PO Box 720949, Pinon Hills, CA ###-###-####; (949) 887 0859 cell ###-###-#### fax

EX-10.111 3 exh10-111.htm PHOENIX - BIOLOGICAL HABITAT ASSESSMENT AGREEMENT. exh10-111.htm
 
Exhibit 10.111
 

 
                                           Phoenix Biological Consulting, LLC
 
Providing proactive biological solutions throughout southern California

PO Box 720949, Pinon Hills, CA ###-###-####; (949) 887 0859 cell ###-###-#### fax

Biological Habitat Assessment Proposals

Date:           November 24, 2012

Client:   Mr. Jeff Thachuck
Coronus Energy Corp.
#1100-1200 West 73rd Avenue
Vancouver, BC Canada V6P 6G5

Phoenix Job Name(s): BIO-COR-12.01

Services to be provided: Phoenix Biological Consulting (Phoenix; consultant) will provide biological consulting services for Coronus Energy Corp (Client) for several project sites listed on page 2-3:

Services will include, but not limited to, the following: Biological Habitat Assessment Scope of Work

1)    Biological Habitat Assessment & Report

A)           Field work will consist of a comprehensive habitat assessment for any sensitive species known to occur within the project vicinity which may include, but not limited to, the following: Desert Tortoises and/or their sign, all Burrowing Owls and/or their sign, Mohave Ground Squirrel, nesting birds, amphibians, fish, rare plants and any other special status species. The project site will also be assessed for jurisdictional drainages to determine if they are present. Vegetation mapping of will also be conducted during the site visit. All vegetation types will be recorded and delineated in the report on aerial/topographic figures. The UTM coordinates of any sensitive species encountered shall be uploaded into an Excel file, plotted on an aerial photo and incorporated into a final report.

B)           Prepare a biological habitat assessment technical report for submittal to the city and/or county planning department to satisfy the initial biological studies component of the California Environmental Quality Act (CEQA). The final report will include, but not limited to: executive summary, description of site, biological resources encountered, an aerial photograph and topographic map with plotted resources, vegetation types, drainages and general overview, photographs of site, soil classification, a detailed analysis of the results of a California Natural Diversity Database Search (CNDDB) and any further mitigation or focused survey recommendations.

If applicable, consultant shall also complete a CNDDB form for each special status species encountered on or adjacent to the project site and submit these to the California Department of Fish and Game.

 

 

 
Cost Estimate:
 

 
 
 
 
Project Name
 
 
 
 
MW/ac
 
 
 
 
AHJ
 
 
 
Lot Size
(acres)
 
 
 
 
APN
 
 
 
 
Site Address
Biological Habitat
Assessment
 
Cost Estimate
 
(Field Effort and
Report)
 
Adelanto
West
4.5
City of
Adelanto
 
[San Bernardino County]
40
3129-251-13-
0000
TBD
 
Cassia Rd & Richardson Rd.
 
Adelanto, CA
$4,800
 
Apple Valley
East
3.0
San Bernardino County
24
0438-212-01-
0000
 
0438-212-02-
0000
10501 Central
Rd.
 
Apple Valley, CA 92308
$4,500
 
Phelan South
3.0
San Bernardino County
20 (project area)
 
40 (property)
3066-561-14-
0000
TBD
 
Nielson Rd & Campanula Rd.
 
Phelan, CA
$4,500
 
Yucca Valley
East
4.5
San
Bernardino
County
20
(project area)
 
34 (property)
0588-131-74-
0000
60097 Alta
Loma Tr.
 
Joshua Tree, CA 92252
$4,500
 
 
Joshua Tree
East
7.5
San
Bernardino
County
56
0608-161-20-
0000
 
0608-161-21-
0000
 
0608-161-22-
0000
6350 Mt.
Shasta Ave.
 
Joshua Tree, CA 92252
$4,800
 
29-Palms
North
4.5
San
Bernardino
County
33
(project area)
 
160 (property)
0620-021-01-
0000
 
(adjacent to
29-Palms
West)
4502 Mesquite
Springs Rd.
 
Twentynine
Palms, CA
92277
$4,700
 
29-Palms
Morongo
3.0
San
Bernardino
24
0620-223-04,
-05, -06
Morongo Rd &
Valle Vista Rd
 
Twentynine
Palms, CA
$4,700
 
Total Cost:
$32,500
 
Biological Services ($115/hr, $100 per diem, $0.55 mileage)

Terms & Condition of Payment:  Phoenix requires half of the total contract value prior to initiating the field effort.  Half of the contract value is: $16,250. This amount is due prior to initiating the field work and should be payable to Phoenix Biological Consulting. The second half of the contract value ($16,250) will be due within thirty (30) business days after receipt of final report for all seven sites listed above.  An invoice will be included with the final reports. A late fee of $250 will be charged if payment is not received within thirty (30) business days after receipt of final report and invoice. This proposal is good for up to three weeks from the date submitted. The consultant reserves the right to cancel this proposal if an executed copy has not been received within three weeks from the date submitted. Any legal fees incurred by the consultant in an attempt to recover expenses associated with this contract will be paid in full by the client. By signing this contract, client and consultant agree to these terms and conditions.

A            The total cost for performing the Scope of Services will be $32,500 (the “Services Fee”). This Services Fee includes all services with details as noted on above Scope of Services.  The total cost is presented as a fixed contract. Any additional services beyond what is stated in this contract must be approved in writing by both parties.

B.           The Consultant shall perform the Scope of Services in compliance with the standards set forth for a pre-construction biological survey. Consultant shall also perform any and all Scope of Services work in accordance with all applicable law in the State of California.

C.           The liability of Client shall be limited to the direct costs related to the Scope of Services and fixed fees that are specifically set forth in this agreement.

D.            Indemnification:
Either party shall indemnify and hold harmless the other party and all of its personnel from and against any and all claims, damages, losses and expenses (including reasonable attorney’s fees), arising out of or resulting from the performance of the services, provided that any such claim, damage, loss or expense is caused in whole or in part by the negligent act, omission, and/or strict liability of the other party, anyone directly employed by that party (except if a party to this agreement) , or any entity or person for whose actions that party may be liable for.

E.           Termination of Services; Term:
This agreement will take effect on the effective date and will continue for a period of forty-five 45 days, unless earlier terminated. Either party may terminate this agreement (a) for any reason upon not less than ten (10) days’ prior written notice to the other party, or (b) immediately upon delivery of written notice if the other party is in material breach of this agreement and the breach either (i) is incapable of being cured or (ii) if capable of being cured, remains uncured for fifteen (15) days after the non-breaching party delivers written notice of the breach to the breaching party. In the event of termination, the Client shall pay the Consultant for all services rendered to the date of termination, and all reimbursable and preapproved expenses.

F.           Independent Contractor Status:
Consultant will provide the services in its role as an independent contractor to Client. Nothing in this agreement will be deemed to place the parties in a relationship of partners, joint ventures, principal and agent, or employer and employee. Consultant will be solely responsible for all federal, state and local taxes due on all compensation paid to Consultant under this agreement and Consultant will indemnify or hold Client free and harmless from any liability resulting from either party’s failure to pay or remit such taxes. Neither Consultant nor any officer, director, employee, agent or representative of Consultant is authorized to represent Client or its affiliates in an agency capacity, bind Client or its affiliates to any written or oral contract, make any representations on behalf of Client or its affiliates,
or otherwise act  on Client's or its affiliates' behalf, except as expressly provided in a Scope of Services.

