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19-050 G. Bortolotto & Co., Inc., Pavement Maintenance Phase 1 Project Contract
This public works contract("Contract") is entered into by and between the City of Cupertino
("City"), a municipal corporation, and G..Bortolotto&Co., Inc. ("Contractor"), for work on the 2019
Pavement Maintenance Phase 1 Project("Project").
The parties agree as follows:
1. Award of Contract. In response to the Notice Inviting Bids, Contractor has submitted a
Bid Proposal and accompanying Bid Schedule, a copy of which is attached for convenience
as Exhibit A, to perform the Work to construct the Project. On February 19, 2019, City
authorized award of this Contract to Contractor for the amount set forth in Section 4 below.
2. Contract Documents. The Contract Documents incorporated into this Contract include
and are comprised of all of the following:
2.1 Notice Inviting Bids;
2.2 Instructions to Bidders;
2.3 Addenda, if any;
2.4 Bid Proposal and attachments thereto;
2.6 Contract;
2.6 Payment Bond, Performance Bond and, if required, a Warranty Bond;
2.7 General Conditions;
2.8 Special Conditions;
2.9 Project Drawings and Specifications;
2.10 Change Orders, if any;
2.11 Notice of Award;
2.12 Notice to Proceed;
2.13 City of Cupertino Standard Details; and
2.14 The following: Location Map
3. Contractor's Obligations. Contractor will perform all of the Work required for the Project,
as specified in the Contract Documents. Contractor must provide,furnish, and supply all
things necessary and incidental for the timely performance and completion of the Work,
including all necessary labor, materials, supplies, tools, equipment, transportation, and
utilities, unless otherwise specified in the Contract Documents. Contractor must use its best
efforts to complete the Work in a professional and expeditious manner and to meet or
exceed the performance standards required by the Contract Documents.
4. Payment. As full and complete compensation for Contractor's timely performance and
completion of the Work in strict accordance with the terms and conditions of the Contract
Documents, City will pay Contractor$2,584,568.12 ("Contract Price")for all of Contractor's
direct and indirect costs to perform the Work, including all labor, materials, supplies,
equipment, taxes, insurance, bonds and all overhead costs, in accordance with the
payment provisions in the General Conditions.
5. Time for Completion. Contractor will fully complete the Work for the Project within 100
working days from the commencement date given in the Notice to Proceed ("Contract
Time"). By signing below, Contractor expressly waives any claim for delayed early
completion.
6. Liquidated Damages. If Contractor fails to complete the Work within the Contract Time,
City will assess liquidated damages in the amount of$1000.00 per day for each day of
2019 Pavement Maintenance Phase 1 CONTRACT
Project No. 2019-103 Page 2
unexcused delay in completion, and such liquidated damages may be deducted from City's
payments due or to become due to Contractor under this Contract.
7. Labor Code Compliance.
7.1 General. This Contract is subject to all applicable requirements of Chapter 1 of
Part 7 of Division 2 of the Labor Code, including requirements pertaining to wages,
working hours and workers' compensation insurance.
7.2 Prevailing Wages. This Project is subject to the prevailing wage requirements
applicable to the locality in which the Work is to be performed for each craft,
classification or type of worker needed to perform the Work, including employer
payments for health and welfare, pension, vacation, apprenticeship and similar
purposes. Copies of these prevailing rates are available online at
httr)://www.dir.ca.aov/DLSR.
7.3 DIR Registration. City may not enter into the Contract with a bidder without proof
that the bidder and its Subcontractors are registered with the California Department
of Industrial Relations to perform public work under Labor Code section 1725.5,
subject to limited legal exceptions.
8. Workers' Compensation Certification. Under Labor Code section 1861, by signing this
Contract, Contractor certifies as follows: "I am aware of the provisions of Labor Code
section 3700 which require every employer to be insured against liability for workers'
compensation or to undertake self-insurance in accordance with the provisions of that
code, and I will comply with such provisions before commencing the performance of the
Work on this Contract."
9. Conflicts of Interest. Contractor, its employees, Subcontractors and agents, may not
have, maintain or acquire a conflict of interest in relation to this Contract in violation of any
City ordinance or policy or in violation of any California law, including under Government
Code section 1090 et seq. and under the Political Reform Act as set forth in Government
Code section 81000 et seq. and its accompanying regulations. No officer, official,
employee, consultant, or other agent of the City("City Representative") may have,
maintain, or acquire a"financial interest"in the Contract, as that term is defined under the
Political Reform Act(Government Code section 81000, et seq., and regulations
promulgated thereunder); or under Government Code section 1090, et seq.; or in violation
of any City ordinance or policy while serving as a City Representative or for one year
thereafter.Any violation of this Section constitutes a material breach of the Contract.
10. Independent Contractor. Contractor is an independent contractor under this Contract and
will have control of the Work and the means and methods by which it is performed. Contractor
and its Subcontractors are not employees of City and are not entitled to participate in any health,
retirement, or any other employee benefits from City.
2019 Pavement Maintenance Phase 1 CONTRACT
Project No. 2019-103 Page 3
11. Notice. Any notice, billing, or payment required by or pursuant to the Contract Documents
must be made in writing, signed, dated and sent to the other party by personal delivery,
U.S. Mail, a reliable overnight delivery service, or by email as a PDF (or comparable)file.
Notice is deemed effective upon delivery unless otherwise specified. Notice for each party
must be given as follows:
City:
Name: City of Cupertino
Address: 10300 Torre Avenue
City/State/Zip: Cupertino, CA 95014
Phone: 408-777-3245
Attn: Director of Public Works
Email:joannej@cupertino.org
Copy to: pwinvoices@cupertino.org
Contractor:
Name: G. Bortolotto&Co.. Inc.
Address:582 Bragato Road
City/State/Zip:San Carlos, CA 94070-6227
Phone(650) 595-2591
Attn: Robert Bortolotto
Email: gbort@pacbell.net
Copy to:
12. General Provisions.
12.1 Assignment and Successors. Contractor may not assign its rights or obligations
under this Contract, in part or in whole,without City's written consent. This
Contract is binding on Contractor's and City's lawful heirs, successors and
permitted assigns.
12.2 Third Party Beneficiaries. There are no intended third party beneficiaries to this
Contract except as expressly provided in the General Conditions or Special
Conditions.
12.3 Governing Law and Venue. This Contract will be governed by California law and
venue will be in the Superior Court of Santa Clara County, and no other place.
12.4 Amendment. No amendment or modification of this Contract will be binding
unless it is in a writing duly authorized and signed by the parties to this Contract.
12.5 Integration. This Contract and the Contract Documents incorporated herein,
including authorized amendments or Change Orders thereto, constitute the final,
complete, and exclusive terms of the agreement between City and Contractor.
12.6 Severability. If any provision of the Contract Documents, or portion of a provision,
is determined to be illegal, invalid, or unenforceable, the remaining provisions of
the Contract Documents will remain in full force and effect.
12.7 Authorization. Each individual signing below warrants that he or she is authorized
to do so by the party that he or she represents, and that this Contract is legally
2019 Pavement Maintenance Phase 1 CONTRACT
Project No. 2019-103 Page 4
binding on that party. If Contractor is a corporation, signatures from two officers of
the corporation are required pursuant to California Corporation Code section 313.
[Signatures are on the following page.]
2019 Pavement Maintenance Phase 1 CONTRACT
Project No. 2019-103 Page 5
The parties agree to this Contract as witnessed by the signatures below:
CONTRACTOR
CITY OF CUPERTINO
G�/Bortolotto&Co., Inc. A Municipal Corporation
B /)) �- By —
Ngme�t Bortolotto i imm Borden/
Title President irector of Publi Wor
Date February 25. 2019 Date 3�
,
By—A-- Z�
Name Gary Bortolotto
Title S ecret ary
Date February 25, 2019
APPROVED AS TO FORM:
By
Name <<,t .e� on. d►�,nrec'
City Attorney`' t CA
Date
ATTEST:,
Grace Schmidt
,;,-Grace
Clerk
Date Lf�R /I
Contract Amount:45 S4-, Vic¢
P.O. No.
Account No.�CL 1--%.
END OF CONTRACT
2019 Pavement Maintenance Phase 1 CONTRACT
Project No. 2019-103 Page 6
Premium: $13 , 881 . 00 Bond No: 12166466
Performance Bond
The City of Cupertino ("City") and G. Bortolotto&Co., Inc. ("Contractor") have entered into a
contract, dated February 26 , 2019 ("Contract")for work on the 2019 Pavement Phase
1 Project ("Project"). The Contract is incorporated by reference into this Performance Bond
("Bond").
The Guarantee Company of
1. General. Under this Bond, Contractor as Principal and North America USA
its surety("Surety"), are bound to City as obligee for an amount not less than
$2,584,568.12. By executing this Bond, Contractor and Surety bind themselves and their
respective heirs, executors, administrators, successors and assigns,jointly and severally,
to the provisions of this Bond.
2. Surety's Obligations. If Contractor fully performs its obligations under the Contract,
including its warranty obligations under the Contract, and Contractor has timely provided a
warranty bond as required under the Contract. Surety's obligations under this Bond will
become null and void upon City's acceptance of the Project, excluding any exceptions to
acceptance, if any. Otherwise Surety's obligation will remain in full force and effect until
expiration of the one year warranty period under the Contract.
3. Waiver. Surety waives any requirement to be notified of and further consents to any
alterations to the Contract made under the applicable provisions of the Contract
Documents, including changes to the scope of Work or extensions of time for performance
of Work under the Contract. Surety waives the provisions of Civil Code sections 2819 and
2845.
4. Application of Contract Balance. Upon making a demand on this Bond, City will make
the Contract Balance available to Surety for completion of the Work under the Contract.
For purposes of this provision,the Contract Balance is defined as the total amount payable
by City to Contractor as the Contract Price minus amounts already paid to Contractor, and
minus any liquidated damages, credits, or back charges to which City is entitled under the
terms of the Contract.
5. Contractor Default. Upon written notification from City that Contractor is in default under
Article 13 of the Contract General Conditions, time being of the essence, Surety must act
within the time specified in Article 13 to remedy the default through one of the following
courses of action:
6.1 Arrange for completion of the Work under the Contract by Contractor, with City's
consent, but only if Contractor is in default solely due to its financial inability to complete the
Work;
6.2 Arrange for completion of the Work under the Contract by a qualified contractor
acceptable to City,and secured by performance and payment bonds issued by an admitted
surety as required by the Contract Documents, at Surety's expense; or
5.3 Waive its right to complete the Work under the Contract and reimburse City the
amount of City's costs to have the remaining Work completed.
6. Surety Default. If Surety defaults on its obligations under the Bond, City will be entitled to
recover all costs it incurs due to Surety's default, including legal, design professional, or
delay costs.
7. Notice. Any notice to Surety may be given in the manner specified in the Contract and
sent to Surety as follows:
2019 Pavement Maintenance Phase 1 PERFORMANCE BOND
Project No. 2019-103
Attn: Kevin Chambers
Address: 1900 Sutter St_ , Ste 880
City/State/Zip: Concord CA 94520
Phone: (925) 566-6040
Fax: (925) 566-6045
Email: kchambers@gcna.com
8. Law and Venue. This Bond will be governed by California law, and any dispute pursuant
to this Bond will be venued in the Superior Court for Santa Clara County in which the
Project is located, and no other place. Surety will be responsible for City's attorneys'fees
and costs in any action to enforce the provisions of this Bond.
9. Effective Date; Execution.This Bond is entered into and effective on
February 26 , 20 19.
SURETY: The Guarantee Company of North America USA
Business Name
s/
Mary Baez, Attorney—in—Fact
Name/Title[print]
(Acknowledgment with Notary Seal for Surety and Surety's Power of Attorney must be attached.)
CONTRACTOR: G. Bortolotto & Co. , Inc.
Business Name
s/
Robert Bortolotto / President
IJa ne/Titl
s/ _
Gary Bo tolotto / Secretary
Name/Title
END OF PERFORMANCE BOND
2019 Pavement Maintenance Phase 1 PERFORMANCE BOND
Project No. 2019-103
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California )
County of San Mateo )
On February 26, 2019 before me, Deborah M. Knipp, Notary Public
Date Here Insert Name and Title of the Officer
personally appeared Mary Baez
Name(s)of Signer(s)
who proved to me on the basis of satisfactory evidence to be the personx whose name( is/XX
subscribed to the within instrument and acknowledged to me that p((she/ )(executed the same in
)(iX/her/XXXauthorized capacity(KX,and that by NXher/)WXsignature(4 on the instrument the person%,
or the entity upon behalf of which the person(,1(} acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
DEBORAH M.KNIPP i WITNESS my hand and official seal.
COMM. #2151035 z
i b Notary Public -California o
San Mateo County Signature
M Comm.Ex Tres Ma Z6,2020 Signature of tary ublic
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Document Date:
Number of Pages: Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑ Corporate Officer — Title(s): ❑Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ Limited ❑General
❑ Individual N Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Other:
Signer Is Representing: Signer Is Representing:
..... -. _
02014 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907
'K VCN,c3ln,,3 Tofto,i Oy
Premium: Included Bond No: 12166466
Payment Bond
The City of Cupertino ("City") and G. Bortolotto&Co., Inc. ("Contractor") have entered into a
contract, dated February 2 6 , 20 19 ("Contract") for work on the 2019 Pavement
Maintenance Phase 1 Project("Project"). The Contract is incorporated by reference into this
Payment Bond ("Bond").
The Guarantee Company of
1. General. Under this Bond, Contractor as principal and North America USA
its surety("Surety"), are bound to City as obligee in an amount not less than$2,584,568,12,
under California Civil Code sections 9550, et seq.
2. Surety's Obligation. If Contractor or any of its Subcontractors fails to pay a person
authorized in California Civil Code section 9100 to assert a claim against a payment bond,
any amounts due under the Unemployment Insurance Code with respect to work or labor
performed under the Contract,or any amounts required to be deducted,withheld, and paid
over to the Employment Development Department from the wages of employees of
Contractor and its Subcontractors, under California Unemployment Insurance Code section
13020,with respect to the work and labor, then Surety will pay the obligation.
3. Beneficiaries. This Bond inures to the benefit of any of the persons named in California
Civil Code section 9100, so as to give a right of action to those persons or their assigns in
any suit brought upon this Bond. Contractor must promptly provide a copy of this Bond
upon request by any person with legal rights under this Bond.
4. Duration. If Contractor promptly makes payment of all sums for all labor, materials, and
equipment furnished for use in the performance of the Work required by the Contract, in
conformance with the time requirements set forth in the Contract and as required by
California law, Surety's obligations under this Bond will be null and void. Otherwise,
Surety's obligations will remain in full force and effect.
5. Waivers. Surety waives any requirement to be notified of alterations to the Contract or
extensions of time for performance of the Work under the Contract. Surety waives the
provisions of Civil Code sections 2819 and 2845. City waives the requirement of a new
bond for any supplemental contract under Civil Code section 9550. Any notice to Surety
may be given in the manner specified in the Contract and delivered or transmitted to Surety
as follows:
Attn: Kevin Chambers
Address: 1800 Sutter St. , Suite 880
City/State/Zip: Concord CA 94520
Phone: (925) 566-6040
Fax: (925) 566-6045
Email: kchambers@acna.com
6. Law and Venue. This Bond will be governed by California law, and any dispute pursuant
to this Bond will be venued in the Superior Court of Santa Clara County in which the Project
is located, and no other place. Surety will be responsible for City's attorneys'fees and
costs in any action to enforce the provisions of this Bond.
2019 Pavement Maintenance Phase 1 PAYMENT BOND
Project No. 2019-103
7. Effective Date; Execution. This Bond is entered into and is effective on February , 6
2019
SURETY: The Guarantee Company of North America USA
Business Name
s/
Mary Baez, Attorney—in—Fact j
Name/Title
(Acknowledgment with Surety's Notary Seal and Surety's Power of Attorney must be attached.)
CONTRACTOR: G, Bortolotto & Co. , Inc.
Business Name
Robert Bortolotto / President
Name/Tit e
Gary Bortolotto / Secretary
Nameditle
END OF PAYMENT BOND
2019 Pavement Maintenance Phase 1 PAYMENT BOND
Project No. 2019-103
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
GC'.�l'.c�6'.c=:C`.c-:f('`C'.�-K`.cC`.c�f'.�fIF!)F F`.F i^.FF`..�.Fc�c=�.,F�,sfY,c-E1,cF`,cA'.c"cY,cA,�-N,F(.�2c=•law-N,=�.=K.�.Flrn��,i;�v.�.,�-n�.Nr....r`
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California )
County of San Mateo )
On February 26, 2019 before me, Deborah M. Knipp, Notary Public
Date Here Insert Name and Title of the Officer
personally appeared Mary Baez
Name(s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the personx whose name( is/XX
subscribed to the within instrument and acknowledged to me that A0�31ne/ xexecuted the same in
X(iX/her/ Xauthorized capacity(Xg, and that by XXher/)MXsignature(4 on the instrument the person(,
or the entity upon behalf of which the person() acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
DEBORAH M. KNIPP WITNESS my hand and official seal.
