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2021/03/01 Roadway Engineering and Contracting Inc.ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 10/15/2021 License # 0C36861 (909) 886-9861 (909) 886-2013 22322 Roadway Engineering & Contracting Inc 10966 Banana Ave Fontana, CA 92337 37885 16045 A 1,000,000 X X NPC100450900 3/1/2021 3/1/2022 100,000 $5,000 PD ded/Occ 5,000 1,000,000 2,000,000 2,000,000 EBL AGGREGATE 1,000,000 1,000,000B X X NBA-1004510-00 3/1/2021 3/1/2022 $1,000 Comp Ded $1,000 Coll Ded 5,000,000A NEC-6006403-00 3/1/2021 3/1/2022 5,000,000 0 C X 7600017355211 3/1/2021 3/1/2022 1,000,000 N 1,000,000 1,000,000 RE: Job #1204, Lazy Creek Recreation Center Parking Lot Improvements, CIP 19-16 City of Menifee and its elected officials, officers, employees, agents, representatives, consultants, contract employees and volunteers are additional insureds, primary and non-contributory, waiver of subrogation as respects to general liability per endorsements attached; additional insureds, primary and non-contributory, waiver of subrogation as respects to auto liability per endorsements attached; waiver of subrogation as respects to workers' compensation per endorsement attached. City of Menifee 29844 Haun Rd. Menifee, CA 92586 ROADENG-01 MAXU Inland Empire-Alliant Insurance Services, Inc. 685 Carnegie Dr Ste 265 San Bernardino, CA 92408 Christina M Mountz cmountz@alliant.com Greenwich Insurance Company XL Specialty Insurance Company Everest Premier Insurance Company Over GL/AL/EL X X X X X X X X X X X X X DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 1 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. ENDORSEMENT # This endorsement, effective 03/01/21 12:01 a.m., forms a part of THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY XL Plus Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE - This endorsement broadens coverage. The following listing is a general coverage description only. Limitations and exclusions may apply to these coverages. Read this endorsement carefully to determine rights, duties, and what is and is not covered. A.Reasonable Force – Bodily Injury or Property Damage B.Damage To Premises Rented To You Extension ƔƔ Perils of fire, lightning, explosion, smoke, aircraft or vehicles, riot or civil commotion, vandalism, leakage from fire extinguishing equipment or water damage Ɣ Limit increased to $300,000 C.Aircraft Chartered with Crew D.Non-Owned Watercraft E.Personal and Advertising Injury – Assumed by Insured Contract F.Increased Supplementary Payments Ɣ Cost for bail bonds increased to $5,000 Ɣ Loss of earnings increased to $1,000 per day G.Broadened Named Insured H.Blanket Additional Insured – Managers or Lessors of Premises I.Blanket Additional Insured – Lessor of Leased Equipment J.Injury to Co-Employees and Co-Volunteer Workers K.Knowledge and Notice of Occurrence or Offense L.Unintentional Omission M.Liberalization N.Blanket Waiver of Subrogation O.Incidental Medical Malpractice Injury P.Extension of Coverage – Bodily Injury Q.Coverage Territory Policy No. NPC100450900 DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 2 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. A. REASONABLE FORCE – BODILY INJURY OR PROPERTY DAMAGE Exclusion a.Expected Or Intended Injury of Part 2., Exclusions of Coverage A. Bodily Injury And Property Damage Liability of Section I – Coverages is deleted in its entirety and replaced by the following: [This insurance does not apply to:) Expected or Intended Injury or Damage “Bodily injury” or “property damage” expected or intended from the standpoint of the insured. This exclusion does not apply to “bodily injury” or “property damage” resulting from the use of reasonable force to protect persons or property. B. DAMAGE TO PREMISES RENTED TO YOU EXTENSION 1.The last paragraph of 2.Exclusions of Coverage A. Bodily Injury And Property Damage Liability of Section I - Coverages is deleted in its entirety and replaced by the following: Exclusions c.through n.do not apply to damages to premises while rented to you, or temporarily occupied by you with permission of the owner, caused by fire, lightning, explosion, smoke, aircraft or vehicles, riot or civil commotion, vandalism, leakage from fire extinguishing equipment or water damage. A separate limit of insurance applies to this coverage as described in Section III- Limits of Insurance. 