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Exhibit A
SAMPLE CERTIFICATE OF INSURANCE TO ALL CONTRACTS/PURCHASE ORDER AGREEMENTS
ACORD
TMC E R T I F I C A T E O F L I A B I L I T Y I N S U R A N C E
Date (MM/DD/YY)PRODUCER
SUBCONTRACTOR’S AGENT /BROKER
ADDRESS
CITY,STATE,ZIP CODE
CONTACT PERSON /PHONE #/FAX #
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC#
INSURED
SUBCONTRACTOR’S FULL NAME (AS IT APPEARS IN THE SUBCONTRACT /PURCHASE ORDER
AGREEMENT) ADDRESS
CITY,STATE,ZIP CODE
CONTACT PERSON /PHONE #/FAX #
INSURER A (EACH INSURANCE CARRIER LISTED MUST HAVE AN
INSURER B A.M.BEST RATING OF “A:VIII” OR BETTER, EXCEPT FOR
INSURER B STATE FUND FOR WORKERS’COMPENSATION COVERAGE) INSURER B
INSURER B COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHINGSTANDING 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
LTR. ADD’L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCURRENCE “XCU” & “BFPD”
CONTRACTUAL LIABILITY (Oral / Written / Implied)
GENERAL AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOCATION
< $10,000DEDUCTIBLE OR SELF INSURED RETENTION
(Current) (Current) (Current) EACH OCCURRENCE $ 1,000,000 “SEVERABILITY OF INTERESTS"
PROVISION APPLIES DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000
Certificates of Insurance from all lower tier contractors, subcontractors, sub-subcontractors, suppliers and hired services must meet the following minimum insurance requirements before their services or products are used:
RYLKO BUILDERS, INC. , Owner(s), Architect, their officers, directors and employees and all other parties as required by written contract oragreement are named as Additional Insured on all policies, except Workers’ Compensation and/or Professional Liability Insurance.
The Additional Insured Endorsement (AIE) to the General Liability policy must include your “ongoing operations” and extend to your “completed operations” for a minimum of five (5) years after completion of contract work or for a longer period of time as required by the Contract Documents. Acceptable endorsements include ISO forms CG2010B (11/85); CG2026 (11/85); CG2010 (07/04) plus CG2037 (07/04); or acceptable equivalent. The CG2010 (10/93) additional insured form “ongoing operations” will be accepted for vendors/suppliers that deliver materials or goods to the job site and do not perform any physical services on the construction project/property.
Certificates of Insurance and Additional Insured Endorsements that restrict coverage to “your ongoing operations” which do not provide coverage for “completed operations” will be rejected.
If either defense costs are included in the General Aggregate limit or the General Aggregate limit does not apply on a per project basis, then the required General Aggregate limit must be at least twice the occurrence limit.
Any coverage afforded to the Additional Insureds must be on a primary and non-contributory basis.
“Claims-Made” or “Modified Occurrence” Commercial General Liability policy forms are NOT acceptable.
Waiver of Subrogation in favor of the Additional Insureds applies on all policies, including Professional Liability.
Aircraft or Helicopter Operations must include Workers’ Compensation & Employer’s Liability for all members of flying crew.
The Actual Endorsement Number(s) must be included on the Certificate.
Required Endorsements must be attached to the Certificate of Insurance.MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
PRODUCTS – COMP/OP AGG $ 2,000,000
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS
COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident)) $ Property damage (Per accident) $ GARAGE LIABILITY AUTO ONLY – EA ACCIDENT
ANY AUTO OTHER THAN EA ACC AUTO ONLY: AGG
EXCESS LIABILITY EACH OCCURRENCE As Required
OCCURRENCE CLAIMS MADE AGGREGATE By Contract
DEDUCTIBLE “DROP-DOWN” PROVISION
RETENTION $ APPLIES
WORKERS’ COMPENSATION AND EMPLOYER’S LIABILITY
ANY PROPRIETORS/PARTNERS/EXECUTIVES OFFICERS MEMBERS EXCLUDED? If yes, describe under SPECIAL PROVISIONS below
WC STAT- TORY LIMITS
OTH- ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE – EA EMPLOYEE $ 1,000,000
E.L. DISEASE – POLICY LIMIT $ 1,000,000
OTHER (must include Limited Contractual Liability)
POLLUTION LIABILITY INCLUDING MOLD AND ASBESTOS PROFESSIONAL LIABILITY WITH A RETROACTIVE DATE OF BEFORE SERVICES START / POLLUTION EXCLUSION DELETED RIGGER’S LIABILITY
AIRCRAFT / HELICOPTER LIABILITY (OWNED & NON-OWNED)
If Applicable
EACH CLAIM / AGGREGATE As Required
EACH CLAIM / AGGREGATE By Contract
EACH OCCURRENCE
(Current) “SEVERABILITY OF INTERESTS"
PROVISION APPLIES
(Current) (Current) EACH OCCURRENCE
(Professional Liability must be maintained for at least 2 years after substantial completion)
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (THE FOLLOWING INFORMATION MUST APPEAR.)
