2022/02/14 Leighton Consulting, Inc. (38)12
THIS CERTIFICATE IS ISSUEO AS A ISATTER OF II{FORUATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOER. THIS
CERTIFICATE DOES NOT AFFIRIIIATIVELY OR NEGATIVELY AiiEI{O, EXTETID OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TH|S CERTIFICATE OF TNSURANCE OOES r{OT COi{ST|TUTE A CONTRACT BETWEEN THE ISSU|NG TNSURER(S), AUTHORTZEO
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER,
IMPORTANT: lf the cortiflcato holdor lr an AODITIONAL INSUREo, tho policy{ios) mu.t havo ADDITIONAL INSUREO provisiona or bo endorsed.
ll SUBROGATION lS wAlvEo, subjoct to tho torm! .nd condltlons ol the pollcy, cort ln pollclo3 may roquiro an ondoBomont. A statomont onlhii cortificate doos not conror rlght! to tho certificalo holdor ln llou of auch ondoEemont(!).
PRooucEF Risk Strateoies Comoanv
2040 Main Street. SLirte 450
lrvine, CA 92614
www.risk-strategies.corn CA DOI License No. 0F06675
ies Com
949-242-9244
syouno@risk'slraleqies ccrn
INSURER{S)AFFORDING COVERAGE
rNsuRER A : Citizens lnsurance ComDany of Amenca 31534
Leiohton Consultino. lnc.17f8't Cowan. Suife 1 OOlrvine CA 92614
rNsuRER B Allmerica Financial Benefil lnsurance Co 41840
rNsuRER c Travelers Prooerlv Casually Co of Amer 25614
|NSURERO : LeXinqton lnsurance comoanY '19437
INSURER E
o.ofu CERTI FICATE OF LIABILITY INSURANCE
COVEFAGES CERTIFICATE NUMBER:8 REVISION NUMAER:
CERTIFICATE HOLDER CANCELLATION
@'1988-20'15 ACORD CORPORATION. All rights reserved
ACORD 25 (2016/03) The ACORD namo and logo ae regisbred marks ofACORD
SHOULD ANY OF THE AAOVE OESCRIBEO POLICIES BE CAiICELLEO BEFORE
THE EXPIRATION OATE TIIEREOF, NOTICE WILL AE OELIVEREO IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
RSC lnsurance Brokerage
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO \A/TiICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROED 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOW\ MAY HAVE EEEN REDUCED BY PAID CLAIMS.
EACHOCCURRENCE $ 1,000,000
DAMAGETO RENTED
PREMISES {Eao@n€^er s1 000 000
t 10.000MEO EXP
PERSONAI & ADV NJI]RY s 1,000,000
GENERALAGGREGATE s2 000.000
PROOJCIS. COMPrcP AGG s2,000,000
COUMERCIAL GENERAL LIABILITY
GEN'LAGGREGATE LIMIT APPLIES PER
JECT LCf
occrJR
POL]CY
I]EF
o83J208488 11t112022 111112023
S
COMBIIIEDSINGLE L MII
BOOILY INJURY (Psr p€r$n)s
tj 000 000
BOOTLY TNJURY (Pd a@d6nl)
5
OVINEDAUIOS OIILY
HIREO
AUTOS OiILY
SCHEDULEDAUIOSNON4VINEOAUIOS ONLY
AUTOSOgILE LIAAiLITY AW3J208478
s
$ 5.000.000UTBRELLAUAB
EXCESSUAB
occuR
CLAIMS-IIAOE
EACHOCCL]RRENCE
AGGREGATE s 5.000.000
DEO nerclqorul0
o83.1208488 1111t2022 11t112023
SIPER I )TH
E L EACHACCIOENT
E L DISEASE. EAEMPLOYEE
s1000 000
$ 1 000 000
C WORXERSCO PENSAIIO'/
ANOE PTOYERS' LIABIUTY
ANYPROPRIETOR/PARTNER/EXECIIIIVF
OFF CEF/MEMBER EXCLUDEO?
o€scR|PToN oF oPERAT0NS b6r*
u81R5099812243G 9t112022 9t112023
E L DISEASE. POIICY LIM T 51 000.000
D Protessional Liability/Pollution Lrab 013001524 2t14t2022 211412023 Per Claim
Aggregate
Deductible
r $2,000,000
r $4,000,000
r S100.000
O€SCFIPTION OF @EFAIOI{S / LC|cAn(,{S, VEHICLES (AC()RD ,Or, Addrddid nin.,t S.h.duh, d.y b. dr.ch.il t n@.p.o 1.,lqdrdl
S€e Additioial Rema*s Schedule
B 1111t2022 11tlt2023
CrtY of Menifee
29714 Haun Road
Menifee CA 92586 tu
Risk Strategies Company Leiohton Consultino lnc
1 7/81 Cowen su'6 l0o
lrvine CA 92614
NA'CCODE
AGENCY CUSTOi'ER IO:
LOC #:
CORi}ADDITIONAL REMARKS SCHEDULE
ADDITIONAL REMARKS
ACORD r01 (2008/01) @ 2008 ACORD CORPORATTON
The ACORD name and logo re rogl3t6r6d marks of ACORD
Page
THIS ADOITIONAL REMARKS FORM IS A SCHEOULE TO ACORO FORIti,
FORM iIUMBER: 25 FORM TITLE: Certificale of Liability (03/16)
HOLOER: City of Menibe
AOORESS: 2971,1 Haun Road irenifre CA 925E6
Certificate is subject to policy limits. conditions and exclusions, Re: Proj #11051 Cityof Meoifee Professional Selvj-ces. City of Menifee are included as additional insured asrespects to GeneraL Liability and Commercial Auto coverages as required by writtenContract. Genera.L Liabi.Iity and Auto Liabilj-ty coverages are prinary and nonconLributoryas requir.ed by written contract. Waiver of Subrogation is included with respect Genera.lLiability. Auto Liabi,lity, Workers Compensation as required by written contract, UmbrelLaLiability is follow form subject to policy forms, terms, conditions, exclusions andendorsements. 90-Day Not.ice of Cancellation, Except for 1o-Days for Nonpal,ment of Premiumapp-Iies to General Liabili-ty as required by written contract.
All rights reserved.
ADDENOUM
o,
Architects and Engineers
The following policy language ls from Eusrnessowners General Liability Coverage Parl
The following are mandatory forms on the policy identified on the Certificate of lnsurance:
391.1586 (08.16) BUSINESSOWNERS GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT
Additional Insured by Contract, Agreement or Permit
A. Section ll - Liability, C - Who 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 "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.
-Definition: "Yourwork" a. Means: (1) Work or operations performed byyouoron behalf; and (2) materials, parts orequipment
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 warnings
or instructions.
This provision does not apply:
(1) Unless the writlen 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 of this 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 sole negligence of the lessor.
(4) To any: (a) Owners or other lnterests ftom whom land has been leased which takes place after the lease for the land
expires, or (b) Managers or lessors ot 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 servic€s.
This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring,
employment, training or monitoring of olhers 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 CONOITIONS, H - Other lnsurance: Additional lnsured
- Primary and Non-Contributory. lf you agree in a written contract, written 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 - LIABILITY of this Coverage Part, our obligations are limited as follows:
(1 ) Primary lnsurancs: 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 contrabution from any other 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 is primary, our
obligations are not affected unless any of the other insurance is also primary.
(2) Excess lnsuranco:
(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, Builde/s Risk, lnstallation Risk or similar 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 lhis Notice, nor can it be construed to replace any provrsions of lhe policy (including its endorsements). ll there is any conflict
belween lhis Nolice and the policy (including the endorcements), lhe provisions ofthe policy (including ils endorsemenls) shall prevail.
16:65?3 ILC) 2022.1rrtr cL-Al,TO-UUS-|C-pL I Sherry \alng I r2/S/2A22 5:13:16 AX lpST) I p,qe I of 3
NAMED INSURED: Leighton Consulting, Inc POLICY NUMBER: o83J208488
(iii) That is insurance purchased by the Additional Insured to cover the Additional lnsured's liability as a tenant for
"property damage" to premises rented to the Additional lnsured or temporarily occupied by the Additionalwith
permission of the owner; or(iv) lf the loss arises out of the maintenance or use of aircrafl, "autos" or watercrafr to the extent not subject to
Exclusion g. of SECTION ll - LIABILITY. B. Exclusions, 1. Applicablo to Eusiness 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 lhat "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) When 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 oe
(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 described 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) Mathod Of Sharing
lf all of the other insurance permits conkibution 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 ,irst. lf any of the other insurance does not permit contribution by equal shares, we will contribute by
limits. Under this method, each insure/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 - LIABILITY, 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
Declarations.
2. For the purpose of coverage provided by this endorsement only, the following is added to SECTION ll - LlABlLlTY, F. Liability
and ltledical Exp6nsos Defi nitions:
1. "Your project" means:
a. Any premises, site or "location" at. on, or in which "your work" is not yet completedi and
b. Does not include any "location" listed in the Declarations.
2. "Location" means premises involving the same or connecting lots, or premises whose conneclion is interrupted only by a
street, roadway, waterway or right-of-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, 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 following:
We waive any right of recovery we may have against the person or organizalion where required by written conlracl because 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 wriften 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 90 Days.
AUTHORIZED REPRESENTATIVE
'Fro,i H.taeq Fonns: 391-l@:l(@/rq;3C1-144t (ovlq;3ei18a (@4q,351-1003 (MO)
No coverage is provided by this Notce, nor can it be conslrusd to.eplace any provisions of the policy (including its endorsements). lflhere is any conffict
between lhis Notic€ and the policy (including the endo6emenls), lhe provisions of the policy (including its endorsements) shall prevail.
@{*^iLt-*1..
A/202: 5:r0:16 rr, tPsr) I P.qe 1 of 0
AW3J208478
Leighton Consulting, lnc.
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
BLANKET ADDITIONAL INSURED - PRIMARY AND NON.CONTRIBUTORY
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FO RM
A. The following is added to SECTION ll -LIABILITY COVERAGE, Paragraph A.1. Who lg
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.l.c. of this Section.
lI 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, the most we will pay on
behalf of such additional "insured" is the lesser of:
(l) The Limits of lnsurance for liability coverage
specified in the written contract, written
agreement or written permit: or
(2) The Limits of lnsurance for Liability Coverage
shown 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 lo this Coverage Part. Regardless ofthe number of covered "autos", "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 following is added to SECTION lV -
BUSINESS AUTO CONDITIONS, Paragraph B.
Genoial Conditions, subparagraph 5. Other
lnsurance:
Primary and Non-Contributory
lf you agree in a written contract, written
agreemenl 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.l. Who ls
An lnsursd, 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 from any other insurance
available to the additional "insured" except:
(l) 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
thal "auto" is a "lrailer" connected to an "auto"
owned by the additional "insured" or by youi 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:
l. 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 expiralion 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 TER[ilS. CONDITIONS. AND EXCLUSIONS REMAIN UN CHANGED
461-047A',1212 lncludes copyrighted malerial of ISO lnsurance Services Offce, lnc , wilh ils permissjon
023 G!-^U1O U{B-IC-PL I sberry youhq 12/A/2O2? 6tt9tt6 rx (psT) p.qe 5 of 3
Page 1 of I
14. AUTO LOAN PHYSICAL DAMAGE
EXTENSION
,I5, AUTO LEASE PHYSICAL DAMAGE
EXTENSION
The following is added to SECTION lll -
PHYSICAL DAMAGE COVERAGE, G.
Limit Of lnsurance provision:
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 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 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.
imposed under a lease for excessive use,
abnormal wear and tear or high mileagel
security deposits not retunded 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.
