Loading...
PROOF OF INSURANCE (2022 - 2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/7/6/2021 Y) 021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 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 NOT 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 require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Cornerstone Kansas City, LLC 4400 College Blvd. Ste. 350 Overland Park KS 66211 NAME: Jerri Fulkerson ACNE. Ext: t913)378-1050 A/C, NO: (913)378-0399 E-MAIL certificates@ckcins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Philadelphia Indemnity Insurance Compar 18058 INSURED VincentBenjamin Group LLC 2415 East Camelback Road Suite 1000 Phoenix AZ 85016 INSURER B: Sentinel Insurance Company Ltd 11000 INSURERC:Allied World Specialty Insurance Co 16624 INSURER D: INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: CL2161829924 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE ❑OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 X MED EXP (Any one person) $ 5,000 Retro 6/26/2009 PHPK2288623 6/25/2021 6/25/2022 PERSONAL & ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 ❑PRO JECTFX LOC 2,000,000POLICY $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ A ANYAUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PHPK2288623 6/25/2021 6/25/2022 X PROPERTY DAMAGE Per accident)$ NON -OWNED HIRED AUTOS M AUTOS X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 A EXCESS LAB CLAIMS -MADE DED X RETENTION $ 10,000 $ PHUB772626 6/25/2021 6/25/2022 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N X PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N /A 59WEZT2245 1/14/2021 1/14/2022 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 C EPLI including Third Party 0310-2092 6/25/2021 6/25/2022 Each Occ/Aggregate $2M/$2M A Professional Liab.- Tech E&O PHPK2288623 6/25/2021 6/25/2022 Each Occ/Aggregate $1M/$3M DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION pharada@elsegundo.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk's Office ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 David Parkhurst/BM ACORD 25 (2014/01) INS025 (201401) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IHIS ENDORSEMENT CPJh14('3ES 71,,,fIE F111' LACY., PL.E"ASE READ IT CNIREEF1.11.,,,III,.,, Y. This endorsement modifies insurance provided under the following: It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposure is provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits of Insurance and additional coverage provided by this endorsement. For complete details on specific coverages, consult the policy contract wording, Coverage Applicable Limit of Insurance Page Damage to Premises Rented to You $1,000,000 2 Expected or Intended Injury — Property Damage Included Limited Rental Lease Agreement Contractual Liability $50,000 2 Non -Owned Watercraft Less than 56 feet 3 Damage to Property You Own, Rent or Occupy $30,000 3 Medical Payments $20,000 3 Medical Payments Reporting Period 3 Years 3 Athletic Activities Amended 3 Supplementary Payments — Bail Bonds _ $2,500 4 Supplementary Payments — Loss of Earnings $500 per day 4 Employee Indemnification Defense Coverage $25 000 4 Who Is An Insured Included 4 Additional Insured — Newly Acquired or Formed Organization Additional Insured — Broadened Named Insured Additional Insured — Blanket Additional Insureds When Required by Contract Duties in the Event of Occurrence, Offense, Claim or Suit Include 4 Transfer of Rights of Recovery Against Others To Us Clarification 5 Liberalization Included 5 Unintentional Failure to Disclose Hazards Included 5 Bodily Injury— Includes Mental Anguish Included 5 Personal and Advertising Injury — Includes Abuse of Process, Included 6 Discrimination Other Insurance —Primary Clarification Clarification PI-GLD-TS (11115) Page 1 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission, PHPK2149134 Staffing Services Exclusions Clarification 7 Staffing Services Definitions Clarification B A. Damage to Premises Rented to You If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part: 1. The Damage To Premises Rented To You Limit section of the Declarations is amended to the greater of: a. $1,000,000; or b. The amount shown in the Declarations as the Damage to Premises Rented to You Limit. This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof; 2. The word fire is changed to fire, lightning, explosion, smoke, or leakage from automatic fire protective systems where it appears in: a. The last paragraph of SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions; b. SECTION III — LIMITS OF INSURANCE, Paragraph 6.; and c. SECTION V — DEFINITIONS, Paragraph 9.a.; and 3. The words fire insurance are changed to insurance for fire, lightning, explosion, smoke, or leakage from automatic fire protective systems where it appears in SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4. Other