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HomeMy WebLinkAboutTim Whittier Welding; 2022-10-05; PWM23-1950UTILPWM23-1950UTIL Agua Hedionda Lift Station Bridge Fence Replacement Page 1 of 6 City Attorney Approved 1/20/2020 CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT AGUA HEDIONDA LIFT STATION BRIDGE FENCE REPLACEMENT This agreement is made on the ______________ day of _________________________, 2022, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and Tim Whittier Welding, a sole proprietorship whose principal place of business is 26830 Kiavo Drive, Valley Center, CA 92082 (hereinafter called "Contractor"). City and Contractor agree as follows: DESCRIPTION OF WORK. Contractor shall perform all work specified in the Contract documents for the project described by these Contract Documents (hereinafter called "Project"). PROVISIONS OF LABOR AND MATERIALS. Contractor shall provide all labor, materials, tools, equipment, and personnel to perform the work specified by the Contract Documents unless excepted elsewhere in this Contract. CONTRACT DOCUMENTS. The Contract Documents consist of this Contract, exhibits to this Contract, Contractor's Proposal, the Plans and Specifications, the General Provisions, addendum(s) to said Plans and Specifications, and all proper amendments and changes made thereto in accordance with this Contract or the Plans and Specifications, all of which are incorporated herein by this reference. When in conflict, this Contract will supersede terms and conditions in the Contractor’s proposal. LABOR. Contractor will employ only skilled workers and abide by all State laws and City of Carlsbad Ordinances governing labor. GUARANTEE. Contractor guarantees all labor and materials furnished and agrees to complete the Project in accordance with directions and subject to inspection approval and acceptance by Jesse Castaneda (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. DocuSign Envelope ID: F498FB10-CE4D-42BC-8F61-78C3CEB637F5 October 5th PWM23-1950UTIL Agua Hedionda Lift Station Bridge Fence Replacement Page 2 of 6 City Attorney Approved 1/20/2020 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. 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 (5) years and that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or subcontractor from participating in contract bidding. Signature: ___________________________________ Print Name: __________Tim Whittier________________ 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 DocuSign Envelope ID: F498FB10-CE4D-42BC-8F61-78C3CEB637F5 PWM23-1950UTIL Agua Hedionda Lift Station Bridge Fence Replacement Page 3 of 6 City Attorney Approved 1/20/2020 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 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. 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 seven (7) working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within fifteen (15) working days after receipt of Notice to Proceed. /// /// /// /// /// /// DocuSign Envelope ID: F498FB10-CE4D-42BC-8F61-78C3CEB637F5 PWM23-1950UTIL Agua Hedionda Lift Station Bridge Fence Replacement Page 4 of 6 City Attorney Approved 1/20/2020 CONTRACTOR’S INFORMATION. Tim Whittier Welding 26830 Kiavo Drive (name of Contractor) 901580 (street address) Valley Center, CA 92082 (Contractor’s license number) C-60, 08/31/2023 (city/state/zip) 760-740-9069 (license class. and exp. date) 1000700702, 06/30/2023 (telephone no.) tw.welding@att.net (DIR registration number and exp. date) (e-mail address) 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 TIM WHITTIER WELDING, a sole proprietorship CITY OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) Tim Whittier, Owner Vicki V. Quiram, Utilities Director, as authorized by the City Manager (print name/title) By: (sign here) (print name/title) If required by City, proper notarial acknowledgment of execution by Contractor must be attached. If a corporation, Agreement must be signed by one corporate officer from each of the following two groups: Group A Group B Chairman, President, or Vice-President Secretary, Assistant Secretary, CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: CINDIE K. McMAHON, City Attorney BY: _____________________________ Assistant City Attorney DocuSign Envelope ID: F498FB10-CE4D-42BC-8F61-78C3CEB637F5 PWM23-1950UTIL Agua Hedionda Lift Station Bridge Fence Replacement Page 5 of 6 City Attorney Approved 1/20/2020 EXHIBIT A LISTING OF SUBCONTRACTORS BY GENERAL CONTRACTOR Set forth below is the full name and location of the place of business of each subcontractor 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 subcontractor for each subcontract. NOTE: The Contractor understands that if it fails to specify a subcontractor 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 Type of Work to be Subcontracted Business Name and Address DIR Registration No. License No., Classification & Expiration Date % of Total Contract NONE Total % Subcontracted: _______________ The Contractor must perform no less than 50% of the work with its own forces. DocuSign Envelope ID: F498FB10-CE4D-42BC-8F61-78C3CEB637F5 PWM23-1950UTIL Agua Hedionda Lift Station Bridge Fence Replacement Page 6 of 6 City Attorney Approved 1/20/2020 EXHIBIT B AGUA HEDIONDA LIFT STATION BRIDGE FENCE REPLACEMENT JOB QUOTATION ITEM NO. UNIT QTY DESCRIPTION PRICE 1 LS 1 Add galvanized pipe to make a 4’ panel and add galvanized expanded metal. This will be at 4 different locations on the sides of the gates on each end of the bridge. $16,000 1 LS 1 Replace chain link with galvanized expanded metal. Location is on 4 different panels between the gates and the fence extension panels. $3,000 TOTAL* $19,000 *Includes taxes, fees, expenses and all other costs. *Includes fabrication, delivery, hardware and install. Prevailing wage for installation. *Does not include barbed wire, paint, drywall, texture, stucco, concrete, tile, carpet or any type of flooring. *Does not include anything not specifically written in this contract. DocuSign Envelope ID: F498FB10-CE4D-42BC-8F61-78C3CEB637F5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE 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 onthis 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. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBRWVDADDLINSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. 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 COMPENSATIONAND 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 OCCURRENCEDAMAGE 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 Murrieta, CA 92564 P.O. Box 947 c/o EXIGIS Insurance Compliance Services City of Carlsbad/CMWD The City of Carlsbad is listed as additional insured and in favor of the waivers of subrogation. 1,000,000 1,000,000 1,000,00009/09/2309/09/22CWC00154001YYB 1,000,000 2,000,000 1,000,000 50,000 50,000 1,000,000 06/27/2306/27/22SCB-GL-000011078YYA Clear Spring Property and Casualty Company Obsidian Specialty Insurance Company 92082CAValley Center, CA 92082 26830 Kiavo Dr. Tim Whittier Welding Tim Whittier (760)687-4007(760)431-0947 Faby Cruz License #: Oceanside, CA 92054 2111 S El Camino Real #201 EMPLOYERS CHOICE INS SVCS INC 09/01/22 ACORD® I ~ I X ~ □ [X] ~ ~ ~ □ □ ~ ~ ~ ~ ~ ~ ~ ~ H I I X I I I □ Obsidian Specialty Insurance Company 1330 Avenue of the Americas, Suite 23A • New York, NY 10019 • 800-684-5428 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OBSIDIAN SPECIALTY INSURANCE COMPANY COMMERCIAL GENERAL LIABILITY POLICY ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION INCLUDING WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. Name of Additional Insured: As required by a legally enforceable written agreement entered into prior to commencement of the Named Insured's work. Designated Project/Location to which this endorsement applies: All Projects and Locations (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section III -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 performed during the policy period for the additional insured(s) at the location(s) designated above. B. This insurance does not apply to "bodily injury" or "property damage" that takes place after, and the Additional Insured's status as an additional insured terminates, upon the earlier of when: I. All work, including materials, parts or equipment furnished by the Named Insured in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor engaged in performing operations for a principal as part of the same project. C. If expressly required by a written and legally enforceable contract entered into by the Named Insured prior to commencement of work by the Named Insured for the Additional Insured, then we waive any right of subrogation we may have against an entity that is an Additional Insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" performed under such written and legally enforceable contract with that Additional Insured. Coverage for any additional insured is governed by the terms, conditions, and exclusions of this policy and all endorsements, including the Insuring Agreement. The coverage provided for any additional insured is only to the extent of and in the proportion the additional Insured is held liable for the negligence or strict liability/conduct/acts of the Named Insured. No coverage is provided for liability based upon the acts, errors or omissions of the Additional Insured. Except as set forth above, all of the terms, conditions and exclusions of this policy apply and remain in effect. Policy No.: SCB-GL-000011078 Date: Time: 06/27/2022 12:01 a.m. OSIC AIE OOPWOS 00 01 0318 Obsidian Specialty Insurance Company By: Secretary Page 1 of 1 Obsidian Specialty Insurance Company 1330 Avenue of the Americas, Suite 23A • New York, NY 10019 • 800-684-5428 TIDS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OBSIDIAN SPECIAL TY INSURANCE COMPANY COMMERCIAL GENERAL LIABILITY POLICY ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION INCLUDING PRIMARY COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. Name of Additional Insured: As required by a legally enforceable written agreement entered into prior to commencement of the Named Insured's work. Designated Project/Location to which this endorsement applies: All Projects and Locations (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section III -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 performed during the policy period for the additional insured(s) at the location(s) designated above. B. This insurance does not apply to "bodily injury" or "property damage" that takes place after, and the Additional Insured's status as an additional insured terminates, upon the earlier of when: 1. All work, including materials, parts or equipment furnished by the Named Insured in connection with such work, on the project ( other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor engaged in performing operations for a principal as part of the same project. C. If expressly required by a written and legally enforceable contract entered into by the Named Insured prior to commencement of work by the Named Insured for the Additional Insured, the insurance afforded by the policy to the Additional lnsured(s) listed in the Schedule for the described location(s) is primary insurance. Any other insurance or self-insurance maintained directly by the Additional lnsured(s) is excess of this insurance and shall not contribute to it. Coverage for any additional insured is governed by the terms, conditions, and exclusions of this policy and all endorsements, including the Insuring Agreement. The coverage provided for any additional insured is only to