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PROOF OF INSURANCE (2013) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE 01 /2013 10/01/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE, ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate bolder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER"" 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. HCC Specialty TYPE OF INSURANCE LTR NCE INSR WVD POLICYNUMBER (MM DON Y MM/DD /YYYY LIMITS .emu ...... ._ .. ..... 401 Edgewater Place, Suite 400 AD11RSS �. w ........... 1 EACH OCCURRENCE OR DU a Wakefield, d, MA 01880 cc6TORi 9P� _ — -----w PR �L�i a� ( ,tddpGk!! Rq) .... pgt INSURER(S) AFFORDING COVERAGE ............ _.... .._ .. �_. . NAIC k INSUREHampshire INSURERA New Insurance Com anyy � 2 Dayton Borders f g) INSURERS: w . m.._ ante Company United States Fire Insurance „3841 531 Main St. #527 ........................................................... ............................... ElSegundo, CA 90245 $. .................2,000,000 INSURERC: _ ..............._..................................................................................................................................................................................................................................................... -.. - -t , X Medical Expense ............................... US000111988 INSURER D : �� .............................................................................................................................. .............................�. _....................-....,.,.,.,.,.,.....-- $ m -$mmm INSURER. E.. ........................:............................................................................................................. ............................... .....n m.,.........,...- .............._.,.,.,.,.,..... INSURERF: PRODUCTS - COMP /OPmAGG 1,000,000 COVERAGES CERTIFICATE NUMBER: POLICY X POLICY PRO• LOC JECT 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. INSf SUB'R ”" "' ____ ____ 4Yf5 C POLICY EXP - - - -- TYPE OF INSURANCE LTR NCE INSR WVD POLICYNUMBER (MM DON Y MM/DD /YYYY LIMITS A GENERAL LIABILITY X SEL083331455 1 1 EACH OCCURRENCE $ 1,000 000 X COMMERCIAL GENE AL LIABILITY PR �L�i a� ( ,tddpGk!! Rq) .... pgt 300,000 , .. .. OCCUR CLAIMS-MADE X f g) $ ,w O Liquor Host Li uor X H P PERSONAL &. ADV INJURY .. ... $. .................2,000,000 B -.. - -t , X Medical Expense US000111988 10/01/2013 1 GENERAL AGGREGATE $ m -$mmm GEN'L AGGREGATE LIMIT^APPLIES PER: PRODUCTS - COMP /OPmAGG 1,000,000 POLICY X POLICY PRO• LOC JECT ................. .............._- ......-- ... - - -- ......-- ...._-- ..-- ........-- .......... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS 111-111.".1111-11".... ..... ........... ................m.... BODILY INJURY (Per accident) — $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accdent) $ NON -OWNED AUTOS ....................................................................................................................... ............................... UMBRELLA LIAR OCCUR EACH OCCURRENCE .................. $ EXCESS CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION uMITS AND EMPLOYERS LIABILITY Y / N ,y ANY PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? ACCIDENT $ (Mandatory in NH) ET E.L. DISEASE MPLOYE $ If yes, describe under - ------ --- -----------------------n..,---------------n. n.--------------- .,..,......... DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only This insurance is primary and non - contributory as required by written contract, This coverage is with respect to El Segundo Halloween Frolic event to be held 10/31/2013 - 10/31/2013 at Streets of El Segundo El Segundo CA CERTIFIC'AT'E HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 Main Street BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED El Segundo, CA 90245 IN ACCORDANCE WITH THE POLICY PROVISIONS. �" "' °•� AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD COMMERCIAL LINES POLICY COMMON POLICY DECLARATIONS ❑ Granite State Insurance Company ❑ Illinois National Insurance Co. ❑X New Hampshire Insurance Company (Each of the above being a capital stock company) 175 Water Street 18'" Floor New York, New York 10038 212 458 5000 RENEWAL OF NUMBER POLICY NO. 83331455 NAMED INSURED Dayton Borders MAILING ADDRESS 531 Main St. #527, El Segundo, CA 90245 POLICY PERIOD: From Oct 01, 2013 to Nov 01, 2013 PRODUCER: HCC Specialty 84213 at 12:01 A.M. Standard Time at your mailing address shown above. BUSINESS DESCRIPTION El Segundo Halloween Frolic to be held 10/31/2013 at Streets of El Segundo, El Segundo, CA 90245 IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Property Coverage Part N/A Commercial General Liability Coverage Part $100.00 Commercial Crime Coverage Part N/A Commercial Inland Marine Coverage Part $0.�00 Boiler and Machinery Coverage Part N/A Commercial Auto Coverage Part $0.00 Liquor Liability Coverage Part $0.00 TRIA $1.00 Damage to Premises Rented to You $0.00 TOTAL $101.00 Premium shown is payable: $101.00 at inception. 