Sample Certificate of Insurance (Example ONLY - See “Exhibit G” CCIP Addendum for requirements) Endorsements are required Subcontractor’s Insurance Broker Name of Subcontractor (It should match the name as written in the Subcontract) Current dates are required Claims Made or Modified Occurrence is not acceptable The two “each” occurrence boxes should total at least as much as required in your contract Boxes must be checked. This section is to evidence Professional Liability or Pollution Liability if required by contract. See Exhibit “G” CCIP Addendum (as required by contract) (as required by contract) Provide these lines of coverage as required by your contract with CF Jordan. See Exhibit “G” CCIP Addendum The totals in each box should be at least $1,000,000 Enrolled Signed by the Broker only This should name CF Jordan Construction LLC with full corporate office address CFJORDAN_SAMPLECERT.CDR(CONST/SAMPLE CERTIFICATES/13) POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR ORGANIZATION 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) A. Section II – Who Is An Insured is amended to include as an insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured(s). B. With respect to the insurance afforded to these additional insureds, the following exclusions is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. We will accept manuscript and blanket additional insured endorsements as long as the coverage is equivalent or greater than the CG 20 10 1001 CG 20 10 10 01 ISO Properties, Inc., 2000 Page 1 of 1 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 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: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Location and Description of Completed Operations: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II – Who is an Insured 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” at the location designated and described in the schedule of the endorsement performed for that insured and included in the “productscompleted operations hazard”. We will accept manuscript and blanket forms as long as the coverage is equivalent or greater than the CG 20 37 1001 CG 20 37 10 01 Copyright, ISO Properties, Inc. 2000 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION – CERTIFICATE HOLDERS The person(s) or organization(s) listed or described in the Schedule below have requested that they receive written notice when this policy is cancelled, or materially altered as determined by us, prior to the expiration date. We will mail or deliver to the Person(s) or Organization(s) listed or described in the Schedule a copy of the written notice of cancellation that we sent to you. Such copies of the notice will be mailed within 45 days, except 10 days for non-payment of premium, of the effective date of the cancellation, to the address or addresses of certificate holders as provided by your broker or agent. SCHEDULE Person(s) or Organization(s) including mailing address: CF Jordan Construction LLC 7700 CF Jordan Drive El Paso, TX 79912 Attn: Luann Folkner This notification of cancellation of the policy is intended as a courtesy only. This endorsement does not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule above to ay benefit, rights or protection under this policy. Any provision of this endorsement that is in conflict with a statute or rule is hereby amended to conform to that statute or rule. All other terms and conditions of the Policy remain unchanged. Issued by: Insurance Company Endorsement Number: Policy Number: Named Insured: Subcontractor Name Endorsement Effective Date: