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2023/02/14 Leighton Consulting, Inc. (10)21812023 THIS CERTIFICATE IS ISSUED AS A ]IIATTER OF INFORiIATION ONLY AND CONFERS NO RIGHTS UPOI{ THE CERTIFICATE HOLDER. THIS CERTIFICATE OOES NOT AFFIR]TIATIVELY OR I{EGATIVELY A]rlET{D, EXTEND OR ALTER THE COVERAGE AFFORDEO AY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CO STITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S}, AUTHORIZEO REPRESEI{TATIVE OR PROOUCER, AXD THE CERTIFICATE HOLDER. IMPORTANT: ll tho certlflcato hold6. is an AOOITIONAL INSUREO, tho pollcy(ios) musl havo ADDITIONAL INSURED provisiona or be endorsod. ll SUBROGATION lS WAIVEO, subjoct to tho to.ms and condltlorB of the policy, cortain policios may requiro an endoBomont. A statoment on this ceatificato doos not confor righb to tho cortlflc.te holdo. in liou ot such ondo6emont(3) PRoDUCER Rrsk Strateoies Comoanv 2040 Main Sheet. Sdire 450 lrvine, CA 92614 www.risk-slralegies.com res 949-242-9240 s stra res com INSU AFFO ROIN G COVERA GE TNSURERA: Citizens lnsurance ofAmerica 31534 Leiohton Consultino. lnc. 2660 Michelson Dr-rve, Suite 400 lrvine CA 926'12 r suRER B : Allmerica Financial Benefil lnsurance Co 41840 rNsuRERc: Travelers ProOerlv Casualty Co of America 25674 19437rr{suRER D : Lexinqton lnsurance company INSI]RER E ACORi} COVERAGES CERTIFICATE OF LIABILIry INSURANCE CERTIFICATE NUMBER:REVISION NUMBER: CANCELLATION O 1988-2015 ACORO CORPORATION. All rights reservod Th€ AcORD name and logo are rogistored mark of ACORD Citv of Menifee 29714 Harrn Road llenitue CA 92586 SHOULD ANY OF THE AAOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION OATE THEREOF, NOTICE WILL BE DELIVEREO IN ACCOROANCE WITH THE POLICY PROVISIONS, AI,lTHORIZEO REPRESENTATIVE RSC lnsurance Brokerage CERTIFICATE HOLDER acoRD 2s (2016/03) rNsRT- - EACH OCCURFENCE s 1,000,000 OAMAGE TORENTED PREMISES rEa oc.umn.61 $ 1.000.000 MEO ExP (Any o.e person) PERSONAL & ADV INJI]RY GENERALAGGREGATE s 10,000 $'t.000,000 $2,000,0m PRODUCIS, COMP/OP AGG s2.000.000 s COMMERCIAf GENERAL IIAAILITY G€N'L AGGREGATE LIMII APPLIES PEF JEcr L l LOC o83J208488 111112022 1111t2023 BODILY INJURY tPerp.rso.) COMBIN'DSINGLE LIMIT BOOITY INJURY 1Pd.CC'd..D jl-qoo,oqo $ 11t112023 S S B AUIOS ONLY HIREO AUTOSONLY SCHEDULED NON.Owl{EO AUIOSONLY AUTOMOBILEIIABILIIY AW3.J208478 EACI] OCCURRENCE111112023 s 3 5._0qq0 00 sgpqq,q00 EXCESS LIA6 OED aerenrtor l0 OCCUR o83J208488 11n12022 OIH SIATI,JTE E L EACH ACCIOENT EL OISEASE EA EMPLOYEE u81R5099812243G 9t1t2022 9t1t2023 E L OISEASE. POLICY LIM I $1 000 000 c1 000 $ C WORI(ERS COI{PENSAIION ANO E PLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECI,]IIVE OFFICER/IIiEMAEREXCLUOED? DESCRIPTION OF OPERATIONS b6I@ Per Claim Aggregate Deductible $2.000.000 $4.000.000 $100,000 D Probssional Liability/tullution Liab Claams Made 013001524 211412023 2t14t2024 oEScRPnO Of OPEiAnO S / LOCATIONS / VEHTGLES (AcORo loi, Addrrlon.l R.m.rk. S.h.dul., m.y b. .tt chld ll molt .p.c. l. nquhd) See Additional Remarks Schedule LCr .'?-?3 GL-AUTO-UMB-|f 2r-24 PL I S.ndi Nor.no | 2/A/2023 9:09:19 rX IPST) I P.qe I of 3 CA DOI Lacense No. 0F06675 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE EEEN ISSUEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWTHSTANOING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOW! MAY HAVE BEEN REDUCED BY PAIO CLAIMS a 1111t2022 tr Rrsk Strategies Company Lemhlon Consullrno lnc 26d0 Mrchelson Dri\,e srnie 400 lrvine CA 92612 NA|C COO€ A,CORiJ AGENCY CUSTOMER IO: LOC *: ADDITIONAL REMARKS SCHED ULE @ 2OO8 ACORD CORPORATION Th6 ACORO name and logo are rogistorsd marks of ACORO ADDITIONAL REMA ACORD 101 (2008/01) Page of THIS AODITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FOR' TITLE: Certifrcale of Lrability (03/16) HOLOER: City oI Menitue AODRESS: 29714 Haun Road t lenitue CA 92586 Certj.ficate is subject to pol.icy linits, conditions and exclusions. Re: Proj *11051.010 CIP 21-13 (Mccall Blvd Resurfacing-Encanto to Antelope) Materi.als Testing & ceotechnical Services. City of Menifee and its officers. empLoyees, agents. and authorized volunteers a.re included as additional insuled as respects to General Liability and Conmeicial, Auto coverages as required by written Contract. General Liability and Auto Liability coveragesare primary and noncontributory as required by written contract, Waiver of Subrogation rsincluded with xespect General Liabi.Iity, Auto Liabi.Iity, workers Compensation as required by written contract. Unc.rella Liabj-Iity is folLow form subject to policy forms, terns,conditions, exclusions and endorsenents. 