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2020/10/01 DBX, Inc. Certificate of Liability Insurance (11) 79/17/2020 E(MM/DDYYY) A�" CERTIFICATE OF LIABILITY INSURANCE /Y 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). CONTACT PRODUCER GMGS Risk Management& Insurance Services NAME, Charise Ferguson 6201 Oak Canyon, Suite 100 p//CNNo Ext: 949 559-3367 A/C No: Irvine, CA 92618 E-MAIL ADDRESS: charisefagmgs.com INSURER(S)AFFORDING COVERAGE NAIC# www.gmgs.com OB84519 INSURERA: Travelers Property Casualty Co of America 25674 INSURED INSURER B: DBX Inc. 42024 Avenida Alvarado, Suite A INSURERC: Temecula CA 92590 INSURERD: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 57616434 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DDIYYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE CLAIMS-MADE1:1 OCCUR PREM SES�RENTE a o_cur ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- POLICY ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION UB 9N101481 10/1/2020 10/1/2021 ,/ STATUTE OERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:CIP 20-06&20-07;Traffic Signal at Menifee/Holland Rd and Menifee/Camino Cristal Rd. As respects Workers'Compensation coverage,a Waiver of Subrogation is hereby included per WC990376 attached. CERTIFICATE HOLDER CANCELLATION CIP 20-06&20-07 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityy of Menifee THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 29844 Haun Road ACCORDANCE WITH THE POLICY PROVISIONS. Menifee CA 92586 AUTHORIZED REPRESENTATIVE Calvin Sistrunk ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 57616434 1 20-21 WC Renewal I Charise Ferguson 1 9/17/2020 1:40:18 PM (PDT) I Page 1 of 2 TRAVELERS WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 99 03 76 ( A) - 001 POLICY NUMBER: UB 9NIO1481 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 2.00 % 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 FURNISH 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 10/1/2020 Policy No.UB 9NIO1481 Endorsement No. Insured DBX Inc. Premium Insurance Company Countersigned by DATE OF ISSUE: 03-14-19 ST ASSIGN: Page 1 of 1 57616434 1 20-21 WC Renewal I Charise Ferguson 1 9/17/2020 1:40:18 PM (PDT) I Page 2 of 2