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2018/11/12 IDS Group, Inc. Certificate of Liability Insurance (3)
L Ro® CERTIFICATE OF LIABILITY INSURANCE � DATE (MMIDDNYYY) 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(ios) 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 endorsoment(sj. PRODUCER Risk Strategies Com anCONTACT f? y ,NAME: Risk Strategies Com an 2040 Main Street, Suite 450 PHONE g4g_242-9240 FAX ac No: Irvine, CA 92614 M, , www.risk-strategies.com INSURED IDS Group Inc. I Peters Canyon Rd., Ste 130 Irvine CA 92606 CA DOI License No. OF06675 COVERAGE Itv Co. of) INSURERC: Travelers Casualty and Surety Co America INSURER D : INSURER E : C0VFRAnI79 r`FRTIFIf`ATR tit IfillRCR• AAA4^Ann nmlllelnu kil-An re. 4E 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 L7R TYPE OF INSURANCE ADDLISUBPOLICY POLICY NUMBER EFF MMIDDIYYYY pOWCY E1LP MMIDDIS YYYI LIMITS A �/ COMMERCIAL GENERAL LIABILITY ✓ 68091-1717919 5/1/2019 5/1/2020 EACHDAMOCCURRENCE $$2000.000 PREMISE Eaoccv $$1 000000 CLAIMS -MADE F/-] OCCUR MED EXP (Any one person) $ 10 000 PERSONAL B ADV INJURY $ $2 000 000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ $4,000,000 POLICY 0 • I JE& LOC PRODUCTS - COMP/OP AGG $ $4 000 000 $ OTHER: A AUTOMOBILE LIABILITY ✓ BA8F335897 5/1/2019 5/1/2020 O I NEDSIN I (Ea✓ rjdelg $$1 000 000 ANY AUTO BOUILY INJURY (Per person,, $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident ( ) $ HIRED NON -OWNED AUTOS ONLY ✓ AUTOS ONLY ✓ p RTY AMAGE Rer aceldenl $ _ $ B �/ UMBRELLA LIAB ,/ OCCUR CUP71<299343 5/1/2019 5/1/2020 EACH OCCURRENCE $ 9000000 AGGREGATE $ 9 000 000 EXCESS LIAB CLAIMS -MADE DED I ✓ I RETENTION O 1$ 1 B WORKERS COMPENSATION �/ U641<463295 51112019 5/1/2020 TAT 7 ERH AND EMPLOYERS' LIABILITY Y / N E.L EACH ACCIDENT $ $1,000,000 'D7 ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDE ❑ N/A E.L. DISEASE - EA EMPLOYEIy $ $1,0Q0,Q00 (Mandatory In NH) If yes, deseri under E.L. DISEASE - POLICY LIMIT $ $1 000,000 DESCRIPTIONN OF OPERATIONS below C Professional Liability 107008332 11/12/2018 1111212019 Per Claim: $3,000,000 Aggregate. $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Projects as an file with the insured including but not limited to CIP 19-16: Lazy Creek Recreation Center Improvement Project. City of Menifee and its officers, officials, employees, and authorized volunteers are named as additional insureds and primary/non-contributory clause applies to the general and auto liability policies and a waiver of subrogation applies to the work comp policy -see attached endorsements. cn i iF-ra..n i r- nULUMM CANCELLATION City of Menifee Attn: Margaret Cornejo, Contract & Procurement Administrator 29844 Haun Rd. Menifee CA 92586-6539 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 Michael Christian ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 1 of 9 Insured: IDS Group, Inc. Policy No.: 6809H717919 COMMERCIAL GENERAL LIABILITY Effective Date:5/1/2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Coverage Part, but: a. Only with respect to liability for "bodily injury", "property damage" or "personal injury'; and b. If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies, or in connection with premises owned by or rented to you. The person or organization does not qualify as an additional insured: c. With respect to the indcpe,.uant arlm ur omissions of such person or organization; or d. For "bodily injury", "property damage" or "personal injury" for which such person or organization has assumed liability in a contract or agreement. The insurance provided to such additional insured is limited as follows: e. This insurance does not apply on any basis to any person or organization for which coverage as an additional insured specifically Is added by another endorsement to this Coverage Part. f. This insurance does not apply to the rendering of or failure to render any "professional services". g. In the event that the Limits of Insurance of the Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the insurance provided to the additional insured shall be limited to the limits of liability required by that "written contract requiring insurance". This endorsement does not increase the limits of insurance described In Section III — Limits Of Insurance. h. This insurance does not apply to "bodily injury" or "property damage" caused by "your work" and included in the "products - completed operations hazard" unless the "written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured applies only to such "bodily injury" or "property damage" that occurs before the end of the period of time for which the "written contract requiring insurance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 2. The following is added to Paragraph 4.a, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: The insurance provided to the additional insured is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover. However, if you specifically agree in the "written contract requiring insurance" that this insurance provided to the additional insured under this Coverage Part must apply on a primary basis or a primary and non-contributory basis, this insurance