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HomeMy WebLinkAboutT-5966 - Certificate of Insurance - 9/3/2010 AG.O1D„ CERTIFICATE OF LIABILITY INSURANCE ogioiiDoli PRODUCER (559)436►-0833 FAX (559)2 56-6594 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION Arthur ). Callagher gr Co. Ins. Brokers of LA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE +F5 East River Park Place West HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. Suite 4018 Fresno, CA 93720 INSURERS AFFORDING COVERAGE NAIL A' INSu-o ON Hudson Ranch, LP irooR1-NA: (;Gneral Fidelity Insurance CO sonadelle Homes. Inc- INSORERS: 7030 N. Fruit, .Ste. 101 INSURCRC: Fresno, CA 93711 IN3U4RER D: INSURER E. F E PO-IC IES OF INSUZANCE LI$TEC BELOW HAVE BEEN ISSUED 70 THE;NSLI RED NAM E D ABOVE FOR THE POLICY PER OD INDICATE D. w-r YITHSTANDINs ,ANY R.EQUIREMEN1,tVVA OR CONVITIwN OF ANY CONTRAVY OR 071ER DOCUMEM W1TIi RESPECT TOWHICH THIS CER'IFICATE MAY BE 16BLED OR MA.Y PER.TAI N,T IE NSUR-\NC E AFFORDED BY-THE PC-:IGIES DESCR13ED HERE IN IS SUBJ ECT TO ALL THE TERMS,EX.LLSIONS A\D CONDITICNS 0=SUC H POLICIES.:CGRE(V%TE_IrArrS SHOWN MAY HAVE BE-=-.v REMIICED 3Y PAID CLAIMS. INSIR D' TYPLTR NS E OF INSURANCE POLICY NUMBER POLICY EFFECTIWE POLICY D(PIRATIOH UMff_1 C.ENEMAL LIABILITY aACOM7286001 10/30/2009 10/3012010 CACi OCCURRENCE $ 1,00D,000. COMMEFC,Vt.GENERAL'-MILITY IztUAGE r�R6Nr F'.0 5 100r 00 5.11365(Eo o=nlrcraI _ C!AIFA1;rIArF M OCw I L4 M-I1 f-XI'cme)he pefi_Y11 5 rj 00 A FIRS u{L SAMirjjURi 5 1.000100 —7 GENERAL AGGFEGI.-E S 2,000 OO GFNT ALUjR_SArr LIMI-APPu6C,PER PFiCOUCTS-CCIP.-3�A13C S 2,000,00 POLICY PRO- L--C JECT A'JfOMi02JLELIA&LI11'' I1Il" K {,ISI .A C�TIENT 1VICIO � Pcf QIy INOLELIMIT 6 ANY Al IH? I\ 1�1� G1V, V v J 1 ALL OPINED ALrrOS Ap rzwe BuolLrlr4LURt 6 scFEruL�OAUTos App ed / nges _ iPBf p@fa r1} i FIR-D~arcs 900 LY IN_UP.� MON-cti,rlu�I,AU-os Sign Date rROrERTY aAMaGE S fPer ac:Carty GARAGE LIABILITY ...-•--- ," ^,!F., AVTJ Ori r_FA 0.4:I:Fn-N- $ AN'AIJI0 U-FER THAN.. EA.,.CC y &VrO ONLV: AGG ExrrESSIUAORELLALIABILITY BAXG00722400 10/30/2009 10/30/2010 cAcioa.LnrEncr s 1 000.00 x .CCCLR ZLAIh18MACE %aGGlik(;A-F S 1,000,000 A 3 I:frnIC-IDLE S PETENTION L T WORKERS COMPENSATION AND I•:caT.+ru- aTly- EHPLOYERV L".Lrr I OFyY AY"PROPR ETORrARTRERI3C=CUTrVE E-.EACH ACCIDEAIT S 0=-1CI=tMEMDEREXCLUCED' E.-.DiSFASE- EtAPL4'r ; If f�r..s,.r4nbc Unj.r APE:'7i�P:C-?vISrNS-I— =.L.D15EASE-:�tILIC'r LIV T i OrIICR Ten Day Notice of Cancellation Would Apply in Event of Cancellation for Non-Payment DFSCF➢PTICN CF OrtNATIONS!LCCATIONS 1 VEHICLES r EXCLU.NONS ADDED Br EA4]ORSENEMT f SPECIAL PROVISIOME e: Final Map of Tract 5966, P.MI. File 11525 itv of Fresno, its officers. Officials, employees, agents, volunteers are included as additional Insured as respects the CL per forms CG 2426 07104 & CC2037 02/04 attached. Primary warding per ends IL 12 01 11 85_ SHOULC ANY OF THE ABOVE D=PJBED PULICIE3 BE CANICEILED BEFORE TiFE EXPIRATION'DATE THEREOF,THE 488111 Ne INSURER YJILL EWEAVOR TC(MAIL 30 15AV3 WRITTEN NOTICE TO THECERTIFICATE MOLDER NPAIED TO THE LETT, City of Fresno B'JTFAT.URETO IMP&SUCH NOTICE SHALL MIPOSE NO OBLIGATION OR WAD LIT? 2600 Fresno Street RIR 4019 OF ANY IONDUPON