2.This insurance does not apply to damage to premises while rented to you, or temporarily occupied by you with permission of the owner, caused by: a.Rupture, bursting, or operation of pressure relief devices; b.Rupture or bursting due to expansion or swelling of the contents of any building or structure, caused by or resulting from water; or c.Explosion of steam boilers, steam pipes, steam engines, or steam turbines. 3.Paragraph 6.of Section III-Limits of Insurance is deleted in its entirety and replaced by the following: 6.a.Subject to Paragraph 5.above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of “property damage” to any one premises while rented to you, or temporarily occupied by you with permission of the owner, caused by fire, explosion, lightning, smoke, aircraft or vehicle, riot or civil commotion, vandalism, leakage from fire extinguishing equipment or water damage. The Damage To Premises Rented To You Limit will apply to all damage proximately caused by the same “occurrence”, whether such damage results from fire, explosion, lightning, smoke, aircraft or vehicle or riot or civil commotion, vandalism, leakage from fire extinguishing equipment or water damage or any combination of any of these. b.The Damage to Premises Rented to You Limit will be the higher of: (1)$300,000; or (2)The amount shown on the Declarations for Damage to Premises Rented to You Limit. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 3 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 4.Paragraph 9.a.of the definition of “insured contract” under Section V-Definitions, is deleted in its entirety and replaced by the following: [“Insured contract” means:] a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, aircraft or vehicle, riot or civil commotion, vandalism, leakage from fire extinguishing equipment or water damage to premises while rented to you, or temporarily occupied by you with the permission of the owner is not an “insured contract”. 5.This Article B. does not apply if coverage for Damage to Premises Rented to You of Coverage A.Bodily Injury And Property Damage Liability of Section I – Coverages is excluded by endorsement. C. AIRCRAFT CHARTERED WITH CREW 1.The following is added to the exceptions contained in Exclusion g., Aircraft, Auto or Watercraft in Part 2., Exclusions of Coverage A. Bodily Injury And Property Damage of Section I – Coverages: [This exclusion does not apply to:) Aircraft chartered with crew to any insured. 2.This Article C.does not apply if the chartered aircraft is owned by any insured. 3.The insurance provided by this Article C.shall be excess over any valid and collectible insurance available to the insured, whether primary, excess, contingent or on any other basis, except for insurance purchased specifically by you to be excess of this policy. D. NON-OWNED WATERCRAFT 1.The exception contained in Subparagraph (2)of Exclusion g.Aircraft. Auto or Watercraft in Part 2., Exclusions of Coverage A.Bodily Injury And Property Damage Liability of Section I – Coverages is deleted in its entirety and replaced by the following: (2)A watercraft you do not own that is: (a)50 feet long or less; and (b)Not being used to carry persons or property for a charge; 2.This Article D.applies to any person who, with your expressed or implied consent, either uses or is responsible for the use of the watercraft. 3.This insurance provided by this Article D.shall be excess over any other valid and collectible insurance available to the insured, whether primary, excess, contingent or on any other basis, except for insurance purchased specifically by you to be excess of this policy. E. PERSONAL AND ADVERTISING INJURY – ASSUMED BY INSURED CONTRACT 1.Exclusion e.Contractual Liability in Part 2., Exclusions of Coverage B.Personal And Advertising Injury Liability of Section I – Coverages is deleted in its entirety and replaced by the following: DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 4 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. [This insurance does not apply to:) e. Contractual Liability “Personal and Advertising Injury” for which the insured has assumed liability in a contract or agreement. This exclusion does not apply to liability for damages: 1.That the insured would have in the absence of the contract or agreement; or 2.Assumed in a written contract or agreement that is an “insured contract”; provided the “personal and advertising injury” is caused by an offense which occurs subsequent to the execution of the contract or agreement. 2.Subparagraph f.of the definition of “insured contract” Section V.