2017/12/31 American Asphalt South, Inc. Certificate of Liability InsuranceACOR " a
AC� CERTIFICATE OF LIABILITY INSURANCE
OATR{MMfDDIYYYY)
Fsrisrzals
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(fes) 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
InterWest Insurance Services
License #OB01094
P.O. Box 255188
NAI4fi CT Joanne Cadarette
PHQNE FAX
, 916-609-8362 arc No): 91fi-979-7562
np REss: cadarette fwins.com
Sacramento CA 95865-5188
INSURERISI AFFORDING COVERAGE
NAIC0
INSURER A.- Financial Pacific Ins Company
31453
INSURED AMER126
American Asphalt South, Inc
14436 Santa Ana Avenue
INSURERS. Arch Insurance Company
11150
INSURER c : Travelers Prop Cas Co of Amer
25674
INSURERD:
Fontana CA 92337
INSURER E :
INSURER F
COVERAGES CERTIFICATE NUMBER:2053138924 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
TR
TYPEOFINSURANCE
ADDL
SUOR
POUCYNUMBER
POLICY EFF
MMIODNYYY)
POLICY EXP
IMMIDDIYYYYI
LIMITS
A
X
COMMERCIAL GENERALLIABILRY
Y
Y
60423382
12131RD17
12r31f2018
EACH OCCURRENCE
32.000OOD
CLAIMS -MADE 7 OCCUR
PR MI E Ea occurrence
$100,000
X
MED EXP (Any one person)
$ 5.000
Contractual Uab
X
3S.000 Ded.
PERSONAL & ADV INJURY
$2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
34,000,000
POLICY El JET LOC
PRODUCTS
$4.oD0,000
5
OTHER:
A
AUTOMOBILE LIABILITY
Y
Y
60423382
12f312017
12l31r1018MIND
SINGLE LIMIT
a e.,nt
S 1 OD0,000
BODILY INJURY (Perperson)
$
X ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
IAUTOS
BODILY INJURY (per accident)
S
X HIRED X NON-0WNED
ONLY AUTOS ONLY
PROPERTY DAMAGE
Per accident
5
S
C
X
UMBRELLALIAB
MCLAW.-MAD,
OCCUR
ZUP71M8933017
12131/2017
12/31/2015EACHOCCURRENCE
5B4O00,000
AGGREGATE
S6.000.0m
EXCESSLIAB
DEC) I X I RETENTIONSa
$
1
8
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
Y
ZAWCI9413901
411/2010
411/2019
X START E X ERH
E.L. EACH ACCIDENT
S 1,000.00D
ANYPROPRIETORIPARTNERIEXECUTIVE
OFFICEMMEMSERE%CLUDED7 ❑
NIA
E.L. DISEASE- EA EMPLOYEE
S 1.000,OOD
(Mandatary In NHI
If yea, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached Irmore space Is required)
Re: PMP #18-01, FYI 8-19 Slurry Seal Program.
Additional Insured status applies if required by written contract per endorsement attached City of Menifee, its elected officials, officers, agents and employees.
representatives, consultants, contract employees and volunteers. Primary warding per attached endorsement. Waiver of Subrogation applies to General
Liability, Automobile Liability and Workers Compensation per the attached endorsements. Excess is "Follow Form". 30 Day notice of cancellation, except 10 day
notice for non-payment of premium applies per policy provisions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Menifee
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Margarita Comejo, Contract & Procurement
Administrator
29714 Haun Road
Menifee CA 92586
AUTHORIZED REPRESENTATIVE
f�f�
9)1988-201S ACORD CORPORATION. All rights reserved.
ACORD 25 (20161031 The ACORD name and logo are registered marks of ACORD
N
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 04 03 06
(Ed. 04-84)
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 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 2 % of the California workers' compensation premium
otherwise due on such remuneration.
SCHEDULE
PERSON OR ORGANIZATION
JOB DESCRIPTION
ANY PERSON OR ORGANIZATION WHERE ALL JOBS UNDER CONTRACT
WAIVER OF OUR RIGHT TO RECOVER IS
PERMITTED BY LAW AND IS REQUIRED
BY WRITTEN CONTRACT PROVIDED SUCH
CONTRACT WAS EXECUTED PRIOR TO
DATE OF LOSS
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 04-01-18
Insured AMERICAN ASPHALT
Policy No. ZAWCI 9 4 13 9 0 1
Insurance Company ARCH INSURANCE COMPANY
Countersigned By
' 1998 by the Workers' Corrpensalon Insurance Radng Bureau d California. All rights reserved.
From the WCIRB's California Workers' Compensation Insurance Forms Manual -, 1999.
Endorsement No.
Premium $ INCL .
v
POLICY NUMBER: so4233a2 COMMERCIAL GENERAL LIABILITY
Named Insured: American Asphalt South, Inc
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: PMP #18-01, FY18-19 Slurry Seal Program.
Additional insured status applies if required by written contract per endorsement attached City of
Menifee, its elected officials, officers, agents and employees, representatives, consultants, contract
employees and volunteers. Primary wording per attached endorsement. Waiver of Subrogation applies
(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 ll) 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: 12/31/2017 Expiration Date: 12/31/2018
When this endorsement applies, such insurance as is afforded by the general
liability policy is primary insurance and other insurance shall be excess to the
insurance afforded by this endorsement.
CG 201011 85 Modified (07-01)
Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
POLICY NUMBER: 60423382
COMMERCIAL GENERAL LIABILITY
CG24041093
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
Re: PMP #18-01, FY18-19 Slurry Seal Program.
Additional Insured status applies if required by written contract per endorsement attached City of Menifee, its
elected officials, officers, agents and employees, representatives, consultants, contract employees and
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER-
CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule above
because of payments we make for injury or damage arising out of your ongoing operations or "your work" done
under a contract with that person or organization and included in the "products -completed operations hazard".
This waiver applies only to the person or organization shown in the Schedule above.
CG 24 0410 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1
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 PMP #1MI. FY18-19 Slurry Seal Program.
Additional Insured status applies If required by written contract per endorsement attached City of Menifee, its
elected officials, officers, agents and employees, representatives, consultants, contract employees and
volunteers. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability,
Automobile liability and Workers Compensation per the attached endorsements, Excess Is "Follow Form". 30
WHO IS AN INSURED (SECTION II) 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 page 1 of 1
POLICY NUMBER:60423382
ASDA AU 07 02
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
SCHEDULE
Name of Person or Organization: City of Menifee
Attn: Margarita Cornejo, Contract & Procurement
Administrator
Menifee CA 92586
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO
CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule above be-
cause of payments wE make for bodily injury or property damage arising out of losses or accidents which occur
during the policy period. This waiver applies only to liability you assume pursuant to a contract with the person or
organization shown in the schedule.
ASDA AU 07 02 Page 1 of 1