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PROOF OF INSURANCE (2020 - 2020) CLOSED (2)RESCH-1 ` C ACORO` CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 01/0712020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this dors 76e B. CPRODUCER ooper Insurance Service, Inc PHONE rights to the 765-534 - 2 � eme5S34»315 way 3 to holder in lieu o suchCarra Alc No Eat : 2 ...........I...... 766'-534-2067 x Pl4yygroulnd Book 534 315' --1 _.._, A3T.._S.�.�......... ... r�r . _aop:................................................____ P.Q. 6#ox 638ks$$ Lapel, IN 46051 Steve B. Carraway 41297 w D IINSURERA:Scottsdale Insurance Co NAI3a............. SUR R National Union Fire Ins Co ��y B :........................................... 19445 � 'g� Ba Ii tree IRF^ ...... Ita Co stru tion, Inc y t� N U ER C Oran, e, CA 9265 ..... su waR.� J,NSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 30LICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IINSR 'ADDL eUBR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXPNDJ2LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. CLAIMS -MADE X OCCUR XX!U X... Cont Liab EI.APOLICY AGGREGATELIMITAPPLIES PER: .Ei' .... X,�PRCO—_I LOC O'T'HER AUTOMOBILE LIABILITY ............ ANY AUTO X X RBS0018684 OWNED SCHEDULED AUTOS ONLY AUUTOS} .._ AUTOS ONLY I,.-......... A'4AS�5T.9 B EXCESS UMBRELLA ABAB X I OCCUR �- X ( CLAIMS -MADE X DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE N1�ndaEitpinNH) EXCLUDED? N I A If Yyes, describe under DESGRIPTION OF OPERATIONS below X BE015104528 04/22/2019 04/22/2020 V$a 09 .RRF [o"n 5 MEII EXP,,(Anv one Person) PERSONAL & ADV INJURY $ „GENERAL AGGREGATE $ PRODUCTS - COM P/OPA„G,G ,,,,,,,,5,,,,,,,,,,,,,,,,,,,,, Prof Liab $ c6mWNED SINGLE LIMIT AdfiM,,,,,,, $ BODILY INJURY (Perpersan) $ INJURY„(Paraccide„n�. $ „8O„D,I,LV DAMAGE f�2".PERTY ,,,,,err arc,I�It3nh,Y $ $ „EACH,OCCURRENCE 8, 04/22/2019 04/22/2020 AGGREGATE $ 5 PERI OTH $TATI,ITE VIER .... E L EACH ACCIDENT, E,,I.PISE,ASE,,.:.IE,A,EMPLf,YE -_$ E DISEASE � POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project Number: W'ashinton Dark Playground Proact, Project Address: 1610 E Maple Ave, El Segundo, A 90245, Pro ect a#:PW 1 '-29--The City of EI Segundo Ist officials & employees are additional insuredregarding the ,general liability coverage on a primary & non-contributory basis including completed operations with a waiver of subrogation per written contract and CERTIFICATE HOLDER City of EI Segundo 350 Main Street EI Segundo, CA 90245 I ACORD 25 (2016/03) ELSEGUN rar�l���i�i<»jai . 1 00,0001 5,000 1,000,000 2,000,000 2,000,000 1,000,000 ,000,000: 3,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ELSEGUN RESCH-1 NOTEPAD. HOLDER CODE OP ID: CS INSURED'S NAME R.E. Schultz Construction, Inc forms CG2033, C'G2001, CG2404 & CG2037 attached. Excess coverage follows form. 30 day notice of cancellation other than cancellation for non- mment of premium in favor of certificate holder applies to the general liability policy. PAGE 2 Date 01/07/2020 COMMERCIAL GENERAL LIABILITY CG 20 33 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property 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 for the additional insured. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 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 the failure to render any professional architectural, engineering or surveying services. CG 20 33 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 2 2. 'Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than 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 b. That portion of "your work" out of 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 project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 33 0413 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. 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 Insured under such other insurance; and CG 20 01 04 13 C Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization with whom the insured has agreed to waive rights of recovery, provided such agreement is made in writing and prior to the loss. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of IL Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above 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 shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 0 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Any person or organization when you and such person or organization have agreed in writing in a contract or agreement, executed prior to the "occurrence" to which this insurance applies, that such person or organization be added as an Additional Insured Installation, inspection or repair of playground equipment, ancillary fencing or playground surfacing as agreed in writing in a contract or agreement. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured 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" or "property damage" caused, in whole or in part, 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 to such additional insured only applies to the extent permitted by law; and 2. If 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. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract 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 shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 37 04 13 13 '` C R CERTIFICATE OF LIABILITY INSURANCE DAM (MMIDD/YYYY) 12/20/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT 1M NAME; Carol Knox, Debbie Taylor or Debbie Waller KGIB, INC. PHONE (714,) 744-3300 FAX 714' 744-6537 KNOX GENERAL INSURANCE BROKERS E-MAIL ADDRESS: .Carol k ibinc.con. Oebbie k ibino.00m, Owaller@kgilbinc.com 226 SOUTH GLASSELL STREET INSURER(S) AFFORDING COVERAGE NAIC # ORANGE CA 92866 INSURERA: CALIFORNIA AUTOMOBILE INSURANCE CO 38342 INSURED INSURER 8: R.E. SCHULTZ CONSTRUCTION, INC INSURER C: 1767 N BATAVIA STREET INSURER D: INSURER E: ORANGE CA 92865-4103 � INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 BY PAID CLAIMS NSA . _ TYPE OF INSURANCE INSD r)) POLICY NUMBER WMOiIPMD1YY 1 (MPAM1'M0�1DVYYY1 LIMITUS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE U S DAMAGE "rte REFiEC CLAIMS -MADE OCCUR PRFMIsFS.(.F_a prti 4!r�^p?) $ ........ MED EXP (Any one person) $ .-N/A-. I PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE I $ ..... POLICY LOC LIC❑ PROD„ -COMP/OP AGG .......................................... ..................- _ � JEt�T _UCTS $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT N $ 1,000,000 " ANY AUTO BODILY INJURY (Per person) $ AOWNED SCHEDULED BA040000046316 06/19/2019 06/19/2020 BODILY INJURY (Per accident) G $ _ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMkAGE AUTOS ONLY AUTOS ONLY ............ UMBRELLA LIAB ............. ....... ... URRENCE .. ........................V.... pppp$ $.........................................................__. EXCESS LIAB CLAIMS -MADE ^-N/A_- R AGGREGATE p$ .. ...� ... .... ........... ....... ... .... .... .. DED.... RETENTIONS....,... $ WORKERS COMPENSATION p iPER G O_RHAND EMPLOYERS' Y� _ UTE_.,J.,'__,_II /EXCLIUDED ECUTIVE E,L EACH�S OFFICER/MEMBER N / A --N/A-- (Mandatory in NH) E, L SEASECIDENT EA EMPLOYE 1 $ describe under DESCRIPTION OF OPERATIONS below EL DISEASE -POLICY LIMIT S PHYSICAL DAMAGE $1000 COMP. DEDUCTIBLE A BA040000046316 06/19/2019 06/19/2020 $1000 COLLISION DEDUCTIBLE DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PROJECT #PW -19-29 - WASHINGTON PARK PLAYGROUND PROJECT, 1510 E MAPLE AVE, EL SEGUNDO, CA 90245. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET AUTHORIZED REPRESENTATIVE EL SEGUNDO CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD _---sa.i Policy Number: Date Entered: 04/09/2019 ICM DATE (MMI DOIYYYY) .. CERTIFICATE OF LIABILITY INSURANCE I 12/23/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT The Hulett Agency NAM: PHONEFAX 13959 Saddlewood Drive (ArC,No.ExtN: (858) 618-5442AIc N,el, (858) 618-5444 ADDRESS: BS: huletta enc sbc lobal.net Poway, CA 92064 ODRE.....W........................................... ........... INSURE R(S) AFFORDING COVERAGE NAIC# INSURER A Insurance Company of the West 27847 INSURED R E Schultz Construction, Inc. INSURER B: INSURER C: 1767 N. Batavia St INSURER D: Orange, CA 92865 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 BY PAID CLAIMS, 'INSR ADPL SUBR POLICY EFF POLICY EXP LTR_1 TYPE OF INSURANCE IN.... Sp WVD POLICY NUMB ER (MMI DDIYYYY) (MMI DOIVYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCELv�m $ CLAIMS -MADE � OCCUR PREMtlScES (ED O=rRumm4lcrarlce)_ I $ MED EXP (Any one Person) $ PERSONALBADV INJURY $ GEML AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ POLICY = JER0. ❑LOC IPRODUCTS-COMP/OPAGG $ OTHER $ AUTOMO BILE LIABILITY I"[.IDwIONeu INULIzLIM i £E8 aorldan7) $ ANY AUTO I BODILY INJURY (Per person) $ OWNEDSCHEDULED I BODILY INJURY (Per aoddent) $ AUTOS ONLY AUTOS — HIREDNON-OWNED rb1 c� a Y s a ana $ AUTOS ONLY AUTOS ONLY (Par accdantt rytl V$ _ UMBRELLA LIABCUR EACH �. EXCESS LIAB MS -MADE AGGREGATERRENCE i $ w......... DED I I RETENTION $I $ WORKERS COMPENSATION 1 STATUTE ERn I ryI AND EMPLOYERS' LIABILITY Y/ N .., I E.L. EACH ACCIDENT 9 $ 1, 0 0 0, 0 0 0 ANY PROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBER EXCLUDED? N/A WSD 504757600 04/14/2019 04/14/2020 (Mandatory in NH) E L DISEASE - EA EMPLOYEE $ 1, 0 0 0 , 0 0 0 If yyes desenbe under DESCRIPTION OF OPERATIONS below E, L, DISEASE - POLICY LIMIT 1 $ 1, 0 0 0 , 0 0 0 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: Washington Park Playground Project Project # : PW 19-29 Project AddresB:1510 E. Maple Ave. E1 Segundo, CA 90245 1-111 Blanket Waiver of Subrogation Attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of E1 Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE 4WWNO,N 2[O�+MtYMESrN1&T YL I 1 6 1988-2015 ACORD CORPORATION. Ali rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forms Bass Plus software www FormsBoss com; Impressive Publishing, LLC 800208-1977 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). The additional premium for this endorsement shall be otherwise due. Person or Organization ANY PERSON/ORGANIZATION WHEN REQUIRED BY WRITTEN CONTRACT 3 % of the total California Workers' Compensation premium Schedule Job Description ALL CA OPERATIONS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 04/14/2019 Policy No. WSD 5047576 00 Endorsement No. Insured R E SCHULTZ CONSTRUCTION INC Premium $ INCL. Insurance Company INSURANCE COMPANY OF THE WEST Countersigned By WC 99 06 34 (Ed. 8-00) INSURED