is primary to other insurance available to the additional insured which covers that person or organizations as a named insured for such loss, and we will not share with the other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal injury" for which coverage is sought arises out of an offense committed; after you have signed that "written contract requiring insurance". But this insurance provided to the additional insured still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the additional insured when that person or organization is an additional insured under any other insurance. CG D3 81 0815 ® 2015 The Travelers Indemnity Company. All rights reserved. Includes the copyrighted material of Insurance Services Office, Inc., with its permission Page 1 of 2 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 2 of 9 COMMERCIAL GENERAL LIABILITY 3. The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: We waive any right of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" performed by you, or on your behalf, done under a "written contract requiring insurance" with that person or organization. We waive this right only where you have agreed to do so as part of the "written contract requiring insurance" with such person or organization signed by you before, and in effect when, the "bodily injury" or "property damage" occurs, or the "personal injury' offense is committed. 4. The following definition is added to the DEFINITIONS Section: "Written contract requiring insurance" means that part of any written contract under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs and the "personal injury" is caused by an offense committed: a. After you have signed that written contract; b. While that part of the written contract is in effect; and c. Before the end of the policy period. Page 2 of 2 ® 2015 The Travelers Indemnity Company. All rights reserved. Includes the copyrighted material of Insurance Services Office, Inc., with its permission CG D3 81 0915 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 3 of 9 POLICY NO.:gA8F335897 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY WITH OTHER INSURANCE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM PROVISIONS 1. The following is added to Paragraph A.1.c., Who Is An Insured, of SECTION II — LIABILITY COVERAGE: This includes any person or organization who you are required under a written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to name as an additional insured for Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured". 2. The following is added to Paragraph B.5., Other Insurance of SECTION IV — BUSINESS AUTO CONDITIONS: Regardless of the provisions of paragraph a. and paragraph d. of this part 5. Other Insurance, this insurance is primary to and non-contributory with applicable other insurance under which an additional insured person or organization is the first named insured when the written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, requires this insurance to be primary and non-contributory. CA T4 74 08 17 © 2016 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 4 of 9 IDS Group, Inc. BA8F335897 5/1 /2019 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE -- This endorsement broadens coverage. However, coverage for any Injury, damage or medical expenses described In any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by suety an endorsement. The following listing Is a general cover- age descriptlon only. Limitations and excluslons may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what Is and Is not covered. A. BROAD FORM NAMED INSURED B. BLANKET ADDITIONAL INSURED C. EMPLOYEE HIRED AUTO D. EMPLOYEES AS INSURED E. SUPPLEMENTARY PAYMENTS — INCREASED LIMITS F. HIRED AUTO — LIMITED WORLDWIDE COV- ERAGE — INDEMNITY BASIS G. WAIVER OF DEDUCTIBLE -- GLASS PROVISIONS A. BROAD FORM NAMED INSURED The following Is added to Paragraph A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any organization you newly acquire or form dur- ing the policy period over which you maintain 50% or more ownership Interest and that is not separately insured for Business Auto Coverage. Coverage under this provision Is afforded only un- til the 180th day after you acquire or form the or- ganizatlon or the end of the policy period, which- ever Is earner. B. BLANKET ADDITIONAL INSURED The following Is added to Paragraph c. In A.1., Who is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any person or organization who Is required under a written contract or agreement between you and that person or organization, that Is signed and executed by you before the "bodily Injury" or "property damage" occurs and that Is In effect during the policy period, to be named as an addi- tional Insured Is an "Insured" for Covered Autos Llablllty Coverage, but only for damages to which H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT J. PERSONAL PROPERTY K. AIRBAGS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS M. BLANKET WAIVER OF SUBROGATION N. UNINTENTIONAL ERRORS OR OMISSIONS this Insurance applies and only to the extent that person or organization quallfies as an "Insured" under the Who Is An Insured provision contained In Section II. C. EMPLOYEE HIRED AUTO 1. The following Is added to Paragraph A.1., Who Is An Insured, of SECTION II -- COV- ERED AUTOS LIABILITY COVERAGE: An "employee" of yours Is an "insured" while operating an "auto" hired or rented under a Contract or agreement In an "employee's" name, with your permission, white performing duties related to the conduct of your busl- ness. 2. The following replaces Paragraph b, In B.6., Other Insurance, of SECTION IV — BUSI- NESS AUTO CONDITIONS: b. For Hired Auto Physical Damage Cover- age, the following are deemed to be cov- ered "autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow; and (2) Any covered "auto" hired or rented by your "employee" under a contract In an "employee's" name, with your CA T3 63 0216 02015 The Travelers Indemnity Company. All rights reserved. Page 1 of 4 Indudes copyrighted material of Insurance 8ervlces OfOce, Inc, with he permission. 49019496 1 19-20 GL-AL-OL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 5 of 9 COMMERCIAL AUTO Permission, while performing duties related to the conduct of your busi- ness, However, any "auto" that Is leased, hired, rented or borrowed with a driver Is not a covered "auto", D. EMPLOYEES AS INSURED The following Is added to paragraph A.1., Who Is An Insured, of SECTION if -- COVERED AUTOS LIABILITY COVERAGE: Any "employee" of yours Is an "Insured" while us- Ing a covered "auto" you don't own, hire or borrow In your business or your personal affairs. E. SUPPLEMENTARY PAYMENTS — INCREASED LIMITS 1. The following replaces Paragraph A.2.a.(2), of SECTION II — COVERED AUTOS LIABIL. ITY COVERAGE; (2) Up to $3.000 for cost of bell bonds (In- cluding bonds for related traffic law viola- tions) required because of an "accident" we cover. We do not have to furnish these bonds, 2. The following replacr_+s perhgrnph of SECTION II -- COVERED AUTOS LIABIL. ITY COVERAGE; (4) All reasonable expenses incurred by the "Insured" at our request, including actual loss of earnings up to $500 a day be- cause of tlme off from worts, F. HIRED AUTO — LIMITED WORLDWIDE COV. ERAGE — INDEMNITY BA518 The following replaces Subparagraph (6) In Para- graph 13.7., Policy Period, Coverage Territory, of SECTION IV -- BUSINESS AUTO CONDI. TIONS: (5) .Anywhere In Vic world, except any country or #urisdlction wtille any trade sanction, am- baroo, or similar regulation imposed by the United Stales of America applles to and pro- hibits the transaction of bus€ness with or withln such country or Jurisdiction, for Cov- ered Autos Unbllity Coverage for any coveted "auto" that you lease, hire, rent or borrow without a driver for a period of 30 days or less and that Is not an "auto" you lease, hire, rent or borrow from any of your "employees", partners (if you are a partnership), members (if you are B limited liability company) or members of their households. (a) With respect to any claim made or "suit" brought outside the United Slates of America, the territories and possessions of the United States of America, Puerto Rico and Canada; (1) You must arrange to defend the "In- surad" against, and investigate or set- tle any such claim or "suit" and keep us advised of all proceedings and ac- tlons. (II) Neither you nor any other Involved "Insured" will make any settlement without our consent, (lit) We may, at our discretion, participate In defending the "Insured" against, or In the settlement of, any claim or "still". (Iv) We will reimburse the "Insured" for sums that the "Insured" legally must Pay as damages because of "bodlly injury" or "property damage" to which ihls insurance applies, that the "in- sured" pays with out consent, but ❑nly up to the limit described In Para- graph C,. Limits Of Insurance, of SECTION 11 — COVERED AUTOS LIABILITY COVERAGE, (v) We will reimburse the "Insured" for the reasonable expenses incurred with our consent for your Invastiga- tion of such claims and your defense of the 'insured" against any such "suit", but only up to and Included wlthln the limit described in Para- graph C,, Limits Of Insurance, of SECTION II — COVERED AUTOS LIABILITY COVERAGE, and not In addition to such 11mit. Our duty to make such payments ends when we have used up the applicable limit of Insurance In payments for damages, settlements or defense expenses. (b) This insurance Is excess over any valid and collectible other Insurance available to the "Insured" whether primary, excess, contingent or on any other basis. (c) This insurance Is not a substitute for re- quirod or compulsory insurance In any country outside the United States, its ter - diodes and possessions, Puerto Rico and Canada. Page 2 of 4 02018 Tho Travalora Indemnity Company, All riphis reserved, CA T3 53 0215 Includes copyrighted matoflal or Irlaurar►ce servIcea ❑Irkce, No. with Its permission. 