PROOF OF INSURANCE (2022) CLOSEDACCORD® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
12/6/2021
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 have ADDITIONAL INSURED provisions or 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
Crystal IBC LLC
32 Old Slip FI 17
York NY 10005
CONTACT
NAME: Kaitlyn Murphy
PHONE FAX
A/c No Ext : 212-504-1802 A/C, No
E-MNew
ADDRESS: Kaitlyn.Murphy@alliant.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA: Berkley National Insurance Com
38911
INSURED
Scantron Corporation
1313 Lone Oak Road
INSURERB: Endurance Risk SolutionsASSur
43630
INSURERC:
INSURERD:
Eagan MN 55121
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1032931970 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE 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
POLICY EXP
MM/DD
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
Y
TCP 7015275-12
12/3/2021
12/3/2022
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 1,000,000
MED EXP (Any one person)
$ 15,000
PERSONAL &ADV INJURY
$ 1,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
POLICY ❑ PRO
JECT LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
OTHER:
A
AUTOMOBILE
LIABILITY
TCA 7015779-16
12/3/2021
12/3/2022
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
X
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
X
BODILY INJURY (Per accident)
$
X
PROPERTY DAMAGE
Per accident
$
HIRED X NON -OWNED
AUTOS ONLY AUTOS ONLY
A
X
UMBRELLA LIAB
X
OCCUR
TCP 7015275-12
12/3/2021
12/3/2022
EACH OCCURRENCE
$ 15,000,000
AGGREGATE
$ 15,000,000
EXCESS LAB
CLAIMS -MADE
DED X RETENTION $ n
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
TWC 7015276-13
12/3/2021
12/3/2022
X PER OTH-
STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$ 1,000,000
OFFICE R/M EMBER EXCLUDED? ❑
N/A
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
B
Cyber/TechE&O
PR030001389801
12/3/2020
12/31/2021
Per Claim/Aggregate
$10,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
City of El Segundo, its officials, and employees are included as Additional Insured with regards to the General Liability as required by written contract subject to
the policy terms and conditions. Coverage is Primary and Non -Contributory as required by written contract subject to the policy terms and conditions. 30 days
notice of cancellation applies, except non payment of premium which is 10 days, in accordance with the terms and conditions of the policy.
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
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Policy Number: TCP 7015275-12
COMMERCIAL GENERAL LIABILITY
CG83601216
TA-i-NDOR-- -iNT C--N--- T-- POLICY-PL---- R--D IT C-R---LLY-
GENERAL LIABILITY EXTENSION FOR TECHNOLOGY
COMPANIES ENDORSEMENT
T::J--::dorA�me- nodiT<✓-i-Air-fie JoJded u::der Ze :OIIo-i-fr
C0MM-RC1-L--N-R-L LI-BILITY CO--R--- -ORM
TJ-e::dorA�me- ro::de--comer-:1e-T:1e :OIIo-i-- A,,:Iedule o-coJar-:1e eo--i-- :1e:1er:1 coJar-
de:P,ri :lo:ly:]-imi-[]:DDi e:rlu:lo mDy :0 7e�0 coJar::ZRe::d :1I ale JoJJo :1o»
