CITY OF PACIFICA
Scope of Work
Arc Flash Study and
Electrical Condition Assessment
Scope of Work
Background
City of Pacifica (City) has requested TJCAA perform short circuit, device evaluation, protective device coordination, and arc flash hazard evaluation studies, conforming with the current NFPA 70E, Electrical Safety in the Workplace for the existing electrical systems at the Calera Creek Water Recycling Plant (Plant). The Project also includes an electrical distribution system assessment task to provide the City with a summary report documenting the present condition of the electrical distribution system at the Plant.
The scope of work is broken into the major tasks with subtasks that provide additional details regarding approaches, assumptions, and specific deliverables. This Scope of Work illustrates the mechanics of completing the work as specified in the RFP and assumes a collaborative interaction with City engineering, operations, and maintenance staff throughout the project. The objective is to provide the technical, managerial, and cost analyses necessary to assist the City in making informed and appropriate engineering decisions that meet the critical requirements of operations and maintenance staff.
Scope of Work
CITY OF PACIFICA
Arc Flash Study and
Electrical Condition Assessment
TASK 1 – Arc Flash Study
SCOPE OF WORK
TASK DESCRIPTION ASSUMPTIONS DELIVERABLES
Task 1.1:
Kickoff Meeting
• Project Kickoff Meeting: TJCAA will facilitate the initial project kickoff meeting to discuss project objectives,
approach, and schedule with City stakeholders.
• City shall coordinate attendance of City personnel attending the kickoff meeting • Project kickoff meeting agenda, presentation, and minutes
Task 1.2:
Reconnaissance and
Data Collection
• Review Available Data: Collect, evaluate, and review
available project data. Document review will include
record drawings, maintenance and test reports and
other related materials that may be available from
the City.
• Perform field investigations at all different sites,
accessing main and distribution equipment, MCCs,
panels, to acquire equipment ratings, protective
device settings, wire sizes. Perform visual condition
assessment for use in remediation report.
• Interview O&M staff to acquire historical perspective of overall electrical system performance.
• Prepare summary Deficiency and Remediation Report
with initial assessment of potential hazard areas;
include operational or procedural methods to mitigate
risk prior to performance of computer analyses and
final recommendations.
• All access to equipment internal components to be performed by APS with certified and trained personnel.
• For data collection at locations with confined space entry, the City staff will enter and obtain data with TJCAA staff nearby for appropriate data collection. • City to provide access to record drawings library, shop drawings, previous studies and test reports.
• Any necessary shutdowns can be coordinated with City operations staff to allow access to equipment in a de-energized state wherever possible. • Data gathering for some locations may not be possible during certain times of year. For scheduling purpose, we have anticipated the entire facility can be shutdown to allow access to de-energized equipment by TJCAA personnel. • One week has been assumed for the duration of the field reconnaissance effort. Arc Flash data reconnaissance task has been combined with the Condition Assessment effort described under Task 2.
• Field electrical data collected at
the facility
• Photograph based library of all
equipment investigated under
this Task. A file share
arrangement will be established
to provide access to all
photographs by the City for
future use.
Task 1.3:
Analyses,
Recommendations,
Report
• Electrical Modeling: Perform electrical studies
including short circuit, selective coordination, and arc flash hazard analysis based on field acquired system
data and available record drawings.
• The project team shall notify the City of any potential problems of the existing protective device settings
• Prepare Electrical Arc Flash Hazard Technical
Memorandum (TM) with calculation results, protective
device coordination recommendations, arc flash
hazard summaries, labeling formats and details, and
remediation recommendations.
• Facilitate a dedicated workshop to review Draft
Electrical Arc Flash Hazard TM.
• Provide installation of labels following approval of
label content and format by City. Label installation is assumed to be completed as a collaborative effort
between City and TJCAA personnel.
• Electrical modeling shall be performed using SKM PowerTools software. • City shall assist TJCAA with contacts to PG&E necessary to obtain the available utility parameters for use in the modeling effort.
• The draft and final Electrical Arc Flash Hazard TM shall be a maximum of 25 pages not including Appendices, Drawings, Figures, or Tables. The draft and final TM shall include the following sections:
Executive Summary: Summary of the recommended approach for electrical improvements
Project Background: Basis for the project
General PPE guidelines and project specific guidelines per location Technical Analyses for the facility including SKM graphical display of results on one-line and TCC
Description of alternatives for arc flash mitigation strategies applicable to the Plant and presentation of pros and cons
• City comments on the Draft Electrical Arc Flash Hazard TM shall be provided in writing to the TJCAA Team.
• Due to the volume and large format of the standard reports generated by SKM, SKM data shall not be included in the final hard copy report delivered to the City.
Rather this data shall be submitted to the City in electronic (PDF format). • Draft Electrical Arc Flash Hazard
TM
• Final Arc Flash Hazard TM
incorporating City comments
and results from workshop (See
Task 3)
• Final SKM database in native
electronic format for use by the
City in future arc flash studies as
required under NFPA 70E
• Labels for all electrical
distribution equipment
Scope of Work
CITY OF PACIFICA
Arc Flash Study and
Electrical Condition Assessment
TASK 2 – Electrical Condition Assessment
SCOPE OF WORK
TASK DESCRIPTION ASSUMPTIONS DELIVERABLES
Task 2.1:
Electrical Condition
Assessment
• Refer also to Task 1.2 above
• Assess condition
• Develop list of recommended projects with key
assumptions, Engineer’s Opinion of Probable Cost, and
priority.
• Condition Assessment Kickoff Meeting to be combined with Arc Flash Report Kickoff Meeting
• Perform Condition Assessment site work during the site visit defined under Task 1 for gathering arc flash data. Refer to Assumptions under Task 1.2 above
• City shall provide guidance to TJCAA in establishing priorities based on budgetary planning horizons, competing projects, and process considerations.
• Condition Assessment, Deficiency, and
Remediation Report
• Report to include planning level
descriptions and recommendation for
electrical improvement projects over a
ten (10) year planning horizon.
Scope of Work
CITY OF PACIFICA
Arc Flash Study and
Electrical Condition Assessment
TASK 3 – Project Management and Controls
SCOPE OF WORK
TASK DESCRIPTION ASSUMPTIONS DELIVERABLES
Task 3.1:
Project Management
• Contract Administration: TJCAA will coordinate the project effort including oversight of subconsultants, invoicing, and preparing monthly progress reports for the City. Contract administration will include monitoring project progress and communicating status throughout the life of the project.
Status monitoring includes verifying planned, actual, and earned progress, adherence to the City’s established project elements, budget status, and communication of potential project issues that could compromise project success.
Prepare, monitor and update the master project schedule; the initial project schedule.
• Develop Project Work Plan Memo: Prepare a project work plan memo to guide the project team in meeting the project objectives, requirements, and constraints; and for
completing the project within the contractual scope, budget, and schedule constraints. Establish communication
protocols and define roles and responsibilities. Create an initial project schedule that conforms to City requirements for project execution and that includes the major tasks, deliverables, and City review efforts.
• Develop a Quality Control Plan documenting procedures for meeting City requirements and conforming to accepted
approaches in the profession.
• Perform the required QA/QC tasks for the project.
• Facilitate workshops for both the Arc Flash Hazard TM (Task 1) and the Condition Assessment (Task 2) Report.
• The project schedule will be developed using Microsoft Project. TJCAA will update the project schedule on a monthly basis as required. The schedule during construction shall be developed and maintained by the construction contractor.
• Electronic delivery of progress reports, invoices, and meeting notes is acceptable.
• Workshops shall be presented using PowerPoint software to facilitate discussion and understanding of the electrical issues.
• Project Work Plan Memo
• Monthly status updates accompanying
Project invoices
• QA/QC implementation documents as
required (e.g., responses to City’s
written review comments).
• Electrical System Arc Flash Hazard TM
Workshop including:
• Agenda
• Workshop meeting minutes and
PowerPoint presentation
• Written responses to City’s written
review comments to Draft
Electrical System Report
• Condition Assessment, Deficiency, and
Remediation Report Workshop
including:
• Agenda
• Workshop meeting minutes and
PowerPoint presentation
• Written responses to City’s written
review comments to Draft
Electrical System Report
Project: Arc Flash Study and Electrical System Condition Assessment Date: 07/23/22 TJCAA Project No: 121050A
By: AMB/PJG Prepared for: City of Pacifica 2022 rates. Proposal (File 1.03)
SHEET LISTING/WORK ITEM HOURS/LABOR
Electrical I&C PJG MJE AR AMB EAN JNA HT MSC BFY BV BV ADM TOTAL $310 $286 $263 $251 $239 $239 $227 $192 $180 $152 $152 $127 HRS 1 Arc Flash Study and Evaluation 25 0 0 96 0 0 0 65 65 16 0 0 267.0 2 Plant Electrical System Condition Assessment 36 0 0 104 0 0 0 0 68 0 0 0 208.0 3 Project Management and Project Controls 19 0 0 45 20 0 0 8 4 0 0 8 104.0
0.0 0.0
0.0 0.0
0.0 0.0
0.0 0.0
0.0 0.0
0.0 80 0 0 245 20 0 0 73 137 16 0 8 579 579.0
Electrical I&C PJG MJE AR AMB EAN JNA HT MSC BFY BV BV ADM TOTAL TOTAL TOTAL $310 $286 $263 $251 $239 $239 $227 $192 $180 $152 $152 $127 Fees ODC's Dollars 1 Arc Flash Study and Evaluation $7,751 $0 $0 $24,090 $0 $0 $0 $12,468 $11,700 $2,431 $0 $0 $58,442 $1,083 $59,524 2 Plant Electrical System Condition Assessment $11,162 $0 $0 $26,098 $0 $0 $0 $0 $12,240 $0 $0 $0 $49,500 $272 $49,772 3 Project Management and Project Controls $5,891 $0 $0 $11,292 $4,782 $0 $0 $1,535 $720 $0 $0 $1,012 $25,232 $403 $25,635 $0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$24,805 $0 $0 $61,481 $4,782 $0 $0 $14,003 $24,660 $2,431 $0 $1,012 $133,174 $1,758 $134,932 Estimated Total Fee: $134,932
Hours below are
Adjusted for: Contract (File 2.04)
Hours
Phase
Dollars
Phase
7/24/2022 2:51 PM 121050A Fee.PJG - ICE Summary Page 1
ID Task
Mode
Task Name Duration Start Finish Predecessors
1 City Council Award Project Contract 0 days Wed 9/7/22 Wed 9/7/22 2 Receive Notice To Proceed (Estimated) 0 days Wed 9/7/22 Wed 9/7/22 13 Data Collection (Common to both Tasks) 38 days Wed 9/7/22 Fri 10/28/224 PG&E data request 0 days Wed 9/7/22 Wed 9/7/22 2FS+1 day5 Receive data from PG&E 0 days Wed 10/5/22 Wed 10/5/22 4FS+20 days6 Review documentation 4 days Wed 9/7/22 Mon 9/12/22 27 Coordinate site visits and outages with City 10 days Mon 9/12/22 Fri 9/23/22 2FS+3 days8 Data collection site visit and assessment 4 days Tue 9/27/22 Fri 9/30/22 7FS+1 day9 Prepare redline updates 20 days Mon 10/3/22 Fri 10/28/22 8 10 Submit redline and AutoCAD files 0 days Fri 10/28/22 Fri 10/28/22 911 Task 1: Arc Flash Study 55 days Thu 10/6/22 Wed 12/21/2212 Prepare SKM system models 10 days Thu 10/6/22 Wed 10/19/22 8,513 Simulations and scenarios 10 days Thu 10/20/22 Wed 11/2/22 1214 Prepare summary of preliminary analyses 5 days Thu 11/3/22 Wed 11/9/22 1315 Identify NFPA 70E compliance and training needs 5 days Thu 11/10/22 Wed 11/16/22 1416 Prepare Draft Arc Flash Labeling Plan 10 days Thu 11/17/22 Wed 11/30/22 1517 Submit Draft Arc Flash Labeling Plan 0 days Wed 11/30/22 Wed 11/30/22 1618 City review Draft Arc Flash Labeling Plan 10 days Thu 12/1/22 Wed 12/14/22 1719 Submit Final Arc Flash Labeling Plan 0 days Wed 12/14/22 Wed 12/14/22 1820 Prepare Draft Arc Flash Report 15 days Thu 11/10/22 Wed 11/30/22 1421 Submit Draft Arc Flash Report 0 days Wed 11/30/22 Wed 11/30/22 2022 City review Draft Arc Flash Report 10 days Thu 12/1/22 Wed 12/14/22 2123 Submit Final Arc Flash Report 0 days Wed 12/21/22 Wed 12/21/22 22FS+5 days24 Task 2: Condition Assessment 75 days Mon 10/3/22 Fri 1/13/2325 Develop inventory of faciility electrical equipment 15 days Mon 10/3/22 Fri 10/21/22 826 Review available equiment O&M data records 10 days Mon 10/17/22 Fri 10/28/22 8FS+10 days27 Perform system analyses and load calculations 5 days Mon 10/24/22 Fri 10/28/22 8FS+15 days28 Assess backup generation capacity 5 days Mon 10/31/22 Fri 11/4/22 2729 Evaulate condition of existing equipment 10 days Mon 10/31/22 Fri 11/11/22 2630 Develop remaining life estimates 10 days Mon 10/31/22 Fri 11/11/22 2631 Prepare business case evaluations/life cycle cost analysis
15 days Mon 11/14/22 Fri 12/2/22 30
32 Identify rehabilitation and repair alternatives 15 days Mon 11/14/22 Fri 12/2/22 3033 Prepare Draft Findings and Recommendations Report
15 days Mon 12/5/22 Fri 12/23/22 31,32
34 Submit Draft Findings and Recommendations
Report
0 days Fri 12/23/22 Fri 12/23/22 33
35 City review Draft Findings and Recommendations
Report
10 days Mon 12/26/22 Fri 1/6/23 34
36 Submit Final Findings and Recommendations
Report
0 days Fri 1/13/23 Fri 1/13/23 35FS+5 days
37 Task 3: Project Management 98 days Wed 9/7/22 Fri 1/20/2338 Kickoff Meeting 1 day Wed 9/14/22 Wed 9/14/22 2FS+5 days39 Arc Flash Label and Report Workshop 1 day Thu 12/1/22 Thu 12/1/22 21,1740 Findings and Recommendations Report Workshop 1 day Mon 12/26/22 Mon 12/26/22 3441 Prepare and package data 5 days Mon 1/16/23 Fri 1/20/23 36,2342 Project Management 95 days Wed 9/7/22 Tue 1/17/23 243 Project Completed 0 days Fri 1/20/23 Fri 1/20/23 36,23,41 9/7
9/7
9/7
10/5
10/28
11/30
12/14
11/30
12/21
12/23
1/13
1/20
4 11 18 25 2 9 16 23 30 6 13 20 27 4 11 18 25 1 8 15 22 September 2022 October 2022 November 2022 December 2022 January 2023 City of Pacifica
Arc Flash Study and
Electrical System Assessment
B-1
Public Works Department Wastewater Division On-Call Electrical Engineering Services City of Pacifica
TJC and Associates, Inc.
Appendix B: Hourly Rate Schedule
TJC and Associates, Inc.
Schedule of Hourly Rates and Costs
2021 through 2023
2021 2022 2023
Engineer
Level 10 (E10) $ 298.00 $ 307.00 $ 316.00
Level 9 (E9) $ 280.00 $ 288.00 $ 297.00
Level 8 (E8) $ 263.00 $ 271.00 $ 279.00
Level 7 (E7) $ 246.00 $ 253.00 $ 261.00
Level 6 (E6) $ 229.00 $ 236.00 $ 243.00
Level 5 (E5) $ 211.00 $ 217.00 $ 224.00
Level 4 (E4) $ 194.00 $ 200.00 $ 206.00
Level 3 (E3) $ 174.00 $ 179.00 $ 184.00
Level 2 (E2) $ 155.00 $ 160.00 $ 165.00
Level 1 (E1) $ 135.00 $ 139.00 $ 143.00
Drafting
Level 7 (C7) $ 190.00 $ 196.00 $ 202.00
Level 6 (C6) $ 165.00 $ 170.00 $ 175.00
Level 5 (C5) $ 148.00 $ 152.00 $ 157.00
Level 4 (C4) $ 138.00 $ 142.00 $ 146.00
Level 3 (C3) $ 118.00 $ 122.00 $ 126.00
Level 2 (C2) $ 100.00 $ 103.00 $ 106.00
Level 1 (C1) $ 78.00 $ 80.00 $ 82.00
Administrative
Level 10 (A10) $ 239.00 $ 246.00 $ 253.00
Level 9 (A9) $ 200.00 $ 206.00 $ 212.00
Level 8 (A8) $ 165.00 $ 170.00 $ 175.00
Level 7 (A7) $ 142.00 $ 146.00 $ 150.00
Level 6 (A6) $ 117.00 $ 121.00 $ 125.00
Level 5 (A5) $ 102.00 $ 105.00 $ 108.00
Level 4 (A4) $ 81.00 $ 83.00 $ 85.00
Level 3 (A3) $ 70.00 $ 72.00 $ 74.00
Level 2 (A2) $ 58.00 $ 60.00 $ 62.00
Level 1 (A1) $ 42.00 $ 43.00 $ 44.00
Reimbursable Expenses
Sub-Consultant Services Cost + 10% Cost + 10% Cost + 10%
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
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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 WVDADDL
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
AUTOS ONLY AUTOS NON-OWNED OWNED SCHEDULED
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 EMPLOYEEE.L. EACH ACCIDENT EROTH- STATUTE PER
(MM/DD/YYYY) LIMITS POLICY EXP(MM/DD/YYYY) POLICY EFFLTR TYPE OF INSURANCE POLICY NUMBER 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
5/25/2022
AssuredPartners Design Professionals Insurance Services, LLC 3697 Mt. Diablo Blvd Suite 230
Lafayette CA 94549
Elise Fisher [email protected] License#: 6003745 Sentinel Insurance Company 11000 TJC&ASS-01 Trumbull Insurance Company 27120 TJC & Associates, Inc.
P.O. Box 2059
Folsom CA 95763
Travelers Casualty and Surety Co of America 31194 1564390956 A X 2,000,000 X 1,000,000 X Contractual Liab 10,000 Included 2,000,000 4,000,000 X Y Y 57SBWKF3500 2/6/2022 2/6/2023
4,000,000
A 2,000,000 X XY Y 57SBWKF3500 2/6/2022 2/6/2023
A X X 3,000,000 Y Y 57SBWKF3500 2/6/2022 2/6/2023
3,000,000 X
10,000
B Y 57WEGAC8DE3 2/6/2022 2/6/2023
X
1,000,000 1,000,000 1,000,000
C Professional Liability
+ Contractor's
Pollution Liability
107576520 2/6/2022 2/6/2023 Per Claim
Annual Aggregate
5,000,000
10,000,000
Umbrella policy is a follow-form to underlying General Liability/Auto Liability. Insured owns no company vehicles; therefore, hired/non-owned auto is the maximum coverage that applies.
Re: Project #121050, CofPacifica, EE On-Call Svcs, Electrical Engineering Services. The City of Pacifica, its City Council, boards, commissions, committees, officers, employees and agents are named as an additional insured as respects general liability as required per written contract or agreement. General Liability is Primary/Non-Contributory per policy form wording. SEVERABILITY OF INTERESTS Separation of Insureds - Except with respect to the Limits of Insurance, and any rights or duties specifically assigned in this Coverage Part to the first Named Insured, this insurance applies: a. As if each Named Insured were the only Named Insured; and b. Separately to each insured against whom claim is made or suit is brought. 30 Days Notice of Cancellation
City of Pacifica
Attn: City Manager
170 Santa Maria Avenue
Pacifica CA 94404
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Form SS 51 14 04 17 Page 1 of 1
© 2017, The Hartford
ADDITIONAL INSURED PROVISIONS - CALIFORNIA
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
A. It is agreed that paragraph (2) of subsections 6.d.
and 6.f. of Section C. - WHO IS AN INSURED is
replaced by the following:
(2) The insurance afforded by paragraph (1) above
does not apply if your acts or omissions, or the
acts or omissions of those acting on your behalf,
that are alleged to have caused the "bodily
injury", "property damage" or "personal and
advertising injury", involve professional
architectural, engineering or surveying services,
including but not limited to:
(a) The preparing, approving, editing of or
failure to prepare or approve, shop
drawings, maps, opinions, reports, surveys,
change orders, field orders, designs,
drawings, specifications, warnings,
recommendations, permit applications
payment requests, manuals or instructions;
(b) Supervisory, inspection, quality control,
architectural, engineering or surveying
activities or services;
(c) Maintenance of job site safety, construction
administration, construction contracting,
construction management, computer
consulting or design software development
or programming service, or selection of a
contractor or programming service;
(d) Monitoring, sampling, or testing service
necessary to perform any of the services
included in a. b. or c. above;
(e) Supervision, hiring, employment, training or
monitoring of others who are performing
any of the services included in a., b. or c.
above.
The insurance afforded to such additional
insured:
(a) Only applies to the extent permitted by law;
and
(b) Will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
B. It is agreed that the following paragraphs are added to the end of subsections 1. and 8. of Section FOPTIONAL ADDITIONAL INSURED COVERAGES; and it is agreed the following
paragraphs replace section b. of subsection 9. of
Section F. - OPTIONAL ADDITIONAL INSURED
COVERAGES. These paragraphs do not attach or
amend the language of any of the other subsections
of Section F - OPTIONAL ADDITIONAL INSURED
COVERAGES:
The insurance afforded by this subsection does not
apply if your acts or omissions, or the acts or
omissions of those acting on your behalf, that are
alleged to have caused the "bodily injury", "property
damage" or "personal and advertising injury",
involve professional architectural, engineering or
surveying services, including but not limited to:
(a) The preparing, approving, editing of or
failure to prepare or approve, shop
drawings, maps, opinions, reports, surveys,
change orders, field orders, designs,
drawings, specifications, warnings,
recommendations, permit applications
payment requests, manuals or instructions;
(b) Supervisory, inspection, quality control,
architectural, engineering or surveying
activities or services;
(c) Maintenance of job site safety, construction
administration, construction contracting,
construction management, computer
consulting or design software development
or programming service, or selection of a
contractor or programming service;
(d) Monitoring, sampling, or testing service
necessary to perform any of the services
included in a. b. or c. above;
(e) Supervision, hiring, employment, training or
monitoring of others who are performing any
of the services included in a., b. or c. above.
The insurance afforded to such additional insured:
(a) Only applies to the extent permitted by law;
and
(b) Will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
3ROLF\
57SBWKF3500
BUSINESS LIABILITY COVERAGE FORM
(b) b. Rented to, in the care, custody or Coverage under this provision does not control of, or over which physical apply to:
control is being exercised for any (1) "Bodily injury" or "property damage" purpose by you, any of your that occurred; or "employees", "volunteer workers", (2) "Personal and advertising injury" any partner or member (if you are arising out of an offense committed a partnership or joint venture), or any member (if you are a limited before you acquired or formed the liability company). organization.
b. Real Estate Manager 4. Operator Of Mobile Equipment
Any person (other than your "employee" or With respect to "mobile equipment" registered in "volunteer worker"), or any organization your name under any motor vehicle registration while acting as your real estate manager. law, any person is an insured while driving such equipment along a public highway with your c. Temporary Custodians Of Your permission. Any other person or organization Property responsible for the conduct of such person is Any person or organization having proper also an insured, but only with respect to liability temporary custody of your property if you arising out of the operation of the equipment, and die, but only: only if no other insurance of any kind is available (1) With respect to liability arising out of the to that person or organization for this liability. maintenance or use of that property; and However, no person or organization is an insured with respect to: (2) Until your legal representative has been appointed. a. "Bodily injury" to a co-"employee" of the d. Legal Representative If You Die person driving the equipment; or Your legal representative if you die, but b. "Property damage" to property owned by, rented to, in the charge of or occupied by only with respect to duties as such. That you or the employer of any person who is representative will have all your rights and an insured under this provision. duties under this insurance.
5. Operator of Nonowned Watercraft e. Unnamed Subsidiary Any subsidiary and subsidiary thereof, of With respect to watercraft you do not own that is less than 51 feet long and is not being used yours which is a legally incorporated entity to carry persons for a charge, any person is an of which you own a financial interest of more than 50% of the voting stock on the insured while operating such watercraft with your permission. Any other person or effective date of this Coverage Part. organization responsible for the conduct of The insurance afforded herein for any such person is also an insured, but only with subsidiary not shown in the Declarations respect to liability arising out of the operation as a named insured does not apply to of the watercraft, and only if no other injury or damage with respect to which an insurance of any kind is available to that insured under this insurance is also an person or organization for this liability. insured under another policy or would be However, no person or organization is an an insured under such policy but for its insured with respect to: termination or upon the exhaustion of its limits of insurance. a. "Bodily injury" to a co-"employee" of the person operating the watercraft; or 3. Newly Acquired Or Formed Organization Any organization you newly acquire or form, b. "Property damage" to property owned by, rented to, in the charge of or occupied by other than a partnership, joint venture or you or the employer of any person who is limited liability company, and over which you maintain financial interest of more than 50% of an insured under this provision. the voting stock, will qualify as a Named 6. Additional Insureds When Required By Insured if there is no other similar insurance Written Contract, Written Agreement Or available to that organization. However: Permit
a. Coverage under this provision is afforded The person(s) or organization(s) identified in only until the 180th day after you acquire Paragraphs through below are additional a. f. or form the organization or the end of the insureds when you have agreed, in a written policy period, whichever is earlier; and
Form SS 00 08 04 05 Page 11 of 24
3ROLF\
57SBWKF3500
BUSINESS LIABILITY COVERAGE FORM
contract, written agreement or because of a Any failure to make such (e) permit issued by a state or political inspections, adjustments, tests or subdivision, that such person or organization servicing as the vendor has be added as an additional insured on your agreed to make or normally policy, provided the injury or damage occurs undertakes to make in the usual subsequent to the execution of the contract or course of business, in connection agreement, or the issuance of the permit. with the distribution or sale of the products; A person or organization is an additional (f) Demonstration, installation, insured under this provision only for that servicing or repair operations, period of time required by the contract, except such operations performed agreement or permit. at the vendor's premises in However, no such person or organization is an connection with the sale of the additional insured under this provision if such product; person or organization is included as an (g) Products which, after distribution additional insured by an endorsement issued or sale by you, have been labeled by us and made a part of this Coverage Part, or relabeled or used as a including all persons or organizations added container, part or ingredient of any as additional insureds under the specific other thing or substance by or for additional insured coverage grants in Section the vendor; or F. – Optional Additional Insured Coverages. (h) "Bodily injury" or "property a. Vendors
damage" arising out of the sole Any person(s) or organization(s) (referred to negligence of the vendor for its below as vendor), but only with respect to own acts or omissions or those of "bodily injury" or "property damage" arising its employees or anyone else out of "your products" which are distributed acting on its behalf. However, this or sold in the regular course of the vendor's exclusion does not apply to: business and only if this Coverage Part (i) The exceptions contained in provides coverage for "bodily injury" or Subparagraphs or ; or (d) (f) "property damage" included within the "products-completed operations hazard". Such inspections, adjustments, (ii) tests or servicing as the vendor (1) The insurance afforded to the vendor has agreed to make or normally is subject to the following additional undertakes to make in the usual exclusions:
course of business, in This insurance does not apply to: connection with the distribution (a) "Bodily injury" or "property or sale of the products. damage" for which the vendor is (2) This insurance does not apply to any obligated to pay damages by insured person or organization from reason of the assumption of whom you have acquired such products, liability in a contract or agreement. or any ingredient, part or container, This exclusion does not apply to entering into, accompanying or liability for damages that the containing such products. vendor would have in the absence b. Lessors Of Equipment of the contract or agreement;
(b) Any express warranty (1) Any person or organization from whom you lease equipment; but only unauthorized by you; with respect to their liability for "bodily (c) Any physical or chemical change injury", "property damage" or in the product made intentionally "personal and advertising injury" by the vendor; caused, in whole or in part, by your (d) Repackaging, except when maintenance, operation or use of unpacked solely for the purpose of equipment leased to you by such inspection, demonstration, testing, person or organization. or the substitution of parts under
instructions from the manufacturer,
and then repackaged in the
original container;
3ROLF\
57SBWKF3500
BUSINESS LIABILITY COVERAGE FORM
(2) e. Permits Issued By State Or Political With respect to the insurance afforded to these additional insureds, this Subdivisions
insurance does not apply to any (1) Any state or political subdivision, but "occurrence" which takes place after only with respect to operations you cease to lease that equipment. performed by you or on your behalf for c. Lessors Of Land Or Premises which the state or political subdivision has issued a permit. (1) Any person or organization from whom you lease land or premises, but With respect to the insurance afforded (2) only with respect to liability arising out to these additional insureds, this of the ownership, maintenance or use insurance does not apply to:
of that part of the land or premises (a) "Bodily injury", "property damage" leased to you. or "personal and advertising (2) With respect to the insurance afforded injury" arising out of operations to these additional insureds, this performed for the state or insurance does not apply to: municipality; or
(a) (b) Any "occurrence" which takes "Bodily injury" or "property damage" place after you cease to lease that included within the "productsland or be a tenant in that completed operations hazard". premises; or f. Any Other Party
(b) Structural alterations, new (1) Any other person or organization who construction or demolition is not an insured under Paragraphs a. operations performed by or on through . above, but only with e behalf of such person or respect to liability for "bodily injury", organization. "property damage" or "personal and d. Architects, Engineers Or Surveyors advertising injury" caused, in whole or in part, by your acts or omissions or (1) Any architect, engineer, or surveyor, but the acts or omissions of those acting only with respect to liability for "bodily on your behalf: injury", "property damage" or "personal and advertising injury" caused, in whole In the performance of your (a) or in part, by your acts or omissions or ongoing operations; the acts or omissions of those acting on (b) In connection with your premises your behalf: owned by or rented to you; or (a) In connection with your premises; (c) In connection with "your work" and or included within the "products-
(b) In the performance of your completed operations hazard", but ongoing operations performed by only if
you or on your behalf. (i) The written contract or written (2) With respect to the insurance afforded agreement requires you to to these additional insureds, the provide such coverage to following additional exclusion applies: such additional insured; and This insurance does not apply to This Coverage Part provides (ii) "bodily injury", "property damage" or coverage for "bodily injury" or "personal and advertising injury" "property damage" included arising out of the rendering of or the within the "productsfailure to render any professional completed operations hazard". services by or for you, including: (2) With respect to the insurance afforded (a) The preparing, approving, or to these additional insureds, this failure to prepare or approve, insurance does not apply to:
maps, shop drawings, opinions, "Bodily injury", "property damage" or reports, surveys, field orders, "personal and advertising injury" change orders, designs or arising out of the rendering of, or the drawings and specifications; or failure to render, any professional (b) Supervisory, inspection, architectural, engineering or surveying architectural or engineering services, including:
activities.
Form SS 00 08 04 05 Page 13 of 24
3ROLF\
57SBWKF3500
BUSINESS LIABILITY COVERAGE FORM
(a) The preparing, approving, or This General Aggregate limit does not failure to prepare or approve, apply to "property damage" to premises maps, shop drawings, opinions, while rented to you or temporarily reports, surveys, field orders, occupied by you with permission of the change orders, designs or owner, arising out of fire, lightning or drawings and specifications; or explosion.
(b) 3. Each Occurrence Limit Supervisory, inspection,
architectural or engineering Subject to or above, whichever 2.a. 2.b activities. applies, the most we will pay for the sum of all The limits of insurance that apply to additional damages because of all "bodily injury", insureds are described in Section – Limits "property damage" and medical expenses D.
Of Insurance. arising out of any one "occurrence" is the How this insurance applies when other Liability and Medical Expenses Limit shown in the Declarations. insurance is available to an additional insured is described in the Other Insurance Condition The most we will pay for all medical expenses in Section – Liability And Medical Expenses because of "bodily injury" sustained by any E.
General Conditions. one person is the Medical Expenses Limit No person or organization is an insured with shown in the Declarations. respect to the conduct of any current or past 4. Personal And Advertising Injury Limit partnership, joint venture or limited liability Subject to above, the most we will pay for 2.b. company that is not shown as a Named Insured in the sum of all damages because of all the Declarations. "personal and advertising injury" sustained by D. LIABILITY AND MEDICAL EXPENSES any one person or organization is the Personal and Advertising Injury Limit shown in the LIMITS OF INSURANCE Declarations.
1. The Most We Will Pay 5. Damage To Premises Rented To You Limit The Limits of Insurance shown in the The Damage To Premises Rented To You Declarations and the rules below fix the most Limit is the most we will pay under Business we will pay regardless of the number of: Liability Coverage for damages because of a. Insureds; "property damage" to any one premises, while b. Claims made or "suits" brought; or rented to you, or in the case of damage by fire, c. Persons or organizations making claims or lightning or explosion, while rented to you or bringing "suits". temporarily occupied by you with permission of the owner. 2. Aggregate Limits
In the case of damage by fire, lightning or The most we will pay for: explosion, the Damage to Premises Rented To a. Damages because of "bodily injury" and You Limit applies to all damage proximately "property damage" included in the caused by the same event, whether such "products-completed operations hazard" is damage results from fire, lightning or explosion the Products-Completed Operations or any combination of these. Aggregate Limit shown in the 6. How Limits Apply To Additional Insureds Declarations.
The most we will pay on behalf of a person or b. Damages because of all other "bodily organization who is an additional insured injury", "property damage" or "personal under this Coverage Part is the lesser of: and advertising injury", including medical expenses, is the General Aggregate Limit a. The limits of insurance specified in a shown in the Declarations. written contract, written agreement or permit issued by a state or political This General Aggregate Limit applies subdivision; or separately to each of your "locations" owned by or rented to you. b. The Limits of Insurance shown in the Declarations. "Location" means premises involving the
same or connecting lots, or premises Such amount shall be a part of and not in whose connection is interrupted only by a addition to the Limits of Insurance shown in street, roadway or right-of-way of a the Declarations and described in this Section. railroad.
3ROLF\
57SBWKF3500
BUSINESS LIABILITY COVERAGE FORM
If more than one limit of insurance under this Immediately send us copies of any (1) policy and any endorsements attached thereto demands, notices, summonses or applies to any claim or "suit", the most we will pay legal papers received in connection under this policy and the endorsements is the with the claim or "suit"; single highest limit of liability of all coverages (2) Authorize us to obtain records and applicable to such claim or "suit". However, this other information; paragraph does not apply to the Medical Expenses (3) Cooperate with us in the investigation, limit set forth in Paragraph above. 3. settlement of the claim or defense The Limits of Insurance of this Coverage Part apply against the "suit"; and separately to each consecutive annual period and to (4) Assist us, upon our request, in the any remaining period of less than 12 months, starting enforcement of any right against any with the beginning of the policy period shown in the person or organization that may be Declarations, unless the policy period is extended liable to the insured because of injury after issuance for an additional period of less than 12 or damage to which this insurance months. In that case, the additional period will be may also apply. deemed part of the last preceding period for purposes d. Obligations At The Insured's Own Cost of determining the Limits of Insurance.
No insured will, except at that insured's own E. LIABILITY AND MEDICAL EXPENSES cost, voluntarily make a payment, assume GENERAL CONDITIONS any obligation, or incur any expense, other
1. Bankruptcy than for first aid, without our consent.
Bankruptcy or insolvency of the insured or of e. Additional Insured's Other Insurance the insured's estate will not relieve us of our If we cover a claim or "suit" under this obligations under this Coverage Part. Coverage Part that may also be covered
2. Duties In The Event Of Occurrence, by other insurance available to an Offense, Claim Or Suit additional insured, such additional insured must submit such claim or "suit" to the a. Notice Of Occurrence Or Offense other insurer for defense and indemnity. You or any additional insured must see to However, this provision does not apply to it that we are notified as soon as the extent that you have agreed in a practicable of an "occurrence" or an written contract, written agreement or offense which may result in a claim. To permit that this insurance is primary and the extent possible, notice should include: non-contributory with the additional (1) How, when and where the "occurrence" insured's own insurance. or offense took place; f. Knowledge Of An Occurrence, Offense, (2) The names and addresses of any Claim Or Suit injured persons and witnesses; and Paragraphs and apply to you or to a. b. (3) The nature and location of any injury any additional insured only when such or damage arising out of the "occurrence", offense, claim or "suit" is "occurrence" or offense. known to:
b. Notice Of Claim (1) You or any additional insured that is If a claim is made or "suit" is brought an individual;
against any insured, you or any additional (2) Any partner, if you or an additional insured must: insured is a partnership; (1) Immediately record the specifics of the (3) Any manager, if you or an additional claim or "suit" and the date received; insured is a limited liability company; and (4) Any "executive officer" or insurance (2) Notify us as soon as practicable. manager, if you or an additional You or any additional insured must see to insured is a corporation; it that we receive a written notice of the (5) Any trustee, if you or an additional claim or "suit" as soon as practicable. insured is a trust; or c. Assistance And Cooperation Of The (6) Any elected or appointed official, if you Insured or an additional insured is a political You and any other involved insured must: subdivision or public entity.
Form SS 00 08 04 05 Page 15 of 24
3ROLF\
57SBWKF3500
BUSINESS LIABILITY COVERAGE FORM
This Paragraph applies separately to We have issued this policy in reliance f. (3) you and any additional insured. upon your representations.
3. Financial Responsibility Laws b. Unintentional Failure To Disclose Hazards a. When this policy is certified as proof of
financial responsibility for the future under If unintentionally you should fail to disclose the provisions of any motor vehicle all hazards relating to the conduct of your financial responsibility law, the insurance business at the inception date of this provided by the policy for "bodily injury" Coverage Part, we shall not deny any liability and "property damage" liability will coverage under this Coverage Part comply with the provisions of the law to because of such failure. the extent of the coverage and limits of 7. Other Insurance insurance required by that law. If other valid and collectible insurance is b. With respect to "mobile equipment" to available for a loss we cover under this which this insurance applies, we will Coverage Part, our obligations are limited as provide any liability, uninsured motorists, follows: underinsured motorists, no-fault or other a. Primary Insurance coverage required by any motor vehicle law. We will provide the required limits for This insurance is primary except when b. those coverages. below applies. If other insurance is also primary, we will share with all that other 4. Legal Action Against Us insurance by the method described in c. No person or organization has a right under below. this Coverage Form:
b. Excess Insurance
a. To join us as a party or otherwise bring us
into a "suit" asking for damages from an This insurance is excess over any of the other insurance, whether primary, excess, insured; or
contingent or on any other basis: b. To sue us on this Coverage Form unless all of its terms have been fully complied (1) Your Work with. That is Fire, Extended Coverage,
A person or organization may sue us to recover Builder's Risk, Installation Risk or on an agreed settlement or on a final judgment similar coverage for "your work"; against an insured; but we will not be liable for (2) Premises Rented To You damages that are not payable under the terms of That is fire, lightning or explosion this insurance or that are in excess of the insurance for premises rented to you applicable limit of insurance. An agreed or temporarily occupied by you with settlement means a settlement and release of permission of the owner; liability signed by us, the insured and the claimant or the claimant's legal representative. (3) Tenant Liability
5. Separation Of Insureds That is insurance purchased by you to cover your liability as a tenant for Except with respect to the Limits of Insurance, "property damage" to premises rented and any rights or duties specifically assigned to you or temporarily occupied by you in this policy to the first Named Insured, this with permission of the owner; insurance applies:
(4) Aircraft, Auto Or Watercraft a. As if each Named Insured were the only Named Insured; and If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to b. Separately to each insured against whom the extent not subject to Exclusion of g. a claim is made or "suit" is brought. Section – Coverages. A.
6. Representations (5) Property Damage To Borrowed a. When You Accept This Policy Equipment Or Use Of Elevators By accepting this policy, you agree: If the loss arises out of "property (1) The statements in the Declarations damage" to borrowed equipment or are accurate and complete; the use of elevators to the extent not subject to Exclusion of Section – k. A. (2) Those statements are based upon Coverages. representations you made to us; and
3ROLF\
57SBWKF3500
BUSINESS LIABILITY COVERAGE FORM
(6) When You Are Added As An When this insurance is excess over other Additional Insured To Other insurance, we will pay only our share of Insurance the amount of the loss, if any, that
exceeds the sum of: That is other insurance available to you covering liability for damages The total amount that all such other (1) arising out of the premises or insurance would pay for the loss in the operations, or products and completed absence of this insurance; and operations, for which you have been (2) The total of all deductible and selfadded as an additional insured by that insured amounts under all that other insurance; or insurance.
(7) When You Add Others As An We will share the remaining loss, if any, with Additional Insured To This any other insurance that is not described in Insurance this Excess Insurance provision and was not That is other insurance available to an bought specifically to apply in excess of the additional insured. Limits of Insurance shown in the
However, the following provisions Declarations of this Coverage Part. apply to other insurance available to c. Method Of Sharing any person or organization who is an If all the other insurance permits additional insured under this Coverage contribution by equal shares, we will follow Part: this method also. Under this approach, (a) Primary Insurance When each insurer contributes equal amounts Required By Contract until it has paid its applicable limit of insurance or none of the loss remains, This insurance is primary if you whichever comes first. have agreed in a written contract, written agreement or permit that If any of the other insurance does not permit this insurance be primary. If other contribution by equal shares, we will insurance is also primary, we will contribute by limits. Under this method, each share with all that other insurance insurer’s share is based on the ratio of its by the method described in applicable limit of insurance to the total c. below. applicable limits of insurance of all insurers.
(b) Primary And Non-Contributory 8. Transfer Of Rights Of Recovery Against To Other Insurance When Others To Us
Required By Contract a. Transfer Of Rights Of Recovery
If you have agreed in a written If the insured has rights to recover all or contract, written agreement or part of any payment, including permit that this insurance is Supplementary Payments, we have made primary and non-contributory with under this Coverage Part, those rights are the additional insured's own transferred to us. The insured must do insurance, this insurance is nothing after loss to impair them. At our primary and we will not seek request, the insured will bring "suit" or contribution from that other transfer those rights to us and help us insurance. enforce them. This condition does not Paragraphs and do not apply to apply to Medical Expenses Coverage. (a) (b) other insurance to which the additional b. Waiver Of Rights Of Recovery (Waiver insured has been added as an Of Subrogation) additional insured. If the insured has waived any rights of When this insurance is excess, we will recovery against any person or have no duty under this Coverage Part to organization for all or part of any payment, defend the insured against any "suit" if any including Supplementary Payments, we other insurer has a duty to defend the have made under this Coverage Part, we insured against that "suit". If no other also waive that right, provided the insured insurer defends, we will undertake to do waived their rights of recovery against so, but we will be entitled to the insured's such person or organization in a contract, rights against all those other insurers. agreement or permit that was executed prior to the injury or damage.
Form SS 00 08 04 05 Page 17 of 24
3ROLF\
57SBWKF3500
ABCDEFGHIJ
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
HIRED AUTO AND NON-OWNED AUTO
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
This coverage is subject to all provisions in the moved from the place where they are BUSINESS LIABILITY COVERAGE FORM not accepted by the "insured" for movement into expressly modified herein: or onto the covered "auto"; or c. After the "pollutants" or any property in
A. Amended Coverage: which the "pollutants" are contained are moved from the covered "auto" to the place Coverage is extended to "bodily injury" and where they are finally delivered, disposed of "property damage" arising out of the use of a "hired or abandoned by the "insured". auto" and "non-owned auto".
