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PROOF OF INSURANCE (2024 - 2024) CLOSEDDATE (MMIDDNYYY) ACC>R" VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE 10/16/2023 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. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER CONTACT Francisco Cruz NAME: .............. ......-...... XeFarM Lisa Simmons Agency PncN10-675-3339 � 310-675-7036 Ext : 3 Hawthorne, CA 90250 CUSTOMER Ift #•.• .. PRODUCER._. 13658 Hawthorne Blvd Ste 100B E-MXIL s franclsco.cruz.vab9cd@stat farm,com INSURERPSORDING COVERAGE NAIC # INSURED INsuRERA: State Farm General Insurance Company 25151 TRACKLESS TRAIN LLC INSURER B : 405 E GARDENA BLVD STE C INSURER C GARDENA CA 90248 INSURER D : IN E DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE I MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 2011 ISUZU NPR BOX TRK _W_.... ............. DESCRIPTION VEHICLEIEQUIPMENT VALUE SERIAL NUMBER Commercial vehicle $46865 rnvr=DAr-17Q r_I=PTIFIrATl= MIJUR1=R' REVISION NUMBER: THIS IS TO CERTIFY "THAT THE POLICYIIESI OF INSURANCE LISTED BELOW HASIHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) 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 POLICY(IES) DESCRIBED HEREIN ISIARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY('IE S). INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYYY) DATE (MM/DD/YYYY) LIMITS X VEHICLE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ 668 4733-B13-75 08/13/2023 02/13/2024 _._._. BODILY INJURY (Per accident) ...... —.- _. $ ----- PROPERTY DAMAGE $ GENERAL LIABILITY EACH OCCURENCE $ OCCURRENCE GENERALAGGREGATE $ CLAIMS MADE ........ 'INSR LOSS POLICY EFFECTIVE POLICY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDNYYY) DATE (MM/DD/YYYY) LIMITS I DEDUCTIBLE m .......... X VEH COLLISION LOSS ® ........ ❑ ACV ❑ AGREED AMT $ LIMIT 668 4733-B13-75 08/13/2023 1 02/13/2024 E] STATED AMT $ 50Q DED VEH COMP VEH OTC X ................. E-]ACVE] AGREED AMT $ LIMIT 668 4733-B13-75 08/13/2023 02/13/2024 E] _-]STATED AMT $ 500 DED EQUIPMENT ❑ ACV ❑ AGREED AMT $ LIMIT BASIC BROAD ❑ RC ❑ STATED AMT $ DED SPECIAL ❑ REMARKS (INCLUDING SPECIAL CONDITIONS / OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ADDITIONAL INTEREST GANGtLLA I IUN Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Ted lastonal int been submitted described below eellowhas been added to the policy(ies) listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE A regwa hasadditional interest described below to the policy(ies) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ramn b CY numkMar VEHICLE I EQUIPMENT INTEREST: FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST ADDITIONAL INSURED R LOSS PAYEE LENDER'S LOSS PAYEE LOAN / LEASE NUMBER ........ .............. ............... ........ AUTHORIZED REPRESENTATIVE Completed by an authorized State Farm representative. If signature is required, please contact a State Farts agent. ©1997-2015 ACORD CORPORATION. All rights reserved. ACORD 23 (2016/03) The ACORD name and logo are registered marks of ACORD 1004361 142967.4 04-24-2020 Policy Number: ZISMB2958 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 : The City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main St El Segundo, CA 90245 Any person or organization for whom the named insured has agreed by written "insured contract" to designate as an additional insured subject to all provisions and limitations of this policy. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the schedule, but only with respect to liability caused, in whole or in part, by your performance of ongoing operations for that insured. 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 written "insured contract', the insurance afforded to such additional insured will not be broader than that which you are required by the written "insured contract' to provide for such additional insured. 3. This coverage is provided on a primary and non-contributory basis. 9267549-23 Dear Policyholder: These endorsements amend and are part of your policy. Please keep them with your documents for future reference. If you have any questions concerning these endorsements, Please contact your local State Fund office. POLICYHOLDER NOTICE Page , of 3 YOUR RIGHT TO RATING AND DIVIDEND INFORMATION PN 04 99 01 1 (Ed. 02-22) POLICY NO. 9267549-23 NR NA TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CALIF 90248 I. Information Available to You A. Information Available from Us - State Compensation Insurance Fund (1) General questions regarding your policy should be directed to: State Fund, Small Commercial Service Center 1020 Vaquero Circle Vacaville, CA 95688 Telephone: 888-782-8338 Website: www.statefundca.com (2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non-payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. Pursuant to California Code of Regulations, Title 10 CCR 2503 (b), under California Law it is unlawful for an insurer [us] to promise the future payment of dividends under an unexpired workers' compensation policy or to misrepresent the conditions for dividend payment. Dividends are payable only pursuant to conditions determined by the [our] Board of Directors or other governing board [of the Company] following policy expiration. Forfeiture of a right to, reduction in the amount of, or delay in the payment of a policyholder's dividend due to the policyholder's failure to accept renewal of the policy or subsequent policies issued by the same insurer is illegal and constitutes an unfair practice. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim.The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan--1995 (USRP) and the California Workers' Compensation Experience Rating Plan--1995(ERP). WCIRB contact information is: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Customer Service; 888-229-2472 (phone); 415-778-7272 (fax); and customerservice@wcirb.com (email). The regulations contained in the USRP and the ERP are available for public viewing through the WCIRB's website at wcirb.com. BROKER COPY SCIF 10610 E (Rev. 03-22) Page 2 of 3 POLICYHOLDER NOTICE Your Right to Rating and Dividend Information POLICY NO. 9267549-23 NR NA (2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415-777-0777 (phone) and 415-778-7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss -Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. You may request in writing that we reconsider a change in classification(s) assignment that results in an increased premium. You may also request, in writing, that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written requests that we reconsider or review our actions should be forwarded to: State Compensation Insurance Fund, Attention: Manager, Customer Assistance Program, 5880 Owens Drive, Pleasanton, CA 94588 or call us at 925-460-6530 or fax us at 707-454-8200. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modificaton, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888-229-2472 (phone), 415-778-7272 (fax) and customerservice@wcirb.com (email If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner SCIF 10610 E (Rev. 03-22) Page 3 of 3 POLICYHOLDER NOTICE Your Right to Rating and Dividend Information POLICY NO. 9267549-23 NR NA as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Complaints and Reconsiderations. The WCIRB's contact information is 888-229-2472 (phone), 415-371-5204 (fax) and customerservice@wcirb.com (email). C. California Department of Insurance - Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Compaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Oakland, California 94612 415-538-4243 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415-778-7159 (phone), 415-371-5288 (fax) and ombudsman@wcirb.com (email). B. California Department of Insurance - Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800-927- HELP (4357) or insurance. ca. gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. SCIF 10610 E (Rev. 03-22) JANUARY 11, 2023 TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 Dear Policyholder IN REPLY REFER TO: 9267549-23 Thank you for choosing us as your workers' compensation insurance carrier. This package contains your renewal documents as listed on the following page. Please keep these together. Our goal is to provide you with fast, efficient, and the most convenient service possible. We truly appreciate your business. If you have any questions about the information in this mailing, please contact your broker of record or your local State Compensation Insurance Fund office. State Compensation Insurance Fund BROKE COPY 5880 Owens Dr a Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 ■ Pleasanton. CA 94588-8792 IN REPLY REFER TO: 9267549-23 WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY STATE COMPENSATION INSURANCE FUND Forms and Endorsements Applicable List Policy FORM NUMBER FORM DESCRIPTION 10963A ANNUAL RATING ENDORSEMENT 10217 9904 - ENDORSEMENT AGREEMENT - WORDING CHANGE ENDORSEMENT 10217 1159 -ENDORSEMENT AGREEMENT- COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA 10217 1951 -ENDORSEMENT AGREEMENT - LIMITED LIABILITY COMPANY COVERAGE/EXCLUSION-CALIFORNIA 10217 2029 -ENDORSEMENT AGREEMENT- CALIFORNIA SHORT -RATE CANCELLATION 10217 2089 -ENDORSEMENT AGREEMENT - STATUTORY ACCOUNTING PRINCIPLES - BILL RECEIVABLE 10217 2437 -ENDORSEMENT AGREEMENT - MEDICAL PROVIDER NETWORK ENDORSEMENT 10217 2567 -ENDORSEMENT AGREEMENT - TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 10217 3017 -ENDORSEMENT AGREEMENT - LIMITED LIABILITY COMPANY MEMBERS - MINIMUM/MAXIMUM LIMITS 10217 9961 -ENDORSEMENT AGREEMENT - CLASS AND RATES AMENDED 10610E POLICY HOLDER NOTICE BROKER COPY 5880 Owens Dr a Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 . Pleasanton, CA 94588-8792 HOME OFFICE SAN FRANCISCO I' ANNUAL RATING ENDORSEMENT IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD BE CORRECTED OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL US. IMPOR 1pT ANT THIS IS NOT A BILL CONTINUOUS POLICY 9267549-23 SEND NO MONEY UNLESS STATEMENT IS ENCLOSED THE RATING PERIOD BEGINS AND ENDS AT 12:01AM RATING PERIOD 1-10-23 TO 1-10-24 PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC DEPOSIT PREMIUM 405 E GARDENA BLVD STE C MINIMUM PREMIUM GARDENA, CALIF 90248 PREMIUM ADJUSTMENT PERIOD NAME OF EMPLOYER- TRACKLESS TRAIN PARTY SERVICES LLC, THE CODE NO. 9016-1 9180-1 PRINCIPAL WORK AND RATES EFFECTIVE FROM 01-10-23 TO 01-10-24 PREMIUM BASE BASIS RATE $1,165.00 $1,165.00 ANNUALLY R NA INTERIM BILLING RATE* AMUSEMENT OR RECREATIONAL FACILITIES-- 0 7.34 8.44 N.O.C.--ALL EMPLOYEES OTHER AMUSEMENT OR RECREATIONAL FACILITIES-- 0 6.94 7.98 N.O.C.--OPERATION OR MAINTENANCE OF AMUSEMENT DEVICES ********BUREAU NOTE INFORMATION******** FEIN 271908566 TOTAL ESTIMATED ANNUAL PREMIUM $1,165 BROKER COPY OUNTERSIGNED AND ISSUED AT SAN FRANC;SCO J)�IUARY 11, 2023 POLICY L PAGE 1 OF cPIC CnDhfi 1nQR4A iMMU 7_7nlAl A\/Co .1 CACC HOME OFFICE SAN FRANCISCO I ANNUAL RATING ENDORSEMENT IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD BE CORRECTED OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL US. IMPORTANT THIS IS NOT A BILL CONTINUOUS POLICY 9267549-23 SEND NO MONEY UNLESS STATEMENT IS ENCLOSED THE RATING PERIOD BEGINS AND ENDS AT 12:01AM RATING PERIOD 1-10-23 TO 1-10-24 PACIFIC STANDARD TIME INTERIM BILLING RATES WILL BE USED ON PAYROLL REPORTS. THEY TAKE INTO ACCOUNT RATING PLAN CREDITS (OR DEBITS) WHICH WILL APPLY AT FINAL BILLING AND AN ESTIMATE OF YOUR PREMIUM DISCOUNT AS DETAILED BELOW. RATING PLAN CREDITS (DEBITS) EFFECTIVE FROM 01-10-23 TO 01-10-24 RATING PLAN MODIFIER 1.15000 ESTIMATED PREMIUM DISCOUNT MODIFIER 1.00000 COMPOSITE FACTOR APPLIED TO BASE RATES TO DERIVE INTERIM BILLING RATES 1.15000 PREMIUM DISCOUNT SCHEDULE EFFECTIVE FROM 01-10-23 TO 01-10-24 ESTIMATED MODIFIED PREMIUM IS DISCOUNTED ACCORDING TO THE FOLLOWING SCHEDULE: FIRST ABOVE $5,000 $5,000 0.0% 11. 3 % THE ESTIMATED PREMIUM DISCOUNT IS BASED ON AN ESTIMATE OF YOUR PAYROLL. ACTUAL PREMIUM DISCOUNT APPLIED AT FINAL BILLING WILL BE BASED ON THE ACTUAL PAYROLL REPORTED ON YOUR POLICY AND SUBJECT TO AUDIT. BROKER CONY OUNTERSIGNED AND ISSUED AT SAN FRANC;�S`CO o� JffUARY 11, 2023 POLICY L PAGE 2 OF cric cnonn inoave iocv 7_on 5nl HOME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. CONTINUOUS POLICY 9267549-23 IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR LOCAL STATE FUND OFFICE BELOW: CSC — POLICY AT VACAVILLE 1020 VAQUERO CIRCLE VACAVILLE CA 95688 (877) 405-4545 Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions agreements or limitations of the Policy other than as herein stated. When countersigned by a duly authorized officer or representative of the State Compensation Insurance Fund, these declarations shall be valid and form part of the Policy. AUTHORIZED REPRESENTATIVE PRESIDENT AND CEO OUNTERSIGNED AND ISSUED AT SAN FRANCISCO JANUARY 11, 2023 POLICY L PAGE 3 OF ENDORSEMENT AGREEMENT ow COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 9267549-23 RENEWAL NA 8-76-90-45 PAGE 1 OF 4 IN ADDITION TO THE REQUIREMENTS UNDER PART 4, "YOUR DUTIES IF INJURY OCCURS" OF YOUR POLICY, IF YOU HAVE FIVE OR MORE EMPLOYEES AND AN EMPLOYEE THAT IS NOT DESCRIBED IN CALIFORNIA LABOR CODE SECTION 3212.87 TESTS POSITIVE FOR COVID-19, YOU ARE REQUIRED TO REPORT THE FOLLOWING INFORMATION AS PROVIDED BELOW. REPORTING COVID-19 POSITIVE TESTS FROM JULY 612020 TO SEPTEMBER 17. 2020 PURSUANT TO CALIFORNIA LABOR CODE SECTION 3212.88(K)(2), IF YOU ARE AWARE OF AN EMPLOYEE TESTING POSITIVE FOR COVID-19 ON OR AFTER JULY 6, 2020 AND PRIOR TO SEPTEMBER 17, 2020, YOU MUST REPORT TO YOUR CLAIMS ADMINISTRATOR IN WRITING VIA ELECTRONIC MAIL OR FACSIMILE WITHIN 30 BUSINESS DAYS OF SEPTEMBER 17, 2020, ALL OF THE FOLLOWING: 1. AN EMPLOYEE HAS TESTED POSITIVE. FOR PURPOSES OF THIS REPORTING, DO NOT PROVIDE ANY PERSONALLY IDENTIFIABLE INFORMATION REGARDING THE EMPLOYEE WHO TESTED POSITIVE FOR COVID-19 UNLESS THE EMPLOYEE ASSERTS THE INFECTION IS WORK RELATED OR HAS FILED A CLAIM FORM PURSUANT TO CALIFORNIA LABOR CODE SECTION 5401. 2. THE DATE THAT THE EMPLOYEE TESTS POSITIVE, WHICH IS THE DATE THE SPECIMEN WAS COLLECTED FOR TESTING. 3. THE SPECIFIC ADDRESS OR ADDRESSES OF THE EMPLOYEE'S CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 1159 AUTHORIZED REPRESENT VVE CrIC cnonn .nf .9 IOC\I '/_fn.n1 JANUARY 11, 2023 PRESIDENT AND CEO nI n f1P 777 ENDORSEMENT AGREEMENT COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. 9267549-23 RENEWAL NA 8-76-90-45 PAGE 2 OF 4 SPECIFIC PLACE OF EMPLOYMENT DURING THE 14-DAY PERIOD PRECEDING DATE OF THE EMPLOYEE'S POSITIVE TEST. 4. THE HIGHEST NUMBER OF EMPLOYEES WHO REPORTED TO WORK AT EACH OF THE EMPLOYEE'S SPECIFIC PLACES OF EMPLOYMENT ON ANY GIVEN WORK DAY BETWEEN JULY 6, 2020 AND SEPTEMBER 17, 2020. REPORTING COVID-19 POSITIVE TEST FROM SEPTEMBER 17, 2020 TO JANUARY 1. 2023 PURSUANT TO CALIFORNIA LABOR CODE SECTION 3212.88(I), WHEN YOU KNOW, OR REASONABLY SHOULD KNOW, THAT AN EMPLOYEE HAS TESTED POSITIVE FOR COVID-19 BETWEEN SEPTEMBER 17, 2020 AND JANUARY 1, 2023, YOU MUST REPORT TO YOUR CLAIMS ADMINISTRATOR IN WRITING VIA ELECTRONIC MAIL OR FACSIMILE WITHIN 3 BUSINESS DAYS ALL OF THE FOLLOWING: 1. AN EMPLOYEE HAS TESTED POSITIVE. FOR PURPOSES OF THIS REPORTING, DO NOT PROVIDE ANY PERSONALLY IDENTIFIABLE INFORMATION REGARDING THE EMPLOYEE WHO TESTED POSITIVE FOR COVID-19 UNLESS THE EMPLOYEE ASSERTS THE INFECTION IS WORK RELATED OR HAS FILED A CLAIM FORM PURSUANT TO CALIFORNIA LABOR CODE SECTION 5401. 2. THE DATE THAT THE EMPLOYEE TESTS POSITIVE, WHICH IS THE DATE THE SPECIMEN WAS COLLECTED FOR TESTING. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 1159 AUTHORIZED REPRESENT IVE C" a iC,;+- ... 'A- a ^P A M JANUARY 11, 2023 / PRESIDENT AND CEO ni f1 nP 717 ENDORSEMENT AGREEMENT COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. 9267549-23 RENEWAL NA 8-76-90-45 PAGE 3 OF 4 3. THE SPECIFIC ADDRESS OR ADDRESSES OF THE EMPLOYEE'S SPECIFIC PLACE OF EMPLOYMENT DURING THE 14-DAY PERIOD PRECEDING THE DATE OF THE EMPLOYEE'S POSITIVE TEST. 4. THE HIGHEST NUMBER OF EMPLOYEES WHO REPORTED TO WORK AT THE EMPLOYEE'S SPECIFIC PLACE OF EMPLOYMENT IN THE 45- DAY PERIOD PRECEDING THE LAST DAY THE EMPLOYEE WORKED AT EACH SPECIFIC PLACE OF EMPLOYMENT. LABOR CODE SECTION 3212.88(J) STATES THAT THE INTENTIONAL SUBMISSION OF FALSE OR MISLEADING INFORMATION OR THE FAILURE TO REPORT THE ABOVE INFORMATION AS REQUIRED MAY SUBJECT YOU TO A CIVIL PENALTY IN THE AMOUNT OF UP TO $10,000 TO BE ASSESSED BY THE LABOR COMMISSIONER. FOR THE PURPOSES OF THESE REQUIREMENTS, CALIFORNIA LABOR CODE SECTION 3212.88(M) PROVIDES THE FOLLOWING: 1. "COVID-19" MEANS THE 2019 NOVEL CORONAVIRUS DISEASE. 2. "TEST" OR "TESTING" MEANS A PCR (POLYMERASE CHAIN REACTION) TEST APPROVED FOR USE OR APPROVED FOR EMERGENCY USE BY THE UNITED STATES FOOD AND DRUG ADMINISTRATION TO DETECT THE PRESENCE OF VIRAL RNA. "TEST" OR "TESTING" DOES NOT INCLUDE SEROLOGIC TESTING, ALSO KNOWN AS ANTIBODY TESTING. "TEST" OR "TESTING" MAY INCLUDE ANY OTHER VIRAL CULTURE TEST APPROVED FOR USE OR CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 11, 2023 1159 AUTHORIZED REPRESENT lV°E PRESIDENT AND CEO CrIC Cn Ol1l1 n]'1 lOc1l '!_fn1n1 ni n na vn ENDORSEMENT AGREEMENT COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. 9267549-23 RENEWAL NA 8-76-90-45 PAGE 4 OF 4 APPROVED FOR EMERGENCY USE BY THE UNITED STATES FOOD AND DRUG ADMINISTRATION TO DETECT THE PRESENCE OF VIRAL RNA WHICH HAS THE SAME OR HIGHER SENSITIVITY AND SPECIFICITY AS THE PCR TEST. 3. "A SPECIFIC PLACE OF EMPLOYMENT" MEANS THE BUILDING, STORE, FACILITY, OR AGRICULTURAL FIELD WHERE AN EMPLOYEE PERFORMS WORK AT THE EMPLOYER'S DIRECTION. "A SPECIFIC PLACE OF EMPLOYMENT" DOES NOT INCLUDE THE EMPLOYEE'S HOME OR RESIDENCE, UNLESS THE EMPLOYEE PROVIDES HOME HEALTH CARE SERVICES TO ANOTHER INDIVIDUAL AT THE EMPLOYEE'S HOME RESIDENCE. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 1159 AUTHORIZED REPRESENT /IVE C /SIC ClIO.A !\f1� IOC\I '1_f!\A1 JANUARY 11, 2023 All ham k: 7 xNz.v`. PRESIDENT AND CEO nl n nP 777 ENDORSEMENT AGREEMENT .�lel � ; w LIMITING AND RESTRICTING THIS INSURANCE LIMITED 'LIABILITY COMPANY COVERAGE EXCLUSION -CA HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 LIMITED IF THE EMPLOYER NAMED IN ITEM 1 OF THE INFORMATION PAGE IS A LIMITED LIABILITY COMPANY, THIS POLICY LIABILITY APPLIES TO ALL WORKING MEMBERS RECEIVING WAGES IRRESPECTIVE OF PROFITS FROM THE LIMITED LIABILITY COMPANY COMPANY, AS EMPLOYEES, EXCEPT THOSE MANAGING MEMBERS EXCLUDED BELOW. MANAGING THE INSURANCE UNDER THIS POLICY IS LIMITED AS MEMBER(S) FOLLOWS: IT IS AGREED THAT, ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, THIS POLICY DOES EXCLUDED NOT INSURE: MANAGING MEMBERS EXCLUDED TITLE CLIFTON BURNLEY MGRMBR IT IS FURTHER AGREED THAT "REMUNERATION" WHEN USED AS A PREMIUM BASIS FOR SUCH INSURANCE AS IS AFFORDED BY THIS POLICY SHALL NOT INCLUDE THE REMUNERATION OF ANY PERSON EXCLUDED FROM COVERAGE IN ACCORDANCE WITH THE FOREGOING. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (LABOR CODE SECTION 3710.1, ET SEQ.) 9267549-23 RENEWAL NA 8-76-90-45 PAGE 1 OF NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 1951 AUTHORIZED REPRESENT IVE chic cno.n .no� ocv �_onn JANUARY 11, 2023 PRESIDENT AND CEO ni n na 117 1 ENDORSEMENT AGREEMENT CALIFORNIA SHORT -RATE CANCELLATION HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.N. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 THE INSURANCE UNDER THIS POLICY IS LIMITED AS FOLLOWS: 9267549-23 RENEWAL NA 8-76-90-45 PAGE 1 OF 2 IT IS AGREED THAT ANYTHING IN THE POLICY TO THE CONTRARY NOTWITHSTANDING, SUCH INSURANCE AS IS AFFORDED BY THIS POLICY IS SUBJECT TO THE FOLLOWING PROVISIONS: IF YOU CANCEL THE POLICY AND A DISCLOSURE WAS PROVIDED IN ACCORDANCE WITH SECTION 481(C) OF THE CALIFORNIA INSURANCE CODE, FINAL PREMIUM WILL BE BASED ON THE TIME THIS POLICY WAS IN FORCE AND INCREASED BY THE SHORT -RATE CANCELLATION TABLE BELOW: SHORT -RATE CANCELLATION TABLE FINAL PREMIUM BASED ON THE TABLE BELOW WILL NOT BE LESS THAN THE MINIMUM PREMIUM FOR THIS POLICY. DAYS = EXTENDED NUMBER OF DAYS = PERCENTAGE OF FULL POLICY PREMIUM DAYS % DAYS % DAYS 1 3% 2 6% 3-4 7% 5-6 8% 7-8 9% 9-10 10% 11-12 11% 13-14 12% 15-16 13% 17-18 14% 19-20 15% 21-22 16% 23-25 17% 26-29 18% 30-32 19% 33-36 20% 37-40 21% 41-43 22% 44-47 23% 48-51 24% 52-54 25% 55-58 26% 59-62 27% 63-65 28% CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2029 AUTHOMZED REPRESENT IVE cric cnonn .nn.� 1oc1 a_nnn1 JANUARY 11, 2023 PRESIDENT AND CEO (11 f1 nP ') 17 ENDORSEMENT AGREEMENT CALIFORNIA SHORT -RATE CANCELLATION HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. 66-69 29% 70-73 30% 74-76 31% 77-80 32% 81-83 33% 84-87 34% 88-91 35% 92-94 36% 95-98 37% 99-102 38% 103-105 39% 106-109 40% 110-113 41% 114-116 42% 117-120 43% 121-124 44% 125-127 45% 128-131 46% 132-135 47% 136-138 48% 139-142 49% 143-146 50% 147-149 51% 150-153 52% 154-156 53% 157-160 54% 161-164 55% 165-167 56% 168-171 57% 172-175 58% 176-178 59% 179-182 60% 183-187 61% 188-191 62% 192-196 63% 197-200 64% 201-205 65% 206-209 66% 210-214 67% 215-218 68% 219-223 69% 224-228 70% 229-232 71% 233-237 72% 238-241 73% 242-246 74% 247-250 75% 251-255 76% 256-260 77% 261-264 78% 265-269 79% 270-273 80% 274-278 81% 279-282 82% 283-287 83% 288-291 84% 292-296 85% 297-301 86% 302-305 87% 306-310 88% 311-314 89% 315-319 90% 320-323 91% 324-328 92% 329-332 93% 333-337 94% 338-342 95% 343-346 96% 347-351 97% 352-355 98% 356-360 99% 361-365 100% 9267549-23 RENEWAL NA 8-76-90-45 PAGE 2 OF 2 NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2029 AUTHORIZED REPRESENT IVE crio ononn no� ooi �_on.n JANUARY 11, 2023 PRESIDENT AND CEO n1 n no ��� ENDORSEMENT AGREEMENT HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME STATUTORY ACCOUNTING PRINCIPLES BILL RECEIVABLE EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 9267549-23 RENEWAL NA 8-76-90-45 PAGE 1 OF ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. IT IS AGREED THAT THIS ENDORSEMENT AMENDS SECTION D. OF PART FIVE OF THE POLICY. YOUR POLICY HAS BEEN WRITTEN ON ANNUAL ADJUSTMENT PERIOD. YOU WILL PAY ALL PREMIUM WHEN DUE. PAYROLL REPORTS AND PREMIUM ARE DUE WITHIN 10 DAYS (TEN) AFTER THE LAST DAY OF THE REPORTING PERIOD. PAYMENT OF OUTSTANDING PREMIUM IS DUE WITHIN 10 DAYS (TEN) FROM THE BILL DATE. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 11, 2023j 2089 AUTHORIZED REPRESENtiNT IVE PRESIDENT AND CEO crio ononn .n�� IGCII �_1niA1 ni n na ;17 1 ENDORSEMENT AGREEMENT MEDICAL PROVIDER NETWORK BROKER . PI HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 9267549-23 RENEWAL NA 8-76-90-45 PAGE 1 OF ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. THE STATE COMPENSATION INSURANCE FUND MEDICAL PROVIDER NETWORK IS ESTABLISHED IN ACCORDANCE WITH CALIFORNIA LABOR CODE 4600 ET SEQ AND APPROVED BY THE CALIFORNIA DIVISION OF WORKERS' COMPENSATION ADMINISTRATIVE DIRECTOR. THE INTENT OF THE 2004 LEGISLATION REQUIRING THE ESTABLISHMENT OF THE MEDICAL PROVIDER NETWORK IS INCREASED EMPLOYER CONTROL OVER THE COSTS OF TREATING EMPLOYEE WORK RELATED INJURIES AND DISEASE. PART FOUR OF THE POLICY, YOUR DUTIES IF INJURY OCCURS, IS AMENDED AS FOLLOWS: IT IS AGREED THAT THE POLICYHOLDER SHALL REFER ALL WORK RELATED INJURIES OR DISEASE TO THE STATE COMPENSATION INSURANCE FUND MEDICAL PROVIDER NETWORK AT THE TIME OF AN OCCUPATIONAL INJURY OR UPON KNOWLEDGE OF AN OCCUPATIONAL INJURY OR DISEASE. IT IS FURTHER AGREED THAT WHEN AN EMPLOYEE NOTIFIES THE POLICYHOLDER OF AN OCCUPATIONAL INJURY OR FILES A CLAIM FOR WORKERS' COMPENSATION WITH THE POLICYHOLDER, THE POLICY- HOLDER SHALL ARRANGE AN INITIAL MEDICAL EVALUATION AND BEGIN TREATMENT WITHIN THE MEDICAL PROVIDER NETWORK. THE POLICYHOLDER SHALL NOTIFY THE EMPLOYEE OF HIS OR HER RIGHT CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2437 AUTHORIZED REPRESENT IVE cric cnonn nn� IOC\/ �_nnn1 JANUARY 11, 2023 PRESIDENT AND CEO ni n na 917 3 ENDORSEMENT AGREEMENT MEDICAL PROVIDER NETWORK : HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. 9267549-23 RENEWAL NA 8-76-90-45 PAGE 2 OF TO BE TREATED BY A PHYSICIAN OF HIS OR HER CHOICE FROM WITHIN THE MEDICAL PROVIDER NETWORK AFTER THE FIRST VISIT. THE POLICYHOLDER SHALL NOTIFY EMPLOYEE OF THE METHOD BY WHICH THE LIST OF PARTICIPATING PROVIDERS MAY BE ACCESSED BY EMPLOYEES. IT IS FURTHER AGREED THAT IF AN INJURED EMPLOYEE DISPUTES EITHER THE DIAGNOSIS OR THE TREATMENT PRESCRIBED BY THE TREATING PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF ANOTHER PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IF THE INJURED EMPLOYEE DISPUTES THE DIAGNOSIS OR TREATMENT PRESCRIBED BY THE SECOND PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF A THIRD PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IT IS FURTHER AGREED THAT THIS ENDORSEMENT IN NO WAY AFFECTS THE RIGHTS OF AN INJURED WORKER TO PREDESIGNATE A PHYSICIAN. AN EMPLOYEE MUST FILE WRITTEN NOTICE OF THE PREDESIGNATION WITH THE EMPLOYER PRIOR TO THE DATE OF INJURY. THE NOTICE MUST INCLUDE THE PHYSICIAN'S SIGNATURE OF AGREEMENT TO THE PREDESIGNATION, AND THE FOLLOWING CONDITIONS MUST APPLY: THE PHYSICIAN IS THE EMPLOYEE'S REGULAR PHYSICIAN. THE PHYSICIAN IS THE EMPLOYEE'S PRIMARY CARE PROVIDER WHO HAS PREVIOUSLY DIRECTED THE MEDICAL TREATMENT OF THE CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2437 AUTHORIZED REPRESENTVIVE JANUARY 11, 2023 PRESIDENT AND CEO ni n na 117 3 ENDORSEMENT AGREEMENT MEDICAL PROVIDER NETWORK "so HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. 9267549-23 RENEWAL NA 8-76-90-45 PAGE 3 OF EMPLOYEE AND RETAINS RECORDS OF THE TREATMENT AND MEDICAL HISTORY. THE EMPLOYER PROVIDES THE STAFF WITH NONOCCUPATIONAL GROUP HEALTH COVERAGE IN A HEALTH-CARE SERVICE PLAN (SUCH AS AN HMO/PPO PROGRAM). OR THE EMPLOYER PROVIDES NONOCCUPATIONAL HEALTH COVERAGE IN A GROUP HEALTH PLAN OR A GROUP HEALTH INSURANCE POLICY, PER LABOR CODE 4616.7. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 11, 2023 2437 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO Crlc CnO.11 nf1l IOL11-1_nn1A1 3 ENDORSEMENT AGREEMENT COMPENSATION TERRORISM RISK INSURANCE PROGRAM INSURANCE REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 9267549-23 FUND RENEWAL NA HOME OFFICE 8-76-90-45 SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. PAGE 1 OF ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 THIS ENDORSEMENT ADDRESSES THE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT OF 2002 AS AMENDED AND EXTENDED BY THE TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2019. IT SERVES TO NOTIFY YOU OF CERTAIN LIMITATIONS UNDER THE ACT, AND THAT YOUR INSURANCE CARRIER IS CHARGING PREMIUM FOR LOSSES THAT MAY OCCUR IN THE EVENT OF AN ACT OF TERRORISM. YOUR POLICY PROVIDES COVERAGE FOR WORKERS COMPENSATION LOSSES CAUSED BY ACTS OF TERRORISM, INCLUDING WORKERS COMPENSATION BENEFIT OBLIGATIONS DICTATED BY STATE LAW. COVERAGE FOR SUCH LOSSES IS STILL SUBJECT TO ALL TERMS, DEFINITIONS, EXCLUSIONS, AND CONDITIONS IN YOUR POLICY, AND ANY APPLICABLE FEDERAL AND/OR STATE LAWS, RULES, OR REGULATIONS. DEFINITIONS THE DEFINITIONS PROVIDED IN THIS ENDORSEMENT ARE BASED ON AND HAVE THE SAME MEANING AS THE DEFINITIONS IN THE ACT. IF WORDS OR PHRASES NOT DEFINED IN THIS ENDORSEMENT ARE DEFINED IN THE ACT, THE DEFINITIONS IN THE ACT WILL APPLY. "ACT" MEANS THE TERRORISM RISK INSURANCE ACT OF 2002, WHICH TOOK EFFECT ON NOVEMBER 26, 2002, AND ANY AMENDMENTS THERETO, INCLUDING ANY AMENDMENTS RESULTING FROM THE TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2019. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2567 AUTHORIZED REPRESENT IVE JANUARY 11, 2023 PRESIDENT AND CEO �r`a..t n np "�`17 4 ENDORSEMENT AGREEMENT �I .1U ®w. • MW COPY COMPENSATION TERRORISM RISK INSURANCE PROGRAM INSURANCE REAUTRORI'ATION ACT DISCLOSURE ENDORSEMENT 9267549-23 FUND RENEWAL NA HOME OFFICE 8-76-90-45 SANFRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. PAGE 2 OF ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. "ACT OF TERRORISM" MEANS ANY ACT THAT IS CERTIFIED BY THE SECRETARY OF THE TREASURY, IN CONSULTATION WITH THE SECRETARY OF HOMELAND SECURITY, AND THE ATTORNEY GENERAL OF THE UNITED STATES AS MEETING ALL OF THE FOLLOWING REQUIREMENTS: A. THE ACT IS AN ACT OF TERRORISM. B. THE ACT IS VIOLENT OR DANGEROUS TO HUMAN LIFE, PROPERTY OR INFRASTRUCTURE. C. THE ACT RESULTED IN DAMAGE WITHIN THE UNITED STATES, OR OUTSIDE OF THE UNITED STATES IN THE CASE OF THE PREMISES OF UNITED STATES MISSIONS OR CERTAIN AIR CARRIERS OR VESSELS. D. THE ACT HAS BEEN COMMITTED BY AN INDIVIDUAL OR INDIVIDUALS AS PART OF AN EFFORT TO COERCE THE CIVILIAN POPULATION OF THE UNITED STATES OR TO INFLUENCE THE POLICY OR AFFECT THE CONDUCT OF THE UNITED STATES GOVERNMENT BY COERCION. "INSURED LOSS" MEANS ANY LOSS RESULTING FROM AN ACT OF TERRORISM (AND, EXCEPT FOR PENNSYLVANIA, INCLUDING AN ACT OF WAR, IN THE CASE OF WORKERS COMPENSATION) THAT IS COVERED BY PRIMARY OR EXCESS PROPERTY AND CASUALTY INSURANCE ISSUED BY AN INSURER IF THE LOSS OCCURS IN THE CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2567 AUTHORIZED REPRESENT IVE- JANUARY 11, 2023 PRESIDENT AND CEO ni n nv 117 H ENDORSEMENT AGREEMENT COM RE N SAT ION TERRORISM RISK INSURANCE PROGRAM INSURANCE REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 9267549-23 FUND RENEWAL NA HOME OFFICE 8-76-90-45 SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. PAGE 3 OF ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. UNITED STATES OR AT THE PREMISES OF UNITED STATES MISSIONS OR TO CERTAIN AIR CARRIERS OR VESSELS. "INSURER DEDUCTIBLE" MEANS, FOR THE PERIOD BEGINNING ON JANUARY 1, 2021, AND ENDING ON DECEMBER 31, 2027, AN AMOUNT EQUAL TO 20% OF OUR DIRECT EARNED PREMIUMS DURING THE IMMEDIATELY PRECEDING CALENDAR YEAR. LIMITATION OF LIABILITY THE ACT LIMITS OUR LIABILITY TO YOU UNDER THIS POLICY. IF AGGREGATE INSURED LOSSES EXCEED $100,000,000,000 IN A CALENDAR YEAR AND IF WE HAVE MET OUR INSURER DEDUCTIBLE, WE ARE NOT LIABLE FOR THE PAYMENT OF ANY PORTION OF THE AMOUNT OF INSURED LOSSES THAT EXCEEDS $100,000,000,000; AND FOR AGGREGATE INSURED LOSSES UP TO $100,000,000,000, WE WILL PAY ONLY A PRO RATA SHARE OF SUCH INSURED LOSSES AS DETERMINED BY THE SECRETARY OF THE TREASURY. POLICYHOLDER DISCLOSURE NOTICE 1. INSURED LOSSES WOULD BE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT. IF THE AGGREGATE INDUSTRY INSURED LOSSES OCCURING IN ANY CALENDAR YEAR EXCEED $200,000,000, THE UNITED STATES GOVERNMENT WOULD PAY 80% OF OUR INSURED LOSSES THAT EXCEED OUR INSURER DEDUCTIBLE. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2567 AUTHORIZED REPRESENT IVE JANUARY 11, 29023 PRESIDENT AND CEO ni n no 1317 4 ENDORSEMENT AGREEMENT comTERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 9267549-23 FUND RENEWAL NA HOME OFFICE 8-76-90-45 SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. PAGE 4 OF ALL EFFECTIVE DATES ARE TO JANUARY 10, 2024 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED. 2. NOTWITHSTANDING ITEM 1 ABOVE, THE UNITED STATES GOVERNMENT WILL NOT MAKE ANY PAYMENT UNDER THE ACT FOR ANY PORTION. THIS ENDORSEMENT CHANGES THE POLICY TO WHICH IT IS ATTACHED AND IS EFFECTIVE ON THE DATE ISSUED UNLESS OTHERWISE STATED. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2567 AUTHORIZEIREPRESENT /IVE rrio ono.. .na� IGL\I -r_nnn\ JANUARY 11, 2023 PRESIDENT AND CEO ni n nc )17 4 ENDORSEMENT AGREEMENT �JROKER COPY HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME LIMITED LIABILITY COMPANY MEMBERS MINIMUM MAXIMUM LIMITS EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 9267549-23 RENEWAL NA 8-76-90-45 PAGE 1 OF ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. IT IS AGREED THAT UNLESS OTHERWISE EXCLUDED BY ENDORSEMENT THE ACTUAL REMUNERATION EARNED BY EACH MEMBER DURING THE POLICY PERIOD SHALL BE USED AS THE BASIS OF PREMIUM, SUBJECT TO THE MINIMUM AMOUNT OF $ 57,200 PER ANNUM AND THE MAXIMUM AMOUNT OF $ 149,500 PER ANNUM AS SPECIFIED IN THE CALIFORNIA WORKERS' COMPENSATION UNIFORM STATISTICAL REPORTING PLAN, FOR WORKERS' COMPENSATION INSURANCE IN EFFECT DURING THE POLICY PERIOD. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 11, 2023 3017 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO f11 n IlP 917 1 ENDORSEMENT AGREEMENT HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.N. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE WORDING FOR THE FOLLOWING CLASSIFICATION APPEARING IN THIS POLICY IS CHANGED TO READ - CLASS DESCRIPTION OF WORK 9180-1 AMUSEMENT OR RECREATIONAL FACILITIES-- N.O.C.--OPERATION OR MAINTENANCE OF AMUSEMENT DEVICES --INCLUDING TICKET COLLECTORS. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 11, 2023 9904 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO w^a^s� r. rrnw.n wrr rlro Ana c°..wr 7_nrs r n.� 9267549-23 RENEWAL NA nl n nP 717 ENDORSEMENT AGREEMENT HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.N. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 BROKEN COPY 9267549-23 RENEWAL NA ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. IT IS AGREED THAT THE FOLLOWING CLASSIFICATION(S) IS (ARE) HEREBY ADDED TO AND MADE A PART OF THIS POLICY. RATE(S) EFFECTIVE UP TO 1/10/24 - STANDARD CLASS DESCRIPTION OF WORK 9180-1 AMUSEMENT OR RECREATIONAL FACILITIES-- N.O.C.--OPERATION OR MAINTENANCE OF AMUSEMENT DEVICES --INCLUDING TICKET COLLECTORS. 9016-1 AMUSEMENT OR RECREATIONAL FACILITIES-- N.O.C.--ALL EMPLOYEES OTHER THAN THOSE ENGAGED IN THE OPERATION OR MAINTENANCE OF AMUSEMENT DEVICES, RESTAURANTS OR RETAIL STORES PAGE INTERIM BASE BILLING RATE'' RATE* 6.94 7.98 7.34 8.44 ''THE BASE RATE IS PROVIDED FOR YOUR INFORMATION. IT IS THE RATE WHICH STATE COMPENSATION INSURANCE FUND HAS FILED WITH THE DEPARTMENT OF INSURANCE. THE INTERIM BILLING RATE WILL BE USED ON PAYROLL REPORTS. IT TAKES INTO ACCOUNT RATING PLAN CREDITS (OR DEBITS) WHICH WILL APPLY AT FINAL BILLING. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 11, 920023 9961 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO Crlr rn onn lnntl to rll l_nnA1 1 OF ni n np )17 2 ENDORSEMENT AGREEMENT BROKER COPY 9267549-23 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 10, 2023 AT 12.01 A.M. PAGE 2 OF 2 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRACKLESS TRAIN PARTY SERVICES LLC 405 E GARDENA BLVD STE C GARDENA, CA 90248 CONTINUED IF THIS CLASSIFICATION CHANGE RESULTS IN INCREASED POLICY PREMIUM, YOU ARE ENTITLED, AS PROVIDED BY INSURANCE CODE SECTION 11753.1, TO REQUEST THAT THE CLASSIFICATION DECISION BE RECONSIDERED BY THE STATE COMPENSATION INSURANCE FUND. PLEASE CONTACT YOUR LOCAL DISTRICT OFFICE. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 11, 220023 9961 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO nl n nP 117