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Home My WebLink AboutThe Don Chapin Company - Sixth Street Improvement Project - Change Order No. 7City of Gilroy Engineering Division 7351 Rosanna St., Gilroy, CA 95020 Phone (408) 846 -0450; Fax (408) 846 -0429 CHANGE ORDER NO. 7 To contract for : Numerous additional items including additional striping and removal of unsuitable soil material at Veteran's Building. Contractor: Don Chapin Company Contract Date: 7/13/2010 This order shall become effective when it has been signed by the City Administrator, City Engineer, Project Engineer, and Contractor. All copies forwarded to Contractor for signature shall be returned to The City of Gilroy properly filled out. Upon acceptance by the City, the Contractor's copy will be returned to him as his authority to proceed with the work. Description of Work This change order provides for the following: (1) Extra subcontractor work for striping and (2) Removal of unsuitable soil material at Veteran's Building. See attached for additional information. All requirements of the original Contract Documents shall apply to the above work except as specifically modified by this Change Order. The contract time shall not extend unless expressly provided for in this Change Order. By signing this Change Order, Contractor acknowledges and agrees that the adjustments to cost and time contained herein are in full satisfaciton and accord, and are accepted as payment in full, for any and all costs and expenses associated with this Change Order, (the "Extra Work "), including but not limited to labor, materials, overhead and profit, delay, disruption, loss of efficiency and any and all other direct and/or indirect costs or expenses associated with the Extra Work and hereby waives any right to claim any further cost and time impacts at any time during and after completion of the Contract associated with the Extra Work. Cost Percentage Initial I (We) agree to make the above change Original Contract Price $1,024,474.00 subject to the terms of this Change Order Previous Change Orders $505,637.95 49.36% for the NET INCREASE of $6,358.35 Total to Date $1,530,111.95 This Change Order $6,358.35 J Total Change Orders to Date $511,996.30 49.98% 601\J C `1Q�(ty �j , 1 IVC . Revised Contract Price $1,536,470.30 CONTRA TOR By-:_( —., Date: v' RECOMMENDED BY: �� 1�L� �J —1 �. C n truction nager Date ACCEPTED BY: City Administrator 5/3/2012 ?A, �� a P. �Y 560 Crazy- Ecorse Canon Road Salinas, California 93907 Phone: (831) 449.4273 Fax: (831) 449 -0700 CONTRACT CHANGE ORDER TO: ; fim Maestri C.O. #: 07 City of Gilroy DATE: April 12,201 2 Community Development Dept. 7351 Rosanna St. JOB NAME: Gilroy 6u' St Improvements Gilroy; CA 95020 JOB NUMBER: 210098 We hereby agree to make the change (s) specified below: (Missed on City Change Order 6) ....... October extra subcontractor work for striping $ 4743.7 0611812011 Remove unsuitable soil material at Veteran's Building $1,614.60 Note: This Change Order becomes part of and in conformance with the existing contract. We hereby AGREE to make the chase (s) specified above at this price: $ 6,358.35 Pr ious Co t Amount: $ 1,530,111.95 Revised Contr, ct Total: $ 1,536,470.30 DATE: 11 �1 ��1 _ BY: CO TRACTOR ACCEPTED — The above prices and specifications of this Change Order are satisfactory and are hereby accepted. All work to be performed under the same terms and conditions as specified in original contract agreement unless otherwise stipulated. DATE: BY: OWNER .I W� 4� ;fit GENERAL ENGINEERING CONTRACTOR 560 CRAZY HORSE CANYON ROAD SALINAS, CALIFORNIA 93907 EXTRA WORK REPORT DATE PERFORMED (DATE OF REPORT ICON. JOB. NO. ICONT. APT. NO. 10/22/2011 11/10/2011 210098 CONTRACT NO. CCO NO. REPORT NO. 76 PAGE 1 $ .W. C. I-" NEW BILL 1- APPROVED FOR PAYMENT 50% FLAG SUB WRK RNV DELAY PARTNERING SWITCH t FA LS I UP FA LS I UP BR r MATERIAL CHARGES CEM -4902D TOTAL