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DATE: Januan 28. 2004 <br />POLICY NUMBER: EOL5281394-00 <br />INSURED NAME: 0375057 Choc V. Le <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY <br />CG 20 10 1185 <br />ADDITIONAL INSURED --OWNERS, LESSEES OR CON TRACTORS (FORM B) <br />This endorsement modifies insurance provided under the fcllowine <br />COM]NIERCLIL GENERAL LIABILITY COVERAGE PART <br />SCHEDULE <br />Name of Perscn or Organization: City of Santa Ana <br />IobrProiect. <br />(If no entryappears above, infermaticn req tired to complete this endorsement wil] De shown ia'lc D:clarationa as <br />applicable to this endorsement.) <br />WHO IS AN LNSTU .ED (Section II) is amended to :ncludc as an insured the person or org„nizati n shy wr in the <br />Schedule, but only with respect to liability arising out of "your work" fef that insured by or fcr y„a <br />Primary Irsuance it is agreed that such insurance ac is afforded by this policy :or the benefit of the ad,!, .anal <br />insured shown shall be pritll insu: ante, and any other jnsuranoe maintained by :he eddition:d in.rad_ steal: be <br />excess and r-on-contributon., 'out only as respects any claim, loss or liability arising out of the eperho: ; f the <br />named ivured(s), or its subcontractors, anc'. only if such claim, loss or liability is c:et^,mine(: to be solo, tl : <br />negligence or responsibility of the named insured. <br />Notice of Cancellation cr Non -renewal it is @€reed that the company will ; rm ide the adds onal insure<: rhown <br />bellow with 30 days notice of canoellction of this policy in the anent o' ccncel:atien sae to eci ollnc e e. )n only <br />Hold Harmless Clause it is agreed that such insurance as is afforded by this policy .,.r the bene:,t cf he.. iditional <br />insured shown below shall indemnif;: and hold u,irm:ess the additional in;.tred, but Drily as -esl:, l .11,;(aint, -loss <br />or liability arairig out of the operations of named insureds) or its sub -contra( tix> <br />Severabili:y of Interes: as is a:Torded by this ool:cy for the benefit of the additiore'. insure, she ,'n ,elow, s'111.1 appl, <br />separately to ea:h additional insured a_ainst whom It claim is made or suit is brow_ i' ex; %Dt with i +sp its :o the <br />limits of insurance under this policy. <br />WAIVER OF SUBROGATION <br />It is agreed that we waive any right of recovery we may Itate a_ains; the, er,, n <br />o. organization shower in the schedule because of pavmr nt s, e nw.ke fcr .!nju 0- <br />damage arising out of "your work" done under a con:rtct with tllu: person <br />oraantzetio:t. The waiver app'.ies only to the person or eVga:iizaoon shoe r the schedule. <br />City of Santa .Ana <br />20 Civic Center Plaza <br />Santa Ana. CA 92702 <br />ccU <br />Assix:uit <br />