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PROOF OF INSURANCE (2019) CLOSED SUPETAN-01 SHARP
CERTIFICATE OF LIABILITY INSURANCE n DATE
8 MM1DDfYYYY)
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 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 not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CN,ONTEACT
James P.Bennett&Company PHONE
License#0210226 INC,Ns,Ext):(310)450-9184 LAIC No);(310)452-7515
E•MAl
2716 Ocean Park Blvd.,Suite 1045 ADa�R"��s,
Santa Monica,CA 90405 INSURER(S)AFFORDING COVERAGE NAIL#
INSURER A:Starr Surplus Lines Insurance Company 13604
INSURED INSURERS:Travelers Indemnity Company of Connecticut „25682
Superior Tank Solutions,Inc. INSURER C:Starr Indemnity&Liability Company 38318
9500 Lucas Ranch Road INSURER D:
Rancho Cucamonga,CA 91730 INSUR
ERE:
INSURER F;
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IR. Ittr. ...SirYNO . POLICY
IC
LTlni. 'XVI
LTR TYPE OF INSURANCE POLICY NUMBER LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000
CLAIMS-MADE X OCCUR 1000066106181 02/01/2018 02/01/2019 DAMAGE TO RENTED 100,000
X X I REMISES(Eo o riwruonw) $
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 5,000,000
jP�7 LOC PRODUCE COMP/OPAGG $ 5,000,000
X II07 UCR10,000,000L AGGREGATE LIMIT 1.1Es PER: GENERA AGGREGATE 5,000,000
POLICY X 7
B AUTOMOBILE LIABILITY COMBINED SINGLE LIMOT 1,000,000
(Ea 4;odonl) $
X ANY AUTO X X 810-1E399655-TIL18 02/01/2018 02/01/2019 BODILY INJURY(Per,person) „$
AAURTEO�S ONLY AUyyTyyOSULED BODILY INJURY(Per accident) $
AUTOS ONLY ALJ'6 UNWk� P.0aP.11!NiIrMACE $
I e $
A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5'000'000
X EXCESS LIAB CLAIMS-MADE 1000336845181 02/01/2018 02/01/2019 AGGREGATE $ 5,000,000
DED RETENTION$ $
AND EMPLOYERS'LIABILITY YIN X STATUTE ERER H
ANYCCPRROR��PMRIIETgOERRIPARTNER/EXECUTIVE X 1000002002 02/01/2018 02/01/2019 EL EACH ACCIDENT $ 1'000'000
aridatory In NH)EXCLUDE" N N/A 1,000,000
E L DISEASE-EA EMPLOYEE $
If yyes,describe under 1,000,000
D6$GRIPTION OF P RATIONS balow . E L DISEASE-POLICY LIMIT $
A Pollution 1000066106181 1 02/01/2018 02/01/2019 Each Occurrence 1,000,000
A Pollution 1000066106181 02/01/2018 02/01/2019 Ea.Occurrence 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addi lonal Remarks Schedule,may be attached If more space Is required)
30 days notice of cancellation except 10 days for non-psymont.
The City of EI Segundo,its officers,officials,employees,agents,and volunteers are hereby included as Additional Insureds as respects General Liability and
Auto Liability. Primary wording and waiver of subrogation applies per company forms attached for General Liability. Waiver of subrogation form for Worker's
Compensation applies.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CI Of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City 9 ACCORDANCE WITH THE POLICY PROVISIONS.
CITY CLERK
350 Main Street
EI Segundo,CA 90245 AU"THORtEED REPRESENTATIVE
ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
INSURED: Superior Tank Solutions
POLICY NUMBER:810-1E399655-TIL-18
POLICY TERM: 2/1/2018 to 2/1/2019 COMMERCIAL AUTO
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
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 H. HIRED AUTO PHYSICAL DAMAGE—LOSS OF
B. BLANKET ADDITIONAL INSURED USE—INCREASED LIMIT
C. EMPLOYEE HIRED AUTO I. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES—INCREASED LIMIT
D. EMPLOYEES AS INSURED J. PERSONAL PROPERTY
E. SUPPLEMENTARY PAYMENTS — INCREASED K. AIRBAGS
LIMITS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
F. HIRED AUTO — LIMITED WORLDWIDE COV- LOSS
ERAGE—INDEMNITY BASIS M. BLANKET WAIVER OF SUBROGATION
G. WAIVER OF DEDUCTIBLE—GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS
PROVISIONS
A. BROAD FORM NAMED INSURED this insurance applies and only to the extent that
The following is added to Paragraph A.1., Who Is person or organization qualifies as an "insured"
An Insured, of SECTION II—COVERED AUTOS under the Who Is An Insured provision contained
LIABILITY COVERAGE: in Section II.
Any organization you newly acquire or form dur- C. EMPLOYEE HIRED AUTO
ing the policy period over which you maintain 1. The following is added to Paragraph A.1.,
50% or more ownership interest and that is not Who Is An Insured, of SECTION II — COV-
separately insured for Business Auto Coverage. ERED AUTOS LIABILITY COVERAGE:
Coverage under this provision is afforded only un- An "employee" of yours is an "insured" while
til the 180th day after you acquire or form the or- operating an "auto" hired or rented under a
ganization or the end of the policy period, which- contract or agreement in an "employee's"
ever is earlier. name, with your permission, while performing
duties related to the conduct of your busi-
B. BLANKET ADDITIONAL INSURED ness.
The following is added to Paragraph c. in A.1., 2. The following replaces Paragraph b. in B.6.,
Who Is An Insured, of SECTION II—COVERED Other Insurance, of SECTION IV — BUSI-
AUTOS LIABILITY COVERAGE: NESS AUTO CONDITIONS:
Any person or organization who is required under b. For Hired Auto Physical Damage Cover-
a written contract or agreement between you and age, the following are deemed to be cov.
that person or organization, that is signed and ered "autos"you own:
executed by you before the "bodily injury' or (1) Any covered "auto" you lease, hire,
"property damage" occurs and that is in effect rent or borrow; and
during the policy period, to be named as an addi- (2) Any covered "auto"hired or rented by
tional insured is an "insured" for Covered Autos your "employee" under a contract in
Liability Coverage, but only for damages to which an "employee's" name, with your
CA T3 53 02 16 0 2015 The Travelers Indemnity Company.All rights reserved. Page 1 of 4
Includes copyrighted material of Insurance Services Office,Inc.with Its permission.
COMMERCIAL AUTO
permission, while performing duties (a) With respect to any claim made or "suit"
related to the conduct of your busi- brought outside the United States of
ness. America, the territories and possessions
However, any"auto"that is leased, hired, of the United States of America, Puerto
rented or borrowed with a driver is not a Rico and Canada:
covered"auto". (i) You must arrange to defend the "in-
D. EMPLOYEES AS INSURED sured"against, and investigate or set-
tle any such claim or "suit" and keep
The following is added to Paragraph A.1., Who Is us advised of all proceedings and ac-
An Insured, of SECTION II—COVERED AUTOS tions.
LIABILITY COVERAGE:
Any"employee"of yours is an "insured"while us- (!I) Neither you nor any other involved
Insured will make any settlement
ing a covered"auto"you don't own, hire or borrow without our consent.
in your business or your personal affairs.
E. SUPPLEMENTARY PAYMENTS — INCREASED (iii)in may, at our discretion, participate
LIMITS in defending the "insured" against, or
in the settlement of, any claim or
1. The following replaces Paragraph A.2.a.(2), "suit".
of SECTION II—COVERED AUTOS LIABIL- (iv)We will reimburse the "insured" for
ITY COVERAGE: sums that the "insured" legally must
(2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily
cluding bonds for related traffic law viola- injury"or"property damage"to which
tions) required because of an "accident" this insurance applies, that the "in-
we cover. We do not have to furnish sured" pays with our consent, but
these bonds. only up to the limit described in Para-
2. The following replaces Paragraph A.2.a.(4), graph C., Limits Of Insurance, of
of SECTION II —COVERED AUTOS LIABIL- SECTION II — COVERED AUTOS
ITY COVERAGE: LIABILITY COVERAGE.
(4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for
"Insured" at our request, including actual the reasonable expenses Incurred
loss of earnings up to $500 a day be- with our consent for your investiga-
cause of time off from work. tion of such claims and your defense
F. HIRED AUTO — LIMITED WORLDWIDE COV- us the "insured" against any such
ERAGE—INDEMNITY BASIS "suit", but only up to and included
within the limit described in Para-
The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of
graph B.7., Policy Period, Coverage Territory, SECTION II — COVERED AUTOS
of SECTION IV — BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in
TIONS: addition to such limit. Our duty to
(5) Anywhere in the world, except any country or make such payments ends when we
jurisdiction while any trade sanction, em- have used up the applicable limit of
bargo, or similar regulation imposed by the insurance in payments for damages,
United States of America applies to and pro- settlements or defense expenses.
hibits the transaction of business with or (b) This insurance is excess over any valid
within such country or jurisdiction, for Cov- and collectible other insurance available
ered Autos Liability Coverage for any covered to the "insured" whether primary, excess,
"auto" that you lease, hire, rent or borrow contingent or on any other basis.
without a driver for a period of 30 days or less (c) This insurance is not a substitute for re-
and that is not an "auto" you lease, hire, rent quired or compulsory insurance in any
or borrow from any of your "employees", country outside the United States, its ter-
partners (if you are a partnership), members ritories and possessions, Puerto Rico and
(if you are a limited liability company) or Canada.
members of their households.
Page 2 of 4 ®2015 The Travelers Indemnity Company.All rights reserved. CA T3 53 02 15
Includes copyrighted material of Insurance Services Olfioe,Inc.with its permission.
COMMERCIAL AUTO
You agree to maintain all required or (2) In or on your covered "auto".
compulsory insurance in any such coun- This coverage applies only in the event of a total
try up to the minimum limits required by theft of your covered"auto".
local law. Your failure to comply with No deductibles apply to this Personal Property
compulsory insurance requirements will coverage.
not invalidate the coverage afforded by
this policy, but we will only be liable to the K. AIRBAGS
same extent we would have been liable The following is added to Paragraph B.3., Exclu-
had you complied with the compulsory in- sions, of SECTION III — PHYSICAL DAMAGE
surance requirements. COVERAGE:
(d) It is understood that we are not an admit- Exclusion 3.a. does not apply to "loss" to one or
ted or authorized insurer outside the more airbags in a covered "auto"you own that in-
United States of America, its territories flate due to a cause other than a cause of"loss"
and possessions, Puerto Rico and Can- set forth in Paragraphs A.1.b. and A.1.c., but
ada. We assume no responsibility for the only:
furnishing of certificates of insurance, or a. If that "auto" is a covered "auto" for Compre-
for compliance in any way with the laws hensive Coverage under this policy;
of other countries relating to insurance. b. The airbags are not covered under any war-
G. WAIVER OF DEDUCTIBLE—GLASS ranty; and
The following is added to Paragraph D., Deducti- c. The airbags were not intentionally inflated.
ble, of SECTION III — PHYSICAL DAMAGE We will pay up to a maximum of $1,000 for any
COVERAGE: one"loss".
No deductible for a covered "auto" will apply to L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
glass damage if the glass is repaired rather than LOSS
replaced. The following is added to Paragraph A.2.a., of
H. HIRED AUTO PHYSICAL DAMAGE— LOSS OF SECTION IV—BUSINESS AUTO CONDITIONS:
USE—INCREASED LIMIT Your duty to give us or our authorized represenla-
The following replaces the last sentence of Para- tive prompt notice of the "accident" or"loss" ap-
graph A-4.b., Loss Of Use Expenses, of SEC- plies only when the "accident" or "loss" is known
TION III—PHYSICAL DAMAGE COVERAGE: to:
However, the most we will pay for any expenses (a) You (if you are an individual);
for loss of use is $65 per day, to a maximum of (b) A partner(if you are a partnership);
$750 for any one"accident". (c) A member (if you are a limited liability com-
I. PHYSICAL DAMAGE — TRANSPORTATION pany);
EXPENSES—INCREASED LIMIT (d) An executive officer, director or insurance
The following replaces the first sentence in Para- manager(if you are a corporation or other or-
graph A.4.a., Transportation Expenses, of ganization), or
SECTION III — PHYSICAL DAMAGE COVER- (e) Any "employee"authorized by you to give no-
AGE: tice of the"accident"or"loss".
We will pay up to $50 per day to a maximum of M. BLANKET WAIVER OF SUBROGATION
$1,500 for temporary transportation expense in- The following replaces Paragraph A.5., Transfer
curred by you because of the total theft of a cov- Of Rights Of Recovery Against Others To Us,
ered"auto"of the private passenger type. of SECTION IV — BUSINESS AUTO CONDI-
J. PERSONAL PROPERTY TIONS:
The following is added to Paragraph AA., Cover- 5. Transfer Of Rights Of Recovery Against
age Extensions, of SECTION III — PHYSICAL Others To Us
DAMAGE COVERAGE: We waive any right of recovery we may have
Personal Property against any person or organization to the ex-
We will a u to $400 for"loss" to wearing a tent required of you by a written contract
pay P 9 P- signed and executed prior to any "accident"
parel and other personal property which is: or"loss", provided that the"accident"or"loss"
(1) Owned by an "insured"; and arises out of operations contemplated by
CA T3 53 02 15 ®2015 The Travelers Indemnity Company.All rights reserved. Page 3 of 4
Includes copyrighted material of Insurance Services 0111ce,Inc.with Its permission.
COMMERCIAL AUTO
such contract. The waiver applies only to the The unintentional omission of, or unintentional
person or organization designated in such error in, any information given by you shall not
contract. prejudice your rights under this insurance. How-
N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col-
The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of
cealment, Misrepresentation, Or Fraud, of cancellation or non-renewal.
SECTION IV—BUSINESS AUTO CONDITIONS;
Page 4 of 4 ©2015 The Travelers indemnity Company.All rights reserved. CA T3 53 0215
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
Starr Surplus Lines Insurance Company
Chicago, IL 1-646-227-6300
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES O
CONTRACTORS - COMPLETED OPERATIONS
Policy Number: 1000066106181 Effective Date: February 1, 2018 at 12:01 A.M.
Named Insured: Superior Tank Solutions, Inc
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
Where Required By Written Contract
Location And Description of Completed Operations:
Where Required By Written Contract
Additional Premium:
Included
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" at the location designated and described in
the schedule of this endorsement performed for that insured and included in the "products-completed operations
hazard".
All other terms and conditions of this Policy remain unchanged.
Signed for STARR SURPLUS LINES INSURANCE COMPANY
Charles H. Da g,'Io, President Nehemiah E.Ginsburg, Genera'ounsel
3L 820 01 (10114) Page 1 of 1
Copyright 0 C.V.Start 8 Company and Starr Surplus Linea Insurance Company. All rights reserved.
Includes copyrighted material of 180 Properties,Inc.,used with Its permission.
gym.
Starr Surplus Liles Insurance Company
Chicago, IL 1-646-227-6300
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — OWNERS, LESSEES Off:
CONTRACTORS — SCHEDULED PERSON OR
ORGANIZATION
Policy Number: 1000066106181 Effective Date: February 1, 2018 at 12:01 A.M.
Named Insured: Superior Tank Solutions, Inc
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
YName of Person or Organization:
Where Required By Written Contract
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
A Section II—Who Is An Insured is amended to include as an insured the person or organization shown
in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that
insured.
B With respect to the insurance afforded to these additional insureds, the following exclusion is added:
2. Exclusions
This insurance does not apply to"bodily injury"or"property damage"occurring after:
1 All work, including materials, parts or equipment furnished in connection with such work, on the
project(other than service, maintenance or repairs)to be performed by or on behalf of the
additional insured(s) at the site 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.
All other terms and conditions of this Policy remain unchanged.
Signed for STARR SURPLUS LINES INSURANCE COMPANY
Charles H. Darrgelo, President Nehemiah E.Ginsburg, Genera ounsel
SL 82101 (10114) Page 1 of 1
Copyright 0 C.V.Start i Company and Starr Surplus Lines Insurance Company. All rights rasarwd.
Includes copyrighted material of 180 Properties,Inc.,used with @e permission.
POLICY NUMBER:1000066106181 COMMERCIAL GENERAL LIABILITY
CO 20 010413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARYAND ON�CONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTSICOMPL ETED OPERATIONS LIABILITY COVERAGE PART
The following Is added to the Other Insurance (2) You have agreed in writing In a contnad or
Condition and supersedes any provision to the agreement that this Insurance would be
contrary: primary and would not seek contribullon
Primary And Noncontributory Insurance from any other Insunrnce available to the
'This Insurance Is primaryto and YAI not seek ,addttlonet Insured.
contribution hm any other Insurance avallabte
to an additional Insured under your policy
provided that:
(1) The additional Insured Is a Named Insured,
under such other insuranw;and
CO 20 010413 0 Insurance Services Office,Inc.,2012 Page 1 of 1
POLICY NUMBER:1000066106181 COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
WAIVER OF TRANSFER OF' RIGHTS OF RECOVERY
G IINST"' OTHERS TO SIS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
Any person or organization to whom you become obligated to waive your rights of recovery against,under any
contract or agreement you enter into prior to the occurrence of loss.
Information required to complete 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—Conditions:
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.
CG 24 04 05 09 0 Insurance Services Office,Inc.,2008 Page 1 of 1
* Starr Surplus sines Insurance Company
Chicago, IL 1-646-227-6300
Primary and lion-contributory, Additional insured and
Waiver of Subrogation
Policy Number: 1000066106181 Effective Date:February 1, 2018 at 12:01 A.M.
Named Insured: Superior Tank Solutions, Inc.
This endorsement modifies the insurance coverage form(s) listed below that have been purchased by you and
evidenced as such on the Declarations page. Please read the endorsement and respective policy(ies)carefully.
Commercial General Liability Coverage Form
Owners and Contractors Protective Liability Coverage Form
Products/Completed Operations Liability Coverage Form
Contractors Pollution Liability Coverage Form
Professional Liability Coverage Form
Site Pollution Liability Coverage Form
SCHEDULE
Where Required By Written Contract
A. SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in
the schedule of this endorsement, but only with respect to liability arising out of"your work"for that insured by or
for you.
B. As respects additional insureds as defined above, this insurance also applies to "bodily injury" or "property
damage"arising out of your negligence when the following written contract requirements are applicable:
1. Coverage available under this coverage part shall apply as primary insurance. Any other insurance
available to these additional insured's shall apply as excess and not contribute as primary to the insurance
afforded by this endorsement.
2. We waive any right of recovery we may have against these additional insured's because of payments we
make for injury or damage arising out of "your work" done under a written contract with the additional
insured.
3. The term insured is used separately and not collectively, but the inclusion of more than one insured shall
not increase the limits or coverage provided by this insurance.
Insureds and Agents are advised that certificates of insurance should be used only to provide evidence of insurance
in lieu of an actual copy of the applicable insurance policy. Certificates should not be used to amend, expand or
otherwise alter the terms of the actual policy.
All other terms and conditions of this Policy remain unchanged.
Signed for STARR SURPLUS LINES INSURANCE COMPANY
Cgaa�Darfgello, President Nehemiah E.Ginsburg,Genera ounsel
SL 023(06111) Page 1 of 1
Copyright m C.V.Starr&Company and Starr Surplus Lines Insurance Company.All rights reserved
Includes copyrighted material of 190 Properties,Inc.,used with Its 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 2.096 of the California workers'compensation premium
otherwise due on such remuneration,
Schedule
Person or Organization Job Description
Where required by contract
Any person or organization to whom you become obligated to waive
your rights of recovery against, under any contract or agreement you
enter into prior to the occurrence of loss.
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: 02/01/2018 Policy No.: 100 0002002 Endorsement No,:001
Insured: SUPERIOR TANK COMPANY,INC, Premium: $295,431.00
Insurance Company:STARR INDEMNITY&LIABILITY CO Countersigned by:
WC 04 03 06
(Ed. 04-84) Page 1 of 1