2022/02/14 Leighton Consulting, Inc. (21)CERTIFICATE OF LIABILITY INSURANCE '12t812022
THIS CERTIFICATE IS ISSUED AS A iiiATTER OF I FORIIATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRIIIATIVELY OR NEGATIVELY AITIENO, EXTEND OR ALTER THE COVERAGE AFFORoEo BY TllE POL|CIES
BELOW. THIS CERTIFTCATE OF INSURANCE OOES NOT CONSTTTUTE A CONTRACT BETWEEN THE tSSUlr{G TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PROOUCER, ANO THE CERTIFICATE HOLOER.
ITTPORTANT: lf tho certlfi cats holdor l..n ADDITIO AL INSURED, the pollcy(lo!l mult havo ADDITIONAL INSURED provlsions or bo ondorssd.
It SUBROGATION lS wAlvED, subJoct to tho torma and condltlonr of tho pollcy, cortaln pollclo3 may rcqulrc an 6ndo.semont. A 3tatement on
thlB certiflcato does not confer rlghta to tho conlflcato holder in lieu ol luch ondorsomont(s).
PRoorJcER Rrsk Strateoies Comoanv
2040 [ilain Street. Sdire 450lrvine, CA 92614
wuw.risk-stralegies.coan CA DOI Lic4nse No.0F06675
Risk Slraleqies Comoany
E 949-242-9240
s
AFfOROIIIG CO/ERAGI
TNSURERA Cilrzens lnsurance Company of America 31534
INSUREO
Leiohton Consultino
17781 Cowan. Suit'e
lrvine CA 92614
lnc.
100
TNSURERB: Alimerica Financial Benefit lnsurance Co
rNsuR€R c : Travelers Property Casually Co of Amer
rNsuRERo : Lexinglon lnsurance ComDany
COVERAGES CERTIFICATE NUMBER: 71626530 REVISION NUMBER:
CANCELLATION
Crtv of lvlenrfee
29644 Haun Road
Sun City CA 92586
SIiOULD ANY OF THE ABOVE OESCRIAEO POLICIES BE CANCELLEO AEFORETHE EXPIRATION OATE THEREOF, NOTICE WILL BE DELIVEREO IN
ACCOROANCE WITH THE POLICY PROVISIONS-
AUTHORIZEO REPRESENTANVE
RSC lnsurance Brokerage
CERTIFICATE HOLDER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE EEEN ISSUEO TO THE INSURED NAMED ASOVE FOR THE POLICY PERIODINDICATED NOTWTHSTANOING ANY REQUIREMENT, TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY gE ISSUEO OR MAY PERTAIN. THE INSURANCE AFFORDEO BY THE POLICIES DESCRIEEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONOITIONS OF SUCH POLICIES LIMITS SHOWl.l MAY HAVE BEEN REDUCEO BY PAIO CLAIMS
EACI-]OCCURRENCE r 1,000,000
PREMISFS IFa@rancl 51 000,000
MEO E/.P (A.y on6p6ron)
PERSONAL & AOVINJURY
$ 10 000
51,000,000
GE NERAL ACGR€GAT E $2.000.000
PROOJCTS - COMP/OP AGG s2.000.000
COIIMERCIAL GENERA! !lAAILITY
GEN'LAGGREGATE LIMIT APPLIES PER
JECT I ]LOCPOLICY
OTHER
o83J208488 11t1t2022 11t112023
s
$ 1 ooo ooo
BOOTLY TNJURY (P€r a@denr)
CO'TBINEDSINGLE LIMITrEE Eccr(& )
EOOTLY TNJURY (P€r p€rson)
B
OwlED
AUTOS OI{LYHIREO
AUTOS Ot'ilY
AUTOI'06ILELIABILITY
SCHEOULEDAUTOSNONOIMIED
AUTOS ONLY
AW3J208478 11t1t2022 1111t2023
s
s
EXCESSIIAB
occ{JR
cLArlrs r\rAoE AGGREGATE
$5,000.000
$5,000,000
nererrprs0
o83J208488 11t112022 1111t2023
$
STATUIE
OIH
ER
E L EACHACCIOENT
E L DISEASE. EAEMPLOYEE
C WORXERS COUPENSANON
ANO EIII PLOYERS' LIABILITY
ANYPROPRIETOfu PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED'
o€scRrPTroN oF oPERAroNs b6rfr
u81R5099812243G 9t112022 9t1t2023
E L OISEASE, POTICY LIM T s 1,000.000
sl 000 000
s 1.000.000
D Probssional Liability/Pollution Liab
Claims Made
013001524 2/14t2022 211412023 Per Claim
AgOregate
Deduclible
s $2,000,000
r$4.000.000
r 5100,000
DESCiIPION OF OPERAiOI{S / LOCATIONS / VEHICLES (ACORO tol, Alldllio.r Rm.rkt S.h.duL. n.y b. .tt.ch.d n 60. !p.€ i. .qui.d)
See Addilional Remarks Schedule
ACORD 25 (2016/03)
ACORi'
@ '1988-2015 ACORD CORPORATION. All rights rGs€rved.
