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PROOF OF INSURANCE (2020 - 2020) CLOSEDA�� ® DATE (MM)DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
September 5, 201
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
NAME:'
Hiscox Inc d/b/a/ Hiscox Insurance Agency in CA PHONE -3007 FAX
i,AIC,,No, E'ndy, ( ) (AIC,, No):
520 Madison Avenue E-MAILs contact@hiscox corn32nd Floor
New York, NY 10022 INSURER(S) AFFORDING COVERAGE NAIC #
INSURER Hiscox Insurance Company Inc 10200
INSURED INSURER B
JWA Urban Consultants Inc
INSURER C
609 Deep Valley Dr #200
Rolling Hills Estates CA 90274 INSURER D
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
ADDU SUBR POLICY EFF POLICY EXP
IN'SR.TYPE
LIMITS
OF INSURANCE
LTR ,INSD 'WVD POLICY NUMBER IM1M,DorYY'YY1 PMP;LLDYM"Yyg
X i COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE S 2,O 0,000
X
ac :J is t'Or4E:H1Er
1,¢�Cya,aro�t^oCo3,,; 00,000
CLAIMS—MADE OCCUR
S iE,.vS
X CGL is on BOP Form
MED EXP f Mir' y one a' d-n,'crhi 5 5 000
A Y Y UDC -4264569 -BOP -19 09/05/2019 09/05/2020
PERSONAL 8, ADV INJURY s S/T Each Occ
CJENL AGGREo= TE LIMIT APPLIES PER
GENERAL AGGREGATE S 2.000,000
G'+r'rl, I{;;'w' PRO JECT LOC
PRODUCTS - COMP/OP AGG s S/T Gen. Ag g
S
AUTOMOBILE LIABILITY
ANY AUTO
BODILY INJURY (Per person) _
OWNED SCHEDULED
BODILY INJURY (Per accident) S
AUTOS ONLY AUTOS
A HIRED I X NON -OWNED UDC -4264569 -BOP -19 09/05/2019 09/05/2020
aN ! rk' E'r T, ::r�;nu,v:'F, s
X AUTOS ONLY _ AUTOS ONLY
i,,r^er 6cc%cerw,,
UMBRELLA LIAB OCCUR
EACH OCCURRENCE .,
EXCESS LIAB CLAIMS -MADE
AGGREGATE S
4,ED P^!'ETFN7K)'N
S
WORKERS COMPENSATION
SiIT;rjL I T E F, R
AND EMPLOYERS' LIABILITY P t+lN1
ANYPROPRI ETOR/PARTNER/EXECUTIVE I
OFFICER/MEMBER EXCLUDED? IW d' A
E L EACH ACCIDENT S
(Mandatory in NH) i'"""""'"
E L DISEASE - EA Epa1Pw',+O' FE S
Ifes, describe under
DESCRIPTION OF OPERATIONS tra."ly&
E L DISEASE - POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of EI Segundo, Its elected or appointed officials, officers, employees, or volunteers are additional insureds The Hiscox Business Owner's Policy is Primary and endorsed with a
Waiver of Subrogation in favor of The City of EI Segundo, its elected or appointed officials, officers, employees, or volunteers, subject to the policy's terms and conditions
CERTIFICATE HOLDER CANCELLATION
The City of EI Segundo
Attn Greg McClain, Planning Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Policy Number:
Named Insured:
Endorsement Number:
Endorsement Effective
UDC -4264569 -BOP -19
JWA Urban Consultants Inc
17
September 5, 2019
Hiscox Insurance Company Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
MODIFIED WAIVER OF TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
The following is added to Subparagraph 2. in
Paragraph K. Transfer Of Rights Of Recovery
Against Others To Us of Section III — COMMON
POLICY CONDITIONS (APPLICABLE TO
SECTION I — PROPERTY AND SECTION II
LIABILITY):
You may waive your rights against another party so
long as you do so in writing prior to: (i) an offense
arising out of your business that caused a "personal
and advertising injury"; or (ii) an "occurrence" that
caused "bodily injury' or "property damage".
