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Ray White Cement; 2021-08-27; PKRC21-0726
Tracking #: CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 Page 1 of 8 City Attorney Approved 1/22/2020 CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 This agreement is made on the ______________ day of _________________________, 20___, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and Ray White Cement whose principal place of business is PO Box 489, Fallbrook, CA 92088 (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 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: __Temujin Matsubara__ (City Project Manager) PAYMENT. The City shall withhold retention as required by Public Contract Code Section 9203. 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: 2873449F-D325-46B1-B5DB-C50426CDB60C 27th August 21 terms and conditions in the Contractor's proposal. DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C Tracking#: 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 subc ntractor 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 CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21 -0726 Page 2 of 8 City Attorney Approved 1/22/2020 DocuSign Envelope ID: 2873449F-O325-46B1-B5OB-C50426CDB60C Tracking#: 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 60 working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within 14 working days after receipt of Notice to Proceed. CONTRACTOR'S INFORMATION. Ray White Cement (name of Contractor) 410673 (Contractor's license number) C-8, 6/30/2022 (license class. and exp. date) 1000003603 (DIR registration number) 6/30/2022 (DIR registration exp. date) CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 Page 3 of 8 2380 Via Monserate (street address) Fallbrook, CA 92028 (city/state/zip) 760-728-0170 (telephone no.) 760-728-5605 (fax no.) -4efl'l@raywhitecement.com (e-mail address) City Attorney Approved 1/22/2020 DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C Tracking#: 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 By: 'PRESIDENT CITY OF CARLSBAD, a municipal corporation of the State of California By: Parks & Recreation Director (print namelte . (J~ By: ::. ATTEST: J~ R.. ~ ~) S.rv. ~ ~ ~ M BARBARA ENGLESON City Clerk If required by City, proper notarial acknowledgment of execution by Contractor must be attached. ~ corporation, Agreement must be signed by one corporate officer from each of the following two groups: CFO GroupA • Chairman, President, or Vice-President Group B . Secretary, Assistant Secretary, CFO or Assistant Treasurer Otherwise, the cotporation 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: OIJuro.-F V'bsr Deputy City Attorney CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 Page 4 of 8 City Attorney Approved 1/22/2020 DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDBS0C Tracking#: 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 be Subcontracted /I l JfJ-// { ,u '/ Total % Subcontracted: CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 \ / Page 5 of 8 DIR Registration No. License No., % of Classification & Total Expiration Date Contract City Attorney Approved 1/22/2020 DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C EXHIBIT B SCOPE OF WORK Chase Field • Sawcut, break and remove existing concrete around drinking fountain o Existing drinking fountain will be removed by city staff o 1 0' x 42" = 35 square feet total • Form and pour new concrete and install base template for new bottle filler station o 1 0' x 42" x 4" thickness = 35 square feet total o Install deep concrete joints with broom finish texture • Remove and haul off all spoils from job site • All plumbing and bottle filler station installation will be completed by city staff Total: $3,100.00 Stagecoach Park; Tennis Court Stairwell & Sidewalk Tracking#: • Scrape and clean out old expansion felt paper joints, dirt and debris using hand tools and compressed high pressure air nozzle • Install new backer rod with Sika flex caulking to all existing joints to prevent moisture intrusion and lifting of concrete panels o All joints will be filled to the top of concrete grade finish Total: $4,000.00 Stagecoach Tennis Court; Drainage Channel • Remove existing decorative rock from drain channel and stockpile for final installation o 75LFx8'wide • Grade from the corner of the sidewalk to the storm drain using an excavator o Slope of grade will be ¼" per LF • Install 75 LF of 4" solid schedule 40 PVC drainpipe o Including 4 -4" drains spaced 18.75' equal distance apart o Core new 4 ½" hole into existing drainage inlet box located at the west end of drain channel to install 4" solid schedule 40 PVC drainpipe • Install new concrete drain box at southeast end at sidewalk to connect 4" solid schedule 40 PVC drainpipe o Form and pour new concrete; 20 LF of 6" x 8" curb on the eastside of drain channel to retain dirt along landscape slope • Form and pour new concrete 1 0" x 12" curb around existing drainage inlet box at the west end of drain channel including a concrete apron 12" x 3.5" thickness wide diameter around existing drainage inlet • Reinstall existing rock over drainage pipe and around new drain inlets • The contractor will provide extra rock as-needed o Extra rock to be determined by city staff for adequate coverage • Remove and haul off all spoils from job site Total: $19,840.00 Total Cost not to exceed $26,940.00 Exemption: All irrigation sprinklers, laterals, mainline, etc. will be removed, relocated and repaired by the landscape contractor under the direction of the city inspector. CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 Page 6 of 8 City Attorney Approved 1/22/2020 DocuSign Envelope ID: 2873449F-D325-4681-85D8-C50426CDB60C EXHIBITC LABOR AND MATERIALS BOND Tracking#: Bond No .: 4437138 Premium: $674.00 Subj~ct tQ adjustment based on tinal contract price. WHEREAS, the City Council of the City of Carlsbad, State of California, has awarded to Ray White Cement (hereinafter designated as the "Principal"}, a Contract for: CONCRETE AND DRAINAGE CHANNEL PROJECT CONTRACT NO. PKRC21-0726 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, Ray White Cement, as Principal, (hereinafter designated as the "Contractor"), and SureTec Insurance Company as Surety, are held firmly bound unto the City of Carlsbad in the sum of twenty-six thousand nine hundred forty Dollars ($26,940), 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. CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 Page 7 of 8 City Attorney Approved 1/22/2020 DocuSign Envelope ID: 2873449F-D325-4681-B5DB-C50426CDB60C Tracking#: 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 ____ ( _C)_it\ ___ day ~ ,20_. CONTRACTOR: Ray White Cement Diane White (print name here) President (tit~nd organization of signatory) By: 7~ -· -NB°AP. T\~. Raymond White (print name here) Chief Financial Officer (title and organization of signatory) Executed by SURETY this _6_t_h ____ day of __ A_u __ g_u_s_t ______ _,, 201.L_. SURETY: SureTec Insurance Company (name of Surety) 3131 Camino Del Rio North, Ste 1450 San Diego, CA 92108 (address of Surety) (619) 400-4100 (telephone number of Surety) By:_j _~_l"'"VV'-_.a_._L _.----'-\~---"--~--- (signature of Attorney-in-Fact) Jerome L. Hren, Attorney-in-Fact (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 ef'l1powering that officer to bind the corporation.) APPROVED AS TO FORM: CELIA A. BREWER City Attorney sy: Oliuf ~ f V'tJsf Deputy City Attorney CONCRETE AND DRAINAGE CHANNEL PROJECT; CONT. NO. PKRC21-0726 Page 8 of 8 City Attorney Approved 1/22/2020 DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C Ray White Cement 2380 VIA MONSERATE Fallbrook, CA 92028 Date: ____ 7.,_'/_.6/_2'--0-'-2-'-1 ___ _ PH; 760-728-0170 FX: 760-728°5605 EMAIL TOM@raywhitecement.com f'REVAILING \X/AGE B1041 I TO: CITY OF CARLSBAD PH: _____ ...;7_6_0_-4;_;,3..,;,4-""'2c.c.8.;..57'------- t 166 CARLSBAD VILLAGE DR CELL: ______ 7_6...;.0-_4'"'"3...;.4-...;.7...;.1.;..85......--____ _ CARLSBAD CA 92008-2428 FAX: --------------- IJl'-tnse f .41063 DIRi 1 00P00.!603 ATTENTION: TEMUJIN MATSUBARA EMAIL: TEMUJIN.MATSUBARA@CARLSBADCA.GOV Project: ____ RE_M_O_V_E_&_R_E_PLA_C_E_C_O_N_C_R_E_T_E_FO_R_N_E_W_D_R_I_N_l<_IN--'G_F_O_U_N_T._'A_I_N __ ~_ Location: CHASE FIELD/ HARDING STREET CARLSBAD OUR WORK SHALL CONSIST OF THE FOLLOWING ITEMS: . ' 1 I SAWCUT, BREAI(, REMOVE APPROXIMATE 10' X 42" = 35 SOFT OF EXISTING CONCRETE AT DRINl<ING FOUNTAIN 2) FORM AND POUR NEW CONCRETE, INSTALL DEEP JOINTS WITH BROOM FINISH TEXTURE PRIME CONTRACTOR OR OWNER SHALL PROVIDE THE FOLLOWING: 1) CITY TO PROVIDE TEMPLATE FOR NEW.BOLTS FOR DRINKING FOUNTAIN 2) PAYMENT DUE WITHIN 30 DAYS OF INVOICE LUMP SUM PRICING: ITEM PRICE 1) BID IS BASED ON REMOVAL AND REPLACEMENT OF 35 SOFT 4" THICK CONCRETE TOTAL: $3,100.00 NC?-TES: ___________________________________ _ RESPECTFULLY SUBMITTED.BY: _____________ _ DATE: 1✓t,, ;;/ ----'-------'----- ACCEPTED BY: _____________ _ DATE: ----------- DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C Ray White Cement 2380 VIA MONSERATI: Fallbrook, CA 92028 Date: ___ ____,7 /,_6,_/2_0_2_1 ___ _ PH: 760-728.0170 FX: 760-728-5605 EMAIL TOM@raywhltecement.com PlxF::VA ILH G W/\GF. TO: CllY OF CARLSBAD PH: 760-434-2857 BID'IM --------------- 1 166 CARLSBAD VILLAGE DR CELL: 760-434-7185 CARLSBAD CA 92008-2428 ATTENTION: TEMUJINMATSUBARA ---------------FAX: ______________ _ EMAIL: TEMUJIN.MATSUBARA@CARLSBADCA.GOV Project: CAULl<ING AT STAIRWELL AND SIDEWALl<S ---------------------------- Location: STAGE COACH PARI( OFF CAMINO DE LOS COACHES OUR WORK SHALL CONSIST OF THE FOLLOWING ITEMS: l I CAULKING AT BOTH SIDES OF STEPS AND STAIRWELL LEADING UP TO TENNIS COURTS INCLUDES SIDEWALKS AS NEEDED DUE TO OLD EXPANSION FELT PAPER DETERIORATION THIS WORI< WILL PREVENT FUTURE DAMAGE CAUSED FROM WATER INTRUSION. INSTALL NEW BACl<ER ROD WITH Sll<A FLEX CAUl,.KING. APPROXIMATE I 00 L/FT ' PRIME CONTRACTOR OR OWNER SHALL PROVIDE THE'FOLLOWING: l I CLOSE OFF ST AIRS FOR 48 HRS DURING WORI< 2) PAYMENT DUE IN FULL WITHIN 30 DAYS OF COMPLETION - LUMP SUM PRICING: ITEM PRICE • 1 I BID INCLUDES ALL WORK AS DESCRIBED ABOVE TOTAL: $4,000.00 - NOlES: ___________________________________ _ d~0~ RESPECTFULLY SUBMITTED BY: _____________ _ DATE: 2:-~.-e:i-/ --~-------- ACCEPTED BY: _____________ _ DATE: __________ _ I I I i DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C Ray White Cement 2380 VIA MONSERATE Fallbrook, CA 92028 Date: --~8/~3~/_2_1 _RE_V_I_SE_D_BI_D __ PH: 760-728-0170 FX: 760-728-5605 EMAIL TOM@raywhitecement.com PREVAILING WAGE 810#3 TO: CITY OF CARLSBAD PH: ______ 7_6_0_-4.....;.3_4-_2-'-8-'-5_7 ____ _ 1166 CARLSBAD VILLAGE OR CELL: 760-434-7185 --------------- FAX: CARLSBAD CA 92008-2428 ATTENTION: TEMUJIN MATSUBARA --------------- EM A IL: TEMUJIN.MATSUBARA@CARLSBADCA.GOV . Project: STAGECOACH DRAINAGE WORK@ TENNIS COURTS ---------------------------- Lo cat Ion: STAGECOACH PARK OFF CAMINO DE LOS COACHES OUR WORK SHALL CONSIST'OF THE FOUOWING ITEMS: DRAINAGE CHANNEL WORK 1) REMOVE EXISTING ROCK FROM DRAIN AND STOCKPILE. INSTALL NEW 4" SOLID SCHEDULE 40 P.V.C PIPE WITH APPROXIMATE 4 DRAINS. CORE NEW 4 1/2" HOLE INTO EXJSTING DRAINAGE INLET BOX. INSTALL NEW CONCRETE DRAIN BOX AT SOUTHEAST END AT SIDEWALK FOR NEW DRAINAGE. FORM AND POUR 20 L/FT OF 6" TO 8" CURB TO RETAIN DIRT AT SLOPE. POUR NEW 1 O" TO 12" CURB AROUND EXISTING INLET BOX AT WEST END WITH CONCRETE APRON INCLUDED. RE INSTALL USED ROCK AROUND NEW DRAINAGE WHEN COMPLETED WITH JOB PRIME CONTRACTOR OR OWNER SHAU PROVIDE THE FOLLOWING: ' 1) PROVIDE AND INSTALL MORE ROCK IF NEEDED IN EXISTING DRAINAGE CHANNEL 2) PAYMENT DUE WITHIN 30 DAYS OF COMPLETION I• LUMP SUM PRICING: i' ! .J - ITEM PRICE 1) BID INCLUDES NEW DRAIN PIPE, CURB AND CONCRETE APRON AROUND DRAIN BOX TO HELP PREVENT EROSION 2) NOTE: BID INCLUDES BOND FOR THIS CONTRACT TOTAL: $ l9,840.oo NOTES: ____________________________________ _ S/~J~ RESPECTFULLY SUBMITTED BY: __ U ___ 1 ________ _ DATE:-'"'--6+--=--/3--=-/z_, _ ACCEPTED BY: _____________ _ DATE: ----------~ DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C C LIFORNIA ALL00 PURPOS CERTIFICATE OF ACKNOWLEDGM NT 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 valid ity of that document. State of California } County of San Diego } On Av~ust ID ir1 toz I before me, }\dssu\. ~~~~~.~.Jrnr.-:!,~.~~;1 ?u\ol il;- personally appeared 1) I ltY\ <:.. W n i \-G lA-0 d R~¼1 YYU>V)d (.A) h-i rG who proved to me on the basis of satisfactory evidence to be the person@ whose name®sl~ subscribed to the within instrument and acknowledged to me that he/she~executed the same in his/herl@" authorized capacity~, and that by his/her/~ignaturE@J on the instrument the person@) or the entity upon behalf of which the person@)acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. , ,eooeeoo+o++oo+oe+oo+eoo•••1 WITNESS my hand and official sea l. ~(Nota,yPoblicSealJ KELSSEA HANSON Commission No. 2298311 g~ NOTARY PUBLIC-CALIFORNIA -• SAN DIEGO COUNTY <",.••••• My Comm. Expires JULY 23, 2023 ADIDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT 1!>o Yl ~ I Lt) ritra&( (Title or description of attached document} (Title or description of attached document continued) Number of Pages __ Document Date ___ _ CAPACITY CLAIMED BY THE SIGNER D Individual (s) D Corporate Officer (Title) D Partner(s) D Attorney-in-Fact □ Trustee(s) □ Other _________ _ -..,...,,.,, ...,,.,.:::::zs;;;;p£;?.,. INSTRUCTIONS FOR COMPLETING THIS FORM This form complies with current California srat111es regarding natal)' wording and. if needed, should be completed and affached ro the documell/. Acknowledgments from ofh£'1' states may be completed.for documenrs being sent lo thaJ state so long as rhe wording does nor 1w111irn the California 11ot01J' to violale C'al/(omia notwJ· 1011•. • State and County information must be the Stale and County where the document signer(s) personally appeared before the notary public for acknowlcdg111tmt. o Dale of nolarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • T11e notary public must prilll his or her name as it appears within his or her commission followed by a comma and then your title (notary public). o Print the namc(s) of document signcr(s) who personally appear at lhc lime of notari7.ation. o Indi cate the concct singular or plural forms by cn)ssing off incorrect limns (i.e. l-!e/she/iliey, is /tffi! ) or cirding the correct forms. Failure lo correctly indicate this information may lead lo rejection of document recording. • The notary seal impression must be clear and photographi,ally reproducible. Impression must not cover text or lines. If seal impression smudges. re-seal if a sufficient area permits. otherwise complete a differenl acknowledgment form. • Signature or the notary public must mmch the signature rm file with U1c nfli<.:c of the county clerk. ❖ Additional infonnation is nut required but could help to ensure this acknowledgment is not misused or atlachcd to a di11crent documenl. ❖ Indicate title or type of attached document, number of pages and date. ❖ Indicate the capacity claimed by the signer. If the claimed capacity is a corporate o!licer, indicate the title (i.e. C'F.O, C'FO, Secretary). • Securely attach this document to lhe signed dncu1ncn1 with a staple. DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C POA/1_5_10_0_1_6 __ JOINT LIMITED POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That SureTec Insurance Company, a Corporation duly organized and existing under the laws of the State of Texas and having its principal office in the County of Harris, Texas and Markel Insurance Company (the "Company"), a corporation duly organized and existing under the laws of the state of Illinois, and having its principal administrative