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PROOF OF INSURANCE (2018 - 2019) CLOSED RINCCON-01 '. ,tL, 9.�?
.......
ACORO° DATE(MMIDD/YYYY)
... CERTIFICATE....OF LIABILITY INSURANCE .5123 2o�8
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 not confer rights to the certificate holder in lieu of such endorsement(s).
License#OE67768 c_..._.Q
PRODUCERCT Elizabeth Leach
Legends Environmental Ins.Services PHONr�,Exry,�949'�297-5537 52011 FAX,N� 949 297-5960
130 Vantin d;(
Suite 250 E°MAIL, Elizabeth.Leach@ioausa.com
ADDREs's;
Aliso Viejo,CA 92656 INSURER(S)AFFORDING COVERAGE MAIC#
INSURER A:Crum Er Forster Specialty Insurance Company 44520
INSURED INSURER B:Trumbull Insurance Company 27120
Rincon Consultants,Inc. ENsuncRc:StarStone National Insurance Company 25495
180 N Ashwood Ave INSURER D:
Ventura,CA 93003
INSURER E;
INSURER F:
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COVERAGES , ,RTIFICATE NUMBER: I, ,WSIO'N 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.
SUBR POLICY EFF POLICY EXP
_ TYPE OF INSURANCE..................................................'Nom'!wVD POLICY NUMBER rMMre, La:.XI'X�l�...dkNk.M/.p.p� 'M�Y�L......,.......ww.. LIMITS ....
�� Rm Xm COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ^^ 3,000,000
CLAIMS-MADE X OCCUR X X IEPK114155 09/22/2016 09/22/2018 pPDAMA ap`m��at(CiRF,,pd�I,e"� ncros) S50,000
X Transportation'Poll. IALD EXP(Ani one rer,son s 10„000
P'E'RSONAL A ADV INJURY „ 3,000,000
GEN'LASG(lREGATELIMIT APPLIES PER: GINE'R4AGGf',EG�ATE;•, $ 4^000"000
POLICY X JE° Loc PROD(.IC'JS COMP'sOPAG3G S 4,000,00'0
X OTHER Contractor's Pollution Liability Deductible 2,500'
13 AUTOMOBILE LIABILITY ...............................................................................................w.... SE';db�p'CCPdD�eCy�'TINGE_E�k.IN011l'��.�.....�.�.m�.�....�._.............. 1,000,000
X ANY AUTO X X 72UUNPT4318 12/17/2017 12/17/2018 BODILY INJURY(Perp�arson,) S.
OWNED SCHEDULED
AUTOS ONLY AUTOS SODII.Y'INA.IRY,iP�er awount) S
XIVI''"" NON- IrED F?E,"IPENI'M MAGE
'T
��AckJTr'S ONLY X AUTOS ONLYaCCi'derkp,b S
X li S�,t�I��plAlt'.'.',oll Ded 'S
11 11�V ..-..,_...............�..,m„-.,..,.,.,.,.,....�.�......._�.�.�.......,..................�.�.�.�.�.�.�.....................................,.,.,.,.,.....,.,.,.....,.,.,....w... 9kiAi'�d��N�.�.�.�.�.�.�...�.�.�..._,......µ.u.�.
OCCUR�RIENCE..... S
UMBRELLA LIAB X OCCUR 5,000,000
X EXCESS LIAB CLAIMS-MADE EFX108624 09/22/2017 09/22/2018 AGGYR'EGATE s 5,000,000
DEDX RETENTION.$..............1.U,OU. ..........................................................................w.......... ............ 'S
C WORKERS COMPENSATION µa
AND EMPLOYERS'LIABILITY X STATUTE ki
AGENCY CUSTOMER ID:RINCCON-01 PHILLIPSC
LOC M 1
ACC>ROO
ADDITIONAL REMARKS SCHEDULE Page I of
AGENCY License#OE67768 NAMED INSURED
Legends Environmental Ins.Services Rincon Consultants,Inc.
180 N Ashwood Ave
POLICY NUMBER Ventura,CA 93003
SEE PAGE I
CARRIER NAIC CODE
SEE PAGE 1 �SEE P 1 EFFECTIVE DATE:
SEEPAGE
.......................... .............................
ADDITIONAL REMARKS
. ..................
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: ACORD 26 FORM TITLE: Certificate of Liability insurance
Description of Operations/LocationslVehicles:
Subrogation applies to General Liability,Auto Liability and Workers Compensation as required by written contract,per Endorsement
EN0147-11 11, HA99160312&WC000313. Excess policy follows General Liability,Auto Liability and Employers Liability form.
................ ....................... .............
.............. ............ ..............
ACORD 101 (2008/01) 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY#: EPK114155
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 Person(s)or Organization(s): Location And Description Of Completed Operations
Where Required b.y Written Contract. Where Required by Written Contract.
Information required to complete this Schedule, if not shown above,will be shown in the Declarations,
A. Section III — Who Is An Insured within the
Common Provisions is amended to include as
an insured the person(s) or organization(s)
shown in the Schedule, but only with respect to
liability for "bodily injury" or "property damage"
caused, in whole or in part, by "your work" at
the location designated and described in the
schedule of this endorsement performed for
that additional insured and included in the
"products-completed operations hazard".
EN0320-0211 Page 1 of 1
POLICY* EPK114155
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
ADDITIONAL i - OWNERS, LESSEES OR CONTRACTORS -
SCHEDULED PERSON OR 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
_._.
Where Required by Written Contract. Where Required by Written Contract.
......................
..._
Information e. if not show .�. � __ ...____.,
ertuired to crrnlplete this Schedule, n above, will be shown in the Declarations.
A. Section III — Who Is An Insured within the With respect to the insurance afforded to these
Common Provisions is amended to include as additional insureds, the following additional
an additional insured the person(s) or exclusions apply:
organizations) shown in the Schedule, but only This insurance does not apply to "bodily injury"
with respect to Ihalbility for "'bodily injury" or"property damage" occurring after:
"property damage" or "personal and advertising 3. All work, including materials, parts or
injury" cause, lin whole or in part, b'y: equipment furnished in connection with
1. Your acts or omissions; or such work, on the project (other than
2. The acts or omissions of those acting on service, maintenance or repairs) to be
your behalf; performed by or on behalf of the additional
in the performance of your ongoing operations insured(s) at the location of the covered
for the additionaP insured(s) at the location(s) operations has been completed; or
designated above. 4. 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.
EN0321-0211 Page 1 of 1
POLICY#EPI(114155
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED
WITH WAIVER OF SUBROGATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
ERRORS AND OMISSIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) or Organization(s)
Where Required By Written Contract.
A. SECTION Ill — WHO IS AN INSURED within the Common Provisions is amended to include as an
additional insured the person(s) or organization(s) indicated in the Schedule shown above, but only with
respect to liability arising out of "your work" for that person or organization performed by you, or by those
acting on your behalf.
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 insureds 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 the person(s) or organization(s) indicated in the
Schedule shown above because of payments we make for injury or damage arising out of "your work"
performed under a written contract with that person(s) or organization(s).
3. The term"additional insured" is used separately and not collectively, but the inclusion of more than one
"additional insured" shall not increase the limits or coverage provided by this insurance.
This Endorsement does not reinstate or increase the Limits of Insurance applicable to any "claim" to which the
coverage afforded by this Endorsement applies.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
EN01 47-1111 Page 1 of 1
Policy Number: 73UUNPT4318 COMMERCIAL AUTOMOBILE
HA8916O%12
THIS ENDORSEMENT CHANGES THE POLICY' PLEASE READ IT CAREFULLY.
COMMERCIAL AUTOMOBILE B
ROD ORM
ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
To the extent that the provisions of this endorsement provide broader benefits to the ''inaumd" than other
provisions ofthe Coverage Form, the provisions ofthis endorsement apply,
1. BROAD FORM INSURED d Any "employee" of yours while using a
A Subsidiaries and Newly Acquired or covered ''uuV»^ you don't m*n, hire o,
A.
Formed Organizationsborrow in your business or your
The Named Insured shown in the personal affairs.
Declarations iaamended toindC.. LesaoraaaInsureds
(1) Any legal business entity other than a Paragraph A.1. 'WHO IS AN INSURED of
partnership or joint venture, hnnned as a Section i| ' Liability Coverage is emended to
subsidiary in which you have an add:
ownership interest of more than 50q& on e. The lessor cda covered "auto"while the
the effective date ofthe Coverage Form. "auUz" is [eased to you under o written
However, the Named Insured does not agreement if:
include any subsidiary that is an (1) The agreement requires you to
"insured" under any other automobile provide direct primary insurance for
policy or would be an "insured" under the lessor and
such a policy but for its termination or
the exhaustion pfits Limit cfInsurance. (2) The''au(o''inleased without pdriver,
(2) Any organization that is acquired or Such a leased "auto" will be considered a
formed by you and over which you covered ''au\o'' you own and not ouvomd
maintain majority ownership However, auto"you hire,
the Named Insured does not include any O� AmditionsNtrismlted it Required by Contract
newly formed or acquired orgonizaMo» (1) �Paragraph h A 1' WHO IS AN INSURED
(a) That is a partnership or joint o/ Section || ' Liability Coverage is
venture, amended toadd,
(b) That is an ^inouned" Linder any other t When you have agreed, in a written
po|k9. contract urwritten agreement, that a
(o) That has exhausted its Limit of person nrorganization be added as
Insurance under any other po|icy, or an additionel insured on your
(d) 180 days or more after its business auto policy, such person or
acquisition or formation by you, organization iaan"insured''. but only
unless you have given us notice of to the extent such person or
the acquisition urformation. organization is liable for 'bodily
Coverage does not apply to "bodily injury" or "property damage" caused
injury" or "property damage" that mou|tn by the conduct ofan "insured" under
from an ''acddent'' that occurred before paragraphs u. or b. of Who Is An
you formed wracquired the organization. Insured with regard to the
ownarahip, maintenance or use of
B. Emp|oyeosao|nourwda covered"auto."
Paragraph A.1. - VVHO |GAN INSURED ' of
SECTION U LIABILITY COVERAGE is
amended k/add:
@2O11. The Hartford (Includes copyrighted material
Form HAg918O312 ofISO Properties, |no..with its permionion.) Page 1of5
The insurance afforded to any such E. Primary and Non-Contributoryif
additional insured applies only if the Rauh by,Contract
"bodily injury" or "property damage" Only with respect to insurance provided to
occurs an additional insured in 1 D. - Additional
(1) During the policy period, and Insured If Required by Contract, the
(2) Subsequent to the execution of such following provisions apply:
written contract, and (3) Primary Insurance When Required By
(3) Prior to the expiration of the period Contract
of time that the written contract This insurance is primary if you have
requires such insurance be provided agreed in a written contract or written
to the additional insured agreement that this insurance be
(2) How Limits Apply primary If other insurance is also
primary, we will share with all that other
If you have agreed in a written contract insurance by the method described in
or written agreement that another Other Insurance 5.d.
person or organization be added as an
additional insured on your policy, the (4) Primary And Non-Contributory To Other
most we will pay on behalf of such Insurance When Required By Contract
additional insured is the lesser of: If you have agreed in a written contract
(a) The limits of insurance specified in or written agreement that this insurance
the written contract or written is primary and non-contributory with the
agreement; or additional insured's own insurance, this
(b) The Limits of Insurance shown in insurance is primary and we will not
the Declarations. seek contribution from that other
insurance.
Such amount shall be a part of and not Paragraphs (3) and (4) do not apply to other
in addition to Limits of Insurance shown insurance to which the additional insured
in the Declarations and described in this has been added as an additional insured.
Section.
(3) Additional Insureds Other Insurance When this insurance is excess, we will have no
duty to defend the insured against any "suit" if
If we cover a claim or "suit" under this any other insurer has a duty to defend the
Coverage Part that may also be covered insured against that "suit" If no other insurer
by other insurance available to an defends, we will undertake to do se, but we will
additional insured, such additional be entitled to the insured's rights against all
insured must submit such claim or "suit" those other insurers
to the other insurer for defense and When this insurance is excess over other
indemnity insurance, we will pay only our share of the
However, this provision does not apply amount of the loss, if any, that exceeds the sum
to the extent that you have agreed in a of:
written contract or written agreement (1) The total amount that all such other
that this insurance is primary and non- insurance would pay for the loss in the
contributory with the additional insured's absence of this insurance; and
own insurance.
(2) The total of all deductible and self-insured
(4) Duties in The Event Of Accident, Claim,
Suitor Loss amounts under all that other insurance.
We will share the remaining loss, if any, by the
If you have agreed in a written contract
or written agreement that another method described in Other Insurance 5.d-
person
.d.person or organization be added as an 2. AUTOS RENTED BY EMPLOYEES
additional insured on your policy, the Any "auto" hired or rented by your "employee"
additional insured shall be required to on your behalf and at your direction will be
comply with the provisions in LOSS considered an"auto" you hire.
CONDITIONS 2. - DUTIES IN THE The OTHER INSURANCE Condition is amended
EVENT OF ACCIDENT, CLAIM , SUIT by adding the following:
OR LOSS — OF SECTION IV —
BUSINESS AUTO CONDITIONS, in the
same manner as the Named Insured.
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 2 of 5
If an "employee's" personal insurance also 5. PHYSICAL DAMAGE - ADDITIONAL
applies on an excess basis to a covered "auto" TEMPORARY TRANSPORTATION EXPENSE
hired or rented by your "employee" on your COVERAGE
behalf and at your direction, this insurance will Paragraph A.4.a. of SECTION III - PHYSICAL
be primary to the "employee's" personal DAMAGE COVERAGE is amended to provide a
insurance limit of $50 per day and a maximum limit of
3. AMENDED FELLOW EMPLOYEE EXCLUSION $1,000.
EXCLUSION 5. - FELLOW EMPLOYEE - of 6. LOANILEASE GAP COVERAGE
SECTION II - LIABILITY COVERAGE does not Under SECTION III - PHYSICAL DAMAGE
apply if you have workers' compensation COVERAGE, in the event of a total "loss" to a
insurance in-force covering all of your covered "auto", we will pay your additional legal
"employees". obligation for any difference between the actual
Coverage is excess over any other collectible cash value of the "auto" at the time of the "loss"
insurance and the"outstanding balance"of the loan/lease
4. HIRED AUTO PHYSICAL DAMAGE COVERAGE "Outstanding balance" means the amount you
If hired "autos" are covered "autos" for Liability owe on the loan/lease at the time of "loss" less
Coverage and if Comprehensive, Specified any amounts representing taxes; overdue
Causes of Loss, or Collision coverages are payments; penalties, interest or charges
provided under this Coverage Form for any resulting from overdue payments; additional
"auto" you own, then the Physical Damage mileage charges; excess wear and tear charges;
Coverages provided are extended to "autos"you lease termination fees; security deposits not
hire or borrow, subject to the following limit. returned by the lessor; costs for extended
The most we will pay for "loss" to any hired warranties, credit life Insurance, health, accident
"auto" is:
or disability insurance purchased with the loan or
lease; and carry-over balances from previous
(1) $100,000; loans or leases.
(2) The actual cash value of the damaged or 7. AIRBAG COVERAGE
stolen property at the time of the"loss"; or Under Paragraph B. EXCLUSIONS - of
(3) The cost of repairing or replacing the SECTION III - PHYSICAL DAMAGE
damaged or stolen property, COVERAGE, the following is added:
whichever is smallest, minus a deductible. The The exclusion relating to mechanical breakdown
deductible will be equal to the largest deductible does not apply to the accidental discharge of an
applicable to any owned "auto" for that airbag.
coverage. No deductible applies to"loss"caused 8. ELECTRONIC EQUIPMENT - BROADENED
by fire or lightning. Hired Auto Physical Damage COVERAGE
coverage is excess over any other collectible
insurance. Subject to the above limit, deductible a. The exceptions to Paragraphs B.4 -
and excess provisions, we will provide coverage EXCLUSIONS -of SECTION III - PHYSICAL
equal to the broadest coverage applicable to any DAMAGE COVERAGE are replaced by the
covered "auto"you own. following:
We will also cover loss of use of the hired "auto" Exclusions 4.c. and 4,d. do not apply to
if it results from an "accident", you are legally equipment designed to be operated solely
liable and the lessor incurs an actual financial by use of the power from the "auto's"
loss, subject to a maximum of $1000 per electrical system that, at the time of"loss",
"accident". is:
This extension of coverage does not apply to (1) Permanently installed in or upon
any "auto" you hire or borrow from any of your the covered "auto";
"employees", partners (if you are a partnership), (2) Removable from a housing unit
members (if you are a limited liability company), which is permanently installed in
or members of their households. or upon the covered "auto";
(3) An integral part of the same unit
housing any electronic
equipment described in
Paragraphs (1)and (2)above; or
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 3 of 5
(4) Necessary for the normal If another Hartford Financial Services Group,
operation of the covered "auto"or Inc. company policy or coverage form that is not
the monitoring of the covered an automobile policy or coverage form applies to
"auto's"operating system the same"accident", the following applies:
b.Section III — Version CA 00 01 03 10 of the (1) If the deductible under this Business Auto
Business Auto Coverage Form, Physical Coverage Form is the smaller (or smallest)
Damage Coverage, Limit of Insurance, deductible, it will be waived:
Paragraph C 2 and Version CA 00 01 10 01 of (2) If the deductible under this Business Auto
the Business Auto Coverage Form, Physical Coverage Form is not the smaller (or
Damage Coverage, Limit of Insurance,
smallest) deductible; it will be reduced by
Paragraph C are each amended to add the the amount of the smaller (or smallest)
following: deductible.
$1.500 is the most we will pay for"loss" in 12. AMENDED DUTIES IN THE EVENT OF
any one "accident" to all electronic ACCIDENT, CLAIM, SUIT OR LOSS
equipment(other than equipment designed
solely for the reproduction of sound, and The requirement in LOSS CONDITIONS 2.a. -
s
solDUTIES IN THE EVENT OF ACCIDENT,CLAIM,
accessories used with such equipment)
that reproduces, receives or transmits SUIT OR LOSS - of SECTION IV - BUSINESS
audio, visual or data signals which, at the AUTO CONDITIONS that you must notify us of
time of"loss", is: an "accident"applies only when the "accident" is
(1) Permanently installed in or upon known to:
the covered "auto" in a housing, (1) You, if you are an individual;
opening or other location that is not (2) A partner, if you are a partnership,-
normally
artnership;normally used by the "auto" (3) A member, if you are a limited liability
manufacturer for the installation of company; or
such equipment: (4) An executive officer or insurance manager, if
(2) Removable from a permanently you are a corporation.
installed housing unit as described 13. UNINTENTIONAL FAILURE TO DISCLOSE
in Paragraph 2.a. above or is an HAZARDS
integral part of that equipment; or
(3)An integral part of such equipment. If you unintentionally fail to disclose any hazards
existing at the inception date of your policy, we
c.For each covered "auto", should loss be limited will not deny coverage under this Coverage
to electronic equipment only, our obligation to Form because of such failure.
pay for, repair, return or replace damaged or 14. HIRED AUTO-COVERAGE TERRITORY
stolen electronic equipment will be reduced by
the applicable deductible shown in the Paragraph e. of GENERAL CONDITIONS 7.
Declarations, or $250, whichever deductible is POLICY PERIOD, COVERAGE TERRITORY -
less. of SECTION IV - BUSINESS AUTO
9. EXTRA EXPENSE - BROADENED CONDITIONS is replaced by the following.-
COVERAGE
ollowing:COVERAGE e. For short-term hired "autos", the coverage
Under Paragraph A. -COVERAGE -of SECTION territory with respect to Liability Coverage is
III - PHYSICAL DAMAGE COVERAGE, we will anywhere in the world provided that if the
pay for the expense of returning a stolen covered "insured's" responsibility to pay damages for
"auto"to you. "bodily injury' or "property damage" is
determined in a "suit,"the "suit" is brought in
10. GLASS REPAIR-WAIVER OF DEDUCTIBLE the United States of America, the territories
Under Paragraph D. -DEDUCTIBLE-of SECTION and possessions of the United States of
III - PHYSICAL DAMAGE COVERAGE, the America, Puerto Rico or Canada or in a
following is added: settlement we agree to
No deductible applies to glass damage if the 15, WAIVER OF S VORMIATION
glass is repaired rather than replaced. TRANSFER OF RIGHTS OF RECOVERY
11. TWO OR MORE DEDUCTIBLES AGAINST OTHERS TO US - of SECTION IV -
Under Paragraph D -DEDUCTIBLE-of SECTION BUSINESS AUTO CONDITIONS is amended by
III - PHYSICAL DAMAGE COVERAGE, the adding the following:
following is added:
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc.,with its permission.) Page 4 of 5
We waive any right of recovery we may have c.Regardless of the number of autos deemed a
against any person or organization with whom total loss, the most we will pay under this
you have a written contract that requires such Hybrid, Electric, or Natural Gas Vehicle
waiver because of payments we make for Payment Coverage provision for any one
damages under this Coverage Form. "loss"is $10,000
16. RESULTANT MENTAL ANGUISH COVERAGE For the purposes of the coverage provision,
The definition of "bodily injury" in SECTION V- a.A "non-hybrid" auto is defined as an auto that
DEFINITIONS is replaced by the following: uses only an internal combustion engine to
"Bodily injury" means bodily injury, sickness or move the auto but does not include autos
disease sustained by any person, including powered solely by electricity or natural gas.
mental anguish or death resulting from any of b.A "hybrid" auto is defined as an auto with an
these. internal combustion engine and one or more
17. EXTENDED CANCELLATION CONDITION electric motors; and that uses the internal
Paragraph 2. of the COMMON POLICY combustion engine and one or more electric
motors to move the auto, or the internal
CONDITIONS - CANCELLATION - applies combustion engine to charge one or more
except as follows: electric motors, which move the auto.
If we cancel for any reason other than 19. VEHICLE WRAP COVERAGE
nonpayment of premium, we will mail or deliver
to the first Named Insured written notice of In the event of a total loss to an "auto" for which
cancellation at least 60 days before the effective Comprehensive. Specified Causes of Loss, or
date of cancellation. Collision coverages are provided under this
Coverage Form, then such Physical Damage
18. HYBRID, ELECTRIC, OR NATURAL GAS
VEHICLE PAYMENT COVERAGE Coverages are amended to add the following:
In addition to the actual cash value of the "auto",
In the event of a total loss to a "non-hybrid" auto we will pay up to $1,000 for vinyl vehicle wraps
for which Comprehensive, Specified Causes of which are displayed on the covered "auto" at the
Loss, or Collision coverages are provided under time of total loss. Regardless of the number of
this Coverage Form, then such Physical autos deemed a,total loss, the most we will pay
Damage Coverages are amended as follows: under this Vehicle Wrap Coverage provision for
a.lf the auto is replaced with a "hybrid" auto or any one "loss" is $5,000. For purposes of this
an auto powered solely by electricity or natural coverage provision, signs or other graphics
gas, we will pay an additional 10%, to a painted or magnetically affixed to the vehicle are
maximum of$2,500, of the "non-hybrid" auto's not considered vehicle wraps.
actual cash value or replacement cost,
whichever is less,
b.The auto must be replaced and a copy of a bill
of sale or new lease agreement received by us
within 60 calendar days of the date of"loss,"
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 5 of 5
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
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.)
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule,
Schedule
WHERE REQUIRED BY WRITTEN CONTRACT, PROVIDED THE
CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF
LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE
SHALL THE PROVISIONS AFFORDED BY THIS ENDORSEMENT
BENEFIT ANY COMPANY OPERATING AIRCRAFT FOR HIRE.
$500: AL,AR,CA,CO, CT,DC,ID, IL, IN, IA,KS, ME,MD,MI,MS,MT,NV, NM,OH,OK,OR, PA,RI,SD, UT,VT,VA,WA,WV
$250: AK, DE, LA,NY
$100: NC
$50: WI
N/A: AZ, FL,GA, HI, MA,MN, MO, NE,SC,TN,TX
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 02/01/18 Policy No. T10180329 Endorsement No. 5
Insured Rincon Consultants, Inc Policy Effective Date 02/01/18
Insurance Company StarStone National Insurance Company
WC 00 03 13
Countersigned By--7'f
-2.
(Ed.4-84)
Copyright 1983 National Council on Compensation Insurance.
