May 8, 2013
► TYLin Golden Avenue Bridge Rehabilitation XI
Local Assistance Procedures Manual
REQUIRED FORMS
EXHIBIT 10-U
Consultant Management Conflict of Interest Statement
EXHIBIT 10-U CONSULTANT IN MANAGEMENT SUPPORT ROLE CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT1
RFP/RFQ PROCUREMENT NUMBERS (if applicable): RFP #PW -25-05 Professional Construction Management and Inspection Services for the PROJECT NAME (and FPN, if applicable)2: Golden Avenue Bridge Rehabilitation Project & Orange County Bikeway Loop Segment D from Station 21+00 North of Golden Avenue to Station 31+00 South of Golden Avenue (FPN BRLS 5269[025])
APPLICABILITY: To be filled out by local agency consultants in management support role. m I am an employee of a consultant under contract to the local agency that is responsible for the procuring and administering of one or more consultant contracts containing either Federal or State funds.
❑ I am in a management position with the local agency, my title is listed below and I have attached my duty statement and scope of work.
m I hereby certify as follows:
1. I recuse myself from all potential conflicts of interest.
2. I will not directly or indirectly participate in, manage, or oversee any consultant selection procurement process in which the consulting firm of which I am employed is competing as a consultant or subconsultant.
3. I will not directly or indirectly influence any employee, staff member, or other individual participating in any consultant selection procurement process in which the consulting firm of which I am employed is as a consultant or subconsultant.
4. I will not directly or indirectly participate in, manage, or oversee any local agency contract that is with the consulting firm of which I am employed, regardless of whether the involvement of my employer in the contract is as a consultant or subconsultant.
Among other things, this includes my not being involved in approving changes in the schedule, scope, deliverables or invoices.
5. I understand that if I am involved in any local agency contract that is with the consulting firm of which I am employed, in violation of 1. or 2. above, that local agency contract will no longer be eligible for Federal or State reimbursement because of my involvement.
m I certify that I have read and understand my responsibilities per 23 CFR 172.7(b)(5) m I fully understand that it is unlawful for a person to utilize any organization name (i.e. local agency) or auxiliary organization information, which is not a matter of public record, for personal gain.
Each consultant staff working in a management support role shall complete a separate form. 2 For on-call contracts or contracts for multiple projects, indicate accordingly.
January 2018
► TYLin I Golden Avenue Bridge Rehabilitation XII
REQUIRED FORMS
Local Assistance Procedures Manual EXHIBIT 10-U
Consultant Management Conflict of Interest Statement
❑✓ I have read and fully understand all of the above.
10/16/2025\K
Date:
Signature:
Name: Joseph Smith
Vice President
Title:
Consultant Firm/Sole Proprietor: T.Y. Lin International k)
REVIEWED BY PUBLIC WORKS DIRECTOR OR AUTHORIZED LOCAL AGENCY
REPRESENTATIVE
I have reviewed the foregoing "Conflict of Interest and Confidentiality Statement" and will ensure:
❑ That the foregoing named local agency consultant who is under contract and in a management support role with our local agency, abides by the foregoing terms and conditions; ❑ That should the foregoing named local agency consultant, who is under contract and in a management support role with our local agency, violate any of the foregoing terns and conditions, the Caltrans DLAE will be notified and such violation will be considered a breach of ethics and could be a basis for ineligibility of State or Federal project funds. ❑ The procedures followed to procure and execute the contract, between the local agency and the consulting firm of which I am employed, comply with all federal and state requirements. Also this contract has a specific date from to
Date:
Signature:
Name:
Title:
Department/Local Agency:
January 2018
► TYLin I Golden Avenue Bridge Rehabilitation XIII
REQUIRED FORMS
Local Assistance Procedures Manual EXHIBIT IO -U
Consultant Management Conflict of Interest Statement
REVIEWED/CONCURRENCE BY FEDERAL HIGHWAYS
I have reviewed the foregoing "Conflict of Interest and Confidentiality Statement" and supervisor's statement.
❑ I concur that the consultant, who is under contract and in a management support role with the local agency, does not appear to present a conflict of interest. The local agency and the consultant should be considered eligible for federal reimbursement.
D I do not concur as I believe that the consultant, who is under contract and in a management support role with the local agency, does appear to present a conflict of interest.
Date:
Signature:
Name:
Position:
Distribution: 1) Copy to: DLAE for each Federal/State funded project 2) Copy to be returned to Local Agency by DLAE with FHWA approval
January 2018
► TYLin 1 Golden Avenue Bridge Rehabilitation XIV
REQUIRED FORMS
Local Assistance Procedures Manual Exhibit 10-1
Notice to Proposers DBE Information
Exhibit 10-1: Notice to Proposers DBE Information
(federally funded projects only)
The Local Public Agency (LPA) has established a DBE goal for this Contract of
1. TERMS AS USED IN THIS DOCUMENT
0.00 The term "Disadvantaged Business Enterprise" or "DBE" means a for-profit small business concern owned and controlled by a socially and economically disadvantaged person(s) as defined in Title 49, Code of Federal Regulations (CFR), Part 26.5.
The term "Agreement" also means "Contract."
• LPA also means the local entity entering into this contract with the Contractor or Consultant. • The term "Small Business" or "SB" is as defined in 49 CFR 26.65.
2. AUTHORITY AND RESPONSIBILITY
A. DBEs and other small businesses are strongly encouraged to participate in the performance of Contracts financed in whole or in part with federal funds (see 49 CFR 26: Participation by Disadvantaged Business Enterprises in Department of Transportation Financial Assistance Programs).
The Consultant must ensure that DBEs and other small businesses have the opportunity to participate in the performance of the work that is the subject of this solicitation and should take all necessary and reasonable steps for this assurance. The proposer must not discriminate on the basis of race, color, national origin, or sex in the award and performance of subcontracts.
B. Proposers are encouraged to use services offered by financial institutions owned and controlled by DBEs.
3. SUBMISSION OF DBE INFORMATION
If there is a DBE goal on the contract, Exhibit 10-01: Consultant Proposal DBE Commitment must be included in the Proposal. In order for a proposer to be considered responsible and responsive, the proposer must make good faith efforts to meet the goal established for the contract. If the goal is not met, the proposer must document adequate good faith efforts. All DBE participation will be counted towards meeting the contract goal; therefore, all DBE participation must be collected and reported.
Exhibit 10-02: Consultant Contract DBE Information must be included in best qualified consultant's executed consultant contract. Even if no DBE participation will be reported, the successful proposer must execute and return the form.
4. DBE PARTICIPATION GENERAL INFORMATION
It is the proposer's responsibility to be fully informed regarding the requirements of 49 CFR 26, and the Department's DBE program developed pursuant to the regulations. Particular attention is directed to the following:
A. A DBE must be a small business firm defined pursuant to 13 CFR 121 and be certified through the California Unified Certification Program (CUCP).
B. A certified DBE may participate as a prime consultant, subconsultant, joint venture partner, as a vendor of material or supplies, or as a trucking company.
C. A DBE proposer not proposing as a joint venture with a non -DBE, will be required to document one or a combination of the following:
1. The proposer is a DBE and will meet the goal by performing work with its own forces.
January 2025
► TYLin I Golden Avenue Bridge Rehabilitation XV
REQUIRED FORMS
Local Assistance Procedures Manual Exhibit 10-1
Notice to Proposers DBE Information
2. The proposer will meet the goal through work performed by DBE subconsultants, suppliers or trucking companies.
3. The proposer, prior to proposing, made adequate good faith efforts to meet the goal.
D. A DBE joint venture partner must be responsible for specific contract items of work or clearly defined portions thereof. Responsibility means actually performing, managing, and supervising the work with its own forces. The DBE joint venture partner must share in the capital contribution, control, management, risks and profits of the joint venture commensurate with its ownership interest.
E. A DBE must perform a commercially useful function pursuant to 49 CFR 26.55, that is, a DBE firm must be responsible for the execution of a distinct element of the work and must carry out its responsibility by actually performing, managing and supervising the work.
F. The proposer must list only one subconsultant for each portion of work as defined in their proposal and all DBE subconsultants should be listed in the bid/cost proposal list of subconsultants.
G. A prime consultant who is a certified DBE is eligible to claim all of the work in the Contract toward the DBE participation except that portion of the work to be performed by non -DBE subconsultants.
5. COUNTING DBE PARTICIPATION
Materials or supplies purchased from DBEs count towards the DBE goal under the following conditions:
A. If the materials or supplies are obtained from a DBE manufacturer, count 100 percent of the cost of the materials or supplies. A DBE manufacturer is a firm that operates or maintains a factory, or establishment that produces on the premises the materials, supplies, articles, or equipment required under the Contract and of the general character described by the specifications.
B. If the materials or supplies purchased from a DBE regular dealer, count 60 percent of the cost of the materials or supplies. A DBE regular dealer is a firm that owns, operates or maintains a store, warehouse, or other establishment in which the materials, supplies, articles or equipment of the general character described by the specifications and required under the Contract are bought, kept in stock, and regularly sold or leased to the public in the usual course of business. To be a DBE regular dealer, the firm must be an established, regular business that engages, as its principal business and under its own name, in the purchase and sale or lease of the products in question. A person may be a DBE regular dealer in such bulk items as petroleum products, steel, cement, gravel, stone or asphalt without owning, operating or maintaining a place of business provided in this section.
C. If the person both owns and operates distribution equipment for the products, any supplementing of regular dealers' own distribution equipment must be, by a long-term lease agreement and not an ad hoc or Agreement -by -Agreement basis. Packagers, brokers, manufacturers' representatives, or other persons who arrange or expedite transactions are not DBE regular dealers within the meaning of this section.
D. Materials or supplies purchased from a DBE, which is neither a manufacturer nor a regular dealer, will be limited to the entire amount of fees or commissions charged for assistance in the procurement of the materials and supplies, or fees or transportation charges for the delivery of materials or supplies required on the job site, provided the fees are reasonable and not excessive as compared with fees charged for similar services
6. RESOURCES
A. The CUCP database includes the certified DBEs from all certifying agencies participating in the CUCP. If you believe a firm is certified that cannot be located on the database, please email DBE.Certification at dot.ca.aov for assistance.
