-7750 Cornerstone Specialty Insurance Services,Inc NExet ( ) (,Arc,m. W............. 14252 Culver Drive,A299 AILtina@cornerstonespecialty coDRESS. INSURER(S)AFFORDING COVERAGE NAIC N CA 92604 Travelers IndemnityCo of Conn 25682 Irvine INSURERA: INSURED INSURER B: Travelers Indemnity Company JASON ADDISON SMITH CONSULTING SERVICES,INC, INSURER C: Travelers Property Casualty Co 25674 DBA:JAS PACIFIC d INSURER D: Continental Casualty Company 20443 P.O. BOX 2002INSURER E: Upland CA 91786 INSURER F: e COVERAGES CERTIFICATE NUMBER: 18/19 COVERAGES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 AD0U'50gt1"""'"'"" POLICY NUMBER .. POLICY YIYEFF M Pd BUYExp -- OLII.'�'EkP LIMITS LTR .... 'INSO WVD ................. ._.� MIDDIYYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �............. �r DAMAGE TO RFNTFtS"" .,., ADDITIONAL INSURED OCCUR I PREMISES $ 1,000,000 !tllNlr,-KWNr",17f:: /^ti�� ......._,... ry D MED EXP(Any one person) $ 5,000 A BLNKTWVROFSUBRO 680-1H359042 08/08/2018 08/08/2019 IPERS014ALBADV INJURY S 1,000,000 2'000,000 l EV,R.f1G'S„3AEI:�A7 E'IJrAII'AP'�PI.FS a E.'R GENERALAGGREGATE 5 mm..._ T P Liw.y ® �.r r10Cr, s-COMP/oPAGG s 2,000,000 M+P�,I' AUTOMOBILE LIABILITY p ye Benefits s 1,000,000 w. W. . .m_ �................_ FEmto OMSINEDSINr, Eh,1MIT $ 1,000,000 I I, :a fa�rcndentY -X ANY AUTO BODILY INJURY(Per person) s A " "" OWNED SCHEDULED BA-OC906515 08/08/2018 08/08/2019 BODILY INJURY(Per accident) $ ,_,,,,,_, AUTOS ONLY AUTOS HIRED NON-OWNED ;' $ . pi rw D 4f✓➢r"E r,,�^ p:�ROP +"""� AUTOS ONLY AUTOS ONLY s 'air'"dr,,n99 MedicaI payments s 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 5 5,000,000 B EXCESS LIABCLAIMS-MADE CUP-3429T370 08/08/2018 08/08/2019 AGGREGATE s 5,000,000 RETENTION$ _ $ ` WORKERS COMPENSATION PER (JCI-i AND EMPLOYERS'LIABILITY YIN STATUTE ER 0 ANY(Mandatary in N PROPRIETOR/PARTNER/EXECUTIVE NIA XJUB-3642T261 08/08/2018 08/08/2019 E "� E L D SEASECIEA EMPLOYEE DENT $ 1 000,000 pFFICER/ R EXCLUDED? S 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ Each Claim $2,000,000 Professional Liability D Claims Made AEH114007309 08/08/2018 08/08/2019 Annual Aggregate $2,000,000 tl 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 CERTIFICATE HOLDER 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, 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 `ddm-t I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 680-1H359042 COMMERCIAL GENERAL LIABILITY NAMED INSURED: Jason Addison Smith POLICY PERIOD: 8/8/2018 to Consulting Services, Inc. dba JAS Pacific 8/8/2019 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 INSURANCE (Section 111) for this Coverage (Section 11): Part. Any person or organization that you agree in a B. The following is added to Paragraph a. of 4. "contract or agreement requiring insurance"to in- Other Insurance in COMMERCIAL GENERAL clude as an additional insured on this Coverage LIABILITY CONDITIONS(Section IV): Part, but only with respect to liability for"bodily in- However, if you specifically agree in a"contract or jury", "property damage" or "personal injury" agreement requiring insurance"that the insurance caused, in whole or in part, by your acts or omis- provided to an additional insured under this Cov- sions or the acts or omissions of those acting on erage Part must apply on a primary basis, or a your behalf: primary and non-contributory basis,this insurance a. In the performance of your ongoing opera- is primary to other insurance that is available to tions; such additional insured which covers such addi- b. In connection with premises owned by or tional insured as a named insured, and we will not rented to you;or share with the other insurance, provided that: c. In connection with "your work" and included (1) The "bodily injury" or "property damage" for within the "products-completed operations which coverage is sought occurs; and hazard". (2) The "personal injury" for which coverage is Such person or organization does not qualify as sought arises out of an offense committed,- an ommitted;an additional insured for "bodily injury", "property after you have entered into that "contract or damage" or "personal injury" for which that per- agreement requiring insurance". But this insur- son or organization has assumed liability in a con- ance still is excess over valid and collectible other tract or agreement. insurance, whether primary, excess, contingent or The insurance provided to such additional insured on any other basis,that is available to the insured is limited as follows: when the insured is an additional insured under d. This insurance does not apply on any basis to any other insurance. any person or organization for which cover- C. The following is added to Paragraph 8. Transfer age as an additional insured specifically is Of Rights Of Recovery Against Others To Us added by another endorsement to this Cover- in COMMERCIAL GENERAL LIABILITY CON- age Part. DITIONS(Section IV): e. This insurance does not apply to the render- We waive any rights of recovery we may have ing of or failure to render any "professional against any person or organization because of services". payments we make for "bodily injury", "property f. The limits of insurance afforded to the addi- damage" or "personal injury" arising out of"your tional insured shall be the limits which you work" performed by you, or on your behalf, under agreed in that "contract or agreement requir- a "contract or agreement requiring insurance"with ing insurance" to provide for that additional that person or organization. We waive these insured, or the limits shown in the Declara- rights only where you have agreed to do so as tions for this Coverage Part, whichever are part of the"contract or agreement requiring insur- less. This endorsement does not increase the ance" with such person or organization entered limits of insurance stated in the LIMITS OF into by you before, and in effect when, the "bodily Page 1 oft ©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- nra]e Pan, provided that the ^uogUy injury" and suna|injury"offense iscommitted. "property damage" occurs, and the "personal in' 0. The following definition isadded tuDEFINITIONS jury"iscaused hyonoffense committed: (Section V): m. After you have entered into that contract or "Contract or agreementrequiting insurance" agreement; means that part o/any contract o,agreement un- b' While that part nfthe contract o,agreement is der which you are required toinclude aperson or ineffect; and organization osanadditional insured onthis Cm+ c. Before the end ofthe policy period. Page 2of2 @TheTravelers Companies,Inc CGD38g1OgO7 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//8/2018 to 8/8/2019 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY_ BLANKET ADDITIONAL INSURED This endorsement noddies insurance provided under the following_ BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorse- a written contract or agreement that is Signed and merit the provisions of the Coverage Form apply executed by you before the"bodily injury"or"properly unless modified by the endorsement damage'occurs and that is in effect during the poky The following is added to the 8oction II —Liability fo od is an damages to which this insud'for trance appliltly esandand only Coverage, Paragraph A.1.Who Is An Insured Pro- to the extent that person or organization qualifies as vision: an 'insured" under the Who Is An Insured provision Any person or organization That you are required Io contained in Section If. include as additional insured on the Coverage Form in CA T4 37 08 08 02oDB The Travelens Companies,Inc Page 1 of 1 w INSURED: Jason Addison Smith POLICY DATES: 8/8/2018 to 8/8/2019 Consulting Services, Inc. dba JAS Pacific JrAM WORKERS COMPENSATION T V' ELERS' AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 (00) - 001 POLICY NUMBER: XJUB-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.