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PROOF OF INSURANCE (2025 - 2025) CLOSED (2)0 DATE (MM/DD/YYYY)
+" CERTIFICATE OF LIABILITY INSURANCE1 9/18/2024
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 Tom Belding _
Arthur J. Gallagher Risk Management Services, LLC (PHON9 X rA
NAMEA w •
500 N Brand Boulevard, Suite 100 g Ig Nay
Glendale CA 91203 EMAIL
rI) 714 ...1 0 {A/
ADDR�s� Tom BaIIn com .� -_
INSURER-(3) AFFORDING COVERAGE NAIC #
...
Licensed OD$,_ 99� INSURER a Travelers Propert y Casualty Co of America_1111 25674
INSURED
Consulting, Inc.
RTicoNs-01 INsuRER•,B Republic Indemnity Company of California 43753ww
8325 McConnell Ave.m.._..__ arty Company _•••,• m m .„_ w a2374
INSURERO HoustonCasu,
Los Angeles, CA 90045 D: INSURER
_..._. .._..............- _ � .- ....... .
INSURER E :
COVERAGES CERTIFICATE NUMBER:84896445 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
m.. e........ .
IIV5F1 .. ......TYPEOFINSURANCE..�,,.., ...... MO1L'SOr f$ .,.�,.._.. POLIC.,..._ m.....,.,. IMMI DIYY' � ---POLICY EXP•
LTR ..YNUMBER MM/DOIYYYY MM/OOlYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY Y Y 6809H2765932447 3/30/2024 3/30/2025 EACH OCCURRENCE $2.000.000
X occuR ?•. E�niSE_(Fa ocpw�enca), $11,000,000
ca�r4o�rt� iil�N"rI_r9
CLAIMS -MADE Ii
MED EXP (Any one person) $10,000 .„
_. ._.. _
PERSONAL & ADV INJURY $ 2,000,000
GEN L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $4000000
_ POLICY PE LOC RODUCTS COMP/OP AGG $ 4 000 000
P.ITm .,.� .._...._
OTHER; I I I $
A AUTOMOBILE LIABILITY Y Y BA-1S98785A-24-47-G 9/12/2024 9/12/2025 ,Or B'INED ING E LIMIT $1 000 000
LE'a euceldenl@.__._ _ ,...- ..—........,.�.,--,,.-._ _ .....
X ANY AUTO BODILY INJURY (Per person) $
- SCHEDULED BODILY INJURY
(Per
_ �•• m
AUTOS ONLY AUTOS ONLY t URY (Per accident) $
OWNED
ONLY ........._ _.,.-,.. AUTOS ...
HIRED NON -OWNED ,n
f'ROX"LR�'Y DAMAGT. $
PprarCo.nm*. ......
$
00 000
A UMBRELLA LIAB X _ OCCUR Y Y CUP4W7386532447 3I30I2024 3/30I2025 EACH OCCURRENCE
X EXCESS LIAB CLAIMS -MADE AGGREGATE $ 2 000 000
......... ...... ,. .�.-. ., ........ ._ .........._ _........ a. .._w.,-., ...
0ED RETENTION$ $
B WORKERS COMPENSATION 25580603 6/1/2024 6/1/2025 X H
AND EMPLOYERS' LIABILITYYIN ___ STE;RATETUETR
ANYPROPRIETOR/PARTNER/EXECUTIVE -- N /A E.L.EACH ACCIDENT $1,000,000
OFFICE(Mandatory
InNEXCLUDED7 E.L DISEASE - EA EMPLOYEE $ 1,000 000 —., (Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000
C Professional Liability HCC2425759 6/25/2024 6/2512025 Per Claim $1,500,000
Aggregate $3,000,000
Retention $10,000
DESCRIPTION'. OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks'Sohadulq maybe attached if more space is required)
EMPLOYMENT PRACTICES LIABILITY INSURANCE - HOUSTON CASUALTY COMPANY - POLICY # H723-936250 - 10/4/2023-10/4/2024 - $1,000,000
EACH CLAIM LIMIT $1,000,000 AGGREGATE LIMIT.
CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED (GENERAL LIABILITY) PER BLANKET ADDITIONAL INSURED
UB
ARCHITECTS,(SENGINEERS AND SURVEYORS) FORM CG D3 8109 15. PRIMARY & NON-OONTMUTORY AND WAIVER OF
ROGATION WHEN REQUIRED BY CONTRACT, DESIGNATED PERSON OR ORGANIZATION — NOTICE OF CANCELLATION OR
NONRENEWAL PROVIDED BY US (30 DAYS) FORM IL T4 00 05 19. CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED (AUTO
LIABILITY) PER AUTO COVERAGE PLUS ENDORSEMENT CA T4 20 02 15. DESIGNATED PERSON OR ORGANIZATION — NOTICE OF CANCELLATION
See Attached...
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
THE CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS.
350 MAIN STREET
EL SEGUNDO CA 90245 AUTHORIZEDREP ESENTATIVE
USA
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LOC #:
ADDITIONAL REMARKS SCHEDULE Page 1 of 1
AGENCY NAMEDINSURED
Arthur J. Gallagher Risk Management Services, LLC RTI Consulting, Inc.
8325 McConnell Ave.
POLICY NUMBER Los Angeles, CA 90045
CARRIER I NAIC CODE
EFFECTIVE DATE:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ..
OR NONRENEWAL PROVIDED BY US (30 DAYS FORM IL T4 00 05
ICY INCLUDES BLANKET WAIVER OF OUR
RIGHTS TO RECOVER FROM OTHERS E'NDOR 19. WORKERS COMPENSATION POLEMENT WC 00 03 13 (Ed. 04-84).
Project: Park Vista Senior Living Center Plumbing Upgrade - 615 East Holly Ave, El Segundo, CA 90245.
ACORD 101 (2008/01) 0 ZUUU AtwUrsu l.;UHI UHA I wrv. All ngnza reserveu.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LOC #:
ADDITIONAL REMARKS SCHEDULE Page 1 of 1
AGENCY NAMED INSURED
Arthur J„ Gallagher Risk Management Services, LLC RTI Consulting, Inc.
8325 McConnell Ave.
POLICY NUMBER I Los Angeles, CA 90045
CARRIER [',, NAIC CODE
EFFECTIVE DATE:
It1 N] I] I I Lou G11
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE _
OR NONRENEWAL PROVIDED BY US (30 DAYS FORM IL T4 00 05 19. WORKER'S COMPENSATION POLICY INCLUDES BLANKET WAIVER OF OUR
RIGHTS TO RECOVER FROM OTHERS ENDOR EMENT WC 00 03 13 (Ed 04.84).
CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL, INSURED (GENERAL LIABILIY) PER BLANKET ADDITIONAL INSURED (ARCHITECTS,
ENGINEERS AND SURVEYORS) FORM CG D3 81 0915. PRIMARY & NON-CONTIBUTORY AND WAIVER OF SUBROGATION WHEN REQUIRED BY
CONTRACT, CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL. INSURED (AUTO LIABILIY) PER AUTO COVERAGE PLUS ENDORSEMENT CA T4 20
02 15. WORKERS COMPENSATION POLICY INCLUDES BLANKET WAIVER OF OUR RIGHTS TO RECOVER FROM OTHERS ENDORSEMENT WC 00 03
13 (Ed. 04-84).
ACORD 101
© 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LOC #:
ADDITIONAL REMARKS SCHEDULE
AGENCY
Arthur J. Gallagher Risk Management Services, LLC
POLICY NUMBER
CARRIER
NAIC CODE
NAMED INSURED
RTI Consulting, Inc.
8325 McConnell Ave.
Los Angeles, CA 90045
EFFECTIVE DATE:
Page 1 of 1
ACORD 101 (200$101) © 2008 ACORD CORPORATION. All flgnts reservea.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LOC #:
ADDITIONAL REMARKS SCHEDULE
AGENCY
Arthur J. Gallagher Risk Management Services, LLC
POLICY NUMBER
CARRIER
NAIC CODE
NAMED INSURED
RTI Consulting, Inc.
8325 McConnell Ave.
Los Angeles, CA 90045
EFFECTIVE DATE:
Page 1 of 1
ACORD 101 (2008/01) c9 2UU8 AcoF1U QaaHFUHA I IUN.. AN rlgnis reserves.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LAC #:
ADDITIONAL REMARKS SCHEDULE
AGENCY
Arthur J. Gallagher Risk Management Services, LLC
POLICY NUMBER
CARRIER
NAIC CODE
NAMED INSURED
RTI Consulting, Inc.
