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HomeMy WebLinkAboutCOI - A. Teichert & Son, Inc. - Expires 2022-03-31ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 3/30/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and 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 CO TACT NAME: Kayla Fritzber Edgewood Partners Insurance Center PHONE 925 822 9044 a No ; 916-583-7613 Po Box 2110 E-MAIL ADDRESS: kayla.fritzberg@epicbrokers.com Sacramento CA 95815 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Fire Insurance Company 23035 License#: OB29370 INSURED TEICCONS INSURER B : Allied World Assurance Company U.S. 19489 A. Teichert & Son, Inc. DBA Teichert Construction INSURER C : INSURER D : PO Box 15002 INSURER E : Sacramento CA 95851 INSURER F : COVERAGES CERTIFICATE NUMBER:569085735 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY MMIDDIYYY;f LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y EB2661067002031 3/31/2021 3/31/2022 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE � OCCUR DAMA T RENTED PREMISES Ea occurrence $1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY RCOT- � LOC PRODUCTS - COMP/OP AGG $ 4,000,000 SIR $ 750,000 OTHER: A AUTOMOBILE LIABILITY Y Y EU266067002041 3/31/2021 3/31/2022 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 X BODILY INJURY (Per person) S ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) S X PROPERTY DAMAGE Per accident S HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY SIR $ 500.000 B UMBRELLA LIAR X OCCUR Y Y 03082614 3/31/2021 3/31/2022 EACH OCCURRENCE $10,000.000 X AGGREGATE $10,000,000 EXCESS LIAR CLAIMS -MADE DED I RETENTION S $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N ANYPROPRIETOR/PARTNERIEXECUTIVE Y EM66NO67002011 3/31/2021 3/31/2022 X PER ERH E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER 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: Annual Moving Permit. Additional Insured: City of Gilroy. When required by written contract, additional insured status with primary coverage applies to General Liability and Automobile, and waiver of subrogation applies to General Liability, Automobile Liability and Excess Workers' Compensation, all per the attached endorsements. XCU, Contractual Liability, and "Broad Form Property Damage" are included per General Liability Form CG0001 04 13. Excess Liability is follow form. See Attached... CERTIFICATE HOLDER CANCELLATION 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 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: TEICCONS LOC #: AC oO ADDITIONAL REMARKS SCHEDULE �� Page 1 of 1 AGENCY NAMED INSURED Edgewood Partners Insurance Center A. Teichert & Son, Inc. DBA Teichert Construction PO Box 15002 POLICY NUMBER Sacramento CA 95851 CARRIER NAIC CODE EFFECTM DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Named Insured is a Califomia qualified self -insurer registered under #1867. IThe Workers' Compensation Policy provides Excess Workers' Compensation / Employer's Liability coverage excess of a $750,000 SIR. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: EB2661067002031 COMMERCIAL GENERAL LIABILITY CG20120413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: All states, governmental agencies, subdivisions, or political subdivisions with whom you or a person or organization whom you are performing work for have entered into a written contract or agreement, prior to an 'occurrence" or offense, to provide additional insured status Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I A. Section II — Who Is An Insured is amended to include as an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 12 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT —SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Person(s) or Organization(s): All persons or organizations as required by written contract prior to a loss occurring. If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4.Other Insurance of Section IV — Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4.Other Insurance of Section IV — Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same 'occurrence", claim or "suit". LC 24 20 11 18 © 2018 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: EB2661067002031 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: As required by written contract or agreement entered into prior to loss. I 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 O Insurance Services Office, Inc., 2008 Page 1 of 1 0 Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - NONCONTRIBUTING This endorsement modifies insurance provided under the following: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY 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. Schedule Name of Person(s) or Organizations(s): Any person(s) or organization(s) to whom you are obligated by a written agreement to procure Additional Insured coverage under your policy Regarding Designated Contract or Project: All contracts or projects Each person or organization shown in the Schedule of this endorsement 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. The following is added to the Other Insurance Condition: If you have agreed that this policy will be primary and without right of contribution from any insurance in force for an Additional Insured for liability arising out of your operations and the agreement was executed prior to the bodily injury or property damage, then this insurance will apply before that other insurance, and we will not seek contribution from such insurance. However, insurance provided to the Additional Insured will subject to the self -insured amount and all other terms and conditions of the policy. AM 76 62 04 17 © 2017 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: EU2661067002041 Issued by: LIBERTY MUTUAL FIRE INSURANCE COMPANY 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: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY SELF -INSURED TRUCKER EXCESS LIABILITY POLICY With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. The Transfer Of Rights Of Recovery Against Others To Us condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization listed in the Schedule of this endorsement because of payments we make for injury or damage arising out of your operations of a covered auto. This waiver applies only to the person or organization listed in the Schedule of this endorsement. Schedule Premium: $ INCL Name of Person or Organization: Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring AM 76 19 07 13 @ 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Where required by contract or written agreement prior to loss and allowed by law. Issued by: Liberty Mutual Fire Insurance Company For attachment to Policy No EW266NO67002011 Effective Date 03/31/2021 Premium $ Issued to: Teichert Inc. WC 00 0313 ©1983 National Council on Compensation Insurance, Inc. Page 1 of 1 Ed. 4/1 /1984 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Or anization s Email Address or mailing address: Number Days Notice: Per schedule on file with broker Per schedule on file with broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Organ izations Email Address or mailing address: Number Days Notice: Per schedule on file with the Broker Per schedule on file with the Broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. ACORO® A� CERTIFICATE OF LIABILITY INSURANCE E(MMI /Y DATE (MMIDDIYYYY) 21 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Edgewood Partners Insurance Center PO BOX 2110 Sacramento CA 95815 CONTACT Kayla Fritzberg PHONE FAX • 925.822.9044 A/C No): 916-583-7613 ADDRIEss: kayla.fritzberg@epicbrokers.com INSURERS AFFORDING COVERAGE NAIC # INSURERA: Liberty Mutual Fire Insurance Company 23035 License#: OB29370 INSURED TEICCONS A. Teichert & Son, Inc. INSURER B : Allied World Assurance Company U.S. 19489 DBA Teichert Construction INSURER C INSURER D : PO Box 15002 Sacramento CA 95851 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: W975985 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 INSURANCEIsmim ADDL SUER POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y EB2661067002031 3/31/2021 3/31/2022 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR DAMAGE T RENTED PREMISES (Ea occurrence) $1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY RQ LOC PRODUCTS - COMP/OP AGG $ 4,ODO,DDD SIR $ 750,000 OTHER: A AUTOMOBILE LIABILITY Y Y EU266067002041 3/31/2021 3/31/2022 COMBINED SINGLE LIMIT Ea accident $ 2,000,OOD X BODILY INJURY (Per person) S ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) S X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident S SIR $ 500.000 B UMBRELLA LIAB X OCCUR Y Y 03082614 3/31/2021 3/31/2022 EACH OCCURRENCE $ 10,000,000 X AGGREGATE $ 10,000,000 EXCESS LIAR CLAIMS -MADE DED RETENTION S $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECU I IVE OFFICER/MEMBEREXCLUDED? ❑ NIA Y EW266NO67002011 3/31/2021 3/31/2022 X PER ERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1.000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) RE: Transportation Permit. Additional Insured: City of Gilroy. When required by written contract, additional insured status with primary coverage applies to General Liability and Automobile, and waiver of subrogation applies to General Liability, Automobile Liability and Excess Workers' Compensation, all per the attached endorsements. XCU, Contractual Liability, and "Broad Form Property Damage" are included per General Liability Form CG0001 04 13. Excess Liability is follow form. See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Gilroy 7351 Rosanna Street Gilroy CA 95020 AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: TEICCONS LOC #: ,a►C R ® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Edgewood Partners Insurance Center A. Teichert & Son, Inc. DBA Teichert Construction PO Box 15002 POLICY NUMBER Sacramento CA 95851 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE (Named Insured is a California qualified self -insurer registered under #1867. Workers' Compensation Policy provides Excess Workers' Compensation / Employer's Liability coverage excess of a $750,000 SIR. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: EB2661067002031 COMMERCIAL GENERAL LIABILITY CG20120413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: All states, governmental agencies, subdivisions, or political subdivisions with whom you or a person or organization whom you are performing work for have entered into a written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I A. Section II — Who Is An Insured is amended to 2. This insurance does not apply to: include as an additional insured any state or a. "Bodily injury", "property damage" or governmental agency or subdivision or political "personal and advertising injury" arising out subdivision shown in the Schedule, subject to the of operations performed for the federal following provisions: government, state or municipality; or 1. This insurance applies only with respect to b. "Bodily injury" or "property damage" operations performed by you or on your behalf included within the "products -completed for which the state or governmental agency or operations hazard". subdivision or political subdivision has issued a permit or authorization. B. With respect to the insurance afforded to these However: additional insureds, the following is added to Section III — Limits Of Insurance: a. The insurance afforded to such additional If coverage provided to the additional insured is insured only applies to the extent permitted required by a contract or agreement, the most we by law; and will pay on behalf of the additional insured is the b. If coverage provided to the additional amount of insurance: insured is required by a contract or 1. Required by the contract or agreement; or agreement, the insurance afforded to such additional insured will not be broader than 2. Available under the applicable Limits of that which you are required by the contract Insurance shown in the Declarations; or agreement to provide for such additional whichever is less. insured. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 12 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT — SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Person(s) or Organization(s): All persons or organizations as required by written contract prior to a loss occurring. If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4.Other Insurance of Section IV — Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4.Other Insurance of Section IV — Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same 'occurrence", claim or "suit". LC 24 28 11 18 © 2018 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: EB2661067002031 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: As required by written contract or agreement entered into prior to loss. I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I 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 © Insurance Services Office, Inc., 2008 Page 1 of 1 0 Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - NONCONTRIBUTING This endorsement modifies insurance provided under the following: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY 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. Schedule Name of Person(s) or Organizations(s): Any person(s) or organization(s) to whom you are obligated by a written agreement to procure Additional Insured coverage under your policy Regarding Designated Contract or Project: All contracts or projects Each person or organization shown in the Schedule of this endorsement 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. The following is added to the Other Insurance Condition: If you have agreed that this policy will be primary and without right of contribution from any insurance in force for an Additional Insured for liability arising out of your operations and the agreement was executed prior to the bodily injury or property damage, then this insurance will apply before that other insurance, and we will not seek contribution from such insurance. However, insurance provided to the Additional Insured will subject to the self -insured amount and all other terms and conditions of the policy. AM 76 52 04 17 © 2017 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: EU2661067002041 Issued by: LIBERTY MUTUAL FIRE INSURANCE COMPANY 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: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY SELF -INSURED TRUCKER EXCESS LIABILITY POLICY With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. The Transfer Of Rights Of Recovery Against Others To Us condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization listed in the Schedule of this endorsement because of payments we make for injury or damage arising out of your operations of a covered auto. This waiver applies only to the person or organization listed in the Schedule of this endorsement. Schedule Premium: $ INCL Name of Person or Organization: Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring AM 76 19 07 13 © 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Where required by contract or written agreement prior to loss and allowed by law. Issued by: Liberty Mutual Fire Insurance Company For attachment to Policy No EW266NO67002011 Effective Date03/31/2021 Issued to: Teichert Inc. WC 00 0313 01983 National Council on Compensation Insurance, Inc. Ed. 4/1/1984 Premium $ Page 1 of 1 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) ! Organ izations : Email Address or mailing address: Number Days Notice: Per schedule on file with broker Per schedule on file with broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 O 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Organ izations : Email Address or mailing address: Number Days Notice: Per schedule on file with the Broker Per schedule on file with the Broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 0511 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Name of Other Person(s) / Organization(s): Schedule on file with the Company SCHEDULE Email Address or mailing address: Schedule on file with the Company All other terms and conditions of this policy remain unchanged. Issued by Liberty Mutual Fire Insurance Company For attachment to Policy No. EW266NO67002011 Effective Date 03/31/2021 Issued toTeichert, Inc. WC 99 20 75 © 2016 Liberty Mutual Insurance Ed. 12/01 /2016 Number Days Notice: ;s f Premium $ Page 1 of 1 NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. SCHEDULE Name of Other Person(s)1 Email Address or mailing address: Number Days Notice: Organization(s): Schedule on file with the Schedule on file with the Company 90 Company All other terms and conditions of this policy remain unchanged. Issued by Liberty Mutual Fire Insurance Company For attachment to Policy No. EW266NO67002011 Effective Date 03/31/2021 Premium $ Issued toTeichert, Inc. WC 99 20 75 © 2016 Liberty Mutual Insurance Page 1 of 1 Ed. 12/01 /2016 ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYI() EJMMIN 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Edgewood Partners Insurance Center PO BOX 2110 Rancho Cordova CA 95670 CONTACT Kayla 2.9 PHONE FAX .8 925.822.9044 A►c No : 916-583-7613 ADMDREss: kayla.fritzberg@epicbrokers.com INSURERS AFFORDING COVERAGE NAIC # INSURER A : Liberty Mutual Fire Insurance Company 23035 License#: OB29370 INSURED TEICCONS A. Teichert & Son, Inc. INSURER B : Allied World Assurance Company U.S. 19489 DBA Teichert Construction INSURER C : INSURER D : PO Box 15002 Sacramento CA 95851 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:389063525 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 ADDL INSD S BR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Y Y EB2661067002031 3/31/2021 3/31/2022 EACH OCCURRENCE S2,000,000 PREMDAMAGE T RENTED PREMISES Ea occurrence) $1,000,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY ECTFT] LOC PRODUCTS -COMP/OP AGG $ 4,000,000 SIR $ 750,000 OTHER: A AUTOMOBILE LIABILITY Y Y EU266067002041 3/31/2021 3/31/2022 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 X BODILY INJURY (Per person) S ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) S X PROPERTY DAMAGE Per accident $ HIRED IX NON -OWNED AUTOS ONLY AUTOS ONLY SIR I $ 500.000 B UMBRELLA LIAB X OCCUR Y Y 03082614 3/31/2021 3/31/2022 EACH OCCURRENCE $10,000,000 X AGGREGATE $10,000,000 EXCESS LIAB CLAIMS -MADE DED F I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE N OFFICER/MEMBER EXCLUDED? N 1 A Y EW266NO67002011 3/31/2021 3/31/2022 X SPER TATUTE ERH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) RE: FY19 Citywide Pavement Maintenance Project (Teichert No. 11178.00). Additional Insured: The City of Gilory, its officers, officials, employees, and volunteers. When required by written contract, additional insured status with primary coverage applies to General Liability and Automobile, and waiver of subrogation applies to General Liability, Automobile Liability and Excess Workers' Compensation, all per the attached endorsements. XCU, Contractual Liability, and "Broad Form Property Damage" are included per General Liability Form CG0001 04 13. See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Gilroy City Engineer ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 7351 Rosanna Street Gilroy CA 95020 I I C- ZA d t, ��;o Ad, "e, &� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: TEICCONS LOC #: AC R ® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Edgewood Partners Insurance Center A. Teichert & Son, Inc. DBA Teichert Construction POLICY NUMBER PO Box 15002 Sacramento CA 95851 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Excess Liability is follow form. Named Insured is a California qualified self -insurer registered under #1867. The Workers' Compensation Policy provides Excess Workers' Compensation I Employer's Liability coverage excess of a $750,000 SIR. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: EB2661067002031 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Oranization(s): I Location(s) Of Covered Operations Any person or organization for whom you are All locations as required by a written contract or. performing operations when you and such person agreement entered into prior to an "occurrence" or organization have agreed in writing in a contract or offense. or agreement that such person or organization be added as an additional insured on your policy; and Any other person or organization you are required to add as an additional insured under the contract or agreement described in Section II below All prior to a loss occurring. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. J A. Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on be- half of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: EB2661067002031 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organzzation(s): Location And Description Of Completed Operations Any person or organization for whom you are All locations as required by a written contract or performing operations when you and such person or agreement entered into prior to an "occurrence" or organization have agreed in writing in a contract or offense. agreement that such person or organization be added as an additional insured on your policy; and Any other person or organization you are required to add as an additional insured under the contract or agreement described in Section II below All prior to a loss occurring. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT — SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Person(s) or Organization(s): All persons or organizations as required by written contract prior to a loss occurring. If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4.Other Insurance of Section IV — Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4.Other Insurance of Section IV — Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same 'occurrence", claim or "suit". LC 24 20 11 18 © 2018 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: EB2661067002031 COMMERCIAL GENERAL LIABILITY CG24040509 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: As required by written contract or agreement entered into prior to loss. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I 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 O Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - NONCONTRIBUTING This endorsement modifies insurance provided under the following: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY 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. Schedule Name of Person(s) or Organizations(s): Any person(s) or organization(s) to whom you are obligated by a written agreement to procure Additional Insured coverage under your policy Regarding Designated Contract or Project: All contracts or projects Each person or organization shown in the Schedule of this endorsement 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. The following is added to the Other Insurance Condition: If you have agreed that this policy will be primary and without right of contribution from any insurance in force for an Additional Insured for liability arising out of your operations and the agreement was executed prior to the bodily injury or property damage, then this insurance will apply before that other insurance, and we will not seek contribution from such insurance. However, insurance provided to the Additional Insured will subject to the self -insured amount and all other terms and conditions of the policy. AM 76 52 04 17 O 2017 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: EU2661067002041 Issued by: LIBERTY MUTUAL FIRE INSURANCE COMPANY 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: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY SELF -INSURED TRUCKER EXCESS LIABILITY POLICY With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. The Transfer Of Rights Of Recovery Against Others To Us condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization listed in the Schedule of this endorsement because of payments we make for injury or damage arising out of your operations of a covered auto. This waiver applies only to the person or organization listed in the Schedule of this endorsement. Schedule Premium: $ INCL Name of Person or Organization: Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring AM 76 19 07 13 © 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Where required by contract or written agreement prior to loss and allowed by law. Issued by: Liberty Mutual Fire Insurance Company For attachment to Policy No EW266NO67002011 Effective Date 03/31/2021 Premium $ Issued to: Teichert Inc. WC 00 03 13 01983 National Council on Compensation Insurance, Inc. Page 1 of 1 Ed. 411 /1984 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s)1 Organizations : Email Address or mailing address: Number Days Notice: Per schedule on file with broker Per schedule on file with broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) 1 Organ izations Email Address or mailing address: Number Days Notice: Per schedule on file with the Broker Per schedule on file with the Broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Name of Other Person(s) I Organization(s): Schedule on file with the Company SCHEDULE Email Address or mailing address: Schedule on file with the Company All other terms and conditions of this policy remain unchanged. Issued by Liberty Mutual Fire Insurance Company For attachment to Policy No. EW266NO67002011 Effective Date 03/31 /2021 Issued toTeichert, Inc. WC 99 20 75 © 2016 Liberty Mutual Insurance Ed. 12/01 /2016 Number Days Notice: Premium $ Page 1 of 1 A�COREO CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 3/30/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and 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 Edgewood Partners Insurance Center PO BOX 2110 Rancho Cordova CA 95670 CONTACT NAMPHONE Kayla Fritzber FAX •925.822.9044 AIc Noll: 916-583-7613 ADDRIESS: kayla.fritzberg@epicbrokers.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Fire Insurance Company 23035 License#: 0829370 INSURED TEICCONS A. Teichert & Son, Inc. INSURER B : Allied World Assurance Company U.S. 19489 DBA Teichert Construction INSURER C : INSURER D : PO Box 15002 Sacramento CA 95851 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:1678338406 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 MMIDDIYYYY ICY EFF MMIDDIYYW LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y EB2661067002031 3/31/2021 3/31/2022 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE a OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4,000,000 POLICY � JECT LOC PRODUCTS -COMP/OP AGG $ 4,000,000 SIR $ 750,000 OTHER: A AUTOMOBILE LIABILITY Y Y EU266067002041 3/31/2021 3/31/2022 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED Ix NON -OWNED AUTOS ONLY AUTOS ONLY SIR S 500,000 B UMBRELLA LIAR X OCCUR Y Y 03082614 3/31/2021 3/31/2022 EACH OCCURRENCE $ 10,000,000 X AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y Y EW266NO67002011 3/31/2021 3/31/2022 X STATUTE ERIPER H E.L. EACH ACCIDENT $ 1.000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE NI OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYEE S 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: FY21 Citywide Pavement Maintenance Project; 21-PW 260 (Teichert Job #11499). Additional Insured: The City of Gilroy, its officers, employees and volunteers. When required by written contract, additional insured status With primary coverage applies to General & Auto Liability and waiver of subrogation applies to General Liability, Automobile Liability and Excess Workers' Compensation, all per the attached endorsements. XCU, Contractual Liability, and "Broad Form Property Damage" are included per General Liability coverage form CG0001 04 13. See Attached... VCK I IrIVA I t MULUCK GANGtLLA I IUN City of Gilroy 7351 Rosanna St. 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 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: TEICCONS LOC #: Ac o® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Edgewood Partners Insurance Center A. Teichert & Son, Inc. DBA Teichert Construction PO Box 15002 POLICY NUMBER Sacramento CA 95851 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS ITHIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Excess liability is follow form. Named Insured is a California qualified self -insurer registered under #1867. The Workers' Compensation Policy provides Excess Workers' Compensation / Employer's Liability coverage excess of a $750,000 SIR. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: EB2661067002031 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ izations : Locations Of Covered Operations Any person or organization for whom you are All locations as required by a written contract or, performing operations when you and such person agreement entered into prior to an "occurrence' or organization have agreed in writing in a contract or offense. or agreement that such person or organization be added as an additional insured on your policy; and Any other person or organization you are required to add as an additional insured under the contract or agreement described in Section II below All prior to a loss occurring. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on be- half of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER: EB2661067002031 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE I Name Of Additional Insured Person(s) I Location And Description Of Completed I Or Organizations}: Operations Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy; and Any other person or organization you are required to add as an additional insured under the contract or agreement described in Section 11 below All prior to a loss occurring. All locations as required by a written contract or agreement entered into prior to an 'occurrence" or offense. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury' or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 13 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT — SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Person(s) or Organization(s): All persons or organizations as required by written contract prior to a loss occurring. If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4.Other Insurance of Section IV — Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4.Other Insurance of Section IV — Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same 'occurrence", claim or "suit". LC 24 20 11 18 © 2018 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: EB2661067002031 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: As required by written contract or agreement entered into prior to loss. I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I 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 © Insurance Services Office, Inc., 2008 Page 1 of 1 13 Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - NONCONTRIBUTING This endorsement modifies insurance provided under the following: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY 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. Schedule Name of Person(s) or Organizations(s): Any person(s) or organization(s) to whom you are obligated by a written agreement to procure Additional Insured coverage under your policy Regarding Designated Contract or Project: All contracts or projects Each person or organization shown in the Schedule of this endorsement 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. The following is added to the Other Insurance Condition: If you have agreed that this policy will be primary and without right of contribution from any insurance in force for an Additional Insured for liability arising out of your operations and the agreement was executed prior to the bodily injury or property damage, then this insurance will apply before that other insurance, and we will not seek contribution from such insurance. However, insurance provided to the Additional Insured will subject to the self -insured amount and all other terms and conditions of the policy. AM 76 52 0417 © 2017 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: EU2661067002041 Issued by: LIBERTY MUTUAL FIRE INSURANCE COMPANY 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: EXCESS AUTOMOBILE LIABILITY INDEMNITY POLICY SELF -INSURED TRUCKER EXCESS LIABILITY POLICY With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. The Transfer Of Rights Of Recovery Against Others To Us condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization listed in the Schedule of this endorsement because of payments we make for injury or damage arising out of your operations of a covered auto. This waiver applies only to the person or organization listed in the Schedule of this endorsement. Schedule Premium: $ INCL Name of Person or Organization: Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring AM 76 19 07 13 © 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Where required by contract or written agreement prior to loss and allowed by law. Issued by: Liberty Mutual Fire Insurance Company For attachment to Policy No EW266NO67002011 Effective Date03131/2021 Issued to: Teichert Inc. WC 00 0313 C 1983 National Council on Compensation Insurance, Inc. Ed. 4/1 /1984 Premium $ Page 1 of 1 Policy Number EB2661067002031 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) ! Organ izations Email Address or mailing address: Number Days Notice: Per schedule on file with broker Per schedule on file with broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number EU2661067002041 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s)1 Organ izations : Email Address or mailing address: Number Days Notice: Per schedule on file with the Broker Per schedule on file with the Broker 90 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Name of Other Person(s) / Organization(s): Schedule on file with the Company SCHEDULE Email Address or mailing address: Schedule on file with the Company All other terms and conditions of this policy remain unchanged. Issued by Liberty Mutual Fire Insurance Company For attachment to Policy No. EW266NO67002011 Effective Date 03/31/2021 Issued toTeichert, Inc. WC 99 20 76 0 2016 Liberty Mutual Insurance Ed. 12/01 /2016 Number Days Notice: .e Premium $ Page 1 of 1