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PROOF OF INSURANCE (2019 - 2020) CLOSEDKOSM&AS-01TERNBERO DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8/22/2019_ 111111111-1-1-........... 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). .... _......................... M�artin� PRODUCER T License # OC36891 _ cr'Brett R Sternberg Ldd Company PHONE 20.:..t� 10) 478-2625 31.7_ ...................... 1..)............................... y30 0 y Ventura Blvd. Suite 340 Woodland Hills, CA 91364 E' I kare I dd martin.com DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ACOR'D 101, Additional Remarks Schedule, may be attached if more apace is required) The City, its officials, and employees are name additional insured per written contract - the Insurance Is primary and non-contributory - see attached Business Liability Form CERTIFICATE HOLDER f•71�LI[+R4xW_11%lrr7h1 Jn/ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Segundo Planning & Building Safe Det THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 9 9 ty P ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo 90245-3813 --• AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD INSURERS) AFFORDIN,G,,,C,O,VERAGE­11111111111.1 NAIC # -- .....,, _ .... ... ............., ........, .......... INSURER A: Sentinel Insurance Company, Ltd .._...... 11000 INSURED INSURERS: Kosmont & Associates, Inc. INSURER C: Dba: Kosmont Companies 1601 N. Sepulveda Blvd. #382 JmURER..P11: ............................___._ ..__. Manhattan Beach, CA 90266 .INSPRER..E.: ................. INSURERF: : . .......... COVERAGES __ ............... RTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES 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 POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLAIMS. INSR ADDL�SUBR POLICY NUMBER LTR TYPE OF INSURANCE.............................._.i,ISD WW ............................ CYEFF....,/�DIVYYYLL.... P POLICY EXP LIMITS tlY! p�1CL RA LIABILITY A X COMMERCIAL GENERAL EACH OCCURRENCE $ 1,O , 00 CLAIMS -MADE OCCUR 72SBABC3942 uX X __ TO 6/27/2019 6/27/202 $ 1 ....... .................... MEDEXP nvonle person)m .'0,10,000 1,000,000 _ 2,000 000 GENL AGGRECATE LIMIT APPLIES PER GENERAL AGGREGATE $, X �OTHER: JE T.......,.❑ LOC PRODUCTS - COMP/OP AGG,._......................__••...._2,0.0.0,'000 ....._................... COMBINED SINGLE: LIMP 1,000,000A AUTOMOBILEABILITY ANY AUTO 72SBABC3942 YY 6/27/2019 6/27/2020 BOlILINJuRY(PerPeD) 'SCHEDULED OWNED ULED AOSONLY BODILYINJUR, eraci ent NON- WNEpp AUTOS , _..... R0PcdTOMAGEX $X o ONLY AUTO) ...... ( q $ UMBRELLA AB X.1 OCCUR 3,000,0001 EXCESS CLAIMS -MADE X X72SBABC3942 S ..EAC....H .,.Cw^,R,,.R.^.E...N...C..E.._......__.....$ 6/27/2019 6/27/2020 AGGREGATE $ 3,000,0001 DED XII RETENTION $ 10,000 $ WORKERS COMPENSATION PEROTH- 9TATOT FR AND EMPLOYERS' LIABILITY YIN ...... ........f. ANY ECUTIVE L' ...E ..-H ACCIDENT $ .......................... OFFICER/MEI BER/EXCLUDED7 .............. NIA (Mandatory in NH) L. DISE�ASENT P EMPLOYEE $ ., ....... If yes, describe under _... . ._. DESCRIPTION OF OPERATIONS below E1 DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ACOR'D 101, Additional Remarks Schedule, may be attached if more apace is required) The City, its officials, and employees are name additional insured per written contract - the Insurance Is primary and non-contributory - see attached Business Liability Form CERTIFICATE HOLDER f•71�LI[+R4xW_11%lrr7h1 Jn/ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Segundo Planning & Building Safe Det THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 9 9 ty P ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo 90245-3813 --• AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", "volunteer workers", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). b. Real Estate Manager Any person (other than your "employee" or "volunteer worker"), or any organization while acting as your real estate manager. c. Temporary Custodians Of Your Property Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of that property; and (2) Until your legal representative has been appointed. d. Legal Representative If You Die Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this insurance. e. Unnamed Subsidiary Any subsidiary and subsidiary thereof, of yours which is a legally incorporated entity of which you own a financial interest of more than 50% of the voting stock on the effective date of this Coverage Part. The insurance afforded herein for any subsidiary not shown in the Declarations as a named insured does not apply to injury or damage with respect to which an insured under this insurance is also an insured under another policy or would be an insured under such policy but for its termination or upon the exhaustion of its limits of insurance. 