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Contract - GCI Construction - 2020-02-25AGREEMENT FOR PUBLIC WORKS Air Vac Replacement This Agreement ("AGREEMENT") is made and effective as of 6%SNgX 2020, between the Costa Mesa Sanitary District, a sanitary district ("DISTRICT'), and GCI Construction, Inc., a corporation ("CONTRACTOR"). In consideration of the mutual covenants and conditions set forth herein, the parties agree as follows: 1. TERM This AGREEMENT shall commence within seven days after date of Notice to Proceed and shall remain and continue in effect until tasks described herein are completed within 25 working days from the date work commenced, unless sooner terminated pursuant to the provisions of this AGREEMENT. 2. SERVICES The SERVICES to be provided are more particularly described in the Scope of Services attached hereto as Exhibit "A" and incorporated herein by reference. 3. PERFORMANCE CONTRACTOR shall perform all SERVICES under this AGREEMENT in a skillful and competent manner, consistent with the standards generally recognized as being employed by CONTRACTORs in the same discipline in the State of California and consistent with all applicable laws. CONTRACTOR shall provide DISTRICT its work product in "turnkey" form. DISTRICT reserves the right to perform reasonable testing of CONTRACTOR's work product before accepting the same. CONTRACTOR shall warrant that all services provided and equipment installed shall perform in a workmanlike manner and be fit for its particular purpose. 4. COMPENSATION Compensation for the SERVICES shall be lump sum for each item as shown on Exhibit "A" and the total shall not exceed Sixteen Thousand Five Hundred Dollars ($16,500.00). The written change order requirement cannot be waived. Failure to submit a written change order and receive written approval by the DISTRICT prior to performing extra work shall constitute a waiver of a claim for additional time or compensation. Invoices shall be submitted to DISTRICT monthly as performance of the SERVICES progresses. DISTRICT shall review and pay the approved charges on such PSA 30U 12 10 invoices in a timely manner. SERVICES on the PROJECT shall begin immediately and be completed Within 25 working days from the date work commenced 6. PREVAILING WAGES CONTRACTOR understands that this job, if over One Thousand Dollars ($1,000.00) in value and not exempt, requires compliance with the prevailing wage law. (Labor Code §§ 1720 et sect►.} As such, DISTRICT will ascertain the prevailing wages to be paid on this job from the Director of Industrial Relations. Said amounts are listed at hftp:/Iwww.dir.ca.gov/disr/pwd/index.htm. CONTRACTOR agrees to pay prevailing wages and maintain prevailing wage records regarding those payments. CONTRACTOR is also required to comply with the apprentice requirements. CONTRACTOR shall defend, indemnify, and hold the DISTRICT, its elected officials, officers, employees, and agents free and harmless from any claim or liability arising out of any failure or alleged failure to comply with the Prevailing Wage Laws. CONTRACTOR recognizes that state law makes eight (8) hours a day's work, and any worker working in excess of that time must be paid overtime. (Labor Code § 1813.) CONTRACTOR acknowledges that if required, it must be registered with the Department of Industrial Relations (DIR) to perform this work and affirms that it is registered. CONTRACTOR agrees to submit electronic payroll information unless this requirement is suspended by the DIR. DISTRICT will file a PWC 100 form with the DIR to register this project. 6. SUBCONTRACTING This paragraph only applies if this Agreement was awarded following a competitive bid. If CONTRACTOR submitted a subcontractors list, CONTRACTORA may only substitute a listed subcontractor by complying with the Subletting and Subcontracting Fair Practices Act. (See Public Contract Code § 4100 et seg.) CONTRACTOR cannot perform work using a subcontractor who is debarred. CONTRACTOR hereby assigns unfair business practice claims (Clayton Act and Cartwright Act) to the DISTRICT. CONTRACTOR declares by signing this Agreement that CONTRACTOR did not collude to obtain this job. (Public Contract Code § 7106.) 7. PROGRESS PAYMENT Progress payment may be authorized if this job will take in excess of thirty (30) days. DISTRICT agrees to promptly make progress payments on undisputed and properly submitted payment request within thirty (30) calendar days and to comply with the provisions of Public Contract Code § 20104.50. If this Agreement is for at least Five Thousand Dollars ($5,000) and progress payments are made, DISTRICT will retain five percent (5%) of the total contract amount until sixty (60) days after the notice of completion is filed. (Public -Contract _gode §§ 2 RSA 30U 12 10 7107, 9203.) CONTRACTOR may substitute securities in lieu of retention pursuant to Public Contracts Code § 22300. 8. INSURANCE CONTRACTOR shall, at its expense, procure and maintain for the duration of this AGREEMENT insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of this AGREEMENT by the CONTRACTOR, its agents, representatives, employees, or subcontractors. CONTRACTOR shall also require all of its subcontractors to procure and maintain the same insurance for the duration of this AGREEMENT. If CONTRACTOR is an employer or otherwise hires one (1) or more employees during the term of this PROJECT, CONTRACTOR shall procure and maintain workers' compensation coverage for such employees which meets all requirements of state law (Labor Code § 1861). At a minimum, CONTRACTOR is required to submit proof of insurance in accordance with the following standards: Minimum Scope of Insurance: Coverage shall be at least as broad as the latest version of the following: (1) General Liability: Insurance Services Office Commercial General Liability coverage (occurrence form CG 0001): (2) Automobile Liability: Insurance Services Office Business Auto Coverage form number CA 0001, code 1 (any auto); and (3) Workers' Compensation and Employer's Liability. Workers' Compensation insurance as required by the State of California and Employers Liability Insurance. Minimum Limits of Insurance: CONTRACTOR shall maintain limits of no less than: (A) General Liability. One Million Dollars ($1,000,000.00) per occurrence for bodily injury, personal injury and property damage. If Commercial General Liability Insurance or other form with general aggregate limit is used, either the general aggregate limit shall apply separately to this AGREEMENT/location or the general aggregate limit shall be twice the required occurrence limit. (B)Automobile Liability. One Million Dollars ($1,000,000.00) per accident for bodily injury and property damage. (C)Workers' Compensation and Employer's Liabili!y. Workers' Compensation limits as required by the Labor Code of the State of California. Employer's Liability limits of One Million Dollars ($1,000,000.00) per accident for bodily injury or disease. Insurance Endorsements: The insurance policies shall contain the following provisions, and a separate endorsement stating to add the following provisions to the insurance policies shall be submitted and approved by DISTRICT: 3 PSA 30U 12 10 (A) General Liability. The general liability policy shall be endorsed to state that: (1) DISTRICT, its directors, officials, officers, employees, agents, and volunteers shall be covered as additional insureds with respect to the work or operations performed by or on behalf of the CONTRACTOR, including materials, parts, or equipment furnished in connection with such work; and (2) the insurance coverage shall be primary insurance as respects DISTRICT, its directors, officials, officers, employees, agents, and volunteers, or if excess, shall stand in an unbroken chain of coverage excess of the CONTRACTOR's scheduled underlying coverage. Any insurance or self-insurance maintained by DISTRICT, its directors, officials, officers, employees, agents, and volunteers shall be excess of the CONTRACTOR's insurance and shall not be called upon to contribute with it in any way. (B) Workers' Compensation and Employer's Liability Coverage. The insurer shall agree to waive all rights of subrogation against DISTRICT, its directors, officials, officers, employees, agents, and volunteers for losses paid under the terms of the insurance policy which arise from work performed by the CONTRACTOR. (C)All Coverage. Each insurance policy required by this AGREEMENT shall be endorsed to state that: (A) coverage shall not be suspended, voided, reduced, or canceled except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to DISTRICT, and (B) any failure to comply with reporting or other provisions of the policies, including breaches or warranties, shall not affect coverage provided to DISTRICT, its directors, official, officers, employees, agents, and volunteers. Acceptability of Insurers: Insurance is to be placed with insurers with a current A.M. Best's rating of no less than A-:Vill, licensed to do business in California, and satisfactory to DISTRICT. All insurance documents must be submitted and approved by the District's Risk Manager prior to execution of any AGREEMENT with DISTRICT. 9. INDEMNIFICATION (a) Indemnification for Professional Liability. When the law establishes a professional standard of care for CONTRACTOR's services, to the fullest extent permitted by law, CONTRACTOR shall indemnify, protect, defend, and hold harmless DISTRICT and any and all of its officials, employees, and agents from and against any and all losses, liabilities, damages, costs, and expenses, including attorney's fees and costs to the extent the same arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of CONTRACTOR, its officers, agents, employees, or subCONTRACTORs (or any entity or individual that CONTRACTOR shall bear the legal liability thereof) in the performance of professional services under this AGREEMENT. 