COMM. #2151035 z
Notary Public-California z
z San Mateo County
M Comm.Expires May 26,2020 Signature
Signature of 4etary ublicU—V
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Document Date:
Number of Pages: Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑Corporate Officer — Title(s): ❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ Limited ❑General
❑ Individual N Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑ Guardian or Conservator
❑Other: ❑ Other:
Signer Is Representing: Signer Is Representing:
02014 National Notary Association -www.NationaiNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907
THE The Guarantee Company of.North America USA
f UARANTEEm Southfield,Michigan
POWER OF ATTORNEY
KNOW ALL BY THESE PRESENTS:That THE GUARANTEE COMPANY OF NORTH AMERICA USA,a corporation organized and existing under the
laws of the State of Michigan,having its principal office in Southfield, Michigan,does hereby constitute and appoint
Gregory McCartney,Steve Suissa,Mary Baez
James E.McGovern,Inc.
its true and lawful attorney(s)-in-fact to execute,seal and deliver for and on its behalf as surety,any and all bonds and undertakings,contracts of indemnity
and other writings obligatory in the nature thereof,which are or may be allowed,required or permitted by law,statute,rule,regulation,contract or otherwise.
The execution of such instrument(s)in pursuance of these presents,shall be as binding upon THE GUARANTEE COMPANY OF NORTH AMERICA USA
as fully and amply,to all intents and purposes,as if the same had been duly executed and acknowledged by its regularly elected officers at the principal
office.
The Power of Attorney is executed and may be certified so,and may be revoked,pursuant to and by authority of Article IX, Section 9.03 of the By-Laws
adopted by the Board of Directors of THE GUARANTEE COMPANY OF NORTH AMERICA USA at a meeting held on the 31s'day of December,2003.
The President,or any Vice President,acting with any Secretary or Assistant Secretary,shall have power and authority:
1. To appoint Attorney(s)-in-fact,and to authorize them to execute on behalf of the Company,and attach the Seal of the Company thereto, bonds
and undertakings,contracts of indemnity and other writings obligatory in the nature thereof;and
2. To revoke,at any time,any such Attorney-in-fact and revoke the authority given,except as provided below
3. In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and authority hereby given
to the Attorney-in-Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and
construction contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida
Department of Transportation making payment of the final estimate to the Contractor and/or its assignee,shall not relieve this surety company
of any of its obligations under its bond.
4. In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given to
the Attorney-in-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner—
Department of Highways of the Commonwealth of Kentucky at least thirty(30)days prior to the modification or revocation.
Further,this Power of Attorney is signed and sealed by facsimile pursuant to resolution of the Board of Directors of the Company adopted at a meeting
duly called and held on the 6th day of December 2011,of which the following is a true excerpt:
RESOLVED that the signature of any authorized officer and the seal of the Company may be affixed by facsimile to any Power of Attorney or certification
thereof authorizing the execution and delivery of any bond, undertaking, contracts of indemnity and other writings obligatory in the nature thereof, and
such signature and seal when so used shall have the same force and effect as though manually affixed.
J�a+rcD IN WITNESS WHEREOF,THE GUARANTEE COMPANY OF NORTH AMERICA USA has caused this instrument to be signed and
° its corporate seal to be affixed by its authorized officer,this 2"d day of October,2015.
�:•/I
�� THE GUARANTEE COMPANY OF NORTH AMERICA USA
niAe 1
STATE OF MICHIGAN Stephen C.Ruschak,President&Chief Operating Officer Randall Musselman,Secretary
County of Oakland
On this 2nd day of October,2015 before me came the individuals who executed the preceding instrument,to me personally known,and being by me duly
sworn, said that each is the herein described and authorized officer of The Guarantee Company of North America USA; that the seal affixed to said
instrument is the Corporate Seal of said Company; that the Corporate Seal and each signature were duly affixed by order of the Board of Directors of
said company.
Cynthia A. Takai IN WITNESS WHEREOF,I have hereunto set my hand at The Guarantee
Notary Public,State of Michigan Company of North America USA offices the day and year above written.
County of Oakland
L }c ? My Commission Expires February 27,2024 J
Acting in Oakland County
I,Randall Musselman,Secretary of THE GUARANTEE COMPANY OF NORTH AMERICA USA,do hereby certify that the above and foregoing is a true
and correct copy of a Power of Attorney executed by THE GUARANTEE COMPANY OF NORTH AMERICA USA,which is still in full force and effect.
_yNTef� IN WITNESS WHEREOF,I have thereunto set m�yj handand attached
ta the s�aal of said Company this 26th day of February ,-2019
P
�NA Randall Musselman,Secretary
Ac`cw& CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
2/26/2019
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).
CONTACT
PRODUCER James E. McGovern, Inc. NAME: James E.McGovern, Inc.
1625 El Camino Real PHONE FAX
Belmont, CA 94002 vc No Ext: 650-593-8216 A/c No: 650-594-9130
E-MAIL
ADDRESS:
INSURERS AFFORDING COVERAGE NAIC#
www.jemins.com INSURERA: Everest National Insurance Comp A+ XV 10120
INSURED INSURER B:
G. Bortolotto& Company, Inc.
582 Bragato Road INSURER C:
San Carlos CA 94070 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 47234849 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 REDUCED BY PAID CLAIMS.
INSR ADDL SUER POLICY EFF POLICY EXP
TYPE OF INSURANCE
LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGETO RENTED
CLAIMS-MADE OCCUR PREMISES Ea occurrence $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PRO-
POLICY JECT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED JURY Per accident
AUTOS ONLY AUTOS BODILY IN ( ) $
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
DED I I RETENTION$ ��! $
A WORKERS COMPENSATION �� 760001816181' 8/21/2018 8/21/201 9V � STATUTE OTH
AND EMPLOYERS'LIABILITYER
ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? ❑ NIA
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under 1 000 000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1 000 000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
RE:Work performed @ 2019 Pavement Maintenance Phase 1 Project Proj#2019-103/#19-785
*30 day written Notice of Cancellation,except for non-pay of premium which is 10 days. V
CERTIFICATE HOLDER CANCELLATION
City of Cupertino SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Hall p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
000 Torre Avenue
Cupertino CA 95014
AUTHORIZED REPRESENTATIVE
Steve Suissa
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
47234849 1 BORTO-1 1 18/19 - WC MaryAnn Worman 12/26/2019 9:45:08 AM (PST) Page 1 of 2
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
enfprce 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 contact 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 worts described In the Schedule.
The additional premium for this endorsement shall be 2%of the California workers'compensation premium
otherwise due on such remuneration.
SCHEDULE
PERSON OR ORGANIZATION JOB DESCRIPTION
ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION
NAMED INSURED HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THIS WAIVER
City of Cupertino,its directors,officers,engineers,agents and employees
This endorsement changes the policy to which it is attached and Is effective on the data Issued unless otherwise stated.
(The information below Is required only when this endomement Is issued subsequent to preparation of the poficy)
Endorsement Effective Policy Policy No600018161 81 Endorsement No.
Insured: G.Bortolotto&Company,Inc. Premium$INCL
Insurance Company EVEREST NATIONAL INSURANC----
lam•[ "�.
Countersigned By:
-1998 by the Workers'Compensation lnsurance.Rating Bureau of California.All rights reserved.
From the WCIRB's California Workers'Compensation Insurance Forms Manual-1999.
47234849 HORTO-1 18/19 - WC MaryAnn Worman 2/26/2019 9:45:08 AM (PST) Page 2 of 2
® DATE(MM/DD/YYYY)
A6Cr RLII CERTIFICATE OF LIABILITY INSURANCE
2/25/2019
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).
GONT IT
PRODUCER NAME: Pat Ellis
Dorsey, Hazeltine & Wynne PHONE (650)858-2375 FAXExit: ,No; 1ssoless-lozd
License # : 0281413 ADDRESS:pellis@dhw-ins.com
155 Bovet Road, Suite 515 INSURERS AFFORDING COVERAGE NAIC p
San Mateo CA 94402 INSURERA:The Travelers Indemnity Co. CT *J 25682
INSURED INSURER B:Travelers Prop Cas Co. of America kk 25674
G. BOrtolotto 6 Co., Inc. INSURER C:
582 Bragato Road INSURERD:
INSURER E:
San Carlos CA 94070 INSURER F:
COVERAGES CERTIFICATE NUMBER:16/19 All Lines but WC 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 REDUCED BY PAID CLAIMS.
INSR ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MMIODIYYYY MM/DDIYYYY
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
DAMA ETORENTED A CLAIMS-MADE ❑X OCCUR / 1/-PREMISES Ea occurrence $ 300,000
X PPA limit applies if X Y DT22-CO-OF027488-TCT-18,�// 8/21/2018 8/21/2019" MED EXP(Any one person) S 5,000
required by contract PERSONAL&ADV INJURY S 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY JECT ❑LOC PRODUCTS-COMP/OPAGG S 2,000,000
OTHER: Deductible $ 5,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Per person) S
A ALL OWNED SCHEOULED X Y I
AUTOS AUTOS DT-810-0F027488-TCT-iB B/21/2018 8/21/2019 iBODILY INJURY(Per accident) S
NON-OWNED PROPERTY DAMAGE S
HIREDAUTOS AUTOS Per accident
Deductible S
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 8,000 000
B EXCESS IJAB CLAIMS-MADE AGGREGATE S 8,000,000
DED I X I RETENTION S 10,000 1 ICUP-BJ389352-18-26 8/21/2018 8/21/20191/ $
WORKERS COMPENSATION PER OTH-
ANDEMPLOYERS'LIABILITY YIN TATU7E ER
ANY PROPRIETORIPARTNERIEXECUTIVE ❑N/A E.L.EACH ACCIDENT S
/M OFFICEREMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S
Ifyas,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
RE: G Bortolotto Job #19-785 1 City of Cupertino 1 2019 Pavement Maintenance Phase 1 Project I City
Project No. 2019-103
As required by written contract: City of Cupertino, its City Council, officers, officials, employees, /
agents, servants and volunteers are named as additional insured with respects to General Liability and t /
Auto Liability. Primary wording applies. Per project aggregate limit applies. Umbrella follows General VVV
Liability and Auto Liability form. Waiver of Subrogation applies to General Liability and Auto Liability.
CERTIFICATE HOLDER CANCELLATION
joannej@cupertino.org
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Cupertino THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Attn: Director of Public Works ACCORDANCE WITH THE POLICY PROVISIONS.
10300 Torre Avenue
AUTHORIZED REPRESENREPRESENTATIVECupertino, CA 95014
Kayla Kerr/KK
©1988-2014 ACORD CORPORATION. All rights reserve
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD q
INS025(201401)
71cy No.DT22-CO-OF027488-TCT-18
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
BLANKET ADDITIONAL INSURED
(CONTRACTORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. WHO IS AN INSURED—(Section II) is amended c) The insurance provided to the additional in-
to include any person or organization that you sured does not apply to "bodily injury" or
agree in a "written contract requiring insurance" "property damage" caused by "your work"
to include as an additional insured on this Cover- and included in the "products-completed op-
age Part, but: erations hazard" unless the "written contract
a) Only with respect to liability for"bodily injury", requiring insurance" specifically requires you
"property damage"or"personal injury';and to provide such coverage for that additional
insured, and then the insurance provided to
b) If, and only to the extent that, the injury or the additional insured applies only to such
damage is caused by acts or omissions of "bodily Injury' or "property damage" that oc-
you or your subcontractor in the performance curs before the end of the period of time for
of "your work" to which the "written contract which the "written contract requiring insur-
requiring insurance" applies. The person or ance" requires you to provide such coverage
organization does not qualify as an additional or the end of the policy period, whichever is
insured with respect to the independent acts earlier.
or omissions of such person or organization. 3, The insurance provided to the additional insured
2. The insurance provided to the additional insured by this endorsement is excess over any valid and
by this endorsement is limited as follows: collectible "other insurance", whether primary,
a) In the event that the Limits of Insurance of excess, contingent or on any other basis, that is
this Coverage Part shown in the Declarations available to the additional insured for a loss we
exceed the limits of liability required by the cover under this endorsement. However, if the
"written contract requiring insurance", the in- "written contract requiring insurance" specifically
surance provided to the additional insured requires that this insurance apply on a primary
shall be limited to the limits of liability re- basis or a primary and non-contributory basis,
quired by that "written contract requiring in- this insurance is primary to "other insurance"
surance". This endorsement shall not in- available to the additional insured which covers
crease the limits of insurance described in that person or organization as a named insured
Section III—Limits Of Insurance. for such loss, and we will not share with that
b) The insurance provided to the additional in- "other insurance". But the insurance provided to
the additional insured by this endorsement still is
sured does not apply to"bodily injury", "prop- excess over any valid and collectible "other in-
erty damage" or "personal injury" arising out surance", whether primary, excess, contingent or
of the rendering of, or failure to render, any on any other basis, that is available to the addi-
professional architectural, engineering or sur- tional insured when that person or organization is
veying services, including: an additional insured under such "other insur-
I. The preparing, approving, or failing to ance".
prepare or approve, maps, shop draw- 4, As a condition of coverage provided to the
ings, opinions, reports, surveys, field or- additional insured by this endorsement:
ders or change orders, or the preparing,
approving, or failing to prepare or ap- a) The additional insured must give us written
prove,drawings and specifications;and notice as soon as practicable of an "occur-
II, Supervisory, inspection, architectural or rence" or an offense which may result in a
claim. To the extent possible, such notice
engineering activities. should include:
CG D2 46 08 05 ©2005 The St. Paul Travelers Companies, Inc. Page 1 of 2
COMMERCIAL GENERAL LIABILITY
I. How,. when and where the "occurrence" any provider of"other insurance"which would
or offense took place; cover the additional insured for a loss we
ii. The names and addresses of any injured cover under this endorsement. However,this
persons and witnesses;and condition does not affect whether the insur-
ance provided to the additional insured by
Ill. The nature and location of any injury or this endorsement is primary to 'other insur-
damage arising out of the"occurrence"or ance" available to the additional insured
offense. which covers that person or organization as a
b) if a claim is made or"suit" is brought against named insured as described in paragraph 3.
the additional insured, the additional insured above.
must: 5. The following definition is added to SECTION V.
I. Immediately record the specifics of the —DEFINITIONS:
claim or"suit"and the date received; and "Written contract requiring insurance" means
li. Notify us as soon as practicable. that part of any written contract or agreement
under which you are required to include a
The additional insured must see to it that we person or organization as an additional in-
receive written notice of the claim or suit .as sured on this Coverage Part, provided that
soon as practicable. the"bodily injury" and"property damage" oc-
c) The additional insured must immediately curs and the "personal injury" is caused by an
send us copies of all legal papers received in offense committed:
connection with the claim or"suit", cooperate a. After the signing and execution of the
with us in the investigation or settlement of contract or agreement by you;
the claim or defense against the "suit', and
otherwise comply with all policy conditions. b. While that part of the contract or
d) The additional insured must tender the de- agreement is in effect;and
fense and indemnity of any claim or "suit'to c. Before the end of the policy period.
�s
Page 2 of 2 ©2005 The St. Paul Travelers Companies,Inc. CG D246 08 05
r22-CO-OF027488-TCT-18
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTORS XTEN® ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage. However,coverage for any
injury,damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to this Coverage Part,and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover-
age description only.Limitations and exclusions may apply to these coverages.Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights,duties,and what is and is not covered.
A. Aircraft Chartered With Pilot H. Blanket Additional insured — Lessors Of Leased
B. Damage To Premises Rented To You Equipment
C. Increased Supplementary Payments 1. Blanket Additional Insured — States Or Political
Subdivisions—Permits
D. Incidental Medical Malpractice
J. Knowledge And Notice Of Occurrence Or Offense
E. Who Is An Insured— Newly Acquired Or Formed
Organizations K. Unintentional Omission
F. Who Is An Insured— Broadened Named Insured L. Blanket Waiver Of Subrogation
—Unnamed Subsidiaries M. Amended Bodily Injury Definition
G. Blanket Additional Insured — Owners, Managers N. Contractual Liability—Railroads
Or Lessors Of Premises
PROVISIONS INJURY AND PROPERTY DAMAGE LI-
A. AIRCRAFT CHARTERED WITH PILOT ABILITY:
The following is added to Exclusion g., Aircraft, Exclusions c. and g. through n. do not apply
Auto Or Watercraft,in Paragraph 2.of SECTION to "premises damage". Exclusion f.(1)(a)
I —COVERAGES—COVERAGE A BODILY IN- does not apply to"premises damage"caused
JURY AND PROPERTY DAMAGE LIABILITY: by:
This exclusion does not apply to an aircraft that a. Fire;
is: b. Explosion;
(a) Chartered with a pilot to any insured; c. Lightning;
(b) .Not owned by any insured;and d. Smoke resulting from such fire,explosion,
(c) Not being used to carry any person or prop- or lightning;or
erty for a charge. e. Water;
B. DAMAGE TO PREMISES RENTED TO YOU unless Exclusion f.of Section 1—Coverage A
1. The first paragraph of the exceptions in Ex- —Bodily Injury And Property Damage Liability
clusion j., Damage To Property, in Para- is replaced by another endorsement to this
graph 2. of SECTION I — COVERAGES — Coverage Part that has Exclusion—All Pollu-
COVERAGE A BODILY INJURY AND tion injury Or Damage or Total Pollution Ex-
PROPERTY DAMAGE LIABILITY is deleted. clusion in its title.
