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PROOF OF INSURANCE (2015) CLOSEDSOUTH -5 OP 1'0: KT CERTIFICATE OF LIABILITY INSURANCE °03/261201YY' 03/204 2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER Phone: 310-370-5000 N PACIFIC UNIFIED INSURANCE — — P.O. Box 88 Fax: 310- 370 -5454 PHONE F I, � m Lawndale, CA 90260 E-MAIL __ w John Huttinger, CIC, CRM INSURER(S) AFFORDING COVERAGE NAIC # ... ..- ......__- __.."..w,... .,..w.. ..... INSURERA :MarkelAmericanInsuranceCo. - - -- ......... ........ INSURED South Bay hildren's Health.... ...... y INSURER - - -RE ,..........r eCompan,)/ -._ Insuranc, CANCELLATION . . .. . Center Association Inc. ' ...... ... ._.......,22357.............� INSURERC:HartfOrd 410 So. Camino Real _-...— ..... — ----- _- Redondo Beach, CA 90277 INSURER D SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE INSURER E: THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IN U ER F: / qL; F COVERAGES CERTIFICATE NUMBER: 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. h AUTHORIZED REPRESENTATIVE .,.,...,. .. �. ILTR . TYPE OF INSURANCE . ,.,...... AISYSL .S�6�Y� ....POLICY NUMBER.........,. _POLICY FF... P...._ .m..m_ . —_ POLICY EXP _._ �. IMMIpO/YYYYI. .,....,... .,m ._ .. , , -� .............. LIMITS _ ......... _.... 0- ENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 GENERAL LIABILITY X �8502SS311218-6 0313112014 03/31/2015 PREMISES Ea occurrence $ ea occurr CLAIMS -MADE X 1 OCCUR d MED EXP (Anyone peDrson) .,, $ 10,000 - ---------.,.. ..........1,000,00 _._.._ .. -.,...._ .. ... ...." ,,,, PERSON. AL & ADV INJURY $ AL MISCONDT -$ GENERAL,,. ,.._ AGGREGATE -. _......__„ $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 3,000,00 Pia IcY Loc Emp Ben. - - - - - -- en — -- - -..._ $ $1 M /$3M AUTOMOBILE LIABILITY C04MBINEC iNCALE Llhtlf _ ._ ..$ _ __ 1,000,0.0 A ANY AUTO 8502SS31121" 03/3112014 03/3112015 BODILY INJURY (Per person) .... $ ALL OWNED SCHEDULED AUTO S AUTOS ..................... `. BODILY INJURY (Per accident) ` ' $ X HIRED AUTOS X NON -OWNED ryr7 ="T'Y ry.,p "C" ... .. "„ -,. -. AUTOS _(Per accident)„ X UMBRELLA LIAR X OCCUR �' EACH OCCURRENCE $ 1,000,00 EXCESS LIAB E 602SS347908 d 03/3112014 03/31/2015 A CLAIMS MAD _..A_.._._ � .. ... ..M_.. AGGREGATE - -— $ 1,000,00 DED X RETENTION_$----__ 1Q,000 $ WORKERS COMPENSATION W STATU� OTRH AND EMPLOYERS' LIABILIT Y Y I j _X 'TORY I IM�T � - B ANY PROPRIETOR/PARTNERIEXECUTIVE 2WECPZ4112 12/0112013 12101/2014 OFFICER /MEMBER EXCLUDED? NIA E L EACH ACCIDENT $ 1,000,00 (Mandatory in NH) E,L- DISEASE - EA EMPLOYEE $ 1,000,00 If DESCRIPTII OF OPERATIONS below E.L DISEASE -POLICY LIMIT $ 1,000,00 A Loc. #1 /Repl Cost 16 S31 6 SPECIAL 03/31/2014 03/31/2015 BUILDING 359,40 A Loc. #1 1Repl Cost 8602 S311218-6 SPECIAL 03131/2014 03/31/2015 CONTENTS 95,200 . ..._ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach A CORD 701, Additional Remarks Schedule, if more space is required) Certificate Holder is included as Additional Insured per the general liability extension form MGL232(05/09). RE:Counseling of abused children and their families who are referred to the South Bay Youth Project. SEE HOLDER NOTES FOR ADDITIONAL POLICY FORMS 6 CONDITIONS. L:EI IH- ItJ;AIt HULLIIzH CANCELLATION CITYOFE "� ^4m SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo CDBG Grant / qL; F ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Tina Gall "; 350 Main Street h AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 4i . •nee nnwn ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD NOTEPAD. HOLDER CODE CITYOFE SOUTH-5 PAGE 2 INSURED'S NAME South Bay Children's Health OP ID KT DATE 03126114 t . � . . . _ __. . . .... **Increased "Rented Prem ise s" and Expense,, cover limiis per the =nercial eneral liability plus extension e ndorsetieTI fo c 5/09) al coverage l inmates,or prisoners, per form CGP, 5 1093.** Workers Compensation olicy includes blanket waiver of subrogation per attached form# 9903 03B(08/00) (p.4 of 6) . ATTACHED TO AND POLJCY NUMBER: W02SS31121 8-5 FORMING PART OF COMMMOAL GENERAL LIABILli Markel Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ 11T CAREFULLY. , COMMERCIAL "71 GENERAL LIABILITY PLUS EXTENSION ENDORSEMENT E S"hl,�� rl r VI I 1 t l f t 1 coverage, 'kY t it e policy carefully in rr hts,�' duties is is t covered Throughout The this r ter "your" refer Insured In the ri , words ," " and r" refer to the company providing this insurance. This endorsement modifies insurance r vi under the ll i COMMERCIAL LIABILITY Unless ii 1 in i II other terms, conditions exclusions li remain The following Is a sunwrnary of the lin ita, additional coverages and extensions provided by this endorsement. For complete details on specific coverages, consult the ,Policy contract wording. As respects any coverage provided by this endor ment, if higher iirnits are provided on any other schedule, declarations, or endorsement attached to this Policy, then the limits and coverage Provided by this endorsement would not apply for that cover Medical SCHEDULE t Increased per person ( 1 l ) Supplementary Bail Bonds to Loss of Earnings to Damage to i UP to the General Liability Each Occurrence Limit Watercraft Increased to 51 feet long Aircraft If rented or loaned with a paid crew Property from r Use Included Broadened i 'on of Insured Included Mental Anguish Resulting from it Injury Included Advertising Injury from r Videotaped Material Included l roedened Definition of Mobile Equipment. Included Per Location and Per project Aggregates Included Additional Insured -Managers or Lessors of Promises Included Additional Insured - Vendors (Limited'!) Included Additional: insured- y Written Contract, Agreement or Permit Included Additional Insur - r Receiver Included Extended "Property Damage" or intended Injury c Property rr owed Equipment UP to Property " to $10,000 " r Medical r , "occurrence" It no r coverage form applies Limited "Product Withdrawal" Expense Coverage $10,000 per " i r " Waiver of"Transfer Of Rights of Recovery Included Duties in the Event of "Occurrence", Claim or "'Suit'" Included Unintentional Failure to Disclose Hazards Included Liberalization Included t, r n 1 f 4& Page I i I I. I +Company, I. The fallowing applies only if Medical Payments Coverage is not excluded from the policy to which this endorsement Is ach III -LIMITS INSURANCE, r raph 7. is et in its entirety and I splaced by the following: 7, Subject to paragraph G., Section Ill - Limits of Insurance, the Medical Expense Limit is ual to the Medical Expense Limit stated in the Declarations subject to a minimum of $10,000 and is the most we will pay under Coverage C for all medical expenses au of "bodily injury" sustained by any one person. II• SUPPLEMENTARY PAYMENTS -BAIL BONDS AND LOSS OF EARNINGS SUPPLEMENTARY PAYMENTS - COVERAGES A AND B, paragraphs I.b. and I.d. are deleted in their entirety and replaced by the follows to $5000 for cost of ball bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which Bodily Injury Liability