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HomeMy WebLinkAboutPATRIOT ENVIRONMENTAL SERVICES (2)iNSURANCE ON FILE MAYOR WORK MAY PROCLLD Vicente Sarmiento UNTIL. INSURANCE EXPIRES MAYOR PRO TEM Phil Bacerra COUNCILMEMBERS CLERK OF COUNCIL Johnathan Ryan HernafWi: Jessie Lopez Nelida Mendoza David Penaloza Thai Viet Phan s®e N-2019-194-01 CITY MANAGER ,yl�r���-__Kristine Ridge JL:IJI ' .y� CITY ATTORNEY CITY OF SANTA ANA e+� Patriot Environmental Services 2151 E. Philadelphia Street Ontario, CA 91761 Attn: Jason Reed PUBLIC WORKS AGENCY 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 www.santa-ana.org August 23, 2022 Sonia R. Carvalho CLERK OF THE COUNCIL Re: Extension of Agreement N-2019-194 to Provide On -Call Debris Removal Services. Pursuant to Section 3 ("Term") of the above -referenced Agreement, entered into by Patriot Environmental Services, and the City of Santa Ana, dated September 25, 2019, the time period of the Agreement is hereby extended for an additional two-year period, from September 25, 2022 through September 24, 2024. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincere, ly h,__ Nabil Saba, P.E. xecutive Director, Public Works Agency CITY OF SANTA ANA — — �or Kristine Ridge City Manager APPROVED AS TO FORM ATTEST "^r i Clerk of the Council PATRIOT ENVIRONMENTAL SERVICES ge radon Salvatierra Oosh Teves Deputy City Attorney President SANTA ANA CITY COUNCIL Vicente Sarmiento Phil Racers Thai Viet Phan Nelida Mendoza Jessie Lopez Johnathan Ryan Hernandez David Penaloza Mayor Mayor Pro Tem, Ward 4 Ward 1 Ward 2 Ward 3 Ward 5 Ward 6 ysarrn!en1.1;.1 `nta-ana.ofn obacerrara�sanla-ana.om tohan(o7.santa-ana Oro nmendo,1;,anla-ana.ore iessieiadezOsanta-ana.orQ d enalaza Santa-ana-of. 9 • 1 Rl 10TOT-1F ,a►coRn® CERTIFICATE OF LIABILITY I E n by An DATE(MMlDDIYYYY) le 1012912021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RitHTS UPON ' HL/ If� HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORALTE E COVER iE /N B THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTR T "®atAem2;0,2,2A�lifED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITICN'.L INSURRMUSIS Wi7,'6ZH_do'rsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies m i+_, require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Arthur J. Gallagher Risk Management Services, Inc. 2345 Grand Blvd., Suite 400 Kansas City MO 64108 CONTACT NAME: PHONE oN Me, Ext: 816-421-7788 FAAIc No): 816-472-,5517 EMAIL ADDRESS: GCSSFCerts a' .corn INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Company 16535 License#'. BR-724491 INSURED PATRENV-02 Patriot Environmental Services, Inc. INSURER B : Steadfast Insurance Company 26387 508 East E. Street, Unit INSURERC: INSURERD: Wilmington, CA 90744 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER:1345643605 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLIO€ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 'NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICYNUMBER POLICY EFF MMlDDIYYYY POLICY EXP MMIDDIYYYY - LIMITS A X COMMERCIAL GENERAL LIABILITY GPL-6024753-01 1111/2021 111112022 EACH OCCURRENCE $2,000,000 CLAIMS -MADE � OCCUR DAMAGETORENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $2,000,000 GEN'LACGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $4,000-,000 POLICY I PE O 171 LOG PRODUCTS - COMPIOP AGG $ 4,000,000 $ 17 OTHER: A AIITOMOBILELIABILiTY BAP 5682677-01 1111t2021 1111/2022 COMBINED SINGLE LIMIT Ea accider $ 1,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS SOD ILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ B UMBRELLALIAB X OCCUR SXS 6182421-01 11/112021 11H12022 EACH OCCURRENCE $ 10,000,000 X AGGREGATE $10,000, 000 EXCESS LIAR CLAIMS -MADE DED X RETENTION $ n $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN WC 5682678-01 111112021 11/1/2022 X I PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 ANYPROPRIETORIPARTNERlEXECUTIVE OFFICERIMEMBER EXCLUDED? NIA E,L. DISEASE - EA EMPLOYEE - $ 1 000,000 (Mandatory in NH) If yes, describe under E.L- DISEASE - POLICY LIMIT S 1 000,000 DESCRIPTION OF OPERATIONS below A Canlractofs Pollution GPL-6024753-01 111112121 11/1/2022 Per OcclPer Claim 1,000.000 Professional Liability Aggregate Deductible Per Claim 1,000.000 20,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana its officers, employees, agents, volunteers and representatives are Additional Insured(s) as per the attached endorsement or policy language. Insurance provided to Additional Insured(s) is primary and non-contributory as per the attached endorsements or policy language. CERTIFICATE HOLDER CANCELLATION City of Santa Ana Risk Management Division, 4th Floor 20 Civic Center Plaza Santa Ana CA 92702 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ORIZED REPRESENTATIVE O 1988-2015 ACORD ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD RiskMlvwganadDiMalrm �+ G REVIEWED & APPROVE BY: Risk Management Specialist Coverage Extension Endorsement 0 ZURICH Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem Return Prem. BAP 5682677-01 11 /01 /2021 11 /01 /2022 11 /01 /2021 18726000 INCL THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Business Auto Coverage Form Motor Carrier Coverage Form A. Amended Who Is An Insured 1. The following is added to the Who Is An Insured Provision in Section II — Covered Autos Liability Coverage: The following are also "insureds": a. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow for acts performed within the scope of employment by you. Any "employee" of yours is also an "insured" while operating an "auto" hired or rented under a contract or agreement in an "employee's" name, with your permission, while performing duties related to the conduct of your business. b. Anyone volunteering services to you is an "insured" while using a covered "auto" you don't own, hire or borrow to transport your clients or other persons in activities necessary to your business. c. Anyone else who furnishes an "auto" referenced in Paragraphs A.1.a. and A.1.b. in this endorsement. d. Where and to the extent permitted by law, any person(s) or organization(s) where required by written contract or written agreement with you executed prior to any "accident", including those person(s) or organization(s) directing your work pursuant to such written contract or written agreement with you, provided the "accident" arises out of operations governed by such contract or agreement and only up to the limits required in the written contract or written agreement, or the Limits of Insurance shown in the Declarations, whichever is less. 2. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance — Primary and Excess Insurance Provisions Condition in the Motor Carrier Coverage Form: Coverage for any person(s) or organization(s), where required by written contract or written agreement with you executed prior to any "accident", will apply on a primary and non-contributory basis and any insurance maintained by the additional "insured" will apply on an excess basis. However, in no event will this coverage extend beyond the terms and conditions of the Coverage Form. B. Amendment — Supplementary Payments Paragraphs a.(2) and a.(4) of the Coverage Extensions Provision in Section II — Covered Autos Liability Coverage are replaced by the following: (2) Up to $5,000 for the cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We do not have to furnish these bonds. Reek MaiagC1 ad DMslon REVIEWED & APPROVED BY: Risk ManagementSpeeial[st NJ Includes copyrighted material of Insurance Services Office, Inc., with its permissic (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work. C. Fellow Employee Coverage The Fellow Employee Exclusion contained in Section II — Covered Autos Liability Coverage does not apply. D. Driver Safety Program Liability and Physical Damage Coverage 1. The following is added to the Racing Exclusion in Section II — Covered Autos Liability Coverage: This exclusion does not apply to covered "autos" participating in a driver safety program event, such as, but not limited to, auto or truck rodeos and other auto or truck agility demonstrations. 2. The following is added to Paragraph 2. in the Exclusions of Section III — Physical Damage Coverage of the Business Auto Coverage Form and Paragraph 2.b. in the Exclusions of Section IV — Physical Damage Coverage of the Motor Carrier Coverage Form: This exclusion does not apply to covered "autos" participating in a driver safety program event, such as, but not limited to, auto or truck rodeos and other auto or truck agility demonstrations. E. Lease or Loan Gap Coverage The following is added to the Coverage Provision of the Physical Damage Coverage Section: Lease Or Loan Gap Coverage In the event of a total 'loss" to a covered "auto", we will pay any unpaid amount due on the lease or loan for a covered "auto", less: a. Any amount paid under the Physical Damage Coverage Section of the Coverage Form; and b. Any: (1) Overdue lease or loan payments at the time of the "loss"; (2) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; (3) Security deposits not returned by the lessor; (4) Costs for extended warranties, credit life insurance, health, accident or disability insurance purchased with the loan or lease; and (5) Carry-over balances from previous leases or loans. F. Towing and Labor Paragraph A.2. of the Physical Damage Coverage Section is replaced by the following: We will pay up to $75 for towing and labor costs incurred each time a covered "auto" of the private passenger type is disabled. However, the labor must be performed at the place of disablement. G. Extended Glass Coverage The following is added to Paragraph A.3.a. of the Physical Damage Coverage Section: If glass must be replaced, the deductible shown in the Declarations will apply. However, if glass can be repaired and is actually repaired rather than replaced, the deductible will be waived. You have the option of having the glass repaired rather than replaced. H. Hired Auto Physical Damage — Increased Loss of Use Expenses The Coverage Extension for Loss Of Use Expenses in the Physical Damage Coverage Section is replaced by the following: Loss Of Use Expenses a „_ RtsleMrnefDiris[on orzl eel< 'Y REmEwEQ & APPRovm By. ;1 Risk Management Specialist Includes copyrighted material of Insurance Services Office, Inc., with its permissic For Hired Auto Physical Damage, we will pay expenses for which an "insured" becomes legally responsible to pay for loss of use of a vehicle rented or hired without a driver under a written rental contract or written rental agreement. We will pay for loss of use expenses if caused by: (1) Other than collision only if the Declarations indicate that Comprehensive Coverage is provided for any covered "`auto"; (2) Specified Causes Of Loss only if the Declarations indicate that Specified Causes Of Loss Coverage is provided for any covered "auto"; or (3) Collision only if the Declarations indicate that Collision Coverage is provided for any covered "auto". However, the most we will pay for any expenses for loss of use is $100 per day, to a maximum of $3000. I. Personal Effects Coverage The following is added to the Coverage Provision of the Physical Damage Coverage Section: Personal Effects Coverage a. We will pay up to $750 for "loss" to personal effects which are: (1) Personal property owned by an "insured"; and (2) In or on a covered "auto". b. Subject to Paragraph a. above, the amount to be paid for "loss" to personal effects will be based on the lesser of: (1) The reasonable cost to replace; or (2) The actual cash value. c. The coverage provided in Paragraphs a. and b. above, only applies in the event of a total theft of a covered "auto". No deductible applies to this coverage. However, we will not pay for "loss" to personal effects of any of the following: (1) Accounts, bills, currency, deeds, evidence of debt, money, notes, securities, or commercial paper or other documents of value. (2) Bullion, gold, silver, platinum, or other precious alloys or metals; furs or fur garments; jewelry, watches, precious or semi-precious stones. (3) Paintings, statuary and other works of art. (4) Contraband or property in the course of illegal transportation or trade. (5) Tapes, records, discs or other similar devices used with audio, visual or data electronic equipment. Any coverage provided by this Provision is excess over any other insurance coverage available for the same "loss". J. Tapes, Records and Discs Coverage 1. The Exclusion in Paragraph 13.4.a. of Section III — Physical Damage Coverage in the Business Auto Coverage Form and the Exclusion in Paragraph 13.2.c. of Section IV — Physical Damage Coverage in the Motor Carrier Coverage Form does not apply. 