2023/02/14 Leighton Consulting, Inc..A( --()Rif CERTIFICATE OF LIABILITY INSURANCE 2023
THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFOR ATION ONLY AI{O CONFERS NO RIGHTS UPOT{ THE CERTIFICATE HOLOER. THIS
CERTIFICATE OOES NOT AFFIRTIIATIVELY OR NEGATIVELY AIIIENO, EXTENO OR ALTER THE COVERAGE AFFOROEO BY THE POLICIES
BELOW. THIS CERTIFICATE OF IHSURA{CE OOES NOT COI{STITUTE A CONTRACT BETWEEI{ THE ISSUING INSURER(S), AUTHORIZEO
REPRESENTATIVE OR PRODUCER, ANO THE CERTIFICATE HOLOER
ItIPORTANT: It tho cortillcato holdor is an ADDITIONAL l]ISURED, tho policy(ie3) must havo ADDITIONAL INSUREO provision3 or bo ondoGod.
It SUBROGATION lS wAlVEO, 3ubjoct to the t ]mr .nd condllloE of the pollcy, conain pollcies may roquiro an endorsomont. A strlemont on
this csatiticato doe3 not conler rights to tho certllicato holdrr in liou ot Buch ondorsoment(B).
eRoDUcEF Risk Strateoies Comoanv
2040 Main Street, SJite 450
lrvine, CA 92614
www.fl sk-strategies.com CA DOI License No 0F06675
Ri
syouno@risk-strategres.com
INSURER{S) AFFOROING COVERAGE
TNSURERA : Cilizens lnsurance Company of America 31534
Leiohton Consultino. lnc.
26d0 Michelson Dr-rve. Suite 4oo
lrvine CA 92612
TNSURERB: Allmerica Financial Benefit lnsurance Co 41840
rNsuRERc: Travelers Property Casually Co ofAmerica 25674
TNSURERO : LeXinOtOn lnsurance comoanv 19437
COVERAGES CERTIFICATE NUMBER: 7 REVISION NUMBER:
CANCELLATION
@ 1988-20i5 ACORD CORPORATION. All rights ro3ervod
The ACORo namo and logo aro,sgi3torod marks oI ACORD
SHOIJLO ANY OF THE ABOVE OESCRIBEO POLICIES BE CANCELLED BEFORE
THE EXPIRATION OATE THEREOF, NOTICE WLL BE OELIVEREO IN
ACCOROANCE WITH THE POLICY PROVISIONS,
AUTHORIZEO REPRESENTATIV€
RSC lnsurance Erokerage
CERTIFICATE HOLOER
ACORO 25 (2016/03)
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELOW HAVE BEEN ISSUEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATEO NOTWTHSTANOING ANY REOUIREMENT, TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFOROEO gY THE POI.ICIES DESCRIBED HEREIN IS SUBJECT IO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHO\AAI MAY HAVE BEEN REOUCED BY PAID CLAIMS.
EACH OCCURRENCE
MED EXP lAny o.e pe.ron)
$1 000 000
11.000,0@
310,0(x1
PERSONAL &ADV NJURY s 1 000,000
GENERALAG6REGATE
PRODIJCTS COMP/OP AGG
COIII'ERCIAf 6EI'IERAL f IAAIf ITY
G€N'LAGGREGATE LIMIT APPLIES PER
LOCJECT
o83J208488 1111t2022 1111t2023
000 000
$ 2.000.000
COMSINEOSINGLE LIMIT $ 1,000,000
BODILY INJURY (P€r accrd6nl)
B
$
$
s
OWNEO
AUTOS ONLY
HIREO
AUTOS ONLY
SCHEDULEO
AUTOS
NON-OWNED
AUTOS ONLY
AUTOMOBILELIABILITY AW3J208478 1111t2022 11t112023
EACH OCCURRENCE
AGGREGATE
s
r5.000.000
0
UiIBRELLALIAB
EXCESSLIAA
occuR o83J208488 1111t2022 11t112023
STATUTE
E L EACIi ACC DENT
EL OISEASE EAEMPLOYEE
c woFxEnscouPENsATtoit
AITO EXPLOYERS' f IABILITY
ANYPfi OPRIEIOR/PARTNER/EXECI]TIVE
OFFICER/I'EMBEREXCLUDEO?