1st Anniversary. 2nd Anniversary * *Plus Form(s) and Endorsement(s) made part of this policy at time of issue *: *Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations. Countersigned: By Authorized Representative THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COV- ERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. T Includes copyrighted materials of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc. 1983, 1984 94858 ADDENDUM TO THE DECLARATIONS By signing below, the President and the Secretary of the Insurer agree on behalf of the Insurer to all the terms of this Policy. I Robert Schimek PRESIDENT Denis M. Butkovic SECRETARY Granite State Insurance Company The Insurance Company of the State of Pennsylvania Illinois National Insurance Co. New Hampshire Insurance Company American Home Assurance Company National Union Fire Insurance Company of Pittsburgh, Pa. Commerce and Industry Insurance Company This Policy shall not be valid unless signed at the time of issuance by an authorized representative of the Insurer, either below or on the Declarations page of the Policy. Ethan D. Allen AUTHORIZED REPRESENTATIVE COUNTERSIGNATURE DATE 7871105 13 COUNTERSIGNED AT Renewal of Number" Policy No. 83331455 COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS Named Insured and Mailing Address (No., Street, Town or City, County, State, zip Code) w COVERAGE IS PROVIDED IN THE COMPANY DESIGNATED BY NUMBER. A STOCK INSURANCE COMPANY (HEREIN CALLED THE COMPANY) Dayton Borders 531 Main St. #527, El Segundo, CA 90245 Policy Period *: From Oct 01, 2013 to Nov 01, 2013 at 12:01 A.M. Standard Time at your mailing address shown above. 1NEW HAMPSHIRE INSURANCE COMPANY 2GRANITE STATE INSURANCE COMPANY 3ILLINOIS NATIONAL INSURANCE COMPANY EXECUTIVE OFFICES 175 WATER STREET, 18TH FL.- NEW YORK, N.Y. 10038 Producer: HCC Specialty 84213 IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE A('RFF WITH YOII TO PROVIDF THE INStJRANCF AS STATFD IN THIS POLICY_ LIMITS OF INSURANCE General Aggregate Limit (Other Than Products - Completed Operations) $2,000,000.00 Products - Completed Operations Aggregate Limit $1,000,000.00 Personal and Advertising Injury Limit $1,000,000.00 Each Occurrence Limit $1,000,000.00 Damage To Premises Rented to You Limit $300,000.00 Medical Expense Limit $0.00 Any One Person DESCRIPTION OF BUSINESS AND LOCATION OF PREMISES Individual ❑ Joint Venture ❑ Partnership ❑ Limited Liability Company ❑ Corporation ❑ Organization (Other than one indicated above) Business Description *: El Segundo Halloween Frolic to be held 10/31/2013 at Streets of El Segundo, El Segundo, CA 90245 Location of All Premises You Own, Rent or Occupy: Streets of El Segundo / Holly and Main St. El Segundo, CA 90245 PREMIUM - SUBJECT TO AUDIT ** Rate Advance Premium Classification Code No. Premium Basis Pr /Co All Other Pr /Co All Other Festival $50.00 N/A $50.00 Additional Insured(s) $50.00 $50.00 TRIA $1.00 $1.00 Tax/Other (if applicable) Total Advance Premium $101.00 * *Audit Period (if applicable): ( ) Annually ( ) Semi - Annually ( ) Quarterly ( ) Monthly Premium shown is payable*: $101.00 at inception; $ 1 st Anniversa ; $ 2nd Anniversa FORMS AND ENDORSEMENTS Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issuet: See attached Forms and Endorsements Schedule Countersigned:* �- By� , " Entry optional if shown in Common Policy Declarations. t Forms and Endorsements applicable to this Coverage Part omitted if shown elsewhere in the policy, Authorized Representative THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS, IF APPLICABLE, TOGETHER WITH THE COMMON POLICY CONDITIONS, COV- ERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. Includes copyrighted material of Insurance Services Office, Inc. with its permission. Copyright, Insurance Services Office, Inc. 1994 * CLAIM REPORTING PROCEDURES During Business Hours of Monday — Friday 9am to 5pm Eastern Time: All claims regardless of severity or location should be reported directly to HCC Specialty [ "HCCS "]. HCCS will forward all claims and appropriate documentation on to YORK Claims Services [ "YORK "] for adjusting of the losses. Please note that each and every claim should be reported through the email address listed below. 