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PROOF OF INSURANCE (2019 - 2019) CLOSED .. - 4411I1, RESCH-1 ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/07/2019 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). PRODUCSteve CCooper Insurance 765-534-3152 .d HONE �'7G5-634 362 '�.............................�.��..................���., ,Net:755-534-2087.......................... lan rondoService,Inc PHON _.....................m ....... Plan �E F P.O.�oX 638 ___ .. Lapel„IN 46051 1a............ ............................................. ..... Steve B.Carrawvay �8su88.41.nLoBoiNG,mcovw►G ........................................................................ionic.#_......._ INSURER A:Scottsdale Insurance Co. 41297 .........................................._...tial U.n. .............'r......................_....................................... ..... ...........................................-. 1 Col�structlon,Inc suEF,c^patio ion Fire Ins Co 19445 ^^�� �"�.C78'�'4Fi "u'"'teat INsuRER$I.. .. . ...................................................................._.���................. .............................. Orange,C926 INsuRER D: INSURER'Ell: 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. I. . TYPE..OF.INSURANCE..................... ..., .... Y 1 OL�'UVIR POLICY NUMBER I POLICY EFF nnnrvYl LIMITS I TPA X li COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 OCCUR DAMAGE TO RENTED ................... 1.................._.. X IX ....� REW$E (EIA MFtQnWJ $ 5000 CLAIMS MADE X RBS0015607 04/22/2018 04/22/2019 00 000 U . i X I X MED EXP(Any..c:nepersan,� 5.....,. ... $ 1,000,000" PERS�NAL,B,,AOVINJURY I PR APPLIES OC P_RODUGTSGGOMP COMP/OP $ 2'000'0001 CEt,eL.AGGR'EGA POLICY CtPt•tER Prof Liab $ 1,000,000' AUTOMOBILE LIABILITY COM6B�NkED SINGLE LIMIT ANY AUTO BODILY INJURY(Perperson), $,,,,,,,,,,,,,,,,,,, ..., AUTOS ONLY ....... AUTOS ..B(J,DI,LYwINJURY�.(Per..�3..aide;n�l).�...�........................... OWRNED SCHEDULED _ AUTOS ONLY ALOdOW& PROPERLY MAGE (p,mr„ ccrdep? ................... $ UMBRELLA EACH OC 3,000,000 CCUR B ..X„d EXCESS ABAB X CCLAIMS MADE X X SE025275637 04/22/2018 04/22/2019_GGR GATERRENGE $ „3,000 000,. 11 DEDRETENTION$ $ WORKERS COMPENSATION PER AND STATU .M PRIMBEREXCLUDED? Y❑ NIA .. LI EAOH ATF ER�,,,,,,,� - E� EMoryRMM�M R/P EXCLUDED? EXECUTIVE E L DISEASE gIEA EMPLOYEE $If DEes,describe under SCRIPTION OF OPERATIONS below ETI.^DISEASE-�POLICY LIMIT is i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Project Na. PW 18-33 Halla Valley I Ia'ygrourad Prsaject Holly Ave Valley St.,EI Se' ands,CA--the ity at EI S'egun�tla 1st a ciai erraplays'es are add'Ina ti insured regardin�q tie gefoeral Ilability caverage on a prlrnaryf!tr non;Cont basis I'ncfudlf�g cafnpleted a eratians Wrtla a WaiveTo/ SubrogatlanOer Written cantract ffars CG233,CG2001,CG2404&CG2037 CERTIFICATE HOLDER CANCELLATION ELSEGUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City g ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE 2 d._ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ........,' RESCH-1 OS R.E.Schultz Construction Inc....................................................�.....,w...,,.,,..,,,,,,-...,,..,,....,,..,,..,....,,,..,.,,,,..,,, HOLDER CODE ELSEGUN aacE 2 ...,,...,,,...,. » NOTEPAD. INSURED'S NAME OP ID- CS Date /07/2019 attached. Excess coverage follows form. 30 enotice lffliofthan cancellatinfor non-payment of premium favor ocertficate der general kr COMMERCIAL GENERAL LIABILITY CG 20 33 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATICS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or additional insureds, the following additional organization for whom you are performing exclusions apply: operations when you and such person or This insurance does not apply to: organization have agreed in writing in a contract or agreement that such person or organization be 1. "Bodily injury", "property damage" or "personal added as an additional