PROOF OF INSURANCE (2017) CLOSEDFSCON -2 OP ID: TC
1" DATE (MMIDDKYYY)
CERTIFICATE OF LIABILITY INSURANCE 0313112016
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(les) 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 CONTACT an Brock
NAME
Sierra Oak Insurance Services HSF a m_ ... x m ...... m ........m
Lie# OC97528 IAIC. No Ent): 916364 -7380 IAt , No) 916- 364 -7381
9700 Business Park Dr. Ste 105 L•Ilfl
ADD ESS:
Sacramento, CA 95827 ������
Daniel E. Brock INSURER(3) AFFORDING COVERAGE NAID
INSURER A: American Fire and Casualtv Co. 24066
INSURED F S Contractors, Inc, INSURER B The Ohio Casualty Insurance Co 24074
14838 Bledsoe Street INSURER TOkio Marine Soeclalty Ins Co 23850
Sylmar, CA 91342 ....w. _.w..w .. �.- ....... a .., ...
INSURER D: National Union Fire Ins Co 19445
INSURER :Insurance Comvanv of the^ Wes t mm. m. "...,....mm.....m.m...m.m.m.. 27 7^ mm
.... INS URER. F.. .................... .............n......... .. .. .. ....................... �,.....,.... �.............,_................................._..................................................... ............,..............
COVERAGES CERTIFICATE NUMBER; REVIS$ON 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. LIMMS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
NSURANCE POLICY NUMBER ..................1 .....
wcn vwn POLL.
LTR ,_. TYPE OF I "ADDt.' R rMMroI NWYI rMMIDDIYWYI LIMBS
C X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
('NW) " i I"", ) 1
CLAIMS-MADE occuR X X PPK7444451 01113!2016 01!1312017 I r
�l r $ 50,000
w....
..............-W.
MED EXP(Anv one person) $ Exluded
PERSONAL & ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00
POLICY ❑ PRO JECT 17
LOC PRODUCTS COMP /OP AGG $ 2,000,00
0 T 4"r
' A LTOMO BILE LIABILITY COMBINED 1.7," K 9 LRA $ 1,000,00
A ANY AUTO X X BAA56680768 08/26/2015 0812612016 BODILY INJURY (Per person) $
................
ALL OWNED " " "' SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X NON -OWNED wand yrut�P"d Y &aF4p'hde ,( -° „.
HIRED AUTOS AUTOS (1 rt 0F,01QRt)
UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 3,000,000
D TX EXCESSLIAB CLAIMS -MADE' EBU32007106 01/13/2016 01/13/2017 AGGREGATE $ 3,000,00
�,,..,.m..,.D ED RETENTION ..g _---------- .....----- -....- .............................. ..... ...... .........�...� .......................... ...... �.�..�.�..�.�.............
WORKERS COMPENSATION -
AND EMPLOYERS' LIABILITY X TATUTE ER YIN E ANY PROPRIETORIPARTNERIEXECUTIVE NIA X WSA 5032771 00 07/31/2015 07/3112016 E L EACH ACCIDENT $ 1,000,00
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) E L DISEASE EA EMPLOYEE $ 1,000 00
If yes, describe under
DESCRIPTION OF OPERATIONS below E L DISEASE- POLICY LIMIT $ 1,000,00
B Equipment Floater SM056680768 08/26/2015 08126/2016 Scheduled 45,00
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Job: Pump Station 17 Storm water BMP Improvements PW- 16 -13. - 1015 E.
Imperial Ave., E1 Segundo, CA 90245. City of E1 Segundo, its officers,
officials, employees, agents, and volunteers are named additional insured.
Primary and Non - Contributory applies to General Liability. Waiver of
Subrogation applies to all policies.
CERTIFICATE HOLDER CANCELLATION
CITYELS
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, "
350 Main St )� AUTHORIZED REPRESENTATIVE
El Segundo, CA 90245
O 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
CG 2010 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ww,* • • •
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organ¢abon(s) Location(s) Of Covered O
AS Wlf .IICE Vtll^A';,,U 1:"E'I) V::�,Y CCOVEl�ED L0C A 1 i;(:)NS .
