2022/02/01 Von Euw Backhoe, Inc.A,CORD"VONEUWB-01
CERTIFICATE OF LIABILITY INSURANCE 2t23t2022
IMPORTANT: lf the certlflcato holdo,ls an ADDITIONAL INSURED, the pollcy(ies) must havo AODIT1ONAL INSUREO provlslons or be endor3ed
, 3ublsct to the totm3 and condltlons of the pollcy, cenaln pollclos may requlre an ondoigemont. A statement onIf SUBROGATION IS WAIVED
th13 certlflcato doos not conf€r hts to the certilicato holder ln llou of such endorsoment s
F?tElcr Ashley Casler
fI8,NrE", e,l, (gsr ) z16-4003 206 [iI, nr,
rNsu RER{S) AFFORDTNG COVEiIAOE i NA|C t
rNsqEqE a: Evanston lnsurance Company 35378
rNsuRER B:Travelers Casualty lnsurance Co of America '19046
rNsunen c : State Compensatlon lnsuranco Fund of Californla 35076
INSI'RER D:
INSURER E I
PFOOUCER
Lgo Rodrlgugz lnsuranco Agoncy
27174 Nowport RdSulte 3 end 4
Menlloo, CA 92584
Von Euw Backhoe, lnc.
P.O. Box 693
Wflchest€r, CA 92596
COVERAGES CERTIFIC REVISION N MBER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIODINDICATED. NOTWTHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY AE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES OESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIIVITS SHO!\N MAY HAVE BEEN REDUCEO AY PAIO CLAIMS
POLICY EFF POLICY EXP
El\Qllcqu RRENcE
OAMAGE TO RENTEDPREMISES (Ea occufi enc€)
MED ExP (Any ono p.rso.)
PERSOtTAT- & AOV!NJURY
!ENERAL AqGREGATE
PRODUCTS. COMP/OPAGG
10t5t2021X X 3A4509317 10t5t2022
X coMMERcTAL GENERAL LtABtuTy
cLA Ms-MAoE X occuR
GEN'L AGCREGATE LIMIT APPUES PER- eouc" [- 569 I,oc
1,000,000
100,000
5,000
1,000,000
2,000,000
2,000,000
OV\NEDAUTOSONLY
ILfi& o,,,"
COMBINEDSINGLE LIMIT
lE@qcrdenrl?2112023 eoo rv rNUuFy (per p6Bon).
[lQO LY INJURY (Par ec.,d€nt
PROPERTY OAMAGE(Pd6erdsnr)
-LLItJ!
It
1,000,000
A0N694947xx
s
2t2112022
B lutomoete ulgruw
SCHEOUI.EOAUlOS
I8td"8xt9
urrBRELlA L|AB I IOCCUREICE!3UAA CLAIMS.MAOE
-14
OEO I |RETENTIONI
EACI] OCCURRENCE
AGGREGATE
C woRKEnscoiiPENsATloNANO EMPLOYERS' UABILITY
ANY PROPR ETOR]PARTNER/EXECUTIVE
OFFICER/MEMAER EXCLUOED?(M.nd.tory l. NH)
21112022 2J1t2023 s
s
1,000,000E L O SEASE. FOLICY LIM T
E.L, EACHACC]DENT
,rfsaRrPr oN oF a,FFeAir)Ns h.,.
',,000,000
't,000,000EL
'J
SFASF . FA FMPL OYE
PER O'H.STAIIJTE ER ]
OESCRIFiON OF OPEiAiONS / LOCAIONS / VEH lctls (ACORD 101, Addrrlon.l R. rt. Sch.dul., tuy b..n ch.d rhor..p.c.l. EqulcdlCity of Menlfoe, 29844 Hsun Rd
Corllllcato holder is named as addjtlonal ln!urod p€r attached bhnketform MEGL0009-01 09 18. Prlmary and Non-Contrlbutory appli6s as
rcqulred por written contract per attachod blankGt form CG 2001 04 13. GL Walver of Subrogatlon applle! e8
required por wltten contrect perrllachod bbnketform MEGL0241-01 05 16. BA Addltional ln3ured andWaiv6r ofSubrogstlon applios per blanketform
CAT420 0215. Waiver of Subrogelion epplier to Worker3 Compen!.tion per form 2572. '30 Day! notice of cancellation .pplle! to !ll liabllityi 10€lays notlce
for non-payment of
promium.
