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PROOF OF INSURANCE (2015) CLOSED (5)ACS CERTIFICATE OF LIABILITY INSURANCE °ATE'MM / ° °"Y'"' �- 09/03/2014 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 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 310- 659 -4950 X99 Michelle 1 950 �, _ .� , NIA INSURANCE AGENCY, INC. LIC #0688707 tII,I ,A9 Ex0 ..._ IA)C, E -MAIL 11041 SANTA MONICA BLVD #719 A kESS, rnichelle niainsurance a�encymmcom LOS ANGELES, CA 90025 ___ rtsut?ERtstA�on�NCCOVERAGE� INSURED INSURER B: SPEC CONSTRUCTION CO, INC. INSURERC: 1870 S. CARLOS AVE INSURER D I ONTARIO, CA 91761 INSURER E: COVERAGES 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. INSRR TYPE OF INSURANCE - WWWWW------WPOI.ICYNUMBER, MPMOLICDYEFF M C1ffV-E7CF'. __________ ___ ____ __ __ LIMITS -- -.... COMMERCIAL GENERAL LIABILITY ✓ ✓ EACH OCCURRENCE s 1,000,0 © D E t�RITS ............... 50,000. CLAIMS -MADE OCCUR I ?I.a�s $µWWµ MED EXP (Any one person) ........... s5000 ......._ _.............� _..... _,.,,, CGD00004043 -01 04/26/2014 04/26/2015 PERSONAL &ADVINJURY "aE'N' GGRREGATE�LIMIT APPLIES PER: ...- . $ (BOO OQQ. q WW uu, DUCTSGCOEGATE PRO. MP /OP AGGmm $mm? ,OOO,Q00. OTH'EW $ AUTOMOBILE LIABILITY / v / 1r COMBINED SINGLE LIMIT LFa aoGdonhh s �m OQ1.000. B,. ANY AUTO BODILY INJURY (Per person) $ ALLOWNED SCHEDULED 57559366 05/07/2014 05/D7/2015 BODILY INJURY (Per accident) $ f UTOI AUTOS NON -OWNED . ......Y...__...,....._.T.._.... PROPERTY OAMACE .............. $ .. Y .HIRED AUTOS AUTOS IPear s«ccidanl _.. . ........................... .............................. $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ RETENTION $ $ WORKERS COMPENSATION PER O'T "H- ER .................... """.... AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR1'PARTNERfEAECUTIV'E i N / A ' E.I_ EACH ACCIDENT ....m. $ - OFFICEWMEMSER EXCLUDED? ""'�_ . (Mandatory In NH) E.L,. DISEASE -.EA EMPLOYEE $ _ ........ ..... . .. ..... it yyes; describe tandem DkSCR:IPTION OF OPERATIONS Wow E.L. DISEASE- POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Additional Insured Endorsement USIC - CMGIA- 0310 -0412. Waiver Of Subrogation USIC -CMGIA 7830, Primary and Non - Contributory wording USIC -CMGIA including Products & Completed Operations are enclosed. The City, its officers, officials, employees and agent will be covered as additional insured as respects: Liability arising out of activities performed by or on behalf of the Contractor. Premises owned, occupied or used by Contractors. Primary and Non - Contributory wording is included for its officers, officials, emloyees and agents. 30 Days notice of cancellation for non - payment of premium. City of El Segundo RSI 59 (14 -15). 1 City of El Segundo, RSI Program 59 (14 -15 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 333 Main Street Unit A ACCORDANCE WITH THE POLtC PROVISIONS El Segundo, CA 90245 E AUTHORIZED REPROSENTi ,.s e Nia ©1g f$-�2;0 14 C O CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered mark OIL, INSURED: SPEC CONSTRUCTION CO, INC. CARRIER: UNITED SPECIALTY INSURANCE COMPANY ATTACHED TO AND FORMING A PART OF ENDORSEMENT EFFECTIVE DATE ADDITIONAL INSURED ENDORSEMENT NO. POLICY NUMBER (12:01 A.M. STANDARD TIME) you and such person or organization have agreed in a. The preparing, approving, or failing to prepare writing, and executed such a contract or agreement or approve, maps, shop drawings, opinions, City of El Segundo, RSI 59 (14 -15). The City, its officers, offi- reports, surveys, field orders, change orders claim, that such person or organization be added as or drawings and specifications; and cials, employees and agents. 333 Main St. Unit A CGD000004043- 04/26/2014 El Segundo, CA 90245 USIC- CMGIA- 01 2. "Bodily injury" or "property damage" occurring Re: City of El Segundo, RSI 59 (14 -15) 0310 (The above information is required only when this endorsement is issued subsequent to preparation of the policy.) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II —Who Is An Insured is amended to in- of, or the failure to render, any professional clude as an additional insured any person or organi- architectural, engineering or surveying services, zation for whom you are performing operations when including: you and such person or organization have agreed in a. The preparing, approving, or failing to prepare writing, and executed such a contract or agreement or approve, maps, shop drawings, opinions, prior to the time of an occurrence giving rise to a reports, surveys, field orders, change orders claim, that such person or organization be added as or drawings and specifications; and an additional insured on your policy. Such person or organization is an additional insured only with respect b. Supervisory, inspection, architectural or engi- to liability for "bodily injury," "property damage" or neering activities. .'personal and advertising injury" caused, in whole or 2. "Bodily injury" or "property damage" occurring in part, by: after: 1. Your acts or omissions; or a. All work, including materials, parts or equip - 2. The acts or omissions of those acting on your ment furnished in connection with such work, behalf; on the project (other than service, mainte- nance or repairs) to be performed by or on in the performance of your ongoing operations for the - behalf of the additional insured(s) at the site additional insured. of the covered operations has been complet- B. With respect to the insurance afforded to these addi- ed; or tional insureds, the following additional exclusions b. That portion of "your work" out of which the in- apply: jury or damage arises has been put to its in- This insurance does not apply to: tended use by any person or organization other than another contractor or subcontrac- 1. "Bodily injury," "property damage" or "personal for engaged in performing operations for a and advertising injury" arising out of the rendering principal as a part of the same project. NIA INSURANCE AGENCY, INC. AUTHORIZED REPRESENTATIVE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 I ICIr._r'.KAf;IA_n41 n 09/03/2014 DATE INSURED: SPEC CONSTRUCTION CO, INC. CARRIER: PROGRESSIVE CASUALTY INSURANCE COMPANY ATTACHED TO AND FORMING A PART OF ENDORSEMENT EFFECTIVE DATE ADDITIONAL INSURED ENDORSEMENT NO. POLICY NUMBER (12:01 A.M. STANDARD TIME) you and such person or organization have agreed in a. The preparing, approving, or failing o prepare g p p writing, and executed such a contract or agreement or approve, maps, shop drawings, opinions, City of El Segundo, RSI 59 (14 -15). The City, its officers, offi- reports, surveys, field orders, change orders claim, that such person or organization be added as or drawings and specifications; and cials, employees and agents. 333 Main St. Unit A 057559366 1 05/07/2014 El Segundo, CA 90245 USIC- CMGIA- "personal and advertising injury" caused, in whole or 2. "Bodily injury" or "property damage" occurring Re: City of El Segundo, RSI 59 (14 -15) 0310 (The above information is required only when this endorsement is issued subsequent to preparation of the policy.) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL AUTO LIABILITY COVERAGE PART A. Section II —Who Is An Insured is amended to in- of, or the failure to render, any professional clude as an additional insured any person or organi- architectural, engineering or surveying services, zation for whom you are performing operations when including: you and such person or organization have agreed in a. The preparing, approving, or failing o prepare g p p writing, and executed such a contract or agreement or approve, maps, shop drawings, opinions, prior to the time of an occurrence giving rise to a reports, surveys, field orders, change orders claim, that such person or organization be added as or drawings and specifications; and an additional insured on your policy. Such person or organization is an additional insured only with respect b. Supervisory, inspection, architectural or engi- to liability for "bodily injury," "property damage" or neering activities. "personal and advertising injury" caused, in whole or 2. "Bodily injury" or "property damage" occurring in part, by: after: 1. Your acts or omissions; or a. All work, including materials, parts or equip - 2. The acts or omissions of those acting on your ment furnished in connection with such work, behalf; on the project (other than service, mainte- in the performance of your ongoing operations for the nance or repairs) to be performed by or on behalf of the additional insured(s) at the site additional insured. of the covered operations has been complet- B. With respect to the insurance afforded to these addi- ed; or tional insureds, the following additional exclusions b. That portion of "your work" out of which the in- apply: jury or damage arises has been put to its in- This insurance does not apply to: tended use by any person or organization other than another contractor or subcontrac- 1. "Bodily injury," "property damage" or "personal for engaged in performing operations for a and advertising injury" arising out of the rendering principal as a part of the same project. NIA INSURANCE AGENCY, INC. AUTHORIZED REPRESENTATIVE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 I ICIr_r.KArIG_n41 n 09/03/2014 DATE INSURED: SPEC CONSTRUCTION CO, INC. CARRIER: PROGRESSIVE CASUALTY INSURANCE CO. ATTACHED TO AND FORMING A PART OF ENDORSEMENT EFFECTIVE DATE ADDITIONAL INSURED ENDORSEMENT NO. POLICY NUMBER (12:01 A.M. STANDARD TIME) City of El Segundo, RSI 59 (14 -15). The City, its officials, its officers, employees, agents . 057559366 05/07/2014 333 Main Street St A USIC -CMGIA El Segundo, CA 90245 7830 (The above information is required only when this endorsement is issued subsequent to preparation of the policy.) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL AUTO LIABILITY COVERAGE PART The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV— COMMERCIAL AUTO LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against an additional insured shown on form USIC- CMGIA- 0310 -0412 or USIC -CMGIA -7900 0414 but only with respect to liability for "bodily injury," "property dam- age" or "personal and advertising injury" caused by: 1. The named insured's acts or omissions; or 2. The acts or omissions of those acting on the named insured's behalf; in the performance of the named insured's ongoing operations for the additional insured shown on form USIC -CMGIA -0310 0412, or USIC -CMGIA -7900. All other Terms and Conditions of this Policy remain unchanged. NIA INSURANCE AGENCY, INC. 09/03/2014 AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 1992, 2003 I ICIr'._r.hA(,IG 7R'ln INSURED: SPEC CONSTRUCTION CO, INC. CARRIER: UNITED SPECIALTY INSURANCE CO. ATTACHED TO AND FORMING A PART OF ENDORSEMENT EFFECTIVE DATE ADDITIONAL INSURED ENDORSEMENT NO. POLICY NUMBER (12:01 A.M. STANDARD TIME) City of El Segundo, RSI 59 (14 -15). The City, its officials, its officers, employees, agents . CGD00004043 -01 04/26/2014 333 Main Street St A USIC -CMGIA El Segundo, CA 90245 7830 (The above information is required only when this endorsement is issued subsequent to preparation of the policy.) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL AUTO LIABILITY COVERAGE PART The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV— COMMERCIAL AUTO LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against an additional insured shown on form USIC- CMGIA- 0310 -0412 or USIC -CMGIA -7900 0414 but only with respect to liability for "bodily injury," "property dam- age" or "personal and advertising injury" caused by: 1. The named insured's acts or omissions; or 2. The acts or omissions of those acting on the named insured's behalf; in the performance of the named insured's ongoing operations for the additional insured shown on form USIC -CMGIA -0310 0412, or USIC -CMGIA -7900. All other Terms and Conditions of this Policy remain unchanged. NIA INSURANCE AGENCY, INC. 09/03/2014 AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 1992, 2003 I ICIr._r.hAr_IG 7A4n Policy Number Named Insured Effective Date CGD00004043 -01 SPEC Construction Co, Inc. 04/26/2014 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The City of El Segundo RSI 59 (14 -15), its officials, officers, agents and employees 333 Main St. Unit A El Segundo, CA 90245 Section II- Who is An insured is amended to include as an additional insured only the person (s) or organization (s) who have entered into a written contract with "you" prior to "your" commencement of work for the person(s) or organization (s) with whom "you" have entered into a written contract and such written contract specifically requires that "you " provide this coverage, but only with respect to liability for "bodily injury" or "property damage" caused in whole and exclusively by "you" performing "your work" on completed operations hazard" under the policy. This amendment does not apply to "your work" on any residential construction project. Terms in quotation marks are defined in the policy to which the endorsement is attached. U S I C -C MG IA -7810 Rev.9/25/2013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY COMMERCIAL GENERAL LIABILITY POLICY NUMBER: CGD00004043 -01 INSURED: SPEC CONSTRUCTION CO, INC. ADDITIONAL INSURED - PRIMARY AND NON - CONTRIBUTORY - OWNERS, LESSORS OR CONTRACTORS COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: The City of El Segundo, RSI 59 (14 -15) its officers, officials, employees, agents. 333 Main Street Unit A El Segundo, CA 90245 Section II -In accordance with the terms, conditions, limitations and provisions of the policy to which this endorsement is attached, Section II -Who is an Insured is amended to include an Additional Insured The Person, organization or entity designated in this endorsement but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work at the designated construction project performed for the designated person, organization or entity and included in the ongoing operations hazard. This endorsement does not create or our part a duty to defend the designated person, organization or entity or contribute to or reimburse the designated person, organization or entity. This endorsement is only applicable it the designated person, organization or entity and the designated project sections are completed. With respect to the Insurance afforded to these Additional Insured , the following additional inclusions apply: This insurance applies 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 by performed by or on behalf of the Additional Insured. At the location of the covered operations has been completed ; or That portion of "Your Work" out of which the injury or damage has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for the principal as part of the same project. PRIMARY /NON- CONTRIBUTORY WORDING: It is agreed that this insurance is primary and non - contributory and that no insurance held or owned by the designated Additional Insured shall be called upon to cover a loss under said policy up to the limits of this policy if loss under this policy arises directly from work performed by Named Insured. All other terms, conditions and exclusions remain unchanged (OMINI 7 EFQA12 -11 -5- 1/12/1203051353) Form Edition 05/10/12 ` DATE(MM /DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/04/2014 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 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 ex Insurance Agency y g ncy Inc PAYCHEX INSURANCE AGENCY INC„ NAME. - PH PHONE 877 2 150 SAWGRASS DRIVE (A/C.. NO -EXI 4 66 6850 ,WC, NA), 585 389 7426 ) ROCHESTER, NY 14620 E -MAIL x.com E-MAIL Certs@paychex.com -A ES:S----------------------- AFFORDING COVERAGE NAIC # � . -.. 4-31470 INSURED — --- - -..,. INSURER NorGUARD Insurance ce Company SPEC CONSTRUCTION CO INC INSURER B: 1870 S. CARLOS AVENUE - _ _ ......... ----- .. ... ..... ........ ONTARIO, CA 91761 INSURER C: .... ................. INSURER D: INSURER E: ------ - -- INSURER F: COVERAGES 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. W�PW... NSR POLICYEFF TYPE OF INSURANCE 'UBDR POLICY NUMBER ouCY EXP LIMITS LrR NSR (MM /DD/YYYY) (MM /DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAdL tl0 RkN"re0— j y I � LAIMS -MADLJ �'JC'CUR C PRf MfSL,S (Laa Dccutranc ). —. $ -- _ ........... .. MED EXP (Any one person} .......... PERSONAL & ADV INJURY ... $ _ ........ ......... GENERAL AGGREGATE $ EN'L, AGGREGATE LIMIT APPLIES PER: ............... ._.....- - ----- --- °'..'. .. "........ ......., PRODUCTS - COMP /OP AGG Po.iry tD c °t Q 1 O 1 l - - - - -- ....... AUTOMOBILE LIABILITY ED SINGLE LIMIT (Ea accident) $ ANY AUTO . .. ..... — -- - -._.. A OWNrD SCHEDULED BODILYINJURY (Per arson ) $ AUTOS .�. AUT NON -oWNEO BODILY INJURY HIRED AUTOS U To .. A (Per accident) ..... $ ....... —_ ......... �..... -,I DAMA PROPERTY GE $ (Per dent) ........_ .....-� .............. $ UMBRELLA LAB ( -. OCCUR EACH OCCURRENCE $ EXCESS LIAB C CLAIMS -MADE AGGREGATE $ bED RETENTION S WORKERS COMPENSATION AND WC STATU OTH- SPWC583326 03/12/2014 03/12/2015 X - ..TnaxYLlMtTS.... .-- ._cH -.- EMPLOYERS' LIABILITY E.L. EACH ACCIDENT S 1 „LII10,0(°)tt..t10 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? YIN. E.L. DISEASE - EA EMPLOYEE "i 1,000,000.001 (Mandatory In NH) "Y' N/A X E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 IP yes, describe under y. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Waiver of Subrogation granted in favor of the certificate holder CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION RSI 59 (14 -15) DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY 333 Main St Unit A PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR El Segundo, CA 90245 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) 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 1.0?__% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver - Any person or organization for whom the All CA Operations Named Insured has agreed by written contract 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 Policy No. SPWC583326 Endorsement No, Insured Insurance Company Countersigned By ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.