2023/02/14 Leighton Consulting, Inc. (9)o.Ro"
COVERAGES
THIS IS TO CERTIFY THAT TI]E POLICIES OF
INDICATED NOTWTHSTANOING ANY REOUI
CERTIFICATE MAY BE ISSUED OR MAY PER
EXCLUSIONS AND CONDITIONS OF SUCH POL
INSURANCE LISTED EELOW HAVE BEEN ISSUEO TO THE INSUREO NAMED ABOVE FOR THE POLICY PERIOD
REMENI TERM OR CONDIIION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WH1CH THIS
TAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE'TERMS
ICIES LIMITS SHowli MAY HAVE BEEN REDUCED 8Y PAIO CLAIMS
COTI ERCIAL GEIiIERAL LIABILITY
GEN'I AGGREGATE lIMIT APPLIES PER
JECT LOC
o83J208488 11t1t2022 11t1t2023 €ACH OCCURRENCE
OAMAGE TO RENTEO
PREMISES lEa occurence)
$1.000,000
$1,000,000
MED EXP (Any one p..eon)$10,000
PERSONAL&AOV NJURY $ 1,000,000
GENERALAGGREG^'IE
PiOOUCTS - COMP/OP AGG
s2.000.000
s2.000.000
s
B AUTOT!OBILELIABiLIIY
HIRED
SCHEOULED
NON-OWNEO
AW3J208478 11t1t2022 11t112023 NEO SINOLE LM T 51.ooo,ooo
goolLY INJURY (P6r p6rson)
BOOIIY INJURY (Ps.@&nl)S
5
5
UMBR€LIALIAB
E,XCESS LIAB
OCCUR o83J208488 1111t2022 $5.000,q90
$5,000,000AGGREGATE
aer:trtoll0 s
c u,oRxERs corPEt{sanoar
ANO EMPLOYERS' UAALITY
ANYPFOPRIEIOR/PARINEREXECUT]VE
CIFFICERJUEMBEREXCLUDEO?
DES CRIPTION OF OPERATIONS bde
u81R5099812243G 91112022 911t2023
E L EACH ACC OENT
EL D SEASE EAEMFLOYEE
s1 000 000
s 1 noo 000
EI DISEASE. POLICY LIMIT s 1,000,000
o Probssional Liability/Pollulion Liab
Claims Made
013001524 2t14t2023 211412024 Per Claim
Aggregale
OeducliUe
$2.000,000
$4,000.000
$100,000
oEscRlPTloN oF oP€RATION S / LOCA TIONS / VEHICLES (ACORO 101, Additio..l R.fr..t. S.h.dut., m.y b. !fi.ch.d r moE rprc. i. roqun d)
See Addilronal Remarks Schedule
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMAER:REVISION NUMBER
CANCELLATION
Crtv of Menrfee
29444 HaUn Road
Sun City CA 92586
SHOULD ANY OF THE ABOVE OESCRIBEO POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVEREO IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUIHORIZED REPRESENIATIVE
RSC lnsurance Brokerage
CERTIFICATE HOLDER
THIS CERTIFICATE IS ISSUED AS A iIATTER OF IiIFOR]TIATION ONLY AND COTIFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIR]{ATIVELY OR I{EGATIVELY A]$END, EXTEND OR ALTER THE COVERAGE AFFOROEO BY THE POLICIES
BELOW. THIS CERTIFICATE OF hTSURANCE DOES NOT CONSTTTUTE A COa{TRACT BETWEEN THE |SSU|NG TNSURER(S}, AUTHORTZED
REPRESENTATIVE OR PROOUGER, ANO THE CERTIFICATE HOLDER.
IMPORTANT: lf the cortltlc.to holder l. an ADDITIONAL INSUREO, tho pollcy(los) mult h.vo ADDITIOIAL INSURED p.oviBions o] bo ondoBod.
lf SUBROGATION lS wAlVED, lubloct to tho torms and condltlons ol the pollcy, co aln policies mry ,oquiie an erdorsoment. A stalgmsnt on
this cenificetg doeg not conto.rights to tho certificate hold.r in lleu o, ruch ondo6emont{s).
eRooucER Risk Strateoies Comoanv
2040 Main Street. sJite 450
lrvine, CA 92614
www.risk-strategies.coln CA DOI Ucense No. 0F06675
COfiIACT Risk Strateqies Company
949-242-9240
u nsk
AFFOROIT,IG COVERA GE
TNSURERA: Cilazens lnsurance Com ofAmerica 31534
ca Financial Benelil lnsuranc€ Co 41840Leiohton Consultino. lnc
26d0 Michelson Drive Suite 400
lrvine CA 92612
rNsuRERc: Travelers Property Casualty Co ofAmerica 2567 4
19437TNsURERO: Lexinqlon lns urance Company
O 1988-2015 ACORD CORPORATION. All righte reserved.
