2021/08/28 Dudek (9)oiQo'
0811812021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE
OR PRODUCER, AT{D THE CERTIFICATE HOLDER.
IMPORTANT: lf tho certificate holder i3 an AOOITIONAL INSUREO, the policy(ies) musl have ADDITIOi{AL INSURED provisions or be endoGed. lf
SUBROGATION lS WAIVEO, subject to the terms and conditions of the policy, certain policies may require an gndoBemeni. A statement on this
cortificate does not conf€r rlght3 to th6 certificate holdsr ln lleu of such endorsement(3).
PROOUCER Lockton Companies
444 W. 47th Street, Suite 900
Kansas City MO 64112-1906
(816) 960-9000
INSU RER(SI AFFORDING COVERAGE
tNsuRER a : Zurich Amelican lnsurance Company 16535
rNsuREo 0UOEK
1474537 605 THIRD STREET
ENCINITAS CA 92024
rr{sunen e , Continental Casualty Company 20443
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER
428t2422
COVERAGES REVISION NUMBER
men
@ 1988-201s CORO CORPORATION. All rights reserved
HOLDER N
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAI\]IED AAOVE FOR THE POLICY
PERIOD INDiCATED NOTWITHSTANDING ANY REOU]REI\,IENT TER[I OR CONDITION OF ANY CONTRACT OR OTHER DOCUi\IENT WITH RESPECT TO
WHICH THIS CERTIFICATE II,IAY BE ISSUED OR i'AY PERTAIN, THE INSURANCE AFFORDED BY THE POLlCIES DESCR]BED HEREIN IS SUBJECT TO
AI I IHE TERIVlS EXCI T]S ONS AND CONDITIONS OF SI]CH POLICIES LIMITS SHOWN MAY HAVE BEEN REDt]CFD BY PAID CLAIMS
INSD
$ 1 000.000
OAMAOE TO RENTEO e 100,000
MEO EXP lAnv one oeBon)s 10.000
PERSONAL & ADV INJURY $ 1.000,000
GENE RAL AGCREGATE $ 2.000.000
PRODUCTS COII,IP/OPAGG s 2 000 000
Y Y
4a28t2021 08t2at202
I
COMI/IERCIAL GENERAL LIABILTTY
GEN'LAGGREGATE L MIT APPLIES PER
X X
X
LOC
OTHER
JECT
G1O0146311
$ 1,000,000
BOOILY NJ!RY (Perperson)$ xxxxxxx
SODILY INJURY (Peraccidenl)S XXXXXXX
$ XXXXXXX
Y Y
8AP0146329 0812812021 08128t2022
$ XXXXXXX
AUTOMOBILE LIABITITY
HIREO
AUTOS ONLY
SCHEOL]LEO
NON!W!ED
AUTOS ONLY
X
EACH OCCL]RRENCE $ XXXXXXX
EXCESS LIAB MAOE $ XXXXXXX
RETENT ON $$
X
s 1,000,000
E L OISEASE. EA EMPLOYEE s 1,000,000
WORKERS COiIPENSATIONANO Ef PLOYERS' LIABILITY
N Y
wc0146330 08t28t2021 08t28t2422
E L OISEASE. POLICY LIM T $ '1,000,000
B PROFESSIONALLIABILITY N N
EEH591932835 INCL POLL oat2at2a21 04124t2022 PER CLATM $1,000,000AGGREGATE $1.OOO,OOO
OESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101 , Addltlonrl R6mark! Schsdul.. m.y b! .tt ch€d if mor€ .prca l! Bqulr.d)
2020.2021 ON-CALL CONSTRUCTION INSPECTION SERVICESi Clry AND ITS OFFICERS OFFICIALS, EMPLOYEES AND AUTHORIZED VOLUNTEERS ARE
INCLUDED AS AN ADDITIONAL INSURED ON THE GENERAL ANO AUTO LIABILITY POLICIES WAIVER OF SUBROGATION IN FAVOR OF THE ADDITIONAL
INSURED ON THE GENERAL, AUTO, AND WORKER'S COMPENSATION POLICIES. 30 OAY NOTICE OF CANCELLATION APPLIES, 10 DAYS NOTICE FOR
NON.PAYMENT OF PREMIUM
SHOULDANY OFTHEABOVE DESCRIBEO POLICIES BE CANCELLEO BEFORE
THE EXPIRATION DATE THEREOF, NOTICE wlLL BE DELIVERED IN
ACCORDANCE IiYITH THE POLICY PROVISIONS,
16828273
CITY OF MENIFEE
29844 HAUN ROAD
MENIFEE CA 92586
AUTHORIZEO REPRESENTATIVE
4*A*l *,
ACORD 2s (2016/03)
The ACORo name and logo arc registercd marks of ACORO
I crerus,raaoe I occun
loeol
NOT APPLICABLE
(/
L.-
Attachment Code : D564542 Certificate lD : 16828273
Loekton Companies
444 W . 47th Street. Suite 900
Kansas City, MO 64112
DUDEK.: 1474537
lo(xrff
t582827 3
CITY OF HENIFEE
29844 HAUN ROAD,
TlENIFEE, CA 92586
Dear Valued Cl i ent:
In our continuing effort to provide timely certificate delivery, Lockton
Companies is utitizing paperless det'ivery of Certificates of Insurance.
To ensure electronic delivery for future renewals of this certificate, we
need your email address. Please contact us via the email below and referenceCertificate ID: 16828273. You must reference this Certificate ID number inorder for us to complete this process.
E Certificate ID: 16828273B Ema i 1: kctsu@lockton. com
U Subject Line: TSU E-Delivery
L
If you received this certificate through ancertificate is v'iewab1e, we have your email
i nte rnet link where the current
and no further action is needed
P1e ase n oteavailable.that after February 2022, printed certificates will no longer be
ina,ti.iA. +^ fh;. inh^v .. -a-^n<c< ui I I ha rlal,vcri n
If you no longer need this certificate, please contact us at the email
address above, reference the Holder ID number and use this subject line:
"Certi f icate Removal "
l,loTE: The above enail is a collector enail regarding electronic delivery ofcertificates only. Please do l,l0T send certificate reouests or other insurance
Thank you for your cooperat'ion and w'illingness in reducing our envi ronmental
footpr i nt.
Lockton Companies
Techni cal Se rv i ces Unit
Emaal/ Marlrng Updale - Liabilily Certificates
Attachment Code : D574649 Certificate lD : 16828273
Additional Insured - Owners, Lessees Or
Contractors - Scheduled Person Or Organization
a
ZURICH
Policy No. G1O0146311 Effective Date: 0812812021
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
SCHEDULE
Name Of Additional lnsured Person(s)
Or Organization(s):Location(s) Of Covered Operations
ANY PERSON OR ORGANIZATION ARE REQUIRED
TO PROVIDE ADDITIONAL INSURED STATUS IN
A WRITTEN CONTRACT, AGREEMENT OR PERMIT
ALL
LOCATIONS
lncludes copyr ghted materal of lnsurance Services Offrce, lnc , with its permission.
u-GL-2169-4 CW (02119)
Page 1 of 2
THIS ENOORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
A. Section ll - Who ls An lnsured is amended to include as an additional insured the person(s) or organization(s)
shown in the Schedule of this endorsement, but only with respect to liability for "bodily injury", "property damage"
or "personal and advertising injury" caused, in whole or in part, by:
'1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s) designated in such
Schedule.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions
apply: This insurance does not apply to "bodily injury" or "property damage" occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the proiect (other
than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the
location of the covered operations has been completed; or
2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any
person or organization other than another contractor or subcontractor engaged in performing operations for a
principal as a part of the same proiect.
All other terms, conditions, provisions and exclusions of this policy remain the same
u-GL-2169-A CW
(02/19)
Paga 2 oI 2
Includes copyrighted material of lnsurance Services Office, lnc., with its permission.
Attachment Code : 0574649 Certificate lD : 16828273
Attachment Code : D574648 Certificate lD . 16828273
Waiver Of Subrogation (Blanket) Endorsement
Policy No.EII. Date of Pol Exp. Date ofPol.Efl Dale ofEnd Add l l,rem
G100146311 08/28/2021 g8/28/2022 0812812022 3738s000 s
INC
L
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
The following is added to thc Transfer Of Rights Of Recovery Against Others To Us Condition:
Ifyou are required by a written contract or agreement, which is executed before a loss, to waive your rights ofrecovery from
others, we agree to waive our rights ol'recovery. This waiver ofrights shall not be construed to be a waiver with rcspect to any
other operations in which the insured has no contractual interest.
u-cL-925-B CW ( l2l01)
Attachment Code : D574648 Certificate lD : 16828273
Page I ol l
Attachment Code : D574651 Certificate lD : 16828273
POLICY NUMBER: BAP0146329 COMMERCIAL AUTO
cA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following
AUTO DEALERS COVERAGE FORt\,1
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage
under the Who ls An lnsured provision of the Coverage Form. This endorsement does not alter coverage provided
in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated
below.
Named lnsured: DUDEK
Endorsement Effective Date: 0812812021
SCHEOULE
Name Of Person(s) Or Organization(s):
ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO
PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON
A PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR
WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH
CONTRACT OR AGREEMENT IS PROHIBITED BY LAW.
lnformation required to complete this Schedule, if not shown abolc-rryjllbetholvor hc
cA 20 48 10 13 O lnsurance Services Office, lnc., 2011 Page 1 of 2
Attachment Code : D574651 Certificate lD : 16828273
Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies
as an "insured" under the Who ls An Insured provision
contained in Paragraph A.'1. of Section ll - Covered
Autos Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms and Paragraph D.2. of
Section I - Covered Autos Coverages of the Auto
Dealers Coverage Form.
cA 20 48 '10 13 O lnsurance Services Offlce, lnc., 2011 Page 2 ol 2
AttachpgLqovqqjPEE{Q€A9€r{46CblD : 1 6828273 COMMERCIAL AUTO
cA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGATNST OTHERS TO US (WAIVER OF SUBROGATTON)
This endorsement modilies insurance provided under the following:
AUTO DEALERS COVERAGE FORN/
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by the endorsemenl.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated
below.
Named lnsured: DUDEK
Endorsement Effective Oate: 0812812O2O
SCHEDULE
Name(s) Of Person(s) Or Organization(s):
ANY PERSON OR ORGANIZATION YOU ARE REOUIRED TO WAIVE YOUR RIGHTS
OF RECOVERY IN A WRITTEN CONTRACT, AGREEMENT OR PERMIT WITH THE
NAMED INSURED,
lnformation required to complete this Schedule, if not shown above, will be shown in the Declarations
The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived prior
to the "accident" or the "loss" under a contract with that
person or organization.
cA 04 44 10 13 O lnsurance Services Office, !nc.,2011 Page 1 of 1
AttasooRfi Sase(ntrt$&QsdnqHtruffiaflEHs LrABtLtry TNSURANGE poLtcy
WC0146330 Dudek 08128120210812812022
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
wc 00 03 13
(Ed.4-84)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule
Schedule
ANY PERSON OR ORGANIZATION YOU ARE REQUTRED TO WA]VE YOUR RIGHTS OF
RECOVERY IN A WRITTEN CONTRACT, AGREEMENT OR PERMIT WITH THE NAME D
INSURED.
wc 00 03 t3
(Ed.4-84)
@ 1983 Natlonal Councll on Compsnsation ln3urance