2. The following replaces the last paragraph of A separate limit of insurance applies to
Paragraph 2., Exclusions, of SECTION 1 — "premises damage' as described in Para-
COVERAGES _ COVERAGE A. BODILY graph 6, of SECTION III — LIMITS OF IN-
SURANCE.
CG D3 16 11 11 ©2011 The Travelers indemnity Company,Alt rights reserved. Page 1 of 6
"?s (L
COMMERCIAL GENERAL LIABILITY
3. The following replaces Paragraph 6. of SEC- C. INCREASED SUPPLEMENTARY PAYMENTS
TION III—LIMITS OF INSURANCE: 1. The following replaces Paragraph 1.b. of
Subject to S. above, the Damage To Prem- SUPPLEMENTARY PAYMENTS— COVER-
ises Rented To You Limit is the most we will AGES A AND B of SECTION I — COVER-
pay under Coverage A for damages because AGE:
of "premises damage" to any one premises. b. Up to.$2,500 for the cost of bail bonds
The Damage To Premises Rented To You required because of accidents or traffic
Limit will apply to all "property damage" law violations arising out of the use of any
proximately caused by the same "occur- vehicle to which the Bodily Injury Liability
rence", whether such damage results from: Coverage applies.We do not have to fur-
fire;explosion;lightning;smoke resulting from nish these bonds.
such fire, explosion, or lightning;or water; or 2. The following replaces Paragraph i.d. of
any combination of any of these causes. SUPPLEMENTARY PAYMENTS COVER-
The Damage To Premises Rented To You AGES A AND B of SECTION I — COVER-
Limit will be: AGES:
a. The amount shown for the Damage To d. All reasonable expenses incurred by the
Premises Rented To You Limit on the insured at our request to assist us in the
Declarations of this Coverage Part;or investigation or defense of the claim or
b. $300,000 if no amount is shown for the "suit",including actual loss of earnings up
Damage To Premises Rented To You to $500 a day because of time off from
Limit on the Declarations of this Coverage work.
Part. D. INCIDENTAL MEDICAL MALPRACTICE
4. The following replaces Paragraph a.. of the 1. The following is added to the definition of"oc-
definition of"insured contract" in the DEFINI- currence"in the DEFINITIONS Section:
TIONS Section: "Occurrence"also means an act or omission
a. A contract for a lease of premises. How- committed in providing or failing to provide
ever, that portion of the contract for a "incidental medical services", first aid or
lease of premises that indemnifies any "Good Samaritan services"to a person.
person or organization for "premises 2, The following is added to Paragraph 2.a.(1)of
damage"is not an"insured contract"; SECTION II—WHO IS AN INSURED:
5. The following is added to the DEFINITIONS Paragraph (1)(d) above does not apply to
Section: "bodily injury"arising out of providing or fail-
"Premises damage" means "property dam- ing to provide:
age"to: (i) "Incidental medical services" by any of
a. Any premises while rented to you or tem- your "employees" who is a nurse practi-
porarily occupied by you with permission tioner,registered nurse,licensed practical
of the owner,or nurse, nurse assistant, emergency medi-
b. The contents of any premises while such cal technician or paramedic;or
premises is rented to you,if you rent such (il) First aid or"Good Samaritan services" by
premises for a period of seven or fewer any of your "employees" or "volunteer
consecutive days. workers", other than an employed or vol-
S. The following replaces Paragraph 4.b.(1)(b) unteer doctor. Any such "employees" or
of SECTION 1V—COMMERCIAL GENERAL "volunteer workers" providing or failing to
LIABILITY CONDITIONS: provide first aid or"Good Samaritan ser-
(b) That is insurance for"premises damage"; vices"during their work hours for you will
or be deemed to be acting within the scope
7. Paragraph 4.b.(1)(c) of SECTION IV — of their employment by you or performing
COMMERCIAL GENERAL LIABILITY CON- duties related to the conduct of your busi-
DITIONS is deleted. ness.
IJ E_
Page 2 of 6 ®2011 The Travelers Indemnity Company.All rights reserved. CG D3 16 1111
COMMERCIAL GENERAL LIABILITY
3. The following is added to Paragraph 5. of 4. Any organization you newly acquire or form,
SECTION III—LIMITS OF INSURANCE; other than a partnership,joint venture or lim-
For the purposes of determining the applica- ited liability company, of which you are the
ble Each Occurrence Limit, all related acts or sole owner or in which you maintain the ma-
omissions committed in providing or failing to jority ownership interest, will qualify as a
provide "incidental medical services", first aid Named Insured if there is no other insurance
or"Good Samaritan services"to any one per- which provides similar coverage to that Or-
son will be deemed to be one"occurrence". ganization.However:
4. The following exclusion is added to Para- a. Coverage under this provision is afforded
graph 2., Exclusions, of SECTION I—COV- only:
ERAGES—COVERAGE A BODILY INJURY (1) Until the 180th day after you acquire or
AND PROPERTY DAMAGE LIABILITY: form the organization or the end of the
Sale Of Pharmaceuticals policy period,whichever is earlier, if you
"Bodily injury" or "property damage" arising do not report such organization in writing
out of the willful violation of a penal statute or to us within 180 days after you acquire or
ordinance relating to the sale of pharmaceuti- form it;or
cals committed by, or with the knowledge or (2) Until the end of the policy period, when
consent of, the insured. that date is later than 180 days after you
5. The following is added to the DEFINITIONS acquire or form such organization, if you
Section: report such organization in writing to us
"Incidental medical services"means: within 180 days after you acquire or form
a. Medical,surgical,dental,laboratory,x-ray it, and we agree in writing that it will con-
or nursing service or treatment, advice or tinue to be a Named Insured until the end
instruction, or the related furnishing of of the policy period;
food or beverages;or b. Coverage A does not apply to "bodily injury"
b. The furnishing or dispensing of drugs or or "property damage" that occurred before
medical, dental, or surgical supplies or you acquired or formed the organization;and
appliances. c. Coverage B does not apply to "personal in-
"Good Samaritan services"means any emer- jury" or "advertising injury" arising out of an
gency medical services for which no compen- offense committed before you acquired or
sation is demanded or received. formed the organization.
6. The following is added to Paragraph 4.b., Ex- F. WHO IS AN INSURED—BROADENED NAMED
cess Insurance, of SECTION IV — COM- INSURED—UNNAMED SUBSIDIARIES
MERCIAL GENERAL LIABILITY CONDI-
TIONS: The following is added to SECTION !t—WHO IS
AN INSURED:
The insurance is excess over any valid and
collectible other insurance available to the in- Any of your subsidiaries,other than a partnership,
sured,whether primary, excess, contingent or joint venture or limited liability company, that is
on any other basis,that is available to any of not shown as a Named Insured in the Declara-
your "employees" or "volunteer workers" for tions is a Named Insured if you maintain an own
"bodily injury" that arises out of providing or ership interest of more than 50% in such subsidi-
failing to provide "incidental medical ser- ary on the first day of the policy period.
vices",first aid or"Good Samaritan services" No such subsidiary is an insured for"bodily injury"
to any person to the extent not subject to or"property damage"that occurred, or"personal
Paragraph 2.a.(1) of Section II —Who Is An injury" or "advertising injury" caused by an of-
Insured: fense committed after the date, if any, during the
E. WHO IS AN INSURED — NEWLY ACQUIRED policy period, that you no longer maintain an
OR FORMED ORGANIZATIONS ownership interest of more than 50%in such sub-
The following replaces Paragraph 4.of SECTION sidiary.
11--WHO IS AN INSURED:
CG D3 16 11 11 0 2011 The Travelers lndemnity Company.All rights reserved. Page 3 of 6
COMMERCIAL GENERAL LIABILITi'
G. BLANKET ADDITIONAL INSURED—OWNERS, H. BLANKET ADDITIONAL INSURED—LESSORS
MANAGERS OR LESSORS OF PREMISES OF LEASED EQUIPMENT
The following is added to SECTION II—WHO IS The following is added to SECTION Ii—WHO IS
AN INSURED: AN INSURED:
Any person or organization that is a premises Any person or organization that is an equipment
owner, manager or lessor and that you have lessor and that you have agreed in a written con-
agreed in a written contract or agreement to in- tract or agreement to include as an insured on
clude as an additional insured on this Coverage this Coverage Part is an insured, but only with re-
Part is an insured, but only with respect to liability spect to liability for"bodily injury", "property dam-
for "bodily injury", "property damage", "personal age","personal injury"or"advertising injury"that:
injury"or"advertising injury"that: a. Is "bodily injury" or "property damage" that
a. Is "bodily injury" or "property damage" that occurs, or is "personal injury" or "advertising
occurs, or is "personal injury" or "advertising injury" caused by an offense that is commit-
injury" caused by an offense that is commit- ted, subsequent to the execution of that con-
ted, subsequent to the execution of that con- tract or agreement;and
tract or agreement;and
b. Is caused,in whole or in part, by your acts or
b. Arises out of the ownership, maintenance or omissions in the maintenance, operation or
use of that part of any premises leased to use of equipment leased to you by such
you. equipment lessor.
