SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A :
NAIC #
NAME:
CONTACT
(A/C, No):
FAX
E-MAIL
ADDRESS:
PRODUCER
(A/C, No, Ext):
PHONE
INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
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).
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.
OTHER:
(Per accident)
(Ea accident)
$
$
N / A
SUBR
WVD
ADDL
INSD
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. $ $
$
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOSAUTOS ONLY
NON-OWNED
SCHEDULEDOWNED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below
If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
$
$
$
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-
STATUTE
PER
LIMITS(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
$
OCCUR
CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE
DAMAGE TO RENTED
$PREMISES (Ea occurrence)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT LOC
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
6/7/2023
HUB International Midwest Limited
1411 Opus Place, Suite 450
Downers Grove IL 60515
630-468-5600
[email protected]
Axis Surplus Insurance Company
26620
SWEECOR-01
Navigators Specialty Insurance Company
36056
SCA of CA, LLC
4141 Rockside Road, Suite 100
Seven Hills OH 44131
Safety National Casualty Corporation
15105
1562212533
C
X
2,000,000
X
1,000,000
X
Contractual Liab
5,000
X
XCU Cov Incl
1,000,000
4,000,000
X
Y
GL6676535
6/1/2023
6/1/2024
4,000,000
C
2,000,000
X
X
X
CA6676536
6/1/2023
6/1/2024
A
X
5,000,000
X
P-001-000882635
6/1/2023
6/1/2024
5,000,000
X
0 C
X
N
LDS4068227 (CA)
6/1/2023
6/1/2024
1,000,000
1,000,000
1,000,000
C
B
Stop Gap Liability - OH
Pollution Liability
GL6676535
CH23ECPZ01ECGIC
6/1/2023
6/1/2023
6/1/2024
6/1/2024
Limit:
Each Incident/Ded:
$1,000,000
$1,000,000
City of Lancaster, its elected officials, officers, employees and volunteers are included as additional insureds under General Liability, when agreed in a written contract, subject to policy terms, conditions and exclusions.
City of Lancaster
44933 North Fern Avenue
Lancaster CA 93534
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SNCA 026 10 13 Safety National Casualty Corporation Page 1 of 2
DESIGNATED ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
COMMERCIAL AUTOMOBILE COVERAGE PART
SCHEDULE
Name of Additional Insured Person(s) or Organization(s):
Person(s) or Organization(s) as required by written contract.
Any individually scheduled Designated Additional Insured shall not be construed to override nor negate this blanket Designated Additional Insured.
CHANGE
The person(s) or organization(s) shown in the Schedule above with whom you have agreed in a written contract to provide insurance such as is afforded under this Coverage Form, is included as an Additional Insured subject to the below:
(1) Insurance for such Additional Insured(s) scheduled above shall be afforded only to the extent that such Additional Insured is liable for “bodily injury” or “property damage” arising out of your operations and resulting from the ownership, maintenance or use of covered “autos” by you while the covered “autos” are on premises owned or leased by the above scheduled Additional Insured(s).
(2) The insurance afforded under this Coverage Form to such Additional Insured(s) applies only:
(a) If the “accident” takes place subsequent to the execution and effective date of such written contract:
and,
(b) While such written contract is in force, or until the end of the policy period, which ever occurs first.
(3) How Limits Apply to Additional Insured(s)
The most we will pay on behalf of the Additional Insured(s) scheduled above is the lesser of:
(a) The limits of insurance specified in the written contract or written agreement; or, (b) The Limits of Insurance provided by the Coverage Form.
The amount we will pay on behalf of such Additional Insured(s) shall be a part of, and not in addition to, the Limits of Insurance shown in the Coverage Form Declarations and described in this section. Such amount will thus not increase the Limits of Insurance shown for the Coverage Form.
(4) Ex clusions
(a) This endorsement does not apply to liability of the Additional Insured which arises out of the ownership of transportation operating rights granted to the Additional Insured by public authority. (b) This endorsement does not apply to the liability of the owner or anyone else from whom you hire or borrow a covered auto.
(5) Obligations at the Additional Insured’s Own Cost
No Additional Insured will, except at their own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent.
The Additional Insured(s) scheduled above shall be subject to all other conditions set forth in the Coverage Form.
This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy to w hich it is attached and is effective on the date issued unless otherw ise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 06/01/2023 Policy No. CA 6676536 Endorsement No.
Named Insured SWEEP AMERICA HOLDINGS, LLC Premium $ Included
Insurance Company Safety National Casualty Corporation
Countersigned By ________________________________
POLICY NUMBER: GL 6676535 COMMERCIAL GENERAL LIABILITY
CG 20 10 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CG 20 10 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2
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) Location(s) Of Covered Operations
As required by written contract or agreement
when such written contract or agreement is
executed prior to an occurrence, offense or
loss to which this endorsement applies, but
only for the limits agreed to in such
contract or the Limits of Liability provided
by this policy, whichever is less. Any
individually scheduled additional insureds
shall not be construed to override nor
negate this blanket additional insured.
All your owned or leased locations or
premises
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.
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.
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 l imits of
insurance;
whichever is less.
This endorsement shall not increase the applicable
limits of insurance.
POLICY NUMBER: GL 6676535 COMMERCIAL GENERAL LIABILITY CG 20 37 12 19
CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1
THIS ENDORSEMENT CH ANGES 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 As required by written contract or
agreement when such written contract or
agreement is executed prior to an
occurrence, offense or loss to which
this endorsement applies, but only for
the limits agreed to in such contract or
the Limits of Liability provided by this
policy, whichever is less. Any
individually scheduled additional
insureds shall not be construed to
override nor negate this blanket
additional insured.
All your owned or leased locations or
premises
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.
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;
whichever is less.
This endorsement shall not increase the
applicable limits of insurance.
POLICY NUMBER: GL 6676535 COMMERCIAL GENERAL LIABILITY
CG 20 10 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CG 20 10 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2
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) Location(s) Of Covered Operations
As required by written contract or agreement
when such written contract or agreement is
executed prior to an occurrence, offense or
loss to which this endorsement applies, but
only for the limits agreed to in such
contract or the Limits of Liability provided
by this policy, whichever is less. Any
individually scheduled additional insureds
shall not be construed to override nor
negate this blanket additional insured.
All your owned or leased locations or
premises
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.
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.
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 l imits of
insurance;
whichever is less.
This endorsement shall not increase the applicable
limits of insurance.
POLICY NUMBER: GL 6676535 COMMERCIAL GENERAL LIABILITY CG 20 37 12 19
CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1
THIS ENDORSEMENT CH ANGES 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 As required by written contract or
agreement when such written contract or
agreement is executed prior to an
occurrence, offense or loss to which
this endorsement applies, but only for
the limits agreed to in such contract or
the Limits of Liability provided by this
policy, whichever is less. Any
individually scheduled additional
insureds shall not be construed to
override nor negate this blanket
additional insured.
All your owned or leased locations or
premises
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.
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;
whichever is less.
This endorsement shall not increase the
applicable limits of insurance.
THIS FORM APPLIES ONLY TO THE FOLLOWING STATE(S) IF COVERED BY YOUR POLICY. IF A STATE IS NOT LISTED BELOW, THIS FORM DOES NOT APPLY IN THAT STATE.
AL, AZ, CA, DE, FL, GA, IL, IN, LA, MD, MI, MS, MO, NC, NJ, PA, SC, TN, TX, VA, WV 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 06/01/2023 Policy No. LDS4068227 Endorsement No.
Insured Premium $ Included
Insurance Company Safety National Casualty Corporation Countersigned By ________________________________
WC 00 03 13 (04 84)
© 1983 National Council on Compensation Insurance.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
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 A WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS IS REQUIRED BY WRITTEN CONTRACT,
SUCH ADDITIONAL ENTITIES SHALL BE CONSIDERED AUTOMATICALLY SCHEDULED BY THE COMPANY.
INDIVIDUALLY SCHEDULED WAIVERS SHALL NOT BE CONSTRUED TO OVERRIDE NOR NEGATE THIS BLANKET WAIVER.