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PROOF OF INSURANCE (2025)WILLPIP-02
.44c"R"" DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 8/27/2024
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 (PNAME;HONE T Lisa Ybarra
CONTACT
LYbair�ra acr
Acrisure Southwest Partners Insurance Services, LLC 51 I N�,) ( ) 965
4000 Westerly Place 0 EXt) (714) 516 2976 FAX 714 516 2
Suite 110 AIaxFR LYbairra@acrisure.com
Newport Beach, CA 92660 , QiiRFRtsr eFFnwnwr. r0VFRnr,F I NAIC p
INsuRER A ..T...he Travelers indemnity Company of Connecticu
t !25682
......_.. --l",I
INSURED INSURERB Travelers Property Casualty of America �25674 ............
m-----..._ ....,.
Williams Pipeline Contractors, Inc. wsuRI w c . .......
P.O. Box 951030 INSURER w
Mission Hills, CA 91395
[INSURER E ............. 11 .,.... _ �,-,�, ,,,, ....... ..,....... _.
_ INSURER F :
COVERAGES CERTIFICATE NUMBER: ......._ REVISION NUMB..._
ER:
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. _
A X I COMM ii
TYPE OF IN GENERAL LIABILITY ADDL�SU 0 _.. ............ .. . 1_(M�, YY ....... LIMITS
COMMERCIAL R� POLICY NUMBER POLICY EFF POLICY EXP
„ ,,,.... INSD_. 01'.,XYY.I EACH OCCURRENCE
1,000,000
CLAIMS MA I Xi OCCUR X 4T22COOP182323TCT24 911/2024 9/1/2025 DAMAGE TO RENTED 300 OOCI
J'b1t B QA ��I rJ t . 1
j�,AAED EXP_LAny onepe sar )$ ... 5 000
GEN L AGGREGATE...... I ........ ..... i
PERSONAL $ ADV (JURY $ 000 000,
rENERALAGGREG2,000,000
fPLIMIT APPLIES PER: I GRODUCTSCOMP OP AGG ,$ 2,000 000
POLICY X JE' LOC P, �....... , .. ...... ......,
OTHER! �rr $ 1,000 000
COMBINE
A X.TANYYAUEOLIABILITY X 8104NO58682242SG 9/1/2024 9/1/2025 -BODILY JU Y,(P per,son) $ ..F . � $
OWNED - SCHEDULED
AUTOS ONLY .1 AUTOS
... t
BODILYINJI Y(Peacc.denNI
X,NON-OWNEDPER
'ONLY
AUTOS ONLY , ...
� 1
UMBRELLA LAB OCCUR EACH OCCURRENCE $ „-
...._ EXCESS LIAB ............ .. �,-CLAIMS-MADE AGGREGATE ..... _ $ ,.
I DED RETENTION $
WOREERS COMPENSATION .. � P.TAT ITE _ l FRPER H �..�
B ANYDPROPRIEEOR/PARTNER/EXECUTIVE I �NIA� X 'UB4J573465242SG 9/1/2024 9/1/2025 X Ep,CHAGCIDENT_ � $ 1,000 000
�OY='q^IC..EPiF4v71';`MBER EXCLUDED?
1,000,006
andalM In NH) E L DISEASE EA EMPLOYEE $, .,,
If f 1
_I es describe under
DESCRIPTION OF OPERATIONS below 1 ;,,,,,,,,, �,,,,,,„„„„„„„„„„„, I EL DISEASE POLICY„LIMIT $ 1,000000
I � 1
�......m. _........ ....... _. [ .._........m.. ........ ........_...__.... _........._
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES MD
101, Additional Remarks Schedule, maybe attached if more space is required)
RE: EMERGENCY ,STORM DRAIN REPAIR AT GftAND AVE. AND INDIANA ST,, PROJECT NO.: PW 24.11. CITY OF EL SEGUNDO, ITS OFFICIALS AND
EMPLOYEES ARE NAMED AS ADDITIONAL INSURED AND PRIMARY 8: NON-CONTRIBUTORY AS RESPECTS GENERAL LIABILITY AND AUTO LIABILITY PER
ENDORSEMENTS ATTACHED. WORKERS COMPENSATION WAIVER OF SUBROGATION APPLIES PER ENDORSEMENT ATTACHED.
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
EL SEGUNDO, CA 90245 _. -------_--
AUTHORIZED REPRESENTATIVE
:
Im ......,............._....-....................._� ��..,._.........._...._
ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
WILLPIP-02 _..._.,..ITIT LYBA13RA
A+I}2 DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE DATE
024
...._ .._.. _ ........
_[
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_.
a. .. _ .... ................_ ....... ......... ........ _ ..
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(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 ofsuchendorsements)
...........
PRODUCER NAMF Lisa Ybarra
CONTACT
...,.. ,,,,,
Acrisure Southwest Partners Insurance Services, LLC PHONe 16 2976c Nr�(714) 516 2965
4000 Westerly Place E d(AIC. No EXI): (714) 5
Sul rt A4 " s LYb--IN URER{�S) AF ,ORp NG COVER.AG. ,
Newport Beach, CA 92660 � E NAIL # ,
®I INSURER Travelers Indemnity Company of Connecticut I1
25682 1
INSURED �INSueeRcTravelers Propa Casual Company of America 25674
Williams Pipeline Contractors, Inc.
P.O. Box 951030 lNsuRElx D
Mission Hills, CA 91395
INSURER E ,.. ., ...... .....-.. ....w .. ,.... .INSURER .,.
F: ....__..,,,,,,..�...... .� ...........
......... ........�..... ........ .......,,,�.�.�...-. ............. ..._,_
OVERAGES !, 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.
I A Xy �.p R POLICY nn POLICY EXP IS
T.t.,... -,,,,�____a,,,,,,..._.,��pMIDD,l1iY`!Xi � 6M1M�1.,1� - ��A��A4aE p'CF RENTED
TYPE OF INSURANCE POLICY NUMBER LIMIT 1,000,000
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
l CLAIMS -MADE X occuR 4T22COOP182323TCT24 9/1/2024 9/1/2025 300 060
fM1S 3(C�aauwa�rVS
�.__, � � �, X X L MED EXP (Anyone Fersgn) ,,,�L$.. 1 5,000
ERSONAL 8 ADV IN,�URY 1,000,000
CiI;,Mp.A43GRkIroATELIMIT APPLIES PER: I PRODUCTS, COMPIO.. �$ 2,000000
�f _GENERAL AGGREGATE _
----------------
POLICY X Pkd " LOC P, AGG „
2 000,000
A X AUTOMOBILE
ABILITY �-------------- COMOINEDSINGLE LIMIT $ 1000000
'
1 �8104N058682242SG 9/1/2024 9/1/2025 poplLY INduRY (Perperson)
OWNED SCHEDULED
1 HIRED Nt3N-rr� NE ODILY INJURY (Per ac..... ) �
AUTOS ONLY AUi0�5�NL I ROPE,RT^I I P4IMAGE .. .
X AUTOS ONLY wX .: AUTOS .... .......... I�d.r aucll9d raC, ..
EXCESS LA LIAR ..-_ ..00CUR -- 1 EGG _QWEGATE RENCE �.�.............
UMBRELLA
LIAB i CLAIMS MADE AACH OCCU
rDE'D...._.....-........ .............. .. I ... ... � $
B -----
WORKERSI RETENTION $ 1 I _ $ ......-
COMPENSATION +/' d C�, XTATUT 1 .ERH .. m... ------
AND EMPLOYERS' LIABILITY /1 /2025 1,000, 000
ANY PROPRIETOR/PARTNER/EXECUTIVE L EACH ACCIDENT $ ___
'I(fFY'NC ERIM�FMBER EXCLUDED? `; N/A'1,000,000
yesdesc,ribefuoder 1 %� UB4J573465242SG 9/1/2024 9 1 E,,;L DISEASE EAEMPL,CYEEa $,..., - 1,000,000
IDESC'RI,PTION,RE_gFFRAT40NSk�elaw..,.,,,w,,..... ......._. E.L DISEASE-POLICY.LIIMIT $ ........,-,,,,
.......................................... .............
...... ._
DESCRIPVON OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, AddVtlonal Remarks Schedule, may be aalloched if more space is re udred)
RE: PROJECT #ENG 24-32 ON -CALL SEWER SYSTEMS MAINTENANCE AND REPAIR SERVICES. CITY OF ELEGUNDO, ITS OFFICIALS AND EMPLOYEES
ARE NAMED AS ADDITIONAL INSURED, PRIMARY 8r NON-CONTRIBUTORY AND WAIVER OF SUBROGATION AS RESPECTS TO GENERAL LIABILITY PER
ENDORSEMENTS ATTACHED. WORKERS COMPENSATION WAIVER OF SUBROGATION APPLIES PER ENDORSEMENT ATTACHED.
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.
PUBLIC WORKS
350 MAIN STREET
EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE
_... _..,,,,_ _ ............. ..........
ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
WILLPIP-02 FLAK
,4coRo CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY)
�� 8127I2024
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 ha
ve 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 L
RAWL-PHONE.,. FAX
Acrisure Southwest Partners Insurance Services, LLC i1 516 2965
4000 Westerly Place A Ex. �714 516 29.— IAJC No}
Suite 110 AQPRE$ �E MAIL .1111 a@acrisure.com
LYba: �,.... e _ .. ,,.
Newport Beach, CA 92660 INQ1IRF1al CI AFFn RnINP. r'nVFRAGF NAIC A
; " Travelers any of Connecticut
..
------
INSURED Travelers Company of America
Williams Pipeline Contractors, Inc. INSURERc.., _
P.O. Box 951030 INSURER..0: _
Mission Hills, CA 91395 i INSURER E
COVERAGES _CERTIFICATE NUMBER _ ....................... ., REVISION NUMBE......
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.
INSRI TYPE OF INSURANCE "�ADDUL�SUR� .,.,., _._. �.. POLICY EFF POLICY EXP LIMITS "
POLICY NUMBER
E71,000 000
A X D $ 5,000
COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE _
one ersan 000
CLAIMS -MADE X ( OCCUR X X 4T22COOP182323TCT24 9/1/2024 91112125 1 D1�MAGE T R ���ld�Pn�el � 1 000
1 DAMAGE TO RENTED 300 000
} ED EXP {,'4?a' P )
..,.,E ..... I GENERAL A 000,000
ADV INJURY 2,000 000
G NL A¢'GRFGATE LIMIT APPLIES PER: �, GGREGATE, $
�.,.__..... POLICY "G J8.r LOC �,"J?RODUCTS,-„COMP(OP AGG 1 $ ............ ".'. ...,
0"fH'ER ___ .....".. 5 ......v.......
...._ _.._.......................................� ......... (, _ I .. m.........,. _._....... 0 ANY AUTO 058682242SG-���9/1/2024 9/1/2025 BooSLv �DIINCLLIIMgT 1 000„000
A J X TOMOBILE LIABILITY
AUTOS ONLY AUTOS ... ..._ (. p m
OWNED SCHEDULED ODILY INJ _ B P $GMt 4i.!q
URY Per er
{� r"lPERTY 'RY Peracr $ ..,
X U
...AUTOS ONLY A "i.y"a" O,Y I I AMAOE
i 7
�X HIRED N WN er 7ca,rdeer?,�, ............ .... ,,,,,,,.. ...
�..,
....-„_.ter.®.. _ ......, j J ................,......,.._ .......,_. .
G, ....... UMBRELLA IAB
EXESS ABCLAIMS MADE €
..--- ...
"
DED J RETENTION $ _ $
AND EMPLOYERS'
' EXCLUDED Y � N NIA ...�� "" ���11
WORKERS COMPENSATION U641 J573465242$G 9/1/2024 9/1/2025 XTATTE EBH I1 1
,AND EMPLOYERS' LIABILITY ;
ANY PROPRIETOR/PARTNER/EXECUTIVE IY X I E.L EACH ACCIDENT '000 000
B W _____I
1f es, dtory in NH) E.L DISEASE -POLICY LIMIT
Q'MI E EA EMPLOYEE.I $ , ,-
Y�s, describe under 1,000,000
DESCRIPTION OF OPERATIONS helot ........ � _ ...._. � P.L DISEAS f-�...... ...IT...... ITIT..
1 _.....
RE: PROJECT # OPERATIONS I
24-33 LOCATIONS
O.S . dd ._ .� _ is re
O S I VEHICLES (ACORD 101, Additional Re-rl+a!rks Schedule, may be attached if more space is re utlrad
ON -CALL WATER SYSTEMS MAINTENANCE AND REPAIR SERVICES. CITY OF EL E"&NDO, ITS OFFICIALS AND EMPLOYEES
ARE NAMED AS ADDITIONAL INSURED, PRIMARY & NON-CONTRIBUTORY AND WAIVER OF SUBROGATION AS RESPECTS TO GENERAL LIABILITY PER
ENDORSEMENTS ATTACHED. WORKERS COMPENSATION WAIVER OF SUBROGATION APPLIES PER ENDORSEMENT ATTACHED.
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.
PUBLIC WORKS
350 MAIN STREET .....
EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE
........................... _....... ...... ................
ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
NAMED INSURED: WILLIAMS PIPELINE CONTRACTORS, INC..
POLICY NUMBER: 422TCOOP182323TCT24 COMMERCIAL GENERAL LIABILITY
POLICY TERM: 09/01/2024 TO 09/01/2025
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
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 © 2018 The Travelers Indemnity Company. All rights reserved. CG D2 46 0419
NAMED INSURED: WILLIAMS PIPELINE CONTRACTORS, INC. POLICY #422TCOOP182323TCT24 POLICY TERM: 09/01/2024 - 09/01/2025
COMMERCIAL GENERAL LIABILITY
c. Method Of Sharing
If all of the other insurance permits contribution
by equal shares, we will follow this method also.
Under this approach each insurer contributes
equal amounts until it has paid its applicable
limit of insurance or none of the loss remains,
whichever comes first.
If any of the other insurance does not permit
contribution by equal shares, we will contribute
by limits. Under this method, each insurers
share is based on the ratio of its applicable limit
of insurance to the total applicable limits of
insurance of all insurers.
.--------------- >d. Primary And Non -Contributory Insurance If
Required By Written Contract
If you specifically agree in a written contract or
agreement that the insurance afforded to an
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 that is available to such insured
which covers such insured as a named insured,
and we will not share with that other insurance,
provided that:
(1) The "bodily injury" or "property damage" for
which coverage is sought occurs; and
(2) The "personal and advertising injury" for
which coverage is sought is caused by an
offense that is committed;
subsequent to the signing of that contract or
agreement by you.
5. Premium Audit
a. We will compute all premiums for this Coverage
Part in accordance with our rules and rates.
b. Premium shown in this Coverage Part as
advance premium is a deposit premium only. At
the close of each audit period we will compute
the earned premium for that period and send
notice to the first Named Insured. The due date
for audit and retrospective premiums is the date
shown as the due date on the bill. If the sum of
the advance and audit premiums paid for the
policy period is greater than the earned
premium, we will return the excess to the first
Named Insured.
PRIMARY & NON-CONTRIBUTORY
a. The statements in the Declarations are
accurate and complete;
b. Those statements are based upon
representations you made to us; and
c. We have issued this policy in reliance upon
your representations.
The unintentional omission of, or unintentional error
in, any information provided by you which we relied
upon in issuing this policy will not prejudice your
rights under this insurance. However, this provision
does not affect our right to collect additional
premium or to exercise our rights of cancellation or
nonrenewal in accordance with applicable insurance
laws or regulations.
7. Separation Of Insureds
Except with respect to the Limits of Insurance, and
any rights or duties specifically assigned in this
Coverage Part to the first Named Insured, this
insurance applies:
a. As if each Named Insured were the only
Named Insured; and
b. Separately to each insured against whom claim
is made or "suit" is brought.
8. Transfer Of Rights Of Recovery Against Others
To Us
If the insured has rights to recover all or part of any
payment we have made under this Coverage Part,
those rights are transferred to us. The insured must
do nothing after loss to impair them. At our request,
the insured will bring "suit" or transfer those rights
to us and help us enforce them.
9. When We Do Not Renew
If we decide not to renew this Coverage Part, we will
mail or deliver to the first Named Insured shown in
the Declarations written notice of the nonrenewal
not less than 30 days before the expiration date.
If notice is mailed, proof of mailing will be sufficient
proof of notice.
SECTION V — DEFINITIONS
1. "Advertisement" means a notice that is broadcast or
published to the general public or specific market
segments about your goods, products or services
for the purpose of attracting customers or
supporters. For the purposes of this definition:
c. The first Named Insured must keep records of a. Notices that are published include material
the information we need for premium placed on the Internet or on similar electronic
computation, and send us copies at such times means of communication; and
as we may request. b. Regarding websites, only that part of a website
6. Representations that is about your goods, products or services
By accepting this policy, you agree: for the purposes of attracting customers or
supporters is considered an advertisement.
Page 16 Of 21 © 2017 The Travelers Indemnity Company. All rights reserved. CG T1 00 02 19
Includes copyrighted material of Insurance Services Office, Inc. with its permission,
NAMED INSURED: WILLIAMS PIPELINE CONTRACTORS, INC.
POLICY NUMBER: 422TCOOP182323TCT24
POLICY TERM: 09/01/2024 - 09/01/2025 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
XTEND ENDORSEMENT FOR CONTRACTORS
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. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Operations
PROVISIONS
A. WHO IS AN INSURED — UNNAMED
SUBSIDIARIES
C. Incidental Medical Malpractice
D. Blanket Waiver Of Subrogation
E. Contractual Liability —Railroads
F. Damage To Premises Rented To You
The following is added to SECTION II — WHO IS
AN INSURED:
Any of your subsidiaries, other than a partnership, B.
joint venture or limited liability company, 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:
a. Before you maintained an ownership interest
of more than 50% in such subsidiary; or
a. An organization other than a partnership, joint
venture or limited liability company; or
b. A trust;
as indicated in its name or the documents that
govern its structure.
BLANKET ADDITIONAL INSURED — <.......
GOVERNMENTAL ENTITIES — PERMITS OR
AUTHORIZATIONS RELATING TO OPERATIONS
The following is added to SECTION II — 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:
b. After the date, if any, during the policy period a. Any "bodily injury', "property damage" or
that you no longer maintain an ownership "personal and advertising injury" arising out of
interest of more than 50% in such subsidiary. operations performed for the governmental
For purposes of Paragraph 1. of Section II — Who entity; or
Is An Insured, each such subsidiary will be b. Any "bodily injury" or "property damage"
deemed to be designated in the Declarations as: included in the "products -completed
operations hazard".
CG D3 16 02 19 © 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 3
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COMMERCIAL GENERAL LIABILITY
C. INCIDENTAL MEDICAL MALPRACTICE
1. The following replaces Paragraph b. of the
definition of "occurrence" in the
DEFINITIONS Section:
b. An act or omission committed in providing
or failing to provide "incidental medical
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.(1) of SECTION II — 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
or paramedic; 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:
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".
pharmaceuticals committed by, or with the
knowledge or consent of, the insured.
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.(1) of Section II — Who Is An
Insured.
D. BLANKET WAIVER OF SUBROGATION ............a
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;
4. The following exclusion is added to subsequent to the execution of the contract or
Paragraph 2., Exclusions, of SECTION I — agreement.
COVERAGES — COVERAGE A — BODILY E. CONTRACTUAL LIABILITY — RAILROADS —
INJURY AND PROPERTY DAMAGE
LIABILITY: 1. The following replaces Paragraph c. of the
Sale Of Pharmaceuticals definition of "insured contract" in the
"Bodily injury" or "property damage" arising DEFINITIONS Section:
out of the violation of a penal statute or c. Any easement or license agreement;
ordinance relating to the sale of
Page 2 of 3 © 2017 The Travelers Indemnity Company. All rights reserved. CG D3 16 02 19
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COMMERCIAL GENERAL LIABILITY
2. Paragraph f.(1) of the definition of "insured a. Any premises while rented to you or
contract" in the DEFINITIONS Section is temporarily occupied by you with permission
deleted. of the owner; or
F. DAMAGE TO PREMISES RENTED TO YOU b. The contents of any premises while such
The following replaces the definition of "premises premises is rented to you, if you rent such
damage" in the DEFINITIONS Section: premises for a period of seven or fewer
consecutive days.
"Premises damage" means "property damage" to:
CG D3 16 02 19 © 2017 The Travelers Indemnity Company. All rights reserved. Page 3 of 3
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
NAMED INSURED: WILLIAMS PIPELINE CONTRACTORS, INC.
POLICY NUMBER: 8104NO58682422SG
POLICY TERM: 09/01/2024 TO 09/01/2025
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXTENSION 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. BROAD FORM NAMED INSURED
B. BLANKET ADDITIONAL INSURED
C. EMPLOYEE HIRED AUTO
D. EMPLOYEES AS INSURED
E. SUPPLEMENTARY PAYMENTS —INCREASED
LIMITS
F. HIRED AUTO — LIMITED WORLDWIDE COV-
ERAGE — INDEMNITY BASIS
G. WAIVER OF DEDUCTIBLE — GLASS
PROVISIONS
A. BROAD FORM NAMED INSURED
The following is added to Paragraph A.1., Who Is
An Insured, of SECTION II — COVERED AUTOS
LIABILITY COVERAGE:
Any organization you newly acquire or form dur-
ing the policy period over which you maintain
50% or more ownership interest and that is not
separately insured for Business Auto Coverage.
Coverage under this provision is afforded only un-
til the 180th day after you acquire or form the or-
ganization or the end of the policy period, which-
ever is earlier.
B. BLANKET ADDITIONAL INSURED
The following is added to Paragraph c. in A.1.,
Who Is An Insured, of SECTION II — 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
H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF
USE — INCREASED LIMIT
I. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES — INCREASED LIMIT
J. PERSONAL PROPERTY
K. AIRBAGS
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
M. BLANKET WAIVER OF SUBROGATION
N. UNINTENTIONAL ERRORS OR OMISSIONS
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.
C. EMPLOYEE HIRED AUTO
1. The following is added to Paragraph A.1.,
Who Is An Insured, of SECTION II — COV-
ERED AUTOS LIABILITY COVERAGE:
An "employee" of yours is an "insured" while
operating an "auto" hired or rented under a
contract or agreement in an "employee's"
name, with your permission, while performing
duties related to the conduct of your busi-
ness.
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
CA T3 53 02 15 © 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 4
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
permission, while performing duties
(a) With respect to any claim made or "suit"
related to the conduct of your busi-
brought outside the United States of
ness.
America, the territories and possessions
However, any "auto" that is leased, hired,
of the United States of America, Puerto
rented or borrowed with a driver is not a
Rico and Canada:
covered "auto".
(i) You must arrange to defend the "in-
D. EMPLOYEES AS INSURED
sured" against, and investigate or set-
tle any such claim or "suit" and keep
The following is added to Paragraph A.1., Who Is
us advised of all proceedings and ac-
An Insured, of SECTION II — COVERED AUTOS
tions.
LIABILITY COVERAGE:
(ii) Neither you nor any other involved
Any "employee" of yours is an "insured" while us-
"insured" will make any settlement
ing a covered "auto" you don't own, hire or borrow
without our consent.
in your business or your personal affairs.
(iii) may, at our discretion, participate
E. SUPPLEMENTARY PAYMENTS — INCREASED
in defending the "insured" against, or
in
LIMITS
in the settlement of, any claim or
1. The following replaces Paragraph A.2.a.(2),
"suit".
of SECTION II — COVERED AUTOS LIABIL-
(iv) We will reimburse the "insured" for
ITY COVERAGE:
sums that the "insured" legally must
(2) Up to $3,000 for cost of bail bonds (in-
pay as damages because of "bodily
cluding bonds for related traffic law viola-
injury" or "property damage" to which
tions) required because of an "accident"
this insurance applies, that the "in -
we cover. We do not have to furnish
sured" pays with our consent, but
these bonds.
only up to the limit described in Para-
2. The following replaces Paragraph A.2.a.(4),
graph C., Limits Of Insurance, of
of SECTION II — COVERED AUTOS LIABIL-
SECTION II — COVERED AUTOS
ITY COVERAGE:
LIABILITY COVERAGE.
(4) All reasonable expenses incurred by the
(v) We will reimburse the "insured" for
"insured" at our request, including actual
the reasonable expenses incurred
loss of earnings up to $500 a day be-
with our consent for your investiga-
cause of time off from work.
tion of such claims and your defense
of the "insured" against any such
F. HIRED AUTO — LIMITED WORLDWIDE COV-
"suit", but only up to and included
ERAGE — INDEMNITY BASIS
within the limit described in Para -
The following replaces Subparagraph (5) in Para-
graph C., Limits Of Insurance, of
graph B.7., Policy Period, Coverage Territory,
SECTION II — COVERED AUTOS
of SECTION IV — BUSINESS AUTO CONDI-
LIABILITY COVERAGE, and not in
TIONS:
addition to such limit. Our duty to
(5) Anywhere in the world, except any country or
make such payments ends when we
jurisdiction while any trade sanction, em-
have used up the applicable limit of
bargo, or similar regulation imposed by the
insurance in payments for damages,
United States of America applies to and pro-
settlements or defense expenses.
hibits the transaction of business with or
(b) This insurance is excess over any valid
within such country or jurisdiction, for Cov-
and collectible other insurance available
ered Autos Liability Coverage for any covered
to the "insured" whether primary, excess,
"auto" that you lease, hire, rent or borrow
contingent or on any other basis.
without a driver for a period of 30 days or less
(c) This insurance is not a substitute for re -
and that is not an "auto" you lease, hire, rent
uired or compulsory insurance in an
or borrow from any of your "employees",
country outside the United States, its ter -
partners (if you are a partnership), members
ritories and possessions, Puerto Rico and
(if you are a limited liability company) or
Canada.
members of their households.
Page 2 of 4 © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
You agree to maintain all required or
compulsory insurance in any such coun-
try up to the minimum limits required by
local law. Your failure to comply with
compulsory insurance requirements will
not invalidate the coverage afforded by
this policy, but we will only be liable to the
same extent we would have been liable
had you complied with the compulsory in-
surance requirements.
(d) It is understood that we are not an admit-
ted or authorized insurer outside the
United States of America, its territories
and possessions, Puerto Rico and Can-
ada. We assume no responsibility for the
furnishing of certificates of insurance, or
for compliance in any way with the laws
of other countries relating to insurance.
G. 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.
H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF
USE — INCREASED LIMIT
The following replaces the last sentence of Para-
graph A.4.b., Loss Of Use Expenses, of SEC-
TION III — PHYSICAL DAMAGE COVERAGE:
However, the most we will pay for any expenses
for loss of use is $65 per day, to a maximum of
$750 for any one "accident".
I. 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.
J. PERSONAL PROPERTY
COMMERCIAL AUTO
(2) In or on your covered "auto".
This coverage applies only in the event of a total
theft of your covered "auto".
No deductibles apply to this Personal Property
coverage.
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. NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
The following is added to Paragraph A.2.a., of
SECTION IV — BUSINESS AUTO CONDITIONS:
Your duty to give us or our authorized representa-
tive prompt notice of the "accident" or "loss" ap-
plies only when the "accident" or "loss" is known
to:
(a) You (if you are an individual);
(b) A partner (if you are a partnership);
(c) A member (if you are a limited liability com-
pany);
(d) An executive officer, director or insurance
manager (if you are a corporation or other or-
ganization); or
(e) Any "employee" authorized by you to give no-
tice of the "accident" or "loss".
M. BLANKET WAIVER OF'SUBROGATION
The following replaces Paragraph A.5., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV — BUSINESS AUTO CONDI-
TIONS:
The following is added to Paragraph A.4., Cover- S. Transfer Of Rights Of Recovery Against
age Extensions, of SECTION III — PHYSICAL Others To Us
DAMAGE COVERAGE: We waive any right of recovery we may have
Personal Property against any person or organization to the ex -
We will a u to $400 for "loss" to wearing a tent required of you by a written contract
pay P 9 P- signed and executed prior to any accident
parel and other personal property which is: or "loss", provided that the "accident" or "loss"
(1) Owned by an "insured"; and arises out of operations contemplated by
CA T3 53 02 15 © 2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 4
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
such contract. The waiver applies only to the The unintentional omission of, or unintentional
person or organization designated in such error in, any information given by you shall not
contract. prejudice your rights under this insurance. How-
N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col -
The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of
cealment, Misrepresentation, Or Fraud, of cancellation or non -renewal.
SECTION IV — BUSINESS AUTO CONDITIONS:
Page 4 of 4 © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
NAMED INSURED: WILLIAMS PIPELINE CONTRACTORS, INC.
POLICY NUMBER: 8104NO58682422SG COMMERCIAL AUTO
POLICY TERM: 09/01/2024 TO 09/01/2025
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - PRIMARY AND
ON -CONTRIBUTORY WITH OTHER INSURANCE -
CONTRACTORS
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
PROVISIONS
1. The following is added to Paragraph c. in A.1.,
Who Is An Insured, of SECTION II — COVERED
AUTOS LIABILITY COVERAGE:
This includes any person or organization who you
are required under a written contract or
agreement, that is signed by you before the
"bodily injury" or "property damage" occurs and
that is in effect during the policy period, to name
as an additional insured for Covered Autos
Liability Coverage, but only for damages to which
this insurance applies and only to the extent of
that person's or organization's liability for the
conduct of another "insured".
2. The following is added to Paragraph B.5., Other
Insurance of SECTION IV — BUSINESS AUTO
CONDITIONS:
Regardless of the provisions of paragraph a. and
paragraph d. of this part 5. Other Insurance, this
insurance is primary to and non-contributory with
applicable other insurance under which an
additional insured person or organization is a
named insured when a written contract or
agreement with you, that is signed by you before
the "bodily injury" or "property damage" occurs
and that is in effect during the policy period,
requires this insurance to be primary and non-
contributory.
CA T4 99 02 16 u 2016 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
��„� WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD, CT 06183
ENDORSEMENT WC 99 03 76 ( A) — 001
POLICY NUMBER: UB4J573465242SG
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 2 % of the California workers' compensation pre-
mium.
Schedule
Person or Organization Job Description
ANY PERSON OR ORGANIZATION FOR
WHICH THE INSURED 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 09/01/2024 Policy No. UB4J573465242SG Endorsement No.
Insured WILLIAMS PIPELINE CONTRACTORS, INC. Premium
Insurance Company Countersigned by
TRAVELERS PROP CAS CO OF AMER
DATE OF ISSUE: 08-27-2024 Page 1 of 1