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PROOF OF INSURANCE (2019 - 2019) CLOSED DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/11/2018 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 CONTACTIAlison Olsen Dealey, Renton &Associates PHONE' FAX 510-465 3D90 N4 5,10-452-2193 P. O. Box 12675 (wc,NQ,ext): 1' E-MAIL Oakland, CA 94604-2675 ADDRESS, Insurance.Certificates@l,)e1qleyrenton,com License#0020739 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A Travelers Property Casualty Co of Anted 25674 INSURED 4 t.a\t t RI,OR INSURER B:XL Specialty Insurance Co. 37885 KOA Corporation 1100 Corporate Center Dr#201 INSURER c Monterey Park, CA 91754 INSURER D: 323-260-4703 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:417793579 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 1N.Sn SvLr�n POLICYNUMBER IMMIDDY/YYYYI IMMIDD/YYYY) LIMITS EFF POLICY EXP LTR „.., A X COMMERCIAL GENERAL LIABILITY Y Y 680BH966428 3/13/2018 3/13/2019 EACH OCCURRENCE S2 000.000 ' e"3&'4M k+GF 1'd:'M RF N?i'I-W1 CLAIMS-MADE X OCCUR PREMISEF,E�}dai:Cw"'+nsrrrt4 $1.000.000 X Contractual Liab MED EXP(Any one person) S10 000 X XCU Included PERSONAL&ADV INJURY „S 2000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 54,000,000 POLICY X iJ"G 1�: yCC PRODUCTS-COMP/OPAGG $4,000,000 $ 7'T B-IE CaE,s wr i ride r)i A AUTOMOBILE LIABILITY BA2A439568 3(13(2018 3/1312019 iEa Iii,den5'I We;dl.r Lp'lulN'7 S1,000,000 o X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED 5,"ioOEHi1,&"I�AMAC,,E S X AUTOS ONLY X AUTOS ONLY IIPer arcidunil S A X UMBRELLA LIAB X OCCUR CUP6464YO33 3/13/2018 3/1312019 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE S 5,000,000 DED X RETENTION S n $ A WORKERS COMPENSATION Y UB21_459350 9/19/2016 9/19/2019 X Pq,EgTU7E LJIY IItl AND EMPLOYERS'LIABILITY - ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1„000.000 B Professional Liability DPR9922841 3/13/2018 3/13/2019 per Claim :',t?Uor,rJi/a 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,/Narne':JB86053 EI Segundo On Call CM&Inspection Service 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 PnlTtarydNon-Contributory per poltcy forin wording. 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. Attn: Orlando Rodriguez 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245-3813 a ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NUMBER:68081-1966428 ISSUE DATE: 9/11/2018 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 Attn: Orlando Rodriguez 350 Main Street EI Segundo CA 90245-3813 PROJECT/LOCATION OF COVERED OPERATIONS: KOA Job No./Name: JB86053 EI Segundo On Call CM & Inspection Service-- 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 omis- 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- ry" is caused by an offense committed: after you have signed that "written contract requir- 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 ©2015 The Travelers Indemnity Company. All rights reserved. CG D3 82 09 15 Includes the copyrighted material of Insurance Services Office, Inc.,with its permission 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 u 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 SUBR,OGATION 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. 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: JB86053 EI Segundo On Call CM & Inspection Service-- 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 RAVELES I WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76(00)—001 POLICY NUMBER: U1321-459350 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 3.00 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS OR ORGANIZATIONS THAT ARE PARTIE TO A CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT, PROVIDED YOU EXECUTED THE CONTRACT BEFORE THE LOSS. DATE OF ISSUE: 9/11/2018 ST ASSIGN: CA 017106