-Definitions is deleted in its entirety and replaced by the following: f.That part of any other contract or agreement pertaining to your business, including an indemnification of a municipality in connection for work performed for a municipality, under which you assume the tort liability of anther party to pay for “bodily injury”, “property damage” or “personal and advertising injury” to a third party or organization. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement. 2.This Article E.does not apply if Coverage B. Personal And Advertising Injury Liability is excluded by endorsement. F. INCREASED SUPPLEMENTARY PAYMENTS Subparagraphs 1. b.and d.of Supplementary Payments – Coverages A And B of Section I - Coverages are amended as follows: 1.In Subparagraph b.,the amount we will pay for the cost of bail bonds is increased up to $5,000. 2.In Subparagraph d.,the amount we will pay for a loss of earnings is increased up to $1,000 a day. G. BROADENED NAMED INSURED 1.The Named Insured in Item 1.of the Declarations is as follows: The person or organizations named in Item 1.of the Declarations and any organization, other than a partnership or joint venture, over which you maintain ownership or majority interest on the effective date of the policy. However, coverage for any such organization will cease as of the date that you no longer maintain ownership of, or majority interest in, such organization. 2.This Article G.does not apply to any person or organization for which coverage is excluded by endorsement. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 5 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. H. BLANKET ADDITIONAL INSURED – MANAGERS OR LESSORS OF PREMISES 1.Section II-Who Is An Insured is amended to include as an insured any person or organization with whom you have agreed in a written contract executed prior to loss (an “additional insured”), but only with respect to liability arising out of the ownership, maintenance or use of that part of any premises leased to you, subject to the following provisions: a.Limits of Insurance. The Limits of Insurance afforded to the “additional insured” shall be the limits you agreed to provide, or the limits shown on the Declarations, whichever is less. b.The insurance afforded to the “additional insured” does not apply to: (1)Any “occurrence” that takes place after you cease to be a tenant in that premises; (2)Any premises for which coverage is excluded by endorsement; or (3)Structural alterations, new construction or demolition operations performed by or on behalf of such “additional insured”. 2.The insurance afforded to the “additional insured” is excess over any valid and collectible insurance available to such “additional insured”, unless you have agreed in a written contract for this insurance to apply on a primary or contributory basis. I. BLANKET ADDITIONAL INSURED – LESSOR OF LEASED EQUIPMENT 1.Section II-Who Is An Insured is amended to include an “additional insured” (as defined in Article H. above), but only with respect to their liability arising out of maintenance, operation or use by you of equipment leased to you by such “additional insured”, subject to the following provisions: a.Limits of Insurance. The Limits of Insurance afforded to the “additional insured” shall be the limits which you agreed to provide, or the limits shown on the Declarations, whichever is less. b.The insurance afforded to the “additional insured” does not apply to: (1)Any “occurrence” that takes place after the equipment lease expires; or (2)“Bodily injury” or “property damage” arising out of the sole negligence of such additional insured. 2.The insurance provided to the “additional insured” is excess over any valid and collectible insurance available to such “additional insured”, unless you have a written contract for this insurance to apply on a primary or contributory basis. J. INJURY TO CO-EMPLOYEES AND CO-VOLUNTEER WORKERS 1.Section II- Who Is An Insured is amended to include your “employees” as insureds with respect to “bodily injury” to a co-“employee" in the course of the co-”employee’s” employment by you, or to your “volunteer workers” while performing duties related to the conduct of your business, provided that this coverage for your “employees” does not apply to acts outside the scope of their employment by you or while performing duties unrelated to the conduct of your business. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 6 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 2.Section II – Who Is An Insured is amended to include your “volunteer workers” as insureds with respect to “bodily injury” to a co-“volunteer worker” while performing duties related to the conduct of your business, or to your “employees” employment by you, provided that this coverage for your “volunteer workers” does not apply while performing duties unrelated to the conduct of your business. K. KNOWLEDGE AND NOTICE OF OCCURRENCE OR OFFENSE The following is added to Paragraph 2.,Duties In The Event of Occurrence, Offense, Claim or Suit of the Section IV -Commercial General Liability Conditions: Notice of an “occurrence” or of an offense which may result in a claim under this insurance shall be given as soon as practicable after knowledge of the “occurrence” or offense has been reported to any insured listed under Paragraph 1.of Section II-Who Is An Insured or any “employee” (such as insurance, loss control, risk manager or administrator) designated by you to give such notice. Knowledge of any other “employee(s)” of an “occurrence” or of an offense does not imply that you also have such knowledge. Notice shall be deemed prompt if given in good faith as soon as practicable to your workers compensation insurer. This applies only if you subsequently give notice to us as soon as practicable after any insured listed under Paragraph 1.of Section II – Who Is An Insured or an “employee” (such as an insurance, loss control, or risk manager or administrator) designated by you to give such notice discovers that the “occurrence”, offense or claim may involve this policy. L. UNINTENTIONAL OMISSION The following is added to Paragraph 6.,Representations, of Section IV-Commercial General Liability Conditions: The unintentional omission of, or unintentional error in, any information provided by you shall not prejudice your rights under this insurance. However, this Article L.does not affect our right to collect additional premium or to exercise our right of cancellation or nonrenewal in accordance with applicable state insurance laws or regulations. M. LIBERALIZATION The following is added to Section IV-Commercial General Liability Conditions: Liberalization After the issuance of this policy, if we adopt a change in our forms or rules which would broaden the coverage provided by any form that is a part of this policy without a premium charge, the broader coverage will apply to this policy. This extension is effective upon the approval of such broader coverage in your state. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 7 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. N. BLANKET WAIVER OF SUBROGATION The following is added to Section IV-Commercial General Liability Conditions: Waiver of Subrogation We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of premises owned or occupied or rented or loaned to you; ongoing operations performed by you or on your behalf, done under a contract with that person or organization; “your work”; or “your products”. We waive this right where you have agreed to do so as part of a written contract, executed by you prior to loss. O. INCIDENTAL MEDICAL MALPRACTICE INJURY 1.For insurance applicable to this Article O, the definition of “bodily injury” in Section V - Definitions is amended to include, “Incidental Medical Malpractice Injury”. 2.The following definition is added to Section V- Definitions: “Incidental medical malpractice injury” means “bodily injury”, mental anguish, sickness or disease sustained by a person, including death resulting from any of these at any time, arising out of the rendering of, or failure to render, the following services: a.Medical, surgical, dental, laboratory, x-ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; b.The furnishing or dispensing of drugs or medical, dental or surgical supplies or appliances; c.First aid; or d.“Good Samaritan Services”. As used in this Article O., “Good Samaritan Services” are those medical services rendered or provided in an emergency and for which no remuneration is demanded or received. 3.Paragraph 2.a.(1)(d)of Section II -Who Is An Insured does not apply to any registered nurse, licensed practical nurse, emergency medical technician or paramedic employed by you, but only while performing the services described in Paragraph 2.above and while acting within the scope of their employment by you. Any “employees” rendering “Good Samaritan Services” will be deemed to be acting within the scope of their employment by you. 4.The following exclusion is added to Paragraph 2.Exclusions of Coverage A.– Bodily Injury And Property Damage Liability of Section I–Coverages: [This insurance does not apply to:) Willful Violation of Penal Statute Liability arising out of the willful violation of a penal statute or ordinance relating to the sale of pharmaceuticals by or with the knowledge or consent of the insured. 