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HomeMy WebLinkAboutEndresen Development PWCA Bid Set E & F Cement Plaster & Exterior Walls City Hall 12-10-2024 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 Agreement No. AGREEMENT FOR PUBLIC WORKS CONSTRUCTION Endresen Development Inc. For the City Hall Bid Set 'E' and 'F' Cement Plaster and Exterior Brick Walls CIP PROJECT NO. Z20006 This Agreement for Public Works Construction ("Agreement") is made and entered into as of December 10, 2024 by and between the City of lake Elsinore, a municipal corporation ("City") and Endresen Development Inc. ("Contractor'). The City and Contractor, in consideration of the mutual promises and covenants set forth herein, agree as follows: 1. The Project and Project Documents. Contractor agrees to construct the following public improvements("work") identified as: City Hall Bid Set`E' and `F' Cement Plaster and Exterior Brick Walls(the"Project") The City-approved plans for the construction of the Project, which are incorporated herein by reference and prepared by Staff, are identified as: Bid Set'E' and `F' Cement Plaster and Exterior Brick Walls The Project Documents include this Agreement and all of the following: (1) the Notice Inviting Bids, Instructions to Bidders, Bid Documents including Bidder's Proposal as submitted by the Contractor, Contract Documents, General Specifications, Special Provisions, and all attachments and appendices; (2) everything referenced in such documents, such as specifications, details, standard plans or drawings and appendices, including all applicable State and Federal requirements; (3) all required bonds, insurance certificates, permits; notices, and affidavits; and (4) any and all addenda or supplemental agreements clarifying, amending or extending the work contemplated as may be required to insure completion in an acceptable manner. All of the provisions of the above-listed documents are made a part of this Agreement as though fully set forth herein. 2. Com ensation. a. For and in consideration of the payments and agreements to be made and performed by City, Contractor agrees to construct the Project, including furnishing all materials and performing all work required for the Project, and to fulfill all other obligations as set forth in the Bidder's Proposal, such contract price being nine hundred sixty thousand dollars and no cents ($960,000.00). 2 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 b- City hereby promises and agrees to employ, and does hereby employ, Contractor to provide the materials, do the work, and fulfill the obligations according to the terms and conditions herein contained and referred to, for the prices set forth, and hereby contracts to pay the same at the time, in the manner, and upon the conditions set forth in the Project Documents. C. Contractor agrees to receive and accept the prices set forth in the Bidder's Proposal as full compensation for furnishing all materials, performing all work, and fulfilling all obligations hereunder. Such compensation shall cover all expenses, losses, damages, and consequences arising out of the nature of work during its progress or prior to its acceptance including those for well and faithfully completing the worm and the whole thereof in the manner and time specified in the Project Documents; and also including those arising from actions of the elements, unforeseen difficulties or obstructions encountered in the prosecution of the work, suspension or discontinuance of the work, and all other unknowns or risks of any description connected with the work. 3. Completion of Work. a. Contractor shall perform and complete all work within 65 working days from the date of commencement specified in the Notice to Proceed, and shall provide, furnish and pay for all the labor, materials, necessary tools; expendable equipment, and all taxes, utility and transportation services required for construction of the Project. b. All work shall be performed and completed in a good workmanlike manner in strict accordance with the drawings, specifications and all provisions of this Agreement as hereinabove defined and in accordance with applicable laws, codes, regulations, ordinances and any other legal requirements governing the Project. C. Contractor shall not be excused with respect to the failure to so comply by any act or omission of the City, the City Engineer, a City inspector, or a representative of any of them, unless such act or omission actually prevents the Contractor from fully complying with the requirements of the Project Documents, and unless the Contractor protests at the time of such alleged prevention that the act or omission is preventing the Contractor from fully complying with the Project Documents. Such protest shall not be effective unless reduced to writing and filed with the City within three (3) working days of the date of occurrence of the act or omission preventing the Contractor from fully complying with the Project Documents. d. City and Contractor recognize that time is of the essence in the performance of this Agreement and further agree that if the work called for under the Agreement is not completed within the time hereinabove specified; damages will be sustained by the City and that, it is and will be impracticable or extremely difficult to ascertain and determine the actual amount of damages the City will sustain in the event of, and by reason of, such delay. It is, therefore, agreed that such damages shall be presumed to be in the amount of $1,000 per calendar day, and that the Contractor will pay to the City, or City may retain from amounts otherwise payable to Contractor, such amount for each calendar day by which the Contractor fails to complete the work; including corrective items of work, under this Agreement within the time hereinabove specified and as adjusted by any changes to the work, 2 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 4. Changes to Work. City and Contractor agree that the City may make changes to the work, or suspend the work, and no matter how many changes, such changes or suspensions are within the contemplation of the Contractor and City and will not be a basis for a compensable delay claim against the City nor be the basis for a liquidated damage claim against the Contractor. Any change to the work shall he by way of a written instrument ("change order") signed by the City and the Contractor, stating their agreement to the following: a. The scope of the change in the work; b. The amount of the adjustment to the contract price, and c. The extent of the adjustment to the Schedule of Performance. The City Engineer is authorized to sign any change order provided that sufficient contingency funds are available in the City's approved budget for the Project. All change in the work authorized by the change order shall be performed under the applicable conditions of the Project Documents. City and Contractor shall negotiate in good faith and as expeditiously as possible the appropriate adjustments for such changes. 5. Bonds. Contractor shall provide, before commencing work, a Faithful Performance Bond and a Labor and Material Bond, each for one-hundred percent (100%) of the contract price in the form that complies with the Project Documents and is satisfactory to the City Attorney. 5. Non-Assignability. Neither this Agreement nor any rights, title, interest, duties or obligations under this Agreement may be assigned, transferred, conveyed or otherwise disposed of by Contractor without the prior written consent of City. 7. Licenses. Contractor represents and warrants to City that it holds the contractor's license or licenses set forth in the Project Documents, is registered with the Department of Industrial Relations pursuant to Labor Code Section 1725.5, and holds such other licenses, permits, qualifications, insurance and approvals of whatsoever nature which are legally required of Contractor. Contractor represents and warrants to City that Contractor shall, at its sole cost and expense, keep in effect or obtain at all times during the term of this Agreement, any licenses, permits, insurance and approvals which are legally required of Contractor to practice its profession. Contractor shall maintain a City of Lake Elsinore business license. 8. Indemnity. Contractor shall indemnify, defend, and hold harmless the City and its officials, officers, employees, agents, the County and Board Supervisors, and volunteers from and against any and all losses, liability, claims, suits, actions, damages, and causes of action arising out of any personal injury, bodily injury, loss of life, or damage to property, or any violation of any federal, state, or municipal law or ordinance, to the extent caused, in whole or in part, by the willful misconduct or negligent acts or omissions of Contractor or its employees, subcontractors, or agents, by acts for which they could be held strictly liable, or by the quality or character of their work. The foregoing obligation of Contractor shall not apply when (1) the injury; loss of life, damage to property, or violation of law arises from the sole negligence or willful misconduct of the City or its officers, employees, agents, or volunteers and (2) the actions of Contractor or its employees, subcontractor; or agents have contributed in no part to the injury, loss of life, damage to 3 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 Property, or violation of law. It is understood that the duty of Contractor to indemnify and hold harmless includes the duty to defend as set forth in Section 2778 of the California Civil Code. Acceptance by City of insurance certificates and endorsements required under this Agreement does not relieve Contractor from liability under this indemnification and hold harmless clause. This indemnification and hold harmless clause shall apply to any damages or claims for damages whether or not such insurance policies shall have been determined to apply, By execution of this Agreement, Contractor acknowledges and agrees to the provisions of this Section and that it is a material element of consideration. 9. Insurance Requirements, a. Insurance. Contractor, at Contractor's own cost and expense, shall procure and maintain, for the duration of the Agreement, unless modified by the City's Risk Manager, the following insurance policies. I. Workers' Compensation Coverage. Contractor shall maintain Workers' Compensation Insurance and Employer's Liability Insurance for his/her employees in accordance with the laws of the State of California. In addition, Contractor shall require each subcontractor to similarly maintain Workers' Compensation Insurance and Employer's Liability Insurance in accordance with the laws of the State of California for all of the subcontractors employees. Any notice of cancellation or non-renewal of all Workers' Compensation policies must be received by the City at least thirty (30) days prior to such change. The insurer shall agree to waive all rights of subrogation against City, its officers, agents, employees and volunteers for losses arising from work performed by Contractor for City. In the event that Contractor is exempt from Worker's Compensation Insurance and Employer's Liability Insurance for his/her employees in accordance with the laws of the State of California, Contractor shall submit to the City a Certificate of Exemption from Workers Compensation Insurance in a form approved by the City Attorney. ii. Commercial General Liability Covera e. Contractor shall maintain commercial general liability insurance in an amount not less than one million dollars ($1,000,000) per occurrence for bodily injury, personal injury and property damage. If a commercial general liability insurance form or other form with a general aggregate limit is used, either the general aggregate limit shall apply separately to the work to be performed under this Agreement or the general aggregate limit shall be at least twice the required occurrence limit. Required commercial general liability coverage shall be at least as broad as insurance Services Office Commercial General Liability occurrence form CG 0001 (ed. 11/88) or Insurance Services Office form number GL 0002 (ed, 1173) covering comprehensive General Liability and Insurance Services Office form number GL 0404 covering Broad Form Comprehensive General Liability. No endorsement may be attached limiting the coverage. iii. Automobile Liability Coverage. Contractor shall maintain automobile liability insurance covering bodily injury and property damage for all activities of the Contractor arising out of or in connection with the work to be performed under this Agreement, including coverage for owned, hired and non-owned vehicles, in an amount of not less than one million dollars ($1,000,000) combined single limit for each occurrence. Automobile liability coverage must be at least as broad as Insurance Services Office Automobile Liability form CA 0001 (ed. 12/90) Code 1 ("any auto"). No endorsement may be attached limiting the coverage. 4 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 iv. Builder's Risk Coverage. Prior to the commencement of any construction of the Project, Design-Builder shall obtain (or cause to be obtained) and keep in force during the term of any construction, builder's risk insurance insuring for all risks of physical loss of or damage [excluding the perils of earthquake and flood]. V. Professional Liability Coverage. Contractor shall maintain professional errors and omissions liability insurance appropriate for Contractor's profession for protection against claims alleging negligent acts, errors or omissions which may arise from Contractor's services under this Agreement, whether such services are provided by the Contractor or by its employees, subcontractors, or sub consultants. The amount of this insurance shall not be less than one million dollars ($1,000,000) on a claims-made annual aggregate basis, or a combined single limit per occurrence basis. b. Endorsements. Each general commercial liability and automobile liability insurance policy shall be with insurers possessing a Best's rating of no less than A:VIi and shall be endorsed with the following specific language: i, The City, its elected or appointed officers, officials, employees, agents and volunteers are to be covered as additional insured with respect to liability arising out of work performed by or on behalf of the Contractor, including materials, parts or equipment furnished in connection with such work or operations. ii. This policy shall be considered primary insurance as respects the City, its elected or appointed officers, officials: employees, agents and volunteers. Any insurance maintained by the City, including any self-insured retention the City may have, shall be considered excess insurance only and shall not contribute with it. iii. This insurance shall act for each insured and additional insured as though a separate policy had been written for each, except with respect to the limits of liability of the insuring company. iv. The insurer waives all rights of subrogation against the City, its elected or appointed officers, officials, employees or agents. V. Any failure to comply with reporting provisions of the policies shall not affect coverage provided to the City, its elected or appointed officers; officials, employees, agents o r vo lu nteers. vi. The insurance provided by this Policy shall not be suspended, voided, canceled, or reduced in coverage or in limits except after thirty (30) days written notice has been received by the City. C. Deductibles and Self-Insured Retentions. Any deductibles or self-insured retentions must be declared to and approved by the City. At the City's option, Contractor shall demonstrate financial capability for payment of such deductibles or self-insured retentions. d. Certificates of Insurance. Contractor shall provide certificates of insurance with original endorsements to City as evidence of the insurance coverage required herein. Certificates of such insurance shall be filed with the City on or before commencement of 5 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 Performance of this Agreement. Current certification of insurance shall be kept on file with the City at all times during the term of this Agreement. 10. Notices. Any notice required to be given under this Agreement shall be in writing and either served personally or sent prepaid, first class mail. Any such notice shall be addressed to the other party at the address set forth below. Notice shall be deemed communicated within 48 hours from the time of mailing if mailed as provided in this section. If to City; City of Lake Elsinore Attn: City Manager 130 South Main Street Lake Elsinore, CA 9253E With a copy to: City of Lake Elsinore Attn: City Clerk 130 South Main Street Lake Elsinore, CA 92530 If to Contractor: Endresen Development Inc. Attn: Josh Endresen 15301 Alvarado Street Lake Elsinore CA 92530 11. Entire Agreement. This Agreement constitutes the complete and exclusive statement of agreement between the City and Contractor. All prior written and oral communications, including correspondence, drafts, memoranda, and representations, are superseded in total by this Agreement. 12. Amendments, This Agreement may be modified or amended only by a written document executed by both Contractor and City and approved as to form by the City Attorney. 13. Assignment and Subcontracting. Contractor shall be fully responsible to City for all acts or omissions of any subcontractors. Assignments of any or all rights, duties for obligations of the Contractor under this Agreement will be permitted only with the express consent of the City. Nothing in this Agreement shall create any contractual relationship between City and any subcontractor nor shall it create any obligation on the part of the City to pay or to see to the payment of any monies due to any such subcontractor other than as otherwise is required by law. 14. Waiver. Waiver of a breach or default under this Agreement shall not constitute a continuing waiver of a subsequent breach of the same or any other provision under this Agreement. 15. Severability. If any term or portion of this Agreement is held to be invalid, illegal; or otherwise unenforceable by a court of competent jurisdiction, the remaining provisions of this Agreement shall continue in full force and effect. 16, Controlling Law Venue, This Agreement and all matters relating to it shall be governed by the laws of the State of California and any action brought relating to this Agreement shall be held exclusively in a state court in the County of Riverside. 6 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 17. Litigation Expenses and Attorneys' Fees. If either party to this Agreement commences any legal action against the other party arising out of this Agreement; the prevailing party shall be entitled to recover its reasonable litigation expenses, including court costs, expert witness fees, discovery expenses, and attorneys' fees. 18. Mediation. The parties agree to make a good faith attempt to resolve any disputes arising out of this Agreement through mediation prior to commencing litigation. The parties shall mutually agree upon the mediator and share the costs of mediation equally. If the parties are unable to agree upon a mediator, the dispute shall be submitted to JAMS or its successor in interest. JAMS shall provide the parties with the names of five qualified mediators. Each party shall have the option to strike two of the five mediators selected by JAMS and thereafter the mediator remaining shall hear the dispute. If the dispute remains unresolved after mediation, either party may commence litigation. 19. Authority to Enter Agreement and Administration. Contractor has all requisite power and authority to conduct its business and to execute, deliver, and perform the Agreement. Each party warrants that the individuals who have signed this Agreement have the legal power, right, and authority to make this Agreement and to bind each respective party. The City Manager is authorized to enter into an amendment or otherwise take action on behalf of the City to make the following modifications to the Agreement: (a) a name change; (b) grant extensions of time; (c) non-monetary changes in the scope of services; and/or (d) suspend or terminate the Agreement. The City Engineer shall act as the Project administrator on behalf of the City. 20. Prohibited Interests, Contractor maintains and warrants that it has not employed nor retained any company or person, other than a bona fide employee working solely for Contractor, to solicit or secure this Agreement. Further, Contractor warrants that it has not paid nor has it agreed to pay any company or person, other than a bona fide employee working solely for Contractor, any fee, commission, percentage, brokerage fee, gift or other consideration contingent upon or resulting from the award or making of this Agreement. For breach or violation of this warranty, City shall have the right to rescind this Agreement without liability. For the term of this Agreement, no member, officer or employee of City, during the term of his or her service with City, shall have any direct interest in this Agreement, or obtain any present or anticipated material benefit arising therefrom. 21. Equal Opportunity Employment. Contractor represents that it is an equal opportunity employer and it shall not discriminate against any subcontractor, employee or applicant for employment because of race, religion, color, national origin, handicap, ancestry, sex or age. Such non-discrimination shall include, but not be limited to, all activities related to initial employment, upgrading, demotion, transfer, recruitment or recruitment advertising, layoff or termination. 22. Prevailing Wages. a. Contractor and all subcontractors shall adhere to the general prevailing rate of per diem wages as determined and as published by the State Director of the Department of Industrial Relations pursuant to Labor Code Sections 1770, 1773, and 1773.2. Copies of these rates and the latest revisions thereto are on file in the office of the City Clerk of the City of Lake Elsinore and are available for review upon request. 7 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 b. Contractor's attention is directed to the provisions of Labor Code Sections 1774, 1775, 1776, 1777.5 and 1777.6. Contractor shall comply with the provisions of these Sections. The statutory provisions for penalties for failure to comply with the State's wage and the hours laws will be enforced. C. Labor Code Sections 1774 and 1775 require the Contractor and all subcontractors to pay not less than the prevailing wage rates to all workmen employed in the execution of the contract and specify forfeitures and penalties for failure to do so. The minimum wages to be paid are those determined by the State Director of the Department of Industrial Relations. Labor Code Section 1776 requires the Contractor and all subcontractors to keep accurate payroll records, specifies the contents thereof, their inspection and duplication procedures and certain notices required of the Contractor pertaining to their location. The statutory penalties for failure to pay prevailing wages will be enforced. If the Project has been awarded to Contractor on or after April 1, 2015, Contractor and its subcontractors must furnish electronic certified payroll records to the Labor Commissioner, Beginning January 1, 2016, Contractor and its subcontractors must furnish electronic certified payroll records to the Labor Commissioner without regard to when the Project was awarded to Contractor. d. Labor Code Section 1777.5 requires Contractor or subcontractor employing tradesmen in any apprenticeable occupation to apply to the Joint Apprenticeship Committee nearest the site of the public works project, which administers the apprenticeship program in that trade for a certificate of approval. The certificate will also fix the ratio of apprentices to journeymen to be used in the performance of the Agreement. The Contractor is required to make contributions to funds established for the administration of apprenticeship programs if the Contractor employs registered apprentices or journeymen in any apprenticeable trade and if other contractors on the public works site are making such contributions. Information relative to apprenticeship standards, contributions, wage schedules and other requirements may be obtained from the State Director of Industrial Relations or from the Division of Apprenticeship Standards, Labor Code Section 1777.6 provides that it shall be unlawful to refuse to accept otherwise qualified employees as registered apprentices solely on the grounds of race, religious creed, color, national origin, ancestry, sex, or age. e. Eight hours labor constitutes a legal day's work, as set forth in Labor Code Section 181 0. 23. Execution. This Agreement may be executed in several counterparts, each of which shall constitute one and the same instrument and shall become binding upon the parties when at least one copy hereof shall have been signed by both parties hereto. In approving this Agreement, it shall not be necessary to produce or account for more than one such counterpart. [Signatures on next page] 8 Docusign Envelope ID:DA1 C6FA2-264C42CB-B06E-1806268C9B40 IN WITNESS WHEREOF, the parties have caused this Agreement to be executed on the date first written above. "CITY" "CONTRACTOR" CITY OF LAKE ELSINORE, a municipal Endresen Development Inc. corporation DOCUSigned by: DocuS[gned by: City Manager By: Josh Endresen Its: Owner ATTEST: Dvcu5igned by: aa,Laie07nRrdnn City Clerk APPROVED AS TO FORM: E City Attorney Assistant City Manager 9 Dccuslgn Envelope ID:DAIC6FA2-264C-42CB-B06E-1806268C9B40 EXHIBIT A CONTRACTOR'S PROPOSAL [ATTACHED] Endresen Development Inc 15301 Alvarado Street Lake Elsinore, CA 92530 ADDRESS Proposal City of Lake Elsinore 130 S. Main Street Lake Elsinore, CA 92530 • A TE 11/07/2024 PROJECT City Hall Stucco DESCRIPTION New construction Lath & Stucco 1 470,000.00 470,000.00 • Finish Smooth Stucco •Lath, Self Furring Structalath Attached with Staples, 2 Layers of 60 minute Grade D Weather Resistant Building Paper, Galvanized Corner and Weep Screed. •Crack Reduction System with Embedded mesh •Samples, We provide up to Three 1'x1' Samples for Color and Texture. Each Additional Sample will Cost $65. •Cracking, Stucco will Crack, we will do our Best to Minimize Cracking. • Debris, Debris to be Placed in Container Supplied by GC/Owner -Thin Brick 1 490,000.00 490,000.00 Running Bond. Pacific Clay, Norman Red Flashed Mortar -Thin Brick Soldier Course. Pacific Clay, Norman Red Flashed Mortar -Thin Brick Medallion Pacific Clay, Norman Red Flashed Mortar TOTAL $961 111 11 Accepted By Accepted Date 71, ACOR" CERTIFICATE OF LIABILITY INSURANCE �MM,DDf!YYY) �� 1 r23'2024 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). PRODUCER CONTACT GUStOmer Service learn NAME: Preferred Amencan Insurance (AIC No Ext): (888) 145 0002 A C.No): (888)834-0006 P.O.Box 79498 E MAIL customerservice(apre`erredamerican com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 Corona CA 92877 INSURER A Scottsdale IIISUidIIGe Company 41297 INSURED INSURER B =ndresen DevelOPment,IH- INSURER C 15301 Alvaradc St. INSURER D INSURER E Lake Elsinore CA 92530 INSURER F: COVERAGES CERTIFICATE NUMBER: 24-25 Corta REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT W'TH 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. IL SR ADDLSUEIR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMI•DDYYYY MM DD YYYICY EFF POLICY P LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1.000,ODO OCCUR r 100,00E C_AINIS-MADE FX E5 Ea OCCU LIED EXP(Any one person) S 5,000 A Y RBS0327156 10/26,2024 1026/2025 PERSONAL B ADV INJURY S 1.000,000 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE S 2.000.ODO X POLICY PRO y 1.000,ODO JECT LOC PRODUCTS COMfVOPAGG S OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ca accident ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S ALTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ ALTOS ONLY AUTOS ONLY Par accident S UMBRELLA LAB OCCUR EACH OCCURRENCE S EXCESS LIAR HCLAILIS-NIADE AGGREGATE S DED RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y r N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S It ves.describe under DESCRIPTION OF OPERATIONS betaw 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) City of Lake Elsinore is named as Additional Insured as required by written ccntract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Lake Elsinore ACCORDANCE WITH THE POLICY PROVISIONS. 130 South Main Street AUTHORIZED REPRESENTATIVE Lake Elsinore CA 92530 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Underwritten by Scottsdale Insurance Company ENDORSEMENT NO. AT IACH6D TO AND ENDORSEMENT EFFECTIVE DATE FORMING A PART OF NAMED INSURED AGENT NO. POLICY NUMBER (12.01 A.M.STANDARD TIME) RBS0327156 10/26"2024 Endresen Development, Inc. 047BZ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED—ONGOING OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION II—WHO IS AN INSURED, paragraph C. is amended to include, for COVERAGE A—BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY AND ADVERTISING INJURY LIABILITY only, as an additional insured, any person, entity or organization for wham the Named Insured is performing ongoing operations only when the Named Insured has agreed with the person, entity or organization in an insured contract to name the person, entity or organization as an additional insured. 1. Such person, entity or organization is only an additional insured with respect to liability for bodi- ly injury or property damage caused, in whole or in part, by the ongoing operations of the Named Insured performed for the additional insured. 2. The insured contract must be currently in effect or become effective during the policy period, be executed prior to the bodily injury or property damage first happening, and be between the Named Insured and the additional insured. 3. This coveragedoes not apply to bodily injury orproperty damage after: a. Your work for the additional insured has been completed; or b. That portion of your work out of which the bodily injury or property damage arises has been put to its intended use by any person or organization. 4. The applicable limit of our liability shall not be increased by the inclusion of the additional in- sured under the policy. 5. We shall have no duty to indemnify the additional insured for damages,claims or any other lia- bilities arising from actions, inactions, errors or omissions of the additional insured. 6. Our duty to indemnify the additional insured under an insured contract pursuant to this en- dorsement shall be limited to that sum derived by applying the percentage of fault of the Named Insured as determined by the trier-of-fact to the total damage sum allocated by the trier-of-fact to the additional insured. Under no circumstances shall we pay more than this proportionate in- demnity share required of the policyholder in the insured contract. 7. Any indemnity payments made on behalf of any additional insured under an insured contract shall reduce the applicable limits of Insurance on a dollar for dollar basis. Any indemnity pay- ments paid to or on behalf of the additional insured pursuant to this endorsement are subject to the terms, conditions and limitations of the policy. Nationwide` SIDS-6(1-19) Page 1 of 2 s-�_, 8. This endorsement does not create a duty on our part to defend the additional insured or to par- ticipate in, contribute to, or reimburse any person, organization or entity for any fees or expenses incurred in the defense of the additional insured_ SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition B. INSUREDS DUTIES IN THE EVENT OF OCCURRENCE. OFFENSE, CLAIM OR SUIT of the policy is amended to include.- An additional insured under this endorsement shall in addition to complying with all provisions of the policy: 1. Give written notice to us of ar occurrence or an offense which may result in a claim or suit with- in thirty (30) days of notice to the additional insured. 2. Give written notice to us of a claim or suit brought against the additional insured within thirty (30) days of the additional insured being served with the claim or suit. 3. Give written notice to any other insurer who has or may have coverage under its policy or policies for a claim,suit or demand for defense or indemnity within thirty (30) days of the additional in- sured being served with the clairn,suit or demand for defense or indemnity Such notice must demand the full coverage available under the policy. The additional insured will not take any ac- tion to waive or limits such other coverage available to it 4. Obtain and provide to us copies of each and every policy from each and every insurer identified pursuant to the preceding paragraph. This endorsement is subject to all terms, conditions and exclusions of the policy, which remain unchanged. 10/23/2024 AUTHORIZED REPRESENTATIVE DATE SDS 6(1-19) Page 2 of 2 4 Nationwide` ENDORSEMENT Aiii SCOTTSDALE INSURANCE COMPANY NO. AT IACH6D TO AND ENDORSEMENT EFFECTIVE DATE FORMING A PART OF NAMED INSURED AGENT NO. POLICY NUMBER (12.01 A.M.STANDARD TIME) RBS0327156 10/26"2024 Endresen Development, Inc. 047BZ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED-ONGOING OPERATIONS-PRIMARY AND NON-CONTRIBUTORY-OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION II—WHO IS AN INSURED. paragraph C. is amended to include, for COVERAGE A—BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY AND ADVERTISING INJURY LIABILITY only, as an additional insured, any person, entity or organization for whom the Named Insured is performing ongoing operations only when the Named Insured has agreed with the person entity or organization in an insured contract to name the person, entity or organization as an additional insured. 1. Such person, entity or organization is only an additional insured with respect to liability for bodi- ly injury or property damage caused, in whole or in part, by the ongoing operations of the Named Insured performed for the additional insured. 2. The insured contract must be currently in effect or become effective during the policy period, be executed prior to the bodily injuryor property damage first happening, and be between the Named Insured and the additional insured. 3. This coveragedoes not apply to bodily injury or property damage after: a. Your work for the additional insuredhas been completed; or b. That portion of your work out of which the bodily injury or property damagearises has been put to Its intended use by any person or organization. 4. The applicable limit of our liability shall not be increased by the inclusion of the additional in- sured under the policy. 5. We shall have no duty to indemnify the additional insured for damages,claims or any other lia- bilities arising from actions, inactions, errors or omissions of the additional insured. 6. Our duty to contractually indemnify the additional insuredunder an insured contract shall be limited to that sum derived by applying the percentage of fault of the Named Insured as deter- mined by the trier the trier-of-fact to the total damage sum allocated by the trier-of-fact to the ad- ditional insured.Under no circumstances shall we pay more than this proportionate contractual Indemnity share 7. Any contractual indemnity payments made on behalf of any additional insured under an in- sured contract shall reduce the applicable limits of insurance on a dollar for dollar basis. Any contractual indemnity payments are subject to the terms, conditions and limitations of the policy. SIDS-8(1-18) Page 1 of 2 8. This endorsement does not create a duty on ourpart to defend the additional insuredor to par- ticipate in, contribute to, or reimburse any person, organization or entity for any fees or expenses incurred in the defense of the additional insured_ SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition B. INSUREDS DUTIES IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUITof the policy is amended to include: An additional insuredunder this endorsement shall in addition to complying with all provisions of the policy: 1. Give written notice tous of an occurrence or an offense which may result in a claim or suit with- in thirty (30) days of notice to the additional insured. 2. Give written notice to us of a claim or suit brought against the additional insured within thirty (30) days of the additional insured being served with the claim or suit. 3. Give written notice to any other insurer who has or may have coverage under its policy or policies for a claim,suit or demand for defense or indemnity within thirty (30) days of the additional in- sured being served with the claim,suitor demand for defense or indemnity.Such notice must demand the full coverage available under the policy.The additional insured will not take any ac- tion to waive or limit such other coverage available to it 4. Obtain and provide to us copies of each and every policy from each and every insurer identified pursuant to the preceding paragraph. The coverage provided by this endorsement is primary and non-contributory and no insurance held or owned by the additional insured shall be called upon to cover damages under this policy up to the limits of this policy, but only if the bodily injury or property damage under this policy is caused directly, in whole or in part, from your ongoing operations performed for the additional insured. This endorsement is subject to all terms, conditions and exclusions of the policy, which remain unchanged. �J 10/23/2024 AUTHORIZED REPRESENTATIVE DATE Sli(1-18) Page 2 of 2 ENDORSEMENT A� SCOTTSDALE INSURANCE COMPANY NO. ATTACKED TO AND ENDORSEMENT EFFECTIVE DATE: FORMING A PART OF NAMED INSURED AGENT NO. POLICY NUMBER (12:01 A.M.STANDARD TIME) RBS0327156 10/26!2024 Endresen Development, Inc. 047BZ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person or Designated Construction Project: Organization: Any person or organization against whom Any construction project performed by you for any subrogation is required to be waived by an person or organization against whom subrogation is "insured contract". required to be waived by an "insured contract'. SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph J. TRANSFER OF RIGHTS OF RECOVERY AGAINST OTIIERS TO US is deleted in its entirety and replaced by the following. J. TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US If any insured has rights to recover all or part of any payment we have made under the applicable Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair such rights. At our request, such insured will bring suit or transfer those rights to us and help us enforce them. 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 bodily injury or property damage arising out of your work done under an insured contract with that person or organization at the designated construction project. This waiver applies only if the designated construction project shown in the Schedule above is completed and only to the construction project designated in the above Schedule. All other terms, conditions and exclusions of the policy remain unchanged. 