2023/01/31 CableCom, LLCo.ofu
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER:REVISION NUMBER: 0
DATE IfM'DD/YYYYI
01121nu3
THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRiIATIVELY OR NEGATIVELY AtrlEND, EXTEND OR ALTER THE GOVERAGE AFFOROED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING II{SURER(S), AUTHORIZED
REPRESENTATIVE OR PROOUCER, AND THE CERTIFICATE HOLDER.
IiTPORTANT: ll the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or bo ondoBsd.
lf SUBROGATION lS WAIVEO, subject to the termg and conditions of the policy, certain policies may roquirG an endorsemont. A statement on
this certificate doos not confer hts to the cortificato holdor in lieu ot such endorso s
PROOUCER
IN COVERAGE
i,,lulual Fire lnsuranceCN1 0298692!uplGAwU-2!24
PHONE
I
NAIC
424c/.
23035
10725
33600
II{SURER E
INSURER D
INSURERC
atonlltsuREo
Cablecom. LLC
19910 Norh Creek Partway Norh, Suite 100
Bohdl, wA 9001 'l
'lrarsh USA, lnc
Two Alliance C6nler
3560 Lenox Road Suite 24t10
Atanta, GA 303m
INSURER A: Li
INSUREfiB]LMINSU'ANC€
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POLICY PERIOD
INDICATEO NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOvvl.I MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR
LTR TYPEOF INSURANCE AODL SUSR
POLICYNUT/lBER
POLICY EFF POLICY EIP L IllS
x COMMERCIAL GENERAf LIABILITY
OCCUR
GEN'L AGGREGATE LIMITAPPLIES PER
POLICY
OTHER
JECT LOC
x
x
T82-631,510825 233 0113112023 01t31t2024 EACH OCCURRENCE $5 000,000
DAMAGE TO RENTED
PREMISES lFa oc.uiiemer $1,000,000
MEO EXP lAny ore p6rson)$
$5 000,000PERSONAL & ADV INJURY
GENERAL AGGREGATE $10000,000
PRODUCTS - COMP/OP AGG $10,000.000
$
AUTOMOAILELIABILIIY
ollarEo
AUTOS ONIY
HIREO
AUTOS ONLY X
A52,631,004260,023 01/31/2023 01t31t2024 COMBINEO SINGLE LIMII $5,000 000
BOOIIY INJURY (Per pers)$
EOOILY INJURY (Psr accrd€oo $
$
$
C X UMBRELIALIAB
EXCESS IIAB
OCCUR RFE-63r-51073!r43 01t3112023 01t3112024 EACH OCCURRENCE $5.000,000
AGGRECATE $
DEI)RLlENIION $$
B
B
D
IIIORI(ERSCO PENSATION
AND E PLOYER8'UABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUOED?
DfscRrPfloN oF oPEF{arroNs beros
N N
wAt63M04260-033 (A0S)
wcF631-004260-043 (r\rN,WD
wA7-63D51068$513 (MA)
01t3112023
01t3 2023
01/3r/2023
01t31t2024
01t31t2024
01t3112024
x STATUTE
OTH
ER
E L EACHACCIDENI 1 000,000$
€ L OISEASE . EA EMPI.OYEE 5 1,000.000
$1,000.000E L DISEASE . POLICY LIMIT
oEsc8rpnoN oF opERAno||a / LocaTlor{s , vEHlcrEs (AcoRo l0l, addlond R.r.rt. s.h.dd., nry !. rti.cEd r mdr .p... b r.qrT.dl
lo C€neral l-iability as rcquiGd by $rinen conlracl.
CERTIFICATE HOLDER CANCELLATION
City ol Menifee
AUn Public Wo.ts oepl. ' Engineering Dept
iB714 Ham Rd Bldg A
Sln Ciry, CA 9258&6540
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLEO BEFORE
rHE EXPIRATION DAIE THEREOF, NOTICE WLL BE DELIVEREO II'I
ACCOROANCE WTH THE POLICY PROVISIOT{S.
AT,IHORIZEO REPRESE?TIANVE
@ 1988-2016 AGORD CORPORAnON. All .ighb 'l orvod.
