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HomeMy WebLinkAboutAce Electric Inc; 2023-12-12; PKRC23-1108Tracking #: POINSETTIA COMMUNITY PARK LIGHT POLE AND FIXTURE REPLACEMENT; CONT. NO. PKRC23-1108 Page 1 of 6 City Attorney Approved 5/3/2023 CITY OF CARLSBAD MINOR PUBLIC WORKS CONTRACT POINSETTIA COMMUNITY PARK LIGHT POLE AND FIXTURE REPLACEMENT; CONT. NO. PKRC23-1108 This agreement is made on the ______________ day of _________________________, 20___, by the City of Carlsbad, California, a municipal corporation, (hereinafter called "City"), and Ace Electric, Inc. whose principal place of business is P.O. Box 601071, San Diego, CA 92160 (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, as contained in the Standard Specifications for Public Works Construction “Greenbook,” latest edition and including all errata; Part 1 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: 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. DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD 12th December 23 Tracking #: POINSETTIA COMMUNITY PARK LIGHT POLE AND FIXTURE REPLACEMENT; CONT. NO. PKRC23-1108 Page 2 of 6 City Attorney Approved 5/3/2023 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 years and that debarment by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contractor or subcontractor from participating in contract bidding. Signature: ___________________________________ Print Name: ___________________________________ REQUIRED INSURANCE. The successful contractor shall provide to the City of Carlsbad, a Certification of Commercial General Liability and Property Damage Insurance and a Certificate of Workers’ Compensation Insurance indicating coverage in a form approved by the California Insurance Commission. The certificates shall indicate coverage during the period of the contract and must be furnished to the City prior to the start of work. The minimum limits of liability insurance are to be placed with California admitted insurers that have a current Best's Key Rating of not less than "A-:VII"; OR with a surplus line insurer on the State of California’s List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best’s Key Rating Guide of at least “A:X”; OR an alien non-admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report. Commercial General Liability Insurance of Injuries including accidental death, to any one person in an amount not less than……..$1,000,000 Subject to the same limit for each person on account of one accident in an amount not less than ….…$1,000,000 Property damage insurance in an amount of not less than……..$1,000,000 Automobile Liability Insurance in the amount of $1,000,000 combined single limit per accident for bodily injury and property damage. In addition, the auto policy must cover any vehicle used in the performance of the contract, used onsite or offsite, whether owned, non-owned or hired, and whether scheduled or non-scheduled. The automobile insurance certificate must state the coverage is for “any auto” and cannot be limited in any manner. The above policies shall have non-cancellation clauses providing that thirty (30) days written notice shall be given to the City prior to such cancellation. The policies shall name the City of Carlsbad as an additional insured. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD Christopher Hinds Tracking #: POINSETTIA COMMUNITY PARK LIGHT POLE AND FIXTURE REPLACEMENT; CONT. NO. PKRC23-1108 Page 3 of 6 City Attorney Approved 5/3/2023 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 60 working days after receipt of Notice to Proceed. Completion: Contractor agrees to complete work within 90 working days after receipt of Notice to Proceed. CONTRACTOR’S INFORMATION. Ace Electric, Inc. P.O. Box 601071 (name of Contractor) 835109 (street address) San Diego, CA 92160 (Contractor’s license number) C-10, A, 3/31/2024 (city/state/zip) 619-814-4768 (license class. and exp. date) 1000001519 (telephone no.) 619-521-9742 (DIR registration number) 6/30/2026 (fax no.) brian.b@aceelectricinc.com (DIR registration exp. date) (e-mail address) /// /// /// /// DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD Tracking #: POINSETTIA COMMUNITY PARK LIGHT POLE AND FIXTURE REPLACEMENT; CONT. NO. PKRC23-1108 Page 4 of 6 City Attorney Approved 5/3/2023 AUTHORITY. The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. CONTRACTOR CITY OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) Christopher Hinds, Co-CEO Parks & Recreation Department Director (print name/title) By: ATTEST: N/A single signer (sign here) SHERRY FREISINGER City Clerk (print name/title) If required by City, proper notarial acknowledgment of execution by Contractor must be attached. If a corporation, Agreement must be signed by one 