Loading...
2018/11/01 Integrated Project Services, Inc. Certificate of Liability Insurance DATE(MMIDD/YYYY) �cc3►zo� CERTIFICATE OF LIABILITY INSURANCE `�. 112/03/2018 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 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:Marsh Sponsored Programs NAME: g00-338-1391 FAX No;888-621-3173 a division of Marsh USA Inc. E-RAIL aeclientre oast@marsh.com PO Box 14404 ADDRESS[ q Des Moines IA 50306 INSURERS AFFORDING COVERAGE NAIL# iNSURERA:SENTINEL INSURANCE COMPANY, LIMITED 11000 INSURED INSURER B: PETT I T INSURER C: AND INTEGRATED PROJECT SERVICES, INC. INSURERD; 1787 POMONA RD STES D & E CORONA, CA 92880 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. IN5ftEXP LTR TYPE OF INSURANCElam A-VP POLICY NUMBER MM1oGYYYYY MMID�YY LIMITS A GENERAL LIABILITY y 84SBALM1831 11/01/2018 11/01/2019 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY Prof. Liab. Excl. PREMISMEA orcu fence $1,000,000 CLAIMS-MADE Cross Liability MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY s2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $4,000,000 POLICY X JECTPRO' LOG $ A AUTOMOBILE LIABILITY Y 84SBALM1831 11/01/2018 11/01/2019 BINS L LIMIT Ea accident) p ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS P r accldenS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION WC gTAT_ OTH• AND EMPLOYERS'LIABILITY y/N Y ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOY $ If yyes,d ibe under DESCRIPTION OF OPERATIONS below I I I I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (Attach ACORD f01,Additional Remarks Schedule,if more space Is required) City of Menifee and its officers, employees, agents, and authorized volunteers are named as additional insured on the above referenced policies when required by written contract. Primary and noncontributory applies to GL and Auto when required by written contract. 30 days notice of cancellation will be given to cert holder per policy endorsement, 10 day notice of cancellation for non-payment of premium. 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 Menifee AUTHORIZED REPRESENTATIVE 29714 Haun Road Menifee, CA 92586 LA 01988 10 ACORD CORPORATION. All rights reserved, ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:84SBALM1831 BUSINESS LIABILITY COVERAGE INSURED:Pettit Inc. SS 00 08 04 05 ADDITIONAL COVERAGES BY WRITTEN CONTRACT, AGREEMENT OR PERMIT This is a summary of the coverage provided under the following form (complete form available): BUSINESS LIABILITY COVERAGE FORM SS 00 08 04 05 Additional Insured When Required by Written Contract, Written Agreement or Permit WHO IS AN INSURED under Section C. is amended to include as an additional insured, but only with respect to liability for"bodily injury", "property damage" or"personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: (a) In the performance of your ongoing operations; (b) In connection with your premises owned by or rented to you; or (c) In connection with "your work" and included within the "products completed operations hazard", but only if (i) The written contract or written agreement requires you to provide such coverage to such additional insured; and (ii) This Coverage Part provides coverage for"bodily injury"or"property damage" included within the "products completed operations hazard". The person(s) or organization(s) are additional insureds when you have agreed, in a written contract, written agreement or because of a permit issued by a state or political subdivision, that such person or organization be added as an additional insured on your policy, provided the injury or damage occurs subsequent to the execution of the contract or agreement, or the issuance of the permit. A person or organization is an additional insured under the provision only for that period of time required by the contract, agreement or permit. With respect to the insurance afforded to the additional insured, this insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services, including: (a) The preparing, approving, or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys,field orders, change orders, designs or drawings and specification:or (b) Supervisory, inspection, architectural or engineering activities. The limits of insurance that apply to additional insureds are described in Section D. Limits Of Insurance. How this insurance applies when other insurance is available to an additional insured is described in the Other Insurance Condition in Section E. Liability And Medical Expenses General Conditions. No person or organization is an insured with respect to the conduct of any current or past partnership,joint venture or limited liability company that is not shown as a Named Insured in the Declarations. Other Insurance If other valid and collectible insurance is available for a loss we cover under this Coverage Part, our obligations are limited as follows: When You Add Others As An Additional Insured To This Insurance: That is other insurance available to an additional insured. HowaVcr, 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 noncontributory with the additional insured's own insurance, this insurance is primary and we will not seek contribution from that other insurance. Rev 5.14 Page 1 of 2 BUSINESS LIABILITY COVERAGE FORM Summary SS 00 08 04 05 Paragraphs(a)and (b)do not apply to other insurance to which the additional insured has been added as an additional insured. 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. Waiver of Subrogation If you have waived any rights of recovery against any person or organization for all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, we also waive that right, provided you waived your rights of recovery against such person or organization in a contract, agreement or permit that was executed prior to the injury or damage Rev 5.14 Page 2 of 2 POLICY NUMBER: 84SBALM1831 COMMERCIAL AUTOMOBILE INSURED: Pettit Inc. HA 99 16 03 12 ADDITIONAL COVERAGES WHEN REQUIRED BY WRITTEN CONTRACT This is a summary of the coverage provided under the following form (complete form available): COMMERCIAL AUTOMOBILE COVERAGE FORM HA 99 16 03 12 Additional Insured if Required by Contract Paragraph A.1. -WHO IS AN INSURED - of Section II - Liability Coverage is amended to add: When you have agreed, in a written contract or written agreement, that a person or organization be added as an additional insured on your business auto policy, such person or organization is an "insured", but only to the extent such person or organization is liable for"bodily injury" or "property damage"caused by the conduct of an "insured" under paragraphs a. or b. of Who is and Insured with regard to the ownership, maintenance or use of a covered "auto." Primary and Non-Contributory Only with respect to insurance provided to an additional insured in I.D. —Additional Insured If Required by contract, the following provisions apply: 1) Primary Insurance When Required By Contract: This insurance is primary if you have agreed in a written contract or written agreement that this insurance be primary. If other insurance is also primary, we will share with all that other insurance by the method described in Other Insurance Clause. 2) Primary and Non-Contributory To Other Insurance When Required By Contract: If you have agreed in a written contract or written agreement 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 (1) and (2) 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 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. 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 that this insurance would pay for the loss in the absence of this insurance; and (2) The total of all deductible and sefinsured amounts under all that other insurance. We will share the remaining loss, if any, by method described in Other Insurance 5.d. Waiver of Subrogation We waive any right of recovery we may have against any person or organization with whom you have a written contract that requires such waiver because of payment we make for damages under the Coverage Form. Rev 7.15 Page 1 of 1 ACORO� CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYY) 11/30/2018 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(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 Cora Lim NAME: SelectSolutions Insurance Services PH(INC E Ex . (866)500-6359 we Noy (925)951-0077 1107 Investment Blvd AIL coral@selectsolutionsins.com ADDRESS- Suite 100 INSURER(S)AFFORDING COVERAGE NAIC# El Dorado Hills CA 95762 INSURERA: Beazley Insurance Company,Inc. 37540 INSURED INSURER B Integrated Project Services, Inc.,DBA:Pettit INSURER C: 1787 Pomona Road,Suites D&E INSURERD: INSURER E: Corona CA 92880 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1821225694 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. ICY EXP LTR TYPE OF INSURANCE JNSD WVD POLICY NUMBER MMIDD EFF MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENT PREMISES Ea occurrence $ MED EXP(Any one Derson) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY D JECTARO- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accldenl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y/N STATUTE JER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ _, PROFESSIONAL LIABILITY V15RDP181201 02/20/2018 02/20/2019 PER CLAIM $1,000,000 AGGREGATE $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:As Per Contract or Agreement on File with the Insured. Professional Liability contain a 30 day notice provision for cancellation/non-renewal endorsement to follow from carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Menifee ACCORDANCE WITH THE POLICY PROVISIONS. 29714 Haun Rd. AUTHORIZED REPRESENTATIVE Menifee CA 92586 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Effective date of this Endorsement:30-Nov-2018 This Endorsement is attached to and forms a part of Policy Number:V15RDP181201 Beazley Insurance Company, Inc.Referred to in this endorsement as either the"Insurer" or the "Underwriters" NOTICE OF CANCELLATION TO CERTIFICATE HOLDER This endorsement modifies insurance provided under the following: AFB A&E MEDIA TECH®POLICY In consideration of the premium charged for the Policy, it is hereby understood and agreed that in addition to the provisions of Clause XVI.CANCELLATION AND NONRENEWAL B., if this policy is cancelled by the Underwriters, other than for non-payment of premium, the Underwriters will provide 30 days written notice to the following party(ies): City of Corona Public Works Department 400 S Vicentia Avenue Corona, CA 92882 City of Corona Department of Water&Power 755 Corporation Yard Way Corona, CA 92882 City of Corona 400 S Vicentia Avnue Corona, CA 92882 City of Menifee 29714 Haun Road. Menifee, CA 92586 All other terms and conditions of this Policy remain unchanged. Authors/dR presentative E01414 Page 1 of 1 082009 ed. ACQRU CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �-� 12/15/2018 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 CONTACT Bryan Wetter Hunter Insurance Services, Inc PHONE 619-713-1011 Nn 619-713-1011 9855 Prospect Ave E-MAIL ADDRESS: bry an hunteronline.com Suite D INSURERS