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2017/11/09 Willdan Engineering Certificate of Liability InsuranceCERTIFICATE OF LIABILITY INSURANCE YYY DAT10/31//22017 ) 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 Aon Risk Insurance services west, Inc. LOS An el es CA Office 9 CONTACT NAME: (A/C. No. Ext : (866) 283-7122 1 ArX. No.): (800) 363-0105 707 wi 1 shire Boulevard Suite 2600 E-MAIL ADDRESS: Los Angeles CA 90017-0460 USA INSURER(S) AFFORDING COVERAGE NAIL # INSURED INSURER A: Travelers Property Cas CO of America 25674 willdan Engineerinq 2401 East Katella Avenue, Suite 300 INSURERB: Lexington Insurance Company 19437 INSURER C: Anaheim CA 92806 USA INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570069105789 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE AD INSD UBR WVD POLICY NUMBER C FF MWDDIYYYY POLICY P MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 7J TIL17 11/09/2017 11 1 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGET RENTED PREMISES Ea occurrence $1,000,000 X MED EXP (Any one person) $15 , 000 Employee Beneras Liability PERSONAL&ADV INJURY $1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: X POLICY ❑ PRO- JECT LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 OTHER: A AUTOMOBILE LIABILITY BA-73365332-TIL-17 11/09/2017 11/09/2018 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY ( Per person) X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) PROPERTYDAMAGE Per accident HIREDAUTOS NON -OWNED ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE DED I RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR PARTNER I EXECUTIVE OFFICERIMEMBER EXCLUDED? N I A UB93558819TIL17 11/09/2017 11/09/2018 X PER OTH- STATUTE I ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below B Archit&Eng Prof 028174912 SIR applies per policy terns 11/09/2017 & conditions 11/09/2018 Aggregate Per Claim $2,000,000 $1,000,000 SIR $250,000'', DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: FY 17/18 Traffic Engineering Support Services. The City of Menifee is included as Additional Insured in accordance with the policy provisions of the General Liability and Automobile Liability policies. General Liability and Automobile Liability policies evidenced herein are Primary and Non -Contributory to other insurance available to an Additional Insured, but only in accordance with the policy's provisions. A waiver of subrogation is granted in favor of certificate Holder in accordance with the policy provisions of the General Liability, Automobile Liability and workers' Compensation policies. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of Meni fee AUTHORIZED REPRESENTATIVE Attn: Administration/Risk Manager 29714 Haun Road Menifee ca, 92586 USA r�n c�:�G�(ccJnQr�layuz �GfiuAxG 1 ��/na ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD rn m rn 0 co 0 0 rn COMMERCIAL GENERAL LIABILITY L How, when and where the 'occurrence" or offense took place; ii. The names and addresses of any injured persons and witnesses; and iii. The nature and location of any injury or damage arising out of the 'occurrence" or offense. b. If a claim is made or "suit" is brought against the additional insured, the additional insured must: Immediately record the specifics of the claim or "suit" and the date received; and ii. Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit" as soon as practicable. c. The additional insured must immediately send us copies of all legal papers received in con- nection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit", and oth- erwise comply with all policy conditions. d. The additional insured must tender the de- fense and indemnity of any claim or "suit" to any provider of other insurance which would cover the additional insured for a loss we cover. However, this condition does not affect whether this insurance provided to the addi- tional insured is primary to that other insur- ance available to the additional insured which covers that person or organization as a named insured. 4. The following is added to the DEFINITIONS Sec- tion: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or or- ganization as an additional insured on this Cover- age Part, provided that the "bodily injury" and "property damage" occurs and the "personal in- jury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 0 2008 The Travelers Companies, Inc. CG D4 14 04 08 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 II — 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 bail 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 replaces Paragraph A.2.a.