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HomeMy WebLinkAboutSANTOLUCITO DORE GROUP, INC. (3) INSURANCE ON FILE WORK MIRY PROCEED I,N rLr su �:la� XMRL A-2021-220-02 MAYOR CFY CLERK CITY MANAGER Valerie Amezcua Alvaro Nunez MAYOR PRO TEM �jt„E. OCT Z 0 2025 �., CITY ATTORNEY Benjamin Vazquez ==,� Sonia R.Carvalho COUNCILMEMBERS /" CITY CLERK Phil Bacerra Jennifer L.Hall Johnathan Ryan Hernandez Jessie Lopez David Penaloza Thai Viet Phan CITY OF SANTA ANA PUBLIC WORKS AGENCY David Rwi rQ-z 07) 20 Civic Center Plaza a P.O.Box 1988 Santa Ana,California 92702 www.santa-ana.org September 24,2025 Santulocito Dore Group, Inc. Attn: Christine S. Santulocito,President 31600 Railroad Canyon Rd., Ste. 100-L Canyon Lake,CA 92587 Re: Second and Final Extension of Agreement(A-2021-220)to Provide On Call Property Appraisal Services Pursuant to Section 4 ("Performance Period") of the above-referenced Agreement, entered into by Santulocito Dore Group, Inc. ("Consultant"), and the City of Santa Ana, dated November 16, 2021, the term of the Agreement is hereby further extended for an additional one-year period through November 15, 2026. 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. Sincerely, Ro olfo Rosas,P.E. Acting Executive Director, Public Works Agency CITY O ANTA A ATTEST �1W - Alvaro Nunez t er a City Manager City Cle APPROVED AS TO FORM SANTULOCITO DORE GROUP,INC. e Nellesen Christin"e4. Santulocito Assistant City Attorney President SANTA ANA CITY COUNCIL Valerie Amenua Bengamin Vazquez Thai Yet Phan Jessie Lopez Phil Baca" Johnathan Ryan Hernandez David Penaloza Mayor Mayor Pro Tem,Ward 2 Ward 1 Ward 3 Ward 4 Ward 5 Ward 8 vamezcuart4sanla-ana-oro bvaznuez(@_la-ana.oro Qhana%nta-ana.org iessiolooez,anla-ana.om ha�certaCQsanla-ana.orn irvanhemardoz(o�santa-ana.om dpenaloza(o]santa-ana.ora CERTIFICATE 4F LIABILITY INSURANCE DATE(MM1DDNYYY) ilh � 12/24/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT Ben Goode NAME: StateFarm State Farm Insurance and Financial Services PHONE (951)501-1000c NQ: (951}501-1001 Agent,Bon Goode E-MAIL ben@goodeagent.com 41880 Kalmia Street,SUlte 125 INSURER 5 AFFORDING COVERAGE NAIL If Murrieta CA 92562 INSURER A: State Farm Fire and Casualty Company 25143 INSURED INSURER B r State Farm Mutual Automobile Insurance Company 25178 Santolucito Dore Group, Inc' INSURER C: 31600 Railroad Canyon Road,Suite 100-L INSURER D: INSURER E: Canyon Lake CA 92587 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE PlhlQn min.DDL SUBR POLICY NUMBER MM DDIYYYY EFF MMIUD�YIYI'xYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 D AMAGE TO RENTED 500,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 A Y Y 92-ES-R3814 0110112025 0110112026 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- ❑ LOG 2,000,000 JECT PRODUCTS-CDMPlOPAGG $ OTHER' $ AUTOMOBILE LIABILITY Y Y 7301128-AO1-75H 01/01/2025 07/0112025 COM1Icde°t$INGLELIMIT $ 2,000,000 ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MAOF AGGREGATE $ DED I I RETENTIONS I $ WORKERS COMPENSATION PER I OTH AND EMPLOYERS'LIABILITY YIN STATUTE I ER A ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? � NIA Y 92-TA-M678-6 01/12/2025 01/1212026 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRfPT10N OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1-000,000 Commercial Liability Umbrella Policy A Y 92-J7-C947-7 01i0112025 01/01/2026 Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space Is required( City of Santa Ana,officers,agents,employees,and volunteers are named a additionally insured on this policy pursuant to written contract,agreement,or memorandum of understanding.Such insurance as is afforded by this policy shall be primary,and any insurance carried by City shall be excess and non contributory. APPROVED By Cynthia Mora at 12:91 pm, Jan 09, 2025 CERTIFICATE HOLDER CANCEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana CA 92702 @ 1988-2015 AC MD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849,12 03-16-2016 DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 01/30/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT Ben Goode NAME: StateFarm State Farm Insurance and Financial Services a/O"N Est: (951)501-1000 ac No): (951)501-1001 Agent, Ben Goode E-MAIL s: ben@goodeagent.com 41880 Kalmia Street,Suite 125 -ADDREINSURER(S)AFFORDING COVERAGE NAIC# Murrieta CA 92562 INSURERA: State Farm Fire and Casualty Company 25143 INSURED INSURER B: State Farm Mutual Automobile Insurance Company 25178 Santolucito Dore Group, Inc. INSURER C 7 31566 Railroad Canyon Road,Suite 2, PMB 10 INSURER D: INSURER E: Canyon Lake CA 92587 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 TED CLAIMS-MADE � OCCUR -PRE'IS SES(DAMAGE ToE.occurrence) $ 500,000 MED EXP(Any one person) $ 5,000 A Y Y 92-AO-0847-7 01/01/2026 01/01/2027 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICYEl PRO LOC PRODUCTS-COMP/OPAGG $ 4,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY Y Y 730 1128-AO1-75 01/01/2026 07/01/2026 COEaMBINED ccidentS INGLE LIMIT $ 2,000,000 a XANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? YI NIA Y 92-TB-Z389-9 01/01/2026 01/01/2027 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Commercial Liability Umbrella Policy A Y 92-J7-C947-7 01/01/2026 01/01/2027 Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Santa Ana,officers,agents,employees,and volunteers are named a additionally insured on this policy pursuant to written contract,agreement, or memorandum of understanding.Such insurance as is afforded by this policy shall be primary,and any insurance carried by City shall be excess and non contributory. APPROVED By Tu Tran Nguyen at 2:46 pm,Feb 02,2026 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana, its City Council, officers,officials,employees, ACCORDANCE WITH THE POLICY PROVISIONS. agents,and volunteers. AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza Santa Ana CA 92701,M-36 @ 1988-2015 A ORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 CERTIFICATE OF INSURANCE Producer: Issue Date:09/05/2025 This Certificate is issued as a matter of information only and LIA ADMINISTRATORS&INSURANCE SERVICES confers no rights upon the Certificate Holder.This Certificate P.O.Box 1319 does not amend,extend or alter the coverage afforded by the Santa Barbara,CA 93102-1319 policy below. Insured: 168656 COMPANY AFFORDING COVERAGE SANTOLUCITO DORE GROUP,INC. 315666 Railroad Cyn Rd Ste 2 PMB 10 Aspen American Insurance Company Canyon Lake,CA 92587 Fax Number: 000-000-0000 Authorized Representative This is to certify that the policy of insurance listed below has been issued to the Insured named above for the policy period indicated. Notwithstanding any requirement,term of condition of any contract or other document with respect to which this Certificate may be issued or may pertain,the insurance afforded by the policy described herein is subject to all the terms,exclusions and conditions of such policy.Limits shown may have been reduced by paid claims. DISCLAIMER: This certificate of insurance does not affirmatively or negatively amend,extend,or alter the coverage afforded by the insurance policy. TYPE OF INSURANCE POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE LIMITS Professional Liability AAI006934-10 09/06/2025 09/06/2026 Each Claim $ 1,000,000 General Aggregate $ 2,000,000 Description of Operations/Locations/Special Items: REAL ESTATE APPRAISERS PROFESSIONAL LIABILITY INSURANCE APPROVED By Tu Tran Nguyen at 2:46 pm,Feb 02,2026 Certificate Holder: Cancellation: City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Risk Management Division BE CANCELLED BEFORE THE EXPIRATION DATE 20 Civic Center Plaza THEREOF,NOTICE WILL BE DELIVERED IN Santa Ana,CA 92702 ACCORDANCE WITH THE POLICY