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HomeMy WebLinkAboutScott Fence; 2018-03-07; PWL18-116GSCITY OF CARLSBAD PUBLIC WORKS LETTER OF AGREEMENT ELMWOOD HOUSE EGRESS GATE PWL18-116GS This letter will serve as an agreement between Scott Fence, a sole proprietorship (Contractor) and the City of Carlsbad (City). The Contractor will provide all equipment, material and labor necessary to install an egress gate into the existing back gate at the Elmwood House located at 2955 Elmwood Street, Carlsbad, CA 92008, per Exhibit "A" and City specifications, for a sum not to exceed three thousand two hundred dollars ($3,200). This work is to be completed within thirty (30) working days after issuance of a Purchase Order. ADDITIONAL REQUIREMENTS 1. City of Carlsbad Business License 2. The Contractor shall assume the defense of, pay all expenses of defense, and indemnify and hold harmless the City, and its agents, officers, officials, employees, and volunteers 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 this Contract or work; or from any failure or alleged failure of the contractor to comply with any applicable law, rules or regulations including those relating to safety and health; except for loss or damage which was caused solely by the active negligence of the City; and from any and all claims, loss, damage, injury and liability, howsoever the same may be caused, resulting directly or indirectly from the nature of the work covered by this Contract, unless the loss or damage was caused solely by the active negligence of the City. The expenses of defense include all costs and expenses, including attorney's fees for litigation, arbitration, or other dispute resolution method. 3. Contractor shall furnish policies of general liability insurance, automobile liability insurance and a combined policy of workers compensation and Employers' Liability in an insurable amount of not less than one million dollars ($1,000,000) each, unless a lower amount is approved by the Risk Manager or the City Manager. Said 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. Insurance is 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. Proof of all such insurance shall be given by filing certificates of insurance with contracting department prior to the signing of the contract by the City. 4. The Contractor shall be aware of and comply with all Federal, State, County and City Statues, Ordinances and Regulations, including Workers Compensation laws (Division 4 California Labor Code) and the "Immigration Reform and Control Act of 1986" (8USC, Sections 1101 through 1525), to include but not limited to, verifying the eligibility for employment of all agents, employees, subcontractors and consultants that are included in this Contract. 5. The Contractor may be subject civil penalties for the filing of false claims as set forth in the California False Claims Act, Go~ Code sections 12650, et seq., and Carlsbad Municipal Code Sections 3.32.025, et seq. __,,.,c....::~'---init ____ init 6. The Contractor hereby acknowledges that debarment by another jurisdictiol1,¾SI a-ro/nds for the City of Carlsbad to disqualify the Contractor from participating in contract bidding._µ init ___ init 7. 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. Elmwood House Egress Gate - 1 -City Attorney Approved 2/29/2016 PWL18-116GS 8. 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 the Section 1770, 1773 and 1773.1 of the California Labor Code. Pursuant to Section 1773.2 of the California Labor code, a current copy of 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 the execution of the work covered by this Letter of Agreement. 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. 9. City Contact: Brian Bacardi 760-434-2944 Contractor Contact: Patrick Glass 760-598-0070 CONTRACTOR Scott Fence, a sole proprietorship 1255 Distribution Way Vista, CA 92081 P: 760-598-0070 F: 760-598-0098 scottfencewefence@yahoo.com (sign here) '=:=-::-~1it-.so« k'6' 7 s-ct, 7 (print name/title) ct)(J...A.,( L By: (sign here) (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California By: Elai~~d:" Won<s Director as authorized by the City Manager Dated: (Proper notarial acknowledgment of execution by Contractor must be attached. Chairman, president or vice-president and secretary, assistant secretary, CFO or assistant treasurer must sign for corporations. 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: Deputy City Attorney Elmwood House Egress Gate - 2 -City Attorney Approved 2/29/2016 EXHIBIT A ELMWOOD HOUSE EGRESS GATE SCOPE OF WORK AND FEE Contractor to provide all materials, tools and labor to install a new 6' X 3' pedestrian egress gate into existing rod iron fence. New gate to include security screen on gate as well as 18" both sides of existing fence where gate is to be cut in. New gate to also include Von Duprin 22 panic hardware, and a 1 O" kick plate. TOTAL* *Includes taxes, fees, expenses and all other costs. Elmwood House Egress Gate Page 3 of 3 $3,200 $3,200 City Attorney Approved 9/27/16 ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY) ~ 02/20/2018 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 ri<1hts to the certificate holder in lieu of such endorsement<sl. PRODUCER CONTACT NAME: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY riti/~N~o Extl: 888-333-4949 I FAX HOME OFFICE: P.O. BOX 328 (A/C Nol: 507-446-4664 OWATONNA, MN 55060 t~o~~ss: CU ENTCONTACTCENTERcaJFEDI NS.COM INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 158-789-8 INSURER B: SCOTT FENCE INSURER C: 1255 DISTRIBUTION WAY VISTA, CA 92081-8817 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 70 REVISION NUMBER: 0 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 IADDL SUBR POLICY NUMBER ,,:~,~g)'yVfyi rJ~h~T>iYWYl LIMITS LTR INSR