2022/03/01 Roadway Engineering & Contracting Inc. (4)ACORD
INSURED
DAIE (IrlM/DD/YYYY)
3t312022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. TH|S CERTTFTCATE OF TNSURANCE OOES NOT CONSTTTUTE A CONTRACT BETWEEN THE |SSUTNG TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER.
pRooucER Llconse # 0C36861
lnland Empirs-Alliant lnsurance Seavicos, lnc
685 Carnesle Dr Ste 265
San Bo.nardino, CA 92408
IMPORTANT; lf the certlficats holder is an ADOITIONAL INSUREO, the policy(les) must havo ADDITIONAL INSUREO provislons or be endorlsdlf SUBROGATION lS WAIVEO, subroct to the lerms and condltions ofthe pollcy, cortaln ollcles may requlre an gndorsement. A stat6mont onthls certlflcalo does not confer r ts to the certiflcato holder ln lieu of such endorseme s
iiilElc' Christina M Mountz
li3.NrE . e,l, (909) 886'9861
!ffi!s" cmountz@alliant.com
[id, no,(909) 886.2013
Roadway Engineering E Contracting lnc
'10966 Banana Avo
Fontana, CA 92337
INSURER(S) AFFORDING COVERAGE
rNsuRER a : Greenwich lnsurance company
rNsuRER B :xL specialty lnsurance company
rNsuRER c : Everest Prcmier lnsurance Company
22322
37885
16045
INSURER O
INSURER E
NUMBER:REVISION NUMBERI
TYPE OF INSIIRANCE
A X coiaMERctAL GEI{ERAL LtAslLrry
CLA|MS-MADE X occuR
X $5,000 PD dEd/occ
GEN'L AGGREGATE LIMIT APPLIES PER
eoLrcv X !lp; Loc
OTHER:
B lutomoatte LngtLtw
X ervauto
OWNEDAUTOS ONLY SCHEDULEDAUTOSY HIRED
X t1,000 comp D6d
NON.OWNEO
$1,000 CollD6d
U'IIBREILAIIAB
X ExcEss L|AB
X occun
CLAIMS.MAOE
0
x x NPC100450901
x x NBA-I004510-0'l
NEC-6006403-0'l
POLICY EFF POLICY EXP
3t112022 3t112023
3t112022 3t1t2023
31112022 31112023
EACH OCCURRENCE
DAMAGE TO RENTED
PREM SES {Ea o@ur€nc€)
MEo ExP (Any o.e psBonl
PERSON'I A AOV LNJURY
GENERAT AGGREGATE
PRODUCTS , COMP/OP AGG
EBL AGGREGATE
ADDL SUBR POLICY NI'MBER LrMrls
1,000,001
'100,00r
5,00r
1,000,00r
2,000,00r
2,000,00r
1,000,00r
't,000,00r
x
x
COMBINEO SINGLE LIMIT
AODILY INJURY (P€r person)
EoDILY INJURY (P€r accidenl)
PROPERIY DAMAGE
A EAC]-] OCCURRENCE
AGGREGATE
Ovsr GUAUEL
s,000,00t
5,000,001
oeo X nrreuror.r s
r,000,00r
1,000,00r
1,000,00r
DEscRlPlloN oF oPERATIoNS /LocATroNs/ VEIIICLES (ACORO 101, Addit'onll Romrrts Schedole, may bo.tt.chod i, mora.p.c. is.eqoi.od)
RE: Job #'120,1, Lazy Creek Rscrsation CentEr Parking Lot lmprovoments, clP '19-16
Cil}, ot Manifo6 and its elecled olticials, ofliceis, employeos, agenk, representatives, consultank, contract employees and volunleers e.e addilional insureds,
primary and non-contributory, waiver ol subrogation as respects to general liability per endorsoments attached; additionel in3ureds, primary and
non-conlributory, waiver of subrogation as aespects to auto liability per endorsements attached; waivei of subrogation as respects lo worters' compensalion
per endorsement attached.
$
$
$
$
C woRKERs cot{PENsaloN
ANO EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNEF'EXECUTIVEOFFICER/MEMBER EXCI UDED?(M.nd.lory in NHI
ll yas, descnbe under
TIFSCRIPT ON OF OPFRATIONS bel6w
X 76000173s5221 31l/2022 3t1no23
v PER OTH-
^ STATUTE ER
E L. EACH ACCIOENT
E L. DISEASE. EA EMPLOYEE
E,L, DISEASE. POLICY LIMIT
City of Menitee
298it4 Haun Rd.