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 6 of 9 You agree to maintain all required or compulsory Insurance In any such coun- try up to the minimum limits required by local law. Your failure to comply with compulsory insurance requirements will not lnvatldate the coverage afforded by this policy, but we will only be liable to The same extent we would have been liable had you complied with the compulsory In- surance requirements. (d) It Is understood that we are not an admit- ted or authorized Insurer outside the United States of America, Its territories and possessions, Puerto Rico and Can- ada. We assume no responsibility for tiie fu nishing of cortiflcates of Insurance, or for compliance In any way with the laws of other countries relatliig to Insurance. G. WAIVER OF DEDUCTIBLE — GLASS The following Is added to Paragraph D., Deducti- ble, of SECTION III — PHYSICAL DAMAGE COVERAGE: No deductibie for a covered "auto" will apply to glass damage if the glass Is repaired rather than replaced. .4. H)Rr-n AUTO PHYSICAi DAMAGE -, LOsa OF USE — INCREASED LIMIT The following replaces the last sentence of Para- graph A,4.b., Loss Of Use Expenses, of SEC- TION III — PHYSICAL DAMAGE COVERAGE: However, tiie most we will pay for any expenses for loss of use Is W per day, to a maximum of $750 for any one "accident". I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES —INCREASED LIMIT The following replaces the first sentence In Para- graph A.4.a,, Transportation Expenses, of SECTION III — PHYSICAL DAMAGE COVER- AGE: WO'will pay up to $50 per day to a maximum of $1,500 for temporary transportatlon expense in- curred by you because of the total theft of a cov- ered "auto" of the private passenger type. J. PERSONAL PROPERTY Tile following Is added to Paragraph A.4„ Cover- age Extensions, of SECTION III — PHYSICAL_ DAMAGE COVERAGE: Personal Property We will pay up to $400 for "loss" to wearing ap- parel and other personal property which Is: (1) Owned by an "Insured", and COMMERCIAL AUTO (2) In or on your covered "auto". This coverage applies only In the event of a total theft of your covered "auto". No deductibles apply to this Personal Property coverage. K. AIRBAGS The following Is added to Paragraph B.3., Exclu- sions, of SECTION III — PHYSICAL DAMAGE COVERAGE: Exclusion 3.8. does not apply to "loss" to one or more alrbags In a covered "auto" you own that In- flate due to a cause other than a cause of "loss" set forth In Paragraphs A.t.b. and A.i.c., but only: a. If that "auto' Is a covered "auto" for Compre- henslve Coverage under this policy; b. Tile alrbags are not covered under any war- ranty; and c. The alrbags were not intentionally inflated. We will pay up to a maximum of $1,000 for any one "loss", L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS The following is added to Paragraph A,2.a., of Your duty to give us er our authorized reprasenta- tive prompt notice of the "accident" or "loss" ap- plies only when the "accident" or "loss" Is known to: (a) You (if you are an individual); (b) A partner Of you are a partnership); (c) A member (if you are a limited liability com- pany) (d) An executive officer, director or Insurance manager (if you are a corporation or other or- ganizatlon); or (a) Any "employee" authorized by you to give no- tice of the "accident" or "loss". M. BLANKET WAIVER OF SUBROGATION The following replaces Paragraph A.S., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — BUSINESS AUTO CONDI- TIONS: 6. "transfer Of Rights Of Recovery Against others To Us We waive any right of recovery we may have against any person or organization to the ex- tent required of you by a written contract signed and executed prior to any "accident" or "loss", provided that the "accident" or "ions" arises out of operations contemplated by CA T3 63 02 16 02016 The Travelers Indemnity company. All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance services office, Inc. with its permission. 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 7 of 9 COMMERCIAL AUTO such contract. The waiver applies only to the person or organizatlon designated in such contract. N. UNINTENTIONAL_ ERRORS OR OMISSIONS The following is added to Paragraph 8.2„ Con- cealment, Misrepresentation, Or Fraud, of SECTION IV — BUSINESS AUTO CONDITIONS - The unintentional omission of, or urllntentional error in, any Information given by you shall not prejudice your rights under this insurance, How- ever this provision does not affect our right to col- lect additional premium or exefclse our right of cancellation or non-renowal. Page 4 Of 4 02016 The Travelers WemnRy Company. All righle reserved. Includes copyrighled malem? of Inswame services 0I11oe, Ino, with Its permission. CA T3 63 0215 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 8 of 9 0 TRAVELERS Insured: IDS Group, Inc. Policy No.: UB4K463295 Effective Date: 5/1 /2019 WORKERS COMPENSATION AND EMPLOYERS LIABILITY ENDORSEMENT WC 99 03 76 (00) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA (BLANKET WAIVER) 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. 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 5.000% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization ANY PERSON OR ORGANIZATION WITH WHOM YOU AGREE IN WRITING TO WAIVE YOUR RIGHT TO RECOVER AGAINST THEM. YOU MUST AGREE TO THIS WAIVER PRIOR TO THE DATE OF LOSS Job Description: Projects as on file with the insured. Authorized Representative 49019496 1 19-20 GL-AL-UL-WC, 18-19 PL I Sandi Moreno 1 5/30/2019 3:38:59 PM (PDT) I Page 9 of 9