The insurance provided to such premises owner, The insurance provided to such equipment lessor
manager or lessor is subject to the following pro- is subject to the following provisions:
visions: a. The limits of insurance provided to such
a. The limits of insurance provided to such equipment lessor will be the minimum limits
premises owner, manager or lessor will be which you agreed to provide in the written
the minimum limits which you agreed to pro- contract or agreement,or the limits shown on
vide in the written contract or agreement, or the Declarations,whichever are less.
the limits shown on the Declarations, which- b. The insurance provided to such equipment
ever are less. lessor does not apply to any"bodily injury"or
b. The insurance provided to such premises "property damage" that occurs, or "personal
owner,manager or lessor does not apply to: injury"or"advertising injury"caused by an of-
(1) Any "bodily injury" or "property damage" fense that is committed, after the equipment
that occurs,or"personal injury"or"adver- lease expires.
tising injury"caused by an offense that is c. The insurance provided to such equipment
committed,after you cease to be a tenant lessor is excess over any valid and collectible
in that premises;or other insurance available to such equipment
(2) Structural alterations,new construction or lessor, whether primary, excess, contingent
demolition operations performed by or on or on any other basis, unless you have
behalf of such premises owner, lessor or agreed in the written contract or agreement
manager. that this insurance must be primary to, or
c. The insurance provided to such premises non-contributory with, such other insurance,
in which case this insurance will be primary
owner,manager or lesser is excess over any to, and non-contributory with, such other in-
valid and collectible other insurance available surance.
to such premises owner, manager or lessor,
whether primary, excess, contingent or on 1. BLANKET ADDITIONAL INSURED — STATES
any other basis, unless you have agreed in OR POLITICAL SUBDIVISIONS—PERMITS
the written contract or agreement that this in- The following is added to SECTION 11—WHO IS
surance. must be primary to, or non- AN INSURED:
contributory with, such other Insurance, In
which case this insurance will be primary to, Any state or political subdivision that has issued a
and non-contributory with, such other insur- permit in connection with operations performed by
ance. you or on your behalf and that you are required
Page 4 of 6 EJ 2011 The Travelers indemnity Company.All rights reserved. CG D3 16 11 11
q 5 �
COMMERCIAL GENERAL LIABILITY
by any ordinance, law or building code to include (ii) A manager of any limited liability
as an additional insured on this Coverage Part is company;or
an insured, but.only with respect to liability for (iii)An executive officer or director of
"bodily injury", "property damage", "personal in- any other organization;
jury"or"advertising injury"arising out of such op- that is your partner, joint venture
erations. member or manager;or
The insurance provided to such state or political (b) Any "employee" authorized by such
subdivision does not apply to: partnership, joint venture, limited ii-
a. Any "bodily injury," "property damage," "per- ability company or other organization
sonal injury"or"advertising injury"arising out to give notice of an "occurrence" or
of operations performed for that state or po- offense.
litical subdivision;or (3) 'Notice to us of such"occurrence"or of an
b. Any "bodily injury" or "property damage" in- offense will be deemed to be given as
cluded in the "products-completed operations soon as practicable if it is given in good
hazard". faith as soon as practicable to your work-
J. KNOWLEDGE AND NOTICE OF OCCUR- ers` compensation insurer. This applies
RENCE OR OFFENSE only if you subsequently give notice to us
The following is added to Paragraph 2.,Duties In of the"occurrence"or offense as soon as
The Event of Occurrence, Offense, Claim or practicable after any of the persons de-
Suit,. of SECTION IV — COMMERCIAL GEN- scribed in Paragraphs e. (1) or(2)above
ERAL LIABILITY CONDITIONS; discovers that the occurrence"or offense
may result in sums to which the insurance
e. The following provisions apply to Paragraph provided under this Coverage Part may
a. above, but only for the purposes of the in- apply.
surance provided under this Coverage Part to
you or any insured listed in Paragraph 1.or 2. However, if this Coverage Park includes an en-
of Section it—Who 1s An Insured: dorsement that provides limited coverage for
"bodily injury" or "property damage" or pollution
(1) Notice to us of such 'occurrence" or of- costs arising out of a discharge, release or es-
fense must be given as soon as practica- cape of"pollutants"which contains a requirement
ble only after the"occurrence"or offense that the discharge, release or escape of"pollut-
is known by you(if you are an individual), ants" must be reported to us within a specific
any of your partners or members who is number of days after its abrupt commencement,
an individual (if you are a partnership or this Paragraph e. does not affect that require-
joint venture), any of your managers who ment.
is an individual(if you are a limited liability K. UNINTENTIONAL OMISSION
company), any of your "executive offi-
cers"or directors(if you are an organiza- The following is added to Paragraph B., Repre.
tion other than a partnership;joint venture sentations, of SECTION IV — COMMERCIAL
or limited liability company) or any em- GENERAL LIABILITY CONDITIONS:
ployee" authorized by you to give notice The unintentional omission of, or unintentional
of an'occurrence"or offense. error in, any information provided by you which
(2) If you are a partnership, joint venture or we relied upon in issuing this policy will not preju-
limited liability company,and none of your dice your rights under this insurance. However,
partners, joint venture members or man- this provision does not affect our right to collect
agers are individuals, notice to us of such additional premium or to exercise our rights of
"occurrence"or offense must be given as cancellation or nonrenewal in accordance with
soon as practicable only after the'occur- applicable insurance laws or regulations.
rence"or offense is known by: L. BLANKET WAIVER OF SUBROGATION
(a) Any individual who is: The following is added to Paragraph 8.,Transfer
(1) A partner or member of any part- Of Rights Of Recovery Against Others To Us,
nership or joint venture; of SECTION IV—COMMERCIAL GENERAL LI-
ABILITY CONDITIONS:
CG D3 16 1111 0 2011 The Travelers Indemnity Company.All rights reserved. Page 5 of 6
COMMERCIAL GENERAL LIABILITY
If the insured has agreed in a contract or agree- 3. "Bodily injury" means bodily injury, mental
ment to waive that insured's right of recovery anguish, mental injury,shock,fright, disability,
against any person or organization, we waive our humiliation, sickness or disease sustained by
right of recovery against such person or organiza- a person, including death resulting from any
tion, but only for payments we make because of. of these at any time.
a. "Bodily injury" or "property damage"that oG N. CONTRACTUAL LIABILITY—RAILROADS
curs;or 1. The following replaces Paragraph c. of the
b. "Personal injury" or "advertising injury" definition of"insured contract"in the DEFINI-
caused by an offense that is committed; TIONS Section:
subsequent to the execution of that contract or
c. Any easement or license agreement;
agreement. 2. Paragraph f.(1) of the definition of "insured
M. AMENDED BODILY INJURY DEFINITION contract" in the DEFINITIONS Section is de-
leted.
The following replaces the definition of "bodily
injury"in the DEFINITIONS Section:
Page 6 of 6 Q 2011 The Travelers Indemnity Company.Ail rights reserved. CG D3 16 11 11
p-
C
i
DT-810-0 F027488-TCT-f 8
— -- COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS ,AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi-
fied by the endorsement.
GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage. However, coverage for any
injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to the Coverage Part,and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover-
age description only. Limitations and exclusions may apply to these coverages.Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights,duties, and what is and is not covered.
A. BROAD FORM NAMED INSURED H. HIRED AUTO PHYSICAL DAMAGE — LOSS
OF USE—INCREASED LIMIT
B. BLANKET ADDITIONAL INSURED 1. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES—INCREASED LIMIT
C. EMPLOYEE HIRED AUTO J. PERSONAL EFFECTS
D. EMPLOYEES AS INSURED K. AIRBAGS
E. SUPPLEMENTARY PAYMENTS — INCREASED L. NOTICE AND KNOWLEDGE OF ACCIDENT
LIMITS OR LOSS
F. HIRED AUTO — LIMITED WORLDWIDE M. BLANKET WAIVER OF SUBROGATION
COVERAGE—INDEMNITY BASIS
G. WAIVER OF DEDUCTIBLE—GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS
PROVISIONS
A. BROAD FORM NAMED INSURED executed by you before the "bodily injury" or
The following is added to Paragraph A.1.,Who Is "property damage" occurs and that is in effect
An Insured, of SECTION 11 — LIABILITY COV- during the policy period, to be named as an addi-
ERAGE: tional insured is an "insured" for Liability Cover-
age, but only for damages to which this insurance
Any organization you newly acquire or form dur- applies and only to the extent that person or or-
ing the policy period over which you maintain ganization qualifies as an "insured" under the
50% or more ownership interest and that is not Who Is An Insured provision contained in Section
separately insured for Business Auto Coverage. II.
Coverage under this provision is afforded only un-
til the 180th day after you acquire or form the or- C. EMPLOYEE HIRED AUTO
ganization or the end of the policy period, which- 1. The following is added to Paragraph A.1.,
ever is earlier. Who Is An Insured, of SECTION It — LI-
S. BLANKET ADDITIONAL INSURED ABILITY COVERAGE:
The following is added to Paragraph c. in A.1., An "employee" of yours is an "insured" while
Who Is An Insured, of SECTION 11 — LIABILITY operating an "auto" hired or rented under a
COVERAGE: contract or agreement in that "employee's"
name, with your permission,while performing
Any person or organization who is required under duties related to the conduct of your busi-
a written contract or agreement between you and ness.
that person or organization, that is signed and
CA T3 53 03 10 ©2010 The Travelers Indemnity Company. Page 1 of 4
Includes copyrighted material of Insurance Services Office,Inc.with its permission. r �
COMMERCIAL AUTO
2. The following replaces Paragraph b. in B.5., within such country or jurisdiction, for Liability
Other Insurance, of SECTION IV — BUSI- Coverage for any covered "auto" that you
NESS AUTO CONDITIONS: lease, hire, rent or borrow without a driver for
b. For Hired Auto Physical Damage Cover- a period of 30 days or less and that is not an
age, the following are deemed to be cov- "auto" you lease, hire, rent or borrow from
aged"autos)you own: any of your "employees", partners (if you are
a partnership), members (if you are a limited
(1) Any covered "auto" you lease, hire, liability company) or members of their house-
rent or borrow;and holds.
(2) Any covered "auto"hired or rented by (a) With respect to any claim made or"suit"
your "employee" under a contract in brought outside the United States of
that individual "employee's" name, America, the territories and possessions
with your permission, while perform- of the United States of America, Puerto
ing duties related to the conduct of Rico and Canada:
your business. (i) You must arrange to defend the "in.
However, any"auto"that is leased, hired, sured"against, and investigate or set-
rented or borrowed with a driver is not a tle any such claim or"suit" and keep
covered "auto". us advised of all proceedings and ac-
D. EMPLOYEES AS INSURED tions.
The following is added to Paragraph AA., Who is (ii) Neither you nor any other involved
An Insured, of SECTION II — LIABILITY COV- "insured" will make any settlement
ERAGE: without our consent.
Any "employee" of yours is an "insured"while us- (iii)We may, at our discretion, participate
ing a covered "auto"you don't own, hire or borrow in defending the"insured" against,or
in your business or your personal affairs. in the settlement of, any claim or
E. SUPPLEMENTARY PAYMENTS —INCREASED "suit".
LIMITS (iv)We will reimburse the "insured" for
1. The following replaces Paragraph A.2.a.(2), sums that the "insured" legally must
of SECTION If—LIABILITY COVERAGE: pay as damages because of bodily
injury"or"property damage" to which
(2) Up to $3,000 for cost of bail bonds (in- this insurance applies, that the "in-
cluding bonds for related traffic law viola- sured" pays with our consent, but
tions) required because of an "accident" only up to the limit described in Para-
we cover. We do not have to furnish graph C., Limit Of Insurance, of SEC-
these bonds. TION It—LIABILITY COVERAGE.
2. The following replaces Paragraph A.2.a.(4), (v) We will reimburse the "insured" for
of SECTION Il—LIABILITY COVERAGE: the reasonable expenses incurred
(4) All reasonable expenses incurred by the with our consent for your investiga-
"insured" at our request, including actual tion of such claims and your defense
loss of earnings up to $500 a day be- of the "insured" against any such
cause of time off from work. "suit", but only up to and included
within the limit described in Para-
F. HIRED AUTO — LIMITED WORLDWIDE COV- graph C., Limit Of Insurance, of
ERAGE—INDEMNITY BASIS SECTION 11 — LIABILITY COVER-
The following replaces Subparagraph (5) in Para- AGE,and not in addition to such limit.
graph B.7., Policy Period, Coverage Territory, Our duty to make such payments
of SECTION IV — BUSINESS AUTO CONDI- ends when we have used up the ap-
TIONS: plicable limit of insurance in pay-
(5) Anywhere in the world, except any country or ments for damages, settlements or
jurisdiction while any trade sanction, em- defense expenses.
bargo, or similar regulation imposed by the (b) This insurance is excess over any valid
United States of America applies to and pro- and collectible other insurance available
hibits the transaction of business with or
Page 2 of 4 ©2010 The Travelers Indemnity Company. CA T3 53 0310
Includes copyrighted material of Insurance Services Office,Inc.with Its permission. j?
COMMERCIAL AUTO
to the "insured" whether primary, excess J. PERSONAL EFFECTS
contingent or on any other basis. The following is added to Paragraph AA., Cover-
(c) This insurance is not a substitute for re- age Extensions, of SECTION III — PHYSICAL
quired or compulsory insurance in any DAMAGE COVERAGE:
country outside the United States, its ter- Personal Effects
ritories and possessions, Puerto Rico and
Canada. We will pay up to $400 for "loss" to wearing ap-
You agree to maintain all required or
parel and other personal effects which are:
compulsory insurance in any such coun- (1) Owned by an"insured"; and
try up to the minimum limits required by (2) In or on your covered"auto",
local law, Your failure to comply with This coverage applies only in the event of a total
compulsory insurance requirements will theft of your covered"auto".
not invalidate the coverage afforded by
this policy, but we will only be liable to the No deductibles apply to this Personal Effects
same extent we would have been liable coverage.
had you complied with the compulsory in- K. AIRBAGS
surance requirements.
The following is added to Paragraph B.3., Exclu-
(d) It is understood that we are not an admit- sions, of SECTION III — PHYSICAL DAMAGE
ted or authorized insurer outside the COVERAGE:
United States of America, its territories Exclusion 3.a. does not apply to "loss" to one or
and possessions, Puerto Rico and Can- more airbags in a covered "auto"you own that in-
ada. We assume no responsibility for the flate due to a cause other than a cause of "loss"
furnishing of certificates of insurance, or set forth in Paragraphs A.1.b. and A.1.c., but
for compliance in any way with the laws only
of other countries relating to insurance.
G. WAIVER OF DEDUCTIBLE—GLASS a. If that"auto" is a covered "auto"for Compre-
hensive Coverage under this policy;
The following is added to Paragraph D., Deducti-ble, of SECTION III — PHYSICAL DAMAGE b. The airbags are not covered under any war-
COVERAGE: ranty; and
No deductible for a covered "auto" will apply to c. The airbags were not intentionally inflated,
glass damage if the glass is repaired rather than We will pay up to a maximum of $1,000 for any
replaced. one"loss".
H. HIRED AUTO PHYSICAL DAMAGE—LOSS OF L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
USE—INCREASED LIMIT LOSS
The following replaces the last sentence of Para- The following is added to Paragraph A.2.a., of
graph AA.b., Loss Of Use Expenses, of SEC- SECTION IV—BUSINESS AUTO CONDITIONS:
TION Ill—PHYSICAL DAMAGE COVERAGE: Your duty to give us or our authorized representa-
However, the most we will pay for any expenses tive prompt notice of the "accident" or"loss" ap-
for loss of use is $65 per day, to a maximum of plies only when the "accident" or"loss" is known
$750 for any one"accident". to:
1. PHYSICAL DAMAGE — TRANSPORTATION (a) You (if you are an individual);
EXPENSES—INCREASED LIMIT (b) A partner(if you are a partnership);
The following replaces the first sentence in Para- (c) A member (if you are a limited liability com-
graph AA.a., Transportation Expenses, of pany);
SECTION III — PHYSICAL DAMAGE COVER- (d) An executive officer, director or insurance
AGE: manager(if you are a corporation or other or-
We will pay up to $50 per day to a maximum of ganization); or
$1,500 for temporary transportation expense in- (e) Any"employee"authorized by you to give no-
curred by you because of the total theft of a cov- tice of the"accident"or"loss".
ered "auto" of the private passenger type.
/�2.5 El
CA T3 53 03 10 ©2010 The Travelers Indemnity Company. Page 3 of 4
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
COMMERCIAL AUTO
M. BLANKET WAIVER OF SUBROGATION such contract. The waiver applies only to the
The following replaces Paragraph A.5., Transfer person or organization designated in such
Of Rights Of Recovery Against Others To Us, contract.
of SECTION IV — BUSINESS AUTO CONDI- N. UNINTENTIONAL ERRORS OR OMISSIONS
TIONS: The following is added to Paragraph B.2., Con-
s. Transfer Of Rights Of Recovery Against cealment, Misrepresentation, Or Fraud, of
Others To Us SECTION IV—BUSINESS AUTO CONDITIONS:
We waive any right of recovery we may have The unintentional omission of, or unintentional
against any person or organization to the ex- error in, any information given by you shall not
tent required of you by a written contract prejudice your rights under this insurance. How-
signed and executed prior to any "accident" ever this provision does not affect our right to col-
or"loss", provided that the"accident"or"loss" lect additional premium or exercise our right of
arises out of operations contemplated by cancellation or non-renewal.