G.            Confidentiality:
In the performance of this agreement, Consultant may have or be given access to Confidential Information (as defined below) of Client and its affiliates, the disclosure of which would cause substantial or irreparable harm to Client. Consultant will not at any time or in any manner, directly or indirectly, without Client's prior written consent: (a) use any Confidential Information except as necessary to perform its obligations under this agreement; (b) divulge, disclose or communicate in any manner any confidential Information to any third party; or (c) reproduce any Confidential Information in any manner. Consultant will exercise the highest degree of care in safeguarding any Confidential Information against loss, theft, or inadvertent disclosure. Consultant acknowledges that Client may be irreparably harmed by a breach of this Section G and Client is entitled to seek specific performance, including seeking issuance of  a temporary restraining order and/or preliminary injunction enforcing this agreement, and to all other remedies provided for by applicable law. Violation of this Section will constitute a material breach of this agreement. This agreement shall survive termination of any discussions between the parties, the return or destruction of Confidential Information or any termination of any other agreement, whether in effect prior to or after the date of this agreement. “Confidential Information” means all of Client's and its affiliates’ Confidential Information, including (i) any information related to Client's interest in a project or a location contemplated by the work product or the services, (ii) the existence of this agreement, or the fact that Consultant did perform or is performing services for Client; (iii) business and marketing plans and strategies; (iv) ideas for research and development; (v) financial data; and (vi) trade secrets and know-how. The obligations imposed by this Section 11 will not apply with respect to (a) any disclosure required by law, regulation or judicial process, provided that consultant will give Client reasonable advance notice of the required disclosure and Consultant will cooperate with Client in limiting such disclosure and in obtaining protective orders where appropriate; or (b) information that is in the public domain, provided it did not enter the public domain as a result of Consultant's breach of this agreement. The terms of this agreement shall also constitute Confidential Information as set forth herein. Parties shall cause their personnel or agents who perform services or other actions pertaining to this agreement to comply with this paragraph.

H.           This agreement shall not merge with, or be terminated or superseded by any future agreement between the parties unless such agreement specifically so provides.

I.           INSURANCE:

Subcontractor and its subcontractors and suppliers of all tiers shall maintain the following insurance for the duration of this Agreement, unless specified longer, in a company or companies admitted to issue insurance in all of the states where any of the work is being performed and where any waste is transported or deposited, with a Best’s rating of not less than A:VII and acceptable to Contractor and Owner.

Required insurance coverage shall follow the schedule attached hereto as Exhibit 1.

A)           Subcontractor shall be obligated to provide evidence of the following:

i.           Written notice of cancellation, termination or any reduction in coverage shall be delivered to Contractor thirty (30) days in advance of the date thereof. Ten (10) days notice of cancellation shall be delivered for non-payment of premium.
ii.           The insurers waive all rights of subrogation against Contractor and Owner.
iii.           Deductibles shall not exceed $50,000 and shall be the responsibility of Subcontractor.

B)           Prior to the start of any Work, Subcontractor shall furnish Contractor with endorsements and Certificates of Insurance from insurers showing all insurance required hereunder is in full force and effect during the entire term of this Agreement.

Authorized Signatures of Acceptance to Proposal:

Phoenix Biological Consulting
Date
Coronus Energy Corp
Date
(Consultant)
 
(Client)
 
       
RYAN YOUNG
November 24, 2012
JEFF THACHUCK
November 24, 2012
Ryan Young, Principal
 
Authorized Representative
 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
This Page Is
 
Intentionally Left Blank
 


 
 

 

 
 
Master Services Agreement for Professional Services and/or Drilling Services
 
Exhibit 1 - Insurance Requirements
 
______________________________________________________________________________________
 
Exhibit 1
 

This checklist outlines the insurance requirements for vendors/subcontractors of Belectric, Inc.  Please provide a certificate of insurance as proof of coverage to:
Belectric, Inc.
Attn:
Diane Padilla
8076 Central Avenue
Phone:
510 ###-###-####
Newark, CA 94560
Fax:
510 ###-###-####
 
Email:
***@***

DATE:  November 25, 2012 _ VENDOR/SUBCONTRACTOR:                                                                                                            Phoenix Biological Consulting                                                      

PROJECT # AND DESCRIPTION: Adelanto West, Apple Valley East, Phelan South, Yucca Valley East, Joshua Tree East, 29 Palms North, 29 Palms Morongo.