LABOR (C) + (D) + SURCHARGE + (E) +-(F) + MARK -UP L $ 4,743.75 TOTAL EQUIPMENT * MATERIALS - TOTAL REGULAR LABOR (C) 11% REGULAR LABOR SURCHARGE I - - I I FOR RESIDENT ENGINEERS USE ONLY ATTACHED TO THIS BILL ARE: $ - DATE RECEIVED I-" NEW BILL 1- APPROVED FOR PAYMENT TOTAL MATERIALS (B) $ r LABOR CHARGES CEM -4902B SUBTOTAL (C) +(D) + REG SURCHARGE + PREM SURCHARGE + (E) + (F) DATE OF ACTION SUBTOTAL EQUIPMENT & MATERIALS (A) + (B) $ r EQUIPMENT CHARGES CEM -4902C 35% STANDARD MARK -UP I " RESUBMITTAL r RETURNED FOR CORRECTION 15% STANDARD MARK -UP $ r MATERIAL CHARGES CEM -4902D TOTAL LABOR (C) + (D) + SURCHARGE + (E) +-(F) + MARK -UP TOTAL COST SUMMARY, STANDARD MARK -UPS & SUBCONTRACTOR MARK -UP TOTAL EQUIPMENT (A) $ - TOTAL OTHER EXPENSE (F) $ $ TOTAL MATERIALS (B) $ 4,125.00 SUBTOTAL (C) +(D) + REG SURCHARGE + PREM SURCHARGE + (E) + (F) - SUBTOTAL EQUIPMENT & MATERIALS (A) + (B) $ 4,125.00 35% STANDARD MARK -UP $ - $ - 15% STANDARD MARK -UP $ • 618.75 TOTAL LABOR (C) + (D) + SURCHARGE + (E) +-(F) + MARK -UP TOTAL EQUIPMENT & MATERIALS (A)+(B) +STANDARD MARK -UP $ 4,743.75 TOTAL EQUIPMENT * MATERIALS $ 4,743.75 TOTAL REGULAR LABOR (C) 11% REGULAR LABOR SURCHARGE $ $ - - TOTAL EQUIPMENT & MATERIALS + TOTAL LABOR $ 4,743.75 TOTAL PREMIUM LABOR (D) $ - SUBCONTRACTED WORK (ONLY) 11% PREMIUM LABOR SURCHARGE $ - 5% OF MARK -UP ON SUBCONTRACTED WORK $ - SUBTOTAL REGULAR & PREMIUM (C +D) $ - GRAND TOTAL $ 4,743.75 SUBTOTAL (C) +(D) +REGULAR SURCHARGE + PREMIUM SURCHARGE $ - TOTAL SUBSISTENCE (E) IN CASE OF QUESTION SIGNATURE (RESIDENT ENGINEER) (RESIDENT ENGINEER USE ONLY) NAME BUSINESS PHONE SIGNATURE (PRIME CONTRACTORS REPRESENTATIVE) DONALD CHAPIN, JR. (831 ) 449 -4273 LN GENERAL CONTRACTOR 560 CRAZY HORSE CANYON ROAD MATERIAL and /or WORK done by specialist SAUNAS. CALIFORNIA 93907 or LUMP SUM or UNIT PRICE PAYMENTS JOB N CONTRACT NO, CCO NO. REPORT NO. PAGE 210098 76 I* p ■ ■ DAILY EXTRA WORK REPORT 560 Crazy Horse Canyon Road Salinas, CA 93907 -8434 Ph. 449 -4273 Fax: 449 -0700 JOB #: a I Q 095 REPORT #: DATE: ' O `oZ� PAGE # JOB NAME: CONTRACT #: OF DESCRIPTION OF WORK: v LABOR EQUIPMENT MATERIALS, SUBCONTRACTORS, & TRUCKING CRAFT NAME HOURS ID DESCRIPTION HOURS - VENDOR NAME INVOICE NUMBER UNIT REG OT REG OT C-o ii��o oG S DESCRIBE WORK PERFORMED: (ALSO LIST CONDITIONS ENCOUNTERED, INSPECTION, AND OTHER COMMENTS) DISTRIBUTION: ORIGINAL- CONTRACTOR 91 YELLOW - FILE / BILLING 3WLIRE PINK - OWNER / CLIENT � , - , L iov 0 8 2011 C- 034612. Rev. 2/ 1 Orr\ INVOICE ID: 11110308 10252 Don Chapin 560 Crazy Horse Canyon Rd. Salinas, CA 93907 e4j"jip Contpapt.", A CAUFOHNIA CORPOnAnON 43650 OSGOOD ROAD P.O. BOX 1368 FREMONT, CA 94538 PHONE (510) 656 -2840 DATE: 10/2212011 YOUR JOB NO: 210098 OUR JOB NO: 1C.0637 CONTRACT NO: BID DB: 8784 PURCHASE ORDER NO: WORK COMPLETED TO: 10/22/2011 PROJECT: SIXTH STREET IMPROVEMENTS CITY: GILROY CONTRACT _M DESCRIPTION UNIT QTY PRICE D. A 8784 -3 5 RMV DTL 21 & DTL 1 LS THERMO ON CONCRETE & 12" WHITE XWALK 16 TRAFFIC CONTROL LS TOTALS CUSTOMER COPY CURRENT BILLING PREVIOUS BILLING BILLINGS TO DATE PAYMENT TO DATE BALANCE OWING AMT QTY AMT QTY AMT QTY AMT QTY AMT QTY AMT f • `` I 1 d 2 soo 00 0.00 1.00 2,900.00 1.00 2,900.00 2,960.00 1.00 2,900.00 0.00 7 1.00 1,225.00 1 225.00 t A.00 225.00 ,. 0.00 tt 1 °.00 1,225.00 1 22 0.00 1.00 5.00 4,25.00 } 5,494.50 4,735.50 LIS`;RET: 412:501 ! # LESS RET: 1,023.00 19,901 00 "' "_ '. 3 71;50 6;105.00' 10,230.00 5,494.50 3,712.50 PLEASE RETURN ONE COPY OF INVOICE WITH PAYMENT NOTE: All accounts are due and payable within 30 days of the data on ti,is inwice. All vast duo neccunis will be charged 11': =per month on th -oast does mount. Page 2 of 2 JOB #: ,/0 0 ` REPORT #: �J DATE: JOB NAME: �Lstj /rs s� " S CONTRACT #: DESCRIPTION OF WORK: /1�.7 t/�' �' ` P GU t/a,5 vi ��i�• ,jam ?