Th€ ACORD nam€ and logo re regisbrod rrlarks ofACORO
41840
__2561_1
19437
I
E**"
I
I
I
I
I
frl{*.^ru-*A
AGENCY CUSTO]TIER IO:
LOC ':o.fu ADDITIONAL REMARKS SCHED ULE
ADDITIONAL REMARKS
ACORD 101 (2008/01)
Tho ACORD nams and logo ae reglEtsrod marks of ACORD
Yotrnq ralB/?o:t
Page ot
O 2008 ACORD CORPORATION. All rights res€rved.
Risk Strategies Company Leiohlon Consullino lnc'17781 cowan srxt-e 1oo
lrvine CA 92614
NAtC COOE
THIS AOOITIONAL REiIARKS FORM IS A SCHEDULE TO ACORO FORT{,
FORM NUITiBER: 25 FORiI TITLE: Cerldlcate of Liabilily (03/16)
HOLDER: City oI Menibe
ADORESS: 29844 Haun Road Sun City CA 925E6
Cer:tificate is subject to policy finilts, conditi-ons and exclusions. REi ContractAgreement: Project *11051.013; Project Name: CIP 22-08 NORMANDY ROAD PEDESTRIAN
IMPROVEMENTS; PRO,JECT (MATERIAL TESTING) i Locatlon: Nor.ilandy Road, Menifee; GeotechnicalConstruction Services. City of Menifee and its officers, employees. agents, and autho!izedvolunteers are inc-luded as additional insured as respects to ceneral Liability andCorunerciaL Auto coverages as required by written Contract. Genela1 L.iability and AutoLiability coverages aie primary and noncontributory as required by written conttact.Waj-ver of Subrogatj.on is included with respect ceneral LiablLity, Auto Liability, WorkersConpensation as requj.red by written contract. Unlcrella Liability is follow form subject topolicy forns. terms, conditions, exc.lusions and endorsements. 90-Day Notice ofCancellation, Except for 1o-Days fo! Nonpa)4nent of Premir.m applies to General Llability asrequlred by written contract.
ADDENDUM
Architects and Engineers
The following policy language ls from Busrnessowners General Liability Coverage Paft
NAMED INSURED: Leishlon Consuttins, 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 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 writlen contract. written agreement or permil but only respect to liability for "bodily injury", "property damage"
or "personal and advertising injury" caused. in whole or in parl, 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(ii0 Your maintenance, operation or use ofequipment leased to you.
*Definition: "Your work" a. Means: (1) Work or operations performed by you or on behalf; and (2) materials, parts or equipment
furnished in conneclion 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:
('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 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 from whom land has been leased which takes place affer the lease for the land
expires; or (b) lvlanagers or lessors of premises if: (i) The occurrence takes place afler 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 servtces.
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 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-Gontributory
The following paragraph is added to SECTION lll - CO illol{ POLICY CONDITIONS, H - Othor 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-contribulory, 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 followsl(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 Insured. We will not seek contribution from any other insurance available to the
Additional Insured 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 pflmary, our
obligations are not affected unless any of the other insurance is also primary.
(2) Excoss lnsurance:
(a) This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any other basas:(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 Nolice, nor can il be conslrued lo replace any provisions of
between this Notice and lhe policy (including the endoGehenls), the provisions of
cy (including ils endorsemenls). lfthere is any conflicl
cy (including its endorsements) shall prevail.
the poli
the poli
71626510 I {LCr 202?-2021 CL-AUrO-UUB-h! tonng L2/A/2O22 6;13:t6 ^x (psT) I p.qe 3 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 Additional with
permission of the ownert or(iv) lf the loss arises out of the maintenance or use of aircrafi, "autos" or watercraft to the extent not subject 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) When 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 "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 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 ofthe Limits of lnsuranc€ shown in the Declarations of this Coverage
part.
(3) Mathod 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 the loss remains,
whichever comes first. lf any of the other insurance does not permit contribution by equal shares, we will contribute by
limits. Under this method, each insurer'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 Exponses LimiE of lnsurance, paragraph 4:
The Aggregate Limits of lnsurance apply separately to each of "your projects" or each "location" Iisted in the
Oeclarations.
2. For the purpose of coverage provided by this endorsement only, the following is added to SECTION ll - LIABILITY, F. Liability
and Modical Expenses Definitions:
1. "Your project" means
a. Any premises, site or "location" at, on, or in which "your work" is not yet completed; and
b. Ooes 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
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 -COMMERCIALGENERAL 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 wiften contracf 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 witten contracl.
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
' From H.t'ov6' Fonns: 391.1@3 @Afl q: gl-|tw @Alq: 391-1 86 @Anq, 391-1N!t OArq
No coverage is provided by thas Nolice, nor can it b€ consl(Ed to replace any provisions of the policy (including its endorsements). lf there is any connict
betvreen this Notice and the policy (includang lhg €ndorsements), tf€ provisions of the policy (including als endorsements) shall prevail.
r162651! r (LCr 202?-202r ']L-AUTO-UI,B-rirc-Pt- Sh€!!y younq 1 l:/0/:02? 6:13:16 a!, (psT) I p.q. I of B
@-6;91-.o
AW3J2O847E
Leighlon Consulting. lnc
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL !NSURED - PRIMARY AND NON-CONTRIBUTORY
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FO RI\iI
A. The following is added to SECTION ll -
LIABILITY COVERAGE, Paragraph A.l. Who ls
An lnsured:
Additional lnsured if Required by Contract
lf you agree in a written contracl, 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 qualilies as an
"insured' under paragraph A.'1.c. of this Section.
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 additional "insured" is the lesser of:
(1) The Limits of lnsurance for liability coverage
specified in the written contract, written
agreement or written permit; or
(2) The Limits of lnsurance for Liabality 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 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.
Gen6ial Conditions, subparagraph 5. Other
lnsurance:
Primary 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 A.'1. Who ls
An lnsured, subparagraph Additional lnsursd if
Requirod 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 addilional "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
that'auto" is a "trailer' connecled to an "auto"
owned by the additional "insured" or by you; or
(3) When 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 permitt and
3. Prior to the expiration of the period of time that
the written contracl, 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
olher "insured" under this Coverage Part.
ALL OTHER TERIVS, CONDITIONS, AND EXCLUSIONS REMAIN UN CHANGED
lnc.ludes clpyrighted matenal of ISO lnsurance &rvices Office. lnc , with its pennission4614478 12 '12
PL r Sherry lou.q I 1
Page 1 of 1
lnsured: Leighton Consulting, lnc.
Policy No.:
AW3J206478
14. AUTO LOAN PHYSICAL DAMAGE
EXTENSION
The following is added to SECTION lll -
PHYSICAL DAMAGE COVERAGE, C.
Limit Of lnsurance provasion:
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" an 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.
1 5, AUTO LEASE PHYSICAL DAMAGE
EXTENSION
The following is added to SECTION lll -
PHYSICAL OAMAGE 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 al the time of
"loss" under the terms of the lease
agreement applicable lo the leased "auto"
which you are required to pay: less any fees
to dispose of the auto; any overdue
payments, linancial 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.
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.
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 Th6 Event Of
Accident, Claam, 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.
17, BLANKET WAIVER OF
SUBROGATION
Paragraph 5. Transfer Ot 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)
1-C) 20..3-?023 sheriy youhg I 1:/S/202! 6:13:16 M lpST) ! p.q. 6 or s
lnsured: 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, Misreprssentation Or
Fraud:
The following is added to SECTION lV -
Business Auto Conditions, B. General
Conditions, paragraph 7. Policy Poriod,
Covorage Torritory 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 direclion,
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 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 Of Recovsry
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 after the
"accident" or "loss" to impair them
19, HIRED AUTO - WORLDWIOE
COVERAGE
Your unintentionalerror in disclosing, or
failure to disclose, any materaalfact
exrstrng after the eftective date of thrs
Coverage Form shall not prejudice your
rights under this Coverage Form.
However, this provision does not affect
our right to collect additional 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., 1996461-0155 (9-97)
?1515530 lLCr cc-pr sh.rry \otng l2/.1/2a22 5:13:16 rly lpsT) I p.q. 7 of s
-.TRAVETERSJ WORKERS CO PENSATION
AND
EUPLOYERS LIABILITY POLICYo!{8 TOWBR SQUAIE
HIR?PORD Cr 0518 3
ENDORSEMENT WC990375( A). oo1
POLICY NUMBER: Uts lRsgeq8 t:21r;
WA]VER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKET WATVER)
Schedule
Person or Orgarlzatlon
AIIY PIRSON OR ORGII|IZATION POR
WXICII TIIE INSURSD HAS AqRBED
BY WRITTCT COITTRTCT AIBCUTED
PRIOR TO LOSS TO FI'RNISH TIIIS
WAIVBR.
Job Descripllon
All Opcra(ions
This endorsem@t changes the policy to which it is attached and is effective on the date issued tnless otherwise
stated.
(ThG lnformaton b.low ls .Gquircd only whGn thlt andorscmant ls issued subscqucnt to Flpara(on otthc policy.)
Endorsement Efteclive 09 to I t2o22
lnsured 1,grgh16n 1.on.u1,nr. lnc
lnsurarce Company
Allmerrca Frnancral l]fie,lt lnsur0nce Co
Policy No. Ug 1tt5o99s 1243C
Comtersigned by
OATE OF ISSUE ST ASSIGN:
?r626530 lLC) a022-202r GL-AUTO-W3-HC-pL I Shorry younq I r2lS/:O?? 6:r6:r6 at{ lFsT) I p.q. s of s
Page 1 of 1
We have the right to recover our payments lrom ayone liable for an hjury covered by this policy. We will not
enforce our right against the persct or orgatizati(n named h the Schedule.
The additialal premium for this endorsement shall be 2, oo % of the Califomia workers' compensation pre-
mlum.