HomeMy WebLinkAboutNBS Government and Finance Group, DBA NBS - 2016-10-03PROFESSIONAL SERVICES CONTRACT BETWEEN
THE CITY OF HUNTINGTON BEACH AND
NBS GOVERNMENT AND FINANCE GROUP, DBA NBS
FOR
GROUND EMERGENCY MEDICAL TRANSPORTATION
COST CONSULTING SERVICES
THIS AGREEMENT ("Agreement") is made and entered into by and between the
City of Huntington Beach, a municipal corporation of the State of California, hereinafter
referred to as "CITY, and NBS Government and Finance Group, dba NBS, a California
corporation, hereinafter referred to as "CONSULTANT."
WHEREAS, CITY desires to engage the services of a consultant to provide Ground
Emergency Medical Transportation ("GEMT') Cost Consulting Services; and
Pursuant to documentation on file in the office of the City Clerk, the provisions of
the Huntington Beach Municipal Code, Chapter 3.03, relating to procurement of
professional service contracts have been complied with; and
CONSULTANT has been selected to perform these services,
NOW, THEREFORE, it is agreed by CITY and CONSULTANT as follows:
1. SCOPE OF SERVICES
CONSULTANT shall provide all services as described in Exhibit "A,"
which is attached hereto and incorporated into this Agreement by this reference. These
services shall sometimes hereinafter be referred to as the "PROJECT."
CONSULTANT hereby designates Greta Davis, who shall represent it and
be its sole contact and agent in all consultations with CITY during the performance of this
Agreement.
RLS 9/27/16/16-5459/144926/DO 1
2. CITY STAFF ASSISTANCE
CITY shall assign a staff coordinator to work directly with CONSULTANT
in the performance of this Agreement.
3. TERM; TIME OF PERFORMANCE
Time is of the essence of this Agreement. The services of CONSULTANT
are to commence on 2 3, 20f,� (the "Commencement Date"). This
Agreement shall automatically terminate one (1) year from the Commencement Date,
unless extended or sooner terminated as provided herein. The time for performance of the
tasks identified in Exhibit "A" are generally to be shown in Exhibit "A." This schedule
may be amended to benefit the PROJECT if mutually agreed to in writing by CITY and
CONSULTANT.
In the event the Commencement Date precedes the Effective Date,
CONSULTANT shall be bound by all terms and conditions as provided herein.
4. COMPENSATION
In consideration of the performance of the services described herein, CITY
agrees to pay CONSULTANT on a time and materials basis at the rates specified in
Exhibit "B," which is attached hereto and incorporated by reference into this Agreement,
a fee, including all costs and expenses, not to exceed Nine Thousand Two Hundred Dollars
($9,200).
5. EXTRA WORK
In the event CITY requires additional services not included in Exhibit "A"
or changes in the scope of services described in Exhibit "A," CONSULTANT will
undertake such work only after receiving written authorization from CITY. Additional
RLS 9/27/ 16/ 16-5459/ 144926/DO 2
compensation for such extra work shall be allowed only if the prior written approval of
CITY is obtained.
6. METHOD OF PAYMENT
CONSULTANT shall be paid pursuant to the terms of ]Exhibit "B."
7. DISPOSITION OF PLANS ESTIMATES AND OTHER DOCUMENTS
CONSULTANT agrees that title to all materials prepared hereunder,
including, without limitation, all original drawings, designs, reports, both field and office
notices, calculations, computer code, language, data or programs, maps, memoranda,
letters and ather documents, shall belong to CITY, and CONSULTANT shall turn these
materials over to CITY upon expiration or termination of this Agreement or upon
PROJECT completion, whichever shall occur first. These materials may be used by CITY
as it sees fit.
8. HOLD HARMLESS
CONSULTANT hereby agrees to protect, defend, indemnify and hold
harmless CITY, its officers, elected or appointed officials, employees, agents and
volunteers from and against any and all claims, damages, losses, expenses, judgments,
demands and defense costs (including, without limitation, costs and fees of litigation of
every nature or liability of any kind or nature) arising out of or in connection with
CONSULTANT's (or CONSULTANT's subcontractors, if any) negligent (or alleged
negligent) performance of this Agreement or its failure to comply with any of its
obligations contained in this Agreement by CONSULTANT, its officers, agents or
employees except such loss or damage which was caused by the sole negligence or willful
misconduct of CITY. CONSULTANT will conduct all defense at its sole cost and expense
RLS 9/27/16/16-5459/144926/DO 3
and CITY shall approve selection of CONSULTANT's counsel. This indemnity shall
apply to all claims and liability regardless of whether any insurance policies are applicable.
The policy limits do not act as limitation upon the amount of indemnification to be
provided by CONSULTANT.
9. PROFESSIONAL LIABILITY INSURANCE
CONSULTANT shall obtain and furnish to CITY a professional liability
insurance policy covering the work performed by it hereunder. This policy shall provide
coverage for CONSULTANT's professional liability in an amount not less than One
Million Dollars ($1,000,000.00) per occurrence and in the aggregate. The above -
mentioned insurance shall not contain a self -insured retention, "deductible" or any other
similar form of limitation on the required coverage except with the express written consent
of CITY. A claims -made policy shall be acceptable if the policy further provides that:
A. The policy retroactive date coincides with or precedes the initiation
of the scope of work (including subsequent policies purchased as
renewals or replacements).
B. CONSULTANT shall notify CITY of circumstances or incidents
that might give rise to future claims.
CONSULTANT will make every effort to maintain similar insurance during
the required extended period of coverage following PROJECT completion. If insurance is
terminated for any reason, CONSULTANT agrees to purchase an extended reporting
provision of at least two (2) years to report claims arising from work performed in
connection with this Agreement.
RLS 9/27/16/16-5459/144926/DO 4
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.
10. CERTIFICATE OF INSURANCE
Prior to commencing performance of the work hereunder, CONSULTANT
shall furnish to CITY a certificate of insurance subject to approval of the City Attorney
evidencing the foregoing insurance coverage as required by this Agreement; the certificate
shall:
A. provide the name and policy number of each carrier and policy;
B. state that the policy is currently in force; and
C. promise that such policy shall not be suspended, voided or canceled
by either party, reduced in coverage or in Iimits except after thirty
(30) days' prior written notice; however, ten (10) days' prior written
notice in the event of cancellation for nonpayment of premium.
CONSULTANT shall maintain the foregoing insurance coverage in force
until the work under this Agreement is fully completed and accepted by CITY.
The requirement for carrying the foregoing insurance coverage shall not
derogate from CONSULTANT's defense, hold harmless and indemnification obligations as
RLS 9/27/16/16-5459/144926/DO 5
set forth in this Agreement. CITY or its representative shall at all times have the right to
demand the original or a copy of the policy of insurance. CONSULTANT shall pay, in a
prompt and timely manner, the premiums on the insurance hereinabove required.
11. INDEPENDENT CONTRACTOR
CONSULTANT is, and shall be, acting at all times in the performance of
this Agreement as an independent contractor herein and not as an employee of CITY.
CONSULTANT shall secure at its own cost and expense, and be responsible for any and
all payment of all taxes, social security, state disability insurance compensation,
unemployment compensation and other payroll deductions for CONSULTANT and its
officers, agents and employees and all business licenses, if any, in connection with the
PROJECT and/or the services to be performed hereunder.
12. TERMINATION OF AGREEMENT
All work required hereunder shall be performed in a good and workmanlike
manner. CITY may terminate CONSULTANT's services hereunder at any time with or
without cause, and whether or not the PROJECT is fully complete. Any termination of this
Agreement by CITY shall be made in writing, notice of which shall be delivered to
CONSULTANT as provided herein. In the event of termination, all finished and
unfinished documents, exhibits, report, and evidence shall, at the option of CITY, become
its property and shall be promptly delivered to it by CONSULTANT.
13. ASSIGNMENT AND DELEGATION
This Agreement is a personal service contract and the work hereunder shall
not be assigned, delegated or subcontracted by CONSULTANT to any other person or
entity without the prior express written consent of CITY. If an assignment, delegation or
RLS 9/27/16/16-5459/144926/DO 6
subcontract is approved, all approved assignees, delegates and subconsultants must satisfy
the insurance requirements as set forth in Sections 9 and 10 hereinabove.
14. COPYRIGHTS/PATENTS
CITY shall own all rights to any patent or copyright on any work, item or
material produced as a result of this Agreement.
15. CITY EMPLOYEES AND OFFICIALS
CONSULTANT shall employ no CITY official nor any regular CITY
employee in the work performed pursuant to this Agreement. No officer or employee of
CITY shall have any financial interest in this Agreement in violation of the applicable
provisions of the California Government Code.
16. NOTICES
Any notices, certificates, or other communications hereunder shall be given
either by personal delivery to CONSULTANT's agent (as designated in Section 1
hereinabove) or to CITY as the situation shall warrant, or by enclosing the same in a sealed
envelope, postage prepaid, and depositing the same in the United States Postal Service, to
the addresses specified below. CITY and CONSULTANT may designate different
addresses to which subsequent notices, certificates or other communications will be sent by
notifying the other party via personal delivery, a reputable overnight carrier or U. S.
certified mail -return receipt requested:
TO CITY:
City of Huntington Beach
ATTN: Kevin Justen
2000 Main Street
Huntington Beach, CA 92648
(714) 536-5235
RLS 9/27/16/16-5459/144926/DO 7
TO CONSULTANT:
NBS Government and Finance Group,
Dba NB S
ATTN: Greta Davis
32605 Temecula Parkway, Suite 100
Temecula, CA 92592
(800)676-7516
17. CONSENT
When CITY's consent/approval is required under this Agreement, its
consent/approval for one transaction or event shall not be deemed to be a consent/approval
to any subsequent occurrence of the same or any other transaction or event.
18. MODIFICATION
No waiver or modification of any language in this Agreement shall be valid
unless in writing and duly executed by both parties.
19. SECTION HEADINGS
The titles, captions, section, paragraph and subject headings, and descriptive
phrases at the beginning of the various sections in this Agreement are merely descriptive
and are included solely for convenience of reference only and are not representative of
matters included or excluded from such provisions, and do not interpret, define, limit or
describe, or construe the intent of the parties or affect the construction or interpretation of
any provision of this Agreement.
20. INTERPRETATION OF THIS AGREEMENT
The language of all parts of this Agreement shall in all cases be construed
as a whole, according to its fair meaning, and not strictly for or against any of the parties.
If any provision of this Agreement is held by an arbitrator or court of competent
jurisdiction to be unenforceable, void, illegal or invalid, such holding shall not invalidate
or affect the remaining covenants and provisions of this Agreement. No covenant or
provision shall be deemed dependent upon any other unless so expressly provided here.
As used in this Agreement, the masculine or neuter gender and singular or plural number
shall be deemed to include the other whenever the context so indicates or requires.
RLS 9/27/16/16-5459/144926/DO 8
Nothing contained herein shall be construed so as to require the commission of any act
i
contrary to law, and wherever there is any conflict between any provision contained herein j
and any present or future statute, law, ordinance or regulation contrary to which the parties
i
have no right to contract, then the latter shall prevail, and the provision of this Agreement
which is hereby affected shall be curtailed and limited only to the extent necessary to bring
i
it within the requirements of the law.
21. DUPLICATE ORIGINAL
The original of this Agreement and one or more copies hereto have been
prepared and signed in counterparts as duplicate originals, each of which so executed shall,
irrespective of the date of its execution and delivery, be deemed an original. Each
duplicate original shall be deemed an original instrument as against any parry who has
signed it.