DFSCRIPIION OF OPERATIONS b.h
u81R5099812243G 9t112022 911t2023
E L OISEASE' POLICY LIMIT
s 1.000.000
s 1.000.000
s 1,000.000
211412023 211412024 Per Claim
Aggregate
Deductible
$2,000.000
$4,000.000
$100,000
D Probssional Liability/Follution Liab
Claims Made
013001524
DESCRIPIION OF OPERATIOIIS , LOCAIIO|I|S / VEHICLES IACORO I01, Addldo..l R.n.ri. Sch.dul., n.y b. .t..h.d lr 60r rp.c. i. DqliEd)
See Addilional Remarks Schedule
-ll GL-AUTo-UuB-r.rc 2l-21 9L I s.ndi ttorcno t 2/Al2O21 9:09:19 Ali (PSt) I P.c. I ot 3
Pftot'tE 949-242-9240
BODILY INJURY (Per p€.son)
s
!5,000,000
Citv of Menifee
29714 Haun Road
[ilenibe CA 92586
Risk Strategies Company Leiohton Consultino. lnc.
26tr0 l\4ichelson Drive. Suite 400
lrvine CA 92612
ACORD-
AGENCY CUSTOI',ER ID
LOC *:
ADDITIONAL REMARKS SCHEDULE Page of
@2008 ACORD CORPORATION. All rights rcsorvEd
Tho ACORD namo and logo ar6 rogistered marks ofACORD ADOENOUI'I
AODITIONAL REMARKS
ACORD 101 (2008/01)
THIS AOOITIOI{AL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Ce.lificate of Liabilily (03/16)
HOLDER| City of lvenifee
AODRESS: 29714 Haun Road [,'lenifee CA 92586
Cerliflcate is subject to pol.icy limits, conditions and exclusions. Re: Proj #11051 Cityof Menifee Professlonal Services. City of Menifee are inc.luded as additional insured asrespects to General Liability and CoNnercial Auto coverages as required by writtenContract. GeneraL Liabifity and Auto Liability coveraqes are primary and noncontributoryas required by written contract. Walver of Subroqation 1s included with respect GeneralLiabifity, Auto Lj-ability, Workers Compensati-on as r:equired by wrj-tten contract. Umbr:e1IaLiabiLity is fo].low form subject to policy forms, terms, conditions, exclusions and
endorsements. 30-Day Notice of Cance].Iat.ion, Except for 1O-Days for Nonpay"ment of Premium
applies to GeneraL Liability as required by written contract,
rrr:r:i4 lrra) wB Bc 23-24 Fr, s.ndi lroreno 2/a/2421 9ta9tt9 Arl (PsT) I Pdqe 2 0f 3
Architects and Engineers
The following policy language is from Businessowners General Liability Coverage Part
NAMED INSURED: Leighton Consutting, tnc. POLICY NUMBER: O83J208488
The following are mandatory forms on the policy identified on the Certificate of lnsurance:
391-,1586 (08-16) BUSINESSO\^NERS GENERAL LIABILIry SUPPLEMENTARY ENDORSEMENT
Additional lnsured by Contracl, Agreement or Permit
A. Section ll - Liability, C - nho is an insured is amended to include as an additional insured any person or organization with
whom you agreed in a written contract, written agreement or permit but only 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 omissaons of those acting
on your behalf, but only with respect toi(i) "Your work" for the additional insured(s) designated in the conkact, agreement or permit including "bodily injury"
or "property damage" included in the "products - completed operations hazard" only if this Coverage Part provides
such coverage;(ii) Premises you own, rent, lease, or occupy; or(iiD Your maintenance, operation or use ofequipment leased lo you.
-Definition: "Your work" a. Means: (1) Work or operations performed by you or on behalf; and (2) materials, parts or equipment
furnished in connection with snch work or operations; b. lncludes (1) warranties or representations made at any time with
respect to the fitness, quality, durability, performance or use of "your work'; and (2) the providing of or failure to provide wamings
or instructions.
This provision does not apply:
(1) Unless the written contract or written agreement has been executed or permit has been issued prior to the "bodily
lnjury", "property damage", "personal injury" or "advertising injury".
