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PROOF OF INSURANCE (2021 - 2021) CLOSED9 � DATE (MM/DDNYYY) ' '"�''0 CERTIFICATE OF LIABILITY INSURANCE �- 10/28/2020 , THIS CERTIFI'CAT'E IS ISSU'E'D AS A MATTER OF INFORMATION ONLY AND CONFERS NO RI'G'HTS 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IM'POR'TANT. If the certificate holder is an ADDITIONAL INS'U'RED, the pollc,y'(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 endorsemenl PRODUCER CONTACT .tlr� Katherine Dumati:nu:.,........_..: _. of � _... SIP Insurance Services - Orange PHONE _ FAX _ 750 The City Drive South, 450 "E�IAI'L �...�,..,_ Nei Orange CA 92868 !?l> .4 _,_...ka4heeririei slpbrokers.com _.,.._ 626m214 -75x2' IArc...,_..._...,,,, _. ._._... NAIC #._.,,,... LI a rlFO l to . ' INSURER A : Travelers Prep rty G s ali m en'tr ofea rnerdca, 25674-111- _ INSURED_., BACVAPP-01 INSURER 8Backflow Apparatus Valve Co. r -�uR c � _.. _.... ._._ .. _...�...� .... .... .,....__..._.. - 20435 S. Susana Road ___-.__:.: _ ...___. Long Beach CA 90510 .wNSyjR !!u.;...._ .,..1.11-11 _...._ I't,SURER 9 . INSURERF :... _.-.,._.„ ,_ ....._ ....._ ._ .__.... ,._.. ..._..,, __......._ COVERAGES CERTIFICATE NUMBER: 1014541473 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 LIESCRMED HEREIN IS SUBJECT TO ALL. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, — RANGE + SD a A D CY NUMBER rM,o LrCY Ei PDLICMY pati» rtLl3R X.., C TYPE OF INS RAA LIABILITY 6L 630-8J664090POLICY NUMBER rM10/31/2021 rA" VENC LIMITs$1,000,000 A COMMERCIAL GENEEACH p L fN I w x.__,..$300,000 CLAIMS -MADE (_x _i OCCUR _FKEM)S ;S E',;, _, __ _..,.,_ ..,. _......_.... MED EXP (Any o person') $5,000.,. _...,..._.,..,.__........_- . DESCRIPTION OF OPERATIONS i LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schoduro, may he ottachod if more $Paco is required) The City of El Segundo, its officers, agents, and employees are added as additional insureds on the general liability policy only per the attached. Waiver of Subrogation is Included in the general liability and Work comp policies only per the attached forms. CERTIFICATE HOLDER City of El Segundo Public Works Dept. 350 Main St. EI Segundo CA 90245 ACORD 25 (2016/03) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BATE THEREOF', NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORISED REPRESENTATIVE ©1988-2015 AC g . .. ORD CORPORA7iON...AB rights reserved. The ACORD name and logo are registered marks of ACORD PERSONAL 8 ADV INJURY $1,,000,000 ..,. .._...G,_....,_.._ _.. N L A LIES PER: I GREGATE LIMIT APP..._ _ _. 0,.. __. ,.,_......„ LAGUFC GEODUCT'S ...... .... ......2.000 $._. ... ..,._."__. 2.000 004 ...._ , _ X PRO- C r�`_Y}j • COMPATE PR IOP AGG 000 $2,000,000 Ir POLICY LOC JECT ... � A AUTOMOBILE LIABILITY BA -7N173419 10!3112020 10/31OME /2021 C�BVc DrSINGLE, LIMIT $1 0 $,000^00 ANY AUTO BODILY OWNED SCHEDULED BODILY accident) AS ONLY AUTOS REDNON-OWNED ' TfAk�%�V�EP .Y._$ „ .._...,_.._...... ...._......_... ,._ AUTOS ONLY AUTOS ONLY $ A X LIAB yI OCCUR,CUP-9J209005 10/31/2020 10/3112021 ACN OC URRENC'E 0EXCESS jIIIUMBRELLA LiAB AGGREGATE �S �,.00_.�0..,.,0_0,_..._, _ .._..... . ^ ^ NS WORKDED ERS COMPENSATION Y A WORKERS COMP NA TION UB3R155740 8/27/2020 8/27/2021 STMi1j,F v EP AND YIN I ANYPROPRIETORWAR1gNEWEXt;%,UTIVE .V, - OFPri 9Rt MEEREXCLUDED? ❑ N!A (Mandatory In In NH)E E.L. DISEASE -EA ... .. EMPLOYEE _. __ if ns. describeuner if os. ., ION OF OPERATION'S below L. D SEASE ., LIMIT 1 51.000,000 DESCRIPTION OF OPERATIONS i LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schoduro, may he ottachod if more $Paco is required) The City of El Segundo, its officers, agents, and employees are added as additional insureds on the general liability policy only per the attached. Waiver of Subrogation is Included in the general liability and Work comp policies only per the attached forms. CERTIFICATE HOLDER City of El Segundo Public Works Dept. 350 Main St. EI Segundo CA 90245 ACORD 25 (2016/03) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BATE THEREOF', NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORISED REPRESENTATIVE ©1988-2015 AC g . .. ORD CORPORA7iON...AB rights reserved. The ACORD name and logo are registered marks of ACORD 630-8J664090 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (Includes Products -Completed Operations If Required By Contract) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that you agree in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only: a. With respect to liability for "bodily