Exhibit A SAMPLE CERTIFICATE OF INSURANCE TO ALL CONTRACTS/PURCHASE ORDER AGREEMENTS ACORD TM CERTIFICATE OF LIABILITY INSURANCE Date (MM/DD/YY) PRODUCER SUBCONTRACTOR S AGENT / BROKER ADDRESS CITY, STATE, ZIP CODE CONTACT PERSON / PHONE # / FAX # INSURED SUBCONTRACTOR S FULL NAME (AS IT APPEARS IN THE SUBCONTRACT / PURCHASE ORDER AGREEMENT) ADDRESS CITY, STATE, ZIP CODE CONTACT PERSON / PHONE # / FAX # THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURER A (EACH INSURANCE CARRIER LISTED MUST HAVE AN A.M. BEST RATING OF A: VIII OR BETTER, EXCEPT FOR STATE FUND FOR WORKERS COMPENSATION COVERAGE) COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHINGSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD L POLICY EFFECTIVE POLICY EXPIRATION LTR. INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS GENERAL LIABILITY (Current) (Current) (Current) EACH OCCURRENCE $ 1,000,000 SEVERABILITY OF INTERESTS" DAMAGE TO RENTED PROVISION APPLIES $ 50,000 CLAIMS MADE OCCURRENCE PREMISES (Ea occurrence) Certificates of Insurance from all lower tier contractors, subcontractors, subsubcontractors, suppliers and hired services must meet the following MED EXP (Any one person) $ 5,000 XCU & BFPD CONTRACTUAL LIABILITY (Oral / Written / Implied) PERSONAL & ADV INJURY $ 1,000,000 minimum insurance requirements before their services or products are used: GENERAL AGGREGATE LIMIT APPLIES PER:, Owner(s), Architect, their officers, directors GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOCATION and employees and all other parties as required by written contract or PRODUCTS COMP/OP AGG $ 2,000,000 agreement are named as Additional Insured on all policies, except Workers < $10,000 DEDUCTIBLE OR SELF INSURED RETENTION Compensation and/or Professional Liability Insurance. AUTOMOBILE LIABILITY The Additional Insured Endorsement (AIE) to the General Liability policy COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO must include your ongoing operations and extend to your completed operations for a minimum of five (5) years after completion of contract BODILY INJURY ALL OWNED AUTOS (Per person) $ work or for a longer period of time as required by the Contract D AUTOS Documents. Acceptable endorsements include ISO forms CG2010B BODILY INJURY (Per accident)) $ HIRED AUTOS (11/85); CG2026 (11/85); CG2010 (07/04) plus CG2037 (07/04); or NON-OWNED AUTOS acceptable equivalent. The CG2010 (10/93) additional insured form Property damage (Per accident) $ ongoing operations will be accepted for vendors/suppliers that deliver GARAGE LIABILITY materials or goods to the job site and do not perform any physical AUTO ONLY EA ACCIDENT ANY AUTO services on the construction project/property. OTHER THAN EA ACC Certificates of Insurance and Additional Insured Endorsements that AUTO ONLY: AGG restrict coverage to your ongoing operations which do not provide EXCESS LIABILITY coverage for completed operations will be rejected. EACH OCCURRENCE As Required OCCURRENCE CLAIMS MADE If either defense costs are included in the General Aggregate limit or the AGGREGATE By Contract DEDUCTIBLE General Aggregate limit does not apply on a per project basis, then the DROP-DOWN PROVISION RETENTION $ required General Aggregate limit must be at least twice the occurrence APPLIES limit. WORKERS COMPENSATION AND WC STAT- OTH- Any coverage afforded to the Additional Insureds must be on a primary EMPLOYER S LIABILITY TORY LIMITS ER and non-contributory basis. ANY PROPRIETORS/PARTNERS/EXECUTIVES Claims-Made or Modified Occurrence Commercial General Liability policy E.L. EACH ACCIDENT $ 1,000,000 OFFICERS MEMBERS EXCLUDED? forms are NOT acceptable. E.L. DISEASE EA EMPLOYEE $ 1,000,000 If yes, describe under Waiver of Subrogation in favor of the