2022/08/28 Dudek (5)A,C:oRi}CERTIFICATE OF LIABILITY INSU RANCE 0811712022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR t{EGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFORDEO BY THE POLICIES BELOW,
THIS CERTIFICATE OF INSURANCE OOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPRESENTATIVE
OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificate hold6r is en ADDITIONAL INSURED, ths policy(l6s) mu3t have ADDITIONAL INSURED provislons or be endorsed. lf
SUBROGATION lS WAIVED, subject to lhe terms and conditions of the policy, certain policies may requir€ an endoBement. A statement on this
c€rtificate do6s not confer rights to the cortificite holcler in lieu of such endoBomont(3).
PRoDUCER LocktonCompanies
444 W 47th Street. Suite 900
Kansas City MO 64112-1906
(816) 960-9000
kctsu@lockton.com INSURERIS) AFFORDING COVERAGE
rNsuRER a: Zurich American lnsurance Company 16535
rNsuREo DUDEK
1474534 60s rHtRD SIREEr
ENCINITAS CA 92024
rNsuRER B: American Guarantee and Liab. lns Co 26247
rNsuRER c : continental casualtv comoanv 20443
8t28t2423
COVERAGES CERTIFICATE NUMBER REVISION NUMBER
CANCELLATION ee men s
o,98E-2015 CORD CORPORATION. All rights reserved
CERTIFICATE HOLOER
rHIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOO INDICATED NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT IO
ATL THE TERMS EXCLUSiONS AND CONDITIONS OF SUCH POLICIFS I IMITS SHOWN MAY HAVE BEEN RETJTICFD BY PAID CLAIMS
ADOLINSD
EACI] OCCURRENCE s 1 000 000
s 100,000
MEO EXP lAny one personl $ 10,000
PERSONAL & AOV INJURY $ '1.000.000
GENERAL AGGREGATE $ 2.000.000
PRODUCTS COMP/OP AGG $ 2.000.000
COil!MERCIAL GEIIERAL LIABILITY
GENL AG6REGATE L MITAPPL!ES PER
X
X X
x
CLA MS,MADE
LOC
OTTIER
JECT
Y Y
GLOo146311 o8t2a2a22 a8t28t2a2
$
coMSINEO SINGLE LIMII $ 1.000,000
$ XXXXXXXBOO LY INJURY (Per pe6on)
BODTLY TNJURY (Pd accrdenr)5 XXXXXXX
5 XXXXXXX
AUTOMOBILE LIABIIIIY
OW!ED
AUTOS ONLYHIREO
SCHEOULEO
AUTOSNON€I{t]EO
X
Y Y
8AP0146329 0812812022 08t28t2023
S XXXXXXX
X EACFi OCCURRENCE r 1.000.000
$ 1,000,000EXCESS LIAB
X
S.MADE
08t28t2422
$
B
OED RETENT ON $
N
aat28t2a23
x tEix,,,,. I t"t#
E L EACI] ACCIOENI $ 1.000,000
E L DISEASE EA EMPLOYEE $ '1,000,000
WORKERS COMPENSATION
AND EMPLOYERS' IIABILITY
OESCRIPT1ON OF OPERAT ONS b.IOW
N Y
wc0146330 08t28t2022 oat2at2023
EL DISEASE POL]CY LMIT $ 1.000.000
C PROFESSIONAL
LIABILITY N N
8EH591932835 INCL POLL aat2at2022 08t28t2423 PER CLAI[.'
AGGREGAT$1.000,000E $1 000,000
OESCRIPITON OF OPERAIIONS ILOCAIIONS TVEHTCLES (ACOFO 101, Addltion.l Rd.rt Sch.d{h, m.y h..rEchcd irmoE.p.@ l. Bqurod}
ALL OPERATIONSi THE CITY OF MENIFEE ANO ITS OFFICERS. EMPLOYEES AGENTS,AND AUTHORIZED VOLUNTEERS ARE ADDITIONAL INSURED ON
GENERAL AND AUTO LIAAILITY COVERAGE ON A PRIMARY, NON.CONTRIBUTORY BASIS IF REQUIRED BY WRITTEN CONTRACT. WAIVER OF SUAROGATION
IN FAVOR OF THE ADDITIONAL INSURED APPLIES ON GENERAL. AUTO, AND UMBRELLA LIABILITY COVERAGE, IF REOUIRED BY WRITTEN CONTRACT AND
WHERE ALLOWED BY LAW, COVERAGE IS SUEJECT TO THE TERMS ANO CONOITIONS OF THE POLICY
SHOULOANY OFTHEABOVE OESCRIAED POLICIES BE CANCELLED BEFOREIHE EXPIRATION DATE THEREOF, NOTICE WILL aE OELIVERED lil
ACCOROANCE WITH THE POLICY PROVISIONS,
AUTHORIZEO REPRESENIAiNE
/v/4
16753187
CITY OF MENIFEE
29714 HAUN ROAD
MENIFEE CA 92586
The ACORD name and logo are registered marks ofACORD
llucorasaoz
"l
/1,.'
IACORD 25 (20r6/03)
Attachment Code . D564542 Certificate lD: '16753'187
DUDEK.;1474534
L
lo(Xrofi
167s3187
CITY OF MENIFEE
29714 HAUN ROAD,
MENIFEE , CA 92586
Dear Valued Client:
ln our continuing effort to provide timely certificate delivery, Lockton Companies is utilizing paperless
delivery of Certificates of lnsurance. To ensure electronic deliveryfor future renewals of this certificate, we
need your email address. Please contact us via the email below and reference Certiflcate lD: 15753187.
You must reference this Certificate lD number in order for us to complete this orocess,
. cerrificate lD: 16753187. Email: kctsu@lockton.com. Subject Line: TSU E-Delivery
Signing up for this will Nq[ sign you up for any solicitation emails - your email will only be used to
forward updated or renewal certificates direct from Lochon. The email you receive will look like this:
too(roIit
t- d tr be a,.r- - tr.rtrt 5.u< e rE i.r. L-l.r.r8
lf you received this letter with a certificate via email, no further action on your part is necessary. lf you no
longer need this certificate, please contact us at the email address above, reference the Holder lD number
and use this subject line: "Certificate Removal"
L
Entarl/ [,,larh1g trpdale - I iabi[] Cerli'rcales
Thank you for your cooperation.
Loclton Companies
Technical Services Unit
Attachment Code : D574649 Certificate lD : 167531 87
Additional Insured - Owners, Lessees Or
Contractors - Scheduled Person Or Organization
@
ZURICH
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Policy No. G1O0146311 Effecti\e Date: oB I 281 2022
This endoBement modifies insurance pro\,ided under the
Commercial General Liability Coverage Part
SCHEDULE
Name Of Additional lnsured Person(s)
Or Orga nization(s):Location(s) Of Covered Operations
ANY PERSON OR ORGANEANON ARE REQUIRED
TO PROVIDE AODIT]ONAI INSURED STATUS IN
A WRIT'TEN CONIRACT, AGREEMENT OR PERMIT,
ALL
LOCATIONS
lncludes copyrighted rnater al of lnsurance Services Office. lnc., w ith its perrnssion
L.LGL-2169-A CW (02/19)
ftage 1 of 2
Attachment Code : D574649 Certificate lD : 16753'187
A. S€ction ll - Who ls An lnsrred 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(9) 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 iniury" or "property damage" occurring
after:
1. All work, including materials, pa rts or equipment furnished in connection with such work, on the project
(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
operationsfor a principal asa part of the same project.
All other terms, conditions, provisions and exclusions of this policy remain the same.
lncludes copyrighted material of lnsurance Services Office, lnc., with its permission.
u-GL-2169-A CW
(02h9)
Page 2 of 2
Attachment Code : D574649 Certificate lD : 16753187
Attachment Code: D574648 Certificate lD: 16753187
Waiver Of Subrogation (Blanket) Endorsement
Polic! No Eff. Dare of Pol.ExD. Dare of Pol.Eff. Darc ol End.
G 1o014 6 311 08 /28 /2022 o8 /28 / 2023 08t28t2023 37185000 $ INCL S
THIS D.,IDORSE\48{T CIIANGES TIIE POUCY. PLMSEREAD m CARffiILLY.
This endorsernent modilies insurance provided under the:
Comnrercial General Liatility Corsrage Part
The foliowing is added to the Transfer Of Righa Of Recorrry Against Others To l-b Condtion;
Ifyou are required by a \\ritten contract or agreerrrcnt. which is elecuted before a loss. to waive your dghts ofrecovery fiorn
olhen, we agree to waive our rights ofrecovery. This waiver olrights shall not be constmed to be a waiver with respect to any
other operations in *hich the insured has no contractual interest.
