contractors shield insurance documents - shopandbind€¦ · quote 177425 railworks inc...

Quote 177425

Railworks Inc805-492-8058

Cover Page and Binding Instructions

Insurance Carrier: AMTrust International Underwriters Ltd. (760) 345-9029Underwriter:

Retail Brokerage: Orr and Associates 951-506-5859Broker / Rep: Patricia Gonzalez

STEP 1 - Review, Sign, and Collect requirementsSigned ApplicationSigned Endorsements (if selected)Signed No Loss LetterSigned Finance AgreementPayment in the amount of: $6,197.88

STEP 2 - Upload, Email, or Fax request to (760) 345-9028Upload or email signed copy to your underwriter

Underwriter will review your submission and bind

STEP 3 - Policy issued via emailPolicy will be emailed to: [email protected]

STEP 4 - Payment Options

STEP 5 - Send SCIS Check Authorization form for amount due at time of binding.

PAY-IN-FULL $6,197.88 LOW-DOWN PFA $1,479.58 3RD PARTY PFA $2,241.08

Quote 177425


Coverage - Pricing - Payment Information

PRICING IS VALID FOR 30 DAYS FROM: 1/6/2017COMMERCIAL GENERAL LIABILITY

EACH OCCURRENCE LIMIT $1,000,000GENERAL AGGREGATE LIMIT $2,000,000HOT TAR & TORCHDOWN $100,000 SUBLIMITFIRE CAUSED BY HEATING DEVICE $100,000 SUBLIMITPRODUCTS/COMPLETED OPERATIONS $2,000,000PERSONAL & ADVERTISING INJURY $1,000,000FIRE LEGAL LIABILITY $50,000MEDICAL PAYMENT LIMIT $5,000

DEFENSE EXPENSES AS THE TERM IS DEFINED IN THE POLICY ARE INCLUDED WITHIN THEINDEMNITY LIMITS AS DEFINED IN THE POLICY

RATING INFORMATIONBASED ON GROSS RECEIPTS/SALES: $450,000SIR (PER CLAIM) $5,000SUNSET TERM: Yes NoPOLICY TERM: 1 YearCLASSIFICATIONS: 91583 - GENERAL CONTRACTOR (REMODEL RESIDENTIAL)

91340 - CARPENTRY- FRAMING91584 - GENERAL CONTRACTOR (REMODEL COMMERCIAL / TI)

PRICING INFORMATIONPREMIUM $4,946.00POLICY FEES $769.00ENDORSEMENTS $0.00Broker Fee $300.00CA Stamping Fee $11.43CA Surplus Lines Tax $171.45

TOTAL: $6,197.88

DOWN PAYMENT, TAX & FEES DUE WITHIN 10 DAYS OF EFFECTIVE DATE OR CANCELLATION NOTICE WILL BE SENT.

Quote 177425


Endorsements Selected

Please note these endorsements were selected for this policy at bind.

Endorsement Name Form #SCIS-CGL-DEC1Declarations PageSCIS-CGL-DEC2Supplemental Declarations PageSCIS-CGL-SCHSchedule of Forms and EndorsementsAIUL SIGNATURE PAGEUSI Signature PageCPS33002Service of SuitCA D2California D-2 Surplus Lines NoticeIL 00 21 09 08Nuclear Energy Liability Exclusion EndorsementCG 21 84 01 08Exclusion of Certified Nuclear, Biological, Chemical or Radiological Acts of TerrorismCG 21 70 01 08Cap on Losses from Certified Acts of TerrorismSCIS-BIP-1Bodily Injury on Property Owned by InsuredShieldSEGLState and Foreign Operations Exclusion and Governing LawSCIS-BAI-3Blanket Additional Insured EndorsementSCIS-CGLCommercial General Liability Coverage Form

ADDITIONAL ENDORSEMENTS ARE AVAILABLE, CONTACT YOUR UNDERWRITER FOR MORE DETAILS.

of 6SCIS-CGL-APPForm Edition 05/10/13

©SCIS All rights reserved

Quote 177425


Application

INSURED'S INFORMATIONEffective Date: 1/10/2017Applicant: Railworks IncContact: Kyle JoachimPhysical Address: 269 Tennyson StCity, St Zip Thousand Oaks, CA 91360Mailing Address: P.O.Box 2090Mailing City, St Zip Thousand Oaks, CA 91358Telephone / Fax: 805-492-8058Email Address: [email protected]'s license #: 628664Business Type: Corporation

WORK EXPERIENCE:States in which you do business: CaYears in business for yourself: 25Years in profession: 35Detail Description of Operation:

Custom new home framing, additions, remodels, service and repair.