2. The following is added to Paragraph 1.a. Comprehensive Coverage under the Coverage Provision of the Physical Damage Coverage Section: We will pay for "loss" to tapes, records, discs or other similar devices used with audio, visual or data electronic equipment. We will pay only if the tapes, records, discs or other similar audio, visual or data electronic devices: (a) Are the property of an "insured"; and (b) Are in a covered "auto" at the time of "loss". The most we will pay for such "loss" to tapes, records, discs or other similar devices is $500. The Physical Damage Coverage Deductible Provision does not apply to such "loss". Rtek Mar,�Divisirnt REVIe&Ef o & APPR6Vmft cll�R�CCS��! yy 4 A6444 �cWlis�a+�Mii'. -� Risk Management Specialist Includes copyrighted material of Insurance Services Office, Inc., with its permissic K. Airbag Coverage The Exclusion in Paragraph 6.3.a. of Section III — Physical Damage Coverage in the Business Auto Coverage Form and the Exclusion in Paragraph B.4.a. of Section IV — Physical Damage Coverage in the Motor Carrier Coverage Form does not apply to the accidental discharge of an airbag. L. Two or More Deductibles The following is added to the Deductible Provision of the Physical Damage Coverage Section: If an accident is covered both by this policy or Coverage Form and by another policy or Coverage Form issued to you by us, the following applies for each covered "auto" on a per vehicle basis: 1. If the deductible on this policy or Coverage Form is the smaller (or smallest) deductible, it will be waived; or 2. If the deductible on this policy or Coverage Form is not the smaller (or smallest) deductible, it will be reduced by the amount of the smaller (or smallest) deductible. M. Physical Damage — Comprehensive Coverage — Deductible The following is added to the Deductible Provision of the Physical Damage Coverage Section: Regardless of the number of covered "autos" damaged or stolen, the maximum deductible that will be applied to Comprehensive Coverage for all "loss" from any one cause is $5,000 or the deductible shown in the Declarations, whichever is greater. N. Temporary Substitute Autos — Physical Damage 1. The following is added to Section I — Covered Autos: Temporary Substitute Autos — Physical Damage If Physical Damage Coverage is provided by this Coverage Form on your owned covered "autos", the following types of vehicles are also covered "autos" for Physical Damage Coverage: Any "auto" you do not own when used with the permission of its owner as a temporary substitute for a covered "auto" you do own but is out of service because of its: 1. Breakdown; 2. Repair; 3. Servicing; 4. "Loss"; or 5. Destruction. 2. The following is added to the Paragraph A. Coverage Provision of the Physical Damage Coverage Section: Temporary Substitute Autos — Physical Damage We will pay the owner for "loss" to the temporary substitute "auto" unless the "loss" results from fraudulent acts or omissions on your part. If we make any payment to the owner, we will obtain the owner's rights against any other party. The deductible for the temporary substitute "auto" will be the same as the deductible for the covered "auto" it replaces. O. Amended Duties In The Event Of Accident, Claim, Suit Or Loss Paragraph a. of the Duties In The Event Of Accident, Claim, Suit Or Loss Condition is replaced by the following: a. In the event of "accident", claim, "suit" or "loss", you must give us or our authorized representative prompt notice of the "accident", claim, "suit" or "loss". However, these duties only apply when the "accident", claim, "suit" or "loss" is known to you (if you are an individual), a partner (if you are a partnership), a member (if you are a limited liability company) or an executive officer or insurance manager (if you are a corporation). The failure of any agent, servant —..:� RtskMougmwntDivision R wF -wEo & AaPizovm BY: Risk Management Specialist Includes copyrighted material of Insurance Services office, Inc., with its permissic or employee of the "insured" to notify us of any "accident", claim, "suit" or "loss" shall not invalidate the insurance afforded by this policy. Include, as soon as practicable: (1) How, when and where the "accident" or "loss" occurred and if a claim is made or "suit" is brought, written notice of the claim or "suit" including, but not limited to, the date and details of such claim or "suit"; (2) The "insured's" name and address; and (3) To the extent possible, the names and addresses of any injured persons and witnesses. If you report an "accident", claim, "suit" or "loss" to another insurer when you should have reported to us, your failure to report to us will not be seen as a violation of these amended duties provided you give us notice as soon as practicable after the fact of the delay becomes known to you. P. Waiver of Transfer Of Rights Of Recovery Against Others To Us The following is added to the Transfer Of Rights Of Recovery Against Others To Us Condition: This Condition does not apply to the extent required of you by a written contract, executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of operations contemplated by such contract. This waiver only applies to the person or organization designated in the contract. Q. Employee Hired Autos — Physical Damage Paragraph b. of the Other Insurance Condition in the Business Auto Coverage Form and Paragraph f. of the Other Insurance — Primary and Excess insurance Provisions Condition in the Motor Carrier Coverage Form are replaced by the following: For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow; and (2) Any covered "auto" hired or rented under a written contract or written agreement entered into by an "employee" or elected or appointed official with your permission while being operated within the course and scope of that "employee's" employment by you or that elected or appointed official's duties as respect their obligations to you. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto R. Unintentional Failure to Disclose Hazards The following is added to the Concealment, Misrepresentation Or Fraud Condition: However, we will not deny coverage under this Coverage Form if you unintentionally: (1) Fail to disclose any hazards existing at the inception date of this Coverage Form; or (2) Make an error, omission, improper description of "autos" or other misstatement of information. You must notify us as soon as possible after the discovery of any hazards or any other information that was not provided to us prior to the acceptance of this policy. S. Hired Auto — World Wide Coverage Paragraph 7a.(5) of the Policy Period, Coverage Territory Condition is replaced by the following: (5) Anywhere in the world if a covered "auto" is leased, hired, rented or borrowed for a period of 60 days or less, T. Bodily Injury Redefined The definition of "bodily injury" in the Definitions Section is replaced by the following: "Bodily injury" means bodily injury, sickness or disease, sustained by a person including death or mental anguish, resulting from any of these at any time. Mental anguish means any type of mental or emotional illness or disease. _-- RisieM�geittere{Divi�icm REVIEWED & APPROVED SY. RiAManagement 5peclahI Includes copyrighted material of Insurance Services Office, Inc., with Its permissic U. Expected Or Intended Injury The Expected Or Intended Injury Exclusion in Paragraph B. Exclusions under Section II — Covered Auto Liability Coverage is replaced by the following: Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the "insured". This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. V. Physical Damage — Additional Temporary Transportation Expense Coverage Paragraph AA.a. of Section III — Physical Damage Coverage is replaced by the following: 4. Coverage Extensions a. Transportation Expenses We will pay up to $50 per day to a maximum of $1,000 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage. We will pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we pay for its "loss". W. Replacement of a Private Passenger Auto with a Hybrid or Alternative Fuel Source Auto The following is added to Paragraph A. Coverage of the Physical Damage Coverage Section: In the event of a total "loss" to a covered "auto" of the private passenger type that is replaced with a hybrid "auto" or "auto" powered by an alternative fuel source of the private passenger type, we will pay an additional 10% of the cost of the replacement "auto", excluding tax, title, license, other fees and any aftermarket vehicle upgrades, up to a maximum of $2500. The covered "auto" must be replaced by a hybrid "auto" or an "auto" powered by an alternative fuel source within 60 calendar days of the payment of the "loss" and evidenced by a bill of sale or new vehicle lease agreement. To qualify as a hybrid "auto", the "auto" must be powered by a conventional gasoline engine and another source of propulsion power. The other source of propulsion power must be electric, hydrogen, propane, solar or natural gas, either compressed or liquefied. To qualify as an "auto" powered by an alternative fuel source, the "auto" must be powered by a source of propulsion power other than a conventional gasoline engine. An "auto" solely propelled by biofuel, gasoline or diesel fuel or any blend thereof is not an "auto" powered by an alternative fuel source. X. Return of Stolen Automobile The following is added to the Coverage Extension Provision of the Physical Damage Coverage Section: If a covered "auto" is stolen and recovered, we will pay the cost of transport to return the "auto" to you. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage. All other terms, conditions, provisions and exclusions of this policy remain the same. __- Risk Mvwg=mtDMamt f gyp, I R+E\AEWM&APPROVED BY. I f�� �7LG4'ei�o Risk Management Specialist Includes copyrighted material of Insurance Services Office, Inc., with its permiss'c Blanket Notification to Others of Cancellation ZURICH Policy No. Eff. Date of Pol. Exp. Date of Pol. Ef. Date of End. Producer Add'4 Prom. Return Prem. GPL 6024753-01 11/0112021 11/01/2022 11/01/2021 18726000 __________ ---------- Named Insured and Mailing Address: PATRIOT ENVIRONMENTAL SERVICES, INC. 508 E E ST STE A WILMINGTON, CA 90744-6024 Producer: ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC 2345 GRAND BLVD STE 400 KANSAS CITY. MO 64108-2625 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Agribusiness Pollution Liability Insurance Policy - Claims Made and Reported Coverage Commercial Umbrella Liability Policy Commercial Umbrella Liability Policy — Claims Made and Reported Coverage Contractor's Pollution Liability Insurance Policy Contractor's Pollution Liability Insurance Policy - Claims Made and Reported Coverage Environmental Cleanup and Liability Insurance Policy - Claims Made and Reported Coverage Environmental Impairment Liability Insurance Policy - Claims Made and Reported Coverage Environmental Services Package Policy Excess Environmental Insurance Policy - Claims Made and Reported Coverage Follow Form Excess Liability Policy Follow Form Excess Liability Policy — Claims Made and Reported Coverage Healthcare Pollution Liability Insurance Policy - Claims Made and Reported Coverage Lender Environmental Collateral Protection and Liability Insurance Outstanding Loan Balance - Claims Made and Reported Coverage Lender Environmental Collateral Protection and Liability Insurance Policy — Claims Made and Reported Coverage Professional Consultant's Liability Insurance Policy - Claims Made and Reported Coverage Professional Environmental Consultant's Liability Insurance Policy Professional Environmental Consultant's Liability Insurance Policy - Claims Made and Reported Coverage Public Entity Pollution Liability - Claims Made and Reported Coverage Real Estate Environmental Liability Insurance Policy - Claims Made and Reported Coverage Remediation Stop Loss Z Choice Pollution Liability Z Choice® Real Estate Environmental Liability - Claims Made and Reported Coverage Z ChoiceT'" Pollution Liability - Claims Made and Reported Coverage Z Link® Commercial General and Pollution Liability A. If we cancel this policy by written notice to the first Named Insured for any reason nthpr than nnnnavmpnt of premium, we will deliver electronic notification that such policy has been cancelled to hiswn shown in a Schedule provided to us by the First Named Insured. Such Schedule: RtakM &APPROaganent APPROVED BY. REV7EWE� & APPROV®BY: �� Risk Management Speaalist 1. Must be initially provided to us within 15 days: a. After the beginning of the policy period shown in the Declarations; or b. After this endorsement has been added to policy; 2. Must contain the names and e-mail addresses of only the persons or organizations requiring notification that such Coverage Part has been cancelled; 3. Must be in an electronic format that is acceptable to us; and 4. Must be accurate. Such Schedule may be updated and provided to us by the First Named Insured during the policy period. Such updated Schedule must comply with Paragraphs 2. 3. and 4. above. B. Our delivery of the electronic notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. Delivery of the notification as described in Paragraph A. of this endorsement will be completed as soon as practicable after the effective date of cancellation to the first Named Insured. C. Proof of emailing the electronic notification will be sufficient proof that we have complied with Paragraphs A. and B. of this endorsement. D. Our delivery of electronic notification described in Paragraphs A. and B. of this endorsement is intended as a courtesy only. Our failure to provide such delivery of electronic notification will not: 1. Extend the Coverage Part cancellation date; 2. Negate the cancellation; or 3. Provide any additional insurance that would not have been provided in the absence of this endorsement. E. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the Schedule provided to us as described in Paragraphs A. and B. of this endorsement. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. _ 'RisleMsr+ngerrten�nivistrnt RP/IEWED& APPRC VSD aY. A &z,44, �— Risk Management Specialist Notice to Others of Cancellation or Nonrenewal 0 ZURICH Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer Add'I Prem. Return Prem. GPL 6024753-01 11/01/2021 11101/2022 11101/2021 18726000-------------------- Named Insured and Mailing Address: Producer: PATRIOT ENVIRONMENTAL SERVICES, INC. ARTHUR J GALLAGHER RISK MANAGEMENT 508 E E ST STE A SERVICES INC WILMINGTON, CA 90744-6024 2345 GRAND BLVD STE 400 KANSAS CITY, MO 64108-2625 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Agribusiness Pollution Liability Insurance Policy - Claims Made and Reported Coverage Commercial Umbrella Liability Policy Commercial Umbrella Liability Policy — Claims Made and Reported Coverage Contractor's Pollution Liability Insurance Policy Contractor's Pollution Liability Insurance Policy - Claims Made and Reported Coverage Environmental Cleanup and Liability Insurance Policy - Claims Made and Reported Coverage Environmental Impairment Liability Insurance Policy - Claims Made and Reported Coverage Environmental Services Package Policy Excess Environmental Insurance Policy - Claims Made and Reported Coverage Follow Form Excess Liability Policy Follow Form Excess Liability Policy — Claims Made and Reported Coverage Healthcare Pollution Liability Insurance Policy - Claims Made and Reported Coverage Lender Environmental Collateral Protection and Liability Insurance Outstanding Loan Balance - Claims Made and Reported Coverage Lender Environmental Collateral Protection and Liability Insurance Policy — Claims Made and Reported Coverage Lender Environmental Collateral Protection and Liability Insurance Policy — Capital Markets - Claims Made and Reported Coverage Professional Consultant's Liability Insurance Policy - Claims Made and Reported Coverage Professional Environmental Consultant's Liability Insurance Policy Professional Environmental Consultant's Liability Insurance Policy - Claims Made and Reported Coverage Public Entity Pollution Liability - Claims Made and Reported Coverage Real Estate Environmental Liability Insurance Policy - Claims Made and Reported Coverage Fixed Price Remediation Insurance Z Choice@ Real Estate Environmental Liability - Claims Made and Reported Coverage Z Choicee Pollution Liability - Claims Made and Reported Coverage Z Link® Commercial General and Pollution Liability Rk`%Mgmwnto`" bn °c REVIEWED & APPRovm BY: +f ICW Wes' '�� Risk Management Specialist A. if we cancel or non -renew this policy by written notice to the first Named Insured shown in the Declarations for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation or non -renewal: 1. To the name and address corresponding to each person or organization shown in the Schedule below; and 2. At least 10 days prior to the effective date of the cancellation or non -renewal, as advised in our notice to the first Named Insured shown in the Declarations, or the longer number of days notice if indicated in the Schedule below. B. If we cancel this policy by written notice to the first Named Insured shown in the Declarations for nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation. C. If notice as described in Paragraphs A. or B. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice. SCHEDULE Name and Address of Other Person(s)1 Organization(s); Number of Days Notice: All persons or organizations as per on file with us"; 30 ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. _ RiskManagemenfDEv Icn REVIEWED & APPROVED BY: °Ie j f1d�i Risk Management Specialist Additional Insured -Automatic -Owners, Lessees Or 0 „h, Contractors ZURICH Coverage Part One -Commercial General Liability Coverage Part Twwo-Contractor's Pollution Liability Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer Add1 Prem. Return Prom. GPL 6024753-01 111/01/2021 11/01/2022 11/01/2021 18726000 __________ __________ Named Insured and Mailing Address: Producer: PATRIOT ENVIRONMENTAL SERVICES, INC. ARTHUR J GALLAGHER RISK MANAGEMENT 508 E E ST STE A SERVICES INC WILMINGTON, CA 90744-6024 2345 GRAND BLVD STE 400 KANSAS CITY, MO 64108-2625 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Environmental Services Package Policy COVERAGE PART ONE -COMMERCIAL GENERAL LIABILITY ❑X COVERAGE PART TWO -CONTRACTOR'S POLLUTION LIABILITY 1. Who is an Insured (Section I.) in the COMMON COVERAGE PROVISIONS is amended to include as an additional insured any person(s) or organization(s) whom you are required to add as an additional insured on this policy under a written contract or written agreement. 2. The insurance provided to the additional insured person(s) or organization(s) applies only to: a. "Bodily injury", "property damage" or "personal and advertising injury" under COVERAGE PART ONE - COMMERCIAL GENERAL LIABILITY, COVERAGE A - BODILY INJURY AND PROPERTY DAMAGE LIABILITY and COVERAGE B - PERSONAL AND ADVERTISING INJURY LIABILITY caused, in whole or in part, by: (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; and resulting directly from: (a) Your ongoing operations performed for the additional insured, which is the subject of the written contract or written agreement; or (b) "Your work" completed as included in the "products -completed operations hazard", performed for the additional insured, which is the subject of the written contract or written agreement; and/or b. "Claims" arising out of a "pollution event" under COVERAGE PART TWO - CONTRACTOR'S POLLUTION LIABILITY, caused, in whole or in part, by: (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf, and resulting directly from: (a) "Covered operations" performed for the additional insured, which is the subject of the written contract or written agreement; or -- Riek Mn%wnmt DMsiun a RE+AEWEE) & AAPRovm 8Y: Risk. Management Specialist (b) "Completed operations" of the "covered operations" performed for the additional insured, which is the subject of the written contract or written agreement. 3. However, regardless of the provisions of paragraphs 1. and 2. above, the insurance afforded to such additional insured: a. Only applies to the extent permitted by law; and b. Will not be broader than that which you are required by the written contract or written agreement to provide to such additional insured. 4. With respect to the insurance afforded to the additional insured under this endorsement, the following is added to Section III — Limits Of Insurance and Deductible: The most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the written contract or written agreement you have entered into with the additional insured, or b. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations 5. The insurance provided to the additional insured person or organization does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering or failure to render any professional architectural, engineering or surveying services including: (1) The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any architectural, engineering or surveying services. 6. The additional insured must see to it that: a. We are notified as soon as practicable of an "occurrence", offense or "pollution event", as applicable, that may result in a claim; b. We receive written notice of a claim or "suit" as soon as practicable; and c. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured, if the written contract or written agreement requires that this coverage be primary and non-contributory. 7. For the coverage provided by this endorsement: a. The following paragraph is added to Paragraph 8.a. Other Insurance, Conditions (Section V.) in the COMMON COVERAGE PROVISIONS: Primary and Noncontributory Insurance This Insurance is primary to and will not seek contribution from any other insurance available to an additional insured under this endorsement provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in a written contract or written agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. b. The following paragraph is added to Paragraph 8.b. Other Insurance, Conditions (Section V.) in the COMMON COVERAGE PROVISIONS: This insurance is excess over; Risk Mougement Vh&inn ol''}N'R "L•"y REMEUJED/A& APPR/OVEE)�BtjY. `1� Risk Management Specialist Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis. 8. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. RA Mu ge ..d Division A.<, RE\AEwE® & APPRovm By. -Yr Risk Management Specialist Additional Insured — Lessor of Leased Equipment - ZURICH Automatic Status When Required in a Lease Agreement With You Coverage Part One — Commercial General Liability Coverage Part Two — Contractor's Pollution Liability Policy Na. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer Add'I Prem, Return Prem. GPL 6024753-01 11/01/2021 11/01/2022 11/01/2021 18726000 ---------- ____------ Named Insured and Mailing Address: Producer: PATRIOT ENVIRONMENTAL SERVICES, INC. ARTHUR J GALLAGHER RISK MANAGEMENT 508 E E ST STE A SERVICES INC WILMINGTON, CA 90744-6024 2345 GRAND BLVD STE 400 KANSAS CITY, MO 64108-2625 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Environmental Services Package Policy [ X ] COVERAGE PART ONE - COMMERCIAL GENERAL LIABILITY COVERAGE PART TWO - CONTRACTOR'S POLLUTION LIABILITY In consideration of the payment of premium and the Deductible by you and in reliance upon the statements in the Application made a part hereof, we agree with you, subject to all the terms, exclusions and conditions that with respect to the coverage parts indicated above: 1. Who is an Insured (Section I.) in the COMMON POLICY PROVISIONS is amended to include as an insured any person or organization from whom you lease equipment when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an insured only with respect to their liability arising out of the maintenance, operation or use by you of equipment leased to you by such person or organization. A person's or organization's status as an insured under the endorsement ends when their contract or agreement with you for such leased equipment ends. 2. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after the equipment lease expires. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. _-_Rime Muisigment DKis[m L . `a,+ REMBNMhh& APPRovm BY: Risk Management Specialist Waiver of Transfer of Rights of Recovery Against Others — Blanket as Required by Contract ZURICH Policy No. Eff, pate of Pol. Exp. Date of PoI, Eff. Date of End. Producer Add9 Prem. Return Prem. GPL 6024753-01 11101/2021 11/01/2022 11/01/2021 18726000---------- Named Insured and Mailing Address: PATRIOT ENVIRONMENTAL SERVICES, INC. 508EESTSTEA WILMINGTON, CA 90744-6024 Producer: ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC 2345 GRAND BLVD STE 400 KANSAS CITY, MO 64108-2625 ITHIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Environmental Services Package Policy [ X ] COVERAGE PART ONE — COMMERCIAL GENERAL LIABILITY [ X ] COVERAGE PART TWO -- CONTRACTOR'S POLLUTION LIABILITY [ X ] COVERAGE PART THREE PROFESSIONAL LIABILITY In consideration of the payment of premium and the Deductible by you and in reliance upon the statements in the Application made a part hereof, we agree with you, subject to all the terms, exclusions and conditions that with respect to the coverage parts indicated above Conditions (Section V.) of the COMMON COVERAGE PROVISIONS, Condition 14. Subrogation is amended by the addition of the following: We waive any right of recovery we may have against any person or organization whom you are required to waive your right of subrogation by a written contract or written agreement executed and effective prior to the performance of your services which is the subject of such written contract or written agreement. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. Mmugmeni DMsian e REmEwED& APPRc)vIDBy�. �yd r Risk Management Specialist Schedule of Underlying Insurance ZURICH Re: PATRIOT ENVIRONMENTAL SERVICES, INC. Coverage: Straight Excess Liability Policy Reference Number: 6182421-04 Our proposal is subject to the underlying limits of liability and coverages as stated below. Alt Underlying Insurance must be provided by a carrier with an A.M. Best rating of A-VII or better. Comprehensive General Liability Carrier Group Name: Zurich Insurance Group LTD Issuing Company: Steadfast Insurance Detailed Description of Policy: Environmental Service Package Policy Number: GPL 6024753 Policy Period: 11101/2021 to 11101/2022 General AggregateType: Per Location /Per Project General Aggregate Application: Term Aggregate General Aggregate Cap Amount: Unlimited Coverages Included: Premises and Products / Completed Ops Premises - Each Occurrence Limit: $2,000,000 Retention Type: Deductible Retention ALAE: In Addition to the Limit Retention Amount: $20,000 Products / Completed Ops - Each $2,000,000 Occurrence Retention Type: Deductible Retention ALAE: In Addition to the Limit Retention Amount: $20,000 General Aggregate: $4,000,000 Products / Completed Operations $4,000,000 Aggregate Employee Benefits- Each Claim: $1,000,000 Employee Benefits - General Aggregate: $1,000,000 Retention Type: Deductible Retention ALAE: In Addition to the Limit Retention Amount: $1,000 Terms and Conditions: d..- Risk MvwWftaatDKiskm REviewm & APPROVED BY. �-s.�a �sttitdo '�l� Risk Management Spec€alist Schedule of Underlying Insurance Auto Liability Carrier Group Name: Issuing Company: Detailed Description of Policy Policy Number: Combined Single Limit: Retention Type: Terms and Conditions: Employers Liability Carrier Group Name: Issuing Company: Detailed Description of Policy: Policy Number: Bodily Injury By Accident - Each Accident: Retention Type: Zurich Insurance Group LTD Zurich American Insurance Business Auto BAP 5682677 Policy Period: 11/01/2021 to 11/01/2022 $1,000,000 None ZURICH Zurich Insurance Group LTD Zurich American Insurance Employers Liability WC 5682678 Policy Period: 11101/2021 to 1110112022 $1,000,000 None Bodily Injury By Disease - Each Employee: $1,000,000 Retention Type: None Bodily Injury By Disease - Policy Limit: Terms and Conditions: Professional Liability Carrier Group Name: Issuing Company: Detailed Description of Policy: Policy Number: Each Occurrence Limit: Aggregate Limit: Retention Type: Retention Amount: Terms and Conditions: $1,000,000 Zurich Insurance Group LTD Steadfast Environmental Services Package GPL 6024753 Policy Period: 11/01/2021 to 11/0112022 $2,000,000 $4,000,000 Deductible Retention ALAE: Erode the Limit $20,000 Rule MAnvgmwntE)Mslan s °F REviELVED & APPROVED BY: r Risk Management Specialist Schedule of Underlying Insurance ZURICH{ Pollution Liability Carrier Group Name: Zurich Insurance Group LTD Issuing Company: Steadfast Insurance Detailed Description of Policy: Environmental