10/23/2024 AUTHORIZED REPRESENTATIVE DATE SDS-17(1-18) Page I of I Standard Workers' Compensation and Employers' Liability Policy 01 Policy Number: ONCC12487-04 Policy Period: 03,106/2025 to 03/06/2026 Om h Coverage By: Omaha National Casualty Company Producer ID: David Levoy Insurance Agency, Inc. NA T 10 N A L Previous Coverage: PSIC12487-03 CASUALTY COMPANY Carrier ID: 00161 NAME AND ADDRESS OF INSURED AGENT 1 Enciresen Development, Inc. David Levoy Insurance Agency, Inc. 15301 Alvardao St. PO Box 30 Lake Elsinore, CA 92530 Loomis, CA 9565C Renewal Contact: Renewal Email Address: FEIN: 824542462 Risk ID Number: Entity of insured: Corporation 2 The Policy period is from 03/C6/2025 to 03/06/2026 12:01 AM Stancard Time at the Insured's mailing address. 3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation law of the states listed here: CA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000.000 Each Accident Bodily Injury by Disease $1,000.000 Policy Limit Bodily Injury by Disease $1,000 000 Each Employee C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here: D. See attached schedule for list of endorsements forming part of this policy. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and adjustment of premium shall be made upon policy expiration. Per Attached Schedule: Minimum Premium: S75C Average Premium Discount: 9.69% Total Estimated Annual Premium: $27,327 Expense Constant: S200 Deposit Premium: $0 Additional Assessments: Policy Issuing Office: PO Box 451139, Omaha, NE 68145 Countersigned by WC000001A Issue Date: 03/03/2025 Copy•igh! 1987 National Council on Compensation Insurance Standard Workers' Compensation rrl and Employers' Liability Policy Policy Number: ONCC12487-04 Policy Period: 03/06/2025 to 03/06/2026 maha Coverage By: Omaha National Casualty Company OProducer ID: David Levoy Insurance Agency, Inc. NATIONALPrevious Coverage: PSIC12487-03 CASUALTY COMPANY Carrier ID: 00161 NAME AND ADDRESS OF INSURED AGENT 1. Endresen Development, Inc. David Levoy Insurance Agency. Inc. 15301 Alvardao St. PO Box 30 Lake Elsinore, CA 92530 Loomis, CA 95650 Renewal Contact: Renewal Email Address: FEIN: 824542462 Risk ID Number: Schedule Page 1 or 1 NAMED INSURED SCHEDULE Named Insured FEIN Eff Date Exp Date Endresen Development, Inc. 824542462 03/06/2025 03/06/2026 WC000001NI Issue Date: 03/03/2025 Copyright 1987 National Council on Compensation Insurance Standard Workers' Compensation and Employers' Liability Policy CM Policy Number: ONCC12487-04 Policy Period: 03'0612025 to 03/06/2026 Om h Coverage By: Omaha National Casualty Company Producer ID: David Levoy Insurance Agency, Inc. N A T 10 N A L Previous Coverage: PSIC124B7-03 CASUALTY COMPANY Carrier ID: 00161 NAME AND ADDRESS OF INSURED AGENT 1. Endresen Development, Inc. David Levoy InSurance Agency, Inc. 15301 Alvardao St. PO Box 30 Lake Elsinore, CA 92530 Loomis, CA 95650 Renewal Contact: Renewal Email Address: FFIN- 824542462 Risk ID Number Schedule Pace 1 of 1 ADDITIONAL LOCATIONS SCHEDULE 0000/ Endresen Development, Inc. FEIN: 82-4542462 15301 Alvarado St SIC: Lake Elsinore,CA 92530 NAIC: Number of Employees:9 Coverage Effective Coverage Expiration Phone: 951-757-2112 03/06/2C25 03/06/2026 WC 00 00 AL Issue Date: 03/03/2025 Cpy•igh! 1987 National Council on Compensation Insurance Standard Workers' Compensation and Employers' Liability Policy Policy Number: ONCC12487-04 Policy Period: 03;06;2025 to 03/06/2026 Om h Coverage By: Omaha National Casualty Company Producer ID: David Levoy Insurance Agency, Inc. N A T 10 N A L Previous Coverage: PSIC12487-03 CASUALTY COMPANY Carrier ID: 00161 NAME AND ADDRESS OF INSURED F AGENT 1 Endresen Development, Inc. David Levey Insurance Agency, Inc. 15301 Alvardao St. PO Box 30 Lake Elsinore,CA 92530 Loomis, CA 9565C Renewal Contact. Renewal Email Address: FEIN: 824542462 Risk ID Number: Schedule Page 1 of 1 ENDORSEMENT SCHEDULE State NUMBER DESCRIPTION OCCURRENCE US WC 00 00 00 C Workers Compensation and Employers Liability Insurance Policy 1 US WC 00 04 06 A Premium Discount Endorsement 1 US WC 00 04 19 Premium Due Date Endorsement 1 US WC 00 04 22 C Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 1 CA WC 04 04 21 Optional Premium Increase Endorsement-California 1 CA WC 04 04 22 California Short-Rate Cancellation Endorsement 1 CA WC 04 06 01 B California Cancelation Endorsement 1 CA WC ON 04 CO Notification of Change in Ownership Endorsement—California 1 CA WC 04 03 01 D Policy Amendatory Endorsement—California 1 CA WC 04 03 03 C Endorsement Agreement Limiting and Restricting this Insurance-Officers and Directors C, 1 CA WC 04 03 10 Duty to Defend—California 1 CA WC 04 03 60 B Employers'Liability Coverage Amendatory Endorsement—California 1 CA PN 04 99 C1 I Policyholder Notice-Your Right to Rating and Dividend Information 1 CA PN 04 99 C2 B Policyholder Notice-California Workers' Compensation Insurance Rating Laws 1 CA PN 04 99 C3 Policyholder Notice - Notice Required by Law—California 1 CA PN 04 99 C4 Policyholder Notice-California Insurance Guarantee Association(CIGA) Surcharge 1 CA PN 04 99 C6 D Policyholder Notice- Payroll Record And Audit Requirements For Dual Wage Construction 1 wcaoo0Es Issue Date: 03/03/2025 CDi 1987 National Council on Compensation Insurance Standard Workers' Compensation and Employers' Liability Policy Policy Number: ONCC12487-04 Policy Period: 010612025 to 03/06/2026 Omaha Coverage By: Omaha National Casualty Company NATIONALProducer ID: David Levoy insurance Agency, Inc. CASUALTY COMPANY Previous Coverage. PSIC12487-03 Carrier ID: 00161 NAME AND ADDRESS OF INSURED AGENT 1. Endresen Development, Inc. David Levoy Insurance Agency, Inc. 15301 Alvardao St_ PO Box 30 Lake Elsinore, CA 92530 Loomis, CA 9565C Renewal Contact. Renewal Email Address: FEIN: 824542462 Risk ID Number: Total cost of policy is located on WCOOOOPS Schedule Pace 1 of 2 SCHEDULE OF OPERATIONS Policy Insured Premium Estimated Loc Loc Code Classifications Basis Rate Premium Endorsement Term : 03/06/2025 to 03/06/2026 State: CA Experience Mod Status Effective Date 0.770 FINAL 03/06/2C25 0000 N/A 004200 Landscape gardening-including maintenance of gardens $200,C00 9.39 $18,780 Class Code:004200 Effective:Expired: 0000 N/A 540300 Carpentry- including the installation of interior trim, doors and cz SO 20.99 $0 Class Code:540300 Effective:Expired: 0000 N/A 543200 Carpentry- including the installation of interior trim, doors and ci $500,000 9.29 $46,450 Class Code:543200 Effective:Expired: 0000 N/A 547401 Painting or wallpaper installation -including shop yard or storag SO 14.90 $0 Class Code:547401 Effective:Expired: 0000 N/A 548201 Painting or wallpaper installation -including shop yard or storag SO 8.47 SO Class Code:548201 Effective:Expired: 0000 N/A 900800 Janitorial services-by contractors SO 12.21 $0 Class Code:900800 Effective:Expired: $700,000 $65,230 Manual Premium $65,230 Manual Premium $65,230 Total Manual Premium $65,230 Subject Premium $65,230 Total Subject Premium $65,230 Experience Modification ($15,003) Total Modified Premium $50,227 Schedule Rating -0.44 ($22,100) Total Standard Premium $28,127 CA Premium Discount ($2,521) CA Terrorism Risk 0.03 $210 WC 00 00 so Policy_DEC_Schedu lcOfOperations.rpt Issue oat'.. 03/03/2025 Copy,ight 1987 National Council on Compensation Insurance Standard Workers' Compensation and Employers' Liability Policy Policy Number: ONCC12487-04 Policy Period: 010612025 to 03/06/2026 Omaha Coverage By: Omaha National Casualty Company NATIONALProducer ID: David Levoy Insurance Agency, Inc. CASUALTY COMPANY Previous Coverage. PSIC12487-03 Carrier ID: 00161 NAME AND ADDRESS OF INSURED AGENT 1, Endresen Development, Inc. David Levoy Insurance Agency, Inc. 15301 Alvardao St_ PO Box 30 Lake Elsinore, CA 92530 Loomis, CA 9565C Renewal Contact: Renewal Email Address: FEIN: 824542462 Risk ID Number: Total cost of policy is located on WCOOOOPS Schedule Pace 2 of 2 SCHEDULE OF OPERATIONS Policy Insured Premium Estimated Loc Loc Code Classifications Basis Rate Premium Endorsement Term : 03/06/2025 to 03/06/2026 State: CA CA Labor Enforcement and Compliance Fund Assessment 0.00 $28 CA Occupational Safety and Health Fund Assessment 0.00 $49 CA Subsequent Injuries Benefits Trust Fund Assessment 0.03 $784 CA Uninsured Employers Benefits Trust Fund Assessment 0.00 $21 CA bVorkers' Compensation Administration Revolving Fund Assessment 0.01 $322 CA Workers' Compensation Fraud Account Assessment 0.00 $107 Total Estimated Premium for Period Effective: 03/06/2025 $28,127 Expense Constant $200 Premium Discount ($2,521) Terrorism Risk $210 Labor Enforcement and Compliance Fund Assessment $28 Occupational Safety and Health Fund Assessment $49 Subsequent Injuries Benefits Trust Fund Assessment $784 Uninsured Employers Benefits Trust Fund Assessment $21 Vdorkers' Compensation Administration Revolving Fund Assessment $322 Workers' Compensation Fraud Account Assessment $107 Policy Charges/Credits for the Period Effective: 03/06/2025 ($800) Total Estimated Premium for the Period Effective: 03/06/2025 $27,327 We 00 00 so Policy_DEC_Schedu IeOfOperations.rpt Issue Date. 03103/2025 Copy,ight 1987 National Council on Compensation Insurance Standard Workers' Compensation and Employers' Liability Policy L, Policy Number: ONCC12487-C4 Policy Period: 03r06(2025 to 03/36/2026 Omaha Coverage By: Omaha National Casualty Company NATIONALProducer ID: David Levoy Insurance Agency, Inc. CASUALTY COMPANY Previous Coverage: PSIC12487-03 Carrier ID: 00161 NAME AND ADDRESS OF INSURED AGENT 1. Endresen Development, Inc_ David Levoy Insurance Agency, Inc. 15301 Alvardao St. Lake Elsinore,CA 92530 PO Box 30 Renewal Contact: Loomis, CA 9565C Renewal Email Address- FEIN: 824542462 Risk ID Number: Summary Page 1 of 1 SCHEDULE OF OPERATIONS Prom Basis Rate Per Policy Insured Total-Est. $100 Remun Estimated Loc Loc Code Classifications Remun Premium POLICY SUMMARY Estimated Premium All Locations Excluding Policy Charges/Credits $28,127 Expense Constant $200 Premium Discount ($2,521) Terrorism Risk $210 Labor Enforcement and Compliance Fund Assessment $28 Occupational Safety and Health Fund Assessment $49 Subsequent Injuries Benefits Trust Fund Assessment $784 Uninsured Employers Benefits Trust Func Assessment $21 Workers' Compensation Administration Revolving Fund Assessment $322 Workers' Compensation Fraud Account Assessment $107 Policy Charges ) Credits ($800) Total Estimated Annual Premium $27,327 WC 00 00 Ps Issue Date: 03/03/2025 Copyright 1987 National Cuuncil un Cumpensaliun Insurance WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 0 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all 1. Bodily injury by accident must occur during the terms of this policy, we agree with you as follows: policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. GENERAL SECTION The employee s last day of last exposure to the A. The Policy conditions causing or aggravating such bodily This pol cy includes at its effective date the Information injury by disease must occur during the policy Page and all endorsements and schedules listed there. period. It is a contract of insurance between you ('he employer B. We Will Pay named in Item 1 of the Information Page)and us (the We will pay promptly when due the benefits required of insurer named on the Information Page). The only you by the workers compensation law. agreements relating to this insurance are stated in this C. We Will Defend policy. The terms of:his policy may not be changed or We have.he right and duty to defend at our expense waived except by endorsement issued by us to be part any claim proceeding or suit against you for benefits of this policy. payable by this insurance. We have the right to B. Who Is Insured investigate and settle these claims, proceedings or You are insured if you are an employer named in Item suits. 