B. Access the CUCP database from the Department of Transportation, Office of Civil Rights website. For guidance on how to search for certified firms using the CUCP database, please visit: DBE Goal Setting I Caltrans
January 2025
► TYLin I Golden Avenue Bridge Rehabilitation XVI
Local Assistance Procedures Manual
REQUIRED FORMS
Exhibit 10-01
Consultant Proposal DBE Commitment
EXHIBIT 10-01 CONSULTANT PROPOSAL DBE COMMITMENT
Reset Form
1. Local Agency: City of Placentia 2. Contract DBE Goal: 0%
3. Project Description: Construction Management and Inspection Services for the Golden Avenue Bridge Rehabilitation Project
4. Project Location: Placentia, California
5. Consultants Name: T.Y. Lin International
7. Description of Work, Service, or Materials
Supplied
Materials testing
Cultural resources
6. Prime Certified DBE: El
8. DBE
Certification 9. DBE Contact Information 10. DBE %
Number
Sz Engineering, Inc. 18608 Utica Ave, Suite 100, Rancho 30866 Cucamonga, CA 9173o 1 SagarPandey 1909.884.8276 I TBD [email protected]
ArchaeoPaleo Resource Management, Inc. 11531 Pontius
35813 Ave., Suite 200 Los Angeles, CA 90025 1 Robin Turner 1 TBD [email protected]
Local Agency to Complete this Section
17. Local Agency Contract Number:
18. Federal -Aid Project Number:
Consultants Ranking after Evaluation:
Local Agency certifies that all DBE certifications are valid and information on this form is complete and accurate.
21. Local Agency Representative's Signature 22. Date
23. Local Agency Representative's Name 24. Phone
25. Local Agency Representative's Title
DISTRIBUTION: Original — Included with consultant's proposal to local agency.
11. TOTAL CLAIMED DBE PARTICIPATION TBD **
IMPORTANT: Identify all DBE firms being claimed for credit, regardless of tier. Written confirmation of each listed DBE is required..,
1\i"7,7! 10/16/2025
12. Preparer's Signature 13. Date
Joseph Smith (619) 908-3306
14. Preparer's Name 15. Phone
Vice President
16. Preparer's Title
** Based on the latest DBE ruling issued as part
of Addendum #2 released on October 7th, 2025.
ADA Notice: For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) 654- 3880 or write Records and Forms Management, 1120 N Street, MS -89, Sacramento, CA 95814.
LPP 18-01 Page 1 of 2
January 2019
► TYLin 1 Golden Avenue Bridge Rehabilitation XVII
Business & Contact Information
BUSINESS NAME
OWNER
ADDRESS
REQUIRED FORMS
ArchaeoPaleo Resource Management, Inc., DBA None
Ms. Robin D Turner
12304 Santa Monica Blvd., Suite 202
Los Angeles, CA 90025
PHONE 424-248-3316
FAX 424-248-3417
EMAIL [email protected]
WEBSITE http://www.archaeopaleo.com
ETHNICITY Caucasian
GENDER Female
COUNTY Los Angeles (CA)
Certification Information
CERTIFYING AGENCY Los Angeles County Metropolitan Transportation Authority CERTIFICATION TYPE DBE - Disadvantaged Business Enterprise CERTIFIED BUSINESS DESCRIPTION Archeological and cultural services Commodity Codes
Code Description
NAICS 541620 Environmental consulting services
NAICS 541690 Other Scientific and Technical Consulting Services NAICS 541990 All Other Professional, Scientific, and Technical Services NAICS 712120 Historical sites
Additional Information
WORK DISTRICTS/REGIONS All work districts/regions
CUCP PUBLIC DIRECTORY 35813
CERTIFICATION NUMBER
TYLin I Golden Avenue Bridge Rehabilitation XVIII
REQUIRED FORMS
Business & Contact Information
BUSINESS NAME S2 ENGINEERING
OWNER Mr. Pavitra Pandey
ADDRESS 8608 UTICA AVE STE 100
SUITE 100
RANCHO CUCAMONGA, CA 91730 [map]
PHONE 909-373-8240
FAX 909-373-8241
EMAIL [email protected]
WEBSITE http://www.s2-ei.com
ETHNICITY Subcontinent Asian American
GENDER Male
COUNTY San Bernardino (CA)
Certification Information
CERTIFYING AGENCY California Department of Transportation CERTIFICATION TYPE DBE - Disadvantaged Business Enterprise CERTIFIED BUSINESS DESCRIPTION MANAGEMENT INFORMATION SYSTEMS; TRAFFIC ENGINEER; CONSULTANT, ENGINEERING; ARCHITECTURAL ENGINEER; CIVIL ENGINEERING; SAFETY STUDIES; CONSTRUCTION MANAGEMENT; LABORATORY TESTING AND ANALYSIS; Engineering services; Building inspection services; Testing Laboratories and Services; Other Management Consulting Services
Commodity Codes
Code Description
CA WCC C8702 MANAGEMENT INFORMATION SYSTEMS
CA WCC C8703 TRAFFIC ENGINEER
CA WCC C8715 CONSULTANT, ENGINEERING
CA WCC C8716 ARCHITECTURAL ENGINEER
https://californiaucp.dbesystem.com 1/2
TYLin I Golden Avenue Bridge Rehabilitation XIX
Construction Management
Inspection Services
Materials Testing
52 Engineering
October 9, 2025
Mazen Mneimneh
Senior Program Manager
TYLin
20 Pacifica
Suite 350
Irvine, CA 92618
REQUIRED FORMS
8608 Utica Avenue, Suite 100 Rancho Cucamonga, CA 91730 Phone: (909) 3731240 . Fax: (909) 373-8241. Website: www. S2-ei.com Subject: City of Placentia 1 Construction Management and Inspection Services for the Golden Avenue Bridge Rehabilitation Project 1 RFP #PW -25-05/ Federal Project #BRLS 5269(025)
Dear Mr. Mneimneh,
S2 Engineering, Inc. (S2) is pleased to commit its services to T.Y. Lin International (TYLin) for the Construction Management and Inspection Services for the Golden Avenue Bridge Rehabilitation Project [RFP #PW-25- 05/Federal Project #BRLS 5269(025)]. We will be assisting TYLin in providing materials testing as a non-exclusive subconsultant.
S2 is a DBE/CBE certified firm, CUCP Certificate Number 30866.
In addition, we have reviewed the RFP for any potential conflicts of interest and have concluded that S2 has no anticipated conflicts of interest to this contract.
1, Sagar Pandey, am authorized to bind the firm to the contract. Should you have any questions, please contact me directly at (909) 884-8276 or [email protected].
Sincerely,
Sagar Pandey, PE
Principal Engineer
► TYLin I Golden Avenue Bridge Rehabilitation XX
REQUIRED FORMS
BIGGS CARDOSA
ASSOCIATES INC
STRUCTURAL ENGINEERS
8B5 The?. Alameda
San Jose, CA 951 26-31 33
Telcphono 408.298.5515
October 9, 2025
Mazen Mneimneh
Senior Program Manager
TYLin
20 Pacifica, Suite 350
Irvine, CA 92618
Subject: City of Placentia 1 Construction Management and Inspection Services for the Golden Avenue Bridge Rehabilitation Project 1 RFP #PW -25-05/ Federal Project #BRLS 5269(025) Dear Mr. Mneimneh,
Biggs Cardosa Associates, Inc. is pleased to commit its services to T.Y. Lin International (TYLin) for the Construction Management and Inspection Services for the Golden Avenue Bridge Rehabilitation Project [RFP #PW-25-05/Federal Project #BRLS 5269(025)]. As an exclusive key subconsultant, we will be assisting TYLin in providing Field Engineering/Inspections and/or Structure Representative services up to the allocated subcontract amount for of at least 25% of the value of the construction management services contract before the required contract distribution of the consultant contact value to DBE firms.
In addition, we have reviewed the RFP for any potential conflicts of interest and have concluded that Biggs Cardosa has no anticipated conflicts of interest to this contract.
I, Ron Oen, am authorized to bind the firm to the contract. Should you have any questions, please contact me directly at 408.550.8566 or [email protected].
Sincerely,
BIGGS CARDOSA ASSOCIATES, Inc.
Ronald L. Oen, PE, QSD
Principal 1 Vice President
► TYLin I Golden Avenue Bridge Rehabilitation XXI
co
REQUIRED FORMS
ArchaeoPaleo Resource Management, inc.
A full-service Archaeology and Paleontology company
SBE/WBE/WOSB/DBE/VSBE/UDBE/LBE/SLBI:,'CBE/MicroBE Certified October 9, 1025
Mazen Mneimnch
Senior Program Manager
TYLin
20 Pacifica
Suite 350
Irvine, CA 92618
Subject: City of Placentia l Construction Management and Inspection Services for the Golden Avenue Bridge Rehabilitation Project RFP #PW -25-05/ Federal Project #BRLS 5269(025)
Dear Mr. Mncimneh,
ArchacoPaleo Resource Management, lnc.is pleased to commit its services to T.Y. Lin International (TYLin) for the Construction Management and inspection Services for the Golden Avenue Bridge Rehabilitation Project [RFP #PW-25-05/Federal Project #BRLS 5269(025)]. We will he assisting TYLin in providing CM Cultural Resources oversight For Tribal Coordination of the assigned Native Ame4rican monitor to ensure compliance with CEQA requirements as a subconsultant.
ArchaeoPalco Resource Management, inc.is a DBE/CBE certified firm, Certificate Number 4867 by Los Angeles Metro and also Caltrans, CUCP, and both L. A. County and City. in addition, we have reviewed the RFP for any potential conflicts of interest and have concluded that ArchaeoPaleo Resource Management, Inc. has no anticipated conflicts of interest to this contract.
I. Robin Turner, am authorized to bind the firm to the contract. Should you have any questions, please contact me directly at (424) 248-3316 or IItinmrri ;ircliac.01.1,00 .
Sincerely,
Robin Turner
President
12304 Santa Monica Blvd., Suite 202 424/248.3316 ph
Los Angeles, CA 90025 424/248-3417 fax
XXII
TYLin I Golden Avenue Bridge Rehabilitation
CITY OF PLACENTIA
CONSTRUCTION MANAGEMENT AND INSPECTION
SERVICES FOR THE GOLDEN AVENUE BRIDGE
REHABILITATION PROJECT
FEDERAL PROJECT NO. BRLS 5269(025)
REQUIRED FORMS
ORANGE COUNTY BIKEWAY LOOP SEGMENT D FROM
STATION 21+00 NORTH OF GOLDEN AVENUE TO
STATION 31+00 SOUTH OF GOLDEN AVENUE
DATE: October 1, 2025
SUBJECT: Addendum # 1
ADDENDUM ACKNOWLEDGMENT:
Firm Name: TYLin
Authorized Signature:
Date: 10/2/25
1 wy6
Acknowledgment of Receipt of Addendum # 1 is required by signing.
► TYLin I Golden Avenue Bridge Rehabilitation XXIII
CITY OF PLACENTIA
REQUIRED FORMS
CONSTRUCTION MANAGEMENT AND INSPECTION
SERVICES FOR THE GOLDEN AVENUE BRIDGE
REHABILITATION PROJECT
FEDERAL PROJECT NO. BRLS 5269(025)
ORANGE COUNTY BIKEWAY LOOP SEGMENT D FROM
STATION 21+00 NORTH OF GOLDEN AVENUE TO
STATION 31+00 SOUTH OF GOLDEN AVENUE
DATE: October 7, 2025
SUBJECT: Addendum # 2
ADDENDUM ACKNOWLEDGMENT:
Firm Name: TYLin
Authorized Signature:
Date: 10/8/25
Acknowledgment of Receipt of Addendum # 2 is required by signing.
► TYLin I Golden Avenue Bridge Rehabilitation XXIV
L
EXHIBIT B
INSURANCE REQUIREMENTS
A. Minimum Scope and Limits of Insurance
City reserves the right to review any and all of the required insurance policies and/or endorsements, but has no obligation to do so. Failure to demand evidence of full compliance with the insurance requirements set forth in this Agreement or failure to identify any insurance deficiency shall not relieve Consultant from, nor be construed or deemed a waiver of, its obligation to maintain the required insurance at all times during the performance, including any extension thereof, of this Agreement.
Consultant shall obtain, maintain, and keep in full force and effect during the life of this Agreement, including any extension thereof, all of the following minimum scope of insurance coverages:
1. Commercial General Liability Insurance
Broad -form commercial general liability, with coverage at least as broad as the most current version of ISO Commercial General Liability coverage form CG 00 01, in a form at least as broad as ISO form CG 00 01 04 13, and shall include insurance for premises and operations, products/completed operations, broad form property damage, blanket contractual liability, independent contractors, personal injury or bodily injury, and personal and advertising injury with a policy limit of not less than Two Million Dollars ($2,000,000.00) per occurrence and Four Million Dollars ($4,000,000.00) general aggregate. The aggregate limit, encompassing the above coverage, shall apply separately to this project/location. If Consultant maintains higher limits than the specified minimum limits, City requires and shall be entitled to coverage for the higher limits maintained by the Consultant.
2. Business Automobile Liability Insurance
Business automobile liability for all owned, hired, leased, and non -owned vehicles at least as broad as the most current version of ISO Business Auto Coverage form CA 00 01, with a policy limit of not Tess than Two Million Dollars ($2,000,000.00) combined single limit per accident. If Consultant maintains higher limits than the specified minimum limits, City requires and shall be entitled to coverage for the higher limits maintained by the Consultant.
3. Workers' Compensation and Employer's Liability Insurance Workers' compensation insurance as required by the State of California and Employer's Liability Insurance with a minimum limit of One Million Dollars ($1,000,000.00) per accident for any employee or employees of Consultant. Consultant agrees to waive and to obtain endorsements from its workers' compensation insurer waiving subrogation rights under its workers' compensation insurance policy against the City, its officers, officials, agents, employees, and volunteers for losses arising from work performed by Consultant for the City and to require each of its subcontractors, if any, to do likewise under their workers' compensation insurance policies.
By signing this Agreement, the Consultant acknowledges and agrees to the following:
I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for Workers' Compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract.
The Consultant shall also comply with Section 3800 of the Labor Code by securing, paying for, and maintaining in full force and effect for the duration of this Agreement, complete workers' compensation insurance, and shall furnish a certificate of insurance to the Project Manager before execution of this Agreement by the City. The City, its officers, officials, agents, employees, and volunteers shall not be responsible for any claims in law or equity occasioned by failure of the Consultant to comply with this Section.
4. Professional Errors and Omissions ("E&O") Liability Insurance Professional errors and omissions ("E&O") liability insurance appropriate to the Consultant's profession, with limits of not less than Two Million Dollars ($2,000,000.00) per occurrence and Three Million Dollars ($3,000,000.00) aggregate. The retroactive date must be shown and must be before the date of the contract or the beginning of contract work. Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the contract of work. If coverage is canceled or non -renewed, and not replaced with another claims -made policy form with a retroactive date prior to the contract effective date, the Consultant must purchase "extended reporting coverage" for a minimum of five (5) years after completion of contract work. A copy of the claims reporting requirements must be submitted to the Project Manager for review. If Consultant maintains higher limits than the specified minimum limits, City requires and shall be entitled to coverage for the higher limits maintained by the Consultant.