(2) To any person or organization lncluded as an lnsured by an endorsement lssued by us and made part ofthis Coverage
Part.
(3) To any lessor of equipment (a) Afler the equipment lease expires, or (b) lf the "bodily lnjury", "property damage",
"personal injury" or "advertising lniury" arises out of sole negligence of the lessor.
(4) To any: (a) Owners or other lnterests from whom land has been leased which takes place after the lease for the land
expires; or (b) Managers or lessors of premises if: (i) The occurrence takes place after you cease to be a tenant in that
premises; or (ii) The "bodily injury", "property damage", "personal injury" or "advertising injury" arises out of structural
alterations, new construction or demolition operations performed by or on behalf of the manager or lessor.
(5) To "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or failure to
render any professional services.
This exclusion applies even if the claims against any insured allege negligence or other Mongdoing in the supervision, hiring,
employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property
damage" or the offense which caused the "personal and advertising injury" involved the rendering of or failure to render any
professional services by or for you.
Other lnsurance Primary & Non-Contributory
The following paragraph is added to SECnON lll - COMMON POLICY CONDITIONS, H - Other lnsurance: Additional lnsured
- Primary and Non-Contributory. lf you agree in a written contract, written agreement or permit that the insurance provided to
any person or organization included as an Additional lnsured under SECION ll - Liability, C. Who is an lnsured is primary and
non-contributory, the following appliesr lf other valid and collectible insurance is available to the Additional lnsured for a loss
covered under SECTION ll - LIABILITY of this Coverage Part, our obligations are limited as follows:
(1) Primary lnsurance: This insurance is primary to other insurance that is available to the Additional lnsured which covers
the Additional lnsured as a Named lnsured. We will not seek contribution from any other insurance available to the
Additional lnsured except: (a) For the sole negligence of the Additional lnsured; (b) When the Additional lnsured is an
Additional lnsured under another primary liability policy; or (c) Vvhen b. below applies. lf this insurance is primary, our
obligations are not affected unless any of the other insurance is also primary.
(2) Excess lnsurance:
(a) This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any other basis:(D That is Fire, Extended Coverage, Builder's Risk, lnstallation Risk or similar coverage tor "your work",(ii) That is Fire insurance for premises rented to the Additional lnsured or terporarily occupaed by the Additional
lnsured with permission of the owneri
No coverage is provided by this Nolice, nor can it be construed to replace any provisions of tlE policy (including its endors€menls). lf here is any conflict
between this Notice and the policy (including the endorsemenls), the provisions olthe policy (including its endorsements) shall prevail.
1Je:84 r (U:) :l-:l C!-AUTC)-UXE-yrC 23-2a PL I S.ndi Uor.no | 2/e/2023 9r09r19 AX (PSI) I Pa96 3 ol 3
state cancellation endorsement. is increased to 30 Da ys
AUTHORIZED REPRESENTATIVE
'Frcn Hrnover Fonns: 3U-1qB (N16);391"144t (0U16);391-1586(6/1q,3efiUB (@/16)
No coverage is provided by this Notice, nor can at be construed to replace any provisions of lhe policy (including its endorsements). lf here is any confict
belween thas Nolice and the policy (including the endorsements), the provisions ofthe policy (including its endorsernents) shall prevail.
(iii) That is insurance purchased by the Additional lnsured to cover the Additional lnsured's liability as a tenant for
"property damage" to premises rented to he Additional lnsured or temporarily occupied by the Additional with
permission ofthe o ner, or(iv) lf the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not sufiect to
Exclusion g. of SECTION ll - LIABILITY. B. Exclusions, 1. Applicable to Business Liability Coverage.(v) That is insurance available to you for your participation in any past or present "unnamed joinl venture".(vi) That is any insurance you may have that provides coverage for your professional services.
(b) \ 'ihen this insurance is excess, we will have no duty to defend the insured against any "suit' if any other insurer has
a duty to defend the insured against that "suit". lf no other insurer defends, we will undertake to do so, but we will be
entitled to the insured's rights against all those other insurers.