Clty ot Menltoo
29E44 Haun Road
Menitee, CA 92586
AUIHORZED REPRESENIANVE
d_ /.ii'
O 1988-2015 ACORD CORPORATION. All rishts reserved.
The ACORD name and logo are registered mark3 of ACORO
ACORD 25 (2016/03)
THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE OOES NOT AFFIR'IIATIVELY OR NEGATIVELY AMEND, EXTENO OR ALTER THE COVERAGE AFFORDED BYTHEPOLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEO
REPRESENTATIVE OR PROOUCER, ANO THE GERTIFICATE HOLOER.
s
X 1863518"21L l N/A
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORETHE EXPIRATION OATE THEREOF, NOTICE W]LL BE OELIVERED IN
ACCORDANCE WTH THE POLICY PROVISIONS,
ill
lncludes copyrighted material of lnsurance Services Offlc6, lnc.,
with rts permission.
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 3A450931 7
MARKET
This endorsement modifles insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
LIQUOR LIABILIry COVERAGE FORM
O\^NERS AND CONTRACTORS PROTECTIVE LIABILIry COVERAGE FORMPRODUCTSiCOMPLETED OPERATIONS LIABILIry COVERAGE FORI\,4
SCHEDULE
EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
Additional Premium: glncluded (Check box if fufly earned X)
Please refer to each Coverage Form to determine which terms are delined. Words shown in quotations on this endorsementmay or may not be deflned in all Coverage Forms.
A. VVho ls An lnsured is amended to include as an additional insured any person or entity to whom you are required byvalid w-ritten contract or agreement to provide such coverage, but only with respect to "bodily injury", ,,property damage;,(including "bodily iniury" and "property damage" included in the "products-completeo operati-ond hizarb"1,'and "perso-natand advertising injury" caused, in whole or in part, by the negligent acts or omissions of the Named lnsured and ontywith respect to any coverage not otheMise excluded in the policy.
However:
1. The insurance atforded to such additional insured only applies to the extent permitted by law; and
2. The insurance afforded to such additional insured will not be broader than that which you are required by the valid
written contracl or agreement to provide for such additional insured.
Oxr agreement to accept an additional insured provision in a valid written contract or agreement is not an acceptanceof any other provisions of such contract or agreement or the contract or agreement in total.
V1/hen coverage does not apply for the Named lnsured, no coverage or defense will apply for lhe additional insured.
No coverage applies to such additional insured for injury or damage of any type to any "employee" of the Named lnsured
or to any obligation of the additional insured to indemnify another because of damages arising out of such injury ordamage.
B. \Mth respect to the insurance afiordod to these additional insured, the following is added to limitsof insurance:
The most we will pay on behalf of tha additional insured is the amount of insurance:
1. Required by the valid written contract or agreement; or
2. Available under the applicable limits of insurance shown in the Declarations;
whichever is less.
This endorsement shall not increas€ ths applicable limits of insurance shown in the Declarations.
All other terms and conditions remain unchanged.
MEGL 0009-01 09 18 Page I of 'l
POLICY NUIVBER: 34,4509317 COMMERCIAL GENERAL LIABILITY
cG 20 01 04 13
THIS ENOORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION
This endorsement modrfies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/CON,IPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to the Other lnsuranceCondition and supersedes any provision to the
contrary:
Prlmary And Noncontrlbutory lnsurance
This insurance is primary to and will not seek
contribution from any other insurance availableto an additional ansured under your policyprovided that:
(1) The additional lnsured is a Named lnsured
under such other insurancei and
(2) You have agreed in writing in a contract or
agreement that this insurance would beprimary and would nol seok contributionfrom any other insurance available to the
additional insured.
cG 20 01 04 13 @ lnsurance Services Office, lnc., 2012 Page 'l of 1
ill
TTIARKTT
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEOULE
All other terms and conditions remain unchanged
lncludes copyrighted material of lnsurance Services Otfice, lnc.,
with its permission.
COMMERCIAL GENERAL LIABILITY
POLICY NUN4BERT 3AAs093't 7
Name Ol Person Or Organization:
Any person(s) or organization(s) with whom the Named lnsured agrees, in a written contract
executed prior to the "occunence", to waive rights of recovery
Additional Premium: $ lncluded
The following is added to Condition 6. Transfer Of Rights Of Recovery Against Others To Us under Section tV -Commerclal General Liability Conditions:
We waive any right of recovery we may have against any person or organization shown in the Schedule of thisendorsement. This waiver applies only to the person or organization shown in the Schedule of this endorsement.