BOP E5213 CW (03/10)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Page 1 of 1
Policy Number:
Named Insured.-
Endorsement
nsured:Endorsement Number:
Endorsement Effective
UDC -4264569 -BOP -19
JWA Urban Consultants Inc
18
September 5, 2019
Hiscox Insurance Company Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CALIFORNIA - DIKED AUTO AND NON -OWNED
AUTO LIABILITY
This endorsement modifies insurance provided under the following.
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Coverage Additional Premium
A. Hired Auto Liability $175.00
B. Non -owned Auto Liability $ 0.00
Information required to complete this Schedule, if not shown above, will be shown in the Declarations„
A. Throughout this endorsement the term spouse
means:
Spouse or a registered domestic partner under
California law.
B. Insurance is provided only for those coverages for
which a specific premium charge is shown in the
Declarations or in the Schedule.
1. Hired Auto Liability
The insurance provided under Paragraph A.1.
Business Liability in Section II — Liability
applies to "bodily injury" or "property damage"
arising out of the maintenance or use of a
"hired auto" by you or your "employees" in the
course of your business.
2. Non -owned Auto Liability
The insurance provided under Paragraph A.I.
Business Liability in Section II — Liability
applies to "bodily injury" or "property damage"
arising out of the use of any "non -owned auto"
in your business by any person.
C. For insurance provided by this endorsement only
1. The exclusions under Paragraph B.1. Appli-
cable To Business Liability Coverage in
Section II — Liability, other than Exclusions a.,
b., d., f. and I. and the Nuclear Energy Liability
Exclusion, are deleted and replaced by the fol-
lowing:
a. "Bodily injury" to:
(1) An "employee" of the insured arising out
of and in the course of:
(a) Employment by the insured; or
(b) Performing duties related to the
conduct of the insured's business; or
(2) The spouse, child, parent, brother or
sister of that "employee" as a conse-
quence of Paragraph (1) above.
This exclusion applies:
(1) Whether the insured may be liable as an
employer or in any other capacity; and
BP 06 86 01 10 ©insurance Services Office, Inc., 2009 Page 1 of 2
(2) To any obligation to share damages with
or repay someone else who must pay
damages because of injury.
This exclusion does not apply to:
(1) Liability assumed by the insured under
an "insured contract"; or
(2) "Bodily injury" arising out of and in the
course of domestic employment by the
insured unless benefits for such injury
are in whole or in part either payable or
required to be provided under any work-
ers' compensation law.
b. "Property damage" to:
(1) Property owned or being transported by,
or rented or loaned to the insured; or
(2) Property in the care, custody or control
of the insured.
2. Paragraph C. Who Is An Insured in Section II
— Liability is replaced by the following:
1. Each of the following is an insured under
this endorsement to the extent set forth be-
low:
a. You;
b. Any other person using a "hired auto"
with your permission;
c. For a "non -owned auto":
(1) Any partner or "executive officer" of
yours; or
(2) Any "employee" of yours;
but only while such "non -owned auto" is
being used in your business; and
d. Any other person or organization, but
only for their liability because of acts or
omissions of an insured under a., b. or
c. above.
2. None of the following is an insured:
Any person engaged in the business of
his or her employer for "bodily injury" to
any co -"employee" of such person in-
jured in the course of employment, or to
the spouse, child, parent, brother or sis-
ter of that co -"employee" as a conse-
quence of such "bodily injury", or for any
obligation to share damages with or re-
pay someone else who must pay dam-
ages because of the injury;
b. Any partner or "executive officer" for any
"auto" owned by such partner or officer
or a member of his or her household;
c. Any person while employed in or other-
wise engaged in duties in connection
with an "auto business", other than an
"auto business" you operate;
d. The owner or lessee (of whom you are a
sublessee) of a "hired auto" or the
owner of a "non -owned auto" or any
agent or "employee" of any such owner
or lessee; or
e. Any person or organization for the con-
duct of any current or past partnership
or joint venture that is not shown as a
Named Insured in the Declarations.
D. For the purposes of this endorsement only, Para-
graph H. Other Insurance in Section III — Com-
mon Policy Conditions is replaced by the follow-
ing:
This insurance is excess over any primary insur-
ance covering the "hired auto" or "non -owned
auto".