e::dorJ�me--10-->i-[]your e»e JDlicy c e:Ully :0 deAMi:le Ile e:EeJD-co:1er :1e ::EOrded
SCHEDULE OF COVERAGE EXTENSIONS
--
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--Ebc�d or I-d ied I -dry or Dirt-
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Bodily I -dry De%JjJD-
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A. ADDITIONAL INSURED - LESSORS OF LEASED EQUIPMENT
-bier Section II - Who Is An Insured --ale :OIIo-i-- i-hided:
Any person or organization that is an equipment lessor is an insured, but only with respect to liability for "bodily
injury", "property damage", "personal and advertising injury" caused, in whole or in part, by your acts or
omi7o--i- Ile m---fie-oar-JJD
-or u by you o e-ui::ne-fie-mod you by Sic-e-ui::rne-eT0r-
The insurance provided to such equipment lessor does not apply to any "bodily injury" or "property damage"
caused by an "occurrence" that takes place, or "personal and advertising injury" caused by an offense that is
commi -Ad -Eer ale e-ui::ne-fie-A� e-ire=
B. ADDITIONAL INSURED - OWNERS, MANAGERS OR LESSORS OF PREMISES
-bier Section II - Who Is An Insured --ale :OIlo-i-- i-hided:
--y �r0-or or--Jzjo-z-�» Jemi�-o-ern---fir or Iezbr i--- i-Airedu -o�y -i reZecEO
-
li�ili� JiJ-: ouJD-Ze o-�r�- -�--fie or u� o-z---� -- semi -le-mod you-
T� i-air-fie JoJded � Aic- Jemi�-o-�r�n---fir or lezbr doe- --- y :
1. Any "bodily injury" or "property damage" caused by an "occurrence" that takes place, or "personal and
advertising injury" caused by an offense that is committed, after you cease to be a tenant in that premises;
or
2.-Tuc:Ur:l Jar- co--Tuck-or demolijJD-oar---:1er:ormed by or o-be--o-Aic-
emi-o-a rn---fir or lezbr-
C- - JO 12 1- I:Plude-co-yri--mod m-Eeri:l o-I-Air-fie P-0 1 o-5
-er:Jce-Ojte:A:c=i-I] i--[] :Iermi=7o--
C. ADDITIONAL INSURED - VENDORS Policy Number: TCP 7015275-12
-bier Section II - Who Is An Insured --ale :OIIo-i-- i-hided:
»y �r0-or or--�zjo-z---Ja�ior - 1 z-you r -weed i - >-ri -co-T -or - eeme--
include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily
injury" or "property damage" that:
1. I-C-uA�d by an "occurrence" that takes place after you have signed and executed that contract or
eeme-z-i
2. Arises out of "your products" which are distributed or sold in the regular course of such vendor's business.
T:10 i-3Ar-fie JoJded :0 AAc-:Ie::dori-3ib:ec-:o Ile :OIlo-i--JoJJo--
1. T:10 limi-]0J-air-fie Jo:Jded :0 AAc-:Ie::dor dill be Ze limi-[]-:Jc-you -Deed :0 JoJde i-Ze -ri-A-
co-T:P-or-Jeeme-7or Ile limi-[]Zo»i:1 Ile DeclJ-i[o-=»c:1e:1er Je lei
2. T:10 i-air-fie :Iro::Jded :0 AAc- :le::dor doe-JD:]--:Iy :0:
a. »y e-je=:Ijr-- JD»uzoriJ�d by your
b. Any change in "your products" made by such vendor;
c. Re-:r1zJ---u:1e=u--:rJ�d JDIely :or ale IrJDJ� o:J-zec:fiD»demo--T---A�:Iil--Jor Ile
AAb::UjJD-o--J-u:Jder i--Tuck--Tom ale m--uzc:1Jrer--:1d 1e-re-:r,z:1ed i-Ze ori:]-
co --ter-
d. --y -llure :0 m-E0 AAc-i-Zec:DD-Z]::dA]-Tne-- A] =or A�r:lci----:1e::dor--Jee :0 :Ier:orm or