Information reauired to complete this Schedule. if not shown
A. Section II — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury ", "property
damage" or "personal and advertising injury"
caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured
is required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
will be shown in the Declarations,
With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"pro perty damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2. That portion of 'your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
CG 2010 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Unft Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance;
1. Required by the contract or agreement; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less,
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations,
Paget of 2 0 Insurance Services Office, Inc., 2012 CG 2010 0413
COMMERCIAL GENERAL LIABILITY
CG 20 37 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
114 II � "" NIr • "" • "
• -0A Ito • 9401101U42 w •
This endorsement modifies insurance provided under the following;
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Oroanization(s) I Location And Desoription Of Completed 0
A,'- W HJ RE Y ,.IE I X11 F,1 "11 V) BY W R t..li 1. EE 1 ALL, C , CI V t�..E D L C) C �°��.11 E. � t,I � -., a
I
Information reauired to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury" or
"property damage" caused, in whole or in part, by
"your work" at the location designated and
described in the Schedule of this endorsement
performed for that additional insured and
included in the "products -completed operations
hazard ",
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured
is required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amountof insurance:
1. Required by the contractor agreement; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less,
This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations.
CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1
PIC -GLN -036 (08/14)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
PRIMARY AND NON- CONTRIBUTORY INSURANCE
This endorsement modifies insurance provided under the following.
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization (Additional Insured):
AS WHERE REQUIRED BY WRITTEN CONTRACT PRIOR TO LOSS,
Effective Date: 01/13/2016
SECTION 11— WHO IS AN INSURED is amended to include as an additional insured the person(s) or
organization(s) shown in the endorsement Schedule, but only with respect to liability for "bodily injury," "property
damage" or "personal and advertising injury" arising out of or relating to your negligence in the performance of
"your work" for such person(s) or organization(s) that occurs on or after the effective date shown in the
endorsement Schedule.
This insurance is primary to and non - contributory with any other insurance maintained by the person or
organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization
This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss
or "occurrence" we cover for this Additional Insured.
The Additional Insured's limits of insurance do not increase our limits of insurance, as described in SECTION III —
LIMITS OF INSURANCE.
All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain
unchanged.
Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
POLICY NUMBER: PPK1444451
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/ COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of Section
IV — Conditions:
waive any right of recover �+ we away have against
the person or or yanizatic s=n in the Schedule
above k caL . o� p"ayrnonts we mako for injury or
damage arising out of your onagoing� operalrons or
" "your work "" done under a contra with That person
or orgamzation and included in the "products -
completed operatlons hazard"''. This waiver applies
only to the person or organization shown in the
Schedule alcove,
CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 p
COMMERCIAL AUTO
CA 8810 01 13
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
BUSINESS AUTO COVERAGE ENHANCEMENT ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified
by the endorsement.
COVERAGE INDEX
SUBJECT P8Qy16ION ER
ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT
3
ACCIDENTAL AIRBAG DEPLOYMENT
12
AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS
19
AMENDED FELLOW EMPLOYEE EXCLUSION
5
AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE
13
BROAD FORM INSURED
1
BODILY INJURY REDEFINED
22
EMPLOYEES AS INSUREDS (including employee hired auto)
2
EXTENDED CANCELLATION CONDITION
23
EXTRA EXPENSE - BROADENED COVERAGE
10
GLASS REPAIR - WAIVER OF DEDUCTIBLE
15
HIRED AUTO PHYSICAL DAMAGE (including employee hired auto and loss of use)
6
HIRED AUTO COVERAGE TERRITORY
20
LOAN / LEASE GAP
14
PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE)
16
PERSONAL EFFECTS COVERAGE
11
PHYSICAL DAMAGE - ADDITIONAL TRANSPORTATION EXPENSE COVERAGE
8
RENTAL REIMBURSEMENT
9
SUPPLEMENTARY PAYMENTS
4
TOWING AND LABOR
7
TWO OR MORE DEDUCTIBLES
17
UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS
18
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
20
SECTION II - LIABILITY COVERAGE is amended as follows:
1. BROAD FORM INSURED
SECTION II - LIABILITY COVERAGE, paragraph A.1. - WHO IS AN INSURED is amended to Include
the following as an insured:
d. Any legally incorporated entity of which you own more than 50 percent of the voting stock
during the policy period. However, "insured" does not include any organization that;
(1) Is a partnership or joint venture; or
(2) Is an insured under any other automobile policy; or
(3) Has exhausted its Limit of Insurance under any other automobile policy.
Paragraph d. (2) of this provision does not apply to a policy written to apply specifically in
excess of this policy.
e. Any organization you newly acquire or form, other than a partnership or joint venture, of which
you own more than 50 percent of the voting stock. This automatic coverage is afforded only for
180 days from the date of acquisition or formation. However, coverage under this provision
does not apply;
(1) If there is similar insurance or a self- insured retention plan available to that organization;
® 2013 Liberty Mutual Insurance
CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 7
(2) If the Llmlts of Insurance of any other insurance policy have been exhausted; or
(3) To "bodily injury" or "property damage" that occurred before you acquired or formed the
organization.
2. EMPLOYEES AS INSUREDS
SECTION II - LIABILITY COVERAGE, paragraph A.I. - WHO IS AN INSURED Is amended to Include
the following as an insured:
f, Any "employee" of yours while using a covered "auto" you do not own, hire or borrow, but
only for acts within the scope of their employment by you. Insurance provided by this endorse-
ment is excess over any other Insurance available to any "employee ".
g. An "employee" of yours while operating an "auto" hired or borrowed under a written contract
or agreement in that "employee's" name, with your permission, while performing duties re-
lated to the conduct of your business and within the scope of their employment. Insurance
provided by this endorsement is excess over any other Insurance available to the "employee ".
3. ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT
SECTION II - LIABILITY COVERAGE, paragraph A.I. - WHO IS AN INSURED is amended to include
the following as an Insured:
h. Any person or organization with respect to the operation, maintenance or use of a covered
"auto ", provided that you and such person or organization have agreed in a written contract,
agreement, or permit issued to you by governmental or public authority, to add such person, or
organization, or governmental or public authority to this policy as an "insured ".
However, such person or organization is an "insured ":
(1) Only with respect to the operation, maintenance or use of a covered "auto ";
(2) Only for "bodily injury" or "property damage" caused by an "accident" which takes
place after you executed the written contract or agreement, or the permit has been
issued to you; and
(3) Only for the duration of that contract, agreement or permit
4. SUPPLEMENTARY PAYMENTS
SECTION II - LIABILITY COVERAGE, Coverage Extensions, 2.a. Supplementary Payments, para-
graphs (2) and (4) are replaced by the following:
(2) Up to $3,000 for cost of bail bonds (including bonds for related traffic violations) required
because of an "accident" we cover. We do not have to furnish these bonds.
(4) All reasonable expenses incurred by the insured at our request, including actual loss of earn-
ings up to $500 a day because of time off from work.
5. AMENDED FELLOW EMPLOYEE EXCLUSION
In those jurisdictions where, by law, fellow employees are not entitled to the protection afforded to
the employer by the workers compensation exclusivity rule, or similar protection, the following
provision is added:
SECTION II - LIABILITY, exclusion B.S. FELLOW EMPLOYEE does not apply if the "bodily injury"
results from the use of a covered "auto" you own or hire.
SECTION III - PHYSICAL DAMAGE COVERAGE is amended as follows:
6. HIRED AUTO PHYSICAL DAMAGE
Paragraph A.4. Coverage Extensions of SECTION III - PHYSICAL DAMAGE COVERAGE, is amended
by adding the following:
If hired "autos" are covered "autos" for Liability Coverage, and if Comprehensive, Specified
Causes of Loss or Collision coverage are provided under the Business Auto Coverage Form for any
"auto" you own, then the Physical Damage coverages provided are extended to "autos ":
a. You hire, rent or borrow; or
® 2013 Liberty Mutual Insurance
CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 7
b. Your "employee" hires or rents under a written contract or agreement in that "employee's"
name, but only if the damage occurs while the vehicle Is being used in the conduct of your
business,
subject to the following limit and deductible:
A. The most we will pay for "loss" in any one "accident" or "loss" is the smallest of:
(1) $60,000; or
(2) The actual cash value of the damaged or stolen property as of the time of the "loss "; or
(3) The cost of repairing or replacing the damaged or stolen property with other property of
like kind and quality, minus a deductible.
B. The deductible will be equal to the largest deductible applicable to any owned "auto" for that
coverage.
C. Subject to the limit, deductible and excess provisions described in this provision, we will
provide coverage equal to the broadest coverage applicable to any covered "auto" you own.
D. Subject to a maximum of $1,000 per "accident ", we will also cover the actual loss of use of the
hired "auto" if it results from an "accident ", you are legally liable and the lessor incurs an
actual financial loss,
E. This coverage extension does not apply to:
(1) Any "auto" that is hired, rented or borrowed with a driver; or
(2) Any "auto" that is hired, rented or borrowed from your "employee ",
For the purposes of this provision, SECTION V -DEFINITIONS is amended by adding the following:
"Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the actual
cash value.
7. TOWING AND LABOR
SECTION III - PHYSICAL DAMAGE COVERAGE, paragraph A.2. Towing, is amended by the addition
of the following:
We will pay towing and labor costs incurred, up to the limits shown below, each time a covered
"auto" classified and rated as a private passenger type, "light truck" or "medium truck" is dis-
abled:
a. For private passenger type vehicles, we will pay up to $50 per disablement.
b. For "light trucks ", we will pay up to $50 per disablement. "Light trucks" are trucks that have a
gross vehicle weight (GVW) of 10,000 pounds or less.
c. For "medium trucks" , we will pay up to $150 per disablement. "Medium trucks" are trucks that
have a gross vehicle weight (GVW) of 10,001 - 20,000 pounds.
However, the labor must be performed at the place of disablement.
8. PHYSICAL DAMAGE - ADDITIONAL TRANSPORTATION EXPENSE COVERAGE
Paragraph A.4.a., Coverage Extension of SECTION III - PHYSICAL DAMAGE COVERAGE, is amend-
ed to provide a limit of $50 per day and a maximum limit of $1,500
0 2013 Liberty Mutual Insurance
CA 8810 0113 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 7
9. RENTAL REIMBURSEMENT
SECTION Ill - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, Is amended by adding the following:
e. We will pay up to $75 per day for rental reimbursement expenses Incurred by you for the rental
of an "auto" because of "accident" or "loss ", to an "auto" for which we also pay a "loss"
under Comprehensive, Specified Causes of Loss or Collision Coverages, We will pay only for
those expenses incurred after the first 24 hours following the "accident" or "loss" to the
covered "auto."
b. Rental Reimbursement will be based on the rental of a comparable vehicle, which In many
cases may be substantially less than $76 per day, and will only be allowed for the period of
time it should take to repair or replace the vehicle with reasonable speed and similar quality, up
to a maximum of 30 days.
c. We will also pay up to $500 for reasonable and necessary expenses incurred by you to remove
and replace your tools and equipment from the covered "auto ",
d. This coverage does not apply unless you have a business necessity that other "autos" avail-
able for your use and operation cannot fill.
e. If "loss" results from the total theft of a covered "auto" of the private passenger type, we will
pay under this coverage only that amount of your rental reimbursement expenses which is not
already provided under Paragraph 4. Coverage Extension.
f. No deductible applies to this coverage.
For the purposes of this endorsement provision, materials and equipment do not include "personal
effects" as defined in provision 11.
10. EXTRA EXPENSE -BROADENED COVERAGE
Under SECTION III -PHYSICAL DAMAGE COVERAGE, A. COVERAGE, we will pay for the expense of
returning a stolen covered "auto" to you. The maximum amount we will pay is $1,000.
11. PERSONAL EFFECTS COVERAGE
A. SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, Is amended by adding the
following:
If you have purchased Comprehensive Coverage on this policy for an "auto" you own and that
"auto" is stolen, we will pay, without application of a deductible, up to $600 for "personal
effects" stolen with the "auto,"
The insurance provided under this provision is excess over any other collectible insurance.
B. SECTION V - DEFINITIONS is amended by adding the following:
For the purposes of this provision, "personal effects" mean tangible property that is worn or
carried by an insured." "Personal effects" does not include tools, equipment, jewelry, money
or securities.
12. ACCIDENTAL AIRBAG DEPLOYMENT
SECTION III - PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS is amended by adding the follow-
ing:
If you have purchased Comprehensive or Collision Coverage under this policy, the exclusion for
"loss" relating to mechanical breakdown does not apply to the accidental discharge of an airbag.
Any insurance we provide shall be excess over any other collectible insurance or reimbursement by
manufacturer's warranty. However, we agree to pay any deductible applicable to the other cov-
erage or warranty.
13. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE
SECTION III - PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS, exception paragraph a. to exclu-
sions 4.c. and 4.d. is deleted and replaced with the following:
m 2013 Liberty Mutual Insurance
CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 7
Exclusion 4.c. and 4.d. do not apply to!
a. Electronic equipment that receives or transmits audio, visual or data signals, whether or not
designed solely for the reproduction of sound, if the equipment is permanently Installed in the
covered "auto" at the time of the "loss" and such equipment is designed to be solely operated
by use of the power from the "auto's" electrical system, in or upon the covered "auto" and
physical damage coverages are provided for the covered "auto ", or
If the "loss" occurs solely to audio, visual or date electronic equipment or accessories used with
this equipment, then our obligation to pay for, repair, return or replace damaged or stolen property
will be reduced by a $100 deductible.
14. LOAN / LEASE GAP COVERAGE
A. Paragraph C., LIMIT OF INSURANCE of SECTION Ili - PHYSICAL DAMAGE COVERAGE Is
amended by adding the following;
The most we will pay for a "total loss" to a covered "auto" owned by or leased to you in any
one "accident" is the greater of the:
1. Balance due under the terms of the loan or lease to which the damaged covered "auto" Is
subject at the time of the "loss" less the amount of;
a. Overdue payments and financial penalties associated with those payments as of the
date of the "loss ",
b. Financial penalties imposed under a lease due to high mileage, excessive use or ab-
normal wear and tear,
c. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability
Insurance purchased with the loan or lease,
d. Transfer or rollover balances from previous loans or leases,
e. Final payment due under a "Balloon Loan ",
f. The dollar amount of any unrepaired damage which occurred prior to the "total loss"
of a covered "auto ",
g. Security deposits not refunded by a lessor,
h. All refunds payable or paid to you as a result of the early termination of a lease
agreement or as a result of the early termination of any warranty or extended service
agreement on a covered "auto ",
i. Any amount representing taxes,
j. Loan or lease termination fees; or
2. The actual cash value of the damage or stolen property as of the time of the "loss ".
An adjustment for depreciation and physical condition will be made in determining the actual
cash value at the time of the "loss ". This adjustment is not applicable in Texas.
B. ADDITIONAL CONDITIONS
This coverage applies only to the original loan for which the covered "auto" that incurred the
loss serves as collateral, or lease written on the covered "auto" that incurred the loss.
C. SECTION V - DEFINTIONS is changed by adding the following;
As used in this endorsement provision, the following definitions apply:
"Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the
actual cash value.
A "balloon loan" is one with periodic payments that are insufficient to repay the balance over
the term of the loan, thereby requiring a large final payment.
® 2013 Liberty Mutual Insurance
CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 7
15. GLASS REPAIR - WAIVER OF DEDUCTIBLE
Paragraph D. Deductible of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by the
addition of the following:
No deductible applies to glass damage if the glass is repaired rather than replaced.
18. PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE)
Paragraph D. Deductible of SECTION III - PHYSICAL DAMAGE COVERAGE Is amended by the
addition of the following:
The deductible does not apply to "loss" caused by collision to such covered "auto" of the private
passenger type or light weight truck with a gross vehicle weight of 10,000 lbs. or less as defined by
the manufacturer as maximum loaded weight the "auto" is designed to carry while It Is:
a. In the charge of an "insured ";
b. Legally parked; and
c. Unoccupied.
The "loss" must be reported to the police authorities within 24 hours of known damage.
The total amount of the damage to the covered "auto" must exceed the deductible shown in the
Declarations.
This provision does not apply to any "loss" if the covered "auto" is In the charge of any person or
organization engaged In the automobile business.
17. TWO OR MORE DEDUCTIBLES
Under SECTION III PHYSICAL DAMAGE COVERAGE, if two or more company policies or coverage
forms apply to the same accident, the following applies to paragraph D. Deductible:
a. If the applicable Business Auto deductible is the smaller (or smallest) deductible it will be
waived; or
b. If the applicable Business Auto deductible is not the smaller (or smallest) deductible it will be
reduced by the amount of the smaller (or smallest) deductible; or
c. If the loss involves two or more Business Auto coverage forms or policies the smaller (or
smallest) deductible will be waived.
For the purpose of this endorsement company means any company that Is part of the Liberty
Mutual Group.
SECTION IV - BUSINESS AUTO CONDITIONS is amended as follows:
18. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS
SECTION IV- BUSINESS AUTO CONDITIONS, Paragraph B.Z. is amended by adding the following:
If you unintentionally fail to disclose any hazards, exposures or material facts existing as of the
inception date or renewal date of the Business Auto Coverage Form, the coverage afforded by this
policy will not be prejudiced.
However, you must report the undisclosed hazard of exposure as soon as practicable after its
discovery, and we have the right to collect additional premium for any such hazard or exposure.
10. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT, OR LOSS
SECTION IV - BUSINESS AUTO CONDITIONS, paragraph A.2.a. is replaced in its entirety by the
foilowi ng:
a. In the event of "accident ", claim, "suit" or "loss ", you must promptly notify us when it is
known to:
1. You, if you are an individual;
2. A partner, if you are a partnership;
3. Member, if you are a limited liability company;
4. An executive officer or the "employee" designated by the Named Insured to give such
notice, If you are a corporation.
0 2413 Liberty Mutual Insurance
CA 88 10 01 13 Includes copyrighted material of Insurance Services office, Inc., with its permission. Page 8 of 7
To the extent possible, notice to us should include:
(1) How, when and where the "accident" or "loss" took place;
(2) The "insureds" name and address; and
(3) The names and addresses of any Injured persons and witnesses.
20. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
SECTION IV • BUSINESS AUTO CONDITIONS, paragraph A.6., Transfer of Rights of Recovery
Against Others to Us, Is amended by the addition of the following:
If the person or organization has waived those rights before an "accident" or "loss ", our rights are
waived also.
21. HIRED AUTO COVERAGE TERRITORY
SECTION IV - BUSINESS AUTO CONDITIONS, paragraph B.7., Policy Period, Coverage Territory, Is
amended by the addition of the following:
f. For "autos" hired 30 days or less, the coverage territory is anywhere in the world, provided that
the Insured's responsibility to pay for damages is determined in a "suit ", on the merits, in the
United States, the territories and possessions of the United States of America, Puerto Rico or
Canada or in a settlement we agree to.
This extension of coverage does not apply to an "auto" hired, leased, rented or borrowed with
a driver.
SECTION V - DEFINITIONS is amended as follows:
22. BODILY INJURY REDEFINED
Under SECTION V - DEFINMONS, definition C. is replaced by the fallowing:
"Bodily injury" means physical injury, sickness or disease sustained by a person, including mental
anguish, mental injury, shock, fright or death resulting from any of these at any time.
COMMON POLICY CONDITIONS
23. EXTENDED CANCELLATION CONDITION
COMMON POLICY CONDITIONS, paragraph A. - CANCELLATION condition applies except as fol-
lows:
If we cancel for any reason other than nonpayment of premium, we will mall to the first Named
Insured written notice of cancellation at least 60 days before the effective date of cancellation. This
provision does not apply in those states which require more than 60 days prior notice of cancella-
tion.
® 2013 Liberty Mutual Insurance
CA 8810 0113 Includes copyrighted material of Insuranre Services Office, Inc., with its permigsinn. Page 7 of 7
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34
(Ed. 8-00)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET
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).
The additional premium for this endorsement shall be 3 % of the total California Workers' Compensation premium
otherwise due.
Schedule
Person or Organization Job Description
ANY PERSON OR ALL CALIFORNIA
ORGANIZATION WHEN OPERATIONS
REQUIRED BY WRITTEN°
CONTRACT
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 05/28/2015 Policy No. WSA 5026584 01 Endorsement No.
Insured FIERROS , JOSE ANGEL ROJO Premium $ INCL .
Insurance Company INSURANCE COMPANY OF THE WEST
Countersigned By
WC 99 06 34
(Ed. 8-00)
INSURED