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Insurance Certificates0 03 -28 -2016 4 :52 PM Fax > Risk Manager ®1 �• T ® ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYYI 3/28/2016 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(les) must 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 InterWest Insurance Services (AMERI22) License #OB01094 3636 American River Dr, #200 NAME: Joanne Cadarette PHONE' 916- 609 -8362 FAX 916- 979 -7562 EMAIL jadarette@iWns.com INSURERS AFFORDING COVERAGE NAIC0 Sacramento CA 95864 7 INSURER A:Financial Pacific Ins Company 31453 12131/2015 INSURED INSURERB:Arch Insurance Company 11150 American Asphalt Repair and Resurfacing Company, Inc 24200 Clawiter Rd. INSURER C : INSURER o: INSURER E Hayward CA 94545 INSURER F: $100:000 X COVERAGES_ CERTIFICATE- NUMBER: 1330816 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. INSR LTR TYPE OF INSURANCE INSD W VD POLICY NUMBER IMM1ODNYyyI (MMIMNYYYI LIMITS A 'X COMMERCIAL GENERAL LIABILITY Y Y 60423382 12131/2015 12/31/2016 EACH OCCURRENCE $2:000:000 CLAIMS -MADE FX OCCUR PREMISES Eaoccunence $100:000 X MED EXP (Any one person) $5;000 Contractual Liab X Ded.$5.000 PERSONALBADVINJURY $2;000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $4.000,000 POLICY F JET LOC PRODUCTS - COMP/OP AGG $4,000;000 OTHER: A AUTOMOBILE LIABILITY 60423382 12131/2015 12/31/2016 Eaaccident $1,000:000 X BODILY INJURY (Perperson) $ ANY AUTO AUTOS OWNED SCHEDULED BODILY INJURY (Peraccident) $ X HIRED AUTOS X NOWOWNED AUTOS IMAUE Per accident)$ $ A UMeREL.LALIAB H OCCUR 60423382 12/31/2015 12131/2016 EACH OCCURRENCE $6,000;000 X AGGREGATE. $6;00.0:000__ _ EXCESSLIAB CLAIMS -MADE _ DED_ X RETENTION $none S B WORKERS COMPENSATION AND EMPLOYERrUABILITY YIN y ZAWC19373300 41112016 i 4/1/2017 OTH- X I STATUTE I I ER E. L. EACH ACCIDENT $1.,000;000 ANYPROPRIETOR /PARTNER /EXECUTIVE OFFICERINEN BER EXCLUDED? ❑ NIA E.L. DISEASE - EA EMPLOYEE $1;000;000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000;000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL/WC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non- Payment Of Premium Applies Per Policy Provisions. I—Il Iiril_A Ir- City of Gilroy 7351 Rosanna Street Gilroy CA 95020 ACORD 25 (2014101) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The ACORD name and logo are registered marks of ACORD All rights reserved. 0 03 -28 -2016 4:52 PM Fax a Risk Manaqer D 2 POLICY NUMBER: 60423392 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 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 SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with. that person or organization and included in the "products - completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 0410 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 03 -28 -2016 4:52 PM Fax > Risk Manager 03 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL /WC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non- Payment Of Premium Applies Per Policy Provisions. (If no entry appears above; information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above Al only Effective from: Effective Date: 12/31/2015 Expiration Date: 12/31/2016 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 1185 Modred (07 -01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 03 -28 -2016 4:52 PM Fax > Risk Manager tMORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY we 0406 06 (Ed. 04.84) POLICY NUMBER ZAWC19373300 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 :he 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 sucti remuneration. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION WHERE WAIVER OS OUR RIGHT TO RECOVER IS PERMITTED BY LAW AND IS REQUIRED BY WRITTEN CONTRACT PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO DATE OF LOSS JOB DESCRIPTION ALL JOBS UNDER CONTRACT This endorsement changes the policy to which it is attachec and is effective on the date issued unless otherwise stated. (Ttte wdorrtation below Is required only when thts endorsement is jawd subsequent to preparation of the policy) Endorsement Effective 4 -1 -16 l Policy No.ZAWC19373300 Endorsement No. Insured AMERICAN ASPHALT Premium S INCL - Insurance Company ARCH INSURANCE COMPANY j Countersigned By DATE OF ISSUE: 3 -25 -16 ®1999 by the Wamre Cons rmolon Insurame Raeng Bureau or Callornla. All rights reserved. f=rom the WCIRB's Caftrnh Workers' Compansatlon Insurance Forms Manual ©1919. 04 O 03 -28 -2016 4:52 PM Fax > Risk Manager 05 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 25 03 03 97 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 Projects: ALL PROJECTS WITH THE POLICY PERIOD. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 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 acci- dents 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 Aggre- gate 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 ". 