Menifee, CA 92586
N
AIJTHORIZEO REPRESENTATIVE
Mt)*
ACORO 2s (20r6103)O 1988-2015 ACORD CORPORATION. All rights reserved
ROADENG.OI
CERTIFICATE OF LIABILITY INSURANCE
rwl
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAI\.,IED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OROTHER DOCUMENTWITH RESPECTTO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS,
NF
SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CATCELLED AEFORE
THE EXPIRATION DATE THEREOF, TIOTICE WILL BE DELIVERED IN
ACCORDAT{CE WlrH THE POLICY PROVISIONS.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY _
OTHER INSURANCE GONDITION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
LIQUOR LIABILIry COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
POLICY NUMBER: NPC I 0045090 I
The following is added to the Other lnsurance
Condition and supersedes any provision to the
contrary:
Primary And Noncontributory lnsurance
This insurance is primary to and will not seek
contribution from any other insurance available to
an additional insured under your policy provided
that:
(1) The additional insured is a Named lnsured
under such other insurance; and
COMMERCIAL GENERAL LIABILITY
cG 20 01 12 19
(2) You have agreed in writing in a contract or
agreement that this insurance would be
primary and would not seek contribulion
from any other insurance available to the
additional insured.
cG 20 01 1219 O lnsurance Services Office, |nc.,2018 Page 1 of 1
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifles insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
POLICY NUMBER: NPCl OO4 50901
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, but only
with respect to liability for "bodily injury", "propefty
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 forthe additional insured(s) at the location(s)
designated above.
However:
1. The insurance afforded lo such additional
insured only applies to the extent permitted by
law; and
2. lf coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
COMMERCIAL GENERAL LIABILITY
cG 20 10 12 19
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 malerials, parts or
equipment furnished in connection with such
work, on the project (other lhan 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 o, 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.
Name Of Additional lnsured Person(s)
Or Organization(s)Location(s) Of Covered Operations
Blanket as required by written contract Blanket as required by written contracL
lnformation required to complete this Schedule, if not shown above, will be shown in the Declarations
cG 20 10 12 19 O lnsurance Services Offlce. lnc.. 2018 Page 1of 2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
C. With respect lo the insurance afforded to these
additional insureds, the following is added to
Section lll - Llmits Of lnsurance:
lf coverage provided to the additional insured is
required by a contract or agreemenl, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contracl or agreement; or
2. Available under the applicable limits of
insurance;
whichever is less.
This endorsem€nt shall not increase th6
applicable limits of insurance.
Page 2 ol z @ lnsurance Services Office, lnc.,2018 cG 20 10 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS _ COMPLETED OPERATIONS
COMIv'IERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
POLICY NUMBER: NPC I OO45O9O I
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, but only
with respecl to liability for "bodily injury" or
"property damage" caused, in whole or in par1, by
"your work" at the location designated and
described in the Schedule of this endorsement
performed for that additional insured and included
in the'products-completed operations hazard".
However:
1. The insurance afforded lo such additional
insured only applies to the extent permitted by
law; and
2- lf coverage provlded to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than thal which you are
required by the contract or agreement to
provide for such additional insured.
COMMERCIAL GENERAL LIABILITY
cG 20 37 12 19
B. With respect to the insurance afforded to theseadditional insureds, the following is added to
Section lll - Limits Of lnsurance:
lf coverage provided to the additional insured is
required by a conlract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable limits of
insurance;
whichever is less.
This endorsement shall not increase the
applicable limits of insurance.
Name Of Additional lnsured Person(s)
Or Organization(s)Location And Description Of Completed Operations
Blanket as required by writ.ten contracL BlankeE as required by wriLten coniract
lnformation required to complete this Schedule, if not shown above, will be shown in the Declarations
cG 20 37 12 19 @ lnsurance Services Office, lnc., 2018 Page 1of I
This endorsement modifies insurance provided under the following:
VVORXERS COMPENSATION AT.ID EMPLOYERS LIABILITY INSURANCE POLICY wc 04 03 06
WAIVER OF OUR RIGHTTO RECOVER FROM OTHERS ENDORSEMENT.
CALIFORNIA
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will nol enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
you perfo.m work under a written contract that requires you to obtain this agreernent from us.)
You must maintain payroll records accurately sogregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsernent shall be 2
otherwise due on such reanuneration.
% of the California workers' compensation premium
SCHEDULE
PERSON OR ORGANIZATION JOB DESCRIPTION
ANY PERSON OR ORGANIZAT]ON FOR
WHOM THE NAMED INSURED HAS AGREED
BY WRITTEN CONTRACT TO EURNISH
TH]S WA]VER
BLANKET WA]VER OF SUBROGATION
-1998 by tlE WdkerJ CqrpeDsation lrrs.irarEe Ratjng &r.eau ofCalift.ria. Al .ighE reerved.
From the vlrclRB's Galifomia Workers' Conpensatbn lnsurance ForfiE Manual - 19{Xl-
A.
B.