1 of the Information Page. If that employer is a We have no duty to defend a claim, proceeding or suit partnership, and if you are one of its partners you are that is not covered by this insurance. insured, but only in your capacity as an employer of the D. We Will Also Pay partnership's employees. We will also pay these costs, in addition to other C. Workers Compensation Law amounts payable under this insurance, as part of any Workers Compensation Law means the workers or claim, proceeding or suit we defend. workmen's compensation law and occupa-ional disease 1. reasonable expenses incurred at our request, but law of each state or territory named in Item 3.A. of the not loss of earnings; Information Page. It includes any amendments to that 2. premiums for bonds to release attachments and for law which are in effect during the policy period. It does appeal bonds in bond amounts up to the amount not include any federal workers or workmen's payable under this insurance; compensation law, any federal occupational disease 3. litigation costs taxed against you:, law or the provisions of any law that provide 4. interest on a judgment as required by law until we nonoccupational disability benefits. offer the amount due under this insurance, and D. State 5. expenses we incur. State means any state of the United States of America, E. Other Insurance and the District of Columbia. We will not pay more than our share of benefits and E. Locations costs covered by this insurance and other insurance or This policy covers all of your workplaces listed it Items self-insurance. Subject to any limits of liability that may 1 or 4 of the Informatior Page; and it coves all other apply, all shares will be equal until the loss is paid. If workplaces in Item 3.A.states unless you nave other any insurance or self-insurance is exhausted, the insurance or are self-insured for such workplaces. shares of all remaining insurance will be equal until the loss is pa.d. PART ONE F. Payments You Must Make WORKERS COMPENSATION INSURANCE You are responsible for any payments in excess of the A. How This Insurance Applies benefits regularly provided by the workers This workers compensation insurance applies to hodily compensation law including those required because' injury by accident or bodily injury by disease. Bodily 1. of your serious and willful misconduct; injury includes resulting death. )Copyright 2013 National Council on Compensation Incurance, Irc. All Rightc Recerved. WIC 000000C 1of6 (Ed. 01-15) WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-15) 2. you knowingly employ an employee it violation of PART TWO law: EMPLOYERS LIABILITY INSURANCE 3. you fail to comply with a health or safety law or A. How This Insurance Applies regulation; or This employers liability insurance applies to bodily 4. you discharge, coerce or otherwise discriminate injury by accident or bodily injury by disease. Bodily against any employee in violation of the workers injury includes resulting death. compensation law. 1. The bodily injury must arise out of and in the If we make any payments in excess of the benefits course of the injured employee's employment by regularly provided by the workers compensation law on you. your behalf. you will reimburse us promptly. 2. The employment must be necessary or incidental G. Recovery From Others to your work in a state or territory listed in Item 3.A. We have your rights, and the rights of persons entitled of the Information Page. to the benefits of;his insurance, to recove,our 3. Bodily injury by accident must occur during the payments from anyone liable for the injury. You will do policy period. everything necessary to protect those rights for us and 4. Bodily injury by disease must be caused or to help us enforce them. aggravated by the conditions of your employment. H. Statutory Provisions The employees last day of last exposure to the These statements apply where they are required by conditions causing or aggravating such bodily law. injury by disease must occur during the policy 1. As between an injured worker and us we have period. notice of the injury when you have no�ice. 5. If you are sued, the original suit and any related 2. Your default or the bankruptcy or insclvency of you legal actions for damages for bodily injury by or your estate will not relieve us of ou,duties under accident or by disease must be brought in the this insurance after an injury occurs. United States of America, its territories or 3. We are directly and primarily liable to any person possessions, or Canada. entitled to the benefits payable by thiE insurance. B. We Will Pay Those persons may enforce our duties; so may an WR will pay all sums that you Iergally must pay as agency authorized by law. Enforcement may be damages because of bodily injury to your employees, against us or against you and us. provided the bodily injury is covered by this Employers 4. Jurisdiction over you is jurisdiction over us for Liability Insurance. purposes of the workers cornpensatian law.We The damages we will pay, where recovery is permitted are bound by decisions against you under that law, by law. include damages: subject to the provisions of this policy that are not 1. For which you are liable to a third party by reason in conflict with that law. of a claim or suit against you by that third party to 5. This insurance conforms to the parts of the recover the damages claimed against such third workers compensation law that apply to: party as a result of injury to your employee; a. benefits payable by this insurance; 2. For care and loss of services;and b. special taxes, payments into security or other 3. For consequential bodily injury to a spouse, child, special funds, and assessments payable by us parent, brother or sister of the injured employee; urder that law. provided that these damages are the direct 6. Terms of this insurance that conflict with the consequence of bodily injury that arises out of and workers compensation law are changed by this in the course of the injured employee's statement to conform to that law. employment by you; and Nothing in these paragraphs relieves you of your duties 4. Because of bodily injury to your employee that under this policy. arises out of and in the course of employment, claimed against you in a capacity other than as employer. O Copyright 2013 National Council on Compensation Incurance, Irc. All Rightc Rocerved. WC000000C 2of6 (Ed. 01-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 0 1-15) C. Exclusions 11. Fines or penalties imposed for violation of federal This insurance does not cover: or state law; and 1. Liability assumed under a contract. This exclusion 12. Damages payable under the Migrant and Seasonal does not apply to a warranty that your work will be Agricultural Worker Protection Act(29 U.S.C. done in a workmanlike manner; Sections 1801 et seq.)and under any other federal 2. Punitive or exemplary damages because of bodily law awarding damages for violation of those laws injury to an employee employed in violation of law: or regulations issued there under, and any 3. Bodily injury to an employee while employed in amendments to those laws. violation of law with your actual knowledge or the D. We Will Defend actual knowledge of any of your executive officers; We have the right and duty to defend, at our expense, 4. Any obligation imposed by a workers any claim. proceeding or suit against you for damages compensation, occupational disease, payable by this insurance. We have the right to unemployment compensation, or disability benefits investigate and settle these claims, proceedings and law, or any similar law; suits. 5. Bodily injury intentionally caused or aggravated by We have no duty to defend a claim, proceeding or suit you; that is not covered by this insurance. We have no duty 6. Bodily injury occurring outside the Un ted States of to defend or continue defending after we have paid our America, its territories or possessions, and applicable limit of liability under this insurance. Canada. This exclusion does not apply to bodily E. We Will Also Pay injury to a citizen or resident of the Urited States of We will also pay these costs, in addition to other America or Canada who is temporarily outside amounts payable under this insurance, as part of any these countries; claim, proceeding, or suit we defend: 7. Damages arising out of coercion, criticism, 1. Reasonable expenses incurred at our request, but demotion,evaluation, reassignment, discipline, not loss of earnings; defamation, harassment,humiliation, 2. Premiums for bonds to release attachments and discrimination against or termination of any for appeal bonds in bond amounts up to the limit of employee. or any personnel practices, policies our liability Linder this insurance; acts or omissions; 3. Litigation costs taxed against you; 8. Bodily injury to any person in work su3ject to the 4. Interest on a judgment as required by law until we Longshore and Harbor Workers' Compensation offer the amount due under this insurance and Act(33 U.S.C. Sections 901 et seq.),the 5. Expenses we incur. Nonappropriated Fund Instrumentalities Act(5 F. Other Insurance U.S.C. Sections 8171 et seq.), the Otter We will not pay more than our share of damages and Continental Shelf Lands Act(43 U.S.C. Sectiors costs covered by this insurance and other insurance or 1331 et seq.), the Defense Base Act (42 U.S.C. self-insurance. Subject to any limits of liability that Sections 1651-1654), the Federal Mire Safety and apply, all shares will be equal until the loss is paid. If Health Act (30 U.S.C. Sections 801 et seq. and any insurance or self-insurance is exhausted, the 901-944),any other federal workers or workmen's shares of all remaining insurance and self-insurance compensation law or other federal occupational will be equal until the loss is paid. disease law,or any amendments to these laws; G. Limits of Liability 9. Bodily injury to any person in work su3ject to the Our liability to pay for damages is limited. Our limits of Federal Employers Liability Act(45 U.S.C. liability are shown in Item 3.B. of the Information Page. Sections 51 et seq.), any other federal laws They apply as explained below. obligating an employer to pay damages to an 1. Bodily Injury by Accident. The limit shown for employee due to bodily injury arising out of or in "bodily injury by accident—each accident"is the the course of employment, or any amendments to most we will pay for all damages covered by this those laws; insurance because of bodily injury to one or more 10. Bodily injury to a master or member of the crew of employees in any one accident. any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages,maintenance, and cure under any applicable maritime law )Copyright 2013 National Council on Compensation Incurance, Irc. All Rightc Roeervod. WIC 000000C 3of6 (Ed. 01-15) WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-15) A disease is not bodily injury by accident unless it all provisions of the policy Nill apply as though that state results directly from bodily injury by accident. were listed in Item 3.A. of the Information Page. 2. Bodily Injury by Disease.The limit shown for 3. We will reimburse you for the benefits required by 'bodily injury by disease—policy limit' is the most the workers compensation law of that state if we we will pay for all damayes covered by this are not permitted to pay the benefits directly to insurance and arising out of bodily injury by persons entitled to them. disease, regardless of the number of employees 4. If you have work on the effective date of this policy who sustain bodily injury by disease.The limit in any state not listed in Item 3.A. of the shown for"bodily injury by disease—each Information Page, coverage will not be afforded for employee'is the most we will pay for all damages that state unless we are notified within thirty days. because of bodily injury by disease to any one B. Notice employee. Tell us at once if you begin work in any state listed in Bodily injury by disease does not include disease Item 3.C. of the Information Page. that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we PART FOUR have paid the applicable limit of our liability under YOUR DUTIES IF INJURY OCCURS this insurance. Tell us at once i`in.ury occurs that may be covered by H. Recovery From Others this policy. Your other duties are listed here We have your rights to recover our payment from 1. Provide for immediate medical and other services anyone liable for an injury covered by this insurance. required by the workers compensation law. You will do everything necessary to protect those rights 2. Give us or our agent the names and addresses of for us and to help us enforce them. the injured persons and of witnesses, and other I. Actions Against Us information we may need. There will be no right of action against us under this 3. Promptly give us all notices, demands and legal insurance unless: papers related to the injury, claim, proceeding or 1. You have complied with all the terms of this policy; suit. and 4. Cooperate with us and assist us,as we may 2. The amount you owe has been determined with request, in the investigation, settlement or defense our consent or by actual trial and final judgment. of any claim, proceeding or suit. This insurance does not give anyone the right to add us 5. Do nothing after an injury occurs that would as a defendant in an action against you to determine interfere with cur right to recover from others. your liability. The bankruptcy or insolvency of you or 6. Do not voluntarily make payments, assume your estate will not relieve us of our obligations under obligations or incur expenses,except at your own this Part. cost. PART THREE PART FIVE— PREMIUM OTHER STATES INSURANCE A. Our Manuals A. How This Insurance Applies All premium for:his policy will be determined by our 1. This other states insurance applies only if one or manuals of rules, rates, rating plans and classifications. more states are shown in Item 3.C. of the We may change our manuals and apply the changes to Information Page. this policy if authorized by law or a governmental 2. If you begin work in any one of those states after agency regulating this insurance. the effective date of this policy and are not insured or are not self-insured