Coverage applies. We do not have to furnish these bonds, . All reasonable exp incurred by the insured at our request to assist us in the )nventigation or defense of the claim or "suit", including actual loss of earnings up to $500 a dey because of time off from work; III. DAMAGE TO PREMISES YOU A. When Damage To Premises Rented To You Limit is shown in the Declarations, Exclusion j. of Coverage Section A. I is replaced y the following: j. Damage To Property " o rty damage" to; (1) Property you own, rent, or occupy, including y costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restoratiorl or maintenance of such property for any reason, Including prevention of injury to a person or damage to another's property-, ( ) PrQmi$es you sell, give away or abandon, If the "property damage" arises out of any part of those promises; ( ) Property loanedto you, ( ) Personal property in the care, custody or control of the insured; ( ) That particular part of real property on which you or any contractors or subcontractors working directly or indirectly on your behalf are performing operations, If the "property damaga~ arises out of those operations; or ( ) That particular part of any property that must be restored, repaired or replaced a "your work" wa6 incorrectly performed on it. Paragraphs (1).. (3) and (4) of this exclusion do riot, apply to "properly damage" (other than damage by fire) to premises, including the contents of such prams , rented to you. A separate limit of Insurance applies to Damage To Premises Rented To You as described in Section III - Limits of Insurance. Paragraph ( ) of this exclusion does not apply if the premises are 'your work" and were never occupied, rented or held for rental by you. L2 ( 1 ) Copyright. Markel Insurance Company, 2009 Page 2 of 1 Includes ht materW of ISO. Inc.with its permission Paragraphs (3), (4). (5) and (6) of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph ( ) of this exclusion does not apply to "property damage" included in the "products-completed operations hazard". B. SECTION I - COVERAGE A.2. Exclusions is amended to delete the last paragraph and is replaced by the following: Exclusions c, through n. do not apply to damage by fire, lightning, explosion, smoke or sprinkler leakage damage to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to this coverage as described in Section III - Lknhs of Insurance. C. SECTION III • LIMITS OF INSURANCE, Par raph 6. is replaced by the following: 6. SubJect to 5. above, the Damage To Premises (tented To You Limit is the most we will pay under Coverage A for damages because of ""property damage,!, to any one premises while rented to you, or, In case of damage by fire, lightning, explosion, smoke, or sprinkler leakage while rented to you or temporarily occupied by you with permission of the owner. The Damage To Premises Rented To You limit is the Each Occurrence Limit shown in the General Liability Declarations. D. COMMERCIAL GENERAL LIA CONDITIONS SECTION, paragraph 4.b.0)(a)jll) or paragraph 4.b.(1)(a)(Il1I) is deleted and replaced by the following: That is fire, lightning, explosion, smoke or sprinkler leakage insurance for premises rented to you or temporarily occupied by you with permission of the owner; or E. DEFINITIONS SECTION , paragraph 9.a. is deleted and replaced by the following: a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifles any person or organization for damage by fire, lightning, explosion, smoke or sprinkler leakage to promises while rented to you or temporarily occupied by you with Permission of the owner Is not an "Insured! contract": IV. NON-OWNED WATERCRAFT AND' NON-OWNED AIRCRAFT RENTED OR LOANED TO YOU WITH A CREW SECTION I - COVERAGES, COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Exclusion g. - Aircraft, Auto of Watercraft, paragraph (2), is deleted in its entirety and replaced with the following; (2) A watercraft you do not own that is: (a) Less than 51 feet long; and (b) Not being used to carry persons or property for a charge. The following is added to . (6) An aircraft not owned by any insured that is rented or loaned to you with a paid crew. If other insurance applies to a loss because of "property damage" to non-owned watercraft or aircraft as described in (2)(a) and (b) or (6) above, the Insurance Provided by this Coverage Form does not apply whether the other insurance is primary, excess, contingent, or issued on any other basis. V. PROPERTY DAMAGE COVERAGE ARISING OUT OF ELEVATOR USE SECTION I - COVERAGES, COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Exclusion I. is amended to include the following: GL2 (051 09) Copyright, Markel Insurance Company, 2009 Page 3 of 1 Includes iahled matiarim mf ion in,, t�e,wo�n.,..:ra__ Paragraphs (3), (4) and (6) shall not apply to liability arising out of the user of elevators. If other valid and collectible insurance applies to a loss because of "property damage" arising out of the use of elevators, this Coverage Form shall apply excess of the other insurance, whether this other insurance is primary, excess, contingent, or issued on any other basis. VI. WHO IS AN INSURED SECTION II -WHO IS AN INSURED, is amended by the following: A. Paragraph 2. is amended to include the following as insureds; e. Any legally incorporated entity of which you own at least 51% of the voting stock on the Inception date of this Coverage Form and on the date of any covered "occurrence", claim or "suit". This insurance shall not apply to any entity that is already an insured under any other Insurance provided by any company or that would be an insured but for the exhaustion of its limits of insurance, B. Newly Acquired or Formed Organizations Paragraph 3.a, is deleted In its entirety and replaced with: a. Coverage for your newly acquired or formed organization shall be: 1. Effective on the date of acquisition or affirmation; and 2. Afforded until the end of the policy period of this Coverage Form. C. The following is added to Paragraph 2.a.: Paragraph (1)does not apply to executive officers, or to managers at the supervisory level or above. VII. MENTAL ANGUISH COVERAGE THAT RESULTS FROM BODILY INJURY DEFINITIONS SECTION, Item 3.. Bodily Injury, is deleted in its entirety and replaced with the following: 3. "Bodily injury" means: a. Bodily injury, sickness or disease sustained by a person, and also includes mental anguish or emotional distress provided such mental anguish or emotional distress results from any of these; and b. Death resulting from bodily injury, sickness or disease. VIIi.ADVERTISING INJURY A. DEFINITIONS SECTION, Item 14, Personal and Advertising Injury, paragraphs d. and e. are deleted in their entirety and replaced with the following: d. Oral, written or professionally produced televised or videotaped publication of material In any manner that slanders or libels a person or organization, or disparages a person's or organization's goods, products or services; e. Oral, written or professionally produced televised or videotaped publication of material in any manner that violates a person's right to privacy; B. SECTION I -COVERAGES, COVERAGE B. PERSONAL AND ADVERTISING INJURY LIABILITY, Exclusions b. and c. are deleted in their entirety and replaced with the following: b. "Personal and advertising injury" arising out of oral, written or professionally produced televised or videotaped publication of material in any manriar, if done by you or at your direction with knowledge of its falsity, MQL232 (05/09) Copyright, Markel Insurance Company, 2009 Page 4 of 14 includes copyrighted material of ISO; Inc. with its permission a. "Personal and advertising injury" arising out of oral, written or professionally produced televised or videotaped publication of material whose first publication took place before the beginning of the Policy period. IX. MOBILE EQUIPMENT DEFINITIONS SECTION, item 12., Mobile Equipment,paragraph f.