POLICY NUMBER: NBA-1 00451 0-01
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
XL PLUS BUSINESS AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
COVERAGE DESCRIPTION
Temporary Substitute Auto Physical Damage
Who ls An lnsured
1. Broad Form lnsured
2. Employees As lnsureds
3. Additlonal lnsured By Contract, Agreement or Permit
4. Employee Hired Autos
Supplementary Payments
Amended Fellow Employee Exclusion
Physical Damage Coverage
1. Rontal Reimbursement
2. ExtIa Expense - Broadened Coverago
3. Personal Effects Coverage
4. Lease Gap
5. Glass Repair - Waiyer Of Deductible
Physical Damage Coverage Extensions
1. AdditionalTransportationExpense
2. Hired Auto Physical Damage
Business Auto Conditions
1. Notice Of Occurrence
2. Waiver Of Subrogation
3. Unintentional Failure To Disclose Hazards
4. Primary lnsurance
Bodily lnjury Redefined
Extended Cancellation Condition
O 2013 X.L. America, lnc. All Rights Reserved.
May not be copied without permission.
lncludes copyrighted material of lnsurance Services Offlce, lnc., with its permission
c
D
E
F
G
H
t.
xtc 421 '10'13 Page 1 of 6
xtc 421 1013
A. Temporary Substitute Auto Physical Oamage
SECTION l- COVERED AUTOS, C. Certain Trailers, Mobile Equipment And Temporary Substitute
Autos is changed by adding the following:
lf Physical Damage coverage is provided by this Coverage Form, the following types of vehicles are also
covered "autos" for Physical Damage coverage:
1. Any "auto" you do not own while used with the permission of its owner as a temporary substitute for
a covered "auto" you own that is out of service because of its:
'Loss"; or
Destruction
B Who ls An lnsured
SECTION ll - COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 1. Who ls An lnsured is
changed by adding the following:
a
b
c
d
e
1 Broad Form lnsured
For any covered "auto", any subsidiary, affiliate or organization, other than a partnership or joint
venture, as may now exist or hereafter be constituted over which you assume active management
or maintain ownership or maiority interest, provided that you notify us within ninety (90) days from
the date that any such subsidiary or affiliale is acquired or formed and that there is no similar
insurance available to that organization- However, coverage does not apply to "bodily injury" or
"property damage" that occurred before you acquired or formed the organization.
Employees As lnsureds
Any "employee" of yours is an "insured" while using a covered 'auto" you don't own, hire or borrow,
in your business or your personal affairs.
Additional lnsured By Contract, Agreement Or Permit
Any person or organization with whom you have agreed in writing in a contract, agreement or
permit, to provide insurance such as is provided under this policy, provided that the'bodily injury'
or "property damage" occurs subsequent to the execution of the written contract, agreement or
permit.
4.Employee Hired Autos
An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or
agreement in that "employee's" name, with your permission, while performing duties related to the
conduct of your business.
2.
3.
@ 2013 X.L. America, lnc. All Rights Reserved.
May not be copied without permission.
lncludes copyrighted material of lnsurance Services Office, lnc., with its permission
xtc 421 1013 Page 2 of 6
Breakdown;
Repair;
Servicing;
D
SECTION lV - BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other lnsurance, b.
is repiaced with the following:
b.For Hired Auto Physical Damage Coverage, lhe following are deemed to be covered
'autos" you own:
(1) Any covered "auto" you lease, hire, rent or borrow; and
(21 Any covered "auto" hired or rented by your "employee" under a contract in that
individual 'employee's" name, with your permission, while performing duties
related to the conduct of your business.
However, any "aulo" that is leased, hired, rented or bonowed with a driver is not a covered
'auto".
C. SupplementaryPayments
SECTION ll - COVERED AUTOS LIABILITY COVERAGE, A. Goverage,2. Coverago Extonsions, a.
Supplemontary Payments is changed as follows:
Item (2) is deleted and replaced by the following:
l2l Up to $3,500 tor cost of bail bonds (including bonds for related traffic law violations) required
because of an "accident" we cover. We do not have to furnish these bonds.
Item (4) is deleted and replaced by the following:
(4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings
up to $500 a day because of time off from work.
Amended Fellow Employo6 Exclusion
SECTION ll - COVERED AUTOS LIABILITY COVERAGE, B. Exclusions, 5. Fellow Employeo does not
apply.
The insurance provided under this Provision D. is excess over any other collectible insurance.
Physical Damag€ Coverage
SECTION lll - PHYSICAL DAMAGE COVERAGE, A. Coverage is changed by adding the following:
'1. Rental Reimbursement
We will pay for rental reimbursemenl expenses incurred by you for the rental of an "auto'
because of "loss" lo a covered ''auto'. Payment applies in addition to the olherwise
applicable amounl of each coverage you have on a covered "auto". No deductibles apply
to this coverage.