for such work, n Copyright 2013 Na:ional Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C 4 of 6 (Ed. 01-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 0 1-15) B. Classifications 2. If you cancel, final premium will be more than pro Item 4 of the Information Page shows the ate and rata; it will be based on the time this policy was in premium basis for certain business or wor< force, and increased by our short-rate cancelation classifications. These classifications were assigned table and procedure. Final premium will not be less based on an estimate of the exposures you would have than the minimum premium. during the policy period. If your actual exposures are F. Records not properly described by those classifications, we will You will keep records of information needed to assign proper classifications, rates and premium basis compute premium.You will provide us with copies of by endorsement to this policy. those records when we ask for them. C. Remuneration G. Audit Premium for each work classification is determined by You will let us examine and audit all your records that multiplying a rate times a premium basis. relate to this policy. These records include ledgers, Remuneration is the most common premium basis. journals, registers,vouchers, contracts, tax reports, This premium basis includes payroll and all other payroll and disbursement records,and programs for remuneration paid or payable during the policy period storing and retrieving data. We may conduct the audits for the services of: during regular business hours during the policy period 1. all your officers and employees engaged in work and within three years after the policy period ends. covered by this policy;and Information developed by audit will be used to 2. all other persons engaged in work that could make determine firal premium. Insurance rate service us Fable under Part One Workers Compensation organizations have the same rights we have under this Insurance)of this policy. If you do not have payroll provision. records for these persons, the contract price for their services and materials may be used as the PART SIX—CONDITIONS premium basis.This paragraph 2 will not apply if A. Inspection you give us proof that the employers of these We have the right, but are not obliged to inspect your persons lawfully secured their workers workplaces at any time. Our inspections are not safety compensation obligations. inspections They relate only to the insurability of the D. Premium Payments workplaces and the premiums to be charged. We may You will pay all premium when due. You ,vill pay the give you reports on the conditions we find. We may premium even if part or all of a workers compensation also recommend changes. While they may help reduce law is not valid. losses, we do not undertake to perform the duly of any E. Final Premium person to provide for the health or safety of your The premium shown on the Information Page, employees or the public. We do not warrant that your schedules,and endorsements is an estimate.The final workplaces are safe or healthful or that they comply premium will be determined after this policy ends by with laws, regulations,codes or standards. Insurance using the actual, not the estimated, premium basis and rate service organizations have the same rights we the proper classifications and rates that lawfully apply have under this prevision. to the business and work covered by this policy. If the B. Long Term Policy firal premium is more than the premium you paid to us, If the policy period is longer than one year and sixteen you must pay us the balance. If it is less, we will refund days, all provisions of this policy will apply as though a the balance to you. The final premium will not be less new policy were issued on each annual anniversary than the highest minimum premium for the that this policy is in force. classifications covered by this policy. C. Transfer of Your Rights and Duties If this policy is canceled, final premium will be Your rights or duties under this policy may not be determined in the following way unless ou,manuals transferred without our written consent. provide otherwise- If you die and we receive notice within thirty days after 1. If we cancel,final premium will be calculated pro your death, we will cover your legal representative as rata based on the time this policy was in force. insured. Final premium will not be less than the pro rata share of the minimum premium. n Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC000000C 5of6 (Ed. 01-15) WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed.01-15) D. Cancellation 4. Any of these provisions that conflict with a law that 1. You may cancel this policy.You must mail or controls the cancelation of the insurance in this deliver advance written notice to us slating when policy is changed by this statement to comply with the cancelation is to take effect. the law. 2. We may cancel this policy.We must mail or deliver E. Sole Representative to you not less than ten days advance written The insured first named in Item 1 of the Information notice stating when the cancelation is to take Page will act on behalf of all insureds to change this effect.Mailing that notice to you at your mailing policy,receive return premium,and give or receive address shown in Item 1 of the Information Page notice of cancelation. will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. t7 Copyright 2013 National Council on Compensation Insurance, Inc.All Rights Reserved. WC000000C 6of6 (Ed.01-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 A (Ed. 7-95) PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, it any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule 1. State Estimated Eligible Premium rirst Next Next 0.14 $5,000 $95,000 $400,000 Balance CA 3.00 0.11 0.13 2. Average percentage discount: 9.69 % 3. Other policies: 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/06/2025 Policy No. ONCC12487-04 Endorsement No. Insured Endresen Development, Inc. Premium: $27,327 /� Insurance Company Countersigned by &ZA, /' z:-_if Omaha National Casualty Company WC000406A (Ed. 7-95) ®1995 National Council on Compensation Insurance,Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INC 00 04 19 (Ed-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is usej to amend: Section D. of Part F ve cf the policy is replaced by this provision. PART FIVE PREMIUM D. Premijm i;amended to read: You w II pay all premium when due. You will Fay the premiin, even if pert or all of a workers compens3tior law is nct valid. The due date for audit and retrospective premiums is the date of the billing. —his endorsement changes the poicy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required ordy when this endorsement is issued subsequent to preparation of the p3licy.) EndOrst,_new Effective 03/06/2025 Poicv No. ONCC12487-04 Endorsement No Insured Endresen Development, Inc. Pr©mll.m $27,327 Insurance Company Cuuntersiyned Ly Omaha National Casualty Company WC000419 i 17,1. 1 01 1 Print Date:618,2023 Page 1 Countrywide WC 00 04 19.rpt WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-2021) Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reautlorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions. exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement Ere based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002. which took effect on November 26, 2002. and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human ife. property, or infrastructure. c. The act resulted in damage within the Unred States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation)that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. 1 of 2 Copyright 2020 National Council on Compensation Insurance,Inc.All Rights Reserved. WC 00 04 22 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-2021) Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000.000,000; and foraggregate Insured Losses up to S100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200.000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA O.C300 S210 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/06/2025 Policy No. ONCC12481-04 Endorsement No. Insured Endresen Development, Inc. Premium $27,327 Insurance Company Countersigned by Omaha National Casualty Company WC 00 04 22 C (Ed. 01-2021) 2 of 2 C Copyright 2020 National Council on Compensation Insurance,Inc.All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 (Ed. 0 1-08) OPTIONAL PREMIUM INCREASE ENDORSEMENT—CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verification audit. If you fail to provide access within 90 days after expiration of the policy,you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for YOU policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments During normal business hours. We will notify you of your failure to provide access by mailing a certified, return-receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s)to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. This endorsement changes the policy to which it is attached and is effective on the date issued unless othenvise stated. iThe information below is required only when this endorsement is issued subsequent to preparation of the policy.) Encorsement Effective 03/06/2025 Policy No. ONCC12487-04 Endorsement No. Insured Endresen Development, Inc. Insurance Company Omaha National Casualty Company Countersigned By WC 04 04 21 (Ed. 01-08) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) CALIFORNIA SHORT-RATE CANCELATION ENDORSEMENT It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: If you cancel the policy and a disclosure was provided in accordance with Section 481(c)of the California Insurance Code, final premium will be based on the time this policy was in force and increased by the short-rate cancelation table below: Short Rate Cancelation Table Days in Force Factor Days in Force Factor Days in Force Factor Days in Force Factor 1 1 0.05 66 69 0.29 154 156 0.53 256 260 0.77 2 2 0.06 70 73 0.30 157 160 0.54 261 264 0.78 3 4 0.07 74 76 0.31 161 164 0.55 265 269 0.79 5 6 0.08 77 BO 0.32 165 167 0.56 270 273 0.80 7 8 0.09 81 63 0.33 168 171 0.57 274 278 0.81 9 10 0.10 84 B7 0.34 172 175 0.58 279 282 0.82 11 12 0.11 88 91 0.35 176 178 0.59 283 287 0.83 13 14 0.12 92 94 0.36 179 182 0.60 288 291 0.84 15 16 0.13 95 98 0.37 183 187 0.61 292 296 OB5 17 18 0.14 99 102 0.38 188 191 0.62 297 301 0.86 19 20 0.15 103 105 0.39 192 196 0.63 302 305 0.87 21 22 0.16 106 109 0.40 197 200 0.64 306 310 0.88 23 25 0.17 110 113 0.41 201 205 0.65 311 314 0.89 26 29 0.18 114 116 0.42 206 209 0.66 315 319 0.90 30 32 0.19 117 120 0.43 210 214 0.67 320 323 0.91 33 36 0.20 121 124 0.44 215 218 0.68 324 328 0.92 37 40 0.21 125 127 0.45 219 223 0.69 329 332 0.93 41 43 0.22 128 131 0.46 224 228 0.70 333 337 0.94 44 47 0.23 132 135 0.47 229 232 0.71 338 342 0.95 48 51 0.24 136 138 0.48 233 237 0.72 343 346 0.96 52 54 0.25 139 142 0.49 238 241 0.73 347 351 0.97 55 58 0.26 143 146 0.50 242 246 0.74 352 355 0.98 59 62 0.27 147 149 0.51 247 250 0.75 356 360 0.99 63 65 0.28 150 153 0.52 251 255 0.76 361 365 1.00 I his endorsement changes the policy to which it is wtached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement 03/06/2025 Policy No. ONCC12487-04 Endorsement No. Effective Insured Insurance Company Omaha National Casualty Company Endresen Development, Inc. Countersigned ByGIGi�v, T WC 04 04 22 (Ed. 01-12) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 B (Ed. 01-22) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six (Conditions)of the policy is replaced by these conditions: Cancelation: 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us. e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Material failure to comply with federal or state safety orders or written recommendations of our designated loss control representatives; h. The occurrence of a material change in the ownership of your business; i. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss, j. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; k. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. 3. If we cancel your policy for any of the reasons listed in(a)through (f),we will give you 10 days advance written notice, statirg when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g)through (k), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reinsuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. If we mail the notice to you, the stated perods of notice and your right to remedy the condition will be extended by 5 days if the place of mailing and your mailing address is within California, 10 days if the place of mailing or your mailing address is outside of California and 20 days if the place of mailing or your mailing address is outside of the United States 5. The policy period will end on the day and hour stated in the cancelation notice. This endorsement changes the policy to which it is attached and is effective cn tre date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/06/2025 Policy No, ONCC12487-04 Endorsement No. Insured Insurance Company Omaha National Casualty Company Endresen Development, Inc. Countorsigned By �/�jy,�, �� ��!