8325 McConnell Ave.
Los Angeles, CA 90045
EFFECTIVE DATE:
Page 1 of
ACORD 101 (2008101) © 2008 ACORD COHPUHATIUN. All rignis reservea.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LOC #:
ADDITIONAL REMARKS SCHEDULE
AGENCY
Arthur J. Gallagher Risk Management Services, LLC
POLICY NUMBER
CARRIER
NAIC CODE
NAMED INSURED
RTI Consulting, Inc.
8325 McConnell Ave.
Los Angeles, CA 90045
EFFECTIVE DATE:
Page 1 of 1
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LOC M:
ADDITIONAL REMARKS SCHEDULE
AGENCY NAMED INSURED
Arthur J. Gallagher Risk Management Services, LLC RTI Consulting, Inc.
8325 McConnell Ave.
POLICY NUMBER Los Angeles, CA 90045
CARRIER I NAIC CODE
EFFECTIVE DATE:
Page 1 of
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: RTICONS-01
LOC #:
ADDITIONAL REMARKS SCHEDULE
AGENCY
Arthur J. Gallagher Risk Management Services, LLC
POLICY NUMBER
CARRIER
NAIC CODE
NAMED INSURED
RTI Consulting, Inc.
8325 McConnell Ave.
Los Angeles, CA 90045
EFFECTIVE DATE:
Page 1 of
ACORD 101 (2008/01) U 200$ ACURU WHFUHAI IUIV. AN rlgnis reservea.
The ACORD name and logo are registered marks of ACORD
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AUTO COVERAGE LUS ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
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 the 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 cover-
age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. BLANKET ADDITIONAL INSURED
B. EMPLOYEE HIRED AUTO
C. EMPLOYEES AS INSURED
D. SUPPLEMENTARY PAYMENTS — INCREASED
LIMITS
E. TRAILERS — INCREASED LOAD CAPACITY
F. HIRED AUTO PHYSICAL DAMAGE
G. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES — INCREASED LIMIT
A. BLANKET ADDITIONAL INSURED
The following is added to Paragraph A.1., Who Is
An Insured, of SECTION 11— COVERED AUTOS
LIABILITY COVERAGE:
Any person or organization who is required under
a written contract or agreement between you and
that person or organization, that is signed and
executed by you before the "bodily injury" or
"property damage" occurs and that is in effect
during the policy period, to be named as an addi-
tional insured is an "insured" for Covered Autos
Liability Coverage, but only for damages to which
this insurance applies and only to the extent that
person or organization qualifies as an "insured"
under the Who Is An Insured provision contained
in Section II.
B. EMPLOYEE HIRED AUTO
1. The following is added to Paragraph A.1.,
Who Is An Insured, of SECTION 11 — COV-
ERED AUTOS LIABILITY COVERAGE:
An "employee" of yours is an "insured" while
operating a covered "auto" hired or rented
under a contract or agreement in an "em-
ployee's" name, with your permission, while
CA T4 20 02 15
H. AUDIO, VISUAL AND DATA ELECTRONIC
EQUIPMENT — INCREASED LIMIT
I. WAIVER OF DEDUCTIBLE — GLASS
J. PERSONAL PROPERTY
K. AIRBAGS
L. AUTO LOAN LEASE GAP
M. BLANKET WAIVER OF SUBROGATION
performing duties related to the conduct of
your business.
2. The following replaces Paragraph b. in B.5.,
Other Insurance, of SECTION IV — BUSI-
NESS AUTO CONDITIONS:
b. For Hired Auto Physical Damage Cover-
age, the following are deemed to be cov-
ered "autos" you own:
(1) Any covered "auto" you lease, hire,
rent or borrow; and
(2) Any covered "auto" hired or rented by
your "employee" under a contract in
an "employee's" name, with your
permission, while performing duties
related to the conduct of your busi-
ness.
However, any "auto" that is leased, hired,
rented or borrowed with a driver is not a
covered "auto".
C. EMPLOYEES AS INSURED
The following is added to Paragraph A.1., Who Is
An Insured, of SECTION II — COVERED AUTOS
LIABILITY COVERAGE:
© 2015 The Travelers Indemnity Company. Al rights reserved, Page 1 of 3
Includes copyrighted material of Insurance Services Office, Inc. with Its permission.
IIfl/`1 `00DE, (",lick herofol,nIole!1d011ruatlull
COMMERCIAL AUTO
Any "employee" of yours is an "insured" while us-
ing a covered "auto" you don't own, hire or borrow
in your business or your personal affairs.
D. SUPPLEMENTARY PAYMENTS — INCREASED
LIMITS
1. The following replaces Paragraph A.2.a.(2) of
SECTION 11— COVERED AUTOS LIABILITY
COVERAGE:
(2) Up to $3,000 for cost of bail bonds (in-
cluding bonds for related traffic law viola-
tions) required because of an "accident"
we cover. We do not have to furnish
these bonds.
2. The following replaces Paragraph A.2.a.(4) of
SECTION li — COVERED AUTOS LIABILITY
COVERAGE:
(4) All reasonable expenses incurred by the
"insured" at our request, including actual
loss of earnings up to $500 a day be-
cause of time off from work.
E. TRAILERS — INCREASED LOAD CAPACITY
The following replaces Paragraph C.I. of SEC-
TION I — COVERED AUTOS:
1. "Trailers" with a load capacity of 3,000
pounds or less designed primarily for travel
on public roads.
F. HIRED AUTO PHYSICAL DAMAGE
The following is added to Paragraph AA., Cover-
age Extensions, of SECTION III — PHYSICAL
DAMAGE COVERAGE:
Hired Auto Physical Damage Coverage
If 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 the Physical Damage Cover-
age is extended to "autos" that you hire, rent or
borrow subject to the following:
(1) The most we will pay for "loss" to any one
"auto" that you hire, rent or borrow is the
lesser of:
(a) $50,000;
(b) The actual cash value of the damaged or
stolen property as of the time of the
"loss"; or
(c) The cost of repairing or replacing the
damaged or stolen property with other
property of like kind and quality.
Page 2 of 3
(2) An adjustment for depreciation and physical
condition will be made in determining actual
cash value in the event of a total "loss".
(3) If a repair or replacement results in better
than like kind or quality, we will not pay for the
amount of betterment.
(4) A deductible equal to the highest Physical
Damage deductible applicable to any owned
covered "auto".
(5) This Coverage Extension does not apply to:
(a) Any "auto" that is hired, rented or bor-
rowed with a driver; or
(b) Any "auto" that is hired, rented or bor-
rowed from your "employee".
G. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES — INCREASED LIMIT
The following replaces the first sentence in Para-
graph A.4.a., Transportation Expenses, of
SECTION III — PHYSICAL DAMAGE COVER-
AGE:
We will pay up to $50 per day to a maximum of
$1,500 for temporary transportation expense in-
curred by you because of the total theft of a cov-
ered "auto" of the private passenger type.
H. AUDIO, VISUAL AND DATA ELECTRONIC
EQUIPMENT — INCREASED LIMIT
Paragraph C.1.b. of SECTION III — PHYSICAL
DAMAGE COVERAGE is deleted.
I. WAIVER OF DEDUCTIBLE — GLASS
The following is added to Paragraph D., Deducti-
ble, of SECTION III — PHYSICAL DAMAGE
COVERAGE:
No deductible for a covered "auto" will apply to
glass damage if the glass is repaired rather than
replaced.
J. PERSONAL PROPERTY
The following is added to Paragraph AA., Cover-
age Extensions, of SECTION III — PHYSICAL
DAMAGE COVERAGE:
Personal Property Coverage
We will pay up to $400 for "loss" to wearing ap-
parel and other personal property which is:
(1) Owned by an "insured"; and
(2) In or on your covered "auto".
This coverage only applies in the event of a total
theft of your covered "auto".
No deductibles apply to Personal Property cover-
age.
m 2015 The Travelers Indemnity Company. Al rights reserved. CA T4 20 02 15
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
I
1R1r1.MODE Click 11cre folrinor inToliriadori
K. AIRBAGS
The following is added to Paragraph B.3., Exclu-
sions, of SECTION III — PHYSICAL DAMAGE
COVERAGE:
Exclusion 3.a. does not apply to 'loss" to one or
more airbags in a covered "auto" you own that in-
flate due to a cause other than a cause of 'loss"
set forth in Paragraphs A.1.b. and A.1.c., but
only:
a. If that "auto" is a covered "auto" for Compre-
hensive Coverage under this policy;
b. The airbags are not covered under any war-
ranty; and
c. The airbags were not intentionally inflated.
We will pay up to a maximum of $1,000 for any
one "loss".
L. AUTO LOAN LEASE GAP
The following is added to Paragraph AA., Cover-
age Extensions, of SECTION III — PHYSICAL
DAMAGE COVERAGE:
Auto Loan Lease Gap Coverage for Private
Passenger Type Vehicles
In the event of a total "loss" to a covered "auto" of
the private passenger type shown in the Schedule
or Declarations for which Physical Damage Cov-
erage is provided, we will pay any unpaid amount
due on the lease or loan for such covered "auto"
less the following:
(1) The amount paid under the Physical Damage
Coverage Section of the policy for that "auto';
and
CA T4 20 02 15
COMMERCIAL AUTO
(2) Any:
(a) Overdue lease or loan payments at the
time of the loss';
(b) Financial penalties imposed under a
lease for excessive use, abnormal wear
and tear or high mileage;
(c) Security deposits not returned by the les-
sor;
(d) Costs for extended warranties, Credit Life
Insurance, Health, Accident or Disability
Insurance purchased with the loan or
lease; and
(e) Carry-over balances from previous loans
or leases.
M. BLANKET WAIVER OF SUBROGATION
The following replaces Paragraph A.S., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV — BUSINESS AUTO CONDI-
TIONS:
S. Transfer Of Rights Of Recovery Against
Others To Us
We waive any right of recovery we may have
against any person or organization to the ex-
tent required of you by a written contract exe-
cuted prior to any "accident" or 'loss", pro-
vided that the "accident" or "loss" arises out of
the operations contemplated by such con-
tract. The waiver applies only to the person or
organization designated in such contract.
© 2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 3
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
l"I"'kl//I 1w:)cnf Cl, ci',iiuo ho7 in ioLfrninalilnn
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
(ARCHITECTS, ENGINEERS AND SURVEYORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. The following is added to SECTION II — WHO IS
AN INSURED:
Any person or organization that you agree in a
"written contract requiring insurance" to include as
an additional insured on this Coverage Part, but:
a. Only with respect to liability for "bodily injury",
"property damage" or "personal injury"; and
b. If, and only to the extent that, the 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
requiring insurance" applies, or in connection
with premises owned by or rented to you.
The person or organization does not qualify as an
additional insured:
c. With respect to the independent acts or
omissions of such person or organization; or
d. For "bodily injury", "property damage" or
"personal injury" for which such person or
organization has assumed liability in a
contract or agreement.
The insurance provided to such additional insured
is limited as follows:
e. This insurance does not apply on any basis to
any person or organization for which
coverage as an additional insured specifically
is added by another endorsement to this
Coverage Part.
f. This insurance does not apply to the
rendering of or failure to render any
"professional services".
g. In the event that the Limits of Insurance of the
Coverage Part shown in the Declarations
exceed the limits of liability required by the
"written contract requiring insurance", the
insurance provided to the additional insured
shall be limited to the limits of liability required
by that "written contract requiring insurance".
This endorsement does not increase the
limits of insurance described in Section III —
Limits Of Insurance.
h. This insurance does not apply to "bodily
injury" or "property damage" caused by "your
work" and included in the "products -
completed operations hazard" unless the
"written contract requiring insurance"
specifically requires you to provide such
coverage for that additional insured, and then
the insurance provided to the additional
insured applies only to such "bodily injury" or
"property damage" that occurs before the end
of the period of time for which the "written
contract requiring insurance" requires you to
provide such coverage or the end of the
policy period, whichever is earlier.
2. The following is added to Paragraph 4.a. of
SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS:
The insurance provided to the additional insured
is excess over any valid and collectible other
insurance, whether primary, excess, contingent or
on any other basis, that is available to the
additional insured for a loss we cover. However, if
you specifically agree in the "written contract
requiring insurance" that this insurance provided
to the additional insured under this Coverage Part
must apply on a primary basis or a primary and
non-contributory basis, this insurance is primary
to other insurance available to the additional
insured which covers that person or organizations
as a named insured for such loss, and we will not
share with the other insurance, provided that:
(1) The "bodily injury" or "property damage" for
which coverage is sought occurs; and
(2) The "personal injury" for which coverage is
sought arises out of an offense committed;
after you have signed that "written contract
requiring insurance". But this insurance provided
to the additional insured still is excess over valid
and collectible other insurance, whether primary,
excess, contingent or on any other basis, that is
available to the additional insured when that
person or organization is an additional insured
under any other insurance.
CG D3 81 0915 © 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 2
Includes the copyrighted material of Insurance Services Office, Inc., with its permission
COMMERCIAL GENERAL LIABILITY
The following is added to Paragraph 8., Transfer
Of Rights Of Recovery Against Others To Us,
Of SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS::
We waive any right of recovery we may have
against any person or organization because of
Payments we make for "bodily Injury"„ itpropertydamage" or "personal injury" arising Out of "Your
work" performed by you, or on your behalf, done
tinder a "written contract requiring insurance" with
that person or organization. We waive this right
only where you have agreed to do so as part of
the "written contract requiring insurance" with
such person or organization signed by yotu
before, and in effect when, the "bodily injury" or
""property damage" occurs, or the "personal injury'
offense is committed.
4. The following definition is added to the
DEFINITIONS Section:
"Written contract requiring insurance" means that
Part of any written contract under which you are
required to include a person or organization as an
additional insured oil this Coverage Pad"
Provided that the "bodily Injury"" and "property
damage" occurs and the "personal injury" is
caused by an offense committed.
a. After you have signed that written contract;
b. While that part of the written contract is in
effect; and
c. Before the end of the policy period.
Page 2 of 2 © 2015 The Travelers Indemnity Company. All rights reserved. Includes the copyrighted material of Insurance Services Office, Inc., with its permission CG D3 81 0915
POLICY NUMBER: 690-9H276593-24-47
ISSUE DATE: 02/14/2024
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED PERSON OR ORGANIZATION
E OF
CANCELLATION O IOI E E L PROVIDED TIC
Y US
This endorsement modifies insurance provided under the following:
ALL COVERAGE PARTS INCLUDED IN THIS POLICY
CANCELLATION: SCHEDULE
Number of Days Notice: 30
WHEN WE DO NOT RENEW (Nonrenewal):
PERSON OR
ORGANIZATION:
Number of Days Notice: 30
ANY PERSON OR ORGANIZATION TO
HAVE AGREED IN A WRITTEN WHOm YOU
CONTRACT
NOTICEOF
CANCELLATIon OR r
rNLY POLICYWILL Bx CIVEN, BUT
1• YOU SEND US A WRITTEN REQUEST TO
PROVIDE SUCH NOTICE„ INCLUDING THE
NAME AND ADDRESS 'op SUCH PERSON OR
ORGANIZATION, AFTER THE FIRST NAMED
INSURED RECEIVES NOTICE FROM US OF
THE CANCELLATION OR XONRENEWAL OF THIS
2. WE RECEIVE SUCH WRITTEN REQUEST AT
LEAST 14 DAYS BEFORE THE BEGINNING OF
THE APPLICABLE E'R OF DAYS SHOWN
IN THIS SCHEDULE.
ADDRESS:
THE ADDRESSFOR THAT PERSON OR ORGANIZ-
ATION INCLUDED IN SUCH WRITTEN REQUEST
FROM YOU TO US.
PROVISIONS
A. If we cancel this policy for any legally permitted
reason other than nonpayment of premium, and a
number of days is shown for Cancellation in the
Schedule above, we will mail notice of
cancellation to the person or organization shown
in such Schedule. We will mail such notice to the
address shown in the Schedule above at least the
number of days shown for Cancellation in.such
Schedule before the effective date of cancellation.
IL T4 00 05 19
POLICY; AND
B. If we do not renew this policy for any legally
permitted reason other than nonpayment of
Premium, and a number of days is shown for
When We Do Not Renew (Nonrenewal) in the
Schedule above, we will mail notice of
nonrenewal to the person or organization shown
in such .Schedule. We will mail such notice to the
address shown in the Schedule above at least the
number of days shown for When We Do Not
Renew (Nonrenewal) in such Schedule before the
effective date of nonrenewal.
© 2019 The Travelers Indemnity Company. All rights reserved.
Page 1 of 1
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 04-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
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.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
State
Person or Organization
.......
Job Description
California
All persons or organizations
All jobs whom the Named
whom the Named Insured has
Insured has agreed by written
agreed by written contract to
contract to furnish this waiver.
furnish this waiver.
The charge for this endorsement shall be 3% of total manual premium, subject to a minimum premium of $100.
This charge will be billed on your next invoice based on current manual premium, and the final charge will be
calculated and billed at the final audit.
WC000313
(Ed.04-84)
1 of 2
Insured Copy
0 1983 National Council on Compensation Insurance.