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Home My WebLink AboutCWE (5) A-2023-075-03A MAYOR 4/.�r U_ _ _ a CITY MANAGER Valerie Amezcua ,Jl ,,,✓ Alvaro Nunez MAYOR PRO TEM at r''s; ,, CITY ATTORNEY David Penaloza MAY l 1 2026 - - Sonia R.Carvalho COUNCILMEMBERS _ CITY CLERK Phil Bacerra ors Jennifer L. Hall Johnathan Ryan Hernandez Jessie Lopez Thai Viet Phan Benjamin Vazquez CITY OF SANTA ANA O:PWr}(+) Micttatl0(ttJ-(lJz) PUBLIC WORKS AGENCY 20 Civic Center Plaza j PO Box 1988 Santa Ana,California 92702 www_santa-an a.org April 17, 2026 CWE Attn: Vik Bapna,Principal 1561 E. Orangethorpe Ave., Suite 240 Fullerton, CA 92831 Re: Extension ofA reement No.A-2023-075-03 to Provide on-call en2ineering services Pursuant to Section 3 ("Term")of the above-referenced Agreement, entered into by CWE and the City of Santa Ana,which commenced on May 2,2023,the parties hereby exercise their option to extend the term of the Agreement for an additional one (1) year through May 1, 2027. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, o o Rosas,P.E. Acting Executive Director, Public Works Agency CITY O SANTA A ATTEST 4, Alvaro Nunez 1 er L. Hal City Manager City Clerk APPROVED AS TO FORM CONSLILTANT L.3�`�•V,.�- ./ GCS- �"� ]�*e Nellesen By:Vik Bapna Assistant City Attorney Title: Principal SANTA ANA CITY COUNCIL Vale..Amezcua David�ena4oza Tha'.vier Fhan Benda mir�'Ja Zgvez Je�ie Lopez Phil 13acena Jnnnathan rxyan Hernandea Mayor Mayor Pro Tem-'+Vanr 6 ',NarC Ward 2 Ward 3 Ward q ward 5 vamezcuafisanta-ana,urp phan<dsan,3-an-c.oL: triazpuezg&santa-ana ora ang erg pbazerr�asanta-and Qrg anhemande atsant"na a CWE0000-01 KSITYAMALA AcoRa CERTIFICATE OF LIABILITY INSURANCE D 19/20Y5 12l19I2025 THIS CERTIFICATE 1S 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). PRODUCER License#0757776 cAME:Nracr Donna Jones NA HUB International Insurance Services Inc. PHONE FAx 600 Corporate Pointe (AIC.No,Ext): (Arc,No): Suite 600 E-MAIL d ones hubinternational.com ADDRESS: onna.1 Culver City,CA 90230 INSURER S APFORDING COVERAGE NAIC H INSURER A:Crum&Forster Specialty Insurance Company 44520 INSURED INSURER B:National Fire&Marine 20079 1561 E.Orangethorpe Avenue CWE INSURER C:Pacific Compensation Insurance Corn a�555 Suite240 INSURERD: _ Fullerton,CA 92831 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. IL SR TYPE OF INSURANCE ADDDL SWVQUIB POLICY NUMBER POLICY EFF POLICY EXP LIM]TS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE )( OCCUR X X 1218/2025 121812026 EPK-164748 DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ MED EXP An one erson $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 4,000,000 _ POLICY PRO LOC PRODUCTS-COMP/OPAGG $ 4,000,000 OTHER: POLLUTION LIABI $ 2,000,00a B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,005,600 Ea accident $ IxANY AUTO X 72APB011724 616/2025 6/6/2026 BODILY INJURY Perperson) $OWNED _ AUTOS ONLY X AUTOS OS BODILY INJURY tPer accident $ HIRED X NON-OWNED PP AUTOS AUTOS ONLY AUTOS ONLY Per accident $ _ A C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 X EXCESS LIAR CLAIMS-MADE EFX-141385 12l8l2025 12I8l2026 AGGREGATE $ 1,000,000 DED RETENTION$ C AND EMPLCOMPENSATION YERS L A IOITNY X STAT E ORH ANY PRO PRI ETOR/PARTNERIEXECUTIVE YIN X 1025483 1211l2025 12l112026 1,000,000 OFFICERIMEMBER EXCLUDED? NIA E.L EACk ACCIDENT $ tMandatory in NH► 1,000,U00 H yes.describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISFASE-POLICY LIMIT $ 1,000,000 A Professional Liabill X EPK-164748 12/8/2025 121812026 Each Wrongful Act 2,000,000 A Professional Liabili X EPK-164748 121812025 121812026 Aggregate 4,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached it more space is required) Re:Project Name:RFP 20-102. The City of Santa Ana,20 Civic Center Plaza,Santa Ana,California 92701;officers,agents,employees,representatives and volunteers are Additional Insured with regard to General Liability when required by written contract per the attached endorsement forms#EN0111 02111 and#EN0147 11111.Primary&Non- Contributory wording applies with regard to General Liability when required by written contract per the attached endorsement form#EN0147 11111,Waiver of Subrogation with regard to General Liability applies when required by written contract per the attached endorsement form#EN0147 11111.Per Project Aggregate applies with regard to the General Liability policy,when required by written contract,per endorsement to follow. SEE ATTACHED ACORD 101 APPROVED CERTIFICATE HOLDER By Tu Tran Nguyen at7:11 am,Dec 23,2025' CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana Tu Tran Dig€ai1ysigred6y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN T,Tran Nguyen ACCORDANCE WITH THE POLICY PROVISIONS. Attn:PWA PFFR DMA 20 s.1223 20 Civic Center Ng uyen mezoi.aaoo• Santa Ana,CA 92701 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) (D 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:CWE0000-01 KSITYAMALA Lac M 1 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License#0757776 NAMED INSURED HUB International Insurance Services Inc. CWE 1561 E.Orangethorpe Avenue POLICY NUMBER Suite 240 SEE PAGE Fullerton,CA 92831 1 CARRIER NAIC CDDE EE PAGE 1 ISEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM 1S A SCHEDULE TO ACORD FORM, FORM NUMBER: &CORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: Waiver of Subrogation with regard to Auto Liability applies when required by written contract per the attached endorsement form #MCA85100817CA. Waiver of Subrogation with regard to Workers Compensation applies when required by written contract per the attached endorsement form WC990315A Ed. 05-2023. Waiver of Subrogation with regard to Professional Liability applies when required by written contract per endorsement to follow. ACORD 101 (2008/01) p 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CRUM&FORSTER° THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)or Organization(s) Blanket when specifically required in a written contract with the named insured. SECTION III — WHO IS AN INSURED within the Common Provisions is amended to include as an additional insured the person(s) or organization(s) indicated in the Schedule shown above, but only with respect to liability caused, in whole or in part, by "your work"for that insured which is performed by you or by those acting on your behalf. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. EN0111-0211 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED WITH WAIVER OF SUBROGATION This endorsement modifies insurance provided and r the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART ERRORS AND OMISSIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)or Organization(s) Blanket when specifically required in a written contract with the named insured. A. SECTION III — WHO IS AN INSURED within the C mmon Provisions is amended to include s n additional insured the person(s) or organization(s) indicat d in the Sch dule shown abov , but only with respect to liability arising out of "your work" for that person r organization performed by you, or by those acting on your behalf. B. As respects additional insureds as defined above, this insurance also applies to "bodily injury" or "property damage" arising out of your negligence when the following written contract requirements are applicable: 1. Coverage avail ble under this cov rage part shall pply s prim ry insurance. Any th r insurance available to thes additional insureds shall apply as xcess and not contribute as primary to the insurance afforded by this endorsement. 2. We waive any right of recov ry w may have against the person(s) or organization(s) indicated in the Schedule shown bove because of p ym nts we m k for injury r damage arising out of"your work" performed under a written contract with th t p rson(s)or organization(s). 3. The term "additional insured" is used separately and not collectively, but the inclusion of more than one "additional insured" shall not increase the limits r coverage pr vid d by this insurance. This Endorsement does not reinstate or increase the Limits of Insurance applicable to any "claim" to which the coverage fforded by this Endorsement appli s. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. EN0147-1111 ge 1 of 1 Insured: CWE Policy #: BA040000089637 Policy Term: 6/6/2025 - 6/6/2026 THIS ENDORSEMENT CHANGESTHE POLICY. PLEASE READ IT CAREFULLY. Business Auto Broadening Endorsement This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM I. NEWLY ACQUIRED OR FORMED ENTITY (BROAD FORM NAMED INSURED) It. EMPLOYEES AS INSUREDS III. AUTOMATIC ADDITIONAL INSURED IV. EMPLOYEE HIRED AUTO LIABILITY V. SUPPLEMENTARY PAYMENTS VI. FELLOW EMPLOYEE COVERAGE VII. ADDITIONALTRANSPORTATION EXPENSE VIII. HIRED AUTO PHYSICAL DAMAGE COVERAGE IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE X. LOAN/LEASE GAP COVERAGE Xi. GLASS REPAIR—DEDUCTIBLE WAIVER XII. TWO OR MORE DEDUCTIBLES XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUITOR LOSS XIV. WAIVER OF SUBROGATION XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT XVIII. HIRED AUTO—COVERAGE TERRITORY XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH Copyright 2017 Mercury Insurance Services,LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office,Inc.,with its Permissior Page 1 of 6 BUSINESS AUTO COVERAGE FORM 1. NEWLY ACQUIRED OR FORMED ENTITY(Broad Form Named Insured) SECTION II-LIABILITYCOVERAGE,A.Coverage, 1.Who Is An Insured, the following is added: d. Any business entity newly acquired or formed by you during the policy period provided you own 50%or more of the business entityand the business entity is not separately insured for Business Auto Coverage.Coverage is extended up to a maximum of 180 days following acquisition or formation of the business entity. Coverage under this provision is afforded only until the end of the policy period. Coverage does not apply to an"accident"which occurred before you acquired or formed the organization. li. EMPLOYEES AS INSUREDS SECTION 11- LIABILITY COVERAGE,A.Coverage,1.Who Is An Insured, the following is added: e. Any "employee"of yours is an "insured" while using a covered"auto"you don't own, hire or borrow in your business or your personal affairs. III. AUTOMATIC ADDITIONAL INSURED SECTION 11-LIABI LITY COVERAGE,A.Coverage,1.Who Is An I nsured, the following is added: f. Any person or organization that you are required to include as additiona I insured on the Coverage Form in a written contract or agreement that is signed a nd executed by you before the "bodily injury" or"property damage"occurs and that is in effect during the policy period is an"insured"for Liability Coverage,but only for damages to which this insurance applies a nd only to the extent that person or organization qualifies as an"insured"under the Who Is An Insured provision contained in Section 11. IV. EMPLOYEE HIREDAUTO LIABILITY SECTION 11-LIABILITY COVERAGE,A.Coverage, 1.Who Is An Insured, thefollowing is added: g. An"employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. V. SUPPLEMENTARY PAYMENTS SECTION II—LIABILITYCOVERAGE,A.Coverage,2.Coverage Extensions, a. Supplementary Payments,Subparagraphs(2) and (4) are replaced by the following: (2) U p to$3,000 for cost of bail bonds (including bonds for related traffic law violations) required because of an"accident"we cover. We are not obligated to furnish these bonds. (4) All reasonable expenses incurred by the "insured" at our request,including actual loss of earnings up to$500 a day because of time off from work. Copyright 2017 Mercury Insurance Services,LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of insurance Services Office,Inc.,with its Permissior Page 2 of 6 VI. FELLOW EMPLOYEE COVERAGE: SECTION il—LIABILITYCOVERAGE,B. Exclusions,5. Fellow Employee This exclusion does not apply if you have workers'compensation insurance in-force covering all of your "employees". Coverage is excess over any other collectible insurance. VI 1. ADDITIONALTRANSPORTATION EXPENSE SECTION III-PHYSICAL DAMAGE COVERAGE,A.Coverage,4.Coverage Extensions, a.Transportation Expenses, is replaced with the following: We will pay up to$50 per day to a maximum of$1000 for temporarytransportation expense incurred by you because of the total theft of a covered "auto"of the private passenger type.We will pay only for those covered "autos"for which you carryeither Comprehensive or Specified Causes of Loss Coverage.We will pay for temporary transportation expenses incurred during the period beginning 48 hours afterthetheft and ending, regardless of the policy's