office in Glen Allen, Virginia, does by these presents make, constitute and appoint: Jerome L. Hren Their true and lawful agent(s) and attorney(s)-in-fact, each in their separate capacity if more than one is named above, to make, e•ecute, seal and deliver for and on their own behalf, individually as a surety or jointly, as co-sureties, and as their act and deed any and all bonds and other undertaking in suretyship provided; however, that the penal sum of any one such instrument eKecuted hereunder shall not eKceed the sum of: Fifteen Million and 00/100 Dollars ($15,000,000.00) This Power of Attorney is granted and is signed and sealed under and by the authority of the following R.esolutions adopted by the Board o.f Directors of SureTec insurance Company and Markel Insurance Company: "RESOLVED, That the President, Senior Vice President, Vice President. Assistant Vice President, Secretary, Treasurer and each of them hereby is authorized to e•ecute powers of attorney, and such authority can be executed by use of facsimile signature, which may bi, attested or acknowledged·by any officer or attorney, of the company, qualifying the attorney or attorneys named in the given power of attorney, to execute in behalf of, and acknowledge as the act and deed of the SureTec Insurance Company and Markel Insurance Company, as the case may be, all bond undertakings and contracts of suretyship, and to affix the corporate seal thereto." IN WITNESS WHEREOF, Markel Insurance Company and SureTec Insurance Company have caused their official seal to be·hereunto affixed and these presents to be signed by their duly authorized officers on the 1111, day of March , 2020 • SureTec Insurance Company By:'1'?~c~ Michael C. Keimig, President _,/ Commonwealth of Virginia County of Henrico 55: Markel lnsuraJ)ce Company 1/.f /I I. // ...---·-_, ( ,(A ,fA.._ I ,•:,-,, ,, 'Ii /1,, ,,,,_ ,. 1/ By: ~/ '~/J~V _______ _ n Russo, Senior Vice President On this 11111 day of March • 2020 A. D., before me, a Notary Public of the Commonwealth of Virginia, in and for the County of Henrico, duly commissioned and qualified, came THE ABOVE OFFICERS OF THE COMPANIES, to me personally known to be the individuals and officers described In, who eKecuted the preceding instrument. and they acknowledged the execution of same, and being by me duly sworn, disposed and said that they are the officers of the said companies aforesaid, and that the seals affixed .to the proceeding instrument are the Corporate Seals of said·Companies; and.the said Corporate Seals and their signatures as officers were dulv affixed and subscribed to the said instrument by the authority and direction of the said companies, and that Resolutions adopted by the Board of Directors of said Companies referred to in the preceding instrument is now in force. , , , "ti 1 • 1 .f,, ••' p,. 0 Otv,4 ,,, IN TESTIMONY WHEREOF, I have·hereunto set my hand, and affixed m~~~'l:l'Sea~a~tbe t~f,~f Henrico, the day and year first above written. • ~~.'• p.Y p, .'· /7, ...... • Q ••-<,.\"-V<5>"• ":>.., : /0 <', . .:•. ~ • • < MY 0 • -;; ,.,---·---.._, ,.,------.,. : : COMMISSION • -By: l~-----~.d -+-: <i; ~ NUivlBER : ~ : Donna Donavan!, Notary Public \ ¾ \ 7083968 /(jf f My commission e•pires 1/31/2023 ... ,,,..o·· .-~ .. ... ,~ I'///," '. ' • • • • • • • ...::,,--.: •• We, the undersigned Officers of SureTec Insurance Company and Marker19sll'r4ifi'll\!L~IQ}'ii.v dJi'l'lerby certify that the·original POWER OF ATTORNEY of which the foregoing is·a full, true and correct copy is still in full force and effect and ht! fv:lt,~';'i~ (fVl>l<\e'ct. IN WITNESS WHEREOF, we have hereunto set our hands, and affixed the Seals of said Companies, on the ~day of_. ___ A_u~g~u_s_t __ ~ __ 2_0_2_1 __ Markel Insurance Company /) ~ () .r--) Ju\ •? ,,, , ,V . ----,,;,----.......~ By:(/ <.:::::,,0 \~",-:,,1:::'. ) ....... ,..,.. I l "\/\ ... ---------- Richard R. Grinnan, Vice President a~ ary Any Instrument Issued in excess of the penalty stated above is totally void and without any validity. 