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HomeMy WebLinkAboutMICHAEL BAKER INTERNATIONAL (FORMERLY PACIFIC MUNICIPAL CONSULTANTS AND RBF CONSULTING )ow City of Santa Ana -Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreemzint mQC1112949 amendments (if any) are no longer in effect. Note: If your agreement is grant related', please ensure that all grant retention requirem;hT Y OF SA! N T# ANA have been satisfied prior to signing the termination form. CLER11k (tFirni wro Is the agreement(s) a permanent record? Yes No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with /'R No. / � CS was completed on (List all amendments. Use space below if needed.) fl —17 a -- 0/ �76 -OS- S and final payment has been made. Department: /v y—� ����7 Aj Phone/Ext.: Signature: U' Date: '1* Revised: I U- 18- 16 MAYOR Miguel A. Pulido MAYOR PRO TEM Michele Martinez COUNCILMEMBERS P. David Benavides Vicente Sarmiento Jose Solorio Sal Tinajero Juan Villages Michael Bruz, PE CITY OF SANTA ANA 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 www.santa-ane.org July 5, 2017 Michael Baker International, Inc. 14725 Alton Parkway Irvine, CA 92618 Reference: First Extension of Consultant Agreement No. A-2015-170 Dear Mr. Bruz: A-2015-170 —DI ACTING CITY MANAGER Cynthia J. Kurtz CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Maria D. Huizar Pursuant to Section 1 of Agreement No. A-2015-170, entered into by Michael Baker International, Inc. and the City of Santa Ana, dated August 5, 2015, the term of the Agreement is hereby extended for an additional one (1) year period from August 6, 2017 to August 6, 2018 to cover existing services that are on-going on the date of this extension. The 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. Sinc -® Fred Mousavipour t Executive Director Public Works Agency CITY OF SANTA ANA �- Cynthia J. I{ur Acting City Man er-- APPROVED AS TO FORM 14 Of✓,. J . Funk sistant City Attorney ATTEST Maria D. Huizar Clerk of the Council SANTA ANA CITY COUNCIL iNSIIRAPkCE ON FILE wORK MAY PROCEED UNTIL INSURANCE FXPIRES CLERK OF COUNCIL. DATE 1'(d1II Yt71I Miguel A. Pulido i Michele Martinez I Vicente Sarmiento Joan Solana i P. David oenavides i Juan villages Sal Tinajero Mayor i Mayor Pro Tem, Ward 2 i Ward i Ward 3 i Ward 4 i Ward 5 Ward 6 MPuldloAsanta-ana oro I MMartinezoggrita-anaorri i Vsarmienloralsanta-ana.org JSolonornlsanta-anaom i DBenalaantaana.oro i JVIlegas0eanta-anaom ST'naiero(a)santa-anaoro i ® ,4o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD,YYYY) 08/17/2018 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). PRODUCER Aon Risk services Central, Inc. Pittsburgh PA office CONTACT NAME: INC. No. Ext): (866) 283-7122 FAX No.): (800) 363-0105 E-MAIL ADDRESS: EQT Plaza - Suite 2700 625 Liberty Avenue INSURER(5) AFFORDING COVERAGE NAIC # Pittsburgh PA 15222-3110 USA INSURED INSURERA: XL Insurance America Inc 24554 Michael Baker International, Inc 5 Hutton Centre Drive suite 500 INSURER B: Liberty Mutual Fire Ins Co 23035 INSURER C: Liberty Insurance Corporation 42404 Santa Ana CA 92707 USA INSURER D: Lloyd's Syndicate No. 2623 AA1128623 INSURER E: EACH OCCURRENCE $2,000,000 INSURER F: COVERAGES CERTIFICATE NUMBER: 570072717609 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. Limits shown are as requested I LTR TYPE OF INSURANCE INSD SUBK WVO POLICY NUMBER MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY TB EACH OCCURRENCE $2,000,000 CLAIMS -MADE X❑ OCCUR General Liability $300,000 PREMISES Ea occurrence MED EXP (Any one person) $10 , 000 p PERSONAL &ADV INJURY $2,000,000 to 1- GENT AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $4,000,000 JECT ❑LOC POLICY xPRO--X , ,r OTHER: O r BA52-681-004145-727 AUTOMOBILE LU181Ln-Y 08/30/2017 08/30/2018 COMBINED SINGLE LIMIT a accident) $2,000,000 U) Commercial Auto - A05 BODILY INJURY ( Per person) X ANY AUTO Z BODILY INJURY (Per accident) OWNED SCHEDULED w AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED t0 PROPERTY DAMAGE ONLY AUTOS ONLY Per accident)V w 1: d A X UMBRELLALIAB X OCCUR U500079952L117A 08/30/2017 08/30/2018 EACH OCCURRENCE $10,000,000 U Umbrella AGGREGATE $10,000,000 EXCESS LU1B CLAIMS -MADE DED X RETENTION $10,000 C WORKERS COMPENSATION AND WA768DO04145777 08 —36-r2 —517 08/30/2018 X I PER STATUTE OTH- ER EMPLOYERS'LIABILITY YIN workers Comp - AOS E.L. EACH ACCIDENT $1,000,000 ANY PROPRIETOR/ PARTNER I EXECUTIVE OFFICER/MEMBER EXCLUDED? N I A E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below -_ E.L. DISEASE -POLICY LIMIT $1,000,000 D E&O-PL-Primary PSDEF1700460 08/31/2011 08/31/2018 Per Claim $5,000,000 Professional Liab. and CP Aggregate $5,000,000 n DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) RE: civic center Stormwater Lift Station Renovation. MB Project No. 167946. Agreement No. A-2016-093 / A-2015-170 / A-2018-177. ". city of Santa Ana, ROSS Anex is included as Additional Insured in accordance with the policy provisions of the General Yi�J Liability policy. General Liability evidenced herein is Primary/Non-Contributory to other insurance available to an Additional Insured, but only in accordance with the rn policy's provisions. Should any of the above described policies be cancelled before the expiration date thereof, the policy provisions will govern how notice of cancellation may be delivered to certificate holders in accordance with the ol" rovisions of each olic . REVIEWED BY: EUNICE HEREDIA (PG i OF, ) CERTIFICATE HOLDER CANCELLATION a:-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE yl EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE _+ �' POLICY PROVISIONS. City of Santa Ana, Ross Anex AUTHORIZED REPRESENTATIVE &� 20 civic center Plaza P.O. BOX 1988 Santa Ana CA 92702-1988 USA n/% it p 9f`Gc ' WQ ' p)�iL ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICYNUMBER: T132-681-004145-717 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILfTY COVERAGE PART 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, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury' caused, in whole or in part, by. 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply. This insurance does not apply to "bodily injury" or "property damage" occurring after: Name Of Additional Insured Person(s) Or Organization(s): 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 apart of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we Will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; SCHEDULE All persons or organizations With whom you have entered into a written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status. whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Location(s) Of Covered Operations All locations as required by a written contract or agreement entered into prior to an "occurrence" or offense. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 10 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 REVIEWED BY: EUNICE HEREDIA (PG) OF Id POLICYNUMBER: TB2-681-004145-717 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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, but only with respect to liability for "bodily injury' or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Name Of Additional Insured Person(s) Or Organization(s): B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. SCHEDULE All persons or organizations with whom you have entered into a written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status. Location And Description Of Completed Operations All locations as required by a written contractor agreement entered into prior to an "occurrence" or offense. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of REVIEWED BY:EUNICE HEREDIA (PGOF ) Policy Number TB2-681-004145-717 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY —UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Organizations : Email Address or mailing address: Number Days Notice: Per schedule on file with the Company 30 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. REVIEWED BY: EUNICE HEREDIA (P4 0 ) Policy Number AS2-681-004145-727 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Organizations : Email Address or mailing address: Number Days Notice: Per schedule on file with the company Per schedule on file with the company 30 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. REVIEWED BY: EUNICE HEREDIA (PG OF% ) NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below by email as soon as practical after notifying the first Named Insured. B. This advance email notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. SCHEDULE Name of Other Person(s) / Organization(s): Email Address: Per schedule on file with the producer Per schedule on file with the producer All other terms and conditions of this policy remain unchanged. Issued by: Liberty Insurance Corporation For attachment to Policy No. WA7-68D-004145-777 Effective Date 8/30/2017 Premium $ Issued to: Michael Baker International, LLC WM 90 17 09 10 © 2010 Liberty Mutual Group of Companies Page 1 of 1 Ed. 09/01/2010 All Rights Reserved REVIEWED BY: EUNICE HEREDIA (PG�j/ OF7 ) COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance 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 contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Policy Number TB2-681-004145-717 Issued by Liberty Mutual Fire Insurance Company CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 REVIEWED BY: EUNICE HEREDIA (PG -1 OF -7 ) A RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/09/05/22017017 ) 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). PRODUCER Aon Risk Services Central, Inc. Pittsburgh PA office CONTACT NAME: PHONE (866) 283-7122 FAX (800) 363-0105 (A/C No. Ext): (ac. No.): Dominion Tower, 10th Floor 625 