HomeMy WebLinkAboutSTETSON ENGINEERS, INC. (2)i i-&RANGE ON FILE
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1ATE. MAY 0 9 2019 CONSULTANT AGREEMENT WITH STETSON ENGINEERS INC.
p,> CITY OF SANI'A ANA
THIS AGREEMENT is made and entered into this I" day of May, 2019 by and between Stetson Engineers
Ino. ("Consultant'), and the City of Santa Ana, a charter city and municipal corporation organized and
existing under the Constitution and laws of the State of California ("City"),
RECITALS
A. The City desires to retain a consultant to provide assistance with preparation of the annual water
quality Consumer Confidence Report and triennial Public health Goals Report,
B, Consultant represents that Consultant is able and willing to provide such services to the City.
C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable
in its field and that any services performed by Consultant under this Agreement will be performed
in compliance with such standards as may reasonably be expected from a professional consulting
firm in the field.
NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms
and conditions hereinafter set forth, the parties agree as follows:
I. SCOPE OF SERVICES
Consultant shall perform during the term of this Agreement, the tasks and obligations including
all labor, materials, tools, equipment, and .incidental customary work required to f ly and adequately
complete the services described and set forth in Exhibit A, attached hereto and incw<, rated by reference,
2. COMPENSATION
a. City agrees to pay, and Consultant agrees to accept as total payment for its services for City,
the rates and charges identified in Exhibit A. The total amount to be expended under this
Agreement shall not exceed $50,000 during the term of this Agreement, including any
extension periods exercised under Section 3.
b. Payment by City shall be made within 45 days (forty-five) days following receipt of proper
invoice evidencing work performed, subject to City accounting procedures. Payment need not
be made for work which fails to meet the standards of performance set forth in the Recitals
which may reasonably be expected by City.
3. TERM
This Agreement shall commence on the date stated above and continue through April 30, 2020,
unless terminated earlier in accordance with Section 16, below. The term of this Agreement may be
extended for up to one (1) year upon a writing executed by the City Manager and City Attorney,
Page 1 of 8
4. PREVAILING WAGES
Consultant is aware of the requirements of California Labor Code Section 1720, et seq., and 1770,
et seq., as well as California Code of Regulations, Title 8, Section 16000, et seq., ("Prevailing Wage
Laws"), which require the payment of prevailing wage rates and the performance of other requirements
on "public works" and "maintenance" projects. If the services being performed are part of an applicable
"public works" or "maintenance" project, as defined by the Prevailing Wage Laws, and the total
compensation is $1,000 or more, Consultant agrees to fully comply with such Prevailing Wage Laws.
Consultant shall defend, indemnify and hold the City, its elected officials, officers, employees and agents
free and harmless from any claim or liability arising out of say failure or alleged failure to comply with
the Prevailing Wage Laws.
S. INDEPENDENT CONTRACTOR
Consultant shall, during the entire term of this Agreement, be construed to be an independent
contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to
create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise
discretion or control over the professional manner in which Consultant performs the services which are
the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided
in a manner consistent with all applicable standards and regulations governing such services. Consultant
shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar
taxes relating to employees and shall be responsible for all applicable withholding taxes.
6. OWNERSHIP OF MATERIALS
This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse,
or sublicense any and all copyrights, designs, and other intellectual property embodied in plans,
specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any
tangible medium of expression, including but not limited to, physical drawings or data magnetically or
otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Consultant
under this Agreement ("Documents & Data"). Consultant shall require all. subcontractors to agree in
writing that City is granted a non-exclusive and perpetual license for any Documents & Data the
subcontractor prepares under this Agreement. Consultant represents and warrants that Consultant has the
legal right to license any and all Documents & Data. Consultant makes no such representation and
warranty in regard to Documents & Data which were provided to Consultant by the City. City shall not
be limited in any way in its use of the Documents and Data at any time, provided that any such use not
within the purposes intended by this Agreement shall be at City's sole risk.
INSURANCE
Prior to undertaking performance of work under this Agreement, Consultant shall maintain and
shall require its subcontractors, if any, to obtain and maintain insurance as described below:
a. Commercial General Liability Insurance. Consultant shall maintain commercial general
liability insurance naming the City, its officers, employees, agents, volunteers and
representatives as additional insured(s) and shall include, but not be limited to protection
against claims arising from bodily and personal injury, including death resulting therefrom
Page 2 of 8
and damage to property, resulting from any act or occurrence arising out of Consultant's
operations in the performance of this Agreement, including, without limitation, acts
involving vehicles. The amounts of insurance shall be not less than the following: single
limit coverage applying to bodily and personal injury, including death resulting therefrom,
and property damage, in the total amount of $1,000,000 per occurrence, with $2,000,000
in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents,
and representatives as additional insured(s); (b) be primary and not contributory with
respect to insurance or self-insurance programs maintained by the City; and (c) contain
standard separation of insureds provisions.
b. Business automobile liability insurance, or equivalent form, with a combined single limit
of not less than $1,000,000 per occurrence. Such insurance shall include coverage for
owned, hired and non -owned automobiles.
C. Worker's Compensation Insurance. In accordance with the provisions of Section 3700 of
the Labor Code, Consultant, if Consultant has any employees, is required to be insured
against liability for worker's compensation or to undertake self-insurance, Prior to
commencing the performance of the work under this Agreement, Consultant agrees to
obtain and maintain any employer's liability insurance with limits not less than $1.,000,000
per accident.
d, If Consultant is or employs a licensed professional such as an architect or engineer:
Professional Iiability (errors and omissions) insurance, with a combined single limit of not
less than $1,000,000 per claim with $2,000,000 in the aggregate,
e. The following requirements apply to the insurance to be provided by Consultant pursuant
to this section:
i, Consultant shall maintain all insurance required above in full force and effect for
the entire period covered by this Agreement.
ii. Certificates of insurance shall be furnished to the City upon execution of this
Agreement and shall be approved by the City.
iii. Certificates and policies shall state that the policies shall not be canceled or reduced
in coverage or changed in any other material aspect without thirty (30) days prior
written notice to the City.
iv. Consultant shall supply City with a fully executed additional insured endorsement.
f. If Consultant fails or refuses to produce or maintain the insurance required by this section
or fails or refuses to furnish the City with required proof that insurance has been procured
and is .in force and paid for, the City shall have the right, at the City's election, to forthwith
terminate this Agreement. Such termination shall not affect Consultant's right to be paid
for its time and materials expended prior to notification of termination. Consultant waives
the right to receive compensation and agrees to indemnify the City for any work performed
prior to approval of insurance by the City.
8. INDEMNIFICATION
Consultant agrees to defend, and shall indemnify and hold harmless the City, its officers, agents,
employees, contractors, special counsel, and representatives from liability: (1) for personal injury,
damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal
Page 3 of 8
injury, including death, and claims for property damage, which may arise from the negligent operations
of the Consultant, its subcontractors, agents, employees, or other persons acting on its behalf which relates
to the services described in section 1 of this Agreement; and (2) from any claim that personal injury,
damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or
effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for
damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have boon
suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising
from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the
defense of the City, including fees and costs for special counsel to be selected by the City, regarding any
action by a third party challenging the validity of this Agreement, or asserting that personal injury,
damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises
by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions
with respect to its representation in any legal proceeding. Notwithstanding the foregoing, to the extent
Consultant's services are subject to Civil Code Section 2782.8, the above indemnity shall be limited, to
the extent required by Civil Code Section 2782.8, to claims that arise out of, pertain to, or relate to the
negligence, recklessness, or willful misconduct of the Consultant.
9. INTELLECTUAL PROPERTY INDEMNIFICATION
Consultant shall defend and indemnify the City, its officers, agents, representatives, and employees
against any and all liability, including costs, for infringement of any United States' letters patent,
trademark, or copyright infringement, including costs, contained in the work product or documents
provided by Consultant to the City pursuant to this Agreement.
Consultant shall keep records and invoices in connection with the work to be performed under this
Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred
under this Agreement and any services, expenditures, and disbursements charged to the City for a
minimum period of three (3) years, or for any longer period required by law, from the date of final payment
to Consultant under this Agreement. All such records and invoices shall be clearly identifiable.
Consultant shall allow a representative of the City to examine, audit, and make transcripts or copies of
such records and any other documents created pursuant to this Agreement during regular business hours.
Consultant shall allow inspection of all work, data, documents, proceedings, and activities related to this
Agreement for a period of three (3) years from the date of final payment to Consultant under this
Agreement.
1.1. CONFIDENTIALITY_
If Consultant receives from the City information which due to the nature of such information is
reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or
disclose such information except in the performance of this Agreement, and further agrees to exercise the
same degree of care it uses to protect its own information of like importance, but in no event less than
reasonable care. "Confidential Information" shall include all nonpublic information. Confidential
information includes not only written information, but also information transferred orally, visually,
electronically, or by other means. Confidential information disclosed to either party by any subsidiary
Page 4 of 8
and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and
nondisclosure shall not apply to any information that (a) bag been disclosed in publicly available sources;
(b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful
possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by
operation of law; or (e) is independently developed by the Consultant without reference to information
disclosed by the City,
12. CONFLICT OF INTEREST CLAUSE
Consultant covenants that it presently has no interests and shall not have interests, direct or
indirect, which would conflict in any manner with performance of services specified under this
Agreement.
13. DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual
orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the
recruitmon4 selection, training, utilization, promotion, termination or other employment related activities,
Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal,
state and local Iaws and regulations,
14. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and Consultant,
and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict
between the terns of this Agreement and any attachments hereto, the terms of this Agreement shall prevail.
This Agreement may not be modified except by written instrument signed by the City and by an authorized
representative of Consultant. The parties agree that any terms or conditions of any purchase order or other
instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or
obligate Consultant or the City. Each party to this Agreement acknowledges that no representations,
inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting
on behalf of any party, which is not embodied herein.
15. ASSIGNMENT
Inasmuch as this Agreement is intended to secure the specialized services of Consultant,
Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written
consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior
written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit
the City's ability to have any of the services which are the subject to this Agreement performed by City
personnel or by other consultants retained by City.
16. TERMINATION
This Agreement may be terminated by the City upon thirty (30) days written notice of termination.
In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for
Page 5 of 8
all services performed by Consultant prior to receipt of such notice of termination, subject to the following
conditions:
a. As a condition of such payment, the Executive Director may require Consultant to deliver
to the City all work product(s) completed as of such date, and in such case such work
product shall be the property of the City unless prohibited by law, and Consultant consents
to the City's use thereof for such purposes as the City deems appropriate.
b. Payment need not be made for work which fails to meet the standard of performance
specified in the Recitals of this Agreement.
17. WAIVER
No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the
provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the
breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a
waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute
a continuing waiver unless the writing so specifies.
