General Liability Endorsement
A. GENERAL LIABILITY POLICY INFORMATION
1. Insurance Company
2.Policy No. Policy Term (from) (to)
3. Endorsement effective date Endorsement expiration date
4. Name of Insured
5. Address of Named Insured
6. Address of Permitted Operations
7. Deductible or Self-insured Retention (nil unless otherwise specified) $
8. Policy Limits: Occurrence $ General Aggregate: $
9. Policy Form equivalent to: CG 00 01 CG 00 02 GL 00 02
B. POLICY AMENDMENTS
This endorsement is issued in consideration of the policy premium. Notwithstanding any inconsistent statement in the policy to
which this endorsement is attached or any other endorsement attached thereto, it is agreed as follows:
1. ADDITIONAL INSURED. The City of Long Beach, its boards and commissions, and their officials, employees, and agents
are included as additional insured with respect to all loss, liability, claims, demands causes of action, damages,
settlement, expenses, and costs (including but not limited to attorney’s fees and defense and investigation expenses)
arising out of, or in any manner incident to, operations performed by or on behalf of the Named Insured related to the
permit issued by the City.
2. PRIMARY AND NONCONTRIBUTORY COVERAGE. The coverage afforded by this policy to the City, its boards and
commissions, and their officials, employees and agents shall be primary insurance. Any other insurance or self-insurance
maintained by the City, its boards, officials, employees, and agents shall be in excess of this insurance and not contribute
to it.
3. SEVERABILITY OF INTERESTS. The insurance afforded by this policy applies separately to each insured that is seeking
coverage or against whom a claim is made or a suit is brought, except with respect to the Insurer’s limit of liability.
4. CROSS LIABILITY. The naming of more than one insured under this policy shall not, for that reason alone, extinguish
any rights of one insured against another, subject to the insurer’s limit of liability.
5. CANCELLATION NOTICE: This insurance shall not be cancelled, nonrenewed, or reduced in coverage or limits except
after thirty (30) days prior written notice has been given to the City (ten (10) days prior written notice if the policy is
cancelled for nonpayment of premium). Such notice shall be addressed to the City of Long Beach at the address above.
C. INCIDENT AND CLAIM REPORTING PROCEDURES
Incident and claims are reported to the insurer at:
ATTENTION:
(Name) (Title) (Company)
ADDRESS:
TELEPHONE: ( ) FAX: ( )
D. SIGNATURE OF INSURER OR AUTHORIZED REPRESENTATIVE OF THE INSURER
I, (print name) , warra
nt that I have authority to bind the
insurance company listed above in Item A.1. and by my signature hereon do so bind this company.
SIGNATURE OF AUTHORIZED REPRESENTATIVE (original signature required) DATE
TITLE: ORGANIZATION:
ADDRESS
TELEPHONE: ( ) FAX NO. ( )
DEPA
RTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
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signature
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