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2018/08/27 American Asphalt South, Inc. Certificate of Liability Insurance - PMP 19-02C 0 DATE (MMIDD/YYYY) A " CERTIFICATE OF LIABILITY INSURANCE 6/4/2019 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 Joanne Cadarette InterWest Insurance Services PHONE FA% License #01301094 (Alp,.Nv.Eat1• 916-609-8362 y9.916-979-75M P.O. Box 255188 ADDRIE_SS: icadarefta@Wns.com Sacramento CA 95865-5188 INSURE S AFFORDING COVERAGE NAIC# INSURED American Asphalt South, Inc 14436 Santa Ana Avenue Fontana CA 92337 AMERI26 INSURERA: Financial Pacific Ins Company 31453 INSURERB: Arch Insurance Company 11150 INSURER C : Travelers Prop Cas Co of Amer 25674 INSURER 0: Westchester SurDlus Lines Ins 10172 COVERAGES CERTIFICATE NUMBER" 1Ari8R17783; RFVISION 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 QR TYPE OF INSURANCEXMP ADDL SURR POLICY NUMBER MAU pY EFF MM/ 0CY 20 LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 60423382 12131/2018 12/31/2019 EACH OCCURRENCE $2,000,000 CLAIMS -MADE FRI OCCUR pREMSESlEa__ $100,000 X MED EXP (Any one person) $ 5.000 Cantradud Uab X Dad: $5.000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 4,000,000 PRO- LOC POLICY JECr PRODUCTS - COMP/OP AGG $ 4.000 000 $ OTHER: A AUTOMOBILE LIABILITY Y Y 60423382 12/31/2018 12/31/2019 COMBINED SINGLE LIMIT Sit) $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS .X BODILY INJURY (Per accident) $ X HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ER DAMAGE Par,�gaderd $ $ C X UMBRELLA LIAB X OCCUR ZUP71M8933018 12/31/2018 12/31/2019 EACH OCCURRENCE $6.000.000 AGGREGATE EXCESS LIAB CLAIMS -MADE $ 6,000,000 TIDED X RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? NIA Y ZAWC19413902 4/1/2019 4/1/2020 Xx I PER - STATUTE E.L. EACH ACCIDENT $ 1 000 000 E L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ 1,000,000 D POLLUTION LIABILITY G70915613001 8/27/2018 8/27/2019 LIMIT/EA OCC $2,000,000 LIMIT/AGG DEDUCTIBLE $2,000,000 $10.000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) Re: PMP #19-02, Quail Valley Street Resurfacing (West). Additional Insured status applies if required by written contract per endorsement attached City of Menifee. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability and Workers Compensation per the attached endorsements. CERTIFICATE HOLDER CANCELLATION 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 ('AA - ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 21 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VOLUNTEER WORKERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART WHO IS AN INSURED (Section II) is amended to include as an insured any person(s) who are volun- teer worker(s) for you, but only while acting at the direction of, and within the scope of their duties for you. However, none of these volunteer worker(s) are insureds for: 1. 'Bodily injury" or "personal injury": a. To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability com- pany), to your other volunteer worker(s) or to your "employees" arising out of and in the course of their duties for you; b. To the spouse, child, parent, brother or sister of your volunteer worker(s) or your "employees" as a consequence of para- graph 1.a. above; c. For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraphs 1.a. or b. above; or d. Arising out of his or her providing or failing to provide professional health care serv- ices. 2. "Property damage" to property: a. Owned, occupied, or used by, b. Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your other volunteer workers, your "employees", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). CG 20 21 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 0 Policy #60423382 COMMERCIAL GENERAL LIABILITY CG 20 32 07 98 Modified THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - ENGINEERS, ARCHITECTS OR SURVEYORS NOT ENGAGED BY THE NAMED INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GEnIERAL LI DILITY COVERACE PART SCHEDULE Name of Engineers, Architects Or Surveyors Not Engaged By The Named Ir1SUred: AS PER ACORD25 CERTIFICATE OF INSURANCE (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II — Who Is An Insured is amended to include as an insured the architects, engineers or surveyors shown in the Schedule, but only to the extent such aruhituot, engineer, ur survuyur iv rield liable for your ongoing operations performed by you or on your behalf. Such architects, engineers or surveyors, while not engaged by you, are con- tractually required to be added as an additional in- sured to your policy. B. With respect to such architects, engineers or sur- veyuls tit lvwrl In It le %-3Glieclule auuve, It IQ Iulluwirlcd exclusion Is added