510016 For verification of the authority of this Power you may call (713)812-0800 on any business day between 8:30 AM and 5:00 PM CST. DocuSign Envelope ID: 2873449F-D325-46B1-B5DB-C50426CDB60C 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 Riverside On August 6 . 2021 before me, Jennifer H. Hoagland, Notary Public (insert name and title of the officer) personally appeared ___ Je_r_o_m_e_L_._H_r_e_n ___________________ _ who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. (Seal) PUIUC · CIIUfOIIMA Cl> RM:IISIOE COUNTY ~ -.e.i, .. .11n.naot1Z ,...-........-.....~ . ., SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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 THISCERTIFICATE 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY 1/6/2021 Silva and Sons Insurance Services Inc.40485 Murrieta Hot Springs, Suite B4-205Murrieta, CA 92563 888-745-8259 951-763-8000 www.Silva-Ins.com Lic #0H99310 James River Insurance Company 12203 Everest National Insurance Company 10120 Liberty Mutual Insurance Company 23043 A 1,000,00000108105-0 10/1/2020 10/1/2021 100,000 3 5,000 3 1,000,000 2,000,000 2,000,0003 Per Project Aggregate 2,000,000 A 00095854-1 10/1/2020 10/1/2021 1,000,0003 1,000,0003 B 7600019547201 10/1/2020 10/1/2021 3 1,000,000Y 1,000,000 1,000,000 C COMMERCIAL PROPERTY BFS(22)56226606 10/15/2021 10/15/2022 LEASED/RENTED EQIUPMENT $50,000 Dennis Silva Dennis Silva Dsilva@Silva-Ins.com Ray White Cement 2380 Via Monserate Fallbrook CA 92028 59569952 3 3 3 3 City of Carlsbad Parks & Recreation Dept Subrogation applies to General liability and Workers Compensation / Primary and Non-Contributory endorsement applies as respects to North County Transit District 810 Mission Ave Oceanside CA 92054 North County Transit District, 3368 Eureka Place Ca - City library center are named additional insured as respects to the General Liability when required by written contract as per the attached form / Waiver of General Liability as per attached form. / Per Project Aggregate applies as respects to General liability per attached /Umbrella is over GL 59569952 | 20-21 GL XS WC CP(21-22) | Tammy Thrasher | 1/6/2021 10:54:24 AM (PST) | Page 1 of 5 This certificate cancels and supersedes ALL previously issued certificates. ACORD® I ~ I -□ □ - - ~ □ □ - -- -- -- -H I I I I I □ POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. 00108105-0 59569952 | 20-21 GL XS WC CP(21-22) | Tammy Thrasher | 1/6/2021 10:54:24 AM (PST) | Page 2 of 5 This certificate cancels and supersedes ALL previously issued certificates. POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Opera- tions Where required by written contract or written agreement. All operations of the Named Insureds. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organiza- tion(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 desig- nated and described in the schedule of this endorse- ment performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 00108105-0 59569952 | 20-21 GL XS WC CP(21-22) | Tammy Thrasher | 1/6/2021 10:54:24 AM (PST) | Page 3 of 5 This certificate cancels and supersedes ALL previously issued certificates. □ 00108105-0 59569952 | 20-21 GL XS WC CP(21-22) | Tammy Thrasher | 1/6/2021 10:54:24 AM (PST) | Page 4 of 5 This certificate cancels and supersedes ALL previously issued certificates. COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS EN DORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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: Any person or organization to which you are obligated by virtue of written contract to provide insurance such as is afforded by this policy, but only with respect to (1) occurrences taking place after such written contract has been executed and (2) occurrences resulting from work performed by you during the policy period, or occurrences resulting from the conduct of your business during the policy period. (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 Condition (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 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 D Ray White Cement 7600019547201 59569952 | 20-21 GL XS WC CP(21-22) | Tammy Thrasher | 1/6/2021 10:54:24 AM (PST) | Page 5 of 5 This certificate cancels and supersedes ALL previously issued certificates. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC040306 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CAI.IFORNIA We have the right lo ·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 otherwise due on such remuneration. % of the California workers' compensation premium SCHEDULE ·PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION -1998 by the Workers Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual• 1999, INSURED COPV Certificate Copy 397325 08-19-21 ENTRADA PREMIER INSURANCE CENTER 27601 FORBES RD STE 54 LAGUNA NIGUEL, CA 92677-1242 CITY OF CARLSBAD 799 PINE AVE STE 200 CARLSBAD, CA 92008-2428 CUSTOMER NUMBER: RUN DATE: Certificate Copy 648690744 10-01-2020 10-01-2021 RAY WHITE CEMENT 2380 VIA MONSERATE FALLBROOK CA 92028-9337 NON-FILL-IN FORMS REQUIRED - MANUALLY ATTACH Page 1 MCP 65 11-10 CERTIFICATE OF INSURANCE MCP 67 08-07 INSURANCE POLICY ENDORSEMENT POLINDEX 01 00 POLICYWRITING INDEX POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE NAMED INSURED AND MAILING ADDRESS ASSEMBLY INFORMATION I I Certificate Copy 648690744 10-01-2020 08-19-21 10-01-2021 ENTRADA PREMIER INSURANCE CENTER RAY WHITE CEMENT 2380 VIA MONSERATE FALLBROOK CA 92028-9337 CERTIFICATE HOLDER CITY OF CARLSBAD, MINOR PUBLIC WORKS ALGA NORE AND POINSETTIA PARK ARE NAMED CITY OF CARLSBAD X $ 2,000,000 AS ADDITIONAL INSURED AS RESPECTS TO THE GENERAL LIABILITY WHEN REQUIRED BY 799 PINE AVE STE 200 WRITTEN CONTRACT AS PER THE ATTACHED FORM/WAIVER OF SUBROGATION APPLIES AS CARLSBAD, CA 92008-2428 RESPECTS... CI CW A02 10 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission CI CW A02 10 11 Allstate Insurance Company Page 1 of 1 CERTIFICATE OF INSURANCE This certificate is issued for informational purposes only. It certifies that the policies listed in this document have been issued to the Named Insured. It does not grant any rights to any party nor can it be used, in any way, to modify coverage provided by such policies. Alteration of this certificate does not change the terms, exclusions or conditions of such policies. Coverage is subject to the provisions of the policies, including any exclusions or conditions, regard- less of the provisions of any other contract, such as between the certificate holder and the Named Insured. The limits shown below are the limits provided at the policy inception. Subsequent paid claims may reduce these limits. Certificate Holder: Named Insured: Automobile Liability Insurer Name: Allstate Insurance Company Policy Number: 1 --- Any Auto 2 --- Owned Autos Only 3 --- Owned Priv. Pass. Autos Only 4 --- Owned Autos Other Than Priv. Pass. Autos Only 5 --- Owned Autos Subject to No Fault 6 --- Owned Autos Subject to a Compulsory UM Law 7 --- Specifically Described Autos 8 --- Hired Autos Only 9 --- Non-owned Autos Only Policy Effective Date: Policy Expiration Date: Combined Single Limit (each accident) Limits Of Insurance: BI Per Person BI Per Accident PD Per Accident Description of Operations/Locations/Vehicles/Endorsements/Special Provisions Interested Party Type: THIS CERTIFICATE DOES NOT GRANT ANY COVERAGE OR RIGHTS TO THE CERTIFICATE HOLDER. IF THIS CERTIFICATE INDICATES THAT THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED, THE POLICY(IES) MUST EITHER BE ENDORSED OR CONTAIN SPECIFIC LANGUAGE PROVIDING THE CERTIFICATE HOLDER WITH ADDITIONAL INSURED STATUS. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ONLY TO THE EXTENT INDICATED IN SUCH POLICY LANGUAGE OR ENDORSEMENT. Producer: Authorized Representative: Date: I