EXPOSURES:a. Gross Receipts for the next 12 months? $450,000b. What are the Gross Receipts for the last 12 months? $450,000c. What are your "Insured" subcontractor costs for the next 12 months? $32,960d. What is payroll for the next 12 months? $75,000e. Number of field employees? 2

WORK EXPERIENCE:Percentage of work Performed:

Residential Commercial New Tract Remodel/Repair/Service90 10 50 0 50

Describe in detail your largest project in the last 5 years along with the receipts $$$. (DETAIL REQUIRED BY CARRIERFOR APPROVAL):

$278,200 - Framing only 1430 Georgina Santa Monica, Ca 90402

Have you been involved or do you subcontract any work involving blasting operations,hazardous waste, asbestos, mold, PCB's or medical and/or industrial life? Yes No



Quote 177425


Application

WORK EXPERIENCE: (continued)Do you use subcontractors? Yes No

What % of your subcontractors do not carry general liability insurance:Do you always collect certificates of insurance from sub-contractors? Yes NoWhat minimum General Liability limit is required: $1,000,000Do you always require sub-contractors to name you as additional insured? Yes NoDo you have a standard formal written contract with sub-contractors? Yes No

If yes, does it have a hold harmless/indemnification agreement in your favor? Yes NoDo you do any work for condominium or townhouse associations? Yes NoDo you do OCIP (Wrap-up) work? Yes NoAny work performed for a fee or with labor and/or material costs paid by others? Yes NoHave you allowed or will you allow your license to be used by any other contractor? Yes NoHas any lawsuit ever been filed, or any claim otherwise been made against yourcompany of any partnership or joint venture of which you have been a member of yourcompany's predecessors in business, or against any person, company or entities onwhose behalf your company has assumed liability?

Yes No

Is your company aware of any facts, circumstances, incidents, situations, damages oraccidents (including but not limited to: faulty or defective workmanship, product failure,construction dispute, property damage or construction worker injury) that a reasonablyprudent person might expect to give rise to a claim or lawsuit, whether valid or not, whichmight directly or indirectly involve the company?

Yes No



Quote 177425


Application

SUPPLEMENTAL QUESTIONS: (work in progress)Yes NoDo you have a project in progress for which you are seeking coverage under this application?

Yes NoX Does the applicant Build Any New Complete Homes?Yes NoX Do you do any new construction? (Residential)Yes NoX Do you do any new construction? (Commercial)

How many new homes will you as the general contractor build next year? 0What is the maximum number of homes built by you as the General Contractor in any one year? 0How many new Commercial Buildings as the General Contractor will you build next year? 0

Yes NoX Blasting, demolition, or wrecking other than incidental use of hand tools?Yes NoX Cranes booms or lifts used?Yes NoX Earthquake retrofitting or updating?Yes NoX Earth bearing retaining wall construction over three feet?Yes NoX Do you purchase or install any imported drywall?

SUPPLEMENTAL QUESTIONS: (litigation against applicant's)Within the past 4 years have you filed any lawsuits and/or arbitration actions against any ofyour customers for nonpayment of your services and/or materials you supplied?

Yes No

X HAS NO LOSSES



Quote 177425


Application Signature Pages

The policy you are applying for is issued by a Surplus Lines Carrier. The Surplus Lines Carrier may not besubject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds arenot available for a Surplus Lines Carrier.