(1) is amended to add the following: This shall not apply to self-propefled vehicles of less than 1000 pounds gross vehicle weight. X. PER LOCATION AND PER PROJECT AG(MEGATES SECTION III - LIMITS OF INSURANCE, is amended to add the.following: A. For all sums which the insured becomes legally obligated to pay as darnage.s caused by "ou,rrences°" under COVERAGE A (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C (SECTION 1), which can be attributed only to operations at a covered "location" or covered' construction project: 1, A separate Per Location or Per Project General Aggregate Limit applies to each covered "location" or covered construction project, and that limit is equal to the amount shown in the declarations, of the General Aggregate Limit 2. The Per Location or Per Project General' Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard", and for medical expenses under COVERAGE C regardless of the number of: a. Insureds; b. Claims made or "suits" brought, or c. Persons or organizations making claims or bringing "suits". ,S. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Per Location or Per Project General Aggregate Limit for each covered "location" or covered project for which payment Is made Such payments shall not reduce time General Aggregate Limit shown In the Declarations nor shall they reduce any other, covered "location" or covered project's general aggregate. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown In the Declarations, such limits will be subject to the applicable Per Location or Per Project General Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused' by accidents under COVERAGE C (SECTION 1), which cannot be attributed only to ongoing operations at a covered "location" or covered project: 1• Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-Completed Operations Aggregate Limit, whichever Is applicable; and 2. Such payments shall not reduce any Per Location or Per Project General Aggregate Limit. MGL232 (05109) Copyright,Markel Insuranoe Company;2049 Page 5 of 14 Includes coovdahted mateial of mn inn .Ak u� ........c�_s__ C. When coverage for liability arising out of the "products-completed operatioris hazard" is provided, any Payments for damages because of "bodily injury" or "Property damage" included In the "products-completed operations hazard" will reduce the Produots-Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Per Location or Per Protect General Aggregate ILirnit, D. For the purposes of this section of this endorsement, "Lor, bon" means premises involving the same or connecting. lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of s railroad. E. If the applicable covered construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deetned to be the same construction project. F. The provisions of Limits of Insurance (SECTION III) not otherwise,modified by this endorsement shall continue to apply as stipulated. XI. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES WHO 1S AN INSURED (SECTION 11) is amended to include as an additional insured any person or organization who leases to you or manages property you rent or lease, but only with respect to liability for "bodily Injury", "property damage" or "personal and advertising injury" caused, in whole or In part, by your acts or omissions or the acts or omissions of those acting on your behalf in connection with that part of the premises leased or rented to you and shown on the Declarations- The following additional exclusions apply- This insurance does not apply toe 1. Any "occurrence" which takes piece after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization who leases to you or manages property you rent or lease. Xll. ADDITIONAL INSUREDS -VENDORS (LIMITED) The following provision applies only if the policy to which this endorsement is attached provides insurance for "bodily injury" and "property damage" included in the "products-completed operations hazard": WHO IS AN INSURED !SECTION II) is amended to include as an additional insured any person or organization (referred to below as vendor) with whom you agree In a written contract or agreement to provide Insurance, but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions. 1. The insurance afforded the vendor does not apply to: a. "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement: b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; a. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products: MGL232(05109) Copyright, Markel Insurance Company, 2009 Page 8 of 14 Includes copyrighted material of ISO, Inc.with its permismon f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; h. Any failure to maintain the product in a merchantable condition; or i. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf, However, this exclusion does not apply to: (1) The exceptions contained in subparagraphs d. or f.; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. 2. This insurance does not apply to any insured person or organization from whom you have acquired such products, or any ingredient, part or container entering into, at or containing such products. XIII. ADDITIONAL INSURED - BY WRITTEN CONTRACT, AGREEMENT, PERMIT OR AUTHORIZATION The following paragraph is added to WHO IS AN INSURED (Section 11): 4. Any person or organization tar whom you are required by written contract, agreement, permit or authorization to provide insurance is an insured, subject to the following additional provisions: a. The contract, agreement, permit or authorization must be in effect during the policy period shown in the Declarations, and must have been executed prior to the "bodily injury", "property damage", or "personal and advertising injury". b. The person or organization is an insured only to the extent you are held liable due to: (1) The ownership, maintenance or use of that part of premises you own, rent, lease or occupy subject to the following additional provisions. la) This insurance does not apply is any "occurrence" which takes place after you cease to be a tenant in any premises leased to or rented to you; (b) This insurance does not apply to any structural alterations, new construction or demolition operations performed by or on behalf of the person or organization: (2) Your ongoing operations for that insured, whether the work Is performed by you or for you; (3) The maintenance, operation or use by you of equipment leased to you by such person or organization, subject to the following additional provisions, (a) The insurance does not apply to any "occurrence" which takes place after the equipment lease expires; ib) This insurance does not apply to "bodily injury" or "property damage" arising out of the sole negligence of such person or organization; 14) Permits or authorizations issued by any state Or politioal subdivision with respect to operations performed by you or on your behalf, subject to the following additional provision: This insurance does not apply to "bodily injury", "property damage", or "personal and advertising injury" arising out of operations performed for that state or municipality. MGL232 (05/09) Copyright, Markel Insurance Company,2.009 Includes coovriahtAd matarini.rf iQn r..,, —m.:.- _ �_•__ Page 7 of 14 c. The Insurance with respect to any architect, engineer, or surveyor, added as an "Insured" by this coverage, does not apply to "bodily injury", "property damage", 'cr "personal and advertising injury" arising out of the rendering or failure to render any professional services by or for you, including: (1) The preparing, approving or failure to prepare or approve maps, drawings, opinions, reports. surveys, change orders, designs or specnificatlons; and (2) Supervisory, Inspection or engineering services, d. This insurance does not apply to "bodily injury" or "property damage" included within the "products- completed operations hazard". A person's or organization's status as an Insured under this endorsement ends when your operations for that insured are completed. No coverage will be provided if, in the absence of this endorsement, no liability will be imposed by law on you. Coverage will be limited to the extent of your negligence or fault according to the applicable principles of comparative fault. This Additional Insured provision does not apply to Managers or Lessors of Premises, Vendors, or Mortgagees, Assignees, or Receivers. For Managers or Lessors of Premises, refer to ADDITIONAL INSURED- MANAGERS OR LESSORS OF PREMISES. For Vendors, refer to ADDITIONAL INSURED - VENDORS. For Mortgagees, Assignees or Receivers, refer to ADDITIONAL INSURED - MORTGAGEE, ASSIGNEE, OR RECEIVER. X1V. ADDITIONAL INSURED - MORTGAGEE, ASSIGNEE, OR RECEIVER WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of premises by you. This Insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization, XV. EXTENDED "PROPERTY DAMAGE" - EXPECTED OR INTENDED INJURY Exclusion 2.a. of SECTION I - COVERAGES, COVERAGE A is deleted in its entirety and replaced by the following: a. "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. XVI. PROPERTY DAMAGE - BORROWED EQUIPMENT A. Paragraph 0) of Exclusion J. of SECTION 1 - COVERAGES, COVERAGE A does not apply to "property damage" to borrowed equipment while that equipment is: 1. Not being used to perform operations; and 2. Away from an insured'b premises. 13. The insurance afforded by this provision is excess over any valid and collectible property insurance (including any deductible) available to *he insured whether primiary, excess, contingent or on any other basis_ C. SECTION III -LIMITS OF INSURANCE is amended to add the following; Subject to the General Aggregate provision, the most we will pay under this provision for "property damage" to borrowed equipment is $10,000 per "occurrence". MGL232 105/09) Copyright, Markel Insurance Company, 2008 Page 8 of 14 Includes copyrighted material of ISO, Inc with its permission XVII, PROPERTY DAMAGE- "CUSTOMERS' GOODS" A. Paragraphs (3}, (4), and (G) of Exclusion J. of SECTION I - COVERAGES, COVERAGE A does not apply to "property damage" to "customers' goods" while on your premises. B. The insurance afforded by this provision is excess over any valid and collectible property insurance (including any deductible) available to the insured whether primary, excess, contingent or on any other basis. C. SECTION III -LIMITS OF INSURANCE is amended to add the following': Subject to the General Aggregate provision, the most we will pay under this provision for "property damage" to "customers` goods" is $10;000 per "occurrence". XViII. MEDICAL PERSONNEL The following applies only If no other similar coverage is included on or added to the policy to which this endorsement is attached: The following is added to SECTION I - COVERAGES, COVERAGE • A - Bodily Injury and Property Damage Liability - Insuring Agreement- A. We will pay those sums the insured becomes legally obligated to pay as a result of an "occurrence"' arising out of your employed registered nurse, licensed practical nurse, certified emergency medical technician or certified paramedic performing professional health care services, This applies only to those professional health care services arising out of duties related to the conduct of your business. The registered nurse, licensed practical nurse, certified emergency medical technician or certified paramedic must be your "employee". B. SECTION II - WHO IS AN INSURED is amended to include the above designated "employees" for acts within the scope of their employment by you while performing duties related to the conduct of your business including duties arising out of his or her providing or failure to provide professional health services. C. SECTION III - LIMITS OF INSURANCE is amended to add the following Subject to the General Aggregate provision, the most we will pay under Medical Personnel coverage is $100,000 for all professional health services sustained by any one person. X)X. LIMITED PRODUCT WITHDRAWAL EXPENSE COVERAGE THIS COVERAGE ONLY PROVIDES REIMBURSEMENT TO YOU FOR EXPENSES INCURRED BECAUSE OF A COVERED "PRODUCT WITHDRAWAL". THiS COVERAGE DOES NOT PROVIDE ANY LIABILITY COVERAGE OR COVERAGE FOR THE COST OR EXPENSE OF DEFENDING ANY CLAIM OR SUiT. A. The following is added to Section 1 - Coverages: SECTION i -LIMITED PRODUCT WITHDRAWAL EXPENSE COVERAGE 1. Insuring Agreernerrt (e) We will reimburse you for "product withdrawal expense" incurred by you because of a "product withdrawal" to which this insurance applies. The amount of such reimbursement is limited as described in Section III - Limits of Insurance. No other obligation or liability to pay sums or perform acts or services is covered, (b) This insurance applies to a "product withdrawal" only if the "product withdrawal" is initiated in the "coverage territory" during the policy period because: (1) You determine that the "product withdrawal" is necessary; or (2) An authorized government entity has ordered you to conduct a "product withdrawal". MGL232 (05/09) Copyright, Markel Insurance Company, 2009 Page 9 of 14 Incl om mrwrinhtm m-*-riftI ..s�r% I.... L- -_-__ (c) We