��G d ��/ e WK < PAGE # OF I Cl1r" tL' /�j CGwS _ ®f-�' G'f�SS 2 �c°r�L.Ei J°�.zr_if- 1 _ ti OWNER /. LIE T REPRESE DISTRIBUTION: ORIGINAL - CONTRACTOR YELLOW - FILE / BILLING PINK - OWNER /CLIENT C- 034612 Rev - 2105 LABOR EQUIPMENT MATERIALS, SUBCONTRACTORS, & TRUCKING CRAFT NAME ` 5 HOURS ID L �`� ( DESCRIPTION (/gyp /Yc� LBO/ I' i - lzG'—I- REG 2 OT HOURS REG OT VENDOR NAME OICE MBER UNIT �rd�,fYj ,tN %� -� � .�'?� F �%ys Z ��v ` fie► /mil %1��1 DESCRIBE WORK PERFORMED: (ALSO LIST CONDITIONS ENCOUNTERED, INSPECTION, AND OTHER COMMENTS) I JUN 2 0 2011 Cl1r" tL' /�j CGwS _ ®f-�' G'f�SS 2 �c°r�L.Ei J°�.zr_if- 1 _ ti OWNER /. LIE T REPRESE DISTRIBUTION: ORIGINAL - CONTRACTOR YELLOW - FILE / BILLING PINK - OWNER /CLIENT C- 034612 Rev - 2105 �A �® CERTIFICATE OF LIABILITY INSURANCE 09/30/2011) 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 LIC #0056172 1 -831- 724 -3841 CONTACT NAME: PHONE FAX A/C No McSherry & Hudson ADDRESS: 575 Auto Center Drive PRODUCER P. 0. Box 2690 Watsonville, CA 95076 PERSONAL & ADV INJURY $ 1,000,000 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: ZURICH AMERICAN INS CO 16535 INSURER B: THE DON CHAPIN COMPANY INC. INSURERC: AUTOMOBILE 560 CRAZY HORSE CANYON ROAD INSURER D: X SALINAS, CA 93907 10 /01 /1 10/01/12 COMBINED SINGLE LIMIT (Ea accident) INSURER E: X INSURER F: $ COVERAGES CERTIFICATE NUMBER: 23389788 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 POLICY NUMBER MM/DD EFF MMIDpY� LIMITS • GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FiI OCCUR X Contractual Liability X X GLO 9674277 -01 10 /01 /1 10/01/12 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEU_ S Ea occurrence $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS- COMP/OP AGG $ 2,000,000 $ • AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS Contractual Liab. X X BAP 9674279 -01 10 /01 /1 10/01/12 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ X $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE a OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA X WC 9674280 -03 10 /O1 /1 10/01/12 X WC STIMIT FR E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 3000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) AS RESPECTS EXTRA LEGAL LOADS - ANNUAL TRANSPORTATION PERMIT CITY OF GILROY IS NAMED ADDITIONAL INSURED PER ENDORSEMENT ATTACHED GL PER ISO FORM CG0001 12/07; AL PER ISO FORM CA0001 03/06 CERTIFICATE HOLDER CANCELLATION yrivera C 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 23389788 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF GILROY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ENGINEERING DIVISION 7351 ROSANA STREET AUTHORIZED REPRESENTATIVE GILROY, CA 95020 USA yrivera C 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 23389788 DATE SUPPLEMENT TO CERTIFICATE OF INSURANCE 09/30/2011 OF INSURED: THE DON CHAPIN COMPANY INC. POLICY NUMBER: GLO 9674277 -01 COMMERCIAL GENERAL LIABILITY ZURICH AMERICAN INS. CO. CG 24 04 10193 / Modified 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 Name of Person or Organization: Any person or organization that requires you to waive your rights of recovery, in a written contract or agreement with the named insured that is executed prior to the accident or loss. (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 — COMMERCIAL 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., Page 1 of 1 a Notification to Others of Cancellation, Nonrenewal ZURICH or Reduction of Insurance Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem Return Prem. GLO9674277 -01 1 10 -1 -2011 1 10 -1 -2012 10 -1 -2011 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part Liquor Liability Coverage Part Products /Completed Operations Liability Coverage Part A. If we cancel or non -renew this Coverage Part(s) by written notice to the first Named Insured for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation or non - renewal: 1. To the name and address corresponding to each person or organization shown in the Schedule below; and 2. At least 10 days prior to the effective date of the cancellation or non - renewal, as advised in our notice to the first Named Insured, or the longer number of days notice if indicated in the Schedule below. B. If we cancel this Coverage Part(s) by written notice to the first Named Insured for nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation. C. If coverage afforded by this Coverage Part(s) is reduced or restricted, except for any reduction of Limits of Insurance due to payment of claims, we will mail or deliver notice of such reduction or restriction: 1. To the name and address corresponding to each person or organization shown in the Schedule below; and 2. At least 10 days prior to the effective date of the reduction or restriction, or the longer number of days notice if indicated in the Schedule below. D. If notice as described in Paragraphs A., B. or C. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice. SCHEDULE Name and Address of Other Person(s) / Organ ization s : Number of Days Notice: Any person or organization to whom you are 30 required by written contract or agreement to mail prior written notice of cancellation, non - renewal, and /or reduction in coverage All other terms and conditions of this policy remain unchanged. U -GL- 1447 -A CW (05/10) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Additional Insured — Automatic — Owners, Lessees Or Contractors 0 ZURICH Policy No. Eff . Date of Pol. Exp. Date of Pol. Agency Addl. Prem. Return Prom. GLO 9674277 -01 10/01/2011 10/01/2012 McSherry & Hudson THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section II — Who Is An Insured is amended to include as an insured any person or organization who you are required to add as an additional insured on this policy under a written contract or written agree- ment. B. The insurance provided to the additional insured person or organization applies only to "bodily injury", "property damage" or "personal and advertising injury" covered under SECTION I - Coverage A - Bodily Injury And Property Damage Liability and Section I - Coverage B - Personal And Advertising Injury Liability, but only with respect to liability for "bodily injury", "property damage" or "personal and advertis- ing injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; and resulting directly from: a. Your ongoing operations performed for the additional insured, which is the subject of the written contract or written agreement; or b. "Your work" completed as included in the "products- completed operations hazard ", performed for the additional insured, which is the subject of the written contract or written agreement. C. However, regardless of the provisions of paragraphs A. and B. above: 1. We will not extend any insurance coverage to any additional insured person or organization: a. That is not provided to you in this policy; or b. That is any broader coverage than you are required to provide to the additional insured person or organization in the written contract or written agreement; and 2. We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of: a. The Limits of Insurance provided to you in this policy; or b. The Limits of Insurance you are required to provide in the written contractor written agreement. D. The insurance provided to the additional insured person or organization does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering or fail- ure to render any professional architectural, engineering or surveying services including: Includes copyrighted material of Insurance Services Office, Inc., with its permission U- GL- 1175 -8 CW (3/2007) Page 1 of 2 1. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and 2. Supervisory, inspection, architectural or engineering activities. E. The additional insured must see to it that: 1. We are notified as soon as practicable of an 'occurrence" or offense that may result in a claim; 2. We receive written notice of a claim or "suit' as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit' will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured, if the writ- ten contract or written agreement requires that this coverage be primary and non - contributory. F. For the coverage provided by this endorsement: The following paragraph is added to Paragraph 4.a. of the Other Insurance Condition of Section IV — Commercial General Liability Conditions: This insurance is primary insurance as respects our coverage to the additional insured person or organization, where the written contract or written agreement requires that this insurance be primary and non - contributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured on which the ad- ditional insured person or organization is a Named Insured. 1. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV — Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional in- sured by attachment of an endorsement to another policy providing coverage for the same "occur- rence", claim or "suit'. This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non - contributory basis. G. This endorsement does not apply to an additional insured which has been added to this policy by an en- dorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. Any provisions in this Coverage Part not changed by the terms and conditions of this endorsement continue to apply as written. Includes copyrighted material of Insurance Services Office, Inc., with its permission. U -GL -1175 B CW (312007) Page 2 of 2 9 ZURIC WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End BAP 9674279 -01 1011/2011 10/1/2012 10/11/2011 This endorsement modifies insurance provided by the following: Business Auto Coverage Part Truckers Coverage Part Garage Coverage Part SCHEDULE Name of Person or Organization: ALL PERSONS AND /OR ORGANIZATIONS THAT REQUIRE BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY. We waive any right of recovery we may have against the designated person or organization shown in the schedule because of payment we make for injury or damage caused by an "accident" or "loss" resulting from the ownership, maintenance, or use of a covered "auto" for which a Waiver of Subrogation is required in conjunction with work performed by you for the designated person or organization. The waiver applies only to the designated person or organization shown in the schedule. U -CA -320 -A (CW) (4/92) POLICY NO.: BAP 9674279 -01 ZURICH AMERICAN INS. CO. COMMERCIAL AUTO CA 2048 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED 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 modified by this endorsement. This endorsement identifies person(s) or organization(s) who are 'insureds" under the Who Is an Insured Provision 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: 10/01/11 ntersigned By: Authorized Representative SCHEDULE Name of Person(s) or Organization(s): Any person or organization to whom or to which you are required to provide additional insured status or additional insured status on a primary, non - contributory basis, in awritten contract or written agreement executed prior to loss, except where such contract or agreement is prohibited by law. (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 0 Notification to Others of Cancellation, Nonrenewal ZURICH4' or Reduction of Insurance Policy No. I Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem Return Prem. BAP 9674279 -01 1 10 -1 -2011 10 -1 -2012 10 -1 -2011 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial Automobile Coverage Part A. If we cancel or non -renew this Coverage Part by written notice to the first Named Insured for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation or non - renewal: 1. To the name and address corresponding to each person or organization shown in the Schedule below; and 2. At least 10 days prior to the effective date of the cancellation or non - renewal, as advised in our notice to the first Named Insured, or the longer number of days notice if indicated in the Schedule below. B. If we cancel this Coverage Part by written notice to the first Named Insured for nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation. C. If coverage afforded by this Coverage Part is reduced or restricted, except for any reduction of Limits of Insurance due to payment of claims, we will mail or deliver notice of such reduction or restriction: 1. To the name and address corresponding to each person or organization shown in the Schedule below; and 2. At, least 10 days prior to the effective date of the reduction or restriction, or the longer number of days notice if indicated in the Schedule below. D. if notice as described in Paragraphs A., B. or C. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice. SCHEDULE Name and Address of Other Person(s) / Organization(s): Number of Days Notice: Any person or organization to whom you are 30 required by written contract or agreement to mail prior written notice of cancellation, non - renewal, and /or reduction in coverage All other terms and conditions of this policy remain unchanged. U -CA -811 -A CW (05/10) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This Endorsement is effective on 10/1/2011 Policy No. WC 9674280 -03 Premium (if any) $ at 12:01 A.M. standard time, forms a part Endorsement No. of the ZURICH AMERICAN INSURANCE COMPANY Authorized Representative 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 0.0% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization ALL PERSONS AND /OR ORGANIZATIONS THAT REQUIRE BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND I OR ORGANIZATION. WC 252 (4 -84) WC 04 03 06 (Ed. 484) Job Description ALL CALIFORNIA OPERATIONS Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34 NOTIFICATION TO OTHERS OF CANCELLATION, NONRENEWAL OR REDUCTION OF INSURANCE ENDORSEMENT This endorsement is used to add the following to Part Six of the policy. PART SIX CONDITIONS A. If we cancel or non -renew this policy by written notice to you for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation or non - renewal to the name and address corresponding to each person or organization shown in the Schedule below. Notification to such person or organization will be provided at least 10 days prior to the effective date of the cancellation or non - renewal, as advised in our notice to you, or the longer number of days notice if indicated in the Schedule below. B. If we cancel this policy by written notice to you for nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation. C. If coverage afforded by this policy is reduced or restricted, except for any reduction of Limits of Liability due to payment of claims, we will mail or deliver notice of such reduction or restriction to the name and address corresponding to each person or organization shown in the Schedule below. Notification to such person or organization will be provided at least 10 days prior to the effective date of the reduction or restriction, or the longer number of days notice if indicated in the Schedule below. D. If notice as described in Paragraphs A., B. or C. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice. SCHEDULE Name and Address of Other Person(s) / Organ ization s : Number of Days Notice: Any person or organization to whom you are 30 required by written contract or agreement to mail prior written notice of cancellation, non - renewal, and /or reduction in coverage All other terms and conditions of this policy remain unchanged. 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: 10/1/2011 Policy No. WC 9674280 -03 Endorsement No. Insured Premium $ Insurance Company: Zurich American Ins. Co. WC 99 06 34 (Ed. 05 -10) Includes copyrighted material of National Council on Compensation Insurance, Inc. with its permission. Page 1 of 1