Additional Insureds applies on all SPECIAL PROVISIONS below E.L. DISEASE POLICY LIMIT $ 1,000,000 OTHER (must include Limited Contractual Liability) POLLUTION LIABILITY INCLUDING MOLD AND ASBESTOS PROFESSIONAL LIABILITY WITH A RETROACTIVE DATE OF BEFORE SERVICES START / POLLUTION EXCLUSION DELETED RIGGER S LIABILITY AIRCRAFT / HELICOPTER LIABILITY (OWNED & NON-OWNED) policies, including Professional Liability. Aircraft or Helicopter Operations must include Workers Compensation & Employer s Liability for all members of flying crew. The Actual Endorsement Number(s) must be included on the Certificate. Required Endorsements must be attached to the Certificate of Insurance. (Current) SEVERABILITY OF INTERESTS" PROVISION APPLIES EACH CLAIM / AGGREGATE EACH CLAIM / AGGREGATE EACH OCCURRENCE (Current) (Current) EACH OCCURRENCE (Professional Liability must be maintained for at least 2 years after substantial completion) If Applicable As Required By Contract DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (THE FOLLOWING INFORMATION MUST APPEAR.) Reference: Project Number, Name and Location, including operations conducted off the construction site or All Operations of the Named Insured, Owner(s), Architect, their officers, directors and employees and all other parties as required by written contract or agreement are included as Additional Insureds on a primary and noncontributory basis per attached Endorsement ##(s) to the General Liability Policy. Additionally, Waiver of Subrogation applies on all policies listed above per attached Endorsement ##(s). CERTIFICATE HOLDER 985 Industrial Road, Suite 101 San Carlos, CA 94070 CANCELLATION *Except 10 Days for Non-Payment of Premium SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE (Original Wet Signature is Required.) ACORD 25 (2001/08) ACORD CORPORATION 1988.
EXHIBIT B ADDITIONAL INSURED ENDORSEMENT ISO CG 20 10 11 85 ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) COVERAGE PART NAME OF PERSON(S) OR ORGANIZATION(S): AND THEIR RESPECTIVE OFFICERS, DIRECTORS AND EMPLOYEES; AND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT, PURCHASE ORDER AGREEMENT AND/OR NECESSITATED BY CONSTRUCTION ACTIVITIES NAME OR LOCATION OF COVERED PROJECT: PROJECT NUMBER, NAME AND LOCATION (IF APPLICABLE, INCLUDING OPERATIONS CONDUCTED OFF THE CONSTRUCTION SITE) OR ALL OPERATIONS BY OR ON BEHALF OF (SUBCONTRACTOR S FULL NAME AS IT APPEARS IN THE SUBCONTRACT / PURCHASE ORDER AGREEMENT) (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured that person or organization shown in the Schedule, but only with respect to liability arising out of YOUR WORK for that insured by or for you. PRIMARY INSURANCE: Such insurance as is afforded by this policy is primary insurance and no other insurance of the additional insured(s) will be called upon to contribute to a loss. LIMITS OF INSURANCE: It is agreed that Endorsement CG2503 (0397) Designated Construction Project(s) General Aggregate Limit or its equivalent is added for this project. SEPARATION OF INSUREDS: It is agreed that this policy contains either a severability of interests, or separation of insureds clause. CANCELLATION CLAUSE: It is understood and agreed that there will be no cancellation, reduction or modification of coverage without thirty (30) days written notice except for non-payment of premium in which case the company will mail ten (10) days written notice. Any claim payment under said policy shall not be construed to be a reduction or modification as respects this clause. CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 PAGE 1 OF 1
EXHIBIT C ADDITIONAL INSURED ENDORSEMENT ISO CG 20 10 07 04 ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS D PERSON OR ORGANIZATION COVERAGE PART NAME OF ADDITIONAL INSURED PERSON(S) OR ORGANIZATION(S) AND THEIR RESPECTIVE OFFICERS, DIRECTORS AND EMPLOYEES; AND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT, PURCHASE ORDER AGREEMENT AND/OR NECESSITATED BY CONSTRUCTION ACTIVITIES LOCATION(S) OF COVERED OPERATIONS PROJECT NUMBER, NAME AND LOCATION (IF APPLICABLE, INCLUDING OPERATIONS CONDUCTED OFF THE CONSTRUCTION SITE) OR ALL OPERATIONS BY OR ON BEHALF OF (SUBCONTRACTOR S FULL NAME AS IT APPEARS IN THE SUBCONTRACT / PURCHASE ORDER AGREEMENT) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. SECTION II WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury, property damage or personal and advertising injury caused, in whole or in part by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to bodily injury or property damage occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. PRIMARY INSURANCE: Such insurance as is afforded by this Policy is primary insurance and no other insurance of the Additional Insured will be called upon to contribute to a loss. CG 20 10 07 04 (OR EQUIVALENT) PLUS CG 20 37 07 04 PAGE 1 OF 1 ISO Properties, Inc., 2004
EXHIBIT D ADDITIONAL INSURED ENDORSEMENT COMPLETED OPERATIONS COVERAGE ISO CG 20 37 07 04 ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS COMPLETED OPERATIONS COVERAGE PART NAME OF ADDITIONAL INSURED PERSON(S) OR ORGANIZATION(S) AND THEIR RESPECTIVE OFFICERS, DIRECTORS AND EMPLOYEES; AND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT, PURCHASE ORDER AGREEMENT AND/OR NECESSITATED BY CONSTRUCTION ACTIVITIES LOCATION AND DESCRIPTION OF COMPLETED OPERATIONS PROJECT NUMBER, NAME AND LOCATION (IF APPLICABLE, INCLUDING OPERATIONS CONDUCTED OFF THE CONSTRUCTION SITE) OR ALL OPERATIONS BY OR ON BEHALF OF (SUBCONTRACTOR S FULL NAME AS IT APPEARS IN THE SUBCONTRACT / PURCHASE ORDER AGREEMENT) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. SECTION II WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". PRIMARY INSURANCE: Such insurance as is afforded by this Policy is primary insurance and no other insurance of the Additional Insured will be called upon to contribute to a loss. LIMITS OF INSURANCE: The General Aggregate Limit under LIMITS OF INSURANCE (SECTION III) applies separately to each of your projects away from premises owned by or rented to you. CG 20 37 07 04 (OR EQUIVALENT) PLUS CG 20 10 07 04 PAGE 1 OF 1 ISO Properties, Inc., 2004
EXHIBIT E WAIVER OF SUBROGATION ENDORSEMENT ISO CG 24 04 10 93 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US COVERAGE PART NAME OF PERSON(S) OR ORGANIZATION(S): AND THEIR RESPECTIVE OFFICERS, DIRECTORS AND EMPLOYEES; AND ANY OTHER PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT, PURCHASE ORDER AGREEMENT AND/OR NECESSITATED BY CONSTRUCTION ACTIVITIES (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or YOUR WORK done under a contract with that person or organization and included in the productscompleted operations hazard. This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc. 1992 PAGE 1 OF 1
EXHIBIT F WAIVER OF SUBROGATION ENDORSEMENT WC 04 03 06 04 84 WORKERS COMPENSATION & EMPLOYERS LIABILITY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers compensation premium otherwise due on such remuneration. PERSON(S) OR ORGANIZATION(S): THE OWNER AND OTHER PARTIES AS REQUIRED BY WRITTEN CONTRACT, PURCHASE ORDER AGREEMENT AND/OR NECESSITATED BY CONSTRUCTION ACTIVITIES. JOB DESCRIPTION: PROJECT NUMBER, NAME AND LOCATION (IF APPLICABLE, INCLUDING OPERATIONS CONDUCTED OFF THE CONSTRUCTION SITE) OR ALL OPERATIONS BY OR ON BEHALF OF (SUBCONTRACTOR S FULL NAME AS IT APPEARS IN THE SUBCONTRACT / PURCHASE ORDER AGREEMENT) WC 04 03 06 04 84 1998 by the Workers Compensation Insurance Rating Bureau of California. All rights reserved.