We will pay only for lhose expenses incurred during the policy period beginning h/venty-four
(24) hours after the "loss" and ending, regardless of the policy's expiration, with the lesser
of the following number of days:
O 2013 X.L. America, lnc. All Rights Reserved.
May not be copied without permission.
lncludes copyrighted material or lnsurance Services Office, lnc., with its permission
E
a
b
xtc 421 1013 Page 3 of 6
e
d
(1)The number of days reasonably required to repair or replace lhe covered "auto". lf
"loss" is caused by theft, this number of days is added to the number of days it
takes to locate the covered "auto" and return it to you.
(21 Thirty (30) days
Our payment is limited to the lesser of the following amounts
(1) Necessary and actual expenses incurred
(21 $50 any one day per private passenger 'auto";
$100 any one day per truck;
$'1,500 any one period per private passenger "auto";
$3,000 any one period per truck; or
Higher limits if shown elsewhere in this policy.
This coverage does not apply while there are spare or reserve "autos" available to you for
your operations.
lf "loss" resulls from the total theft of a covered "auto" of the private passenger type, we will
pay under this coverage only that amount of your r€ntal reimbursement expenses which is
not already provided for under the Physical Damage Coverage Extension.
O 2013 X.L. America, lnc. All Rights Reserved.
May not be copied without permission.
lncludes copyrighted material of lnsurance Services Office, lnc., with its permission
2.Extra Expense - Broadened Coverage
We will pay for lhe expense of retuming a stolen covered "auto" to you
3.Personal Effects Coverage
lf you have purchased Comprehensive Coverage on this policy for an "auto' you own and that
"auto" is stolen, we will pay, without application ol a deductible, up to $500 for "personal effects"
stolen from the 'auto'.
As used in this endorsement, "personal effects" means tangible property that is worn or carried by
an "insured'. "Personal effects" does not include tools, jewelry, money or securities.
4.Lease Gap
ln the event of a total "loss" to a covered "auto" shown in the Declarations, we will pay any unpaid
amount due on the lease or loan for a covered 'auto", less:
The amount paid under the Physical Damage Coverage Section of the policy; and
Any:
(1) Overdue lease/loan payments al the time of the "loss";
(21 Financial penalties imposed under a lease for excessive use, abnormal wear and
tear or high mileage;
(3) Security deposits not returned by the lessor;
(4) Costs for extended warranties, Credit Life lnsurance, Health, Accident or Disability
lnsurance purchases with the loan or lease; and
(5) Carry-over balances from previous loans or leases.
a
b
xtc 421 1013 Page 4 of 6
c.
F
5. Glass Repalr - Walver Of Deductlble
No deductible applies to glass damage if the glass is repaired rather than replaced.
Physical Damage Coverage Extonsions
SECTION lll - PHYSICAL DAMAGE COVERAGE, A. Covsrage,4. Goverage Extensions is amended by
the following:
'1. AdditionalTransportationErpense
Sectlons a. and b. are amended to provide a limit of $50 per day and a maximum limit of $1,000.
2. Hired Auto Physical Damage
The following section is added:
Any "auto" you lease, hire, rent or borrow is deemed to be a covered "auto" for physical damage
coverage. Tho most we will pay for each covered "aulo" is the lesser of:
(1) the actual cash value;
l2l the cost for repair or replacement; or
(3) $50,000, or higher limit if shown on the Declarations for Hired Auto Physical Damage
Coverage.
For each covered 'auto" a deductible of $100 for Comprehensive Coverage and $1,000 for
Collision Coverage will apply.
Businoss Auto Conditions
SECTION lV- BUSINESS AUTO CONDITIONS, A. Loss Conditions is changed by the following:
1. Notlce Of Occurrence
Section 2. - Duties ln The Event Of Accident, Claim, Suit Or, Loss, a. is changed by adding the
following:
lf you report an injury to an "employee" lo your workers' compensation carrier and if it is
subsequently determined that the injury is one to which this insurance may apply, any failure lo
comply with this condition will be waived if you provide us with the required nolice as soon
thereafter as practicable after you know or reasonably should have known that this insurance may
apply.
2. Waiver Of Subrogalion
Section 5. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the
following:
However, this Condition does not apply to any person(s) or organization(s) with whom you have a
written contract, but only to the extenl that subrogation is waived prior to the 'accident" or the "loss"
under such contract with that person or organization.
G
O 2013 X.L. America, lnc. All Rights Reserved.
May not be copied without permission.
lncludes copyrighted material of lnsurance Services Office, lnc., with its permission
xrc 421 1013 Page 5 oI 6
H
SECTION lV - BUSINESS AUTO CONDITIONS, B. General Conditions is changed by the following:
3. Unintentional Failure To Disclose Hazards
The following condition is added:
Your unintentional failure to disclose all hazards as of the inception date of the policy shall not
prejudice any insured with respect to the coverago afforded by this policy.
4. Primary lnsurance
Condition 5. Other lnsuranco is changed by adding the following:
For any covered "auto" this insurance shall apply as primary and not contribute with any other
insurance where such requirement is agreed in a written contracl executed prior to a 'loss".
Bodily lnjury Redefined
SECTION V - DEFII{ITIONS, C. "Bodily injury" is replaced by the following:
"Bodily injury" means bodily injury, sickness or diseaso sustained by a person including mental anguish,
menlal injury, shock, fright or death resulting from any of these at any time.
Extended Cancellation Condition
COMMON POLICY CONDITIONS (Form lL 00 17), A. Cancellation, 2.b. is replaced by the following:
The greater of sixty (60) days or the time required by any applicable state amendatory endorsement before
the effective date of cancellation if we cancel for any other reason.
All other terms and conditions of this policy remain unchanged
@ 2013 X.L. America, lnc. All Rights ReseNed.
May not be copied without permission.
lncludes copyrighted materialof lnsurance Services Office, lnc., with its permission
xtc 421 1013 Page 6 of 6
t.
ENDORSEMENT #
This endorsement, effective 03101122 12:01 a.m., forms a part of
Policy No. NPC100450901
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
XL Plus Endorsement
This endorsement modifies insurance provided under the following
COI\4MERCIAL GENERAL LIABILIry COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE - This endorsement broadens coverage. The
following listing is a general coverage description only. Limitations and exclusions may apply
to these coverages. Read this endorsement carefully to determine rights, duties, and what is
and is not covered.
A. Reasonable Force - Bodily lnjury or Property Damage
B. Damage To Premises Rented To You Extension
. Perils of fire, lightning, explosion, smoke, aircraft or vehicles, riot or civil commotion,
vandalism, leakage from fire extinguishing equipment or water damage
o Limit increased to $300,000
C. Aircraft Chartered with Crew
D. Non-Owned Watercraft
E. Personal and Advertising lnjury - Assumed by lnsured Contract
F. lncreased Supplementary Payments
o Cost for bail bonds increased to $5,000
r Loss of earnings increased to $1,000 per day
G. Broadened Named lnsured
H. Blanket Additional lnsured - Managers or Lessors of Premises
l. Blanket Additional lnsured - Lessor of Leased Equipment
J. lnjury to CoEmployees and Co-Volunteer Workers
K. Knowledge and Notice ofOccunence or Offense
L. Unintentional Omission
M. Liberalization
N. Blanket Waiver of Subrogation
O. lncidental Medical Malpractice lnjury
P. Extension of Coverage - Bodily lnjury
Q. Coverage Territory
Form xll 436 1208 @ 2008, XL America, lnc.
lncludos copyrighted material of lnsurance Services Office, lnc., with its permission
Page '1 of I
A. REASONABLE FORCE _ BODILY INJURY OR PROPERTY DAMAGE
Exclusion a. Expected Or lntended lnjury of Part 2., Exclusions of Coverage A. Bodily lnjury
And Property Damage Liability of Section I - Coverages is deleted in its entirety and replaced
by the following:
flhis insurance does not apply to:)
Expected or lntended lnJury or Oamage
"Bodily injury" or "property damage" expected or intended from the slandpoint of the insured.
This exclusion does not apply to 'bodily injury" or "property damage" resulting from the use of
reasonable force to protect persons or property-
B. DAMAGE TO PREilIISES RENTED TO YOU EXTENSION
1. The last paragraph of 2. Exclusions of Coverage A. Bodily lnjury And Property Damage
Liability of Section I - Coverages is deleted in its entirety and replaced by lhe following:
Exclusions c. through n. do not apply to damages to premises while rented to you, or
temporarily occupied by you with permission of the owner, caused by fire, lightning,
explosion, smoke, aircrafl or vehicles, riot or civil commolion, vandalism, leakage from fire
extinguishing equipment or water damage. A separate limit of insurance applies to this
coverage as described in Section lll- Limits of lnsurance.
2- This insurance does not apply to damage to premises while rented to you, or temporarily
occupied by you with permission of the owner, caused by:
a. Rupture, bursting, or operation of pressure relief devicesi
b. Rupture or bursting due to expansion or swelling of the contents of any building or
structure, caused by or resulting from water; or
c. Explosion of steam boilers, steam pipes, steam engines, or steam turbines.
3. Paragraph 6. of Section lll- Limits of lnsurance is deleted in its entirety and replaced by the
following:
6.a. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the
mosl we will pay under Coverage A for damages because of "property damage" to any
one premises while rented lo you, or temporarily occupied by you with permission of
the owner, caused by fire, explosion, lightning, smoke, aircraft or vehicle, riot or civil
commotion, vandalism, leakage from fire extinguishing equipment or water damage.