1. Email: claims @totaleventinsurance.com 2. Telephone: 781 - 994 -6000 Important' • Notices that do not require action ( "incident reports ") should be clearly marked "REPORT ONLY ". HCCS will review all claims notices upon receipt and send to YORK for assignment to the YORK handling branch office. A claim acknowledgement will then be transmitted to the designated individual advising of the YORK claim number and the adjuster assigned to the claim. During Weekends, After Business Hours; Claims should be reported directly to York Claim Services [ "YORK "] for assignment to the YORK handling branch office by one of the following methods: 1. Email: yorkclaimsintake(aD-york- claims.com 2. Telephone: 1- 866 - 391 -9675 A claim acknowledgement will then be transmitted to the designated individual advising of the YORK claim number and the adjuster assigned to the claim. Important! To expedite the handling of your newly reported loss, please be sure to include your YORK Client Code with each new loss report! The YORK Client Code for the HCC Special Event Liability program is 1799. • Notices that do not require action ( "incident reports ") should be clearly marked "REPORT ONLY ". FORMS and ENDORSEMENTS SCHEDULE FORMS PART OF POLICY NO.: 83331455 ISSUED TO: Dayton Borders BY: New Hampshire Insurance Company Description Form Number Declaration Page 94858 Addendum To Declarations 78711 0513 CGL Coverage Part Declarations JDL 190 (2) -X -A (1 -95) Claims Reporting Instructions n/a Forms And Endorsements List n/a AIG Policyholder Notice n/a Common Policy Conditions IL 00 17 11 98 CGL Coverage Form CG 00 01 04 13 CGL Enhancement Endorsement 86563 12 04 Abuse or Molestation Exclusion CG 21 46 07 98 Asbestos and Silica Exclusion 82540 (8/07) Assault & Battery Exclusion 101145409 Attendance Limitation Exclusion 100461 309 Field of Entertainment Exclusion 603685 Fireworks Exclusion 96725 1207 Limited Event Coverage 100472 (3/09) Limited Event Cov ADDENDUM Short Term JDL 190(2) X -A (1 -95) Nuclear Energy Exclusion IL 00 21 05 04 Prof Liab Excl 97020208 MedPay Exclusion CG 21 35 10 01 Securities and Financial Interest 73003499 Silicosis Exclusion 64003 901 Sports Leisure Entertainment Exclusions 100456309 Stunt Exclusion 72981 499 Total Lead Exclusion 58332 793 Violation Statutes Exclusion 87295 105 War Exclusion CG 00 63 12 Al - Managers Lessors CG 20 11 04 13 Al - Subdivision CG 20 12 07 98 Al - Designated Persons CG 20 26 04 13 Amendment of Liquor Liability CG 21 50 04 13 TRIA Disclosure 96556 (2/08) Chartis Privacy Notice 78052 Rev 12 09 Chartis 2009 -37 NY AG Notice n/a ENTERTAINERS PROMOTIONAL ACTIVITIES LIMITATION 100466 3_09 ENDORSEMENT 102215 (7/10) Time Stamp Endorsement 89644 OFAC Endorsement POLICYHOLDER NOTICE Thank you for purchasing insurance from a member company of American International Group, Inc. (AIG). The AIG member companies generally pay compensation to brokers and independent agents, and may have paid compensation in connection with your policy. You can review and obtain information about the nature and range of compensation paid by AIG member companies to brokers and independent agents in the United States by visiting our website at www.aila.coM�producercompensation or by calling 1- 800 -706- 3102. 91222 (4/13) COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions. A. Cancellation 1. The first Named Insured shown in the Declara- tions may cancel this policy by mailing or deliv- ering to us advance written notice of cancella- tion. 2. We may cancel this policy by mailing or deliv- ering to the first Named Insured written notice of cancellation at least: a. 10 days before the effective date of cancel- lation if we cancel for nonpayment of pre- mium; or b. 30 days before the effective date of cancel- lation if we cancel for any other reason. 3. We will mail or deliver our notice to the first Named Insured's last mailing address known to us. 4. Notice of cancellation will state the effective date of cancellation. The policy period will end on that date. 5. If this policy is cancelled, we will send the first Named Insured any premium refund due. If we cancel, the refund will be pro rata. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will be ef- fective even if we have not made or offered a refund. 6. If notice is mailed, proof of mailing will be suffi- cient proof of notice. B. Changes This policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in the Declara- tions is authorized to make changes in the terms of this policy with our consent. This policy's terms can be amended or waived only by endorsement issued by us and made a part of this policy. C. Examination Of Your Books And Records We may examine and audit your books and re- cords as they relate to this policy at any time dur- ing the policy period and up to three years after- ward. D. Inspections And Surveys 1. We have the right to: a. Make inspections and surveys at any time; IL 0017 11 98 b. Give you reports on the conditions we find; and c. Recommend changes. 2. We are not obligated to make any inspections, surveys, reports or recommendations and any such actions we do undertake relate only to in- surability and the premiums to be charged. We do not make safety inspections. We do not un- dertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions: a. Are safe or healthful; or b. Comply with laws, regulations, codes or standards. 3. Paragraphs 1. and 2. of this condition apply not only to us, but also to any rating, advisory, rate service or similar organization which makes in- surance inspections, surveys, reports or rec- ommendations. 