5.For the purposes of determining the applicable Limits of Insurance, any act or omission, together with all related acts or omissions in the furnishing of services described in Paragraph 2.a.through 2.d.above to any one person, will be considered one “occurrence”. 6.This Article O.does not apply if you are in the business or occupation of providing any of the services described in Paragraph 2.above. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 Form XIL 436 1208 ©2008, XL America, Inc. Page 8 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 7.The insurance provided by this Article O.shall be excess over any other valid and collectible insurance available to the insured, whether primary, excess, contingent or on any other basis, except for insurance purchased specifically by you to be excess of this policy. P. EXTENSION OF COVERAGE – BODILY INJURY The definition of “bodily injury” Section V- Definitions is deleted in its entirety and replaced by the following: 3.“Bodily injury” means bodily injury, mental anguish, mental injury, shock, fright, disability, humiliation, sickness or disease sustained by a person, including death resulting from any of these at any time. Q. COVERAGE TERRITORY The definition of “coverage territory” Section V- Definitions is deleted in its entirety and replaced by the following: 4.“Coverage territory” means anywhere in the world. This insurance does not apply to: a.“bodily injury” or “property damage” that takes place; or b.“personal and advertising injury” caused by an offense committed outside the United States of America (including its possessions and territories), Canada and Puerto Rico, unless a “suit” on the merits (to determine the insured’s responsibility to pay damages to which this insurance applies) is brought in the United States of America (including its possessions and territories), Canada or Puerto Rico. This insurance does not apply to damage, loss, cost or expenses in connection with any “suit” brought outside the United States of America (including its possessions and territories), Canada or Puerto Rico. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 1 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. " " ! ! This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM COVERAGE DESCRIPTION '.103#3:6$45+565' 650*:4+%#-#.#)' *04 //463'& 30#&03./463'& .1-0:''4 4/463'&4 &&+5+0/#-/463'&:0/53#%5 )3''.'/503'3.+5 .1-0:''+3'& 6504 611-'.'/5#3:#:.'/54 .'/&'&'--08.1-0:''9%-64+0/ *:4+%#-#.#)'07'3#)' '/5#-'+.$634'.'/5 953#91'/4'<30#&'/'&07'3#)' '340/#-(('%5407'3#)' '#4'#1 -#44'1#+3< #+7'3('&6%5+$-' *:4+%#-#.#)'07'3#)'95'/4+0/4 &&+5+0/#-3#/41035#5+0/91'/4' +3'& 650*:4+%#-#.#)' 64+/'44 6500/&+5+0/4 05+%'(%%633'/%' #+7'3(6$30)#5+0/ /+/5'/5+0/#-#+-63'0+4%-04'#;#3&4 3+.#3:/463#/%' 0&+-:/,63:'&'(+/'& 95'/&'&#/%'--#5+0/0/&+5+0/ POLICY NUMBER: NBA-1004510-00 XIC 421 1013 DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 2 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. '.103#3:6$45+565' 650*:4+%#-#.#)' < ,'35#+/3#+-'340$+-'26+1.'/5 /&'.103#3:6$45+565' 6504 is changed by adding the following: If Physical Damage coverage is provided by this Coverage Form, the following types of vehicles are also covered “autos” for Physical Damage coverage: Any “auto” you do not own while used with the permission of its owner as a temporary substitute for a covered “auto” you own that is out of service because of its: # Breakdown; $ Repair; % Servicing; & “Loss”; or ' Destruction. *04 //463'& < " 07'3#)' *0 4 / /463'& is changed by adding the following: 30#&03./463'& For any covered “auto”, any subsidiary, affiliate or organization, other than a partnership or joint venture, as may now exist or hereafter be constituted over which you assume active management or maintain ownership or majority interest, provided that you notify us within ninety (90) days from the date that any such subsidiary or affiliate is acquired or formed and that there is no similar insurance available to that organization. However, coverage does not apply to “bodily injury” or “property damage” that occurred before you acquired or formed the organization. .1-0:''4 4/463'&4 Any “employee” of yours is an “insured” while using a covered “auto” you don’t own, hire or borrow, in your business or your personal affairs. &&+5+0/#-/463'&:0/53#%5 )3''.'/53'3.+5 Any person or organization with whom you have agreed in writing in a contract, agreement or permit, to provide insurance such as is provided under this policy, provided that the “bodily injury” or “property damage” occurs subsequent to the execution of the written contract, agreement or permit. .1-0:''+3'& 6504 An “employee” of yours is an “insured” while operating an “auto” hired or rented under a contract or agreement in that “employee’s” name, with your permission, while performing duties related to the conduct of your business. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 3 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. < '/'3#-0/&+5+0/45*'3/463#/%'$ is replaced with the following: $For Hired Auto Physical Damage Coverage, the following are deemed to be covered “autos” you own: Any covered “auto” you lease, hire, rent or borrow; and Any covered “auto” hired or rented by your “employee” under a contract in that individual “employee’s” name, with your permission, while performing duties related to the conduct of your business. However, any “auto” that is leased, hired, rented or borrowed with a driver is not a covered “auto”. 611-'.'/5#3:#:.'/54 < " 07'3#)'07'3#)'95'/4+0/4# 611-'.'/5#3:#:.'/54 is changed as follows: Item is deleted and replaced by the following: Up to $3,500 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We do not have to furnish these bonds. Item is deleted and replaced by the following: All reasonable expenses incurred by the “insured” at our request, including actual loss of earnings up to $500 a day because of time off from work. .'/&'&'--08.1-0:''9%-64+0/ < " 9%-64+0/4'--08.1-0:'' does not apply. The insurance provided under this Provision is excess over any other collectible insurance. *:4+%#-#.#)'07'3#)' <" 07'3#)'is changed by adding the following: '/5#-'+.$634'.'/5 # We will pay for rental reimbursement expenses incurred by you for the rental of an “auto” because of “loss” to a covered “auto”. Payment applies in addition to the otherwise applicable amount of each coverage you have on a covered “auto”. No deductibles apply to this coverage. $ We will pay only for those expenses incurred during the policy period beginning twenty-four (24) hours after the “loss” and ending, regardless of the policy’s expiration, with the lesser of the following number of days: DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 4 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. The number of days reasonably required to repair or replace the covered “auto”. If “loss” is caused by theft, this number of days is added to the number of days it takes to locate the covered “auto” and return it to you. Thirty (30) days. % Our payment is limited to the lesser of the following amounts: Necessary and actual expenses incurred. $50 any one day per private passenger “auto”; $100 any one day per truck; $1,500 any one period per private passenger “auto”; $3,000 any one period per truck; or Higher limits if shown elsewhere in this policy. & This coverage does not apply while there are spare or reserve “autos” available to you for your operations. ' If “loss” results from the total theft of a covered “auto” of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided for under the Physical Damage Coverage Extension. 953#91'/4'<30#&'/'&07'3#)' We will pay for the expense of returning a stolen covered “auto” to you. '340/#-(('%5407'3#)' If you have purchased Comprehensive Coverage on this policy for an “auto” you own and that “auto” is stolen, we will pay, without application of a deductible, up to $500 for “personal effects” stolen from the “auto”. As used in this endorsement, “personal effects” means tangible property that is worn or carried by an “insured”. “Personal effects” does not include tools, jewelry, money or securities. '#4'#1 In the event of a total “loss” to a covered “auto” shown in the Declarations, we will pay any unpaid amount due on the lease or loan for a covered “auto”, less: # The amount paid under the Physical Damage Coverage Section of the policy; and $ Any: Overdue lease/loan payments at the time of the “loss”; Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; Security deposits not returned by the lessor; Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchases with the loan or lease; and Carry-over balances from previous loans or leases. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 5 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. -#44'1#+3< #+7'3('&6%5+$-' No deductible applies to glass damage if the glass is repaired rather than replaced. *:4+%#-#.#)'07'3#)'95'/4+0/4 <" 07'3#)' 07'3#)'95'/4+0/4 is amended by the following: &&+5+0/#-3#/41035#5+0/91'/4' '%5+0/4 #and$ are amended to provide a limit of $50 per day and a maximum limit of $1,000. +3'& 650*:4+%#-#.