MEGL 0241-0t 05 16 Page 1 of 1
EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
ill COMMERCIAL GENERAL LIABILITY
POLICY NUN4BER: 3AA50931 7
MARKET
EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REAO IT CAREFULLY,
coNSTRUCTtON pROJECT(S) cENERAL AGGREGATE LtMtT
This endorsement modifles insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
l\,laximum Annual Limit Of lnsurance: $S,0OO,OOO
The following changes are subject to the Maximum Annual Limit Of lnsurance shown in the Schedule of this endorsement.ln no event will we be liable for damages in excess of the l\,laximum Annual Limit Of lnsurance shown in the Schedule ofthis endorsement.
A. For all sums which the insuled becomes legally obligated to pay as damages caused by "occurrences', under Sectionl- Coverage A, and for all medical expenses caused by accidents und;r Section l- Coverage C, whach can beatlributed only to ongoing operations at a single designated construction pOect:
1. A separate Construction Project General Aggregate Limit applies to each conslruction project, and that limit isequal to the amount of the General Aggregate Limit shown in the Oeclarations.
2. The Construction Project General Aggregate Limit is the most we will pay for the sum of a damages undercoverage A, except damages because of "bodily injury" or "property damage" included in the "products-
completed operations hazard", and for medical expenses under Coverage C regardless of the number of:
a, Insureds,
b. Clalms made or "suits" brought; or
c. Persons or organizations making claims or bringing ,,suits,,.
3. Any payments made under Coverage A for damages or under Coverage C for medical expenses will reduce the
Construction Proiect General Aggregate Limit for that construction project and the Maximum Annual Limit Oflnsurance shown in the Schedul€ of this endorsement. Such payments will not reduce the General AggregateLimit shown in the Declarations nor will they reduce any other Construction Project General Aggregate Limii for
any other construction project.
4. The limits shown in the Declarations for Each Occunence, Damage To Premises Rented To You and MedicatExpense continue to apply. However, instead of being subject to the General Aggregate Limit shown in theDeclarations, such limits will be subject to the applicable Construction Project General Aggrcgate Limit.
B' For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Sectionl- Coverage A, and for all medical expenses caused by accidents under Section l- Coverage C, which csnnot be
attributed only to ongoing operations at a single construction project:
1. Any payments made under Coverage A for damages or under Coverage C for medical expenses wilt reduce the
amount available under the General Aggregate Limit or the Products-Complsted Operations Aggr6gat6 Limit,
whichever is applicable, and the Maximum Annual Limit Of lnsurance shown in the Schedule of this endorsementl
and
2. Such payments will not reduce any Construction Project General Aggregate Limit.
MEGL031302 17 lncludes copyrighted material of lnsurance Services Otfice, lnc., ?age,l ol2
with its permission.
Vvhen cov€rag€ for liability arising out of the "products-compl€ted operations hazard" is provided, any payments fordamages be-cause of "bodily injury" or "property damage" included in the "products-completed operations hazard,, willreduce the Products-Completed Operations Aggregate Limit and Maximum Annual Limit Of lnsurance shown in theSchedule of this endorsement, but not reduce the General Aggregate Limit nor the Construction project GeneratAgglegate Limit.
lf the applicable construction project ias been abandoned, delayed, or abandoned and then restarted, or if theauthorized contracting parties deviate from plans, blueprints, designs, specillcations or timetables, the project wilt stillbe deemed to be the same construction project.
The provisions of Sectlon lll - Limits Of lnsurance not otheMise modified by this endorsement wi continue to applyas stipulated.
All other terms and conditions remain unchanged
D
E.
lncludes copyrighted material of lnsurance Services Office, lnc.,
with its permission.
MEGL 0313 02 17 Page 2 of 2
POLICY NUMBER: 8A0N694947 COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ tf CAREFULLY.
