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HomeMy WebLinkAboutJMG Security Systems Inc; 2019-11-12; 2019-MPW/IT12Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 1 of 8 City Attorney Approved 1/25/2019 CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT LIBRARY VIDEO PROJECT ($60,000 or Less) This agreement is made on the ______________ day of _________________________, 20___, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and JMG Security Systems, whose principal place of business is 17150 Newhope Street, Ste. 109, Fountain Valley, CA 92708 (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: Javier Ruiz (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. DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 1912thNovember Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 2 of 8 City Attorney Approved 1/25/2019 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 participating 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. 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 DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 Gil Ledesma Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 3 of 8 City Attorney Approved 1/25/2019 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 sixty (60) working days after receipt of Notice to Proceed. CONTRACTOR’S INFORMATION. JMG Security Systems 8148 Ronson Rd, Suite “H” (name of Contractor) 575070 (street address) San Diego, CA 92111 (Contractor’s license number) C-7, C-10 8/31/2021 (city/state/zip) 760-497-8820 (license class. and exp. date) 1000005703 (telephone no.) 714-545-0352 (DIR registration number) 6/30/2020 (fax no.) mtremblay@jmgsecurity.com (DIR registration exp. date) (e-mail address) /// /// /// /// /// /// /// /// DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 4 of 8 City Attorney Approved 1/25/2019 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. CONTRACTOR CITY OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) Maria Callander, Information Technology Director (print name/title) By: ATTEST: (sign here) BARBARA ENGLESON City Clerk (print name/title) If required by City, proper notarial acknowledgment of execution by Contractor must be attached. If a corporation, Agreement must be signed by one corp orate officer from each of the following two groups: Group A Group B Chairman, President, or Vice-President 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: CELIA A. BREWER, City Attorney BY: _____________________________ Assistant City Attorney DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 Gil Ledesma VP Sales for Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 5 of 8 City Attorney Approved 1/25/2019 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 be Subcontracted Business Name and Address DIR Registration No. License No., Classification & Expiration Date % of Total Contract Total % Subcontracted: _______________ DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 None 0 Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 6 of 8 City Attorney Approved 1/25/2019 EXHIBIT B CITY OF CARLSBAD – LIBRARY VIDEO PROJECT DOVE LIBRARY 3 - Connection to Client Owned 1G Network Switches 1 - Installation of Samsung-Hanwha QNV-7080R 4.0-Megapixel External Dome 5 - Installation of Samsung-Hanwha QND-7080R 4.0-Megapixel Internal Dome Cameras with Auto Iris Varifocal Lens (2M-12M) 6 - Installation of Samsung XNV-8020R External 5.0 Megapixel Vandal Resistant Domes with IR and Auto Iris Fixed Lens (3.7MM) 7 - Installation of Samsung Dome Camera Wall Mounts 1 - Installation of Samsung-Hanwha PNM-9081VQ 20.0MP Multi-Sensor Dome 1 - Installation of Altronix Netway Hardened 4port POE Outdoor Switch 2 - Installation of Ubiquiti Wireless Transceiver and Receiver * Material, Conduit, Lift Rental, Camera Adjustments Included * Client to Provide ONSSI VMS Software & All Network Switches PURCHASE: Equipment & Installation Total - $25,485.00 General Information; Taxes are included in all totals. Requirements: All network switches and confirmation of available ports on city’s existing network patch panel or network switch. 110v power required in AV room near existing gallery room. All VSM software (ONSSI) licensing and programming provided by the City of Carlsbad. One 8 port switch will be located in the A/V room near the gallery. DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 7 of 8 City Attorney Approved 1/25/2019 CITY OF CARLSBAD – COLE LIBRARY 1 - Connection to Client Owned 1G Network Switch 1 - Installation of Samsung PNM-9020V 7.3-Megapixel Internal 180 Degree Panoramic Dome Camera with Wall Mount 3 - Installation of Samsung XNV-8020R External 5.0 Megapixel Vandal Resistant Domes with IR and Auto Iris Fixed Lens (3.7MM) 3 - Installation of Samsung Dome Camera Wall Mounts * Material, Conduit, Camera Adjustments Included * Client to Provide ONSSI VMS Software PURCHASE: Equipment & Installation Total - $9,150.00 General Information; Taxes are included in all totals. Requirements: All network switches and confirmation of available ports on city’s existing network patch panel or network switch. All VSM software (ONSSI) licensing and programming provided by the City of Carlsbad. Optional Camera Locations: 1-External XNV-8020R northwest corner - $1,850.00 Optional cameras include equipment, installation labor, material and tax. DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 Tracking #: 2019-MPW/IT12 LIBRARY VIDEO PROJECT Page 8 of 8 City Attorney Approved 1/25/2019 CITY OF CARLSBAD – LEARNING CENTER 1 - Connection to Client Owned 1G Network Switch 1 - Installation of Samsung-Hanwha QND-7080R 4.0-Megapixel Internal Dome Camera with Auto Iris Varifocal Lens (2M-12M) 2 - Installation of Samsung XNV-8020R External 5.0 Megapixel Vandal Resistant Domes with IR and Auto Iris Fixed Lens (3.7MM) 2 - Installation of Samsung Dome Camera Wall Mounts * Material, Conduit, Camera Adjustments Included * Client to Provide ONSSI VMS Software PURCHASE: Equipment & Installation Total - $6,275.00 General Information; Taxes are included in all totals. Requirements: All network switches and confirmation of available ports on city’s existing network patch panel or network switch. All VSM software (ONSSI) licensing and programming provided by the City of Carlsbad. DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDD/YYYY) ~ 7/25/2019 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 endorsement(s). PRODUCER ~~Me':'CT Jessica Wilkison Tolman & Wiker Insurance Services LLC #OE52073 PHONE (661)616-4700 I FAX (661) 616-4500 IA/C No Ext\, IA/C.Nol: 5001 California Ave. ~6'1lJ~ss: jwilkison@tolmanandwiker.com Suite 150 INSURER(Sl AFFORDING COVERAGE NAIC # Bakersfield CA 93309 INSURERA: Steadfast Ins Co 26387 INSURED INSURER B: American Guarantee & Liability Ins Co 26247 INSURER C: Zurich American Ins Co 16535 JMG Security Systems, Inc. INSURER D: Hartford Fire Insurance Company 19682 17150 Newhope #109 INSURERE: Fountain Valley CA 92708 INSURERF: COVERAGES CERTIFICATE NUMBER: 19/20 GL/UMB/WC/CR ., 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. NOTWTHSTANDING 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE "'on '"",n POLICY NUMBER IMMIDD/YYYYl IMMIDD/YYYYl LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 -D CLAIMS-MADE W OCCUR DAMAGE TO RENTED A PREMISES !Ea occurrence! s 100,000 ~ Errors & Omissions X EOL066286400 8/1/2019 8/1/2020 MED EXP (Any one person) s 10,000 ~ $1,000 Deductible PERSONAL & ADV INJURY s 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ~ □PRO-□Loe PRODUCTS -COMP/OPAGG s 2,000,000 POLICY JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s /Ea accidentl - ANY AUTO BODILY INJURY (Per person) s -ALLO'il'l'IED -SCHEDULED AUTOS AUTOS Agency Does Not Write BODILY INJURY (Per accident) $ - -NON-O'il'l'IED PROPERTY DAMAGE HIRED AUTOS AUTOS ( Per accident) $ - -$ X UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ 5 000,000 - B EXCESS LIAB CLAIMS-MADE AUC873202800 8/1/2019 8/1/2020 AGGREGATE $ 5,000,000 DED I I RETENTION s (Follows GL, PL, AU & WC) $ WORKERS COMPENSATION X I ~-\°fTuTE I I OTH- AND EMPLOYERS' LIABILITY ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE 0 E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A C (Mandatory in NH) y WC016987500 8/1/2019 8/1/2020 E.L. DISEASE· EA EMPLOYEE $ 1,000,000 lf yes, describe under E.L. DISEASE· POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS below D Employee Dishonesty 51BDDIE1561 8/1/2019 8/1/2020 Limit 100,000 Deductible 2,500 DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GL: The City of Carlsbad is Additional Insured as respects to operations of the Named Insured per form (GL)UGL1175FCW0413. WC: A Waiver of Subrogation is added in favor of the Additional Insured per form (WC)WC040306. Endorsements apply only as required by current written contract on file. CERTIFICATE HOLDER CANCELLATION certificates-carlsbad@riskwoz SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Carlsbad/CMWD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN c/o EXIGIS Insurance Compliance Services ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 4668-ECM #35050 New York, NY I ACORD 25 (2014/01) INS025 (201401) 10163-4668 AUTHORIZED REPRESENTATIVE Shaun Kelly/ITZELM ~ © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 Additional Insured -Automatic -Owners, Lessees Or Contractors Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem EOL0662864-00 08/01/2019 08/01/2020 ZURICH Return Prem. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: JMG Security Systems, Inc. 17150 Newhope #109 Fountain Valley, CA 92708 Address (including ZIP Code): · This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part ® A. Section II -Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement. Such person or organization is an additional insured 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 or "your work" as included in the "products-completed operations hazard", which is the subject of the written contract or written agreement. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. Includes copyrighted material of Insurance Services Office, Inc., with its permission. U-GL-1175-F CW (04/13) Page 1 of 2 DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV - Commercial General Liability Conditions: The additional insured must see to it that: 1. We are notified as soon as practicable of an "occurrence" or offense that may result in a claim; 2. We receive written notice of a claim or "suit" as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured if the written contract or written agreement requires that this coverage be primary and non-contributory. D. For the purposes of the coverage provided by this endorsement: 1. The following _is added to the Other Insurance Condition of Section IV-Commercial General Liability Conditions: Primary and Noncontributory insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured provided that: a. The additional insured is a Named Insured under such other insurance; and b. You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV -Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by a written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis. E. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to Section Ill -Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement; or 2. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations .. All other terms and conditions of this policy remain unchanged. Includes copyrighted material of Insurance Services Office, Inc., with its permission. U-GL-1175-F CW (04/13) Page 2 of 2 DocuSign Envelope ID: E2775AB8-9120-478C-B2D9-3C166252E889 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 mium otherwise due on such remuneration. % of the California workers' compensation pre- Person or Organization WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Schedule Job Description "ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION." Page 1 of 1