The Applicant acknowledges that Applicant has read or has had the opportunity to read a sample of the Policy form thatwill be issued to the Applicant as well as commonly used endorsements. The Applicant further acknowledges that thesample may not contain all of the endorsements, restrictions that may be ultimately issued to the Applicant. The Applicantfurther acknowledges that a copy of the Policy form and commonly used endorsements has been made available toApplicant’s broker. Further the Applicant acknowledges that a copy of the Contractors Shield Policy form and commonlyused endorsements are available for review by either the Applicant or the Applicant’s broker by contacting ShieldCommercial Insurance Services at 760-345-9029x223 or

Applicant’s Initials:

THERE ARE EXCLUSIONS, RESTRICTIONS, SUBLIMITS AND CONDITIONS IN THE POLICY THAT LIMITCOVERAGE. SOME, BUT NOT ALL OF THESE ARE TITLED AS FOLLOWS:.

b DEFENSE COSTS REDUCE INDEMNITY LIMITSb BINDING ARBITRATION CLAUSEb SELF INSURED RETENTIONb TORCH AND HOT TAR SUBLIMIT OF $100,000

○ Applicant confirms that a 2 hour fire watch is required for sub limit coverageb HEATING DEVICE SUBLIMIT OF $100,000b SOME OF THE EXCLUSIONS

○ SUB-CONTRACTOR RELATED CLAIMS UNLESS INDEMNITEE AGREEMENTS, CERTIFICATES EVIDENCING QUALOR GREATER LIMITS AND ADDITIONAL INSURED STATUS ARE OBTAINED PRIOR TO COMMENCEMENT OFWORK

○ OPEN ROOF WATER DAMAGE EXCLUSION○ TOTAL POLLUTION○ VARIOUS MATERIAL, BIOLOGIC AND RADIATION EXCLUSIONS: ASBESTOS; CHROMATER COPPER ARSENATE;

CONCRETE SULFATES; ELECTROMAGNETIC RADIATION; LEAD; MOLD; BACTERIA AND OTHER ORGANICALLY-CAUSED DAMAGES; CHINESE DRYWALL AND OTHER IMPORTED BUILDING MATERIALS; FIBERGLASS;FORMALDEHYDE; ARSENIC; FIRE RETARDANT TREATED PLYWOOD; ENTRAN PIPE; CCA WOODPRESERVATIVES; AIRBORNE MANGANESE; DIOXIN; SILICA; MIXED DUST; POLYCHLORINATED BIPHENYLS;TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHY; COMMUNICABLE DISEASE

○ EARTH MOVEMENT○ BLASTING OPERATIONS○ LIABILIITY TO EMPLOYEES (ACTION OVER)○ EXTERIOR INSULATION AND FINISH SYSTEMS (E.I.F.S)○ PAST PROJECTS/PRIOR WORK (Unless in continuous and unbroken renewal under the policy)○ JOBS IN PROGRESS REQUIRE ENDORSEMENT○ CONDOMINIUM AND TOWNHOUSE EXCLUSION EXCEPT FOR REPAIR TO INDIVIDUAL UNIT FOR UNIT OWNER○ WRAP-UP/OCIP○ EXCAVATION FOR OTHER THAN SINGLE FAMILY HOUSING, AND EXCAVATION OVER 8'○ FOUNDATION REPAIR○ GREEN BUILDING○ MULTIFAMILY DWELLINGS IN EXCESS OF 15 UNITS○ TRACTS IN EXCESS OF 15 HOMES○ NON-COMPLIANCE WITH BUILDING CODES○ UNLICENSED WORK○ PROFESSIONAL LIABILITY○ TERMINATION OF COVERAGE FOR FAILURE TO PAY OR COOPERATE WITH AUDIT

The Applicant further acknowledges the Policy has other restrictions in coverages.




Quote 177425



The Applicant authorizes the Broker to sign on behalf of the Applicant any documents modifying the terms and conditionsof the policy including but not limiting to the purchase of additional endorsements, changes in coverage including policylimits, and the execution of any documents necessary to obtain a renewal and/or extension of the policy.


The Applicant warrants that after inquiry, no one employed by or associated with Applicant is aware of any complaints,allegations, demand for payment of money or the performance of services, claims, incidents, potential claims, acts, errors,omissions, facts, circumstances, situations, events or transactions that could reasonably result in a claim or lawsuit beingpresented against Applicant or anyone employed by or associated with Applicant

The Applicant warrants that the above statements and particulars, together with any attached or appended documents ormaterials (this application), are true and complete, and do not misrepresent misstate, or omit any material facts.Furthermore, the Applicant authorizes SCIS as administrative and servicing manager, to make any investigation andinquiry in conjunction with the application as it may deem necessary. The Applicant agrees to notify SCIS of any materialchanges in the answers to the questions on this application which may arise prior to the effective date of our Policy issuedin pursuant to this application and the Applicant understands that any outstanding quotations may be modified orwithdrawn based upon such changes at the sole discretion of SCIS.