Insurance, Paragraph b. Excess Insurance. B. Expected or Intended Injury — Property Damage SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclusions, Paragraph a. Expected Or Intended Injury is deleted in its entirety and replaced by the following: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. C. Limited Rental Lease Agreement Contractual Liability SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclusions, Paragraph b. Contractual Liability is amended by adding the following: Based on the named insured's request at the time of claim, we agree to indemnify the named insured for their liability assumed in a contract or agreement regarding the rental or lease of a premises on behalf of their client, up to $50,000. PI-GLD-TS (11/15) Page 2 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. PHPK2149134 This coverage extension only applies to rental lease agreements and is excess over any renter's liability insurance of the client. D. Non -Owned Watercraft SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclusions, g. Aircraft, Auto Or Watercraft, Paragraph (2) is amended to read as follows: (2) A watercraft you do not own that is: (a) Less than 58 feet long; and (b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingent. E. Damage to Property You Own, Rent or Occupy SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclusions, j. Damage To Property, Paragraph (1) is deleted in its entirety and replaced with the following: (1) Property you own, rent or occupy, including any costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property, unless the damage to property is caused by your client, up to a $30,000 limit. A client is defined as a person under your direct care and supervision. F. Medical Payments 1, If COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part the Medical Expense Limit is changed subject to all of the terms of SECTION III — LIMITS OF INSURANCE to the greater of: a. $20, 000; or b. The Medical Expense Limit shown in the Declarations of this Coverage Part. 2. Under SECTION I — COVERAGES, COVERAGE C MEDICAL PAYMENTS, Subsection 1. Insuring Agreement, Paragraph a., Item (b) is amended to read: (b) The expenses are incurred and reported to us within three years of the date of the accident; and G. Athletic Activities SECTION I — COVERAGES, COVERAGE C MEDICAL PAYMENTS, 2. Exclusions, Paragraph e. Athletics Activities is deleted in its entirety and replaced with the following: PI-GLD-TS (11115) Page 3 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission, ill111K214913d e. Athletics Activities To a person injured while taking part in athletics, H. Supplementary Payments SECTION I — COVERAGES, SUPPLEMENTARY PAYMENTS — COVERAGES A AND B, Items 1.b. and 1.d. are amended as follows: b. The limit for the cost of bail bonds is changed from $250 to $2,500; and d. The limit for loss of earnings is changed from $250 a day to $500 a day. I. Employee Indemnification Defense Coverage SECTION I — COVERAGES, SUPPLEMENTARY PAYMENTS — COVERAGES A AND B is amended to include the following: We will pay, on your behalf, defense costs incurred by an "employee" in a criminal proceeding. The most we will pay for any "employee" who is directly involved in a criminal proceeding is $25,000 regardless of the numbers of "employees," claims or "suits" brought or persons or organizations making claims or bringing "suits." J. Who is An Insured SECTION II — WHO IS AN INSURED is amended as follows 1. Newly Acquired or Formed Organization If coverage for newly acquired or formed organizations is not otherwise excluded from this Coverage Part, Paragraph 3. is deleted in its entirety and replaced with the following. - Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as an insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded until the end of the policy period; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. 2. Each of the following is also an insured: a. Broadened Named Insured — Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, coverage does not apply to any organization or subsidiary not named in the Declarations as Named Insured, if they are also insured under another similar policy, but for its termination or the exhaustion of its limits of insurance. PI-GLD-TS (11/15) Page 4 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. b. Blanket Additional Insureds When Required by Contract — Any person or organization where required by a written contract executed prior to the occurrence of a loss. Such person or organization is an additional insured for "bodily injury," "property damage" or "personal and advertising injury" but only for liability arising out of the negligence of the named insured. The limits of insurance applicable to these additional insureds are the lesser of the policy limits or those limits specified in a contract