-orm:11y u::derz::o :0 :Ier:orm i- Ile re-ul:lr court o::buJ-e-FFJ-co-:1ec:�0»i 11 Ile di::TibujjD-or
sale of "your products";
e. Demo- --:J-Zd1::k=- OrJci--or re -fir oar--Tje:Pe--Sic-oar---:1er:0rmed =AAc-
vendor's premises in connection with the sale of "your products"; or
f. "Your products" which, after distribution or sale by you, have been labeled or relabeled or used as a
co--ter--�-or i-Jedie--o---y ozer --or 3ibZ-fie by or o- be--o-3ic- D ior-
Comer-:Ie u::der:IF1JoJJO-doe- :0:
1. --y :1er0-or orAnization from whom you have acquired "your products", or any ingredient, part or
co --ter e-T;ri--i- - com---yi--or co-J-- Sic- Joduc=-or
2. --y Ja::dor :or -:Jc-comer-:1e ---- ::ddi:DD-J i-aired Zeci1c:11y i-:c:1eduled by e::dor�0me-11
D. ADDITIONAL INSURED -WRITTEN CONTRACTOR AGREEMENT
-bier Section II -Who Is An Insured --:Ile :0IIo-i-- i-hided:
--y fro -or or--�zjo-z-�-JD-Ozer-ice --i-bred u�ier-Comer- P�--1 z-you --Elie -weed
i---ri-e-co-T:c-or-jeeme i:clude -:1 ::ddi:fiD- i-aired o-:IJ-Comer PJJ---i-3ired:]bu-
only with respect to liability for "bodily injury" or "property damage" that:
1. Is caused by an "occurrence" that takes place after you have signed and executed that contract or
eeme-z-1
2. I-c-uA�d:J- -Dole or i- —_J=by your :c- or omi=7o--i- :1er:orm-fie o4our o-Joi--oar-JJD--
-�c- z- co-T�-or-Jeeme----Aie-or Ze ]or omi=7o--o---y �rAD-or or--:JzjJD- :1er:0rmi--
Sic-oar-jo--o-your be-J-]
T:10 limi-]oJ-air-fie JoAded :0 AAc-i-aired All be Ile limi-[]-:Jc-you -feed :0 JoAde i-ze -ri-�-
co-T -or-Jeeme-7or Ile limi-[]Zb--i-Ze DeclJ--=-Jc:1e:1er Je le=
E. AGGREGATE LIMIT PER LOCATION
1. -bier Section III -Limits Of Insurance, Ile :oIlo-i--i-hided:
The General Aggregate Limit applies separately to each of your "locations" owned by or rented or leased to
you:]
2. -bier Section V -Definitions :0IIo-i--i-hided:
"Location" means premises i-E0IJ--ze =me or co-:1ecT--lo=Or Jemi�0---off co-:1ec:fiD-i-
i-T;rru-T;d o:]y by - ::Tee=ro::d--y---fir--y or o-- r:Jlro::d-
P-� 2 0-5 I�lude-co-yri--Td m-T;ri� o-1-air-fie C- -:1 12 1-
-erJce-O:ke:A:c=i-] i-] :]armi=70--
F. AMATEUR ATHLETIC PARTICIPANTS
Policy Number: TCP 7015275-12
:]::der Section II -Who Is An Insured ze :0I1o:]i i:]::dded:
»y �r0�reJe� T you »le i� n:�ur =ems i �= you =o �r=ode r�
AAc:1 :]arAD:1 i:1 i aired fir:
1. "Bodily injury" to:
a. :1 co -participant, your "employee" or "volunteer worker" while participating in amateur athletic :cjLJjJ�
=4ou :Tor-or
b. Your Dy jZer or member ioue JZer:TJor :oi=:1ereZory member Thoue
limited liability company), or any "executive officer" (if you are an organization other than a partnership,
bi Jaure70r limited li::bili:y com yZbr
2. "Property damage" to property owned by, occupied or used by, rented to, in the care, custody, or control of,
or oar »c:l co col i:lbei :]ejarci�Od :Or y :IrJDA� by:
a. :1 co -participant, your "employee" or "volunteer worker"; or
b. Your Dy jZer or member ioue JZer:TJor :oi=E0reZory member Thoue
limited liability company), or any "executive officer" (if you are an organization other than a partnership,
