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2020/10/01 DBX, Inc. Certificate of Liability InsuranceSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 2/24/2021 GMGS Risk Management & Insurance Services 6201 Oak Canyon, Suite 100 Irvine, CA 92618 (949)559-3367 www.gmgs.com 0B84519 Calvin Sistrunk Charise Ferguson charisef@gmgs.com DBX Inc. 42024 Avenida Alvarado, Suite A Temecula CA 92590 60300086 This certificate may be relied upon only if the certificate addendum referred to herein is attached hereto. City of Menifee 29844 Haun Road Menifee CA 92586 RE: CIP 20-06 & 20-07; Traffic Signal at Menifee/Holland Rd and Menifee/Camino Cristal Rd. A 1,000,0004T22-CO-7202P439-TCT-21 3/1/2021 3/1/2022 300,000 3 5,000 3 1,000,000 3 XCU; Contractual Liability 2,000,000 2,000,000 A 810-2P785885-21-2S-G 3/1/2021 3/1/2022 1,000,000 3 3 3 B CUP-1J930129-21-2S 3/1/2021 3/1/2022 10,000,00033 10,000,000 3 10,000 B UB 9N101481 10/1/2020 10/1/2021 3 1,000,000 1,000,000 1,000,000 Travelers Indemnity Company of Connecticut 25682 Travelers Property Casualty Co of America 25674 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 1 of 11 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: RE: CIP 20-06 & 20-07; Traffic Signal at Menifee/Holland Rd and Menifee/Camino Cristal Rd. As respects General Liability coverage, City of Menifee, its officers, agents and employees are added as Additional Insured per CGD2460419 attached, and this insurance is primary per CGT1000219 attached. As respects General Liability coverage, a Waiver of Subrogation is hereby included, per CGD3160219 attached. As respects General Liability coverage, a $5,000 Property Damage Deductible applies per Occurrence. As respects Automobile Liability coverage, City of Menifee, its officers, agents and employees are added as Additional Insured, per CAT3530215 attached. As respects Automobile Liability coverage, No Deductible applies. As respects Workers’ Compensation coverage, a Waiver of Subrogation is hereby included per WC990376 attached. GMGS Risk Management & Insurance Services DBX Inc. 42024 Avenida Alvarado, Suite A Temecula CA 92590 25 Certificate of Liability (03/16) ADDENDUM HOLDER: ADDRESS: City of Menifee 29844 Haun Road Menifee CA 92586 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 2 of 11 DBX Inc. 4T22-CO-7202P439-TCT-21 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 3 of 11 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 4 of 11 DBX Inc. 4T22-CO-7202P439-TCT-21 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 5 of 11 DBX Inc.4T22-CO-7202P439-TCT-21 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 6 of 11 DBX Inc. 810-2P785885-21-2S-G 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 7 of 11 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 8 of 11 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 9 of 11 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 10 of 11 DBX Inc. UB 9N101481 UB 9N10148110/1/2020 60300086 | 21-22 A/G/U/W-R&L | Charise Ferguson | 2/24/2021 9:37:07 AM (PST) | Page 11 of 11