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PROOF OF INSURANCE (2025) CLOSEDDATE (MM/DDIYYYY)
C"J?" CERTIFICATE OF LIABILITY INSURANCE
�.s. 11120l2024
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 endorsements),
co �c
PRODUCER .......
Acrisure Southwest Partners Insurance Services, LLC PHONE "". -_7
18952 MacArthur Blvd., Suite #300 ws cc..t (94s„ assasoo ww a edg N4: _ �..........._...m
E MA(t
Irvine, CA 92612 AD s
www.patrisk.com OK07568
_............... ....... ....
INSURED
Su erior Pavement Markings, Inc.
532 Cypress St.
Cypress CA 90630
AFFORDING COVERAGE
An!
Indemnitty Inc. A++ XV ......_.
35181ITmmm
ce Clanpany A++ Xis ., ......_.
20281ITmmm
rplusmLines Insurance Co A*+ XV
10172mm
altv Insurance Comoanv
16992
IC =111«lnm MIIMRFR-
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 IES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM
ONS AND CONDITIONS OF SUCH POLICIES. _.._. ...........
.....__.m.. .. _.. _.
gi ADOL sRR POLIaY EFfr POLICY ap— LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER IMMtDDIYYyn (MMIDPIYYYY)-
A
✓
COMMERCIAL GENERAL LIABILITY
�/
�/
54326762
9/18/2024
6/1/2025
EACH OCCURRENCE
$1,000�00Qwwwwwwwwwm
......, OCCUR
CLAIMS -MADE C �
PA;�.riS�R�"dbfU"m
PREMISi;:. Do u7r.uarglnce).,,,,:
_$,,0,t1.O00 ,,.....
MED EXP (An one person)
$ 5,000 .......
..... .... .........
PERSONAL &ADVINJU
, INJURY ............
...
$1 000000
�z—s _ ,w,wwwwwwwwwwwwwmm,
GEN
L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,0O0
POLICY 0 PR' LOC
PRODUCTS COMP/OP AGG
$ 2,000e000
O'Qt•BIL
B
AUTOMOBILE LIABILITY
✓
�/
54326761
9/18l2024
6/1/2025
� oMeINFD sl'fIGLE; I.uNl('r
� .._....__ ....
.. Ea a�ciderlOS
$ 1 000 000........._.....�
�. ANY AUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
BODILY INJURY (Per accident)
$
„,. AUTOS ONLY ''. AUTOS
WW HIRED NON -OWNED
mPROERT�'LYAMyFAOeE P
w••••
$
AUTOS ONLY AUTOS ONLY
„(Pr*r acciderrl) ........ _
„„„„„„..
$
B
/
B ,/ occuR
UMBRELLA�RETENTI!ON
56717371
9/18/2024
6/1/2025
EACH OCCURRENCE....
$5,000,000 ...........
EXCESS LICLAIMS -MADE
AGG
.__. AGGREGATE _..._._...._.__._..,,..
$ 5,000,000
DED $
-
$
B
WORKERS COMPENSATION
�/
54326701
6/1/2024
611/2025
✓ PER
ERH
AND EMPLOYERS' LIABILITY Y I N
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUI
N / A
„STATUTE
E L EACH,ACCIDENT
_
m$_1 R000,000 wwwwwww
(Mandatory in NH)
E L DISEASE - EA EMPLOYEE
$ 1((T(00Q
If yes, describe under
DESCRIPTION OF OPERATIONS below____T
El, DISEASE - POLICY LIMIT
$ 1 000 000
C
Contractors Pollution Liability
G74464518002
9/13/2024
6/1/2025
Ea Occ: $2,000,000
Aggregate: $4,000,000
D
Excess Liability
XSL408079POl
10/21/2024
6/1/2025
Occurrence: $4,000,000
Aggregate: $4,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
ICE: SPM Job #10298 ! Jab Location: On Call l Thermoplastic Striping Services, Pro°ect No. St 24-02 / El Segundo, California.
tua L Auto Liability the endorsements attached as required
City of EI Segundo Public Works are named as Additional Insured with respects and per
by Written contract.. Coverage is Primary and Non-contributory. Waiver of subrogation apples to GL, Auto and WC.
30 days notice of cancellation / 10 days notice for non payment
City of El Segundo
CIO El Segundo Public Works
350 Main Street
EI Se undo 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.
g AUTHORIZED REPRESENTATIVE
Dave Jacobson
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
62787527 1 24/25 GWBA116p B(WC/PtML I Kelly Vincent 1 11/.20✓2024 7:47:05 AM (PST) I Page 1 of 10
This certificate cancels and supersedes ALL previou0 y issued certificates.
Superior Pavement Markings, Inc.
POLICY NUMBER: 54326762
COMMERCIAL GENERAL LIABILITY
CG 20 10 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES E S OIL
CONTRACTORS - SCHEDULED PERSON O
ORGANIZATION
IZA'TION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organizations) Location(s) Of Covered Operations
WHERE REQUIRED BY WRITTEN CONTRACT ALL LOCATIONS WHERE REQUIRED BY WRITTEN
CONTRACT
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions 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 repairs) to be performed by or
on behalf of the additional 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
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
r i
82787527 1 24/25 GL/BAd'piM'.trVWC/P0LL I Kelly Vincent 1 11/20J2024 7:47:05 AM (PST) I Page 2 of 10
This certificate cancels and supersedes ALL previolAsly issued certificates.
Page 1 of 2
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;
whichever is less.
This endorsement shall not increase the
applicable limits of insurance.
p . - • s ! :]
CG20101219
82787527 1 24/25 GL/BA/UME/WU'POLL I Kelly Vincent 111/.;2Of2O24 7t47:05 AM (PST) I Page 3 of 10
This certificate cancels and supersedes ALL previously t.,Sijed certificates.
%rI3�%Ingg�ings, Inc.
COMMERCIAL GENERAL LIABILITY
CG20371219
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Or anization(s)
Location And Description Of Completed Operations
WHERE REQUIRED BY WRITTEN CONTRACT,
BUTONLY WHEN THE CONTRACT SPECIFIES
COVERAGE FOR COMPLETED OPERATIONS
ALL LOCATIONS WHERE REQUIRED BY WRITTEN
CONTRACT
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury" or
"property damage" caused, in whole or in part, by
"your work" at the location designated and
described in the Schedule of this endorsement
performed for that additional insured and
included in the "products -completed operations
hazard".
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
2. If coverage provided to the additional insured
is required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
N
B. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations.
4 • 1
Page 1 of 1
82787527 1 24/25 GL/BA r6P9�BNCI,i"OLL I Kelly Vincent 1 11/ 0/2024 A 7:05 AM (PST) I Page 4 of 10
This certificate can:;Q.'!.s and supersedes ALL previ misl.y issued certificates.
Superior Pavement Markings„ Inc.
POLICY NUMBER: 54326762
COMMERCIAL GENERAL LIABILITY
10-02-2461 (Ed. 7-15)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
"NNEII I� IMu • '"
This endorsement modifies insurance provided under the following;
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Additional Insured: Location Of Covered Operations:
WHERE REQUIRED BY WRITTEN CONTRACT. ALL LOCATIONS
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
With respect only to the Additional Insured and at the
Location Of Covered Operations shown in the
Schedule, the following is added to SECTION IV —
COMMERCIAL GENERAL LIABILITY CONDITIONS,
Paragraph 4. Other Insurance and supersedes any
provision to the contrary:
Primary And Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other insurance available to
the Additional Insured with respect to the Location
Of Covered Operations shown in the Schedule
under this policy provided that:
(1) The Additional 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 the
Additional Insured.
10-02-2461 (Ed. 7-15) Includes copyrighted material of Insurance Services Office, Inc.,
with its permission.
Page 1 of 1
.. r I 1 .0 024 7,97:05 A1N O'ST) I v3..90 `x a£ :1.0
7?1H"7,>77 ( ��17.� GLl1.iY4d tl0"^�f%�W( dfi�',�L ( Ke.11r Vincent I II(s`„Vd i",
This certificate caflCe7.., ate ✓.i. su ez.-sE.cie=s ALI, previously issued cert.:Lfa. ates.
54326761
Superior Pavement Markings, Inc.
COMMERCIAL AUTOMOBILE
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL AUTOMOBILE BROAD FORM ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
This endorsement modifies the Business Auto Coverage Form.
1. EXTENDED CANCELLATION CONDITION
Paragraph A.2.b. — CANCELLATION - of the
COMMON POLICY CONDITIONS form IL 00 17 is
deleted and replaced with the following:
b. 60 days before the effective date of cancellation if
we cancel for any other reason.
2. BROAD FORM INSURED
A. Subsidiaries and Newly Acquired or Formed
Organizations As Insureds
The Named Insured shown in the Declarations is
amended to include:
1. Any legally incorporated subsidiary in which
you own more than 60% of the voting stock on
the effective date of the Coverage Form.
However, the Named Insured does not include
any subsidiary that is an "insured" under any
other automobile policy or would be an
"insured" under such a policy buffor its
termination or the exhaustion of its Limit of
Insurance.
2. Any organization that is acquired or formed by
you and over which you maintain majority
ownership. However, the Named Insured
does not include any newly formed or acquired
organization:
(a) That is an "insured" under any other
automobile policy;
(b) That has exhausted its Limit of Insurance
under any other policy; or
(c) 180 days or more after its acquisition or
formation by you, unless you have given
us written notice of the acquisition or
formation.
Coverage does not apply to "bodily injury" or
"property damage" that results from an "accident"
that occurred before you formed or acquired the
organization.
B. Employees as Insureds
Paragraph A.1. — WHO IS AN INSURED — of
SECTION II — LIABILITY COVERAGE is amended to
add the following:
d. Any "employee" of yours while using a
covered "auto" you don't own, hire or
borrow in your business or your personal
affairs.
C. Lessors as Insureds
Paragraph A.I. —WHO IS AN INSURED — of
SECTION II — LIABILITY COVERAGE is
amended to add the following:
e. The lessor of a covered "auto" while the
"auto" is leased to you under a written
agreement if:
(1) The agreement requires you to
provide direct primary insurance for
the lessor; and
(2) The "auto" is leased without a driver.
Such leased "auto" will be considered a
covered "auto" you own and not a covered
"auto" you hire.
However, the lessor Is an "insured" only
for "bodily injury" or "property damage"
resulting from the acts or omissions by:
1. You;
2. Any of your "employees" or agents;
or
3. Any person, except the lessor or
any "employee" or agent of the
lessor, operating an "auto" with the
permission of any of 1. and/or 2.
above.
D. Persons And Organizations As Insureds
Under A Written Insured Contract
Paragraph A.1 —WHO IS AN INSURED —of
SECTION II — LIABILITY COVERAGE is
amended to add the following:
f. Any person or organization with respect to
the operation, maintenance or use of a
covered "auto", provided that you and
such person or organization have agreed
under an express provision in a written
"Insured contract", written agreement or a
written permit issued to you by a
governmental or public authority to add
such person or organization to this policy
as an "insured".
However, such person or organization is
an "insured" only:
Form: 16-02-0292 (Rev. 11-16) Page 1 of 3
"Includes copyrighted material of Insurance Services Office, Inc. with its permission"
82787527 1 24/25 GL/BA/UM;BNC.+POLL I Kelly Vincent 1 11/2012024 7:47:05 AM (PST) I Page 6 of 10
This certificate cancels and, supersedes ALL previw,' au�,,ly issued certificates.
(1) with respect to the operation,
maintenance or use of a covered
"auto"; and
(2) for "bodily injury" or "property damage"
caused by an "accident" which takes
place after:
(a) You executed the "insured
contract" or written agreement; or
(b) The permit has been issued to
you.
3. FELLOW EMPLOYEE COVERAGE
EXCLUSION B.5. - FELLOW EMPLOYEE — of
SECTION II — LIABILITY COVERAGE does not apply.
4. PHYSICAL DAMAGE — ADDITIONAL TEMPORARY
TRANSPORTATION EXPENSE COVERAGE
Paragraph A.4.a. — TRANSPORTATION EXPENSES
— of SECTION III — PHYSICAL DAMAGE
COVERAGE is amended to provide a limit of $50 per
day for temporary transportation expense, subject to a
maximum limit of $1,000.
5. AUTO LOANILEASE GAP COVERAGE
Paragraph A. 4. — COVERAGE EXTENSIONS - of
SECTION III — PHYSICAL DAMAGE COVERAGE is
amended to add the following:
c. Unpaid Loan or Lease Amounts
In the event of a total "loss" to a covered "auto", we will
pay any unpaid amount due on the loan or lease for a
covered "auto" minus:
1. The amount paid under the Physical Damage
Coverage Section of the policy; and
2. Any:
a. Overdue loan/lease 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 lessor:
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.
We will pay for any unpaid amount due on the loan or
lease if caused by:
1. Other than Collision Coverage only if the
Declarations indicate that Comprehensive
Coverage is provided for any covered "auto";
2. Specified Causes of Loss Coverage only if the
Declarations indicate that Specified Causes of
Loss Coverage is provided for any covered "auto";
or
3. Collision Coverage only if the Declarations indicate
that Collision Coverage is provided for any
covered "auto.
6. RENTAL AGENCY EXPENSE
Paragraph A. 4. — COVERAGE EXTENSIONS — of
SECTION III — PHYSICAL DAMAGE COVERAGE
is amended to add the following:
d. Rental Expense
We will pay the following expenses that you or
any of your "employees" are legally obligated
to pay because of a written contract or
agreement entered into for use of a rental
vehicle in the conduct of your business:
MAXIMUM WE WILL PAY FOR ANY ONE
CONTRACT OR AGREEMENT:
1. $2,500 for loss of income incurred by the
rental agency during the period of time that
vehicle is out of use because of actual
damage to, or "loss" of, that vehicle, including
income lost due to absence of that vehicle for
use as a replacement;
2. $2,500 for decrease in trade-in value of the
rental vehicle because of actual damage to
that vehicle arising out of a covered "loss"; and
3. $2,500 for administrative expenses incurred
by the rental agency, as stated in the contract
or agreement.
4. $7,500 maximum total amount for paragraphs
1., 2. and 3. combined.
7. EXTRA EXPENSE — BROADENED COVERAGE
Paragraph A.4. — COVERAGE EXTENSIONS — of
SECTION III — PHYSICAL DAMAGE COVERAGE
is amended to add the following:
e. Recovery Expense
We will pay for the expense of returning a
stolen covered "auto" to you.
8. AIRBAG COVERAGE
Paragraph B.3.a. - EXCLUSIONS — of SECTION
III — PHYSICAL DAMAGE COVERAGE does not
apply to the accidental or unintended discharge of
an airbag. Coverage is excess over any other
collectible insurance or warranty specifically
designed to provide this coverage.
9. AUDIO, VISUAL AND DATA ELECTRONIC
EQUIPMENT - BROADENED COVERAGE
Paragraph C.1.b. — LIMIT OF INSURANCE - of
SECTION III - PHYSICAL DAMAGE is deleted
and replaced with the following:
b. $2,000 is the most we will pay for "loss" in any
one "accident" to all electronic equipment that
reproduces, receives or transmits audio, visual
or data signals which, at the time of "loss", is:
(1) Permanently installed in or upon the
covered "auto" in a housing, opening or
other location that is not normally used by
the "auto" manufacturer for the installation
of such equipment;
(2) Removable from a permanently installed
housing unit as described in Paragraph
2.a. above or is an integral part of that
equipment; or
(3) An integral part of such equipment.
10. GLASS REPAIR —WAIVER OF DEDUCTIBLE
Form: 16-02-0292 (Rev. 11-16) Page 2 of 3
"Includes copyrighted material of Insurance Services Office, Inc. with its permission"
82787527 1 29/25 GL/BA/0..SMS/WC,'V0 L I Kelly Vincent I 11/20M24 7:47:05 AM (PST) I Page 7 of 10
This certificate cancels ,ndtcm supersedes ALL previously issued certificates,.
Under Paragraph D. - DEDUCTIBLE — of
SECTION III — PHYSICAL DAMAGE COVERAGE
the following is added:
No deductible applies to glass damage if the glass
is repaired rather than replaced.
11. TWO OR MORE DEDUCTIBLES
Paragraph D.- DEDUCTIBLE — of SECTION III —
PHYSICAL DAMAGE COVERAGE is amended to
add the following:
If this Coverage Form and any other Coverage
Form or policy issued to you by us that Is not an
automobile policy or Coverage Form applies to the
same "accident", the following applies:
1. If the deductible under this Business Auto
Coverage Form is the smaller (or smallest)
deductible, it will be waived; or
2. If the deductible under this Business Auto
Coverage Form is not the smaller (or smallest)
deductible, it will be reduced by the amount of
the smaller (or smallest) deductible.
12. AMENDED DUTIES IN THE EVENT OF
ACCIDENT, CLAIM, SUIT OR LOSS
Paragraph A.2.a. - DUTIES IN THE EVENT OF
AN ACCIDENT, CLAIM, SUIT OR LOSS of
SECTION IV - BUSINESS AUTO CONDITIONS is
deleted and replaced with the following:
a. In the event of "accident", claim, "suit" or
"loss", you must promptly notify us when the
"accident" is known to:
(1) You or your authorized representative, if
you are an individual;
(2) A partner, or any authorized
representative, if you are a partnership;
(3) A member, if you are a limited liability
company; or
(4) An executive officer, insurance manager,
or authorized representative, if you are an
organization other than a partnership or
limited liability company.
Knowledge of an "accident", claim, "suit" or
"loss° by other persons does not imply that the
persons listed above have such knowledge.
Notice to us should include:.
(1) How, when and where the "accident" or
"loss" occurred;
(2) The "insured's" name and address; and
(3) To the extent possible, the names and
addresses of any injured persons or
witnesses.
13. WAIVER OF SUBROGATION
Paragraph A.5. - TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS TO US of
SECTION IV — BUSINESS AUTO CONDITIONS is
deleted and replaced with the following:
5. We will waive the right of recovery we would
otherwise have against another person or
organization for "loss" to which this insurance
applies, provided the "insured" has waived
their rights of recovery against such person or
organization under a contract or agreement
that is entered into before such "loss".
To the extent that the "insured's" rights to
recover damages for all or part of any
payment made under this insurance has not
been waived, those rights are transferred to
us. That person or organization must do
everything necessary to secure our rights and
must do nothing after "accident" or "loss" to
impair them. At our request, the insured will
bring suit or transfer those rights to us and
help us enforce them.
14. UNINTENTIONAL FAILURE TO DISCLOSE
HAZARDS
Paragraph B.2. — CONCEALMENT,
MISREPRESENTATION or FRAUD of SECTION
IV — BUSINESS AUTO CONDITIONS - is deleted
and replaced with the following:
If you unintentionally fail to disclose any hazards
existing at the inception date of your policy, we will
not void coverage under this Coverage Form
because of such failure.
15. AUTOS RENTED BY EMPLOYEES
Paragraph B.5. - OTHER INSURANCE of
SECTION IV — BUSINESS AUTO CONDITIONS -
is amended to add the following:
e. Any "auto" hired or rented by your "employee"
on your behalf and at your direction will be
considered an "auto" you hire. If an
"employee's" personal insurance also applies
on an excess basis to a covered "auto" hired
or rented by your "employee" on your behalf
and at your direction, this insurance will be
primary to the "employee's" personal
insurance.
16. HIRED AUTO — COVERAGE TERRITORY
Paragraph B.7.b.(5). - POLICY PERIOD,
COVERAGE TERRITORY of SECTION IV —
BUSINESS AUTO CONDITIONS is deleted and
replaced with the following:
(5) A covered "auto" of the private passenger
type is leased, hired, rented or borrowed
without a driver for a period of 45 days or
less; and
17. RESULTANT MENTAL ANGUISH COVERAGE
Paragraph C. of - SECTION V — DEFINITIONS is
deleted and replaced by the following:
"Bodily injury" means bodily injury, sickness or
disease sustained by any person, including
mental anguish or death as a result of the "bodily
injury*' sustained by that person.
Form: 16-02-0292 (Rev. 11-16) Page 3 of 3
"Includes copyrighted material of Insurance Services Office, Inc. with its permission"
B2767527 1 24/25 GL/BA,A..&hiB/WC/1%1)LL I Kelly Vincent I 11/' J(2024 7:47:05 AM (PST) I Page 8 of 10
This certificate cancels a td supersedes ALL previously issued certificates.
t a
superior Pavement Markings, Inc.
POLICY NUMBER: 54326761
COMMERCIAL AUTO
16-02-0316 Ed. 10 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY IM NON
-CONTRIBUTORY
IUSURANCE
This endorsement modifies insurance provided under the following:
BUSINESS AUTO 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.
Named Insured: SUPERIOR PAVING COMPANY, INC. DBA UNITED PAVING CO.
Endorsement Effective Date: 06/0I/2024
SCHEDULE
Name(s) Of Person(s) Or Organization(s);
WHERE REQUIRED BY WRITTEN CONTRACT
Information re uired to complete this Schedule, if not shown above, will be shown in the Declarations.
The following is added to Item 5. — "Other
Insurance" of Item B. — "General Conditions" under
Section IV — "Business Auto Conditions":
e. Regardless of the provisions of Paragraph 5.a.
through d. above, for any liability arising out of the
ownership, maintenance, use, rental, lease, loan, hire
or borrowing by an "insured" of a covered "auto" for
which an "insured" is contractually obligated to
provide primary insurance coverage to a client, this
Coverage Form will be primary and non-contributory
with respect to the Persons or Organizations in the
schedule, regardless of the availability or existence of
other collectible insurance under any other Coverage
Form or policy that applies on a primary basis.
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This certificate cancels and supersedes ALL previously issued certificates.
Workers' Compensation and Employers" Liability policy
Named Insured
Endorsement Number
Superior Pavement Markings, Inc.
Policy Number
Symbol: Number: 54326701
Policy Period
Effecfive ate of Endorsement
06/01 /2024 06/01 /2025
06/01 /2024
Issued By (Name of Insurance Company)
Westchester Surplus Lines Insurance Co A++ XV
Insert the poli number. The remainder of the information is to be completed only when this endorsement is issued subse uent to the preparation of the policy.
CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of
the Information Page.
We have the light 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, but this waiver applies only with respect
to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract
to obtain this waiver from us.
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
Schedule
1. ( ) Specific Waiver
Name of person or organization:
( X ) Blanket Waiver
Any person or organization for whom the Named Insured has agreed by written contract to furnish this
waiver.
2. Operations:
ALL OPERATIONS
3. Premium:
The premium charge for this endorsement shall be 1.0 percent of the California premium developed
on payroll in connection with work performed for the above person(s) or organization(s) arising out of the
operations described.
4. Minimum Premium: $0
Authorized Representative
WC 90 03 75 (05/18)
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"1.'hr. certificate r-ui.rAr.els and stiper,edeS A. �.7, previously issued certificates,