Page 4 of 4 ©2010 The Travelers Indemnity Company. CA T3 53 03 10
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
DT-81 O-OF027488-TCT-18 COMMERCIAL AUTO
THIS INDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - PRIMARY AND
NON-CONTRIBUTORY WITH OTHER INSURANCE
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi-
fied by this endorsement.
PROVISIONS B. The following is added to Paragraph 5., Other
A. The following is added to Paragraph c. in A. 1., Insurance, in B. General Conditions of SEC-
Who Is An Insured, of SECTION II— LIABILITY TION IV—BUSINESS AUTO CONDITIONS:
COVERAGE: Regardless of the provisions of paragraph a. and
Any person or organization who is required under paragraph d. of this part 5. Other Insurance, this
a written contract or agreement between you and insurance is primary to and non-contributory with
that person or organization, that is signed and applicable other insurance under which an addi-
executed by you before the "bodily injury" or tional insured person or organization is the first
"property damage" occurs and that is in effect named insured when the written contract or
during the policy period, to be named as an addi- agreement between you and that person or cr-
tional insured is an "insured" for Liability Cover- ganization, that is signed and executed by you
age, but only for damages to which this insurance before the "bodily injury" or "property damage"
applies and only to the extent that person or or- occurs and that is in effect during the policy pe-
ganization qualifies as an "insured" under the riod, requires this insurance to be primary and
Who Is An Insured provision contained in non-contributory.
Section II.
CA T4 74 02 12 ©2012 The Travelers Indemnity Company.All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: DT22-CO-OF027488-TCT-18 ISSUE DATE:08/21/18
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
DESIGNATED PROJECT(S)
GENERAL AGGREGATE LIMIT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Designated Project
Designated Project(s): General Aggregate(s):
EACH "PROJECT" FOR WHICH YOU HAVE AGREED, IN GENERAL, AGGREGATE
A WRITTEN CONTRACT WHICH IS IN EFFECT DURING LIMIT SHOWN ON THE
THIS POLICY PERIOD, TO PROVIDE A.SEPARATE DECLARATIONS.
GENERAL AGGREGATE LIMIT, PROVIDED THAT THE
CONTRACT IS SIGNED AND EXECUTED BY YOU
BEFORE THE "BODILY INJURY" OR "PROPERTY
DAMAGE" OCCURS.
A. For all sums which the insured becomes legally 3. Any payments made under COVERAGE A.
obligated to pay as damages caused by"occur- for damages or under COVERAGE C, for
rences" under COVERAGE A. (SECTION 1), and medical expenses shall reduce the Desig-
for all medical expenses caused by accidents un- nated Project General Aggregate Limit for
der COVERAGE C (SECTION 1), which can be that. designated "project Such payments
attributed only to operations at a single desig- shall not reduce the General Aggregate Limit
nated"project"shown in the Schedule above: shown in the Declarations nor shall they re-
1. A separate Designated Project General Ag- duce. any other Designated Project General
gregate Limit.applies to each designated"pro- Aggregate Limit for any other designated
ject", and that limit is equal to the amount of "project"shown in the Schedule above.
the General Aggregate Limit shown In the 4. The limits shown in the Declarations for Each
Declarations, unless separate Designated Occurrence, Damage To Premises Rented
Project General Aggregate(s) are sched- To You and Medical Expense continue to
uled above. apply. However, instead of being subject to
2. The Designated Project General Aggregate the General Aggregate Limit shown in the
Limit is the most we will pay for the sum of all Declarations, such limits will be subject to the
damages under COVERAGE A., except applicable Designated Project General Ag-
damages because of"bodily injury" or"prop- gregate Limit.
erty damage" included in the "products- B. For all sums which the insured becomes legally
completed operations hazard", and for medi- obligated to pay as damages caused by "occur-
cal expenses under COVERAGE C, regard- rences" under COVERAGE A. (SECTION 1), and
less of the number of: for all medical expenses caused by accidents un-
a. Insureds; der COVERAGE C. (SECTION I), which cannot
be attributed only to operations at a single desig-
b. Claims made or"suits"brought;or nated"project"shown in the Schedule above:
c. Persons or organizations making claims
or bringing"suits".
CG D2 11 01 04 Copyright,The Travelers Indemnity Company,2004 Page 1 of 2
COMMERCIAL:GENERAL LIABILITY
1. Any payments made under COVERAGE A. vided, any payments for damages because of
for damages or under COVERAGE C. for "bodily Injury' or "property damage" included in
medical :expenses .shall reduce.the amount the "products-completed operations hazard" will
available. under the General Aggregate Limit reduce the Products-Completed Operations.Ag-
or the Products-Completed. Operations .Ag- gregate Limit,and not reduce the General Aggre=
gregate Limit,whichever is applicable;;and gate Limit nor. the Designated_ Project General
2. Such payments shall not reduce any Desig- Aggregate Limit. i
nated Project General Aggregate Limit. E. For the purposes of this endorsement the Deflnl-
C. Part:2.of SECTION III LIMITS OF INSURANCE Lions Section is amended.by the addition of the
is deleted and replaced by the following; following definition:
2. The General Aggregate Limit Is the most we "Project" means an area .away from premises.
will pay for the sum of, owned by or rented to you at which you are per-
forming operations: pursuant to a contract or
a. Damages under Coverage B;and agreernent. For the purposes of determining the
.b. Damages from "occurrences" under applicable aggregate g PP 9gate limit of insurance,. each g_
.COVERAGE A (SECTION I) and for all "project" that includes premises involving the
medical .expenses caused by accidents same or connecting lots, or premises whose ccn-
under COVERAGE C{SECTION I)'which nection is interrupted only by a street, roadway;
cannot be attributed only to operations at waterway or right-of-way of a railroad shall be
a single designated"project"shown in the considered a single"project".
SCHEDULE above. F. The provisions of SECTION III — LIMITS OF
D. When coverage for liability arising. out. of the INSURANCE not.otherwise modified by this en
"products-completed operations hazard" is pro- dorsement shall continue to apply as stipulated.
i
I
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I
i
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7 �
Page 2 of 2 Copyright,The Travelers.Indemnity Company,2004 CG D2 11 01 04
Form W=9 Request �.,)r Taxpayer Give Form to the
(Rev.December entoft20ea Identification Number and Certification requester. 4 not
Department of the Treasury Send to the"i-24.
Internal Revenue Service
1 Name(as shown on your income tax return).Name is requir•-: on this line;do not leav this line blank.
G. Bortolotto&Co.,Inc.
N 2 Business name/disregarded entity name,if different from above
am
to
m —
° 3 Check appropriate box for federal tax classification;check only one of the following se•vcn boxes: 4 Exemptions(codes apply only to
0 certain entities,not individuals;see
v)
° ❑Individual/sole proprietor or ❑ C Corporation ❑✓ S Corporation ❑ Partnership ��Trust/estate
instructions on page 3):
a: single-member LLC
a ° Limited liabilit company.Enter the tax classification C=C corporation,S=S cor orat!c-i,P= artnershi ► Exempt payee code(if any)
o Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for Exemption from FATCA reporting
m the tax classification of the single-member owner. code(if any)
aC (Applies t accounts maintained outside the U.S.)
❑Other(see instructions)► IMa'e�o
:a-U 5 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
COL 582 Bragato Road
CO 6 City,state,and ZIP code City of Cupertino
10300 Torre Avenue
un San Carlos,CA 94070 Cupertino,CA 95014-3255
7 List account number(s)here(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(page However,for a -m -
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN on page 3. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number
guidelines on whose number to enter.
i [9F4 -HE2 0 [T69
Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I rem waiting for a number to be issued to me);and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3. 1 am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from F-,ATCA reporting isl correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 3. {
Sign Signature of 2 r 5,/7 j
Here I- ► J U.S.person Date
General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. .Form 1099-C(canceled debt) pp
Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property) i
as legislation enacted after we release it)is at www.irs.gov/fw9.
Use Form W-9 only if you are a U.S.person(including a resident alien),to
Purpose of Form provide your correct TIN.
An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2.
which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you:
number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
identification number(EIN),to report on an information return the amount paid to to be issued),
you,or other amount reportable on an information return.Examples of information
returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or j
•Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If
•Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of
any partnership income from a U.S.trade or business is not subject to the
•Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
•Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are
brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
•Form 1099-S(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat.No.10231X Form W-9(Rev.12-2014)
