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PROOF OF INSURANCE (2020) CLOSED' 0 I DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/22/2019 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(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 endorsement(s). PRODUCER. .... CONTACT Tina Cowie NAME; Cornerstone Specialty Insurance Services, Inc. PHO N , E10: (714) 731-7700 (AIC, Nc mm (714) 731-7750 14252 Culver Drive, A299 EMAIL tina@cornerstonespecialty.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Irvine CA 92604 INSURERA : Travelers Indemnity Cc of Conn 25682 _.... _ .................. INSURED INSURER B : Travelers Indemnity Company JASON ADDISON SMITH CONSULTING SERVICES, INC., INSURER C: Travelers Property Casualty Co 25674 DBA: JAS PACIFIC INSURER D Continental Casualty Company 20443 P.O., BOX 2002 INSURER E: Upland CA 91786 INSURER F: COVERAGES CERTIFICATE NUMBER: 19/20 CERTS REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 .......... AUDL"S'UBRPOLICY LTR TYPE OF INSURANCE INS_D WVD POLICY NUMBER EFF POLICY EXP _(MMIDDIYYYY) EMWDDAYYYY) LIMITS COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE � $ 1,000,000 CLAIMS -MADE ,X OCCUR C � TA�°4 � RENTED PRFMa1, 5�ES IE'a mc�wro wMl? $ 1,000,000 X ADDITIONAL INSURED MED EXP Any one person) $ 5,000 A BLNKT WVR OF SUBRO 680-1H359042 08/08/2019 08/08/20201,000,000 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMITAPPLIES PER:GENERALAG GREGATE $ 2,000,000 POLICY JECT ❑LOC PRODUCTS- OMP/OPA I C GG $ 2,000,000 OTHER:6 AUTOMOBILE LIABILITY ._. COMBINED O aB.INEDroIySINGLE: I.IMll $ 1,000,000.......... X'ANY AUTO 1 BODILY INJURY (Per person) $ ._... A OWNED SCHEDULED BA-OC906515 08/08/2019 08/08/2020 BODILY INJURY (Per accident) AUTOS ONLY HIRED AUTOS NON -OWNED (PERTY DAMAGE •••-� $ AUTOS ONLY AUTOS ONLY a' tlF'er G;a;dt)enfy� _ _ �- Medical payments $ 5,000 Xi UMBRELLA LIAB X OCCUR _ EACH OCCURRENCE m........... $ 5,000,000 .._.._. B EXCESS LIAB ® CLAIMS -MADE CUP -3429T370 08/08/2019 08/0812020 AGGREGATE $ 5,000,000 I DED N RETENTION $ $ N _...._.... WORKERS COMPENSATION �._ PER OTH- X STATUTE G ER _ AND EMPLOYERS' LIABILITY Y/ N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE C N NIA XJUB-3642T261 � 08/08/2019 08/08/2020 EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT $ 1,000.000 Each Claim $2,000,000 Professional Liability D AEH114007309 08/08/2019 08/08/2020 Annual Aggregate $2,000,000 Claims Made ......... ......_ 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 ld� d�l9 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 680-1 H359042 COMMERCIAL GENERAL LIABILFFY NAMED INSURED: Jason Addison Smith POLICY PERIOD: 8/8/2019 to Consulting Services, Inc. dba JAS Pacific 8/8/2020 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 (Section II): Any person or organization that you agree in a "contract or agreement requiring insurance" to in- clude as an additional insured on this Coverage Part, but only with respect to liability for "bodily in- jury", "property damage" or "personal injury" caused, in whole or in part, by your acts or omis- sions or the acts or omissions of those acting on your behalf: a. In the performance of your ongoing opera- tions; b. In connection with premises owned by or rented to you; or c. In connection with "your work" and included within the "products -completed operations hazard". Such person or organization does not qualify as an additional insured for "bodily injury", "property damage" or "personal injury" for which that per- son or organization has assumed liability in a con- tract or agreement. The insurance provided to such additional insured is limited as follows: d. This insurance does not apply on any basis to any person or organization for which cover- age as an additional insured specifically is added by another endorsement to this Cover- age Part. e. This insurance does not apply to the render- ing of or failure to render any "professional services". f. The limits of insurance afforded to the addi- tional insured shall be the limits which you agreed in that "contract or agreement requir- ing insurance" to provide for that additional insured, or the limits shown in the Declara- tions for this Coverage Part, whichever are less. This endorsement does not increase the limits of insurance stated in the LIMITS OF INSURANCE (Section III) for this Coverage Part. B. The following is added to Paragraph a. of 4. Other Insurance in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): However, if you specifically agree in a "contract or agreement requiring insurance" that the insurance provided to an additional insured under this Cov- erage Part must apply on a primary basis, or a primary and non-contributory basis, this insurance is primary to other insurance that is available to such additional insured which covers such addi- tional insured as a named insured, and we will not share with the other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal injury" for which coverage is sought arises out of an offense committed; after you have entered into that "contract or agreement requiring insurance". But this insur- ance still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the insured when the insured is an additional insured under any other insurance. C. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us in COMMERCIAL GENERAL LIABILITY CON- DITIONS (Section IV): We waive any rights of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" performed by you, or on your behalf, under a "contract or agreement requiring insurance" with that person or organization. We waive these rights only where you have agreed to do so as part of the "contract or agreement requiring insur- ance" with such person or organization entered 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 darnage" occurs, or the "per- sonal injury" offense is committed. D. The following definition is added to DEFINITIONS (Section V): "Contract or agreement requiring insurance" means that part of any contract or agreement un- der which you are required to include a person or organization as an additional insured an this Cov- erage Part, provided that the "bodily injury" and "property damage" occurs, and the "personal in- jury" is caused by an offense committed: a. After you have entered into that contract or agreement; b. While that part of the contract or agreement is in effect-, and c. Before the end of the policy period. Page 2 of 2 @The Travelers Companies, Inc. CG D3 89109 07 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//8/2019 to 8/8/2020 1117111-MMATT, �-Mf - 13 -IMTAT-�- - M 43i Illi 1: C = Z 1,T,602 W11 =1 1jZ"*1WF Witih respect to coverage provided by this endome. merit, the provisions of the Coverage Foun apply unless motlifled by the endorsement The forllov4ng is added to the Settion 11 — Liability Caverage, Paragraph A.1. Who Is An Insured Fln vision: Any person or organizallon that you are requiired to [01011f, U1z:kw-1 W-11 I a wMen contract or agreement that Is signed 1 4- 0 w M& an 'Insured' under the Who Is An Insured contained in Sec-6on 111, CA T4 37 08 48 0 MOB Die TrsvelWai CamWiar., ho, Page 1 01' 1 INSURED: Jason Addison Smith Consulting Services, Inc. dba JAS Pacific POLICY DATES: 8/8/2019 to 8/8/2020 WORKERS COMPENSATION 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.