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HomeMy WebLinkAboutContract 1679-1 ACORO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/6/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 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). CONT PRODUCER NAMEACT Wella Campbell Alliant Insurance Services, Inc. PHONE 619-849-3924 FAX 701 B Street,6th Floor (A/C Nn Fla). t vc.Not: 619-699-2164 E-MAIL wcam bell alliant.com San Diego CA 92101 ADDRESS: p @ INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Old Republic General Insurance Corp 24139 INSURED CALSTRI-01 INSURER B:Continental Casualty Company 20443 Cal Stripe, Inc. INSURER C: 2040 E.Steel Road Colton CA 92324 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1362889599 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. ILT S R TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MMIDD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y A-1CG-442116-09 7/1/2016 7/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 X X,C.U Included MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 — GE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X , JECOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY Y Y A-1CA-442116-09 7/1/2016 7/1/2017 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALTOS AWNED ^ CHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) B X UMBRELLALIAB X OCCUR 6021089167 7/1/2016 7/1/2017 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$10,000 $ A WORKERS COMPENSATION y A-1CW-442116-09 7/1/2016 7/1/2017 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? Y N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:CS 17046, Citywide Striping Program,Cathedral City. City of Cathedral City,and its respective elected and appointed officers,officials,and employees and volunteers are included as Additional Insureds on primary and non-contributory basis,waiver of subrogation applies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Cathedral City THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 68700 Avenida Lalo Guerrero ACCORDANCE WITH THE POLICY PROVISIONS. Cathedral City CA 92234 AUTHORIZED REPRESENTATIVE C- . 9 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:A-1CG-442116-09 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - 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. 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 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of 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 04 13 ©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 required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement;or Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 2010 0413 POLICY NUMBER:A-1CG-442116-09 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations WHERE REQUIRED BY WRITTEN CONTRACT, BUT ONLY WHEN COVERAGE FOR COMPLETED OPERATIONS IS SPECIFICALLY REQUIRED BY THAT CONTRACT. 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 is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage"caused, in whole or in part, by required by a contract or agreement, the most we "Your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the "products-completed operations 1. Required by the contract or agreement;or hazard". 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 applicable by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is 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 37 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 OLD REPUBLIC GENERAL INSURANCE CORPORATION CHANGES ADDITIONAL INSURED PRIMARY WORDING SCHEDULE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Name of Additional Insured Person(s) Location(s)of Covered Operations Or Organization(s): Where required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The insurance provided by this endorsement is primary insurance and we will not seek contribution from any other insurance of a like kind available to the person or organization shown in the schedule above unless the other insurance is provided by a contractor other than the person or organization shown in the schedule above for the same operation and job location. If so, we will share with that other insurance by the method described in paragraph 4.c.of Section IV—Commercial General Liability Conditions. All other terms and conditions remain unchanged. Named Insured CAL STR=PE, :NC. Policy Number A-1 CG-442116-09 Endorsement No. 003 Policy Period 07/01/2016-07/01/2017 Endorsement Effective Date: 07/01/2016 Producer's Name: OLD RErUBL:C CONSTRUCT:ON :NSUR.ANCE AGENCY, :NC. Producer Number: 7000 AUTHORIZED REPRESENTATIVE DATE CG EN GN 0029 09 06 POLICY NUMBER: A-1CG-442116-09 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): EACH OF YOUR CONSTRUCTION PROJECTS. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by "occur- damages or under Coverage C for medical rences" under Section I—Coverage A,and for all expenses shall reduce the Designated Con- medical expenses caused by accidents under struction Project General Aggregate Limit for Section I — Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag- construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con- 1. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla- cept damages because of "bodily injury" or rations, such limits will be subject to the appli- "property damage" included in the "products- cable Designated Construction Project Gen- completed operations hazard", and for medi- eral Aggregate Limit. cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or"suits" brought; or c. Persons or organizations making claims or bringing "suits". CG 25 03 05 09 ©Insurance Services Office, Inc., 2008 Page 1 of 2 ❑ B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by "occur- "products-completed operations hazard" is pro- rences"under Section I—Coverage A,and for all vided, any payments for damages because of medical expenses caused by accidents under "bodily injury" or "property damage" included in Section I — Coverage C, which cannot be at- the "products-completed operations hazard" will tributed only to ongoing operations at a single reduce the Products-completed Operations Ag- designated construction project shown in the gregate Limit, and not reduce the General Ag- Schedule above: gregate Limit nor the Designated Construction 1. Any payments made under Coverage A for Project General Aggregate Limit. damages or under Coverage C for medical D. If the applicable designated construction project expenses shall reduce the amount available has been abandoned, delayed, or abandoned under the General Aggregate Limit or the and then restarted, or if the authorized contract- Products-completed Operations Aggregate ing parties deviate from plans, blueprints, de- Limit,whichever is applicable:and signs, specifications or timetables, the project will 2. Such payments shall not reduce any Desig- still be deemed to be the same construction pro- nated Construction Project General Aggre- ject. gate Limit. E. The provisions of Section III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 O Insurance Services Office, Inc., 2008 CG 25 03 05 09 O POLICY NUMBER: A-1CG-442116-09 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US 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 0 POLICY NUMBER: A-1CG-442116-09 COMMERCIAL GENERAL LIABILITY CG 02 2410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EARLIER NOTICE OF CANCELLATION PROVIDED BY US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Number of Days'Notice 60 (If no entry appears above, information required to complete this Schedule will be shown in the Declarations as applicable to this endorsement.) For any statutorily permitted reason other than nonpayment of premium, the number of days required for notice of cancellation, as provided in paragraph 2.of either the CANCELLATION Common Policy Condition or as amended by an applicable state cancellation endorsement, is increased to the number of days shown in the Schedule above. CG 02 24 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 ❑ POLICY NUMBER: A-1CA-442116-09 COMMERCIAL AUTO CA 20 48 1013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE 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 this endorsement. This endorsement identifies person(s)or organization(s)who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not atter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: CAL STRIPE, INC. Endorsement Effective Date: 07/01/2016 SCHEDULE Name Of Person(s)Or Organization(s): WHERE REQUIRED BY WRITTEN CONTRACT. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured"for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 1013 ©Insurance Services Office, Inc., 2011 Page 1 of 1 OLD REPUBLIC GENERAL INSURANCE CORPORATION AMENDMENT OF OTHER INSURANCE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING BUSINESS AUTO COVERAGE FORM Section IV—Business Auto Conditions, B. —General Conditions, 5 —Other Insurance, a is replaced by the following: a. For any covered "auto'you own, this Coverage Form provides primary insurance. However, if there is other collectible insurance, the insurance provided by this Coverage Form with respect to such covered auto, is excess over such other collectible insurance. For any covered "auto" you don't own, the insurance provided by this Coverage Form is excess over any other collectible insurance. However, while a covered "auto"which is a "trailer"is connected to another vehicle, the Liability Coverage this Coverage Form provides for the"trailer"is: (1) Excess while it is connected to a motor vehicle you do not own: (2) Primary while it is connected to a covered "auto" you own. However, if there is other collectible insurance with respect to such "trailer,"the insurance provided by this Coverage Form is excess over such other collectible insurance. Named Insured Cal Stripe, Inc. Policy Number A-1CA-442116-09 Endorsement No Policy Period Endorsement Effective Date: �07/01l2016-07/0112017 07/01/2016 Producer's Name: Producer Number: AUTHORIZED REPRESENTATIVE DATE CA EN GN 0019 09 06 OLD REPUBLIC GENERAL INSURANCE CORPORATION ADDITIONAL INSURED-PRIMARY AND NON-CONTRIBUTORY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s)or organization(s)who are"insureds"under the Who Is An Insured Provision of the Coverage Form.This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. SCHEDULE Name of Person(s)or Organization(s) : (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an"insured"for Liability Coverage,but only to the extent that person or organization qualifies as an "insured"under the Who Is An Insured Provision contained in Section II of the Coverage Form. If the person or organization shown in the schedule qualifies as an 'insured'for Liability Coverage,and they have coverage as a first named insured under another policy, this policy is primary to and non-contributory with that other insurance. All other terms, conditions, and exclusions apply. Named Insured Cal Stripe, Inc. Policy Number A-1 CA-442116-09 Endorsement No. Policy Period 07/01/2016 to 07/01/2017 • Endorsement Effective Date: 07/01/2016 Producer's Name: OLD REPUBLIC CONSTRUCTION INSURANCE AGENCY, INC. Producer Number: 7000 AUTHORIZED REPRESENTATIVE DATE CA EN GN 0044 02 12 Page 1 of 1 POLICY NUMBER: A-1CA-442116-09 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: CAL STRIPE, INC. Endorsement Effective Date: 07/01/2016 SCHEDULE Name(s)Of Person(s)Or Organization(s): WHERE REQUIRED BY WRITTEN CONTRACT. Infommation 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 ©Insurance Services Office, Inc., 2011 Page 1 of 1 OLD REPUBLIC GENERAL INSURANCE CORPORATION CANCELLATION OR NON-RENEWAL TO SPECIFIED PERSONS OR ORGANIZATIONS ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: BUSINESS AUTO COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART If we cancel or non-renew this policy for any reason other than non-payment, we will deliver notice of the cancellation or non-renewal to all Specified Persons or Organizations on file with us THIRTY (30) days prior to the effective date of cancellation or non-renewal. If we cancel this policy for non-payment, we will deliver notice of the cancellation to all Specified Persons or Organizations on file with us TEN (10)days prior to the effective date of cancellation. If notice is mailed, proof of mailing will be sufficient proof of notice. Named Insured CAL STRIPE, INC. Policy Number A-1CA-442116-09 Endorsement No. 000 Policy Period 07-01-16 to 07-01-17 Endorsement Effective Date: 07-01-16 Producer's Name: OLD REPUBLIC CONSTRUCTION INSURANCE AGENCY, INC. Producer Number. 0000007000 AUTHORIZED REPRESENTATIVE DATE IL EN GN 0004 09 11 Page 1 of 1 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 anyone not named in the Schedule. Schedule WHERE REQUIRED BY WRITTEN CONTRACT IN ALL STATES WHERE APPLICABLE. This endorsement changes the policy to which it is attached 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 07/01/2016 Policy No. A-1CW-442116-09 Endorsement No. 000 Insured CAL STRIPE, INC. Premium$ Insurance Company Countersigned by OLD REPUBLIC GENERAL INSURANCE CORPORATION WC 00 03 13 (Ed.4-84) e 1983 National Council on Compensation Insurance. OLD REPUBLIC GENERAL INSURANCE CORPORATION WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY_ PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE 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 anyone not named in the Schedule. Schedule WHEN REQUIRED BY WRITTEN CONTRACT. The premium charge for this endorsement is $0.00 Named Insured CAL STRIPE, INC. Policy Number A-1 CW-442116-09 Endorsement No. 000 Policy Period 07/01/2016 to Endorsement Effective Date: 07/01/2016 07/01/2017 Producer's Name: OLD REPUBLIC CONSTRUCTION INSURANCE AGENCY, INC. Producer Number: 0000007000 AUTHORIZED REPRESENTATIVE DATE WC 99 03 15(09/06) OLD REPUBLIC GENERAL INSURANCE CORPORATION WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY CANCELLATION PROVISION THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: Part Six-Conditions, Item D. Cancellation, Number 2, is changed to read: 2. We may cancel this policy. We must mail or deliver to you not less than 60 days advance written notice stating when the cancellation is to take effect, unless cancellation is for nonpayment of premium, in which event our obligation is mailing not less than 10 days prior to the effective date of cancellation. Mailing notice to you at your mailing address shown in Item 1 on the Information Page will be sufficient to prove notice. Named Insured CAL STRIPE, INC. Policy Number A-1CW-442116-09 Endorsement No. 000 Policy Period 07/01/2016 to Endorsement Effective Date: 07/01/2016 07/01/2017 Producer's Name: OLD REPUBLIC CONSTRUCTION INSURANCE AGENCY, INC. Producer Number: 0000007000 AUTHORIZED REPRESENTATIVE DATE WC 99 03 14(01107)