PROOF OF INSURANCE (2022) CLOSEDOAT061252021
CERTIFICATE OF LIABILITY INSURANCE
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: It the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. It
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 CONTACT
Aon Risk Services Central, Inc, NAME..
Omaha NE Office per, Na, Ext); (402) 697-1400 NO ! (402) 697-0017
17807 Burke Street EMAIL
Suite 401 ADDRESS:
Omaha NE 68118 USA
INSURER(S) AFFORDING COVERAGE NAIC q
INSURED
Musco Sports Lighting, LLC
c/o Musco corporation
100 15t Ave W
Oskaloosa IA 52577 USA
INSURER A: Sentry Insurance Company
'..24988
INSURER 0: sentry Casualty Company
INSURER C: Travelers Property Cas Co Of America
28460
25674
INSURERD: Indian Harbor insurance company
36940
INSURER E;
...........
INSURER F:
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 CONTRACT 08 OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN tS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as re uesled
RXP
1 TYPE OF INSURANCE INSD VyVn POLICY NUMBER ,Mph yyryy ML'W 'y yyy LIMITS
X
COMMERCIAL GENERrA-L LIABILITY
EACH OCCURRENCE
$1,000,000
X II CLAIMS -MADE @ OCCUR
k�IIEE wII P Rn arreauro
$300, 000
NED EXP (Any one person)
S10, 000
PERSONAL& AOV INJURY
S1,000,000
GEN'L AGGREGGAAT�E LIMITAPPLIES PER:
GENERALAGGREGATE
$2,000,000
POLICY y do IPRO iX LOC
L.....7 J'ECT L�
PRODUCTS - COIdP/OP AGO
52,000, 000
OTHER:
A
AUTOMOBILE LIABILITY
9016977-003
07/01/202107/01/2022
COMBINED SINGLE LIMIT
51,000,000
X ANYAUTO
BODILY INJURY ( Per person)
BODILY INJURY (Per accident)
'..
OWNED SCHEDULED
- AUTOS ONLY AUTOS
X HIREDAUTOS X NON -OWNED
PROPERTY DAMAGE
ONLY AUTOS ONLY
IPor accident)
X
UMBRELLALIAB X OCCUR
CUP3S6333 6021NF
07 U1 20210
011202
EACH OCCURRENCE
S10,060,00N
LC
EXCESS LIAR CLAIMS -MADE
AGGREGATE
S10,000,000
OED X RE1"ENT10N S10, 004
B
WORKERS COMPENSATION AND
9 1 77 0
77. .. .
0 1 " 0' 2
PER STATUTE OTH.:
X R
EMPLOYERS' LIABILITY
E.L,EACH ACCIDENT
$1,000,000i
B
7
�ICERIMEM °".JI
N/A
9016877002
07/01/2021..07/01/2022
ERIEXCLUDED7EXECUTIVE
(Mandatory In NFQ II'
AZ, WI
E.L. DISEASE -EA EMPLOYEE
ry �.
$1, 000, 000
If yyes, & c4bo under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
S1,000,000
0 Archit&Eng Prof 07/01/2021 07/O1/2022 AAgggregate S5-made,000,000
CE0742113901
lr�
SIR applies per policy ter' s & condiions Each claim 55,000,000
' DESCRIPTION OF OPERATIONS ) LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached I1 more space to required)
'RE: Musco Project No. SVC-450542 - Recreation Park - El Segundo. city of El Segundo, its Officers officials, employees,
agents and volunteers are included as Additional Insured in accordance with the policy provisions otit the General Liability and °
Automobile Liability policies. General Liability and Automobile Liability policies evidenced herein are Primary and
Non -Contributory to other insurance available to an Additional Insured, but only in accordance with the policy's provisions. A'.j
Waiver Subrogation is in favor Certificate Holder in the the
of granted of accordance with policy provisions of General
Liability, Automobile Liability and workers' Compensation policies. I
I
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
City Of El Segundo AUTHORIZED REPRESENTATIVE '
350 Main Street
El Segundo CA 90245 USA od re!:
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
SENTRY INSURANCE A MUTUAL COMPANY
STEVENS POINT, WISCONSIN
(A PARTICIPATING MUTUAL COMPANY)'
A -MEMBER OF THE'SENTRY FAMILY OF•INSURANCE COMPANIES
COMMERCIAL GENERAL LIABILITY
NAMED INSURED• ENDORSEMENT EFFECTIVE POLICY'NUMBER
MUSCO CORPORATION 07-01-21 90'-16877-04
ADDITIONAL'INSURED - OWNERS', LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
------- -- ----------.--------------------------------------------------
INAME OF•ADDITIONAL.INSURED PERSON(S) OR ORGANIZATIONS) -I
--------------------------------------------------------------- ---------
]ANY & ALL OWNERS, LESSES OR CONTRACTORS I
f----------------------------------------------------------.------------+
ILOCATION(S) OF COVERED'OPERATIONS I
+-----------------------------------------------------------------------+
ANY -AND ALL PROJECTS FOR WHICH:THE CONTRACT REQUIRES COVERAGE I
FOR COMPLETED OPERATIONS ]
*---------------------------------------------------------__---_-_------T
IInformation:required to complete this Schedule, if not shown above, I
]will be shown in the Declarations. I
-----__---------_------------------------------------------------------ -
CG' 20 10 04 13
Copyright, Insurance Services Office, Inc., 2012
MUS 90-16877-04 01 191
PAGE 001 of 002
#03
00707
OITIBORG
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION - CONTINUED
A. Section II - WHO IS AN INSURED is amended to include as an additional
insured the person(s) or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury", "property damage"
or "personal and advertising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional
insured(s) at the location(s) designated above.
