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2020/07/01 Roy Allan Slurry Seal, 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 6/30/2020 Patriot Risk & Insurance Services 2415 Campus Drive, Suite #200 Irvine, CA 92612 (949) 486-7900 (949) 486-7950 www.patrisk.com 0K07568 XL Specialty Insurance Company 37885 Great American Insurance Company 16691 Redwood Fire and Casualty Insurance Co 11673 A 1,000,000NGL-1003791-00 7/1/2020 7/1/2021 100,000 3 5,000 3 1,000,000 2,000,000 2,000,0003 A NBA-1003792-00 7/1/2020 7/1/2021 1,000,000 3 3 3 B TUE316189101 7/1/2020 7/1/2021 5,000,00033 5,000,000 3 10,000 C ROWC123122 7/1/2020 7/1/2021 3 1,000,000 1,000,000 1,000,000 Dave Jacobson Roy Allan Slurry Seal, Inc. 11922 Bloomfield Avenue Santa Fe Springs CA 90670 56299528 3 3 3 City of Menifee and Its Officers, Employees, Agents and Authorized Volunteers are named as Additional Insured includes Primary and required by written contract. City of Menifee 29844 Haun Road Menifee CA 92586 Re: PMP 20-01 / Arterial Roads Resurfacing Project - Various Arterial Streets in Menifee Non-contributory and Waiver of subrogation applies to GL and WC and in favor of the additional insureds per endorsements attached as *30-day notice of cancellation / 10-days for non-payment of premium. 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 1 of 20 Roy Allan Slurry Seal, Inc. NGL-1003791-00 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 2 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 3 of 20 Roy Allan Slurry Seal, Inc. 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NGL-1003791-00 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 5 of 20 Roy Allan Slurry Seal, Inc.NGL-1003791-00 07/01/2020 XL Specialty Insurance Company 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 6 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 7 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 8 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 9 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 10 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 11 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 12 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 13 of 20 Roy Allan Slurry Seal, Inc. NBA-1003792-00 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 14 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 15 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 16 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 17 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 18 of 20 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 19 of 20 Roy Allan Slurry Seal, Inc. ROWC12312207/01/2020 56299528 | 20/21 GL/AU/UMB/WC | Annette Romero | 6/30/2020 11:34:13 AM (PDT) | Page 20 of 20