WVD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 - CLAIMS-MADE 0 OCCUR ~~:ii~l?E~~~~~~ncel $100,000 -MED EXP (Any one person) $5,000 -A y N 0770613 12/24/2017 12/24/2018 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 ~POLICY D ffg,: D LOC PRODUCTS • COMPIOP AGG $2,000,000 OTHER: ~TOMOBILE LIABILITY ~~~~~~;~11SINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY (Per person) --SCHEDULED A OWNED AUTOS ONLY AUTOS N N 0770613 12/24/2017 12/24/2018 BODILY INJURY (Per accident) ----X X NON-OWNED tP~~~~~!:n~AMAGE HIRED AUTOS ONLY AUTOS ONLY ----X SEE BELOW· 4A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 -~ I A EXCESS LIAB CLAIMS-MADE N N 0770616 12/24/2017 12/24/2018 AGGREGATE $5,000,000 OED I I RETENTION WORKERS COMPENSATION IPER STATUTE I I OTH· AND EMPLOYERS' LIABILITY ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE D E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L. DISEASE • EA EMPLOYEE If yes, describe under E.L DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SEE ATTACHED PAGE CERTIFICATE HOLDER CANCELLATION 158-789-8 70 0 CITY OF CARLSBAD/CMWD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE C/O EXIGIX INSURANCE COMPLIANCE SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 4668 ACCORDANCE WITH THE POLICY PROVISIONS. NEW YORK, NY 10163-4668 AUTHORIZED REPRESENTATIVE . & )~ ~ © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: _15_8_-7_8_9-_8 _______________ _ LOC#: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED FEDERATED MUTUAL INSURANCE COMPANY SCOTT FENCE POLICY NUMBER 1255 DISTRIBUTION WAY SEE CERTIFICATE# 70.0 VISTA, CA 92081-8817 CARRIER I NAIC CODE SEE CERTIFICATE# 70.0 EFFECTIVE DATE: SEE CERTIFICATE # 70.0 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: -~2=5 __ FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE SYMBOL 4A: AUTOMOBILE LIABILITY INCLUDES OWNED AUTOS OTHER THAN PRIVATE PASSENGER AUTOS ONLY. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU ENDORSEMENT FOR GENERAL LIABILITY. FOR REASONS OTHER THAN NON-PAYMENT OF PREMIUM, 30 DAYS NOTICE WILL BE PROVIDED TO THE CERTIFICATE-HOLDER IN THE EVENT THAT THE ISSUING COMPANY CANCELS THE POLICY BEFORE THE EXPIRATION DATE OF THE POLICY. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 33 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ~ OWNERS, LESSEES OR CONTRACTORS D AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insumnce provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II -\'Vho Is An Insured is amended to include as an additional insurnd 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 "persona! and advertising injury'' caused, in whole or in pa:i, 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. However, the insurance afforded to such additional insured: 1. Oniy applies to !he extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person"s or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exciusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "persona! and advertising injury" arising out of !he rendering of. or the failure lo render, any professional architectural, engineering or surveying sentices, including: a. The preparing. approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, sur1eys, fie!d orders, change orders or drawings and specifications: or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured ailege negligence or other wrongdoing in the supervision, hiring, employment, training or monitorlng of others by that insured, if !he ''occurrence" which caused the "bodily injury" or "property damage'·, or the offense w!1ich caused t11e "personal and advertising injl1ry", involved the rendering of or the failure to render any professional architeciurai, engineering or surveying services. © Insurance Services Office. Inc., 2012 Page 1 of 2 CG 20 33 04 13 Policy Number: 0770613 ./ Trnnsaction Effective Date: 02-09-2018 2. "Bodily injury" or ,;property damage" occu rri n-~ ufter: a. All work. including materials, parts or equipment furnished in connection with such work, on t11e projec.-t (other than serv<ice, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the !ocation of the covered operations has been completed: or b, Thai portion ot "your work'' out of which the injury or damage arises has been put to its Intended use by any person or organ izaticn other than another contractor or subcontractor engaged in performing operations tor a principa! as a part of the same project. C, With respect to the insurance afforded to these additional insureds, !he followin-~ is added to Section Ill -limits Of Insurance: The most we wi!I pay on behalf of the additional insured is the arnount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured: or 2. Available under the applicable Limits of Insurance shown in the Declarations: wriichever is less. Th;s endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office. inc., 2012 CG 20 33 04 13 Policy Nun,ber: 0770613 Transaction Effective Date: 02-09-2018 COMMERCIAL GENERAL LIABILITY CG 20 33 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS D AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COM MERCI.AL GENER.AL LIABILITY COVERAGE PART A. Section II -ir'Vho Is An Insured is amended to include as an additional 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 nn additional insured on your policy. Such person or organization is an additional insured oniy 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. However, the insurance afforded to such additional insured: 1. Only applies to lhe extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: Tr1is insurance does not apply to: 1. "Bodily injury", ~property damage" or "personal and advertising injury" arising out of !he 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, rnaps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and spec!fications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured ailege negligence or other wrongdoing in the supervision, hiring, employment, training or monilor!ng of others by that insured, if the ''occurrence" which caused the "bodily injury" or "property damage'·. or the offense w!lich caused t11e "personal and advertising injury", involved the rendering of or the failure to render any profession.ii arch!teciural, engineering or surveying services. © Insurance Services Office. Inc., 2012 Page 1 of 2 CG 20 33 04 13 Policy Number: 0770613 Trnnsaction Effective Date: 02·09·2018 2. ''Bodiiy injury·• or ,;property darm;ge" occurrin·~ after: a. All work. ;ncluding materials, parts or equipment furn;shed in connection with such work, on the project (other than sen.lice, maintenance or rep2.lrs) to be performed by or on behalf of the add,tional insured(s) al the !ocation of the covered op,3rations 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 enga-~ed in performing operations tor a principa: as a part ot the same project. C. w;th respect io the insurance afforded to these additional insureds, the following is added to Section !II -Limits Of Insurance: The most we wi!I pay on behalf of the additional insured is the arnourit of insurance: 1. Required by the contract or agreement you have entered into with the additional insured: or 2. Avai!2.bie 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. Page 2of 2 © Insurance Services Office. inc., 2012 CG 20 33 04 13 Policy Number: 0770613 Transaction Effective Date: 02·09-2018 SCOTFEN-01 BSURESH ACORD" CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) ~ 02/20/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # 0757776 ~2AA!~cT Kathleen Malone HUB International Insurance Services Inc. rit:8,Nr.l'o, Ext): (858) 768-7325 I rie~. No):(951) 231-2572 5375 Mira Sorrento Place #400 it1DA~~ss: Cal.CPU@hubinternational.com San Diego, CA 92121 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Falls Lake Fire & Casualtv Companv 15884 INSURED INSURER B: Scott Fence dba: Stilson Kent Scott INSURERC: 1255 Distribution Way INSURER D: Vista, CA 92081 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER· REVISION NUMBER· THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ----INSR TYPE OF INSURANCE ADDL ~i POLICY NUMBER POLICY EFF POLICY EXP LIMITS I TR 1••~n fMM/DDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ -D CLAIMS-MADE D OCCUR DAMAGE TO RENTED PREMISES /Ea occurrence\ $ MED EXP fAnv one oersonl $ - PERSONAL & ADV INJURY $ - GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ Fl POLICY D j'r8i= DLOC PRODUCTS -COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT fEa accident\ $ ANY AUTO BODILY INJURY (Per person) $ ---~ -OWNED -SCHEDULED -AUTOS ONLY r--AUTOS BODILY INJURY (Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE --AUTOS ONLY r--AUTOS ONLY /Per accident) $ $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED I I RETENTION$ $ A WORKERS COMPENSATION XI ~ffTUTE I I OTH-AND EMPLOYERS' LIABILITY ER Y/N X FLA00589800 06/01/2017 06/01/2018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE [Y] E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA 1,000,000 (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $ / If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The General Liability, Auto Liability and Excess Policy have been cancelled effective 12/24/2017. This certificate rescinds all coverage beyond 12/24/2017 and supersedes any and all prior certificates issued on behalf of the named insured. Hub International Insurance Services, Inc. is no longer the insurance agent for the Commercial General Liability, Commercial Auto and Excess Liability policies. Revised 2/20/2018 -This certificate rescinds and supersedes any and all prior certificates issued on behalf of the Named Insured. SEE ATTACHED ACORD 101 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 New York, NY 10163-4668 AUTHORIZED REPRESENTATIVE ~ I ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: SCOTFEN-01 BSURESH -------------------LO C #: 1 -------- ADDITIONAL REMARKS SCHEDULE AGENCY License# 0757776 HUB International Insurance Services Inc. POLICY NUMBER SEE PAGE 1 CARRIER I NAICCODE SEE PAGE 1 SEEP 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: NAMED INSURED Scott Fence dba: Stilson Kent Scott 1255 Distribution Way Vista, CA 92081 EFFECTIVE DATE: SEE PAGE 1 Page 1 of 1 Waiver of Subrogation with regard to Workers Compensation applies when required by written contract per the attached endorsement form WC040306 04/84. Should the policies be cancelled before the expiration date, Hub International Insurance Services Inc. (Hub), independent of any rights which may be afforded within the policies to the certificate holder named below, will provide to such certificate holder notice of such cancellation within thirty (30) days of the cancellation date, except in the event the cancellation is due to non-payment of premium, in which case Hub will provide to such certificate holder notice of such cancellation within ten (10) days of the cancellation date. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0403 06 Ed. 4-84 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2.5% of the California workers' compensation premium otherwise due on such remuneration. Person or Organization Blanket Waiver of Subrogation Schedule Job Description As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement Is issued subsequent to preparation of the policy.) Endorsement Effective 06-01-2017 insured Stilson, Kent Scott (An Individual) Policy No. FLA005898-00 Insurance Company Falls Lake Fire & Casualty Company Endorsement No. Countersigned By _____________________ _ ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.