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2018/10/01 TRL Systems, Inc. Certificate of Liability InsuranceCERTIFICATE OF LIABILITY INSURANCE DATE (MMI DIY ) 018 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 Woodruff -Sawyer & Co. 2 Park Plaza, Suite 500 CONTACT NAME: Sergio Nilchian PHONE FAX AIC No Ext : 949-435.7358 A/c No): 949-476.3118 Irvine CA 92614 ADDRESS: snilchian woodruffsaw er.com INSURERS AFFORDING COVERAGE NAIC # INSURERA: Philadelphia Indemnity Insurance Company 18058 INSURED TRLSYST-01 TRL Systems, Inc. 9531 Milliken Ave INSURER B : Hartford Insurance Company of the Midwest 37478 INSURERC: Hartford Fire Insurance Company 19682 INSURERD: Rancho Cucamonga CA 91730 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:317607944 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. ILTR TYPE OF INSURANCE INDL SWVDR NUMBER POLICPOLICY MM DDY EFF POLICY PY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR Y Y ! PHPK1888416 City of Menifee City Clerk OCT 12 2018 eceived 10/1/2018 10/1/2019 EACH OCCURRENCE S 1,000.000 DAMAGE TO RENTED PREMISES Ea occurrence S 100,000 MED EXP (Any one person) S 5,000 PERSONAL & ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- X POLICY El JECT LOC OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMP/OP AGG S 2,000,000 No GL Deductible S C AUTOMOBILE X X LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY Y Y 72UENFN6030 10/1/2018 10/1/2019 ! I COMBINED SINGLE LIMIT Ea accident S 1,000,000 BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accident S S A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE Y 1 Y PHUB649517 10/1/1018 10/1/2019 EACH OCCURRENCE S 10.000,000 AGGREGATE S 10,000,000 DED I X I RETENTIONS 10 000 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under D DESCRIPTION OF OPERATIONS below N / A Y 72WEZR5673 10/1/2011 10/1/2019 X I PER STATUTE OERH E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE Project: CS025 -AMR Skate Park Security Enhancements -Security Cameras. CITY OF MENIFEE, a California municipal corporation is included as additional insureds under the Commercial General Liability Policy and such insurance afforded to the additional insureds includes products/completed operations and shall apply as primary insurance. Also a waiver of subrogation and 30 day notice of cancellation apply. lIam 1 lr-11 MI C riVLUCR %,AN VLLHI IUN CITY OF MENIFEE, a California municipal corporation 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Policy No. PHPK1888416 TRL Systems, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY/NON-CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Schedule Name and Address of Person or Organization: Any Person or Organization as Required by Written Contract. It is understood and agreed that coverage for the person or organization shown in the above schedule is primary and non-contributory as respects liability created by the errors, acts or omissions of the named insured herein and subject to the terms and conditions in the Additional Insured Endorsement attached hereto. All other terms, conditions, limitations, and exclusions of this policy are unchanged and applicable. Policy No. PHPK1888416 PI-TECH-010 (02/15) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies and is subject to the insurance provided under the following: COMMERCIAL GENERAL LIABILTY COVERAGE FORM The following is added to SECTION II — WHO IS AN INSURED: Any person or organization where required by a written contract executed prior to the occurrence of a loss. Such person or organization is an additional insured for "bodily injury," "property damage" or "personal and advertising injury" but only for liability arising out of the negligence of the named insured. The limits of insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreement. These limits are included within and not in addition to the limits of insurance shown in the Declarations. ©2015 Philadelphia Indemnity Insurance Company Page 1 of 1 PI-TECH-010 (02/15) Policy No. PHPK1888416 TRL Systems, Inc. PI-AM-014 (08/06) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART It is agreed that, notwithstanding anything to the contrary in paragraph 8. Transfer of Rights of Recovery Against Others To Us of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, in the event of any payment under this policy, we waive our right of recovery against any person or organization with respect to which the insured has waived its right of recovery. It is further agreed that work commenced under letter of intent or work order, subject to subsequent reduction to writing, with customers whose customary contracts would require a waiver of recovery rights against them also falls within this blanket waiver of subrogation. Page 1 of 1 Policy No. PHPK1888416 PI-CANXAICH-002 (05/11) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTICE TO SCHEDULED ADDITIONAL INSURED OR CERTIFICATE HOLDER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROFESSIONAL LIABILITY COVERAGE PART COMMERCIAL CRIME COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART SCHEDULE OF ADDITIONAL INSUREDS OR CERTIFICATE HOLDERS Al or CH Additional Insured or Certificate Holder Address The following is added to A. CANCELLATION of the Common Policy Conditions of the above applicable coverage part: A. In the event we cancel the policy in accordance with the policy's terms and conditions, we will endeavor to mail written notice of cancellation to Additional Insureds or Certificate Holders, shown in the above SCHEDULE within the time frame listed below. However, failure to mail such notice shall impose no obligation of any kind upon us, our agents or representatives. 1. 30 days before the effective date of cancellation if we cancel for any reason other than for non - payment of premium. As respects Additional Insureds, the above cancellation provision applies only when the Additional Insured shown in the above SCHEDULE is added to the policy by a separate additional insured endorsement as the CANCELLATION NOTICE TO ADDITIONAL INSURED OR CERTIFICATE HOLDER does not provide additional insured coverage. Page 1 of 1 POLICY NUMBER: PHPx1888416 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 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 Organization(s) Locations Of Covered Operations Any person or organization included per written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment 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 intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: PHPK1888416 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations KW 150 El Camino, LLC, Kennedy -Wilson Properties, LTD, Kennedy -Wilson Tech, LTD and IMAGINE PHASE II Job No.: 18-3671 their respective members, shareholders, agents 150 South El Camino Drive and employees, Imagine Holding Company, LLC, Beverly Hills, CA 90212 Imagine Entertainment and their respective members, managers, agents and employees, and Taslimi Construction Company, Inc. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WORKERS' COMPENSATION BROAD FORM ENDORSEMENT EXTENDED OPTIONS Policy Number: 72WEZR5673 Endorsement Number: Blanket Effective Date: 10/01/2018 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: TRL Systems, Inc. 9531 Milliken Ave Rancho Cucamonga, CA 91730 Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section III of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: INDEX SUBJECT PAGE SUBJECT SECTION 1 2 B. Part One Does Not Apply PARTS ONE and TWO 2 C. Application of Coverage 01 We Will Also Pay 2 D. Additional Exclusions PART -THREE 2 E. West Virginia 02 How This Insurance Works 2 EXTENDED OPTIONS PART - SIX 2 01 Employers' Liability Insurance 03 Transfer of Your Rights and Duties 2 02 Unintentional Failure to Disclose 04 Liberalization 2 Hazards SECTION If 2 03 Waiver of Our Right to Recover from VOLUNTARY COMPENSATION 2 Others INSURANCE 04 Foreign Voluntary Compensation 05 Voluntary Compensation Insurance 2 A. How This Reimbursement Applies A. How This Insurance Applies 2 B. We Will Reimburse B. We Will Pay 3 C. Exclusions C. Exclusions 3 D. Before We Pay D. Before We Pay 3 E. Recovery From Others E. Recovery From Others 3 F. Reimbursement For Actual Loss F. Employers' Liability Insurance 3 Sustained EMPLOYERS' LIABILITY STOP GAP 3 G. Repatriation ENDORSEMENT H. Endemic Disease 06 Employers' Liability Stop Gap 3 05 Longshore and Harbor Workers' Coverage Compensation Act Coverage A. Stop Gap Coverage Limited to 3 Endorsement Montana, North Dakota, Ohio, SECTION III Washington, West Virginia and 01 Schedule of Covered States Wyoming PAGE 3 3 3 3 4 4 4 4 4 4 4 4 5 5 5 Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 1 of 6 © 2000, The Hartford SECTION I PARTS ONE and TWO PART THREE 1. WE WILL ALSO PAY 2. How This Insurance Applies D. We Will Also Pay of Part One (WORKERS' Paragraph 4. of A. How This Insurance COMPENSATION INSURANCE); and Applies of Part 3 (Other States Insurance) is E. We Will Also Pay of Part Two replaced by the following: (EMPLOYERS' LIABILITY INSURANCE) is 4. If you have work on the effective date of this replaced by the following: policy in any state not listed in Item 3.A. of We Will Also Pay the Information Page, coverage will not be afforded for that state unless we are notified We will also pay these costs, in addition to within sixty days. other amounts payable under this insurance, as part of any claim, proceeding, or suit we PART SIX defend: 3. Transfer Of Your Rights and Duties 1. reasonable expenses incurred at our request, INCLUDING loss of earnings; C. Transfer Of Your Rights and Duties of 2. premiums for bonds to release Part 6 (Conditions) is replaced by the following: attachments and for appeal bonds in bond amounts up to the limit of our Your rights or duties under this policy may liability under this insurance; not be transferred without our written 3. litigation costs taxed against you; consent. 4. interest on a judgment as required by If you die and we receive notice within sixty law until we offer the amount due under days after your death, we will cover your legal representative as insured. this law; and 4. 5. incur. Liberalization expenses we If we adopt a change in this form that would broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. SECTION II VOLUNTARY COMPENSATION AND 3. The bodily injury must occur in the EMPLOYERS' LIABILITY COVERAGE United States of America, its territories 5. Voluntary Compensation Insurance or possessions, or Canada, and may occur elsewhere if the employee is a A. How This Insurance Applies United States or Canadian citizen, or This insurance applies to bodily injury by otherwise legal resident, and legally accident or bodily injury by disease. Bodily employed, in the United States or injury includes resulting death. Canada and temporarily away from 1. The bodily injury must be sustained by those places. any officer or employee not subject to 4. Bodily injury by accident must occur the workers' compensation law of any during the policy period. state shown in Item 3.A. of the 5. Bodily injury by disease must be caused Information Page. or aggravated by the conditions of the 2. The bodily injury must arise out of and in the course of employment or incidental to work in a state shown in Item 3.A. of the Information Page. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 2 of 6 officer's or employee's employment. The officer's or employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay an amount equal to the benefits that would be required of you as if you and your employees were subject to the workers' compensation law of any state shown in Item 3.A. of the Information Page. We will pay those amounts to the persons who would be entitled to them under the law. C. Exclusion This insurance does not cover: 1. any obligation imposed by workers' compensation or occupational disease law or any similar law. 2. bodily injury intentionally caused or aggravated by you. 3. officers or employees who have elected not to be subject to the state workers' compensation law. 4. partners or sole proprietors not covered under the Standard Sole Proprietors, Partners, Officers and Others Coverage Endorsement. D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. Employers' Liability Insurance Part Two (Employers' Liability Insurance) applies to bodily injury covered by this endorsement as though the State of Employment was shown in Item 3.A. of the Information Page. This provision 5. does not apply in New Jersey or Wisconsin. EMPLOYERS' LIABILITY STOP GAP COVERAGE 6. Employers' Liability Stop Gap Coverage A. This coverage only applies in Montana, North Dakota, Ohio, Washington, West Virginia and Wyoming. B. Part One (Workers' Compensation Insurance) does not apply to work in states shown in Paragraph A above. C. Part Two (Employers' Liability Insurance) applies in the states, shown in Paragraph A., as though they were shown in Item 3.A. of the Information Page. D. Part Two, Section C. Exclusions is changed by adding these exclusions. This insurance does not cover; 5. bodily injury intentionally caused or aggravated by you or in Ohio bodily injury resulting from an act which is determined by an Ohio court of law to have been committed by you with the belief than an injury is substantially certain to occur. However, the cost of defending such claims or suits in Ohio is covered. 13. bodily injury sustained by any member of the flying crew of any aircraft. 14. any claim for bodily injury with respect to which you are deprived of any defense or defenses or are otherwise subject to penalty because of default in premium under the provisions of the workers' compensation law or laws of a state shown in Paragraph A. E. This insurance applies to damages for which you are liable under West Virginia Code Annot. S 23-4-2. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 3 of 6 EXTENDED OPTIONS 1. Employers' Liability Insurance Item 3.13. of the Information Page is replaced by the following: B. Employers' Liability Insurance: 1. Part Two of the policy applies to work in each state listed in Item 3.A. The Limits of Liability under Part Two are the higher of: Bodily Injury by Accident $500,000 Each Accident Bodily Injury by Disease $500,000 Policy Limit Bodily Injury by Disease $500,000 Each Employee OR 2. The amount shown in the Information Page. This provision 1 of EXTENDED OPTIONS does not apply in New York because the Limits Of Our Liability are unlimited. In this provision the limits are changed from $500,000 to $1,000,000 in California. 2. Unintentional Failure to Disclose Hazards If you unintentionally should fail to disclose all existing hazards at the inception date of your policy, we shall not deny coverage under this policy because of such failure. 3. Waiver of Our Right To Recover From Others A. 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 any person or organization for whom you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit anyone not named in the agreement. B. This provision 3. does not apply in the states of Pennsylvania and Utah. 4. Foreign Voluntary Compensation and Employers' Liability Reimbursement A. How This Reimbursement Applies This reimbursement provision applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an officer or employee. 2. The bodily injury must occur in the course of employment necessary or incidental to work in a country not listed in Exclusion C.1. of this provision. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The officer or employee's last exposure to those conditions of your employment must occur during the policy period. B. We Will Reimburse We will reimburse you for all amounts paid by you whether such amounts are: 1. voluntary payments for the benefits that would be required of you if you and your officers or employees were subject to any workers' compensation law of the state of hire of the individual employee. 2. sums to which Part Two (Employers' Liability Insurance) would apply if the Country of Employment were shown in Item 3.A. of the Information Page. C. Exclusions This insurance does not cover: 1. any occurrences in the United States, Canada, and any country or jurisdiction which is the subject of trade or economic sanctions imposed by the laws or regulations of the United States of America in effect as of the inception date of this policy. 2. any obligation imposed by a workers' compensation or occupational disease law, or similar law. 3. bodily injury intentionally caused or aggravated by you. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 4 of 6 4. liability for any consequence, whether of America necessarily incurred as a direct direct or indirect, of war, invasion, act of result of bodily injury. Foreign enemy, hostilities (whether war Our reimbursement shall be limited as be declared or not), civil war, rebellion, follows: revolution, insurrection or military or usurped power. No endorsement now 1. to the amount by which such expenses or subsequently attached to this policy exceed the normal cost of returning the shall be construed as overriding or officer or employee if in good health, or waiving this limitation unless specific 2. in the event of death, to the amount by reference is made thereto. which such expenses exceed the normal D. Before We Pay cost of returning the officer or employee Before we reimburse you for the benefits to if alive and in good health. the persons entitled to them, you must have In no event shall our reimbursement exceed them: the bodilyu b accident limit shown in injury Y 1. release you and us, in writing, of all Item 3.13. of the Information Page as responsibility for the injury or death, respects any one such officer or employee whether dead or alive. 2. transfer to us their right to recover from H. Endemic Disease others who may be responsible for their injury or death, The word "disease" includes any endemic 3. cooperate with us and do everything diseases. necessary to enable us to enforce the The coverage applies as if endemic right to recover from others. diseases were included in the provisions of If the persons entitled to the benefits paid fail the workers' compensation law. to do these things, our duty to reimburse 5. Longshore and Harbor Workers' ends at once. If they claim damages from Compensation Act Coverage us for the injury or death, our duty to General Section C. Workers' Compensation reimburse ends at once. Law is replaced by the following: E. Recovery From Others C. Workers' Compensation Law If we make a recovery from others, we will Workers' Compensation Law means the keep an amount equal to our expenses of workers or workers' compensation law and recovery and the benefits we reimbursed. occupational disease law of each state or We will pay the balance to the persons territory named in Item 3.A. of the entitled to it. If persons entitled to the Information Page and the Longshore and benefits make a recovery from others, they Harbor Workers' Compensation Act (33 must repay us for the amounts that we have USC Sections 901-950). It includes any reimbursed you. amendments to those laws that are in effect F. Reimbursement for Actual Loss during the policy period. It does not include Sustained any other federal workers or workers' This endorsement provides only for compensation law, other federal reimbursement for the loss you actually occupational disease law or the provisions of sustain. In order for you to recover loss or any law that provide nonoccupationaldisability expenses under this reimbursement you benefits. must: Part Two (Employers' Liability Insurance), C. 1. actually sustain and pay the loss or Exclusions, exclusion 8, does not apply to expense in money after trial, or work subject to the Longshore and Harbor Workers' Compensation Act. 2. secure our consent for the payment of This coverage does not apply to work the loss or expense. subject to the Defense Base Act, the Outer G. Repatriation Continental Shelf Lands Act, or the Our reimbursement includes the additional Nonappropriated Fund Instrumentalities Act. expenses of repatriation to the United States Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 5 of 6 SECTION III 1. SCHEDULE OF COVERED STATES A. This endorsement only applies in the states listed in this Schedule of Covered States. C. Schedule of Covered States: ALL Waiver of Our Right To Recover From Others Schedule: As required by written contract Countersigned by B. If a state, shown in Item 3.A. of the Information Page, approves this endorsement after the effective date of this policy, this endorsement will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. Authorized Representative Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 6 of 6 WOODRUFF SAWYER & COMPANY 50 CALIFORNIA ST FL12 SAN FRANCISCO CA 94111-4646 CITY OF MENIFEE, A CALIFORNIA MUNICIPAL CORPORATION 29714 HAUN RD MENIFEE CA 92586-6540 IS