18. TURIS.DICTION - VENUE
This Agreement has been executed and delivered in the State of California and the validity,
interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined
and governed by the laws of the State of California. Both parties further agree that Orange County,
California, shall be the venue for any action or proceeding that may be brought or arise out of, in
connection with or by reason of this Agreement.
19. PROFESSIONAL LICENSES
Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits,
approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by
the laws and regulations of the United States, the State of California, the City of Santa Ana and all other
governmental agencies. Consultant shall notify the City immediately and in writing of its inability to
obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be
cause for termination of this Agreement.
20. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature herein below has the power,
authority and right to bind their respective parties to each of the terms of this Agreement,
and shall indemnify City fully, including reasonable costs and attorney's fees, for any
injuries or damages to City in the event that such authority or power is not, in fact, held by
the signatory or is withdrawn.
b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth
in the body of this Agreement.
21. NOTICE
Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be
in writing and shall be deemed to be properly given if delivered in person or mailed by first class or
certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided
in this Section, to the following persons:
To City:
Clerk of the City Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, CA 92702-1988
Fax: 714- 647-6956
With courtesy copies to:
Executive Director, Public Works Agency
City of Santa Ana
20 Civic Center Plaza (M-21)
P.O. Box 1988
Santa Ana, California 92702
To Consultant:
Stephen B. Johnson, P.E„ President
Stetson Engineers Inc.
861 Village Oaks Drive, Suite 100
Covina, CA 91724
Fax: 626-331.7065
A party may change its address by giving notice in writing to the other party. Thereafter, any
communication shall be addressed and transmitted to the new address. If sent by mail, communication
shall be effective or deemed to have been given three (3) days after it has been deposited in the United
States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by
fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time
set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth
above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays
shall be excluded.
Page 7of8
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above
written.
n �*
Norma
Acting Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
By:
John ilc
Assistant City Attorney
RECOMMENDED FOR APPROVAL:
Fuad S. Si
Executive
Public We
PE, PLS
Agency
CITY OF SANTA ANA
Kristine Ridge
City Manager
CONSULTANT:
Stephen B. Johnson, P 4
President
TaxIDi
Page 8 of 8
EXHIBIT A
661 Village Oaks Drive, Sulte 100 • Covina , California 91724
Phone; (626)967-6202•Fax: (626)331-7065 Webslte:wwwstetsoneng(neers.eom
Northern California o Southern California Arizona • Colorado • Oregon
1543-32
April 9, 2019
Mr. Robert Y Hernandez
City of Santa Ana
220 South Daisy Avenue, Building A
Santa Ana, California 92703
RE: Consumer Confidence Report —Calendar Years 2018, 2019, and 2020
Dear Mr. Hernandez:
The California Health and Safety Code Section 116470 (Title 22, Chapter
15, Article 20) requires every community water system to prepare an annual Consumer
Confidence Report (CCR) and deliver the CCR to customers by July 1 of each year.
Stetson Engineers Inc. (Stetson) is pleased to submit this proposal to assist the City of
Santa Ana (City) with CCR preparation services. The CCR will be prepared in accordance
with State Water Resources Control Board, Division of Drinking Water (DDW) regulations
and guidance.
Stetson has reviewed the City's water system and determined the proposed
budgets to assist the City with CCR preparation services are $1,900 for the calendar year
2018 report, $2,000 for the calendar year 2019 report, and $2,100 for the calendar year
2020 report, based on our prior work and scope of services in preparing the CCR for the
City (Stetson's Standard Billing Rate Schedule is attached).
Please feel free to contact me should you have any questions.
Sincerely,
Yuen Yap
Stetson Engineers Inc.
J: IUM1a4317 9aMaAnal9a1B1amuNuCCRCwMq.fNYJar 0M
WATER RESOURCE PROFESSIONALS
LICENSED BY THE STATE BOARD OF CONSUMER AFFAIRS
EXWBIT A
861 Village oaks Drive,Sulte 100 • Covina, California 91724
Phone; (626) 967.6202 + Fax: (626) 331-7065 • Webskei WwwatatSonenginartmCOtn
Northern California • Southern California • Arizona o Colorado . Oregon
April 9, 2019
Mr, Robert Y Hernandez
City of Santa Ana
220 South Daisy Avenue, Building A
Santa Ana, California 92703
RE: City of Santa Ana
Triennial Public Health Goal Report - Calendar Years 2019 and
2022
Dear Mr. Hernandez:
State law requires the California Office of Environmental Health Hazard
Assessment (OEHHA) to develop public health goals (PHGs) for regulated drinking water
contaminants. The Caidaron-Sher Safe Drinking, Water Act of 1996 (Senate Bltl 1307)
required public water systems with more than 10,000 service connections which detect
one or more contaminants in drinking water exceeding an applicable PHG to prepare a
brief written report (PHG Report) In plain language on or before July 1, 1998, and every
three years thereafter. Senate Bill 1307 lists the six requirements that must be included
in a triennial PHG report, which are also listed in California Health and Safety Code
Section 116470(b). Public water systems required to prepare a triennial PHG Report also
are required to hold a public hearing for the purpose of receiving public comment on the
PHG Report. Public water systems may hold the public hearing as part of any regularly
scheduled meeting. The next triennial PHG Report is due by July 1, 2019.
Stetson is pleased to submit this proposal to prepare the triennial PHG
Report for your water system. The triennial PHG Report will be prepared In accordance
with California Health and Safety Code Section 116470(b) and Association of California
Water Agencies (ACWA) guidance documents. We will need to contact you for water
quality data and other information on your water system.