Reference: “Project Number, Name and Location, including operations conducted off the construction site” or “All Operations” of the Named Insured
RYLKO BUILDERS, INC. , Owner(s), Architect, their officers, directors and employees and all other parties as required by written contract or agreement are included as Additional Insureds on a primary and noncontributory basis per attached Endorsement ##(s) to the General Liability Policy. Additionally, Waiver of Subrogation applies on all policies listed above per attached Endorsement ##(s).
CERTIFICATE HOLDER CANCELLATION *Except 10 Days for Non-Payment of Premium
RYLKO BUILDERS, INC.
985 Industrial Road, Suite 101 San Carlos, CA 94070
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30* DAYS WRITTEN NOTICE
TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE (Original Wet Signature is Required.)
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XHIBIT
B
A
DDITIONAL
I
NSURED
E
NDORSEMENT
–
ISO CG 20 10 11 85
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
NAMED INSURED:
INSURANCE COMPANY:
POLICY PERIOD:
EFFECTIVE DATE:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
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(S) OR ORGANIZATION(S):
R
YLKOB
UILDERS,
I
NC.
T
HEO
WNER(
S)
T
HEA
RCHITECTAND THEIR RESPECTIVE OFFICERS
,
DIRECTORS AND EMPLOYEES;
A
ND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT,
PURCHASE ORDERAGREEMENT AND
/
OR NECESSITATED BY CONSTRUCTION ACTIVITIESNAME OR LOCATION OF COVERED PROJECT:
“P
ROJECTN
UMBER,
N
AME ANDL
OCATION(
IF APPLICABLE,
INCLUDING OPERATIONS CONDUCTED OFF THECONSTRUCTION SITE
)”
OR“A
LLO
PERATIONS”
BY OR ON BEHALF OF(S
UBCONTRACTOR’
SF
ULLN
AME AS IT APPEARS IN THESUBCONTRACT
/
PURCHASE ORDER AGREEMENT)
(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 that 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.
P
RIMARYI
NSURANCE: Such insurance as is afforded by this policy is primary insurance and no other insurance of the
additional insured(s) will be called upon to contribute to a loss.
L
IMITS OFI
NSURANCE: It is agreed that Endorsement CG2503 (0397) Designated Construction Project(s) General Aggregate
Limit or its equivalent is added for this project.
S
EPARATION OFI
NSUREDS: It is agreed that this policy contains either a severability of interests, or separation of insureds clause.
C
ANCELLATIONC
LAUSE: It is understood and agreed that there will be no cancellation, reduction or modification of coverage
without thirty (30) days’ written notice except for non-payment of premium in which case the company will mail ten (10)
days’ written notice. Any claim payment under said policy shall not be construed to be a reduction or modification as
respects this clause.
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A
DDITIONAL
I
NSURED
E
NDORSEMENT
–
ISO
CG
20
10
07
04
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
NAMED INSURED:
INSURANCE COMPANY:
POLICY PERIOD:
EFFECTIVE DATE:
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
SCHEDULE
NAME OF ADDITIONAL INSURED PERSON(S)
OR ORGANIZATION(S)
LOCATION(S) OF COVERED OPERATIONS
R
YLKOB
UILDERS,
I
NC.
T
HEO
WNER(
S)
T
HEA
RCHITECTAND THEIR RESPECTIVE OFFICERS
,
DIRECTORS AND EMPLOYEES;
A
ND ANY OTHER PERSON OR ORGANIZATION ASREQUIRED BY WRITTEN CONTRACT
,
PURCHASEORDER AGREEMENT AND
/
OR NECESSITATED BYCONSTRUCTION ACTIVITIES
“P
ROJECTN
UMBER,
N
AME ANDL
OCATION(
IF APPLICABLE,
INCLUDING OPERATIONS CONDUCTED OFF THE CONSTRUCTION SITE)”
OR“A
LLO
PERATIONS”
BY OR ON BEHALF OF(S
UBCONTRACTOR’
SF
ULLN
AME AS IT APPEARS IN THE SUBCONTRACT/
PURCHASE ORDER AGREEMENT)
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. S
ECTIONII
–
W
HOI
SA
NI
NSURED is amended to includeas 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
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:
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.
