2022/02/14 Leighton Consulting, Inc. (39)1
THIS CERTIFICATE IS ISSUEO AS A ITIATTER OF INFORI{ATIOI{ ONLY AND CONFERS I{O RIGHTS UPON THE CERTIFICATE HOLOER. THIS
CERTIFICATE OOES NOT AFFIRIXATIVELY OR NEGATIVELY AXIENO, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF TNSURAI{CE OOES NOT CONSTTTUTE A CONTRACT BETWEEN THE |SSU|NG TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, A D THE CERTIFICATE HOLDER.
IIIIPORTANT: lI tho cortlflc.to hotdor t. .n AODITTONAL |I{SUREO, th6 policy(lo!l mu.t havo ADDITIONAL INSURED provisionr or bo ondoraod.lf SUBROGATION lS WAIVED, subjoct to tho t6rms and condt0on! of tho policy, certaln policies may require an ondor3omont. A statemgnt onthls cortificato does not conler rightr to tho cortificato holdor ln lieu of !uch ondoI3emenl(!)
Risk Slraleqies ComDany
949 242 9240
res.corn
tNSTJRER(S) AFFOROTT{G COVERAGE
TNSURERA : Cilizens lnsurance ComDanv of America 31534
Leiohton Consultino lnc'17781 cowan. Suii6 l oo
lrvine CA 92614
rflsuRERB: Allmerica Financial Benefit lnsurance Co 41840
rNsuRERc: Travelers Properly Casually Co ofAmer 25674
INSURER o: Lexington lnsurance Company 19437
^cAD"CERTIFICATE OF LIABILITY INSURANCE
COVERAGES CERTIFICATE NUMBER: 7 REVISION NUMBER
CERTIFICATE HOLDER CANCELLATION
@ 1988-2015 ACORD CORPORATION. All.ight5 reserv€d.
ACORD 25 (2016/03) The ACORD name and togo ao regtsbrod .narb of ACORD
Crtv of Menifee
29714 Haun Road
Menifee CA 92586
SHOIJLO ANY OF THE ABOVE OESCRIBEO POLICIES 8E CANCELLED BEFORETHE EXPIRATIOI{ OATE THEREOF. NOTICE wlLL BE DELIVERED IN
ACCOROANCE wlTH THE POLICY PROVISIOI{S,
AUTHORIZED REPRESENf ATIVE
RSC lnsurance Brokerage
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOW HAVE
INDICATEO. NOIWTHSTANOING ANY REQUIREMENT TERM OR CONDIfION OF
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, IHE INSURANCE AFFORDED
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOW! MAY HAVE AE
BEEN ISSUEO fO THE INSURED NAMED ABOVE FOR TT]E POLICY PERIOO
ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
EN REOUCEO BY PAIO CLAIMS.
COMMERCIAL GENERAL LIABIT ITY
occUR
GEN'LAGGREGATE LIMlT APPLI€S PER
POLICY 5S fl,*
o83J208488 1111t2022 1111t2023 EACHOCCURRENCE $ 1.000.000
PREMISFS lFa.@/r6ncl $1 000 000
MED E/,P (Any on9l6lon)
PERSONAL A ADVINJI]RY
$10 000
! 1.000.000
CFNFFALAG',RFT]AIF r2 000,000
PRODUCIS, COMP/@ AGG s2.000.000
6
I AUTOX OBILE LIAEILITY
OI4NED
AUTOS ONLY
H REOAUTOS ONIY
SCHEDL'LEDAUIOSNOl.l'O r.rED
AUTOSONLY
AW3J208478 111112022 1111t2023
BOOTLY TNJURY (Per porsn)
ti,ooo,olo
s
$AODILY INJURY (Pera@d6nr)
s
EXCESS L]48
OCCUR oB3J208488
OED aErcrrort0 scWORXERS CO PENSATTON
AND E PLOYERS' UABITITY
ANYPROPRIETOR/PARTNEFYEXECUTIVE
OFFICEfu MEMBER EXCLUDEO'
O€SCRIPTTON OF OPERATONs bdtu
u81R5099812243G 911t2022 911t2023 / ] STA]UTE OTH
ER
E L EACIIACCIOENT s 1.000.000
E L D1SEASE, EAEMPLCVEE s 1 000 000
E L OISEASE POLICY LIM]T 51,000,000
D Protussional Liabilily/Pollution Liab
Claims Made
013001524 2114t2022 2114t2023 Per Claim
Aggregate
Deduct,ble
r $2,000,000
r $4,000,000
r $100.000
oESCRPIO OF @ERAiO S / LOCAIO(S / VENTCLES IACORO lot, A.ldrllo..r Rm.ri. S.h.<lub. n.y b..tt chf,l r non .p.o l. rqui6d)
