CERTIFICATE OF LIABILITY INSURANCE

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Exhibit A

SAMPLE CERTIFICATE OF INSURANCE TO ALL CONTRACTS/PURCHASE ORDER AGREEMENTS

ACORD

TM

C 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 or

agreement 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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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

YLKO

B

UILDERS

,

I

NC

.

T

HE

O

WNER

(

S

)

T

HE

A

RCHITECT

AND THEIR RESPECTIVE OFFICERS

,

DIRECTORS AND EMPLOYEES

;

A

ND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT

,

PURCHASE ORDER

AGREEMENT AND

/

OR NECESSITATED BY CONSTRUCTION ACTIVITIES

NAME OR LOCATION OF COVERED PROJECT:

“P

ROJECT

N

UMBER

,

N

AME AND

L

OCATION

(

IF APPLICABLE

,

INCLUDING OPERATIONS CONDUCTED OFF THE

CONSTRUCTION SITE

)”

OR

“A

LL

O

PERATIONS

BY OR ON BEHALF OF

(S

UBCONTRACTOR

S

F

ULL

N

AME AS IT APPEARS IN THE

SUBCONTRACT

/

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

RIMARY

I

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 OF

I

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 OF

I

NSUREDS

: It is agreed that this policy contains either a severability of interests, or separation of insureds clause.

C

ANCELLATION

C

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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DDITIONAL

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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

YLKO

B

UILDERS

,

I

NC

.

T

HE

O

WNER

(

S

)

T

HE

A

RCHITECT

AND THEIR RESPECTIVE OFFICERS

,

DIRECTORS AND EMPLOYEES

;

A

ND ANY OTHER PERSON OR ORGANIZATION AS

REQUIRED BY WRITTEN CONTRACT

,

PURCHASE

ORDER AGREEMENT AND

/

OR NECESSITATED BY

CONSTRUCTION ACTIVITIES

“P

ROJECT

N

UMBER

,

N

AME AND

L

OCATION

(

IF APPLICABLE

,

INCLUDING OPERATIONS CONDUCTED OFF THE CONSTRUCTION SITE

)”

OR

“A

LL

O

PERATIONS

BY OR ON BEHALF OF

(S

UBCONTRACTOR

S

F

ULL

N

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

ECTION

II

W

HO

I

S

A

N

I

NSURED 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

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

RIMARY

I

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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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

YLKO

B

UILDERS

,

I

NC

.

T

HE

O

WNER

(

S

)

T

HE

A

RCHITECT

AND THEIR RESPECTIVE OFFICERS

,

DIRECTORS AND

EMPLOYEES

;

A

ND ANY OTHER PERSON OR ORGANIZATION AS

REQUIRED BY WRITTEN CONTRACT

,

PURCHASE

ORDER AGREEMENT AND

/

OR NECESSITATED BY

CONSTRUCTION ACTIVITIES

“P

ROJECT

N

UMBER

,

N

AME AND

L

OCATION

(

IF

APPLICABLE

,

INCLUDING OPERATIONS CONDUCTED OFF

THE CONSTRUCTION SITE

)”

OR

“A

LL

O

PERATIONS

BY OR ON BEHALF OF

(S

UBCONTRACTOR

S

F

ULL

N

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.

S

ECTION

II

W

HO

I

S

A

N

I

NSURED 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".

P

RIMARY

I

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 OF

I

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

YLKO

B

UILDERS

,

I

NC

.

T

HE

O

WNER

(

S

)

T

HE

A

RCHITECT

AND THEIR RESPECTIVE OFFICERS

,

DIRECTORS AND EMPLOYEES

;

A

ND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT

,

PURCHASE ORDER

AGREEMENT 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

F

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

YLKO

B

UILDERS

,

I

NC

.

T

HE

O

WNER

T

HE

A

RCHITECT

A

ND OTHER PARTIES AS REQUIRED BY WRITTEN

CONTRACT

,

PURCHASE ORDER AGREEMENT AND

/

OR

NECESSITATED BY CONSTRUCTION ACTIVITIES

“P

ROJECT

N

UMBER

,

N

AME AND

L

OCATION

(

IF

APPLICABLE

,

INCLUDING OPERATIONS CONDUCTED

OFF THE CONSTRUCTION SITE

)”

OR

“A

LL

O

PERATIONS

BY OR ON BEHALF OF

(S

UBCONTRACTOR

S

F

ULL

N

AME AS IT APPEARS IN

THE SUBCONTRACT

/

PURCHASE ORDER AGREEMENT

)

.

WC 04 03 06 04 84

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