PROVISIONS. LIA0001 (11/97) StateFarm STATE FARM • • •. PO Box 853922 Richardson, TX 75085-3922 CITY OF SANTA ANA ITS CITY COUNCIL, OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, NOTE: PLEASE NOTIFY STATE FARM AT THE AND VOLUNTEERS ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF 20 CIVIC CENTER PLAZA ADDRESS INFORMATION. SANTA ANA CA 92701,M-36 0 S ADDITIONAL INSUREDS NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 2408-FA71-A NAMED INSURED: POLICY NO: 730 1 128-AO1-75 COVERAGE: SANTOLUCITO DORE GROUP,INC BI AND PD LIABILITY 31600 RR CYN RD 2 MIL S N 100 DIED.COMP. CANYON LAKE CA 92587-9462 AGENT NAME: GOODE INS AND FIN SVCS INC S500 DIED.COLL. 4 AGENT PHONE: (951)501-1000 o ENDORSEMENT NO: 6028BU POLICY EFFECTIVE c DEC 14 2021 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy#4287450-75Q. The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance o provided and subject to all policy provisions.The additional insured will be given 30 days notice if the policy is terminatedUntil such notice is provided,it shall be presumed that the required renewal premiums have been paid.The additional insured must notify us within 10 days of o any change of interest or ownership coming to their attention.Failure to do so will render this policy null and void. 0 N FRT 75 Policy No_ 730 1128-A01-75 AU CMP-4787TOMOBILE LIABILITY Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 730 1128-A01-75 Named Insured: SANTOLUCITO DORE GROUP INC 31566 RAILROAD CANYON ROAD, SUITE 2,PMB 10 CANYON LAKE CA 92587-9462 Name And Address Of Person Or Organization: CITY OF SANTA ANA ITS CITY COUNCIL,OFFICERS, OFFICIALS,EMPLOYEES,AGENTS, AND VOLUNTEERS 20 CIVIC CENTER PLAZA SANTA ANA CA 9270I,M-36 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 1006225 137715.1 11-19-2013 ©,Copyright,State Farm Mutual Automobile Insurance Company,2008 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. CG Policy No. 92-AO-0847-7 372C—FA71 CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92-AO-0847-7 Named Insured: SANTOLUCITO DORE GROUP INC 31600 RAILROAD CANYON RD CANYON LAKE CA 92587-9461 Name And Address Of Additional Insured Person Or Organization: CITY OF SANTA ANA ITS CITY COUNCIL, OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS 20 CIVIC CENTER PLAZA SANTA ANA CA 92701,M-36 1. SECTION II — WHO IS AN INSURED of b. If coverage provided to the additional in- SECTION II — LIABILITY is amended to in- sured is required by a contract or agree- clude, as an additional insured, any person or ment, the insurance provided to the organization shown in the Schedule, but only additional insured will not be broader than with respect to liability for "bodily injury", that which you are required by the contract "property damage", or "personal and advertis- or agreement to provide for such addition- ing injury" caused, in whole or in part, by: al insured; and a. Ongoing Operations c. If the contract or agreement between you (1) Your acts or omissions; or and the additional insured is governed by (2) The acts or omissions of those acting California Civil Code Section 2782 or on your behalf; 2782.05, the insurance provided to the additional insured is the lesser of that in the performance of your ongoing opera- which: tions for that additional insured; or (1) Is allowed for the satisfaction of a de- b. Products—Completed Operations fense or indemnity obligation by Cali- "Your work" performed for that additional fornia Civil Code Section 2782 or insured and included in the "products- 2782.05 for your sole liability; or completed operations hazard". (2) You are required by contract or However, Paragraph 1. above is subject to the agreement to provide for such addi- following: tional insured. a. The insurance afforded to the additional We have no duty to defend or indemnify the insured only applies to the extent permit- additional insured