Liberty Avenue E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Pittsburgh PA 15222-3110 USA INSURED INSURERA: XL insurance America Inc 24554 Michael Baker International, Inc 5 Hutton centre Drive Suite 500 INSURER B: Liberty Mutual Fire Ins CO 23035 INSURER C: Liberty Insurance Corporation 42404 Santa Ana CA 92707 USA INSURER D: Lloyd's Syndicate No. 2623 AA1128623 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570068250186 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MM/DDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY TB EACH OCCURRENCE $2,000,000' General Liability A. N $300,000 PREMISES Ea occurrence CLAIMS -MADE X❑ OCCUR MED EXP (Any one person) $10,000 PERSONAL &ADV INJURY $2,000,000 GEML AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $4,000,000 POLICYPRO LOC EJECT PRODUCTS - COMP/OPAGG $4,000,000 OTHER: B AUTOMOBILE LIABILITY AS2-681-004145-727 08/30/201708/30/2018 COMBINED SINGLE LIMIT $2,000,000 Ea accident Commercial Auto - ADS BODILY INJURY ( Per person) X ANYAUTO OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS ONLY AUTOS PROPERTY DAMAGE HIREDAUTOS NON -OWNED ONLY AUTOS ONLY Per accident A X UMBRELLALIAB X OCCUR US00079952LI17A 08/30/2017 08/30/2018 EACH OCCURRENCE $10,000,000 umbrella AGGREGATE $ZO, OOO,000 EXCESS LIAR CLAIMS -MADE DED X RETENTION SID, 000 C ORKS SCOM�PBENSATIONAND WORKERS wA768DO04145777 08/30/2017 08/30/2018 X STATUTE OTH- ER v/N workers Comp - ADS E.L. EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N OFFICER/MEMBER EXCLUDED? N / A E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NHi If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 D E&O-PL-Primary PSDEF170046008/31/2017 08/31/2018 Per Claim $5,000,000 Professional Liab. and CP Aggregate $5,000,000 SIR applies per policy ter s & condi ions DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) For Named Insured Only: Kim Hartsfield. RE: Project Name: Agreement Numbers A-2016-093 & A-2015-170. City of Santa Ana, its officers, employees, agents and representatives are included as Additional Insured in accordance with the policy provisions cf thz Gene; i^bil ity ^1 icy. General Liability --i-ed is Primary and Non -Contributory to Dther ilisUi'diiCe available to an�AdditionalIVlnsured'but only in accordance with the policy's provisions. Should General Liability, Automobile Liability and Workers' Compensation policies be cancelled before the expiration date there f, the policy provisions will govern how notice of cancellation may be delivered to certificate Holders in accordance with t olicy provisions of each policy, REVIEWED BY: EUNICE HEREDIA (PGJ OF ) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana AUTHORIZED REPRESENTATIVE Attn: Ross Annex '.. 20 Civic Center Plaza, Po Box 1988 Santa Ana CA 92702-1988 USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD m 6 to cc 0 LnO h- 0 Z d W V 4� t W U POLICYNUMBER: T132-681-004145-717 COMMERCIAL GENERAL LIABILITY C{S201O0413 ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section U — Who Is An Insured is amended to include as an additional insured the n(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury', 11property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts nromissions; or 2. The ads or omissions of those acting on your behalf, in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not bebroader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds' the following additional exclusions apply: This insurance does not apply to "bodily injury" or ''pmpedydamage" Occurring after: Name OfAdditional Insured Penson(s) Or Organ ization(s): All persons cxorganizations with whom you have entered into awritten contract oragreement, prior toan "occurrence"oroffense, krprovide additional insured 1. All work, including matereb, parts or equipment furnished in connection with such wmdk, 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 Z. 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 asapart of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III —Limits Of Insurance: If coverage provided to the additional insured is required byacontract oragreement, the most we will pay on behalf of the additional insured is the amount ofinsurance: 1. Required bythe contract u/agveement;or 2. Available under the applicable Limits of insurance shown inthe Declarations; whichever isless. This endorsement shall not increase the applicable Limits of insurance shown in the Declarations. Locadon(s)OfCovered Operations All locations asrequired byawritten contract or agreement entered into prior to an "occurrence" or Information required Vucomplete this Schedule, if not shown above, will beshown inthe Declarations, CG 20 10 04 13 (D Insurance Services Office, Inc., 2012 COMMERCIAL GENERAL LIABILITY CG2037O413 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Section