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2015/06/15 Copp Contracting, Inc. Certificate of Liability InsuranceDATE (MMIDDIYYYY) A o CERTIFICATE OF LIABILITY INSURANCE 10/26/2015 INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF ELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIV 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). CONTACT Jeremy Seltzer PRODUCER compass Direct Insurance Services, Inc. NAME: 1368p Newport Ave., Ste 8 #622 PHONE 714-665 9800 Fn FAX No : 714 665-9801 p C o Ext: Tustin, CA 92780 E-MAIL erem cdisi.com ADDRESS: _, -,_ „ www.cdisi.com License #OH16100 INSURER A: Wesco Insurance Company 501 2 501 INSURERB: Everest National Insurance Company 1 012 INSURED Cop Contracting, Inc. INSURERC: PO Box 457 INSURER D : Buena Park CA 90621-0457 Nov o q 2015 INSURER E COVERAGES CERTIFICATE NUMBER: 27058183 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERT CERTIFICATE MAYnBESISSUED OR MAY PERTAIN, THETERM OR N URANCEONDITION AFFORDEOF ANY D BY THEOPOLLIICIES DESCRIBED THER OCUMENT TH RESPECT TO HE HEREIN S SUBJECT TO ALL OD THE( TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED POLICY BY PAID CL IMS LIMITS INSR ADDL SUBR POLICY NUMBER MMIDDIYYYY MMIDDM/YY TYPE OF INSURANCE 1,000,( 11/1/2015 11/1/2016 EACH OCCURRENCE S A ✓ COMMERCIAL GENERAL LIABILITY / �/ WPP1051283 04 DAMAGE TO RENTED S 100,( PREMISES Ea occurrence CLAIMS -MADE a OCCUR 5,( MED EXP (Any one person) S / Owner's/Cont. Pro PERSONAL & ADV INJURY S 1,000'I ✓ XCU / Deductible $1,000 GENERAL AGGREGATE S 2,000,1 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S 2,000,RO- POLICY ✓❑ JECT E LOC 15 1,000, Em to Be Benifits OTHER: WPP105128304 11/1/2015 11/1/2016 COMBINED SINGLE LIMIT I S Ea accident 1,000,E A AUTOMOBILE LIABILITY ✓ ✓ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) S ALL OWNED SCHEDULED AUTOS PROPERTY DAMAGE S AUTOS NON -OWNED Per accident ✓ HIRED AUTOS ✓ AUTOS S ✓ Om /Coll Ded $1 00 EACH OCCURRENCE 5 UMBRELLA LIAB OCCUR I AGGREGATE S EXCESS LIAB CLAIMS -MADE I I S DED RETENTIONS 7600015069151 6/15/2015 6/15/2016PE ✓ STATUTE OERH B WORKERS COMPENSATION ✓ I S 1,000, AND EMPLOYERS' LIABILITY YIN i E.L. EACH ACCIDENT ANY PROPRIETOR/PARTNERIEXECUTIIJE D NIA E.L. DISEASE - EA EMPLOYE S OFFICERIMEMBER EXCLUDED? 1,000, (Mandatory in NH) E.L. DISEASE - POLICY LIMIT S If yes, describe under DESCRIPTION OF OPERATIONS below (LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) DESCRIPTION OF OPERATIONS RE: Encanto Drive Street Resurfacing No.15-03 add of d Menifee and its additional insures but only as respects work done by, for, oronbehalf of the named insuoredract employees and volunteers are hereby CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City Of Menifee THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 29714 Haun Road ACCORDANCE WITH THE POLICY PROVISIONS. Menifee CA 92586 AUTHORIZED REPRESENTATIVE Jeremy Seltzer ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORG 2705B1B3 1 15/16 GL AU UMB WC I Jeremy Seltzer 10/26/2015 ` ..3 PM (MDT) I Page 1 of 9 Copp Contracting, Inc. COMMERCIAL GENERAL LIABILITY CG 2010 07 04 WPP1051283 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Locations Of Covered Operations It is agreed that such insurance as is afforded by this policy for the benefit of the additional insured shown shall be pri- City of Menifee and its elected mary insurance, and any other insurance maintained by the official, officers, employees, agents, additional insured(s) shall be excess and noncontributory as representatives, consultants, respects any claim, loss or liability allegedly arising out of contract employees and volunteers the operations of the named insured, provided however that this insurance will not apply to any claim loss or liability which is determined to be solely the result of the additional insured's negligence or solely the additional insured's re- sponsibility. Information required to complete this Schedule if not shown above will be shown in the Declarations. I A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. CG 20 10 07 04 B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or .,property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location 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 in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. © ISO Properties, Inc., 2004 Page 1 of 1 27058183 1 15/16 GL AU UMB WC I Jeremy Seltzer 110/26/2015 5:15:29 PM (MDT) I Page 2 of 9 WPP1051283 04 Copp Contracting, Inc. COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Location And Description Of Completed Operations It is agreed that such insurance as is afforded by this City of Menifee and its elected official, policy for the benefit of the additional insured shown officers, employees, agents, shall be primary insurance, and any other insurance maintained by the additional insured(s) shall be excess representatives, consultants, contract and noncontributory as respects any claim, loss or employees and volunteers liability allegedly arising out of the operations of the named insured, provided however that this insurance will not apply to any claim loss or liability which is de- termined to be solely the result of the additional in- sured's negligence or solely the additional insured's responsibility. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products - completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 2705B183 1 15/16 GL AU UMB WC I Jeremy Seltzer 1 10/26/2015 5:15:29 PM (MDT) I Page 3 of 9 WPP1051283 04 Copp Contracting, Inc. COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF. RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: City of Menifee and its elected official, officers, employees, agents, representatives, consultants, contract employees and volunteers Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: 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 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ 27058183 1 15/16 GL AU UMH WC I Jeremy Seltzer 10/26/2015 5:15:29 PM (MDT) I Page 4 of 9 WPP1051283 04 Copp Contracting, Inc. COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 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 Project(s): This endorsement applies only to your projects away from premises owned by or rented to you for which you have certificates of insurance on file at your office. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by 'occur- damages or under Coverage C for medical rences" under Section I — Coverage A, and for all expenses shall reduce the Designated Con - medical expenses caused by accidents under struction Project General Aggregate Limit for Section I — Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag- construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con- t. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla- cept damages because of "bodily injury" or rations, such limits will be subject to the appli- "property damage" included in the "products- cable Designated Construction Project Gen - completed operations hazard", and for medi- eral Aggregate Limit. cal 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". CG 25 03 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 2 ❑ 27058183 1 15/16 GL AU UMB WC I Jeremy Seltzer 1 10/26/2015 5:15:29 PM (MDT) I Page 5 of 9 B. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occur- rences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be attri- buted only to ongoing operations at a single des- ignated construction project shown in the Sche- dule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical D. expenses shall reduce the amount available under the General Aggregate Limit or the Products -completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. Page 2 of 2 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. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, 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 Section III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. © Insurance Services Office, Inc., 2008 CG 25 03 05 09 ❑ 27058183 1 15/16 GL AU UMH WC I Jeremy Seltzer 1 10/26/2015 5:15:29 PM (MDT) I Page 6 of 9 WPP1051283 04 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: 11/1/2015 Countersigned By: Named Insured: Copp Contracting, Inc. Authorized Representative) SCHEDULE Name of Person(s) or Organization(s): City of Menifee and its elected official, officers, employees, agents, representatives, consultants, contract employees and 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 II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ 27058183 1 15/16 GL AU UMB WC I Jeremy Seltzer 1 10/26/2015 5:25:29 PM (MDT) I Page 7 of 9 WPP1051283 04 COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE 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 the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Copp Contracting, Inc. Endorsement Effective Date: 11/1/2015 SCHEDULE Name(s) Of Person(s) Or Organization(s): City of Menifee and its elected official, officers, employees, agents, representatives, consultants, contract employees and volunteers Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident' or the "loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 27058183 1 15/16 GL AU UMB WC I Jeremy Seltzer 1 10/26/2015 5:15:29 PM (MDT) I Page 8 Of 9 Page 1 of 1 ❑ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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. PERSON OR ORGANIZATION City of Menifee and its elected official, officers, employees, agents, representatives, consultants, contract employees and volunteers SCHEDULE JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION 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 06-15-15 Policy No. 7600015069151 Insured COPP CONTRACTING INC Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By -1998 by the Workers' Compensation Insurance Rating Bureau of California. Al rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. Endorsement No. 001 Premium $ INCL . 27058183 1 15/26 GL AU UMH WC I Jeremy Seltzer 1 10/26/2015 5:15:29 PM (MDT1N$URf9bQD P 9