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HomeMy WebLinkAboutCertificate of Insurance 2018 (2)ACC)R V CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) TYPE OF INSURANCE 11/5/2018 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 Bolton & Company NAME: 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 PHONE FAX AIC No Ext : 626 799-7000 A/C No): 626 583-2117 EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # www.boltonco.com 0008309 INSURERA: Old Republic General Insurance Corp24139 INSURED O'Grady Paving, Inc. DBA: A & D Trucking; Best Equipment Rentals 2513 Wyandotte Street Mountain View CA 94043 -INSURER B: Starr Indemnity& LiabilityCompany 38318 INsuRERc: Underwriters at Lloyd'sLondon INSURER D: INSURER E: INSURER F 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, TN SR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A �/ COMMERCIALGENERALLIABILITY CLAIMS -MADE / OCCUR AlCG44181800 7/1/2018 7/1/2019 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ✓� jE O LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY AlCA44181800 7/1/2018 7/1/2019 EaaBINEDtSINGLELIMIT $1,000,000 ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Pe (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ B UMBRELLA LIAB EXCESS LIAB �/ OCCUR CLAIMS -MADE 1000585182181 7/1/2018 7/1/2019 EACH OCCURRENCE s 10 000,000 AGGREGATE $ 10,000,000 DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/M EMBER EXCLUDED? N/A AlCW44181800 7/1/2018 7/1/2019 STATUTE EERH 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 C Pollution Liability PGIARK0873600 7/1/2018 7/1/2019 Limit: $1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required) Re: Job #18174, Install Sharrows at Elena Rd and Moody Road. GL Additional Insured applies per CG20100413 & CG20370413 attached, only if required by written contract/agreement. GL, Auto and WC Notice of Cancellation clauses apply per IL02700912 and WC9903140107 attached. Additional Insured(s): The Town of Los Altos Hills, its elective and appointed officers, employees, and volunteers. ""„ wr„ w�.✓�.i� t'HIVIIMLLH 1 IVIV Town of Los Altos Hills 26379 Fremont Road Los Altos Hills, CA 94022 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 Chau Tran V 1UBU-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 45246868 1 OGRAPAV-C1 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3:24;01 PM (PST) I Page 1 of 13 POLICY NUMBER: A -ICG -441818-00 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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 Organization(s) Locations Of Covered Operations THE OWNER AND CONTRACTOR, IF REQUIRED LOCATIONS AS REQUIRED BY AN EXECUTED BY THE TERMS OF A WRITTEN CONTRACT THAT WRITTEN CONTRACT. WAS FULLY EXECUTED PRIOR TO THE DATE OF THE "OCCURRENCE", AND ANY OTHER PERSONS OR ENTITIES SPECIFICALLY REQUIRED BY, AND IDENTIFIED BY NAME IN, THAT SAME CONTRACT. 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) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. 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. CG 20 10 04 13 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © Insurance Services Office, Inc., 2012 45246868 1 OGRAPAV-C1 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3:24:01 PM (PST) I Page 2 of 13 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III — Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 45246868 1 OGRAPAV-C1 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3;24:01 PM (PST) I Page 3 of 13 AlCA44181800 IL 02 70 09 12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA CHANGES - CANCELLATION AND NONRENEWAL This endorsement modifies insurance provided under the following: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART EMPLOYMENT-RELATED PRACTICES LIABILITY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART MEDICAL PROFESSIONAL LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Paragraphs 2. and 3, of the Cancellation Common Policy Condition are replaced by the following: 2. All Policies In Effect For 60 Days Or Less If this policy has been in effect for 60 days or less, and is not a renewal of a policy we have previously issued, we may cancel this policy by mailing or delivering to the first Named Insured, at the mailing address shown in the policy, and to the producer of record, advance written notice of cancellation, stating the reason for cancellation, at least: a. 10 days before the effective date of cancellation if we cancel for: (1) Nonpayment of premium; or (2) Discovery of fraud by: (a) Any insured or his or her representative in obtaining this insurance; or (b) You or your representative in pursuing a claim under this policy. b. 30 days before the effective date of cancellation if we cancel for any other reason. 