the extent of and in the proportion the additional Insured is held liable for the negligence or strict liability/conduct/acts of the Named Insured. No coverage is provided for liability based upon the acts, errors or omissions of the Additional Insured. Except as set forth above, all of the terms, conditions and exclusions of this policy apply and remain in effect. Policy No.: SCB-GL-000011078 Date: Time: 06/27/2022 12:01 a.m. OSIC AIE OOP 00 01 0318 Obsidian Specialty Insurance Company Page 1 of 1 Obsidian Specialty Insurance Company 1330 Avenue of the Americas, Suite 23A • New York, NY 10019 • 800-684-5428 TIDS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OBSIDIAN SPECIALTY INSURANCE COMPANY COMMERCIAL GENERAL LIABILITY POLICY ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON ORGANIZATION ONGOING OPERATIONS ONLY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. Name of Additional Insured: As required by a legally enforceable written agreement entered into prior to commencement of the Named Insured's work. Designated Project/Location to which this endorsement applies: All Projects and Locations (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section III -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 performed during the policy period for the additional insured(s) at the location(s) designated above. B. This insurance does not apply to "bodily injury" or "property damage" that takes place after, and the Additional Insured's status as an additional insured hereunder terminates, upon the earlier of: 1. All work, including materials, parts or equipment furnished by the Named Insured in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor engaged in performing operations for a principal as part of the same project. Coverage for any additional insured is governed by the terms, conditions, and exclusions of this policy and all endorsements, including the Insuring Agreement. The coverage provided for any additional insured is only to the extent of and in the proportion the additional Insured is held liable for the negligence or strict liability/conduct/acts of the Named Insured. No coverage is provided for liability based upon the acts, errors or omissions of the Additional Insured. Except as set forth above, all of the terms, conditions and exclusions of this policy apply and remain in effect. Policy No.: SCB-GL-000011078 Date: Time: 06/27/2022 12:01 a.m. OSIC AIE ONO 00 01 0318 Obsidian Specialty Insurance Company Secretary Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) 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. on such remuneration. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT 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: 09/09/2022 Policy No. CWC00154001 Endorsement No. 0 Insured Whittier, Timothy (An Individual)Insurance Company Clear Spring Property and Casualty Company The additional premium for this endorsement shall be 0.025 % of the California workers' compensation premium otherwise due • INTERINSURANCE EXCHANGE of the Automobile Club MAILING ADDRESS: P. 0. BOX 25001 , SANTA ANA, CALIFORNIA 92799-5001 BINDER OF INSURANCE Additonal Insured Provided For: Policy Number CAA 139551837 Control Number CITY OF CARLSBAD/CMWD C/0 EXIGIS INSURAN P.O. BOX 947 NOTICE TO LIENHOLDER IN THE EVENT OF CANCELLATION OF THIS BINDER, THE EXCHANGE WILL GIVE THE LIENHOLDER 10 DAYS WRITTEN NOTICE OF CANCELLATION. MURRIETA CA 92564 Loan Number ---------- Po Ii c y Effective Dates: 04/02/2022 -04/02/2023 The lnterinsurance Exchange of the Automobile Club hereby acknowledges itself bound to the named insured for the coverages specified in the schedule subject to all the provisions of the Exchange's applicable policy form. The issuance of a policy to the named insured or, if a policy is in force, the issuance of an endorsement covering the automobile, boat or trailer described herein shall void this binder. A pro rata premium charge computed for the term of coverage in accordance with the current rates of the Exchange in effect at the inception of the binder will be made unless such a policy or policy endorsement is issued. This binder shall not be construed to afford cumulative insurance with any existing policy. Name of Insured TIMOTHY ALAN WHITTIER DESCRIPTION OF AUTOMOBILE, BOAT, OR TRAILER Car# Year Trade Name Type of Body or Boat Identification Number 1 2004 DODG RAM 3500 CREW C 3D3LU38614G107580 AUTOMOBILE INSURANCE LIMITS OF LIABILITY "x" indicates Coverage bound and afforded Bodily Injury Liability $1 Million dollars, each person Car#1 Car#2 Car # $1 Million dollars, each occurrence X Property Damage $1 Million dollars, each occurrence X Medical Payments each person Underinsured/U ninsured Motorist Not less Than 100,000 each person/$300,000 each accident X Comprehensive (include Fire and (a) Actual Cash Value less $1 ,000 deductible X Theft) (b) Limit of Liability of less deductible Collision (a) Actual Cash Value less $0 deductible (b) Limit of Liability of less deductible Uninsured Deductible Waiver Uninsured Collision X RENTERS INSURANCE LIMITS OF LIABILITY "x" indicates Coverage bound and afforded Renters Insurance thousand dollars, each occurrence Actual Cash Value not to exceed Limit of Liability of less deductible Effective Date of Binder September 15, 2022 12:01 AM This binder shall expire 30 days from the effective date or may be canceled by the named insured at any time during such 30 day period. The Exchange may cancel this binder by mailing to the named insured at the address shown above written notice stating when, not less than 19 days thereafter, such cancellation shall be effective. The mailing of such notice shall be sufficient proof of notice. District Office By 30510 E B~B7 EZEQUIEL CHAVEZ (Authorized Representative) ACSC Management Services, Inc ATTORNEY-IN FACT