4. Paragraph 2. of this condition does not apply to any inspections, surveys, reports or recom- mendations we may make relative to certifica- tion, under state or municipal statutes, ordi- nances or regulations, of boilers, pressure ves- sels or elevators. E. Premiums The first Named Insured shown in the Declara- tions: 1. Is responsible for the payment of all premiums; and 2. Will be the payee for any return premiums we pay. F. Transfer Of Your Rights And Duties Under This Policy Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual named in- sured. If you die, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal represen- tative. Until your legal representative is appointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. IL 00 1711 98 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ COMMERCIAL GENERAL LIABILITY CG 00 01 0413 COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage. Read the entire policy carefully to determine rights, duties and what is and is not covered. Throughout this policy the words "you" and "your" refer to the Named Insured shown in the Declarations, and any other person or organization qualifying as a Named Insured under this policy. The words "we ", "us" and 'bur" refer to the company providing this insurance. The word "insured" means any person or organization qualifying as such under Section II — Who Is An Insured. Other words and phrases that appear in quotation marks have special meaning. Refer to Section V — Definitions. SECTION I — COVERAGES COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY 1. Insuring Agreement a. We will pay those sums that the insured becomes legally obligated to pay as damages because of "bodily injury" or "property damage" to which this insurance applies. We will have the right and duty to defend the insured against any "suit" seeking those damages. However, we will have no duty to defend the insured against any "suit" seeking damages for "bodily injury" or "property damage" to which this insurance does not apply. We may, at our discretion, investigate any 'occurrence" and settle any claim or "suit" that may result. But: (1) The amount we will pay for damages is limited as described in Section III — Limits Of Insurance; and (2) Our right and duty to defend ends when we have used up the applicable limit of insurance in the payment of judgments or settlements under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments — Coverages A and B. b. This insurance applies to "bodily injury" and "property damage" only if: (1) The "bodily injury" or "property damage" is caused by an 'occurrence" that takes place in the "coverage territory' (2) The "bodily injury" or "property damage" occurs during the policy period; and (3) Prior to the policy period, no insured listed under Paragraph 1. of Section II — Who Is An Insured and no "employee" authorized by you to give or receive notice of an "occurrence" or claim, knew that the "bodily injury" or "property damage" had occurred, in whole or in part. If such a listed insured or authorized "employee" knew, prior to the policy period, that the "bodily injury" or "property damage" occurred, then any continuation, change or resumption of such "bodily injury" or "property damage" during or after the policy period will be deemed to have been known prior to the policy period. c. "Bodily injury" or "property damage" which occurs during the policy period and was not, prior to the policy period, known to have occurred by any insured listed under Paragraph 1. of Section II — Who Is An Insured or any "employee" authorized by you to give or receive notice of an 'occurrence" or claim, includes any continuation, change or resumption of that "bodily injury" or "property damage" after the end of the policy period. d. "Bodily injury" or "property damage" will be deemed to have been known to have occurred at the earliest time when any insured listed under Paragraph 1. of Section II — Who Is An Insured or any "employee" authorized by you to give or receive notice of an 'occurrence" or claim: (1) Reports all, or any part, of the "bodily injury" or "property damage" to us or any other insurer; (2) Receives a written or verbal demand or claim for damages because of the "bodily injury" or "property damage "; or (3) Becomes aware by any other means that "bodily injury" or "property damage" has occurred or has begun to occur. e. Damages because of "bodily injury" include damages claimed by any person or organization for care, loss of services or death resulting at any time from the "bodily injury". CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 16 2. Exclusions This insurance does not apply to: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" resulting from the use of reasonable force to protect persons or property. b. Contractual Liability "Bodily injury" or "property damage" for which the insured 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: (1) That the insured would have in the absence of the contract or agreement; or (2) Assumed in a contract or agreement that is an "insured contract ", provided the "bodily injury" or "property damage" occurs subsequent to the execution of