under this endorsement un- ted by law; til a claim or "suit" is tendered to us. ©,Copyright,State Farm Mutual Automobile Insurance Company,2013 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. CONTINUED CMP-4786.1 Page 2 of 2 2. Any insurance provided to the additional in- (3) The nature and location of any injury sured shall only apply with respect to a claim or damage arising out of the "occur- made or a "suit" brought for damages for rence" or offense; which you are provided coverage. b. Tender the defense and indemnity of any 3. With respect to the insurance afforded to the claim or "suit" to us and to all other insur- additional insured, the following is added to ers who may have insurance potentially SECTION II — LIMITS OF INSURANCE: available to the additional insured; and If coverage provided to the additional insured c. Agree to make available any other insur- is required by contract or agreement, the most ance the additional insured has for de- we will pay on behalf of the additional insured fense or damages for which we would will be the lesser of the amount of insurance: provide coverage under SECTION II — a. Required by the contract or agreement; or LIABILITY. b. Available under the applicable Limits Of 5. With respect to the insurance afforded the ad- Insurance shown in the Declarations. ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other This endorsement shall not increase the ap- Insurance of SECTION I AND SECTION II — plicable Limits Of Insurance shown in the COMMON POLICY CONDITIONS: Declarations. a. This insurance is primary to and will not 4. With respect to the insurance afforded to the seek contribution from any other insurance additional insured, the following is added to available to the additional insured, provided Paragraph 3. Duties In The Event Of Occur- that the additional insured is a named in- rence, Offense, Claim Or Suit of SECTION sured under such other insurance. II — GENERAL CONDITIONS: b. Regardless of any agreement between The additional insured must: you and the additional insured, this insur- ance is excess over any other insurance a. See to it that we are notified as soon as whether primary, excess, contingent or on practicable of an "occurrence" or an of- any other basis for which the additional in- fense which may result in a claim. To the sured has been added as an additional in- extent possible, notice should include: sured on other policies. (1) How, when and where the "occur- There will be no refund of premium in the event rence" or offense took place; this endorsement is cancelled. (2) The names and addresses of any in- jured persons and witnesses; and All other policy provisions apply. CMP-4786.1 1007033 148011 08-21-2014 ©,Copyright,State Farm Mutual Automobile Insurance Company,2013 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. CG Policy No. 92-AO-0847-7 372C—FA71 CMP-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92-AO-0847-7 Named Insured: SANTOLUCITO DORE GROUP INC 31600 RAILROAD CANYON RD CANYON LAKE CA 92587-9461 Name And Address Of Person Or Organization: CITY OF SANTA ANA ITS CITY COUNCIL, OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS 20 CIVIC CENTER PLAZA SANTA ANA CA 92701,M-36 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 1006225 137715.1 11-19-2013 ©,Copyright,State Farm Mutual Automobile Insurance Company,2008 Includes copyrighted material of Insurance Services Office, Inc.,with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization CITY OF SANTA ANA ITS CITY COUNCIL, OFFICERS, OFFICIALS, EMPLOYEES, A6ENIS, AND VOLUNTEERS 20 CIVIC CENTER PLAZA SANTA ANA CA 92701,M-36 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 01/01/2026 Policy No. 92-TB-Z389-9 Insured SANTOLUCITO DORE GROUP INC Insurance Company State Farm Fire and Casualty Company Countersigned By WC 04 03 06 (Ed. 4-84) 1007722 124282.2 01-25-2019