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2012/11/01 Adame Landscape, Inc. Certificate of Liability Insurance (4)'4� br CERTIFICATE OF LIABILITY INSURANCE DATE 5/15/2013� 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 R. David Bulen Insurance P.O. Box 115 Lake Elsinore CA 92531-0115 CONTACT Laura Bramer NAME: VINN E (951) 674-0675 FAX, No: (951)674-2375 ADDRESS: laurab@bulen . COm PRODUCERCUSTOMER ID 00019857 INSURER(S) AFFORDING COVERAGE NAIC# INSURED Adame Landscape, Inc. 41863 Juniper St. Murrieta CA 92562 INSURERA:Golden Eagle Ins. Corp. 10836 INSURER B : INSURER C : INSURERD: INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER:2012-2013 PKG/AUTO 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DDNYYY POLICY EXP MM/DDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X X CBP8935410 11/1/2012 11/1/2013 DAMAGE TO RENTED PREMISES Ea occurrence PREMISES $ r 10O 000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEMLAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2,000,000 X POLICY PE LOC $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS X BA8935710 1/1/2012 11/l/2013 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) $ Medical payments $ NON -OWNED AUTOS Uninsured motorist combined $ 100,000 UMBRELLA LIAB EACH OCCURRENCE $ FOCCUR AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A T RY LIMIT ER E.L. EACH ACCIDENT $ E.L.DISEASE - EA EMPLOYE $ (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Equipment Floater BP8935410 1/1/2012 11/1/2013 $287,600/$500deductible Sched Equip $50,000 / $500 deductible Rented/Lease DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: Newport Road Widening Project. City of Menifee, its officers, employees, representatives, attorneys and authorized volunteers, (excl Professional Liability), are included as Additional Insured in regards to General Liability per attached GECG970 1/11 and to Auto Liability per the attached CA2048. Insurance is Primary and Non Contributory per the attached. *30—day notice of cancellation, except for 10—day notice of cancellation for L,rrf I It -ILA I t r1ULUrH GANGtLLA I IUN City of Menifee City Clerk 29714 Haun Rd. Sun City, CA 92586 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 S Alvarado/SONDRA ACORD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BA8935710 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 11/01/2012 Countersigned By: (� Named Insured: Sondra Alvarado V — Adame Landscape, Inc Authorized Representative) SCHEDULE Name of Person(s) or Organization(s): City of Menifee, its officers, employees, representatives, attorneys and authorized volunteers, (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section If of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 13 COMMENTS/REMARKS nonpayment of premium. OFREMARK COPYRIGHT 2000, AMS SERVICES INC. Policy Number:CBP8935410 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL LIABILITY GOLD ENDORSEMENT - CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION I — COVERAGES COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY 2. Exclusions Item 2.g. 2) is replaced with the following: 2.g. 2) a watercraft you do not own that is: a) less than 50 feet long; and b) Not being used to carry persons or property for a charge. Item 2.g. 6) is added: 6) An aircraft in which you have no ownership interest and that you have chartered with crew. The last paragraph of 2. Exclusions is replaced with the following: Exclusions c. through n. do not apply to damage by fire, explosion, sprinkler leakage, or lightning to premises while rented to you, temporarily occupied by you with the permission of the owner, or managed by you under a written agreement with the owner. A separate limit of insurance applies to this coverage as described in Section III — Limits of Insurance. SECTION I —COVERAGES COVERAGE C. MEDICAL PAYMENTS If Medical Payments Coverage is provided under this policy, the following is changed: 3. Limits The medical expense limit provided by this policy shall be the greater of: a. $10,000; or b. The amount shown in the declarations. Coverage C. Medical Payments is primary and not contributing with any other insurance, even if that other insurance is also primary. The following is added: COVERAGE D. PRODUCT RECALL NOTIFICATION EXPENSES Insuring Agreement We will pay "product recall notification expenses" incurred by you for the withdrawal of your products, provided that: a. Such withdrawal is required because of a determination by you during the policy period, that the use or consumption of your products could result in "bodily injury" or "property damage"; and b. The "product recall notification expenses" are incurred and reported to us during the policy period. The most we will pay for "product recall notification expenses" during the policy period is $100,000. SUPPLEMENTARY PAYMENTS — COVERAGES A AND B Item b. and d. are replaced with: b. The cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit" including actual loss of earnings up to $500 a day because of time off from work. Includes copyrighted material of Insurance Services Offices Inc., with its permission. GECG 970 (01/11) Page 1 of SECTION II —WHO IS AN INSURED Item 4. is replaced with: 4. Any subsidiaries, companies, corporations, firms, or organizations you acquire or form during the policy period over which you maintain a controlling interest of greater than 50% of the stock or assets, will qualify as a Named Insured if: a) you have the responsibility of placing insurance for such entity; and b) coverage for the entity is not otherwise more specifically provided; and c) the entity is incorporated or organized under the laws of the United States of America. However; coverage under this provision does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the entity, or "personal injury" or "advertising injury" arising out of an offense committed before you acquired or formed the entity. Coverage under this provision is afforded only until the end of the policy period, or the twelve (12) month anniversary of the policy inception date whichever is earlier. SECTION III — LIMITS OF INSURANCE Paragraph 2. is amended to include: The General Aggregate Limit of Insurance applies separately to each "location" owned by you, rented to you, or occupied by you with the permission of the owner. Paragraph 6. is replaced with the following: 6. Subject to 5. above, the Fire Damage Limit is the most we will pay under Coverage A for damages because of "property damage" to premises while rented to you, temporarily occupied by you with permission of the owner, or managed by you under a written agreement with the owner, arising out of any one fire, explosion or sprinkler leakage incident. The Fire Damage Limit provided by this policy shall be the greater of: a. $500,000 or b. The amount shown in the Declarations. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS Item 2. a. is replaced with: 2. Duties In The Event of Occurrence, Offense, Claim or Suit a. You must promptly notify us. Your duty to promptly notify us is effective when any of your executive officers, partners, members, or legal representatives is aware of the 'occurrence", offense, claim, or "suit'. Knowledge of an "occurrence", offense, claim or "suit' by other employee(s) does not imply you also have such knowledge. To the extent possible, notice to us should include: 1) How, when and where the "occurrence" or offense took place; 2) The names and addresses of any injured persons and witnesses; and 3) The nature and location of any injury or damage arising out of the "occurrence", offense, claim or "suit'. Item 4. b. 1) b) is replaced with: b. Excess Insurance 1) b) That is Fire, Explosion or Sprinkler Leakage insurance for premises while rented to you, temporarily occupied by you with permission of the owner, or managed by you under a written agreement with the owner; or Item 6. is amended to include: 6. Representations d. If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not deny coverage under this Coverage Part because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. Includes copyrighted material of Insurance Services Offices Inc., with its permission. GECG 970 (01111) Page 2 of Item 8. is replaced with: B. Transfer of Rights Of Recovery Against Others To Us a. If the insured has rights to recover all or part of any payment 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. b. If required by a written "insured contract", we waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under that written "insured contract" for that person or organization and included in the "products -completed operations hazard". Item 10. and Item 11. are added: 10. Cancellation Condition If we cancel this policy for any reason other than nonpayment of premium we will mail or deliver written notice of cancellation to the first Named Insured at least 60 days prior to the effective date of cancellation. 11. Liberalization If we adopt a change in our forms or rules which would broaden your coverage without an extra charge, the broader coverage will apply to this policy. This extension is effective upon the approval of such broader coverage in your state. SECTION V — DEFINITIONS The following definitions are added or changed: 9. "Insured contract" a. Is changed to: a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, explosion or sprinkler leakage to premises while rented to you, or temporarily occupied by you with permission of the owner, or managed by you under a written agreement with the owner is not an "insured contract". 23. and 24. are added: 23. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. 24. "Product recall notification expenses" means the reasonable additional expenses (including, but not limited to, cost of correspondence, newspaper and magazine advertising, radio or television announcements and transportation cost), necessarily incurred in arranging for the return of products, but excluding costs of the replacement products and the cash value of the damaged products. The following Provisions are also added to this Coverage Part: A. ADDITIONAL INSUREDS — BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2. under SECTION II — WHO IS AN INSURED is amended to include as an insured any person or organization when you and such person or organization have agreed in writing in a contract, agreement or permit that such person or organization be added as an additional insured on your policy to provide insurance such as is afforded under this Coverage Part. Such person or organization is not entitled to any notices that we are required to send to the Named Insured and is an additional insured only with respect to liability arising out of: a. Your ongoing operations performed for that person or organization; or b. Premises or facilities owned or used by you. With respect to provision 1.a. above, a person's or organization's status as an insured under this endorsement ends when your operations for that person or organization are completed. With respect to provision 1.b. above, a person's or organization's status as an insured under this endorsement ends when their contract or agreement with you for such premises or facilities ends. Includes copyrighted material of Insurance Services Offices Inc., with its permission. GECG 970 (01/11) Page 3 of 2. This endorsement provision A. does not apply: a. Unless the written contract or agreement has been executed, or permit has been issued, prior to the "bodily injury", "property damage" or "personal and advertising injury"; b. To "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, in the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project; c. To the rendering of or failure to render any professional services including, but not limited to, any professional architectural, engineering or surveying services such as: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities; d. To "bodily injury", "property damage" or "personal and advertising injury" arising out of any act, error or omission that results from the additional insured's sole negligence or wrongdoing; e. To any person or organization specifically designated an additional insured for ongoing operations by a separate ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS endorsement issued by us and made a part of this policy B. PRIMARY NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION Condition 4. Other Insurance of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: a. The following is added to paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written "construction contract" to provide the additional insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover. For the purposes of this endorsement, "construction contract" means a written contract or written agreement other than a premises lease, facilities rental contract or agreement, an equipment rental or lease agreement, or a permit issued by a state, county, municipality or other governmental authority. b. The following is added to paragraph b. Excess Insurance: (3) Except as specified in paragraph a., above, any other insurance in which a parry who is an additional insured hereunder is designated as a Named Insured. Regardless of the terms of any written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured. Includes copyrighted material of Insurance Services Offices Inc., with its permission. GECG 970 (01111) Page 4 of EBS1 A Humor Resource Management Company May 15, 2013 ADAME LANDSAPE, INC 41863 JUNIPER STREET SAN DIEGO, CA 92562 Re: Barrett Business Services, Inc. ("BBSI") Letter of Self -Insurance for Workers' Compensation Coverage For ADAME LANDSAPE, INC, CSLB license number 643164 832519 As the named addressee of this Letter, your company's required workers' compensation coverage is provided through BBSI's state approved Self -Insured Workers' Compensation Plan. As a party to a co -employment contract with BBSI, which is effective from 4/1/2013 until 4/1/2014, California Labor Code §3602 allows ADAME LANDSAPE, INC to obtain its workers' compensation coverage from BBSI. BBSI's California customers can also verify BBSI's state certification at http://www.dir.ca.gov/osip/PrivateRoster.pdf; then scroll down to Barrett (the list is alphabetical by company name). Additional information is as follows: State: California Employer Liability Limits: Self Insurance Certification #: 2246 $5,000,000.00 Each Accident $5,000,000.00 Disease Coverage Limit by Client $5,000,000.00 Disease; Each Employee Notice of Termination: In the event the contract between BBSI and ADAME LANDSAPE, INC is terminated, BBSI must provide notice of the termination within seven (7) days to the California Contractors State License Board ("CSLB"). Other Comments (place an ' X' if applicable): Waiver of Subrogation: BBSI and ADAME LANDSAPE, INC agree to waive their right of subrogation for the benefit of: City of Menifee at X� Named "Letter Holder": City of Menifee 29714 Haun Rd Sun City, CA 92586 ® Other: Project Name: Newport Road Widening Project Additionally, BBSI's self -insured program is further supported by an excess workers' compensation insurance policy with ACE American Insurance Co. Copy of certificate is available upon request. For additional information, please contact your local BBSI office at: Very truly yours, Michael L. Elich President and Chief Executive Officer SAN DIEGO (858) 314-1100 10935 Vista Sorrento Parkway Suite 150 San Diego, CA 92130 doc: LOSI-3