(4), of SECTION II — COVERED AUTOS LIABIL- ITY COVERAGE: (a) With respect to any claim made or "suit" brought outside the United States of America, the territories and possessions of the United States of America, Puerto Rico and Canada: (i) You must arrange to defend the "in- sured" against, and investigate or set- tle any such claim or "suit" and keep us advised of all proceedings and ac- tions. (ii) Neither you nor any other involved "insured" will make any settlement without our consent. (iii) We may, at our discretion, participate in defending the "insured" against, or in the settlement of, any claim or "suit". (iv) We will reimburse the "insured" for sums that the "insured" legally must pay as damages because of "bodily injury" or "property damage" to which this insurance applies, that the "in- sured" pays with our consent, but only up to the limit described in Para- graph C., Limits Of Insurance, of SECTION II — COVERED AUTOS LIABILITY COVERAGE. (4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for "insured" at our request, including actual the reasonable expenses incurred loss of earnings up to $500 a day be- with our consent for your investiga- cause of time off from work. tion of such claims and your defense F. HIRED AUTO — LIMITED WORLDWIDE COV- of the "insured" against any such "suit", but only up to and included ERAGE — INDEMNITY BASIS within the limit described in Para - The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of graph B.7., Policy Period, Coverage Territory, SECTION II — COVERED AUTOS of SECTION IV — BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in TIONS: addition to such limit. Our duty to (5) Anywhere in the world, except any country or make such payments ends when we jurisdiction while any trade sanction, em- have used up the applicable limit of bargo, or similar regulation imposed by the insurance in payments for damages, United States of America applies to and pro- settlements or defense expenses. hibits the transaction of business with or (b) This insurance is excess over any valid within such country or jurisdiction, for Cov- and collectible other insurance available ered Autos Liability Coverage for any covered to the "insured" whether primary, excess, "auto" that you lease, hire, rent or borrow contingent or on any other basis. without a driver for a period of 30 days or less (c) This insurance is not a substitute for re - and that is not an "auto" you lease, hire, rent quired or compulsory insurance in any or borrow from any of your "employees", country outside the United States, its ter - partners (if you are a partnership), members ritories and possessions, Puerto Rico and (if you are a limited liability company) or Canada. members of their households. Page 2 of 4 © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL AUTO such contract. The waiver applies only to the The unintentional omission of, or unintentional person or organization designated in such error in, any information given by you shall not contract. prejudice your rights under this insurance. How- N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col - The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of cealment, Misrepresentation, Or Fraud, of cancellation or non -renewal. SECTION IV — BUSINESS AUTO CONDITIONS: Page 4 of 4 © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY committed by any of your "employees" who is employed by you as a registered nurse, li- censed practical nurse, emergency medical technician or paramedic, in providing or failing to provide "incidental medical services" or "Good Samaritan services" to a person. 2. The following is added to the DEFINITIONS Section: a. "Incidental medical services" means medical, surgical, dental, laboratory, x-ray or nursing service, treatment, advice or instruction; the related furnishing of food or beverages; the furnishing or dispens- ing of drugs or medical supplies or appli- ances; or first aid. b. "Good Samaritan services" means those medical services rendered or provided in C an emergency and for which no remu- neration is demanded or received. 3. The following is added to Paragraph 2.a.(1) of SECTION II —WHO IS AN INSURED Paragraphs (1) (a), (b), (c) and (d) above do not apply to any of your "employees" who are employed by you as a registered nurse, li- censed practical nurse, emergency medical technician or paramedic but only while per- forming the services described in Paragraph 1. above and while acting within the scope of their employment by you. Any such "employ- ees" rendering "incidental medical services" or "Good Samaritan services" will be deemed to be acting within the scope of their employ- ment by you. 4. The following exclusion is added to Para- graph 2. Exclusions of SECTION I — COV- ERAGES — COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY: Sale of Pharmaceuticals "Bodily injury" or "property damage" arising out of the willful violation of a penal statute or ordinance relating to the sale of pharmaceuti- cals committed by or with the knowledge or consent of the insured. 5. The following is added to Paragraph 4.b., Ex- cess Insurance, of SECTION IV — COM- MERCIAL GENERAL LIABILITY CONDI- TIONS: This insurance is excess over any valid and collectible 'other insurance", whether primary, excess, contingent or on any other basis, that is available to you or any of your "employees" for "bodily injury" that arises out of providing or failing to provide "incidental medical ser- vices" or "Good Samaritan services", except for insurance purchased specifically by you to apply in excess of the Limits of Insurance shown in the Declarations for this Coverage Part. 6. The following is added to Paragraph 5. of SECTION III — LIMITS OF INSURANCE: For the purposes of determining the applica- ble Each Occurrence Limit, all related acts or omissions committed by any of your "employ- ees" in providing or failing to provide "inciden- tal medical services" or "Good Samaritan ser- vices" to any one person will be deemed to be one 'occurrence". REASONABLE