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2012/12/31 American Asphalt South, Inc. Certificate of Liability InsuranceAC" " CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/31 /2012 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: InterWest Insurance Services PHONE FAX License #0601094 A/c No, Ern :916-609-8416 A/c No :916-979-7516 P.O. Box 255188 aDDRESS:cleifker iwins.com Sacramento CA 95865-5188 INSURER(S) AFFORDING COVERAGE NAIC a INSURED AMER122 INSURER B: American Asphalt South, Inc. INSURERC: 14436 Santa Ana Avenue INSURER D: Fontana CA 92337 INSURER E: COVERAGES CERTIFICATE NUMBER- szal o'Dann RFVISION NIIMRFR- 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/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FTI OCCUR Y 60423382 12/31/2012 12/31/2013 EACH OCCURRENCE $1,000,000 AMA O N TED PREMISES Ea occurrence $100,000 MED EXP (Any one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GENERALAGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC JECT PRODUCTS - COMP/OP AGG $2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS Ded SO unles Y 60423382 12/31/2012 12/31/2013 Eaaccidern) $1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per..-den,) $ $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 60423382 12/31/2012 12/31/2013 EACH OCCURRENCE $5,000,000 AGGREGATE 1 $5,000,000 DED X I RETENTION $none $ g WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A y ZAWC19286300 1/1/2013 1/1/2014 X WCSTATU- OTH- TORY IMITS ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY Lim IT $1,o00,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) RE: 2012 Slurry Seal Project, Phase I/CIP02-013 City of Menifee is additional insured (GUALITO) per endorsement attached. Primary and non contributory wording applies per attached. Per Project Aggregate per attached. Waiver of subrogation applies to workers compensation per endorsement attached. 30 day notice of cancellation except 10 day for non payment of premium per policy provisions. 1.Cr11 Ir-II.A I t MULVtrt L;ANUtLLA I IUN City of Menifee 29714 Haun Road Menifee 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 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: RE: 2012 Slurry Seal Project, Phase I/CIP02-013 City of Menifee is additional insured (GL/AUTO) per endorsement attached. Primary and non contributory wording applies per attached. Per Project Aggregate per attached. Waiver of subrogation applies to workers compensation per endorsement attached. 30 day notice of cancellation except 10 day for non payment of premium per policy provisions. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above Al only Effective from: Effective Date:12/31/2012 Expiration Date:12/31/2013 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 11 85 Modified (07-01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: 60423382 ASDA AU 07 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE NAMED INSURED: American Asphalt South, Inc. 14436 Santa Ana Avenue Fontana CA 92337 ADDITIONAL INSURED: RE: 2012 Slurry Seal Project, Phase I/CIP02-013 City of Menifee is additional insured (GL/AUTO) per endorsement attached. Primary and non contributory wording applies per attached. Per Project Aggregate per attached. WHO IS AN INSURED (SECTION ll) is amended to include as an insured the organization shown in the Schedule above, but only with respect to the operation of vehicles owned by the named insured and operated on behalf of the named insured. This endorsement does not apply to any operations for other than the named insured. Each person or organization named above 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 of Section II Liability Coverage. The additional insured is not required to pay for any premiums stated in the policy or earned from the policy. Any return premium, if applicable, declared by us shall be paid to you. You are authorized to act for the additional insured in all mailers pertaining to this insurance. We will mail the additional insured notice of any cancellation of this policy. If the cancellation is by us, we will give thirty days notice to the additional insured. The additional insured will retain any right of recovery as a claimant under this policy. ASDA AU 07 01 Pagel of 1 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA This endorsement changes the policy to which it is attached effective on the 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 12/31/2012 at 12:01 A.M. standard time, forms a part of (DATE) Policy No.ZAWC19286300 Endorsement No. of the Arch Insurance Company issued to American Asphalt South, Inc. Premium (if any) $ (NAME OF INSURANCE COMPANY) Authorized Representative 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 '% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS AND/OR ORGANIZATIONS THAT REQUIRE A WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Page 1 of 1 POLICY NUMBER: 180632C COMMERCIAL GENERAL LIABILITY CG 25 03 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: ALL PROJECTS WITH THE POLICY PERIOD. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused by acci- dents under COVERAGE C (SECTION 1), which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggre- gate Limit shown in the Declarations 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard", and for medical expenses under COVERAGE C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Desig- nated Construction Project General Aggre- gate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Decla- rations nor shall they reduce any other Des- ignated Construction Project General Aggre- gate Limit for any other designated construc- tion project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Ex- pense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Con- struction Project General Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused by acci- dents under COVERAGE C (SECTION 1), which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products -Completed Operations Ag- gregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. C. When coverage for liability arising out of the "products -completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -Completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. CG 25 03 03 97 Copyright, Insurance Services Office, Inc., 1996 Paae 1 of 2 D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restated, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Limits Of Insurance (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. Pangs 9 of 2 C:nnvrinht InSiirance Services Office. Inc.. 1996 CG 25 03 03 97