to Paragraph 2., Exclusions of Section I — Coverage A — Bodily Injury And Property IDamaOe Liability and fiction I — Cov- erage B — Personal And Advertising Injury Li- ability: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or the failure to render uny prufes�iunul services, inuludiriy: 1. The preparing, approving, or failing to prepare or approve maps, drawings, opinions, reports, c_urvpys, ohango orders, do.60ns nr s�__cifica- tions; and 2. Supervisory, inspection or engineering serv- ices. CG 20 32 07 98 Modified Page 1 of 1 ❑ Includes copyrighted material of insurance Services Office, Inc., with its permission. POLICY NUMBER: 60423382 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 I), 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 Q. 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. pnnn 9 r%f 9 C:nnvrinht Insurance Services Office. Inc.. 1996 CG 25 03 03 97 POLICY NUMBER: 60423382 CG24171001 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTUAL LIABILITY - RAILROADS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Scheduled Railroad: Designated Job Site: ALL JOB5ZTE8 (If no entry appears above, Information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) With respect to operations performed for, or affecting, a Scheduled Railroad at a Designated Job Site, the definition of "insured contract" in the Definitions section is replaced by the following: 9. "Insured Contract" means: 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 to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract"; . b. A sidetrack agreement; c. Any easement or license agreement; d. An obligation, as required by ordinance, to indemnify a municipality, except in connection with work for a municipality; e. An elevator maintenance agreement; If. That part of any other contract or agreement pertaining to your business (including an indemnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury" or "property damage" to a third person or organization. Tort liability means a liability that would be imposed by law In the absence of any contract or agreement. Paragraph If. does not include that part of any contract or agreement: (1) That Indemnifies an architect, engineer or surveyor for injury or damage arising out of: (a) Preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (b) Giving directions or instructions, or failing to give them, If that Is the primary cause of the injury or damage; (2) Under which the insured, if an architect, engineer or surveyor, assumes liability for an Injury or damage arising out of the insured's rendering or failure to render professional services, including those listed in Paragraph. (1) above and supervisory, inspection, architectural or engineering activities. CG 24 17 10 01 0180 Properties, Inc., 2000 Page 1 of 1 *49006550* 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: PMP #19-02, Quail Valley Street Resurfacing (West). Additional Insured status applies if required by written contract per endorsement attached City of Menifee. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability and Workers Compensation per the attached endorsements. (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: 12/31/2018 Expiration Date: 12/31/2019 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 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 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 *19-02, Quail Valley Street Resurfacing (West). Additional Insured status applies if required by written contract per endorsement attached City of Menifee, Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability and Workers (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 04 10 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: P,nierican Asphalt Sout17, Inc 14436 Santa Ana Avenue Fontana CA 92337 ADDITIONAL INSURED: Re: PMP #19-02. Quail Valley Street Resurfacing (West). Additional Insured status applies 1€ required by written contract per endorsement attached City of McNfee. Primary warding per attached endorsement. Waiver of Subrogation applies to General Liability and Workars Compensation per the attached endorsements. WHO IS AN INSURED (SECTION )1) 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: Re: PMP #19-02, Quail Valley Street Resurfacing (West). Additional Insured status applies if required by written contract per endorsement attached City of Menifee. Primary wording per attached 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 te- 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 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 6/4/2019 at 12:01 A.M. standard time, forms a part of (DATE) Policy No. ZAWC19413902 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