U—VVho Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury' or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included inthe "prod mc1s-comp|etedoperations hazand" t The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Name OfAdditional Insured Person(s) Or Organization(s): B. With respect to the insurance afforded to these additional insuneds, the following is added to Section III —Limits Of Insurance: U coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured is the amount ofinsurance: 1. Required bythe contractor agreement; or 2. Available under the applicable Limits of Insurance shown inthe Declarations, whichever isless. This endorsement shall not increase the applicable Limits ofInsurance shown inthe Declarations. SCHEDULE All persons ororganizations with whom you have entered into awritten contract oragreement, prior toan ,occunence"oroffense, bzprovide additional insured status. Location And Description Of Completed Operations All locations required by a written contract or agreement entered into prior Loan"occunence^or Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 04 13 @ Insurance Services Office, Inc,2O1J - COMMERCIAL GENERAL LIABILITY CG2OO1O413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROD U CTS/COM PLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance 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 Named Insured under such other insurance; and (2) You have agreed in writing in o contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG2OO1O413 @ Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number AS2-681-004145-727 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Organizations : Email Address or mailing address: Number Days Notice: Per schedule on file with the company Per schedule on file with the company 30 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. FZElf9'EwEC iSY: EUNICE HEIREDIA (FIG C71 CERTIFICATE OF LIABILITY INSURANCE rATE(MMI08/24/20118 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). PRODUCER Aon Risk Services Central, Inc. Pittsburgh PA Office CONTACT NAME' PHONE (866) 283-7122 FAX (800) 363-0105 (AIC. No. Ext): (AIC. No.): EQT Plaza - Suite 2700 625 Liberty Avenue E-MAIL ADDRESS: Pittsburgh PA 15222-3110 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: Liberty Mutual Fire Ins CO 23035 Michael Baker International, Inc S Hutton Centre Drive suite 500 INSURER B: Liberty insurance Corporation 42404 syndicate No. 2623 AA1128623 INSURER C: Lloyd's S Y Y Santa Ana CA 92707 USA INSURER D: XL Insurance America Inc 24554 POLICY ❑X PRO- LOC JECT INSURER E: INSURER F: \ WV"r%P%WF—Q \ r_rxiiri,-AIC Illuivi CI[: O/UU/L/OOOOI KtVIJIUN NUIVItStK: 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. Limits shown are as requested LTPO R TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY TB EACH OCCURRENCE $2 , 000,000 CLAIMS -MADE X❑ OCCUR General Liability A $300,000 PREMISES Ea occurrence) $10,000 $2,000,000 $4,000,000 $4,000,000 O 0 r` $2,000,000 0 Z d UV i. d 10,007000 U 10,000,000 $1,000,000 $1,000,000 $1,000,000 — $5,000,000 — $5,000,000 DESCRIPTION OF OPERATIONS (LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Civic Center Stormwater Lift Station Renovation. MB Project No. 167946. Agreement NO. A-2016-093 / A-2015-170 / A-2018-177. City of Santa Ana, Ross Anex is included as Additional Insured in accordance with the policy provisions of the General Liability policy. General Liability evidenced herein is Primary/Non-Contributory to other insurance available to an Additional Insured, but only in accordance with the policy's Provisions. Should any of the above described policies be cancelled before the expiration date thereof, the policy provisions will govern how notice of cancellation may be delivered to certificate holders in accordance with the policy provisions of each policy. REVIEWED BY. EUNICE HEREDIA (PG P OF F ) CERTIFICATE HOLDER C I ull= Q Ijl v SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MED EXP (Any one person) City Of Santa Ana, ROSS Anex 20 Civic Center Plaza PERSONAL& ADV INJURY P.O. BOX 1988 Santa Ana CA 92702-1988 USA ��QQ �/% ec911 ttl m0 Q GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY ❑X PRO- LOC JECT PRODUCTS - COMPIOP AGG OTHER: A AUTOMOBILE LIABILITY AS2-681-004145-728 08/30/2018 08/30/2019 COMBINED SINGLE LIMIT Commercial Auto - AOS Ea accident BODILY INJURY ( Per person) X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident HIREDAUTOS NON -OWNED ONLY AUTOS ONLY D X UMBRELLA LAB X OCCUR US00079952L118A 08/30/2018 08/30/2019 EACH OCCURRENCE Umbrella — AGGREGATE EXCESS LIAB CLAIMS -MADE DED I X RETENTION $10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN WA768DO04145778 work workers Comp - AOS 08/30/2018 08730/2019 X PER OTF STATUTE E.L. EACH ACCIDENT ANY PROPRIETOR/ PARTNER/ EXECUTIVE OFFICER/MEMSER EXCLUDED? NIA E.L. DISEASE -EA EMPLOYEE (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT C E&O-PL-Primary PSDEF1800460 08/31/2018 08/30/2019 Per Claim Professional Liab, and CP I I Aggregate $10,000 $2,000,000 $4,000,000 $4,000,000 O 0 r` $2,000,000 0 Z d UV i. d 10,007000 U 10,000,000 $1,000,000 $1,000,000 $1,000,000 — $5,000,000 — $5,000,000 DESCRIPTION OF OPERATIONS (LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Civic Center Stormwater Lift Station Renovation. MB Project No. 167946. Agreement NO. A-2016-093 / A-2015-170 / A-2018-177. City of Santa Ana, Ross Anex is included as Additional Insured in accordance with the policy provisions of the General Liability policy. General Liability evidenced herein is Primary/Non-Contributory to other insurance available to an Additional Insured, but only in accordance with the policy's Provisions. Should any of the above described policies be cancelled before the expiration date thereof, the policy provisions will govern how notice of cancellation may be delivered to certificate holders in accordance with the policy provisions of each policy. REVIEWED BY. EUNICE HEREDIA (PG P OF F ) CERTIFICATE HOLDER C I ull= Q Ijl v ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of Santa Ana, ROSS Anex 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE P.O. BOX 1988 Santa Ana CA 92702-1988 USA ��QQ �/% ec911 ttl m0 Q ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: TB2-681-004145-718 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 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, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury' caused, in whole or in part, by. 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law, and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply. This insurance does not apply to "bodily injury' or "property damage" occurring after: Name Of Additional Insured Person(s) Or Organization(s): 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: SCHEDULE All persons or organizations with whom you have entered into a Written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status. If coverage provided to the additional insured is required by a contract or agreement, the most we Will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Location(s) Of Covered Operations All locations as required by a written contract or agreement entered into prior to an "occurrence" or offense. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 10 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 REVIEWED BY: EUNIGE HEREDIA (PG - &F , ) POLICYNUMBER: T132-681-004145-718 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only With respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Name Of Additional Insured Person(s) Or Organization(s): B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required bythe contractor agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. SCHEDULE All persons or organizations with whom you have entered into a Written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status. Location And Description Of Completed Operations All locations as required by a written contract or agreement entered into prior to an "occurrence" or offense. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of REVIEWED BY: EUNICE HEREDIA (PG OF Ld Policy Number TB2-681-004145-718 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT —SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person or organization shown in the Schedule of this endorsement that qualifies as an additional insured on this policy, this policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV - Conditions will not apply. If the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV - Conditions will govern. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured by attachment of an endorsement to another policy providing coverage for the same "occurrence", claim or "suit'. Schedule Person or Organization: All persons or organizations with whom you have entered into a written contract or agreement, prior to an "occurrence" or offense, to provide additional insured status. LC 24 20 0213 © 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. REVIEWED BY: EUNICE HEREDIA (PG LOF ) Policy Number TB2-681-004145-718 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Organization(s): Email Address or mailing address: Number Days Notice: Per schedule on file with the Company 30 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. REVIEWED BY: EUNICE HEREDIA (PG.,,) OF ) Policy Number: AS2-681-004145-728 Issued By: Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Other Person(s)/ Organization(s): Email Address or mailing address: Number Days Notice: Per schedule on file with the Company Per schedule on file with the Company 30 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 0105 11 © 2011, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. REVIEWED BY: EUNICE HEREDIA (PG OF j