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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