Paragraph above does not apply to fuels, a. B. Paragraph B. EXCLUSIONS is amended as lubricants, fluids, exhaust gases or other follows: similar "pollutants" that are needed for or
1. Exclusion g. Aircraft, Auto or Watercraft does result from the normal electrical, hydraulic not apply to a "hired auto" or a "non-owned or mechanical functioning of the covered auto". "auto" or its parts, if:
2. Exclusion e. Employers Liability does not (1) The "pollutants" escape, seep, migrate, apply to "bodily injury" to domestic "employees" or are discharged or released directly not entitled to workers’ compensation benefits from an "auto" part designed by its or to liability assumed by the "insured" under an manufacturer to hold, store, receive, or "insured contract". dispose of such "pollutants"; and
3. f. Pollution Exclusion is replaced by the (2) The "bodily injury" and "property following: damage" does not arise out of the
operation of any equipment listed in "Bodily injury" or "property damage" arising out paragraphs 15.b. and 15.c. of the of the actual, alleged or threatened discharge, definition of "mobile equipment". dispersal, seepage, migration, release or escape of "pollutants": Paragraphs b. and c. above do not apply to a. That are, or that are contained in any "accidents" that occur away from premises owned by or rented to an "insured" with property that is: respect to "pollutants" not in or upon a (1) Being transported or towed by, handled, covered "auto" if: or handled for movement into, onto or (1) The "pollutants" or any property in from, the covered "auto"; which the "pollutants" are contained are (2) Otherwise in the course of transit by or upset, overturned or damaged as a on behalf of the "insured"; or result of the maintenance or use of a (3) Being stored, disposed of, treated or covered "auto"; and processed in or upon the covered
"auto".
b. Before the "pollutants" or any property in
which the "pollutants" are contained are
Form SS 04 38 09 09 Page 1 of 3
© 2009, The Hartford
(Includes copyrighted material of ISO Properties, Inc., with its permission) 3ROLF\
57SBWKF3500
(2) The discharge, dispersal, seepage, company) for an "auto" owned by him or her migration, release or escape of the or a member of his or her household. "pollutants" is caused directly by such d. Anyone liable for the conduct of an "insured" upset, overturn or damage as a result of described above but only to the extent of that the maintenance or use of a covered liability. "auto". D. With respect to the operation of a "hired auto" and 4. With respect to this coverage, the following "non-owned auto", the following additional additional exclusions apply: conditions apply:
a. Fellow employee 1. OTHER INSURANCE
Coverage does not apply to "bodily injury" to a. Except for any liability assumed under an any fellow "employee" of the "insured" "insured contract" the insurance provided by arising out of the operation of an "auto" this Coverage Form is excess over any owned by the "insured" in the course of the other collectible insurance. fellow "employee’s" employment. However, if your business is the selling, b. Care, custody or control servicing, repairing, parking or storage of Coverage does not apply to "property "autos", the insurance provided by this damage" involving property owned or endorsement is primary when covered transported by the "insured" or in the "bodily injury" or "property damage" arises "insured’s" care, custody or control. out of the operation of a customer’s "auto" C. With respect to "hired auto" and "non-owned auto" by you or your "employee". coverage, Paragraph C. WHO IS AN INSURED is b. When this Coverage Form and any other deleted and replaced by the following: Coverage Form or policy covers on the same basis, either excess or primary, we The following are "insureds": will pay only our share. Our share is the a. You. proportion that the Limit of Insurance of our b. Your "employee" while using with your Coverage Form bears to the total of the permission: limits of all the Coverage Forms and policies covering on the same basis. (1) An "auto" you hire or borrow; or (2) An "auto" you don’t own, hire or borrow in 2. TWO OR MORE COVERAGE FORMS OR your business or personal affairs; or POLICIES ISSUED BY US (3) An "auto" hired or rented by your If the Coverage Form and any other Coverage Form or policy issued to you by us or any "employee" on your behalf and at your company affiliated with us apply to the same direction. "accident", the aggregate maximum Limit of c. Anyone else while using a "hired auto" or "non- Insurance under all the Coverage Forms or owned auto" with your permission except: policies shall not exceed the highest applicable (1) The owner or anyone else from whom you Limit of Insurance under any one Coverage hire or borrow an "auto". Form or policy. This condition does not apply to (2) Someone using an auto while he or she is any Coverage Form or policy issued by us or an working in a business of selling, servicing, affiliated company specifically to apply as excess insurance over this Coverage Form. repairing, parking or storing "autos" unless that business is yours. E. The following definitions are added:
(3) Anyone other than your "employees", G. LIABILITY AND MEDICAL EXPENSES partners (if you are a partnership), members DEFINITIONS:
(if you are a limited liability company), or a 1. "Hired auto" means any "auto" you lease, lessee or borrower or any of their hire, rent or borrow. This does not include "employees", while moving property to or any auto you lease, hire, rent or borrow from an "auto". from any of your "employees", your partners (4) A partner (if you are a partnership), or a (if you are a partnership), members (if you member (if you are a limited liability are a limited liability company),
3ROLF\
57SBWKF3500
or your "executive officers" or members of
their households.
This does not include a long-term leased
"auto" that you insure as an owned "auto"
under any other auto liability insurance
policy or a temporary substitute for an
"auto" you own that is out of service
because of its breakdown, repair, servicing
or destruction.
2. "Non-owned auto " means any "auto" you
do not own, lease, hire, rent or borrow
which is used in connection with your
business. This includes:
a. "Autos" owned by your "employees" your
partners (if you are a partnership),
members (if you are a limited liability
company), or your "executive officers",
or members of their households, but
only while used in your business or your
personal affairs.
b. Customer’s "auto" that is in your care,
custody or control for service.
Form SS 04 38 09 09 Page 3 of 3
3ROLF\
57SBWKF3500
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Countersigned by
Authorized Representative
Form WC 04 03 06 (1) Printed in U.S.A.
Policy Expiration Date:
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
Policy Number: Endorsement Number:
Effective Date: Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address:
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.) 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 2 % of the California workers' compensation premium otherwise due on such remuneration.
SCHEDULE
Person or Organization Job Description
Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights from us
57WEGAC8DE3 02/06/2022
TJC & Associates, Inc.
P.O. Box 2059
Folsom, CA 95763
02/06/2023