Stetson has reviewed your water system and determined the proposed
budgets to prepare the triennial PHG Report are $3,500 for the calendar year 2019 report,
and $4,100 forthe subsequent calendar year 2022 report (Stetson's Standard Billing Rate
Schedule is attached). Stetson will provide you with a draft of the calendar year 2019
triennial PHG Report by May 24, 2019, and a final draft of the calendar year 2019 triennial
WATER RESOURCE PROFESSIONALS
LICENSED BY THE STATE BOARD OF CONSUMER AFFAIRS
EXHIBIT A
F/ STETSON ENGINEERS INC.
Mr. Robert Y Hernandez
April 9, 2019
Page 2
PHG Report by June 17, 2019. 'Stetson's proposed budget does not include assisting
your water system with holding the required public hearing and providing any required
State Water Resources Control Board, Division of Drinking Water (DDW) notification of
completion of the requirements. However, Stetson is prepared to assist your water
system with holding the public hearing and providing any required DDW notification of
completion of the requirements on a time and materials basis.
If you are in agreement with this proposal, please provide this office with
written authorization to proceed In the space provided below. Please feel free to contact
me should you have any questions.
Sincerely„
Tom"
Yuen Yap
Stetson Engineers Inc.
Authorization to Proceed Date��
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EXHIBIT A
2171 E.Francisco Blvd„ Suite K -San Rafael, California 04901
Phone: (415)457.0701 - Fax:(41S)457d638 - Website:www,stetsonengineers.com
Northern California • Southern California • Arizona . Colorado • Oregon
Standard Billins Rate Schedule
Professional Pees
Principal
$237.00
Per Hour
Special Project Director
$237,00
Per Hour
Project Manager, Senior
$206.00
Per Hour
Supervisor I
$206.00
Per Hour
Supervising Soil Scientist
$191.00
Per Hour
Supervisor II
$191.00
Per Hour
Supervisor II1
$185.00
Per Hour
Senior I
$165.00
Per Hour
Senior II
$149.00
Per Hour
Senior III
$134.00
Per Hour
Construction Manager
$134.00
Per Hour
Construction Manager / Oversight
$118.00
Per Hour
Senior Construction Inspector
$118.00
Per Hour
Senior Field Geologist
$134.00
Per Hour
Senior Associate
$128.00
Per Hour
Associate 1
$122.00
Per Hour
Associate II
$116.00
Per Hour
Associate 11I
$111,00
Per Hour
Associate Soil Scientist
$111.00
Per Hour
Senior Assistant
$103.00
Per Hour
Assistant I
$98.00
Per Hour
Assistant I1
$93.00
Per Hour
Assistant Soil Scientist
$93.00
Per Hour
Assistant III
$88.00
Per Hour
GIS Manager
$122.00
Per Hour
GIS Specialist I
$101.00
Per Hour
GIS Specialist 11
$91.00
Per Hour
Technical Illustrator
$88.00
Per Hour
AutoCAD Technician
$88.00
Per Hour
Soil Technician
$77.00
Per Hour
Aide I
$72.00
Per Hour
Aide 11
$62.00
Per Hour
Aide III
$57.00
Per Hour
Project Coordinator I
$134.00
Per Hour
Project Coordinator1I
$98.00
Per Hour
Project Coordinator1II
$88.00
Per Hour
Contract Management
$103.00
Per Hour
Administrative 1
$72.00
Per Hour
Administrative II
$67.00
Per hour
Administrative III
$62.00
Per Hour
Effective January 1, 2019
W A T I f R R 1''. S U U R C 1:1 P R O F R S S I 0 N A 1. S
SERVING C I. 1 E N IS S I N C IC 1 9 5 1
EXHIBIT A
Direct Expense Rates
Expense .Description
Fax
Mileage
Reproduction: Black & White (In -House)
Reproduction: Color - 8.5" x I (In -House)
Reproduction: Color - I V x 17" (In -House)
Plotter Reproduction (In -House)
Specialty Computer Expense (In -House)
4x4 Truck with Drill Rig
Survey Equipment
STETSON
Billing Rate
$0.30 / Page
$* / Mile
$0.15 / Page
$0.89 / Page
$1.89 / Page
$1.50 / Sq. Pt.
$15.00 / Hour
$150.00 / Day
$120.00 / Day
Notes:
1) "Mileage is billed at the current IRS approved mileage rate and may be subject to change.
2) Subcontractor services will be charged at cost plus 10% administration fee,
3) All other project reimbursable expenses (i.e., telephone, commercial transportation, meals, lodging,
postage, outside reproduction, etc.) will be billed at cost.
4) Testimony fees are 150% of standard rates and apply to depositions, court time and lime spent on stand-by
at attorneys request. Travel time and preparation time is charged at standard rates. Stetson Engineers Inc.
authorizes only staff at associate classification or higher to testify as expert witnesses.
W A T E R R E S O U R C Il P R O F 1°. S S I O N A I. S
S t: R U I N C; C; I. 1 B. N 1 S S I N C[ 1 9 5 7
^^ " STETS-1
CERTIFICATE OF LIABILITY INSURANCE DATE 06/2
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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 poiicy(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
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INSURED Stetson Engineers, Inc.
2171 E. Francisco Blvd, Ste. K
San Rafael, CA 94901
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THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.,
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DESCRIPTION OF OPERATIONS I LOCATION8 J VEHICLES (ACORD 101, Additional Rsma SPIedule, my b st(sc lod If man speoe Is requima)
City of Santa Ana its officers, employees, agents and representatives are
Insured by contract with respect to
additional as required written § 1
of the named insured por form SB300176D and CA20481013 attached. ( c
9orations
Waiver of subrogation per attached WC9903038.
