Loading...
PROOF OF INSURANCE (2026)Page I of 2 40 DATE (MM/DDNYYY) 10 CERTIFICATE OF LIABILITY INSURANCE ITO1 2D 2 5 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 cerfificale holder Is an ADDITIONAL INSURED, the policy(les) 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 cerfificate does not confer rl his to the certificate holder In lieu of such endorsernent(s). PRODUCER CONTACT Marie Hofer Willis Towers Watson Northeast, Inc. PHONE ' c/o 26 Century Blvd JAnNa,9XU. 1-877-945-737 F'X - 8 2-888-467-2378 P.O. Box 305191 E-MAIL 4S: certificates @ wtwco. com ,APPng ..... . ........... Nashville, TIN 372305191 USA INSURER AFFORDING COVERAGE NAIL INSURED Eleanor Belco Electric, Inc, 14320 Albers Way Chino, CA 91710 INSURERA: North Pointe Insurance Company 27740 INSURER B: QBE Insurance Corporation i 392171 INSURERC: Navigators Insurance Company 42307 COVERAGES CERTIFICATE NUMBER: W41548399 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUEDTOTHE INF—MRED 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, , IN POLICY k1dY EXP LI'R TYPED' LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMS MADE PREHISES (Ei4 ucci 300,000 A M 10,000 -D l� �g­2��u! Oman) Y Y 175001144 11/01/2025 11/01/2026 PERSONAL &ADV INJURY 1,000,000 PERSONAL GEN'L AGGREGATE LIMIT PER: $ 2,000,000 POLICY "RO, EST LOC I.P� 5GDUCISOMP/OP AGG 1 $ 2, 000, 000 OTHER� AUTOMOBILELIABILITY I'll""' M ME 5 9, 1 N (." C -CL I K4 r $ t' 000, 000 is rrzaralciertii).. ANYAUTO DODIL YINJURY (Perposi $ A OWNED HEDULED Y Y 165001222 111/01/2025 11/01/2026 _BODILY INZ'Ri(F., ccid.nl) AUTOS ONLY .......... . AS UG S T HIRED NON -OWNED PfOPERI Y D'AWri-bE $ AUTOS ONLY AUTOS ONLY 90�1­ $ B X UMBRELLA LIAB OCCUR 4,000,000 EXCESS UAB CLAMAS'40ADL 195001123 11/01/2025 11/01/2026 AGGIRIE�GATE $ 4 000 000 [$ DED F-7 nCTEW BONS WORKERS COMPENSATION PEN a I+ AND EMPLOYERS' LIABILITY Yt tt A ANYPROPRIETOR/PARTNER/EXECUTIVE Y ri, FAC"ACCMEUT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NIA 155000127 11/01/2025 11/01/2026 (Mandatory in NH) I DISEASE, EA EMPLOYEEf $ 1,000,000 11 yes, describe under DESCRIPTION OF OF - - E'l. O!SEASE, POLICY LIPMT S 1,000, 000 C 1st Excess Liability RK25EXC9189061V 11/01/2025 11/01/2026 Each Occurrence $3,000,000 $3M xe $4M Aggregate $3,000,000 DESCRIPTION OF OPERATIONS t LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached IImore space Is required) Re: On -Call Traffic Signal Repair Services Project No. ENG 24-56 Certificate Holder is included as an Additional Insured as respects to General Liability and Auto Liability. General Liability and Auto Liability shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insured. Waiver of Subrogation applies In favor of Additional Insured with respects to General Liability, Auto Liability and CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY CLERK City of El Segundo AUTHORIZED REPRESENTATIVE 350 Main Street El Segundo, CA 90245 . . . .. ..... 0 1-988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD an ID: 28764404 RhTcH: 4187304 AGENCY CUSTOMER ID: LOC #: ACOWAD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willie Towers Watson Northeast, Inc, Eleanor Selco Electric, Inc. 14320 Alborg Way POLICY NUMBER Chino, CA 91710 See Page 1 CARRIER NAIC CODE Page 4 EFFECTIVE DATE: Sea Page .....w �. ...... _ _� See Pa 1 .Sae page 1 e l ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID:28764404 RATCH:4187304 CERT:W41548399 533: 2 of! Page 1 of 2 A""RV CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) C" 10/30/2025 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 CONTACT ra® Hofer Willis Towers Watson Northeast, Inc, NAMC "11 PHONE1-877 945-7378 FAX 1- 888- 4672378 -ryW c/o 26 Century Blvd 1 � _111". ificates@wtwco.com ( C�Nra _ F MANL P.O. Box 305191 ADORES.+: Nashville, TN 372305191 USA INSURER S AFFORDING COVERAGE NAIC # INSURED Eleanor Belco Electric, Inc. 14320 Albers Way Chino, CA 91710 INSURERA: North Pointe Insurance Company 27740 INSURERS QBE Insurance Corporation 39217 .,., INSURERC Navigators Insurance Company 42307 INSURER D : COVERAGES CERTIFICATE NUMBER: W41548470 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE I INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 1IBIS 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, INTR TYPEOFINSURANCE „ADOnSvu R, POUCYNU6IRER M� ryY VY t YY LIMITS XI COMMERCIAL GENERAL LIABILITY �. EACH OCCURRENCE 1,000,000 �'', F I A t�Tk 9Ti 1_. _��.. _. ... , 00 300,000 �I CLAIMS -MADE OCCUR HC twII ,F, `-1 ,� cr t rrredr ,) s A 10,000 Y Y I 175002144 11/01/2025 11/O1/2026I PERSOA ADV INJURY `1 u 1,000,000 UENl AGGlMCIA-TE LIMIT APPLIES PER: GENERAL AGGREGATE '; 2,000,000 X Il . f IC J EC r LOG � PRODUCTS COMP/OP AGG 1 z0000 � 0 0 ^mJ OOI . w �w- ��..__ AUTOMOBILE LIABILITY JBINEDSINGLE Obli5 00 S 1,000,0X -_ FEI'�0611!Y ANY AUTO INJURY (Per p®rsoin f WNED SCHEDULED Y 165001222 A �_. ATYDAMAGE AUTOS ONLY AUTOS 11/01/2025 11/O1/2026INJURY (E'er u.c;rir.Ienly ,� ._...�,.,.,. .m.m...,.. 11:90171I Y 16rIJV,)� e .,.. NON -OWNED I Il AUTIRED OS LY UTOS ONLY 1 (F�trOf''E I� r $ X OCCUR EACHOCCURRENCE 4,000,000 CLLAId�RS MAI'Jli1.. B EXCESS ABA 195001123 11/01/2025 11/01/2026� AGCtl�Fi�lkTl' _....... T � 4, 000, 000 _ - ....... 1 -- T b DED RE IONS WORKERS COMPENSATION � AND EMPLOYERS'LIABILITY �(I PPC. H LII y,N 1 A ANYPROPRIETORIPARTNER/EXECUTIVE ° No N / A OFFICERIMEMBEREXCLUDED, 155000127 El, EACHACCIDENT$ 1 000,000 11/01/2025 11/01/2026y (Mandate In NH C.L. DISEASE EA EM 1,000,000 9 II yes, describe ender DESCRIPTION OF OPERATIONS below i _ El. DISEASE - POLICYL LIMIT 000,0001 Y LIM17 ;6 C let Excess Liability RK25EXC918906IV 111/01/2025 11/01/2026 Each Occurrence $3,000,000 $3M xe $4M Aggregate $3,000,000 I DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 11 more space Is required) Certificate Holder is included as an Additional Insured as respects to General Liability and Auto Liability. General Liability and Auto Liability shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insured. Waiver of Subrogation applies in favor of Additional Insured with respects to General Liability, Auto Liability and Worker Compensation, as permitted by law. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of El Segundo - Dept. of Public Works AUTHORIZED REPRESENTATIVE Attn: John Gilmour 350 Main Street E1 Segundo, CA 90245 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD sa ID: 28764404 BATCH: 4187304 53Z 2 " of I AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis Towers Watson Northeast, Inc. '.Elecnor Belco Electric, Inc.. .._ . .. '..... 14320 Albers Way POLICY NUMBER Chino, CA 91710 See Page 1 CARRIER See Page 1 NAIC CODE FECTIVE D q 1 g EF....� ATE: See Page See Page 1 f t,VMU lul kduu ru'I,I © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID:28764404 BATCH:4187304 CERT: W41548470 532: 2 of 9 COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 lir lil' 11,11i�liriii:i 1 11 1 1 1 1 COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE N�rne Of Additional Insured Person(s) . . . . ............ . .... . ......... Or Oraa-,-6;--1.% Location(s) Of Covered Operations Any person or organization you are 'Any location where you are performing required under a written contract or operations and you are required to add agreement in affect prior to loss or �the person or organization described in damage to add as an additional insured to Name of Additional insured Person(s) Or this policy. lOrganization(s) of this SCHEDULE as an additional insured. opurip fl" III! Ilk I off of A. Section 11 - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" '1property damage" occurring after: caused, in whole or in part, by: 1 . All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law;and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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. CG 20 10 12 19 @ Insurance Services Office, Inc., 2018 Page 1 of 2 531 3 ' ofl, C. With respect to the insurance afforded to these 2. Available under the applicable limits of additional insureds, the following is added to insurance; Section III — Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable limits of insurance. will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 2010 12 19 531 3 of 9 POLICY NUMBER: 175001144 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY CG20371219 COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization(s)Location And Des: tion Of Completed Operations Any person -or organization you are Any location where you are performing required under a written contract or operations and you are required to add agreement in effect prior to loss or the person or organization described in �damage to add as an additional insured Name Of Additional Insured Person(s) Or to this policy. Organization(s) of this SCHEDULE as an additional insured. 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 B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III — Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included 1. Required by the contract or agreement; or in the "products-complet�;d operations hazard". However: 2. Available under the applicable limits of 1. The insurance afforded to such additional insurance; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the 2. If coverage provided to the additional insured is applicable limits of insurance. 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. CG 20 37 12 19 OO Insurance Services Office, Inc., 2018 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured. contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 1219 © Insurance Services Office, Inc., 2018 Page 1 of 1 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS contractAny person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the executed prior to the injury or damage occurring. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 0412 19 @ Insurance Services Office, Inc., 2018 Page 1 of 1 533: 5 " of'. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT _ NOTICE TO OTHERS OF CANCELLATION, Name of Insured: Elecnor Belco Electric, Inc. Policy Number: 175001144 Endorsement Number: GL-U-2008 (08-20) Effective Date of Endorsement: 11/01/2025 r------............... Name of Insurer: I NORTH POINTE INSURANCE COMPANY All Coverage Parts and Coverage Forms included in this policy are subject to the following: SCHEDULE Number of Days Name and Address of Person or Organization Notice Per Schedule on File with the First Named Insured. 30 . .......... _.. ....... .............. ... ................... i . I._ The following is added to the policy: A. If we cancel the policy by notice to the first Named Insured, for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the person(s) or organization(s) shown in the SCHEDULE above. B. Any copy of notice per paragraph A. above will be mailed or delivered: 1. To the address corresponding to each person or organization indicated in the SCHEDULE above; and © 9BE., 2020 GL-U-2008 (08-20) Includes copyrighted material of Insurance Services Office, Inc., with its permission, Page 1 of 2 533: 5 of 9 2. At least the number of days set forth in the SCHEDULE prior to the cancellation date applicable to the policy, as advised in our notice to the first Named Insured. C. If notice per paragraph A. is mailed, proof of mailing will be sufficient proof of notice. D. Written notices mailed or delivered by us pursuant to the terms of this endorsement are intended only to be an advance notification to the person(s) or organization(s) named in the SCHEDULE of this endorsement in the event of a pending cancellation and shall not operate or be deemed to benefit, directly or indirectly, any person or organization not named in the SCHEDULE above. All other terms and conditions of the policy remain unchanged. © GBE., 2020 GL-U-2008 (08-20) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 2 533: 6 ' of 9 POLICY NUMBER:165001222 POLICY TERM: 11/1/2025 to 11/1/2026 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. a This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect, to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement dares not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Elecnor Belco Electric, Inc. Endorsement Effective Date: 11 /01 /2025 SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization you are required under a written contract or agreement in effect prior to loss or damage to add as an additional insured to this policy, but only to the extent required by the written contract or agreement, including any limits of insurance specified therein. Information required to complete this Schedule„ if not shown above, will be shown in the Deciarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualities as an "insured" under the Who Is An Insured provision contained in Paragraph A,1, of erection ill - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto i eatem Coverage Form. CA20481013 © Insurance Services Office, Inc., 2011 Page 1 of 1 *OLICY NUMBER: 165001222 COMMERCIAL AUTO -*OLICY TERM: 11/1/2025 to 11/l/2026 CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) 111111"Wommy M1913001 ITKA-0 IrelyK41-AIMI I =L"J'Ay Azy-,191 =as] 1.1 1kTA 11 itn respect to coverage p1I is entorserliell7lyfe-7 4,y the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated Welow. Named Insured: Elecnor Belco Electric, Inc. Endorsement Effective Date: 11/01/2025 Name(s) Of Person(s) Or Organization(s): Any person or organization for whom you perform work under a written contract if the contract requires you t# obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. . will ......... The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the pers,on(s) oIr organization(s) shown in the Schedule, but oniy to the extent (hat subrogafloprior to the "accident" or the "loss" under a contract with that person or organization. CA 04 44 10 13 Q Insurance Services Office, Inc., 2011 Page 1 of I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE TO OTHERSO CANCELLATION Name of Insured., Elecnor Belco Electric, Inc. Policy Number: 165001222 Endorsement Number: CA-U-2025 (12-20) Effective Date of Endorsement: 11/01/2025 Name of insurer: NORTH POINTE INSURANCE COMPANY SCHEDULE Number Name and Address of Person or Organizatlon of Days Notice Per Schedule on File with the First Named 30 14320 Albers V"Va Chino, CA 91710 a.. ©* If this box is checked, notice will not be sent in the event of nonpayment of premium. Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations. The following is added to the policy: 1.To the address corresponding to each person or organization indicated in the SCHEDULE above; A. If we cancel the policy by notice to the first Named and Insured, we will mail or deliver a copy of such written notice of cancellation to the person(s) or 2. At least the number of days set forth in the organization(s) shown in the SCHEDULE above. SCHEDULE prior to the cancellation date appli- However, no notice will be mailed or delivered if cable to the policy, as advised in our notice to cancellation is for nonpayment of premium and the the first Named Insured, box in the SCHEDULE above is checked. C. If notice per paragraph A. is mailed, proof of mailing B. Any copy of notice per paragraph A. above will be will be sufficient proof of notice. mailed or delivered: © ®BE., 2020 CA-U-2025 (12-20) Includes copyrighted material of Insurance Services Office, Inc., Pagel of 2 with its permission. 533: 7 of 9 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2.0% of the California workers' compensation premium otherwise due on such remuneration. Any person or organization for which you have agreed to waive your rights of recovery in a written contract, provided such contract was executed prior to date of loss. Schedule Person or Organization Job Description Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring. 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 Insured Insurance Company WC 04 03 06 (Ed. 04-84) 11 /01 /2025 Elecnor Belco Electric, Inc. NORTH POINTE INSURANCE COMPANY Policy No. 155000127 Endorsement No. 000 Premium Countersigned by Page 1 of 1 D. Written notices mailed or deliveved y us pumusnt to the terms of this endorsement are intended only to be an advance notification to the person(s) or organization(s) named in the SCHEDULE of this endorsement in the event of a pending cancellation and shall not operate or be deemed to benefit, directly or indirectly, any person or organization not named in the SCHEDULE above. All other terms and conditions of the policy remain unchanged. 0 ®BE., 2020 CA-U-2025 (12-20) Includes copyrighted material of Insurance Services Office, Inc., Page 2 of with Its permission. g 533: 8 ' of 9 II (Ed. 6-12) The following is added to Part Six (Conditions): A. If we cancel this policy for any reason other than nonpayment of premium, by delivering written notice of cancellation to you, we will mail or deliver a copy of such notice to the person(s) or organization(s) shown in the Schedule. B. The notice of cancellation will be mailed or delivered: 1. To the address corresponding to each person or organization shown in the Schedule. 2. At least the number of days set forth in the Schedule prior to the cancellation date. C. Proof of mailing will be sufficient proof of notice. D. This is intended only to be advance notification to the person(s) or organization(s) shown in the Schedule in the event of a pending cancellation and will not operate or be deemed to benefit, directly or indirectly, any person or organization not shown in the Schedule. Schedule Name and Address of Person or Organization Per Schedule on File with the First Named Insured ATMM!"arl-TIPTAWIM KI 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 11/01/2025 Policy No. 155000127 Endorsement No. 000 Insured Elecnor Belco Electric, Inc. Insurance Company NORTH POINTE INSURANCE COMPANY Countersigned By C 99 03 06 (d. 6-12)