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PROOF OF INSURANCE (2019 - 2019) CLOSED DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 11/29/2018 THIS CERTIFICATE TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS RTIDOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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 endorsernent(s). PRODUCER I C(yNfAel Aimee Guesno NAME; _ Cornerstone Specialty Insurance Services,Inc. IORESS: ONE (714)731-7700 PAX (714)731-7750 C No Ext): (AIC.NoE: 14252 Culver Drive,A299 aimee@corrlerstonespec(alty.com I INSURER(S)AFFORDING COVERAGE NAIC# Irvine CA 92604 I INSURER A: Travelers Property Casualty Cc 25674 INSURED I INSURER B; Travelers Casualty&Surety Co.Of America 31194 HAYER CONSULTANTS,INC. INSURER C: 4067 Hardwick St, V INSURER D: Q PNB 250INSURER E: Lakewood CA 90712 O INSURER F: 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 CONTRACTOR 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. 1ffsR• 1A1DDL SUBR ...... - PaLIcr EFF � POLICY EXPLIMITS TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR � SES a rronce) $ 1,000,000 X ADDT'L INSURED/PRIMARY MED EXP(Any one person) $ 5,000 A X BLNKT WVR OF SUBRO Y 680-2J009914-18 06/13/2018 06/13/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POCYH [g PRO- JECT F—] LOG PRODUCTS-COMP/OPAGG $ ,2,000,000 OTER. NUTOMOBILE LIABILITY _ 'U'M 1'7N�4GLE LIMIT $ INCLUDED .,w,_.. tta accrdedtlP ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED 4 AUTOS ONLY AUTOS Y 680-2J009914-18 06/13/2018 06/13/2019 BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPER'L'Y DAMAGE $ x AUTOS ONLY X AUTOS ONLY Per a'ecldenO X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB ��CLAIMS-MADE CUP-6536Y635-18 06/13/2018 06/13/2019 AGGREGATE $ 2,000,000 . DED ENTI RETON$ �� m... $ WORKERS COMPENSA nON I PER �ER """ AND EMPLOYERS'LIABILITY Y/N STATUTE V ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICERWeMBER EXCLUDED? El (Mandatory In NPG) EL.DISEASE-EA EMPLOYEE $ U' es,dcrwcrq",b'"�dar _.._........,. _.m_.. SCRIPI'ION QF O,1ERATtl4'.'tNS balow E.L DISEASE-POL'CY LIMIT .... EACH CLAIM $2,000,000 .m. PROFESSIONAL LIABILITY B Claims Made 106639088 12/01/2018 12I01I2019 ANNUAL AGGREGATE $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) City of EI Segundo 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 CAN'CELLA'TION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo-Attn:Building&Safety Department ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 680-2J009914-18 NAMED INSURED: Hayer Consultants,Inc. COMMERCIAL GENERAL LIABILITY 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 1. The following is added to SECTION II — WHO IS h. This insurance does not apply to "bodily AN INSURED: injury" or "property damage" caused by "your Any person or organization that you agree in a work" and included in the "products- „ "" written contract requiring Insurance to include as completed operations hazard" unless the an additional insured on this Coverage Part, but: "'written contract requiring insurance" specifically requires you to provide such a. Only with respect to liability for "bodily injury", coverage for that additional insured, and then "'property damage" or"personal injury"; and the insurance provided to the additional b. If, and only to the extent that, the injury or insured applies only to such "bodily injury" or damage is caused by acts or omissions of "property damage"that occurs before the end you or your subcontractor in the performance of the period of time for which the "written of "your work" to which the "written contract contract requiring insurance" requires you to requiring insurance applies, or in connection provide such coverage or the end of the with premises owned by or rented to you. policy period, whichever is earlier. The person or organization does not qualify as an 2. The following is added to Paragraph 4.a. of additional insured: SECTION IV -- COMMERCIAL GENERAL c. With respect to the independent acts or LIABILITY CONDITIONS: omissions of such person or organization; or The insurance provided to the additional insured d, For "bodily injury", "property damage" or is excess over any valid and collectible other "personal injury" for which such person or insurance, whether primary, excess, contingent or organization has assumed liability in a on any other basis, that is available to the additional insured for a loss we cover. However, if contract or agreement. you specifically agree in the "written contract The insurance provided to such additional insured requiring insurance" that this insurance provided is limited as follows: to the additional insured under this Coverage Part e. This insurance does not apply on any basis to must apply on a primary basis or a primary and non-contributory basis, this insurance is primary any person or organization far which to other insurance _available to the additional coverage as an additional insured specifically insured which covers that person or