THE INSURERrrSAGENTS ORREPRESENTATVES. Fresno, CA 93721 AUTHOPMrDRCPRESENMATIVE ` f Donna Sni th DONNAkx. %sr ACORD 25{2001J0ay @ACORD CORPORATION 1988 IMPORTANT If the certifir:aie holder is an ADD IT[ONAL INSURED, the policy(ies)must be endorsed.Astatement kin this certincaie dons not confer rightA to the oortlryrzte holder in lieu of such endomornent(s), It SLIBROGATION IS'NAIVED,subject to the terms and conditions of the policy,certain pDlicios may require on endcr$cmcnt,A statement on th Is eertificat-3 docs not confor rights to the certificate holder in lieu Df such cndorsomcnt(s). DISCLAIMED The Certificate of Insurance on the revere side of this form does not constitute a contract between tha issuing irisurer�sl,authorized repm5entativeor producer,and the ceQificate holder,nor does it affinnati"ly or npgatlwty amend, extend or alter the coverage afforded by the policies lls*d thereon. I ACO RD 25(2001108) POLICY NUMBER:F =C;:C C-Oil COMMERCIAL GENERAL LIABILITY CG 20 26 OT 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additiona l Insured Person(s)Or OrQanization(s) C1Ly of F CsT�, _l.ti ;�II.i�:p�_ nhf ,r.iala, e7pl�,)yee3, agerts & vrlUr-teer{ GCO Fres Street En 401- RE: SJc6, =.W. F__e nfarmation requirod to mnpiata this Schariule,rf nM shown above,tiwitl be shown in the Declaralians, Section II - Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zatun(s) shown in the Schedule, but only vrith respcct to liability for 'bodiiy injury "property damage" or 'personal and ddVeltising injury' causud, in whole ur in part, by your acts or amissions err the act5 or 4miS- s6ns of those acting on your behalf A. In Ula pwforniance of your ongoing operations;or B. In connection with your premises owned by or rented to you. 015 20 26 07 D4 0ISO Properties, Inc., 2004 Page 1 of 1 11 POLICY NUMULR: COWERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsampm nuxiifias insurartoe pruvided under it-10 following'. COMMERCIAL GENERAL LIABI'Li I Y COVERAGE PART SCHEDULE NamsOf Additional Ind Person(s) Or Organ iretion(3). Location And DescripUen or Completed Oparauonr Ci=y of C rc;r_: , i,... .�irirlr,y:^.•.�:, as.-rt..3 tti v:,__�ntae�3 26:�o R?, P.W. File lie%.a Information required to complete this Schedule.if riot shown ahave,will he shown in the Declaratiorrs. Section II - Who Is An Insurod is amended to include as an addMonal Insured the person(s) or organiration(s) -,Imven in the Schr;rlule, but only with respect to liability for`bodily injury'or"property dam- aqa" caused, in whole ur in pan, by 'your work' at LW location designaked and described in the sched- ule of:his endorsement performed fcr that additional insured and included in th4 Tpf'oducts-CUmpleled operations hazard". CG 2037 07 04 0ISO Properties,Inc., 2004 Page 1 or 1 ❑ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, POLICY CHANGES RMiry Change Numb& g POLICY NUMBER POLICY CHANGES CCIVPANY EFFECTIVE E,r•�CJ7?