22. IMMIGRATION
CONSULTANT shall be responsible for full compliance with the
immigration and naturalization laws of the United States and shall, in particular, comply
with the provisions of the United States Code regarding employment verification.
23. LEGAL SERVICES SUBCONTRACTING PROHIBITED
CONSULTANT and CITY agree that CITY is not liable for payment of any
subcontractor work involving legal services, and that such legal services are expressly
outside the scope of services contemplated hereunder. CONSULTANT understands that
pursuant to Huntington Beach City Charter Section 309, the City Attorney is the exclusive
legal counsel for CITY; and CITY shall not be liable for payment of any legal services
expenses incurred by CONSULTANT.
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24. ATTORNEY' S FEES
In the event suit is brought by either party to construe, interpret and/or
enforce the terms and/or provisions of this Agreement or to secure the performance hereof,
each party shall bear its own attorney's fees, such that the prevailing party shall not be
entitled to recover its attorney's fees from the non -prevailing party.
25. SURVIVAL
Terms and conditions of this Agreement, which by their sense and context
survive the expiration or termination of this Agreement, shall so survive.
26. GOVERNING LAW
This Agreement shall be governed and construed in accordance with the
laws of the State of California.
27. SIGNATORIES
Each undersigned represents and warrants that its signature hereinbelow has
the power, authority and right to bind their respective parties to each of the terms of this
Agreement, and shall indemnify CITY fully 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.
28. ENTIRETY
The parties acknowledge and agree that they are entering into this
Agreement freely and voluntarily following extensive arm's length negotiation, and that
each has had the opportunity to consult with legal counsel prior to executing this
Agreement. The parties also acknowledge and agree that no representations, inducements,
promises, agreements or warranties, oral or otherwise, have been made by that party or
anyone acting on that party's behalf, which are not embodied in this Agreement, and that
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that party has not executed this Agreement in reliance on any representation, inducement,
promise, agreement, warranty, fact or circumstance not expressly set forth in this
Agreement. This Agreement, and the attached exhibits, contain the entire agreement
between the parties respecting the subject matter of this Agreement, and supersede all prior
understandings and agreements whether oral or in writing between the parties respecting
the subject matter hereof.
29. EFFECTIVE DATE
This Agreement shall be effective on the date of its approval by the City
Attorney. This Agreement shall expire when terminated as provided herein.
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IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be
executed by and through their authorized officers.
CONSULTANT,
NBS GOVERNMENT AND
FINANCE GRo , dbaNBS
By: j
vz
print nam�eCIt/V
'ITS: (circle one) Chairman/Presidsident
AND
By.
st�
ITS: (circle on Secretary/C ief Financial Officer/Asst.
Secretary - Treas re
CITY OF HUNTINGTON BEACH,
a municipal corporation of the State of California
di
11✓-66 Pf/.�' Director/Chief
(Pursuant to HBMC § 3.03,100)
APPROVED AS
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City Attorney VIM t0 I J 11�o ,�
Receive and File
City Clerk
EXHIBIT A
SCOPE OF SERVICES
A. OMB A-87 COST ALLOCATION PLAN
The OMB CAP, dated 11-10-15 will be utilized for purposes of inclusion of the full cost for GEMT
reimbursement.
B. FIRE DEPARTMENT INDIRECT AND DIRECT COST ANALYSIS
Task B-1 - Commencement and Data Collection
The purpose of this task is to initiate the project on solid footing and establish common
understanding. A detailed initial data request will be submitted to the City at project
commencement to include items such as detailed revenue and expense FY 2015/16, any
timekeeping data currently recorded by City staff, and any relevant volume/activity statistics
currently tracked by the City.
Task B-2 - Gather and Analyze Initial Data
Review and Analyze information and data received.
Task B-3 - Identify and Discuss Cost Analysis
Dick -off project to discuss and identify indirect and direct cost analysis based on organization,
staffing and functions for the City. Review, discuss and confirm volume/activity data and any time
tracking data as needed. If needed, discuss the use of time estimates for providing the treatment
and transport services.
Task B-4 - Full Cost Analysis Preparation
The purpose of this task is to develop the customized technical cost model capable of performing
the necessary cost calculations and generating the outcomes desired by the City from this effort.
a. Preparation of the Fire Department Indirect and Direct Costs
Prepare the Fire Department Indirect and Direct costs related to treatment and transportation of
Emergency Medical Services Citywide FY 2015/16. The Cost Analysis preparation involves the
following: Analysis of expense, staffing, support activities, functional distribution and allocation data
for determination of the Fire Department full cost.
C. PREPARATION OF THE REQUIRED FORMS FOR SUBMISSION TO THE DEPARTMENT OF
HEALTH CARE SERVICES ("DHCS")
Task C-1 — Prepare Forms for City Review
Prepare the required forms for submission to DHCS related to treatment and transportation of
Emergency Medical Services Citywide FY 2015/16.
Task C-2 — Finalize Forms
Provide opportunity for City to review forms and request revisions if necessary; One round of
revisions is included if necessary.
EXHIBIT B
FEES
Based on the scope of services for the Cost Consulting Services, NBS provides the following
contracting options for FY 2015/16 based on the City's request: FY 2015/16 - $10,400. NBS has
included a table for the detail cost breakdown for the project:
The breakdown is derived as follows:
Based on our best understanding of the scope of services for the Cost Consulting Services, NBS
provides the following contracting option for FY 2015/16 based on the City's request: FY 15/16 -
$10,400. NBS has included a table for the detail cost breakdown for the project:
City of Huntington Beach
Cost Consulting Services
Contract Year
Fiscal Year
Submittal Deadline
OMB CAP
Fire Fee
Calculation
Forms
Total
Year 1
FY 15l16
11/30/2016
$ -
$ 6,320
$ 4,080
$ 10,400
FY 2015/16:
The breakdown is derived as follows-
B. FIRE DEPARTMENT FULL COST ANALYSIS
Consultant Labor (Hours)
Grand Totals
Task Plan
Project
Manager
Analyst
Consultant
Labor (Hours)
Consultant
Costs ($)
Hourly Rate
$160
$120
1- Commencement and Data Collection
2.0
2.0
320
2 - Gather and Analyze Data
2.0
2.0
4.0
560
3 - Identify and discuss Cost Analysis
8.0
16.0
24.0
3,200
4 - Full Cost Analysis Preparation
8.0
8.0
16.0
2,240
GRAND TOTAL NOT TO EXCEED
20.0
26.0
46.0
6,320
C. FORM PREPARATION
Task Plan
Consultant Labor (Hours)
Project
Manager Analyst
Grand Totals
Consultant
Labor (Hours)
Consultant
Costs ($)
Hourly Rate
$160
$120
1 - Prepare Forms - Draft
2 - Finalize Forms
16.0
2.0
8.0
2.0
24.0
4.0
3,520
560
GRAND TOTAL NOT TO EXCEED
18.0
10.0
28.0
4,080
NBSGOVE-01 PA3'
AC�R� CERTIFICATE OF LIABILITY INSURANCE
DATE(10.11DDIYYYY)
912212016
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 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 endorsernent(s).
Vanorsdate Insurance Services
PRODUCER (858) 869-8300FADDRESS:
6165Greenwich Drive, Suite 200 San Diego, CA 92122
anet Darby
-869-8300 1 (ac No: 858.869-83fl1
NAIC t!Hanover
Insurance Company
22292
INSURED NBS Government Finance Group
32605 Temecula Parkway, Suite 100 & 101
Temecula, CA 92592
INSURERB:Ailmerica Financial Benefit
41840
INSURERC:Gemini Insurance Company
10833
INSURER D
INSURER E :
INSURER F :
TIC!(` a A11111ROCO• MY VI`IIJN 1Vlllvini m
v 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 1"0 ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. —
INSR
LTR
TYPE OF INSURANCE
ADDL
p
SUBRtt
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POLICY NUMBER
POLICY EFF
i'dAVDO
POLICY EXP
Mhi1DD/YYYY
t_NdITS
A f
X COMMERCIAL GENERAL LIABILITY
i
EACH OCCURRENCE
$ 2,00000
_
PRErM SEESIfEa occufr�ence
S 2,000,00
CLAIDS-MADE X OCCUR
X
'IOH3A43196302
9124/2016
9/24/2017
MEDEXP (Any one pe,5on)
$ _ ,._. 10,00
—�
PERSONAL & ADV INJURY
S 2,000,00
GEN'L AGGREGATE LIh117 APPLIES PER:
GENERAL AGGREGATE
S 4,000,00
PRODUCTS-CO?,!PLOPAGO
S 4,000,00
X POLICY ❑PRO' El LOC
JEC7
OTHER:
S
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea aoddenl1—� _
S 1,000,00
BODILY INJURY (Per person)
S
B
X ANY AUTO
AW3A42745802
9/2412016
912412017
BODILY INJURY (Per accident}
$
ALLO'NNED SCHEDULED
AUTOS AUTOS
NON-0WNED
HIRED AUTOS AUTOS
j
---.
PROPERTY DAMAGE
Per acsddent)_
—.
S
5^
X
UMBRELLA LIAR
X
OCCUR
I
-
EACH OCCURRENCE
S 1,000,00
AGGREGATE
S
A
EXCESS LIAS
CLAIMS -MADE
OH3A43196302
9/2412016
9/24/2017
DED RETENTION S _
S
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPMETORMARTNERiEXECUTIVE YIN
OFFICERItd Ed BER 6YCLUDED?
(MandatorylnNIL)
N 1 A
WH3A42745703
9/2412016
9/2412017
X STATUTE EORH
E.L EACH ACCIDENT
$ 1,000,00
E.L.OISEASE- EAEhiPLOYE
S 1,000,00
E. DISEASE -POLICY Li8.1lT
$ 1,000,00
If yes, describe under
DESCRIPTION OF OPERATIONS bNoa
C
Professional Liability
CPLO64725
9124/2016
9/24/2017
Each Wrongful Act $2,000,00
C
Professional: Liability
VCPL064726
9124/2016
9/24/2017
Annual Aggregate $2,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD lei, Additional Remarks Schedule, maybe attached it more space is required)
See attached page.
APPROVED AS TO FORM
By
,.e ' MICHAEL E. GATES
CITY ATTORNEY
CITY OF HUNTING10N REACH
l;tKl lt-IVA 1 t rYVLVtK vnlw��.-.1
City of Huntington Beach
2000 Main Street
Huntington Beach, CA 92648-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
iJ'I`.saa-Lu 14 A I.%j mLi u%j ecr u Rtl uvlr: nu i ly n u 1 v a 1 v eu.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
NBSGOVE-01 PA3 PAGE 1 OF 1
DESCRIPTION OF OPERATIONS -
NBS Government Finance Group City of Huntington Beach
32605 Temecula Parkway, Suite 100 & 101 2000 Main Street
Temecula, CA 92592 Huntington Beach, CA 92648-
City of Huntington Beach is named additional insured regarding General Liability for operations of the named insured.