organizations is added by another endorsement to this as a named insured for such loss, and we will not Coverage Part, share with the other insurance, provided that: f, This insurance does not apply to the (1) The "bodily injury" or "property damage" for rendering of or failure to render any which coverage is sought occurs; and "professional services". In the event that the Limits of Insurance of the (2) The "personal injury" for which coverage is 9.' sought arises out of an offense committed; Coverage Part shown in the Declarations exceed the limits of liability required by the after you have signed that "written contract "written contract requiring insurance", the requiring insurance". But this insurance provided insurance provided to the additional insured to the additional insured still is excess over valid shall be limited to the limits of liability required and collectible other insurance, whether primary, by that "written contract requiring insurance". excess, contingent or on any other basis, that is This endorsement does not increase the available to the additional insured when that limits of insurance described in Section III — person or organization is an additional insured Limits Of Insurance. under any other insurance. CG D3 81 09 15 ©2015 The Travelers Indemnity Company.All rights reserved, Page 1 of 2 Includes the copyrighted rnatoriai of Insurance services Office,Inc,„Mh Its permission COMMERCIAL GENERAL LIABILITY 3. The following is added to Paragraph 8., Transfer 4. The following definition is added to the Of Rights Of Recovery Against Others To Us, DEFINITIONS Section: of SECTION IV — COMMERCIAL GENERAL "Written contract requiring insurance" means that LIABILITY CONDITIONS: part of any written contract under which you are We waive any right of recovery we may have required to include a person or organization as an against any person or organization because of additional insured on this Coverage Part, payments we make for "bodily injury". '"property provided that the "bodily injury" and "property damage" or "personal injury" arising out of "your damage" occurs and the "personal Injury" is work" performed by you, or on your behalf, done caused by an offense committed: tinder a "written contract requiring insurance"with that person or organization. We waive this right a. After you have signed that written contract; only where you have agreed to do so as part of b. While that part of the written contract is in the "written contract requiring insurance" with effect: and such person or organization signed by you before, and in effect when, the "bodily injury" or c. Before the end of the policy period. "property damage" occurs, or the"personal injury" offense is committed. Page 2 of 2 0 2015,The Travelers indemnity Company.All rights reserved. CG D3 8109 15 Includes the copyrighted material of insurance Services Office, Inc.,with Us permission POLICYHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 a CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 09-05-2018 GROUP: POLICY NUMBER: 9100543-2018 CERTIFICATE ID: 17 CERTIFICATE EXPIRES: 05-24-2019 OS-24-2018/05-24-2019 CITY OF EL SEGUNDO SC 350 MAIN ST 05-24-2018 EL SEGUNDO CA 90245-3813 HO This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the pos icy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Ito, +«w le ,W� �crrt c.a Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1550 - JASVINDER KAUR PRESIDENT - EXCLUDED. ENDORSEMENT #1650 - NAVDEEP KAUR SEC,TRES - EXCLUDED. EMPLOYER HAYER CONSULTANTS, INC. SC 4067 HARDWICK ST PMB 250 LAKEWOOD CA 90712 [P15,HO] (REV.7-2014) PRINTED 09-05-2018 POLICYHOLDER COPY Sc P.O. BOX 8192, PLEASANTON, CA 94588 ■ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 09-06-2018 GROUP: POLICY NUMBER: 9100543-2018 CERTIFICATE ID: 18 CERTIFICATE EXPIRES: 05-24-2019 05-24-2018/05-24-2019 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 17 DATED 09-05-2018 CITY OF EL SEGUNDO SC 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the poiwcy listed herein, hvvvithsGanding any requirement, term or condition of any contract or other document with respect to which this cerlificaie of insurance may be issued or to which it may pertain, the insurance afforded by the ,policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-09-06 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2018-09-08 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO ENDORSEMENT #1650 - JASVINDER KAUR PRESIDENT - EXCLUDED. ENDORSEMENT #1650 - NAVDEEP KAUR SEC,TRES - EXCLUDED. EMPLOYER HAYER CONSULTANTS, INC. SC 4067 HARDWICK ST PMB 250 LAKEWOOD CA 90712 [MBQ,CN] (REV.7-2014) PRINTED 09-06-2018 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advisedthat a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to, maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5, 000 . 00 Sample Rate : 13 .300 Regular Premium equals : $ 665 . 00 Surcharge: 3 . 00-0. Additional Waiver charge: $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95)