insured on your policy. and advertising injury" arising out of the Such person or organization is an additional rendering of, or the failure to render, any insured only with respect to liability for "bodily professional architectural, engineering or injury", "property damage" or "personal and surveying services, including: advertising injury" caused, in whole or in part, by: a. The preparing, approving, or failing to 1. Your acts or omissions; or prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, 2. The acts or omissions of those acting on your change orders or drawings and behalf; specifications; or in the performance of your ongoing operations for b. Supervisory, inspection, architectural or the additional insured. engineering activities. However, the insurance afforded to such This exclusion applies even if the claims against additional insured: any insured allege negligence or other wrongdoing 1. Only applies to the extent permitted by law; in the supervision, hiring, employment, training or and monitoring of others by that insured, if the 2. Will not be broader than that which you are "occurrence" which caused the "bodily injury" or required by the contract or agreement to "property damage", or the offense which caused provide for such additional insured. the "personal and advertising injury", involved the rendering of or the failure to render any A person's or organization's status as an professional architectural, engineering or additional insured under this endorsement ends surveying services. when your operations for that additional insured are completed. CG 20 33 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 2 2. "Bodily injury" or "property damage" occurring C. With respect to the insurance afforded to these after: additional insureds, the following is added to a. All work, including materials, parts or Section III—Limits Of Insurance: equipment furnished in connection with The most we will pay on behalf of the additional such work, on the project (other than insured is the amount of insurance: service, maintenance or repairs) to be 1. Required by the contract or agreement you performed by or on behalf of the additional have entered into with the additional insured; insured(s) at the location of the covered or operations has been completed; or portion of"your work" out of which the 2. Available under the applicable Limits of b. That p y Insurance shown in the Declarations; injury or damage arises has been put to its intended use by any person or organization whichever is less. other than another contractor or This endorsement shall not increase the subcontractor engaged in performing applicable Limits of Insurance shown in the operations for a principal as a part of the Declarations. same project. Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 20 33 0413 i AC`s CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDIYYYY) ...-�-" I 031061201'9 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 PRODUCER certificate OAbe Rader Insurance rights to the certificate holder In lieu of such oendorsement(s).E ) 2endez Fnx 714 921�I1 8 730E. Lincoln E-MAILDR ,Ss: a'Ce:a aiaror lderins.com_......_............... :.ap NSI_�... .._...... ..._M... Orange,CA 928651. License#:OC28298 1NSUl__R,LSIAFFORDINc COVERAGE NaIG# NSURfiRA: Mercury In_$Mf nCe,Com,Pa0y 38342- INSURED ,...mm, mmW SURER 8: R.E. SCHULTZ CONSTRUCTION, INC INSURERCc 1767 N Batavia St INSURER D Orange,CA 92865.4103 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000.0 REVISION NUMBER: '1 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 CONTRACTOR 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. INS�R TYPE OF INSURANCE ADOI"SUSIR ., POLICY EFF POLICY MKP ......,,-„.._, ._...,�_._.... ......,.® -I.TFk I .... Ir+c,n�ytrn POLICY NUMBER f,AWIDDI wyl IMWOONYM"r7 LIMITS .... COMMERCIAL GENERAL UA131UTY OCCURRENCE { CLAIMS-MADE ., OCCUR EMI, e.m 'I•TEO SES tEe nccnY $ ........................ EXP(Anyone person) $ ............................ ............... ,,,RSONAL&ADV INJURY $ OEN%AGGREGATE 'APPLIES PER: GENE LAG C GREGATE $ OTYI'ER• JEC F]LOC PROORATS-,COMPlOPAGG $ _ ... .... . $ AATOMOBILE OWNEDTOIABILITY SCHEDULED BA040000046316 06!1972018 08!1912019�CCMO,INED BODILYdINJIURY(Paracidenl $ 7aOja0.00Q AUTOS ONLY ,, AUTOS „� _V PIIIIIILR rY'DAMAGE AUTOS ONLY HIRED �� NON-OWNED .....�,..Y C_...... AUTOS ONLY �P�N9�iT5'S7GCIWG:11.............................................5, UMBRELLA LIAR UR EACH OCCURRENCE.......................S.......�.........,.,.,.........,., fiXCfi35 LIAR CLAIMS-MADE AGGREGATE E DED ( RETENTION$ S WORKERS R EXCLUDRIE E,L;J,EA AH CC OTH- ANY PROP IETRS'LIABILITY' YIN NIA $T6Y,U...�.:........ COMPENSATION PE AND EMPLOYfi rc ORfPARTNER/F�(ECUTIVE ”'""""'""""'" OFFCERdME0.1T1„ A IDENT $ IT a describe under _ .-FA MPLOYE is IMandal0ry In NHJ(Y; RAPTICN O vGB'In,rtA�1'fC.7NS,B;o6'cvd' E L.DISPJiSE PO - LICY LIMIT S DESCRIPTION OF OPERATIONS LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is rcquired) Project: Project No.PW 18-33 Holly Valley Playground Project Holly Ave&Valley St.,El Segundo,CA CER7IFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE T REOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCOROANC ITH THE OLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REP �ES� T d (JAH) -2015 RD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registere arks ACO 'D r'il Ilett by JAH on March O6,2019 at 03:28PM XIV. WAIMOFSLIBROISATION SECTION IV-BUSINESS AUTO CONDITIONS,A.Loss CondIt1=6 S.Transfer of Rights Of Recovery Against Others To Us,section Is replaced by the following: S. Transfer Of Rights Of Recovery Against Others To Us c j We waive any right of recovery we may have against any person or organization to the extent required of you by a written contract executed prior to any%cddent"or "foss" provided that the'accident"or'loss"arise4 out of the operations tis onlyto the person or contemplated by such contract.The waiver arior organization designated in such contract. XV. UNINTENT710NAL ERROR,OMISSION,OR FAILURE TO DISCLOSE HAZARDS SECTION IV-BUSINESS AUTO CONDITIONS,B.Geheral Condition3,2.Concealment, Misrepresentation,or Fraud,the following Is added: Any unintentional omission of or error in inforTation given by you,or unintentional failure to disclose all exposures or hazards existing as of the effective date or at any time during the policy period shall not Invalidate or adversely affect the coverage for such exposure or hazard or prejudice your rights under th 13 Insurance. However,you must report the if i: undisclosed exposure or hazard to us as soon as reasonably possible after its discovery. II This provision does not affect our right to collect additional premium or exercise our right of cancellation or nort-renewal. XVI. EMPLOYEE KRED AUTO PHYSICAL DAMAGE SECTION IV—8 UN NESS AUTO CONDITIONS,IL General Conditions,5.other Insurance,b,For Hired Auto Physical Damage Coverage,Is replaced by the following: b. For Hired Auto Physical Damage Coverage,the fbilowing are deemed tib be covered "autos"you own: 1. Any covered"auto"you lease,hire,rent or borrow;and I Any covered"auto"hired or rented by your"employed'under a contract in that Individual"employeds"name,with,yourpermisslon,while performing dutlas related to the conduct of your business. However,any"autoi'that is leased,hired,rented or borrowed with a driver Is not a covered XVII_PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT SECTION IV--BUSINESS AUTO CONDITIONS,R.General Conditions,5.Other insurance,the following is added and supersedes any provision to the confrary- e. 'This Insurance Is primary to and will notseekicont6bution from any othe,insurance avallabfe to an addlVanal,insured underybur policy provided that: (1) The additional insured Is a Named insured under such other Insurance,and (2) You have agreed in writing In a contract or agreement that this Insurance would be prImM and would norseek contribution from any other Insurance available to the addit"onal insured. CtipVTxghr 2017 Mercury frisurance Services,LLC.Aff rights resezvecl. MCA95100917-CA $rdudascoupyrfghtedimterlal ofinsurance-Serfices Office,Tnc.,with Its Permission Pages aF 6 i n w d y � 9 M o THIS ENmR-sEi F.NT cttANGr=s THE PDt1cy PLEASE Pz-AvrrcAR—wmLy. 9 . BLANKET ADDMONAL INSURES] � TFdsazidar9em�tsEnadideslrvaraeprovtdedunderthefairs*«a4s � � s, BUMEWAUM COMM G a FORA d ' Nr20TOR CARRIER COVERASE FORM TRUCKERS COVERAGE FOFUW � h t s F aYrr(Ua raapaat to srrtraaa e R by Ws endarsetneat,the pmvisdens cf to cova7sa Potm spm ualaas � $ raid&by the anderrao'mert F The fnffawing Ts added to the 8eftn 1!—Ltabit#y Caaera ,;'az graph A.4.101ha is An hrsnred;Pravtston: Asagr p Boas ear arg r&aiton Si ptyau errs saxlat ed to In dwe as addlowal fn re+i on the coverQQ poet,do a vreCpt:�ara safra or sgrerttttrot ds ad�rtadd� �aatrxt talc�u tro�ra ttxe'tacd4�C�luar"�r arm d brat!a in Qgect dtarhi'g trap,policy perdad an linswad'ror�ly Com*q.bar Wy fcrd nag to wrhiadt Ols Inswen eppties arras*to ij,,e extent Umtpea cl orar}Xaarv'r a'lfom qumrges as art Inscsec?under than � 44!halsr'Ir�urrP,per+�ssaracant':rtsedfrt 'addarttt. � � g E � . t a s g P a r. t<hCR20480719 t r r � d Policy Number: Date Entered: 04/10/2018 AC RVQ CERTIFICATE OF LIABILITY INSURANCE °ATE'""°°"YYYt 3/6/2019 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). yy PRODUCER e.E„hut tta eTrc @ akrc lobal.net The Agency PHONE AX (858)618-5444 13959uSaddlewood Drive (oN'r� sAl�Net N Poway, CA 92064 A90REs3. 9 y .......... _ 1111.... INSURER(Sy AFFORDING COVERAGE NAIC# INSURER A::Falls Lwco'nra s Casualty coupany 15884 INSURED R E Schultz Construction, Inc, (INSURERa INSURER C: V 1767 N. Batavia St 91NSURER D: Orange, CA 92865 IINSUPER Er INSURER F: p COVERAGES THIS IS O CERTIFY THAT THE POLICIE*OFICATE UMBER: REVISION NUMBER: NCE 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 (NSR 'ADDL SUUR POLICY'F,FF POLICY ERP LIMITS LTR TYPE OF INSURANCE rN,SD WVO POLICY NUMB ER VAW DOOY'YYY'r r DDMYY'Yr COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ L)AIVVk6ia�iumt:iwltu' CLAIMS-MADE 0 OCCUR PREMISES IEe.aaegar w $ MED EXP(Any one pers w1) $ PERSONAL$.A,DV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY a PRT 0 LOC PRODUCTS-COMP/Op AGG $ OTHER: $ ar AUTOMO BILE LIABILITY ( h1' tIdOnp� 'INlr�LE l=IP4�I M' $ -_- ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLYAUTOS HIRED — AUTOS ONLY NON-OWNED b t�rc x Lµtimw $ AUTOS ONLY Pw add atR rr9g UMBRELLA LIABI OCCUR EACH OCCURRENCE $ EXCESS LIAB � I CLAIMS-MADE AGGREGATE $ �I DED I I RETENTION$ I $ WORKER$COMPENSATION �:'� `'Ip I•t• AND EMPLOYERS'LIABILITYYIN ATU'TE �R EL.EACH ACCIDENT $ 1,000,000 ANY 9CER ElASEREXCTNERME1fEGU�YI'ME� � NIA FLA008969-00 VcrrJ14/zoie D /xa/zax9 A (Man atMI1BERE:xCLUDEDP Y �EL DISEASE-�LCYILMITEI$ 1,000,000 (Mandrrtaey In NHI Il yas desvibe under $ 1,0 0 0,0 0 0 I'TESL"RIIPTW J OF OPERATIONS below F� I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) (Project: PW 18-33 Holly Valley Playground Project Holly Ave 6 Valley Street E1 Segundo, CA 14 Blanket Waiver of Subrogation Attached. CERTIFICATE HOLDER C'ANCELLATI'ON' City of E1 Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN E1 Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I AUTHORIZED. R.EPRESENTATNE 16,n 1. (j\ .......... X1''1988.2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using Farms Boss Plus software www FormsBosscom;Impressive Publishing,LLC 800-208-1977 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.4-84) 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_5% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. 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 04-14-2018 Policy No. FLA008969-00 Endorsement No. Insured Insurance Company R E Schultz Construction,Inc.(A Corp) Falls Lake Fire&Casualty Company Countersigned By ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved.