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Insurance Certificates 2020/21 PWLC II, IncANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTR INSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 12/14/2020 License # 0E67768 (619) 788-5798 50212 (619) 574-6288 13978 PWLC II, Inc. PO Box 986 Vista, CA 92085 12177 A 1,000,000 XXBP15867 3/10/2020 3/10/2021 1,000,000 10,000 1,000,000 2,000,000 2,000,000 EB Aggregate 1,000,000 1,000,000A FMA011477 3/10/2020 3/10/2021 Comp.: $1k Per Claim Coll.: $1k Per Claim 4,000,000A EX11308 3/10/2020 3/10/2021 4,000,000 10,000 B X WCV5504144 3/10/2020 3/10/2021 1,000,000 1,000,000 1,000,000 Re: All Operations City of La Quinta is Additional Insured with respect to General Liability per the attached endorsement as required by written contract. Insurance is Primary and Non-Contributory. Waiver of Subrogation applies to General Liability and Workers’ Compensation. 30 Days Notice of Cancellation with 10 Days Notice for Non-Payment of Premium in accordance with the policy provisions. City of La Quinta 78-495 Calle Tampico La Quinta, CA 92253 PWLCIII-01 AUSTINA IOA Insurance Services4370 La Jolla Village DriveSuite 600 San Diego, CA 92122 Laurie Lloyd Laurie.Lloyd@ioausa.com Florists' Mutual Insurance Company CompWest Insurance Company X X X X X XX X X X ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 5/27/2020 License # 0E67768 (619) 574-6220 (619) 574-6288 13978 PWLC II, Inc. PO Box 986 Vista, CA 92085 12177 A 1,000,000 X X BP15867 3/10/2020 3/10/2021 1,000,000 10,000 1,000,000 2,000,000 2,000,000 EB Aggregate 1,000,000 1,000,000A FMA011477 3/10/2020 3/10/2021 Comp.: $1k Per Claim Coll.: $1k Per Claim 4,000,000A EX11308 3/10/2020 3/10/2021 4,000,000 10,000 B X WCV5504144 3/10/2020 3/10/2021 1,000,000 1,000,000 1,000,000 Re: All Operations City of La Quinta is Additional Insured with respect to General Liability per the attached endorsement as required by written contract. Insurance is Primary and Non-Contributory. Waiver of Subrogation applies to General Liability and Workers’ Compensation. 30 Days Notice of Cancellation with 10 Days Notice for Non-Payment of Premium in accordance with the policy provisions. City of La Quinta 78-495 Calle Tampico La Quinta, CA 92253 PWLCIII-01 LLOYDL IOA Insurance Services 4370 La Jolla Village Drive Suite 600 San Diego, CA 92122 Florists' Mutual Insurance Company CompWest Insurance Company X X X X X X X X X X & 04�P PWLCIII-01 AUSTINA CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDlYYYY)3/4/2020 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 endorsemen s . PRODUCER License # OE67768 rg2 EAcT Laurle Lloyd ICA Insurance Services PHONE ) Vic, No):(619) 574-6288 4370 La Jolla Village Drive (A/C, No, E:t): (619 788-5798 50212 Suite 600 s agrie,L_ loyd ioausa.com San Diego, CA 92122 INSUREfj(S)_AFFORDING COVERAGE NAIC#-T, INSURER A:Florists' Mutual Insurance Company 13978 INSURED INSURER B:Com West Insurance Company, 12177 PWLC II, Inc. INSURER C: PO BOX 986 INSURER D: _ Vista, CA 92085 INSURER E INSURER F.: 'OVERAGES CERTIFICATE NUMBER: 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 R_ EDUCED BY PAID CLAIMS. ISR TYPE OF INSURANCE ADDL SUBn POLICY NUMBER POLICY EFF POLICY EXP LIMITS 9INSO A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0 I DAMAGE TO RENTED 1 �000�0 CLAIMS -MADE f X OCCUR X X BP15867 3/10/2020 3/10/2021 PREMISE$.(Ea oc,C.ufr4rJG4 ' $ l VIED EXP [&ny oneperson) $ 10'0 � _PERSONALB.ADVINJURY S 1,000,0 _ - GEN'LAGGREGATE LIMIT APPLIES PER: POLICY u PEef LOC GtNtKALA(i (jAlt PRODUCTS -COMP/OP AGO Y - - S 2,000,000 OTC $ 1,000,000 EB Aggregate A AUTOMOBILE LIABILITY X 7 ANY AUTO IFMA011477 COMBINED SINGLE LIMIT _iEaacsklent 3/10/202, 3/10/2021 BODILY 1NJURY Per erson 1,000,000 $ $ S $ -- AIIU��T��OppS ONLY WNED I A�UT�O(7SWULNEEDp RL1TO5 ONLY _ . RLITOS DfQILY X .: $1k Per i X ,Call.: $Ik Per Claim 8IQDILY INJURY. Per accident . (Pa PERTY lDAMAGE $ A X UMBRELLA LAB X OCCUR EACH OCCURRENCE_ _ S 4,000,000 I EXCESS LIAB CLAIMS -MADE IEX11308 3/10/2020 3/10/2021 AG>;REGATE is 4,000,000 1 S DED I X I RETENTION $ 10,000 B . WORKERS COMPENSATION ' AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / NI 0FCEXCLUDED? _ anFIdatory In NH) N / A X IWCV5504144 3/10/2020 I 3/10/2021 + PER 07FI- X 8 TUT E 1,000,000 $ - _ _ ..