3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Desig- nated Construction Project General Aggre- gate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Decla- rations nor shall they reduce any other Des- ignated Construction Project General Aggre- gate Limit for any other designated construc- tion project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Ex- pense 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 Con- struction 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 acci- dents 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 Ag- gregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. C. 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 Genera[ Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. CG 25 03 03 97 Copyright, Insurance Services Office, Inc.. 1996 Pace 1 of 2 O 03 -28 -2016 4:52 PM Fax > Risk Manager 06 D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restated, 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 project. E. The provisions of Limits Of Insurance (SECTION 111) not otherwise modified by this endorsement shall continue to apply as stipulated. . Psna 7 of 9 rnnvrioht Inciirance Sprvices Office. Inc.. 1996 CG 25 03 03 97 A � CERTIFICATE OF LIABILITY INSURANCE 3/2s/2o�4 ° / " "" 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 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 ....�. L..,....,. r'- .,r- ..,,••,. InterWest Insurance Services (AMER122) PHONE FAx License #0601094 a No x11916-609-8362 ac No : 1 - 7 E -MAIL 3636 American River Dr, #200 ADDRESS . cadarette(a)iwins com Sacramento CA 95864 INSURER (S) AFFORDING COVERAGE NAIC # INSURER A:Financial Pacific Ins Company 14 INSURED INSURERS. Arch Insurance Compan 111 American Asphalt Repair INSURER C and Resurfacing Company, Inc INSURER D 24200 Clawiter Rd Hayward CA 94545 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 11RSaa47P 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. INSR LTR TYPE OF INSURANCE LI IN WV POLICY NUMBER POUCY EFF MM /DD/VVVY POLICY EXP MM /OD /YYV LIMITS A GENERAL LIABILITY X CoMMERCIAL GENERAL LIABILITY aCLAIMS -MADE OCCUR X Contractual Liab Y IY 60423382 12/31/2013 12/31/2014 EACH OCCURRENCE $2,000,000 DAMAGE: 170FIENTEU-_ PREMISES :a occurrence $100,000 MED EXP (Any one person) $5,000 PERSONAL E ADV INJURY $2,000,000 X Ded. $5,000 GENERALAGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER POLICY X PRO LOC PRODUCTS COMP/OP AGG $4,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS H#iEDAUTOS X NON -OWNED AUTOS 60423382 12/31/2013 12/31/2014 Ea at5lNt: it ) S1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ A rEXCESS UMBRELLALIAB LIAR X OCCUR CLAMS -MADE 60423382 12131/2013 12/31/2014 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 lDED X RETENTION$none $ g WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE = OFFICER/MEMBER EXCLUDEDI (Mandatory in NH) II yes, describe udder DESCRIPTION OF OPERATIONS below NIA Y ZAWC19316500 /1/2014 11/2015 X WCSTATU- OTH- T RY IMIT R E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT 1 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) Re Project #13 -PW -204, Pavement Maintenance City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GUWC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non - Payment Of Premium Applies Per Policy Provisions. 11,111 a:111201-111 aak SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Gilroy ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street Gilroy CA 95020 AUTHORIZED REPRESENTATIVE a C 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 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 SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM 6) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL /WC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non- Payment Of Premium Applies Per Policy Provisions. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section ll) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above Al only Effective from: Effective Date: 12/31/2013 Expiration Date: 12/31/2014 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 11 85 Modified (07 -01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 60423382 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 03 03 97 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 Projects: ALL PROJECTS WITH THE POLICY PERIOD. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 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 acci- dents 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 Aggre- gate 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 ". 3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Desig- nated Construction Project General Aggre- gate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Decla- rations nor shall they reduce any other Des- ignated Construction Project General Aggre- gate Limit for any other designated construc- tion project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Ex- pense 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 Con- struction 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 acci- dents 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 Ag- gregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. C. 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. CG 25 03 03 97 Copyright, Insurance Services Office, Inc., 1996 Pace 1 of 2 D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restated, 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 project. E. The provisions of Limits Of Insurance (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. p2no 7 of 2 ronvrinht InSllrgncP. Services Office. Inc.. 1996 CG 25 03 03 97 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 POLICY NUMBER: ZAWC19316500 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 AS REQUIRED BY WRITTEN CONTRACT ALL JOBS UNDER CONTRACT PRIOR TO A LOSS 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 04 -01 -14 Policy No. ZAWC19316500 Endorsement No. Insured AMERICAN ASPHALT REPAIR Premium $ INCL. Insurance Company ARCH INSURANCE COMPANY Countersigned By UAIE OF ISSUE: 03 -25 -14 V 1998 by the Workers' compensation Insurance Rating Bureau d California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. ACCO °R CERTIFICATE OF LIABILITY INSURANCE DATE (MM /00 /VVVY) L 12/18/2014 THIS CE14TIFICATE 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 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 InterWest Insurance Services (AMER122) License #01301094 3636 American River Dr, #200 Sacramento CA 95864 ONT T Joann NAME: PH, 916-609- Ac No: 1 79-7562 E -MAIL ADDRESS e Cadaretteaiwins.com INSURER(S) AFFORDING COVERAGE NAICO INSURER A:Ein n i I Pacific Ins Company 4 INSURED American Asphalt Repair and Resurfacing Company, Inc 24200 Clawiter Rd. Hayward CA 94545 INSURERB:Arch Insurance n 111 INSURER C: 60423362 INSURER D: 12/31/2015 INSURER E $2,000,000 INSURER F: $100,000 COVERAGES CERTIFICATE NUMBER: 1628310399 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. INSR LTR TYPE OF INSURANCE A L INSR U WVD POLICY NUMBER POLICY EFF MM /DD/YYVV POLICY EXP MM /DO/VYYY LIMITS A GENERAL LIABILITY X C0MMERCIALGENERALLIABILITY CLAIMS -MADE FTI OCCUR X Contractual Liab Y Y 60423362 12/31/2014 12/31/2015 EACH OCCURRENCE $2,000,000 DAMAGE PREMISES Ea occurrence $100,000 ME EXP (Any one person) $5,000 PERSONAL E ADV INJURY $2,000,000 X Ded. $5,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: F_IPOLICY X PRO- LOC PRODUCTS - COMP /OP AGG $4,000,000 $ A AUTOMOBILE UABIU7Y ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS X AUTOS 60423382 12/31/2014 12/31/2015 Eaaccidera $1,000,000 BODILY INJURY (Per person) $ Ix BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ Is A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 60423382 2/3112014 12/31/2015 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DIED X I RETENTION$none $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE F—] OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A y ZAWC19316500 /1/2014 /1/2015 X I WCSTATLI OTH- T CRY IM IT R E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIM rr $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GUWC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non - Payment Of Premium Applies Per Policy Provisions. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Gilroy ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street Gilroy CA 95020 AUTHORIZED REPRESENTATIVE / ® 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD It POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 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 SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL /WC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non - Payment Of Premium Applies Per Policy Provisions. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: see Above Location of Job: see Above Al only Effective from: Effective Date: 12/31/2014 Expiration Date: 12/31/2015 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 11 85 Modified (07 -01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 60423382 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 03 03 97 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 Projects: ALL PROJECTS WITH THE POLICY PERIOD. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 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 acci- dents 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 Aggre- gate 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 ". 3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Desig- nated Construction Project General Aggre- gate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Decla- rations nor shall they reduce any other Des- ignated Construction Project General Aggre- gate Limit for any other designated construc- tion project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Ex- pense 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 Con- struction 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 acci- dents 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 Ag- gregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. C. 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. CG 25 03 03 97 Copyright, Insurance Services Office, Inc., 1996 Paae 1 of 2 D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restated, 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 project. E. The provisions of Limits Of Insurance (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. Penn 9 of 2 c'nnvrinht Insi,rance Services Office. Inc.. 1996 CG 25 03 03 97 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 POLICY NUMBER: ZAWC19316500 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 AS REQUIRED BY WRITTEN CONTRACT ALL JOBS UNDER CONTRACT PRIOR TO A LOSS 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 04 -01 -14 Policy No. ZAWC19316500 Insured AMERICAN ASPHALT REPAIR Insurance Company ARCH INSURANCE COMPANY Countersigned By DAIS OF ISSUE: 03 -25 -14 ©1998 by the Workers' Compensation Insurance Rating Bureau d California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. Endorsement No. Premium $ INCL . FROM: 800 - 391 -6687 TO: 14088460429 me CA'WFuja( ing 1'uriding',, FiftyThoLLSandDollarsa rid l)1)/IUU:r-:r-a=:r-:r-:r.:::r-:I::r-:r-:c:ra=r:a:a::r•:r-a::r.a::r- Amount: TO: Smsall'Rusiness Owner (Jnilcd States of An1Cr1C11 12/18/14 11:03 Pg 1 of 1 (-:licnt. Code: 50- 46673A I)oIlars ('cnls N OT/ CHH('K Short Term Business Loan — AL Quick Loans Quick and Simple We offer a quick and simple alternative to traditional bank financing. Our cutting edge technology allows us to approve loans quickly and get you the capital to push your busi- CALL NOW: ness furward. 877- 373 -8 '591 www.cywfiinding.coni Loan Size: 55,0004500,000 Term: B -18 months Security: No collateral needed Timing: Approval in 24 hours; Funding in 2 business days Qualifications: Min. 500 credit score; At least 3 months time in business Details: True Business Loan: "NOT" a Merchant Cash Advance CALL NOW TO SPEAK WITH A FINANCE SPECIALIST: 877 - 373 -8591 Our mission is to provide capital for small businesses when traditional lenders are not Our clients use our capital to fund anything Irom inventory to rcnov ations, tcmlx)rrry cash now to markcling....'I'akc advanbig c of our working capital for anything to plash your husincss forward! Co to cywfunding.com I:eccutl_v LAtuaoti I., X' iuc'-+sc-:- ,;Q,000 PlAULiuq Iuvr_ulvey 3Llcu>. +.u, C:A ;G, 000 Tru•!6 nq C:wh T'I•:•w =;an rl•::i;.)•::, l'T, 241004 A.rLv P.;:1',;.iir W;Jrkitiy CuF,i{.cil N +:w Yaik, PTY 3154, 444 Tutapu, FL No rcm=, -,ev interested'? Please call 1 855 595 376 1. DATE (MM/DD /YVVV) CORD CERTIFICATE OF LIABILITY INSURANCE I 1,/,1 „n„ 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 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). NTACT PRODUCER NAME InterWest Insurance Services (AMER122) HOO” o Ext 916 609 836 ac No : 7 License #OBO1094 E -MAIL 3636 American River Dr, #200 ADDRESS: d re iwin m Sacramento CA 95864 INSURER(S) AFFORDING COVERAGE F NAIC p INSURED American Asphalt Repair and Resurfacing Company, Inc 24200 Clawiter Rd. Hayward CA 94545 INSURER B INSURER C INS F: COVERAGES CERTIFICATE NUMBER: 117SUS `)Saq 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. INSR LTR TYPE OF INSURANCE ADDLSUBR IN SR WVQ POLICVNUMBER POLICY EFF MM /DD /YYYV POLICY EXP MM/DD /YVVV LIMITS A GENERAL LIABILITY Y Y 60423382 12/31/2013 12/31/2014 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE RENTED PREMISESOEa occurrenae $100,000 CLAIMS -MADE FTI OCCUR MED EXP (Any one person) $5,000 PERSONAL 8 ADV INJURY $2,000,000 X Ded. $5,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER : PRODUCTS - COMP /OPAGG $4,000,000 $ POLICY M_ LOC A AUTOMOBILE LIABILITY 60423382 12/31/2013 12/31/2014 COMBINED SINGrFT= Ea accident ) $1,000,000 X BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED AUTOS X NON -OWNED AUTOS $ A UMBRELLA LIAO X OCCUR 60423382 12/31/2013 12/31/2014 EACH OCCURRENCE $5,000,000 X AGGREGATE $5,000,000 EXCESS LIAB CLAIMS -MADE DED X I RETENTION none $ g WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N y ZAWC19290000 /1/2013 /1/2014 X WC LIMIT TORY LIMITS ER R ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICYLIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL/WC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non - Payment Of Premium Applies Per Policy Provisions. lyaa�l�l�Jt \�aa�l��la: �l_l�LyaA +ABNI� City of Gilroy 7351 Rosanna Street Gilroy CA 95020 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 r f ® 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 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 SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL /WC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non - Payment Of Premium Applies Per Policy Provisions. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above Al only Effective from: Effective Date .- 1231/2013 Expiration Date: 12/31/2014 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 11 85 Modified (07 -01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 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 ANY PERSON (S) OR ORGANIZATION (S) FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER PRIOR TO A LOSS JOB DESCRIPTION ALL JOBS UNDER CONTRACT This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective OV01713 Policy No ZAWCI9290000 Insured AMERICAN ASPHALT REPAIR Insurance Company ARCH INSUPUA14CE COMPANY Countersigned By 1998 by the Workers' Compensation Insurance Rating Bureau of California_ All rights reserved_ Fromthe WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. Endorsement No. Premium $ TBA 1-•- A..� CERTIFICATE OF LIABILITY INSURANCE DATE (M(m 4 / 04TE M /DO /VVVY) 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 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 InterWest Insurance Services (AMER122) License #0601094 3636 American River Dr, #200 NT CT EA Joanne Cadarette PHONE FAx N 1 - wC No : 1 79-7 E -MAIL ADDRESS m INSURER (S) AFFORDING COVERAGE NAICR Sacramento CA 95864 INSURER A:Fin i Pacific Ins Company 14 DAMAGE TO RENTEIT__ PREMISES Ea occurrence INSURED INSURER B Arch Insurance Compan 111 INSURER C: $1,000,000 American Asphalt Repair and Resurfacing Company, Inc 24200 Clawiter Rd. INSURER D: $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY X PRO- LOC PRODUCTS - COMP/OP AGG Hayward CA 94545 INSURER E: $ INSURER F: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS COVERAGES CERTIFICATE NUMBER: 1822112639 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. INSR LTR TYPE OF INSURANCE ADDLSUBR IN SR WVD POLICY NUMBER POLICY EFF MM /DD/VYVV POLICY EXP MM/DD/YVYV LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX7 OCCUR X Contractual Liab Y Y I 60423382 I 12/31/2012 12/31/2013 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTEIT__ PREMISES Ea occurrence $100 000 ME EXP (Any one son) $5,000 PERSONAL E ADV INJURY $1,000,000 X Ded_ $5,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY X PRO- LOC PRODUCTS - COMP/OP AGG $2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS 60423382 12/31/2012 2/31/2013 Eaaocident 1000000 X BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAMS -MADE 60423382 12/31/2012 12/31/2013 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED X RETENTKXJ$none $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNEREXECUTIVE OFFICERMIEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A Y I ZAWC19290000 /1/2013 /112014 X WCSTATU- OTH- T CRY IMIT R E.L. EACH ACCIDENT $1,000,000 E.L DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICYLMIr $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL/WC Waivers Attached 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non - Payment Of Premium Applies Per Policy Provisions rz nvt_ucn City of Gilroy 7351 Rosanna Street Gilroy CA 95020 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 z ! 0 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 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 SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHFRS TO US Condition (Section IV - COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the acro .., -, ,ping: We waive any right of recovery we may have against the pers - u, shown in the 5cneuui- al = _.� because of payments we make for injury or damage arising out of your ongoi rve.- '' rk" done under a contract with that person or organization and includq in the "pro mop ations hazard': s This waiver applies only to the person or organization shown i e Schedul CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #13 -PW -204, Pavement Maintenance. City Of Gilroy, Its Elected And Appointed Officials, Officers, Employees, Volunteers Are Included As Additional Insured Acting Within The Scope Of Their Duties Controlled /Supervised By The Primary (First) Additional Insured, Primary Wording, GL /WC Waivers Attached. 30 -Day Notice Of Cancellation, Except 10 -Day Notice For Non - Payment Of Premium Applies Per Policy Provisions. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above Al only Effective from: Effective Date: 12/31/2012 Expiration Date: 12/31/2013 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 11 85 Modified (07 -01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 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 Z % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION ANY PERSONS) OR ORGANIZATIONS) FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER PRIOR TO A LOSS JOB DESCRIPTION ALL JOBS UNDER CONTRACT This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 04/01713 Policy No ZAWCI9290000 Endorsement No. Insured AMERICAN ASPHALT REPAIR Premium $TBA Insurance Company ARCH 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.