5. Standards for Insurance Companies
All insurance policies shall be issued by an insurance company currently authorized by the Insurance Commission to transact business of insurance or is on the List of Approved Surplus Line Insurers in the State of California, with an assigned policyholders' rating of A- (or higher) and Financial Size Category Class VII (or larger) in accordance with the latest edition of Best's Key Rating Guide.
B. Documentation and Other Provisions
1. The commercial general liability insurance policy and business automobile liability policy shall be endorsed to contain the following: The City of Placentia, its officers, officials, agents, employees, and volunteers are additional insureds with respect to: liability arising out of activities performed by or on behalf of the Consultant pursuant to its contract with the City; products and completed operations of the Consultant; premises owned, occupied, or used by the Consultant; and automobiles owned, leased, hired, or borrowed by the Consultant. General liability coverage can be provided in the form of an endorsement to the Contractor's insurance at least as broad as one of the following ISO ongoing operations forms: CG 20 10 or CG 20 26 or CG 20 33 (not allowed from subcontractors), or CG 20 38; and one of the following ISO completed operations forms:
CG 20 37, 2039 (not allowed from subcontractors), or CG 20 40.
2. Said policies shall not terminate, nor shall they be cancelled or coverage reduced, without
at least thirty (30) days' written notice to the City. In the event of any cancellation or reduction in coverage or limits of any insurance, Consultant shall forthwith obtain and submit proof of substitute insurance. Should Consultant fail to immediately procure other insurance, as specified, to substitute for any cancelled policy or reduction in the required coverage limits, the City may procure such insurance at Consultant's sole cost and expense.
3. The Consultant's insurance coverage shall be primary insurance coverage at least as broad as ISO CG 20 01 04 13 as respects the City of Placentia, its officers, officials, agents, employees, and volunteers. Any other insurance maintained by the City of Placentia shall be excess and not contributing with the insurance provided by this policy.
4. Any failure to comply with the reporting provisions of the policies shall not affect coverage provided to the City of Placentia, its officers, officials, agents, employees, and volunteers.
5. Defense fees and costs shall not deplete the limits of any insurance provided under this Agreement.
6. The Consultant's insurance shall apply separately to each insured against whom claim is made or suit is brought, except with respect to the limits of the insurer's liability.
7. Consultant shall require and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and Consultant shall ensure the City is an additional insured on insurance required from subcontractors.
8. Consultant agrees to waive, and to obtain endorsements from insurers waiving, subrogation rights against the City, its officers, officials, agents, employees, and volunteers for losses arising from work performed by Consultant for the City and to require each of its subcontractors, if any, to do likewise under their insurance policies.
9. Coverage shall be on a standard occurrence form. Claims -made forms are not acceptable, except under the Professional Errors & Omissions ("E&O") Liability policy.
Modified, limited, or restricted occurrence forms are not acceptable.
EXHIBIT C
CERTIFICATES OF INSURANCE AND ENDORSEMENTS
15 4jnnterna%lOn=11
Rev. 01/2024
AC D®
�.� 11/1/2026
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
12/9/2025
PRODUCER Lockton Companies, LLC
DBA Lockton Insurance Brokers, LLC in CA
CA license #0F15767
444 W. 47th St., Ste. 900
Kansas City MO 64112-1906
(816) 960-9000 [email protected]
T.Y. LIN INTERNATIONAL
404 CAMINO DEL RIO SOUTH, SUITE 700
SAN DIEGO CA 92108
INSURED
1494343
COVERAGES
CONTACT
NAME:
I PHONE
!/1('Nl o. Extl:
AD/D`RESS:
I
FAX
(A/C, No):
INSURER(S) AFFORDING COVERAGE
INSURER A : Zurich American Insurance Company
INSURER B : Lloyds of London
1 INSURER C :
I INSURER D
NAIC #
16535
1 INSURER E :
1 INSURER F :
CERTIFICATE NUMBER: 22618749 REVISION NUMBER: XXXXXXX
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.
INSR
LTR
A X
TYPE OF INSURANCE
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE [ X OCCUR
X SEVERABILITY
X CLAUSE
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY X PECO- LOC
OTHER:
A AUTOMOBILE LIABILITY
X ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
X HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
DED RETENTION $
WORKERS COMPENSATION
A AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
B PROFESSIONAL
LIABILITY
Y/N
N
ADDL SUBR
INap WVD
POLICY EFF POLICY EXP
POLICY NUMBER (MM DD/YYYY) (MM/DDIYYYYI
Y Y GL03021088 11/1/2025 11/1/2026
y y BAP 3021090
NOT APPLICABLE
Y WC 3021089
NIA
N N B0713GLCON2500104
11/1/2025 11/1/2026
11/1/2025 11/1/2026
11/1/2025 11/1/2026
LIMITS
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
EACH OCCURRENCE
AGGREGATE
2,000,000
1,000,000
25,000
2,000,000
4,000,000
4,000,000
2,000,000
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
$ XXXXXXX
X STATUTE EORH
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1.000.000
$3,000,000 PER CLAIM; ::3,000,000
ANNUAL AGGREGATE
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED.