P
RIMARYI
NSURANCE: Such insurance as is afforded by this Policy is primary insurance and no other insurance of the
Additional Insured will be called upon to contribute to a loss.
CG 20 10 07 04 (OR EQUIVALENT) PLUS CG 20 37 07 04 PAGE 1 OF 1
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XHIBIT
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A
DDITIONAL
I
NSURED
E
NDORSEMENT
–
C
OMPLETED
O
PERATIONS
C
OVERAGE
–
ISO
CG
20
37
07
04
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
NAMED INSURED:
INSURANCE COMPANY:
POLICY PERIOD:
EFFECTIVE DATE:
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
SCHEDULE
NAME OF ADDITIONAL INSURED PERSON(S)
OR ORGANIZATION(S)
LOCATION AND DESCRIPTION OF COMPLETED
OPERATIONS
R
YLKOB
UILDERS,
I
NC.
T
HEO
WNER(
S)
T
HEA
RCHITECTAND THEIR RESPECTIVE OFFICERS
,
DIRECTORS ANDEMPLOYEES
;
A
ND ANY OTHER PERSON OR ORGANIZATION ASREQUIRED BY WRITTEN CONTRACT
,
PURCHASEORDER AGREEMENT AND
/
OR NECESSITATED BYCONSTRUCTION ACTIVITIES
“P
ROJECTN
UMBER,
N
AME ANDL
OCATION(
IFAPPLICABLE
,
INCLUDING OPERATIONS CONDUCTED OFFTHE CONSTRUCTION SITE
)”
OR“A
LLO
PERATIONS”
BY OR ON BEHALF OF(S
UBCONTRACTOR’
SF
ULLN
AME AS IT APPEARS IN THESUBCONTRACT
/
PURCHASE ORDER AGREEMENT)
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
S
ECTIONII
–
W
HOI
SA
NI
NSURED is amended to include as anadditional 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".
P
RIMARYI
NSURANCE: Such insurance as is afforded by this
Policy is primary insurance and no other insurance of the
Additional Insured will be called upon to contribute to a loss.
L
IMITS OFI
NSURANCE: The General Aggregate Limit under
LIMITS OF INSURANCE (SECTION III) applies separately
to each of your projects away from premises owned by or
rented to you.
CG 20 37 07 04 (OR EQUIVALENT) PLUS CG 20 10 07 04 PAGE 1 OF 1
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AIVER OF
S
UBROGATION
E
NDORSEMENT
–
ISO
CG
24
04
10
93
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
NAMED INSURED:
INSURANCE COMPANY:
POLICY PERIOD:
EFFECTIVE DATE:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
NAME OF PERSON(S) OR ORGANIZATION(S):
R
YLKOB
UILDERS,
I
NC.
T
HEO
WNER(
S)
T
HEA
RCHITECTAND THEIR RESPECTIVE OFFICERS
,
DIRECTORS AND EMPLOYEES;
A
ND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT,
PURCHASE ORDERAGREEMENT AND
/
OR NECESSITATED BY CONSTRUCTION ACTIVITIES(If no entry appears above, information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV –
COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule
above because of payments we make for injury or damage arising out of “your ongoing operations” or
“YOUR WORK” done under a contract with that person or organization and included in the
“products-completed operations hazard”. This waiver applies only to the person or organization shown in the
Schedule above.
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XHIBIT
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W
AIVER OF
S
UBROGATION
E
NDORSEMENT
–
WC
04
03
06
04
84
POLICY NUMBER:
WORKERS’ COMPENSATION & EMPLOYERS LIABILITY
NAMED INSURED:
INSURANCE COMPANY:
POLICY PERIOD:
EFFECTIVE DATE:
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 _______% of the California workers’
compensation premium otherwise due on such remuneration.
SCHEDULE
PERSON(S) OR ORGANIZATION(S): JOB
DESCRIPTION:
R
YLKOB
UILDERS,
I
NC.
T
HEO
WNERT
HEA
RCHITECTA
ND OTHER PARTIES AS REQUIRED BY WRITTENCONTRACT
,
PURCHASE ORDER AGREEMENT AND/
ORNECESSITATED BY CONSTRUCTION ACTIVITIES
“P
ROJECTN
UMBER,
N
AME ANDL
OCATION(
IFAPPLICABLE
,
INCLUDING OPERATIONS CONDUCTEDOFF THE CONSTRUCTION SITE
)”
OR“A
LLO
PERATIONS”
BY OR ON BEHALF OF(S
UBCONTRACTOR’
SF
ULLN
AME AS IT APPEARS INTHE SUBCONTRACT
/
PURCHASE ORDER AGREEMENT)
.
WC 04 03 06 04 84
