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Surf City INSURANCE AND INDEMNIFICATION WAIVER
H
MODIFICATION REQUEST
Huningon Beach o
1. Requested: Risk Management
2. Date: February 1, 2024
3. Name of contractor/permittee: Allied Universal Topco, LLc
4. Description of work to be performed: Street Sweeping Enforcement
5. Value and length of contract: $1,119,000 - (1) Year Term
6. Waiver/modification request: $1.75 Million SIR on General Liability
7. Reason for request and why it should be granted: We do not allow SIR. Please see attached financial statement.
Identify the risks to the City in approying this waiver/modification: Low 216|24
Department Head Signature Date:
APPROVALS
Approvals must be obtained in the order listed on this form. Two approvals are required for a request to be granted. Approval from the City Administrator's Office is only required if Risk Management and the City Attorney's Office disagree.
1. Risk Management
selmaste 2~1-24
Approved • Denied
Signature Date
2. City Attorney's Office
'Approved • Denied 2/8/24
Signature Date
3. City Manager's Office
• Approved Denied
Signature Date
If approved, the completed waiver/modification request is to be submitted to the City Attorney's Office along with the contract for approval. Once the contract has been approved, this form is to be filed with the Risk Management Division of Human Resources RISK Mgt-FEB 7'24AM10:28
Waiver Form - Vianate 2/1/20244:19:00 PM
ACORD® DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 01/23/2024
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 INSURERS), 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 endorsements).
Marsh | U.S. Operations
Philadelphia, PA 19103 [email protected]
Attn: [email protected] / Fax: (212) 948-0360 INSURERS) AFFORDING COVERAGE NAIC #
CN118025105-ALL-STAND-24-25 36940
INSURER A: Indian Harbor Insurance Company
INSURED INSURER B : Greenwich Insurance Company 22322
Allied Universal Topco, LLC
(See Attached for Additional Named Insureds) INSURER C: XL Insurance America 24554 161 Washington Street, Suite 600 INSURER D: Indemnity Insurance Company of North America 43575 Conshohacken, PA 19428
INSURERE: XL Specially Insurance Company.
CERTIFICATE NUMBER: CLE-006502213-24
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.
POLICY NUMBER
EACH OCCURRENCE 30,000,000
CLAIMS MADE X OCCUR DAMAGE TO RENTEO 30,000,000
PREMISES (Ea occurrence) $
X CONTRACTUAL LIABILITY MED EXP (Any one person) $
X SIR $1,750,000 PERSONAL & ADV INJURY 30,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,00000 X POLICY! PRO- 55,00000đ
JECT PRODUCTS - COMP/OP AGG
OTHER:
AUTOMOBILE LIABILITY RAD943781807 0170172024 T017012025 COMBINED SINGLE LIMIT 5,000,000 (Ea accident)
ANY AUTO BODILY INJURY (Per person)
OWNED SCHEDULED BODILY INJURY (Per accident)
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident)
UMBRELLA LIAB X OccUR SM 72500027004 101/01/2024 101/01/2025 EACH OCCURRENCE 10,000,000 EXCESS LIAB Excess of General Liability, 10,000,000
CLAIMS-MADE AGGREGATE $
Auto Liability, and Workers' Comp
DED, RETENTIONS
WORKERS COMPENSATION RWD300120308 (AOS) 0T0172024 T017012025 OTH- ER
AND EMPLOYERS' LIABILITY Y/N 01/01/2024 /01/01/2025
ANYPROPRIETOR PARTNER/EXECUTIVE RWR300120408 (WI EL. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N NIA
(Mandatory in NH) RWE943548208 (CA, OH) 01/01/2024 01/01/2025 1,000,000 EL. DISEASE - EA EMPLOYEE S 1,000,000
STOP OPERATIONS below E.L. DISEASE - POLICY LIMIT
A Professional Liability RES943799404 01/01/2024 01/01/2025 Claim 2,000,000 SIR: $1,750,000 Aggregate 2,000,000
SCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is require e City of Huntington Beach, its officers, elected or appointed officials, employees, agents, and volunteers are included as additional insured (except workers' compensation and crime) where required by will contracl. Liability coverage shall be primary and non-contributory where required by willen contract. Waiver of subrogation is applicable where required by witten contract.
CERTIFICATE HOLDER CANCELLATION
The Do Hansen Beach SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2000 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
Huntington Beach, CA 92648
AUTHORIZED REPRESENTATIVE
March USA cle
© 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:_ CN118025105
LOC #: Philadelphia
ACORD' ADDITIONAL REMARKS SCHEDULE Page 2 of 2
AGENCY NAMED INSURED
MARSH USA LLO Allied Universal Topco, LLC
(See Altached for Addilional Named Insureds)
POLICY NUMBER 61 Washington Street, Suite 60
onshohocken, PA 194:
CARRIER TNAIC 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 Workers' Compensation
Policy No.: RWE943548208
Insurer: X. Specially Insurance Company
Effecive Dates: 1/1/2024 - 1/1/2025
Limit:
Employers Liability Each Accident: $1,000,000
Employers Liabilly Disease-Policy Limit: $1,000,000
Employers Liabilty Disease-Each Employee: $1,000,000
SIR: $1,000,000
Crime
Policy No.: 03-821-02-02
Insurer: Nationat Union Fire Insurance Co.
Elective Dates: 08/1/2023-08/15/2024
Limil:
Employee Theft or Dishonesty: $2,000,000
Clients" Property: $2,000,000
Deductible: $750,000
Contraciors Pollution Liability
Policy No.: CP013303734
Insurer. Commerce and Industry Insurance Company
Effective Dates: 01/01/2024 - 01/01/2026
Limil: 5,000,000
Deductible: $250,000
The General Liability and Professional Liability policies evidenced above share in the limits showm. The limits do not apply separately to the individual coverages ACORD 101(2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Waiver Procedure
To request a waiver, indicate here and provide a brief description (1 - 2 sentences) of the proposed work/project, its dollar value (if not a specific dollar amount, use an average, annual estimate or non-profit) and projected timeframe (per job or as-needed basis.
For substantial dollar deductible/SIR amounts, a financial statement is required (Balance Sheet, Budget Reports, Dun & Bradstreet Report, etc.).
Waiver Requested: SIR WIMIT
Encroachment PermitO Private Property Work Permit Consultant Services Other:
Proposed Work: PROVIDE STREET CM SWEEPING ENFORCEMENT SERVICES TO 1, 121 MILES OF MOSTLY RESIDENTIAL RONDS.
Dollar Value:
Projected Timeframe: HOMDAY - FRIDAY 8AM TO A PM
ENDORSEMENT #181
This endorsement, effective on 01/01/2024 at 12:01 A.M. standard time, forms a part of Policy No. RES943799404 of the INDIAN HARBOR INSURANCE COMPANY Issued to ALLIED UNIVERSAL TOPCO, LLC
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
(Based on CG2026 04/13)
This endorsement modifies insurance provided by the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name of Additional Insured Person(s) or Organization(s) City of Huntington Beach, its officers, elected or
appointed officials, employees agents and volunteers
200 Main Street
Huntington Beach, CA 92648
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 your acts or omissions or the acts or omissions of those acting on your behalf:
1. In the performance of your ongoing operations; or
2. In connection with your premises owned by or rented to you.
However:
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:
MANUS @ 2024 X. L. America Inc. All Rights Reserved
May not be copied without permission
Includes copyrighted material of Insurance Services Office, Inc. with its permission •
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 the policy remain the same.
MANUS @ 2024 X. L. America Inc. All Rights Reserved
May not be copied without permission
includes copyrighted material of Insurance Services Office, Inc. with its permission •
•
ENDORSEMENT #050
This endorsement, effective on 01/01/2024 at 12:01 A.M. standard time, forms a part of Policy No. RES943799404 of the INDIAN HARBOR INSURANCE COMPANY Issued to ALLIED UNIVERSAL TOPCO, LLC
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided by the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
A. SECTION II - Who Is an Insured is amended to include as an additional insured a person(s) or organization(s) who is required to be added by written contract or written agreement which does not require that a specific form number be used.
B. The insurance provided to additional insureds applies only to "bodily injury", "property damage", "professional liability" or "personal and advertising injury" caused, in whole or in part, by:
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; or "your work" performed for that
additional insured and included in the "products-completed operations hazard" However:
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.
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 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.
MANUS @ 2024 X. L. America Inc. All Rights Reserved
May not be copied without permission
Includes copyrighted material of Insurance Services Office, Inc. with its permission D. The additional insured must see to it that:
1. We are notified as soon as practicable of an "occurrence" or offense that may result in a claim.
We receive written notice of a claim or "suit" as soon as practicable; and A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured also has rights an insured or additional insured.
E. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that:
1. The additional insured is a Named Insured under such other insurance; and
2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured.
All other terms and conditions remain as written.
MANUS @ 2024 X. L. America Inc. All Rights Reserved
May not be copied without permission
Includes copyrighted material of Insurance Services Office, Inc. with its permission ENDORSEMENT #024
This endorsement, effective on 01/01/2024 at 12:01 A.M. standard time, forms a part of Policy No. RES943799404 of the INDIAN HARBOR INSURANCE COMPANY Issued to ALLIED UNIVERSAL TOPCO, LLC
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name of person or Organization:
Where required by written contract.
(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 RECOVERY AGAINST OTHERS TO US Condition (Section IV - CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard." This waived applies only to the person or organization shown in the Schedule above.
All other terms and conditions remain as written.
MANUS @2024 X. L. America Inc. All Rights Reserved
May not be copied without permission
Includes copyrighted material of insurance Services Office, Inc. with its permission WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84)
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
Any person or organization where waiver of our right to recover is required by written contract with such person or organization provided such contract was executed prior to the 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 01-01-2024 Policy No. RWD3001203-08 Endorsement No.
Insured Allied Universal Topco, LLC
Sarat
Insurance Company Countersigned by
XL Insurance America, Inc.
WC 00 03 13
(Ed. 4-84)
© 1983 National Council on Compensation insurance.
•
POLICY NUMBER: RAD943781807 XIC 414 1013
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
AUTO DEALERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
Schedule
Additional Insured(s) Work
Any person or organization you have agreed to All Operations include as an additional insured under written contract, provided such contract was executed prior to the date of loss.
COVERED AUTOS LIABILITY COVERAGE, Who Is An Insured, is amended to include as an "insured" the person or organization listed in the Schedule above, but only with respect to liability for "bodily injury" or "property damage" otherwise covered under this policy caused, in whole or in part, by the negligent acts or omissions of:
You, while using a covered "auto"; or
2. Any other person, except the additional insured or any employee or agent of the additional insured, operating a covered "auto" with your permission;
in the performance of your work as described in the Schedule above.
In no event shall any person or organization listed in the Schedule become an "insured" pursuant to this Endorsement if such person or organization is solely negligent.
IT IS FURTHER AGREED THAT IN NO EVENT SHALL ANY CONTRACT OR AGREEMENT ALTER THE CONDITIONS, COVERAGES OR EXCLUSIONS SET FORTH IN THIS POLICY.
All other terms and conditions of this policy remain unchanged.
XIC 414 1013 © 2013 XL. America, Inc. All Rights Reserved. Page 1 of 1 VHAR 12/02/2019 May not be copied without permission.
Includes copyrighted material ofinsurance Services Office, Inc., with its permission.
OMMERCIAL AUT
POLICY NUMBER: RAD943781807
A 04 44 10 1
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: ALLIED UNIVERSAL TOPCO, LLC
Endorsement Effective Date:
January 1, 2024
SCHEDULE
Name(s) Of Person(s) Or Organization(s):
Any person or organization where waiver of our right to recover is required by written contract with such person or organization provided such contract was executed prior to the date of loss.
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
organizations) shown in the Schedule, but only to the
extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or
organization.
CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1