The Damage To Premises Rented To You Limit will apply to all damage proximately
caused by the same "occurrence", whether such damage resulls from flre, explosion,
lightning, smoke, aircraft or vehicle or riot or civil commotion, vandalism, leakage from
fire extinguishing equipment or water damage or any combination of any of these.
b. The Damage to Premises Rented to You Limit will be the higher of:
(1) $300,000; or
(2) The amount shown on the Declarations for Damage to Premises Rented to You
Limit.
Form XIL 436 1208 O 2008, XL America, lnc.
lncludos copyrighted material of hsuranco Sorvic€s Offics, lnc., with its permissaon.
Page 2 of 8
4. Paragraph 9.a. of the definition of insured contract" under Section V- Definitions, is deleted
in its entirety and replaced by the following:
["lnsured contract" means:l
a. A contract for a lease of premises. However, that po on of the contract for a lease of
premises that indemnifies any person or organization for damage by fire, lightning,
explosion, smoke, aircraft or vehicle, riot or civil commotion, vandalism, leakage from
fire extinguishing equipment or water damage to premis€s while rented to you, or
temporarily occupied by you with the permission of the owner is nol an "insured
contract".
5. This Article B. does not apply if coverage for Damage to Premises Rented to You of
Coverage A. Bodily lnjury And Property Damage Liability of Section I - Coverages is
excluded by endorsement.
C. AIRCRAFT CHARTERED WTH CREW
1. The following is added to the exceptions contained in Exclusion 9., Aircraft, Auto or
Watercraft in Part 2., Exclusions of Coverage A. Bodily lniury And Property Oamage of
Section I - Coverages:
Fhis exclusion does not apply to:)
Aircraft chartered with crew to any insured.
2. This Article C. does not apply if the chartered aircraft is owned by any insured.
3. The insurance provided by this Article C. shall bs sxcess over any valid and collectible
insurance available to the insured, whether primary, excess, contingent or on any other
basis, except for insurance purchased specifically by you to be excess of this policy.
D. NON-OWNED WATERCRAFT
1. The exception contained in Subparagraph (2) of Exclusion g. Aircraft. Auto or Watercraft
in Part 2., Exclusions of Coverage A. Bodily lnjury And Property Damage Liability of
Section I - Coverages is deleted in its entirety and replaced by the following:
(2) A watercraft you do not own that is:
(a) 50 feet long or less; and
(b) Not being used to carry persons or property for a charge;
2. This Article D. applies to any person who, wilh your expressed or implied consent, either
uses or is responsible for the use of the watercraft.
3. This insurance provided by this Article D. shall be excess over any other valid and
collectible insurance available lo the insured, whether primary, excess, contingent or on
any other basis, except for insurance purchased specifically by you to be excess of this
policy.
E. PERSONAL AND ADVERTISING INJURY - ASSUMED BY INSURED CONTRACT
1. Exclusion e. Contractual Liability in Part 2., Exclusions of Coverage B. Personal And
Advertising lnjury Liability of Seclion I Coverages is deleted in its entirety and replaced
by the following:
Form XIL 436 1208 @ 2008, XL America, lnc.
lncludes copyrighled materialof lnsurance Services Oflice, lnc., with its permission.
Page 3 of I
ffhis insurance does not apply to:)
e. Contractual Liability
"Personal and Advertising lnjury" for which the insured has assumed liability in a contract
or agreement. This exclusion does not apply to liability for damages:
1. That the insured would have in the absence of the contract or agreement; or
2. Assumed in a written contract or agreement that is an "insured contract"; provided the
"personal and advertising injury" is caused by an offense which occurs subsequent to
the execution of the contract or agreement.
2. Subparagraph f. of the definition of insured contract" Section V.- Definitions is deleted in its
entirety and replaced by the following:
f. That part of any other contract or agreement pertaining to your business, including an
indemnification of a municipality in connection for work performed for a municipality,
under which you assume the tort liability of anther party to pay for "bodily injury",
"property damage" or'personal and advertising injury" to a third party or organization.
Tort liability means a liability that would be imposed by law in the absence of any
contract or agreement.
2. This Article E. does not apply if Coverage B. Personal And Advertising lnjury Liability is
excluded by endorsement.
F. INCREASED SUPPLEMENTARYPAYMENTS
Subparagraphs 1. b. and d. of Supplementary Payments - Coverages A And B of Section I
Coverages are amended as follows:
1 . ln Subparagraph b., the amount we will pay for the cost of bail bonds is increased up to
$5,000.
2. ln Subparagraph d., the amount we will pay for a loss of earnings is increased up to
$1 ,000 a day.
