CERTIFICATE OF LIABILITY INSURANCE

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CERTIFICATE HOLDER

© 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

LOC JECT

PRO-POLICY

GEN'L AGGREGATE LIMIT APPLIES PER: OCCUR CLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

GENERAL LIABILITY

PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $

MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $

$ RETENTION DED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $ UMBRELLA LIAB EXCESS LIAB

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSR

LTR TYPE OF INSURANCE POLICY NUMBER (MM/DD/YYYY)POLICY EFF (MM/DD/YYYY)POLICY EXP LIMITS

WC

STATU-TORY LIMITS OTH-ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT

$ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under

DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $

$ $ $

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident)

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 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).

The ACORD name and logo are registered marks of ACORD

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

XX/XX/XX 1,000,000 1,000,000 LIC # A Address

Your Agent Name

A X *EVIDENCE OF COVERAGE XX/XX/XX 1234 Fake Street X

City, STATE, ZIP

1,000,000 XX/XX/XX N N a Phone

Insurance Carrier/Best Rating (A-VI or greater)

1,000,000 Name (must read same as subcontract agreement)

Address City, State ZIP

XYZ-POLICY NUMBER

Lathrop Construction Associates, Inc. and its officers, directors & employees 400 Park Road P.O. Box 2005 Benicia, CA 94510-0819 1,000,000 1,000,000 100,000 10,000 XYZ-POLICY NUMBER 2,000,000 1,000,000 X XX/XX/XX XX/XX/XX X X A X XX/XX/XX XYZ-POLICY NUMBER 1,000,000 1,000,000 1,000,000

A Professional Liability XYZ-POLICY NUMBER XX/XX/XX XX/XX/XX $ X,XXX,XXX Limit X

Example:

Job #1234-56 / Contract #890-10 / RE: 123 Main Street / San Francisco, CA / ADDITIONAL INSURED: Rosendin Electric, Inc., Owner, and Contractor

Rosendin Electric, Inc. 880 Mabury Road

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POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 oo

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – (FORM B)

This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART.

SCHEDULE Name of Person or Organization:

BLANKET AS REQUIRED BY WRITTEN CONTRACT

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you.

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POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 10 10 01

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE Name of Person or Organization:

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

A. Section II – Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured.

B. With respect to the insurance afforded to these additional insureds, the following exclusion is added:

2. Exclusions

This insurance does not apply to "bodily in-jury" or "property damage" occurring after:

(1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the addi-tional insured(s) at the site of the cov-ered 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 con-tractor or subconcon-tractor engaged in performing operations for a principal as a part of the same project.

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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 37 10 01

ADDITIONAL INSURED – OWNERS, LESSEES

ORCONTRACTORS – COMPLETED

OPERATIONS

SCHEDULE

Section II – Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" at the location designated and described in the schedule of this endorsement performed for that insured and included in the "products-completed operations hazard".

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART

CG 20 37 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 Name of Person or Organization:

BLANKET WHEN REQUIRED BY WRITTEN CONTRACT

Location And Description of Completed Operations: BLANKET WHEN REQUIRED BY WRITTEN CONTRACT

Additional Premium: NONE

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Page 1 of 1 90533 (3/06)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 12:01 A. M. forms part of

Policy No. Issued to:

PRIMARY COVERAGE FOR SPECIFIED PERSONS OR ORGANIZATIONS

NAMED AS ADDITIONAL INSUREDS –

ONGOING AND COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM

The following paragraph is added to SECTION II – WHO IS AN INSURED and applies only to persons or organizations we have added to your policy as additional insureds by endorsement to comply with insurance requirements of written contracts relative to: a) the performance of your ongoing operations for the additional insureds; or b) “your work” performed for the additional insureds and included in the “products-completed operations hazard:

This insurance is primary over any similar insurance available to any person or organization we have added to this policy as an additional insured. However, this insurance is primary over any other similar insurance only if the additional insured is designated as a named insured in the Declarations of the other similar insurance. We will not require contribution of limits from the other similar insurance if the insurance afforded by this endorsement is primary.

This insurance is excess over any other valid and collectible insurance, whether primary, excess, contingent or on any other basis, if it is not primary as defined in the paragraph above. All other terms and conditions of the policy are the same.

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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS

ENDORSEMENT-CALIFORNIA

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.)

You must maintain payroll records accurately segregating the remuneration of your

employees while engaged in the work described in the Schedule.

The additional premium for this endorsement shall be 2 % of the Califoria workers'

compensation premium otherwise due on such remuneration.

Schedule

Person or Organization

Job Description

From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. - 1998 by the Workers' Compensation Insurance Rating Bureau of Caliofnira. All rights reserved.

ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED

INSURED HAS AGGREED BY WRITTEN CONTRACT TO FURNISH

THIS WAIVER.

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POLICY NUMBER:

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