However:
1. The insurance afforded to such additional insured only applies to
the extent permitted by law; and
2. If coverage provided to the additional insured is required by a
contract or agreement, the insurance afforded to such additional
insured will not be broader than that which you are required by
the contract.or agreement to provide for such additional insured.
B. With respect to the insurance afforded to these additional insureds,
the following additional exclusions apply:
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 location of
has been completed; or the covered operations
2. That portion of "your work" out of which the injury or damage
arises has been put to its intended use by anyperson or
organization other than another contractor or subcontractor
engaged in performing operations for a principal as a part of the
same project.
C. With respect to the:insurance afforded to these additional insureds,
the following is added to SECTION:III - LIMITS OF INSURANCE:
If coverage provided to the additional insured is required by a
contract or agreement, the most we will pay on behalf of the
additional insured is the amount of insurance.
1. Required by the contract -or agreement; or
2. Available under the applicable Limits of Insurance shown in the
Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of
Insurance shown in the Declarations.
CG 20 10 04 13
Copyright; Insurance Services Office, Inc., 2012
MUS 90-16877-04 01 191
PAGE _002 of 002
OITIOONG 00708
COMMERCIAL GENERAL LIABILITY
CG 20 37 04 13
POLICY NUMBER: 90-16877-04
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
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
NAME OF ADDITIONAL INSURED PERSON(S) LOCATION AND DESCRIPTION
OR ORGANIZATION(S) OF COMPLETED OPERATIONS
+.-.--_.- ---.----------- ---I - -„--__.--_-__------_--..........+
ANY AND ALL OWNERS, LESSEES OR
CONTRACTORS
ANY AND ALL PROJECTS FOR WHICH
THE CONTRACT REQUIRES COVERAGE
FOR COMPLETED OPERATIONS
------------------------------------ ---------------------------------
Iwill be shown nthe Declarations.
1f not shown above
Information required to complete this Schedule
+W-------- ------,----_--------.--,----- ------.--.,.-----------___---,-.
A. SECTION II - WHO IS AN INSURED is amended to include as an additional
insured the persons) or organization(s) shown in the Schedule, but
only with respect to liability for "bodily injury" or "property
damage" caused, in whole or in part, by "your work" at the location
designated and described in the Schedule of this endorsement
performed for that additional insured and included in the "products -
completed operations hazard".
However:
1. The insurance afforded to such additional insured only applies to
the extent permitted by law; and
2. If coverage provided to the additional insured is required by a
contract or agreement, the insurance afforded to such additional
insured will not be broader than that which you are required by
the contract or agreement to provide for such additional insured.
CG 20 37 04 13
Copyright, Insurance Services Office, Inc., 2012
MUS 90-16877-04 01 191
#AGE 001 OF 002
COMMERCIAL GENERAL LIABILITY
ADDITIONAL INSURED - OWNERS LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS - CONTINUED
B. With respect to the insurance afforded to these additional insureds,
the following is added to SECTION III - LIMITS OF INSURANCE:
If coverage provided to the additional insured is required by a
contract or agreement, the most we will pay on behalf of the
additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Insurance shown in the
Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of
Insurance shown in the Declarations.
CG 20 37 04 13
Copyright, Insurance Services Office, Inc., 2012
MUS 90-16877-04 01 191
PAGE 002 OF 002
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
NAMED INSURED ENDORSEMENT EFFECTIVE POLICY NUMBER
MUSCO CORPORATION 07-01-21 90-16877-04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
--------------_-.-.----_..----.----.....------ -_-- -,-,---_----------
INAME OF PERSON OR ORGANIZATION:
�IALL WRITTEN CONTRACTS PROVIDED SUCH
CONTRACT WAS MADE PRIOR TO LOSS.
+-----------------------------------------------------------------------+
Ilnformation required to complete this Schedule, if not shown above,
(will be shown in the Declarations.
+-----------------------------------------------------------------------+
The following is added to Paragraph B. TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US of SECTION IV - CONDITIONS:
We waive any right of recovery we may have against the person or organi-
zation shown in the Schedule above because of payments we make for injury
or damage arising out of your ongoing operations or "your work" done
under a contract with that person or organization and included in the
"products -completed operations hazard". This waiver applies only to the
person or organization shown in the Schedule above.
CG 24 04 05 09
Copyright, Insurance Services Offices, Inc., 2008
MUS 90-16877-04 01 201
PAGE 001
OITIBORG 01561
SENTRY CASUALTY COMPANY
Carrier Code No. 37877
WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLI
POLICY NUMBER: 90-16877-01 00 201
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
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.)
This agreement shall not operate directly or indirectly to benefit
any one not named in the Schedule.
Schedule
"ALL WRITTEN CONTRACTS PROVIDED SUCH CONTRACT WAS MADE PRIOR TO LOSS"
WC 00 03 13 (Ed. 04-84)
Copyright 1983 National Council on Compensation Insurance.
MUS 90-16877-01 00 201 MUSCO CORPORATION
PAGE 001
o,T,BORG 01028
0
COMMERCIAL GENERAL LIABILITY
CG 20 01 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to the OTHER INSURANCE Condition and supersedes
any provision to the contrary:
PRIMARY AND NONCONTRIBUTORY INSURANCE
This insurance is primary to and will not seek contribution from any
other insurance available to an additional insured under your policy
provided that:
(1) The additional insured is a Named Insured under such other
insurance; and
(2) You have agreed in writing in a contract or agreement that this
insurance would be primary and would not seek contribution from
any other insurance available to the additional insured.
CG 20 01 04 13
Copyright, Insurance Services Office, Inc., 2012
MUS 90-16877-04 01 191
PAGE 001
o1T1B0% 00784
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ'IT CAREFULLY.
NOTICE OF CANCELLATION - CERTIFICATE HOLDERS
This endorsement modifies the coverage provided under the following:
BUSINESSOWNERS COVERAGE FORM
COMMERCIAL AUTOMOBILE COVERAGE PARTS
COMMERCIAL PROPERTY COVERAGE PART
CRIME AND FIDELITY COVERAGE PART
COMMERCIAL INLAND MARINE COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PARTS
COMMERCIAL EXCESSIUMBREL•LA LIABILITY"COVERAGE FORM
EMPLOYMENT RELATED: PRACTICES LIABILITY
POLLUTION LIABILITY COVERAGE
ERRORS AND OMISSIONS COVERAGE -FORM
In the event we can cancel this policy, we shall endeavor to•also mail to
the person(s) or. organization(s)'listed in the Schedule for this endorsement,
advance written notice of cancellation.
This notification of cancellation of -the policy is intended as a courtesy
only. Our failure to provide such notification to the Person(s) or
organizations) shown.in the Schedule will•not.extend any policy cancel-
lation 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 below to any benefit, rights or protection
under this policy.
Failure by us to provide this notice of cancellation-to•the person(s)
or organization(s) listed or described in the Schedule below will not
impose liability of any kind upon us.
Any of these provisions that conflict with a law that controls the notice -
of cancellation of the insurance in this endorsement is changed by this
statement to comply with the law.
SCHEDULE-
Person(s) or Organization(s) including mailing address:
PER SCHEDULE ON FILE WITH AGENT
30 DAY NOTICE OF CANCELLATION
All other terms and conditions of this policy remain unchanged.
IL 70 58 02 14
MUS 90-16877-03 00 191
PAGE 001
oirleoac 00666
COMMERCIAL AUTO
CA 80 07 06 18
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - AUTOMATIC STATUS WHEN
REQUIRED BY CONTRACT OR AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
A. The Who Is An Insured provision of Covered
Autos Liability Coverage is amended to include
as an additional insured any person or
organization for whom you are performing
operations when you and such person or
organization have agreed in writing in a contract
or agreement that such person or organization be
added as an additional insured on your policy.
The status of an additional insured under this
endorsement ends when your operations for that
additional insured are completed.
B. The most we will pay on behalf of the additional
insured is the lesser of the amount payable under
the Limit of Insurance for Covered Autos
Liability Coverage or the amount of insurance
required by the contract or agreement.
C. Notwithstanding any requirement, term or
condition of any contract or agreement with
respect to which this endorsement may pertain,
the insurance afforded to the additional insured is
subject to all the terms, exclusions and conditions
of the COMMERCIAL AUTO COVERAGE FORM
to which this endorsement is attached.
CA 80 07 06 18 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1
with its permission.
0
COMMERCIAL AUTO
CA 04 44 10 13
POLICY NUMBER: 90-16877-03 00 191
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
WAIVER OF TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS TO US
(WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following.:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to -coverage provided by this endorsement, the provisions of
the Coverage Form apply unless modified by the endorsement.
This endorsement changes the.policy effective on the inception date of
the policy unless another date is indicated below.
+--------------.------------------- --------------------------------------+
INAMED'INSURED: MUSCO•CORPORATION- I
I ENDORSEMENT EFFECTIVE DATE: 07-01-21
I
SCHEDULE
+-----------------------------------------------------------------------+
INAME(S-) OF PERSON(S) OR ORGANIZATIONS(S):
l'TOLLWRITTEN CONTRACTS PROVIDED SUCH CONTRACT WAS MADE PRIOR
+-------------------^-----------..-----------------------..--------__-w---
IInformation required to complete this:Schedule, if not shown above,
Iwill be shown in the Declarations.
+---------------------..__..---,-------------------------_...._..-.-----_ -----
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition does
not apply to the person(s) or organizations(s) shown in the Schedule, but,
only to the extent that subrogation isiwaived prior to the "accident" or
the "loss" under a contract with that person or organization.
CA 04 44 10 13
Copyright, Insurance Services Office, Inc., 2011
MUS 90-16877-03 00 191
Page ::01
oiivaonc 00649
POLICY NUMBER: 901687703
COMMERCIAL AUTO
CA 76 01 06 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED - PRIMARY AND
NONCONTRIBUTORY - COVERED AUTOS
LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
AUTO DEALERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage
under the Who Is An Insured provision of the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is
indicated.
Named Insured: MUSCO CORPORATION
Endorsement Effective Date: 07-01-2021
SCHEDULE
Name Of Person(s) Or Organization(s):
ANY PERSON OR OGRANIZATION THAT HAS A WRITTEN CONTRACT
PROVIDED SUCH CONTRACT WAS MADE PRIOR TO LOSS
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Each person or organization shown in the
Schedule is an "insured" for Covered Autos
Liability Coverage, but only to the extent that
person or organization qualifies as an "insured"
under the Who Is An Insured provision contained
in:
(1) Paragraph A.I. of Section II - Covered Autos
Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms; or
(2) Paragraph D.2. of Section I - Covered Autos
Coverages of the Auto Dealers Coverage
Form.
CA 76 01 06 15
MUS 90-16877-03 00 191
1 D0001 0000000029 19187 0 N
B. Primary And Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other auto insurance issued
to the person or organization in the schedule
under your policy provided that:
(1) The person or organization is a Named Insured
under such other insurance; and
(2) Prior to the "accident" you have agreed in
writing in a contract or agreement that this
insurance would be primary and would not
seek contribution from any other insurance
available to the person or organization.
Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1
with its permission.
2A017196 -D5A2 -45CA -9141-19470AWMC
NAMED INSURED ENDORSEMENT EFFECTIVE POLICY NUMBER
MUSCO CORPORATION 07-01-21 90-16877-01
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELATION-CERTIFICATE HOLDERS
WORKERS COMPENSATION
The person(s) or organization(s) listed or described in the Schedule
below have requested that they receive written notice of cancelation•when
this policy is cancelled by us. 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 cancelation that we sent to you. Such copies of the
notice will be mailed as soon as practicable to the address or addresses
provided by your broker or agent.
This notification of cancelation of the policy is intended as a courtesy
only. Our failure to provide such notification to the persons) or
organization(s) shown in the Schedule will not extend any policy cancela-
tion date nor impact or negate any cancelation of the policy. This
endorsement does not entitle the person(s) or organization(s) listed or
described in the Schedule below to any benefit, rights or protection
under this policy.
Failure by us to provide this notice of cancelation to the person(s) ar
organization(s) listed or described in the Schedule below will not impose
liability of•any kind upon us.
Any of these provisions that conflict with a law that controls the notice
of cancelation of the insurance in this endorsement is changed by this
statement to comply with the law.
SCHEDULE
Person(s) or Organization(s) including mailing address:
PER LIST ON FILE WITH AGENT
30 DAY NOTICE OF CANCELLATION
All other terms and conditions of this policy remain unchanged.
WC 99 06 72 09 11
MUq 90-16877-01 00 191
Page 001
o,,,aoRG , 01364