G. BROADENED NAMED INSURED
1. The Named lnsured in ltem 1. of the Declarations is as follows:
The person or organizations named in ltem '1. of the Declaralions and any organization,
other than a partnership or joint venture, over which you maintain ownership or majority
inlerest on the effective date of the policy. However, coverage for any such organization
will cease as of the date that you no longer maintain ownership of, or majority interest in,
such organization.
2. This Article G. does not apply to any person or organization for which coverage is excluded
by endorsement.
Page 4 of 8Form XIL 436 '1208 @ 2008, XL America, lnc.
lncludes copyrighted material of lnsurance Sorvices office, lnc., with its permission.
H. BLANKET ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES
1. Section ll-Who ls An lnsured is amended to include as an insured any person or
organization with whom you have agreed in a written contract executed prior to loss (an
"additional insured"), but only with respect to liability arising out of the ownership,
maintenance or use of that part of any premises leased to you, subject to the following
provisions:
a. Limits of lnsurance. The Limits of lnsurance afforded to the "additional insured" shall
be the limils you agreed to provide, or the limits shown on the Declarations, whichever
is less.
b. The insurance afforded to the "additional insured" does not apply to:
(1) Any "occurrence" that takes place after you cease to be a tenant in that premises;
(2) Any premises for which coverage is excluded by endorsement; or
(3) Structural alterations, new construction or demolition operalions performed by or
on behalf of such "additional insured".
2. The insurance afforded to the "additional insured" is excess over any valid and collectible
insurance available to such "additional insured", unless you have agreed in a written
contract for this insurance to apply on a primary or contributory basis.
I, BLANKET ADOITIONAL INSUREO - LESSOR OF LEASEO EQUIPMENT
1. Section ll-Who ls An lnsured is amended to include an "additional insured" (as defined in
Article H. above), but only with respect to their liability arising out of maintenance, operation
or use by you of equipment leased to you by such "additional insured", subject to the
following provisions:
a. Limits of lnsurance. The Limits of lnsurance afforded to the'additional insured" shall
be the limits which you agreed to provide, or the limits shown on the Declarations,
whichever is less.
b. The insurance afforded to the "additional insured" does not apply to:
(1) Any "occurrence" that takes place after the equipment lease expires; or
(2) "Bodily injury" or "property damage" arising out of the sole negligence of such
additional insured.
2. The insurance provided to the 'additional insured" is excess over any valid and collectible
insurance available to such 'additional insured", unless you have a written contract for this
insurance to apply on a primary or contributory basis.
J. INJURY TO CO-EMPLOYEES AND CO.VOLUNTEER WORKERS
1. Seclion ll Who ls An lnsured is amended to include your "employees" as insureds with
respect to "bodily injury" to a co-"employee" in the course of the co-"employee's"
employment by you, or lo your "volunteer workers' while performing duties related to the
conduct of your business, provided that this coverage for your "employees" does not
apply to acts outside the scope of their employment by you or while performing duties
unrelated to the conduct of your business.
Form XIL 436 1208 O 2008, XL America, lnc.
lncludes copyrighted material of lnsurance Services Ofiice, lnc., with its pormission
Page 5 of I
2. Section ll - Who ls An lnsured is amended to include your'volunteer workers" as
insureds with respect to "bodily injury" to a co-"volunteer worke/ while performing duties
related to the conduct of your business, orto your "employees" employment by you,
provided that this coverage for your "volunteer workers" does not apply while performing
duties unrelated to the conduct of your business.
K. KNOWLEDGE AND NOTICE OF OCCURRENCE OR OFFENSE
The following is added to Paragraph 2., Duties ln The Event of Occurence, Offense, Claim or
Suit of the Section lV - Commercial General Liability Conditions:
Notice of an "occurrence" or of an offense which may result in a claim under this insurance
shall be given as soon as practicable after knowledge of the "occunence' or offense has
been reported lo any insured listed under Paragraph 1. of Section ll-Who ls An lnsured or
any "employee" (such as insurance, loss control, risk manager or administrator) designated
by you to give such notice.
Knowledge of any other 'employee(s)" of an "occurrence" or of an offense does not imply that
you also have such knowledge.
Notice shall be deemed prompt if given in good faith as soon as practicable lo your workers
compensation insurer. This applies only if you subsequently give notice to us as soon as
practicable after any insured listed under Paragraph '1. of Section ll - Who ls An lnsured or
an 'employee" (such as an insurance, loss control, or risk manager or administrato0
designated by you to give such notice discovers that the 'occurrence", offense or claim may
involve this policy.
The following is added to Paragraph 6., Representations, of Section lV- Commercial General
Liability Conditions:
The unintentional omission of, or unintentional error in, any information provided by you shall
not prejudice your rights under this insurance. However, this Article L. does not affect our
right to collect additional premium or to exercise our right of cancellation or nonrenewal in
accordance with applicable state insurance laws or regulations.