(c) Vvhen this insurance is excess over other lnsurance, we will pay only our share of the amount of the loss, if any, that
exceeds the sum of:
(i) The total amount that all such other insurance would pay for the loss in the absence of this insurance: and
(ii) The total of all deductible and self-insured amounts under all that other insurance.
We will share lhe remaining loss, if any, with any other insurance lhat is not described in this Excess lnsurance provision
and was not bought specifcally to apply in excess of he Limits of lnsurance shown in the Declarations of this Coverage
part.
(3) Method Of Sharing
lf all of the other insurance permits conkibution by equal shares, we will follow this method also. Under thi6 approach,
each insurer contributes equal amounts until it has paid its apdicable limit of insurance or none of the loss remains,
whichever comes first. lf any of the other insurance does not permit contribution by equal shares, we will contrihite by
limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total
applicaUe limits of insurance of all insurers.
Per Project Aggregate
The following changes are made to SECTION ll - LIABILITY:
1. The following is added to SECTION ll - LlABlLlry, O. Liabillty and Medical Expenses Limits of lnsurance, paragraph 4l
The Aggregate Limits of lnsurance apply separately to each of "your projects" or each "location" listed in the
Declarations.
2. For the purpose of coverage provided by this endorsement only, the following is added to SECTION ll . LIABILITY, F. Liability
and Medical Expensos Definitions:
1. "Your project" means:
a. Any premises, site or "location" at, on, or in which "your work" is not yet comdeted; and
b. Does not include any "location" listed in the Declarations.
2. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a
slreet, roadway, waterway or righlof-way of a railroad.
Separation Of lnsureds
Except with respect to the Limits of lnsurance, and any rights or duties specifically assigned in this Coverage Part to the first
Named lnsured, this insurance applies: a. As if each Named lnsured were the only Named lnsured; and, b. Separately to each
insured against whom claim is made or "suit" is brought.
Waiver Of Subrogation
The TF.ANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section lV * COMMERCIAL
GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
We tlvaive any right of recovery we may have against the person or organization where required by witten contractbecause of
payments we make for injury or damage arising out of your ongoing operations or 'your work" done under a contract with that
person or organization and included in lhe "products-completed operations hazard". This waiver applies only to the person or
organization where required by witten contract.
Notice Of Cancellation
For any statutorlly permitted reason other than non-payment of premium, the number of days required for notice of cancellation,
as provided in paragraph 2. of either the CANCELLATION Common Policy Condition or as amended by an applicable
-13 GL-AUTO-UMB-m 23 24 P! I Sandl ateno | 2/A/2O21 9:09:t9 }J,l tPS?) | Paq. 4 of 3
POLICY No. : AW3J208478
Leighton Consulting, lnc.
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
A. The following is added to SECTION ll -
LIABILITY COVERAGE, Paragraph A.1. Who ls
An lnsured:
Additional lnsured if Required by Contract
lf you agree in a written contract, written
agreement or written permit that a person or
organization be added as an additional "insured"
under this Coverage Part, such person or
organization is an "insured"; but only to the extent
that such person or organization qualifies as an
"insured" under paragraph A.'1.c. of this Section.
lf you agree in a written contract, written
agreement or written permit that a person or
organization be added as an additional "insured"
under this Coverage Part, the most we will pay on
behalf of such additional "insured" is the lesser of:
(1) The Limits of lnsurance for liability coverage
specified in the written contract, written
agreement or written permit, or
(2) The Limits of lnsurance for Liability Coverage
shown in the Declarations applicable to this
Coverage Part.
Such amount shall be part of and not in addition to
the Limits of lnsurance shown in the Declarations
applicable to this Coverage Part. Regardless of
the number of covered "autos", "insureds",
premiums paid, claims made or vehicles involved
in the "accadent", the most we will pay for the total
of all damages and "covered pollution cost or
expense" combined resulting from any one
"accident" is the Limit of lnsurance for Liability
Coverage shown in the Declarations.
B. The following is added to SECTION lV -
BUSINESS AUTO CONDITIONS, Paragraph B.