FORCE PROPERTY DAMAGE — EXCEPTION TO EXPECTED OR INTENDED IN- JURY EXCLUSION The following replaces Exclusion a., Expected Or Intended Injury, in Paragraph 2. of SECTION I — COVERAGES — COVERAGE A BODILY IN- JURY AND PROPERTY DAMAGE LIABILITY: a. Expected Or Intended Injury Or Damage "Bodily injury" or "property damage" expected or intended from the standpoint of the in- sured. This exclusion does not apply to "bod- ily injury" or "property damage" resulting from the use of reasonable force to protect any person or property. D. NON -OWNED WATERCRAFT — INCREASED TO UP TO 75 FEET 1. The following replaces Paragraph (2) of Ex- clusion g., Aircraft, Auto Or Watercraft, in Paragraph 2. of SECTION I — COVERAGES — COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY: (2) A watercraft you do not own that is: (a) Less than 75 feet long; and (b) Not being used to carry any person or property for a charge. 2. The following is added to SECTION II — WHO IS AN INSURED: Any person who, with your expressed or im- plied consent, either uses or is responsible for the use of a nonowned watercraft that is less than 75 feet and not being used to carry per- son or property for a charge is included as an insured under this Coverage Part. Page 2 of 8 © 2008 The Travelers Companies, Inc. CG D4 15 05 08 (Rev. 10-08) COMMERCIAL GENERAL LIABILITY 2. The following replaces Paragraph 1.d. of SUPPLEMENTARY PAYMENTS — COVER- AGES A AND B of SECTION I — COVER- AGES: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. I. ADDITIONAL INSURED — OWNER, MANAGER OR LESSOR OF PREMISES 1. The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that you have agreed in a "written contract requiring insur- ance" to include as an additional insured on this Coverage Part is an insured, but: a. Only with respect to liability for "bodily in- jury" or "property damage" that occurs, or "personal injury" caused by an offense committed, after you have entered into that "written contract requiring insurance"; and b. Only if the "bodily injury", "property dam- age" or "personal injury" is caused, in whole or in part, by acts or omissions of you or any person or organization per- forming operations on your behalf, and arises out of the ownership, maintenance or use of that part of any premises leased to you under that "written contract requir- ing insurance". 2. The insurance provided to such additional in- sured under this Provision I. is subject to the following provisions: a. The limits of insurance afforded to such additional insured shall be the limits which you agreed to provide in the "writ- ten contract requiring insurance", or the limits shown in the Declarations for this Coverage Part, whichever are less; and b. The insurance afforded to such additional insured does not apply to: (1) Any "bodily injury" or "property dam- age" that occurs, or "personal injury" caused by an offense committed, af- ter you cease to be a tenant in that premises; (2) Any structural alterations, new con- struction or demolition operations performed by or on behalf of such additional insured; or (3) Any premises for which coverage is excluded by another endorsement to this Coverage Part. 3. This Provision I. does not apply on any basis to any person or organization for which cov- erage as an additional insured specifically is added by another endorsement to this Cover- age Part. J. ADDITIONAL INSURED — LESSOR OF LEASED EQUIPMENT 1. The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that you have agreed in a "written contract requiring insur- ance" to include as an additional insured on this Coverage Part is an insured, but: a. Only with respect to liability for "bodily in- jury" or "property damage" that occurs, or "personal injury" caused by an offense committed, after you have entered into that "written contract requiring insurance"; and b. Only if the "bodily injury", "property dam- age" or "personal injury" is caused, in whole or in part, by acts or omissions of you or any person or organization per- forming operations on your behalf, in the maintenance, operation or use of equip- ment leased to you by such additional in- sured. 2. The insurance provided to such additional in- sured under this Provision J. is subject to the following provisions: a. The limits of insurance afforded to such additional insured shall be the limits which you agreed to provide in the "writ- ten contract requiring insurance", or the limits shown in the Declarations for this Coverage Part, whichever are less; and b. The insurance afforded to such additional insured does not apply: (1) To any "bodily injury" or "property damage" that occurs, or "personal in- jury" caused by an offense commit- ted, after the equipment lease ex- pires; or (2) If the equipment is leased with an operator. Page 4 of 8 © 2008 The Travelers Companies, Inc. CG D4 15 05 08 (Rev. 10-08) COMMERCIAL GENERAL LIABILITY Suit of SECTION IV — COMMERCIAL GENERAL ance" by the method described in c. LIABILITY CONDITIONS: below. Notice of an "occurrence" or of an offense which b. Excess Insurance may result in a claim must be given as soon as This insurance is excess over any of practicable after knowledge of the "occurrence" or the "other insurance", whether pri- offense has been reported to you, one of your mary, excess, contingent or