bi Jaure70r limited li::bili:y com Dy=
G. BODILY INJURY
:]::der Section V - Definitions, the definition of "bodily injury" is deleted and replaced by the following:
"Bodily injury" means physical injury, sickness, or disease sustained by a person, including death resul i== rom
any of these. "Bodily injury" also means mental injury, mental anguish, humiliation, or shock sustained by a
:1er 0 :IdirecTy reAAlT :1 Tom iiory c=e=or dim A� 3i=J:Ied by z r�
H. BROADENED NAMED INSURED
:]::der Section II -Who Is Insured:]ze :OIlo:li :]i:]::dded:
»y :1er0:1or or ^:J=ion Wined i:1 ale DeclJ :1 orFT1�4i you o:]=Ele:lly :c::uire or :ormioler
__ limited li::bili:y com Dy:]::d oar »c:lyou m=:Ij:lmore z=50:1 o
ale i:Eere=e Tied � rely i ze elec o�7e o�r�= body o:I3ic or = »ill i
N ned 1 aired i�zere i � oiler Emil i air �e = I le 3ic�or _�� u Ze e�i o�1e 70licy
:1eriod
Comer u::der iJ :1 Jo:1:1 o :1 d oe :1 JD y :0 :]arAD:1Oror = :1 :0r »c:1coJar a i:1e:Pluded by
e::dorj�me ]
I. BROADENED PROPERTY DAMAGE - BORROWED EQUIPMENT, CUSTOMERS' GOODS AND USE OF
ELEVATORS
The insurance for "property damage" liability is subject to the following:
1. ❑::der Section I - Coverages❑Coverage A❑Bodily Injury and Property Damage Liability2.❑
Exclusions:] A�m j.::DamageTo Property i:]::ne::ded :1:0Ilo»
a. T:1e e:rlu:1o:1 :or :1erADJo:10r:y i:1 Ile cJeA,-u:lbdy or co col ooze i aired does = y
"property damage" to equipment you borrow while at a job site and provided it is not being uA�d by
yob :0 :1er:0rm oar- = ze ne oho=
b. T:1e e:rlu:10 :1:or:
(1) Pro:ler:y to d :0 your
(2) Perms Jo:10r:y i:1 Ile cJe:culody or co rol ooze i 3ired :]i
(3) Ti—:= ku1J J70 Dy Jo:10r:y =::nuZbe relored::re fired or replaced because "your work"
:1=i:correc1y :Ier:ormed obi 11
do not apply to "property damage" to "customers' goods" while on your premises nor do they apply to
"property damage" arising from the use of elevators at premises you own, rent, lease or occupy
2. Subject to the Each Occurrence Limit, the most we will pay for "property damage" to "customers' goods" is
$25,000 per "occurrence".
3. :]::der Section V -Definitions ze :0I1o:]i i:]::dded:
"Customers' goods" means goods of your customer on your Jemi�0:1:0r Ile IrJDA� o:ADei —r
a. Re7 red -or
b. :]A�d i:1your m uzc ri Joce=
C _ JD 12 1 :1I�lude�coDyri d m:�ri� 0�1 afir e P 0 :I0:i5
:]er:1Ce:1OJke:A :c=i 11i11 :]armi=Jo
Policy Number: TCP 7015275-12
4. :]::der Section IV -Commercial General Liability Conditions ze i air :rle girded by :1Jo:11o:1i
ewe=oar y oiler »id ::d colleciible Jo:lery i 3ir :rle T:cludi :1 Dy deducible »»I le :0 Ile
i Aired �-ezer 3ic� i Air �e i� JimJy��e=_co T nor o� Dy oiler b �Z7�� me by u
dill :oIlo:1 ale Ozer l Air :r1e - =Pe=l 3ir=ce Jo:]:Io
J. GOOD SAMARITAN SERVICES
1. :]::der Section II -Who Is Insured:iJ J :12.:J�em d. ze :OIlo:li i:]::dded:
T:J:le:rlu:lo:ldoe»off y :0 your em:loyee:lor 70lu der :Iorj�r=ozer z em:loyed or
volunteer physician, rendering "Good Samaritan services".
2. :]::der Section V - Definitions the following definition is added:
"Good Samaritan services" means any emergency medical services for which no compensation is
dem died or receiJad
K. DUTIES IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT
:]::der Section IV - Commercial General Liability Conditions2.::Duties In The Event Of
Occurrence, Claim or Suit i:]::ne::ded :0 i:clude ale :OIlo:li fr
1. T� re�uireme z Dyou mu=
a. Notify us of an "occurrence" offense, claim or "suit"; and
b. :le::d u:1docume _1]co:cer:J> :]claim or "suit" apply only when such accident claim, "suit" or loss is
(1) Your ou Je i::di::Jdu
(2) :1 JIle r:J4ou Je :1 JIle r:
(3) »eJacujDe o er ooze cor70r ��or i Air e m �r�4ou Je �COr7br 1 Jor
(4) :1 m �r:J4ou Je :1limiA�d li:]Dili:y com Dye
2. The requirement that you must notify us as soon as practicable of an "occurrence" or an offense that may
result in a claim does not apply if you report an "occurrence" to your workers compensation insurer c
I �er deJalo :1i :o :1liJDili:y clam :or »c:lcojer :10 i:1Jo:Jded by :IJ»olicy»o:1e:1er :1ADo»>you
have definite knowledge that the particular "occurrence" is a liability claim rather than a workers'
comma z]b�cl�mDyou muTcom�y �i 11 Ile Dui0�I�T� :� �O-Occurre:ce-O-AA�:1Cl:1m Or dui
Co::di10
L. EXPECTED OR INTENDED INJURY OR DAMAGE (PROPERTY DAMAGE)
:]::der Section I - Coverages Coverage A::Bodily Injury And Property Damage Liability J J :12.
Exclusions:]�em a.::Expected Or Intended Injury:J:Idele�ed d re:1:ced by Ile :0I1o:Ii fr
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
:Orce :0 Jo�ec :Ier 0=or Jo:ler:y
M. MEDICAL PAYMENTS
1. :]::der Section I - Coverages Coverage CAAedical Payments: J J :1 1.:Ansuring Agreement=e
re::uireme z Je:I]e:lie i:curred d reJor�ed :0 u»i:IJ :1o:le ye ooze d A� ooze :ccide :i
c :1ed :0 wee yeJ=
2. T:1e Medici Limit»15:000 :1er :1er0:1or Ile ::nou zb»i:1ze DeclJ Sze Medici
»� Limi- Jc:1eJar i:iJe �er
3. T:J:Ijo:]:Io:]M. doe:] i Coverage C Medical Payments:J:Ioler:ice e luded eizer by ale
Jo:1:10 :1o=le Cojer Ele dorm or by e::dorA�me ]
N. NON -OWNED AIRCRAFT
1. :]::der Section I - Coverages Coverage A:]Bodily Injury and Property Damage Liability:]�em 2.
Exclusions:] A�m g.�-Aircraft, Auto Or Watercraft doe❑:0 C:Jrcr:1zz—:J:1
a. Aredic Jtired or to d A 11 :1 d cre»- d
b. No-0:1Jed by Dy i aired
2. T:1e i Air e ::�rded by :1Jo:1Ao:1N. i:1e:re=oJar yoiler »id ::d colleciible i Air e
T:cludi :1 Dy deducible or :1el:1l Aired Rem »1]iI::ble :0 Ze i Aired :1:1ezer 3ic:1 i AAr:I]ce i
JimJy—JeAae=co T nor o� y oiler b �Z7»y Lyme by u»ill Ilo� ale Oiler 1 Air e -
�e l lir e Jo:J:10 :1i:1 Ze Commerci:1 :1e:1er:1 Li::bili:y Co::diio Z7
P �o�5 I�lude�coDyri d m��ri� oil Air e C� » 12 1
:]er:1ce:1O e:A:c=i 11i11 :]armi=Jo
O. NON -OWNED WATERCRAFT
Policy Number: TCP 7015275-12
1. -flier Section II -Who Is Insured-:IrneAied--�Ilo--
To i:clude ----i-Aired :Or -- rcr-zz-:J-cored by-l-70licy---y :1erAD--JD»i-[]your
e-JeTod or im:lied co-A�--]eizer u�O-or i-rezb»ble :Or Ile uA� o-->-A�rcr----o-ear-7o :1er0-
or or -- z---� ii-aired :1i 11 reZec::
a. "Bodily injury" to a co -"employee" of the person operating the watercraft; or
b. "Property damage" to property owned by, rented :O:J- Ze c-J:1e o-or occuJed by you or Ile
em:loyero---y :1er0--JD i:1 i-Aired u::der :IJ:lJoJ:10-
2. I- Ile ewe- - :o Ile Aircraft, Auto Or Watercraft e:Plu:lo- uAier Coverage A::Bodily Injury And
Property Damage Liability-ze limi-[]10�o�ze le--:--:-o»>- rcr»di re -mod 75 e
3. T:1e i-Air-fie :: lorded by:J:1JoJ:A0-0. i-e:ce=oJar --y oiler -Aid -Ai colleciible i-Air-fie
T:cludi----y deducible or -el-I-Aired Rem----1]iI::ble :0 Ze i-Aired--filer Sic-i-air-fie i-
JimJy-e�e=co-T-�--or o- --y oiler b-� --y --yme- by u»ill Ilo- ale Oiler 1-air-fie -
-ce=l-_Air-fie JoJ:10--i-Ze Commerci:1 -e:1er:1 Li::bili:y CoAiijjD-Z]
P. NEWLY ACQUIRED OR FORMED ORGANIZATIONS
-flier Section II -Who Is An InsuredJ�m 3.a. i-deleted -A1 re��ed by Ze �Ilo-i-
a. Comer- uAier iJ:1JoJ:1O-i---larded o:ly u- Ile eAi o-Ze curre--70licy-eriod-
Q. SUPPLEMENTARY PAYMENTS
-flier Section I - Coverages -Supplementary Payments - Coverages A and B i-::neAied--�Ilo--
1. T:le limi-fir ale co=O:lb:Jl boAi-i-::neAied :0 1 00--Ai
2. The limit for reasonable expenses incurred by the "insured" is amended to $500 a day.
R. UNINTENTIONAL OMISSION
-::der Section IV - Commercial General Liability Conditions-- ----6.:]2epresentations-ale :OIlo-i--
i-Aided:
T:le uJ-A�- - omi=7o-o--or uJ-A�- - error i----y i-arm- - Jo1ded by you -::Jc- -e relied u-o-i-
i�i - �-70licy -ill JD-JeA]dice your ri-- uAier -i-Air-�e--o-ear- -JoJo-doe- -- c ur
ri--- collec-AidijjD-Jemium or :o ejarci�0 our ri--__110-c-well- -or JDje:le-:I i- cord -fie -i-[]
-- idle i-Air-fie 1---or re-ul-jb-Z]
S. WAIVER OF SUBROGATION - BLANKET
-::der Section IV - Commercial General Liability Conditions-- - ---8.-Transfer of Rights of
Recovery Against Others to Us Ile :0I10-i--i-Aided:
:1e -ill -� --y ri---oecory -e m-y --ie ---z--y :1er0-or or--Jz-bec-uA� o---yme-�]-e
rn �r i-ory or din- a JiJ--ou704our o--oi--oar-ib--doh uAier :1 -ri -co-T� r - eeme--
with that person or organization and included in "your work" or the "prod ucts-com:leA�d oar-JJD----1Td"-
T:J--:J:Ier --die-o:]y :0 :1erJD or or--Jzjb---i-[] -Jom you -ri-�-co-T:czeJacu�ed Jior
the "bodily injury" or "property damage", that requires you to waive your rights of recovery.
C- -- -D 12 1- I�lude-co-yri--mod m-�ri� o-I-Air-fie P-0 5 0-5
-er:1ce-Ojte:A:c=i1] i-] :Iermi=70--
COMMERCIAL GENERAL LIABILITY
CG 83 63 01 12
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY NON-CONTRIBUTORY ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERICAL GENERAL LIABILITY COVERAGE PART
Under Section IV, Commercial General Liability Conditions, paragraph 4., Other Insurance, item a., Primary
Insurance is amended to include the following:
However, if you are obligated pursuant to a written contract or agreement entered into prior to a loss to provide
a person or organization that is included in the Who Is An Insured section of this insurance with primary
insurance such as is afforded by this policy, then this insurance is primary and we will not seek contribution
from insurance available to such person or organization.
THIS ENDORSEMENT MUST BE ATTACHED TO A CHANGE ENDORSEMENT WHEN ISSUED AFTER THE
POLICY IS WRITTEN.
CG 83 63 01 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1