SECTION IV. CONDITIONS
16 DUTIES IN THE EVENTOF
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.
d. Knowledge of any "accident",
claim, "suit" or "loss" will be
deemed knowledge by you when
notice of such "accident".
claim. "suit" or "loss" has been
received by:
('l) 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.
The following is added to SECTION lll -
PHYSICAL DAMAGE COVERAGE. C.
Limit Of lnsurance provisionl
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 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; Iinancial penalties
17 BLANKET WAIVER OF
SUBROGATION
Paragraph 5. Transfer Of Rights Of
Rocovory Against Others To Us,
SECTION IV - BUSINESS AUTO
CONDITIONS, A. Loss Conditions is
replaced by the following:
lncludes copyrighted material of lnsurance Services Offlce, lnc. with its permission
Copyright, lnsurance Services Office, lnc., 1996451-015s (9-97)
lnsured: Leighton Consulting, lnc.
Policy No.:
AW3J208478
lnsured: Leighton Consulting, lnc
Policy No.:
4W3J208478
18, UNINTENTIONAL FAILURE TO
DISCLOSE INFORMATION
The following is added to SECTION lV
BUSINESS AUTO CONOITIONS. B.
General Conditions, paragraph 2.
Concealment, Misrep16aentation Or
Fraud:
The following is added to SECTION lV -
Business Auto Conditions, B. General
Conditions, paragraph 7. Policy Period,
Coverage Territory provision:
Outside the coverage territory
described in a., b., c., and d.
above for an "accident" or "loss"
resulting ftom 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 - OEFINITIONS
20, MENTAL ANGUISH
Paragraph C. "Bodily in,ury", 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 Of Rscovery
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,
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 afler the
"accident" or "loss' to impair them
,19, HIRED AUTO - WORLDWIDE
COVERAGE
e
Your unintentional error in disclosing, or
farlure to disclose. any material fact
existing after the effective date of this
Coverage Form shall not prejudice your
rights under this Coverage Form.
However, this provision does not affect
our right to collect additaonal premium or
exercise our right of cancellation or
nonrenewal.
lncludes copyrighted material of Insurance Services Office, lnc. with its permission
Copyright, lnsurance Services Office, lnc., 1996451-0155 (9-97)
r1525s23 I ILC) r022-a0?l cL-auTo-wB-ll younq I l:/3/i022 5:13:t6 lx (psT) I p.so 7 0f 3
TRAYEtER6?WORKERS COMPENSATION
ANO
EMPLOYERS LIABILIIY POLICYo!{B TOWER S9UI.RE
H}RTFORD cr 06183
ENDORSEMENT WC990375( A). oo1
POLICY NUMBER: gB lRsgceg t22,tjc
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKET WATVER)
We have the right to recover our payments lrom atyone tiable for an hjury covered by this policy. We will not
enforce our right against the persm or organazaticn named h the Schedule.
The additimal premium for this endorsement shall be 2, Oo % of the Califomia workers' compensation pre-
mlum.
Schedule
Person or Org.nlzatlon
A![Y PERSON OR ORGIIIIZI,TION FOR
WHIG' THE INAURBD IIAS AGREED
BY I{RIITEN COIITRICT AIECUTID
PRIOR TO IrOSS TO PIJRIIISH 1EIS
WTIVBR.
Job Desctiption
AII Opcrations
This endorsement changes the policy to which it is attached and is effective on the date issued urless otherwise
stated.
(The lnformation below ls requlred only when this Gndorscmrnt ls issued subsGqu€nt to prGparation oftha policy.)
Endorsement Effectiv e 09 n I DO22
lnsured 1-g;a61.r, 6'onrr11,nr. 1n6
Policy No. gg1t5699s 12436
lnsurance Company
Allmerica lrrnancral Reiclit lnsurance Co
Corntersigned by
DATE OF ISSUE:ST ASSIGN:
716r5523 1LC) 2022-202t Gi-AUTo-UMB-tlc-pl, sherry t.rng t?/g/?A22 6:1s:16 A, (psr) I prge s of s
Page 1 of 1
tu