Tho ACORD namo and logo are i€gistered marks of ACORDACORD 25 (20r6/03)
ATL-004595347-24
SCHEDTILED
AUTOS
NON-Olrl]liEO
AUTOS ONTYX
X
5 000,000
%a.aaZ 2/.94 ?ae.
0002168 SP 0035 -C01.PO2r69-r
City ol Menilee
Alln: Public Works Dept. - Engineering Dept.
29714 Haun Rd Bldg A
Sun City, CA 92586-6540 ffi
0035-01 .00.0002 r 6a-@o 1 .001 3094 ffii
POLICY NUMBER: A52-631 -004260-023 COMi,ERCLAL AUTO
cA 20 {8 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifios insurance provided under the following
With rsspect to coverage provided by this endorsement, the provisions of th€ Coverage Form apply unless modifiod
by lhis ondorsoment-
This endorsemont identifios person(s) or organization(s) who a/e 'insureds' for Covered Autos Liability Coverage
under the Who ls An lnsured provision of the Coverago Form. This eMorsement does not alter coverage provided
in the Coverage Form.
SCHEDULE
l{ams Of Peraon(B) Or Organlzation(s):
Any Person(s) or Organization(s) as requited by u/ritten contract prior to loss on llle with the broker
lnformatbn required to complete this Scheduls, if not sho'rvn above, will be shown in the Declaratbns
Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Cov€rage, but
only to the extent that person or organization qualifies
as an "insurod' under the Who ls An lnsured provision
contained in Paragraph A.1. of Saction ll - Covered
Autos Liability Coverage in tho Business Aulo and
Motor Canier Covorage Forms and Paragraph D.2. ot
Section I - Covered Autos Coverages ol the Auto
Dealers Coverage Form.
cA 20 48 .t0 13
@35-01-00.0002168,@02 001 3095
O lnsurance Services Oftice, lnc., 201 I ffii
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
Page 1 of I
Policy Nmber
lsruod by
AS2€3t{XX2E0{il3
Libedy Mufual Fitr hatrrtcc Company
THIE E1{DORSEXE'{T C1IAXGE8 IHE FOLICY. PLEAEE READ IT CAREFULLY.
M'NCE OF CAT'CELI.ATK)I{ TO THIRD PARTIES
This endorsemont modills inarance provtsod und€r the lbllowlng:
BUSINESS AUTO COVERAGE PART
MOTOR CARRIER COVERAGE PART
CTARAGE COVERAGE PART
TRUCKERS COVERAGE PART
EXGESS AUTOII,IOBILE LIABIUTY INDEMNITY COVERAGE PART
SELF-INSURED TRUCKER EXCESS LI,ABIUTY COVERAGE PART
COMMERCIAL GENERAL UABIUTY COVERAGE PART
EXCESS COMMERCIAL GENEML LIABILITY @VERAGE PART
PROOI.,CTS'COMPLETEO OPERATIOMT LIABIUTY @VERAOE PART
UQI'OR LIABILTTY @VERAGE PART
COMMERCIAL LIABLTTY - UMBREII.A @VERAGE FORM
&h.dr-
ilrnc of O$r Prron(r) /
OmrnLrlion{r):
Etllll Addlt . a mrlllng add!.t:
Fer Schedule on File With
The Company
Per Schedule on File With The
Company
75 or as required by writ-
ten contract, whichever is
less, per the schedule on
Irle wrtn the company
Dry.
A. lf wr cilcd this polry tur sry Erson othlr lhIl nonpayflrfit of Fsrium. wr wll mrufr tho p.rssl! a
orgatlzations shown h thc schcdub ebow. Wo wll sand notcr to th. crnal or mrlng addrus tsbd !bo\r.
at lca.t '10 day!, or thc numbcr of dayr lsbd sbotrq lf any, bcfqr thc cancalaflon becors cfiadhr. ln no
6y.nt do6 tho notice b $. thld psrty .x6ad th. nodcr to tho frtt namcd lnruld.
B. Thb advanE nouncatbn of € p.ndlng cgncrlhtofl of cortr.go b lnbndcd .. . couilley only. Our hllu]! b
prwldc sudr edvgrcs nodicadon wlll not dnd tr. pollcy cencolatlon detr nor negab cancslgton d lh.
pollcy.
