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2018/07/01 ADP TotalSource DE IV, Inc. Certificate of Liability Insurance
ACCOR0 TIFI F LIABILITY INSURANCE T DDrYYYY) 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 ARisk Services, IncOf Florida Aon Risk SeOn rvices, Inc of Florida NAME: - on -_•--- ---------------------- ----__--_--- 1001 Brickel! Bay Drive, Suite #1100 PHONE FAX Miami, FL 33131.4937 A/C, No, Exf : 800-743-8130 AIC No): 600-522-7514 EMAIL ADDRESS: ADP.COI.CenterSAon.rorn INSURER(S) AFFORDING COVERAGE NAIC N INSURER A: American Home Assurance Co 19380 INSURED INSURER 6 : ADP TotalSource DE IV. Inc. 10200 Sunset Drive INSURER C : Miami, FL 33173 LJC/F' INSURER D : Keyser Marston Associates, Inc. INSURER E : 1299 Fourth Str_-ei. Suite 408, San Rafae[, CA 94901 INSURER F : COVFRACFR r-FRTIFIC:ATF DdI]MRFR- JnQ4Q99 RFVI.qIr)NI RIIIMRF:R- 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. I_Ihrll"£ 81 i:: trbN MRE :,S I�EOLIE l I ). iNSR LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MM/DDIYYYY)LIMITS COMMERCIAL GENERAL.I-iA,Bit.ITY EACH OCCURRENCE S ❑OCCUR DA'ASSTOEcTED RoNurClAIv1S-MAD° EP, rence) ' S MED EXP (Any one arson) S [`7or 0 jrp( PERSONAL 3 ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY n PROJECT n LOC OTHER �j�� 03 PRODUCI'S-COMP/OPAGG c AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident "a ANY AUTO i i keCe BODILY INJURY Per person)S OWNED ( SCHEDULED AWOS ONLY ; AUTOS I I I I j Vj BODILY INJURY (Per accident) S PROPERTY DAMAGE HIRED I NON -OWNED AUTOS ONLY ! AUTOS ONLY i (Par accident) 3 S UMBRELLA LIAB J OCCUR EACH OCCURRENCE S AGGREGATE 5 EXCESS LIAB i CLAIMS -MADE I DEC I I RISTENTTONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N X PER STATUTE O'TH- ER E.L. EACH ACCIDENT S 2,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBE:REXCLUDE:D? NI X WC 047018568 CA 7/1/2018 7/1/2019 E.L. DISEASE - EA EMPLOYEE S 2,000,000 (Mandatory in NH) If yes, descnbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 5 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) See attached Certificate Holder Cancellation Notice. All worksite emp!oyees working for KEYSER MARSTON ASSOCIATES, INC., paid under AOP TOTALSOURCE, INC's payroll; are covered under the above stated policy. WAIVER OF SUBROGATION IN FAVOR OF CITY OF MENIFEE ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENT, REPRESNI"ATIVES AND VOLUNTEERS AS RESPECTS OF JOB PERFORMED BY KEiYSE:R MARSTON ASSOCIATES, INC AS REQUIRED BY WRI1TEN CONTRACT, RE-: Retail and Office Study CERTIFICATE HOLDER CANCELLATION City of Menifee SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 29714 Haan Rd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Menifee. CA 92556 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ,r Off, okah &4"'1 3f&eL 12ne. i7 ©198$-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1013105 Aon Risk Services, Inc. of Florida 1001 Brickell Bay Drive, Suite 1100 Miami, FL 33131 1013105 CITY OF MENIFEE { 29714 HAUN RD MENIFEE CA 92586-6540 a. 1013105 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following" attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement. Effective on 07/01/2018 at 12:01 AM, forms a part of Policy No. WC 047018568 Issued to: ADP TotalSource DE IV, Inc. 10200 Sunset Drive Miami, FI_ 33173 uC/F Keyser Marston Associates, Inc. 1299 Fourth Street, Suite 408 San Rafael, CA 94901 Premium: N/A By: American Home Assurance Co. 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. (This agreement applies only to the extent that you perform work under a written contract that requires 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 Additional Premium Percent% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization .Sob Description City of Menifee RE: Sun City Core Retail Study its officers, officials, employees, agent, represntatives and volunteers 29714 Haun Rd Menifee, CA 92586 WC 04 03 06 Countersigned by (Ed. 4-8 4) Authorized Representative �;��Cr. 1013105 POLICY HOLDER NOTICE C.I+.I nFiC„A7"EHOLDER CANC,I+,I1 A.TION NOTICE E Should this policy be cancelled before the expiration date hereof, the producer will endeavor to mail 30 days written notice to the certificate holder named herein, but failure to do so shall impose no obligation or liability of any Kind capon the insurer, the producer, or the respective agents or representatives of each. SCHEDULE: CER 'II;I ATE HOLDERS AS IDENTIFIED ON THE=. MMOST RE=.CEN'r QIJAR'Y-ERI.;Y SCHEDULE OF CFRT'IFICATE HOLDERS PROVIDED BYTHE', INSURI D'S BROKER OF RECORD TO THE INSURER. 1013105