The Applicant further understands that, if a Policy is issued, this Application will be incorporated into and form a part ofsuch Policy and any false information provided in this application will result in nullification of the Policy. The Applicantunderstands that information contained herein is specifically relied upon by SCIS in the issuance of the Policy. Theundersigned, therefore, warrants that the information contained herein is true and correct. The Applicant understands thatmisrepresentation or omission shall constitute grounds for either an early cancellation or denial of coverage of claims, ifany. It is understood that the Applicant and or affiliated companies are under a continuing obligation to immediately notifySCIS of any material alteration of the information given. The Applicant also acknowledges, that the Applicant has notsustained a loss nor has any claim been made against the Applicant within the last 5 years unless otherwise disclosed inthis application.


The Applicant understands that if the Applicant utilizes the premium finance arrangement provided through SCIS theprogram & filing fees, inspection fee and agency fee will be fully earned and Applicant is responsible for and will guarantythose payments.




Quote 177425



Notwithstanding any of the foregoing, the Applicant understands SCIS is not obligated nor under any duty toissue a Policy of insurance based upon this application. SCIS is relying on the statements in issuing the policy.The Applicant's statements are material and truthful. The applicant is signing this statement under penalty ofperjury.

NOTICE: In some states, any person who knowingly, and with the intent to defraud any insurance company or otherperson, files an application for insurance or statement of claim containing any materially false information, or, for thepurpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insuranceact which is a crime in many states.

Please bind per quote with the effective date of 1/10/2017

Date:__________________

Signature of Applicant:_________________________________________

Title (Owner, Office, Partner):___________________________________________________

UCISG Notice of Terrorism

NOTICE OF TERRORISM INSURANCE COVERAGE

I

You are hereby notified that under the federal Terrorism Risk Insurance Act, as amended ("the Act"), the Company

must make available insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of

the Act. This policy includes such coverage for damages arising out of certified acts of terrorism and is limited by

the terms, conditions, exclusions, limits, other provisions of the coverage quote or renewal

application/questionnaire to which this offer is attached and by the policy, any endorsements to the policy and

The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the

Secretary of State, and the Attorney General of the United States to be an act of terrorism; to be a violent act or an

act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States,

or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to

have been committed by an individual or individuals as part of an effort to coerce the civilian population of the

United States or to influence the policy or affect the conduct of the United States Government by coercion.

YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES RESULTING

FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY

THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BY FEDERAL LAW.

UNDER THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES 85% OF

COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE

NO PREMIUM IS CHARGED FOR THIS COVERAGE NOR IS ANY CHARGE MADE FOR THE

PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE

YOU SHOULD ALSO KNOW THAT THE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S

GOVERNMENT REIMBURSEMENT, AS WELL AS INSURERS' LIABILITY FOR LOSSES, RESULTING FROM

CERTIFIED "ACTS OF TERRORISM" WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR

EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION,

YOUR COVERAGE MAY BE REDUCED.

COVERAGE FOR "INSURED LOSSES" AS DEFINED IN THE ACT IS SUBJECT TO THE COVERAGE

TERMS, CONDITIONS, AMOUNTS AND LIMITS IN THIS POLICY APPLICABLE TO LOSSES ARISING

FROM EVENTS OTHER THAN "ACTS OF TERRORISM".

INSTRUCTIONS FOR COMPLETING CALIFORNIA SL-2 FILING

SECTION 1: Please provide the full name of the licensed individual who performed or supervised the diligent search. Ifthe search was performed under the individual's license number, enter his/her license number in section (A) or if theindividual was authorized as an endorsee under an organizational license, enter the name of the organization and itslicense number in section (B).

SECTION 6: Please provide a complete response on section (A). Note: The Insurance Commissioner or his designeemay require the surplus line broker to conduct a further or additional search among admitted insurers for similarplacements in the future. [California Insurance Code Section 1763(b)] An incomplete response may unnecessarily resultin a request for a further search to be conducted. If the individual named on line 1 did not perform the diligent search,please provide the full name of the individual who performed the search on section (B).

SECTION 7(B): To avoid mis-identification among insurers with similar names, please provide the complete name of theadmitted insurer as listed in the CDI Official Publication of Admitted Companies.

Insurer group names, such as Cigna Group, Chubb Group, California Ins. Group, Hartford Group, etc., are acceptable ifthe person performing the search verifies that the representative of the group, who declines the risk, does in factrepresent an admitted insurer in the group that actually writes the particular type of insurance being sought. (For a list goto http://www.sla-cal.org/ You will find a look up site under Fast Link on the left of the page.)

IMPORTANT: Persons who are licensed only as an agent may only submit a risk to admitted insurers that have appointedthem as their agent. Agents are not authorized to offer a risk to admitted insurers for which they are not appointed agents.A search which is limited to only those companies that have appointed the agent may not necessarily constitute a diligentsearch of the admitted market.

CODE TYPE OF INSURANCE This list does not include those coverages on the export list.

050 Auto Liability-Private051 Auto Liability-Commercial100 Auto Physical Damage-Private101 Auto Physical Damage-Commercial150 Crime151 Crime-Kidnap & Ransom200 Combined Auto Liability & P.D.-Private201 Combined Auto Liability & P.D.-Comm.300 Excess Liability (Incl. Umbrella)350 Fidelity Surety & Bonds-Bonds351 Fidelity Surety & Bonds-Fidelity400 Fire-Single Family Dwelling, Duplex401 Fire-Commercial402 Fire-Homeowners403 Fire-Homeowners Multiple Peril404 Fire-Farm Owners Multiple Peril414 Residential Earthquake450 Inland Marine500 General Liability501 Gen. Liability-Pollution Legal Liability502 General Liability-Product Tampering

510 Aviation550 Errors & Omissions-All Others551 Errors & Omission-Directors & Officers600 Malpractice-All Other606 Malpractice-Hospitals650 Miscellaneous651 Miscellaneous-Glass652 Miscellaneous-Boiler & Machinery653 Miscellaneous-Nuclear Risks655 Miscellaneous-Political Risks700 Accident701 Accident-Disability Income702 Accident-Group Health Ins.703 Accident-Ind. Health Ins.800 Garage Liability980 Excess Workers Compensation990 Commercial Property-All Risk994 Commercial Property-Special Multi-Peril996 Commercial Property-DIC997 Commercial Property-Earthquake998 Commercial Property-Terrorism999 Commercial Property-Special Multi-Peril

MOST COMMON MISTAKES MADEPlease make sure your binding request contain an accurate SL-2. The following are the most common SL-2 errors:

1. Full name of individual submitting the SL-2 (Section 1)2. Address of insured matches address on Acord application (Section 2)3. Sufficient and adequate diligent efforts were taken (Section 6)4. Full name of admitted company (Section 7) See above under section 7(B) for the most updated current list.5. First & last name of company representative AND telephone number (Section 7)6. Signature of licensee match name on line 1 and dated

DILIGENT SEARCH REPORT(Please Refer to the Instructions on Page 3 of This Form)

1. hereby submits that he/she is:(Full Name of the Individual)

(A) Duly licensed under California Department of Insurance license number ;,

OR (B) Duly licensed and authorized to act as an endorsee on the organizational license of, California Department of Insurance license number ;,

(Name of Organization)

an (C) that he/she or said organization licensee was engaged by the insured named herein, or the insured's broker, toobtain insurance as described in this report;

an (D) is the licensee who performed or supervised this diligent search.

2. (A) Name of Insured Railworks Inc

(B) Address of Insured P.O.Box 2090(Street and Number)

Thousand Oaks, CA 91358(City) (State) (Zip Code)

(C) Description of the Risk Contractor(e.g. Laundromat, Liquor Store, -NOT TYPE OF COVERAGE)

(D) Location of Risk 269 Tennyson St(Street and Number)

Thousand Oaks, CA 91360(City) (State) (Zip Code)

(E) Type of Insurance coverage 500 - General Liability(Enter Appropriate Code Number from Pg. 3)

3. If Private Passenger Automobile Liability Insurance is identified on line 2(E), complete the following:(A) Does the insured qualify as a "Good Driver" under Section 1861.025 of the California Insurance Code?

(CHECK ONE) Yes No

(B) Does the coverage that you have placed include, in whole or in part, the limits of coverage provided under theCalifornia Automobile Assigned Risk Plan (CAARP)? (CHECK ONE) Yes No

(C) If Yes, has this risk been submitted to and found to be ineligible by CAARP?(CHECK ONE) Yes No

If your answer is NO, then this coverage cannot be placed with a non-admitted insurer. (See Insurance Code section 1763.5)

4. If Health Insurance is identified on line 2(E), does the insured qualify as a "Small Employer" under Section 10700(x) ofthe California Insurance Code? (CHECK ONE) Yes No

5. If this insurance was placed pursuant to Section 125 et seq. of the Califonia Insurance Code governing transactionswith risk purchasing groups authorized by the Federal Liability Risk Retention Act of 1986, complete the following:

(A) Provide the name and address of the purchasing group of which the insured is a member

6. (A) Describe the diligent efforts made to place this coverage with admitted insurers and describe how the searchwas performed (please add additional pages if necessary):

SL-2 (Revised 06/2004)

(B) If search was performed by someone other than the person named on line 1, please provide full name of thatindividual:

7. (A) Was the risk described in Section 2 submitted by you or by someone under your supervision to at least (3) insurers thatare admitted in California and who actually write the type of insurance described on lines 2(C) and 2(E)?

(CHECK ONE) Yes No

(B) If YES, please complete ALL sections of the following table; if NO, skip to Section 8:

Full Name of Admitted Company First & Last Name of Company Check if Month, Year DeclinationRepresentative AND Telephone Employee (E) of Declination Code*Number or Agent (A)

1. E ( X )

or "Online Declination" A ( )Website

2. E ( X )


3. E ( X )


Declination Codes: 1-Company's capacity reached 2-underwriting reason 3-refused to state 4-other

8. If 7(A) was answered NO, complete the following:

(A) Did you determine that fewer than 3 admitted insurers actually write the type of insurance described on lines 2(C)and 2(E)? (CHECK ONE) Yes No

(B) If NO, please explain in detail why the risk was subitted to less than three admitted insurers in California that writethis type of insurance.

(C) If Yes, please describe how you made this determination.

The undersigned licensee hereby certifies that this report is true and correct, and that this risk is not being placed with a non-admittedinsurer for the sole purpose of securing a rate or premium lower than the lowest rate or premium available from an admitted insurer.

(Signature of Licensee Named on Line 1) (Date)

SL-2 (Revised 06/2004)

NOTICE:

1. THE INSURANCE POLICY THAT YOU ARE APPLYING TO PURCHASE IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED “NONADMITTED” OR “SURPLUS LINE” INSURERS.

2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS.

3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED.

4. THE INSURER SHOULD BE LICENSED EITHER AS A FOREIGN INSURER IN ANOTHER STATE IN THE UNITED STATES OR AS A NON-UNITED STATES (ALIEN) INSURER. YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR “SURPLUS LINE” BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE AT THE FOLLOWING TOLL-FREE TELEPHONE NUMBER: 1-800-927-4357 OR INTERNET WEB SITE WWW.INSURANCE.CA.GOV. ASK WHETHER OR NOT THE INSURER IS LICENSED AS A FOREIGN OR NON-UNITED STATES (ALIEN) INSURER AND FOR ADDITIONAL INFORMATION ABOUT THE INSURER. YOU MAY ALSO CONTACT THE NAIC’S INTERNET WEB SITE AT WWW.NAIC.ORG.

5. FOREIGN INSURERS SHOULD BE LICENSED BY A STATE IN THE UNITED STATES AND YOU MAY CONTACT THAT STATE’S DEPARTMENT OF INSURANCE TO OBTAIN MORE INFORMATION ABOUT THAT INSURER.

6. FOR NON-UNITED STATES (ALIEN) INSURERS, THE INSURER SHOULD BE LICENSED BY A COUNTRY OUTSIDE OF THE UNITED STATES AND SHOULD BE ON THE NAIC’S INTERNATIONAL INSURERS DEPARTMENT (IID) LISTING OF

http://www.naic.org/

APPROVED NONADMITTED NON-UNITED STATES INSURERS. ASK YOUR AGENT, BROKER, OR “SURPLUS LINE” BROKER TO OBTAIN MORE INFORMATION ABOUT THAT INSURER.

