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PROOF OF INSURANCE (2015) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDmYY)
�. 10/2��
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
Dealey, Renton & Associates
P. O. Box 10550
Santa Ana CA 92711 -0550
INSURED
Willdan Energy Solutions
DBA Intergy Corporation
6130 Stoneridge Mall Rd., #380
Pleasanton CA 94588
INSURER A:
INSURER C
INSURER E
COVERAGES CERTIFICATE NUMBER: 1811408255 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.
-_ §
LTR
ILTR
TYPE OF INSURANCE
ADDL
POLICY NUMBER
POLICY
MMIDDN YX
LIMITS
A
GENERAL LIABILITY
Y
Y
6301158PO20
11/9/2014
11/9/2015
EACH OCCURRENCE
$1,000,000
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
PREMISES CE a o C'i"u"ren `e"
$1,000,000
ME.. E 2P ..y one on
µPERSONAL
$10,000
X Contractual
& ADV INJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
X BFPD, XCU
PRODUCTS - COMP /OP AGG
$2,000,000
AGGREGATE LIMIT APPLIES PER:
_
$
PR�7•
POLICY' x .. LOC
A
AUTOMOBILE
LIABILITY
Y
Y
8101158PO20
11/9/2014
11/9/2015
Ea &gc!d 1
1 000 000
X,
ANY AUTO
BODILY INJURY (Per person)
$
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
.. . ...
. $ .. .... ......... ..
X
NON -OWNED
HIRED AUTOS X AUTOS
PROPERIYDAMAdE
leerarciden) m ........................w
$
A
FUMBRELLA LIAB X I OCCUR
CUP1158PO20
11/9/2014
1/9/2015
EACH OCCURRENCE
$2,000,000
LIAB CLAIMS -MADE
AGGREGATE
$2,000,000
$
iqEXCESS
DED I J RETENTION $
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
Y
UB713417816
11/9/2014
1/9/2015
OTH-
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED? N
N/A
E.L. EACH ACCIDENT
- -- - -
$1,000,000
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
B
Professional Liability
AED977441115
11/9/2014
1/9/2015
Per Claim $1,000,000
Claims Made
Annual Aggregate $2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
General Liability policy excludes claims arising out of the performance of professional services.
Independent Contractors are included as respects to General Liability.
Excess Liability Coverage Excludes Professional Liability.
30 Day NOC /10 Day for NonPay of Prem
Re: Professional consulting services for the implementation of the city's energy efficiency strategic plan. City of El Segundo, its officials and
employees, and Southern California Edison, its officers, agents, and employees are additional insured as respects to General and Auto
See Attached...
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.
Stephanie Katsouleas, Public Works Director, V"
Dept of Public Works, 350 Main Street Au HORIZED REPRESENTATIVE
El Segundo CA 90245
©1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID;
LOC #:
AC ADDITIONAL REMARKS SCHEDULE
AGENCY
Dealey, Renton & Associates
.......... ____ ........... . ....... _ .........
POLICY NUMBER
CARRIER
NAIC CODE
NAMED INSURED
Willdan Energy Solutions
DBA Intergy Corporation
6130 Stoneridge Mall Rd., #380
Pleasanton CA 94588
EFFECTIVE DATE:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE
Page 1 of 1
Liability as required by written contract. Primary and Non - Contributing coverage, Cross Liability coverage, Waiver of Subrogation applies to
GL as required by written contract. Waiver of subrogation for Work Comp is included as required by written contract. Primary and
Non - Contributing coverage applies to Auto Liability as required by written contract. (WES MONROVIA)
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
6301158PO20
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - WRITTEN
CONTRACTS ARCHITECTS, ENGINEERS AND
SURVEYORS)
\V
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1, The following is added to SECTION II —WHO IS
AN INSURED:
Any person or organization that you agree in a
"written contract requiring insurance" to include as
an additional insured on this Coverage Part, but:
a. Only with respect to liability for "bodily injury",
"property damage" or "personal injury"; and
b. If, and only to the extent that, the injury or
damage is caused by acts or omissions of
you or your suntractor in the performance
of "your work' to which the "written contract
requiring insurance" applies. The person or
organization does not qualify as an additional
insured with respect to the independent acts
or omissions of such person or organization.
The insurance provided to such additional insured
is limited as follows:
c. In the event that the Limits of Insurance of
this Coverage Part shown in the Declarations
exceed the limits of liability required by the
"written contract requiring insurance ", the in-
surance provided to the additional insured
shall be limited to the limits of liability required
by that "written contract requiring insurance ".
This endorsement shall not increase the limits
of insurance described in Section III — Limits
Of Insurance.
d. This insurance does not apply to the render-
ing of or failure to render any "professional
services" or construction management errors
or omissions.
e. This insurance does not apply to "bodily in-
jury" or "property damage" caused by "your
work" and included in the "products -
completed operations hazard" unless the
"written contract requiring insurance" specifi-
cally requires you to provide such coverage
for that additional insured, and then the insur-
ance provided to the additional insured ap-
plies only to such "bodily injury" or "property
damage" that occurs before the end of the pe-
riod of time for which the "written contract re-
quiring insurance" requires you to provide
such coverage or the end of the policy period,
whichever is earlier.
2. The following is added to Paragraph 4.a, of SEC-
TION [V — COMMERCIAL GENERAL LIABILITY
CONDITIONS:
The insurance provided to the additional insured
is excess over any valid and collectible 'other in-
surance", whether primary, excess, contingent or
on any other basis, that is available to the addi-
tional insured for a loss we cover. However, if you
specifically agree in the "written contract requiring
insurance" that this insurance provided to the ad-
ditional insured under this Coverage Part must
apply on a primary basis or a primary and non-
contributory basis. this insurance is primary to
"other insurance" available to :he additional in-
sured which covers that person or organization as
a named insured for such loss, and we will not
share with that 'other insurance But this insur-
ance provided to the additiona! insured still is ex-
cess over any valid and collectible 'other insur-
ance", whether primary, excess, contingent or on
any other basis, that is available to the additional
insured when that person or organization is an
additional insured under any 'other insurance ".
3. The following is added to SECTION IV — COM-
MERCIAL GENERAL LIABILITY CONDITIONS:
Duties Of An Additional Insured
As a condition of coverage provided to the addi-
tional insured:
a. The additional insured must give us written
notice as soon as practicable of an 'occur-
rence" or an offense which may result in a
claim. To the extent possible, such notice
should include:
CG D4 14 04 08 © 2008 The Travelers Compares, nc. Page 1 of 2
COMMERCIAL GENERAL LIABILITY
i. How, when and where the "occurrence"
or offense took place;
Ii. The names and addresses of any injured
persons and witnesses; and
Ill. The nature and location of any injury or
damage arising out of the "occurrence" or
offense.
b. If a claim is made or "suit" is brought against
the additional insured, the additional insured
must:
i. Immediately record the specifics of the
claim or "suit" and the date received; and
ii. Notify us as soon as practicable.
The additional insured must see to it that we
receive written notice of the claim or "suit" as
soon as practicable.
c. The additional insured must immediately send
us copies of all legal papers received in con-
nection with the claim or "suit ", cooperate with
us in the investigation or settlement of the
claim or defense against the "suit ", and oth-
erwise comply with all policy conditions.
d. The additional insured must tender the de-
fense and indemnity of any claim or "suit" to
any provider of other insurance which would
cover the additional insured for a loss we
cover. However, this condition does not affect
whether this insurance provided to the addi-
tional insured is primary to that other insur-
ance available to the additional insured which
covers that person or organization as a
named insured.
4. The following is added to the DEFINITIONS Sec-
tion:
"Written contract requiring insurance" means that
part of any written contract or agreement under
which you are required to include a person or or-
ganization as an additional insured on :his Cover-
age Part, provided that the "bodily injury" and
"property damage" occurs and the "personal in-
jury" is caused by an offense committed:
a. After the signing and execution of the contract
or agreement by you;
b. While that part of the contract or agreement is
in effect; and
c. Before the end of the policy period.
Page 2 of 2 0 2008 The Travelers Companies, Inc. CG D4 14 04 08
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF SUBROGATION
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorse-
ment, the provisions of the Coverage Form apply
unless modified by the endorsement.
Paragraph S. Transfer of Rights Of Recovery
Against Others To Us of the CONDITIONS section
is replaced by the following:
5. Transfer Of Rights Of Recovery Against Oth-
ers To Us
We waive any right of recovery we may have
against any person or organization to the extent
required of you by a written contract executed
prior to any "accident" or "loss ", provided that the
"accident" or 'loss" arises out of the operations
contemplated by such contract. The waiver ap-
plies only to the person or organization desig-
nated in such contract.
CA T3 40 08 08 0 2008 The Travelers Companies, Inc. Page 1 of 1
COMMERCIAL AUTO
8101158PO20
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi-
fied by the endorsement.
GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any
injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover-
age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. BROAD FORM NAMED INSURED
B. BLANKET ADDITIONAL INSURED
C. EMPLOYEE HIRED AUTO
D. EMPLOYEES AS INSURED
E. SUPPLEMENTARY PAYMENTS — INCREASED
LIMITS
F. HIRED AUTO — LIMITED WORLDWIDE
COVERAGE — INDEMNITY BASIS
G. WAIVER OF DEDUCTIBLE — GLASS
PROVISIONS
A. BROAD FORM NAMED INSURED
The following is added to Paragraph A.1., Who Is
An Insured, of SECTION 11 — LIABILITY COV-
ERAGE:
Any organization you newly acquire or form dur-
ing the policy period over which you maintain
50% or more ownership interest and that is not
separately insured for Business Auto Coverage.
Coverage under this provision is afforded only un-
til the 180th day after you acquire or form the or-
ganization or the end of the policy period, which-
ever is earlier.
B. BLANKET ADDITIONAL INSURED
H. HIRED AUTO PHYSICAL DAMAGE — LOSS
OF USE — INCREASED LIMIT
I. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES — INCREASED LIMIT
J. PERSONAL EFFECTS
K. AIRBAGS
L. NOTICE AND KNOWLEDGE OF ACCIDENT
OR LOSS
M. BLANKET WAIVER OF SUBROGATION
N. UNINTENTIONAL ERRORS OR OMISSIONS
executed by you before the "bodily injury" or
"property damage" occurs and that is in effect
during the policy period, to be named as an addi-
tional insured is an "insured" for Liability Cover-
age, but only for damages to which this insurance
applies and only to the extent that person or or-
ganization qualifies as an "insured" under the
Who Is An Insured provision contained in Section
II.
C. EMPLOYEE HIRED AUTO
1. The following is added to Paragraph A.1.,
Who Is An Insured, of SECTION II — LI-
ABILITY COVERAGE:
The following is added to Paragraph c. in A.1., An "employee" of yours is an "insured" while
Who Is An Insured, of SECTION 11 — LIABILITY operating an "auto" hired or rented under a
COVERAGE: contract or agreement in that "employee's"
name, with your permission, while performing
Any person or organization who is required under duties related to the conduct of your busi-
a written contract or agreement between you and ness.
that person or organization, that is signed and
CA T3 53 03 10 © 2010 The Travelers Indemnity Company. Page 1 of 4
Includes copyrighted material of Insurance Services office, Inc, with Its permission.
COMMERCIAL AUTO
2. The following replaces Paragraph b. in B.5.,
Other Insurance, of SECTION IV — BUSI-
NESS AUTO CONDITIONS:
b. For Hired Auto Physical Damage Cover-
age, the following are deemed to be cov-
ered "autos" you own:
(1) Any covered "auto" you lease, hire,
rent or borrow; and
(2) Any covered "auto" hired or rented by
your "employee" under a contract in
that individual "employee's" name,
with your permission, while perform-
ing duties related to the conduct of
your business.
However, any "auto" that is leased, hired,
rented or borrowed with a driver is not a
covered "auto ".
D. EMPLOYEES AS INSURED
The following is added to Paragraph A.1., Who Is
An Insured, of SECTION 11 — LIABILITY COV-
ERAGE:
Any "employee" of yours is an "Insured " while us-
ing a covered "auto" you don't own, hire or borrow
in your business or your personal affairs.
E. SUPPLEMENTARY PAYMENTS — INCREASED
LIMITS
1. The following replaces Paragraph A.2.a.(2),
of SECTION 11— LIABILITY COVERAGE:
(2) Up to $3,000 for cost of bail bonds (in-
cluding bonds for related traffic law viola-
tions) required because of an "accident"
we cover. We do not have to furnish
these bonds.
2. The following replaces Paragraph A.2.a.(4),
of SECTION II — LIABILITY COVERAGE:
(4) All reasonable expenses incurred by the
"insured" at our request, including actual
loss of earnings up to $500 a day be-
cause of time off from work.
F. HIRED AUTO — LIMITED WORLDWIDE COV-
ERAGE — INDEMNITY BASIS
The following replaces Subparagraph (5) in Para-
graph B.7., Policy Period, Coverage Territory,
of SECTION IV — BUSINESS AUTO CONDI-
TIONS:
(5) Anywhere in the world, except any country or
jurisdiction while any trade sanction, em-
bargo, or similar regulation Imposed i by the
United States of America applies to and pro-
hibits the transaction of business with or
within such country or jurisdiction, for Liability
Coverage for any covered "auto" that you
lease, hire, rent or borrow without a driver for
a period of 30 days or less and that is not an
"auto" you lease, hire, rent or borrow from
any of your "employees ", partners (if you are
a partnership), members (if you are a limited
liability company) or members of their house-
holds.
(a) With respect to any claim made or "suit"
brought outside the United States of
America, the territories and possessions
of the United States of America, Puerto
Rico and Canada:
(i) You must arrange to defend the "in-
sured" against, and investigate or set-
tle any such claim or "suit" and keep
us advised of all proceedings and ac-
tions.
(ii) Neither you nor any other involved
"insured" will make any settlement
without our consent.
(iii) We may, at our discretion, participate
in defending the "insured" against, or
in the settlement of, any claim or
"suit ".
(Iv) We will reimburse the "insured" for
sums that the "insured" legally must
pay as damages because of "bodily
injury" or "property damage" to which
this insurance applies, that the "in-
sured" pays with our consent, but
only up to the limit described in Para-
graph C., Limit Of Insurance, of SEC-
TION II — LIABILITY COVERAGE.
(v) We will reimburse the "insured" for
the reasonable expenses incurred
with our consent for your investiga-
tion of such claims and your defense
of the "insured" against any such
"suit ", but only up to and included
within the limit described in Para-
graph C., Limit Of Insurance, of
SECTION II — LIABILITY COVER-
AGE, and not in addition to such limit.
Our duty to make such payments
ends when we have used up the ap-
plicable limit of insurance in pay-
ments for damages, settlements or
defense expenses.
(b) This insurance is excess over any valid
and collectible other insurance available
Page 2 of 4 © 2010 The Travelers Indemnity Company. CA T3 53 03 10
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
to the "insured" whether primary, excess
contingent or on any other basis.
(c) This insurance is not a substitute for re-
quired or compulsory insurance in any
country outside the United States, its ter-
ritories and possessions, Puerto Rico and
Canada.
You agree to maintain all required or
compulsory insurance in any such coun-
try up to the minimum limits required by
local law. Your failure to comply with
compulsory insurance requirements will
not invalidate the coverage afforded by
this policy, but we will only be liable to the
same extent we would have been liable
had you complied with the compulsory in-
surance requirements.
(d) It is understood that we are not an admit-
ted or authorized insurer outside the
United States of America, its territories
and possessions, Puerto Rico and Can-
ada. We assume no responsibility for the
furnishing of certificates of insurance, or
for compliance in any way with the laws
of other countries relating to insurance.
G. WAIVER OF DEDUCTIBLE — GLASS
The following is added to Paragraph D., Deducti-
ble, of SECTION III — PHYSICAL DAMAGE
COVERAGE:
No deductible for a covered "auto" will apply to
glass damage if the glass is repaired rather than
replaced.
H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF
USE — INCREASED LIMIT
The following replaces the last sentence of Para-
graph A.4.b., Loss Of Use Expenses, of SEC-
TION III — PHYSICAL DAMAGE COVERAGE:
However, the most we will pay for any expenses
for loss of use is $65 per day, to a maximum of
$750 for any one "accident ".
1. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES — INCREASED LIMIT
The following replaces the first sentence in Para-
graph A.4.a., Transportation Expenses, of
SECTION III — PHYSICAL DAMAGE COVER-
AGE:
We will pay up to $50 per day to a maximum of
$1,500 for temporary transportation expense in-
curred by you because of the total theft of a cov-
ered "auto" of the private passenger type.
COMMERCIAL AUTO
J. PERSONAL EFFECTS
The following is added to Paragraph AA., Cover-
age Extensions, of SECTION III — PHYSICAL
DAMAGE COVERAGE:
Personal Effects
We will pay up to $400 for "loss" to wearing ap-
parel and other personal effects which are:
(1) Owned by an "insured "; and
(2) In or on your covered "auto ".
This coverage applies only in the event of a total
theft of your covered "auto ".
No deductibles apply to this Personal Effects
coverage.
K. AIRBAGS
The following is added to Paragraph B.3., Exclu-
sions, of SECTION III — PHYSICAL DAMAGE
COVERAGE:
Exclusion 3.a. does not apply to "loss" to one or
more airbags in a covered "auto" you own that in-
flate due to a cause other than a cause of "loss"
set forth in Paragraphs A.1.b. and A.1.c., but
only:
a. If that "auto" is a covered "auto" for Compre-
hensive Coverage under this policy;
b. The alrbags are not covered under any war-
ranty; and
c. The airbags were not intentionally inflated.
We will pay up to a maximum of $1,000 for any
one "loss ".
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
The following is added to Paragraph A.2.a., of
SECTION IV — BUSINESS AUTO CONDITIONS:
Your duty to give us or our authorized representa-
tive prompt notice of the "accident' or "loss" ap-
plies only when the "accident' or 'loss" is known
to:
(a) You (if you are an individual);
(b) A partner (if you are a partnership);
(c) A member (if you are a limited liability com-
pany);
(d) An executive officer, director or insurance
manager (if you are a corporation or other or-
ganization); or
(e) Any "employee" authorized by you to give no-
tice of the "accident" or "loss ".
CA T3 53 03 10 © 2010 The Travelers Indemnity Company. Page 3 of 4
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
M. BLANKET WAIVER OF SUBROGATION
The following replaces Paragraph A.5., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV — BUSINESS AUTO CONDI- N
TIONS:
5. Transfer Of Rights Of Recovery Against
Others To ifs
We waive any right of recovery we may have
against any person or organization to the ex-
tent required of you by a written contract
signed and executed prior to any "accident'
or "loss ", provided that the "accident" or "loss"
arises out of operations contemplated by
such contract. The waiver applies only to the
person or organization designated in such
contract.
UNINTENTIONAL ERRORS OR OMISSIONS
The following is added to Paragraph B.2., Con-
cealment, Misrepresentation, Or Fraud, of
SECTION IV — BUSINESS AUTO CONDITIONS:
The unintentional omission of, or unintentional
error in, any information given by you shall not
prejudice your rights under this insurance. How-
ever this provision does not affect our right to col-
lect additional premium or exercise our right of
cancellation or non - renewal.
Page 4 of 4 0 2010 The Travelers Indemnity Company, CA T3 53 03 10
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 99 03 76 (00) -
POLICY NUMBER., tJR7D417816
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA �
(BLANKET WAIVER)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our fight against the person or organization named in the Schedule.
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 % of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization:
Jodi Description:
Any person or organization for which the Insured has completed a written
agreement to provide this waiver
DATE OF ISSUE: "11/9/2014- 11/9/2015