the contract or agreement. Solely for the purposes of liability assumed in an "insured contract ", reasonable attorneys' fees and necessary litigation expenses incurred by or for a party other than an insured are deemed to be damages because of "bodily injury" or "property damage ", provided: (a) Liability to such party for, or for the cost of, that party's defense has also been assumed in the same "insured contract "; and (b) Such attorneys' fees and litigation expenses are for defense of that party against a civil or alternative dispute resolution proceeding in which damages to which this insurance applies are alleged. c. Liquor Liability "Bodily injury" or "property damage" for which any insured may be held liable by reason of: (1) Causing or contributing to the intoxication of any person; (2) The furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol; or (3) Any statute, ordinance or regulation relating to the sale, gift, distribution or use of alcoholic beverages. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in: (a) The supervision, hiring, employment, training or monitoring of others by that insured; or (b) Providing or failing to provide transportation with respect to any person that may be under the influence of alcohol; if the "occurrence" which caused the "bodily injury" or "property damage ", involved that which is described in Paragraph (1), (2) or (3) above. However, this exclusion applies only if you are in the business of manufacturing, distributing, selling, serving or furnishing alcoholic beverages. For the purposes of this exclusion, permitting a person to bring alcoholic beverages on your premises, for consumption on your premises, whether or not a fee is charged or a license is required for such activity, is not by itself considered the business of selling, serving or furnishing alcoholic beverages. d. Workers' Compensation And Similar Laws Any obligation of the insured under a workers' compensation, disability benefits or unemployment compensation law or any similar law. e. Employer's Liability "Bodily injury" to: (1) An "employee" of the insured arising out of and in the course of: (a) Employment by the insured; or (b) Performing duties related to the conduct of the insured's business; or (2) The spouse, child, parent, brother or sister of that "employee" as a consequence of Paragraph (1) above. This exclusion applies whether the insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the injury. This exclusion does not apply to liability assumed by the insured under an "insured contract ". Page 2 of 16 0 Insurance Services Office, Inc., 2012 CG 00 0104 13 f. Pollution (d) At or from any premises, site or location (1) "Bodily injury" or "property damage" arising on which any insured or any contractors out of the actual, alleged or threatened or subcontractors working directly or discharge, dispersal, seepage, migration, indirectly on any insured's behalf are release or escape of "pollutants ": performing operations if the pollutants are brought on or to the premises, site (a) At or from any premises, site or location or location in connection with such which is or was at any time owned or operations by such insured, contractor occupied by, or rented or loaned to, any or subcontractor. However, this insured. However, this subparagraph subparagraph does not apply to: does not apply to: (i) "Bodily injury" or "property damage" (i) "Bodily injury" if sustained within a arising out of the escape of fuels, building and caused by smoke, lubricants or other operating fluids fumes, vapor or soot produced by or which are needed to perform the originating from equipment that is normal electrical, hydraulic or used to heat, cool or dehumidify the mechanical functions necessary for building, or equipment that is used to the operation of "mobile equipment" heat water for personal use, by the or its parts, if such fuels, lubricants building's occupants or their guests; or other operating fluids escape from (ii) "Bodily injury" or "property damage" a vehicle part designed to hold, store for which you may be held liable, if or receive them. This exception does you are a contractor and the owner not apply if the "bodily injury" or or lessee of such premises, site or "property damage" arises out of the location has been added to your intentional discharge, dispersal or policy as an additional insured with release of the fuels, lubricants or respect to your ongoing operations other operating fluids, or if such performed for that additional insured fuels, lubricants or other operating at that premises, site or location and fluids are brought on or to the such premises, site or location is not premises, site or location with the and never was owned or occupied intent that they be discharged, by, or rented or loaned to, any dispersed or released as part of the insured, other than that additional operations being performed by such insured; or insured, contractor or subcontractor; (iii) "Bodily injury" or "property damage" (ii) "Bodily