ACORD 25 (20i5/03) The ACORD namo and logo are registorod marks of ACORD
a
s
1111t2023
fi
Risk Stralegies Company Leiohton Consultino. lnc.
26f0 Mrchelson Dn-ve Su e 4m
Irvine CA 92612
AGENCY CUSTOMER ID:
LOC t:
--^
^<:ORt)'ADDITIONAL REMARKS SCHED ULE Page of
ADDITIONAL REMARKS
ACORD l0l (2008101) O 2008 ACORD CORPORAT|ON. A[ rights .osorvod
The ACORD namo and logo aro rsgiltorod mark3 of ACORD AODENDU I
1i,.r la-rr,,1"a010-uMB-wc a_1-:r4 rL sdndl H.ri:no :/3/:0:l 9r0c:r9 An rpsT) I FaqE:6f rl
THIS AODITIONAL REMARKS FORII' IS A SCHEOULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certifcate of Liabi 03/1
HOLDER: CitY of [renitue
AODRESS: 29844 Haun Road Sun cA 92586
Certificate is subject to policy limits, conditions and excl.usions. RE: ContractAgreement: Project #11051.013, project Name: CIp 22-08 NORMANDY ROAD PEDESTRIAN
TMPROVEMENTS; PROJECT (MATERTAL TESTTNG) ; Location: Normandy Road, Menifeei GeotechnicaLconstruction selvices. city of Menlfee and its officers, employees, agents, and authorizedvoLunteers are included as additionar insured as respects to eeneral iiabirity andcorunercial Auto coverages as lequired by written contract. General Liabirity and Autol,iability coverages are primary and noncontributory as requi.red by wri.tten contract.Waiver of Subrogation is inc.Iuded with respect General Liibility, Auto Liability, Worker:sCompensation as .requj-red by wrj.tten contract. Unbrella Liability is follow folrn subject topo]icy forms, ter:ms, conditions, excl-usions and endorsements. 3b-Oay Notice ofCancell'ation. Except fo! lo-Days for Nonpaynent of Premiun applies Lo ceneral Liability asrequired by wlitten contract.
Architects and Engineers
The following policy language ls from Buslnessowners General Liability Coverage Paft
NAMED INSURED: Leighron Consutting, tnc. POLICY NUMBER: O83J208488
The following are mandatory forms on the policy identified on the Certificate of lnsurance:
391-1586 (08-10) BUSINESSO\^NERS GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT
Additional lnsured by Contracl, Agreement or Permit
A. Section ll - Liability, C - l4/ho 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 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 "prope y 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.
.Delinition: "Yourwork" a. Means: (1) Work or operations pedormed by you oron 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:
('l) 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) After the equipment lease expires; or (b) lf the "bodily lnjury", "property damage",
"personal injury" or "advertising lnjury" arises out of soh negligence of the lessor.
(4) To any: (a) Owners or other lnterests from whom land has been leased which takes place afrer 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 wrongdoing in the supervisaon, 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 - LIAHLIry of this Coverage Part, our obligations are limited as follows:
(1) Primary lnsuranc6: 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 olher 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 rs pflmary, our
obligataons are not affecled 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:(i) That is Fire, Extended Coverage, Builder's Risk, lnstallation Risk or similar coverage for "your work";(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 Notice, nor can it be conslrued to replace any provisions of the policy (including ils endorsements). lf here is any conflcl
belween this Notice and lhe policy (including lhe endorsemenls), the provisions oflhe policy (including ils endorsemenls) 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 of the owner, or(iv) lf the loss arises out 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 "suat". lf no other insurer defends, we will undertake to do so, but we will be
entitled to the insured's rights against all those ottEr 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 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 contribution by equal shares, we will follow this method also. Under this approach,
each insurer contributes equal amounts until it has paid its apdicaue 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
limils. 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 sECTlol{ ll - LlABlLlTy:
1. The following is added to SECTION ll - LIABILITY, D. Liability and Medical Expenses Limits of lnsurance, paragraph 4:
The Aggregate Limits of lnsurance apply separately to each of "your prolects" 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 Expenses Deflnitions:
1. "Your prorect" means:
a. Any premises, site or "location" al, on, or in which "your work" is nol yet completed; 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
skeet, roadway, wateMay or right-of-way of a railroad.
Separation Of lnsureds
Except with respect to the Limits of lnsurance, and any rlghts or duties specifically assigned in thas 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 TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section lV - COMMERCIAL
GENERAL LIABILITY CONDITIONS) is amended by the addition of the fottowing:
We waive any right of recovery we may have against the person or organization where required by written 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 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
state cancellation endorsement. is increased to 30 Oa ys
'Ftom Henovef Foms: 391-1U,3 (W16);3Y-1/U!t OAlq;391.186 (MG),391-1UB Oe4q
No coverage is provided by this Notice, nor can it be conskued to replace any provisions of tlE policy (including its endorsements) lf here is any coniicl
between this Nolice and lhe policy (including the endorsements), the provisions of the policy (including ils endorsements) shall prevail.