GENERAL
Yes
No
Insured box complete with subcontractor information (1)
   
Certificate Holder complete as outlined in contract requirements (2)
   
Project name and number correct  (3)
   

GENERAL LIABILITY
Yes
No
Policy number and period current (4)
   
Occurrence Form (5)
   
Each Occurrence Limit of $1,000,000 (6)
   
Personal & Advertising Injury Limit of $1,000,000 (7)
   
General Aggregate Limit of $1,000,000 (8)
   
Products / Completed Operations Aggregate Limit of $1,000,000 (9)
   
Additional Insured Endorsement naming certificate holder as an Additional Insured (CG 20 10 11 85 Form or Equivalent) – See Sample Endorsement
   
Primary and Non-Contributory Endorsement in favor of certificate holder – See Sample Endorsement
   
Waiver of Subrogation Endorsement in favor of certificate holder – See Sample Endorsement
   
Per Project and Per Location General Aggregate boxes checked (10)
   

AUTOMOBILE LIABILITY
Yes
No
Policy number and period current (11)
   
Automobile Liability:  Any Auto (12)
   
Combined Single Limit of $1,000,000 (13)
   
Additional Insured Endorsements naming certificate holder as an Additional Insured – See Sample Endorsement
   
Waiver of Subrogation Endorsement in favor of certificate holder – See Sample Endorsement
   
 

 
 
Master Services Agreement for Professional Services and/or Drilling Services
 
Exhibit 1 - Insurance Requirements
 
______________________________________________________________________________________

WORKERS COMPENSATIN
WORKERS COMPENSATION
Yes
No
Policy number and period current (14)
   
WC Statutory Limits box checked (15)
   
Employers Liability Limits of $1,000,000 Each Accident, $1,000,000 Disease Each Employee, and $1,000,000 Disease Policy Limit (16)
   
Waiver of subrogation endorsement in favor of certificate holder – See Sample Endorsement
   

UMBRELLA LIABILITY
Yes
No
Policy number and period current (17)
   
Occurrence Form (18)
   
Each Occurrence Limit $1,000,000 / Aggregate Limit $1,000,000 (19)
   

PROFESSIONAL LIABILITY
Yes
No
Policy number and period current (20)
   
Each Occurrence Limit $1,000,000 / Aggregate Limit $1,000,000 (21)
   
 

 

 

 


 
 

 

 
                                                                           SAMPLE DOCUMENT
 
Master Services Agreement for Professional Services and/or Drilling Services
 
Exhibit 1 - Insurance Requirements
 
___________________________________________________________________________________________________________________________________________
 
[ACORD LOGO]                                                                           CERTIFICATE OF LIABILITY INSURANCE Date (MM/DD/YYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER 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 NOTE 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 required an endorsement.  A statement of this certificate does not confer rights to the  certificate holder in lieu of such endorsement(s).
 
PRODUCER:
Barney & Barney LLC
Contact Name:
 
 
CA Insurance Lic:0C03950
Phone (A/C No. Ext):                                                                      FAX (A/C No.)
 
 
9171 Towne Centre Drive, Suite 500
E-Mail Address:
 
 
San Diego, Ca 92122
Insured Affording Coverage
NAIC #
 
 
858 ###-###-####
INSURED A: ABC INSURANCE COMPANY
   
INSURED:
 
SUBCONTRACTOR/VENDOR NAME
Address
City, State Zip
 
INSURED B: XYZ INSURANCE COMPANY
   
INSURED C: ZZZ INSURANCE COMPANY
   
INSURED D:
   
INSURED E:
   
INSURED F:
   
Coverages
Certificate Number:
MST 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.
 