General Conditions, subparagraph 5. Other
lnsurance:
Primary and Non-Contributory
lf you agree in a written contract, written
agreement or written permit that the insurance
provided to a person or organization who qualifies
as an additional "insured" under SECTION ll -
LIABILITY COVERAGE, Paragraph A.1. who ls
An lnsured, subparagraph Additional lnsured if
Required by Contract is primary and non-
contributory, the following applies:
The liability coverage provided by this Coverage
Part is primary to any other insurance available to
the additional "insured" as a Named lnsured. We
will not seek contribution from any other insurance
available to the additional "insured" except:
('l) For the sole negligence of the additional
"insured"; or
(2) For negligence arising out of the ownership,
maintenance or use of any "auto" not owned
by the additional "insured" or by you, unless
that "auto" is a "trailer" connected to an "auto"
owned by the additional "insured" or by you; or
(3) Vvhen the additional "insured" is also an
additional "insured" under another liability
policy.
C. This endorsement will apply only if the "accident"
occurs:
1. During the policy period;
2. Subsequent to the execution of the written
contract or written agreement or the issuance
of the written permit; and
3. Prior to the expiration of the period of time that
the written contract, written agreement or
written permit requires such insurance to be
provided to the additional "insured".
D. Coverage provided to an additional "insured" will
not be broader than coverage provided to any
other "insured" under this Coverage Part.
461-04781212 lncludes copyrighted material of ISO lnsurance Services Office, lnc., with its permission
Page 1 of 'l
ALL OTHER TERMS, CONDITIONS, AND EXCLUSIONS REMAIN UNCHANGED,
,rers:8,r rl.r tr :l cL AUT. FL I sandi loreno | 2/a/xor3 e:oe:'Ie Ar, lPsr) Paq€ 5 ot 3
Insured: Leighton Consulting, lnc
Policy No.:
AW3J208478
14, AUTO LOAN PHYSICAL DAMAGE
EXTENSION
The following is added to SECTION lll -
PHYSICAL DAMAGE COVERAGE, C.
Limit Of lnsurance provision:
When a "loss" results in a total loss to a
covered auto you own for which a Loss
Payee is designated in this policy, the most
we will pay for "loss" in any one "accident" is
the greater of:
The actual cash value of the
damaged or stolen property as of
the time of the "loss"; or
2. The outstanding balance of the
initial loan, less any amounts for
taxes, overdue payments, overdue
payment charges, penalties,
interest , any charges for early
termination of the loan, costs for
Credit Life lnsurance, Health,
Accident or Disability lnsurance
purchased with the loan, and
carry-over balances from previous
loans.
15, AUTO LEASE PHYSICAL DAMAGE
EXTENSION
The following is added to SECTION lll -
PHYSICAL DAMAGE COVERAGE, C.
Limit Of lnsurance provision:
lf, because of damage, destruction or theft of
a covered "auto", which is a long{erm
leased "auto", the lease agreement between
you and the lessor is terminated, "we" will
pay the ditference between the amount paid
under paragraph C. LIMIT OF INSURANCE
1. or 2. and the amount due at the time of
"loss" under the terms of the lease
agreement applicable to the leased "auto"
which you are required to pay: less any fees
to dispose of the auto, any overdue
payments, f inancial penalties
imposed under a lease for excessive use,
abnormal wear and tear or high mileage,
security deposits not refunded by the lessor;
cost for extended warranties, Credit Life
lnsurance, Health, Accident or Disability
lnsurance purchased with the loan, and
carry over balances from previous leases.
This coverage applies only to the initial
lease for the covered "auto" which has not
previously been leased. This coverage is
excess over all other collectible insurance.
,16, DUTIES IN THE EVENT OF
ACCIDENT, CLAIM, SUIT OR LOSS
d. Knowledge of any "accident",
claim. "suit" or "loss" will be
deemed knowledge by you when
notice of such "accident",
claim, "suit" or "loss" has been
received by:
(1) You, if you are an individual;
(2) Any partner or insurance
manager if you are a
partnership' or
(3) An executive officer or
insurance manager if you are
a corporation.
'I7, BLANKET WAIVER OF
SUBROGANON
Paragraph 5. Transfer Of Rights Of
Recovery Against Others To Us,
SECTION IV . BUSINESS AUTO
CONDITIONS, A. Loss Conditions is
replaced by the following:
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
Copyright, lnsurance Services Office, lnc., 1996
461-01s5 (9-97)
:3-?{ .r I sandl ',orena l2/S/2021 9:09:19 N IPST) I Paqe 6 or 3
SECTION IV - CONOITIONS
The following is added to SECTION lV -
BUSINESS AUTO CONDITIONS, A. Loss
Conditions, 2. Duties ln The Event Of
Accident, Claim, Suit Or Loss:
Irsurcd: Leighton Consulting, lnc
Policy No.:
AW3J208478
18. UNINTENTIONAL FAILURE TO
DISCLOSE INFORMATION
The following is added to SECTION lV
BUSINESS AUTO CONDITIONS. B.
General Conditions, paragraph 2.
Concealment, Misrepresentation Or
Fraud:
The following is added to SECTION lV -
Business Auto Conditions, B. General
Conditions, paragraph 7. Policy Period,
Coverage Territory provision:
Outside the coverage territory
described in a., b., c., and d.
above for an "accident" or "loss"
resulting from the use of a
covered "auto" you hire, without a
driver, or your employee hires
without a driver, at your direction,
for the purpose of conducting your
business, for a period of 30 days
or less, provided the suit is
brought within The United States
of America or its territories or
possessions.
C. "Bodily injury" means bodily injury,
sickness or disease sustained by a
person including death or mental
anguish resulting from any of these
5. Transfer Of Rights Of Recovery
Against Others To Us
lf any person or organization to or
for whom we make payment under
this Coverage Form has rights to
recover damages from another,
which have not been waived
through the execution of an "insured
contract", written agreement, or
permit, prior to the "accident" or
"loss" giving rise to the payment,
those rights to recover damages
from another are transferred to us.
That person or organization must do
everything necessary to secure our
rights and must do nothing after the
"accident" or "loss" to impair them.
19. HIRED AUTO - WORLDWDE
COVERAGE
Your unintentional error in disclosing, or
failure to drsclose. any materialfact
existing after the effective date of this
Coverage Form shall not prejudice your
rights under this Coverage Form.
However, this provision does not affect
our right to collect additional premium or
exercise our right of cancellation or
nonrenewal.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
Copyright, lnsurance Services Office, lnc., 1996451-0'ls5 (9-97)
SECTION V . DEFINITIONS
20, MENTAL ANGUISH
Paragraph C. "Bodily injury", SECTION V -
DEFINITIONS is replaced by the following:
r:9rar34 I lLC) 23-2{ Pr sandi qorcno ) 7/a/2a23 9:09:19 Ax lFsr) I Paqe 7 of a
TRAVELER6?WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICYoNE TOWEn SQUIRE
TU.RTFORD er 0518 3
ENDORSET{ENT WC990376( A)- oor
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKETWAIVER)
We have the rilht to recover our payments from anyone liable for an hiury covered by this policy. We will not
entorce oUI right against the perso or orgaizatim named it the Schedule.
The additiaral p{emium for this endorsement shall be 2.oo % of the Califomia workers' compensation pre-
mtum.
Schedule
PG6on ol Organlzatlon
AltY PBN,6O}I OR OROTITIZATION POR
XSICU TEE INSUR@ IITS IGREED
EY ttxrTralt coltTRlct BxBcuraD
PRIOR TO I.OSS TO FI'X!iI$T THIS
TAIVER.
Job Oasc.iption
All Operalions
Endorsement Efteclive oe /\J t t2022
lnsured lsigtr16n 1 ..rutn1t. 1n.
lNo
lnsurrlce Company
Iravc,rrs I'ropen]* Casualty Co of America
Col.r|tersigned by
OATE OF ISSUE:ST ASSIGN:Page 1 ol I
POLICY NUMBER: I 11R5r)L)qst:l{l(;
This endorsement chanqes the policy to which it is attached and is effective on the date issued rnless otherwise
stated.
(Thr hformatlon bllorv ls r.quirad only whGn this GndoEamsnt ls issuGd subsequent to prGparation of
the pollcy.)
Policy No. t lt] | R5( )998 | 2:.13( i
,ior11:3{ | rra) 2r-23 GL-Ar,'ro-u!rB-{c 2l-:1 PL I sandi Moreno I :/3/2023 9:09rr9 4.1 IPSTt Paq? 3 0f 3