=s? -r,n GR;_ i 2U1G �anEria I F.de.l i Ey Trnsuranr., CcTVar_y NAMED INSURED AUTHORIZED REPRESENTATIVE hcr:iaid.l _r tl'.::�r_::, T:,c: T14,;r•31ra $f;a�j.9Lty r^_'1St=llC=_Ur lrJ';� Per haxed I:_au_ed Erdo sen nz 95x1 Ci c1t> 7E Ekw-;,, ,quite "3i1 F!. FKUi L, .ilii t.P0 30339 Frev�r., C:A .S':3:11 COVERAGE PART5AFFECTED CHANGES IncortsideretinnoFthe(additiionalrnmtvrn)premium specified on this endorsement and subjecito all of the terms and conditions of the policy, it is hereby u nderstood and agreed the following change is made to the policY: s,4dc,d the 'c.11otti_ Ig a•ic._=i•_nal 'n5vxc-d: C'_ty Of Frf�'sro, itn C"_-_arS, •�f'icdals, a,n lc fees, �yenL= Cr7111i__5?Y= 2(700 S.rPPt Rx. =Cly E•aainr:".A 937:>_] 1e cG.e_.dg_ protiik;'e:. for -he C__';r �f =res;c, 5x55 r.ur. __le _15�5 r nez `n .r1u r__2J_n G ­G2C3; prinix._y an' ror_-crnt_—kbu=ory with aOf otre1 ir_surance =. :_lahlr lr__ler otr•�r L_ri_d p -L'S} lalbil '_y poli^y Atl other policy terms and eanditions namoin unchanged. Authorized Representative Signature IL 12 01 1185 nSLFBnCe Services Otfioe, Inc.,Inc. 1983 0 Copyright, I Page 1 of 1 C'.opyTiyht, ISS]Commercial Risk Sarvicesr Inc_, 1983 DATE ACORP. CERTIFICATE OF LIABILITY INSURANCE 09/03/2010) PRODUCER (559)436-0833 FAX (559)256-6590 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur 1. Gallagher & Co. Ins. Brokers of CA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 45 East River Park Place West HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 408 Fresno, CA 93720 INSURERS AFFORDING COVERAGE NAIC# INSURED BN Hudson Ranch LP INSURERA: Peerless Insurance Company Bonadelle Homes, Inc. INSURERB: Topa Insurance Company 7030 N. Fruit, Suite 101 INSURER C: Fresno, CA 93711 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR DATE(MMIDDIYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES(F mzpa—) CLAIMS MADE ❑ OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY 7 PROECT LOC J AUTOMOBILE LIABILITY CBP 8364480 12/31/2009 12/31/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ A SCHEDULED AUTOS RISK �A AG �ViLIN I. ! 1+1��� (Per person) HIRED AUTOS [_ V BODILY INJURY NON-OWNED AUTOS Approve 1 (� (Per accident) $ A ro ° geS• ! PROPERTY DAMAGE $ �J (Per accident) GARAGE LIABILITY S'� AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000 X OCCUR FICLAIMSMADE XL27119 12/31/2009 12/31/2010 AGGREGATE $ 1,000,000 B $ DEDUCTIBLE $ RETENTION $ $ WC STATU- OTH- WORKERS COMPENSATION AND R EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER Ten Day Notice of Cancellation Would Apply in Event of Cancellation for NonPayment DESCRIPTION OF OPERATIONS].LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS e: 5966, P.W. Fite 11525 City of Fresno, its officers, officials, employees, agents, volunteers included as additional insured per CA2048 02/99 attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of Fresno BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 2600 Fresno Street Rm 4019 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Fresno, CA 93721 AUTHORIZED REPRESENTATIVE S. Donna Smith/DONNA r,r«:-2 =•y ACORD 25(2001108) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) POLICYNUMBER. CSP&W"80 CGMMERCIALAUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED Thlt 2ndor_carnp.nt mmlifip--,irisnranrA pnj%&Ipd iindrtrtFe fr)lluwino BUSrNESS AUTO COVERAGE FORM GARAGE:OVEPACE FORM MOTOR CARRIER.COVERAGE FORM TRUCKERS COVERAGE FORM With respect tD coverage provided by this endorsement.-lie provisions of One Coverage Four aprty unless modi- fied t!y ill is fmdorsemen1. This endorsement identfies person(3)or orgenizatixn(s)who®re"insureds"under the Who I_An Irsumd Pr"i- sion o`thts Coverage Fomn.This endonsemsnt does not alter coverage provided in the Coverage Form. 7NK F,.n tnrsRmeni rhAn3p�the pf)llry PW.tiva.nn the inrx*rtlnn hula of the pnliry iin wee A 1n1ha4 CA.P i4 Gldil',NlfL1 Gelow, Endwsemm EffecVvE; O6l0212C.1D Codnbusignea By: INamed Insu=: Barrsdalle rWnew,in--,,SN-Judson Ranch LP ' uthoruod R fesentativo) SCHEDULE Name of Person(s)ni OrganizAtion(s): City of f rrsno 267a Frosna St,Rm 45'9,Fr=o.CA 33721 (if no ealry appears ebewo..Informarlon requlmd to mm:IIHIp lltix errcleus-Irwm will be bl"uw,i in ttw Declarations es appllr.AJle bo iha eatl(Wsament.) Each person or orijanliatlon shown in the SChecule is uu"insumd"for Liao lity Coverage,bir orly to the extent Ilial Lummi or urganizal.luii rp41f1P% rte an "IrlMirmi' under mp VkMry Is An Insured ProMsICn coniainad in Section 11 niche Cowrage h9m CA 2D 49 02 09 Copyn3ht,Insurance Ser vires Oftice,Inc., 1996 Cage 1 of i O ACORD, CERTIFICATE OF LIABILITY INSURANCE 09101po101 PRODUCER [559)43fi-G$33 FAX (559)256-6590 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Arthur 3. Callagher & Co. Ins. Brokers of CA Inc. ONLY AND CONFERS NO RIGHTS UPON THF-CERTINCATE 45 East River Park Place West HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR A=THE COVERAGE AFFORDED BY THE POLICIES 9ELOW- Sui to 406 Fresno, CA 93720 INSURERS AFFORDING COVERAGE NAIL 4 INSURED Bonadelle Homes, Inc. INSURERA DeloS TITS Co Ronddelle Development Corporation INSURER P,: 7030 N. Fruit Ave, 5ui to 100 INSURER c: Fresno. CA 93711 INSURER D: T INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I$SUECI TO THE!NSURCD NAMED ADOVE FOR THE POLICY PER OC-INDICATED. VQTIYITHSTkN[tlN ' ANY REOUIREMFNT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTYVITH RESPECTTO%1-IICH TH5CERTIFICATE MAY BE 135UF--DOR LIMY PERTAIN,TI IC IN6L.RIkNCCAr-rQRDCD BY?1IE POLICIES DESCR13ED HEREIN IS SUBJECT TO ALL T-JE TERLIS.EX`:LLSION3 AND CONDITIONS Oz SUCH POLICIES,A3GRCGATC-P-0ITS SI IOWN MAY HAVE BE-=,%J REDUCED BY PAID CLAIMS. iHSR Dd YYFE OF 1N3URANCE POLICY NUMBER PDLICY EfFGrTWr POLICY HI(PIRATIDA LJMfTS GENERALLIA&LITf FAI;A r)I;C'.JRRENCE 5 (;r1LIIAFw w r�FNFPAL-MILIIY DAMAI ET•11RENTEa s CL AIPAS r)ADF 11 OCCUR M_13 EXP(arr;mo pawn) IS PCRWNAL S AVC INJURY S r GENERA-AGGREGATE S MJPOLICYF-� L A.GGRrC.ATL LNIT A-P-£4?=R: PPJOEYLIM-ZONP.CP AGG S F!=,:' LCC ...... F AUTOMOBILE LIABILITY ^Ok61VED SIYGLE L I'AI I : AW AII)TC TCB ectdcal:) AL-owVEJAUTDS ';'� iti,J-tl l'i'..J� VILIVI Lr I.JII.Je . ... RODILY NJUFYY f I SCHEDULED AU7a I .pp QVed: (For p-%Dnl j NIR}OPlITUS Appy Ved /Changes: 6071Ly IYJURY NONJ()Vrt,60Al;TOS f'' :ferxcideeLl f sie6ed, Date 1 ROPE TlI).WWE f ntl GARAGE LIABILITY AUTO ONLY E,}AQ,-IDEM S j ANYAUTC -nTHER THAN Ch.4•CC S .•.UTO ONLY_ AGC- ; 6%CESSiUM9RELLALIABIU7Y EACH OCGJRP.-NCE S CD(:Lik ❑:..aIMS F.tAiIF 41y�}lFr;.gtF S -.r-., ,- .,.._. H f RETENTIh'1 S S WORICERSCOMPENSATION AND DUWRMI-21307-9$0 10/41/2009 10/01/2010 ]{ �vC STn'Il. hi'i-I EMPLDY S'I.IA6ILRY E.L.EACHA0.11DENT f L,IIQO A ANY Fhb'FRIETOW-ARTNS+'EXECU-NE 0-7ICE-PeTACIADCROcCAJOED^: FA. 15EASE-E.AIE AP-CfYI_ f 1 000,ON IL yes,rcoraEran�- SPECyTFFO_STONE below .___ _--•._„ F..L UIyfASE--C:LA:'w UFAT f L.00014000 OTHER Ten Day Notice of Cancellation would Apply in Event of Cancellation for Non-Payment UE9CFtIM TIGN OF Oh'L:KAYION31 L OC:A1 TUN$t YlNICLtB,tLCLJ$IONS Al1UlU Br rYDUN$BNEYi f 1EE�IAL rRCJ VIaIDN3j Re: Tract 5966, P.W. File 11525 14aiver of Subrogation in favor of City of Fresno attached. i R I I T ER CANCELLATION I SHOULD ANTDF THE ABOVE DESCRIBED Pbuums,Eircmwr:Ei.l E7 RF.FORF THE ' EXPIRAMON I)ATETHEREAF,THEISSUTAG INSURER WILLENIDEAVDR TO MAIL DID PAYS■YRITTEN NOTICE TO THE L ELKR KATE HOLDER HOMED TD THE LEFT, City of Fresno BUT FAILURE TOVAILSUCH H(MII!SHIALLINP06ENOOBLIWLTI�WORr.ik@MUTT 2640 Fr4Sn4 Street Rm 4419 Of ANY KURD UPON THE INIBNNM,119 AC ENTS OR RiEPRESEINTATNES. Fresno, CA 93721 ALJTHDREEDREYRESENTATNVE Donna Smith/DONNA AGORD 25(2007108) 0AACORD CORPORATION 1988 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 040306 IEP•4-84? WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA '%Ve have tfe Tight to recover from our payments from anyGne!able far an injury covered iYV this 9dicy.We will not antorce nil r d ght against the person c r orgarrizatio n named it d-e SGI-ed ule. (This ag-eemsnt applies only to t-ie exbert teat You perform we rk u oder a written contract that requires yoj to obtain his atgreement f•cm us-) You must maintalr payroll rtcords accurately segregative the remuneration of your employees While engaged'nth e work described in the sehedr_le. The additional premir.rn for this endorsermentshall be 5%of the Californiaworkers'compensation oremium cthenvise cue on sucl remunerabon. SCHEDULE Person or Orgonizatian Job Description Cily of Fresw All Prcjec�s 2600 Fresno St Rm 4719 Trac[5966 S=regnri.CA M721 =_W.File 11525 Minimum Premium$5l) -hi5 endaraernert changes:ha policy m which it i�i attached and is effective on the date issue-unless atherwire stated. (The information below is required only when this endorsement is Issued subsequent to preparation of the Policy.) Endarsament Effective 811!2010 Policy No. D1 DKRVII-2007-906 Endorsement No-5 Insurcd Eonadelle Hones,lrc Insurance Campany:❑elos Insurance Company-354CB 5onadelle LWmiopanent Corporatlon ODA:BDG >'xf 45e— (' �5e C.ountersigrred By: 01996 by[het Workers'CtxnpmFMan Iro anm RatIng Braeauof Cdllfomld All r("reserved, Ftorn the WUIRINs Ca lil amia Workers'Compensation Insurance Forms r&nuel COM_ smw o sn IMPORTANT If.ho omtficate holder is an ADDITIONAL 114SLIRE0,the,eKIl yQgs)must be endorsed.A statement or.this certificate does nat confer rights to the cartificato holder in lieu of such endorsement(s). If SUEIROGATION IS VJAIV£D.subject to the terms and conditions of the policy,certain policies may reauirean endorsement,A statement cn this oertlAcate does not conferrlghts to the ce0115cate holder in%u of such endorsoment(s), DISCLAIMER The Certificate of L,isurance on the reverse side of this form does not constitute a oantraot between) the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it dfirrriatively ur negatively amend,extnnd orrltarthe coveraga afforded by the policies listed thereon. ACORD 25(2001M)