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HomeMy WebLinkAboutDon Chapin Co. - 2014 Agreement - Project No. 15-PW-216 - Change Order No. 7Crt:tp of Oitrop Public Works Department - Engineering Division 7351 Rosanna St., Gilroy, CA 95020 Phone (408) 846 -0451; Fax (408) 846 -0429 CHANGE ORDER NO. 7 To contract for: 6th Street Improvements, LED Trail and Led Upgrad City Project No.: 15 -PW -216 Contractor: Don Chapin Company Contract Date: Oct. 22, 2014 This order shall become effective when it has been signed by the City Administrator, City Engineer, Project Engineer, and Description of Work Credit to Contract for deletion of labor and material associated with the installation of the trail lighting (item 54 $27,800), credit for holophane lighting install ($1,800) and credit for cobra head removal, Milias Restaurant, ($300). Total credit for agreed is a deduction from the total contract value of $29,900.00 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 satisfaction 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. Change in working time granted by this change order ► All Extra Work authorized under this Change Order must be billed separately from the original contract. All bills for work done under this Change Order shall reference this Change Order No. 7. I (We) agree to make the above change subject to the terms of this Change Order for a NET DECREASE of $29.900.00. � �-�'O� CONTRACTOR Working Days Cost Percentage Original Contract Price $805,729.00 Previous Change Orders $206,860.00 25.67% of bid Total to Date $1,012,58100 This Change Order ($29.900.00) Total Change Orders to Date $176,960.00 21.96% of bid Revised Contract Price $982,689.00 /Z -3i City Ad istrator Date �``� °® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 09/34/2015 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 McSherry & Hudson CONTACT NAME: PHONE FAX A/C No EMAIL ADDRESS: 575 Auto Center Drive P. 0. Box 2690 Watsonville, CA 95076 INSURERS AFFORDING COVERAGE NAIC4 INSURER A: ZURICH AMERICAN INS CO 16535 10/01/16 _ INSURED INSURER B: STARR IND & LIAB CO 38318 THE DON CHAPIN COMPANY INC. IGLO INSURER C: INSURER D: ~� I $300,000 560 CRAZY HORSE CANYON ROAD INSURER E. PERSONAL &ADVI�$1,000,000 SALINAS, CA 93907 X Contractual Liability INSURER F: COVERAGES CERTIFICATE NUMBER: 45162732 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 ADOL SUER POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY I MM! D LIMITS • GENERAL LIABILITY X X 9674277 -05 10 /01 /1! 10/01/16 EACHOCCURRENCE ($1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR IGLO A TO RAE T11 PIZQMj�, @S IEa occurrence I $300,000 MED EXP (An one person) $5,000 PERSONAL &ADVI�$1,000,000 _ X Contractual Liability 1 GENERAL AGGREGATE $2,000,000 i GENtAGGREGATEUMtTAP PLIES PER: PRODUCTS - COMPIOPAGG $2,000,000 X PRO- POLICY LOC $ • AUTOMOBILE LIABILITY X X BAP 9674279 -05 10 /01 /1 10/01/161 COMBINED SINGLE LIMIT 1,000,000 BODILY INJURY (Per 1$ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS t�t7 NON -OWNED X I HIRED AUTOS (X AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Par n 1$ � $ X ! Contractua B UMBRELLA LIAO X :OCCUR X EXCESS LIAB CLAIMS -MADE( 1000021295 i 10 /Ol /15 10/01/16. EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10, 000, 000 DED I I RETENTION$ IFollows Form $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YINi ANY CERIM PROPRIETOR/PARTNERtEXECUTIVE OFFICERlMEMBER EXCLUDED? � (Mandatory In NH) I N / A X WC 9674260 -07 10/01/1 10101116 X WCSTATU• 0TH- - - - - -- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE; _ $ 1,000,000 If yes dascribeunder DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT $ 1,000,000 i I i DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mom space is required) RE: PROJECT NO. 15 -PW -216, SIXTH STREET IMPROVEMENTS, LED TRAIL LIGHTING, LED UPGRADES AND FIBER OPTICE REPAIR CITY OF GILROY, ITS ELECTED & APPOINTED OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED PER THE ATTACHED ENDORSEMENTS. GL PER ISO FORM CG0001 04/13; AL PER ISO FORM CA0001 10/13 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. RISK MANAGER 7351 ROSANA STREET AUTHORIZED REPRESENTATIVE GILROY, CA 95020 _ USA ACORD 25 (2010105) mgarcia 45162732 ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SUPPLEMENT TO CERTIFICATE OF INSURANCE 09/DATE 30/2015 NAME OF INSURED: THE DON CHAPIN COMPANY INC. Additional Insured - Automatic - Owners, Lessees Or ZURICH. Contractors Policy No. Eft. Date of Pol. Ex p. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem Return Prem. GLO9674-277 -05 10/01/2015 10/01/2016 10/01/2015 Mc3herry & Hudson THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. The Don Chapin Company, Inc. / Landset Engineers, Inc. / Tom's Site Named Insured: Services/Tom's Septic Construction Address (including MP Code): 520 Crazy Horse Canyon Road, Salinas, CA 93907 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section 11 — Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations or "your work" as included in the "products- completed operations hazard ", which is the subject of the written contract or written agreement. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2 Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or 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 drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage ", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. U -GL- 1175 -F CW (04! 13) Page f d2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV — . Commercial General Liabiltty Conditions: 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 written contract or written agreement requires that this coverage be primary and non - contributory. D. For the purposes of the coverage provided by this endorsement: 1. The following is added to the Other Insurance Condition of Section IV — Comirnercial General Liability Conditions: Primary and Nonoontributory insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured provided that: a. The additional insured is a Named Insured under such other insurance; and b. You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV— Commercial GeneraltiabNrity 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 insured on another policy providing coverage for the same "occurrence", offense, 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 a written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. E. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement; or 2. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. All other terms and conditions of this policy remain unchanged. U- GL-117&F Cw (04! 13) Page 2 ot`2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: GLO9674277 -05 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): A General Aggregate Limit applies to each construction project where the Named Insured Is performing operations, however, a General Aggregate Limit does not apply to any construction project where the Named Insured is performing operations that are insured under a wrap up or any other consolidated or similar Insurance program. Information required to com fete this Schedule, if not shown above, will be shown in the Declarations. A For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by "occur- damages or under Coverage C for medical rences" under Section I — Coverage A, and for all expenses shall reduce the Designated Con - medical expenses caused by accidents under struction Project General Aggregate Limit for Section 1— Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag- construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con - 1. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ' ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the however, instead of being subject to the General Aggregate Limit shown in the Decia- sum of all damages under Coverage A, ex- "bodily rations, such limits will be subject to the appli- cept damages because of injury" or "property "products cable Designated Construction Project Gen - damage" included in the - ", eras Aggregate Limit. completed operations hazard and for medi- cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits ". CG 25 03 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 2 Wolters Kfuwer Financial Services I Uniform FormsT"" B. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occur- rences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be at- tributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical D. expenses shall reduce the amount available under the General Aggregate Limit or the Products - completed Operations Aggregate Limit, whichever Is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. When coverage for liability arising out of the "products - completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products - completed operations hazard" will reduce the Products - completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction pro- ject. E. The provisions of Section III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 © Insurance Services Office, Inc., 2008 CG 25 03 05 09 POLICY NUMBER: GL09674277 -05 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 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 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 acci- dent or loss. 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. CG 24 04 05 09 C Insurance Services Office, Inc., 2008 Page 1 of 1 Wolters Kluwer Financial Services I Uniform Forms7A 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. AddT Prem Return Prem. GLO9674277 -05 1 10/01/2015 10/01/2016 1010112015 Mc5h*ny & Hudson 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) ! 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 -GL- 1447 -A CW (05/10) Page 1 of 1 Includes copyrighted material of insurance Services Office, Inc., with its permission. POLICY NUMBER: BAP 9674279 -05 COMMERCIAL AUTO CA 20 481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form appiy unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are " insureds" for Covered Autos Liability Coverage 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. Named Insured: The Don Chapin Company Inc. / Landset Engineers, Inc. / Tom's Site Services/Tom's Septic Construction Endor rl ont Eft fie: 10/01/2015 Mum Of fie wn(s) Or Orgsnbmdon(s): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON — CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. the Each person or organization shown In the Schedule Is an "Insured' for Covered Autos Liability Coverage, but only to the extent that person or organization quaBfles as an "Insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section it — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph DA of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 1013 0 Insurance Services Office, Inc., 2011 Pap 1 of 1 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, Nandi Instsed- The Don Chapin Company Inc. I Landset Engineers, Inc. I Tom's Site Services/Tom's Septic Construction Endorsena t Eff Dofe: 10/01/2015 4 Name(s) Of Pawn(s) Or Orgeniaad*s): ALL PERSONS AND /OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER 'THIS POLICY. In The Transfer Of fthb Of Recovery AgeAlet Othts's 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 0310 0 Insurance Services Office, Inc., 20M Page 1 of 1 0 Notification to others of Cancellation, Nonrenewal ZURiCH O or Reduction of Insurance Policy No. I Eff. Date of Pol. Exp, Date of Pol. Eff. Date of End. Producer No. AWL Prem Return Prem. BAP 9674279 -05 1 10/01/2015 10/01/2016 10/01/2015 enashers7r a Hutlaon 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 (05i10) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NO.: WC9674280 -07 VV0RKMS'COMPENSA'nON AND EMPLOYERS! LIANUTY INSURANCE POLICY VIA 04 03 06 - JEd,4 -84) 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. VIA 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 0.00 % of the California workers' compensation pre- mium otherwise due on such remuneration. Person or O ALL PERSONS AND /OR ORGANIZATION THAT ARE REQUIRED 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 /OR ORGANIZATION. WC 252 (4-84} WC 04 03 06 (Ed. 4.84) Schedule Job DewApdw ALL CA 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) I 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. 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 /1/2016 Policy No. WC 9674280 -07 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