Insur
Ltr
Type of Insurance
Addl
Insur
Issuer
WVD
Policy Number
Policy Eff
(MM/DD/YY)
Policy Exp
(MM/DD/YY)
Limits
 
A
General Liability
x
x
123456789
 
xx/xx/xxxx
-(4)-
xx/xx/xxxx
 
Each Occurrence
(6)                           1,000,000
 
x
Commercial General Liability
Damage To Rented Premises (Each occurrence)
50,000
 
   
Claims-Made
x
Occur
Med Exp (Auto one person)
5,000
 
 
                                           (5)
Personal & Adv Injury
 (7)                           1,000,000
 
   
General Aggregate
(8)                           2,000,000
 
 
Genl Aggregate Limit Applies Per:
Products Comp or Agg
(9)                           2,000,000
 
   
Policy
x
Project
x
Loc
     
A
(12)
Automobile Liability                     (10)
x
x
123456789
xx/xx/xxxx
-(11)-
xx/xx/xxxx
Combined Single Limit (if a accident)
(13)                         1,000,000
 
x
Any Auto
Bodily Injury (per person)
   
 
All Owned
 
Scheduled
Bodily Accident (per accident)
   
 
Hired Autos
 
Non-Owned
Property Damage (per accident
   
A
x
Umbrella Liab
x
Occur (18)
   
123456789
xx/xx/xxxx
-(17)-
xx/xx/xxxx
Each Occurrence
(19),                         1,000,000
 
 
Excess Liab
 
Claims
Aggregate
1,000,000
 
     
Made
     
B
Workers Compensation and Employers’ Liability Any proprietor, partnership Executive officer member excluded (Mandatory in NH) If yes, describe under
Description of Operations below:
Y/N
[ ]
N/A
X
123456789
xx/xx/xxxx
-(14)-
(15)
 
 
xx/xx/xxxx
 
WC State
Tory Limits
 
Other
(16)                          1,000,000
E.L. Each Accident
                                      1,000,000
 
E.L Disease - Ea Employee
                                      1,000,000
 
E. L. Disease - Policy Limited
   
C
Professional Liab
     
123456789
xx/xx/xxxx
-(20)-
xx/xx/xxxx
Each Occurrence                           (21)
(21)                            2,000,000
 
Aggregate
2,000,000
 
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ATTACHED ACORD 161, ADDITIONAL REMARKS SCHEDULE, IF MORE SPACE IS REQUIRED)
 RE: PROJECT NAME & NUMBER (3)
 CERTIFICATE HOLDER IS ADDITIONAL INSURED ON GENERAL LIABILITY AND AUTOMOBILE LIABILITY PER THE ATTACHED ENDORSEMENTS. GENERAL LIABILITY COVERAGE IS PRIMARY AND NON-CONTRIBUTORY PER THE ATTACHED ENDORSEMENT.  WAIVER OF SUBROGATION APPLIES TO GENERAL LIABILITY, AUTOMOBILE LIABILITY, AND WORKERS COMPENSATION PER THE ATTACHED ENDORSEMENTS.
 
CERTIFICATE HOLDER
CANCELLATION
 
(2) Belectric, Inc.
8076 Central Avenue
Newark, CA 94560
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
 
 
 


 
 

 

 

 
                                                                                     SAMPLE DOCUMENT
 
Master Services Agreement for Professional Services and/or Drilling Services
 
Exhibit 1 - Insurance Requirements
 
______________________________________________________________________________________
 

 

INSURED:
POLICY#:
COMPANY:
POLICY PERIOD:                                           TO
 
EFFECTIVE DATE:
 

 
COMMERCIAL GENERAL LIABILITY
 

 
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
 

 
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B)
 

 
This endorsement modifies insurance provided  Under the following:
 

 
COMMERCIAL GENERAL LIABILITY  COVERAGB PART
 

 
SCHEDULE
 

 
Name of Person or Organization:
 

 

 
PRIMARY INSURANCE: Such insurance as is afforded by the General Liability policy is  primary insurance and no other insurance of the additional insured shall be called upon to contributed to a loss.
 

