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Insurance - GCI Construction - 2021-4-01 (3)ACt7►R 7 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 4/1/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and c r ftpolicy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate hol of such endorsement(s). PRODUCER Compass Direct Insurance Services, Inc. 13681 Newport Ave., Ste 8 #622 APR 2 Tustin, CA 92780 CONTACT E: Jeremy Seltzer C"No 714-665-9800 1 ac No: 714-665-9801 EMAIL ADDRESS: jeremy@cdisi.com D);St)"iCt INSURERS) AFFORDING COVERAGE NAIC # www.cdisi.com License #01-1161(roosts mesa Sanity INSURERA: Greenwich Insurance Company 22322 INSURED GCI Construction, Inc. 1031 Calle Recodo, Ste. D San Clemente CA 92673 INSURER B : Everest National Insurance Compariv 10120 INSURERC: Westchester Surplus Lines Insurance Co 10172 INSURER D : INSURER E : INSURER F : <041T/4C1r_1C1 M:3a9l:1(K.r9:0:IILT, :i:3: _-7:iUh-iCeTTETIILT, 1.l3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 TR TYPE OF INSURANCE INSD WVD SUER POLICY NUMBER MM/DD POLICY EFF MM1DI D1 EXP LIMITS A �/ COMMERCIAL GENERAL LIABILITY ✓ NPC-1003310-01 4/1/2021 4/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ❑✓ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 50 000 ✓ MED EXP (Any one person) $ Excluded Owner's/Copt. Pro ✓ XCU/Deductible $5 000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY a EC LOC PRODUCTS - COMP/OP AGG $ 2,000,000 Em to ee Benifits $1,000,000 OTHER: I A AUTOMOBILE LIABILITY ✓ NBA-1003312-01 4/1/2021 4/1/2022 COEa accciden SINGLE LIMIT $1,000,000 ✓ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ ✓ Perr accidenDAMAGE $ HIRED NON -OWNED AUTOS ONLY ✓ AUTOS ONLY Comp/Coll Ded $1,000 $ No Liability Deductible A �/ UMBRELLA LIAB ,/ OCCUR N EC-6006091-01 4/1/2021 4/1/2022 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4 000,000 EXCESS LIAB CLAIMS -MADE $0 Deductible DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N / A ✓ 7600019322201 8/1/2020 8/1/2021 ,/ SPER TATUTE ERH E.L. EACH ACCIDENT $ 1.000 000 E.L. DISEASE - EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below I $0 Deductible E.L. DISEASE - POLICY LIMIT $1,000,000 A IM-Eqp./Lesd-Hrd-R NIM-1003311-01 4/1/2021 4/1/2022 Sch/Per:481K/100K Deductible $1,000 A BPP NIM-1003311-01 4/1/2021 4/1/2022 $100,000 Deductible $1,000 C Pollution G46866435 004 2/2/2021 2/2/2022 2,000,000 Deductible $5,000 D Builders Risk ER73822219 1 1/28/2021 1/28/2022 1$244,200 Deductible $2 500 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) The Costa Mesa Sanitary District, the City of Costa Mesa, it's elected and appointed officials, agents, officers, volunteers and employees are additional insureds as per attached endorsements with respects to the operations of the named insured as per contract. GCI Job# 616 Job Name: #318 President Pump Station Reconstruction Project No. 318 Gt:K 1 It'IGA I It MULUtK GANGtLLA I IUN GCI Job #616 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 290 Paularino Avenue u ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa CA 92626 f AUTHORIZED REPRESENTATIVE Jeremy Seltzer ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 91 IT71 r'71 I 'iT-')') (:T. DTT TTMR TT(` TMT'/T.WT7 I Mi- T.­it .,h1-, I A/1 PM91 1-'47./77 DM IDT)T1 I Dino 1 of 1r. POLICY NUMBER: NPC-1003310-01 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE I Name Of Additional Insured Person(s) I I Or Oroanization(s) Location And Description Of Completed Operations lanket as required by written contract. lanket as required by written contract. 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 04 13 O Insurance Services Office, Inc., 2012 61021571 1 21-22 GL AU UMB WC IME/LHR I Nina Lautenschlacxer 1 4/1/2021 3:37:03 PM (PDT) I Paae 2 of 15 Page 1 of 1 POLICY NUMBER: NPC-1003310-01 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES Oli 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) I Location(s) Of Covered Operations Blanket as required by written contract. (Blanket as required by written contract. 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) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 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 or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 O Insurance Services Office, Inc., 2012 CG 20 10 04 13 61021571 1 21-22 GL AU UMB WC IME/LHR I Nina Lautenschlaaer 1 4/1/2021 3:37:03 PM (PDT) I Paste 4 of 15 POLICY NUMBER: NPC-1003310-01 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Policy aggregate limit applies per work site. I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by "occur- damages or under Coverage C for medical rences" under Section I — Coverage A, and for all expenses shall reduce the Designated Con - medical expenses caused by accidents under struction Project General Aggregate Limit for Section I — Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag- construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con- 1. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla- cept damages because of "bodily injury" or rations, such limits will be subject to the appli- "property damage" included in the "products- cable Designated Construction Project Gen - completed operations hazard", and for medi- eral Aggregate Limit. cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits' . CG 25 03 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 2 0 B. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occur- rences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section 1 — Coverage C, which cannot be at- tributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical D. expenses shall reduce the amount available under the General Aggregate Limit or the Products -completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. When coverage for liability arising out of the "products -completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction pro- ject. E. The provisions of Section III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 © Insurance Services Office, Inc., 2008 61021571 1 21-22 GL AU UMB WC IME/LHR I Nina Lautenschlacrer 1 4/1/2021 3:37:03 PM (PDT) I Paqe 6 of 15 CG 25 03 05 09 ❑ Policy Number: NPC-1003310-01 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number: NPC-1003310-01 BLANKET WAIVER OF SUBROGATION The following is added to Section IV -Commercial General Liability Conditions: Waiver of Subrogation We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of premises owned or occupied or rented or loaned to you; ongoing operations performed by you or on your behalf, done under a contract with that person or organization; "your work"; or "your products". We waive this right where you have agreed to do so as part of a written contract, executed by you prior to loss. Form XIL 436 1208 © 2008, XL America, Inc. Page 7 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 61021571 1 21-22 GL AU UMB WC IME/LHR I Nina Lautenschlacter 1 4/1/2021 3.37:03 PM (PDT) I Paae 8 of 15 POLICY NUMBER: NBA-1003312-01 XIC 421 1013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XL PLUS BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM COVERAGE DESCRIPTION A. Temporary Substitute Auto Physical Damage B. Who Is An Insured 1. Broad Form Insured 2. Employees As Insureds 3. Additional Insured By Contract, Agreement or Permit 4. Employee Hired Autos C. Supplementary Payments D. Amended Fellow Employee Exclusion E. Physical Damage Coverage 1. Rental Reimbursement 2. Extra Expense — Broadened Coverage 3. Personal Effects Coverage 4. Lease Gap 5. Glass Repair — Waiver Of Deductible F. Physical Damage Coverage Extensions 1. Additional Transportation Expense 2. Hired Auto Physical Damage G. Business Auto Conditions 1. Notice Of Occurrence 2. Waiver Of Subrogation 3. Unintentional Failure To Disclose Hazards 4. Primary Insurance H. Bodily Injury Redefined I. Extended Cancellation Condition XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 1 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. A. Temporary Substitute Auto Physical Damage SECTION 1 — COVERED AUTOS, C. Certain Trailers, Mobile Equipment And Temporary Substitute Autos is changed by adding the following: If Physical Damage coverage is provided by this Coverage Form, the following types of vehicles are also covered "autos" for Physical Damage coverage: 1. Any "auto" you do not own while used with the permission of its owner as a temporary substitute for a covered "auto" you own that is out of service because of its: a. Breakdown; b. Repair; C. Servicing; d. "Loss"; or e. Destruction. B. Who Is An Insured SECTION II — COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured is changed by adding the following: 1. Broad Form Insured For any covered "auto", any subsidiary, affiliate or organization, other than a partnership or joint venture, as may now exist or hereafter be constituted over which you assume active management or maintain ownership or majority interest, provided that you notify us within ninety (90) days from the date that any such subsidiary or affiliate is acquired or formed and that there is no similar insurance available to that organization. However, coverage does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization. 2. Employees As Insureds Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow, in your business or your personal affairs. 3. Additional Insured By Contract, Agreement Or Permit Any person or organization with whom you have agreed in writing in a contract, agreement or permit, to provide insurance such as is provided under this policy, provided that the "bodily injury" or "property damage" occurs subsequent to the execution of the written contract, agreement or permit. 4. Employee Hired Autos An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 2 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 61021571 1 21-22 GL AU UMB WC IME/LHR I Nina Lautenschlaaer 1 4/1/2021 3:37:03 PM (PDT) I Pane 10 of 15 SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, b. is replaced with the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow; and (2) Any covered "auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". C. Supplementary Payments SECTION 11 — COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 2. Coverage Extensions, a. Supplementary Payments is changed as follows: Item (2) is deleted and replaced by the following: (2) Up to $3,500 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We do not have to furnish these bonds. Item (4) is deleted and replaced by the following: (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work. D. Amended Fellow Employee Exclusion SECTION 11— COVERED AUTOS LIABILITY COVERAGE, B. Exclusions, 5. Fellow Employee does not apply. The insurance provided under this Provision D. is excess over any other collectible insurance. E. Physical Damage Coverage SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage is changed by adding the following: 1. Rental Reimbursement a. We will pay for rental reimbursement expenses incurred by you for the rental of an "auto" because of "loss" to a covered "auto". Payment applies in addition to the otherwise applicable amount of each coverage you have on a covered "auto". No deductibles apply to this coverage. b. We will pay only for those expenses incurred during the policy period beginning twenty-four (24) hours after the "loss" and ending, regardless of the policy's expiration, with the lesser of the following number of days: XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 3 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. (1) The number of days reasonably required to repair or replace the covered "auto". If "loss" is caused by theft, this number of days is added to the number of days it takes to locate the covered "auto" and return it to you. (2) Thirty (30) days. C. Our payment is limited to the lesser of the following amounts: (1) Necessary and actual expenses incurred. (2) $50 any one day per private passenger "auto"; $100 any one day per truck; $1,500 any one period per private passenger "auto"; $3,000 any one period per truck; or Higher limits if shown elsewhere in this policy. d. This coverage does not apply while there are spare or reserve "autos" available to you for your operations. e. If "loss" results from the total theft of a covered "auto' of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided for under the Physical Damage Coverage Extension. 2. Extra Expense — Broadened Coverage We will pay for the expense of returning a stolen covered "auto' to you. 3. Personal Effects Coverage If you have purchased Comprehensive Coverage on this policy for an "auto' you own and that "auto" is stolen, we will pay, without application of a deductible, up to $500 for "personal effects" stolen from the "auto". As used in this endorsement, "personal effects" means tangible property that is worn or carried by an "insured". "Personal effects" does not include tools, jewelry, money or securities. 4. Lease Gap In the event of a total "loss" to a covered "auto' shown in the Declarations, we will pay any unpaid amount due on the lease or loan for a covered "auto', less: a. The amount paid under the Physical Damage Coverage Section of the policy; and b. Any: (1) Overdue lease/loan payments at the time of the "loss"; (2) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; (3) Security deposits not returned by the lessor; (4) Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchases with the loan or lease; and (5) Carry-over balances from previous loans or leases. XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 4 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 61021571 1 21-22 GL AU UMB WC IME/LHR I Nina LautenschlaQer 1 4/1/2021 3:37:03 PM (PDT) I Pacre 12 of 15 5. Glass Repair — Waiver Of Deductible No deductible applies to glass damage if the glass is repaired rather than replaced. F. Physical Damage Coverage Extensions SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions is amended by the following: 1. Additional Transportation Expense Sections a. and b. are amended to provide a limit of $50 per day and a maximum limit of $1,000. 2. Hired Auto Physical Damage The following section is added: Any "auto" you lease, hire, rent or borrow is deemed to be a covered "auto" for physical damage coverage. The most we will pay for each covered "auto" is the lesser of: (1) the actual cash value; (2) the cost for repair or replacement; or (3) $50,000, or higher limit if shown on the Declarations for Hired Auto Physical Damage Coverage. For each covered "auto" a deductible of $100 for Comprehensive Coverage and $1,000 for Collision Coverage will apply. G. Business Auto Conditions SECTION IV — BUSINESS AUTO CONDITIONS, A. Loss Conditions is changed by the following: 1. Notice Of Occurrence Section 2. — Duties In The Event Of Accident, Claim, Suit Or, Loss, a. is changed by adding the following: If you report an injury to an "employee" to your workers' compensation carrier and if it is subsequently determined that the injury is one to which this insurance may apply, any failure to comply with this condition will be waived if you provide us with the required notice as soon thereafter as practicable after you know or reasonably should have known that this insurance may apply. 2. Waiver Of Subrogation Section 5. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the following: However, this Condition does not apply to any person(s) or organization(s) with whom you have a written contract, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under such contract with that person or organization. XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 5 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions is changed by the following: 3. Unintentional Failure To Disclose Hazards The following condition is added: Your unintentional failure to disclose all hazards as of the inception date of the policy shall not prejudice any insured with respect to the coverage afforded by this policy. 4. Primary Insurance Condition 5.Other Insurance is changed by adding the following: For any covered "auto" this insurance shall apply as primary and not contribute with any other insurance where such requirement is agreed in a written contract executed prior to a "loss". H. Bodily Injury Redefined SECTION V — DEFINITIONS, C. "Bodily injury" is replaced by the following: "Bodily injury" means bodily injury, sickness or disease sustained by a person including mental anguish, mental injury, shock, fright or death resulting from any of these at any time. I. Extended Cancellation Condition COMMON POLICY CONDITIONS (Form IL 00 17), A. Cancellation, 2.b. is replaced by the following: The greater of sixty (60) days or the time required by any applicable state amendatory endorsement before the effective date of cancellation if we cancel for any other reason. All other terms and conditions of this policy remain unchanged. XIC 421 1013 © 2013 X.L. America, Inc. All Rights Reserved. Page 6 of 6 May not be copied without permission. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 61021571 121-22 GL AU UMB WC IME/LHR I Nina Lautenschlaaer 1 4/1/2021 3:37:03 PM (PDT) I Page 14 of 15 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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: 8i1i2020 Policy No. 7600019322201 Insured: GCI Construction, Inc. Insurance Company: Everest National Insurance Company Countersigned By: -1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999. Endorsement No. 001 Premium $ INCL.