RE: 3010.0103115.000 THE GOLDEN AVENUE BRIDGE REHABILITATION PROJECT & ORANGE COUNTY BIKEWAY LOOP SEGMENT D. THE CITY OF PLACENTIA, ITS OFFICERS,
OFFICIALS, EMPLOYEES, AND VOLUNTEERS ARE ADDITIONAL INSUREDS AS RESPECTS GENERAL LIABILITY AND AUTO LIABILITY, AND THESE COVERAGES ARE PRIMARY AND NON-CONTRIBUTORY, IF REQUIRED BY WRITTEN CONTRACT. WAIVER OF SUBROGATION APPLIES TO GENERAL LIABILITY, AUTO LIABILITY AND WORKERS COMPENSATION/EMPLOYER'S LIABILITY WHERE ALLOWED BY STATE LAW AND IF REQUIRED BY WRITTEN CONTRACT. RETROACTIVATE DATE: FULL PRIOR ACTS.
CERTIFICATE HOLDER
22618749
CITY OF PLACENTIA
401 E. CHAPMAN AVE.,
PLACENTIA, CA 92870
ACORD 25 (2016/03)
CANCELLATION See Attachments
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE'
© 1988C2015'ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Attachment Code: D581105 Certificate ID: 22618749
Additional Insured — Owners, Lessees Or Contractors —
Scheduled Person Or Organization
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Policy No. GL03021088
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
Name Of Additional Insured Person(s)
Or Organization(s):
Any person or organization you are required to add
as an additional insured under a written contract or
written agreement.
Effective Date: 11/1/2025
SCHEDULE
Location(s) Of Covered Operations
ALL LOCATIONS
A. Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule of this endorsement, 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 in such Schedule.
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.
All other terms, conditions, provisions and exclusions of this policy remain the same.
U -GL -2169-A CW (02/19)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D581105 Certificate ID: 22618749
Additional Insured — Owners, Lessees Or Contractors —
Completed Operations
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Policy No. GL03021088
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
Effective Date: 11/1/2025
SCHEDULE
Name Of Additional Insured Person(s) Location And Description Of Completed Operations Or Organization(s):
Any person or organization you are required to add ALL LOCATIONS as an additional insured under a written contract or
written agreement.
Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule of this endorsement, 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 such Schedule, performed for that additional insured and included in the "products -completed operations hazard".
All other terms, conditions, provisions and exclusions of this policy remain the same.
U -GL -2168-A CW (02/19)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D582601 Certificate ID: 22618749
POLICY NUMBER: GL03021088
Other Insurance Amendment - Primary And
Non -Contributory
ZURICH
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part
1. The following paragraph is added to the Other Insurance Condition of Section IV - Commercial General Liability Conditions:
This insurance is primary insurance to and will not seek contribution from any other insurance available to an additional insured under this policy provided that:
a. The additional insured is a Named Insured under such other insurance; and b. You are required by a written contract or written agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured.
2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV - Commercial General Liability Conditions:
This insurance is excess over:
Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis.
All other terms and conditions of this policy remain unchanged.
U -GL -1327-B CW (04/13)
Attachment Code: D581108 Certificate ID: 22618749
POLICY NUMBER: BAP 3021090 COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Endorsement Effective Date: 11/1/2025
SCHEDULE
Name Of Person(s) Or Organization(s): Any person or organization you are required to provide additional insured status or additional insured status on a primary, non-contributory basis, in a written contract or written agreement executed prior to loss, except where such contract or agreement is prohibited by law.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form
Attachment Code: D590579 Certificate ID: 22618749
Policy No.
BAP 3021090
Coverage Extension
Endorsement
Eff. Date of Pol.
11/1/2025
Exp. Date of Pol.
11/1/2026
Eff. Date of End.
11/1/2025
Producer No.
37385000
Add'I. Prem
INCL
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Business Auto Coverage Form
Motor Carrier Coverage Form
Return Prem.
A. Amended Who Is An Insured
1. The following is added to the Who Is An Insured Provision in Section II — Covered Autos Liability Coverage:
The following are also "insureds":
a. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow for acts performed within the scope of employment by you. Any "employee" of yours is also an "insured" while operating an "auto" hired or rented under a contract or agreement in an "employee's" name, with your permission, while performing duties related to the conduct of your business. b. Anyone volunteering services to you is an "insured" while using a covered "auto" you don't own, hire or borrow to transport your clients or other persons in activities necessary to your business. c. Anyone else who furnishes an "auto" referenced in Paragraphs A.1.a. and A.1.b. in this endorsement. d. Where and to the extent permitted by law, any person(s) or organization(s) where required by written contract or written agreement with you executed prior to any "accident", including those person(s) or organization(s) directing your work pursuant to such written contract or written agreement with you, provided the "accident" arises out of operations governed by such contract or agreement and only up to the limits required in the written contract or written agreement, or the Limits of Insurance shown in the Declarations, whichever is less.
2. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance — Primary and Excess Insurance Provisions Condition in the Motor Carrier Coverage Form:
Coverage for any person(s) or organization(s), where required by written contract or written agreement with you executed prior to any "accident", will apply on a primary and non-contributory basis and any insurance maintained by the additional "insured" will apply on an excess basis. However, in no event will this coverage extend beyond the terms and conditions of the Coverage Form.
U -CA -424-F CW (04-14)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D581100 Certificate ID: 22618749
POLICY NO. WC 3021089
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000313
(Ed. 4-84) 1
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 form us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
If you are required by a written contract or agreement, which is executed before a loss, to waive your rights of recovery from others, we agree to waive our rights of recovery.
Attachment Code: D581097 Certificate ID: 22618749
POLICY NUMBER: GLO3021088
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization: If you are required by a written contract or agreement, which is executed before a loss, to waive your rights of recovery from others, we agree to waive our rights of recovery.
I Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions:
We waive any right of recovery we may have against the
person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the
"products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.
CG 24 04 05 09
© Insurance Services Office, Inc., 2008
Attachment Code: D581101 Certificate ID: 22618749
POLICY NUMBER: BAP 3021090 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Endorsement Effective Date: 11/1/2025
SCHEDULE
Name(s) Of Person(s) Or Organization(s): If you are required by a written contract or agreement, which is executed before a loss, to waive your rights of recovery from others, we agree to waive our rights of recovery.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived
prior to the "accident" or the "loss" under a contract
with that person or organization.
Attachment Code: D582603 Certificate ID: 22618749
Notification to Others of Cancellation, Nonrenewal
or Reduction of Insurance
1 Policy No,
GL03021088
Eff. Date of Pol.
11/1/2025
Exp. Date of Pol.
11/1/2026
Eff. Date of End.
11/1/2025
Producer No.
37385000
Add'I. Prem
N/A
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
Liquor Liability Coverage Part
Products/Completed Operations Liability Coverage Part
Return Prem.
N/A
A. If we cancel or non -renew this Coverage Part(s) by written notice to the first Named Insured for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation or non -renewal:
1. To the name and address corresponding to each person or organization shown in the Schedule below; and
2. At least 10 days prior to the effective date of the cancellation or non -renewal, as advised in our notice to the first Named Insured, or the longer number of days notice if indicated in the Schedule below.
B. If we cancel this Coverage Part(s) by written notice to the first Named Insured for nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation.
C. If coverage afforded by this Coverage Part(s) is reduced or restricted, except for any reduction of Limits of Insurance due to payment of claims, we will mail or deliver notice of such reduction or restriction:
1. To the name and address corresponding to each person or organization shown in the Schedule below; and
2. At least 10 days prior to the effective date of the reduction or restriction, or the longer number of days notice if indicated in the Schedule below.
D. If notice as described in Paragraphs A., B. or C. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice.
SCHEDULE
Name and Address of Other Person(s)
/ Opaanization(s):
Number of Days Notice:
As required by written contract, agreement or permit 90 days' notice All other terms and conditions of this policy remain unchanged.
U -GL -1447-A CW (05/10)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D589042 Certificate ID: 22618749
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY U -WC -3078-A CW (08/17)
CANCELLATION AND NONRENEWAL NOTICE ENDORSEMENT
A. Part Six — Conditions, Paragraph D.2. is replaced by the following:
D. Cancellation
2. We may cancel this policy. We must mail or deliver to you not less than 90 days advance written notice stating when the cancellation is to take effect except for cancellation for non-payment of premium. If we cancel this policy for non-payment of premium we must mail or deliver to you not less than 10 days advance written notice. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice.
B. Part Six — Conditions, Paragraph F. is added.
F. Nonrenewal Notice
We will mail or deliver to you not less than 90 days advance written notice of our intention to nonrenew this policy. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice.
All other terms, conditions, provisions and exclusions of this policy remain the same.
U -WC -3078-A CW (08/17)
Attachment Code: D604303 Certificate ID: 22618749
Notification to Others of Cancellation, Nonrenewal
or Reduction of Insurance
Policy No.
BAP 3021090
Eff. Date of Pol.
11/1/2025
Exp. Date of Pol.
11/1/2026
Eff. Date of End.
11/1/2025
Producer No.
37385000
Add'I. Prem
$ INCL
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Commercial Automobile Coverage Part
ZURICH
Return Prem.
A. If we cancel or non -renew this Coverage Part by written notice to the first Named Insured for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation or non -renewal:
1. To the name and address corresponding to each person or organization shown in the Schedule below; and
2. At least 10 days prior to the effective date of the cancellation or non -renewal, as advised in our notice to the first Named Insured, or the longer number of days notice if indicated in the Schedule below.
B. If we cancel this Coverage Part by written notice to the first Named Insured for nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation.
C. If coverage afforded by this Coverage Part is reduced or restricted, except for any reduction of Limits of Insurance due to payment of claims, we will mail or deliver notice of such reduction or restriction:
1. To the name and address corresponding to each person or organization shown in the Schedule below; and
2. At least 10 days prior to the effective date of the reduction or restriction, or the longer number of days notice if indicated in the Schedule below.
D. If notice as described in Paragraphs A., B. or C. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice.
SCHEDULE
Name and Address of Other Person(s) / Organization(s):
AS REQUIRED BY WRITTEN CONTRACT OR AGREEMENT
All other terms and conditions of this policy remain unchanged.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Number of Days
Notice:
90 U -CA -811-A CW (05/10)