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: _____________________________ Deputy / Assistant City Attorney DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD Tracking #: POINSETTIA COMMUNITY PARK LIGHT POLE AND FIXTURE REPLACEMENT; CONT. NO. PKRC23-1108 Page 5 of 6 City Attorney Approved 5/3/2023 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 Type of Work to be Subcontracted Business Name and Address DIR Registration No. License No., Classification & Expiration Date % of Total Contract Total % Subcontracted: _______________ The Contractor must perform no less than 50% of the work with its own forces. DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD 0 Tracking #: POINSETTIA COMMUNITY PARK LIGHT POLE AND FIXTURE REPLACEMENT; CONT. NO. PKRC23-1108 Page 6 of 6 City Attorney Approved 5/3/2023 EXHIBIT B SCOPE OF WORK SUMMARY Furnish and install one 25’ light pole with fixture at the north entrance to Poinsettia Community Park. Labor includes: • Removing the old base plate and cleaning the area. • Verifying bolt circle prior to procurement. • Lifting equipment. • Lamp disposal. • Prevailing wage. Exclusions: • Temporary power and lighting. • Electrical permits and fees. • Repairs to existing electrical system. • Payment and performance bonds. JOB QUOTATION ITEM NO. UNIT QTY DESCRIPTION PRICE 1 1 Parts and materials: • Valmont Pole R24084060T4, Bronze color • Luminaire Fixture Lithonia DSX2LED, Bronze color $8,521 2 1 Labor $2,980 3 1 Lift equipment $1,985 TOTAL* $13,486 *Includes taxes, fees, expenses, prevailing wage and all other costs. DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD P.O. Box 601071 Lic. No. 835109 A,C10 Tel (619) 814-4768 San Diego, CA 92160-1071 www.AceElectricInc.com Fax (619) 521-9742 DIR #1000001519 October 30, 2023 City of Carlsbad 1166 Carlsbad Village Dr. Carlsbad, CA 92008 Attention: Rodney Nishimoto Project: Poinsettia Park Replace One Damaged Pole Light Carlsbad, CA 92010 We are pleased to submit our proposal for the re-wire work on the above referenced project. Our price is based upon our site visit, and is subject to the following inclusions and exclusions: Inclusions:  Furnish and install one 25’ pole with fixture  Remove old base plate, clean area  Verify bolt circle prior to procurement  Lift equipment  Prevailing wages  Access is clear, with no obstructions  Work during normal business hours ( 7-3:30 M-F ) Exclusions:  Temporary power and lighting  Electrical permits and fees  Repairs to existing electrical system  Payment and performance bonds Pricing: Materials, Parts and Shipping $ 8,521 Labor 2,980 Equipment 1,985 Total $ 13,486 Please call us if you have any questions or need additional information. Thank you, BrianABarrett Brian A. Barrett DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD 0 ACE ELECTRIC DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD 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 3/21/2023 Cavignac451 A Street, Suite 1800San Diego CA 92101 Certificate Department 619-744-0574 619-234-8601 certificates@cavignac.com Travelers Indemnity Co of Amer 25666 ACEEL00001 Travelers Indemnity Co of Conn 25682Ace Electric, Inc.PO Box 601071San Diego CA 92160 Travelers Property Casualty Company of America 25674 559195990 A X 1,000,000 X 300,000 5,000 1,000,000 2,000,000 X Y DTCO4W080574-TCT-23 3/25/2023 3/25/2024 2,000,000 B 1,000,000 X 8104W079876-23-26-G 3/25/2023 3/25/2024 C X 8,000,000 X CUP-4W080838-23-26 3/25/2023 3/25/2024 8,000,000 X 10,000 C XYUB1W363753-23 1/1/2023 1/1/2024 1,000,000 1,000,000 1,000,000 AAA Leased/Rented EquipmentInstallation FloaterTransit Limit DTCO4W080574-TCT-23DTCO4W080574-TCT-23DTCO4W080574-TCT-23 3/25/20233/25/20233/25/2023 3/25/20243/25/20243/25/2024 LimitLimitLimit $250,000$500,000$250,000 Re: All Projects. Additional Insured coverage applies to General Liability for 'The City of Carlsbad' per policy form. Waiver of subrogation applies to WorkersCompensation per policy form. Excess/Umbrella policy follows form over underlying policies: General Liability, Auto Liability & Employers Liability (additionalinsured and waiver of subrogation apply when afforded on underlying policies). If the insurance company elects to cancel or non-renew coverage for any reasonother than nonpayment of premium Cavignac will provide 30 days notice of such cancellation or nonrenewal. City of Carlsbad/CMWDc/o EXIGIS Insurance Compliance ServicesP.O. Box 947Murrieta CA 92564 DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD ACORD® I ~ I ~ □ □ ~ ~ Fl □ □ ~ ~ ~ ~ ~ ~ ~ ~ H I I I I I □ I Policy No. DTCO4W080574-TCT-23 DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (Includes Products-Completed Operations If Required By Contract) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS The following is added to SECTION II -WHO IS AN INSURED: Any person or organization that you agree in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only: a. With respect to liability for "bodily injury" or "property damage" that occurs, or for "personal injury" caused by an offense that is committed, subsequent to the signing of that contract or agreement and while that part of the contract or agreement is in effect; and b. If, and only to the extent that, such injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the written contract or agreement applies. Such person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. The insurance provided to such additional insured is subject to the following provisions: a. If the Limits of Insurance of this Coverage Part shown in the Declarations exceed the minimum limits required by the written contract or agreement, the insurance provided to the additional insured will be limited to such minimum required limits. For the purposes of determining whether this limitation applies, the minimum limits required by the written contract or agreement will be considered to include the minimum limits of any Umbrella or Excess liability coverage required for the additional insured by that written contract or agreement. This provision will not increase the limits of insurance described in Section Ill -Limits Of Insurance. b. The insurance provided to such additional insured does not apply to: (1) Any "bodily injury", "property damage" or "personal injury" arising out of the providing, or failure to provide, any professional architectural, engineering or surveying services, including: (a) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders or change orders, or the preparing, approving, or failing to prepare or approve, drawings and specifications; and (b) Supervisory, inspection, architectural or engineering activities. (2) Any "bodily injury" or "property damage" caused by "your work" and included in the "products-completed operations hazard" unless the written contract or agreement specifically requires you to provide such coverage for that additional insured during the policy period. c. The additional insured must comply with the following duties: (1) Give us written notice as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, such notice should include: (a) How, when and where the "occurrence" or offense took place; (b) The names and addresses of any injured persons and witnesses; and (c) The nature and location of any injury or damage arising out of the "occurrence" or offense. (2) If a claim is made or "suit" is brought against the additional insured: CG D2 46 0419 © 2018 The Travelers Indemnity Company. All rights reserved. Page 1 of 2 Policy No. DTCO4W080574-TCT-23DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD COMMERCIAL GENERAL LIABILITY (a) Immediately record the specifics of the claim or "suit" and the date received; and (b) Notify us as soon as practicable and see to it that we receive written notice of the claim or "suit" as soon as practicable. (3) Immediately send us copies of all legal papers received in connection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit'', and otherwise comply with all policy conditions. (4) Tender the defense and indemnity of any claim or "suit" to any provider of other insurance which would cover such additional insured for a loss we cover. However, this condition does not affect whether the insurance provided to such additional insured is primary to other insurance available to such additional insured which covers that person or organization as a named insured as described in Paragraph 4., Other Insurance, of Section IV -Commercial General Liability Conditions. Page 2 of 2 © 2018 The Travelers Indemnity Company. All rights reserved. CG D2 46 0419 DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD ~ TRAVELERSJ , ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A)-001 POLICY NUMBER: UB-1W363753-23 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be 2. oo % of the California workers' compensation pre- mium. Person or Organization ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. Schedule Job Description 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 Insured Insurance Company DATE OF ISSUE: 12-20-22 Policy No. Endorsement No. Premium Countersigned by ___________ _ ST ASSIGN: Page 1 of 1 DocuSign Envelope ID: 69A4EC88-920A-4437-8BA8-9F70472C4CAD ~ TRAVELERSJ , ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 0313 (00) -001 POLICY NUMBER: UB-1W363753-23· WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. SCHEDULE DESIGNATED PERSON: DESIGNATED ORGANIZATION: ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. DATE OF ISSUE: 12-20-22 ST ASSIGN: PAGE 1 OFl