See Additional Remarks Schedule
PRooucER Risk Strateoies ComDanv
2040 Main Street. Sr.iite 4S0lrvine, CA 926'14
www.risk-strategies.com CA DOI License No. OFO6675
$
I
^v l11hr2o22 11t1t2023 LAcHoccJRRENcE t5ooo,ooo
AGGREGAIE t5,OOO,OOO
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Risk Strategies Company Leiohton Consultino lnc
17781 Cowan. Suit-e 100lrvine CA 92614
AGENCY CUSTO"ER IO:
LOC t:
ACORiJ ADDITIONAL REMARKS SCHED ULE
ADOITIONAL REMARKS
AcoRD toi (zDUot) @ 2008 AcoRD coRpoRATtoN
Tho ACORD namo and looo re registsrod marls of ACORD
sherry yo)nq 12/B/ia:1 6:\ct16 M lpsT) raq., ; Df 3
Page of
THIS AODITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM.
FORiI NUUBER: 25 FORM TITLE: Certificate ot Liability (03/16)
Certificate is subject to policy lim.its, conditions and exc.Iusions. Re: proj #11051,00?PMP 20-02: Quail Va11ey Street Resurfacing Project. Menifee. City of Menifee and itsofficers, employees, agents, and authorized volunteers are included as additional insuredas respects to Genelal Liability and Commercial Aulo coverages as requ.ired by writtenContract. General Liabilj.ty and Auto Liability covelages are primary and noncont r -ibutoryas required by written conLract. VJaiver of Subrogation is included with respect GeneialLiability, Auto Liability, Workers Compensation as required by written contract. UmbreflaLiability is foIlow form subject to polj-cy forms, terns, conditions/ exc-Iusions andendorseinents. 90-Day Notice of Cancellation, Except for 10-Days for Nonpal,ment of Premiurnapp-Iies to General Liabilj.ty as required by written contract.
AJI rights r6erved.
ADDET.IDUM
HOLOER: CitY of Menitue
AOORESS:297'14 Haun Road ireniGe CA 92586
Architects and Engineers
The following policy language ls from Eusrnessowners General Liability Coverage Pad
NAMEO lt{SURED: Leighton consulting, lnc POLICY NUMBER: o83J208488
The following are mandatory forms on the policy identified on the Certificate of lnsurance:
391-1586 (08.16) BUSINESSOWNERS GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT
Additional lnsured by Contract, Agreement or Permii
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 respecl 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(iiD Your maintenance, operation or use of equipment leased to you.
'Delinition: 'Your work' a. Means: (1) Work or operations performed by you or on 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'i and (2) the providing of or fuilure to provide warnings
or inslructions
This provision does not apply:
(1) 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 of this Coverage
Part.
(3) To any lessor of equipment (a) Affer 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 from whom land has b€en leased which takes place after 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 ol or failure to
render any professional services
This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring,
employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property
damage" or the offense whi6h caused the "personal and advertising iniury" involved the rendering of or failure to render any
professional services by or for you.
Other lnsuranc6 Primary & Non-Contributory
The following paragraph is added to SECTION lll - GOMMON POLICY CONDITIONS, H - Othor lnsuranco: Additional lnsursd
- 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 lnsurance: 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 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 policyi 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) Exces3 ln3urance:
(a) Thas ansurance is excess over any ot 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";(iD 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 provid€d by this Notice, nor can it b€ construed to replace any provisions ot the policy (including its endorsements). lf there is any conflict
belween lhas Nolice and the polacy (including the endorsem6nts), the provisions oflhe policy (including its endoFements) shall prevail
I sh.i!y young t t7/a/2a22 6ttBt16 ax lpsr) I p.q. I of 3
(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 the Additional lnsured or temporarily occupied by the Additionalwith
permission of the owneri or(iv) lf the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to
Exclusion g. of SECTION ll - LIABILITY. B. Exclusions, l. 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 thal provides coverage for your professional services.
(b) Vvhen this insurance is excess, we will have no duty to defend the insured againsl any "suit" if any other insurer has
a duty to defend the insured against that "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) 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 described in this Excess lnsurance provision
and was not bought specifically to apply in excess of the Limits of lnsurance shown in the Oeclarations 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 applicable limit of insurance or none of lhe loss remains,
whichever comes frst. 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 lo SECTION ll - LIABILITY:
1. The following is added to SECTION ll - LlABlLlW, O. Liability and Medical Expenses Limits of lnsuranco, paragraph 4:
The Aggregate Limits of lnsurance apply separately to each of "your projects" or each "location" listed in the
Declaralions.
2. For the purpose of coverage provided by this endorsement only, the following is added to SECTION ll - LIABILITY, F. Liability
and Medical Exponses Definitions:
l. "Your project" means:
a. Any premises, site or "location" at, on, or in which "your work" is not yet completed; and
b. Does not include any "location" listed in the Declarations.
2. "Location" means premises involving the same or connecling lots, or premises whose connection 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 witten contract 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 wiften 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 Oays.
AUTHORIZED REPRESENTATIVE
'From Hat'ov8' Fotus: 3!r1.1@3 (0A/1q; 391-114t (0U16);39145e6(W,q,391-10,3 (NnA)
No coverage is provided by lhis Notice, nor can it be constru€d to replac€ any provisions of lhe policy (including ds endorsemenls) lf there is any confjct
between this Nolice and tlrc policy (including the endorsomenls), the provisions of the policy (including ils endorsements) shall prevail.
<<'{"-*^ru'+-t*
U B-NC-PL I sh6trV Younq I t2l3/20?i 6:13:16 Ax (PsT) P.qp ,l ot 3
AW3J208478
Leighlon Consulling, lnc.
THIS ENDORSEMENT CHANGES TH E POLICY, PLEASE READ IT CAREFULLY,
BLANKET ADDITIONAL INSURED - PRIMARY AND NON.CONTRIBUTORY
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
A. The following is added to SECTIOI{ ll -LIABILITY COVERAGE, Paragraph A.l. Who tg
An lnsured:
Additional lnsured if Roquired 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 Seciion.
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, the most we will pay on
behalf of such ad dilional "insured" is the lesser of:
(1) The Limits of lnsurance for liability coverage
specified in the written contract, written
agreement or writlen 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 to 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 tor the total
of all damages and "covered pollution cost or
expense" combined resulting ,rom 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.
General Conditions, subparagraph 5. Othor
lnsurance:
Primary and Non-Contributory
ALL OTHER TER|\ilS, CONDITIONS, AND EXCLUSIONS REMAIN UNCHANGED
461 -0178 12 12 lncludes copyrighted material of ISO lnsuranc€ Services Office, lnc., with ils permission
?r6265re I (Lcr ?0?2-20?r Gr, sh.rry you^q 12/a/202? 6trstt6lx (psT) p.g. 5 0f 3
Page 1 of I
lf you agree in a written contract, written
agreement or wratten permit that the insurance
provided to a person or organization who qualilies
as an additional "insured" under SECTION ll -LIABILITY COVERAGE, Paragraph A.1. Who ls
An lnsured, subparagraph Additional lnsured if
Rsquired by Contract is primary and non-
contributory, the following applies:
The liability coverage provided by this Coverage
Parl 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:
(1) 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
that'auto" is a'trailed 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 lhe 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.
lnsured: Leighton Consulting, lnc
Policy No.:
AW3J208478
14, AUTO LOAN PHYSICAL DAMAGE
EXTENSION
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, Heelth, Accident or Disability
lnsurance purchased with the loan, and
carry over balances ftom previous leases.
SECTION IV - CONOITIONS
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. Duties ln Th6 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:
(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.
The following is added to SECTIOI{ lll -
PHYSICAL DAMAGE COVERAGE, C.
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 Ioan, 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.
15, AUTO LEASE PHYSICAL DAMAGE
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 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 lhe leased "auto"
which you are required to pay: less any fees
to dispose of the auto; any overdue
payments, financial penalties
17. BLANKET WAIVER OF
SUBROGATION
,r625529 I {r,C) t0?2-2023 6r-A010 u}{B,Hc-pL I sh.rry \ao^g t t2/a/2022 6:13:15 At (lsl) I p.ge 6 0f a
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.
Paragraph 5. Transfer Of Rights Of
Recovery Against Othsrs 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., 1996461-0155 (9-97)
lnsured: Leighton Consulting, lnc
Policy No.;
AW3J2O847E
,18, UNINTENTIONAL FAILURE TO
DISCLOSE INFORMATION
The following is added to SECTION lV
BUSINESS AUTO CONOITIONS. B.
General Conditiong, paragraph 2.
Concealment, Misrepresentation Or
Fra u d:
The following is added to SECTION lV -
Business Auto Conditions, B. General
Conditions, paragraph 7. Policy Poriod,
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 injury", SECTION V -
DEFINITIONS is replaced by the lollowing:
C. "Bodily injury" means bodily injury,
sickness or disease sustained by a
person including death or mental
anguish resulting from any of these
5. Transfor Of Rights Of Recovery
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 lo us
That person or organization must do
everything necessary to secure our
rights and must do nothing afrer the
"accident" or "loss" to impair them.
19. HIRED AUTO " WORLDWIDE
COVERAGE
Your unintentional error in disclosing, or
failure to disclose. any materialfact
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 addilional premium or
exercise our right of cancellation or
nonrenewal.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
Copyright, lnsurance Services Office, lnc., 1996461-015s (9-97)
,1615519 r (Lc) c-PL I sherry yolnq I 1213/1022 6:t3:I6 A|t tpsT) pag. ? o( a
TRAYEtERJ?WORKERS COMPENSATION
AT{DE PLOYERS LIABILITY POLICYoNB TOWER S9UAXEI{TRfFORD CT 05183
ENDORSEMENT WC990376( A)- oo1
POLICY NUMBER: UBIR5()9e3122.1.(j
UYAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT _ CAL!FORNIA
(BLANKET WATVER)
We have the riJht to recover our payments from anyqle liable for an hjury covered by this policy. We will not
enforce our right against the persst or orqanazatio named h the Schedule.
The additifial premium for this endorsemeflt shall be 2 . oo % of the Califomia workers' compensation pre-
mtum.
Schedule
Job D6scripUon
All Opcrations
716165;19 iLCt tonng r2/B/2A2? 6:13:16 A],l lpsTt I paqo 0 of S
PeEon or Organlzatlon
IIIY PERSON OR ORGAIIIZAIION FORI{SIOI THE INSURED HT.6 AGRBBD
BY WRITTE}I CO! TRACT EXEC(rIED
PnlOR TO IJO88 TO NJR}IIAH TEIS
WAIVER.
This endorsement changes the poky to which it is attached and is effective on the date issued tnless otherwise
stated.
(ThG informauon bclow lr raqulrad only whan thlr andorrcmGnt lr lssuGd subtcqulnt to prcparatlon otthr pollcy.)
EndorsementEflediveoe[)1nt)22 policyNo.UgtRsoqgstz+tc
lnsuredLeighlonConsUhn&lncro[cyllo.[JBIR50998',,'o
lnsurarce company cortersiged by-
Allmerica Ftnancral Berrcfit lnsuranl} Co
DATE OF TSSUE: 5T ASSIGN: Page 1 of 1