Blanket forms apply when required by written contract:
GENERAL LIABILITY:
Additional Insured -Special Broadening Endt: 391-1006 06 09
Additional Insured -Completed Operations: 391-1602 12 11
Primary & Non -Contributory: 391-1331 06 09
Waiver of Subrogation: BP0497 07 02
AUTO:
Additional Insured: 461-0478 12 12
Primary & Non -Contributory: 461-0478 12 12
Waiver of Subrogation: 461-0500 11 13
WORKERS' COMPENSATION:
Waiver of Subrogation: WC040306 4.84
"CERTIFICATE ISSUED DUE TO POLICY RENEWAL`
POLICY #OH3 A43196302
BUSINESSOWNERS UABUTY SPECIAL BROADENING ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
SUMMARY OF COVERAGES limits Page
1. Additional Insured by Contract, Agreement or Permit 1
2, Additional Insured - Broad Form Vendors 2
3. Alienated Premises 2
4. Bodily injury Redefined 2
5. Broad Form Property Damage - Borrowed Equipment, Customers 2
Goods and Use of Elevators
6. Incidental Malpractice (Employed Nurses, EMT's and Paramedics) 3
7. Personal and Advertising Injury - Broad Form 3
8. Product Recall Expense $25,000 Occurrence
$50,000 Aggregate 3
9. Unintentional Failure to Disclose Hazards 5
10. Unintentional Failure to Notify 5
This endorsement amends coverages provided under the Businessowners Coverage Form through new
coverages and broader coverage grants. This coverage is subject to the provisions applicable to the
Businessowners Coverage Form, except as provided below.
1. Additional Insured by Contract, Agreement or
Permit
Under SECTION II - LIABILITY, C. Who Is An
Insured, Paragraph 4, is added as follows:
a. Any person or organization for whom you
are performing operations when you and
such person or organization have agreed in
writing in a contract, agreement or permit
that such person or organization be added
as an additional insured on your policy. Such
person or organization is an additional
insured only with respect to liability for
'bodily injury", "property damage" or
"Personal and advertising injury" caused, in
whole or in part, by:
(1) Your acts or omissions; or
(2) The acts or omissions of those acting
on your behalf,
but only with respect to:
(3) "Your work" for the additional insured(s)
at the location designated in the
contract, agreement or permit; or
(4) Premises you own, rent, lease, control or
occupy.
This insurance applies on a primary basis if
that is required by the written contract,
agreement or permit.
b. This provision does not apply:
(1) Unless the written contract or written
agreement has been executed or permit
has been issued prior to the "bodily
injury", "property damage" or "personal
and advertising injury";
(2) To any person or organization included
as an insured by an endorsement
issued by us and made part of this
Policy;
(3) To any person or organization included
as an insured under Item 1.a.2. of this
endorsement;
(4) To any lessor of equipment:
(a) After the equipment lease expires;
or
(b) If the "bodily injury", "property
damage" or "personal and
advertising injury" arises out of the
sole negligence of the lessor;
391.1006 06 09 Inckides copyrighted material of Insurance Services Office, Inc. Page 1 of 5
2,
(5) To any:
(a) Owners or other interests from
whom land has been leased which
takes place after the lease for that
land expires, or
(b) (Managers or lessors of premises if:
(i) The occurrence takes place after
you cease to be a tenant in that
premises; or
(ii) The "bodily injury', "property
damage" or "personal and
advertising injury" arises out of
structural alterations, new
construction or demolition
operations performed by or on
behalf of the manager or lessor;
or
(6) To "bodily injury", "property damage" or
"personal and advertising injury" arising
out of the rendering of or the failure to
render any professional services.
c. Additional insured coverage provided by
this provision will not be broader than
coverage provided to any other insured,
d. All other insuring agreements, exclusions,
and conditions of the policy apply.
Additional Insured - Broad Form Vendors
Under SECTION II - LIABILITY, C. Who Is An
Insured, paragraph 5. is added as follows:
5. Any person or organization with whom you
agreed, because of a written contract or
written agreement to provide insurance, but
only with respect to "bodily injury" or
"property damage" arising out of "your
products" which are distributed or sold in
the regular course of the vendor's business,
The insurance afforded the vendor does not
apply to:
a. "Bodily injury" or "property damage" for
which the vendor is obligated to pay
damages by reason of the assumption of
liability in a contract or agreement, This
exclusion does not apply to liability for
damages that the vendor would have in
the ahsence of the contract or
agreement:
b. Any express warranty unauthorized by
you;
c. Any physical or chemical change in the
product made intentionally by the
vendor;
d. Repackaging, unless unpacked solely
for the purpose of inspection,
Hanover
yy ` r
�C a /over
Insulano, Goollp-
Of 13 A43 1963 1001554
demonstration, testing, or the
substitution of parts under instruction
from the manufacturer, and then
repackaged in the original container;
e. Any failure to make such inspection,
adjustments, tests or servicing as the
vendor has agreed to make or normally
undertakes to make in the usual course
of business in connection with the
distribution or sale of the product;
f. Demonstration, installation, servicing or
repair operations, except such
operations performed at the vendor's
premises in connection with the sale of
the product;
g, Products which, after distribution or sale
by you, have been labeled or relabeled
or used as a container, part or
Ingredient of any thing or substance by
or for the vendor; or
h. "Bodily injury" or "property damage"
arising out of the sole negligence of the
vendor for its own acts or omissions or
those of its employees or anyone else
acting on its behalf. However, this
exclusion does not apply to:
(1) The exceptions contained in
paragraphs 5.d. or 5.f.; or
(2) Such inspections, adjustments, test
or servicing as the vendor has
agreed to make or normally
undertakes to make in the usual
course of business, in connection
with the distribution or sale of the
products.
This insurance does not apply to any
insured person or organization, from whom
you have acquired such products, or any
ingredient, part or container, entering into,
accompanying or containing such products.
3. Alienated Promises
Under SECTION It - LIABILITY, 13. Exclusions,
paragraph 1.1l is replaced in its entirety with
the following:
(2) premises you sell, give away or abandon, if
the "property damage" arises out of any part
of those premises and occurred from
hazards that were known by you, or should
have reasonably been known by you, at the
time the property was transferred or
abandoned.
4. Bodily InjL" Redefined
Lender SECTION II • LIABILITY, F. Liability and
Medical Expenses Definitions, definition 4. is
replaced in its entirety by the following:
391-1006 06 09 Includes copyrighted material of Insurance Services Office, Inc. Paqe 2 of 5
4. "Bodily injury" means bodily injury,
disability, sickness or disease sustained by
a person, including death resulting from any
of these at any time. "Bodily Injury" includes
mental an uish or other mental injury
resulting from "bodily Injury"
5. Broad Form Property Damage - Borrowed
Equipment, Customers Goods, Use of Elevators
a. Under SECTION 1) - LIABILITY, B.
Exclusions, paragraph 1.k., the following is
added:
Paragraph (4) does not apply to "property
damage" to borrowed equipment while at a
jobsite and not being used to perform
operations.
Paragraph (3), (4) and (6) do not apply to
"property damage" to "customers goods"
while on your premises nor to the use of
elevators.
b. Under SECTION 11 - LIABILITY, F. Liability
and Medical Expenses Definitions, the
following additional definition Is added:
"Customers goods" means property of your
customer on your premises for the purpose
of being:
a. Worked on; or
b. Used in your manufacturing process.
c. The insurance afforded under this provision
is excess over any other valid and
collectible property insurance (Including
deductible) available to the insured whether
primary, excess, contingent or on any other
basis_
6, Incidental Malpractice - Employed Nurses,
EMT's and Paramedics
Under SECTION II - LIABILITY, C. Who Is An
Insured, paragraph 2.a.(1)(d) does not apply to a
nurse, emergency medical technician or
paramedic employed by you if you are not
engaged in the business or occupation of
providing medical, paramedical, surgical,
dental, x-ray or nursing services.
7. Personal and Advertising ln;ury - Broad Form
Under SECTION Il - LIABILITY, F. Liability and
Medical Expenses Definitions, definition 15,
"Personal and Advertising Injury", paragraph h.
is added as follows:
h. Discrimination or humiliation (unless
insurance thereof is prohibited by law) that
results in injury to the feelings or reputation
of a natural person, but only if such
discrimination or humiliation is:
(1) Not done intentionally by or at the
direction of:
(a) The insured; or
(b) Any officer of the corporalion,
director, stockholder, partner or
member of the insured; and
(2) Not directly or indirectly related to an
"employee", nor to the employment,
prospective employment or termination of
any person or persons by an insured.
8. Product Recall Expense
a. Under SECTION II - LIABILITY, B.
Exclusions, Paragraph 1. o. is replaced in its
entirely by the following:
o. Recalt of Products, Work or Impaired
Property
Damages claimed for any loss, cost or
expense incurred by you or others for
the loss of use, withdrawal, recall,
inspection, repair, replacement,
adjustment, removal or disposal of:
(1) "Your product";
(2) "Your work"; or
(3) "Impaired property";
If such product, work or property is
withdrawn or recalled from the market
or from use by any person or
organization because of a known or
suspected defect, deficiency, inadequacy
or dangerous condition in it, but this
exclusion does not apply to "product
recall expenses" that you incur for the
"covered recall" of 'your product". The
exception to the exclusion does not
apply to "product recall expenses"
resulting from:
(1) Failure of any products to
accomplish their intended purpose;
(2) Breach of warranties of fitness,
quality, durability or performance;
(3) Loss of customer approval, or any
cost incurred to regain customer
approval;
(4) Redistribution or replacement of
"your product" which has been
recalled by like products or
substitutes;
(5) Caprice or whim of the insured;
(6) A condition likely to cause loss of
which any insured knout or had
reason to know at the inception of
this insurance:
(7) Asbestos, including loss, damage
or clean up resulting from asbestos
or asbestos containing materials; or
391.1006 06 09 Includes copyrighted material of insurance Services Office. Inc. Page 3 of 5
(8) Recall of "your products" that have
no known or suspected defect
solely because a known or
suspected defect in another of
"your products" has been found.
b. Under SECTION It • LIABILITY, C. Who
Is An Insured, paragraph 4.c. is added
as follows:
c. "Bodily injury" or "properly damage"
do not apply to "product recall
expense" arising out of any
withdrawal or recall that occurred
before you acquired or formed the
organization.
c. Under SECTION 11 - LIABILITY, E.
Liability and Medical Expense General
Conditions, 2. Duties in the Event of
Occurrence, Offense, Claim or Suit,
paragraph e. is added as follows:
e. You must see to it That the following
are done in the event of an actual or
anticipated "covered recall" that
may result in "product recall
expense":
(1) Give us prompt notice of any
discovery or notification that
Your product" must be
withdrawn or recalled. Include a
description of 'your product'
and the reason for the
withdrawal or recall;
(2) Cease any further release,
shipment, consignment or any
other method of distribution of
like or simiiar products until it
has been determined that all
such products are free from
defects that could be a cause of
loss under this insurance.
d, Under SECTION! 11 - LIABILITY, F.
Liability and Medical Expenses
Definitions, the following additional
definitions are added:
"Covered recalt" means a recall made
necessary because you or a government
body has determined that a known or
suspected defect, deficiency,
inadequacy, or dangerous condition in
.your product" has resulted or will result
in "bodily injury" or "property damage".
"Product recall expense(s)" means:
a. Necessary and reasonable expenses
for:
(1) Communications, including radio
or television announcements or
\ � hover
insuclnce Gnr.ip.
CH3 A431963 1C01554
printed advertisements including
stationary, envelopes and
postage;
(2) Shipping the recalled products
from any purchaser, distributor
or user to the place or places
designated by you;
(3) Remuneration paid to your
regular "employees" for
necessary overtime;
(4) Hiring additional persons, other
than your regular "employees";
(5) Expenses incurred by
"employees" including
transportation and
accommodations;
(6) Expenses to rent additional
warehouse or storage space;
(7) Disposal of "your product", but
only to the extent that specific
methods of destruction other
than those employed for trash
discarding or disposal are
required to avoid "bodily injury"
or "property damage" as a result
of such disposal,
you incur exclusively for the purpose
of recalling "your product"; and
b. Your lost profit resulting from such
"covered recall".
e. Under SECTION It - LIABILITY, D.
Liability and Medical Expenses Limits of
Insurance, the following is added:
S. The Limits of Insurance and rules
stated below fix the most that we
will pay under this Product Recall
Expense Coverage.
(1) The Aggregate Limit Is the most
that we will reimburse you for
the sum of all "product recall
expenses" incurred for all
"product recall expenses"
initfated during the policy period.
(2) The Occurrence Limit shown on
the Summary of Coverages is
the most we will pay in
connection with any one detect
or deficiency.
(a) All "product recall
expenses" in connection
with substantially the same
general harmful condition
will be deemed. to arise out
of the same defect or
deficiency and considered
one 'occurrence'.
391.1006 06 09 Includes col7yrighted material of Insurance Services Office, Inc. Page 4 of 5
(b) Any amount reimbursed
for "product recall
expenses" in connection
with any one "occurrence"
will reduce the amount of
the Aggregate Limit
available for
reimbursement of "product
recall expenses" in
connection with any other
defect or deficiency.
(c) If the Aggregate Limit has
been reduced by
reimbursement of "product
recall expenses" to an
amount that Is less than
the Occurrence Limit, the
remaining Aggregate Limit
is the most that will be
available for
reimbursement of "product
recall expenses" in
connection with any other
defect or deficiency.
6, A deductible of $500 applies per
each "Occurrence".
9. Unintentional Failure to Disclose Hazards
Under SECTION 11 - LIABILITY, E. Liability and
Medical Expenses General Conditions,
paragraph 6, is added as follows.
6. Representations
We will not disclaim coverage .under this
Coverage Form if you fail to disclose all
hazards existing as of the inception date of
the policy provided such failure is not
intentional.
10. Unintentional Failure to Notify
Under SECTION II - LIABILITY, E. Liability and
Medical expenses General Conditions, 2. Duties
in the Event of Occurrence, Offense, Claim or
Suit, paragraph f. is added as follows:
f. Your rights afforded under this Coverage
Form shall not be prejudiced if you fail to give
us notice of an "occurrence", offense, claim
or "suit", solely due to your reasonable and
documented belief that the "bodily injury" or
"property damage" is not covered under this
Policy.
391-1006 06 09 Includes copyrighted material of insurance Services Office, Inc. Page 5 of 5
POLICY #OH3 A43196302
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s)
Or Orclanization{s) I Location And Description Of Completed Operations
ANY PERSON) OR ORGANIZATION WHEN REQUIR I AS REQUIRED BY CONTRACT
Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I
The following is added to Paragraph C. Who Is An
insured in Section ll -Liability:
Any persons) or organizalion(s) shown in the
Schedule is also an additional insured, but only
with respect to liability for "bodily injury" or
"property damage" caused, in whole or in part, by
your work" at the location designated and de-
scribed in the Schedule of this endorsement per-
formed for that additional insured and included in
the "products -completed operations hazard".
391-1602 1211 Includes copyrighted maleriel of Insurance Services [(fires, Inc, with its permission Page 1 of f
POLICY #OH3 A43196302
OTHER INSURANCE - PRIMARY AND NON-CONTRIBUTORY
(ADDITIONAL. INSURED) ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies Insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
The following is added to SECTION III - COMMON POLICY CONDITIONS;
M. Other Insurance
1, Additional Insureds
If you agree in a written contract, written
agreement or permit that the insurance
provided to any person or organization
included as an Additional Insured under
SECTION II - LIABILITY, Part C - Who is An
Insured, is primary and non-contributory,
the following applies:
If other valid and collectible insurance is
available to the Additional Insured for a loss
we cover under SECTION It - LIABILITY,
Part A. Coverages, Paragraph 1., Business
Liability our obligations are limiled as
follows:
a. Primary Insurance
This insurance is primary to other
insurance that is available to the
Additional Insured which covers the
Additional Insured as a Named Insured,
We will not seek contribution from any
other insurance available to the
Additional Insured except;
(1) For the sole negligence of the
Additional Insured;
(2) When the Additional Insured is an
Additional Insured under another
primary liability policy; or
(3) When b.(2) below applies.
If this insurance is primary, our
obliga(icns are not affected unless any
of the other insurance is also primary.
Then, we will sham with all that other
insurance by the method described in
b.(3) below.
b. Excess Insurance
This insurance is excess over:
(1) Any of the other insurance, whether
primary, excess, contingent or on
any other basis:
(b) That is Fire insurance for
premises rented to the
Additional Insured or
temporarily occupied by the
Additional Insured with
permission of the owner;
(c) That Is insurance purchased by
the Additional Insured to cover
the Additional Insured's liability
as a tenant for "property
damage" to premises rented to
the Additional Insured or
temporarily occupied by the
Additional Insured with
permission of the owner: or
(d) If the loss arises out of the
maintenance or use of aircraft,
"autos" or watercraft to the
extent not subject to Exclusion g.
of SECTION II - LIABILITY, Part
A. Coverages, 1. Business
Liability.
When this insurance is excess, we will
have no duty under SECTION 11 -
LIABILITY, Part A. Coverages, 1.
Business Liability to defend the insured
against any "suit" if any other insurer
has a duty to defend the Insured against
that "suit". If no other insurer defends,
we will undertake to do so, but we will
be entitled to the 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 stun of:
(2) The total amount that all such other
insurance would pay for the loss in
the absence of this Insurance: and
(3) The total of all deductible and
self -insured amounts under all that
other insurance.
(a) That is Fire, Extended Coverage, We will share the remaining loss, if any,
Builder's Risk, Installation Risk with any other insurance that is not
or similar coverage for "your
work".
391.1331 06 0 includes copyrighted material of insurance Servicc^ Offices, Inc , with its permission Page 1 of 2
R� Ha" ngver°
lnsurancc croup.
CH3A431963 10a1554
described in this Excess Insurance
provision and was not bought
specifically to apply in excess of the
Limits of Insurance shown in the
Declarations of this Coverage Part.
c. Method Of Sharing
If all of the other insurance permits
contribution by equal shares, we will
follow this method also. Under this
approach each insurer contributes equal
amounts until It has paid its applicable
limit of insurance or none of the loss
remains, whichever comes first.
If any of the other insurance does not
permit contribution by equal shares, we
will contribute by limits. Under this
method, each insurer's share is based
on the ratio of its appticable limit of
insurance to the total applicable limits of
insurance of all insurers.
391-1331 06 09 Includes coriyrignled material of Insurance Services Offices, Inc, with its permission Page 2 of 2
POLICY #OH3 A43196302
1 h..
Hanover
Insurance C,tc3up.
QH3 A4319o3 1 C01554
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
f3uSINFSSOWNERS COVERAGE FORM
SCHEDULE'
Name Of Person Or Organization:
ANY PERSON OR ORGANIZATION WHEN REQUIRED BY A WRITTEN CONTRA
CT, WRITTEN AGREEMENT OF PERMIT"
" Information required to complete this Schedule, if not shown on this endorsement, will be shown in the
Declarations.
Paragraph K. Transfer Of Rights Of Recovery
Against Others To Us in Section III - Common Pol-
ley Conditions is amended by the addition of the
following:
We waive any right of recovery we may have
against the person or organization shown in the
Schedule above because of payments we make for
injury or damage arising out of your ongoing cp-
erations or "your work" done under a contract with
that person or organization and included in the
"products -completed operations hazard". This
waiver aoplies only to the person or organization
shown in the Schedule above.
BP 04 97 07 02 Copyrighl, ISO Properties, Inc., 2001 Page 1 of 1
rnt
POLICY #AW3 A427�45802 insurance Group.
AW3A427458 ' 1001554
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE PART
A. The following is added to SECTION II "
LIABILITY COVERAGE, Paragraph A.1, Who Is
An Insured:
Additional Insured if Required by Contract
If you agree in a written contract, written
agreement or written permit that a person or
organization be added as an additional
"insured" under this Coverage Part, such
person or organization is an "insured"; but only
to the extent that such person or organization
qualifies as an "insured" under paragraph A.I.e.
of this Section.
If you agree in a written contract, written
agreement or written permit that a person or
organization be added as an additional
"insured" under (his Coverage Part, the most
we wiil pay on behalf of such additional
"Insured" is the lesser of:
(1) The Limits of Insurance for liability coverage
specified in the written contract, written
agreement or written permit; or
(2) The Limits of Insurance for Liability
Coverage shown in the Declarations
applicable to this Coverage Part.
Such amount shall be part of and not in addition
to the Limits of Insurance shown in the
Declarations applicable to this Coverage Part.
Regardless of the number of covered "autos",
"insureds", premiums paid, claims made or
vehicles involved in the "accident".the most we
will pay for the total of all damages and
"covered pollution cost or expense" combined
resulting from any one "accident" is the Limit of
Insurance for Liability Coverage shown in the
Declarations.
B. The following is added to SECTION IV
BUSINESS AUTO CONDITIONS, Paragraph B,
General Conditions, subparagraph 5. Other
Insurance:
Primary and Non -Contributory
If you agree in a written contract, written
agreement or written permit that the insurance
provided to a person or organization who
qualifies as an additional "insured" under
SECTION 11 - LIABILITY COVERAGE, Paragraph
A.I. Who Is An Insured, subparagraph
Additional Insured it Required by Contract is
primary and non-contributory, the following
applies:
The liability coverage provided by this Coverage
Part is primary to any other insurance available
to the additional "insured" as a Named Insured.
U'/e will not seek contribution from any other
insurance available to the additional "insured"
except:
(1) For the sole negligence of the additional
"insured"; or
(2) For negligence arising out of the ownership,
maintenance or use of any "auto" not owned
by the additional "insured" or by you, unless
that "auto' is a "trailer" connected to an
"auto" owned by the additional "insured" or
by you; or
(3) When the additional "insured" is also an
additional "insured" under another liability
policy.
C, This endorsement will apply only if the
"accident" occurs:
1. During the policy period;
2. Subsequent to the execution of the written
contract or written agreement or the
issuance of the written permit; and
3. Prior to the expiration of the period of time
that the written contract, written agreement
or written permit requires such insurance to
be provided to the additional "insured
Coverage provided to an additional "insured"
will not be broader than coverage provided to
any other "insured" under this Coverage Part.
ALL OTHER TERMS, CONDITIONS, AND EXCLUSIONS REMAIN UNCHANGED.
451-047812 12 Includes copyrighted material of ISO Insurance Services Office, Inc , wilh its permission Faye t of S
POLICY #AW3A42745802
� �* Hanover
lrssurance Group,
AW3A427458 1001554
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
WNANER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAMER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is
indicated below.
Named Insured: NBS GOVERNMENT FINANCE GROUP
Endorsement EffectivJWA�2016
SCHEDULE
Names) Of Persons) Or Organization(s):
ANY PERSON OR ORGANIZATION WHEN REQUIRED BY A WRIT
Information required to complete this Schedule, if not shown above, will be shown in the Declarations
The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or
organization(s) shown in the Schedule, but only to the extent that subrogation is valved prior to the
"accident" or the "loss' under a contract with that person or organization.
461-0500 11 13 Includes copyrighted material of insuranre Services Office, Inc., with its permission Page 1 of 1
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 lhat you perform
work under a written contract that requires you to obtain this agreement from us.)
You most 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 2 °� of the California workers' compensation premium otherwise
due on such remuneration.
Schedule
Person or Organization Job Description
ONLY WHERE REQUIRED BY CONTRACT
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 9/24/2016 Policy No. WH3A42745702 Endorsement No.
Insured Premium `S
NBS GOVERNMENT FINANCE GROUP
Insurance CompanyTR6 RAnovER INSURANCE COMPANY
�T�aAl�Countersigned By_..
WC 04 03 06 (Ed. 04-84)