ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDYYYY) 6/16/2022
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 or this certificate does not confer rights to the certificate holder in lieu of such endorsements) PRODUCER NAME: GONE Katie Sell
InterWest Insurance Services, LLC PHONE FAC, No): 916-609-8374 P.O. Box 8110 (A/C, No, ExI): 916-609-8374
E-MAIL
Chico CA 95927-8110 ADDRESS: [email protected]
INSURERS) AFFORDING COVERAGE NAIC #
License#: 0801094 INSURERA: Pennsylvania Mir's Assn Ins Co 12262 INSURED AMERASP-02 INSURER B: Travelers Property & Casualty Co of America 25674
American Asphalt South, Inc. INSURER C: Westchester Surplus Lines Ins 10172 PO Box 310036
Fontana CA 92331 INSURER D: Arch Insurance Company 11150 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 642445106 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 LIMITS
LEACH OCCURRENCE $1,000,000
] CLAIMS MADE [X] OCCUR DAMAGE TO RENTED
PREMISES (Ea occurrence) $ 300,000
MED EXP (Any one porson) $10,000
APPROVED AS TO FORM PERSONAL. & ADV INJURY $ 1,000,000
GEN'L. AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY X PRO
JECT LOC
BY: TAICHAEL E. GATES PRODUCTS- COMPOP AGG $2,00,000
OTHER:
A AUTOMOBILE LIABILITY y 1521011368497 $ 1,000,000
CITY OFTEN BA202 MEER SINGLE LOIT (Ea accident)
X ANY AUTO BODILY INJURY (Per person)
OWNED SCHEDULED BODILY INJURY (Per accident) s
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY $
AUTOS ONLY (Per accident)
$
UMBRELLA LIAB OCCUR ZUP71M8933021 12/31/2021 12/31/2022 EACH OCCURRENCE $6,000,000 EXCESS LIAB CLAIMS-MADE $6,000,000
AGGREGATE
DED RETENTIONS $
D WORKERS COMPENSATION ZAWC19413905 4/1/2022 4/1/2023 X I STATUTE T
AND EMPLOYERS' LIABILITY YIN
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFSICER/MEMBEREXCLUDED? N/ A
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 _DESCRIPTION OF OPFRATIONS below. E.L. DISEASE - POLICY LIMIT$1,000,000 | Pollution Liability G70915613003 8127/2020 8/2712022 Each Pollution Cond 2,000,000 2,000,000
10,000
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THEREOF, NOTICE WILL BE DELIVERED IN
City of Huntington Beach
Risk Management Specialist
2000 Main Street AUTHORIZED REPRESENTATIVE
Huntington Beach CA 92648
go Sconce
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD •
Policy Number: 3021011368497 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 Organization(s): Locations) Of Covered Operations
The City of Huntington Beach, its officers, elected or As Required by Written Contract. appointed officials, employees, agents and volunteers
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section I - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or ox- additional insureds, the following additional exdu ganizations) shown in the Schedule, but only with sions apply:
respect to liability for "bodily injury", "property dam- This insurance does not apply to "bodily injury" ol age" or "personal and advertising injury" caused, in property damage" occuring after whole or in part, by:
1. All work, including materials, parts or equipment
1. Your acts or omissions; or furnished in connection with such work, on the
2. The acts or omissions of those acting on your project (other than service, maintenance or re- behalf; pairs) to be performed by or on behalf of the ad- in the performance of your ongoing operations for ditional insured(s) at the location of the covered the additional insured(s) at the locations) desig-
nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in-
CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER: 3021011368497 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 Organization(s): Location And Description Of Completed Operations The City of Huntington Beach, its officers, elected or As Required by Written Contract appointed officials, employees, agents and volunteers
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 in-
clude as an additional insured the person(s) or or-
location designated and described in the schedule of
this endorsement performed for that additional insured
and included in the "products-completed operations
CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER: 1521011368497 COMMERCIAL AUTO
CA 04 49 11 16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
. The following is added to the Other Insuranc B. The following is added to the Other Insurance condition in the Business Auto Coverade Forn Condition in the Auto Dealers Coverage Form and and the Other Insurance - Primary And Excess supersedes any provision to the contrary:
This Coverage Form's Covered Autos Liability
Coverage Form and supersedes any provision to Coverage and General Liability Coverages are the contrary: primary to and will not seek contribution from any his Coverade Form's Covered Autos Liabilit other insurance available to an "insured" under Coverage is primary to your policy provided that:
contribution from any other insurance available to 1. Such "insured" is a Named Insured under such an "insured" under your policy provided that: other insurance; and . Such "insured" is a Named Insured under suc 2. You have agreed in writing in a contract or ther insurance: ant
agreement that this insurance would be
• You have agreed in writina in a contract o primary and would not seek contribution from agreement that this insurance would b any other insurance available to such primary and would not seek contribution from "insured". any other insurance available to such
"insured".
CA 04 49 11 16 © Insurance Services Office, Inc., 2016 Page 1 of 1 Westchester
A Chubb Company
ADDITIONAL INSURED ENDORSEMENT - ONGOING WORK OR OPERATIONS Named Insured Endorsement Number
American Asphalt South, Inc.
Policy Symbol Policy Number Policy Period Effective Date of Endorsement CPW G70915613 003 8/27/2020 To 8/27/2022 8/27/2020
Issued By (Name of Insurance Company)
Westchester Surplus Lines Insurance Company
Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
SCHEDULE:
Name of Person(s) or Organization(s):
As required by written contract or agreement signed by both parties prior to a loss to which this insurance applies.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
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 insureds.
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.
B. With respect to the insurance afforded to these additional insureds, the following exclusion is added:
Exclusions
This insurance does not apply to injury or damage occurring after:
a. All work or operations, including materials, parts or equipment furnished in connection with such work or operations, on the project (other than service, maintenance or repairs) to be performed by you or on your behalf at the site of the covered operations has been completed; or ENV-3250 (12/18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 2 (221012.1)
Westchester
A Chubb Company
b. That portion of your work out of which the injury or damage arises has been put to its intended se by any person or organization other than another contractor or subcontractor engaged rforming operations for the additional insured as a part of the same proje C. 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.
All other terms and conditions of this policy remain unchanged.
ENV-3250 (12/18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 2 of 2 (221012.1)
Westchester
A Chubb Company
ADDITIONAL INSURED ENDORSEMENT - PRODUCTS-COMPLETED OPERATIONS HAZARD Named Insured Endorsement Number
American Asphalt South, Inc.
Policy Symbol Policy Number Policy Period Effective Date of Endorsement™ CPW G70915613 003 8/27/2020 To 8/27/2022 8/27/2020
Issued By (Name of Insurance Company)
Westchester Surplus Lines Insurance Company
Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
As required by written contract or agreement signed by both parties prior to a loss to which this insurance applies.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
A. SECTION II - WHO IS AN INSURED is amended to include as an additional insured the person(s) or rganization(s) shown in the Schedule, but only with respect to liability for injury or damage, to which thi nsurance applies, caused by or resulting from your work performed for that additional insured an included in the products-completed operations hazard, and only to the extent that such injury or damage is caused, in whole or in part, by your negligence or the negligence of those acting on your behalf.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and . 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.
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.
All other terms and conditions of this policy remain unchanged.
ENV-3251 (12/18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 (221012.2)
Westchester
^ Chubh Company
PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION Named Insured Endorsement Number
American Asphalt South, Inc.
Policy Symbol Policy Number [ Policy Period Effective Date of Endorsement CPW G70915613 003 8/27/2020 To 8/27/2022 8/27/2020
Issued By (Name of Insurance Company)
Westchester Surplus Lines Insurance Company
Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THEFOLLOWING:
CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART
The following is added to the Other Insurance Condition and supersedes any provision to the contrary:
Primary and Noncontributory Insurance
This policy is primary to, and will not seek contribution from, any other insurance available to an additional insured under this policy, provided that:
a. The additional insured is a named insured under such other insurance; and b. The named insured has agreed in a written contract or agreement that this insurance would:
(1) act as primary insurance; and
(2) would not seek contribution from any other insurance available to the additionalinsured.
All other terms and conditions of this policy remain unchanged.
ENV-3253 (12-18) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 (266562.2)
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Named Insured Endorsement Number
American Asphalt South, Inc.
Policy Symbol Policy Number Policy Period Effective Date of Endorsement CPW G70915613 003 8/27/2020 To 8/27/2022 8/27/2020
Issued By (Name of Insurance Company)
Westchester Surplus Lines Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products-completed operations hazard.
This waiver applies only to the person or organization shown in the Schedule above.
All other terms and conditions remain the same.
ENV-3143(03-05) Includes copyrighted material of insurance Services Office, Inc. with its permission Page 1 of 1 POLICY NUMBER: 1521011368497 COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Named Insured:American Asphalt South, Inc.
Endorsement Effective Date: 12/31/2021
SCHEDULE
Name Of Person(s) Or Organization(s): As required by written contract.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations. ach person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained ir ParagraphA.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. © Insurance Services Office, Inc.
Policy Number:3021011368497 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the greement that this insurance would b contrary: rimary and would not seek contributio
Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek
contribution from any other insurance avallable to
an additional insured under your policy provided
(1) The additional insured is a Named Insured
under such other insurance; and
CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: 1521011368497 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Named Insured: American Asphalt South, Inc.
Endorsement Effective Date: 12/31/2021
SCHEDULE
Name(s) Of Person(s) Or Organization(s): As required by written contract.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The Transfer Of Rights Of Recovery Against
Others To Us Condition does not apply to the
person(s) or organization(s) shown in the Schedule
prior to the theidener or the us® under a contract
with that person or organization.
CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER: 3021011368497 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: Where required by written contract or Agreement.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The followino is added to Paragraph 8. Transfer Of
Richts 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 hat pastr
or organization and included in the
completed operations hazard". This walver applies
only to the person or organization shown in the
CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -
CALIFORNIA
Ne 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 tha you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule.
The additional premium for this endorsement shall be INCL % of the California workers' compensation premium otherwise due on such remuneration.
SCHEDULE
PERSON OR ORGANIZATION JOB DESCRIPTION
ANY PERSON OR ORGANIZATION WHERE ALL JOBS UNDER CONTRACT
WAIVER OF OUR RIGHT TO RECOVER IS
PERMITTED BY LAW AND IS REQUIRED
BY WRITTEN CONTRACT PROVIDED SUCH
CONTRACT WAS EXECUTED PRIOR TO
DATE OF LOSS
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 04-01-2022 Policy No. ZAWCI9413905 Endorsement No.
Insured AMERICAN ASPHALT REPAIR Premium $ INCH.
Insurance Company ARCH INSURANCE COMPANY
Countersigned By
© 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.
From the WCIRB's California Workers' Compensation Insurance Forms Manual @ 1999.