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Planes Boats and Automobiles Ltd; 2018-03-05; PWM18-115GS
CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT EMERGENCY PROJECT -ECR ROAD FILL FAILURE This agreement is made on the 5-/::b day of ~fi.17..tJ,r. -< of Carlsbad, California, a municipal corporation, (hereinafter called "City"), Automobiles, a limited liability company whose principal place of business is Escondido, CA 92027 (hereinafter called "Contractor"). City and Contractor agree as follows: PWM 18-llSGS , 2018, by the City and Planes, Boats & 2029 E. Mission Ave., 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: John Maashoff (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. Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 1 of 8 City Attorney Approved 9/27 /16 PWM18-115GS 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 deb ment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or subcontr to 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. 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. Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 2 of 8 City Attorney Approved 9/27 /16 PWM18-115GS 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 five (5) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within fourteen (14) working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. Planes, Boats & Automobiles, LTD. (name of Contractor) 816826 (Contractor's license number) A: General Engineering; B: General Building Contractor 1 /31 /19 Ill Ill Ill Ill Ill Ill (license class. and exp. date) 1000018273 (DIR registration number) 6/30/18 (DIR registration exp. date) Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 3 of 8 2029 E. Mission Ave. (street address) Escondido, CA 92027 (city/state/zip) 760-729-7913 (telephone no.) 760-729-7913 (fax no.) pbalimited@gmail.com (e-mail address) City Attorney Approved 9/27 /16 PWM18-115GS 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, PLANES, BOATS & AUTOMOBILES, a limited liability company By: (sign here) &~ }' h ~J /(ZY (print name/title) By: ( 1g ere J<ev,)" Dob~t tlt. 2telvP (print name/title) 7 ' / CITY OF CARLSBAD, a municipal corporation of the State of California By: laine Llic Works Director as authorized by the City Manager If required by City, proper notarial acknowledgment of execution by Contractor must be attached . .!f....E. 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: CELIA A. BREWER, City Attorney BY Vk_a~ Deputy Cityorriey Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 4 of 8 City Attorney Approved 9/27 /16 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT 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 ~'{\ 'S:),%)0 ) On O~\ ~\ \. lt3 before me, PrM\a.x: ffi(X)::(, K)~ Vu\o\\C.,, Date Here Insert Name and Title of the O · r personally appeared G\ \ \.xx--~ ~ ~\.e._~ f KQM.\{) ~ C)on.u--.J_..._ Name(s) of Signer(s) V ~ ~\ who proved to me on the basis of satisfactory evidence to be the per~on s) whose namwis~ subscr~1 to the within instruHand acknowledge~me that ~sh the executed the sam~ his/he their uthorized capacit (ies and th~ his/he~signatur~on e instrument the perso~ or the en 1ty upon behalf of whic he pers~acted, executed the instrument. Place Notary Seal Above 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. Signature_a~~--------~h~,.__ _______ _ Signat~tary Public ---------------oPTIONAL--------------- Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached DocuJ(lent , ' \~· / [ Title or Type of DocuJI;:1_ent: CCU. ~Q.J-0 Ji\\ ~\ Docu:fnt Date: _0_'~~-'~'-1'-----,_1~8 __ Number of Pages: -~--Signer(s) Other Than Named Above: ~~~~---------- Capacity(ies) Claimed by Signer(s) Signer's Name: ___________ _ Signer's Name: ___________ _ D Corporate Officer -Title(s): ______ _ [] Corporate Officer -Title(s): ______ _ D Partner -[] Limited D General D Partner -n Limited D General D Individual [l Attorney in Fact D Individual D Attorney in Fact D Trustee lJ Guardian or Conservator D Trustee D Guardian or Conservator [J Other: ______________ _ D Other: _____________ _ Signer Is Representing: _________ _ Signer Is Representing: ________ _ ©2014 National Notary Association· www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907 PWM 18-llSGS 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 V r·Y I /) 1// ~ / I The Contractor must perform no less than fifty percent (50%) of the work with its own forces Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 5 of 8 City Attorney Approved 9/27 /16 PWM18-115GS EXHIBIT B Emergency Project -ECR Road Fill Failure Contractor to repair 3 slide areas: Access from N/E corner of Tamarack Ave. and El Camino Real. All work to be from the east side of El Camio Real ROW. At each location, dig keyway length of failure 3' x 4'. Install filter fabric (2 layers) in keyway and all of slide area. Place¼ ton rocks (fractured) in keyways and backfill with ¼ ton rocks. JOB QUOTATION ITEM UNIT QTY DESCRIPTION PRICE NO. 1 LS 1 Repair 3 slide areas: Access from N/E corner of $44,850 Tamarack Ave. and El Camino Real. All work to be from the east side of El Camino Real ROW. At each location, dig keyway length of failure 3' x 4'. Install filter fabric (2 layers) in keyway & all of slide area. Place 1/4 ton rocks (fractured) in keyways & backfill with 1 /4 ton rocks. TOTAL* $44,850 *Includes taxes, fees, expenses and all other costs. Ill Ill Ill Ill Ill Ill Ill Ill Ill Ill Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 6 of 8 City Attorney Approved 9/27 /16 ar= I lEGEND LOCATION C TYPICAL SECTION HOfrDSCAI.£ OCSCRIPT/00 ~ 1/, -TOH AHO Y2-RW RIP RAP, INTfRM/XE.D '\....... MIR.AF! FABRIC .......... OUANnn' 200 C.Y. LOCATION B NOTES (D l!E1'!.Aa"Ct!SIWGfUfJfCl/0Wf/Q.. (l) INSTAU.ROOl'll.(Jl[PR01£CTm ¼-Yi rtrt Cl) INSTAil. IMlNI FNBC. (!) CCWllfACrtM' JO BC RE!iPONSIIJt.£ mt IIAINTNNMG SrABIJrY OF DttSlm ~r tulWC OC.O'AIICW ANO Pl.ACDO'T OF,. MP. LOCATION A REVISION DESCRIPTION \ SCAl.£1"•20' Exhibn "B" "AS BUILT'' RC<--EXP----°'lt REVltWEDSY: ~ fsHE'tr I[ CITY OF CARLSBAD 11'!11lml1 L...!...J TRANSPORTATION DEPARTMENT L....1__J EL CAMINO REAL RIP RAP REPAIR RIP RJ.P REPAIR AMJDETAILS l"""'-1[ ~~--T6~2MO. II~ Bond Number CE11510701260 PWM18-115GS EXHIBIT C LABOR AND MATERIALS BOND WHEREAS, the City Council of the City of Carlsbad, State of California, has awarded Planes, Boats & Automobiles, a limited liability company (hereinafter designated as the "Principal"), a Contract for: EMERGENCY PROJECT -ECR ROAD FILL FAILURE CONTRACT NO. 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, Planes, Boats & Automobiles, a limited liability company, as Principal, (hereinafter designated as the "Contractor"), and Philadelphia Indemnity Insurance Company as Surety, are held firmly bound unto the City of Carlsbad in the sum of FORTY FOUR THOUSAND EIGHT HUNDRED FIFTY Dollars ($44,850), 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 about the 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. Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 7 of 8 City Attorney Approved 9/27 /16 PWM18-115GS 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. Executed by CONTRACTOR this _ ...... i'----'1"---=s_l--__ day of -6---""e'--~---' 20-1i. CONTRACTOR: Planes, Boats & Automobiles Ltd (name of Contractor) ;·---'2.,.,~ By: ____ ..,-,,,:.:..__ ________ _ (sign here) ~\+' (print name here) ~ By: ------,l~~~tA.,,J....4~~~' ------ (ti Executed by SURETY this __ 1::..:6:.;t;:.:.h ___ day of February , 20.!!_ SURETY: By: Philadelphia Indemnity Insurance Company (name of Surety) One Bala Plaza, Suite 1 oo Bala Cynwyd, PA 19004 (address of Surety) 800-765-9794 (telephone number of. ~s:;;.aa-o_,._ ~"'7,,-.,,a___ t,._. Steven A. Swartz (printed name of Attorney-in-Fact) (attach corporate resolution showing current power of attorney) (Proper notarial acknowledgment of execution by CONTRACTOR and SURETY must be attached.) (President or vice-president and secretary or assistant secretary must sign for corporations. If only one officer signs, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering that officer to bind the corporation.) APPROVED AS TO FORM: CELIA A. BREWER c;tyAttom¼ By: (/, ~ oiputy City Attorney Emergency Project-ECR Road Fill Failure Cont. No. 6622 Page 8 of 8 City Attorney Approved 9/27 /16 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT 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 Ca~nia , County of ~,-_,'(\ SJ\(~-()() On O d-1 ~It I B before me, i?