�2-1) elj Pa
City of Santa Ana
Aftn; Purchasing Dept.
20 Civic Center Plaza
Santa Ana, CA 92701
ACORn 25 i7ninitum
CITY-18
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE NTH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
Q 1911&.2019 ACORD CORPORATION. All riehts mmarvad_
V
The ACORD name and logo are registered marks of ACORD
C N A Insurance
SB300176D (Ed 6-16)
13. BLANKET ADDITIONAL INSURED WITH PRODUCTS COMPLETED OPERATIONS
COVERAGE AND BLANKET WAIVER OF SUBROGATION
A. WHO IS AN INSURED is amended to include as an insured, any person or organization who
you are required to add as an additional insured on this policy under a written contract or
written agreement, but the written contract or written agreement must be:
1. Currently in effector becoming effective during the term of this policy, and
2. Executed prior to the:
a. "Bodily Injury" or "Property Damage", or
b. Offense that caused the "personal and advertising injury" for which the additional
insured seeks coverage.
B. The insurance provided to the additional insured is limited as follows:
That person or organization is an additional insured only with respect to such person
or organization's liability for:
a. "Bodily injury", "property damage" or "personal and advertising injury" to the
extent caused by:
(1) Your acts or omissions; or
(2) Acts or omissions of those acting on our behalf; in the performance of your
ongoing operations specified in the written contract; or
b. "Bodily injury" or "property damage" to the extent cause by "your work" specified
in the written contract or written agreement and included in the "products
completed operations hazard", but only if:
(1) The written contract or written agreement requires you to provide the
additional insured such coverage; and
(2) This coverage part provides such coverage.
2. The Limits of Insurance applicable to the additional insured are those specified in the
written contract or written agreement or in the Declarations of this policy, whichever
is less. These limits of Insurance are inclusive of, and not in addition to, the Limits of
Insurance shown in the Declarations.
3. The insurance provided to the additional insured does not apply to "bodily injury",
"property damage", "personal and advertising injury" arising out of an architect's,
engineers, or surveyor's rendering of or failure to render any professional services,
including;
a. The preparing, approving, or failing to prepare or approve maps, shop drawings,
opinions, reports, surveys, field orders, change orders or drawings and
specifications by any architect, engineer or surveyor performing services on a
project of which you serve as a construction manager, or
b. Inspection, supervision, quality control, engineering or architectural services done
by you on a project of which you serve as construction manager.
4. This insurance provided to the additional insured does not apply to "bodily injury",
"property damage" or "personal and advertising injury" arising out of construction or
demolition work while you are acting as a construction or demolition contractor.
C. Under Businessowners Liability Conditions, the condition entitled Duties in the Event of
Occurrence, Offense, Claim or Suit is amended to add the following;
An Additional Insured under this policy will as soon as practicable
1. Give written notice of an occurrence or an offense to us which may result in a claim or
"suit" under this insurance
2. Tender the defense and indemnity of any claim or "suit" to us for a loss we cover
under this coverage part;
3. Except as provided for in paragraph D.2. below;
a. Tender the defense and indemnity of any claim or "suit" to any other insurer
which also has insurance for a loss we cover under this coverage part, and
b. Agree to make available any other insurance which the additional insured has for a
loss we cover under this coverage part.
We have no duty to defend or indemnify an additional insured under this endorsement
until we receive written notice of a claim or "suit" from the additional insured.
D. With respect only to the insurance provided by this endorsement, the condition entitled
Other Insurance of the BUSINESSOWNERS COMMON POLICY CONDITIONS is amended to
delete paragraphs 2. And 3. And replace them with the following; 2. This insurance is
excess over any other insurance available to the additional insured, whether primary,
excess, contingent or any other basis. But if required by written contract or written
agreement, this insurance will be primary and noncontributory relative to insurance on
which the additional insured is a Named Insured. 3. When this insurance is excess, we will
have no duty under Business Liability insurance to defend the additional insured against
any "Suit" if any other insurer has a duty to defend the additional insured against that
"Suit" if no other insurer defends, we will undertake to do so, but we will be entitled to
the additional insured's rights against all those other insurers. When this insurance is
excess over other insurance, we will pay only our share of the amount of the loss, if any,
that exceeds the sum of: (a) The total amount that all such other insurance would pay for
the loss in the absence of this insurance; and (b) The total of all deductible and self -
insured amounts under all that other insurance; We will share the remaining loss, if any,
with any other insurance this is not described in this Excess Insurance provision and was
not brought specifically to apply in excess of the Limits of Insurance shown in the
Declarations of this Coverage Part.
E. Additional Insured — Extended Coverage
When an additional insured is added by this or any other endorsement attached to this
Coverage Part, Who Is An Insured is amended to make the following natural person
insureds;
If the additional insured is:
a. An individual, then his or her spouse is an insured
b. A partnership or joint venture, then its partners, members and their spouses are
insureds
C. A limited liability company, then its members and managers are insured; or
d. An organization other thank a partnership, joint venture or limited liability company,
then its executive officers, directors and shareholders are additional insureds;
But only with respect to locations and operations covered by the additional insured
endorsement's provisions, and only with respect to their respective roles within their
organizations.
