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Dunrite Tile and Coping Inc; 2019-12-23; PWM20-932GS
DOC# 2020-0085503 111111111111 lllll 11111111111111111111111111111111111 IIIII 1111111111111 RECORDED REQUESTED BY CITY OF CARLSBAD Feb 20, 2020 11 :43 AM OFFICIAL RECORDS Ernest J. Dronenburg, Jr, AND WHEN RECORDED PLEASE MAIL TO: SAN DIEGO COUNTY RECORDER FEES $0.00 (SB2 Atkins $0 00) City Clerk City of Carlsbad 1200 Carlsbad Village Drive Carlsbad, California 92008 PAGES 1 Space above this line for Recorder's use. PARCEL NO: NOTICE OF COMPLETION Notice is hereby given that: 213-110-04-00 1. The undersigned is owner of the interest or estate stated below in the property hereinafter described. 2. The full names of the undersigned are City of Carlsbad, a municipal corporation. 3. The full address of the undersigned is 1200 Carlsbad Village Drive, Carlsbad, California 92008. 4. The nature of the title of the undersigned is: In fee. 5. A work or improvement on the property hereinafter described was completed on: Jan. 30, 2020. 6. The name of the contractor for such work or improvement is Dunrite Tile & Coping, Inc. 7. The property on which said work or improvement was completed is in the City of Carlsbad, County of San Diego, State of California, and is described as follows: Project No. PWM20-932GS, Project Name: Alga Norte Bench Tile Replacement. 8. The street address of said property is 6565 Alicante Road, Carlsbad, CA 92009, in the City of Carlsbad. I, the undersigned, say: Y Scott Chadw· , ity Manager VERIFICATION OF CITY CLERK I am the City Clerk of the City of Carlsbad, 1200 Carlsbad Village Drive, Carlsbad, California, 92008; the City Manager of said City on Feb01iil_ /§ ilk . 20 ::ID, accepted the above described work as completed and ordered that a No ce of Completion be filed. I declare under penalty of perjury that the foregoing is true and correct. Executed on febrUJ /ti)-,, 20 )0, at Carlsbad, California. CITYOFC~ <(~ l-lecior Gtirnt2 Dep~ {,, B~A~ I C1i"i City Clerk Q:\Public Works\General Services\Agreements & Contracts\Dunrite Tile and Coping, lnc\Alga Norte Bench Tile Replacement -PWM20-932GS\4. NOC\2.NOC - Alga Norte Bench Tile Replacement -PWM20-932GS.docx CJe1L CITY OF CARLSBAD ACCEPTANCE OF PUBLIC IMPROVEMENTS COMPLETION OF PUBLIC IMPROVEMENTS Dunrite Tile & Coping, Inc. has completed the contract work required for PWM20-932GS -Alga Norte Bench Tile Replacement. City forces have inspected the work and found it to be satisfactory. The work consisted of: IMPROVEMENTS Remove and replace 64 locations of bench tile at Alga Norte Aquatic Center. VALUE $30,855.00 CERTIFICATION OF COMPLETION OF IMPROVEMENTS ~~ ~\JV\ ,Z -W2LLo John Maashoff, Public Works Manager Date CITY MANAGER'S ACCEPTANCE OF PUBLIC IMPROVEMENTS The construction of the above described contract is deemed complete and hereby accepted. The City Clerk is hereby authorized to record the Notice of Completion and release the bonds in accordance with State Law and City Ordinances. is hereby directed to commence maintaining the above described ick, City Manager Date APPROVED AS TO FORM: CELIA BREWER, City Attorney By &.b-~ Deputy City Attorney Q \Public Works\General Services\Agreements & Contracts\Dunrite Tile and Coping, lnc\Alga Norte Bench Tile Replacement -PWM20-932GSl4. NOC\3.API -Alga Norte Bench Tile Replacement -PWM20-932GS.docx CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT ALGA NORTE BENCH TILE REPLACEMENT PWM20-932GS This agreement is made on the c2, f rd day of-1,.,t.:...J...."'""-'.a.J.-"-"''-=-='-----· 2019, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and Dunrite Tile and Coping, Inc., a California corporation whose principal place of business is 20699 Grand Ave., Wildomar, CA 92595 (hereinafter called "Contractor"). City and Contractor agree as follows: DESCRIPTION OF WORK. Contractor shall perform all work specified in the Contract documents for the project described by these Contract Documents (hereinafter called "Project"). PROVISIONS OF LABOR AND MATERIALS. Contractor shall provide all labor, materials, tools, equipment, and personnel to perform the work specified by the Contract Documents unless excepted elsewhere in this Contract. CONTRACT DOCUMENTS. The Contract Documents consist of this Contract, exhibits to this Contract, Contractor's Proposal, the Plans and Specifications, the General Provisions, addendum(s) to said Plans and Specifications, and all proper amendments and changes made thereto in accordance with this Contract or the Plans and Specifications, all of which are incorporated herein by this reference. When in conflict, this Contract will supersede terms and conditions in the Contractor's proposal. LABOR. Contractor will employ only skilled workers and abide by all State laws and City of Carlsbad Ordinances governing labor. GUARANTEE. Contractor guarantees all labor and materials furnished and agrees to complete the Project in accordance with directions and subject to inspection approval and acceptance by: Ron Haugland (City Project Manager). WAGE RATES. The general prevailing rate of wages for each craft or type of worker needed to execute the Contract shall be those as determined by the Director of Industrial Relations pursuant to Sections 1770, 1773 and 1773.1 of the Labor Code. Pursuant to Section 1773.2 of the Labor Code, a current copy of the applicable wage rates is on file in the Office of the City Engineer. Contractor shall not pay less than the said specified prevailing rates of wages to all workers employed by him or her in execution of the Contract. Contractor shall be responsible for insuring compliance with provisions of section 1777. 5 of the Labor Code and section 4100 et seq. of the Public Contracts Code, "Subletting and Subcontracting Fair Practices Act." The City Engineer is the City's "duly authorized officer" for the purposes of section 4107 and 4107.5. The provisions of Part 7, Chapter 1, of the Labor Code commencing with section 1720 shall apply to the Contract for work. A contractor or subcontractor shall not be qualified to bid on, be listed in a bid proposal, subject to the requirements of Section 4104 of the Public Contract Code, or engage in the performance of any contract for public work, unless currently registered and qualified to perform public work pursuant to Section 1725.5. This project is subject to compliance monitoring and enforcement by the Department of Industrial Relations. Contractor and any subcontractors shall comply with Section 1776 of the California Labor Code, which generally requires keeping accurate payroll records, verifying and certifying payroll records, and making them available for inspection. Contractor shall require any subcontractors to comply with Section 1776. Alga Norte Bench Tile Replacement Page 1 of 10 City Attorney Approved 1/25/2019 PWM20-932GS FALSE CLAIMS. Contractor hereby agrees that any contract claim submitted to the City must be asserted as part of the contract process as set forth in this agreement and not in anticipation of litigation or in conjunction with litigation. Contractor acknowledges that California Government Code sections 12650 et seq., the False Claims Act, provides for civil penalties where a person knowingly submits a false claim to a public entity. These provisions include false claims made with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of the information. The provisions of Carlsbad Municipal Code sections 3.32.025, 3.32.026, 3.32.027 and 3.32.028 pertaining to false claims are incorporated herein by reference. Contractor hereby acknowledges that the filing of a false claim may subject the Contractor to an administrative debarment proceeding wherein the contractor may be prevented from further bidding on public contracts for a period of up to five years and that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or subcontractor from parti · ating in contract bidding. Signature: Print Name: REQUIRED INSURANCE. The successful contractor shall provide to the City of Carlsbad, a Certification of Commercial General Liability and Property Damage Insurance and a Certificate of Workers' Compensation Insurance indicating coverage in a form approved by the California Insurance Commission. The certificates shall indicate coverage during the period of the contract and must be furnished to the City prior to the start of work. The minimum limits of liability insurance are to be placed with California admitted insurers that have a current Best's Key Rating of not less than "A-:VII"; OR with a surplus line insurer on the State of California's List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best's Key Rating Guide of at least "A:X"; OR an alien non-admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report. Commercial General Liability Insurance of Injuries including accidental death, to any one person in an amount not less than ........ $1,000,000 Subject to the same limit for each person on account of one accident in an amount not less than ....... $1 ,000,000 Property damage insurance in an amount of not less than ........ $1,000,000 Automobile Liability Insurance in the amount of $1,000,000 combined single limit per accident for bodily injury and property damage. In addition, the auto policy must cover any vehicle used in the performance of the contract, used onsite or offsite, whether owned, non-owned or hired, and whether scheduled or non- scheduled. The automobile insurance certificate must state the coverage is for "any auto" and cannot be limited in any manner. The above policies shall have non-cancellation clauses providing that thirty (30) days written notice shall be given to the City prior to such cancellation. The policies shall name the City of Carlsbad as an additional insured. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY. Workers' Compensation limits as required by the California Labor Code. Workers' Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. BUSINESS LICENSE. The Contractor and all subcontractors are required to have and maintain a valid City of Carlsbad Business License for the duration of the contract. Alga Norte Bench Tile Replacement Page 2 of 10 City Attorney Approved 1/25/2019 PWM20-932GS INDEMNITY. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold harmless the City, and its officers and employees, from all claims, loss, damage, injury and liability of every kind, nature and description, directly or indirectly arising from or in connection with the performance of the Contract or work; or from any failure or alleged failure of Contractor to comply with any applicable law, rules or regulations including those related to safety and health; and from any and all claims, loss, damages, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by the Contract, except for loss or damage caused by the sole or active negligence or willful misconduct of the City. The expenses of defense include all costs and expenses including attorneys' fees for litigation, arbitration, or other dispute resolution method. JURISDICTION. The Contractor agrees and hereby stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this agreement is San Diego County, California. Start Work: Contractor agrees to start within ten (10) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within thirty (30) working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. DUNRITE TILE AND COPING, INC., a California corporation Ill Ill Ill Ill Ill Ill Ill (name of Contractor) 555854 (Contractor's license number) C54 -Ceramic and Mosaic 2/29/2020 (license class. and exp. date) 1000465152 (DIR registration number) 6/30/2020 (DIR registration exp. date) Alga Norte Bench Tile Replacement Page 3 of 10 20699 Grand Ave. (street address) Wildomar, CA 92595 (city/state/zip) 951-265-5250 (telephone no.) N/A (fax no.) dunritetileandcoping@gmail.com ( e-mail address) City Attorney Approved 1/25/2019 PWM20-932GS AUTHORITY. The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. By: 6·a CG--lflEGt=-c:_ (print name/title) (sign here) (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California Certificate Attached for Callfornia Notary Wordin<j If required by City, proper notarial acknowledgment of execution by Contractor must be attached. If a corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Chairman, President, or Vice-President Group B Secretary, Assistant Secretary, CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: Alga Norte Bench Tile Replacement Page 4 of 10 City Attorney Approved 1/25/2019 CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT (CALIFORNIA CIVIL CODE§ 1189) A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA COUNTY OF RIVERSIDE -------------- before me, B. Laws, Notary Public On 11/13/2019 (Date) (Here Insert Name and Title of the Officer) personally appeared Greg Biegel , who proved to me on the basis of satisfactory evidence to be the person¢ whose name{.sf ~_i,e subscribed to the within instrument and acknowledg;-d~ me that8s.t>4HJ,e'y executed the same in@~/t~ir authorized capacity(~, and that b~/~ir signatur~ on the instrument the person~, or the entity upon behalf of which the person~ acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. (Notary Seal) __________ ADDITIONAL OPTIONAL INFORMATION _________ _ Description of Attached Document T·tl T fD t CityofCarlsbadMinorPublicWorksContract D tD t 09/19/2019 1 e or ype o acumen : ____________ acumen a e: _____ _ Number of Pages: 10 Signer(s) Other Than Named Above: _n_l_a _________ _ Additional Information: loose attachment used for CA notarial wording revision date 01/01/2015 PWM20-932GS EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each sub-contractor whom the Contractor proposes to subcontract portions of the Project in excess of one-half of one percent of the total bid, and the portion of the Project which will be done by each sub-contractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a sub-contractor for any portion of the Project to be performed under the contract in excess of one-half of one percent of the bid, the contractor shall be deemed to have agreed to perform such portion, and that the Contractor shall not be permitted to sublet or subcontract that portion of the work, except in cases of public emergency or necessity, and then only after a finding, reduced in writing as a public record of the Awarding Authority, setting forth the facts constituting the emergency or necessity in accordance with the provisions of the Subletting and Subcontracting Fair Practices Act (Section 4100 et seq. of the California Public Contract Code). If no subcontractors are to be employed on the project, enter the word "NONE." SUBCONTRACTORS Portion of Project to Business Name and Address DIR Registration License No., %of be Subcontracted No. Classification & Total Expiration Date Contract / / ~\ ~ "'\ 0 \ Total% Subcontracted: --~N""'--"'o---'-ll_l_C_ The Contractor must perform no less than fifty percent (50%) of the work with its own forces Alga Norte Bench Tile Replacement Page 5 of 10 City Attorney Approved 1/25/2019 PWM20-932GS EXHIBIT B Alga Norte Bench Tile Replacement Overview: Contractor to provide all labor, equipment, and materials to demo and remove glass tile on 12 benches (3'x6') and 54 seat wall locations (1 'x2') at Alga Norte Aquatic Center located at 6565 Alicante Road, Carlsbad, CA, 92008. Scope of Work shall consist of all items mentioned in the contractor's proposal dated September 19, 2019 and in accordance with the Scope of Work. Ounrte Tile and Cop,ng Inc. 20699 Gland Ave UC.655854 Widomar, CA 92595 (951) 26&-5250 dunntetJleandC-'O@omal com vrww d\lnritelieanda,pong com ADDRESS Alga Norte Aquatic Center 6565 A.lcanle Rd caitsbad, ca ESTIMA.TI: I 1394 DA.TE 09/19/2019 r•~ MIIC. TileR- llleR- Misc. TdeR_. 8ond Perlonnance Bond Q"Y 12 54 Demo and remcwe glass tie on 12 benclle9 (SIZed appx. TOTAL 3'X6') and 54 seat -1 locabons (szed -x.1'1<2') Grind down an tied areas to accommodate depth of new ''° lnslall ~ tile (llmlshed by lhe a,ty) Gn:,ut.and-- Job completion In 14 bu9iness days or less ~ $1455.00 !or labor and malerials bond 3 year warranty on labot c.ty ID purchaoe ~le. if needed Accepted By A.ccel)led Date Thank you fof" the opportunity to serve youJ Alga Norte Bench Tile Replacement Page 6 of 10 sso oo 1 .aoo oo 400 00 21,600 00 1,455 00 1,455.00 $30,855.00 City Attorney Approved 1/25/2019 a••••••••----•-- LOCATION MAP Scope of work to include the following: 1. Demo and remove glass tile. . A PWM20-932GS EXHIBIT B Continued 2. Contractor to construct a temporary enclosure around work areas to mitigate dust and debris. 3. Grind down all tile areas to accommodate depth of new tile. 4. Install Laticrete 254 Platinum thin-set mortar per manufacturer's recommendations. 5. Install Custom Polyblend Non-Sanded grout per manufacturer's recommendations. 6. Install 511 Impregnator by Miracle Sealants Company. 511 Grout Sealer penetrates into the surface and forms an invisible barrier that is resistant to moisture and stains while allowing vapor to escape. 7. Contractor to provide three (3) year warranty on labor. Notes: Alga Norte Bench Tile Replacement Page 7 of 10 City Attorney Approved 1/25/2019 PWM20-932GS Contractor shall submit a construction schedule to the city's project manager within five (5) working days after the issuance of a Notice to Proceed. Prior to commencement of work the schedule must be approved by the city. EXHIBIT B (Continued) JOB QUOTATION ITEM UNIT QTY DESCRIPTION PRICE NO. 1 EA 12 Tile Repair -Large Benches $7,800 2 EA 54 Tile Repair -Seating Benches $21,600 3 LS 1 Labor and Materials Bond $1,455 TOTAL* $30,855 *Includes taxes, fees, expenses and all other costs. Alga Norte Bench Tile Replacement Page 8 of 10 City Attorney Approved 1/25/2019 EXHIBIT C LABOR AND MATERIALS BOND PWM20-932GS Bond Number: 1001128535 Premium: $620 WHEREAS, the City Council of the City of Carlsbad, State of California, has awarded to Dunrite Tile & Coping, Inc., a California corporation, (hereinafter designated as the "Principal"), a Contract for: ALGA NORTE BENCH TILE REPLACEMENT in the City of Carlsbad, in strict conformity with the drawings and specifications, and other Contract Documents now on file in the Office of the City Clerk of the City of Carlsbad and all of which are incorporated herein by this reference. WHEREAS, Principal has executed or is about to execute said Contract and the terms thereof require the furnishing of a bond, providing that if Principal or any of its subcontractors shall fail to pay for any materials, provisions, provender or other supplies or teams used in, upon or about the performance of the work agreed to be done, or for any work or labor done thereon of any kind, the Surety on this bond will pay the same to the extent hereinafter set forth. NOW, THEREFORE, WE, Dunrite Tile and Coping, Inc., as Principal, (hereinafter designated as the "Contractor"), and American Contractors Indemnity Company, 801 S Figueroa St. STE 700, Los Angeles, CA 90017 as Surety, are held firmly bound unto the City of Carlsbad in the sum of thirty thousand eight hundred fifty-five Dollars ($30,855), said sum being an amount equal to: One hundred percent (100%) of the total amount payable under the terms of the Contract by the City of Carlsbad, and for which payment well and truly to be made we bind ourselves, our heirs, executors and administrators, successors, or assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH that if the Contractor or his/her subcontractors fail to pay for any materials, provisions, provender, supplies, or teams used in, upon, for, or aboutthe performance of the work contracted to be done, or for any other work or labor thereon of any kind, consistent with California Civil Code section 9100, or for amounts due under the Unemployment Insurance Code with respect to the work or labor performed under this Contract, or for any amounts required to be deducted, withheld, and paid over to the Employment Development Department from the wages of employees of the contractor and subcontractors pursuant to section 13020 of the Unemployment Insurance Code with respect to the work and labor, that the Surety will pay for the same, and, also, in case suit is brought upon the bond, reasonable attorney's fees, to be fixed by the court consistent with California Civil Code section 9554. This bond shall inure to the benefit of any of the persons named in California Civil Code section 9100, so as to give a right of action to those persons or their assigns in any suit brought upon the bond. Surety stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract, or to the work to be performed hereunder or the specifications accompanying the same shall affect its obligations on this bond, and it does hereby waive notice of any change, extension of time, alterations or addition to the terms of the contract or to the work or to the specifications. Alga Norte Bench Tile Replacement Page 9 of 10 City Attorney Approved 1/25/2019 PWM20-932GS In the event that Contractor is an individual, it is agreed that the death of any such Contractor shall not exonerate the Surety from its obligations under this bond. SIGNED AND SEALED, this __ 2_0_t_h_--=a=--day of _N_o_v_e_m_be_r ________ , 20_1_9_ _____________ (SEAL) American Contractors Indemnity Company (SEAL) • (Principal)Q By: _ _,q._.;c."'-=-"""4----~---'""'~'""-=-------~c-----/ ,~~ / (SEAL AND NOTARIAL ACKNOWLEDGEMENT OF SURETY-ATTACH ATTORNEY-IN-FACT CERTIFICATE) APPROVED AS TO FORM: CELIA A. BREWER City Attorney L By: 0 g/ Deputy City Attorney 6 Alga Norte Bench Tile Replacement Page 10 of 10 City Attorney Approved 1/25/2019 TOKIO MARINE HCC POWER OF ATTORNEY AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY UNITED STATES SURETY COMPANY U.S. SPECIAL TY INSURANCE COMPANY KNOW ALL MEN BY THESE PRESENTS: That American Contractors Indemnity Company, a California corporation, Texas Bonding Company, an assumed name of American Contractors Indemnity Company, United States Surety Company, a Maryland corporation and U.S. Specialty Insurance Company, a Texas corporation (collectively, the "Companies"), do by these presents make, constitute and appoint: Rainy Robinson of Merced, California its true and lawful Attomey(s)-in-fact, each in their separate capacity if more than one is named above, with full power and authority hereby conferred in its name, place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings or other instruments or contracts of suretyship to include riders, amendments, and consents of surety, providing the bond penalty does not exceed •••••one Million••••• Dollars ( ***$1,000,000.00*** ). This Power of Attorney shall expire without further action on April 23rd, 2022. This Power of Attorney is granted under and by authority of the following resolutions adopted by the Boards of Directors of the Companies: Be it Resolved, that the President, any Vice-President, any Assistant Vice-President, any Secretary or any Assistant Secretary shall he and is hereby vested with full power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings, including any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts, and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved, that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is attached. IN WITNESS WHEREOF, The Companies have caused this instrument to be signed and their corporate seals to be hereto affixed, this 1st day of June, 2018. State of California County of Los Angeles A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accurac or validi of that document On this pt day of June, 2018, before me, Sonia 0. Carrejo, a notary public, personally appeared Daniel P. Aguilar, Vice President of American Contractors Indemnity Company, Texas Bonding Company, United States Surety Company and U.S. Specialty Insurance Company who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal.. f·• ~ no ;;,..:0~~ cc f Signature ~ A1IY (seal) J · MrComm.t.puMAprll,2022 ,.~,00:1'1.Jf\. i ·-' 7£:5:· t~ I, Kio Lo, Assistant Secretary American Contractors Indemnity Company, Texas Bonding Company, United States Surety Company and U.S. Specialty Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said Companies, which is still in full force and effect; furthermore, the resolutions of the Boards of Directors, set out in the Power of Attorney are in full force and effect. In Witness Whereof, I have hereunto set my hand and affixed the seals of said Companies at Los Angeles, California this ____ day of ______________ _ Corporate Seals Bond No. Agency No. _2_00_4 __ 1 _____ _ visit tmhcc.com/surety for more information HCCSMANPOA06/2018 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Merced on t I·-l.D ·-I'/ before me, David Robinson, Notary Public -----------(insert name and title of the officer) personally appeared _R_a_i_n_y_R_o_b_in_s_o_n ____________________ _ who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies}, and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. (Seal) DAVID ROBINSON COMM. #2215705 z Notary Public • California ~ Contra Costa County ... Comm. Ex ires Se . 24 2021 Policy Number U19AC119220-00 Date Entered: 1111912019 ACC:,Rc:,-CERTIFICATE OF LIABILITY INSURANCE I DATE /MM/DD/YYYY) ~ 12/3/2019 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 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 endorsementtsl. PRODUCER CONTACT NAME: Joseph Pappalardo CA Contractors Insurance Services, Inc. PHONE (916) 363-2663 1~:;, No): (916) 363-2662 (A/C,No, Ext): 9848 Business Park Drive E-MAIL certificates@ccisbonds.com ADDRESS: Suite H Sacramento, CA 95827 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: U.S. Specialty Insurance Company 29599 INSURED INSURER B: DUN RITE TILE AND COPING INC INSURER C: 20699 GRAND AVE INSURER D: WlLDOMAR, CA 92595 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF THE 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. INSR ADDL SUBR POLICYEFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) LIMITS GENERAL LIABILITY U 19AC 119220-00 11/19/2019 11/19/2020 EACH OCCURENCE $ 1,000,000 A IX COMMERCIAL GENERAL LIABILITY [X] [X] DAMAGE TO RENTED $ 100,000 pocu1c:Es {Ea,..,.,.,,~ .. ,.,...,.\ ~D CLAIMS-MADE [X] OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 ~ ~ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPIOP-AGG $ 2,000,000 00 POLICY nPROJECT n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ □ □ (Ea accident) f---ANY AUTO BODILY INJURY (Per person) $ ~ ~ ALLOIM>JED SCHEDULED BODILY INJURY (Per accident) $ ~ AUTOS ~ AUTOS HIRED AUTOS NON-O\M>JED PROPERTY DAMAGE $ AUTOS ✓n-• ·-' , _ _., f---,- UMBRELLA LIAB OCCUR □ □ EACH OCCURRENCE $ ~ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED I I RETENTION $ WORKERS COMPENSATION □ I WCSTATU-I I OTH- Y/N N/A TORY LIMITS ER AND EMPLOYERS' LIABILITY ANY E. L. EACH ACCIDENT $ PROPRIETOR/PARTNER/EXECUTIVE (Mandalory in N/H) E. L. DISEASE -EA EMPLOYEE $ ~ yes, describe under E. L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS below $ □ DESCRIPTION OF OPERATIONS/LOCATIONS NEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of Carlsbad/CMWD is named as additional insured on the General Liability policy, per attached endorsements. Insurance is primary and noncontributory. Waiver of subrogation included for the General Liability. 30 day written notice of cancellation, 10 day notice of nonpayment of premium. License # 555854 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH City of Carlsbad/CMWD THE POLICY PROVISIONS. c/o EXIGIS Insurance Compliance Services P.O. Box 4668-ECM #35050 AUTHORIZED REPRESENTATIVE New York, NY 10163-4668 ')~ I © 1988-201 0 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: U19AC119220-00 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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 City of Carlsbad/CMWD c/o EXIGIS Insurance 6565 Alicante Rd., Carlsbad, CA Compliance Services P.O. Box 4668 -ECM #35050, New York, NY 10163-4668 Description of Operations: Commercial -Retiling the tile inserts in concrete benches at the City of Carlsbad aquatic center. 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 □ POLICY NUMBER: U19AC119220-00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 Insured Person(s) Location And Description Of Completed Or Organization(s): Operations City of Carlsbad/CMWD c/o EXIGIS Insurance 6565 Alicante Rd., Carlsbad, CA Compliance Services P.O. Box 4668 -ECM #35050, New York, NY 10163-Commercial -Retiling the tile inserts in concrete benches 4668 at the City of Carlsbad aquatic center. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II -Who Is An Insured is amended to include as an additional 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". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 □ ~ ~~~OMARINE Named Insured: DUNRITE TILE AND COPING INC Policy Number: U19AC119220-00 Endorsement Effective Date: 12/02/2019 Change Endorsement Number: 1 Insurer U.S. Specialty Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY GENERAL CHANGE ENDORSEMENT The following endorsement modifies policy terms provided by the above listed policy number. Form CG 20 10 07 04 -Additional Insured -Owners, Lessees or Contractors -Scheduled Person or Organization is added to the policy with the following scheduled information: Name of Additional Insured Person(s) or Organization(s): City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 4668 -ECM #35050, New York, NY IO 163-4668 Location(s) of Covered Operations: 6565 Alicante Rd., Carlsbad, CA Description of Operations: Commercial -Retiling the tile inserts in concrete benches at the City of Carlsbad aquatic center. Form CG 20 37 07 04 -Additional Insured -Owners, Lessees or Contractors -Completed Operations is added to the policy with the following scheduled information: Name of Person or Organization(s): City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 4668 -ECM #35050, New York, NY 10163-4668 Location: 6565 Alicante Rd., Carlsbad, CA Description of Completed Operations: Commercial -Retiling the tile inserts in concrete benches at the City of Carlsbad aquatic center. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED G~ HCS 060 081112 Page 1 of 1 POLICY NUMBER: U19AC119220-00 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY AND BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO OTHER INSURANCE With respect to any person or organization that is an additional insured under this Coverage Part, the following is added to paragraph 4. of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS: If you have agreed in writing in a contract or agreement that this insurance is primary and non- contributory relative to an additional insured's own insurance, then this insurance is primary and we will not seek contribution from that other insurance. For the purpose of this endorsement, the additional insured's own insurance means insurance on which the additional insured is a Named Insured. When this endorsement is attached to the policy it supersedes all other insurance conditions within. HCS 040 06 10 13 B. WAIVER OF SUBROGATION -BLANKET Under SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, The Transfer Of Rights Of Recovery Against Others To Us Condition is amended by the addition of the following: We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" included in the "products- completed operations hazard". However, this waiver applies only when you have agreed in writing to waive such rights of recovery in a contract or agreement, and only if the contract or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. luo11111~d1~ <umfwp;i JO ,rom1 I"'"' :111111 ·:>111 llui<k>:) 1)U8 au UWl.111(1 i!JePIHJd l;,iun:-JJ _________ ____:.. 1t.&te ~•s ~ ~ Dl-" .l.3U\UT\CUJ AP.l!qe!l .~lba1JU11 UO~~ ,WJ;!'t~ u.,tp (~lluaq If ttl(l ~JO i:»fwdJouc,~J llllllci~"'ION.Wi.-,:,ueqp~ .JOJ plqtl#:>JO~~ ~Ip lll!M ~ Olf'IJCI 11W11 :11p Jaµnp l~J0--1 uoucl.{m «.-"11141111dDa puet11111111' P1"C'I\S ~ M!lf'll!fl .~-~~...-OJ~Ml~•,ipaa.~onnq l'lllllfmm JO amuJ lnterinsurance Exchange of the Automobile Club Automobile Insurance Policy Change Confirmation 11/27/2019 Named Insured and Mailing Address: BIEGEL, LINNETH J AND GREGORY T 20699 xxxxxxxxx Wildomar, CA 92595 Policy Number: CAA071911923 Policy Term Dates: 07/30/2019 -07/30/2020 Your Agent is: Christine Mitchell 25125 Madison Ave Murrieta, CA 92562 IMPORTANT NOTICE: This will confirm the policy change(s) you recently made effective 11/28/2019. You will be receiving a Policy Change Declaration in the mail shortly. DRIVER INFORMATION: Drivers' Names (Last, First) Biegel, Linneth Biegel, Gregory Biegel, Andrew VEHICLE INFORMATION: No. Year Vehicle Make/Model 2003 FORD/E250 ECONO CG SUPER 2 2004 CHEV/SUBURBAN 3 2004 HOND/CIVIC EX VEHICLE PREMIUM INFORMATION: Coverages Bodily Injury Property Damage Medical Payments Uninsured/Underinsured Motorist Bodily Injury Comprehensive Collision Car Rental Expense Uninsured Collision Uninsured Deductible Waiver I 12-MONTH VEHICLE PREMIUM: LIMIT OF LIABILITY (IF APPLICABLE) No. Year Date of Birth Gender Rated Veh XX-XX-1966 F 02 XX-XX-1961 M 01 Excluded M Garage Annual Verified Zip Code Garaged Miles Mileage No 11,374 No 20,696 No 16,671 Limits($) 1,000,000/1,000,000 1,000,000 X5000 1,000,000/1,000,000 (See Deductibles) (See Deductibles) (See Above) Yes Vehicle Make/Model Yes Yes Yes Driving Safetl£ Record Year First GDD Chargeable Citations Chargeable Accidents Licensed 1984 y 0 0 1978 y 0 0 0 0 Ded!J!,'.!ibles Special Car Rent. Primary Salvage Comp. Collision Equip. Expense Driver No $250 $500 $35 02 No $250 $500 $35 01 No 01 Vehicle 1 Vehicle 2 Vehicle 3 $352 $435 $297 $221 $292 $177 $15 $18 $16 $179 $268 $182 $101 $127 $214 $293 $45 $59 $9 Included Included $1,127 $1,492 $6811 Limit of Liability POLICY DISCOUNTS: Please review these carefully as you are warranting that you are entitled to the following discounts. Good Driver Yes Good Student Yes Student Away No Multi - Vehicle Yes CURRENT 12-MONTH POLICY PREMIUM TOTAL: SUBJECT(S) OF POLICY CHANGE: Auto -Add/Change Liability Auto -Correction $3,730 Multi- Policy No Mature Driver No Driving Course No Loyalty Yes Grp-Deg. Professional No Verified Mileage Yes NEW 12-MONTH POLICY PREMIUM TOTAL after Policy Changes: $4,868 THIS IS NOT A BILL This policy change will increase your premium by $763 for the remainder of the term. LCAA0203A E20160803 112719 Insurance provided to qualified Auto Club members by the lnterinsurance Exchange of the Automobile Club. CA Dept. of Insurance Lie. #0003259 Page 1 of 2 8010 (1/19) lnterinsurance Exchange of the Automobile Club Automobile Insurance Policy Change Confirmation 11/27/2019 Named Insured and Mailing Address: BIEGEL, LINNETH J AND GREGORY T 20699 xxxxxxxxx Wildomar, CA 92595 Policy Number: CAA071911923 Policy Term Dates: 07/30/2019 -07/30/2020 Your Agent is: Christine Mitchell 25125 Madison Ave Murrieta, CA 92562 IMPORTANT NOTICE: This will confirm the policy change(s) you recently made effective 11/28/2019. You will be receiving a Policy Change Declaration in the mail shortly. DRIVER INFORMATION: Drivers' Names (Last, First) Biegel, Rebekah Biegel, Julia VEHICLE INFORMATION: No. Year Vehicle Make/Model 4 2006 NSSN/SENTRA VEHICLE PREMIUM INFORMATION: Coverages Bodily Injury Property Damage Medical Payments Uninsured/Underinsured Motorist Bodily Injury Comprehensive Collision Car Rental Expense Uninsured Collision Uninsured Deductible Waiver 112-MONTH VEHICLE PREMIUM: LIMIT OF LIABILITY (IF APPLICABLE) No. Year Driving Safety Record Date of Birth Gender Rated Veh Year First GOD Ch bl c· t· Licensed argea e 1ta ions Chargeable Accidents XX-XX-2000 XX-XX-2001 F F 01 04 2018 2018 Garage Annual Verified Zip Code Garaged Miles Mileage Salvage No 5,000 Limits($) 1,000,000/1 ,000,000 1,000,000 X5000 1,000,000/1,000,000 (See Deductibles) (See Deductibles) (See Above) Yes Yes No N N 0 0 0 0 Deductibles Special Car Rent. Primary Comp. Collision Equip. Expense Driver Vehicle 4 $722 $540 $20 $267 $19 $1,568 05 Vehicle Make/Model Limit of Liability POLICY DISCOUNTS: Please review these carefully as you are warranting that you are entitled to the following discounts. Good Driver Yes Good Student Yes Student Away No Multi- Vehicle Yes CURRENT 12-MONTH POLICY PREMIUM TOTAL: SUBJECT(S) OF POLICY CHANGE: $3,730 Multi- Policy No Mature Driver No Driving Course No Loyalty Yes Grp-Deg. Professional No Verified Mileage Yes NEW 12-MONTH POLICY PREMIUM TOTAL after Policy Changes: $4,868 THIS IS NOT A BILL This policy change will increase your premium by $763 for the remainder of the term. LCAA0203A E20160803 112719 Insurance provided to qualified Auto Club members by the lnterinsurance Exchange of the Automobile Club. CA Dept. of Insurance Lie. #0003259 Page 2 of 2 8010(1/19) CAA0195A.3 E20140825 1127191 lnterinsurance Exchange of the Automobile Club P.O. Box 25001, Santa Ana CA 92799-5001 AAA.com (877) 422-2100 November 27, 2019 AUTO INSURANCE POLICY CHANGE Policy Number: CM 071911923 BIEGEL, LINNETH J AND GREGORY T 20699 GRAND AVE WI LDOMAR CA 92595-9442 Thank you for your 31 years of membership with the Auto Club. A change was recently made to your auto policy. The enclosed declarations page reflects this change. This policy change will increase your premium by $763.00 for the remainder of this policy period. Your account will be adjusted to reflect this premium change for future payments. Our records indicate you currently have a billing statement with an amount due. Please continue to make your payment by the due date. We are pleased to have the opportunity to be of service to you. If you have any questions, please call one of our Policy Service Representatives at the number below, weekdays from 7 a.m. to 9 p.m. or Saturday from 8 a.m. to 5 p.m. or visit your local Auto Club branch. Sincerely, /:~t'.5~ Katrina Bradley Vice President Member Service Center Billing Status (THIS IS NOT A BILL) Prior Balance:* Current Balance:* Minimum Due:* Current Due Date:* $2,167.69 $2,930.69 $383.29 11/30/2019 Your account will be adjusted to reflect this premium change for future payments. Please continue to make your payment by the due date shown above. Save time with AAA Auto Pay -enroll online at AAA.com/autopay. *Billing information is subject to change if additional changes or transactions are applied to the policy. POLICYHOLDER SAVINGS DIVIDEND You could get money back just for insuring your car with us. Qualifying auto policyholders have received a Policyholder Savings Dividend in each year since 1990. Last year, you received a Policyholder Savings Dividend of: $493 As a convenience, your dividend was applied to reduce the premium balance at the beginning of your current policy period. Click AAA.com/myaccount to access your I Visit or call your local Auto Club branch I Call (877) 422-2100 policy and pay your bill online AAA.com/branches Insurance provided to qualified Auto Club members by the lnterinsurance Exchange of the Automobile Club. lnterinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Policy Change Declarations Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. NAMED INSURED (Item 1.) BIEGEL, LINNETH J AND GREGORY T 20699 GRAND AVE WILDOMAR CA 92595-9442 SUBJECT OF POLICY CHANGE ADD/CHANGE LIABILITY AUTO -CORRECTION ADD/CHG/DEL UM/UIM VEHICLES VEH. YEAR MAKE MODEL IDENTIFICATION NO. NUMBER 4 2003 FORD E250 ECONO CG SUPER 1 FTNS24L93HB91309 5 2004 CHEV SUBURBAN 3GNEC16T94G183170 7 2004 HOND CIVIC EX 1 HGEM219X4L059324 9 2006 NSSN SENTRA 3N1CB51036L503817 COVERAGES AND LIMITS Coverage is not in effect unless a premium or the word "included" is shown. COVERAGES LIMITS OF LIABILITY Liability Bodily Injury $1,000,000 each person/ $1,000,000 each occurrence Property Damage $1,000,000 each occurrence Medical Excess Medical Payments $5,000 each person Physical Damage (Actual Cash Value unless otherwise stated, less deductible) Vehicle 4 Vehicle 5 Comprehensive ACV ACV (Less Deductible) $250 $250 Collision ACV ACV (Less Deductible) $500 $500 Car Rental Expense (Per Day) $35 $35 Uninsured Motorist Bodily Injury -$1,000,000 each person/ Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Uninsured Collision Total Premium PREMIUM DISCOUNTS Vehicle 7 Vehicle 9 No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage $1,000,000 each accident Vehicle AUTO POLICY NUMBER: CAA 071911923 POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 07-30-19 12:01 A.M. POLICY EXPIRATION DATE: 07-30-20 12:01 A.M. POLICY CHANGE EFFECTIVE DATE: 11-28-19 12:01 A.M. THIS 15 NOT A BILL This policy change will increase your premium by $763. VEHICLE GARAGE ANNUAL VERIFIED SALVAGE USE ZIP CODE MILES MILEAGE BUSINESS 92595 10,001 -12,500 VERIFIED NO PLEASURE 92595 20,001 -25,000 VERIFIED NO PLEASURE 92595 15,001 -17,500 VERIFIED NO PLEASURE 92595 4,501 -5,500 VERIFIED NO ANNUAL PREMIUMS Vehicle 4 Vehicle 5 Vehicle 7 Vehicle 9 Vehicle $ 352 $435 $297 $ 722 $ 221 $292 $177 $ 540 $15 $18 $16 $20 $101 $127 No Coverage , No Coverage , $ 214 $293 No Coverage : No Coverage : $45 $ 59 No Coverage No Coverage $179 $ 268 $182 $ 267 Included Included No Coverage No Coverage : No Coverage , No Coverage , $9 $19 ' ' $1127 $1492 $ 681 $1568 "No Coverage" indicates coverage not purchased. Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy." Adjusted Total Annual Premium* $ 4868 * If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. CAA0200A E20190107 112719 PROCESS DATE 11-27-19 PLEASE ATTACH TO YOUR POLICY (Includes all applicable discounts.) Less Policyholder Savings Dividend $ 493 (Previously applied to your premium balance) Adjusted Net Annual Premium* $ 4375 (Balance after previous dividend) (SEE REVERSE) lnterinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Policy Change Declarations (continued) AUTO POLICY NUMBER: CAA 071911923 POLICY CHANGE EFFECTIVE DATE: 11-28-2019 DRIVERS (Coverage may differ for each driver. Please see each section of the policy contract for the definition of "Persons Insured".) DRIVER NUMBER 1 2 3 4 5 NAME BIEGEL, LINNETH J BIEGEL, GREGORYT BIEGEL, ANDREW L BIEGEL, REBEKAH BIEGEL, JULIA -EXCLUDED* GENDER FEMALE MALE MALE FEMALE FEMALE MARITAL STATUS YEAR FIRST LICENSED MARRIED 1984 MARRIED 1978 SINGLE 2015 SINGLE 2018 SINGLE 2018 * IMPORTANT: NO COVERAGE IS PROVIDED BY THIS POLICY WHILE ANY VEHICLE IS BEING OPERATED BY AN EXCLUDED DRIVER. PLEASE READ THE "EXCLUSION OF DESIGNATED PERSON ENDORSEMENT" AGREEMENT PREVIOUSLY PROVIDED TO YOU. (Endorsement No. 2184.) DRIVING RECORD RATED DRIVER NUMBER OF I NUMBER OF TRAFFIC CONVICTIONS DRIVER STATUS VEHICLE PRINCIPALLY NUMBER 2 3 4 5 AT-FAULT ACCIDENTS I ENDORSEMENTS AND CERTIFICATES NUMBER I TITLE MINOR I SERIOUS I MAJOR 2011 MEMBER'S AUTOMOBILE POLICY -POLICY NUMBER CHANGE 2052 LOSS PAYABLE -NOTICE TO LIENHOLDER 2184 EXCLUSION OF DESIGNATED PERSON 2367 AMENDATORY ENDORSEMENT I SEVERE I SUSPENSIONS SPECIAL EQUIPMENT** VEH. CAMPER/ OTHER NO. VANCONV. 4 5 7 9 PRIMARY PRIMARY EXCLUDED ADDITIONAL PRIMARY NUMBER 5 4 9 SOUND EQUIPMENT** 2-WAY TELE· RADIO OTHER RADIO PHONE ** Coverage is indicated by a "YES" in the appropriate equipment column. Coverage limitations apply unless coverage was purchased specifically for certain equipment. ANY PHYSICAL DAMAGE LOSS MAY BE MADE PAY ABLE TO YOU AND ANY INTEREST LISTED BELOW: VEH NO. 4 WFS FINANCIAL INC PO BOX52044 PHOENIX AZ_ 85072 PERSON DESIGNATED TO RECEIVE NONPAYMENT OF PREMIUM NOTICES: CAA0200B E20180807 112719 An individual designated by a policyholder to receive notice of lapse, termination, expiration, nonrenewal, or cancellation of the policy for nonpayment of premium does not have any rights, whether as an additional insured or otherwise, to any benefits under the policy, other than the right to receive notice. Click AAA.com/myaccount to access your policy information online, pay your bill or print additional proof of insurance cards lnterinsurance Exchange of the Automobile Club Premium Discounts Applied to Your Automobile Policy Auto Policy Number: CAA 071911923 The following automobile premium discounts are available from the lnterinsurance Exchange. If you meet the discount requirements, an "X" will appear in the box next to the discount name and you will receive a premium reduction on all coverages that qualify for the discount. □ 00 □ 00 □ □ □ 00 00 00 M UL Tl-POLICY MUL Tl-VEHICLE SELECT PROFESSIONALS & GROUPS LOYALTY DRIVING COURSE MATURE DRIVER STUDENT AWAY GOOD STUDENT BIEGEL, JULIA GOOD DRIVER BIEGEL, LINNETH J VERIFIED MILEAGE 2003 FORD E250 ECONO CG SUPER 2004 HOND CIVIC EX BIEGEL, GREGORY T 2004 CHEV SUBURBAN 2006 NSSN SENTRA If you need additional information about any of the above discounts, please refer to the Available Automobile Premium Discounts insert included with your renewal offer (or the insert provided with your application). If you have additional questions about premium discounts or your auto policy, please call us at 1-877-422-2100. CAA0201A E20160721 112719 8208 Ed.02-17