30-Day Notice of Cancel.Iation, Except for 1o-Daysfor Nonpalment of Premium applies to General Liability as required by written contract- I {Lcl ::-i3 :l-21 PL I sandi Moleno I l/3/2023 9:09:19 l,i (PSfl I P.q€ 2 or 3 All righb reserved AOOENDUIt, Architects and Engineers The fallowing policy language ls from Eusrnessowners General Liability Coverage Paft NAMED INSURED: Leighton Consutting, tnc. POLICY NUMBER: O83J208488 The following are mandatory forms on the policy identilied on the Certificate of lnsurance: 391-,1586 (08.16) BUSINESSOV1NERS GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT Additional lnsured by Contract, Agreement or Permit A. Section ll - Liability, C - \ rtho is an insured is amended to include as an additional insured any person or organization with lvhom you agreed in a written contract, written agreement or permit but only respectto liability for "bodily injury", "property damage" or "personal and advertising injury' caused, in whole or in part, by your acts or omissions; or the acts or omissions of those acting on your behalf, but only with respect to:(i) "Your work" for the additional insured(s) designated in the contract, 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(iii) Your maintenance, operation or use of equipment leased to you. .Deflnition: "Yourwork" a. Means: ('l)Work or operations performed by you or on behalf; and (2) materials, parts or equipment furnished in connection with such 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 equipmenl (a) After the equipment lease expiresi or (b) lf the "bodily lnjury", "property damage", "personal iniury" or "advertising lnjury" 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 premisesi or (ii) The "bodily injury", "property damage", "personal injury" or "advertising injury" arises out of slructural alterations, new construction or demolition operations performed by or on behalf of the manager or lessor. (5) To "bodily injury', "properly 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 wrongdoing 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 SECTION lll- COMMON POLICY CONDITIONS, H - Other lnsurance: Additional lnsured - Primary and Non-Contributory. lf you agree in a written contract, Mitten agreement or permit that the insurance provided to any person or organization included as an Additional lnsured under SECTION ll - Liability, C. Who is an lnsured is primary and non-contributory, the following applies: lf other valid and collectible insurance is available to the Additional lnsured for a loss covered under SECTION ll - LlABlLlw of this Coverage Part, our obligations are limited as follows: (1) Primary lnsurance: This insurance is primary to other insurance that isavailableto 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) Vvhen 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) Exc6s lnsurance: (a) This insurance is excess over any of the other insurance, whether primary, excess, contangent or on any other basis: (i) That is Fire, Extended Coverage, Builder's Risk, lnstallation Risk or simiiar coverage for "your work"i (ii) That is Fire insurance for premises rented to the Additional lnsured or temporarily occupied by the Additional lnsured with permission of the owner; No coverage is provided by this Notic4. nor can it be construed to replac€ any paovisions of the policy (including its endorsemenls). lf here is any conflicl b€tween this Notice and the policy (including th€ endorsements), the proMsions oflhe policy (including its endorsemenls) shall Prevail -rr cL-ALiIo l,uB tsc ll-:1 PL I sadi co..no I a/A/?o23 9:a9tr9 r}1 lPsT) Paqe 3 or 3 (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 owneri or(iv) lf the loss arises oul of the maintenance or use of aircraft, "autos" or watercraft to the extent not suqect 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 joint venture".(vi) That is any insurance you may have that provides coverage for your professional services. (b) Vvhen 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 the remaining loss, if any, with any other insurance that is not dessibed in this Excess lnsurance provision and was not bought specifically to apply in excess of the Limits of lnsurance shown in the Declarations of this Coverage part. (3) Method Of Sharing lf all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach, each insurer contributes equal amounts until it has paid its applicable 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 contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable 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 - LlABlLlTY, D. Liability and Medical Expenses Limits of lnsurance, paragraph 4: The Aggregate Limits of lnsurance apply separately to each of "your projects" or each "location" listed in the Oeclarations. 2. For the purpose of coverage provided by this endorsement only, the following is added to SECTION ll - LIABILITY, F. Liability and Medical Expenses Definitions: 1. "Your project" means: a. Any premises, site or "location" at, on, or in which "your work" is not yet completed, and b. Does not include any "location" listed in the Oeclarations. 2. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, wateMay 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, lhis 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 TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section lv - COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization where required by written contract because ol 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 the "products-completed operations hazard". This waiver applies only to the person or organization where required by witten contract. Notice Of Cancellation For any statutorily 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 slate cancellation endorsement. is increased to 30 Days. AUTHORIZED REPRESENTATIVE 'From Hanovq Forms: 391-1N3 (oLnq; 391-1tu5 (0E/16); 391-1586 (N16),391-1008 (W16) No coverage is provided by lhis Notice, nor can it be conslrued to replace any provisions of the policy (including its endorsements). lf here is any conflict belween this Notice and the policy (including the endorsemenls), the provisions oflhe policy (including ils endo.sements) shall prevail. 2:l-24 Pr Sandi U.rc.o 7/3/2A23 9:09:19 AX IPST) I Paqe 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 modifles insurance provided under the following: BUSINESS AUTO COVERAGE FORM A. The following is added to SECTION ll -LIABILITY COVERAGE, Paragraph A.1. Who ts 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 cont act, 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 writlen contract, written agreement or written permit; or (2) The Limits of lnsurance for Liability Coverage sho^/n 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 ofthe number of covered "aulos", "insureds", premiums paid, claims made or vehicles involved in the "accident", 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 follor/r/ing is added to SECnON 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- contibutory, 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 lo the addilional "insured" except: (11 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) !,/hen 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 periodi 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 contracl, written agreement or written permit requires such insurance lo be provjded 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. ALL OTHER TERMS, CONDITIONS, AND EXCLUSIONS REMAIN UNCHANGED 461-047812 '12 lncludes copyrighted malorial of ISO lnsurance Services Oflice, lnc., with its permission Page I of I The following is added to SECTION lll - PHYSICAL OAMAGE COVERAGE, C. Limit Of lnsurance provision: The actual cash value of the damaged or stolen property as of the time of the "loss": or 2. The outstanding balance ofthe 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 lf, because of damage, destruction or theft of a covered "auto", which is a long{erm leased "auto", the lease agreemenl between you and the lessor is terminated, "we" will pay the difference 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 SECTION IV - CONDITIONS 16, DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS The following is added to SECTION lV - BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties ln The Event Of Accident, Claim, Suit Or Loss: (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. 17, BLANKET WAIVER OF SUBROGANON Paragraph 5. Transfer Of Rights Of Recovery Against Others To Us, SECTION IV - BUSINESS AUTO cONOITIONS, A. Loss Conditions rs replaced by the Iollowing: lncludes copyrighted material of lnsurance Services Office, lnc. with its permission Copyright, lnsurance Services Office, lnc., 1996 461-015s (9-97) -:] GL-ArrO-UnE ric ?l-:r PL I S.ndi rroreno I :/3/20.'3 9:09:19 r,X {PST| I P.g€ 6 0f 3 Insurcd: Leighton Consulting, Inc. Policy No.: AW3J208478 14 AUTO LOAN PHYSICAL DAMAGE EXTENSION 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 following is added to SECTION lll - PHYSICAL DAMAGE COVERAGE. C. Limit Of lnsurance provision: 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 rs excess over all other collectible insurance. d. Knowledge of any "accident", claim, "suit" or "loss" will be deemed knowledge by you wtlen notice of such "accident", claim, "suit" or "loss" has been received by: lnsured: Leighton Consulting, lnc. Policv 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: 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, whach 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 imparr them 19, HIRED AUTO - WORLDWDE COVERAGE The following is added to SECTION lV - Business Auto Conditions, B. General Conditions, paragraph 7. Policy Period, Coverage Territory provision: e. Outside the coverage territory described in a., b., c., and d. above for an "accident" or "loss" resulting from the use of a covered "aulo" you hire, without a driver, or your employee hires wjthout 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. SECTION V - OEFINITIONS 20. MENTAL ANGUISH Your unrntentional error in disclosing. or failure to disclose, any materialfact exsting after the effective date of thrs Coverage Form shall not prejudice your rights under this Coverage Form. However, this provision does not affect our right to collect additional premium or exercEe our right of cancellation or nonrenewal. lncludes copyrighted material of lnsurance Services Office, lnc. with its permission Copyright, lnsurance Services Office, lnc., 1996 461-01ss (9-97) Paragraph C. "Bodily injury", SECTION v - DEFINITIONS is replaced by the following: C. "Bodily inJury" means bodily inlury, sickness or disease sustained by a person including death or mental anguish resultang from any of these. TRAYEtER6T WORKER,S CO PENSATION AND EMPI-OYERS LIABILITY POLICY ENDOR.SEITENT WC 99 03 75 ( A) ' ool POLICY NUITIBER: L1] t Rsor)eli t ?:.1 t(; WAIVER OF OUR RIGHT TO REGOVER FROM OTHERS ENDORSEMEiIT - CALIFORNIA (BLANKETWATVER) We have the right to recover our payments Irom ,yone liable for an irjury cov€red by this policy. We will not enforce our right against the perso or org rizatim named h the Schedule. The additrmal premium for this endo.sement shall be 2. oo % ol the califomia workers' compensation pre- mum. schcdulc Job Description AIL Oprralions This endqrsement changes the policy to which it is attached and is effedive on the date lssued tnless otherwrse stated. (Tha lnformatlon bclow 15 rcqulrcd only wh.n thir cndorsGmGr ls issurd subscquent to preparation of the pollcy.) Endorsement Effeclive oe I 0 I 11022 Insured l.crghlon Consultrng. Inc Policy No. IrB tRs0,)98t:1.11(; lnsur rce Company Travelers Propetr,-. Casual r_v Co of Amenca ST ASSIGN: tNn 3r3r 1Lc) 2?-2r 23-21 PI I s.ndl ltoL.no I 2/s/2o23 9:09:19 lX IPST) 1 P.q.3 of 3 Page 1 of 1 oNE tot{ER soutRB INaFORD Cr 05183 Pcison or Org.nlzatlon A]TT PERSOIT OR ORCTXIZATION FOR MIICTI TIIE INSURED HTS AORBED EY WRIIIEI| COIITRACT EXECI.ITED PRIOR TO ITOSS TO FI'RTISH THIA I{AIVBR. Col.ntersigned by DATE OF ISSUE: