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2020/03/15 Ascent Environmental, Inc. Certificate of Liability InsuranceThe ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECTPRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-MADE COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence)$DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $RETENTIONDED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $ UMBRELLA LIAB EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSRLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)LIMITS PERSTATUTE OTH-ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNEDAUTOSAUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: INSURED PHONE(A/C, No, Ext): PRODUCER ADDRESS:E-MAIL FAX(A/C, No): CONTACTNAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6/25/2020 Dealey,Renton &Associates License #0020739 P.O.Box 12675 Oakland CA 94604-2675 Nancy Ferrick 510-465-3090 nferrick@dealeyrenton.com Travelers Property Casualty Company of America 25674 ASCENENVI The Travelers Indemnity Company of Connecticut 25682AscentEnvironmental,Inc. 455 Capitol Mall,Suite 300 Sacramento CA 95814-4405 Underwriters at Lloyd's,London 1408328140 A X 2,000,000 X 1,000,000 10,000 2,000,000 4,000,000 X Y Y 6806H400124 3/15/2020 3/15/2021 4,000,000 B 1,000,000 XX Y Y BA3710P295 3/15/2020 3/15/2021 A X X 1,000,000YYCUP3384T427 1,000,000 3/15/2020 3/15/2021 A N Y UB7K512607 3/15/2020 3/15/2021 X 1,000,000 1,000,000 1,000,000 C Professional Liability W123BD190901 3/15/2020 3/15/2021 2,000,000 3,000,000 per Claim Annual Aggregate RE:All Operations of the Named Insured.The City of Menifee and its officers,employees,agents and authorized volunteers are named as Additional Insured for General and Automobile Liability as required by written contract or agreement.General Liability Insurance is Primary and Non-Contributory per policy form. The Named Insured has no company owned autos.Umbrella is follow form over General,Auto and Employer's Liability.A Waiver of Subrogation applies per the attached endorsement(s).Professional Liability is Claims-made.Professional Liability Deductible:$25,000 per claim.Professional Liability Retroactive Date: 01/15/2010.30 Days Notice of Cancellation. 30 Days Notice of Cancellation City of Menifee 29844 Haun Road Menifee,CA 92586 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. 6806H400124 6/25/2020 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. 6/25/20206806H400124 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. Ascent Environmental,Inc. 6806H400124 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. AUTO COVERAGE PLUS ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE This endorsement broadens coverage.However,coverage for any injury,damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part,and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement.The following listing is a general cover- age description only.Limitations and exclusions may apply to these coverages.Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights,duties,and what is and is not covered. A.BLANKET ADDITIONAL INSURED H.AUDIO,VISUAL AND DATA ELECTRONIC EQUIPMENT INCREASED LIMITB.EMPLOYEE HIRED AUTO I.WAIVER OF DEDUCTIBLE GLASSC.EMPLOYEES AS INSURED J.PERSONAL PROPERTYD.SUPPLEMENTARY PAYMENTS INCREASED LIMITS K.AIRBAGS E.TRAILERS INCREASED LOAD CAPACITY L.AUTO LOAN LEASE GAP F.HIRED AUTO PHYSICAL DAMAGE M.BLANKET WAIVER OF SUBROGATION G.PHYSICAL DAMAGE TRANSPORTATION EXPENSES INCREASED LIMIT A.BLANKET ADDITIONAL INSURED performing duties related to the conduct of your business.The following is added to Paragraph A.1.,Who Is An Insured,of SECTION II COVERED AUTOS 2.The following replaces Paragraph b.in B.5., LIABILITY COVERAGE:Other Insurance,of SECTION IV BUSI- NESS AUTO CONDITIONS:Any person or organization who is required under a written contract or agreement between you and b.For Hired Auto Physical Damage Cover- that person or organization,that is signed and age,the following are deemed to be cov- executed by you before the "bodily injury"or ered "autos"you own: "property damage"occurs and that is in effect (1)Any covered "auto"you lease,hire,during the policy period,to be named as an addi-rent or borrow;andtionalinsuredisan"insured"for Covered Autos (2)Any covered "auto"hired or rented byLiabilityCoverage,but only for damages to which your "employee"under a contract inthisinsuranceappliesandonlytotheextentthat an "employee's"name,with yourpersonororganizationqualifiesasan"insured" permission,while performing dutiesundertheWhoIsAnInsuredprovisioncontained related to the conduct of your busi-in Section II. ness.B.EMPLOYEE HIRED AUTO However,any "auto"that is leased,hired,1.The following is added to Paragraph A.1.,rented or borrowed with a driver is not aWhoIsAnInsured,of SECTION II COV-covered "auto".ERED AUTOS LIABILITY COVERAGE: C.EMPLOYEES AS INSUREDAn"employee"of yours is an "insured"while The following is added to Paragraph A.1.,Who Isoperatingacovered"auto"hired or rented An Insured,of SECTION II COVERED AUTOSunderacontractoragreementinan"em- LIABILITY COVERAGE:ployee's"name,with your permission,while CA T4 20 02 15 ©2015 The Travelers Indemnity Company.All rights reserved.Page 1 of 3 Includes copyrighted material of Insurance Services Office,Inc.with its permission. BA3710P295 COMMERCIAL AUTO (2)An adjustment for depreciation and physicalAny"employee"of yours is an "insured"while us- ing a covered "auto"you don't own,hire or borrow condition will be made in determining actual in your business or your personal affairs.cash value in the event of a total "loss". D.SUPPLEMENTARY PAYMENTS INCREASED (3)If a repair or replacement results in better LIMITS than like kind or quality,we will not pay for the amount of betterment.1.The following replaces Paragraph A.2.a.(2)of SECTION II COVERED AUTOS LIABILITY (4)A deductible equal to the highest Physical COVERAGE:Damage deductible applicable to any owned covered "auto".(2)Up to $3,000 for cost of bail bonds (in- (5)This Coverage Extension does not apply to:cluding bonds for related traffic law viola- tions)required because of an "accident"(a)Any "auto"that is hired,rented or bor- we cover.We do not have to furnish rowed with a driver;orthesebonds. (b)Any "auto"that is hired,rented or bor-2.The following replaces Paragraph A.2.a.(4)of rowed from your "employee".SECTION II COVERED AUTOS LIABILITY G.PHYSICAL DAMAGE TRANSPORTATIONCOVERAGE: EXPENSES INCREASED LIMIT (4)All reasonable expenses incurred by the The following replaces the first sentence in Para-"insured"at our request,including actual graph A.4.a.,Transportation Expenses,oflossofearningsupto$500 a day be-SECTION III PHYSICAL DAMAGE COVER-cause of time off from work. AGE:E.TRAILERS INCREASED LOAD CAPACITY We will pay up to $50 per day to a maximum ofThefollowingreplacesParagraphC.1.of SEC-$1,500 for temporary transportation expense in- TION I COVERED AUTOS:curred by you because of the total theft of a cov- 1."Trailers"with a load capacity of 3,000 ered "auto"of the pri ate passenger type.v pounds or less designed primarily for travel H.AUDIO,VISUAL AND DATA ELECTRONIC on public roads.EQUIPMENT INCREASED LIMIT F.HIRED AUTO PHYSICAL DAMAGE Paragraph C.1.b.of SECTION III PHYSICAL The following is added to Paragraph A.4.,Cover-DAMAGE COVERAGE is deleted. age Extensions,of SECTION III PHYSICAL I.WAIVER OF DEDUCTIBLE GLASS DAMAGE COVERAGE: The following is added to Paragraph D.,Deducti- Hired Auto Physical Damage Coverage ble,of SECTION III PHYSICAL DAMAGE COVERAGE:If hired "autos"are covered "autos"for Covered Autos Liability Coverage but not covered "autos"No deductible for a covered "auto"will apply to for Physical Damage Coverage,and this policy glass damage if the glass is repaired rather than replaced.also provides Physical Damage Coverage for an owned "auto",then the Physical Damage Cover-J.PERSONAL PROPERTY age is extended to "autos"that you hire,rent or The following is added to Paragraph A.4.,Cover-borrow subject to the following:age Extensions,of SECTION III PHYSICAL DAMAGE COVERAGE:(1)The most we will pay for "loss"to any one "auto"that you hire,rent or borrow is the Personal Property Coverage lesser of:We will pay up to $400 for "loss"to wearing ap- (a)$50,000;parel and other personal property which is: (1)Owned by an "insured";and(b)The actual cash value of the damaged or stolen property as of the time of the (2)In or on your covered "auto". "loss";or This coverage only applies in the event of a total (c)The cost of repairing or replacing the theft of your covered "auto". damaged or stolen property with other No deductibles apply to Personal Property cover- property of like kind and quality.age. Page 2 of 3 ©2015 The Travelers Indemnity Company.All rights reserved.CA T4 20 02 15 Includes copyrighted material of Insurance Services Office,Inc.with its permission. COMMERCIAL AUTO K.AIRBAGS (2)Any: The following is added to Paragraph B.3.,Exclu-(a)Overdue lease or loan payments at the sions,of SECTION III PHYSICAL DAMAGE time of the "loss"; COVERAGE:(b)Financial penalties imposed under a Exclusion 3.a.does not apply to "loss"to one or lease for excessive use,abnormal wear more airbags in a covered "auto"you own that in-and tear or high mileage; flate due to a cause other than a cause of "loss"(c)Security deposits not returned by the les-set forth in Paragraphs A.1.b.and A.1.c.,but sor;only: (d)Costs for extended warranties,Credit Lifea.If that "auto"is a covered "auto"for Compre- Insurance,Health,Accident or DisabilityhensiveCoverageunderthispolicy; Insurance purchased with the loan orb.The airbags are not covered under any war-lease;andranty;and (e)Carry-over balances from previous loansc.The airbags were not intentionally inflated.or leases. We will pay up to a maximum of $1,000 for any M.BLANKET WAIVER OF SUBROGATIONone"loss". The following replaces Paragraph A.5.,TransferL.AUTO LOAN LEASE GAP Of Rights Of Recovery Against Others To Us, The following is added to Paragraph A.4.,Cover-of SECTION IV BUSINESS AUTO CONDI- age Extensions,of SECTION III PHYSICAL TIONS:DAMAGE COVERAGE: 5.Transfer Of Rights Of Recovery AgainstAutoLoanLeaseGapCoverageforPrivateOthersToUsPassengerTypeVehicles We waive any right of recovery we may haveIntheeventofatotal"loss"to a covered "auto"of against any person or organization to the ex-the private passenger type shown in the Schedule tent required of you by a written contract exe-or Declarations for which Physical Damage Cov- cuted prior to any "accident"or "loss",pro-erage is provided,we will pay any unpaid amount vided that the "accident"or "loss"arises out ofdue on the lease or loan for such covered "auto" the operations contemplated by such con-less the following: tract.The waiver applies only to the person or(1)The amount paid under the Physical Damage organization designated in such contract.Coverage Section of the policy for that "auto"; and CA T4 20 02 15 ©2015 The Travelers Indemnity Company.All rights reserved.Page 3 of 3 Includes copyrighted material of Insurance Services Office,Inc.with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A) POLICY NUMBER: 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 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description 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.) Insurance Company Countersigned by DATE OF ISSUE:Page 1 of 1 "OZ1FSTPOPSPSHBOJ[BUJPOGPSXIJDIUIFJOTVSFEIBTBHSFFECZXSJUUFODPOUSBDUFYFDVUFEQSJPSUP MPTTUPGVSOJTIUIJTXBJWFS UB7K512607