The URL can be used to link to this page

2021/04/07 KOA Corporation Amendment No. 1 to Agreement between KOA Corporation and the City of Menifee for FY20/21 On-Call Engineering Services (Non-Recoverable) Grant Management Services AMENDMENT NO. 1 TO AGREEMENT BETWEEN KOA CORPORATION AND THE CITY OF MENIFEE FOR FY2020/21 ON-CALL ENGINEERING SERVICES (NON-RECOVERABLE) GRANT MANAGEMENT SERVICES This is Amendment No. 1 to that certain AGREEMENT for Professional Services Agreement (“Agreement”) made on and between the City of Menifee (“City”) and KOA CORPORATION (“Consultant”) for FY2020/21 ON-CALL ENGINEERING SERVICES (NON- RECOVERABLE)GRANT MANAGEMENT SERVICES which Amendment is made and entered into on ______________, 2021 to increase the compensation amount as indicated below: Section 1.6, “Covid-19 Safety” is included to read as follows: 1.6 Covid-19 Safety. If Consultant enters City property or meets in person with City employees during the performance of the Services, Consultant shall comply with all State, County, and local emergency orders, directives, protocols, and best practices related to the COVID-19 pandemic, including, but not limited to: (A) wearing facial coverings, (B) maintaining adequate physical distancing when possible, (C) regular hand washing, and (D) regular hand sanitizing. 1. Section 2, “Compensation” is amended to read as follows: increasing the contract amount by: $30,000.00 (THIRTY THOUSAND DOLLARS AND ZERO CENTS) Section 2. City hereby agrees to pay Contractor a sum not to exceed $80,000.00 (EIGHTY THOUSAND DOLLARS AND ZERO CENTS) notwithstanding any contrary indications that may be contained in Contractor's proposal, for services to be performed and reimbursable costs incurred under this Agreement. In the event of a conflict between this Agreement and Exhibit A, regarding the amount of compensation, this Agreement shall prevail. City shall pay Contractor for services rendered pursuant to this Agreement at the time and in the manner set forth herein. The payments specified below shall be the only payments from City to Contractor for services rendered pursuant to this Agreement. Contractor shall submit all invoices to City in the manner specified herein. Except as specifically authorized in advance by City, Contractor shall not bill City for duplicate services performed by more than one person. 2. All other terms and conditions of the Agreement remain in full force and effect. DocuSign Envelope ID: C57781D6-68F1-43C3-86D5-CE80873B7F20DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 April 7 Professional Services Amendment No. 1 with KOA Corporation CITY OF MENIFEE KOA Corporation _______________________________ _______________________________ Armando G. Villa, City Manager Min Zhou, Vice President Attest: ________________________________ Jimmy Lin, President/CEO _______________________________ Sarah A. Manwaring, City Clerk Approved as to Form: _______________________________ Jeffrey T. Melching, City Attorney DocuSign Envelope ID: C57781D6-68F1-43C3-86D5-CE80873B7F20DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 SHOULD 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 3/11/2021 Dealey,Renton &Associates 790 E Colorado Blvd #460 Pasadena,CA 91101 License #0020739 510-465-3090 Certificates@Dealeyrenton.com XL Specialty Insurance Co.37885 KOACORPOR Travelers Property Casualty Company of America 25674KOACorporation 1100 Corporate Center Drive #201 Monterey Park,CA 91754 (323)260-4703 The Travelers Indemnity Company