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2018/08/01 All American Asphalt Certificate of Liability Insurance (3)
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 Edgewood Partners Insurance Center LAJNIA T Certificates Department P.O. Box 5003 PHONE — San Ramon, CA 94583 (A(C. Na. Ext1:_ 925-244-?700 1(AJc. Ne) �J25.901 0671 ADDRESS:__. - EPICcerts�epicbrokers.com INSURER(S)AFFORDING COVERAGE NAIC# www.epicbrokers.Corn CA LICENSE #01329370 INSURER A. Arch Specialty Insurance.Convagy 21199 INSURED INSURER B: Zurich American Insurance Com2any 16535 All American Asphalt P.O. BOX 2229 INSURER C : American Guarantee and Liability Ins Co 26247 Corona CA 92878 INSURERD: INSURER E ; INSURER F C-nVFRAC;FS CPDTICIr`ATC h111a11QC0. THIS )S 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. th SR TYPE OF INSURANCE AD UBR Pop- EFF� POLICY E1LP Tl�POLICY NUMBER MMID MM/DD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1/J OCCUR DPC1005856-02 8/1/2018 8/1/2019 EACHOCCURRENCE _n_wGE TO RENTED PREMISES_ Es �.m�l� 610000 0 $ 100 0 00 D EXP .one eon $ _ME PERSONAL & ADV INJURY $ 1 0001000 GEN'L AGGREGATE LIMIT APPLIES PER: -- POLICY / 1.4E LOC PR GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2 000 000 $ OTHER: B AUTOMOBILE LIABILITY BAP5571088-06 8/1/2018 8/1 /2019 �° BIINEEDD�St GLE UMITacci $ 2 OOa 000 ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY.- BODILY INJURY (Per accident) $ 15R0aE $ $ C UMBRELLA LIAB OCCUR SXS019797002 8/1/2018 8/1/2019 EACH OCCURRENCE $5,000,000 AGGREGATE S5,000,000 EXCESS LIAB CLAIMS -MADE FoiloWn -Form DED ✓ RETENTIONs10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNEREKECUT[VE OFF)CERIiMEMSVREXCLUDED? N/A WC593205705 8/1/2018 8/1/2019 S7ATLf1'E ETH E.L. EACH ACCIDENT 51 000000 EL. DISEASE -EA EMPLOYEE E.L_ DISEASE - POLICY LIMIT $'� Q� $1 000 000 (Mandatory InIn NH) if yyes, da5crON under DESCRIPTION OF gPERATION)S INtkw DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) RE: Rustler's Ranch Phase II Resurfacing Project - CIF 19-01 Certificate Holder is Additional Insured if Required by Written Contract Excluding Workers Compensation k.AINIUCLLA I IUiN Cityy of Menifee SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 29714 Haun Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Menifee CA 92586 AUTHORIZED REPRESENTATIVE Certificates Department ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 442827BO 1 18 [01) Standard with $Smm XS I Kris Stubbs 19/1B/2018 1:39:47 PM (PDT) I Page 1 of 8 1AINUIR PO Box 5003 San Ramon, CA 94583 Phone: 925.244.7700 Fax: 925.901-0244 Email: EPICcerts@epicbrokers.com CERTIFICATE HOLDER: Cityy of Menifee 29714 Haun Road Menifee CA 92586 To: Whom it may concern Regarding: Notice of Cancellation Date Issued: 9/18/2018 Named Insured(s): All American Asphalt Policy Number(s): DPC1005856-02 BAP5571088-06 WC593205705 SXS019797002 Should the above described policy be cancelled before the expiration date thereof, we will mail 30 days written notice to the above referenced Certificate Holder; except, 10 days notice for non-payment of premium. Sincerely, Dan Ryan, Managing Principal epicbrokers.com edgewood partners insurance center ca license OB29370 44282780 1 18 [01) Standard with $5mm XS I Kris Stubbs 19/18/2018 1:39:47 PM (PDT) I Page 2 of 8 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF -INSURED RETENTION COVERAGE FORM SECTION II — WHO IS AN INSURED is amended to include as an additional insured those persons or organizations who are required under a written contract with you to be named as an additional insured, but only with respect to liability for "bodily injury", "property damage", or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of your subcontractors: A. In the performance of your ongoing operations or "your work", including "your work" that has been completed; or B. In connection with your premises owned by or rented to you. As used in this endorsement, the words "you" and "your" refer to the Named Insured. All other terms and conditions of this Policy remain unchanged. REFERENCE: RE: Rustler's Ranch Phase II Resurfacing Project - CIF 19-01 Endorsement Number: SCHEDULE: City of Menifee, its officers, agents and employees This endorsement is effective on the inception date of this policy unless otherwise stated herein. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Number: DPC1005856-02 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 00 CGL0006 00 05 07 Page 1 of 1 44282780 118 (011 Standard with $5mm XS I Kris Stubbs 19/18/2018 1:39:47 PM (PDT) I Page 3 of 8 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE - BROAD FORM, CGL POLICY ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF -INSURED RETENTION COVERAGE FORM Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, the following paragraph is added to Condition 4. Other Insurance: Where the Named Insured is required by a written contract to provide insurance that is primary and non-contributory, and the written contract so requiring is executed by the Named Insured before any .,occurrence" or offense, this insurance will be primary, but only if and to the extent required by that written contract. All other terms and conditions of this Policy remain unchanged. REFERENCE: RE: Rustler's Ranch Phase II Resurfacing Project - CIF 19-01 Endorsement Number: SCHEDULE: City of Menifee, its officers, agents and employees This endorsement is effective on the inception date of this policy unless otherwise stated herein. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Number: DPC1005856-02 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 00 CGLO130 00 09 06 Page 1 of 1 44282780 118 (01) Standard with $Smm XS I Kris Stubbs 19/18/2018 1:39:47 PM (PDT) I Page 4 of 8 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF -INSURED RETENTION COVERAGE FORM SCHEDULE Name of Person or Organization: Where required by written contract. Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 8. Transfer Of Rights Of Recovery Against Others To Us is amended by the addition of the following provision: We waive any right of recovery we may have against the person or organization shown in the SCHED- ULE above because of payments we make for injury or damage arising out of your operations or "your work" done under a written contract with that person or organization. All other terms and conditions of this Policy remain unchanged. REFERENCE: RE: Rustler's Ranch Phase II Resurfacing Project - CIF 19-01 Endorsement Number: SCHEDULE: City of Menifee, its officers, agents and employees This endorsement is effective on the inception date of this policy unless otherwise stated herein. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Number: DPC1005856-02 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 00 CGLO121 00 09 06 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 44282780 118 [01) Standard with $5mm XS I Kris Stubbs 19/18/2018 1:39:47 PM (PDT) I Page 5 of B POLICY NUMBER: BAP5571088-06 COMMERCIAL AUTO 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: 08/01/2018 Named Insured: All American Asphalt SCHEDULE Name of Person(S) or Organ ization(s): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. REFERENCE: SCHEDULE: RE: Rustler's Ranch Phase II Resurfacing Project - City of Menifee, its officers, agents and employees CIF 19-01 (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 ❑ 44282780 1 18 [01] Standard with $5mm XS I Kris Stubbs 1 9/16/2018 1:39:47 PM (PDT) I Page 6 of 8 POLICY NUMBER: BAP5571088-06 COMMERCIAL AUTOMOBILE CA 04 44 03 10 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 under the 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: All American Asphalt Endorsement Effective Date: 08/01/2018 SCHEDULE Name(s) Of Person(s) Or Organization(s): ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTIED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY REFERENCE: SCHEDULE: RE: Rustler's Ranch Phase II Resurfacing Project - City of Menifee, its officers, agents and employees CIF 19-01 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others 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 "accident" or the "loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 44282780 1 18 [01] Standard with $5mm XS I Kris Stubbs 1 9/18/2018 1:39:47 PM (PDT) I Page 7 of 8 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 0.00 % of the California workers' compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION SCHEDULE: City of Menifee, its officers, agents and employees Policy Number: WC593205705 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Job Description ALL CALIFORNIA OPERATIONS REFERENCE: RE: Rustler's Ranch Phase II Resurfacing Project - CIF 19-01 Page 1 of 1 442B2780 1 18 [01] Standard With $5mm XS I Kris Stubbs 1 9/18/2018 1:39:47 PM (PDT) I Page 8 of 8