or agreement. These limits are included within and not in addition to the limits of insurance shown in the Declarations c. Interns — Your interns only while performing duties related to the conduct of your business, 1. SECTION IV —COMMERCIAL GENERAL LIABILITY CONDITIONS, you must see to it that we are notified as soon as practicableaoor ►: applies to: a. You, if you are an individual; b. A partner, if you are a partnership; or c. An "executive officer' or insurance manager, if you are a corporation.. c. +► �' •i a �, w'M 10,144 0'VNIIII , K111,111Known I'll c. An "executive officer" or insurance manager, if you are a corporation. ,T y r a *rrT +r provideds written contract M. Liberalization SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is amended to include the following additional condition: PI-GLD-TS (1Ill 5) Page 5 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission., PHPK2149134 revision is effective in your state. N. Unintentional Failure To Disclose Hazards SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is amended to include the following additional condition: Unintentional Failure To Disclose Hazards It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. O. Bodily Injury— Mental Anguish SECTION V — DEFINITIONS, Paragraph 3. is amended to read: "Bodily injury": a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these; and b. Except for mental anguish, includes death resulting from the foregoing (Item a. above) at any time. P. Personal and Advertising Injury — Abuse of Process, Discrimination If COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is not otherwise excluded from this Coverage Part, the definition of "personal and advertising injury" is amended as follows: 1. SECTION V — DEFINITIONS, Paragraph 14., Item b. is revised to read: b. Malicious prosecution or abuse of process; 2. SECTION V — DEFINITIONS, Paragraph 14. is amended to include the following: "Personal and advertising injury" also means discrimination based on race, color, religion, sex, age or national origin, except when: a. Done intentionally by or at the direction of, or with the knowledge or consent of: (1) Any insured; or (2) Any executive officer, director, stockholder, partner or member of the insured; or b. Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an insured; or c. Directly or indirectly related to the sale, rental, lease or sublease or prospective sale, rental, lease or sub -lease of any room, dwelling or premises by or at the direction of any insured; or PI-GLD-TS (11/15) Page 6 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. PHPK2149134 d. Insurance for such discrimination is prohibited by or held in violation of law, public policy, legislation, court decision or administrative ruling. The above does not apply to fines or penalties imposed because of discrimination. 0. Section IV— Commercial General Liability Conditions is amended by the addition of the following: The following language is added to Item 4. Other Insurance: Insurance under this endorsement is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or "occurrence" we cover for this Additional Insured, R. Staffing Services Exclusions The following exclusions are added to SECTION I — COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE: Actions Or Activities Of PEO Worker "Bodily injury" or "property damage" arising from the actions or activities of any "PEO worker". Professional Services Exclusion "Bodily injury" or "property damage" due to the rendering of or failure to render any professional service. This exclusion does not apply to your liability for "bodily injury" or "property damage" arising out of your "employee's" providing or failing to provide professional health care services to another of your "employees", but no "employee" is an insured for his or her providing or failure to provide such professional health care services. Wrongful Acts "Bodily injury" or "property damage" arising from a wrongful act in the rendering or failure to render services to or for your client. For the purposes of this exclusion, wrongful act shall mean any actual or alleged act, error, or omission, misstatement, or misleading statement in the course of providing "staffing services" to your clients by you or by any person for whose acts you are legally responsible. SECTION I — COVERAGES, COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is amended as follows: 1. Exclusion k. does not apply. 2. Exclusions a., b., e., f., g., h., i., I., and p, do not apply to any insured who did not personally acquiesce in or remain passive after having personal knowledge of such conduct. Our obligation to pay shall begin once the full extent of the assets of the responsible insured has been exhausted and once the Deductible as shown in the Declarations of the policy has been satisfied,. 3. The following exclusions are added to Paragraph 2. Exclusions: Actions Or Activities Of PEO Worker PI-GLD-TS (11/15) Page 7 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. l' I II K2 ]I 9134 "Personal and advertising injury" arising from the actions or activities of any "PEO worker Professional Services Exclusion "Personal and advertising injury" due to the rendering of or failure to render any professional service, Wrongful Acts "PersonM and advertising injury" arising from a wrongful act in the rendering or failure to render services to or for your client, For the purposes of this exclusion, wrongful act shall mean any actual or alleged act„ error, or omission, misstatement, or misleading statement in the course of providing "staffing services" to your clients by you or by any person for whose acts you are legally responsible. S. Staffing Services Definitions 10 SECTION V — DEFINITIONS, Paragraph 5. is revised to read. "Employee" includes but is not limited to a "leased worker" and a "staffing service employee "Employee" does not include a "temporary worker" or a "PEO workerr'. 1 The following definitions are added to SECTION V — E INITIO S- as "PEO service" means staffing related services as a Professional Employer Organization (PEO) you provide to your clients and to "PEO workers" in connection with employment of such workers. b� "PEO worker" means a person you lease to your client under a written "PEO service" agreement or contract. c. "Staffing Services" means services provided by a staffing company to their clients including but not limited to: (1) Fulfillment of any of the administrative functions which would otherwise be normally fulfilled by an employer's human resource function; (2) Staffing related administrative services provided by an Administrative Services Organization (ASO); () "PEO service"; () Staffing related services provided to your clients for the recruitment, selection and placement of a person for employment with a client. (5) Temporary, contingent or contract placement services; () Vendor Management Service (VMS), means the facilitation, purchase and management of "staffing services" for clients including the placement and fulfillment of orders for °staffing service employees", (T) Services performed on behalf of your client by a "staffing service employee" who is not a direct hire or permanent placernenti PI-GLD-TS (11115) Page 8 of 9 includes copyrighted material of Insurance Services Office, Inc., with its permission. 1911119�I (8) Services performed for a client company to supply that client company with a "staffing service employee". d. "Staffing service employee" means a person who is furnished by you to your client to perform the duties to which you have agreed. PI-GLD-TS (11/15) Page 9 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ALTERNATE EMPLOYER ENDORSEMENT Policy Number: 59 WE ZT2245 Endorsement Number: Effective Date: 01/14/21 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: VINCENTBENJAMIN GROUP LLC 2415 E CAMELBACK RD STE 1000 PHOENIX AZ 85016 This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be cancelled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. SCHEDULE 1. Alternate Employer Guidant Global, Inc. 2. State of Special or Temporary Employment CO Contract or Project Computer - Programming Work Countersigned by Address 720 S Colordo Blvd, Denver, CO 80246 Authorized Representative Form WC 00 03 01 A Printed in U.S.A. Process Date: 01 /14/21 Policy Expiration Date: 01/14/22 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Policy Number: 59 WE ZT2245 Endorsement Number: Effective Date: 01/14/21 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: VINCENTBENJAMIN GROUP LLC 2415 E CAMELBACK RD STE 1000 PHOENIX AZ 85016 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 named in the Schedule. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.. SCHEDULE Any person or organization for whom you are required by contract or agreement to obtain this waiver from us. Endorsement is not applicable in KY, NH, NJ or for any MO construction risk Countersigned by Authorized Representative Form WC 00 03 13 Printed in U.S.A. Process Date: 01 /14/21 Policy Expiration Date: 01/14/22 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 59 WE ZT2245 Endorsement Number: Effective Date: 01/14/21 Effective hour is the same as stated on the Information Page of the policy, Named Insured and Address: VINCENTBENJAMIN GROUP LLC 2415 E CAMELBACK RD STE 1000 PHOENIX AZ 85016 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 named 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 from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description Any person or organization for whom you are required by written contract or agreement to obtain this waiver of rights from us Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 01 /14/21 Policy Expiration Date: 01/14/22