E. The following additional definitions apply:
1. "Auto business" means the business or occu-
pation of selling, repairing, servicing, storing or
parking "autos".
2. "Hired auto" means any "auto" you lease, hire,
rent or borrow. This does not include any
"auto" you lease, hire, rent or borrow from any
of your "employees", your partners or your "ex-
ecutive officers" or members of their house-
holds.
3. "Non -owned auto" means any "auto" you do
not own, lease, hire, rent or borrow which is
used in connection with your business. This in-
cludes "autos" owned by your "employees",
your partners or your "executive officers", or
members of their households, but only while
used in your business or your personal affairs.
Page 2 of 2 0 Insurance Services Office, Inc., 2009 BP 06 86 01 10
AC"R,a DATE (MM/DD/YYYY)
� CERTIFICATE OF LIABILITY INSURANCE 07/30/2019
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 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 §Urb andorsement(s).
PRODUCER WT
SNAME:Karen Bronson
G ME:
CorRisk Solutions PHONE 'FAX
180 N Stetson Ave Suite 4500 I"'°"°E"I' 312-637-8755 AC, N°. EW:
EMAIL
Chicago, IL 60601 ADDRESS: kbronson@corrisksolutions.com
INSURERIS) AFFORDING COVERAGE NAIC #
INSURER A: New Hampshire Insurance Company 23841
INSURED INSURER B:
JWA Urban Consultants, Inc. INSURER C:
PO Box 9493
Marina del Rey, CA 90295 INSURER D:
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.
INSH AUD'L SUBR POLICY EFF POLICY EXP
TYPE OF INSURANCE POLICY NUMBER � LIMITS
LTR M'
INSRD WVD (MMIDDYY) IMMIDDM/YYI
GENERAL LIABILITY
EACH OCCURANCE
DAMAGE TU RENTED
COMMERCIAL GENERAL LIABILITY
PREMISES (Ea occurance)
CLAIMS MADE OCCUR
MED EXP (Any one person)
DOES NOT APPLY
PERSONAL & AND INJURY
GENERAL AGGREGATE
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
II POLICY n PROJECT LOC
AUTOMOBILE LIABILITY
GOMBINtU SINOLt UMII (te
accident)
PANY AUTO
BODILY INJURY (Per person)
ALL OWNED
SCHEDULED
DOES NOT APPLY
BODILY INJURY (Per accident)
„,,.... AUTOS
HIRED AUTOS
AUTOS
NON -OWNED
'rrc¢.Iwdk:Mn r^ I,AAsnA6n�k� dMda
acc�dann
AIITnc
UMBRELLA LIAB
OCCUR
EACH OCCURANCE
EXCESS LIAB
CLAIMS MADE
DOES NOT APPLY
[AGGREGATE
.� DED I IRETENTION$
WORKERS COMPENSATION
1, JOTHER�
AND EMPLOYERS' LIABILITY
T RY LIMITS
ANY PROPRIETOR/PARTNER/EXECUTIVE
E L EACH ACCIDENT
OFFICE/MEMBER EXCLUDED?
Y/N N/A
DOES NOT APPLY
N
E.L. DIJtbAt - to
(Mandatory in NH)
❑
EMPLOYEE
It yes, describe under DESCRIPTION OF
EL DISEASE -POLICY LIMIT
OPERATIONS below
064991328-
Per occurrence: $1,000, 000
A Professional Liability
03/23/19 03/23/20
03
Annual Aggregate: $1,000, 000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACCORD 101,
Additional Remarks Schedule, if more space is required)
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
El Segundo Planning & Building Safety Dept.
350 Main St. AUTHORIZED REPRESENTATIVE
El Segundo, CA 90245
ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. Allrights reserved.
The ACORD name and logo are registered marks of ACORD
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement
with the City of EI Segundo.
Policy No.
C_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance
of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone #
Z) I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those provisions o reement will automatically become void.
Signature of Applicant Date
Print Name
Agreement for: JWA-I I rl ` "SIA [+740,S , l h-(,
Dated: ®k � ) q
Reviewed by: