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PROOF OF INSURANCE (2019) CLOSED ,11 '"^ DATE(MMIDD/YYYY) � CERTIFICATE OF LIABILITY INSURANCE 3/27/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: McClain Alliant Insurance Services, Inc. PHONE FAX 1301 Dove Street, Suite 200 WCl 149,Inx (AIC,No); E-MAIL .. Newport Beach CA 92660-2436 ADDRE$s: CMcCiain@aNllanLcom INSURERS)AFFORDING COVERAGE NAIC# INSURER Starr Indemnity&Liability Company 38318 INSURED INSURER B:American Guarantee and Liability Insurance 26247 The Rados Companies dba: Steve P. Rados, Inc. INSURE C Travelers Property Casualty Company of America 25674 2002 E McFadden INSURER D R Santa Ana CA 92705 II INSURER i ....,.... INSURER F: COVERAGE'S CERTIFICATE NUMBER;1804119014 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, IL7R TYPE OF INSURANCE ..AINSD SUI§ POLICY NUMBER L,t POLICY EFF POLICY EXP .. ..... C LIMITS DIXYYYI -(MM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY 1000025801181 4/12018 4/12019 I EACH OCCURRENCE $2.DOO,DDO CLAIMS-MADE X i OCCUR DAMAGE TO RERENTEDPREMISE..S,(Eaoccurronca) $300,000 MED EXP(Anyone person) $10.000 PERSONAL&ADV INJURY $2,000,ODO GEN°L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $4,000,000 POLICY X I dEC T LOC PRODUCTS-COMP/OP AGG $ i 4000000 OTHER' $ A AUTOMOBILE LIABILITY 1000198585181 4/12018 4/12019 ) $ [-,O�a,aca�rla kSINGLE'tl.6MllY.. 1,000d0DO X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accmdent II HIRED AUTOS )( AUTOS ), $, NON-OWNED .( eracad'W a�+M (L.. $ „x AUTOS ... „ AUTOS Pam retxialauad Medical Payment $5,000 , 1318303 C V OCCUR P112019 EACH OCCURRENCE II $25,000,000® X UMBRELLA LIAB ZUP12T7903018NF 4/1/2018 4/X EXCESS LIAB CLAIMS-MADE AGGREGATE $25,00 , 00 DED RETENTION$ Each Occur/App $10,000.DOO A WORKERS COMPENSATION 1000003175 4/12018 4/12019 X PER O H- AND EMPLOYERS'LIABILITY Y/N STATUTE ER Y�I ANY PROPRIETORIPARTNER/EXECUTIVE $1, (Mandatory SCR describe under OPERATIONS below E DI ACCIDENTEOMI I OYFn E $1.D00.000 OFFICER/MEMBER EXCLUDED? NIA A . ) E.. .a'SEA9 A L ISE L f 'SE.A: LICY LIMIT $1.000.000 ..-.... - — ------------ - - - DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached IF more space is required) Re:Project#PW1'6-07,Pump Station#1 &#7 Modification City„its officials and employees are named as Additional Insured per attached endorsements on Primary and Non-Contributory basis.Waiver of Subrogation applies per attached endors'emen'ts. CERTIFICATE HOLDER CANCELLATION 30 Days SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Lifan Xu The City The Contractor Public Works 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ry , Starr Indemnity & Liability Company Dallas,TX 1-866-519-2522 Amendment of Limits of Insurance (Per Project, Per Location or Per Project and Per Location Limit) Policy Number: 1000025601181 Effective Date: at 12:01 A.M. Named Insured: The Rados Companies This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM It is hereby agreed as follows: l., The Limits of Insurance shown in the Declarations are deleted in their entirety and replaced by the following: 1. Your policy includes either i) a Per Project Limit, ii) a Per Location Limit or iii) a Per Project and Per Location Limit. Please select only one of the following: [ ] Per Project Limit $ [ ] Per Location Limit $ [x ] Per Project and Per Location Limit $ 10,000,000 THIS ENDORSEMENT IS VOID IF: NONE OF THE BOXES LISTED ABOVE ARE CHECKED; OR MORE THAN ONE OF THE BOXES LISTED ABOVE ARE CHECKED; OR ONLY ONE OF THE BOXES LISTED ABOVE IS CHECKED BUT IS UNACCOMPANIED BY AN ASSOCIATED DOLLAR AMOUNT. Manuscript Page 1 of 4 Copyright© C.V.Starr&Company and Starr Indemnity&Liability Company. All rights reserved. Includes copyrighted material of ISO Properties,Inc.,used with its permission. 2. General Aggregate Limit $4,000,000 Each Occurrence Limit $ 2,000,000 Products-Completed Operations Aggregate Limit $4,000,000 Personal &Advertising Injury Limit $ 2,000,000 Damage to Premises Rented to You $ 100,000 Medical Expense Limit $ 5,000 III. SECTION III—LIMITS OF INSURANCE is deleted in its entirety and replaced by the following: 1. The Limits of Insurance and the rules below fix the most we will pay regardless of the number of: a. Insureds; b. Claims made or"suits" brought; or c. Persons or organizations making claims or bringing "suits". 2. The General Aggregate Limit is the most we will pay under Coverages A, B, and C combined for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the products-completed operations hazard"; and c. Damages under Coverage B. regardless of the number of projects or"locations." 3. The Products-Completed Operations Aggregate Limit is the most we will pay under Coverage A for damages because of "bodily injury" and "property damage" included in the "products-completed operations hazard". 4. Subject to Paragraph 2 above, the Personal and Advertising Injury Limit is the most we will pay under Coverage B for the sum of all damages because of all "personal and advertising injury" sustained by any one person or organization. 5. Subject to Paragraph 2 or 3 above, whichever applies, the Each Occurrence Limit is the most we will pay for the sum of: a. Damages under Coverage A; and b. Medical expenses under Coverage C because of all "bodily injury" and "property damage" arising out of any one"occurrence". 6. Subject to Paragraph 5 above, the Damage to Premises Rented to You Limit is the most Manuscript Page 2 of 4 Copyright© C.V.Starr&Company and Starr Indemnity&Liability Company. All rights reserved. Includes copyrighted material of ISO Properties,Inc.,used with its permission. we will pay under Coverage A for damages because of "property damage" to any one premises, while rented to you, or in the case of damage by fire, while rented to you or temporarily occupied by you with permission of the owner. 7. Subject to Paragraph 5 above, the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person. 8. Subject to Paragraphs 2, 4, 5, 6, and 7 above, the Per Project Limit is the most we will pay under Coverages A, B, and C combined for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of"bodily injury" or "property damage" included in the products-completed operations hazard"; and c. Damages under Coverage B. arising out of any single Project. 9. Subject to Paragraphs 2, 4, 5, 6, and 7 above, the Per Location Limit is the most we will pay under Coverages A, B, and C combined for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of"bodily injury" or "property damage" included in the products-completed operations hazard"; and c. Damages under Coverage B. arising out of any single"location." 10. Subject to Paragraphs 2, 4, 5, 6, and 7 above, the Per Project and Per Location Limit is the most we will pay under Coverages A, B, and C combined for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of"bodily injury" or "property damage" included in the products-completed operations hazard"; and c. Damages under Coverage B. arising out of any single Project or"location," as applicable. The Limits of Insurance of this Coverage Part apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. III. SECTION V—DEFINITIONS is amended to include the following: "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway, or right-of-way railroad. Manuscript Page 3 of 4 Copyright© C.V.Starr&Company and Starr Indemnity&Liability Company. All rights reserved. Includes copyrighted material of ISO Properties,Inc.,used with its permission. All other terms and conditions of this policy remain the same. Signed for STARR INDEMNITY& LIABILITY COMPANY Charles H. DangelorPresident Nehemiah E. Ginsburg, General Founsel Manuscript Page 4 of 4 Copyright© C.V.Starr&Company and Starr Indemnity&Liability Company. All rights reserved. Includes copyrighted material of ISO Properties,Inc.,used with its permission. POLICY NUMBER: 1000025601181 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS S - SCHEDULED PERSON O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) ...............ww Or Organization(s) Location(s) Of Covered Operations 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 to B. With respect to the insurance afforded to these 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 not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts 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 However. 2. That portion of"your work"out of which the injury or damage arises has been put to its intended 1. The insurance afforded to such additional use by any person or organization other than insured only applies to the extent permitted by another contractor or subcontractor engaged in law; and performing operations for a principal as a part of 2. If coverage provided to the additional insured is the same project. 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. CG 20 10 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the applicable required by a contract or agreement, the most we Limits of Insurance shown in the Declarations. will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 0413 POLICY NUMBER: 1000025601181 COMMERCIAL GENERAL LIABILITY CG 20 11 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL. INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): Name Of Person(s) Or Organization(s) (Additional Insured): Additional Premium: $ 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 to 2. If coverage provided to the additional insured include as an additional insured the person(s) or is required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured with respect to liability arising out of the will not be broader than that which you are ownership, maintenance or use of that part of the required by the contract or agreement to premises leased to you and shown in the provide for such additional insured. Schedule and subject to the following additional B. With respect to the insurance afforded to these exclusions: additional insureds, the following is added to This insurance does not apply to: Section III—Limits Of Insurance: 1. Any 'occurrence" which takes place after you If coverage provided to the additional insured is cease to be a tenant in that premises. required by a contract or agreement, the most we 2. Structural alterations, new construction or will pay on behalf of the additional insured is the demolition operations performed by or on amount of insurance: behalf of the person(s) or organization(s) 1. Required by the contract or agreement; or shown in the Schedule. 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the by law; and applicable Limits of Insurance shown in the Declarations. CG 20 11 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 1000025601181 COMMERCIAL GENERAL LIABILITY CG 20 28 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL. INSURE - LESSOR O LEASED EQUIPMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): 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 to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, this insurance does not apply organization(s) shown in the Schedule, but only to any 'occurrence" which takes place after the with respect to liability for "bodily injury", "property equipment lease expires. damage" or "personal and advertising injury" C. With respect to the insurance afforded to these caused, in whole or in part, by your maintenance, additional insureds, the following is added to operation or use of equipment leased to you by Section III—Limits Of Insurance: such person(s) or organization(s). If coverage provided to the additional insured is However: required by a contract or agreement, the most we 1. The insurance afforded to such additional will pay on behalf of the additional insured is the insured only applies to the extent permitted by amount of insurance: law; and 1. Required by the contract or agreement; or 2. If coverage provided to the additional insured is 2. Available , under the applicable Limits of required by a contract or agreement, the Insurance shown in the Declarations; insurance afforded to such additional insured will not be broader than that which you are whichever is less. required by the contract or agreement to This endorsement shall not increase the provide for such additional insured. applicable Limits of Insurance shown in the Declarations. CG 20 28 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 1000025601181 COMMERCIAL GENERAL LIABILITY CG 20 12 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: G 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 to 2. This insurance does not apply to: include as an additional insured any state or a. "Bodily injury", "property damage" or governmental agency or subdivision or political "personal and advertising injury" arising out subdivision shown in the Schedule, subject to the of operations performed for the federal following provisions: government, state or municipality; or 1. This insurance applies only with respect to b. "Bodily injury" or "property damage" operations performed by you or on your behalf included within the "products-completed for which the state or governmental agency or operations hazard". subdivision or political subdivision has issued a permit or authorization. B. With respect to the insurance afforded to these additional insureds, the following is added to However: Section III—Limits Of Insurance: a. The insurance afforded to such additional If coverage provided to the additional insured is insured only applies to the extent permitted required by a contract or agreement, the most we by law; and will pay on behalf of the additional insured is the b. If coverage provided to the additional amount of insurance: insured is required by a contract or 1. Required by the contract or agreement; or agreement, the insurance afforded to such additional insured will not be broader than 2. Available under the applicable Limits of that which you are required by the contract Insurance shown in the Declarations; or agreement to provide for such additional whichever is less. insured. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 12 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 f. �Starr Indemnity& Liability Company Dallas, TX 1-866-519-2522 Primary and Non-Contributory Condition Policy Number: 1000025601181 Effective Date: Named Insured:. The Rados Companies This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A.SECTION IV—CONDITIONS,condition 4.Other Insurance is amended as follows: 1. The following is added to paragraph 4.a.of the Other Insurance condition: This insurance is primary insurance as respects our coverage to the additional insured, where the written contract or written agreement requires that this insurance be primary and non-contributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured on which the additional insured is a Named Insured. ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. Signed for STARR INDEMNITY&LIABILITY COMPANY 1 Charles H. Dangelo,,President Nehemiah E.Ginsburg,GeneraWounsel OG 107(04111) Page 1 of 1 Copyright©C.V.Starr&Company and Starr Indemnity&Liability Company.All rights reserved. Includes copyrighted material of ISO Properties,Inc.,used with its permission. Starr Indemnity& Liability Company Dallas, TX 1-866-519-2522 AMENDMENT - 30 DAY NOTICE OF CANCELLATION FOR THIRD PARTIES Policy Number: 1000025601181 Effective Date: at 12:01 A.M. Named Insured: The Rados Companies 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 Products Completed Operations Coverage Form Business Auto Coverage Form It is agreed thirty (30) days' notice of cancellation will be given as respects the following certificate holder(s), except as respects non-payment of any premium, non-renewal, and/or per the First Named Insured's request: SCHEDULE The insurer will endeavor to provide advice of cancellation (the"Advice")to the certificate holders listed in the schedule by e-mail. Certificate holders include only those entities where thirty (30) days notice of cancellation is required by an "insured contract" but only with respects to an entity for which "you"are directly or indirectly performing "your work". This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such Advice will neither extend the policy cancellation nor negate cancellation of the policy; nor will this failure result in obligation or liability of any kind upon the issuing insurer, its agents or representatives. This endorsement does not affect, in any way, coverage provided under this policy, nor the cancellation of this policy or the effective date thereof. The following definitions apply to this endorsement: 1. 'First Named Insured' means the named insured shown in the Declarations Page of this policy. 2. 'Insurer' means the insurance company shown in the header on the Declarations Page of this policy. 1 Starr indemnity& Liability Company Dallas, TX 1-866-519-2522 ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED, Signed for STARR INDEMNITY&LIABILITY COMPANY 2 POLICY NUMBER: 1000025601181 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO ISS 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: Where required by written contract. 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 ©Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ G Starr Indemnity & Liability Company Dallas, TX 1-866-519-2522 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy Number: 1000198565181 Effective Date: at 12:01 A.M. Named Insured: The Rados Companies ADDITIONAL INSURED - WHERE REQUIRED UNDER CONTRACT OR AGREEMENT This policy is amended as follows: BUSINESS AUTO COVERAGE FORM SCHEDULE ADDITIONAL INSURED ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE CONTRACTUALLY BOUND TO PROVIDE ADDITIONAL INSURED STATUS BUT ONLY TO THE EXTENT OF SUCH PERSON OR ORGANIZATIONS LIABILITY ARISING OUT OF THE USE OF A COVERED "AUTO" I. SECTION II — LIABILITY COVERAGE A. Coverage, 1. Who is Insured, is amended to add: d. Any person or organization, shown in the schedule above, to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of use of a covered "auto". However, the insurance provided will not exceed the lesser of: (1) The coverage and/or limits of this policy, or (2) The coverage and/or limits required by said contract or agreement. Signed for STARR INDEMNITY & LIABILITY COMPANY Charles 1. Nungelo, resident Nehemiah E. Ginsburg, GeneraVCounsel SICA 1016 (02/12) Page 1 of 1 Copyright©C.V.Starr&Company and Starr Indemnity&Liability Company. All rights reserved. Includes copyrighted material of ISO Properties,Inc.,used with its permission. POLICY NUMBER: 1000198565181 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Endorsement Effective Date: SCHEDULE Name(s) Of Person(s) Or Organization(s): - ---- ........... .................... Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the 'loss" under a contract with that person or organization. CA 04 44 10 13 C Insurance Services Office, Inc., 2011 Page 1 of 1 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 20 w %of the California workers'compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Where required by 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: Policy No.: Endorsement No.: Insured: Premium: Insurance Company: Countersigned by: WC 04 03 06 (Ed.04-84) Page 1 of 1