$_ _ _1,000,000 EL EACiiACC1DENT E.L. DISEASE =EA EMPLOYEE If yes, describe under 1 1 _nnn_nnn DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Re: All Operations City of La Quinta is Additional Insured with respect to General Liability per the attached endorsement as required by written contract. Insurance is Primary and Non -Contributory. Waiver of Subrogation applies to General Liability and Workers' Compensation. 30 Days Notice of Cancellation with 10 Days Notice for Non -Payment of Premium in accordance with the policy provisions. 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. AUTHORIZED REPRESENTATIVE City of La Quinta 78-495 Calle Tampico ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BP-15867 COMMERCIAL GENERAL LIABILITY L CA 20 31 07 12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA CONTRACTORS BLANKET ADDITIONAL INSURED - WHEN REQUIRED BY WRITTEN CONTRACT ONGOING & COMPLETED OPERATIONS — BLANKET WAIVER OF SUBROGATION — PRIMARY & NONCONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE (optional -see Paragraph A.) IName Of Person(s) Or Organization(s) Location(s) And Description of Covered Operations as required by "written contract': I ner the "written contract": A. ADDITIONAL INSURED - CONTRACTORS SECTION 11— WHO IS AN INSURED is amended to include as an additional insured any person(s) or or- ganizations) you are required by a "written contract" to add as an additional insured on this Coverage Part. The "written contract" requirement for additional in- sured status is automatically fulfilled for any addi- tional insured shown in the Schedule above. However: 1. If an additional insured(s) is a builder, general contractor or contractor not affiliated with the builder; and 2. You have entered into a residential construction contract subject to the requirements of California Civil Code Section 2782(c) with such builder or contractor; then such builder or contractor is an additional in- sured under this endorsement but only to the extent of the liability for "bodily injury", "property damage" or "personal and advertising injury" that you have assumed in the residential construction contract with that party. B. Coverage provided to such additional insured(s) is limited as follows: L CA 20 31 0712 Florists' Mutual Insurance Company - Edwardsville, Illinois Page 1 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 1. ONGOING OPERATIONS: Such person(s) or organization(s) is an addi- tional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: (a) Your acts or omissions; or (b) The acts or omissions of those acting on your behalf; in the performance of your ongoing operations as specified in the "written contract". 2. COMPLETED OPERATIONS: (a) Such person(s) or organization(s) is an addi- tional insured with respect to liability includ- ed in the "products -completed operations hazard" for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" only if: i. The "written contract" requires you to pro- vide the additional insured such cover- age; and ii. "Your work" included in the "products - completed operations hazard" is limited to the location designated and described in the "written contract". (b) Such coverage for the additional insured ends at the earliest of the following: i. The date specified in the "written con- tract'; or ii. Five years from the completion of "your work" included in the "products - completed operations hazard" as desig- nated and described in the "written con- tract". 3. Coverage provided to such additional insured(s) described in Paragraph A is limited as follows: (a) The insurance afforded to such additional insured only applies to the extent permitted by law; and (b) Will not be broader than the lesser of what is afforded to you under this Coverage Part or that which you are required by the "writ- ten contract" to provide for the additional insured. (c) Does not apply to any person(s) or organi- zations) covered as an additional insured on any other endorsement attached to this Coverage Part. C. ADDITIONAL INSURED - EXCLUSIONS With respect to the insurance afforded to these addi- tional insureds, the following additional exclusions apply: This insurance does not apply to: 1. The sole negligence of the additional insured. 2. The rendering of, or the failure to render, any professional architectural, engineering or sur- veying services, including: (a) The preparing, approving, or failing to pre- pare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifica- tions; or (b) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitor- ing of others by that insured, if the "occurrence" which caused the "bodily injury" or "property dam- age", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, en- gineering or surveying services. D. ADDITIONAL INSURED - LIMITS With respect to the insurance afforded to these addi- tional insureds, the following is added to SECTION III — LIMITS OF INSURANCE: The most we will pay on behalf of the additional in- sured is the amount of insurance: 1. Required by the "written contract"; or 2. Available under the applicable Limits of Insur- ance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. E. ADDITIONAL INSURED —PRIMARY AND NONCONTRIBUTORY SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. OTHER INSURANCE is amended for the additional insured by the addition of the following, superseding any provision to the contrary: If required by "written contract", this insurance is primary to and will not seek contribution from any other insurance maintained by an additional insured under your policy if the additional insured is a Named Insured under such other insurance. F. ADDITIONAL INSURED - DUTIES: SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS 2. DUTIES IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT are amended to add the following conditions applicable to the additional insured: An additional insured under this endorsement will as soon as practical: 1. Give us written notice of an "occurrence" or an offense which may result in a claim or "suit" under this insurance. L CA 20 31 07 12 Florists' Mutual Insurance Company - Edwardsville, Illinois Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 2. Provide us any written documentation which triggered additional insured status or waiver of recovery rights. 3. Provide us copies of all legal papers received and otherwise cooperate with us in the investi- gation, defense or settlement of the claim or suit". We have no duty to defend or indemnify an addi- tional insured under this endorsement until we re- ceive written notice of a claim or "suit" from the ad- ditional insured. G. ADDITIONAL INSURED — DEFINITIONS: SECTION V — DEFINITIONS is amended for this endorsement by the addition of the following: 1. "Written contract" means a written contract or written agreement that requires you to make a person or organization an additional insured on this Coverage Part, provided the written contract or written agreement: (a) Is effective during the term of this Cover- age Part; and (b) Was signed by you prior to the "bodily inju- ry", "property damage" or "personal and advertising injury" offense applicable to this Coverage Part; and (c) Pertains to your ongoing operations or ..your work" included in the "products - completed operations hazard" for the addi- tional insured. 2. The definition of "insured contract" is modified for the additional insured as follows: Paragraph f. of the "insured contract" definition does not apply to "bodily injury" or "property damage" included within the "products - com- pleted operations hazard" unless required by the "written contract". H. BLANKET WAIVER OF SUBROGATION SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer Of Rights Of Recovery Against Others To Us is amended by the addition of the following: We waive any right of subrogation we may have against any person(s) or organization(s) with whom you have signed a written contract or written agree- ment that requires such a waiver. This waiver applies only if the written contract or written agreement is: 1. Signed by you prior to the "bodily injury", "prop- erty damage" or "personal and advertising inju- ry" offense applicable to this Coverage Part and; 2. Effective during the term of this Coverage Part and is an "insured contract" and; 3. Applicable to your ongoing operations or "your work" included in the "products -completed op- erations hazard". L CA 20 31 07 12 Florists' Mutual Insurance Company - Edwardsville, Illinois Page 3 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 03 13 C (Ed. 7-09) 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 $ Schedule Any person or organization that you perform work for that is liable for an injury, covered by this policy, that prior to the injury has written contract requiring a waiver of our right to recover from them. Person or Organization Job Description This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise slated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. WCV5504144 Endorsement No, Insured PWLC II, Inc. Insurance Company Countersigned by WC 99 03 13 C (Ed. 7-09)