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2012/10/01 Hillcrest Contracting, Inc.; Ros Mar Equipment Co., Inc. Certificate of Liability Insurance --"'� OP ID:JR CERTIFICATE OF LIABILITY INSURANCE DATE 06126BIYYYY) s_res11 a 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 certifiie to 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 endorsements. PRODUCER Phone:949-SSa• CONTACT 9800 NAME: The Wooditch Company Insurance Fax:949.553-0670 ° E Services,Inc. AIC No EXt: AIQ,Na): 1 Park Plaza,Suite 400 A L ADORESS: Irvine,CA 92614 Marc Ramirez CUSTOMER ID m HILLCRE INSURERS)AFFORDING COVERAGE NAICN INSURED Hiilcrest Contracting, Inc. INSURER A:Old Republic General Ins.Corp 24139 _ Ros Mar Equipment Co. Inc. INSURERS:Great American Ins.Co. 16691 1467 Circle City Drive R E _ Corona,CA 92879.168 INsuasac: INSURER D INSURER E: INSURER P COVERAGES CERTIFICATE NUMBER: 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, INTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY X X A1CG93281201 10/01/12 10/01/13 PREMISES Es occu re rnae $ 100,000 CLAIMS-MADE X]OCCUR MED EXP(Any one person)_ S 5,00 X DED:$5,000 PERSONAL&ADV INJURY $ 1,000,0000 t GENERAL AGGREGATE $ 2,000,00 SENT.AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOP AGG $ 2,000,0013 PRO- _ POLIO X LOD, $ AUTOMOaiLE LIABILITY X X COMBINED SINGLE OMIT S 1,000,00 (Ea seddem) A X ANYAUTO A1CA93281201 10/01112 10i01113 BODILY INJURY(Par person) $ ALL OWNED AUTOS BODILY INJURY(Par accitlent) S SCHEDULED AUTOS PROPERTY DAMAGE S HIRED AUTOS (Per accitlent) NON-OWNEDAUTOS $ $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 42000,00 )( EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 B — — -- -- T00026300301 10/01/12 10/01/13 — -- __ DEDUCTIBLE $ _ RETENTION S WORKERS COMPENSATION X WC STATW OTH- AND EMPLOYERS'LIABILITY TORT LIMITS _LR _------ -_ A ANY PROPRIETORIPARTNERIEXECUTNE YIN NIA X AICW93281201 10/01/12 10/01113 E.L EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE.EA EMPLOYEE $f,dr 1,ODO,OO DESCRIPTION OF E,L,DISEASE-POLICY LIMIT $ 1,000,00 DESCRI scrON OF OPERATIONS below DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES lAttach ACORD 101,Additional Remarks Schedule,if more space is required) RE: All operations performed by the Named Insured during the current policy period. City of Menifee, its elected and appointed officers, directors, officials, employees, agents and volunteers are named as Additional Insureds as respects General and Auto Liability per attached endorsements. *SEE NOTES* glaipwv/auaiwv/wcwv CERTIFICATE HOLDER CANCELLATION MENIFEE 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 Menifee 29714 Haun Rd. Menifee,CA 92586 AUTHORIZED REPRESENTATIVE ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD HILLCRE PAGE 2 NOTEPAD INSURED'S NAME Hillcrest Contracting,Inc. OP ID:JR DATE 06126/13 *Should this policy be cancelled before the expiration date, The Wooditch Company will mail 30 (thirty) days written notice to those Certificate Holders which require such action per contract or agreement.* NOTEPAD HOLDER CODE MENIFEE HILLCRE PAOE3 INSURED'S NAME Hillcrest Contracting,Inc. OP ID:JR DATE 06/26/13 *Except 10 Days Notice of Cancellation for Non-Payment of Premium. This Insurance shall apply as Primary and Non-Contributory per attached endorsement. Waiver of Subrogation for General and Auto Liability and Workers' Compensation:�as Attached Endorsements. POLICY NUMBER: AlCG93281201 COMMERCIAL GENERAL LIABILITY CG 2010 07 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 Organization(s): _ Location(s)Of Covered Operations WHERE REQUIRED BY 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 S. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for"bodily injury", "property This insurance does not apply to"bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. Your acts or urnissions;or 1. All work, including materials, pars awufp- ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, mofnten- behalf; ante or repairs) to be performed by or on be- in the performance of your ongoing operations for half of the additional insured(s) at the location the additional Insureds) at the looation(s) desig- of the covered operations has been completed; hated above. 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. CG 2010 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 ❑ POLICY NUMBER: Al CG93281201 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) Location Arid Description Of Completed Opera- Or Organizations : tions WHERE REQUIRED BY WRITTEN CONTRACT,BUT ONLY WHEN COVERAGE FOR COMPLETED OPERATIONS IS SPECIFICALLY REQUIRED BY THAT CONTRACT. Information required to complete this Schedule if not shown above,will he shown in the Declarations. Section 11 -- Who Is An Insured is amended to Include as an additional insured the persons) or organizatlon(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". Ora 20 37 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 13 OLD REPUBLIC GENERAL INSURANCE CORPORATION CHANGES ADDITIONAL INSURED PRIMARY WORDING SCHEDULE THIS ENDORSEMENT CHANCES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Name of Additional Insured Person(s) Location(s)of Covered Operations Or Organization(s): As required by written contract, Information required to complete this Schedule, if not shown above,will be shown In the Declarations. The insurance provided by this endorsement is primary insurance and we will not seek contribution from any other insurance of a like kind available to the person or organization shown in the schedule above unless the other insurance is provided by a contractor other than the person or organization shown in the schedule above for the same operation and job location. If so,we will share with that other insurance by the method described in paragraph 4.G.of Section IV—Commercial General Liability Conditions, All other terms and conditions remain unchanged. Named Insured Hillcrest Contracting, Inc. Policy Number Al CG93281201 JEndorsmetPolicy Period 10/01/2012 10/01/20dorsement EfFeetive Date: 1 010 1/20 1 2 Producer'sName: ............ Producer Number: 10/01/2012 AUTHORIZED REPRESENTATIVE DATE CG EN GN 0029 09 06 POLICY NUMBER: Al CG93281201 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: Where Required by Written Contract. 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 11 of 1 13 POLICY NUMBER: AlCA93281201 COMMERCIALAUTO 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 modified 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 indi- cated below. Endorsement Effective: 10/01/2012 Countersigned By: Named Insured: Hillcrest Contracting, Inc. Authorized Representative) SCHEDULE Name of Person(s) or Organization(s): Where required by written contract (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 13 POLICY NUMBER: AICA93281201 COMMERCIAL AUTO CA 04 44 0310 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 underthe 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: Hlllcrest Contracting, Inc. Endorsement Effective Date: 10/01/2012 SCHEDULE Name(s)Of Person(s)Or Organization(s): Where Required by Written Contract. 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 0310 0 Insurance Services Office, Inc., 2009 Page 1 of 1 13 OLD REPUBLIC GENERAL INSURANCE CORPORATION WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE 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. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule WHEN REQUIRED BY WRITTEN CONTRACT. The premium charge for this endorsement is $0.00 �I Named Insured HILLCREST CONTRACTING, INC. Policy Number A-ICW-932812-01 Endorsement No. 000 Policy Period 1 0/0112 01 2 to Endorsement Effective Date: 10/01/2012 10/01/2013 Producer's Name: OLD REPUBLIC CONSTRUCTION INSURANCE AGENCY, INC. Producer Number: 0000007000 AUTHORIZED REPRESENTATIVE DATE WC 99 03 15(09106)