injury" or "property damage" that occurs, or for "personal injury" caused by an offense that is committed, subsequent to the signing of that contract or agreement and while that part of the contract or agreement is in effect; and b. If, and only to the extent that, such injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the written contract or agreement applies. Such person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. The insurance provided to such additional insured is subject to the following provisions: a. If the Limits of Insurance of this Coverage Part shown in the Declarations exceed the minimum limits required by the written contract or agreement, the insurance provided to the additional insured will be limited to such minimum required limits. For the purposes of determining whether this limitation applies, the minimum limits required by the written contract or agreement will be considered to include the minimum limits of any Umbrella or Excess liability coverage required for the additional insured by that written contract or agreement. This provision will not increase the limits of insurance described in Section III — Limits Of Insurance. (1) Any "bodily injury", "property damage" or "personal injury" arising out of the providing, or failure to provide, 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 or change orders, or the preparing, approving, or failing to prepare or approve, drawings and specifications; and (b) Supervisory, inspection, architectural or engineering activities. (2) Any "bodily injury" or "property damage" caused by "your work" and included in the "products -completed operations hazard" unless the written contract or agreement specifically requires you to provide such coverage for that additional insured during the policy period. c. The additional insured must comply with the following duties: (1) Give us written notice as soon as practicable of an 'occurrence" or an offense which may result in a claim. To the extent possible, such notice should include: (a) How, when and where the 'occurrence" or offense took place; (b) The names and addresses of any injured persons and witnesses; and (c) The nature and location of any injury or damage arising out of the 'occurrence" or offense. b. The insurance provided to such additional (2) If a claim is made or "suit" is brought against insured does not apply to: the additional insured: CG D2 46 0419 ® 2018 The Travelers Indemnity Company. All rights reserved, Page 1 of 2 51761205 119-20 CL, Aulo, Umb, WC I Katherine Dumatol 10/11/2019 11:40:36 AM (PDT) I Page 8 or 10 COMMERCIAL GENERAL LIABILITY (a) Immediately record the specifics of the claim or "suit" and the date received; and (b) Notify us as soon as practicable and see to it that we receive written notice of the claim or "suit" as soon as practicable. (3) Immediately send us copies of all legal papers received in connection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. (4) Tender the defense and indemnity of any claim or "suit" to any provider of other insurance which would cover such additional insured for a loss we cover. However, this condition does not affect whether the insurance provided to such additional insured is primary to other insurance available to such additional insured which covers that person or organization as a named insured as described in Paragraph 4., Other Insurance, of Section IV — Commercial General Liability Conditions. Page 2 of 2 ® 2016 The Travelers Indemnity Company. All rights reserved. 51761205119-20 GL, Auto, Umb, WC I Katherine Dumatol 110/11/2019 11:48:36 AM (PDT) I Page 9 of 10 CG D2 46 0419 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTEND ENDORSEMENT FOR MANUFACTURERS ANI WHOLESALERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to The extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. Who Is An Insured — Unnamed Subsidiaries B. Who Is An Insured — Employees And Volunteer Workers — Bodily Injury To Co -Employees And Co -Volunteer Workers C. Who Is An Insured — Newly Acquired Or Formed Limited Liability Companies D. Blanket Additional Insured — Broad Form Vendors E. Blanket Additional Insured — Controlling Interest F. Blanket Additional Insured — Mortgagees, Assignees, Successors Or Receivers G. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Premises PROVISIONS A. WHO IS AN INSURED — UNNAMED SUBSIDIARIES The following is added to SECTION 11 — WHO IS AN INSURED: Any of your subsidiaries, other than a partnership or joint venture, that is not shown as a Named Insured in the Declarations is a Named Insured if: a. You are the sole owner of, or maintain an ownership interest of more than 50% in, such subsidiary on the first day of the policy period; and b. Such subsidiary is not an insured under similar other insurance. No such subsidiary is an insured for "bodily injury" or '°property damage" that occurred, or "personal and advertising injury" caused by an offense committed: H. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Operations 1. Blanket Additional Insured — Grantors Of Franchises J. Incidental Medical Malpractice K. Medical Payments — Increased Limit L. Blanket Waiver Of Subrogation M. Contractual Liability — Railroads a. Before you maintained an ownership interest of more than 50% in such subsidiary; or b. After the date, if any, during the policy period that you no longer maintain an ownership interest of more than 50% in such subsidiary. For purposes of Paragraph 1. of Section 11— Who Is An Insured, each such subsidiary will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that govern its structure. CG D4 58 02 19 0 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 5 Includes copyrighted material of Insurance Services Office, Inc, with its permission COMMERCIAL GENERAL LIABILITY B. WHO IS AN INSURED — EMPLOYEES AND VOLUNTEER WORKERS — BODILY INJURY TO CO -EMPLOYEES AND CO -VOLUNTEER WORKERS The following is added to Paragraph 2.a.(1) of SECTION 11 — WHO IS AN INSURED: Paragraphs (1)(a), (b) and (c) above do not apply to "'bodily injury" to a co -""employee'" while in the course of the co -"employee's" employment by you or performing duties related to the conduct of your business, or to "bodily injury" to your other "volunteer workers"' while performing duties related to the conduct of your business, C. WHO IS AN INSURED — NEWLY ACQUIRED OR FORMED LIMITED LIABILITY COMPANIES The following replaces Paragraph 3. of SECTION 11— WHO IS AN INSURED: 3. Any organization you newly acquire or form, other than a partnership or joint venture, and of Which you are the sole owner or, in which you maintain an ownership interest of more than 50%, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only: (1) Until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier, if you do not report such organization in writing to us within 180 days after you acquire or form it; or (2) Until the end of the policy period, when that date is later than 180 days after you acquire or form such organization, if you report such organization in writing to us within 180 days after you acquire or form it; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury' arising out of an offense committed before you acquired or formed the org.nization, For the purposes of Paragraph 1, of Section 11 — Who Is An Insured, each such organization Will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization, other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that govern its structure. D. BLANKET ADDITIONAL INSURED — BROAD FORM VENDORS The following is added to SECTION 11— WHO IS AN INSURED: Any person or organization that is a vendor and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury' or "property damage" that: a. Occurs subsequent to the signing of that contract or agreement; and b. Arises out of "your products" that are distributed or sold in the regular course of such vendors business. The insurance provided to such vendor is subject to the following provisions: a. The limits of insurance provided to such vendor will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. b. The insurance provided to such vendor does not apply to: (1) Any express warranty not authorized by you or any distribution or sale for a purpose not authorized by you; (2) Any change in "your products" made by such vendor; (3) Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; (4) Any failure to make such inspections, adjustments, tests or servicing as vendors agree to perform or normally undertake to perform in the regular course of business, in connection with the distribution or sale of "your products"; Page 2 of 5 0 2017 The Traveters Indemnity Company, Ali rights reserved, CG D4 58 02 19 Includes copyrighted material of Insurance Services Office, Inc. with Its permission (6) Demonstration, installation, servicing or repair operations, except such operations performed at such, vendor's premises in connection with the sale of "your products"; or (6) "Your products" that, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or on behalf of such vendor. Coverage under this provision does not apply to: a. Any person or organization from whom you have acquired "your products", or any ingredient, part or container entering into, accompanying or containing such products; or b. Any vendor for which coverage as an additional insured specifically is scheduled by endorsement. E. BLANKET ADDITIONAL INSURED — CONTROLLING INTEREST 1. The following is added to SECTION 11 — WHO IS AN INSURED: Any person or organization that has financial control of you is an insured with respect to liability for "bodily injury", "property damage"' or "'personal and advertising injury"' that arises out of: a. Such financial control; or b. Such person's or organization's ownership, maintenance or use of premises leased to or occupied by you. The insurance provided to such person or organization does not apply to structural alterations, new construction or demolition operations performed by or on behalf of such person or organization. G 2. The following is added to Paragraph 4. of SECTION 11— WHO IS AN INSURED: This paragraph does not apply to any premises owner, manager or lessor that has financial control of you. F. BLANKET ADDITIONAL INSURED — MORTGAGEES, ASSIGNEES, SUCCESSORS OR RECEIVERS The following is added to SECTION 11 — WHO IS AN INSURED: Any person or organization that is a mortgagee, assignee, successor or receiver and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to its COMMERCIAL GENERAL LIABILITY liability as mortgagee, assignee, successor or receiver for "bodily injury", "property damage" or "personal and advertising injury" that: a. Is "bodily injury" or "property damage" that occurs, or is "personal and advertising injury' caused by an offense that is committed, subsequent to the signing of that contract or agreement; and b. Arises out of the ownership, maintenance or use of the premises for which that mortgagee, assignee, successor or receiver is required under that contract or agreement to be included as an additional insured on this Coverage Part. The insurance provided to such mortgagee, assignee, successor or receiver is subject to the following provisions: a. The limits of insurance provided to such mortgagee, assignee, successor or receiver will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. b. The insurance provided to such person or organization does not apply to: (1) Any "bodily injury" or "property damage" that occurs, or any "personal and advertising injury" caused by an offense that is committed, after such contract or agreement is no longer in effect; or (2) Any "bodily iniLify", "property damage" or "personal and advertising injury"' arising out of any structural alterations, new construction or demolition operations performed by or on behalf of such mortgagee, assignee, successor or receiver. BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO PREMISES The following is added to SECTION 11 — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to premises owned or occupied by, or rented or loaned to, you and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage or "personal and advertising injury" arising out of the existence, ownership, use, maintenance, repair, construction, erection or removal of any of the following for which that governmental entity has CG D4 68 02 19 0 2017 TheTravelers Indemnity company. All rights reserved. Page 3 of 5 Includes copyrighted material of Insurance Services office, Inc, with its permission COMMERCIAL GENERAL LIABILITY issued such permit or authorization: advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, elevators, street banners or decorations. H BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO OPER- ATIONS The following is added to SECTION 11— WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to operations performed by you or on your behalf and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of such operations. The insurance provided to such governmental entity does not apply to: a. Any "bodily injur)(, "property damage" or "personal and advertising injury" arising out of operations performed for the governmental entity; or b. Any "bodily injury" or "property damage" included in the "products -completed operations hazard". 1. BLANKET ADDITIONAL INSURED — GRANTORS OF FRANCHISES The following is added to SECTION III — WHO IS AN INSURED: Any person or organization that grants a franchise to you is an insured, but only with respect to liability for "bodily injury", "property damage" or '"personal and advertising injury" arising out of your operations in the franchise granted by that person or organization. services", first aid or "Good Samaritan services" to a person, unless you are in the business or occupation of providing professional health care services. 2. The following replaces the last paragraph of Paragraph 2.a.(I) of SECTION 11 — WHO IS AN INSURED: Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury" arising out of providing or failing to provide: (a) "Incidental medical services" by any of your "employees" who is a nurse, nurse assistant, emergency medical technician, paramedic, athletic trainer, audiologist, dietician, nutritionist, occupational therapist or occupational therapy assistant, physical therapist or speech- language pathologist; or (b) First aid or "Good Samaritan services" by any of your "employees" or "volunteer workers", other than an employed or volunteer doctor. Any such "employees" or "volunteer workers" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed to be acting within the scope of their employment by you or performing duties related to the conduct of your business. 3. The following replaces the last sentence of Paragraph 5. of SECTION III — LIMITS OF INSURANCE: If a written contract or agreement exists between you and such additional insured, the limits of insurance provided to such insured will be the 4. minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. J. INCIDENTAL MEDICAL MALPRACTICE For the purposes of determining the applicable Each Occurrence Limit, all related acts or omissions committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to any one person will be deemed to be one "occurrence". The following exclusion is added to Paragraph 2., Exclusions, of SECTION I — COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY: 1. The following replaces Paragraph b. of the Sale Of Pharmaceuticals definition of "occurrence" in the "Bodily injury' or "property damage" arising DEFINITIONS Section: out of the violation of a penal statute or b. An act or omission committed in providing ordinance relating to the sale of or failing to provide "incidental medical pharmaceuticals committed by, or with the knowledge or consent of, the insured. Page 4 of 5 C 2017 The Travelers Indemnity Company. All rights reserved, CG D4 58 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission 5. The following is added to the DEFINITIONS Section: "Incidental medical services" means: a. Medical, surgical, dental, laboratory, x-ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; or b. The furnishing or dispensing of drugs or medical, dental, or surgical supplies or appliances. 6. The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: This insurance is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to any of your "employees" for "bodily injury" that arises out of providing or failing to provide "incidental medical services" to any person to the extent not subject to Paragraph 2.a.(I) of Section 11 — Who Is An Insured. K. MEDICAL PAYMENTS — INCREASED LIMIT The following replaces Paragraph 7. of SECTION III — LIMITS OF INSURANCE: 7. Subject to Paragraph 6. above, the Medical Expense, Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person, and will be the higher of: COMMERCIAL GENERAL LIABILITY a. $10,000; or b. The amount shown in the Declarations of this Coverage Part for Medical Expense Limit. L. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If the insured has agreed in a contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: a. "Bodily injury" or "property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the execution of the contract or agreement. M. CONTRACTUAL LIABILITY — RAILROADS 1. The following replaces Paragraph c. of the definition of "insured contract" in the DEFINITIONS Section: c. Any easement or license agreement; 2. Paragraph L(11) of the definition of "insured contract" in the DEFINITIONS Section is deleted. CG D4 68 0219 0 2017 The Travelers Indemnity Company. All rights reserved. Page 5 of 5 Includes copyrighted material of Insurance Services Office, Inc. with its permission A011111k WORKERS COMPENSATION TRAVELERSJ AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A) — POLICY NUMBER: WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSRED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER 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 Policy No. Endorsement No. Insured Premium Insurance Company Travelers Property Casualty Countersigned by Company of America DATE OF ISSUE: ST ASSIGN: Page 1 of 1