AUTO COVERAGE PLUS ENDORSEMENT
This endorsement modifes insurance provided under ihe followng
BUSINESS AUTO COVERAGE FORI\4
GENERAL DESCRIPTIoN cF covERAGE - This endorsement broadens coverage. However, coverage for anyinjury, damage or medical expenses described h any ofthe provisions ol this en;orsement may Oe eicluoeO drlirnited by another endorsement to the coverage part, and these coverage broadenlhg provisioni do not apply tothe extent that coverage is excluded or limited by such an endorsement. The following listing b a general cover-age description only. Limilations and exclusions may apply to these coverages, Read all the provisions ol this en-dorsement and the rest of your policy carefully to delermine rights, duties, and what E and b not covered.
A BLANKET ADDITIONAL INSURED
B, EMPLOYEE HIRED AUTO
C EMPLOYEES AS INSURED
D SUPPLEMENTARY PAYI,,IENTS . INCREASED
LII',lITS
E TRAILERS . INCREASED LOAD CAPACITY
F, HIRED AUTO PHYSICAL DAMAGE
G PHYSICAL DAIVIAGE - TRANSPORTATIoN
EXPENSES - INCREASED LIMIT
A. BLANKET ADDITIONAL INSURED
The lollowing b added to Paragraph A1., Who ls
An lnsured, of SEC]ION ll - COVERED AUTOS
LIABILITY COVERAGEI
Any per'son or organization who b required under
a written contract or agreement behreen you andthat person or organization, that b signed and
executed by you before the "bodily injury" or
"property damage" occurs and that b n etfeci
during the policy period, to be named as en addi-lional insured b 4l "insured" for Covered Autos
Liability Coverage, but only for darnages to v,fiich
thrs insurance applies and only to the extent thatperson or organization oualilles a6 an ,,insured,,
under the lrylo b An lnsured provision containedn Section ll.
B EI PLOYEE HIRED AUTO
1. The following b added to paragraph A'1.,\rvho ls An lnsured, of SECTION II - CDV-
EFIED AUTOS LIABILIry COVERAGE:
An "ernployee" of yours 6 an "insured" whileoperating a covered "auto" hired or renledunder a contract or agreement h an ,em-
pToyee's" name with your permission, while
H AUDIO, VISUAL AI.ID DATA ELECTRONIC
EQUIPI\,IENT . INCREASED LIMIT
I WAIVER CF DEDUCTIBLE . GLASS
J, PERSONALPROPERTY
K AIRBAGS
L AUTO LOAN LEASE CTAP
M BLANKET WAIVER CF SUBROGATION
performing duties related to the conduct of
your business.
2. The following replaces Paragr.aph b. h 8.S,,
Other lnsurance, of SECTION V - BUSh
NESS AUTO CONDITIONSI
b, For Hired Auto Physical Damage Cover-
age, the followlng are deemed to be cov-
ered "autos" you owhi
(1) Any covered 'auto" you lease, hire,
rent or bonow and
(2) Any covered "auto" hired or rented byyour "employee" under a contract han "employee's" name, with your
permission, while performing duties
related to the conduct of your busi-
ne3s.
However, any "auto" that b leased hired,
rented or boffowed with a driver is not a
covered "auto".
G EMPLOYEES AS INSURED
The following b added to Paragraph A1., Who bAn lnsurod, of SECTION ll - COVERED AUTOS
LIABILITY COVERAGE:
cAT420@ 15 @ 2015 The T6velers tndemntty Comp3ny. At Ohls rese sd.lncludes copyrighlEd mslerial of hsursnce Servlcgs Otfico, lnc with als D€rmtssion,
Page 1 of 3
D
COI\/1[./ERCIAL AUTO
Any "employee" of yours b an "insured" while us-
ing a covered "aulo" you don't own, hire or borrowil your bus ness o'your personal alairs
SUPPLEMENTARY PAYVIENTS . INCREASED
LIMITS
1 The following l eplaces Paragraph L2.a.(2) al
SECI'ION 11- COVERED AUTOS LIABILITY
COVERAGE:
(4 Up to $3,000 for cost of bail bonds (n-
cluding bonds for related traffic law viola-
tions) required because of an "accident"!!e cover. V\b do not have to fumish
these bonds.
2 The following replaces Paragraph L2.a.(4) ol
SECTION I. COVERED AUTOS LIABILITY
COVERAGE:
(4) AII reasonable expenses incurred by the
"insured" al our request, including actualloss of earnings Lp to $500 a day be-
cause of time off from wo*.
TRAILERS . INCREASED LOAD CAPACITY
The following repl6ces Paragraph C,1. of SEC
ION I- MVERED AUTOS:
1 "Trailers" wlh a load capacity of 3,OOOpounds or less desjgned pnmarily lor travel
on public roads.
HIRED AUTO PHYSICAL DAMAGE
The following b added to Pa.agraph A.4., Cover-
6ge Extenslons, of SECTION lll - PHYSICAL
DAMAGE COVEFAGE:
Hted Auto Physlcal Damago Coverago
lf hired 'autos" are covered 'autos' for Covered
Autos Liability Coverage but not covered "autos"for Physical Damage Coverage, and this policy
also provides Physical Damage Coverage for an
owned "auto", then lhe Physical Darnago Cover-
age 6 extended to "autcs" that you hire, reni o.
borrow subiect to the following:
('1) The most u,e Wll pay for 'loss" to any one
"auto" that you hire, renl or borrow b lhe
lesser of
(a) $50,000,
(b) The actual cash value of the damaged or
stolen properly as of the time of the'loss"i or
(c) The cost of repairing or replacing the
damaged or stolen property with other
property of like kind ard quality.
(4 An adjustment lor depreciaton and physicat
cond tion will be made h detenr ning actual
cash value h the evenl of a total "loss,,.
(O lf a reparr or replacement results h bette.
than like kind or quality, Me will not pay for the
amount of betterment.
(4) A deductible equal to the highest Physicat
Damage deductible applicable to any owned
covered "auto"
F) This Coverage Exension does not apply to:
(6) Any 'auto" thai b hrred, rented or bor-
rowed wlth a driver; or
(b) Any 'auto" t11d E hired, rented or bor-
rowed from your "employee".
G PHYSICAL DAMAOE - TRANSPORTATION
EXPENSES - INCREASED LIMIT
The followlng rcplaces the firsl sentence n Para-graph 44.a., Transportatlon Expensss, of
SECTION III . PHYSICAL DAMAGE COVER-
AGE:
l ,b w ll pay r+ to $50 per day to a maximun of
$1,500 for temporary l.ansportation expense in-
curred by you because of the total theft of a cov-
ered "auto" ofthe privale passenger type.
H AUDIO, VISUAL AND DATA ELECTRONIC
EOUIPMENT - INCREASED LIMIT
Paragraph C.1.b. of SECION ttt - PHYS|CAL
DAMAGE COVERAGE b deleted.
L WAIVER CF DEDUCTIBLE " GLASS
The folowing b added to Paragraph D, D€duc{-
ble, of SECTION lll - PHYSICAL DAMAGE
COVERAGEI
l'lo deductible for a covered "auto" will apply toglass damage if lhe glass b repalred rather than
replaced,
J, PERSONAL PROPERTY
The following b added to Paragraph A.4., Cover-age Extenslons, of SECTION lll - PHYSTCAL
DAMAGE COVERAGE.
P€rsonal Property Coverag€
\ E will pay W to $400 for "loss" lo wearing ap-parel and olher personal propedy which ist
(1) Owned by an "insurcd"; and
(2) ln or cn your covered "auto'.
This coverage only applies h the event of a tolal
lhefl of your covered "auto".
l.b deductibles apply to Personal Property cover-
age.
E
E
Page 2 of 3 @ 2015 The Trav€le6 lndsmnlly Codpany. Alt rtghrs reserved.
lncludes copyrlghred mat€ral ol lnsurcnce Servjc€s Offlce, tnc. wilh its permisslon.
cAT420@15
K AIRBAGS
The following b added to Paragraph B_3., Exclu-
slon6, of SECTION tll . PFIYS|CAL DAMAGE
COVERAGE:
Exclusion 3,a. does not apply to "loss" to one or
more aibags h a covered "auto" you own lhat in-
llate due to a cause olher lhan a cause of ,'loss,'
set forlh in Paragraphs A1,b, and A,1,c,, but
only:
a lf that "auto" b a covercd "auto" for Compre-
hensivB Coverage under his policy;
b. The airbags are not covered under any war-
rantyi and
c The airbags were not intentionally inllated.