AUiHoRTzEDa-EPREsENTATTvE-
PoLICY No. : 4W3J208478
Leighton Consulting, lnc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY
This endorsement modities 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 witten permit that a person or
organization be added as an additional "insured"
under lhis 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
specitied in the written contract, written
agreement or written permit; or
(2) The Limits of lnsurance for Liability Coverage
shown in the Oeclarations 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 ot
the number of covered "autos", "insureds",
premiums paid, claims made or vehicles involved
in the "accider ", 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 Oeclarations.
B. The follor/ing is added to SECTION lV -
BUSINESS AUTO CONDITIONS, Paragraph B.
General Conditions, subparagraph 5. Other
lnsurance:
Prlmary 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 4.1. 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 ftom any other insurance
available to the additional "insured" except:
(1) For the sole negligence of the additaonal
"insured", or
(2) For negligence arising oul of the ownership,
maintenance or use of any "auto" not owned
by the additional "insured" or by you, unless
that "auto" is a "trailei' 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.
ALL OTHER TERMS, CONOITIONS. ANO EXCLUSIONS REMAIN UNCHANGED
461 .0474 12 12 lncludes copyrighted material of ISO lnsuranc€ Services Office, lnc., with its permission
Page 'l of I
r:sr36 r rl,cr a2-al 6l -Auro-uxB-llc 23-21 PL I sandi t10r. o I 2/a/2023 9:09,19 ll, lPsr) | P.9. 5 0l 3
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:
1 . 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 paymenls, 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 OAMAGE
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-term
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, financial 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.
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. Outies ln 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, "suil" or "loss" has been
received byi
(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
CONDITIONS, A. Loss Conditions rs
replaced by the following:
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
Copyright, lnsurance Services Office, lnc., 1996461-01s5 (9-97)
The following is added to SECTION lll -
PHYSICAL DAMAGE COVERAGE, C.
Limit Of lnsurance provision:
Insurcd: Leighton Consulting, lnc.
Policy No.:
AW3J208476
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.
-.il 6,,-AUTo-tr{A-rr 23-24 P! I S.ndi xot..6 I 2/9/2011 9:09:19 Attt tPST, r Paq.6 ot 3
Insurcd: Leighton Consulting, lnc
Policy No.:
AW3J208478
18. UNINTENTIONAL FAILURE TO
DISCLOSE INFORMATION
The following is added to SECTION lV
BUSINESS AUTO CONOITIONS. 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:
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 "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.
SECTION V . DEFINITIONS
20, MENTAL ANGUISH
Paragraph C. "Bodily iniury", SEcTION v -
OEFINITIONS is replaced by the following:
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 Ol Recovery
Against Others To Us
19, HIRED AUTO - WORLDWDE
COVERAGE
Your unintentionalerror in disclosing. or
failure to disclose, any material fact
exrsting afier the effective date of thrs
Coverage Form shall not prejudice your
rights under this Coverage Form.
However, this provision does not atfect
our right to collect additional premium or
exercise our right of cancellation or
nonrenewal.
lncludes copyrighted material of lnsurance Services Office, lnc. wlth its permission
Copyright, lnsurance Services Office, lnc., '1996
461-0155 (9-97)
2l-:1 PL I s.ndi or.no I :/8/1021 9!09,19.{, lPsT) I P.q€ r or 3
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 rmpair them.
.-,
TRAVETERSJ WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICYoNE TOWBR SoUlnB
IltRaFoRD Cr 0618!
ENDORSEMENT WC990375( A). ool
POLICY NUMBER: lll Rsoeell:t.lri
WAIVER OF OUR RIGHT TO REGOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKETWATVER)
We have the dght to recover our payments from ,ryone liable for an hjury covered by this policy. We will not
enforce our right againsl the perssr or organizatim named h the Schedule.
The additifial premium for this endorsement shall be 2. oo % of the Califomia workers' compensation pre-
mtum.
Schedule
Person or Orglnkatlon
IITY PBRSOT OR ONOTSIZATION FOR
IIHICB :tEE INEURED HAS ACRBED
BY IIXITTEN COIITRASI EXECUTED
PRIOR TO I.OS8 TO PI'RNISII TEIS
*AIVER.
Job Dcscription
All Opcrations
This endorsement changes the policy to which it is attached and is effeclave on the date rssued tnless otherwise
stated.
(The information brlow ls rsqulred only v{hrn this endo6omGnt ls issued subsequent to prepal.tion of
the pollcy.)
Endorsement Effeciive 09/0 l/2022
lnsured L(,rghton Consultrng. lnc
Policy No- 111g Ip5999g12;111;
lnsurarce Company
liavelers Propenr' Casualty Co of Afircrica
Col'r|tersigned by
DATE OF ISSUE:ST ASSIGN:
7lortr36 I {Lc) ,l-21 PL I Sa^dr Moreno I :/3/20?1 9:09:19 rX IPST) P.qe 3 af 3
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