on any "executive officers" (if you are a corporation), one other basis: of your partners who is an individual (if you are a (1) That is Fire, Extended Coverage, partnership), one of your managers (if you are a Builder's Risk, Installation Risk, limited liability company), one of your trustees or similar coverage for "your who is an individual (if you are a trust), or an work"; "employee" (such as an insurance, loss control or risk manager or administrator) designated by you (2) That is Fire insurance for prem- to give such notice. ises rented to you or temporarily occupied by you with permission Knowledge by any other "employee" of an "occur- of the owner; rence" or offense does not imply that you also (3) That is insurance purchased by have such knowledge. you to cover your liability as a Notice of an "occurrence" or of an offense which tenant for "property damage" to may result in a claim will be deemed to be given premises rented to you or tempo - as soon as practicable to us if it is given in good rarily occupied by you with per - faith as soon as practicable to your workers' com- mission of the owner; or pensation, accident, or health insurer. This ap- (4) If the loss arises out of the main - plies only if you subsequently give notice of the tenance or use of aircraft, "occurrence" or offense to us as soon as practi- "autos", or watercraft to the ex - cable after you, one of your "executive officers" (if tent not subject to Exclusion g. of you are a corporation), one of your partners who Section I — Coverage A — Bodily is an individual (if you are a partnership), one of Injury And Property Damage Li - your managers (if you are a limited liability com- ability; or pany), one of your trustees who is an individual (if (5) That is available to the insured you are a trust), or an "employee" (such as an in- when the insured is an additional surance, loss control or risk manager or adminis- insured under any other policy, trator) designated by you to give such notice dis- including any umbrella or excess covers that the "occurrence" or offense may in- policy. volve this policy. When this insurance is excess, we Q. OTHER INSURANCE CONDITION will have no duty under Coverages A 1. The following replaces Paragraph 4., Other or B to defend the insured against Insurance"suit" Insurance of SECTION IV —COMMERCIAL if any provider of "other in - surance" has a duty to defend the in- sured against that "suit". If no pro- 4. Other Insurance vider of "other insurance" defends, If valid and collectible "other insurance" is we will undertake to do so, but we will available to the insured for a loss we be entitled to the insured's rights cover under Coverages A or B of this against all those providers of "other Coverage Part, our obligations are limited insurance". as follows: When this insurance is excess over a. Primary Insurance "other insurance", we will pay only This insurance is primary except our share of the amount of the loss, if any, that exceeds the sum of: when b. below applies. If this insur- ance is primary, our obligations are (1) The total amount that all such not affected unless any of the "other "other insurance" would pay for insurance" is also primary. Then, we the loss in the absence of this in - will share with all that "other insur- surance; and Page 6 of 8 © 2008 The Travelers Companies, Inc. CG D4 15 05 08 (Rev. 10-08) COMMERCIAL GENERAL LIABILITY son, including death resulting from any of these at any time. U. AMENDED INSURED CONTRACT DEFINITION — RAILROAD EASEMENT 1. Subparagraph c. of the definition of "insured contract" in the DEFINITIONS Section is re- placed by the following: c. Any easement or license agreement; 2. Subparagraph f.(1) of the definition of "in- sured contract' in the DEFINITIONS Section is deleted. V. ADDITIONAL DEFINITION — WRITTEN CON- TRACT REQUIRING INSURANCE The following definition is added to the DEFINI- TIONS Section: "Written contract requiring insurance" means that part of any written contract or written agreement 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 the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 8 of 8 © 2008 The Travelers Companies, Inc. CG D4 15 05 08 (Rev. 10-08) TRAVELERS WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A) — POLICY NUMBER: UB9J558819TIL17 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. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FUNISH THIS WAIVER. 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 11/09/2017 Policy No. UB9J558819TIL17 Endorsement No. Insured Premium Insurance Company Countersigned by Travelers Property Casualty Company of America DATE OF ISSUE: - - ST ASSIGN: Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 42 03 04 ( B) POLICY NUMBER: UB9J558819TIL17 TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the Schedule. Schedule 1. ❑ Specific Waiver Name of person or organization x❑ Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be percent of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Advance Premium: 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 11/09/2017 Policy No. UB9J558819TIL17 Endorsement No. Insured Premium Insurance Company Countersigned by Travelers Property Casualty Company of America DATE OF ISSUE: ST ASSIGN: © Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 1