3. Newly Acquired Or Formed Organization Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain financial interest of more than 50% of the voting stock, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; and Form SS 00 08 04 05 BUSINESS LIABILITY COVERAGE FORM b. Coverage under this provision does not apply to: (1) "Bodily injury" or "property damage" that occurred; or (2) "Personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. 4. Operator Of Mobile Equipment With respect to "mobile equipment" registered in your name under any motor vehicle registration law, any person is an insured while driving such equipment along a public highway with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the equipment, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to: a. "Bodily injury" to a co -"employee" of the person driving the equipment; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 5. Operator of Nonowned Watercraft With respect to watercraft you do not own that is less than 51 feet long and is not being used to carry persons for a charge, any person is an insured while operating such watercraft with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the watercraft, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to: a. "Bodily injury" to a co -"employee" of the person operating the watercraft; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 6.. Addltionat Insureds „Whe'nRequired ,By Wrlttbn Contract; WdI1 ensu Agt+eernenf." Permit The, person(s) or, organization(s)i,ldentifred, In Paragraphs a'. 'through: f beloWw ,,additional insureds when yow,,h'ave agreed in r'a'„written /(X Page 11 of 24 BUSINESS LIABILITY COVERAGE FORM contract; "wriHen' agreemente,,.or because of a (e) Any failure to make such perMit' issues by a state 'or political' inspections, adjustments, tests or subdiWsior>i '' hat such person; or organization! servicing as the vendor has be a as ani additbntit I'° insured on your agreed to make or normally Policy, provided the ' injury 'or damage occurs undertakes to make in the usual subsequent, ,to the execution of the contract or course of business, in connection agreement, 'or the,issuance of the permit. with the distribution or sale of the A person or '°' organization is an additional products; insured 11;, under "this, provision only for that (f) Demonstration, installation, period;"; :oftime i, required by the contract, servicing or repair operations, agreementorpermit. except such operations performed However, no such person or organization is an at the vendor's premises inconnection additional insured under this provision if such with the sale of the person or organization is included as an product; additional insured by an endorsement issued (g) Products which, after distribution by us and made a part of this Coverage Part, or sale by you, have been labeled including all persons or organizations added or relabeled or used as a as additional insureds under the specific container, part or ingredient of any additional insured coverage grants in Section other thing or substance by or for F. — Optional Additional Insured Coverages. the vendor; or a. Vendors (h) "Bodily injury" or "property Any person(s) or organization(s) (referred to damage" arising out of the sole below as vendor), but only with respect to negligence of the vendor for its "bodily injury" or "property damage" arising own acts or omissions or those of out of "your products" which are distributed its employees or anyone else or sold in the regular course of the vendor's ev acting on its behalf. However, this business and only if this Coverage Part exclusion does not apply provides coverage for "bodily injury" or (i) The exceptions contained in "property damage" included within the() Subparagraphs d or or (f1; "products -completed operations hazard". (ii) Such inspections, adjustments, (1) The insurance afforded to the vendor tests or servicing as the vendor is subject to the following additional has agreed to make or normally exclusions: undertakes to make in the usual This insurance does not apply to: course of business, in connection with the distribution (a) "Bodily injury" or "property or sale of the products. damage" for which the vendor is (2) This insurance does not apply to any obligated to pay damages by insured person or organization from reason of the assumption of whom you have acquired such products, liability in a contract or agreement. or any ingredient, part or container, This exclusion does not apply to entering into, accompanying or liability for damages that the containing such products. vendor would have in the absence of the contract or agreement; b. Lessors Of Equipment (b) Any express warranty (1) Any person or organization from unauthorized by you; whom you lease equipment; but only (c) Any physical or chemical change with respect to their liability for "bodily "property in the product made intentionally injury", damage" or "personal by the vendor; and advertising injury" caused, in whole or in part, by your (d) Repackaging, except when maintenance, operation or use of unpacked solely for the purpose of equipment leased to you by such inspection, demonstration, testing, person or organization. or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container: Page 12 of 24 Form SS 00 08 04 05 (6) When You Are Added As An Additional Insured To Other Insurance That is other insurance available to you covering liability for damages arising out of the premises or operations, or products and completed operations, for which you have been added as an additional insured by that insurance; or (7) When You Add Others As An Additional Insured To This Insurance That is other insurance available to an additional insured. However, the following provisions apply to other insurance available to any person or organization who is an additional insured under this Coverage Part: (a) Primary Insurance When Required By Contract This insurance is primary if you have agreed in a written contract, written agreement or permit that this insurance be primary. If other insurance is also primary, we will share with all that other insurance by the method described in c. below. (b) Primary And Non -Contributory To Other Insurance When Required By Contract If you have agreed in a written contract, written agreement or permit that this insurance is primary and non-contributory with the additional insured's own insurance, this insurance is primary and we will not seek contribution from that other insurance. Paragraphs (a) and (b) do not apply to other insurance to which the additional insured has been added as an additional insured. When this insurance is excess, we will have no duty under this Coverage Part to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. BUSINESS LIABILITY COVERAGE FORM When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (2) The total of all deductible and self- insured amounts under all that other insurance. We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Method Of Sharing If all the other insurance permits contribution by equal shares, we will follow this method also. Under this approach, each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. 8. Transfer Of Rights Of Recovery Against Others To Us a. Transfer Of Rights Of Recovery If the insured has rights to recover all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. This condition does not apply to Medical Expenses Coverage. b. Waiver Of Rights, Of Recovery° (Waiver Of Subrogation) If the insured has waived any rights of recovery against any person or otbanhMdr ri'a6 a OAK,,mf':aoi nt, including Supplementary. ,Payments,we have made under this Coverage Part, we also waive that right, provided the. Insured waived their rights of recovery, against such person or organization in a contract, agreement or permit that was executed prior to the injury or damage. Form SS 00 08 04 05 Page 17 of 24 o''#C7tr7R" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) fir■,..✓' 08/26/2019 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(ies) must 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 Rick Powell NAME:.... Rick Powell Insurance Agency, LlcC Mo EM); (818) 861-7440 (AdC Nol; (760).804-9710 3500 West Olive Ave, Suite 300 �Aii E$S; rdck insurance4ca.com Burbank, CA 91505 INSURER(S) AFFORDING, COVERAGE NAIC # Phone (818) 861-7440 Fax (760) 804-9710 INSURER A: HISCOX INSURANCE COMPANY INC. 110200 INSURED INSURER 6: Kosmont & Associates, Inc. dba Kosmont Companies INSURER C: 1601 N Sepulveda Blvd #382 INSURER D: INSURER E: Manhattan Beach CA 90266 INSURERF: 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 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 WVDSUBR POLICY EFF POLICY EXP ILT..............._..ITIT^^ITIT TYPE OP INSURANCE A L POLICYNU (MMIDDIYYYYI IMMIDD/YYYYI LIMITS ❑ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ F-1CLAIMS-MADE F-1OCCUR„PREMISE,$E a occuE once,) „$ ❑ ,MED EXP (Ani„ one person) $ ElPERSONA ................ .. ..................AL & ADV INJURY ..... S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ❑ POLICY ❑ jE O- 11 LOC PRODUCTS - COMP/OP AGG $ ❑ OTHER $ AUTOMOBILE LIABILITY EOMaBINEDiSINGLE LIMIT ( $ ❑ ANY AUTO BODILY INJURY (Per person) „ $ ❑ ALL OWNED SCHEDULED ❑ BODILY INJURY (Per accident) $ AUTOS AUTOS HIREDAUTOS NON -OWNED F-1❑ AUTOS TY DAMAGE (Per accident) ( $ ❑ ❑ $ ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE S ❑ EXCESS LIAB ❑ CLAIMS -MADE AGGREGATE $ DED„ El RETENTION$ $ ...., 'El WORKERS COMPENSATION ❑ OTTH- ❑ PER AND EMPLOYERS' LIABILITY Y / N ANY PRC„PIR'IETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA — (Mandatory In NHI E.,L. USEASE - E4 EMPLOYEE S If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ A Errors & Omissions Coverage Y MPL1425837.19 03/15/2019 03/15/2020 $2,000,000/$2,000,000 Per Claim/Aggregate .......... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER EI Segundo Planning & Building Safety Dept 350 Main Street El Segundo, CA 90245-3813 .._. ................................... ......... ACORD 25 (2014/01) QF CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 71,;1 ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DATE (MM/DD/YYYY) C>R"� CERTIFICATE OF LIABILITY INSURANCE Acct#: 1171322 I 8/26/20'19 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 CONTACT 888-828-8365 Lockton Companies, LLC PHONE FAX 5847 San Felipe, Suite 320(n/.. ryq,.5titlr AVC, Not: E-MAIL Houston, TX 77057 APPL'3E5 : DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Notice to Others Endorsement Included WAIVER OF SUBROGATION IN FAVOR OF CITY OF EL SEGUNDO WHEN REQUIRED BY WRITTEN CONTRACT CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF EL SEGUNDO AUTHORIZED REPRESENTATIVE ATTENTION: GREGG MCCLAIN, PLANNING MANAGER 350 MAIN STREET EL SEGUNDO, CA 90246 G 1986-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD INSURERS) AFFORDING COVERAGE NAIC # ..... ......... ............. INSURER A : Ace American Insurance Co. 22667 INSURED Insperity, Inc. L/CIF INSURER 8: .1 ...... KOSMONT & ASSOCIATES, INC.INSURER C. 19001 Crescent Springs Drive ......................................................................................................................................... Kingwood, TX 77339 IN9(JIrR..11,a, INSURER E 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 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 ADDIUSLFWA POLICY too POL9C'y EXP............................................................LIML..............,.,.,,.,,................................._______.. TYPE OF INSURANCE LTR I1 POLICY NUMBER IMMIODNYYYI TS COMMERCIAL GENERAL LIABILITY „IMMI'OOIYYYYI EACH OCCURRENCE $ TO C CLAIMS -MADE OCCUR''NAMA06 $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY[ JEST I LOC' ......$ P. ODUCTS -„COMP/OP AGG .............................. ...... ... ry u I', AUTOMOBILE LIABILITY ...k .�PM�rB.INo.Ee„CDu,NSINGLE LIMI'l .$...................................................__.............. ANY AUTOBODILY INJURY (Per person) $ ...... ALL OWNED SCHEDULED .......... ............_ BODILY INJURY (Per accident) .,.,.,.............,_............. _............. ........... $ AUTOS AUTOS _. w. NON -OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (;;Ipr mcE dla...._............ UMBRELLIAB OCCUR LIABAB EACHOCCURRENCE ............._........J.. CLAIMS -MADE AGGREGATE A $ .�.....EX...... DED RETENTION $ .. ..........................................., ...._.___.-..� $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS' LIABILITY Y / N - _ �R 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE A EXCLUDED N / A X 065746645 E L EACH ACCIDENT 10/1/2018 10/1/2019 _11111111-111-1 _T______...__... $ Mandato In NH (Mandatory ► E L. DISEASE EA EM PLOYEEj $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E L, DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Notice to Others Endorsement Included WAIVER OF SUBROGATION IN FAVOR OF CITY OF EL SEGUNDO WHEN REQUIRED BY WRITTEN CONTRACT CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF EL SEGUNDO AUTHORIZED REPRESENTATIVE ATTENTION: GREGG MCCLAIN, PLANNING MANAGER 350 MAIN STREET EL SEGUNDO, CA 90246 G 1986-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number Insperity, INC. UC/F KOSMONT & ASSOCIATES, INC. Policy Number 19001 Crescent Springs Drive Symbol: RWC Number: C65746645 Kingwood, TX 77339 Policy Period Effective Date of Endorsement 10/1/2018 TO 10/1 /2019 1011/2018 Issued By (Name of Insurance Company) Ace American Insurance Co. Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule (X) Specific Waiver Name of person or organization: CITY OF EL SEGUNDO 350 Main Street EI Segundo, CA 90245 A ( ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be INCLUDED percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: INCLUDED a"u"ftiorized" Representative WC 99 03 22