expiration,when the covered"auto" is returnedto use or we pay for its"loss". If your business shown in the Declarations is other than an auto dealership, we will also pay up to$1,000for reasonable and necessary costs incurred by you to return a stolen covered auto from the place where it is recovered to its usual garaging location. Vill. HIRED AUTO PHYSICAL DAMAGE COVERAGE SECTION III—PHYSICAL DAMAGE COVERAGE,A.Coverage,4.Coverage Extensions, the following is added: c. If Liability Coverage is provided in this policy on a Symbol 1 or a Symbol 8 basis and Comprehensive, Specified Causes of Loss, or Collision coveragesare provided under this coverage form for any"auto"you own, then the Physical Damage Coverages provided are extended to"autos"you hire, subject to the following limit: (1) The most we will pay for"loss" to any hired "auto" is$50,000or Actual Cash Value or Cost of Repair,whichever is less (2) $500 deductible will apply to any loss under this coverage extension, exceptthat no deductible shall apply to"loss" caused by fire or lightning Subject to the above limit and deductible we will provide coverage equal tothe broadest coverage applicable toany covered "auto"you own of similar size and type. This coverage extension is excess coverage over any other collectible insurance. IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE SECTION III-PHYSICAL DAMAGE COVERAGE, B. Exclusions, 3.a.,is amended to add the following: This exclusion does not apply to the accidental discharge of an airbag. Copyright 2017 Mercury Insurance Services,l LC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office,Inc.,with its Permissior Page 3 of 6 X. LOAN/LEASE GAP COVERAGE SECTION III-PHYSICAL DAMAGE COVERAGE C. Limit of Insurance,the following is added: 4. In the event of a"total loss" to a covered "auto"shown in the schedule or declarationsfor which Collision and Comprehensive Coverage apply,we will payany unpaid amount due on the lease or loan for that covered "auto,"less: a. The amount paid underthe Physical Damage Coverage Section of the policy; and b. Any: (1) Overdue lease/loan payments at the time of the"loss"; (2) Financial penalties imposed under a lease for excessive use, abnormal wear and tearor high mileage. (3) Security deposits not returned by the lessor; (4) Costs for extended warranties,Credit Life Insurance, Health,Accident or Disability Insurance purchased with the loan or lease; and (5) Carry-over balances from previous loans or leases. The most we will pay under Auto Loan/Lease Gap Coverage for an insured auto is 25%of the actual cash value of that insured auto at the time of the loss. XI. GLASS REPAIR—DEDUCTIBLE WAIVER SECTION III-PHYSICAL DAMAGE COVERAGE, D. Deductible,the following is added: No deductible applies to glass damage ifthe glass is repaired ratherthan replaced. XII. TWO OR MORE DEDUCTIBLES SECTION 1I1-PHYSICAL DAMAGE COVERAGE, D. Deductible,the following is added: If two or more "company"policies or coverage forms apply to the same accident: 1. If the applicable Business Auto deductible is the smallest, it will be waived;or 2. If the applicable Business Auto deductible is not the smallest, it will be reduced by the amount of the smallest deductible; or 3. If the loss involves two or more Business Auto coverage forms or policies the smallest deductible will be waived. For the purpose of this endorsement "company"means the company providing this insurance and any of the affiliated members of the Mercury Insurance Group of companies. XI I I. AMENDED DUTIES IN EVENT OF ACCIDENT,CLAIM, SUITOR LOSS The requirement in SECTION IV, BUSINESSAUTO CONDITIONS,A. Loss Conditions, 2. Dutiesln The Event Of Accident,Claim, Suit,Or Loss, a., In the event of "accident",you must notify us of an "accident"applies only when the"accident" is known to: (1) You,if you are an individual; (2) A partner,if you area partnership; (3) A member,if you area limited liability company; or (4) An executive officer or insurance manager,ifyou area corporation. Copyright 2017 Mercury Insurance Services,LLC. All rights reserved. MCA851GO817-CA Includes copyrighted material of Insurance Services office,Inc.,with its Permissior page 4 of 6 XIV. WAIVER OF SUBROGATION SECTION IV-BUSINESS AUTO CONDITIONS,A. Loss Conditions, 5. Transfer of Rights Of Recovery Against Others To Us, section is replaced by the following: 5. Transfer Of Rights Of Recovery Against Others To Us We waive any right of recoverywe may have against any person or organization to the extent required of you by a written contract executed prior to a ny"accident"or "loss", provided that the"accident"or"loss" arises out of the operations contemplated by such contract.The waiver a pplies only to the person or organization designated in such contract. XV. UNINTENTIONAL ERROR,OMISSION,OR FAILURE TO DISCLOSE HAZARDS SECTION IV-BUSINESSAUTO CONDITIONS, B.General Conditions, 2. Concealment, Misrepresentation,or Fraud, the following is added: Any unintentional omission of or error in information given by you, or unintentional failure to disclose all exposures or hazards existing as of the effective date or at any time during the policy period shall not invalidate or adversely affect the coverage for such exposure or haza rd or prejudice your rights under this insurance. However,you must report the undisclosed exposure or hazard to us as soon as reasonably possible after its discovery. This provision does not affect our right to collect additional premium or exercise our right of cancellation or non-renewal. XVI. EMPLOYEE HIREDAUTO PHYSICALDAMAGE SECTION IV—BUSINESSAUTO CONDITIONS, B.General Conditions, 5.Other Insurance, b. For Hired Auto Physical Damage Coverage, is replaced by the following: b. For Hired Auto Physical Damage Coverage,the following a re deemed to be covered ."autos"you own: 1. Any covered"auto"you lease, hire, rent or borrow; and 2. Any covered "auto" hired or rented by your"employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However,any"auto"that is leased, hired, rented or borrowed with a driver is not a covered "auto", XVII.PRIMARY AND NONCONTRIBUTORYIF REQUIRED BYCONTRACT SECTION IV—BUSINESS AUTO CONDITIONS, B.General Conditions, 5.Other Insurance,the following is added and supersedes any provision tot he contrary: e. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contractor agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Copyright 2017 Mercury Insurance Services,LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office,Inc.,with its Permissior Page 5 of 6 XVIII. HIRED AUTO-COVERAGE TERRITORY SECTION IV-BUSINESSAUTO CONDITIONS, B.General Conditions, 7. Policy Period, Coverage Territory,e.Anywhere in the world if:, is replaced by the following: e. Anywhere in the world if: (1) A covered"auto"is leased, hired, rented or borrowed without a driver for a period of 30 days or less; and (2) The "insured's" responsibility to pay damages is determined in a "suit"on the merits,in the United Statesof America,the territoriesand possessions of the United Statesof America, Puerto Rico,or Canada or in a settlement we agree to. XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH SECTION V--DEFINITIONS,C. "Bodily Injury" is amended by adding the following: "Bodily injury" also includes mentalanguish but only when the mental anguish arises from other bodily injury, sickness, or disease. Copyright 2017 Mercury Insurance Services,LLC. All rights reserved. MCA85100817-CA Includes copyrighted materia I oflnsurance Services Office,Inc.,with its Permissior Page 6 of 6 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Gopp,W.?0int, Insurance Companies COPPERPOINT • ALASKA NATIONAL CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- BLANKET 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). Schedule Anyone for whom you have agreed to provide this Waiver subject to the terms of the endorsement This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy. The information below is required only when this endorsement is issued subsequent to commencement of the policy, Endorsement Effective 12/01/2025 Policy No. WC1025483 Endorsement No. Insured CWE Premium$ 00.00 Policy Term: 12/01/2025- 12/01/2026 Insurance Company Pacific Compensation Insurance Company Countersigned by ��. Authorized Representative WC 99 03 15 A (Ed. 05-2023) Contains Copyrighted material of VVCIRB,used with permission