 
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
 

 
WHO IS INSURED (Section II is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you
 


 
 

 

 

 
                                                                           SAMPLE DOCUMENT
 
Master Services Agreement for Professional Services and/or Drilling Services
 
Exhibit 1 - Insurance Requirements
 
______________________________________________________________________________________
 

POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
 
CG 24 04 10 93
 

 
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:
 
COMMERCIAL GENERAL LIABILITY COVERAGE PART
 

 
SCHEDULE
 

 
Name of Person or Organization:
 

 

 
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
 

 
The 'TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMERCIAL GENERAL LIABILITY CONDITIOSN) 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 operations or "your work: done under a 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 above
 

 

 

 

 

 

 

 

 
CG 24 04 10 93  Copyright, Insurance Service Office, Inc., 1992                                                                                                                               Page 1 or 1
 


 
 

 

 
                                                                             SAMPLE DOCUMENT
 
Master Services Agreement for Professional Services and/or Drilling Services
 
Exhibit 1 - Insurance Requirements
 
______________________________________________________________________________________
 

INSURED:
POLICY#:
COMPANY:
POLICY PERIOD:                   TO
 
EFFECTIVE DATE:
 

---REPRINTED FROM THE FORMS LIBRARY---

THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.

CA 71 35 12 93
ADDITIONAL INSURED

This endorsement modifies insurance provided  under the following:

BUSINESS AUTO 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,

Endorsement effect
 
 
Name Insured
 
Countersigned by

Schedule:
 
 
Name of Person or Organization:
Address:
 
 
Premium: $

(If no entry appears above information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

A.           Under LIABILITY COVERAGE WHO IS AN INSURED is changed to include as an insured theperson(s) ororganization(s) shown in the Schedule, but only with respect to "bodily injury" or "propertydamage" resulting fromthe acts or omissions of:
1.           You:
2.           Any or your employees or agents:
3.           Any person, except the additional insured or any employee or agent of the additional insured, operating a covered"auto" with the permission of any of the above.

B.           The insurance afforded by the endorsement does not apply:
1.           To "bodily injury" or "property damage" arising out of the sole negligence of the person(s) ororganization(s)shown in the Schedule

 
 

 


 
                                                                           SAMPLE DOCUMENT
 
Master Services Agreement for Professional Services and/or Drilling Services
 
Exhibit 1 - Insurance Requirements
 
______________________________________________________________________________________

Waiver of Transfer of Rights of Recovery Against Others to Us
___________________________________________________________________________________
Policy No.
 
 
Eff. Date of Pol.
Exp. Date of Pol.
Eff. Date of End
Agency No.
Add.. Prem.
Return Prem.

This endorsement is issued by the company named in the Declarations. It changes the policy on the effective date listed above at the hour stated in the Declarations.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Named Insured:
Address (Including ZJP code):

This endorsement modifies insurance provided under the:

BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM

SCHEDULE

Name of Person(s) of Organizations(s),




We waive any right of recovery we may have against the designated person or organization shown in the schedule because of payments we make for injury or damage caused  by an "accident" or "loss" resulting from the ownership, maintenance, or use of a covered "auto" for which  a Waiver of Subrogation is required in conjunction with work performed by you for the designated person or organization.   The waiver applies only to the designated person or organization shown n the schedule.



Countersigned By                                ____________________________________________                                                                                                Date: __________________
Authorized Representative
U-CA-320-B CW (4/94)


SAMPLE DOCUMENT

WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

        WC 00 03 13
(Ed. 4-84)



WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS  ENDORSEMENT

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 name 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 with us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.



Schedule





This endorsement changes this policy to which it is attached and is effective on the date issued unless otherwise state.  (This information below is required only when this endorsement is issued subsequent to preparation of the policy.)


Endorsement Effective:
Policy No.
Endorsement No.
Insured:
   
Insurance Company:
 
Premium: $
 
Countersigned by:
 






WC 80 03 13 (Ed. 4-84)