\m 'a?.x--l'Qmr<. I\)~ Pv\ol\(_ ate Here Insert Name and fitle of~ r personally appeared ~ \ vx,,.c\ ~ -R ~ r Klv\ (\ ~(N .. :~ \-X) J\Uk Nam<IJ!})of Signe@ ~ ~ V).. who proved to me on the basis of satisfactory evidence to be the perso s hose namE(@) is@ subsc~ib . to the within instrua and acknowledge=t e that ih they executed the sam~ his/he thei uthorized capacit (ies and tha:Pf ,his/hell hei signatur (s) n instrument the persoe or the 1ty upon behalf of wh1 e perso~cted, e uted the i ument. f 0 ~ 5 .:~ssacn ':ie~0 Moof:ersl ~ COMM. #2189235 ~ • NOTARY PUBLICCALIFORNIA - ;. SAN DIEGO COUNTY I I ~ .... ,• My Comm. Expires APRIL 1, 2021 ssuuccsucss uucsss uccssosa Place Notary Sea/ Above 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. Signature____:~=----=--~::.__L-....___~,,,,_~=------- Signature of Notary Public ---------------OPTIONAL--------------- Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document \ Title or Type of Document: lc.....'oos-Q ~v--b "QQ(\C Document Date: -=O_d._\ ;\.-----'-\---1-~---'-\-=e __ Number of Pages: L-/ Signer(s) Other Than Named Above: --1\~l-'-..... l ~-=---------- Capacity(ies) Claimed by Signer(s) Signer's Name: ___________ _ Signer's Name: ___________ _ D Corporate Officer -Title(s): ______ _ D Corporate Officer -Title(s): ______ _ [l Partner -D Limited D General D Partner -[J Limited D General n Individual D Attorney in Fact D Individual D Attorney in Fact D Trustee [J Guardian or Conservator Cl Trustee [J Guardian or Conservator D Other: ______________ _ D Other: ______________ _ Signer Is Representing: _________ _ Signer Is Representing: ________ _ •'™~ ©2014 National Notary Association· www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907 California All-Purpose Certificate of 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 _O=-'-'ra.,_,_n~g,..,.e'------------ S.S. On February 16, 2018 personally appeared ___ ____,,S=te"'"'v,_,e'-'-n'---"A_,_,.'--'S"'"'w'-'-'a=rt-=z~--------------- who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s:) isMPe subscribed to the within instrument and acknowledged to me that he/s1(00'~¥ executed the same in his/l(~)ll( authorized capacity(~). and that by his~~ij~ signature()() on the instrument the person(¾i(), or the entity upon behalf of which the person(X) 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. BETHANY JOHNSON Notary Public -California Orange County Commission# 2207129 My Comm. Expires Jul 27, 2021 ;~~ \ .... \ OPTIONA!:.\JNFORMA TION ------------- ' .. r:":tr' Description of Attached Document The preceding Certificate of Acknowledgment is attached to a r document titled/for the purpose of CE11510701260 Payment Bond -Planes, Boats and Airplanes -City of Carlsbad containing _2_ page~. and dated February 16, 2018 The signer(s) capacity or authority is/are as: D lndividual(s) IZI Attorney-in-fact D Corporate Officer(s) _____________ _ D Guardian/Conservator D Partner -Limited/General D Trustee(s) D Other: _________________ _ representing: Philadelphia Indemnity Insurance Company Method of Sig.~er Identification Proved to me on the basis of satisfactory evidence: D form(s) of identification O credible witness(es) Notarial event is detailed in notary journal on: Page#__ Entry# __ Notary contact: ________ _ 0 Additional Signer O Signer(s) Thumbprints(s) o ____________ _ PHILADELPHIA INDEMNITY INSURANCE COMPANY One Bala Plaza, Suite I 00 Bala Cynwyd, PA 19004-0950 Power of Attorney 11077 KNOW ALL PERSONS BY THESE PRESENTS: That PHILADELPHIA INDEMNITY INSURANCE COMPANY (the Company), a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, does hereby constitute and appoint Steven A. Swartz, Kelly Specht, Lorie Mandell and Nicki Swartz, Michael Herranen and Thomas C. Buckner of the City of San Clemente, State of California of South Coast Surety, its true and lawful Attorney-in-fact with full authority to execute on its behalf bonds, undertakings, recognizances and other contracts of indemnity and writings obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an amount not to exceed $25.000.000.00. This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of Directors of PHILADELPHIA INDEMNITY INSURANCE COMPANY on the 14th ofNovember, 2016. RESOLVED: FURTHER RESOLVED: That the Board of Directors hereby authorizes the President or any Vice President of the Company: (I) Appoint Attorney(s) in Fact and authorize the Attorney(s) in Fact to execute on behalf of the Company bonds and undertakings, contracts of indemnity and other writings obligatory in the nature thereof and to attach the seal of the Company thereto; and (2) to remove, at any time, any such Attorney-in-Fact and revoke the authority given. And, be it That the signatures of such officers and the seal of the Company may be amxed to any such Power of Attorney or certificate relating thereto by facsimile, and any such Power of Attorney so executed and certified by facsimile signatures and facsimile seal shall be valid and binding upon the Company in the future with respect to any bond or undertaking to which it is attached. IN TESTIMONY WHEREOF, PHILADELPHIA INDEMNITY INSURANCE COMPANY HAS CAUSED THIS INSTRUMENT TO BE SIGNED AND ITS CORPORATE SEAL TO BE AFFIXED BY ITS AUTHORIZED OFFICE THIS 27Tl1 DAY OF OCTOBER, 2017. (Seal) Robert D. O'Leary Jr., President & CEO Philadelphia Indemnity Insurance Company On this 27"' day of October, 2017, before me came the individual who executed the preceding instrument, to me personally known, and being by me duly sworn said that he is the therein described and authorized officer of the PHILADELPHIA INDEMNITY INSURANCE COMPANY; that the seal affixed to said instrument is the Corporate seal of said Company; that the said Corporate Seal and his signature were duly affixed. (Notary Seal) Notary Public: residing at: My commission expires: Bala Cynwyd PA September 25 2021 I, Edward Sayago, Corporate Secretary of PHILADELPHIA INDEMNITY INSURANCE COMPANY, do hereby certify that the foregoing resolution of the Board of Directors and this Power of Attorney issued pursuant thereto on this 27th day of October, 2017 are true and correct and are still in full force and effect. I do further certify that Robert D. O'Leary Jr., who executed the Power of Attorney as President, was on the date of execution of the attached Power of Attorney the duly elected President of PHILADELPHIA INDEMNITY INSURANCE COMPANY, In Testimony Whereof! have subscribed my name and affixed the facsimile seal of each Company this Edward Sayago, Corporate Secretary PHILADELPHIA INDEMNITY INSURANCE COMPANY ;</ ,204-. ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY) ~ 10/18/2017 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDmONAL INSURED, the pollcy(les) 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 endorsementfs\. PRODUCER CONTACT NAME: Brown & Brown Insurance Brokers of Sacramento. Inc r.~'!.t c-·-91a-630-B643 J f~ MA•• 800--783-0083 P. 0. Box 619043 Lic#OH38004 E-MAIL Roseville CA 95661-9043 •nnncac,. INSIJRF'RIS}AFFORDINGCOVERAGE NAIC# INsuRERA ,Acceotance Casualtv Ins. Co. 10349 INSURED PLANE-4 INSURER B ,California Automobile Ins. Co. 38342 Planes Boats and Automobiles INSURER c ,Kinsale Insurance Comoanv 38920 LTD INSURERD: 800 Grand Ave. Ste. A 9 Carlsbad CA 92008 INSURERE: INSURERF: COVERAGES CERTIFICATE NUMBER· 1186144127 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. INSR TYPE OF INSURANCE ,{.?};;,~, POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER A X COMMERCIAL GENERAL LIABILITY y y IARG1200042700 10/12/2017 10/12/2018 EACH OCCURRENCE $1,000,000 -D CLAIMs-MADE w OCCUR ~~~iJ~e';~nce\ -$50,000 MED EXP fAnv one person) $5,000 -i PERSONAL & ADV INJURY $1,000,000 ,_ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 =i 0 PRO-OLoc PRODUCTS -COMP/OP AGG $2,000,000 POLICY _ X JECT OTHER: $ B AUTOMOBILE LIABILITY BA040000013231 3f7/2017 317/2018 IE'ii7'~~;;'l'N\_jLt: LIMI I s1.ooo.ooo ~ ANY AUTO BODILY INJURY (Per person) s ! ALL OWNED -SCHEDULED BODILY INJURY (Per accident) $ _j AUTOS AUTOS -·-NON-OWNED l"'_KUO-l:1:(TY DAMAGE HIRED AUTOS AUTOS /Per accident\ $ --$ C UMBRELLA LIAB HOCCUR y 01000436351 10/12/2017 10/12/2018 EACH OCCURRENCE $1,000,000 "---------- X EXCESSLIAB CLAIMs-MAOE AGGREGATE $1,000,000 OED I I RETENTION$ $ WORKERS COMPENSATION I PER I I OTH- AND EMPLOYERS" LIABILITY STATUTE ER YIN , ANY PROPRIETOR/PARTNER/EXECUTIVE D NIA E.L. EACH ACCIDENT $ i OFFICER/MEMBER EXCLUDED? i (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Certificate holder is included as Additional Insured under Commercial General Liability policy per endorsements TMGL 172 1011 & TMGL 175 10 11. RE: PONTO BEACH MEDIANS; CONT. NO. 7550, Agreement Number: PWM17-113TRAN. CERTIFICATE HOLDER City of Carlsbad/CMWD c/o EXIGIS Insurance Compliance Services P.O. Box 4668 -ECM #35050 New York NY 10163-4668 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ED REPRESENTATIVE c~ © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POqcv NUMBER: IARG12000427-00 NAMED INSURED: Planes Boats and Automobiles COMMERCIAL GENERAL LIABILITY TMGL 172 10 11 ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS-AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU (PRIMARY & NONCONTRIBUTORY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A Section II • Who is An Insured is amended to include as an insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. 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 for the additional insured. A person's or organization's status as an insured under this endorsement ends when your operations for that additional insured are completed. B With respect to the insurance afforded these additional insureds, the following additional exclusion apply: This insurance does not apply to: 1 "Bodily injury", "property damage", "personal and advertising injury" arising out of the rendering of, or the 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. 2 "Bodily Injury", "property damage" occurring after: a 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 b 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; or c "Property Damage" which manifests after expiration of the Policy. If required by written contract or agreement, such insurance as is afforded by this policy shall be primary insurance, and any insurance or self insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the Named Insured and shall not contribute to it. ALL OTHER TERMS, CONDITIONS ANO EXCLUSIONS REMAIN UNCHANGED. TMGL 172 10 11 POLICY NUMBER: IARG12000427-00 NAMED INSURED: Planes Boats and Automobiles COMMERCIAL GENERAL LIABILITY TMGL 1751011 ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS (PRIMARY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART: Name ci Acklitiooal Insured Person(s) Or Organizatioo. Locatioo and Description ci Completed Operatioos: We shall name person(s) cr crganizatiai(s) as additional fAny q:>erations as required under written cootract. insured(s) to this insurance as required under a written cootract Vvith the Named Insured entered into before the daim or loss for which this policy awlies. No coverage, indemnity and/or defense obligatia,s shall be provided under this endorsement to any persoo(s) a a-ganizatioo(s) claiming to be acklitiooal insured(s) for daims er losses which cb not arise frcrn tile Named lnsured's work cr q:>erations under a written contract and competed during the policy period. The Named lnsured's mere presence at a work site shall not be deemed sufficient cause to require coverage, indemnity and/or defense to any person(s) or organi=tion{s) daiming to be an additional nsured under this endorsement. !There shall be no coverage, indemnity, and/or duty to defend any person(s) cr a-ganization(s) claiming to be an acklitiooal insured under this endorsement if 1he claim or loss does not arise, in \l\lhde cr in part, frcrn 1he negligence and/er fault ci the Named Insured. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section 11-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 ins1.,rl:\d ::ind inch.rding in the "prod1.1cts-comp!eted oper::itions hazard: If required by written contract or agreement, such insurance as is afforded by this policy shall be primary insurance, and any insurance or self insurance maintained by the above additional insured{s) shall be excess of the insurance afforded to the Named Insured and shall not contribute to it. ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. TMGL 1751011 ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY) ~ 11/10/2017 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu ofsuch endorsement(s). PRODUCER CONTACT Paula Jameson NAME: E360 Insurance Services PHONE (888) 862-6750 I FAX (888) 256-0809 IA/C No Extl: IA/C Nol: 16542 Ventura Blvd., Suite 300 ~-M!l-1\cM. paula@e360insurance.com Encino, CA 91436 INSURER($) AFFORDING COVERAGE NAIC# Phone (888) 862-6750 Fax (888) 256-0809 INSURER A: State Fund INSURED INSURER B: P.B.A. LTD. INSURERC: 800 Grand Ave Suite A9 INSURER D: INSURER E: Carlsbad CA 92008 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDI SUBR POLICY EFF POLICY EXP LTR IN!':R WVD POLICY NUMBER IMM/DD/YYYYl IMM/DD/YYYYl LIMITS D COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ D CLAIMS-MADE D OCCUR DAMAGE TO RENTED PREMISES !Ea occurrence) $ D MED EXP (Any one person $ D PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ D POLICY D PRO-JECT D LOC PRODUCTS -COMP/OP AGG $ D OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ !Ea accident) D ANYAUTO BODILY INJURY (Per person) $ D SCHEDULED D ~::;-;.~~0oNLY AUTOS BODILY INJURY (Per accident) $ D lI\%~oNLY D NON-OWNED iPRe?~~~J.in8AMAGE $ AUTOS ONLY D D $ D UMBRELLA LIAB D OCCUR EACH OCCURRENCE $ D EXCESS LIAB D CLAIMS-MADE AGGREGATE $ D OED D RETENTION $ $ WORKERS COMPENSATION ~ ~ffrtlTE DOTH- AND EMPLOYERS' LIABILITY YIN ER ANY PROPRIETOR/PARTNER/EXECUTIVm E.L. EACH ACCIDENT $ 1,000,000.00 A OFFICER/MEMBER EXCLUDED? Y N/A 9219205-17 09/30/2017 09/30/2018 (Mandatory in NH) E.L. DISEASE -EA EMPLOYE $ 1,000,000.00 If yes, describe under E.L. DISEASE -POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) *** 30 days written notice of cancelation ••• Proof of Workers Compensation Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Carlsbad /CMWD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. c/o EXIGIS Insurance Compliance Services P.O. Box 4668 -ECM #35050 AUTHORIZED REPRESENTATIVE New York, NY 10163-4668 ' ..... / ,,,,;,"" , ,, I -:_, _,,,_ . , __ © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) QF The ACORD name and logo are registered marks of ACORD STATE ENDORSEMENT AGREEMENT ADDITIONAL INSURED EMPLOYER BROKER COPY COMPENSATION INSURANCE FUND 9219205-17 NEW SC HOME OFFICE SAN FRANCISCO 6-49-53-71 PAGE 1 OF 3 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE NOVEMBER 5, 2017 AT 12.01 A.M. PB A, LTD 800 GRAND AVE CARLSBAD, CA 92008 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT CITY OF CARLSBAD IS HEREBY NAMED AS AN ADDITIONAL INSURED EMPLOYER ON THIS POLICY BUT ONLY AS RESPECTS EMPLOYEES WHOSE NAMES APPEAR ON THE PAYROLL RECORDS OF PB A, LTD (HEREIN CALLED THE PRIMARY INSURED) WHILE THOSE EMPLOYEES ARE ENGAGED IN WORK UNDER THE SIMULTANEOUS DIRECTION AND CONTROL OF THE PRIMARY INSURED AND THE ADDITIONAL INSURED EMPLOYER. IT IS FURTHER AGREED THAT THE PAYMENT OF THE FULL PREMIUM DUE AND PAYABLE UNDER THIS POLICY SHALL REMAIN THE SOLE RESPONSIBILITY OF THE PRIMARY INSURED. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ~~~ NOVEMBER 8, 2017 PRESIDENT AND CEO SCIF FORM 10217 IREV.7-2014) 0015 OLD DP 217 STATE ENDORSEMENT AGREEMENT ADDITIONAL INSURED EMPLOYER BROKER COPY COMPeNSATION INSURANCE FUNO 9219205-17 NEW SC HOME OFFICE SAN FRANCISCO 6-49-53-71 PAGE 2 OF 3 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE NOVEMBER 5, 2017 AT 12.01 A.M. PB A, LTD 800 GRAND AVE CARLSBAD, CA 92008 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT CMWD IS HEREBY NAMED AS AN ADDITIONAL INSURED EMPLOYER ON THIS POLICY BUT ONLY AS RESPECTS EMPLOYEES WHOSE NAMES APPEAR ON THE PAYROLL RECORDS OF PB A, LTD (HEREIN CALLED THE PRIMARY INSURED) WHILE THOSE EMPLOYEES ARE ENGAGED IN WORK UNDER THE SIMULTANEOUS DIRECTION AND CONTROL OF THE PRIMARY INSURED AND THE ADDITIONAL INSURED EMPLOYER. IT IS FURTHER AGREED THAT THE PAYMENT OF THE FULL PREMIUM DUE AND PAYABLE UNDER THIS POLICY SHALL REMAIN THE SOLE RESPONSIBILITY OF THE PRIMARY INSURED. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ~!.~ NOVEMBER 8, 2017 PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 0015 OLD DP 217 STATE ENDORSEMENT AGREEMENT ADDITIONAL INSURED EMPLOYER BROKER COPY COMPENSATION INSURANCE FUND 9219205-17 NEW SC HOME OFFICE SAN FRANCISCO 6-49-53-71 PAGE 3 OF 3 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE NOVEMBER 5, 2017 AT 12.01 A.M. PB A, LTD 800 GRAND AVE CARLSBAD, CA 92008 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT EXIGIS INSURANCE COMPLIANCE SERVICES IS HEREBY NAMED AS AN ADDITIONAL INSURED EMPLOYER ON THIS POLICY BUT ONLY AS RESPECTS EMPLOYEES WHOSE NAMES APPEAR ON THE PAYROLL RECORDS OF PB A, LTD (HEREIN CALLED THE PRIMARY INSURED) WHILE THOSE EMPLOYEES ARE ENGAGED IN WORK UNDER THE SIMULTANEOUS DIRECTION AND CONTROL OF THE PRIMARY INSURED AND THE ADDITIONAL INSURED EMPLOYER. IT IS FURTHER AGREED THAT THE PAYMENT OF THE FULL PREMIUM DUE AND PAYABLE UNDER THIS POLICY SHALL REMAIN THE SOLE RESPONSIBILITY OF THE PRIMARY INSURED. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ~i:::!t;,{~ NOVEMBER 8, 2017 PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 0015 OLD DP 217 STATE ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BROKER COPY COMPE;NSATION INSURANCE: FUNO 9219205-17 NEW SC HOME OFFICE SAN FRANCISCO 6-49-53-71 PAGE 1 OF 3 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE NOVEMBER 5, 2017 AT 12.01 A.M. AND EXPIRING SEPTEMBER 30, 2018 AT 12.01 A.M. PB A, LTD 800 GRAND AVE CARLSBAD, CA 92008 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF CARLSBAD WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, PB A, LTD IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ~i~ NOVEMBER 8, 2017 PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 2570 OLD DP 217 STATE ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BROKER COPY COMF=>eNSATION INSURANCE FUNO 9219205-17 NEW SC HOME OFFICE SAN FRANCISCO 6-49-53-71 PAGE 2 OF 3 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE NOVEMBER 5, 2017 AT 12.01 A.M. AND EXPIRING SEPTEMBER 30, 2018 AT 12.01 A.M. PB A, LTD 800 GRAND AVE CARLSBAD, CA 92008 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CMWD WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, PB A, LTD IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ~;{.~ NOVEMBER 8, 2017 PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 2570 OLO OP 217 STATE ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BROKER COPY COMPCNSATION INSURANCE FUNO 9219205-17 NEW SC HOME OFFICE SAN FRANCISCO 6-49-53-71 PAGE 3 OF 3 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE NOVEMBER 5, 2017 AT 12.01 A.M. AND EXPIRING SEPTEMBER 30, 2018 AT 12.01 A.M. PB A, LTD 800 GRAND AVE CARLSBAD, CA 92008 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, EXIGIS INSURANCE COMPLIANCE SERVICES WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, PB A, LTD IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: ~;,{~ NOVEMBER 8, 2017 PRESIDENT AND CEO SCIF FORM 10217 IREV.7-2014) 2570 OLD DP 217 Dear Policyholder: BROKER COPY PLEASE KEEP THIS ENDORSEMENT WITH YOUR POLICY These endorsements amend and are part of your policy. Please keep them with your documents for future reference. 9219205-17 NEW SC If you have any questions concerning these endorsements, Please contact your local State Fund office. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: AH clients of the insured where required by written contract. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condftion (Section IV- COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: 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 24041093