will reimburse "product withdrawal expenses" only If: (1) The expenses are incurred within one year of the date the "product withdrawal" was initiated; (2) The expenses are reported to us within one year of the date the expenses were incurred; and (3) The product that is the subject of the "product withdrawal" was produced after the inception date of this policy or the date this endorsement was added, whichever is earlier. (d) The initiation of a 'product withdrawal" will be deemed to have been made only at the earliest of the following times: (1) When you first announced, in any manner, to the general public, your vendors, or to your employees (other than those directly Involved; in making the determination) your decision to conduct or participate in a "product withdrawal!". This applies regardless of whether the determination to conduct a 'product withdrawal"' Is made by you or Is requested by a third party; or (2) When you first received, either orally or in writing, notification of an order from an authorized government entity to conduct a "product withdrawal". (e) "Product withdrawal expenses" incurred to withdraw "your products" which contain the same or substantially similar "defects" will be deemed to have arisen out of the same "product withdrawal". 2. Exdusions This insurance does not apply to "product withdrawal expenses" arising nut of: (a) Breech Of Warranty And Failure To Conform To Intended Purpose Any "product withdrawal" Initiated due to the failure of "your product" to accomplish their Intended purpose, Including any breach of warranty of fitness, whether written or implied. This exclusion does not apply if such failure is reasonably expected to cause "'bodily injury" or "physical d'a'mage" to tangible property other then "your product".. (b) Infringement Of Copyright, Patent,Trade Secret, Trade Dress Or Trademark Any "product withdrawal" initiated due to copyright, patent, trade secret, trade dress or trademark Infringements. (c) Deterioration, Decomposition Or Chemical Transformation Any "product withdrawal" Initiated due to transfoi oration of a chemical nature, deterioration or decomposition of "your product". This exclusion does not apply if it is caused by: (1) An error in manufacturing, design or processing; (2) Transportation of "your product"; or (3) "Product tampering", (d) Goodwill, Market Share, Revenue, Profit Or Redesign The costs of goodwill, market share, revenue or "profit" or the costs of redesigning "your product". (6) Expiration Of Shelf Life Any "product withdrawal" initiated due to expiration of the designated shelf life of "your product". MGL232 (09109) Copyright,Markel Insurance Company,2008 Page 10 of 14 Includes copyrighted material of ISO: Inc with its permission (f) Known Defect A "product withdrawal" initiated because of a "defect" in "your product" known to exist by the Named Insured or the Named Insureds "executive officers", prior to the date when this Coverage Part was first issued to you or prior to the time *your product! leaves your control or possession. (g) Otherwise Excluded Products A recall of any specific products for which "bodily injury" or "property damage" is excluded under Coverage A - Bodily Injury and Property Dames Liability by endorsement. (h) Governmental Ban A recall when "your product" or a component contained within "your product" has been- (I I Banned from the market by an authorized government entity prior to the policy period; or (2) Distributed or sold by you subsequent to any governmental ban. (1) Defense Of Claim The defense of a claim or "suit" against you for liability arising out of a "product withdrawal". �) Third Party Damages, Fines And Penalties Any compensatory damages, fines, penalties, punitive or exemplary or other non-compensatory damages imposed upon the insured. (k) PolNrtion-Related Expenses Any loss, cost, or expense due to any_ 11) Request, demand, order, statutory or regulatory requirement that any insured or others test for, monitor, dean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, "pollutants"; or 12) Claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to or assessing the effects of, "pollutants". B. For purposes of this endorsement, Section III -LIMITS OF INSURANCE is replaced by the following: SECTION III - LIMITS OF INSURANCE The most that we will reimburse you for under this coverage is $10,000 regardless of the number of: Is) Insureds; (b) "Product withdrawals" initiated; or 1c) Number of "your products" withdrawn. The $10,000 limit is the most that we will reimburse you for the sum of all "product withdrawal expenses" incurred for all "product withdrawals" initiated during the policy period. MGL232 (05109) Copyright, Markel Insurance Company,2009 Page 11 of 14 Irw4mr6se ennuAnhom.4 nnft*,&Aid .-s ee^ e__ .._.a_ e.- --- C. For the purposes of this coverage, the Duties In The Event Of Occurrence, Claim Or Suit Condition under Section IV - Conditions is replaced by the following: 2. Duties In The Event Of A "Defect" Or A 'Product Withdrawal" a. You must see to it that we are notified as soon as practicable of any actual, suspected or threatened "defect" in "your product", or any governmental investigation, that may result in a "product withdrawal". To the extent possiNe, notice should include: (1) How, when and where the "defect" was discovered; (2) The names and addresses of any injured persons and witnesses; and (3) The nature, location and circumstances of any injury or damage arising out of use or consumption of "your product". b. If a "product withdrawal" is initiated, you must: (1) Immediately record the specifics of the "product withdrawal" and the date where it was initiated; and (2) Notify us as soon as practicable. You must see to it that we receive written notice of the "product withdrawal" as soon as practicable. c. You must promptly take all reasonable steps to mitigate the expenses associated with a "product withdrawal". Any "profit" that you receive from mitigating the expenses will be deducted from the amount of reimbursement that you will receive for "product withdrawal expenses". d. You and any other involved insured must: 11) Immediately send us copies of pertinent correspondence received in connection with the "product withdrawal"; (2) Authorize us to obtain records and other information; and (3) Cooperate with us In our investigation of the "product withdrawal". D, For the purposes of this coverage, the following is added to Section IV -Conditions: Concealment Or Fraud We will not provide coverage under Section 1 to you; or any other insured, who at any time: 1. Engaged in fraudulent conduct; or 2. Intentionally concealed or misrepresented a material fact concerning a "product withdrawal" or "product withdrawal expenses" incurred by you under Section I of this coverage. XX. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Item 8., Transfer of Rights of Recovery Against Ethers to Us of SECTION IV - COMMERCIAL GENERAL LIAMLIITY CONDITIONS is amended by the addition of the following: We agree to wave any right of recovery we may have against any person or organization with whom you have agreed by contract prior to an "occurrence" to waive such rights 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". The waiver applies only to the person or organization with whom you have agreed in a contract prior to an "occurrence" to waive such rights. MGL232(05109) Copyright, Market Insurance Company,2009 Page 12 of 14 Includes copyrighted material of ISO, Inc.with Its permission XXI. DUTIES IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Item 2., Duties in the Event of Occurrence. Claim or Suit, is amended to include the following- e. Your obligation to notify us as soon as practicable of an "occurrence", offense, claim or "suit" is satisfied If you send us written notice as soon as practicable after any of your "executive officers", directors, partners, insurance managers or legal representatives becomes aware of or should have become aware of such "occurrence". offense, claim or "suit". XXII. UNINTENTIONAL FAILURE TO DISCLOSE ALL HAZARDS SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, is emended to include the following: Based on our reliance on your representations as: to existing hazards, if you unintentionally fail to disclose all such hazards prior to the beginning of the policy period of the Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. XXIII. LIBERALIZATION SECTION IV - COMMERCIAL GENERAL LIANUTY CONDITIONS, is amended to include the following! If we revise this Coverage Form to provide more coverage without additional premium charge, your policy will automatically provide the additional coverage as of the day the revision is effective in your state. XXIV- DEFINITIONS The following definitions are added; 1. "Customers' goods" mean tangible persona] property belonging to your customers and left with you for storage, service or repair. "Customers' goods" do not include: a. Accounts, bills, currency, deeds, fond stamps or other evidences of debt, money, notes or securities. Lottery tickets held for sale are not securities; b. Animals; e. Contraband, or property in the course of illegal transportation or trade; d. Personal property while airborne or waterborne; a. Property that is covered under another coverage form of this or any other policy in which it is more specifically described, except for the excess of the amount due (whether you can collect on it or not) from treat other insurance; f. Vehicles or self-propelled machines (including aircraft or watercraft) that are licensed for use on public roads. This paragraph does not apply to: {1) Vehicles or self-propelled machines, other than "autos", you hold for sale; or (2) Rowboats or canoes out of water at the described premises; g. The following property while outside of buildings: (1) Grain, hay, straw or other crops; (2) Fences, radio or television antennas (including satellite dishes) and their lead-in wiring, masts or towers, signs iother than signs attached to buildings), trees, 'shrubs or plants (other than trees, shrubs or plants hold for sale). MOL232 (05109) Copyright, Markel Insurance Company.2009 Page 13 of 14 Includes convrfahted malarial of I..qn Irv+ ,u#k #& 2. "Defect" means a defect, deficiency or inadequacy that creates a dangerous condition. 3. "Product tampering" is an act of intentional alteration of "your product" which has caused or is reasonably expected to cause "bodily injury" or physical injury to tangible property other than "your product". When "product tampering" is known, suspected or threatened, a "product withdrawal" will be limited to those batches of "your product" which are known or suspected to have been tampered with. For purposes of this insurance, electronic data is not tangible property. As used in this definition, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and application software. hard or floppy disks, CD-ROMs. tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment_ 4. "Product withdrawal" means the recall or withdrawal: a. From the market; or b. From use by any other person or organization; of "your products" or products which contain "your products", because of known or suspected "product tampering", which has caused or is reasonably expected to cause "bodily injury" or physical injury to tangible property other than "your product". For purposes of this insurance, electronic data is not tangible property. As used in this definition, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD-ROMs, tapes, drives, cells, data processing devices, or any other media which are used with electronically controlled equipment. 5. "Product withdrawal expenses" means those reasonable and necessary extra expenses, listed below, paid and directly related to a "product withdrawal": a. Costs of notification; b. Costs of stationery, envelopes, production of announcements and postage or facsimiles; c. Costs of overtime paid to your regular non-salary employees and costs incurred by your employees, including costs of transportation and accommodations; d. Costs of computer time; e. Costs of hiring independent contractors and other temporary employees; f. Costs of transportation, shipping or packaging; g. Costs of warehouse or storage space; or h. Costs of proper disposal of "your products" or products that contain "your products" that can not be reused, not exceeding your purchase price or your cost to produce the products. 6. "Profit" means the positive gain from business operation after subtracting for all expenses. All other terms and conditions remain the same. MOL232 105/09? Copyright, Markel Insurance Company,2009 Page 14 of 14 Includes copyrighted material of ISO, Inc. with its permission THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WORKERS' COMPENSATION BROAD FORM ENDORSEMENT EXTENDED OPTIONS m Policy Number: 72 WEC Pz4112 Endorsement Number: oEffective Date: 12/01/13 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: SOUTH BAY CHILDREN' S HEALTH CENTER ASSOCIATION, INC. 410 CAMINO REAL ~M REDONDO BEACH, CA 90277 a Section I of this endorsement expands coverage provided under WC 00 00 00. n Section II of this endorsement provides additional coverage usually only provided by endorsement. o Section III of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: Ln INDEX W SUBJEC PAO SU114 EST EAM SECTION 1 2 B. Part One Does Not Apply 3 PARTS ONE and TWO 2 C. Application of Coverage 3 01 We Will Also Pay 2 D. Additional Exclusions 3 PART-THREE 2 E. West Virginia 3 02 How This Insurance Works 2 EXTENDED OPTIONS 4 PART-SIX 2 01 Employers' Liability Insurance 4 03 Transfer of Your Rights and Duties 2 02 Unintentional Failure to Disclose 4 04 Liberalization 2 Hazards SECTION If 2 03 Waiver of Our Right to Recover from 4 VOLUNTARY COMPENSATION INSURANCE 2 Others ®0 04 Foreign Voluntary Compensation 4 05 Voluntary Compensation Insurance 9 ry P A. How This Insurance Applies 2 A. How This Reimbursement Applies 4 B. We Will Pay 2 B. We Will Reimburse 4 C. Exclusions 3 C. Exclusions 4 D. Before We Pay 3 D. Before We Pay 5 E. Recovery From Others 3 E. Recovery From Others 5 F. Employers' Liability Insurance 3 F. Reimbursement For Actual Loss 5 EMPLOYERS'LIABILITY STOP GAP 3 Sustained ENDORSEMENT 3 G. Repatriation 5 06 Employers' Liability Stop Gap H. Endemic Disease 5 Coverage 3 05 Longshore and Harbor Workers' 5 A. Stop Gap Coverage Limited to Compensation Act Coverage assn Montana, North Dakota, Ohio, 3 Endorsement Washington,West Virginia and SECTION III 6 ll�l Wyoming 01 Schedule of Covered States 6 Form WC 99 03 03 B Printed in U.S.A. (Ed.8/00) Page 1 of 6 Process Date: 10/12/13 Policy Expiration Date: 12/01/14 0 2000,The Hartford SECTION I PARTS ONE and TWO PART THREE 1. WE WILL ALSO PAY 2. How This Insurance Applies D. We WIII Also Pay of Part One (WORKERS' Paragraph 4. of A. How This Insurance Applies COMPENSATION INSURANCE);and of Part 3 (Other States Insurance) is replaced by E. We Will Also Pay of Part Two(EMPLOYERS' the following: LIABILITY INSURANCE) is replaced by the 4. If you have work on the effective date of this following: policy in any state not listed in Item 3.A. of the Information Page, coverage will not be We Will Also Pay afforded for that state unless we are notified We will also pay these costs, in addition to within sixty days, other amounts payable under this insurance, as part of any claim, proceeding, or suit we PART SIX defend: 1. reasonable expenses incurred at our 3. Transfer Of Your Rights and Duties request,INCLUDING loss of earnings; C. Transfer Of Your Rights and Duties of Part 6 2. premiums for bonds to release (Conditions) is replaced by the following: attachments and for appeal bonds in bond Your rights or duties under this policy may not amounts up to the limit of our liability be transferred without our written consent. under this insurance; If you die and we receive notice within sixty 3. litigation costs taxed against you; days after your death, we will cover your legal representative as insured. 4. interest on a judgment as required by law 4. Liberalization until we offer the amount due under this law;and If we adopt a change in this form that would 5. expenses we incur. broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective In your state. SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS' 3. The bodily injury must occur in the United LIABILITY COVERAGE States of America, its territories or 5. Voluntary Compensation Insurance possessions, or Canada, and may occur elsewhere if the employee is a United A. How This Insurance Applies States or Canadian citizen, or otherwise This Insurance applies to bodily injury by legal resident, and legally employed, in the accident or bodily injury by disease. Bodily United States or Canada and temporarily Injury includes resulting death. away from those places. I. The bodily injury must be sustained by any 4. Bodily injury by accident must occur officer or employee not subject to the during the policy period. workers' compensation law of any state 5. Bodily injury by disease must be caused shown in Item 3.A. of the Information or aggravated by the conditions of the Page. 2. The bodily injury must also out of and in the course of employment or incidental to work in a state shown in Item 3.A. of the Information Page. Form WC 99 03 03 B Printed in U.S.A.(Ed.8/00) Page 2 of 6 w officer's or employee's employment. The If the persons entitled to the benefits of this officers or employee's last day of last insurance make a recovery from others, they exposure to the conditions causing or must reimburse us for the benefits we paid aggravating such bodily injury by disease them. must occur during the policy period. F. Employers'Liability Insurance S. We Will Pay Part Two (Employers' Liability Insurance) We will pay an amount equal to the benefits applies to bodily injury covered by this that would be required of you as if you and endorsement as though the State of your employees were subject to the workers' Employment was shown in Item 3.A. of the compensation law of any state shown in Item Information Page. 3,A, of the Information Page. We will pay This provision 5. does not apply in New Jersey or CD those amounts to the persons who would be Wisconsin. CD entitled to them under the law. EMPLOYERS' LIABILITY STOP GAP COVERAGE C. Exclusion ri This insurance does not cover: S. Employers'11-lability Stop Gap Coverage CD 0 1. any obligation imposed by workers' A. This coverage only applies in Montana, North Dakota, Ohio, Washington, West Virginia and N N compensation or occupational disease law Wyoming. 10 or any similar law. w 2. bodily Injury intentionally caused or B. Part One (Workers' Compensation Insurance) CN aggravated by you. does not apply to work in states shown in C, Paragraph A above. 0 3. officers or employees who have elected C. Part Two (Employers' Liability Insurance) Ln not to be subject to the state workers' applies in the states, shown in Paragraph A., * compensation law. as though they were shown in Item 3.A. of the 4. partners or sole proprietors not covered Information Page. under the Standard Sole Proprietors, D. Part Two, Section C. Exclusions is changed : Partners, Officers and Others Coverage by adding these exclusions. Endorsement. D. Before We Pay This insurance does not cover; Before we pay benefits to the persons entitled 5. bodily injury intentionally caused or aggravated by you or in Ohio bodily injury to them,they must: resulting from an act which is determined 1. Release you and us, in writing, of all by an Ohio court of law to have been _ responsibility for the injury or death. committed by you with the belief than an 2. Transfer to us their right to recover from injury is substantially certain to occur. others who may be responsible for the However, the cost of defending such injury or death. claims or suits in Ohio is covered. 3. Cooperate with us and do everything 13, bodily injury sustained by any member of necessary to enable us to enforce the right the flying crew of any aircraft. to recover from others.' 14. any claim for bodily injury with respect to If the persons entitled to the benefits of this which you are deprived of any defense or insurance fall to do those things, our duty to defenses or are otherwise subject to pay ends at once. If they claim damages from penalty because of default in premium you or from us for the injury or death, our duty under the provisions of the workers' to pay ends at once, compensation law or laws of a state E. Recovery From Others shown in Paragraph A. If we make a recovery from others, we will E. This insurance applies to damages for which keep an amount equal to our expenses of you are liable under West Virginia Code Annot. _ recovery and the benefits we paid. We will S23-4-2. pay the balance to the persons entitled to it. Form WC 99 03 03 0 Printed in U.S.A. (Ed. 8/00) Page 3 of 6 EXTENDED OPTIONS 1. Employers'Liability Insurance 4. Foreign Voluntary Compensation and Item 3.B. of the Information Page is replaced by Employers'Liability Reimbursement the following: A. How This Reimbursement Applies B. Employers'Liability Insurance: This reimbursement provision applies to bodily 1. Part Two of the policy applies to work in injury by accident or bodily injury by disease. each state listed in Item 3.A. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an The Limits of Liability under Part Two are officer or employee. the higher of: 2. The bodily injury must occur in the course of employment necessary or incidental to Bodily Injury work in a country not listed in Exclusion by Accident $500,000 Each Accident C.1.of this provision. 3. Bodily Injury by accident must occur Bodily Injury during the policy period. by Disease $500,000 Policy Limit 4. Bodily injury by disease must be caused or aggravated by the conditions of your Bodily Injury employment. The officer or employee's by Disease $500 000 Each Employee last exposure to those conditions of your employment must occur during the policy OR period. B. We Will Reimburse 2. The amount shown in the Information We will reimburse you for all amounts paid by Page• you whether such amounts are: This provision 1 of EXTENDED OPTIONS does not 1. voluntary payments for the benefits that apply in New York because the Limits Of Our would be required of you if you and your Liability are unlimited, officers or employees were subject to any In this provision the limits are changed from workers' compensation law of the state of $500,000 to$1,000,000 in California. hire of the individual employee. 2. Unintentional Failure to Disclose Hazards 2. sums to which Part Two (Employers' If you unintentionally should fail to disclose all Liability Insurance) would apply if the existing hazards at the inception date of your Country of Employment were shown in policy, we shall not deny coverage under this Item 3.A.of the Information Page. policy because of such failure. C. Exclusions 3. Waiver of Our Right To Recover From Others This insurance does not cover: A. We have the right to recover our payments 1. any occurrences in the United States, from anyone liable for an Injury covered by this Canada, and any country or jurisdiction policy. We will not enforce our right against which is the subject of trade or economic any person or organization for whom you sanctions imposed by the laws or perform work under a written contract that regulations of the United States of requires you to obtain this agreement from us. America in effect as of the inception date This agreement shall not operate directly or of this policy. Indirectly to benefit anyone not named in the 2. any obligation imposed by a workers' agreement. compensation or occupational disease B. This provision 3. does not apply in the states law,or similar law. of Pennsylvania and Utah. 3. bodily injury intentionally caused or aggravated by you. Form WC 90 03 03 8 Printed in U.S.A. (Ed. 8/00) Page 4 of 6 4. liability for any consequence, whether of America necessarily incurred as a direct direct or indirect, of war, invasion, act of result of bodily injury. Foreign enemy, hostilities(whether war be Our reimbursement shall be limited as follows: declared or not), civil war, rebellion, 1. to the amount by which such expenses revolution, insurrection or military or exceed the normal cost of returning the usurped power. No endorsement now or subsequently attached to this policy shall officer or employee if in good health, or be construed as overriding or waiving this 2. in the event of death, to the amount by limitation unless specific reference is which such expenses exceed the normal made thereto. cost of returning the officer or employee if D. Before We Pay alive and in good health. co Before we reimburse you for the benefits to the in no event shall our reimbursement exceed o persons entitled to them,you must have them: the bodily injury by accident limit shown in ri Item 3.B. of the Information Page as respects 1. release you and us, in writing, of all any one such officer or employee whether T., responsibility for the injury or death, dead or alive. 2. transfer to us their right to recover from H. Endemic Disease others who may be responsible for their The word "disease" includes any endemic injury or death, diseases. NN 3, cooperate with us and do everything The coverage applies as if endemic diseases necessary to enable us to enforce the right were included in the provisions of the workers' cto recover from others. compensation law. to If the persons entitled to the benefits paid fail V to do these things, our duty to reimburse ends 5. Longshoro and Harbor Workers' Compensation at once. If they claim damages from us for the Act Coverage Injury or death, our duty to reimburse ends at General Section C. Workers' Compensation t� once. Law is replaced by the following: E. Recovery From Others C. Workers' Compensation Law If we make a recovery from others, we will Workers' Compensation Law means the MMMM keep an amount equal to our expenses of workers or workers' compensation law and recovery and the benefits we reimbursed. We occupational disease law of each state or will pay the balance to the persons entitled to territory named in Item 3.A. of the Information it. If persons entitled to the benefits make a Page and the Longshore and Harbor Workers' recovery from others, they must repay us for Compensation Act (33 USC Sections 901- mm the amounts that we have reimbursed you. 950). It includes any amendments to those F. Reimbursement for Actual Loss Sustained laws that are in effect during the policy period. It does not include any other federal workers This endorsement provides only for or workers' compensation law, other federal reimbursement for the loss you actually occupational disease law or the provisions of sustain. In order for you to recover loss or expenses under this reimbursement you must: any law that provide nonoccupational disability benefits. °— 1. actually sustain and pay the loss or Part Two (Employers' Liability Insurance), C. expense in money after trial,or Exclusions, exclusion 8, does not apply to 2. secure our consent for the payment of the work subject to the Longshore and Harbor loss or expense. Workers'Compensation Act. G. Repatriation This coverage does not apply to work subject Our reimbursement includes the additional to the Defense Base Act, the Outer expenses of repatriation to the United States Continental Shelf Lands Act, or the Nonappropriated Fund instrumentalities Act. Form WC 99 03 03 B Printed in U.S.A. (Ed.8/00) Page 5 of 6 SECTION III 1. SCHEDULE OF COVERED STATES B. If a state, shown in Item 3.A. of the Information A. This endorsement only applies in the states rage, approves this endorsement after the listed in this Schedule of Covered States. effective date of this policy, this endorsement will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. C. Schedule of Covered States: CA Countersigned by Authorized Representative Form WC 29 03 03 B Printed in U.S.A. (Ed.8100) Page 6 of 0