7. CALIFORNIA MAINTAINS A LIST OF APPROVED SURPLUS LINE INSURERS. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: WWW.INS URANCE.CA.GOV.

8. IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER’S FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU.

Date: _______________________________

Insured: _____________________________

D-1 (Effective January 1, 2017)

http://www.ins/

Railworks IncP.O.Box 2090Thousand Oaks, CA 91358

Loss Warranty Letter

During the last five (5) years, we warrant that with respect to the insurance being applied for:

1. I/We have not sustained a loss,2. I/We have not had a claim made against us,3. I/We have no knowledge or a reason to anticipate a claim or loss.

If my business is less than five (5) years old, the above referenced warranty applies to workperformed through all my prior business entities whether as an owner or an employee.

I understand that this warranty will be incorporated into the insurance contract.

Railworks IncDBA Date

Signature of Partner, Officer, Principal or Owner Title

Warranty: The purpose of this no loss letter is to assist in the underwriting process.Information contained herein is specifically relied upon in determination of insurability. Thisletter warrants that the information contained herein is true and accurate to the best of his/herknowledge and belief. This no loss letter shall be the basis of any insurance that may beissued and will be a part of such policy. It is understood that any misrepresentation oromission shall constitute grounds for immediate cancellation of coverage or rescission ofpolicy and denial of claims, if any. It is further understood that the applicant and or affiliatedcompany is under a continuing obligation to immediately notify his/her underwriter throughhis/her broker of any material alteration of the information given.

All loan amounts under $1,000 will be subject to a $10

payment processing fee, which will be added to the

payment shown on the monthly invoce.

Originated by MW Premium Finance Corp. Lic. #2126 Serviced by PREMCO FINANCIAL CORPORATION P.O. BOX 19367 KALAMAZOO, MI 49019-0367 Phone (269) 375-3936 fax (269) 375-6913 LENDING DISCLOSURE

Premco Financial Corp.

COMMERCIAL

6,197.88

1,479.58

4,718.30

4,718.30

473.98

5,192.28

23.5%

Orr and Associates28780 Single Oak,Dr#255Temecula, CA 92590951-506-5859

Railworks IncP.O.Box 2090Thousand Oaks, CA 91358805-492-8058

576.92 2/10/2017 10 9

1/10/2017AMTrust International Underwriters Ltd.Administered by:Shield Commercial Insurance Services, Inc.

GL 124,946.00

Fee: 769.00Tax: 182.88

Broker Fee: 300.00TOTAL: 6,197.88

Railworks Inc

P REMCO FINANCIAL CORPORATION

(269) 375-3936 ph• (269) 375-6913 fax po

box 19367• kalamazoo, mi 49019-0367

www.go-premco.com

EFT AUTHORIZATION AGREEMENT Account Information: You are the Agent the Insured

Name: PREMCO Loan / Quote #:

Address:

I (we) hereby make, constitute, appoint and authorize Premco Financial Corporation, hereinafter called COMPANY, as my/our true and lawful attorney to charge to my/our account at the financial institution named below, hereinafter-called DEPOSITORY, and to credit the same to my account with COMPANY. I/We acknowledge that charges to my/our account will occur in accordance with my/our Loan / Quote# as indicated above (and subsequent accounts) and may be adjusted or corrected for events including but not limited to endorsements, administrative error, and/or insufficient funds until my/our account balance is paid in full.

Bank Account Information

Bank Name: City: State:

Routing # Account # Type: □Checking □Savings

This Power of Attorney and authorization is to remain in full force and effect for this account and all of my/our subsequent accounts until COMPANY has received written notification from me (us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it, but in no event will occur later than three business days prior to the scheduled date of transaction. I/We further understand that sufficient funds must be available at the time each transfer is processed. In the event that there are insufficient funds, Premco will charge up to the maximum NSF fee permitted by law. If this authorization is for a Corporation or LLC, the undersigned is an officer of said Corporation or a member of the LLC and authorized to execute this authorization on behalf of the Corporation or LLC.

Tape a voided check (checking) or deposit slip (savings) here. Please verify that the account and routing transit numbers are correct.

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Signatures: DO NOT SIGN UNLESS YOU HAVE READ AND UNDERSTAND ALL TERMS AND CONDITIONS OF THIS DOCUMENT

Name: (Please Print)

Signed: Date:


Signed: Date:


Signed: Date:

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