All other bms and condltlons ol tN8 pollcy ramaln uncftang6d.
O 201t Lborty Muttel Gronp of Comp6nlo6. AI dghts rfi.rvod.
lndudo! oopyilghbd mebrH of lnrurenco Son lcas Ofllca, lnc., wltr
lb pormbCon.
Llt 9!t 0r 05 {{Pego I of I
POLICY NUMBER: AS2-631 -004260-023 COMTTTERCIAL AUTO
GA 04 .t{ 10 13
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGATNST OTHERS TO US (WATVER OF SUBROGATION)
This endorsement modifies insurance provid6d under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provision$ of the Coverage Form apply unless modified
by the endorsemeni.
SCHEDULE
Name(s) Of Person(s) Or Organizatlon(s):
Any person or organization for whom you perform work under a written contract if the contract requires you to
obtain this agreemenl from us, but ooly if the contract is executed prior to the injury or damage occurring.
lnformation required to complete this Schedule, if not shown atove, will be shown in the Declarations.
The TranEfer Of Rights Of Recovery Against Othere
To Us condition doos not apply to the person(s) or
organization(s) shown in the Schedule, but only to ttle
extent that subrogation is waived prior to tho 'a6cidont"
or the 'loss" under a contract with that p6rson or
organization.
cA 04 44 10 13
0035 01-00-00021 68-0003 00r3096
@ lnsurance Services Office, lnc., 201 1 Pago 1 of I ffi#fflH
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED OWNERS, LESSEES OR
CONTRACTORS GOMPLETEDOPERATIONS
This endorsement modifies insurance provided under tho following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
PoLrcY NUMBER: T82-631-510825-233 COMI/lERCIAL GENERAL LIABILITY
cG 20 37 04 t3
B. With respoct to the insurance afforded to thBse
additional insureds, the following is added to
Section lll Llmlts Of lnsuranco:
lf covcrage provided to the additional insurod is
required by a contract or agreement, tho most we
will pay on behalf of the additional insured is the
amounl of insurance:
1. Roquired by the contract or agreementi or
2. Available under the applicable Limits of
lnsurance shown in the Declarations:
whichever is less.
This endors€ment shall not inerease the applicable
Limits of lnsurance shown in the Declarations.
Namo Of Additional lnsured Person(s)
Or Organizatlon(sl Location And Dosc.iption Of Completed Operatlons
AII persons or organizations for whom you
have agreed in a written contract or agree-
rnent, prior to an "occurrence" or offense, to
provide additional insured status
lnformation roquired to comptqte this Schedulo, if not shown above, will be shown in the Oeclaratlon$.
cG2037lX13 O lnsurance Servic€s Office, lnc-.2A12 Page I of 1
A. Section ll Who ls An lnaured is amsnded to
include as an additional insured the person(s) or
orgaoization(s) shown in the Schedul€, but only
with respect to liability for "bodily iniury" or
"proporty damage' caused, in whole or in part, by
'your wo*' at the location destgnated and
doscribed in the Schedule of this endorsam€nt
parformed for that additional insured and
included in the "products{ompleted operations
hazard".
However:
l. Th6 insuranco afforded to such additional
in8ured only applias to tho sxtent permitt8d
by law; and
2. lf coverage provided to the addilional insured
is required by a contract or agreement, the
insuranco afforded to such additional iosurod
will not be broader than that which you are
required by tha contract or agroement to
provide for such additional in$ured.
THls EiIDORSEHENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AI'DITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS . SGHEDULED PERSON OR
ORGANIZATION
Thb rn lanrrmt modfi.. lnaurmor ptovHcd und.r th.lUlowlng:
@i,MERCIAL GENEML I.IABILITY COVERAGE PART
POLICY NUMBER: T82431 -510825-233
A 8rcfon Il - Who lr An lnrurrd h amoded b
l.rdudo as an addldonal h$r€d tho por&n(s) r
ooentsston(r) 3lrown ln the Sdrduh, hn ql[
wlth ,€6p6ct b lhulty lbr lodlly lnjurf, Droportydrrr{p' or lersonal arrd a.hrodlhg ldrrf
cal3rd, in rhdc or h parq bf
l. Your !c!r o. anblbns; a
2. The acts o ombdons of thce acJng on your
boftalt
h thr perfoirnancc of your orpdng oFratom fur
tho addthld lmund(r) €t th. locauon(s)
dclgnabd abota
tlorsvrr:
'1. Thc lrruram afiordad to such ddtrqrd
ilgircd only apdl.. b thr .J6nt p.rmltbd by
htf end
Z lt @lrorage provldsd b tho lddtonal lmul€d b
nqulod by a conblcl c ag nnr( thc
hEurglca frrdod to rucfi addlflonel lnsu]ad
wll nol b. brcad$ $rr th8t wtrir! you rr
llqullld by lhe contrect or agrromont b p(wldo
fu. tucfr sddltional lrr3rirsd.
B. WDt r!8p.at b th. lndrrarEo afurdcd b tlr.a.
addluonal lrEurqb, th. dloflirE .ddiuon l
otcbCons apply
Thb hsur$o. do.o not apdy b lodly lnluQ/ c
?rcFrty ddnagd occunhg aftor:
GO 20 10 0'l lS
COIXERCIAL GEI{ERAL LIABIUTY
GG 20'10 0/t'13
t. Al uro.lq lndudlng mat*lals, partr or €qulpment
fumilh€d h cmnocdon yulth luch u,od( m tho
plqloat (o0rar than scrvioc, mdntenanoc or
7!pdt!) b bc p.rbm.d I or an bchalf ol ho
additlon l lnrund(a) at h. loce0on of thc
co\roEd opea0ons has boon coolplot d; d
2 That po.ton of lour m.k' out of nfrich thc
lnJury or demagc !rb6 h8! b..n Fd to it!
lnbnd.d u!. by any perron or orgEnhatbn
ohor Ulan andrrr conbsctor or subconffir
qreagcd h pedormlng operadons for a prlnc$d
es a pail of the same p{ed
C. Wtrr rlsp€d b th. lnarrano do.d.d b thc.c
additional lmuodr. the fo[oillng ls eddod b
8rcdon lll - Umlb (lf lnrur:rct:
ll covrragc pruvid.d b thc a.Hltbml l.rEuEd b
roqdrd by a contact or agrr.mdrt iha moat w!
wlll pay on bohdf of Ule adddonal lrpumd ls the
grrcunt of lmurancc:
l. R6quirrd by thc conkact c agllqr.flh o.
Z Avdlabb under the applhable Lhtlts ot
lnsurarrcc ahorYn h lh! t).chrsthm;
whLfi€t€. b l€sg.
Thls adorsarcnt dtall not lncreae the appllcaHe
llmltr of lnrrama dronn ln tho DedaraUonr.
0035.01 -00-000216a,@04.001 3097
O ISO Pmperlht, lttc.,2012 Prgc t oI ffi
ECHEDULE
illnc Ol Addltlond lnrumd Penon(rl
OrOmnEdon(rl Locrtlon(r) Ol Govlltd OpGrrflon3
All persons or organizations for whom you
have agreed in a written contract or agree-
ment, prior to an "occurrence" or offense, to
provide additional
insured status-
All locations as required by a written con-
tract or agreement entered into prior to an
'occurrence" or offense.
lnfonnatbn t€quird b completo thb Schedlle, lf not shofln 8bovo, u,f bs sflown ln tho Dedqlltielg.
GG 20 l0 0'l lt O lnsurame Sorirhos Offlc3, lnc., 20'12 fii2ol2
THIS EI{DORSEIIENT CHANGES THE P'OLICY. PLEASE READ IT CAREFULLY.
This endorsement modifi$ insuranc€ providod under tho full(Ifling:
BUSINESS AUTO COVERAGE PART
MOTOR CARRIER COVERAGE PART
GARAGE COVERAGE PART
TRUCKERS COVERAGE PART
EXCESS AUTOMOBILE LIABIUTY INDEMNITY COVERAGE PART
SELF-INSURED TRUCKER E(CESS LIABIUTY COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
EXCESS COMMERCIAL GENEML LIABILITY GOVERAGE PART
PROOUCTS/COMPLETED OPERATIONS LIAEIUTY COVERAGE PART
UOUOR LLqBILITY COVERAGE PART
COMMERCIAI. LIAEILrI-Y - UMBREI.I.A COVERAGE FORM
Schrdulr
ilrme of Othcr P.r.on(.) ,
Omenization(r):
Em.ll Addrrar or malllng lddll !:Numbff Daya Nodc.:
Per Schedule on File With
The Company
Per Schedule on File With The
Company
75 or as required by writ-
ten contract, whichever is
less, per the schedule on
lrle wttn tne company
A" lf w. eancd thls polcy fu ary lEas(rr oth.r lhan nonpaynent of pr.rlum, s! will noufy tho prrsorE or
orlanizatiom shown h thc Schcdulo above. We wll s.nd nolice to thc crnal or mailng addtms llsbd abovc
at lca8t 10 dryr, or thc numbcr of day! tsbd abovc, lf arry, before hc cancclaton bocomes gffacthr€. ln no
ovent does th6 notcs b tha third party oxcood tho noticc to tho lld namod lnBrad.
B. Thls advanE notiflatlon of a p€ndin! cancdhtlon of co{rerage h lnbnd€d a8 a courtEsy only. Our lailurE to
provlde su$ advsrce nofffca0on will not extond tre polhy canelstbn date nor negab cancsllsfon of lhe
polby.
All other bnnB ard condniotB d t s pdicy romsin urr'lrdlgsd.
Policy Nrmber
lssued by
L[r 99 0,r 05 t{O 2ol l Liberty Mutd Goup of Companlot. AI rights rosoilod.
lndudos copyrlghbd mabrtd of lnsurance Senr'rces Ofih6. lnc., with
lbPemislidl.
H#14Et'fli+li'iFf,
IIOTICE OF CAI{CELLATIOI{ TO THIRD PARTIES
TB2S31S't082$233
Liberty Mutral Fire hturance Gompany
0o3s 01 -oo-0002168-000s 001 3094
Page I of 'l
Polhy Number TB2{31-510&!5-233
lsand by UBERryMUTUAL FIRE INSURANCE COMPANY
THIS EilDORSETIEIIT CIIA}IOE8 TIIE FOUCT. PLEASE READ IT OIREFUI-LY,
PRI'IIARY AI{D IiIONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endoGement modifiee in8urance provlded under the followirg:
Tho follouring is added lo Saction IV - Conditions 4, Othor lnsurarEe and Eupera8ds€ any provi8ion to th6 contrary:
P.lm$y And N onoontribubry lnararrce
This insranco iB primsry to ond will not so6k contrluJtion from arry oth6r insuanca avalable b an addltbnal
insurod urul€r your pdicy pmvk sd tEt:
(1) The additional hsur€d is . Nemed lnsorcd under suc-h other hsurance; and
(2) Yott have agrced pdor to e brs, th.t lhis lnsurance would be prlmary and trodd not s€ek contrlbulbn fiom
any olher insuranca evailablo to the addltiort61 iniurad.
(3) Thls lnourance li excoss over any dher insurance avallable b he additional lnsured for whkfi lt lr also
co\r6tad as an addiliond lnrurcd by attiachm6nt of an ondo[semcnt lo anoth€r polcy pio\rirhS covaragc
for lhe sane "occunorre", daim or 'suif.
e 2016 Lbqty Muhtd lnsunonco
lnclud.r copyrighbd matErial of lnsuranc. Servi6s Ofr6, lnq, wilh ib p.rmlookrn.
LD 2.t ltt 0E la Pog6 | of I
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTSICOMPLETED OPERAT|oNS LIABILITY COVERAGE PART
PollcY NUMBER: T82-631-510825-233 COMi' ERCIAL GENERAL LIABILITY
cG 2a 0{ 05 09
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under tho fotlowing:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PROOUCTS/COMPLETED OPERATIONS LIABILIfi COVERAGE PART
SCHEDULE
Nam€ Of Person Or Organlzatlon:
As required by agreement entered into prior to loss.
lnformation Lqquired to complete this Schedule, if not shown above, wiu be shown in the Declarations
The folbwing is added to Paragraph 8. Transtor Of
Rlghts Of Recovery Agalnsl Others To Us of
Sec-tlon w Conditions:
We waive any right of recovery we may have against
th€ pe.son or organization shown in lh6 Schedul€
above because of payments we make for iniury or
damage arising out of your ongoing operations or
'your work" done under a conlract with that person
or organizatlon and included in the "products"
completod oporations hazard". This waiver ar)pli€s
only trc lhe person or o€anization shown in the
Sch€dule abovs.
CG 24 0/t 05 09
0035-01-00-0002 168.m06-001 3099
O tnsuranco Servicos Office, lnc., 2008 Page 1 of 1 ffiiHffiT
A. lf wu canccl thlc polby for tty Erron othcr tt|trl nonpsym.flt of prumlum, m wll noflry fic Pcnorlr or
oryankatlons rhorrn tr tho S.rr€dde below. We wll rend notle to he a.nill or trdllng lddr€sr I&d belil,
Et lo!.t 10 day!, a the numbor ol dryr lhbd bdour, lf any, befoo cancdldon becorrr efisctvo. ln m over
doo thc notbc b thr thlrd porv.xc..d ft. notc. b ht tht mlrld lnar.d.
B- TH! rdvanc. milf,E tbn of ! p.ndlrp arcclatbn d covrngp b lnbnd.d s r courbrry only. Ourhlh]!b
provldc rudr dvancc noffllca0qr ul not .r&.rd tE pollcy canc.laton datr IDr n $[l cuctldon d h.
pollsy,
NONCE OF CAiICELIATIOil TOTHIRD PARTES
scltEDutr
Emdl Ad&... ornalngaddn .:l{rrrr 010th.r Prron(r} I
OrgrnLrdon(r):
List on Flo
$th tho brd(er
Al other bnrE and condltbns ol tHs pollcy rcmaln u;drangsd.
l58ued by Lll lnsurnc. Corpo]alion
Foras.clrnErrto poricy WA5{3}004260-033 Erlldll Dob 113112023 to 113112024
hlrr.d bDyEorn lndurli[., lnc.
wc9Da75
Ed. t2l01/2016
l{rrnbrr Dlyr }lodcr:
30
02016 t"b6rv Mutlal hrllr ce P8{.e'l o,l1
NONCE OF CA}ICELLATIoI{ TOTHIRD PARTIEE
A- lf wa cacol firlg pollcy for any leesdr othcr lhan nonpaymanl of pramlum, w! t/yll noilry thc pcrcons or
orgenizations shovm h the Schedde bebw. We wll land notioe to the emall or malllng addresa lk*ed belor
at least '10 dap, or the number of dayr liabd below lf any, beforc carrcdlsthn becomas sftdlve. ln no ovent
&cE the notico b tho third party cx6.d lhc notlcc b thc il,d namcd lnuEd.
B- Ttis d\rancc noliflcathn of a pcndlng arcclatlon of cowlagc b lntandad ac a courbay only. Our hlhra b
prcn id. Eudr dvanoc notillce0m u not lr(bnd tr. pollcy cancrlation dd. mr mgsb crncalaton d hc
polrcy.
SC}IEDULE
Endl Adtlrr or malng addo..:ilrmr of Othor Prrron(r) I
O,mrrnLdion(r):
List on Fib
with tho bm*or
All other brmo and conditions of ttis pollcy remaln urrcharigsd.
lssued by LM lnsurance Corporalion
Foratbdrmentto Pollcy l/t/C5S31-004260-043 Eltbcdvt Dab '11311202X Prsmlum I
Eau.d bDycom lndu$lh.s, lnc.
Xunbrr Dlyr llodcr:
t0
0035 01-00-000216a-0007'00 r 3100
O 2016 Lb€rty Mrrlual hsurfico Pa0s I ot 'wc9D20 75
Ed. 12tO1n0I6 ffi
Wo have th€ right to r€co\Ior our paym6.rt fiorn aryom lhble fur m lnJury oovemd by thb polcy. We wll not
enlbrce our right .g.imt the perlon a orIE {z.tdr named ln lh6 s.*redub. (Thh aglEerient appl€! orly fo tho
o)dsnt fiaf yorJ p€rlbmr work under. $rrlt!.n @nfact that Equhel you b obt|h lhh .elEfient frun u..)
Thk ag]ldrcm lhal not op!.ar dt!.ily or lndlErily b b.nClt anlon n ,l namrd ln thr Sdrrdra.
S.tr.dd.
Where Required By Contract Or Writlen Agreement Prior To Loss And Allowed
By Law.
Alabama, Arizona, Arkansas, Colorado, Delaware, Dist. Of Col, Georgia,
ldaho, lllinois, lndiana, Kansas, Maine, Michigan, Mississippi, Missouri,
Montana, Nevada, New Mexico, North Carolina, Oklahoma, Pennsylvania,
Rhode lsland, South Carolina, South Dakota, Vermont, West Virginia
The premium charge is 2o/o ol lhe total manual premium, subject to a minimum
premium of $100 per policy.
Connecticut, Florida, lowa, Maryland, Nebraska, Oregon
The premium charge is 1 % of the total manual premium, subject to a minimum
premium of $250 per policy.
Hawaii
The premium charge is $250 and determined as follows: The premium charge
for this endorsemenl is 1 % of the total manual premium, subject to a
minimum premium of $250 per policy.
Louisiana
The premium charge is 2o/o ol lhe total standard premium, subject to a
minimum premium of $250 per policy.
Massachusetts
The premium charge is 1 % of the total manual premium
New York, Tennessee
The premium charge is 2o/o of the total manual premium, subject to a minimum
premium of $250 per policy.
Virginia
The premium charge is 5olo of the total manual premium, subject to a minimum
premium of $250 per policy.
h.u!d br LM lnsurance Corporation
For rtlalhnlnt b FoIc? t{o
wA563IL00420G03it
lrr.db:
wc 00 0t 13
Ed. rut11304
Prxr r.m S
@ 1g6il Natlonal Councll on CompcnEelbn lniurlnco, lnc.Ptgc 1 of 1
WAIVER OF OUR RIGHT TO RECOVER FROTI OTHERS ENDORSEiIENT
EltotlYr Ddt
1131120231o 113112024
Wr hrvc lhc dght b rrcov€r our paynEnts lhom fiyonc lhbL for sn injuy covl]ld by this po0cy. Wc wtl nol
onfucs our dght eg€lr,rrt lho po.lon or organkatlon named ln tho Sdlqtde. (Thb agiEemant apCos mly to tho
od.nt tlEt you p.rfdfli work undor a writbn conbad lhat ruquil3 lrou b obtdn hb agEem.nt fiom ua)
Thb agm.fiEnt shal rct operato dhrc0y or hdmcfy b benefit aryone rd nfitod ln the Safirdule.
WAIVER OF OUR RIGHT TO RECOVER FROil OTHERS ENDORSEMENT
Thb udv.r do6 not spdy to any dghil to .€cowr paym6nt8 whidr lhe
Mlnnesob Wortar Compansaton R.lra.rrElce Assodatbn ma!, ltayD or pursu.
undrr M.S. 78.!16.
Sch€dde
lrJhac Rrquhcd By C.anfad Or Wrltbn Agildmnt P,br To Lst And Alou,ld
ByLff.
Mhn mb
Thc p(trnbm cfiaEp b 296 of thr btll milual p(tmlun, u.lblGct b a mhlmum
famlun of $l m por pollc,.
Whmrdn
The prflntJm chsrgE b 296 o, fia bbl m'luel p.Bml[m, ruqect b a mhimum
pramlrn of $50 per polcy.
lrurod br tu trrurno corpof3ldt
For..Lorn ntb Polcy noWC5-631-004260-04Glhdiw w 113112023 to 1/31/2024 Ppilirm $
b$rd h Dycom ldutr., hG.
WG 00 Gl 13 O 1983 NaUonal Counc[ on Comp€nletlon lruuranco, lnc.
Ed. tltlflt04
0035-01-00-0002168.0004-0013101
PagE I of t
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