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PROOF OF INSURANCE (2018 - 2018) CLOSED TG CONSTRU _A-MR15 , CERTIFICATE OF DATE(MM/DD/YYYY) LIABILITY INSURANCE 12/27/2017 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... s to the certificate holder in lieu of such endorsement(s). .°t.. .°. .fs...n hI ......................................... ............. PRODUCER CONTACT NAME: THE BROKERAGE COMMERCIAL INSURANCE SERVICES,Inc. PHONE ; '94 287-5677 FAX 20261 SW Acacia St.,Suite 200 Ext): IA°c,N°)' Newport Beach,CA 92660 nr . INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Associated Industries Ins.Co. 23140 INSURED INSURER B:Wesco Insurance Company 25011 TG Construction,Inc. INSURER C:Travelers Property Casualty Company of America 25674 139 Nevada St. INSURER D:Security National Insurance Co 19879 EI Segundo,CA 90245 INSURER E:Arch Specialty Insurance Company 21199 INSURER F ..E.OV 4 ,ES 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. IINSR ADDL SUBR POLICY EFF POLICY EXP I TYPE OF INSURANCE POLICY NUMBER Ikl�Awaa.KYYYJ (II�AAIDD/YYYY1 A. .......................................... IN WVD IM LIMITS ..LTR... X COMMERCIAL GENERAL LIABILITY EAO i O'CCURRr.NCE�.....................$..............................._11000,000 CLAIMS-MADE X OCCUR X X AES1038411-01 06/01/2017 06/01/2018 DAMAGE 4 a ocxwi-r on,(e) $ 1100,000 MVO EXP(NV rsne parson) $ PERSONAL&ADV INJURY $ 1,000'000 GEN'L AGGREGATE LIMIT:'%Plll:�11I..I1111::",;;,PER: GENERAL,AGGR'EGAI'F' $ 2,000,000 POI..ICY X PEC LOC PRODUCTS-COMPIO�P'AGG $ 2,000,000 OTHER: ..,�....................................................................................................... ........................................www_..,... .,.�,.,...... $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT' 1,000,000 (Ea ac;idant) $ X ANY AUTO X X WPP1556738 00 06/01/2017 06/01/2018 BODILY INJURY(Per parson)_ $ OWNED SCHEDULED AUTOS ONLY AUTOS r� BODILY INJURY(Par occident) $ AUTOS ONLY A't1Tf?S ONLLr'e tG�Atl�%f4GF" $ ..................................... P $ _........ C X UMBRELLA LIAR X i OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE ZUP-41M77872-17-NF 06/01/2017 06/01/2018 AGGRECAr'E $ 4,000,000 .....,,..�......................DED.,......X.......RETE,NTIION$...................10,,,000' ...........................................................,...... ........................................................................,,,,. NIS"A PER D AND EMPLOYERS'LIABILITY YIN X STATUTE ERH ANY PnGP'RIETGJRIPARTNERfEXEcuTIVE X SW�:�"111154390 06/01/2017 06/01/2016 1,000,000 EL EACH ACCIDENT $ OFFICERIMEMtBER EXCLUDED? N/A (Mandatory in NH) El DISEASE-EA EMPLOYEE $ 1'000'000 O 1.'000,000, E,, � en sO.......rP aRATIONSb..._w.. Professional L: ye ase lab. slow PDCPP0019501 12129/2017 12/2912018 Aggregate/Per Claim __ 1,000,000 ...................__....,.,.,.....,. ................. DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Rornarks Schodwte,may be attached If more space is required) RE:Engineering Plan Check Svcs,City of EI Segundo. glaipwvda1Jadwv/WCwv The City of EI Segundo,its officials,officers,agents and employees are included as Additional Insureds as respects General and Auto Liability per attached endorsements. This Insurance shall apply as Primary and Non-Contributory per attached endorsement. Waiver of Subrogation for Workers'Compensation,General Liability,and Auto Liability:See Attached Endorsements. *Excess Liability follows form. ,CERTIFICATE HOLDER .............................._ ANgELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Se THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Floriza Rivera,PW Dept. 350 Main St. ..m................................._....................................... EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE e `. . Al ATIO ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER:AES1038411 01 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, L SS S OR CONTRACTORS - SCHEDULED E SOLI O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s)Of Covered Operations All persons or organizations where required by written contract with the Named Insured 1 I 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 B. With respect to the insurance afforded to these to 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 nota I to "bodilyinjury" or 'property damage occurring after: damage" or "personal and advertising injury" apply 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 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 20 10 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: AES1 03841101 COMMERCIAL GENERAL LIA1ffiLrrY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR, CONTRACTORS - COMPLETED OPERATIONS: This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations(!)L. Location And Description Of Completed Operations All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Section 11 — 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 dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products- completed operations hazardn. CO 20 37 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 POLICY NUMBER: AES1038411 01 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY -C II TII INSURANCE (THIRD-PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4.of SECTION IV: COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy,shall in no instance be considered as primary,co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER: AES1 03841101 COMMERCIAL GENERAL L11A1BILrff CG 24 04 05 0 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: All persons or organizations where required by written contract with the Named Insured Information required to=lots 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—Condhions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work"done under a contract with that person or organization and included in the"products- completed operations hazard".This waiver applies only to the person or organization shown in the ,Schedule above. CO 24 04 05 09 0 Insurance Services Office, Inc.,2008 Pago 1 of I POLICY NUMBER: WPP1556738 00 COMMERCIAL AUTO CA990187 0715 This Endorsement Changes The Policy. Please Read It Carefully BUSINESS AUTO COVERAGE EXPANSIO ENDORSEMENT This endorsement modifies insurance provided by the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement,the provisions of the COVERAGE FORM apply unless modified by the endorsement. A. Newly Acquired or Formed e. An"employee"of yours is an"insured" Organizations, Employee Hired Car while operating an "auto"hired or rented Liability and Blanket Additional Insured under a contract or agreement in that Status for Certain Entities. "employee's"name,with your Item 1..hods...Bn..ltt .4"ired of Paragraph A. permission,while performing duties Coverage under SECTION II–COVERED related to the conduct of your business. AUTOS LIABILITY COVERAGE is f—nn,,Any.pef sma.,.C�.r., amended to add; r .Q4tICs. y tl..ttsn. O.tf . .t..CC:. d. Any organization you newly acquire or grl0np tst n0'. . tl.M�� O�. form, other than a partnership,Joint I.► . .C. . 1"..'.. .pj., .rgky..rW'I.h...I;O.si. . l.lp.. venture or limited liability company, and 40041.t'y pl'.s' t,O Ir!.wjio is.... rJp part by over which you maintain ownership of a sl -Ogrpl . pt majority interest(greater than 50%),will B. Increase Of Loss Earnings Payment qualify as a Named Insured; however, Subpart(4)of a. Supplementary Payments (1) coverage under this provision is of Item 2. Coverage Extensions of afforded only until the 180th day Paragraph A. Coverage under SECTION II after you acquire or form the –COVERED AUTOS LIABILITY organization or the end of the policy COVERAGE is amended to read: period,whichever is earlier; (4) We will pay reasonable expenses (2) coverage does not apply to"bodily incurred by the"insured"at our injury", "property damage"or request, including actual loss of "covered pollution cost or expense" earnings up to$1,000 per day that results from an"accident"which because of time off from work. occurred before you acquired or C. Fellow Employee Injured By Covered formed the organization; and Auto You Own Or Hire (3) coverage does not apply if there is Item S. Fellow Employee of Paragraph B. other similar insurance available to Exclusions under SECTION II–COVERED that organization, or if similar AUTOS LIABILITY COVERAGE is insurance would have been amended to add: available but for its termination or the exhaustion of its limits of This exclusion does not apply if the"bodily insurance. injury" results from the use of a covered "auto"you own or hire. Such coverage as This insurance does not apply is afforded by this provision is excess over coverage for the newly acquired or formed organization is excluded either any other collectible insurance. by the provisions of this coverage form or by endorsement. CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 5 Used with permission D. Limited Automatic Towing Coverage G. "Personal Effects" Coverage Item 2.Towing,of Paragraph A. Coverage, Item 4.Coverage Extensions of Paragraph under SECTION III—PHYSICAL DAMAGE A. Coverage, under SECTION III - COVERAGE is amended to read: PHYSICAL DAMAGE COVERAGE,is 2. Towing amended to add: We will pay for towing and labor costs "Personal Effects" Coverage each time that a covered "auto" is We will pay actual cash value for"loss"to disabled. All labor must be performed at "personal effects"of the"insured"while in the place of disablement of the covered a covered"auto"subject to a maximum "auto". limit of$2,500 per"loss", for that covered "auto"caused by the same"accident". No a. The limit for towing and labor for deductible will apply to this coverage. each disablement is$500; H. "Downtime Loss" Coverage b. No deductible applies to this cover- Item 4. Coverage Extensions, of age. Paragraph A. Coverage, under SECTION E. Item 3. Glass Breakage—Hitting A Bird III. PHYSICAL DAMAGE COVERAGE, is Or Animal—Failing Objects or Missiles of amended to add: Paragraph A. Coverage under SECTION III "Downtime Loss" Covera e —PHYSICAL DAMAGE COVERAGE, is 9 amended to add: We will pay any resulting"downtime loss" Glass Repair Coverage expenses you sustain as a result of a covered physical damage"loss"to a We will waive the Comprehensive covered "auto"up to a maximum of$100 deductible for Glass, if one is indicated on per day,for a maximum of 30 days for the your covered "auto", for glass repairs. We same physical damage"loss",subject to will repair at no.cost to you, any glass that the following conditions: can be repaired without replacement, provided the"loss"arises from a covered a. We will provide"downtime loss"beginning Comprehensive"loss"to your"auto". on the 5th day after we have given you F. Increase Of Transportation Expense our agreement to pay for repairs to acovered "auto"and you have given the Coverage repair facility your authorization to make Subpart a. Transportation Expenses of repairs; Item 4. Coverage Extensions of Paragraph b. Coverage for"downtime loss"expenses A. Coverage under SECTION III— will end when any of the following occur: PHYSICAL DAMAGE COVERAGE is amended to read: (1) You have a spare or reserve"auto" available to you to continue your a. Transportation Expenses operations. We will pay up to$50 per day to a (2) You purchase a replacement"auto". maximum of$1,000 for temporary transportation expense incurred by you (3) Repairs to your covered "auto" have because of the total theft of a covered been completed by the repair facility "auto"of the private passenger type. and they determine the covered We will pay only for those covered "auto" is road-worthy. "autos"for which you carry either (4) You reach the 30 day maximum Comprehensive or Specified Causes of coverage. Loss Coverage or Theft Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we pay for its "loss". CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 2 of 5 Used with permission I. Item 4. Coverage Extensions, of d. Contraband or property in the course Paragraph A. Coverage, under SECTION of illegal transportation or trade. III. PHYSICAL DAMAGE COVERAGE, is e. "Loss"caused by theft,unless there is amended to add: evidence of forced entry into the We will pay any resulting rental covered"auto" and a police report is reimbursement expenses incurred by you for filed. a rental of an"auto"because of"loss"to a K. Accidental Airbag Discharge Coverage covered "auto" up to a maximum of$100 per ra Item 3.a.of Paragraph B. Exclusions under day,for a maximum of 30 days for the same 9 P physical damage"loss",subject to the SECTION III—PHYSICAL DAMAGE following conditions: COVERAGE is amended to read: a. We will provide rental reimbursement a. Wear and tear,freezing, mechanical incurred during the policy period or electrical breakdown.The beginning 24 hours after the"loss"and exclusion relating to mechanical ending, regardless of the policy break-down does not apply to the expiration,with the number of days accidental discharge of an air bag. reasonably required to repair or replace L. Loan or Lease Gap Coverage the covered "auto". If the"loss"is Paragraph C. Limit Of Insurance under caused by theft,this number of days is SECTION III—PHYSICAL DAMAGE the number of days it takes to locate the COVERAGE is amended to add: covered "auto"and return it to you or the number of days it takes for the claim to If a covered"auto"is owned or leased and be settled,whichever comes first. if we provide Physical Damage Coverage b. Our payment is limited to necessary and on it,we will pay, in the event of a covered total "loss", any unpaid amount due on the actual expenses incurred. lease or loan for a covered"auto", less: c. This coverage does not apply while a. The amount paid under the Physical there are spare or reserve 'autos" Damage Coverage Section of the available to you for your operations. policy;and d. If a"loss"results from the total theft of a b. Any: covered"auto"of the private passenger type,we will pay under this coverage ( 1) Overdue lease or loan only that amount of your rental payments including penalties, reimbursement expenses which is not interest or other charges already provided for under the Physical resulting from overdue Damage Coverage Extension. payments at the time of the J. "Personal Effects" Exclusion "lose; Paragraph B. Exclusions under SECTION (2) Financial penalties imposed III—PHYSICAL DAMAGE COVERAGE, is under a lease for excessive use, amended to add: abnormal wear and tear ivor high mileage; "Personal Effects" Exclusion (3) Costs for extended warranties, We will not pay for"loss"to"personal Credit Life Insurance, Health, effects"of any of the following: Accident or Disability Insurance a. Accounts, bills, currency, deeds, purchased with the loan or evidence of debt, money, notes, lease; securities or commercial paper or (4) Security deposits not refunded other documents of value. by the lessor; and b. Bullion,gold, silver, platinum, or other (5) Carry-over balances from precious alloys or metals;furs or fur previous loans or leases garments;jewelry;watches; precious or semi-precious stones. c. Paintings, statuary and other works of art. CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 3 of 5 Used with permission M. Aggregate Deductible (3) An"executive officer"or director, if Paragraph D. Deductible under SECTION you are a corporation; III—PHYSICAL DAMAGE COVERAGE is (4) A manager or member, if you are a amended to add: limited liability company; Regardless of the number of covered (5) Your insurance manager; or "autos"involved in the same"loss", only (6) Your legal representative. one deductible will apply to that"loss". If P WaivCf���a � �iy the deductible amounts vary by"autos", then only the highest applicable deductible ,gs Assume er Insured C9DUart will apply to that"loss". Item 5.Transfer Of Rights Of Recovery N. Diminishing Deductible Against Others To Us of Paragraph A. Loss Conditions under SECTION IV— Paragraph D. Deductible under SECTION BUSINESS AUTO CONDITIONS is III—PHYSICAL DAMAGE COVERAGE is amended to read: amended to add: Any deductible will be reduced by the 5. Transfer of Rights of Recovery percentage indicated below on the first Against Others To Us "loss"reported during the corresponding If any person or organization to or for policy period: whom we make payments under this Coverage Form has rights to recover damages from another,those rights are Loss Free Policy Periods Deductible transferred to us.That person or With the Expansion Reduction on the organization must do everything Endorsement first"loss" necessary to secure our rights and must t 0% do nothing after an"accident'or"loss" z zs�io to impair them. kl. + �°tt.l...if . ed those ej 4 60%w h- j .�a act.we will written contract, ill waive, I ht to recovery Aoinaybay6„ M 5 100% mer this Coveraoe Form. If we pay a Physical Damage"loss"during s rT"rirnary arrod the policy period under any BUSINESS Noncontaribu'to►v AUTO COVERAGE FORM you have with Subpart a. of Item 5.Other Insurance of us,your deductible stated in the Paragraph B. General Conditions under Declarations page of each such SECTION IV—BUSINESS AUTO COVERAGE FORM will not be reduced on CONDITIONS is amended to read: any subsequent claims during the remainder 6 if�60 i6fi�ty 611 of your policy period and your deductible noncontribu � 0�tt reduction will revert back to 0%for each insur,nm ff6gttiC6 i6? Ikl such COVERAGE FORM if coverage is gontract with voice renewed. O. Knowledge of Loss and Notice To Us R. Other Insurance—Hired Auto Physical Damage Subsection a. of Item 2. Duties In the Event Subpart b. of Item 5..Other Insurance of of Accident, Claim, Suit or Loss of Paragraph B. General Conditions under Paragraph A. Loss Conditions under SECTION IV—BUSINESS AUTO SECTION IV--BUSINESS AUTO CONDITIONS is amended to add: CONDITIONS is amended to read: However, prompt notice of the "accident", b. For Hired Auto Physical Damage claim, "suit'or"loss"to us or our Coverage,the following are deemed authorized representative only applies to be covered autos you own: after the"accident', claim, "suit'or"loss" is (1) Any covered"auto"you lease, known to: hire, rent or borrow;and (1) You, if you are an individual; (2) A partner, if you are a partnership; CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 4 of 5 Used with permission (2) Any covered "auto" hired or rented by your "employee"under a contract in that individual "employee's" name, with your permission,while performing 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". S. Unintentional Failure To Disclose Hazards Paragraph B.General Conditions under SECTION IV—BUSINESS AUTO CONDI- TIONS is amended to add: 9. Your failure to disclose all hazards existing as of the inception date of this policy shall not prejudice the coverage afforded by this policy, provided that such failure to disclose all hazards is not intentional. However, you must report such previously undisclosed hazards to us as soon as practicable after its discovery. T. Additional Definition SECTION V—DEFINITIONS is amended to add: "Personal effects"means personal property owned by the"insured". "Downtime,loss"means actual loss of "business income"for the period of time that a covered"auto": 1. Is out of service for repair or replacement as a result of a covered physical damage "loss"and 2. Is in the custody of a repair facility if not a total "loss". "Business Income"means: 1. Net Income(Net Profit or Loss before income taxes)that would have been earned or incurred; and 2. Continuing normal operating expenses incurred, including payroll. In this endorsement, L4eadlncts arld Titles are inserted solely for the convenience and ease of reference. They do not affect the coverage provided by this endorsement, nor do they constitute any part of the terms and conditions of this endorsement. All other policy wording not specifically changed, modified, or replaced by this endorsement wording remains in effect. CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 5 of 5 Used with permission 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 2.00%of the California workers'compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any person or organization as required by written contract Notes, T. This endorsement may be used to waive the company's right of subrogation against named third parties who may be responsible for an injury. 2. The sentence in( )is optional with the company.It limits the endorsement to apply only to specific jobs of the insured,and only to the extent that the insured Is required to obtain 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 611!2017 Policy No. SWC1154390 Endorsement No. Insured TG Construction,Inc. Insurance Company Security National Insurance Company Countersigned By