Automobile Liability Special Endorsement Instructions

Please read and follow these instructions before completing and submitting this endorsement form.
1. Endorsement Number: Fill in the endorsement number if one is issued.
2. Effective Date: This field should have the date the endorsement becomes effective. For new contracts, this
date must either precede or coincide with the start date of the contract. For renewal policies, this date must
coincide with the start date of the policy period.
3. Producer: This box should contain the company name, address, and telephone number of the insurance broker
or agent that services the policy.
4. Policy Information: This box must contain the exact name of the insurance company that issued the policy, the
policy number, and the policy period.
5. Deductible And/Or Self-Insured Retention: If the policy has a deductible or self-insured retention, these must
be shown in this area. If the policy has both, then both need to be shown.
6. Named Insured & Address: This field must contain the name of the company that has the contract or
agreement with the Port. If the policy is in the name of a parent company, then the parent company should be
listed as the first named insured, followed by the name and address of the company contracting with the Port.
7. Type of Insurance: The type of insurance policy must be checked.
8. Applicability: This field is where you can limit coverage to a specific contract or agreement. In an effort to be
green and save time for everyone involved, the Port prefers that the document covers all agreements with the
Port so that it is not necessary to obtain separate documents for each agreement.
9. Other Provisions: This is a free-form text area where additional information can be included if there isnt
another designated place for the information to be provided.
10. Liability Limit: The limit should be shown in dollars, not thousands of dollars.
11. Claims: Indicate the name, address, and telephone number of the underwriters representative where claims
should be submitted (this area must be completed if the information is different than the producer).
12. Scope of Coverage: Check the box for each type of vehicle covered by the policy.
13. Authorized Representative: The first line should be the printed name of person signing the document. The
signature, title, employer of the person signing the form, telephone number, and date signed all need to be
completed.

Note: This is a stand-alone endorsement form; it is not a certificate of insurance. Any reference to the
policy terms and/or conditions will require that this endorsement form be accompanied by a complete copy
of the policy. Any reference to policy forms or other endorsements will require that this endorsement form
be accompanied by a copy of the referenced form. The endorsement form may be photocopied; however, it
cannot be altered or recreated. The form must be legible and the current version of the form must be
submitted. Outdated, incorrectly completed, or incomplete endorsement forms will be rejected and
revisions or replacements will need to be provided to the Port. The endorsement form may be saved for
future use; however, before using the form, you must ensure that you are using the most current version of
the form that is available from the Ports website (www.polb.com). A link to the list of forms is here:
http://www.polb.com/economics/contractors/forms_permits/insurance.asp. The forms may be completed
directly on the computer screen, then printed, signed by an authorized representative for the insurance
company, and sent to the Port (forms sent via email or fax are acceptable as long as the forms are legible).
Revised 9-13

Print Form
Please note that this endorsement form may be photocopied; however, it may not be altered or recreated.

AUTOMOBILE LIABILITY SPECIAL ENDORSEMENT

ENDORSEMENT NO.

EFFECTIVE DATE (MM/DD/YY)

FOR THE CITY OF LONG BEACH, HARBOR DEPARTMENT

PRODUCER

POLICY INFORMATION
Insurance Company:
Policy No.:
Policy Period: (from)
Deductible $___________OR

Telephone

NAMED INSURED & ADDRESS

(to)
Self-Insured Retention of $___________

APPLICABILITY. This insurance pertains to the operations and

activities of the Named Insured under all written permits and
agreements in force with the City unless checked here
in which
case only the following specific permits and agreements with the City
are covered:
AGREEMENTS/PERMITS:

TYPE OF INSURANCE

OTHER PROVISIONS

BUSINESS AUTO POLICY

TRUCKERS AND MOTOR CARRIER LIABILITY POLICY
GARAGEKEEPERS LIABILITY
STUNT ACTIVITY
OTHER _____________________________

CLAIMS: Underwriter's Representative for claims pursuant to this

Insurance (must be completed if different than producer)

LIABILITY LIMIT IN $
Name:
$ ____________ each accident, for bodily injury and property damage

Address:

liability
Telephone: (
)
In consideration of the premium charged and notwithstanding any inconsistent statement in the policy to which this endorsement is attached or any
endorsement now or hereafter attached thereto, it is agreed as follows:

1.

ADDITIONAL INSURED. The City of Long Beach, its Board of Harbor Commissioners, individually and collectively, and their officers and
employees ("City") are included as additional insureds with regard to liability and defense of suits or claims arising from the operations and activities
performed by or on behalf of the Named Insured.

2.

CONTRIBUTION NOT REQUIRED. This insurance shall be primary. Any other insurance, deductible, or self-insurance available to the insureds
added by this endorsement shall be in excess of and shall not contribute with this insurance.

3.

CANCELLATION NOTICE. With respect to the interests of City, this insurance shall not be cancelled, or the scope or limits of coverage reduced by
endorsement, except after thirty (30) days prior written notice has been given to City at address indicated below. (Except 10 days advance notice
shall be allowed for non-payment of premium.)

4.

SCOPE OF COVERAGE. This endorsement shall afford coverage at least as broad as Insurance Services Office form number CA0001.
Symbol 1(any auto)

Symbol 2 (owned autos)

Symbol 7 (scheduled autos)

Symbol 8 (hired autos)

Symbol 9 (non-owned autos)

Except as stated above, nothing herein shall be held to waive, alter or extend any of the limits, conditions, agreements or exclusions of the policy to
which this endorsement is attached.

ENDORSEMENT HOLDER / ADDITIONAL INSURED

CITY OF LONG BEACH
BOARD OF HARBOR COMMISSIONERS
4801 AIRPORT PLAZA DR.
LONG BEACH, CA 90815
ATTENTION:
TELEPHONE:
FAX:
E-MAIL:

Risk Management Division

562-283-7475
562-283-7499
riskmgmt@polb.com

AUTHORIZED REPRESENTATIVE
I __________________________(print/type name), warrant that I have
authority to bind the above-mentioned insurance company and by my
signature hereon do so bind this company to this endorsement.
Signature _____________________________________
Title ___________________________________________
Employer of Signatory ______________________________
Telephone: (

Revised 3-14

) _______________ Date Signed _______________