Loading...
PROOF OF INSURANCE (2022 - 2023) CLOSEDA DATE (MMIDDIYYYY) CC) CERTIFICATE OF LIABILITY INSURANCE 3/28/2022 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 NAMl Katie Snell InterWest Insurance Services, LLC PHONE FAX P.O. Box 8110 E �� pXt)- 916-60978374 (A. Noi 916-609-8374 (A'& IC Chico CA 95927-8110 ADDRESS ksnell@imjns.com INSURED American Asphalt South, Inc. PO Box 310036 Fontana CA 92331 AMERASP-02 COVERAGES CERTIFICATE NUMBER: r,74Fg1gq REVISION NUMBER! NAIC # 12262 25674 10172 11150 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. -,,,,,,,. ,,,,, ......,,,,,,,, ,,,, w... YLTR. .... TYPEOFINSURANCE..... .... INSD SIIBR POLICYNUM.BER. PO PO MNOI/DDYIYYYY LIMITS LTR A X COMMERCIAL GENERAL LIABILITY Y Y 3021011368497 12/31/2021 12/31/2022 EACH OCCURRENCE $1,000,000 ,.., ........ .,....... ,.,... _,� -_ ...... yYAI�IAGE 1$,� I�F(�i160p . CLAIMS -MADE X OCCUR PRLewMtlSES,B=�a us.( urtr�av'I.C,1 w . . MED EXP (Any one person) $ 10,000 PERSONAL $. ADV INJURY $ 1,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000„000 POLICY X JECT ....J IL.00 PRODUCTS COMP(OP AGG S 2,000,000 07HE'Ra $ A _AUTOMOBILE LIABILITY Y Y 1521011368497 12/31/2021 12/31/2022 COMMNEDSINGLE OMIT $1,000,000 X ANY AUTO BODILY INJURY (Per person) $� OWNED SCHEDULED AUTOS ONLY AUTOS (Per accien} BODILY INJURYS Pdt X HIRED X NON -OWNED '"ROPrRIW fAA9m1AG.I,.� "-- AUTOS ONLY L.....,mm AUTOS ONLY ,..lyl^);eP tt'.oCIurIY1e®,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, .. B X UMBRELLA LIAB X OCCUR ZUP71M8933021 12/31/2021 12/31/2022 EACH OCCURRENCE S6,000,000 EXCESS LAB i.. CLAIMS -MADE AGGREGATE S 6.000.000 DCO REENTION $ S li WORKERS COMPENSATION ZAWC19413905 4/1/2022 4/1/2023 X PER OTH AND EMPLOYERS' LIABILITY YIN STATUTE ER" ANYPROPRIETORIPARTNER/EXECUTIVE E L EACH ACCIDENT $ 1,000 000 OFFICEPJMEMBER EXCLUDED? ❑ ..NIA ... -.. ..... ......... ....... (Mandatory in NH) EL DISEASE- EA EMPLOYEE S1,000,000 If yes, describe under --- -- -...... DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT $ 1.000.000 C Pollution Liability G70915613003 8/27/2020 8/27/2022 Each Pollution Condit 2,000,000 Aggregate Limit 2,000,000 Deductible 10,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Additional Insured status applies to requested entities, if required by written contract, per the attached policy forms/endorsements. Waiver of subrogation applies to requested entities, if required by written contract, per the attached policy forms/endorsements. Primary non-contributory applies to requested entities, if required by written contract, per the attached policy forms/endorsements. Re: Project #PW19-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of El Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the attached endorsement. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation per the attached endorsements. l:tK 111-1k A I t: MULUtK City of El Segundo Public Works Department Engineering Division 350 Main Street El Segundo CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTH RI2CD REPRESENTATIVE r� ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 3021011368497 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 SCHEDULE Name Of Additional Insured Person(s) Or Organ izations : Location And Description Of Completed Operations As required by written contract. If required by your As Required by Written Contract agreement with such Additional Insured, this Insurance shall be primary insurance and non-contributory for that Additional Insured. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured, then this insurance will apply as outlined in SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph 4, Other Insurance, subpara- graph c., Method of Sharing. The Inclusion of one or more Insured under the terms of this endorsement does not increase our limits of liability. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" 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". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 Policy Number:3021011368497 Effective Date: 3/28/2022 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Locations Of Covered Operations As required by written contract. If required by your agree- As Required by Written Contract. ment with such Additional Insured, this Insurance shall be primary insurance and non-contributory for that Additional Insured. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured, then this insur- ance will apply as outlined in SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph 4, Other Insurance, subparagraph c., Method of Sharing. The Inclu- sion of one or more Insured under the terms of this endorse- ment does not increase our limits of liability,_ 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 or- ganization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property dam- age" 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(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or re- pairs) to be performed by or on behalf of the ad- ditional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 Policy Number:3021011368497 COMMERCIAL GENERAL LIABILITY CG2001 1219 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 LIQUOR 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 This insurance is primary to and will not seek additional insured. 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 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 AGENT Westchester A Chubb Company ADDITIONAL INSURED ENDORSEMENT — PRODUCTS -COMPLETED OPERATIONS HAZARD Named Insured ................�� �.. ._ _.......................................................................... _. Endorsement Number ...........­...___­- 11 American Asphalt South, Inc. Policy —Policy Number Policy Period Effective Date Symbol G70915613 m003 8/27/2020 To 8/27/2022 WWW m W W W W mmmmmmmmmmmmmmm m8/27/2020 of Endorsement W S m �.CP... Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the police number, The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Nktnic of 1'ct:mtiit r r, ml' � � : lrw akiaa't'. As required by written contract or agreement signed by both parties prior to a loss to which this insurance applies. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 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 injury or damage, to which this insurance applies, caused by or resulting from your work performed for that additional insured and included in the products -completed operations hazard, and only to the extent that such injury or damage is caused, in whole or in part, by your negligence or the negligence of those acting on your behalf. However: i. 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. 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: i. 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. All other terms and conditions of this policy remain unchanged. ENV-3251 (12/18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page t of i (22uot2.2) Westchester A Chubb Company ADDITIONAL INSURED ENDORSEMENT — ONGOING WORK OR OPERATIONS Nar Wi'nsured��............. ........................................_ ...� ...Endorseme.n�t..rnbe Nu�� �rm.. American ....... m Asphalt South, Inc. Policy Symbol Policy Number �.......��.........�.........Policy ..Period Effecti��....... ..._.."......... . . a-t-e ve Date of Endorsement CPW G70915613 003 8/27/2020 To 8/27/2022 8/27/2020 Issued By (Name of Insurance C_..._........... .... � -------------- ......................_.__.. Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE: As required by written contractor agreement signed by both parties prior to a loss to which this insurance ipplies. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II - WHO IS AN INSURED is amended to include as an additional insured the persons or organizations shown in the Schedule, but only with respect to liability for injury or damage, to which this insurance applies, 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 insureds. However: i. The insurance afforded to such additional insured only applies to the extent permitted bylaw; 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. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: Exclusions This insurance does not apply to injury or damage occurring after: a. All work or operations, including materials, parts or equipment furnished in connection with such work or operations, on the project (other than service, maintenance or repairs) to be performed by you or on your behalf at the site of the covered operations has been completed; or ENV-3250 (12/18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page i of 2 (22ioi2.1) Westchester A Chubb Company 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 the additional insured 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: 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. All other terms and conditions of this policy remain unchanged. ENV-3250 (12/18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 2 of 2 (221012.1) Westchester A Chubb Company PRIMARY AND NONCONTRIBUTORY — OTHER INSURANCE CONDITION Named Insured - ��......� - ..�_ ...��..�..... �...... wwww � �-.._._............ .�...�.. ................... r Endorsement Number American Asphalt South, Inc. icy ,,,,....... G70915613 003 _.. _. / /20�.........._ To 8 �27 /2022 ��_..._ ............. B27 2 20 ... CPlSymbol Policy Number 8 Policy 27od Effective of Endorsement Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert thepolicynumber. The remainder of the informa tion is to be completed only when this endorsement is issued subsequent to the preparation of the policy„ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary and Noncontributory Insurance This policy is primary to, and will not seek contribution from, any other insurance available to an additional insured under this policy, provided that: a. The additional insured is a named insured under such other insurance; and b. The named insured has agreed in a written contract or agreement that this insurance would: (i) act as primary insurance; and (2) would not seek contribution from any other insurance available to the additional insured. All other terms and conditions of this policy remain unchanged. ENV-3253 (12-18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of i (266562.2) WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US -Named _...__...�________... ....���..........� """"° Endorsement Number American Asphalt South, Inc. Policy Symbol Policy Number Policy Period .................._........ ..,........................................,......................,........................................,.................. Effective Date..�of Endorsement... CPW G70915613 003 8/27/2020 To 8/27/2022 8/27/2020 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: 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. All other terms and conditions remain the same. ENV-3143 (03-05) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 POLICY NUMBER:1521011368497 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured:American Asphalt South, Inc. Endorsement Effective Date: 12/31/2021 SCHEDULE Name Of Person(s) Or Organization(s): As required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in ParagraphA.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. © Insurance Services Office, Inc. POLICY NUMBER:1521011368497 COMMERCIAL AUTO CA 04 49 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONICONTRIBUTORY- OT E INSURANCE CONDITION This endorsement modifies insurance provided under the following; AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance — Primary And Excess Insurance Provisions in the Motor Carrier Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage is primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that: 1. Such "insured" is a Named Insured under such other insurance; and 2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured". B. The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage and General Liability Coverages are primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that: 1. Such "insured" is a Named Insured under such other insurance; and 2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured". CA 04 49 11 16 © Insurance Services Office, Inc., 2016 Page 1 of 1 POLICY NUMBER: 1521011368497 COMMERCIAL AUTO CA04441013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Asphalt S ................ ._ Named Insured: American As ..................,_ p South, Inc. Endorsement Effective Date:12/31 /2021 SCHEDULE Name(s) Of Person(s) Or Organization(s): As required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident' or the 'loss" under a contract with that person or organization. CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER:3021011368497 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: Where required by written contract or Agreement. 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 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO 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 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be INCL % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION WHERE ALL JOBS UNDER CONTRACT WAIVER OF OUR RIGHT TO RECOVER IS PERMITTED BY LAW AND IS REQUIRED BY WRITTEN CONTRACT PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO DATE OF LOSS 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 04-01-2022 Policy No. ZAWCI9413905 Endorsement No. Insured AMERICAN ASPHALT REPAIR Insurance Company ARCH INSURANCE COMPANY Countersigned By ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. Premium $ INCL.