#)' The following section is added: Any “auto” you lease, hire, rent or borrow is deemed to be a covered “auto” for physical damage coverage. The most we will pay for each covered “auto” is the lesser of: the actual cash value; the cost for repair or replacement; or $50,000, or higher limit if shown on the Declarations for Hired Auto Physical Damage Coverage. For each covered “auto” a deductible of $100 for Comprehensive Coverage and $1,000 for Collision Coverage will apply. 64+/'44 6500/&+5+0/4 < 0440/&+5+0/4 is changed by the following: 05+%'(%%633'/%' '%5+0/<65+'4/*'7'/5( %%+&'/5-#+.6+53044# is changed by adding the following: If you report an injury to an “employee” to your workers’ compensation carrier and if it is subsequently determined that the injury is one to which this insurance may apply, any failure to comply with this condition will be waived if you provide us with the required notice as soon thereafter as practicable after you know or reasonably should have known that this insurance may apply. #+7'3(6$30)#5+0/ '%5+0/3#/4('3(+)*54('%07'3: )#+/455*'3404 is changed by adding the following: However, this Condition does not apply to any person(s) or organization(s) with whom you have a written contract, but only to the extent that subrogation is waived prior to the “accident” or the “loss” under such contract with that person or organization. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 6 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. < '/'3#-0/&+5+0/4 is changed by the following: /+/5'/5+0/#-#+-63'0+4%-04'#;#3&4 The following condition is added: Your unintentional failure to disclose all hazards as of the inception date of the policy shall not prejudice any insured with respect to the coverage afforded by this policy. 3+.#3:/463#/%' 0/&+5+0/5*'3/463#/%' is changed by adding the following: For any covered “auto” this insurance shall apply as primary and not contribute with any other insurance where such requirement is agreed in a written contract executed prior to a “loss”. 0&+-:/,63:'&'(+/'& < “Bodily injury” is replaced by the following: “Bodily injury” means bodily injury, sickness or disease sustained by a person including mental anguish, mental injury, shock, fright or death resulting from any of these at any time. 95'/&'&#/%'--#5+0/0/&+5+0/ "03. #/%'--#5+0/$ is replaced by the following: The greater of sixty (60) days or the time required by any applicable state amendatory endorsement before the effective date of cancellation if we cancel for any other reason. All other terms and conditions of this policy remain unchanged. DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 - 1998 by the Workers’ Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB’s California Workers’ Compensation Insurance Forms Manual - 1999. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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 % of the California workers’ compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION 2 ANY PERSON OR ORGANIZATION FOR BLANKET WAIVER OF SUBROGATION WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 POLICY NUMBER: © Insurance Services Office, Inc., 2018 Page of CG 20 10 12 19 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Name Of Additional Insured Person(s) Or Organization(s) Blanket as required by written contract Blanket as required by written contract 12 NPC100450900 DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 © Insurance Services Office, Inc., 2018 CG 20 10 12 19Page of C.With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. 22 DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 POLICY NUMBER: © Insurance Services Office, Inc., 2018 Page ofCG 20 37 12 19 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1.The insurance afforded to such additional insured only applies to the extent permitted by law; and 2.If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B.With respect to the insurance afforded to theseadditional insureds, the following is added to Section III – Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or 2.Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. Location And Description Of Completed Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Name Of Additional Insured Person(s) Or Organization(s) Blanket as required by written contract Blanket as required by written contract 11 NPC100450900 DocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21 &200(5&,$/*(1(5$//,$%,/,7< &* 7+,6(1'256(0(17&+$1*(67+(32/,&<3/($6(5($',7&$5()8//< &*,QVXUDQFH6HUYLFHV2IILFH,QF3DJHRI 35,0$5<$1'121&2175,%8725<±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ocuSign Envelope ID: B1885269-FA06-47AF-A190-810020660A21