Services Package Policy Number: GPL 6024753 Policy Period: 11101/2021 to 11/01/2022 Coverages Included: Environmental Services Package Each Incident Limit: $2,000,000 Policy Aggregate Limit: $4,000,000 Retention Type: Deductible Retention ALAE: Erode the Limit Retention Amount: $20,000 Products/Completed Operations Aggregate: $4,000,000 Terms and Conditions: P&I Coverage Carrier Group Name: Issuing Company: Detailed Description of Policy: Policy Number: Per Occurrence Limit: Retention Type: Retention Amount: Terms and Conditions: Liberty Mutual Insurance Companies Liberty Mutual Insurance Companies P&I Coverage LIUH-00222-04 Policy Period: 11101l2021 to 11(0112022 $1,000,000 Deductible Retention ALAE: In Addition to the Limit $2,500 -- _ R�ekMa�agernen4T}ivisirni REMeNED & APPROV®8Y: A+.p A,,v4dz,, " RiAManagement Speaalu� WORKERS COMPENSATION CHANGE ENDORSEMENT Insurance for this coverage part provided by: Policy NumberWC 5682678-01 ZURICH AMERICAN INSURANCE COMPANY NCCI Comoanv No.1 0 8 6 3 NAMED INSURED ENDORSEMENT EFFECTIVE DATE I POLICY NUMBER PATRIOT ENVIRONMENTAL 11-05-21 WC 5682678-01 POLICYTERM: 11-01-2021 TO 11-01-2022 ENDORSEMENT NUMBER 002 Change Description THE FOLLOWING FORM(S) HAS BEEN A -MENDED: WC 00 03 01 A 02-89 ALTERNATE EMPLOYER ENDORSEMENT PREMIUM CHANGE PRO-RATA FACTOR Additional Coverage Premium STA Return Coverage Premium STA Additional Taxes & Surcharges Return Taxes & Surcharges Total Additional Premium STA Total Return Premium STA Countersigned: Date By PJA Mougement Div slm t - REmEWED�y& APPROvpa_By. Risk Management Specialist WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 01 A (Ed. 2-89) ALTERNATE EMPLOYER ENDORSEMENT This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be canceled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Schedule Alternate Employer PLAINS MARKETING, L.P., PLAINS PIPELINE, L.P., PLAINS MIDSTREAM CANADA ULC, PLAINS LPG SERVICES, L.P., PACIFIC PIPELINE SYSTEM LLC, ROCKY MOUNTAIN PIPELINE SYSTEM LLC, PLAINS PRODUCTS TERMINALS LLC, PLAINS GAS SOLUTIONS, LLC, PLAINS PIPELINE — NORTH DAKOTA LLC, PAA NATURAL GAS STORAGE LLC, BLUEWATER GAS STORAGE LLC, PINE PRAIRIE ENERGY CENTER LLC, SG RESOURCES MISSISSIPPI LLC, PLAINS ALL AMERICAN PIPELINE, L.P., PAA GP LLC Address 333 CLAY STREET, STE 1600, HOUSTON, TX 77002 2. State of Special or Temporary Employment CA 3. Contract or Project MASTER SERVICE AGREEMENT C-0419 WC 00 03 01 A (Ed. 2-89) © 1984, 1988 National Council on Compensation Insurance. Risk Mougmeni Divisi in REVIEWED & APPROVED BY. A Acre tda Risk Management Specialist Insurance for this coverage part provided by: ZURICH AMERICAN INSURANCE COMPANY NCC1 COfnDanv No.l 0 8 6 3 WORKERS COMPENSATION CHANGE ENDORSEMENT Policy Number,WC 5682678-01 NAMED INSURED ENDORSEMENT EFFECTIVE DATE POLICY NUMBER PATRIOT ENVIRONMENTAL 11-01-21 WC 5682678-01 POLICYTERM: 11-01-2021 TO 11-01-2022 ENDORSEMENT NUMBER 009 Change Description THE FOLLOWING FORM(S) HAS BEEN ADDED: WC 00 03 01 A 02-89 ALTERNATE EMPLOYER ENDORSEMENT PREMIUM CHANGE PRO-RATA FACTOR Additional Coverage Premium STA Return Coverage Premium STA Additional Taxes & Surcharges Return Taxes & Surcharges Total Additional Premium STA Total Return Premium STA Countersigned: Date By �kn�gnt�t��l�t REVIEWED & APPROVED BY: �r Risk Management Specialist WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 01 A (Ed. 2-89) ALTERNATE EMPLOYER ENDORSEMENT This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be canceled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Schedule Alternate Employer ANY PERSON OR ORGANIZATION TO WHOM OR TO WHICH YOU ARE REQUIRED TO ADD AS AN ALTERNATE EMPLOYER IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS POHIBITED BY LAW Address 2. State of Special or Temporary Employment ANY STATE LISTED IN ITEM 3 A. OF THE INFORMATION PAGE 3. Contract or Project ANY WRITTEN CONTRACT OR AGREEMENT 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 11-01-21 Policy No. WC 5682678-01 Endorsement No. 009 Insured PATRIOT ENVIRONMENTAL SERVICES, INC. Insurance Company ZURICH AMERICAN INSURANCE COMPANY Countersigned By WC000301 A (Ed. 2-89) O 1984, 1988 National Council on Compensation Insurance. Premium $ INCL . °-- _ Risk Manugemwnt Division REVIEWEE> & APPROVW BY. �� Risk Management Specialist NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Patriot Environmental Services, Inc. Name: Project N-2019-194-01 Number: Project Extension of Agreement N-2019-194 to Provide On-Call Debris Name: Removal Services The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: POLICY EXPIRATION COI TYPE OF INSURANCE FILE NAME NUMBER DATE DATE City of Santa Ana- AUTOMOBILE LIABILITY AS2641445774032 06/01/2023 11/01/2022 570096314997.pdf City of Santa Ana- GENERAL LIABILITY IEPICB9067002 06/01/2023 11/01/2022 570096314997.pdf Patriot Environmental PROFESSIONAL LIABILITY TEPICB9067002 06/01/2023 01/04/2023 Services, Inc.-City of Santa Ana- 23010426100699.pdf WORKERS COMPENSATION City of Santa Ana- AND EMPLOYERS' WA264D445774012 06/01/2023 11/01/2022 570096314997.pdf LIABILITY Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/9/2023 5:20 PM NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Patriot Environmental Services, Inc. Name: Project N-2019-194-01 Number: Project Agreement to Provide On-Call Debris Removal Services Name: The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: TYPE OF EXPIRATION COI POLICY NUMBER FILE NAME INSURANCE DATE DATE AUTOMOBILE City of Santa Ana- AS2641445774033 06/01/2024 06/02/2023 LIABILITY 570099752743.pdf CONTRACTORS City of Santa Ana- POLLUTION IEPICB9067003 06/01/2024 06/02/2023 570099752743.pdf LIABILITY City of Santa Ana- GENERAL LIABILITY IEPICB9067003 06/01/2024 06/02/2023 570099752743.pdf WORKERS COMPENSATION AND City of Santa Ana- WA264D445774013WCAOS 06/01/2024 06/02/2023 EMPLOYERS' 570099752743.pdf LIABILITY Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 6/30/2023 5:23 PM