V1,b wll pay rp to a maximum of $1,000 for any
one "loss'-
L ATJTO LOAN LFASE GAP
Tile following b added to Paragraph A4., Cover-
ags Extenslons, of SECT1ON l - pHyStCAL
DAMAGE COVEMGE:
Auto Loan Lsa6e @p Coverage for prlvate
Pa8s€nger Typs V€hlcles
ln lhe event of a total "loss" to a covered "auto" of
the privste passenger type shown h the Scheduleor Declarations for which Physlcal Damage Cov-erage b provided, we will pay any unpaid amount
due on the lease or loan for such covered ,'auto,,
less lhe followingi
{1) The amount paid under the Physical Damago
Coverage Section ofthe policy for that ,,auto,,
AM
COMMERCIAL AUIO
@ Anyi
(B) Overdue lease or loan paymenls at the
time of the "loss"i
(b) Financal penalties imposed under a
lease for excessive use, abnormal wear
and tear or high mileage;
(c) Security deposits not returned by lhe les-
sori
(d) Costs for extended warranlies Credlt Life
lnsurance, Health, Accident or Disability
lnsurance purchased with the loan or
lesse; and
(6) Carry-over balances from previous loans
or leases.
M BLANKET WATVER CF SUAROGATION
The following replaces Paragraph A5. Iransforof Rlghts Of Recovory Against others To Lls,of SECTION IV - BUSINESS AUTO CONDL
TIONS:
5 Transfer Ol Rlghts Of Recovery Agalnst
Others To Lb
VVe waive any right of recovery $,e may have
against any percon or organization to the ex-
tent required ofyou by 6 written contract exe-
cuted prior to any "accident" or "loss", pro-
vided that the "accident" or'loss" arises out ofhe operations contemplaled by such col1.
tract, The waivsr applies only to the person or
organization designated h such contract.
cA1420@15 O m15 Th€ Tmvetels tndemnity Comprhy. A! d0hrs rcs€rvs{,.lncludes copyrlght€d mst6dat of tnllr.nco Setulc6s Offce; [E with its p€rmislion
Page 3 of 3
STATE
FUNtr,
HOME OFFICE
SAN FRANCISCO
BLANKET BASIS
EFFECTIVE FEBRUARY I,
AND EI{PIRING FEBRUARY
2022 AT 12.01 A,U.l, 2023 AT 12.01 A.M.
ENDORSEMENT AGREEMENT
9IA TVER OE SUBROGATION
BROKER COPY
1
ALL EFFECTIVE DATES ARE
AT 12:01 AM PAC lFlC
STANDARD TIME OR TItE
TIME INDiCATEO AT
PACIFIC STANDARD TIME
VON EUII BACKHOE.
PO BOX 593
IfINCHESTER, CA
I NC.
92596
PERSON OR ORGANI ZAT ION
WE HAVE THE RIGHT IO RECOVER OUR PAYUENTS FROT ANYONE
LIABLE FOR AN INJURY COVERED BY IHIS POLICY. 9IE WILL
NOT ENFORCE OUR RIGHT AGAINST IHE PERSON OR
ORGAJ'IIZATION NA},IED IN THE SCHEDULE.
THIS AGREEI.IENT APPLIES ONLY TO THE EXTENI THAT YOU
PERFORX WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU
TO OBTAIN THIS AGREEIENT FRO},I US.
THE ADDITIONAL PRE},iIU}i FOR THIS ENDORSEHENT SHALL BE
2.007 OF THE TOTAL POLICY PREHIUH.
SCHEDULE
JOB DESCRIPTION
ANY PERSON OR ORGANIzATION
FOR hIIiOT{ THE NAHED INSURED
HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THI S
VIAI VER
COUNTERSIGNEo ANo lsSUEo AT SAN FRANCISCOi FEBRUARY 3-/',6.-{re71dr/
A--F,6RtzED aaoaasan'lra
sc tF FoFM 1021, iBEV.7-20141
NOTHING IN THIS ENDORSEMENT CONTAINEO SHALL BE HELD TO VAFY, ALTER, WAIVE
OR EXTENO ANY OF THE TERMS, CONOITIONS, AGREEMENTS, OB LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELO TO VABY, ALTEB, WAIVE OB LIMIT THE IERMS, CONOITIONS, AGBEEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
ELANKEI IIAI VER OF
SUBROGATION
2022
/ ,1, ,/1-,.^ d-".._^_
PRESiDENT AND CEO 257 2
oLD OP 217
1853518-2
2 RENEI{AL
SP
7- 13- I8-0 6PAGE 1 OF