of Connecticut 25682 483789639 B X 2,000,000 X 1,000,000 X Contractual Liab 10,000 X XCU Included 2,000,000 4,000,000 X Y Y 6808H966428 3/13/2021 3/13/2022 4,000,000 C 1,000,000 X X X Y Y BA4R681356 3/13/2021 3/13/2022 B X X 5,000,000CUP6464Y0333/13/2021 3/13/2022 5,000,000 X 0 B XYUB2L4593509/19/2020 9/19/2021 1,000,000 1,000,000 1,000,000 A Professional Liability Pollution Liability Included DPR9974753 3/13/2021 3/13/2022 Per Claim Annual Aggregate 2,000,000 4,000,000 AM Best's Rating on all policies above:A/XII or greater.Umbrella Liability policy is follow-form to its underlying Policies:General Liability/Auto Liability/Employers Liability. Re:KOA Job No./Name:JB91167 Grant Management for Menifee City of Menifee and its officers,employees,agents,and volunteers are Additional Insured as respects to General &Auto Liability as required per written contract or agreement.Insurance coverage includes waiver of subrogation per the attached. 30 Day Notice of Cancellation City of Menifee Attn:Margarita Cornejo 29844 Haun Road Menifee CA 92586 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 ÐÑÔ×ÝÇÒËÓÞÛÎæ COMMERCIAL GENERAL LIABILITY ISSUED DATE: ÌØ×ÍÛÒÜÑÎÍÛÓÛÒÌÝØßÒÙÛÍÌØÛÐÑÔ×ÝÇòÐÔÛßÍÛÎÛßÜ×ÌÝßÎÛÚËÔÔÇò   Ì¸·»²¼±®»³»²¬³±¼·º·»·²«®¿²½»°®±ª·¼»¼«²¼»®¬¸»º±´´±©·²¹æ ÝÑÓÓÛÎÝ×ßÔÙÛÒÛÎßÔÔ×ßÞ×Ô×ÌÇÝÑÊÛÎßÙÛÐßÎÌ    ×²º±®³¿¬·±²®»¯«·®»¼¬±½±³°´»¬»¬¸·Í½¸»¼«´»ô·º²±¬¸±©²¿¾±ª»ô©·´´¾»¸±©²·²¬¸»Ü»½´¿®¿¬·±²ò ·¿³»²¼»¼¬±·²ó ´±½¿¬·±²¼»·¹²¿¬»¼¿²¼¼»½®·¾»¼·²¬¸»½¸»¼«´»±º ½´«¼»¿¿²¿¼¼·¬·±²¿´·²«®»¼¬¸»°»®±²ø÷±®±®ó ¬¸·»²¼±®»³»²¬°»®º±®³»¼º±®¬¸¿¬¿¼¼·¬·±²¿´·²ó ¹¿²·¦¿¬·±²ø÷¸±©²·²¬¸»Í½¸»¼«´»ô¾«¬±²´§©·¬¸ «®»¼¿²¼·²½´«¼»¼·²¬¸»þ°®±¼«½¬ó½±³°´»¬»¼±°»®¿ó ®»°»½¬¬±´·¿¾·´·¬§º±®þ¾±¼·´§·²¶«®§þ±®þ°®±°»®¬§¼¿³ó ¬·±²¸¿¦¿®¼þò ¿¹»þ½¿«»¼ô·²©¸±´»±®·²°¿®¬ô¾§þ§±«®©±®µþ¿¬¬¸» ×ÍÑÐ®±°»®¬·»ô×²½òôîððì Ð¿¹»ï±ºï Any person or organization that you agree in a written contract to include as an additional insured on this Coverage Part for "bodily injury" or "property damage" included in the "products- completed operations hazard", provided that such contract was signed and executed by you before, and is in effect when, the bodily injury or property damage occurs. Any project to which an applicable contract described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. 3/11/20216808H966428 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 ÐÑÔ×ÝÇÒËÓÞÛÎ COMMERCIAL GENERAL LIABILITY ISSUED DATE: ÌØ×ÍÛÒÜÑÎÍÛÓÛÒÌÝØßÒÙÛÍÌØÛÐÑÔ×ÝÇòÐÔÛßÍÛÎÛßÜ×ÌÝßÎÛÚËÔÔÇò    Ì¸·»²¼±®»³»²¬³±¼·º·»·²«®¿²½»°®±ª·¼»¼«²¼»®¬¸»º±´´±©·²¹æ ÝÑÓÓÛÎÝ×ßÔÙÛÒÛÎßÔÔ×ßÞ×Ô×ÌÇÝÑÊÛÎßÙÛÐßÎÌ    ø×²º±®³¿¬·±²®»¯«·®»¼¬±½±³°´»¬»¬¸·Í½¸»¼«´»ô·º²±¬¸±©²¿¾±ª»ô©·´´¾»¸±©²·²¬¸»Ü»½´¿®¿¬·±²ò÷ Í»½¬·±²×× É¸±×ß²×²«®»¼·¿³»²¼»¼¬±·²ó Ì¸··²«®¿²½»¼±»²±¬¿°°´§¬±þ¾±¼·´§·²¶«®§þ±® ½´«¼»¿¿²¿¼¼·¬·±²¿´·²«®»¼¬¸»°»®±²ø÷±® þ°®±°»®¬§¼¿³¿¹»þ±½½«®®·²¹ô±®°»®±²¿´·²¶«®§Œ ±®¹¿²·¦¿¬·±²ø÷¸±©²·²¬¸»Í½¸»¼«´»ô¾«¬±²´§ ±®¿¼ª»®¬··²¹·²¶«®§Œ¿®··²¹±«¬±º¿²±ºº»²» ©·¬¸®»°»½¬¬±´·¿¾·´·¬§º±®þ¾±¼·´§·²¶«®§þôþ°®±°»®¬§ ½±³³·¬¬»¼ô¿º¬»®æ ¼¿³¿¹»þôþ°»®±²¿´·²¶«®§Œ±®¿¼ª»®¬··²¹·²¶«®§þ ß´´©±®µô·²½´«¼·²¹³¿¬»®·¿´ô°¿®¬±®»¯«·°ó½¿«»¼ô·²©¸±´»±®·²°¿®¬ô¾§æ ³»²¬º«®²·¸»¼·²½±²²»½¬·±²©·¬¸«½¸©±®µô Ç±«®¿½¬±®±³··±²å±®±²¬¸»°®±¶»½¬ø±¬¸»®¬¸¿²»®ª·½»ô³¿·²¬»ó ²¿²½»±®®»°¿·®÷¬±¾»°»®º±®³»¼¾§±®±²Ì¸»¿½¬±®±³··±²±º¬¸±»¿½¬·²¹±²§±«®¾»¸¿´º±º¬¸»¿¼¼·¬·±²¿´·²«®»¼ø÷¿¬¬¸»´±½¿ó¾»¸¿´ºå ¬·±²±º¬¸»½±ª»®»¼±°»®¿¬·±²¸¿¾»»²½±³ó·²¬¸»°»®º±®³¿²½»±º§±«®±²¹±·²¹±°»®¿¬·±²º±®°´»¬»¼å±®¬¸»¿¼¼·¬·±²¿´·²«®»¼ø÷¿¬¬¸»´±½¿¬·±²ø÷¼»·¹ó Ì¸¿¬°±®¬·±²±ºþ§±«®©±®µþ±«¬±º©¸·½¸¬¸»²¿¬»¼¿¾±ª»ò ·²¶«®§±®¼¿³¿¹»¿®·»¸¿¾»»²°«¬¬±·¬·²óÉ·¬¸®»°»½¬¬±¬¸»·²«®¿²½»¿ºº±®¼»¼¬±¬¸»»¬»²¼»¼«»¾§¿²§°»®±²±®±®¹¿²·¦¿¬·±²¿¼¼·¬·±²¿´·²«®»¼ô¬¸»º±´´±©·²¹¿¼¼·¬·±²¿´»¨½´«ó ±¬¸»®¬¸¿²¿²±¬¸»®½±²¬®¿½¬±®±®«¾½±²¬®¿½ó·±²¿°°´§æ ¬±®»²¹¿¹»¼·²°»®º±®³·²¹±°»®¿¬·±²º±®¿ °®·²½·°¿´¿¿°¿®¬±º¬¸»¿³»°®±¶»½¬ò Ý±°§®·¹¸¬îððëÌ¸»Í¬òÐ¿«´Ì®¿ª»´»®Ý±³°¿²·»ô×²½òß´´®·¹¸¬®»»®ª»¼ò Ð¿¹»ï±ºï ×²½´«¼»½±°§®·¹¸¬»¼³¿¬»®·¿´±º×²«®¿²½»Í»®ª·½»Ñºº·½»ô×²½ò©·¬¸·¬°»®³··±²ò Any person or organization that you agree in a written contract, on this Coverage Part, provided that such written contract was signed and executed by you before, and is in effect when the "bodily injury" or "property damage" occurs or the "personal injury" or "advertising injury" offense is committed. Any project to which an applicable written contract with the described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. 6808H966428 3/11/2021 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 NAMED INSURED: POLICY NUMBER: <PNUM> ADDITIONAL COVERAGES BY WRITTEN CONTRACT OR AGREEMENT This is a summary of the coverages provided under the following forms (complete forms available): Page 1 COMMERCIAL GENERAL LIABILITY COVERAGE Excerpt from COMMERCIAL GENERAL LIABILITY COVERAGE (FORM #CG T1 00 02 19) SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS 4. OTHER INSURANCE - d. PRIMARY AND NON-CONTRIBUTORY INSURANCE IF REQUIREDBY WRITTEN CONTRACT: If you specifically agree in a written contract or agreement that the insurance afforded to an insured under this Coverage Part must apply on a primary basis, or a primary and non-contributory basis, this insurance is primary to other insurance that is available to such insured which covers such insured as a namedinsured, and we will not share with that other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and(2) The "personal and advertising injury" for which coverage is sought is caused by an offense that iscommitted; subsequent to the signing of that contract or agreement by you. Excerpt from XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS AND SURVEYORS (FORM #CG D3 79 02 19) PROVISION M. - BLANKET WAIVER OF SUBROGATION - WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT: If the insured has agreed in a written contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person ororganization, but only for payments we make because of: a."Bodily injury" or "property damage" that occurs; orb. "Personal and advertising injury" caused by an offense that is committed; subsequent to the signing of that contract or agreement. KOA Corporation 6808H966428 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 ANY PERSON OR ORGANIZATION THAT YOU ARE REQUIRED TO INCLUDE AS ADDITIONAL INSURED ON THE COVERAGE FORM IN A WRITTEN CONTRACT OR AGREEMENT THAT IS SIGNED AND EXECUTED BY YOU BEFORE THE BODILY INJURY OR PROPERTY DAMAGE OCCURS AND THAT IS IN EFFECT DURING THE POLICY PERIOD. COMMERCIAL AUTO POLICY NUMBER: THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s)or organization(s)who are "insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form.This endorsement does not alter coverage pro- vided in the Coverage Form. SCHEDULE Name Of Person(s)Or Organization(s): Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Each person or organization shown in the Schedule is ered Autos Liability Coverage in the Business Auto an "insured"for Covered Autos Liability Coverage,but and Motor Carrier Coverage Forms and Paragraph only to the extent that person or organization qualifies D.2.of Section I Covered Autos Coverages of the as an "insured"under the Who Is An Insured provi-Auto Dealers Coverage Form. sion contained in Paragraph A.1.of Section II Cov- CA 20 48 10 13 Insurance Services Office,Inc.,2011 Page 1 of 1 BA4R681356 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 COMM RCI L AUTOE A T IS ENDORSEMENT CHANGES T E POLICY.PL ASE READ IT CAREFULLY.H H E BLANKET ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY WITH OTHER INSURANCE Thi e dorseme t m d fie i surance prov ded under he f l o ing:s n n o i s n i t o l w BUS NE S A TO OV RAGE F RMI S U C E O 2.PROVISIONS The fol o ing i added to Paragraphl w s B 5..,O het r In u ances r of SE TION IV BUSIN SS AUTCE O1.The fo lowing is added to Paragraphl A.1.c.,Who COND T ONI I S:Is An Insu edr,of SE TION Il COV REDCE AU OS LIAB LIT CO E AGET I Y V R :Re ardle s o the prov sions o pa ag aph a.a dg s f i f r r n Thi i cludes any pe son or organization who yos n r u pa ag aphr r d.of this part 5.O her Insurance,t this are requi ed under a writ en co tra t ort n c r i suran e i prim ry to and non-contri utory witn c s a b h ag ee ent betwee yo and that perso or m n u n r appl cable othe in urance under which anir s organi a ion,that is signed by you be o e thez t f r addi ional insured person o o ganiza io is thetr r t n "bodi y inju y or "property dam ge o curs andl r "a " c fi st nam d insured when the writ en co tra t or e t n c r that i i e fe t during the poli y period,to nams n f c c e ag ee ent be ween you and that person or m t r a an addit onal i sured fo Cov red Autos i n r e s organi ation,that is signed by you be o e thezf r Lia il ty Cov rage,but only fo dam ges to whi hb i e r a c "bo ily inj ry or "property dam ge o curs andd u "a " c th s insuran e applie and only to the ex ent oi c s t f that i in e fe t duri g the pol cy period,requi es f c n i r sthatpersonsoroganizaio's l abi i y fo the' r t n i l t r th s i surance to be prim ry an non-contri utory.i n a d bconductoanothe"in ured".f r s CA 4 74 2 16T 0 ©2016 The T avelers Indemnit Company.All righryts reserved.Pa e 1 of 1g Includes copyrighted material of nsurance Services OfIf ce,Inc.with its permis ion.i s Policy No. BA4R681356 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following replaces Paragraph A.5.,Transfer of required of you by a written contract executed Rights Of Recovery Against Others To Us,of the prior to any "accident"or "loss",provided that the CONDITIONS Section:"accident"or "loss"arises out of the operations 5.Transfer Of Rights Of Recovery Against Oth-contemplated by such contract.The waiver ap- ers To Us plies only to the person or organization desig- nated in such contract.We waive any right of recovery we may have against any person or organization to the extent CA T3 40 02 15 ©2015 The Travelers Indemnity Company.All rights reserved.Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.with its permission. Policy #BA4R681356 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8 WORKERS COMPENSATION (BLANKET WAIVER) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS AND EMPLOYERS LIABILITY POLICY ENDORSEMENT – CALIFORNIA ENDORSEMENT WC 99 03 76 ( A) - POLICY NUMBER: UB-2L459350 HARTFORD CT 06183 ONE TOWER SQUARE 001 Schedule Person or Organization 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. 2.00 Job Description ALL LOCATIONSANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. Countersigned byInsurance Company PremiumInsured Endorsement No.Policy No.Endorsement Effective 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.) ST ASSIGN: Page of11 DocuSign Envelope ID: E65F2A4F-0595-4944-B6E7-C813AE33B5A8