M. LIBERALIZATION
The following is added to Section lV-Commercial General Liability Conditions
Liberalization
After the issuance of this policy, if we adopt a change in our forms or rules which would
broaden the coverage provided by any form that is a part of this policy without a premium
charge, the broader coverage will apply to this policy. This extension is effective upon the
approval of such broader coverage in your state.
Form XIL 436 1208 O 2008, XL America, lnc.
lncludes copyrighted material of lnsurance Services Office, lnc., with its p€rmission
Page 6 of 8
L. UNINTENTIONALOMISSION
We waive any right of recovery we may have against any person or organization because of
payments we make for injury or damage arising out of premises owned or occupied or rented
or loaned to you; ongoing operations performed by you or on your behalf, done under a
contract with that person or organization; "your work"; or "your products". We waive this right
where you have agreed to do so as part of a written contract, executed by you prior to loss.
Page 7 of 8
N. BLANKET WAIVER OF SUBROGATION
The following is added to Section lv-Commercial General Liability Conditions:
Waivor of Subrogation
O. INCIDENTAL MEDICAL MALPRACTICE INJURY
1. For insurance applicable to this Article O, the definition of "bodily injury" in Section V -
Deflnitions is amended to include, "lncidental Medical Malpractice lnjury".
2. The following definition is added to Section V- Definitions:
"lncidental medical malpractice injury" means "bodily injury', mental anguish, sickness or
disease sustained by a person, including death resulting from any of these at any time,
arising out of the rendering of, or failure to render, the following services:
a. Medical, surgical, dental, laboratory, x-ray or nursing servic€ or treatment, advice or
instruction, or the related furnishing of food or beverages;
b. The furnishing or dispensing of drugs or medical, dental or surgical supplies or
appliances;
c. First aid; or
d. "Good Samaritan Services". As used in this Article O., "Good Samaritan Services" are
those medical services rendered or provided in an emergency and for which no
remuneration is demanded or received.
3. Paragraph 2.a.(1Xd) of Section ll -Who ls An lnsured does not apply to any registered
nurse, licensed practical nurse, emergency medical technician or paramedic employed by
you, but only while performing the services described in Palagraph 2. above and while
acting within the scope of their employment by you. Any "employees' rendering "Good
Samaritan Services" will be deemed to be acting within the scope of their employment by
you
4. The following exclusion is added to Paragraph 2. Exclusions of Coverage A. - Bodily
lnjury And Property Damage Liability of Section I - Coverages:
f[his insurance does not apply to:)
Willful Violation of Penal Statute
Liability arising oul of the willful violation of a penal statute or ordinance relating to the
sale of pharmaceuticals by or with the knowledge or consent of the insured.
5. For the purposes of determining the applicable Limits of lnsurance, any act or omission,
together with all related acts or omissions in the furnishing of services described in
Paragraph 2.a. through 2.d. above to any one person, will be considered one "occurrence".
6. This Article O. does not apply if you are in the business or occupation of providing any of
the services described in Paragraph 2. above.
Form XIL 436 1208 @ 2008, XL America, lnc.
lncludes copyrighted material of lnsurance SeNices Oflice, lnc., with its pe.mission.
7. The insurance provided by this Article O. shall be excess over any other valid and
collectible insurance available to the insured, whether primary, excess, contingent or on
any other basis, except for insurance purchased specifically by you to be excess of this
policy.
P. EXTENSION OF COVERAGE - BODILY INJURY
The definition of "bodily in.iury'Seclion V- Definitions is deleted in its entirety and replaced by
the following:
3. "Bodily injury" means bodily injury, mental anguish, mental injury, shock, fright, disability,
humiliation, sickness or disease sustained by a person, including death resulting from
any of these at any time.
Q. COVERAGE TERRITORY
The deflnition of "coverage territory" Section V- Definitions is deleled in its entirety and
replaced by the following:
4. "Coverage tenitory" means anywhere in the world.
This insurance does not apply to:
a. "bodily injury" or'property damage" that takes place; or
b. "personal and advertising injury" caused by an offense commitled
outside the United States of America (including its possessions and territories),
Canada and Puerto Rico, unless a "suit'on the merits (to determine the insured's
responsibility to pay damages to which this insurance applies) is brought in the
United States of America (including its possessions and tenitories), Canada or
Puerto Rico.
This insurance does not apply to damage, loss, cosl or expenses in connection with any
"suit" brought outside the United States of America (including its possessions and
territories), Canada or Puerto Rico,
Form XIL 436 1208 @ 2008, XL America, lnc.
lncludes copyrighted material of lnsu.ance Services Ofilce, lnc., with its pormission
Page 8 of 8