F. Estates, Legal Representatives and Spouses
The estates, heirs, legal representatives and spouses of any natural person shall also be
insured under this policy; provided, however; coverage is afforded to such estates, heirs,
legal representatives and spouses only for claims arising solely out of their capacity as
such and, in the case of a spouse, where such claim seeks damages from marital common
property, jointly held property or transferred from such natural person insured to such
spouse. No coverage is provided for any act, error or omission of an estate, heir, legal
representative or spouse outside the scope of such person's capacity as such, provided
however that the spouse of a natural person Named Insured and the spouse of members
or partners of joint ventures or partnership Named Insureds are insureds with respect to
such spouse' acts, errors or omissions in the conduct of the Named Insured's business.
G. Blanket Waiver of Subrogation
The condition entitled TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US of the
Businessowners Common Policy Conditions is amended to delete paragraph 2.and replace
it with the following:
3. We waive any right of recovery we may have against any person or organization
against whom you have agreed to waive such right of recovery in a written contract or
agreement because of payments we make for injury or damage arising out of your
ongoing operations or "your work" done under a contract with that person or
organization and included within the "products completed operations hazard".
NAMED INSURED: STETSON ENGINEERS INC.
Policy Number: B2099943204
Policy Term: July 1, 2018 to July 1, 2019
SB300176D (Ed. 6-16) This is an abbreviated portion of the form. The entire 16 page form is
available for review upon request. All other terms and conditions of the policy remain
unchanged.
11�7�[NI.IIIGL113: .it'iT.iTi11rL87
COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by
this endorsement.
This endorsement Identifies persons) or organization(s) who are "insureds" for Covered Autos Liability Coverage under
the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided In the
Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated
below.
Named Insured: Stetson Engineers Inc
Endorsement Effective Date: 07 / 01 / 2 018
SCHEDULE
Name Of Person(s) Or Organization(s):
ANY PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT
Information required to com fete this Schedule, if not shown above, will be shown in the Declarations.
Each person or organization shown in the Schedule is an Autos Liability Coverage in the Business Auto and Motor
"insured" for Covered Autos Liability Coverage, but only Carrier Coverage Forms and Paragraph D.2, of Section I
to the extent that person or organization qualifies as an — Covered Autos Coverages of the Auto Dealers
"Insured" under the Who Is An Insured provision Coverage Form.
contained in Paragraph A.1. of Section II — Covered
CA 20 48 1013 Copyright, Insurance Services Office, Inc., 2011 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WORKERS' COMPENSATION BROAD FORM ENDORSEMENT
EXTENDED OPTIONS
Policy Number: 57 WEC ZX9384 Endorsement Number:
Effective Date: 07/01/18 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address: STETSON ENGINEERS INC
2171 E FRANCISCO BLVD SUITE K
SAN RAFAEL CA 94901
Section I of this endorsement expands coverage provided under
WC 00 00 00.
Section II of this endorsement provides additional
coverage usually
only provided by endorsement.
Section III of this endorsement is a Schedule of Covered States.
You may use the index to locate these coverage features quickly.
INDEX
SUBJECT
PAGE
SUBJECT
PAGE
SECTION 1
2
B. Part One Does Not Apply
3
PARTS ONE and TWO
2
C. Application of Coverage
3
01 We Will Also Pay
2
D. Additional Exclusions
3
PART- THREE
2
E. West Virginia
3
02 How This Insurance Works
2
EXTENDED OPTIONS
4
PART- SIX
2
01
Employers' Liability Insurance
4
03 Transfer of Your Rights and Duties
2
02
Unintentional Failure to Disclose
4
04 Liberalization
2
Hazards
SECTION II
2
03
Waiver of Our Right to Recover from
4
VOLUNTARY COMPENSATION
2
Others
INSURANCE
04
Foreign Voluntary Compensation
4
05 Voluntary Compensation Insurance
2
A. How This Reimbursement Applies
4
A. How This Insurance Applies
2
B. We Will Reimburse
4
B. We W ll Pay
3
C. Exclusions
4
C. Exclusions
3
D. Before We Pay
5
D, Before We Pay
3
E. Recovery From Others
5
E. Recovery From Others
3
F, Reimbursement For Actual Loss
5
F, Employers' Liability Insurance
3
Sustained
EMPLOYERS' LIABILITY STOP GAP
3
G. Repatriation
5
ENDORSEMENT
H. Endemic Disease
5
06 Employers' Liability Stop Gap
3
05
Longshore and Harbor Workers'
5
Coverage
Compensation Act Coverage
A. Stop Gap Coverage Limited to
3
Endorsement
Montana, North Dakota, Ohio,
SECTION 111
6
Washington, West Virginia and
01
Schedule of Covered States
6
Wyoming
AA tt
Form WC 99 03 03 B Printed In U.S.A. (Ed. 8I00)
Page 1 of 6
Process Date: 05122f18
Policy Expiration Date:
07/01/19
0 2000, The
Hartford
SECTION I
PARTS ONE and TWO
PART THREE
1. WE WILLALSO PAY 2.
How This Insurance Applies
D. We Will Also Pay of Part One (WORKERS'
Paragraph 4. of A. How This Insurance Applies of
COMPENSATION INSURANCE); and
Part 3 (Other States Insurance) is replaced by the
E. We Will Also Pay of Part Two
following:
(EMPLOYERS' LIABILITY INSURANCE) is
4. If you have work on the effective date of this
replaced by the following:
policy in any state not listed in Item 3.A, of the
We Will Also Pay
Information Page, coverage will not be afforded
We will also pay these costs, in addition to
for that state unless we are notified within sixty
days.
other amounts payable under this insurance,
as part of any claim, proceeding, or suit we
PART SIX
defend
3.
