PROOF OF INSURANCE (2026 - 2026)AC"R" CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYYYY)
10/17/2025
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
SIP Insurance Services- Orange
790 The City Drive South, Ste 210
Orange CA 92868
CONTACT
NAME: Heidi Farmanl
PHONE g51 365-3850 FAC, No:626-564-6565
AIC No Ext : ( )
AI
ADDRESS: heidif@sipbrokers.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A: Travelers Property Casualty Company of America
25674
License#: 0M93299
INSURED BACKAPP-01
Backflow Apparatus & Valve Co.
20435 S. Susana Road
INSURER B : The Travelers Indemnity Company of Connecticut
25682
INSURER C
INSURER D :
Long Beach CA 90810
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 111681853 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.
INSR
LTR
OF INSURANCE
ADDLSUBRTYPE
INSD
WVD
POLICY NUMBER
POLICY EFF
MM DDIIYYYY
POLICY EXP
MM DD
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
Y
6308J664090
10/31/2025
10/31/2026
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 300,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
� PECOT- LOC
PPOLICY
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
OTHER:
B
AUTOMOBILE LIABILITY
BA7N173419
10/31/2025
10/31/2026
COMBINED SINGLE LIMIT
Ea accident
$1,000,000
BODILY INJURY (Per person)
$
X ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
X HIRED LNON-OWNED
AUTOS ONLY AUTOS ONLY
A
X
UMBRELLALIAB
X
OCCUR
CUP9J209005
10/31/2025
10/31/2026
EACH OCCURRENCE
$5,000,000
AGGREGATE
$ 5,000,000
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE
Y
UB-3R155740-25-14-G
8/27/2025
8/27/2026
X PER STATUTE OTH-
ER
E.L. EACH ACCIDENT
$ 1,000,000
OFFICER/MEMBER EXCLUDED?
NIA
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
A
Property
6308J664090
10/31/2125
10/31/2026
Bus Personal Property
Included
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Subject to all policy terms, exclusions and conditions.
RE: Annual testing and maintenance of backflow devices; City of El Segundo is an Additional Insured with respects to attached General Liability endorsement if
required by written contract. Attached Workers Compensation Waiver of Subrogation endorsement applies to City of El Segundo if required by written contract.
CERTIFICATE HOLDER CANCELLATION
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 Dept.
350 Main St.
AUTHORIZED REPRESENTATIVE
cz� //-
El Segundo CA 90245
United States
'
ACORD 25 (2016/03)
@ 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any
injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general
coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to
determine rights, duties, and what is and is not covered.
A. Who Is An Insured —Unnamed Subsidiaries
B.. Who Is An Insured — Employees And Volunteer
Workers — Bodily Injury To Co -Employees And
Co -Volunteer Workers
C. Who Is An Insured — Newly Acquired Or Formed
Limited Liability Companies
D. Blanket Additional Insured — Broad Form Vendors
H. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Operations
I. Blanket Additional Insured — Grantors Of
Franchises
J. Incidental Medical Malpractice
M1
E. Blanket Additional Insured — Controlling Interest L.
F. Blanket Additional Insured -- Mortgagees, M
Assignees, Successors Or Receivers
G. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Premises
PROVISIONS
A. WHO IS AN INSURED — UNNAMED
SUBSIDIARIES
The following is added to SECTION 11 — WHO IS
APB INSURE D�
Any of your subsidiaries, other than a partnership
or joint venture, that is not shown as a Named
Insured in the Declarations is a Named Insured if;
a. You are the sole owner of, or maintain an
ownership interest of more than SO% 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:
Medical Payments — Increased Limit
Blanket Waiver Of Subrogation
Contractual Liability — Railroads
a. Before you maintained an ownership interest
of more than 50% 1 n such subsidiary; or
b. After the date, if any, during the policy period
that you no longer maintain an ownership
interest of more than 50% in such subsidiary.
For purposes of Paragraph 1. of Section 11 — Who
Is An Insured, each such subsidiary will be
deemed to be designated in the Declarations as:
a. A limited liability company;
b. An organization other than a partnership, joint
venture or limited liability company; or
c. A trust;
as indicated in its name or the documents that
govern its structure.
CG D4 58 02 19 C 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 5
Includes copyrighted material of Insurance Services Office, Inc. with its permission
COMMERCIAL GENERAL LIABILITY
B. WHO IS AN INSURED — EMPLOYEES AND
VOLUNTEER WORKERS — BODILY INJURY TO
CO -EMPLOYEES AND CO -VOLUNTEER
WORKERS
The following is added to Paragraph 2.a.(1) of
SECTION 11 — WHO IS AN INSURED:
Paragraphs (1)(a), (b) and (c) above do not apply
to "bodily injury" to a co-"emp�oyee" while in the
course of the co -."employee's" employment by you
or performing duties related to the conduct o f your
business, or to "bodily injury" to your other
"volunteer workers" while performing duties
related to the conduct of your business.
C. WHO IS AN INSURED — NEWLY ACQUIRED
OR FORMED LIMITED LIABILITY COMPANIES
"The following replaces Paragraph 3. of SECTION
III —WHO IS AN INSURED:
3. Any organization you newly acquire or form,
other than a partnership or joint venture, and
of which you are the sole owner or in which
you maintain an ownership interest of more
than 50%, will quality as a Named Insured if
there is no other similar Insurance available to
that organization. However:
a. Coverage under this provision is afforded
only:
Until the 180th day after you acquire
or form the organization or the end of
the policy period, whichever is earlier,
if you do not report such organization
in writing to us within 180 days after
you acquire or form It, or
(2) Until the end of the policy period,
when that date is later than 180 days
after you acquire or form such
organization, if you report such
organization in writing to us within
180 days after you acquire or form it;
b. Coverage A does not apply to "bodily
injury" or "property damage" that occurred
before you acquired or formed the
organization; and
c. Coverage B does not apply to "personal
and advertising injury" arising out of an
offense committed before you acquired or
formed the organization.
For the purposes of Paragraph 1. of Section 11
— Who Is An Insured, each such organization
will be deemed to be designated in the
Declarations as:
a. A limited liability company;
b. An organization, other than a partnership,
joint venture or limited liability company;
or
as indicated in its name or the documents
that govern its structure.
D. BLANKET ADDITIONAL INSURED — BROAD
FORM VENDORS
The following is added to SECTION 11 — WHO IS
ANINSURED:
Any person or, organization that is a vendor and
that you have agreed in a written contract or
agreement to include as an additional insured on
this Coverage Part is an insured, but only with
respect to liability for "bodily injury" or "property
damage" that:
a. Occurs subsequent to the signing of that
contract or agreement; and
b, Arises out of "your products" that are
distributed or sold in the regular course of
such vendor's business.
The insurance provided to such vendor is subject
to the following provisions:
a. The limits of insurance provided to such
vendor will be the minimum limits that you
agreed to provide in the written contract or
agreement, or the limits shown in the
Declarations, whichever are less.
b. The insurance provided to such vendor does
not apply to:
(1) Any express warranty not authorized by
you or any distribution or sale for a
purpose not authorized by you;
(2) Any change in "'your products" made by
such vendor;
(3) Repackaging, unless unpacked solely for
the purpose of inspection, demonstration,
testing, or the substitution of parts under
instructions from the manufacturer, and
then repackaged in the original container;
(4) Any failure to make such inspections,
adjustments, tests or servicing as
vendors agree to perform or normally
undertake to perform in the regular
course of business, In connectio n with the
distribution or sale of "'your products";
Page 2 of 5 0 2017 The TravOers Inderninity Company, All rights reserved. CG D4 58 02 19
Includes copyrighted mate(ol of Insurance Services Office, Inc. with its permission
(5) Dernonstration, nstahkition, seirvi6ng or
repair op, eraUoris, except SUChl op erzifloins
performed at sudh veindou's pirerrdses ill
conner:flon with the sauce Of "YOUIr
prodUCtS"." oir
(6) "Youir produc ts'll that, after distiriilllxition or
saWe by you, save I. ab6ed or,
r6abeie(J or used as as contalner, ICiart or
ingre6eint of any otheir thMg or substaince
by or on Ib6hnf (�A` such veindoir.
( overage uir ider this piro\6shoirii does riot qpply to,
a. Any person or organizaflon Croirn whor7i you
foive acquired "your prodiucts", or any
Ungredierrt, Ipuarh or, cointauiiier, enterli-ig into,
accompanying or coritakiing such products",
or
�b. Any vendor for wkikdh (:oveiraf.e as an
additionaU insured specrhcafly is schedUed by
enctor'sernerit,
E. BLANKET ADDI'TIONAL., INSUIRIED
1:0141"ROLLING IN 11ERIES1"
I. 'The fo kaMng hs added to SEC"I"101M II -- W110
IS AN INSURE:D�
Any person or orgairkzzition that has firiain64
contro� of you os an �nSL,llired with respect to
flabiky for "bo&y hinlury", "property dairnage"
or "persorW and adveirtsring Injury" that adses
Out rife
a. Such financial cointiroLl, or
b. Such person's or orgaHzation's
ownerslfflp, niaMterrance or LlSe Of
U,xernises IIeaaserh to or o(:cupied by you,
The insurance pirevkiecl to skic h I)ersoin air
orqanizatiori does not apip�y to strurfturaG
zihetaflons, new ccristruction oir dernoftion
operations perforryied by or con behaff of such
pers(�)n or orgallllZation,
2, f-he frjUoMng lis added to Flaragraph 4. of
SECTION IIII ...... WHO IS A14 RM IR D
This paragraph does not appy to arry
pp irernises owner, n-rainager or lessor that Ihnaas
fnanciah Mltr'16 Of YOU,
F. BLANKET ADIDI 11101MAL INSURED --
MQUGAGEES, ASSIGNEES, SUCCESSORS
GR RECEIVERS
The lotlov6ng is added to SECTIDN II Mfl() IIIS
AN INSURED:
Any person or orgaNzation, that rs a r-nortgagee,
assignee, successor or receiver and that you
have agreed n) a writter",r contract or agreement to
irr(Aude as an addftioi,4l il`Mlired an this Coverage
J�)art is an �insuired, but oNy Mh respe(ft to its
COMMER0AL GENERAL IJAMLITY
kabflity as mortgagee, assignee, successor oir
receiver for "bodfly kiJury", "pirc)l,)eirly dairnage" oir
llpeirscrnah and adverUskig irijuiry" that -
a. hs "bo(ffly Miury" or "propeirty daarage" that
o(:,curs, am is ll"pi eirsoinah and adveirti§iing Uinjury'll
caused by an offerrise that ��s cornir nftted,
subsei'ulueint to the i;ig61ng of that contract or
agreernent, and
lhm Arises out (�yf the owneirs[hp, uyrakitenancr oir
UScn, (4 the pr'E:rnhses for M*h that rnortgagee,
assignee, successor of reCEM'veir iis ii,equh,ed
Under that concract or agreenierft to be
rnciuded as ain additionM insured on h,fls
("overage IPart,
The insurance provided to such mortgagee,
as§lgnee, successor 'Dr receiver ps subiect to the
f6k)Mng provusk)ns:
a. The Ny0ts of insurairrice I,,)rrovided to such
rnortgagee, asa'' riee, successor or receiver
Ml be the rnpNrnurri UhahL; that YOU agreed to
provide hn the written cointiact or agreernent,
or the Uhiirts stwwn iin the De(.JaratUons,
whichever are Uess,
b. The Msurance prov,rded to such I'Mrson or
organization does riot anal dy tcx
(1) Any "bo&y Mjiury' or ll'prqperty damagie"
that occurs, or any "personaU and
advertisUng injuiry" caused by, an offense
Cheat is committed, after such contract or
agreement is no Uongleir M effector
(2) Any "bo&y injury', "properly damage" or
"lpersonM and adveirtsing injury" arising
out of any Str'UcturaU dteraUons, new
construction oir dernoftion operatioris
perforrried by or, on beharf of such
mortgagee, assignee, successor or
receiver,
GIBL/ylYKEI AUDMDIYkC INSL)RED,
G0VEIlNM!!!J9TAL EN III TIES RERMITS 011
ICII I 1ORVA I IONS REL.KruNG TO RIC�UEMSES
The foUoMrig is added to SI! °TI(Mg 11 — W11110 IIG
ANIII IIaISURED:
Any governmerit4l eirifily that has issued as peirrnit
or authorizatiori Mth respect to pirenrihses owned
or occupied by, or rented oir Uoaried to, YOU and
that you are requned by any o41naince, Law,
b0dirig code or written cointract oiir agreerTrent to
McUe as an addifionM 41SLffed on t[os Coverage
Part its an insuired, but oNy with respect to iabflity
for "bo(fly injury", ""prop enty damage" oir "personail
and adverfisnq i nj u ry 11' aris4q out of the
ex�stence, ownership, Use, rnaintena�nce, rqo4r,
coinstnic tion, erectiori or rerrrrov4� at any of the
foUoMng for whk,Ji that goverrilrTreintai entity has
CG IM 58 02 19 0 2.017The Fravellers Viiideiruiiriiityc.oiiiip)aiiny, Mhghts mseyved. Page 3 of 5
Includes copyrighted irrraterdraan of Insurance SeMces Office, Mc, vvith Vts 1peirmssbn
COPAMERCIM. GENERAL UABIL]TY
dssued such perrnit air authorrZatdon, adveirfising
signs, awrungs, canqples, ceHar entrainces, coali
ho�ii:!s, ddvevvays, mairrhO!s, irnarquees, h6st
away operflngs, sidewailk vau[ts, devators, street
i!uanrx:Ys or der-,loraflorrs.
H BLANKET' ADDMONA�i IMSUIRED
GOVERIMiijiMTAL EI'Ili 111 riES ............ PERMIT'S 011
At 11 110RIZATIONf 1RELAI iNG ro aii,Ii,1d1114-
ATIONS
1he fisilk�wMng is added to SEC I ION il — W140 b5
AN INSI JRMi)��
Any governmental enfity that has ussued as perrnit
or authodzation Mthi respect to oper6ons
per -Formed by you or ori your bei,41' arid that you
are reqOred by any orcfinarice, iaw, bUiii(firIg code
or written contract or agreen,ient to incilude as an
addiitiorW insured on tNs Coverage Flail, ds an
dnsuired, but oMy wrth respect to Habi fty tor, 'bodHy
inJuirry", "proper�y daiTiiaige" or, "�.)ersonai aind
advertis4ig Unj upy" arisirig out of, suc[�, operations,
The insuIrlance provided to such governimerritai
entb�y does not apply to"
a. Any "bodHy 'uirijur%/', ),)irorrerrdwy darnage" or
"personai and adveirth;lng injuiry" airising out of
operations perforimed for the goverriniental
entity; or
�b. Any "'bodily injuvy' or "properly darnage"
inciuded in the 11'pro&CtS-cornpfete
operations hazard".
k BLANKET ADDITIONAI.. INSURED --
GRANTORS QFIFRANCI-IISES
'rhe toHowing is added to SEC I M Iii Mf l�H, 0 1 S
AN INSUIMi.)",
Any person or orrgairflzatdoir tf,iat grants a frainc[flse
to you is arr i1r6UHred, but oirify with respect to
HabMity for, "bo&y rri�uryl% "properly darriage" oir
1personad arid advertiising injury" a6sotg OLAt Of
your operafions in the ftaiinchuse girainted by that
person or orgarrizabon .
V a w6tten (:ontract or agreeirneint, exibts between
you and such zVJdWorriai dnsured, the R-nits of
rnSUraince Iprovided tO SLICh drrsured Mi be the
m4*nUirn fimfts that you agreed to pairoviide in the
written conbact or agreernent, or the Hrruts shown
in the DecJarations, whcheveir are Iless,.
,J. INCIDENTAL MEMCAL MALPRAC I ICE
services", first aid oir "Good San ailItairr
seMces" to a person, Uiriiless )(OL9 are IIIr11
the itiu§rness or OCCUpafion of pirovkfing
profiessioneat heahh care services,
2. The foflkWng irepllaces the (last paragiraph of
Paragraph 2,,a.(l) of 91'IIIIICT�i(w'XM fli ........... WHO IS
AN INStPREIIiJi)-1
Lh*ss you are in 'ttie tnjsdness oir occqpatJoin
(it provi61ng pyofesskxr4i heakh (:aire setvices:,
Paragraphs (1)(a), (b), (c) and (d) above do
not appty to "bodify injury'll ariispng out of
providrng or faifing to p�)rovW(:,-.
(a) Incklentdi ME"dicai services" try airiy of
your "erripktyees" who is a nurse, nLrrsie
assistant, erneirgency rnediicai tectrirriician,
paramedic, athledc ti audiologiist,
6eficiian, nut166oiriist, occupational
therappst or occiji°jiatkur ap tim 'Wrapy
assistant, physical therqidst or, speech,
Uariguage p-)atholog�st oii.
(b) First aiid or "Good Sainaritan services" by
any of your "eirri-qJoyees"' oir "voWrfteer
workers", other than an enii or
vodi,unteer doctor, Any such "ernpiqyees"'
or "voUnteer workeirs" proviftg or faMng
to proMe first aud or "Good Sani
services" diurrrig theu, work hours for you
wfli be deerned to be actirig MtHin the
scope of their empioyrneirit by you or
perforrniirig &Jfies relate to the condUCt
of your biusness.
I The foflovyririg repWces the last serftenr:e of
Paragraph S, of SIIIlIXf FMN HI — LIM'S 0iii
INSURAIlly CIi,!!!,.,
�For the PLUrposes of deterrrunoig the
appHcaWe Each Occurrence Urri aili r6ated
acts or ornissions coninrOtted in proviiding or,
faiiHng to jxrov�de IncWeraai rinerficai
services", first ally (n "Good Sarnaritan
servdces" to any oine Ipersorn wHi be deemed to
be one "occurrence",
4. 'Ir"he f0flowfirrg ex(JUSkWil is ackled to
Paragraph 2., Exclusions, of SEMION I ---
COVERAGES — COVERAGE A --- B0DH..Y
INJURY AND PRORMR-w DAMAGE
if IABII 11i Ya
1. 'ni,iie foflowing repiaces Paragraph b. of the Sale Of PlharnriaceUticais
definition of Iloccurrence" in the ""Bo duly injUlry' or '11Iproperty damage" aihsiing
DERMI IONS Sectiionl' out of the vVatk)n of a perraf statute or
b. An act Or cm�s§oir carninfltted in provii6ng or6nance re[afing to tire saile of
pharynaceulJcMs cornIrrOtted by, oir Mth the
ot faiHng to pirovWie 'Ini:JdentW rne&ai knoWedge or corisent of, the uisiigired,
Page 4 of 5 Q 20 n 7The Traveiers indemniry Company Ar dghts reserved, CG D4 58 02 19
inciludes colpyrighled materar of insurwice Services Offlice, arts:, Yvith i1rs !)ermission
S. 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 If — Who Is An
Insured,
The -following replaces Paragraph 7. of SECTION
III — LIMITS OF INSURANCE:
7. Subject to Paragraph 5. above, the Medical
Expense Limit is the most we will pay under
Coverage C for all medical expenses
because of "bodily injury" sustained by any
one person, and will be the higher of:
b. The amount shown in the Declarations of
this Coverage Part for Medical Expense
Limit.
L. BLANKET WAIVER OF SUBROGATION
The following is added to Paragraph 8., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS:
If the insured has agreed in a contract or
agreement to waive that insured's right of
recovery against any person or organization, we
waive our right of recovery against such person or
organization, but only for payments we make
because of:
a. "Bodily injury" or "property damage" that
occurs', or
b. "'Personal and advertising injury" caused by
an offense that is committed;
subsequent to the execution of the contract or
agreement,
vil. CONTRACTUAL LIABILITY — RAILROADS
1 . The following replaces Paragraph c. of the
definition of "insured contract" in the
DEFINITIONS Sectiom
c. Any easementor license agreement;
2. Paragraph f.(1) of the definition of "insured
contract" in the DEFINITIONS Section is
deleted.
CG D4,58 02 19 (0 2017 The Travelers InderrEnity Company. All rights reserved. Page 5 of 5
Includes copyrighted material of Insurance Services Office, Inc, with its permission
WORKERS COMPENSATION
AND I
F
WAIVER)WAIVER OF OUR RIGHT
RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
e 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. 00 % of the California workers' compensation pre-
mium.
PersonrJob Descriptier
ANY PERSON OR ORGANIZATION FOR
WHICH THE INSURED HAS AGREED
BY WRITTEN CONTRACT EXECUTED
PRIOR TO DOSS 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 reparation of
the policy.)
Endorsement Effective 08/27/2025 Policy No. Endorsement No.
Insured Backflow Apparatus & Valve Co. Premium
Insurance Company Countersigned by
DATE OF ISSUE: 08-12-2025 ST ASSIGN: page Il of I