AFFORDING COVERAGE NAIC# Santee CA 92071 INSURERA: Everest National Insurance Company 10120 INSURED INSURER B Pettit,Inc. INSURERC: 1787 Pomona Rd Suite D INSURER D: INSURER E: Corona CA 92880 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. �LFt TYPE OF INSURANCE IN -MQ POLICY NUMBER ADOLSUOR MMIJDD EFF MM%DD ExP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 171 OCCUR R fSES Ea occurran $ _ MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY jE O- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED$I GLlw LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY AUTOS ONLY AUTOS (Per accident) $ HIRED NON-OWNED PROPERTYDAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ EXCESS LIAB 11 CLAIMS-MADE AGGREGATE $ DIED I I RETENTION$ $ WORKERS COMPENSATION /\ STATllT ER AND EMPLOYERS'LIABILITY Y/N A OFF CER/MEMB REXCLUDED?ECUTIVE ❑ N/A Y 7600009787181 9/23/2018 9/23/2019 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of Menifee,its directors,officials,officers,employees,agents,and volunteers are Certificate Holder.Thirty(30)Day Notice of Cancellation endorsement applies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Menifee ACCORDANCE WITH THE POLICY PROVISIONS. 29714 Haun Road AUTHORIZED REPRESENTATIVE Menifee CA 92586 M"k.Hu—fev ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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 organizatign,named in the Schedule: (This agreement applies anly to the extent that you perform work under n written contraof that eequires.you to obtain this agreement from us:) 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 2 % of the 'California workers" compensation premium otherwise due on such remuneration. SCHEDULE: PERSON OR-ORGANIZATION :1OB DESCRIPT:I.ON ANY PERSON OR ORGANIZATION FOR BLANKET WAIVER :OF SUBROGATION WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy. to which it is attached and is effective on the:date issued unless otherwise stated. (The information below is required only when this endorsement.is issued subsequent to preparation of the policy.) Endorsement Effective 09-27-18 Policy No. 7.6000097.87181 Endorserrient No. l)42 Insured PETTIT INC Premium $: INCL. Insurance Company EVEREST NATIONAL INSURANCE COMPANY Stephanie Countersigned By Watson �;.,,,,,,.>, -1998 by the Workers'Cot*erm ion Insurance Rating.Suneau of California. All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual °1599. INSURED COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B (Ed.741) The following Item(s) POLICY INFORMATION PAGE ENDORSEMENT insured's Name(WC 89 06 01) Item 3.B. Limits (WC 89 0612) Polley Number (WC 89 06 02) Item 3.C. States (WC 89 0613) Effective Date(WC 89 06 03) X Item 3.D. Endorsement Numbers (WC 89 0614) Expiration Date(WC 89 06 04) Item 4. *Class, Rate, Other(WC 89 0415) Insured's Mailing Address (WC 89 06 05) Interim Adjustment of Premium(WC 89 0416) Experience Modification (WC 89 04 06) Carrier Servicing Office(WC 89 0617) Producer's Name(WC 89 06 0-1) Interstate/Intrastate Fisk I.D. Number(WC 89 0618) Change in Workplace of Insured (WC 89 06 08) Carrier Number (WC 89 0619) Insured's Legal Status (WC 89 06 10) Issuing Agency/Producer Office Address(WC 89 06 25) Item 3.A. States (WC 89 0611) is changed to read: THE FOLLOWING FORM(S) HAS BEEN ADDED: WC 99 06 76 04-11 NOTICE OF CANCEL TO DESIGNATED PERSON `Item 4.Change To: Premium Basis Hate Per$100 Classifications Code Total Estimated of Estimated No, Annual Remuneration Annual Premium Remuneration SEE ATTACHED WIC 39 06 00 B 07-01) EXTENSION Total Estimated Annual Premium$ 3,471 Minimum Premium$ 750 Deposit Premium$ 1,189 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which It is attached and is effective on the date issued unless otherwise stated. (The Information below Is required onlywhen this endorsement is rued subsequent to preparation of the polity.) Endorsement Effective 12/06/2018 Policy No.7600009787181 Endorsement No. 003 Insured PETTIT INC Premium: NO CHARGE CORONA, CA 92880 Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By WC 89 06 OOB (Ed. 7-01) ®2001 National Council on Compensation insurance,Inc. 94SURM COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 76 (Ed.04-11) NOTICE OF CANCELLATION TO DESIGNATED PERSON OR ORGANIZATION If we cancel this policy for any statutorily permitted reason other than nonpayment of premium,we shall endeavor to mail or deliver a written notice in accordance with state law to the person or organization shown in the Schedule below. Proof of mailing will be sufficient proof of such notice. This endorsement shall not operate directly or indirectly to benefit any person or organization not named in the schedule below. SCHEDULE Designated Person or Organization: DEPARTMENT OF FINANCE City of Menifee Designated Person or Organization Address: 29714 HAUN ROAD Menifee, CA 92586 Contract, Permit or Job Number: Number of Days Notice: 30 All other terms and conditions of this policy remain unchanged, This endorsement changes the policy to which it Is attached and is effective on the date issued unless otherwise stated. (The inforfmdon below is required only when this endorsement is Issued subsequent to preparsdon of the poNcy.) Endorsement Effective 12-06-18 Policy No. 7600009787181 Endorsement No. 003 insured PETTIT INC Premium $ INCL. Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By --- - WC 99 06 76 (Ed. 04-11) Copyright,Everest Reinsurance Company,2011 Includes copyrighted material of National Council on Compensation Insurance,Inc.used with its permission. INSURED COPY