3. All Policies In Effect For More Than 60 Days a. If this policy has been in effect for more than 60 days, or is a renewal of a policy we issued, we may cancel this policy only upon the occurrence, after the effective date of the policy, of one or more of the following: (1) Nonpayment of premium, including payment due on a prior policy we issued and due during the current policy term covering the same risks. (2) Discovery of fraud or material misrepresentation by: (a) Any insured or his or her representative in obtaining this insurance; or (b) You or your representative in pursuing a claim under this policy. (3) A judgment by a court or an administrative tribunal that you have violated a California or Federal law, having as one of its necessary elements an act which materially increases any of the risks insured against. IL 02 70 09 12 © Insurance Services Office, Inc., 2012 Page 1 of 4 45246868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3:24:01 PM (PST) I Page 4 of 13 A1CA44181800 (4) Discovery of willful or grossly negligent acts or omissions, or of any violations of state laws or regulations establishing safety standards, by you or your representative, which materially increase any of the risks insured against. (5) Failure by you or your representative to implement reasonable loss control requirements, agreed to by you as a condition of policy issuance, or which were conditions precedent to our use of a particular rate or rating plan, if that failure materially increases any of the risks insured against, (6) A determination by the Commissioner of Insurance that the: (a) Loss of, or changes in, our reinsurance covering all or part of the risk would threaten our financial integrity or solvency; or (b) Continuation of the policy coverage would: (i) Place us in violation of California law or the laws of the state where we are domiciled; or (ii) Threaten our solvency. (7) A change by you or your representative) in the activities or property of the commercial or industrial enterprise, which results in a materially added, increased or changed risk, unless the added, increased or changed risk is included in the policy. b. We will mail or deliver advance written notice of cancellation, stating the reason for cancellation, to the first Named Insured, at the mailing address shown in the policy, and to the producer of record, at least: (1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium or discovery of fraud; or (2) 30 days before the effective date of cancellation if we cancel for any other reason listed in Paragraph 3.a. Page 2 of 4 B. The following provision is added to the Cancellation Common Policy Condition: 7. Residential Property This provision applies to coverage on real property which is used predominantly for residential purposes and consisting of not more than four dwelling units, and to coverage on tenants' household personal property in a residential unit, if such coverage is written under one of the following: Commercial Property Coverage Part Farm Coverage Part — Farm Property — Farm Dwellings, Appurtenant Structures And Household Personal Property Coverage Form a. If such coverage has been in effect for 60 days or less, and is not a renewal of coverage we previously issued, we may cancel this coverage for any reason, except as provided in b. and c. below. b. We may not cancel this policy solely because the first Named Insured has: (1) Accepted an offer of earthquake coverage; or (2) Cancelled or did not renew a policy issued by the California Earthquake Authority (CEA) that included an earthquake policy premium surcharge. However, we shall cancel this policy if the first Named Insured has accepted a new or renewal policy issued by the CEA that includes an earthquake policy premium surcharge but fails to pay the earthquake policy premium surcharge authorized by the CEA. c. We may not cancel such coverage solely because corrosive soil conditions exist on the premises. This restriction (c.) applies only if coverage is subject to one of the following, which exclude loss or damage caused by or resulting from corrosive soil conditions: (1) Commercial Property Coverage Part — Causes Of Loss — Special Form; or (2) Farm Coverage Part — Causes Of Loss Form — Farm Property, Paragraph D. Covered Causes Of Loss — Special. © Insurance Services Office, Inc., 2012 45246868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3:24:01 PM (PST) I Page 5 of 13 IL 02 70 09 12 Al CA44181800 C. The following is added and supersedes any (2) The Commissioner of Insurance finds provisions to the contrary: that the exposure to potential losses will Nonrenewal threaten our solvency or place us in a 1. Subject to the provisions of Paragraphs C.2. hazardous condition. A hazardous condition includes, but is not limited to, a and C.3. below, if we elect not to renew this condition in which we make claims policy, we will mail or deliver written notice, payments for losses resulting from an stating the reason for nonrenewal, to the first earthquake that occurred within the Named Insured shown in the Declarations, and preceding two years and that required a to the producer of record, at least 60 days, but reduction in policyholder surplus of at not more than 120 days, before the expiration least 25% for payment of those claims; or anniversary date. or We will mail or deliver our notice to the first (3) We have: Named Insured, and to the producer of record, at the mailing address shown in the policy. Lost or (a)experienced a substantial 2. Residential Property reduction availability or scope of reinsurance coverage; or This provision applies to coverage on real (b) Experienced a substantial increase property used predominantly for residential in the premium charged for purposes and consisting of not more than four reinsurance coverage of our dwelling units, and to coverage on tenants' residential property insurance household property contained in a residential policies; and unit, if such coverage is written under one of the following: the Commissioner has a roved a Ian Commercial Property Coverage Part for the nonrenewals that is fair and Farm Coverage Part — Farm Property — Farm equitable, and that is responsive to the changes in our reinsurance position. Dwellings, Appurtenant Structures And Household Personal Property Coverage Form c. We will not refuse to renew such coverage a. We may elect not to renew such coverage solely because the first Named Insured has for any reason, except as provided in b., c. cancelled or did not renew a policy, issued by the California Earthquake Authority, that and d. below. included an earthquake policy premium b. We will not refuse to renew such coverage surcharge. solely because the first Named Insured has d. We will not refuse to renew such coverage accepted an offer of earthquake coverage, solely because corrosive soil conditions However, the following applies only to exist on the premises, This restriction (d.) insurers who are associate participating applies only if coverage is subject to one of insurers as established by Cal. Ins. Code the following, which exclude loss or Section 10089.16. We may elect not to damage caused by or resulting from renew such coverage after the first Named corrosive soil conditions: Insured has accepted an offer of (1) Commercial Property Coverage Part — earthquake coverage, if one or more of the Causes Of Loss — Special Form; or following reasons applies: (1) The nonrenewal is based on sound (2) Farm Coverage Part — Causes Of Loss Form — Farm Property, Paragraph D. underwriting principles that relate to the Covered Causes Of Loss — Special. coverages provided by this policy and that are consistent with the approved 3. We are not required to send notice of rating plan and related documents filed nonrenewal in the following situations: with the Department of Insurance as a. If the transfer or renewal of a policy, without required by existing law; any changes in terms, conditions or rates, is between us and a member of our insurance group, IL 02 70 09 12 © Insurance Services Office, Inc., 2012 45246868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3:24;01 PM (PST) I Page 6 of 13 Page 3 of 4 Al CA44181800 b. If the policy has been extended for 90 days or less, provided that notice has been given in accordance with Paragraph C.1. c. If you have obtained replacement coverage, or if the first Named Insured has agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. d. If the policy is for a period of no more than 60 days and you are notified at the time of issuance that it will not be renewed. e. If the first Named Insured requests a change in the terms or conditions or risks covered by the policy within 60 days of the end of the policy period. f. If we have made a written offer to the first Named Insured, in accordance with the timeframes shown in Paragraph C.1., to renew the policy under changed terms or conditions or at an increased premium rate, when the increase exceeds 25%, Page 4 of 4 © Insurance Services Office, Inc., 2012 IL 02 70 09 12 45246868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3;29;01 PM (PST) I Page 7 of 13 Al CG44181800 (4) Discovery of willful or grossly negligent acts or omissions, or of any violations of state laws or regulations establishing safety standards, by you or your representative, which materially increase any of the risks insured against. (6) Failure by you or your representative to implement reasonable loss control requirements, agreed to by you as a condition of policy issuance, or which were conditions precedent to our use of a particular rate or rating plan, if that failure materially increases any of the risks insured against. (6) A determination by the Commissioner of Insurance that the: (a) Loss of, or changes in, our reinsurance covering all or part of the risk would threaten our financial integrity or solvency; or (b) Continuation of the policy coverage would: (i) Place us in violation of California law or the laws of the state where we are domiciled; or (ii) Threaten our solvency. (7)- A change by you or yourrepresentative in the activities or property of the commercial or industrial enterprise, which results in a materially added, increased or changed risk, unless the added, increased or changed risk is included in the policy. b. We will mail or deliver advance written notice of cancellation, stating the reason for cancellation, to the first Named Insured, at the mailing address shown in the policy, and to the producer of record, at least: (1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium or discovery of fraud; or (2) 30 days before the effective date of cancellation if we cancel for any other reason listed in Paragraph 3.a. Page 2 of 4 B. The following provision is added to the Cancellation Common Policy Condition: Residential Property This provision applies to coverage on real property which is used predominantly for residential purposes and consisting of not more than four dwelling units, and to coverage on tenants' household personal property in a residential unit, if such coverage is written under one of the following: Commercial Property Coverage Part Farm Coverage Part — Farm Property — Farm Dwellings, Appurtenant Structures And Household Personal Property Coverage Form a. If such coverage has been in effect for 60 days or less, and is not a renewal of coverage we previously issued, we may cancel this coverage for any reason, except as provided in b. and c. below. b. We may not cancel this policy solely because the first Named Insured has: (1) Accepted an offer of earthquake coverage; or (2) Cancelled or did not renew a policy issued by the California Earthquake Authority (CEA) that included an earthquake policy premium surcharge, However, we shall cancel this policy if the first Named Insured has accepted a new or renewal policy issued by the CEA that includes an earthquake policy premium surcharge but fails to pay the earthquake policy premium surcharge authorized by the CEA. C. We may not cancel such coverage solely because corrosive soil conditions exist on the premises. This restriction (c.) applies only if coverage is subject to one of the following, which exclude loss or damage caused by or resulting from corrosive soil conditions: (1) Commercial Property Coverage Part — Causes Of Loss — Special Form; or (2) Farm Coverage Part — Causes Of Loss Form — Farm Property, Paragraph D. Covered Causes Of Loss — Special. © Insurance Services Office, Inc., 2012 45246868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3:24:01 PM (PST) I Page 9 of 13 IL 02 70 09 12 AlCG44181800 C. The following is added and supersedes any provisions to the contrary: Nonrenewal 1. Subject to the provisions of Paragraphs C.2. and C.3. below, if we elect not to renew this policy, we will mail or deliver written notice, stating the reason for nonrenewal, to the first Named Insured shown in the Declarations, and to the producer of record, at least 60 days, but not more than 120 days, before the expiration or anniversary date. We will mail or deliver our notice to the first Named Insured, and to the producer of record, at the mailing address shown in the policy. 2. Residential Property This provision applies to coverage on real property used predominantly for residential purposes and consisting of not more than four dwelling units, and .to coverage on tenants' household property contained in a residential unit, if such coverage is written under one of the following: Commercial Property Coverage Part Farm Coverage Part — Farm Property — Farm Dwellings, Appurtenant Structures And Household Personal Property Coverage Form a. We may elect not to renew such coverage for any reason, except as provided in b., c. and d. below. b. We will not refuse to renew such coverage solely because the first Named Insured has accepted an offer of earthquake coverage. However, the following applies only to insurers who are associate participating insurers as established by Cal. Ins, Code Section 10089.16. We may elect not to renew such coverage after the first Named Insured has accepted an offer of earthquake coverage, if one or more of the following reasons applies: (1) The nonrenewal is based on sound underwriting principles that relate to the coverages provided by this policy and that are consistent with the approved rating plan and related documents filed with the Department of Insurance as required by existing law; (2) The Commissioner of Insurance finds that the exposure to potential losses will threaten our solvency or place us in a hazardous condition. A hazardous condition includes, but is not limited to, a condition in which we make claims payments for losses resulting from an earthquake that occurred within the preceding two years and that required a reduction in policyholder surplus of at least 25% for payment of those claims; or (3) We have: (a) Lost or experienced a substantial reduction in the availability or scope of reinsurance coverage; or (b) Experienced a substantial increase in the premium charged for reinsurance coverage of our residential property insurance policies; and the Commissioner has approved a plan for the nonrenewals that is fair and equitable, and that is responsive to the changes in our reinsurance position. c. We will not refuse to renew such coverage solely because the first Named Insured has cancelled or did not renew a policy, issued by the California Earthquake Authority, that included an earthquake policy premium surcharge. d. We will not refuse to renew such coverage solely because corrosive soil conditions exist on the premises. This restriction (d.) applies only if coverage is subject to one of the following, which exclude loss or damage caused by or resulting from corrosive soil conditions: (1) Commercial Property Coverage Part — Causes Of Loss — Special Form; or (2) Farm Coverage Part — Causes Of Loss Form — Farm Property, Paragraph D. Covered Causes Of Loss — Special. 3. We are not required to send notice of nonrenewal in the following situations: a. If the transfer or renewal of a policy, without any changes in terms, conditions or rates, is between us and a member of our insurance group. IL 02 70 09 12 © Insurance Services Office, Inc., 2012 Page 3 of 4 45246868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3;24;01 PM (PST) I Page 10 of 13 AlCG44181800 b. If the policy has been extended for 90 days or less, provided that notice has been given in accordance with Paragraph C.1. c. If you have obtained replacement coverage, or if the first Named Insured has agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. d. If the policy is for a period of no more than 60 days and you are notified at the time of issuance that it will not be renewed. Page 4 of 4 e. If the first Named Insured requests a change in the terms or conditions or risks covered by the policy within 60 days of the end of the policy period. f. If we have made a written offer to the first Named Insured, in accordance with the timeframes shown in Paragraph C.1., to renew the policy under changed terms or conditions or at an increased premium rate, when the increase exceeds 25%. © Insurance Services Office, Inc., 2012 45296868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3;29;01 PM (PST) I Page 11 of 13 IL 02 70 09 12 OLD REPUBLIC GENERAL INSURANCE CORPORATION WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY CANCELLATION PROVISION THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: Part Six - Conditions, Item D. Cancellation, Number 2, is changed to read: 2. We may cancel this policy. We must mail or deliver to you not less than 60 days advance written notice stating when the cancellation is to take effect, unless cancellation is for nonpayment of premium, in which event. our obligation is mailing not less than 10 days prior to the effective date of cancellation. Mailing notice to you at your mailing address shown in Item 1 on the Information Page will be sufficient to prove notice. Named Insured O'GRADY PAVING, INC. Policy Number AlCW44181800 Endorsement No. 000 Policy Period 07/01/2018 to 07/01/2019 Endorsement Effective Date: 07/01/2018 Producer's Name: OLD REPUBLIC CONTRACTORS INSURANCE AGENCY, INC. Producer Number: 0000007000 AUTHORIZED REPRESENTATIVE WC 99 03 14 (01/07) DATE 45296868 1 OGRAPAV-C1 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3:24:01 PM (PST) I Page 12 of 13 POLICY NUMBER: A-1CG-441818-00 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations THE OWNER AND CONTRACTOR, IF REQUIRED LOCATIONS AS REQUIRED BY AN EXECUTED BY THE TERMS OF A WRITTEN CONTRACT THAT WRITTEN CONTRACT. WAS FULLY EXECUTED PRIOR TO THE DATE OF THE "OCCURRENCE", AND ANY OTHER PERSONS OR ENTITIES SPECIFICALLY REQUIRED BY, AND IDENTIFIED BY NAME IN, THAT SAME CONTRACT. 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. 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. CG 20 37 04 13 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: It 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. © Insurance Services Office, Inc., 2012 45246868 1 OGRAPAV-Cl 1 18-19 WC, Auto, GL, XS, POLL I Bolton Certificate Processing 1 11/5/2018 3;24;01 PM (PST) I Page 13 of 13 Page 1 of 1