✓ WC040601B (Ed. 01-22) VVUHK17HS CUMPtNSA I IUN AND tMPLUYtKS LIABILI I Y INSURANCE POLICY WC ON 04 CO (Ed.6-18) NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT -CALIFORNIA Changes in ownership may impact your experience modification factor. Ownership changes incl,de the sales, transfer, conveyance. dissolution, merging, or consolidation of entities or formation of a new entity and any other changes contained within the California Workers'Compensation Experience Rating Plan. Any owi i:';3itip dkinges must be reported in writing immediately following such change. The change in ownership may resuP-'an a revis4cm of the experience rating modi`ication factor used to determine your premium. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 03i0612025 Policy No.: ONCC12487-04 Endorsement No.: Insured Endresen Development, Inc. Premium $27,327 Insurance Company Omaha National Casualty Company Countersigned byGGrhw� WC ON 04 CO ('`d 6-18) Print Date: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 02-18) POLICY AMENDATORY ENDORSEMENT—CALIFORNIA It is agreed that. anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed—Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California. by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages— Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment—Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d)of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7)days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit.You will have 60 days, following notice of the obligation to reimburse. to appeal the decision of the insurer to the Department of Insurance. 4. Application of Policy. Part One "Workers Compensation Insurance". A, "How This Iisurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The prerniurn and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code 6. Long Term Policy. If this policy is written for a period longer than one year,all the provisions of this policy shall apply separately:o eacn consecutive twelve-month period or, if the first or last consecutive period is less than twelve months,to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. 8. Part Five, "Premium', E, "Final Premium",is amended to read as follows. The premium shown on the Information Page, schedules, and endorsements is an estimate The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less,we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium wil be determined in the following way unless our manuals provide otherwise: a. If we cancel,final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b. If you cancel. final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short-rate cancelaticn table and procedure. Final premium will not be less than the pro rata share of the minimum premium. 1 of 2 WC040301 D (Ed. 02-18) WC 04 03 01 D WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 02-18) It is further agreed that this policy,including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition. provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights,duties, or privileges arising therefrom. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/06/2025 Policy No. ONCC12487-04 Endorsement No. Insured Endresen Development, Inc. Insurance Company Omaha National Casualty Company Countersigned By 2of2 WC 04 03 01 D (Ed. 02-18) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 03 C (Ed. 07-18) ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE OFFICERS AND DIRECTORS COVERAGE / EXCLUSION—CALIFORNIA If the employer named in Item 1 of the Information Page is a quasi-public or private corporation,this policy applies to all officers and members of boards of directors while rendering actual service for the corporation for pay, as employees,except those excluded below who 1. individually own at least 10 percent of the corporation's issued and outstanding stock. or 2. individually own at least 1 percent of the corporation's issued and outstanding stock if that officer's or member's parent, grandparent,sibling, spouse, or child owns at least 10 percent of the corporation's issued and outstanding stock and that officer or member is covered by a health insurance policy or a health care service plan,or 3. are officers or members of the board of directors of a cooperative corporation organized pursuant to the Cooperative Corporation Lav✓(Corporations Code.Sections 12200- 12704)who state that he or she is covered by both a health care service plan or health insurance policy, and a disability insurance policy that is comparable in scope and coverage,as determined by the Insurance Commissioner, to a workers' compensation policy. If the employer named in Item 1 of the Information Page is a private corporation,or a private cooperative corporation organized pursuant to the Cooperative Corporation Law, this policy applies to an officer or director who is the sole shareholder of the corporation, as an employee, except if excluded below. The insurance under this policy is limited as follows: It is AGREED that,anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE.- Officers, Directors and Trustees Excluded Title Jessica Endresen CFO Joshua Endresen CEO Nothing in this endorsement shall be held to vary,alter,waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that"remuneration"when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded 'rom coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and s effective on the date issued unless otherwise slated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/06/2025 Policy No. ONICC12487-04 Endcrsement No. Insured Endresen Development, Inc. Insurance Company Omaha National Casualty Company Countersigned By /�G✓dyly �✓ Page 1 of 1 WC 04 03 03 C (Ed. 07-18) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 10 (Ed. 01-95) DUTY TO DEFEND CALIFORNIA The insurance affo ded by Part One, Section C, "We Will Defend". s hereby deleted and replaced with tie following: WE WILL DEFEND We have the right and duty to defend at our expense any claim or proceeding against you be`ore the California Workers' Compensation Appeals Board or its equivalent in any other state(and any appeal of a decision therefrom)for the benefits payable by this workers' compensation insurance.We have the right to investigate and settle these claims or proceedings. We have no duty to defend a claim, proceeding, or suit that is not covered by this insurance. Nothing contained in this Section shall amend,modify, restrict. or otherwise alter any obligations or conditions under Part Two— Employer's Liability Insurance of the policy. This endorsement changes the policy to which it is atldched ands effective on the dale issued unless otherwise slated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/06/2025 Policy No. ONCC12487-04 Endorsement No. Insured Endresen Development, Inc. Insurance Company Omaha National Casualty Company Countersigned By WC 04 03 10 I Ed. 01-95) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B (Ed. 01-15) EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT CALIFORNIA The insurance affo-ded by Part Two (Employers' Liability Insurance)by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: A. How This Insurance Apples This employers'liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including resulting death. 1. The bodily injury must arise out cf and in the course of the injured employee's employment by you. 2 Thp pmpinyment muct he neressary nr incidental to yniir wnrk in California_ 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are suea, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C. The"Exclusions" section is modified as follows (all other exclusions in the"Exclusions"section remain as is): 1. Exclusion 1 is amended to read as follows: 1. liability assumed under a contract. 2. Exclusion 2 is deleted. 3. Exclusion 7 is amended to read as follows: 7. damages arising out of coercion, criticism, demotion,evaluation, reassignment, discipline,defamation, harassment, humiliation,discrimination against or termination of any employee, termination of employment, or any personnel practices, policies, acts or omissions. 4. The following exclusions are addad: 1. bodily injury to any member of the flying crew of any aircraft. 2. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s) applicable to you or otherwise fail to comply with that law. 3. liability arising from California Labor Code Section 2810.3 which relates to labor contracting. This endorsement changes the policy to which it is attached and s effective on the date issued unless otherwise staled. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03/06/2025 Policy No. ONCC12487-04 Endorsement No. Insured Endresen Development, Inc. Insurance Company Omaha National Casualty Company Countersigned By WC 04 03 60 B lEd. 01-15) PN 04 99 01 1 (Ed. 02-22) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I. Information Available to You A. Information Available from Us (1) General questions regarding your policy should be directed to. Omaha National PO Box 451139 Omaha, NE 68145 Telephone: 844-761-8400 Fax: 844-761-8402 www.orrahanational.com (2) Dividend Calculation. If this is a participating policy(a policy on which a dividend may be paid), upon payment or non- payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB)no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time.At twelve-month intervals thereafter,we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim.The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the Caffornia Workers'Compensation Uniform Statistical Reporting Plan- 1995(USRP) and the California Workers'Compensation experience Rating Pian-1995(ERP). WCIRB contact information is: WCIRB, 1901 Harrison Street. 17th Floor, Oakland. CA 94612,Attn: Customer Service;888.229,2472(phone);415.778.7272 (fax); and customersery ceta�wcirb.com(email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2) Policyholder Information. Pursuant to California Insurance Code(CIC)Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims,classification assignments,and policy contracts as well as rating plans, rating systems, manual rules,or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to.WCIRB, 1901 Harrison Street, 17th Floor. Oakland, CA 94612,Attn:Custodian of Records. The Custodian of Records can be reached at 415.777_3777 (phone)and 415.778.7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss-Free Rating, which is the experience modification that would have been calculated if$0 (zero)actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. 11. Dispute Process You may dispute our actions er the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. [Optional language for insurers that have adopted the WCIRB's Advisory Basic Underwriting Manual If you are aggrieved by our decision adopting a change in a classif cation assignment that results in increased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below.] You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you Written Complaints and Requests for Action should be forwarded to. Omaha National Casualty Company, PO Box 451139, Omaha, NE 68145 Telephone. (844)761-8400, Fax: (844)761-8402 PN 04 99 01 1 1 of 2 (Ed. 02-22) PN 04 99 01 1 (Ed. 02-22) After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating ,whether your written request will be reviewed. If wo agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decsion upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision,action, or omission to act of the WCIRB, you may request. in writing, that the WCIRB reconsider its decision, action,or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later,except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry.Written Inquiries should be sent to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland,CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone),415.778.7272 (fax) and customerservice(a)wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the 1NCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the 'dVCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612,Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472(phone), 415.371.5204(fax) and customerservicepwcirb.com (email). C. California Department of Insurance—Appeals to the Insurance Commissioner.After you follow the appropriate dispute resolution process described above, if 11)we or the WCIRB decline to review your request, (2)you are dissatisfied with the decision upon review, or(3)we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752-6, 11753-1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is. Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Mailroom Oakland, CA 94612 415.538.4243 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commiss oner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1901 Harrison Street, 17th Floor.Oakland, CA 94612.Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (taxi and ombudsmancywcirb.com (email). B. California Department of Insurance— Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP(4357)or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. PN 04 99 01 1 2 of 2 (Ed. 02-22) PN 04 99 02 B (Ed. 05-02) POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. 1. We establish our own rates for workers'compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20%or more of that part of the California workers compensation insurance that is not written by the State Compersation Insurance Fund. If the insurance commissioner disapproves our rates. rating plans. or classifications. he or she may order an increase in the rates applicable to outstanding policies. 3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner's approval.A pure premium rate reflects the anticipated cost and expenses of claims per 5100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experence rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is develuped by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. 5. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses,and other costs of claims in a way that is consistent witn the uniform statistical plan or the standard classification system. 6. Our rates and classificat ons may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you 7o appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. California Workers' Compensation Insurance Notice of Nonrenewal Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to norrenew your policy,we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier thar 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change it the premium rate until 60 days after we provide you with the required notice. PN 04 99 02 B 1 of 2 (Ed.05-02) PN 04 99 02 B (Ed.05-02) We are not required to provide you with a notice of nonrenewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms o•conditions or the rate on which the premium s based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be rerewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate" means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. PN 04 99 02 B 2 of 2 (Ed.05-02) PN 04 99 03 (Ed. 11-99) NOTICE REQUIRED BY LAW—CALIFORNIA Since our offer to renew your coverage reflects a premium rate increase of 25 percent or more in your governing classification, California law(Insurance Code section 11664)requires us to send you a"notice of nonrenewal",even though we do intend to renew your policy. This constitutes the required notice. For purposes of this Notice, premium rate means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. Insured Endresen Development, Inc. Date of Notice 03/06/2025 Policy No. ONCC12487-04 Policy Period 03/06/2025 to 03/06/2026 PN 04 99 04 (Ed. 12-01) POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requ res all companies to surcharge policies to recover these assessments. If your policy is surcharged, "CA Surcharge"or"CA Surcharge (CIGA Surcharge)"with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. PN 04 99 06 D (Ed. 01-20) POLICYHOLDER NOTICE PAYROLL RECORD AND AUDIT REQUIREMENTS FOR DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Your policy includes one or more construction or erection classifications. Dual wage classifications are pairs of classif,cations that describe the same construction or erection operation yet are assigned based upon whether the employee's hourly wage is above or below a specified threshold. Each pair of dual wage classifications contains one `high wage"classification that is assignable to payrolls earned by employees whose regular hourly wage equals or exceeds a specified wage threshold and ono"low wage"classification that is assignable to payrolls earned by employees whose regular hourly wage is less than the specified threshold. Payroll Record Requirements The assignment of a high wage classification is contingent on verifying that the employee's hourly wage equals or exceeds the specified wage threshold. The determination of the regular hourly wage for any non-salaried employee must be supported by one of the following sources: • Original time rams or time hank Pnt-ips for each Pmpinypp 0ri0inal records must include the operations performed,the total hours worked each day and the times the employee started and ended each work period throughout the workday. At job locations where all of the employer's operations cease for a uniform unpaid meal period, recording the start and stop times of the uniform break period is not required. • A valid collective bargaining agreement that shows the regular hourly wage rate by job classification of a worker. If using a collective bargaining agreement, the records must include an employee roster by jab classification that permits the reconciliation of individual employees to the job classifications set forth in the collective bargaining agreement. The non-salaried employee's regular hourly wage shall be determined by dividing that employee's total remuneration by the hours worked during the pay period, irrespective of whether the employee is paid on an hourly, piecework, production or commission basis. The payroll earned by any non-salaried employees for whom trip records sopcified above are not maintained and/or made available will be assigned to the low wage classification that describes the operations performed. The regular hourly wage of salaried employees is determined by dividing the total annual remuneration by 2000 hours. If an employee is salaried for less than 12 months, the regular hourly wage for the salaried period is calculated on a prorated basis. Audit Requirements If your policy has an effective date on or after January 1, 2020 and produces a final premium of$10,5C0 or more, a physical audit is required at least once a year; if it produces a final premium of less than $10,50C and develops payroll in a high wage classification, a physical audit of the policy is required unless the policy is a renewal and a physical audit was completed for one of the two immediately preceding policy periods. A"physical audit" is defined as an audit of payroll,whether conducted at the policyholder's location or at a remote site,that is based upon an aucitor's examination of the policyholder's books of accounts and original payroll records (in either electronic or hard copy form)as necessary to determine and verify the exposure amounts by classification. If you hold a C-39 Roofing Contractor license from the California Contractors State License Board, a physical audit is required on the complete policy period of each policy regardless of the amount of final premium. See California Insurance Code Section 11665(a)for additional requirements regarding the audit of C-39 license holders. AMERICAN NATIONAL PROPERTY AND CASUALTY CO 1949 E.SUNSHINE POLICY NUMBER THIS FAMILY AUTOMOBILE RENEWAL DECLARATION REPLACES SPRINGFIELD,MISSOURI 65899-0001 04-V-0058L0-9 ALL PRIOR DECLARATIONS, IF ANY, AND WITH POLICY (417)887-0220 POLICY TERM PROVISIONS AND ANY ENDORSEMENTS ISSUED TO FORM A PART www.AmericanNational.com 04-16-2025 TO 10-16-2025 THEREOF COMPLETES THIS POLICY. AND SUBSEQUENT RENEWALS. NAMED INSURED AND ADDRESS SMALL-ENDRESEN,JESSICA& ENDRESEN,JOSHUA J 15301 ALVARADO ST LAKE ELSINORE CA 92530-6963 AGENT: D5195-P 1-RX7 RATING ADDRESS: BILLY MCDOUGALL 15301 ALVARADO ST 32174 CALA TORRENTE FOR CUSTOMER SERVICE: LAKE ELSINORE CA 92530-6963 TEMECULA CA 92592-3649 951-302-9429 DESCRIPTION OF INSURED PROPERTY RATED VEH DR DESCRIPTION ID NUMBER TYPE 1 0 2004 CHE TAHOE LS 4D 4 1 GNEK13T74R293500 AUTO 2 0 2016 RAM 5500 CREW CC 3C7WRMFL4GG363631 PICKUP 3 1 2014 AUD Q7 4D QUATTRO WAl WMAFE6ED018696 AUTO 4 2 2021 RAM 2500 CREW CAB 3C6UR5DL5MG515528 PICKUP RATING INFORMATION,COVERAGES,PREMIUMS,AND LIMITS OF LIABILITY INSURANCE IS PROVIDED ONLY WITH RESPECT TO THOSE OF THE FOLLOWING COVERAGES WHICH ARE INDICATED BY A SPECIFIC LIMIT OF LIABILITY AND/OR PREMIUM APPLICABLE THERETO. VEHICLE 04 CHE TAHOE LS 4D 16 RAM 5500 CREW C 14 AUD Q7 4D QUATT 21 RAM 2500 CREW C EXPIRING POLICY VERIFICATION VERIFIED VERIFIED VERIFIED VERIFIED EXPIRING POLICY ANNUAL MILEAGE 2,292 9,118 23,274 27,297 CURRENT POLICY VERIFICATION VERIFIED VERIFIED VERIFIED VERIFIED CURRENT POLICY ANNUAL MILEAGE 2,292 11,058 13,560 25,717 BODILY INJURY LIABILITY $103.00 $140.00 $132.00 $228.00 LIMIT PER PERSON/OCCURRENCE 250,000/500,000 250,000/500,000 250,000/500,000 250,000/500,000 PROPERTY DAMAGE LIABILITY $81.00 $87.00 $83.00 $153.00 LIMIT PER OCCURRENCE 100,000 100,000 100,000 100,000 UNINSURED&UNDERINSURED MOTORIST $58.00 $79.00 $84.00 $88.00 LIMIT PER PERSON/ACCIDENT 250,000/500,000 250,000/500,000 250,000/500,000 250,000/500,000 UNINSURED PROPERTY DAMAGE INCLUDED INCLUDED INCLUDED INCLUDED LIMIT PER ACCIDENT 3,500 3,500 3,500 3,500 COMPREHENSIVE $54.00 $214.00 $148.00 $112.00 DEDUCTIBLE 500 500 500 500 ADDED COVERAGE ENDORSEMENT NO NO NO NO LIMIT OF CUSTOMIZED EQUIPMENT 2,000 9,999 2,000 2,000 COLLISION $88.00 $625.00 $373.00 $327.00 DEDUCTIBLE 1,000 1,000 1,000 1,000 ADDED COVERAGE ENDORSEMENT NO NO NO NO LIMIT OF CUSTOMIZED EQUIPMENT 2,000 9,999 2,000 2,000 REIMBURSEMENT OF RENTAL EXPENSE INCLUDED INCLUDED INCLUDED INCLUDED LIMIT PER DAY/AGGREGATE 25/750 25/750 25/750 25/750 --------------- --------------- --------------- --------------- TOTAL $384.00* $1,145.00* $820.00* $908.00* *THIS PREMIUM REFLECTS A 30%CALIFORNIA GOOD DRIVER DISCOUNT. IMPORTANT NOTICE: THIS POLICY REDUCES THE APPLICABLE LIMITS FOR BODILY INJURY LIABILITY, PROPERTY DAMAGE LIABILITY, UNINSURED AND UNDERINSURED MOTORIST COVERAGES SHOWN ON THIS DECLARATIONS PAGE TO THE LEGALLY REQUIRED MINIMUM FINANCIAL RESPONSIBILITY LIMITS IN THE STATE WHEN AN INSURED VEHICLE IS OPERATED BY ANYONE OTHER THAN YOU,OR A RELATIVE, OR A PERSON LISTED ON THE DECLARATIONS AS AN OPERATOR. VEHICLES ENDORSEMENTS TAX/FEE TOTAL PREMIUM BILLY MCDOUGALL TOTAL PREMIUMS $3,257.00 $0.00 $0.00 $3,257.00 AUTHORIZED REPRESENTATIVE DATE 03-12-2025 THIS IS NOT A BILL. SEE DECLARATION SECTION II FOR ADDITIONAL INFORMATION PRINTED SEE REVERSE SIDE FOR IMPORTANT INFORMATION SM-484(1-06) IMPORTANT INFORMATION ON HOW TO REPORT A CLAIM BUCKLE UP AND DRIVE DEFENSIVELY One in five drivers will have an accident this year. We hope it is not you. However, if it happens, remember to get the following information from the other driver: 1. Vehicle Owner's Name, Address, and Telephone Numbers 2. Make and Model of Vehicle 3. Car License Plate Number 4. Driver's Name (if other than owner), Address, and Telephone Numbers 5. Driver's License Number 6. Insurance Company Name and Policy Number 7. Owner's and Driver's Place of Employment 8. Promptly File State Safety Responsibility Forms REMEMBER TO REPORT YOUR CLAIM TO ANPAC® IMMEDIATELY (TOLL FREE) 1-800-333-2860 04-V-0058L0-9 SMALL-ENDRESEN, JESSICA& 04-16-2025 DECLARATIONS, SECTION II PAGE 1 POLICY TERM: 04-16-2025 TO 10-16-2025 VEH. DR.# RATING INFORMATION 1 0 ANNUAL MILEAGE IS LESS THAN 2,500, MILEAGE IS VERIFIED 2 0 ANNUAL MILEAGE IS 11,000 TO 11,999,MILEAGE IS VERIFIED 3 1 DRIVER HAS 31 YEARS DRIVING EXPERIENCE,ANNUAL MILEAGE IS 13,000 TO 13,999,MILEAGE IS VERIFIED,WORK USE 10+ MILES 4 2 DRIVER HAS 31 YEARS DRIVING EXPERIENCE,ANNUAL MILEAGE IS 20,000 OR GREATER,MILEAGE IS VERIFIED,BUSINESS USE VEH. DR.# OPERATOR INFORMATION ACCDT/CONV 3 1 PRINCIPAL MAR SMALL-ENDRESEN JESSICA 0 0 4 2 PRINCIPAL MAR ENDRESEN JOSHUA J 0 0 VEH. POLICY DISCOUNTS 1 GOOD DRVR; MULTI-CAR; RENEWAL 2 GOOD DRVR; MULTI-CAR; RENEWAL 3 GOOD DRVR; MULTI-CAR; RENEWAL 4 GOOD DRVR; MULTI-CAR; RENEWAL VEH. THIS POLICY IS SUBJECT TO THE FOLLOWING FORMS AND ENDORSEMENTS 1,2,3,4 FV2476 10-22 CUSTOMIZED EQUIPMENT POL FV405CA 10-22 CALIFORNIA AUTO POLICY 4 FV768 10-22 INTERESTED PARTY POL SA3004C 04-20 LIMITED DELIVERY ENDORSEMENT LOSS PAYEES)/ADDITIONAL INTEREST(S) VEHICLE:4 VEHICLE:4 VEHICLE:4 CITY OF LAKE ELSINORE CHRYSLER CAPITAL ALLY FINANCIAL 130 S MAIN ST PO BOX 3610 PO BOX 380901 LAKE ELSINORE CA 92530-4109 CARMEL IN 46082-3610 BLOOMINGTON MN 55438-0901 INTERESTED PARTY LOSS PAYEE LOSS PAYEE LOAN:0024887773 IMPORTANT POLICY INFORMATION #NM158 0618 #IV913 0219 #IA292 1022 #FM159 0215 #NM270 0722 #NM372 1123 0 M W N BUSINESS LICENSE CITY OF LAKE ELSINORE This business license is issued for revenue purposes only and does not grant authorization Administrative Services-Licensing to operate a business. This business license is issued without verification that the holder is 130 South Main Street, Lake Elsinore, CA 92530 subject to or exempted from licensing by the state, county,federal government, or any PH (951) 674-3124 other governmental agency. Business Name: ENDRESEN DEVELOPMENT,INC BUSINESS LICENSE NO. 020309 Business Location: 15301 ALVARADO ST Business Type: GENERAL BUILDING CONTRACTOR LAKE ELSINORE,CA 92530-6963 Owner Name(s): JOSH ENDRESEN Issue Date: 10/1/2024 Expiration Date: 9/30/2025 ENDRESEN DEVELOPMENT, INC 15301 ALVARADO ST LAKE ELSINORE, CA 92530-6963 Starting January 1,2021,Assembly Bill 1607 requires the prevention of gender-based discrimination of business establishments.A full notice is available in English or other M languages by going to:https://www.dca.ca.gov/publications/ TO BE POSTED IN A CONSPICUOUS PLACE THIS IS YOUR LICENSE • NOT TRANSFERABLE I