1, reasonable expenses incurred at our
Transfer Of Your Rights and Duties
request, INCLUDING loss of earnings;
C. Transfer Of Your Rights and Duties of Part 6
2. premiums for bonds to release
(Conditions) Is replaced by the following:
attachments and for appeal bonds in
Your rights or duties under this policy may not be
bond amounts up to the limit of our
transferred without our written consent.
liability under this insurance;
If you die and we receive notice within sixty days
3. litigation costs taxed against you;
after your death, we will cover your legal
4.. interest on a judgment as required by law
representative as insured,
until we offer the amount due under this 4.
Liberalization
law; and
If we adopt a change in this form that would broaden
5. expenses we incur,
the coverage of this form without extra charge, the
broader coverage will apply to this policy. it will apply
when the change becomes effective in your state.
SECTION If
VOLUNTARY COMPENSATION ANDEMPLOYERS'
3. The bodily injury must occur in the United
LIABILITY COVERAGE
States of America, Its territories or
5. Voluntary Compensation Insurance
possessions, or Canada, and may occur
A. How This Insurance Applies
elsewhere if the employee is a United States
This insurance applies to bodily injury by
or Canadian citizen, or otherwise legal
resident, and legally employed, in the United
accident or bodily Injury by disease. Bodily
injury
States or Canada and temporarily away from
includes resulting death.
those places.
1. The bodily injury must be sustained by
4. Bodily injury by accident must occur during
any officer or employee not subject to the
the policy period.
workers' compensation law of any state
shown in Item 3.A. of the Information
5. Bodily injury by disease must be paused or
Page,
aggravated by the conditions of the
2. The bodily injury must arise out of and in
the course of employment or incidental to
work in a state shown in Item 3.A. of the
Information Page,
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 2 of 6
officer's or employee's employment. The
officer's or employee's last day of last
exposure to the conditions causing or
aggravating such bodily injury by disease
must occur during the policy period.
B. We Will Pay
We will pay an amount equal to the benefits
that would be required of you as if you and
your employees were subject to the workers'
compensation law of any state shown in Item
3.A. of the Information page. We will pay
those amounts to the persons who would be
entitled to them under the law.
C. Exclusion
This insurance does not cover:
1. any obligation imposed by workers'
compensation or occupational disease
law or any similar law.
2. bodily injury intentionally caused or
aggravated by you.
3. officers or employees who have elected
not to be subject to the state workers'
compensation law.
4. partners or sole proprietors not covered
under the Standard Sole Proprietors,
Partners, Officers and Others Coverage
Endorsement.
D. Before We Pay
Before we pay benefits to the persons
entitled to them, they must:
1. Release you and us, in writing, of all
responsibility for the injury or death.
2. Transfer to us their right to recover from
others who may be responsible for the
injury or death.
3. Cooperate with us and do everything
necessary to enable us to enforce the
right to recover from others,
If the persons entitled to the benefits of this
insurance fail to do those things, our duty to
pay ends at once. If they claim damages
from you or from us for the Injury or death,
our duty to pay ends at once.
E. Recovery From Others
If we make a recovery from others, we will
keep an amount equal to our expenses of
recovery and the benefits we paid. We will
pay the balance to the persons entitled to it.
If the persons entitled to the benefits of this
insurance make a recovery from others, they
must reimburse us for the benefits we paid them.
Employers' Liability Insurance
Part Two (Employers' Liability Insurance) applies
to bodily Injury covered by this endorsement as
though the State of Employment was shown in
Item 3.A. of the Information Page.
This provision 5, does not apply in New Jersey or
Wisconsin.
EMPLOYERS' LIABILITY STOP GAP COVERAGE
6. Employers' Liability Stop Gap Coverage
A. This coverage only applies in Montana, North
Dakota, Ohio, Washington, West Virginia and
Wyoming.
B. Part One (Workers' Compensation Insurance)
does not apply to work in states shown In
Paragraph A above.
C. Part Two (Employers' Liability Insurance) applies
in the states, shown in Paragraph A., as though
they were shown in Item 3.A, of the Information
Page.
D. Part Two, Section C. Exclusions is changed by
adding these exclusions.
This Insurance does not cover;
5. bodily injury intentionally caused or
aggravated by you or in Ohio bodily Injury
resulting from an act which is determined by
an Ohio court of law to have been committed
by you with the belief than an injury is
substantially certain to occur. However, the
cost of defending such claims or suits in Ohio
Is covered.
13. bodily injury sustained by any member of the
flying crew of any aircraft.
14. any claim for bodily injury with respect to
which you are deprived of any defense or
defenses or are otherwise subject to penalty
because of default in premium under the
provisions of the workers' compensation law
or laws of a state shown in Paragraph A,
E. This insurance applies to damages for which you
are liable under West Virginia Code Annot, S 23-
4-2.
/f17A06d,
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 3 of 6
EXTENDED OPTIONS
Employers' Liability Insurance 4. Foreign Voluntary Compensation and Employers'
Item 3.13. of the Information Page is replaced by Liability Reimbursement
the following: A, How This Reimbursement Applies
B. Employers' Liability insurance: This reimbursement provision applies to bodily
1. Part Two of the policy applies to work in injury by accident or bodily injury by disease.
each state listed in Item 3.A, Bodily Injury includes resulting death.
The Limits of Liability under Part Two are
the higher of:
Bodily Injury
by Accident $500,000 Each Accident
Bodily Injury
by Disease $500,000 Policy Limit
Bodily Injury
by Disease $500,000 Each Employee
OR
2. The amount shown in the Information
Page.
This provision 1 of EXTENDED OPTIONS does
not apply in New York because the Limits Of Our
Liability are unlimited.
In this provision the limits are changed from
$500,000 to $1,000,000 in California.
2. Unintentional Failure to Disclose Hazards
If you unintentionally should fail to disclose all
existing hazards at the inception date of your
policy, we shall not deny coverage under this
policy because of such failure.
3. Waiver of Our Right To Recover From Others
A. We have the right to recover our payments
from anyone liable for an injury covered by
this policy. We will not enforce our right
against any person or organization for whom
you perform work under a written contract
that requires you to obtain this agreement
from us.
This agreement shall not operate directly or
Indirectly to benefit anyone not named in the
agreement.
B. This provision 3. does not apply in the states
of Pennsylvania and Utah.
1. The bodily injury must be sustained by an
officer or employee.
2. The bodily injury must occur in the course of
employment necessary or incidental to work
in a country not listed in Exclusion C.1, of this
provision.
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 officer or employee's last
exposure to those conditions of your
employment must occur during the policy
period.
B. Ws Will Reimburse
We will reimburse you for all amounts paid by
you whether such amounts are:
1. voluntary payments for the benefits that
would be required of you if you and your
officers or employees were subject to any
workers' compensation law of the state of
hire of the individual employee.
2. sums to which Part Two (Employers' Liability
Insurance) would apply if the Country of
Employment were shown in Item 3.A. of the
Information Page,
C. Exclusions
This insurance does not cover:
1. any occurrences in the United States,
Canada, and any country or jurisdiction
which is the subject of trade or economic
sanctions imposed by the laws or regulations
of the United States of America in effect as of
the inception date of this policy.
2. any obligation imposed by a workers'
compensation or occupational disease law,
or similar law.
3. bodily injury intentionally caused or
aggravated by you.
Form WC 99 03 03 8 Printed in U.S.A. (Ed 9J00) Page 4 of 6
4. liability for any consequence, whether
of America necessarily incurred as a direct result
direct or indirect, of war, invasion, act of
of bodily injury.
Foreign enemy, hostilities (whether war
be declared or not), civil war, rebellion,
Our reimbursement shall be limited as follows:
revolution, Insurrection or military or
1. to the amount by which such expenses
usurped power. No endorsement now or
exceed the normal cost of returning the
subsequently attached to this policy shall
officer or employee if in good health, or
be construed as overriding or waiving
2. in the event of death, to the amount by which
this limitation unless specific reference is
such expenses exceed the normal cost of
made thereto,
returning the officer or employee if alive and
D. Before We Pay
in good health.
Before we reimburse you for the benefits to
In no event shall our reimbursement exceed the
the persons entitled to them, you must have
bodily injury by accident limit shown in Item 3.13.
them:
of the Information Page as respects any one
1. release you and us, In writing, of all
such officer or employee whether dead or alive,
responsibility for the injury or death,
H. Endemic Disease
2. transfer to us their right to recover from
The ward "disease" includes any endemic
others who may be responsible for their
diseases.
injury or death,
The coverage applies as if endemic diseases
3. cooperate with us and de everything
were included in the provisions of the workers'
necessary to enable us to enforce the
compensation law,
right to recover from others.
5, Longshore and Harbor Workers' Compensation
If the persons entitled to the benefits paid fall
Act Coverage
to do these things, our duty to reimburse
General Section C. Workers' Compensation Law
ends at once. If they claim damages from us
is replaced by the following:
for the injury or death, our duty to reimburse
ends at once.
C. Workers' Compensation Law
E. Recovery From Others
Workers' Compensation Law means the workers
or workers' compensation law and occupational
If we make a recovery from others, we will
disease law of each state or territory named in
keep an amount equal to our expenses of
Item 3.A, of the Information Page and the
recovery and the benefits we reimbursed.
Longshore and Harbor Workers' Compensation
We will pay the balance to the persons
Act (33 USC Sections 901-950). It includes any
entitled to it. If persons entitled to the
amendments to those laws that are in effect
benefits make a recovery from others, they
during the policy period. It does not include any
must repay us for the amounts that we have
other federal workers or workers' compensation
reimbursed you.
law, other federal occupational disease law or the
F. Reimbursement for Actual Loss
provisions of any law that provide
Sustained
nonoccupational disability benefits.
This endorsement provides only for
Part Two (Employers' Liability Insurance), C.
reimbursement for the loss you actually
Exclusions, exclusion 8, does riot apply to work
sustain. In order for you to recover loss or
subject to the Longshore and Harbor Workers'
expenses under this reimbursement you
Compensation Act.
must:
This coverage does not apply to work subject to
1. actually sustain and pay the loss or
the Defense Base Act, the Outer Continental
expense in money after trial, or
Shelf Lands Act, or the Nonappropriated Fund
2. secure our consent for the payment of
Instrumentalities Act.
the loss or expense.
G. Repatriation
Our reimbursement includes the additional
expenses of repatriation to the United States
Farm WC 99 03 03 B Printed in U.S.A. (Ed, 8/00)
Vega 5 of 6
1. SCHEDULE OF COVERED STATES
A. This endorsement only applies in the states
listed in this Schedule of Covered States,
C. Schedule of Covered States:
SECTION III
Countersigned by
B. It a state, shown In Item 3.A. of the Information
Page, approves this endorsement after the
effective date of this policy, this endorsement will
apply to this policy. The coverage will apply in
the new state on the effective date of the state
approval
�! Authorized Representative
i
Form WC 99 03 03 8 Printed In U.S.A. (Ed. WO) Page 6 of 6