4 PSA 30U 12 10 (b) Indemnification for Other than Professional Liability. Other than in the performance of professional services and to the fullest extent permitted by law, CONTRACTOR shall indemnify, defend, and hold harmless DISTRICT and any and all of its employees, officials, and agents from and against any liability (including liability for claims, suits, actions, arbitration proceedings, administrative proceedings, regulatory proceedings, losses, expenses, or costs of any kind, whether actual, alleged, or threatened, including attorney's fees and costs, court costs, interest, defense costs, and expert witness fees) where the same arise out of, pertain to, relate to, are a consequence of, or are in any way attributable to, in whole or in part, the performance of this AGREEMENT by CONTRACTOR or by any individual or entity for which CONTRACTOR is legally liable, including, but not limited to, officers, agents, employees, or subCONTRACTORs of CONTRACTOR. 10. SAFETY AND SITE CONDITION CONTRACTOR shall perform all operations with due regard for safety and in strict compliance with all applicable laws relating thereto. It shall be CONTRACTOR'S responsibility to keep the site in a clean, neat and orderly condition. It shall also be CONTRACTOR'S duty to dust -palliate all working areas and access routes, if applicable. All operations shall be conducted by CONTRACTOR so that no fire hazards are created. 11. TERMINATION DISTRICT may terminate this AGREEMENT at any time with or without cause. If DISTRICT terminates this AGREEMENT without cause before PROJECT completion, CONTRACTOR shall be entitled to be paid for SERVICES adequately completed prior to the notification of termination. CONTRACTOR may terminate this AGREEMENT for cause only. 12. WARRANTY CONTRACTOR shall perform, at its own cost and expense and without reimbursement from DISTRICT, any services necessary to correct errors or omissions which are caused BY CONTRACTOR's failure to comply with the standard of care provided for herein. CONTRACTOR shall guarantee work done on the PROJECT for a one-year (1) period commencing on the date of substantial completion. CONTRACTOR shall warrant that all services provided and equipment installed shall perform in a workmanlike manner and be fit for its particular purpose. 13. MISCELLANEOUS This AGREEMENT shall be interpreted according to the laws of the State of California and any action arising from this AGREEMENT shall be brought in the superior or federal district court with jurisdiction over DISTRICT. This AGREEMENT and the attachments hereto shall contain the entire agreement between the parties. This AGREEMENT cannot be modified except in a .writing signed by both parties. In the event of inconsistency between this AGREEMENT and any attachment hereto, this AGREEMENT shall control in all respects. 5 PSAsou 1210 DISTRICT shall own all work product prepared in the course of providing the .SERVICES under this AGREEMENT. In the event of termination of this AGREEMENT, CONTRACTOR shall immediately turn all work product over to DISTRICT. If specialized software or computer hardware is required to view or transmit said work product, CONTRACTOR shall make that software and hardware available to the DISTRICT at no cost during normal business hours. If the Services and Equipment required by this Agreement exceed $25,000 the CONTRACTOR shall obtain a labor and material bond and a faithful performance bond on District forms both in the amount of 100% of the contract value. (Civil Code § 9550). This AGREEMENT cannot be assigned without the prior written consent of the DISTRICT. DISTRICT acknowledges that if it provides CONTRACTOR with locations of underground pipelines and DISTRICT is incorrect and those utilities must be relocated, DISTRICT will pay for those relocation costs in accordance with statutory requirements. (Government Code § 4215.) If excavation is required, CONTRACTOR agrees to comply with Gov. Code § 2016 and delineate any area to be excavated before contacting The Regional Notification Center and obtaining authorization to excavate. CONTRACTOR agrees to provide DISTRICT with notice of any hazardous materials or subsurface or latent physical site conditions it encounters if this work involves excavation deeper than four feet (4'). If this exceed Twenty -Five Thousand Dollars($25,000.00) and the excavation exceed five feet (5'), CONTRACTOR must provide a detailed trenching plan. Public Contracts Code § 7104; Labor Code § 6705.) For claims that are less than Three Hundred Seventy Five Thousand Dollars ($375,000.00), the provisions of the Public Contracts Code § 20104 et seg. (Article 1.5 — Resolution of Construction Claims) shall be followed. CONTRACTOR is and shall at all times remain as to DISTRICT an independent contractor. No employee benefits shall be available to CONTRACTOR in connection with the performance of this AGREEMENT. Except for the fees paid to CONTRACTOR as provided in this AGREEMENT, DISTRICT shall not pay salaries, wages, or other compensation to CONTRACTOR for performing any services hereunder for DISTRICT. DISTRICT shall not be liable for compensation or indemnification to CONTRACTOR for injury or sickness arising out of performing any services hereunder. All information gained by CONTRACTOR in the performance of this AGREEMENT shall be considered confidential and shall not be released by CONTRACTOR without DISTRICT's prior written authorization. CONTRACTOR shall not, without written authorization from the General Manager or unless requested by the District Counsel, voluntarily provide declarations, letters of support, testimony at depositions, response to interrogatories, or other information concerning the work 6 PSA 30U 12 10 performed under this AGREEMENT. Response to a subpoena or court order shall not be considered "voluntary" provided CONTRACTOR gives DISTRICT notice of such court order or subpoena. CONTRACTOR warrants that the individual who has signed this AGREEMENT has the legal power, right, and authority to make this AGREEMENT and bind the CONTRACTOR hereto. If you agree with the terms of this AGREEMENT, indicate by signing and dating two original agreements where indicated below and return both to the undersigned. Once the documents are fully executed, one original will be returned to you for your records. DISTRICT Approved by: General Manager Approved as to Form: Harper & Burns LLP District Counsel 7 PSA 30U 12 10 CONTRACTOR Reviewed ajfdAcceDted a Name Title Date ma Exhibit A Scope of Service (Attached) CONSTRUCTION,iNC. Attn: Mr. Rob Hamers CM SD Project: Air Vac Replacement ITEMS All Work Except EldcniMesa 1 R&R AV - Fair Dr 2 R&R AV 21st Pump Station Forece Main 3 R&R AV South Coast Plaza Work on Mesa 1 R&R AV - Mesa Dr 2 R&R AV - Mesa Dr AV Between Irvine and Elden Lift Stations Terry Gillespie, President (714)957-0233 x 218 CCI CONSTRUCTION, INC. License No.. 755356A 1`031 Calle Recodo, Ste. D San Clemente, CA 92673 Phone (714) 957-0233 Fax (714) 540-1148 11/21/191:09 PM OTY UNIT TOTALS 1 EA $4,500.00 $4,500.00 1 LS $6,000.00 $6,000.00 1 LS $6,000.00 $6,000.00 GRAND TOTAL;— $16,500.00 1 LS $100,000.00 $100,000.00 1 EA $6,000.00 $6,000.00 GRAND TOTAL:J $106,000.001 Excludes: Inspection, Permits, Fees, Testing, Bond, Survey, Night Work, Construction water Inspection fees, Permit Fees, Caltrans Permits, City Permits, TC Plan Date ACORN® CoO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 2/19/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Compass Direct Insurance Services, Inc. 13681 Newport Ave., Ste 8 #622 Tustin, CA 92780 CONTACT NAME: Jeremy Seltzer BONE 714-665-9800 FAX No): 714-665-9801 E-MAIL ADDRESS: erem cdisi.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Great American Assurance Company 26344 www.cdisi.com License #01­116100 INSURED INSURER B : Wesco Insurance Company 25011 GCI Construction, Inc. 1031 Calle Recodo, Ste. D San Clemente CA 92673 INSURERC: Everest National Insurance Company 10120 INSURER D: AGCS Marine Insurance Company 22837 INSURER E : Westchester Surplus Lines Insurance Co 10172 INSURER F : COVERAGES CERTIFICATE NUMBER: 54175626 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRPOLICY LTR TYPE OF INSURANCE INSD WVD SUER POLICY NUMBER EFF MM DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY �/ �/ GLP2969247 4/1/2019 4/1/2020 EACH OCCURRENCE $1 000 000 CLAIMS -MADE ✓ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 50 000 ✓ MED EXP (Any one person) $ Excluded Owner's/Cont. Pro ✓ XCU/Deductible $5 000 PERSONAL & ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ✓� JE F I LOC PRODUCTS - COMP/OP AGG $ 2 000 000 Em Io ee Benifits $1 000 000 OTHER: B AUTOMOBILE LIABILITY ✓ WPP1516201 02 4/1/2019 4/1/2020 (Ea aBINEDISINGLE LIMIT $1 000 000 BODILY INJURY (Per person) $ ✓ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED ✓ AUTOS ONLY ✓ AUTOS ON Y Comp/Coll Ded $1,000 (Per accidenDAMAGE $ $ No Liability Deductible A �/ UMBRELLA LIAB vl OCCUR LIMB 2969248 4/1/2019 4/1/2020 EACH OCCURRENCE $5 000 000 AGGREGATE $ 5 000 000 EXCESS LIAB CLAIMS -MADE $0 Deductible DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N ✓ 7600019322191 8/1 /2019 8/1 /2020 1 PER STATUTE ERH E.L. EACH ACCIDENT $1 00O 000 OFFICER/MEMBEREXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below $0 Deductible E.L. DISEASE - EA EMPLOYEE 1.000.000 E.L. DISEASE - POLICY LIMIT I $1,000,000 D IM-Eqp./Lesd-Hrd-R SML93076269 4/1/2019 4/1/2020 Sch/Per:481K/100K Deductible $1,000 D BPP SML93076269 4/1/2019 4/1/2020 $100,000 Deductible $1,000 E Pollution G46866435 002 2/2/2019 2/2/2020 2,000,000 Deductible 5,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) A & V Replacement Costa Mesa Sanitary District GCI Job No. 576 Certificate holder is named as additional insured as per attached endorsements, with respects to the operations of the named insured as per contract. EHTIFIGAIt: HOLUtH GCI Job #576 Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa CA 92626 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 1 of 15 Great American Assurance Company GLP2969247 CG 20 33 GCI Construction, Inc. (Ed. 07 04} THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION 11 - WHO IS AN INSURED is amended to include as an Additional Insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an Additional In— sured on your policy. Such person or or— ganization is an Additional Insured only with respect to liability for "bodily injury," "prop— erty damage" or "personal and advertising in— jury" 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 oper— ations for the Additional Insured. A person's or organization's status as an Ad— ditional Insured under this endorsement ends when your operations for that Additional In— sured are completed. B. With respect to the insurance afforded to these Additional Insureds, the following addi— tional exclusions apply: This insurance does not apply to: 1. "Bodily injury," "property damage" or "per— sonal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. the preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or draw— ings and specifications; or b. supervisory, inspection, architectural or engineering activities. 2. "Bodily injury," or "property damage" oc— curring after: a. 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 b. that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than an— other contractor or subcontractor en— gaged in performing operations for a principal as a part of the same project_ Copyright, ISO Properties, Inc., 2004 CG 20 33 (Ed. 07/04) XS 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10-32:15 AM (PST) I Page 2 of 15 Great American Assurance Company GLP2969247 GCI Construction, Inc. CG 20 37 (Ed. 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 Name of Additional Insured Person(s) or Organ!zation(s): Any person or organization that "you" and such person or organiza- tion have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on "your" policy, but only for "your work" performed during this policy period. Schedule Location and Description of Completed Operations: Per Certificate(s) of Insurance "Your work" performed during this policy period, Additional Premium: Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. SECTION 11 - 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." Copyright, ISO Properties, Inc., 2004 CG 20 37 (Ed. 07t04) PRO (Page 1 of 1) 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 3 of 15 Great American Assurance Company GLP2969247 GCI Construction, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 9 l : • � � � 0 :V This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM GAC 3649CG (Ed. 11 06) This insurance is primary to any other insurance held by third parties with respect to work performed by you under written contractual agreements with such third parties and any other insurance which may be available to such third parties shall be non—contributory. GAC 3649CG (Ed. 1 1 /06) XS 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 4 of 15 Great American Assurance Company GLP2969247 GCI Construction, Inc. 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 Designated Construction Projects: CG 25 03 (Ed. 03 97) Any construction project where "you" are performing operations when "you" have agreed in writing in a contract or agreement that a separate General Aggregate Limit shall apply to such construction project, but only if "your work" on or at the construction project is performed during the period of this policy. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A. (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C. (SECTION 1), which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A. except damages because of "bodily injury" or "property damage" included in the "products —completed operations hazard," and for medical 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." Copyright, Insurance Services Office, Inc., 1996 CG 25 03 (Ed. 03/97) PRO (Page 1 of 2) 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 5 of 15 3. Any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. B. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A. (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C. (SECTION 1), which cannot be attributed 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 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 Designated Construction Project General Aggregate Limit. C. When coverage for liability arising out of the "products -completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of LIMITS OF INSURANCE (SECTION 111) not otherwise modified by this endorsement shall continue to apply as stipulated. Copyright, Insurance Services Office, Inc., 1996 CG 25 03 (Ed. 03197) PRO (Page 2 of 2) 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 6 of 15 Great American Assurance Company CG 24 04 GLP2969247 GCI Construction, Inc. (Ed. 05 09) THIS ENDORSEMENT 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 PRODUCTS/ COMPLETED OPERATIONS LIABILITY COVERAGE PART Schedule Name of Person or Organization: Any person or organization for wham or on whose behalf "you" are performing operations when "you" and such person or organization have agreed in writing in a contract or agreement to waive any right of recovery "we" may have against such person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to paragraph 8. Transfer of Rights of Recovery Against Others to Us of SECTION IV - CONDITIONS: 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. Copyright, ISO Properties, Inc., 2008 CG 24 04 (Ed. 05/09) PRO (Page 1 of 1) 54175626 1 19-20 GL AU UMB WC ZME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 7 of 15 WPP 1516201 02 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 4/1 /2019 Countersigned By: 13 Authorized Representative) Named Insured: GCI Construction, Inc. SCHEDULE Name of Person(s) or Organization(s): Blanket as required by written contract. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 8 of 15 POLICY NUMBER: WPP1516201 02 COMMERCIAL AUTO CA990187 0715 This Endorsement Changes The Policy. Please Read It Carefully • COVERAGE EXPANSION -154DOTSEIREVT This endorsement modifies insurance provided by the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the COVERAGE FORM apply unless modified by the endorsement. A. Newly Acquired or Formed Organizations, Employee Hired Car Liability and Blanket Additional Insured Status for Certain Entities. Item 1. Who is an Insured of Paragraph A. Coverage under SECTION II — COVERED AUTOS LIABILITY COVERAGE is amended to add: d. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership of a majority interest (greater than 50%), will qualify as a Named Insured; however, (1) coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; (2) coverage does not apply to "bodily injury", "property damage" or "covered pollution cost or expense" that results from an "accident" which occurred before you acquired or formed the organization; and (3) coverage does not apply if there is other similar insurance available to that organization, or if similar insurance would have been available but for its termination or the exhaustion of its limits of insurance. This insurance does not apply if coverage for the newly acquired or formed organization is excluded either by the provisions of this coverage form or by endorsement. e. 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. f. Any person or organization you are required by written contract or agreement to name as an additional "insured", but only with respect to liability created in whole or in part by such agreement. B. Increase Of Loss Earnings Payment Subpart (4) of a. Supplementary Payments of Item 2. Coverage Extensions of Paragraph A. Coverage under SECTION II — COVERED AUTOS LIABILITY COVERAGE is amended to read: (4) We will pay reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $1,000 per day because of time off from work. C. Fellow Employee Injured By Covered Auto You Own Or Hire Item 5. Fellow Employee of Paragraph B. Exclusions under SECTION II — COVERED AUTOS LIABILITY COVERAGE is amended to add: This exclusion does not apply if the "bodily injury" results from the use of a covered "auto" you own or hire. Such coverage as is afforded by this provision is excess over any other collectible insurance. CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 5 Used with permission 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 9 of 15 D. Limited Automatic Towing Coverage Item 2. Towing, of Paragraph A. Coverage, under SECTION III — PHYSICAL DAMAGE COVERAGE is amended to read: 2. Towing We will pay for towing and labor costs each time that a covered "auto" is disabled. All labor must be performed at the place of disablement of the covered "auto". a. The limit for towing and labor for each disablement is $500; b. No deductible applies to this cover- age. E. Item 3. Glass Breakage — Hitting A Bird Or Animal — Falling Objects or Missiles of Paragraph A. Coverage under SECTION III — PHYSICAL DAMAGE COVERAGE, is amended to add: Glass Repair Coverage We will waive the Comprehensive deductible for Glass, if one is indicated on your covered "auto", for glass repairs. We will repair at no cost to you, any glass that can be repaired without replacement, provided the "loss" arises from a covered Comprehensive "loss" to your "auto". F. Increase Of Transportation Expense Coverage Subpart a. Transportation Expenses of Item 4. Coverage Extensions of Paragraph A. Coverage under SECTION III — PHYSICAL DAMAGE COVERAGE is amended to read: a. Transportation Expenses We will pay up to $50 per day to a maximum of $1,000 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage or Theft Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we pay for its "loss". G. "Personal Effects" Coverage Item 4. Coverage Extensions of Paragraph A. Coverage, under SECTION III - PHYSICAL DAMAGE COVERAGE, is amended to add: "Personal Effects" Coverage We will pay actual cash value for "loss" to "personal effects" of the "insured" while in a covered "auto" subject to a maximum limit of $2,500 per "loss", for that covered "auto" caused by the same "accident". No deductible will apply to this coverage. H. "Downtime Loss" Coverage Item 4. Coverage Extensions, of Paragraph A. Coverage, under SECTION Ill. PHYSICAL DAMAGE COVERAGE, is amended to add: "Downtime Loss" Coverage We will pay any resulting "downtime loss" expenses you sustain as a result of a covered physical damage "loss" to a covered "auto" up to a maximum of $100 per day, for a maximum of 30 days for the same physical damage "loss", subject to the following conditions: a. We will provide "downtime loss" beginning on the 5th day after we have given you our agreement to pay for repairs to a covered "auto" and you have given the repair facility your authorization to make repairs; b. Coverage for "downtime loss" expenses will end when any of the following occur: (1) You have a spare or reserve "auto" available to you to continue your operations. (2) You purchase a replacement "auto". (3) Repairs to your covered "auto" have been completed by the repair facility and they determine the covered "auto" is road -worthy. (4) You reach the 30 day maximum coverage. CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 2 of 5 Used with permission 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 10 of 15 I. Item 4. Coverage Extensions, of Paragraph A. Coverage, under SECTION 111111. PHYSICAL DAMAGE COVERAGE, is amended to add: We will pay any resulting rental reimbursement expenses incurred by you for a rental of an "auto" because of "loss" to a covered "auto' up to a maximum of $100 per day, for a maximum of 30 days for the same physical damage "loss", subject to the following conditions: a. We will provide rental reimbursement incurred during the policy period beginning 24 hours after the "loss" and ending, regardless of the policy expiration, with the number of days reasonably required to repair or replace the covered "auto'. If the "loss" is caused by theft, this number of days is the number of days it takes to locate the covered "auto' and return it to you or the number of days it takes for the claim to be settled, whichever comes first. b. Our payment is limited to necessary and actual expenses incurred. c. This coverage does not apply while there are spare or reserve "autos" available to you for your operations. d. If a "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. J. "Personal Effects" Exclusion Paragraph B. Exclusions under SECTION III — PHYSICAL DAMAGE COVERAGE, is amended to add: "Personal Effects" Exclusion We will not pay for "loss" to "personal effects" of any of the following: a. Accounts, bills, currency, deeds, evidence of debt, money, notes, securities or commercial paper or other documents of value. b. Bullion, gold, silver, platinum, or other precious alloys or metals; furs or fur garments; jewelry; watches; precious or semi-precious stones. c. Paintings, statuary and other works of art. d. Contraband or property in the course of illegal transportation or trade. e. "Loss" caused by theft, unless there is evidence of forced entry into the covered "auto" and a police report is filed. K. Accidental Airbag Discharge Coverage Item 3.a. of Paragraph B. Exclusions under SECTION III — PHYSICAL DAMAGE COVERAGE is amended to read: a. Wear and tear, freezing, mechanical or electrical breakdown. The exclusion relating to mechanical break -down does not apply to the accidental discharge of an air bag. L. Loan or Lease Gap Coverage Paragraph C. Limit Of Insurance under SECTION I11— PHYSICAL DAMAGE COVERAGE is amended to add: If a covered "auto' is owned or leased and if we provide Physical Damage Coverage on it, we will pay, in the event of a covered total "loss", 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 or loan payments including penalties, interest or other charges resulting from overdue 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) Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; (4) Security deposits not refunded by the lessor; and (5) Carry-over balances from previous loans or leases CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 3 of 5 Used with permission 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 11 of 15 M. Aggregate Deductible Paragraph D. Deductible under SECTION III — PHYSICAL DAMAGE COVERAGE is amended to add: Regardless of the number of covered "autos" involved in the same "loss", only one deductible will apply to that "loss". If the deductible amounts vary by "autos", then only the highest applicable deductible will apply to that "loss". N. Diminishing Deductible Paragraph D. Deductible under SECTION III — PHYSICAL DAMAGE COVERAGE is amended to add: Any deductible will be reduced by the percentage indicated below on the first "loss" reported during the corresponding policy period: Loss Free Policy Periods With the Expansion Endorsement Deductible Reduction on the first "loss" 1 0% 2 25% 3 50% 4 75% 5 1 100% If we pay a Physical Damage "loss" during the policy period under any BUSINESS AUTO COVERAGE FORM you have with us, your deductible stated in the Declarations page of each such COVERAGE FORM will not be reduced on any subsequent claims during the remainder of your policy period and your deductible reduction will revert back to 0% for each such COVERAGE FORM if coverage is renewed. O. Knowledge of Loss and Notice To Us Subsection a. of Item 2. Duties In the Event of Accident, Claim, Suit or Loss of Paragraph A. Loss Conditions under SECTION IV -- BUSINESS AUTO CONDITIONS is amended to add: However, prompt notice of the "accident', claim, "suit" or 'loss" to us or our authorized representative only applies after the "accident', claim, "suit" or "loss" is known to: (1) You, if you are an individual; (3) An "executive officer" or director, if you are a corporation; (4) A manager or member, if you are a limited liability company; (5) Your insurance manager; or (6) Your legal representative. P. Waiver Of Subrogation For Auto Liability Losses Assumed Under Insured Contract Item 5. Transfer Of Rights Of Recovery Against Others To Us of Paragraph A. Loss Conditions under SECTION IV — BUSINESS AUTO CONDITIONS is amended to read: 5. Transfer of Rights of Recovery Against Others To Us If any person or organization to or for whom we make payments under this Coverage Form has rights to recover damages from another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after an "accident' or "loss" to impair them. However, if the insured has waived those rights to recover through a written contract, we will waive any right to recovery we may have under this Coverage Form. Q. Insurance is Primary and Noncontributory Subpart a. of Item 5. Other Insurance of Paragraph B. General Conditions under SECTION IV — BUSINESS AUTO CONDITIONS is amended to read: a. This insurance is primary and noncontributory, as respects any other insurance, if required in a written contract with you. R. Other Insurance — Hired Auto Physical Damage Subpart b. of Item 5..Other Insurance of Paragraph B. General Conditions under SECTION IV — BUSINESS AUTO CONDITIONS is amended to read: 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) A partner, if you are a partnership; CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Used with permission 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 12 of 15 Page 4 of 5 (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". S. Unintentional Failure To Disclose Hazards Paragraph B. General Conditions under SECTION IV — BUSINESS AUTO CONDI- TIONS is amended to add: 9. Your failure to disclose all hazards existing as of the inception date of this policy shall not prejudice the coverage afforded by this policy, provided that such failure to disclose all hazards is not intentional. However, you must report such previously undisclosed hazards to us as soon as practicable after its discovery. T. Additional Definition SECTION V — DEFINITIONS is amended to add: "Personal effects" means personal property owned by the "insured". "Downtime loss" means actual loss of "business income" for the period of time that a covered "auto": 1. Is out of service for repair or replacement as a result of a covered physical damage "loss" and 2. Is in the custody of a repair facility if not a total "loss". "Business Income" means: 1. Net Income (Net Profit or Loss before income taxes) that would have been earned or incurred; and 2. Continuing normal operating expenses incurred, including payroll. In this endorsement, Headings and Titles are inserted solely for the convenience and ease of reference. They do not affect the coverage provided by this endorsement, nor do they constitute any part of the terms and conditions of this endorsement. All other policy wording not specifically changed, modified, or replaced by this endorsement wording remains in effect. CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 5 of 5 Used with permission 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 13 of 15 WPP1516201 02 COMMERCIAL AUTO CA 04 44 0310 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: GCI Construction, Inc. Endorsement Effective Date: 4/1 /2019 SCHEDULE Name(s) Of Person(s) Or Organization(s): Blanket as required by written contract I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident" or the "loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 14 of 15 Page 1 of 1 ❑ 5 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: 8/1/2019 Policy No. 7600019322191 Insured: GCI Construction, Inc. Endorsement No. 001 Premium $ INCL. Insurance Company: Everest National Insurance Company Countersigned By: t ► +: .r a ►� -1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999. 54175626 1 19-20 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 2/19/2020 10:32:15 AM (PST) I Page 15 of 15