U,GL-925-B CW
(r2l0t)
Pase I of l
Attachment Code : D574648 Certificate lD : 16753187
Attachment Code : D574651 Certiflcate lD : 16753187
POLICY NUMBER; 8AP0146329
COMMERCIAL AUTO
AUTO DEALERS COVERAGE FORN/
BUSINESS AUTO COVERAGE FORN/
MOTOR CARRIER COVERAGE FORM
CA 20 /A 10 '13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LABILITY COVERAGE
This endorsement modifies insurance pro\ided under the following
With respect to co\erage pro\,ided by this endorsement, the pro\,isions of the Co\erage Form apply unless modified
by this endorsement.
This endoBement identifes person(s) or organization(s) who are "insureds" for Co\ered Autos Liability Co\erage
under the Who ls An lnsured provision of the Co\€rage Form. This endorsement does not alter co\erage pro\,ided in
the Co\€rage Form.
This endorsement changes the policy effecti\e on the inception date of the policy unless another date is indicated
below.
Named lns red: DUDEK
Endorsement Effective Date : 081 2812022
SCHEDULE
Name Of Person(s) Or Organization(s):
ANY PERSON OR ORGANZCNON 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 WRITIEN
AGREEMENT E)ECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR
AGREEN,4ENT IS PROHIBITED BY LAW,
lnformation required to comolete this Schedule, if not shown abo\e, will be shoxm{ lhe Declalatjats-
Attachment Code : 057465'1 Certificate lD : '16753'187
cA 20 48 10 13 @ lnsurance Sen/ices Offce, lnc., 20'11 Page 1of 2
Attachment Code : 0574651 Certiflcate lD : 1 6753'187
Each person or organization shown in the Schedule is an
''insured" for Co\€red Autos Liability Co\erage, but only to
the extent that peBon or organization qualifes as an
"insured" under the Who ls An lnsured pro\,ision
contained in Paragraph 4.1. of Section ll - Co\€red
Autos Liability Cowrage in the Business Auto and Motor
Canier Cowrage Forms and Paragraph D.2. of Section I
- Cowred Autos Co\erages of the Auto Dealers Co\erage
Form.
cA 20 48 10 13 O lnsurance Senices Offce, lnc., 2O11 Page 2 oI 2
Attachpousp(tuiffiAqahF0!4g/g I D : 1 67531 87
Name(s) Of Person(s) Or Organization(s):
ANY PERSON OR ORGANIZATION YOU ARE REQUIRED TO WAIVE YOUR RIGHTS
OF RECOVERY IN A WRITTEN CONTRACT, AGREEMENT OR PERMIT WITH THE
NA[,4ED INSURED,
COMMERCIAL AUTO
cA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAMER OF TRANSFER OF RIGHTS OF RECOVERY
AGATNST OTHERS TO US (WATVER OF SUBROGATTON)
This endorsement modifies insurance pro\,ided under the following
AUTO DEALERS COVERAGE FORI\,4
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to co\,erage provided by this endorsement, the pro\,isions of the Co\erage Form apply unless modified
by the endorsement.
This endorsement changes the policy efrecti\e on the inception date of the policy unless another date is indicated
below.
Named lnsured: DUDEK
Endorseme nt Effective Date : 081281 2022
SCHEDULE
ton red to com ete this Sc if S abo\e 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 wai\ed prior to lhe "accident"
or the "loss" under a contract with that person or
organization.
ca 04 44 10 13 O lnsurance Senices Ofice, lnc., 2011 Page 1 of 1
Attachment Code: D574651 Certificate lD: 16753187
Atta90oR*digjebDfl685Afi uifrAilo EriptQSitk8 r-raBr Lrry TNSURANcE poLrcy
wc0'146330 Dude k 08t28t202208D8t2023
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We ha\€ the right to reco\er our payments from anyone liable for an injury co\ered 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 REQUIRED TO WAIVE YOUR RIGHTS OF
RECOVERY IN A WRITTEN CONTRACT, AGREEMENT OR PERMIT WITH THE NAMED
INSURED.
wc0003't3
(Ed. 4{4)
O 1983 Naoonal Councll on componmtlon lnsurance.
wc 00 03 13
(Ed. 4€4)