injury" or "property damage" arising out of heat, smoke or fumes sustained within a building and from a "hostile fire "; caused by the release of gases, (b) At or from any premises, site or location fumes or vapors from materials which is or was at any time used by or brought into that building in for any insured or others for the connection with operations being handling, storage, disposal, processing performed by you or on your behalf or treatment of waste; by a contractor or subcontractor; or (c) Which are or were at any time (iii) "Bodily injury" or "property damage" transported, handled, stored, treated, arising out of heat, smoke or fumes disposed of, or processed as waste by from a hostile fire". or for: (e) At or from any premises, site or location (i) Any insured; or on which any insured or any contractors or subcontractors working directly or (ii) Any person or organization for whom indirectly on any insured's behalf are you may be legally responsible; or performing operations if the operations are to test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, "pollutants ". CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 3 of 16 (2) Any loss, cost or expense arising out of any: (a) Request, demand, order or statutory or regulatory requirement that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, "pollutants "; or (b) 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 ". However, this paragraph does not apply to liability for damages because of "property damage" that the insured would have in the absence of such request, demand, order or statutory or regulatory requirement, or such claim or "suit" by or on behalf of a governmental authority. g. Aircraft, Auto Or Watercraft "Bodily injury" or "property damage" arising out of the ownership, maintenance, use or entrustment to others of any aircraft, "auto" or watercraft owned or operated by or rented or loaned to any insured. Use includes operation and "loading or unloading ". This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage" involved the ownership, maintenance, use or entrustment to others of any aircraft, "auto" or watercraft that is owned or operated by or rented or loaned to any insured. This exclusion does not apply to: (1) A watercraft while ashore on premises you own or rent; (2) A watercraft you do not own that is: (a) Less than 26 feet long; and (b) Not being used to carry persons or property for a charge; (3) Parking an "auto" on, or on the ways next to, premises you own or rent, provided the "auto" is not owned by or rented or loaned to you or the insured; (4) Liability assumed under any "insured contract" for the ownership, maintenance or use of aircraft or watercraft; or (5) "Bodily injury" or "property damage" arising out of: (a) The operation of machinery or equipment that is attached to, or part of, a land vehicle that would qualify under the definition of "mobile equipment" if it were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where it is licensed or principally garaged; or (b) The operation of any of the machinery or equipment listed in Paragraph f.(2) or f.(3) of the definition of "mobile equipment ". h. Mobile Equipment "Bodily injury" or "property damage" arising out of: (1) The transportation of "mobile equipment" by an "auto" owned or operated by or rented or loaned to any insured; or (2) The use of "mobile equipment" in, or while in practice for, or while being prepared for, any prearranged racing, speed, demolition, or stunting activity. i. War "Bodily injury" or "property damage ", however caused, arising, directly or indirectly, out of: (1) War, including undeclared or civil war; (2) Warlike action by a military force, including action in hindering or defending against an actual or expected attack, by any government, sovereign or other authority using military personnel or other agents; or (3) Insurrection, rebellion, revolution, usurped power, or action taken by governmental authority in hindering or defending against any of these. j. Damage To Property "Property damage" to: (1) Property you own, rent, or occupy, including any costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property; (2) Premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises; (3) Property loaned to you; Page 4 of 16 © Insurance Services Office, Inc., 2012 CG 00 01 0413 (4) Personal property in the care, custody or control of the insured; (5) 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 damage" arises out of those operations; or (6) That particular part of any property that must be restored, repaired or replaced because "your work" was incorrectly performed on it. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire) to premises, including the contents of such premises, rented to you for a period of seven or fewer consecutive days. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section III — Limits Of Insurance. Paragraph (2) of this exclusion does not apply if the premises are "your work" and were never occupied, rented or held for rental by you. Paragraphs (3), (4), (5) and (6) of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph (6) of this exclusion does not apply to "property damage" included in the "products - completed operations hazard ". k. Damage To Your Product "Property damage" to "your product" arising out of it or any part of it. I. Damage To Your Work "Property damage" to "your work" arising out of it or any part of it and included in the "products - completed operations hazard ". This exclusion does not apply if the damaged work or the work out of which the damage arises was performed on your behalf by a subcontractor. m. Damage To Impaired Property Or Property Not Physically Injured "Property damage" to "impaired property" or property that has not been physically injured, arising out of: (1) A defect, deficiency, inadequacy or dangerous condition in "your product" or "your work "; or This exclusion does not apply to the loss of use of other property arising out of sudden and accidental physical injury to "your product" or "your work" after it has been put to its intended use. n. Recall Of Products, Work Or Impaired Property Damages claimed for any loss, cost or expense incurred by you or others for the loss of use, withdrawal, recall, inspection, repair, replacement, adjustment, removal or disposal of: (1) "Your product "; (2) "Your work "; or (3) "Impaired property "; if such product, work, or property is withdrawn or recalled from the market or from use by any person or organization because of a known or suspected defect, deficiency, inadequacy or dangerous condition in it. o. Personal And Advertising Injury "Bodily injury" arising out of "personal and advertising injury". p. Electronic Data Damages arising out of the loss of, loss of use of, damage to, corruption of, inability to access, or inability to manipulate electronic data. However, this exclusion does not apply to liability for damages because of "bodily injury". As used in this exclusion, 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. q. Recording And Distribution Of Material Or Information In Violation Of Law "Bodily injury" or "property damage" arising directly or indirectly out of any action or omission that violates or is alleged to violate: (1) The Telephone Consumer Protection Act (TCPA), including any amendment of or addition to such law; (2) The CAN -SPAM Act of 2003, including any amendment of or addition to such law; (2) A delay or failure by you or anyone acting (3) The Fair Credit Reporting Act (FCRA), and on your behalf to perform a contract or any amendment of or addition to such law, agreement in accordance with its terms. including the Fair and Accurate Credit Transactions Act (FACTA); or CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 5 of 16 (4) Any federal, state or local statute, ordinance or regulation, other than the TCPA, CAN -SPAM Act of 2003 or FCRA and their amendments and additions, that addresses, prohibits, or limits the printing, dissemination, disposal, collecting, recording, sending, transmitting, communicating or distribution of material or information. Exclusions c. through n. do not apply to damage by fire 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 — Limits Of Insurance. COVERAGE B — PERSONAL AND ADVERTISING INJURY LIABILITY 1. Insuring Agreement a. We will pay those sums that the insured becomes legally obligated to pay as damages because of "personal and advertising injury" to which this insurance applies. We will have the right and duty to defend the insured against any "suit" seeking those damages. However, we will have no duty to defend the insured against any "suit" seeking damages for "personal and advertising injury" to which this insurance does not apply. We may, at our discretion, investigate any offense and settle any claim or "suit" that may result. But: (1) The amount we will pay for damages is limited as described in Section III — Limits Of Insurance; and (2) Our right and duty to defend end when we have used up the applicable limit of insurance in the payment of judgments or settlements under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments — Coverages A and B. b. This insurance applies to "personal and advertising injury" caused by an offense arising out of your business but only if the offense was committed in the "coverage territory" during the policy period. 2. Exclusions This insurance does not apply to: a. Knowing Violation Of Rights Of Another "Personal and advertising injury" caused by or at the direction of the insured with the knowledge that the act would violate the rights of another and would inflict "personal and advertising injury". b. Material Published With Knowledge Of Falsity "Personal and advertising injury" arising out of oral or written publication, in any manner, of material, if done by or at the direction of the insured with knowledge of its falsity. c. Material Published Prior To Policy Period "Personal and advertising injury" arising out of oral or written publication, in any manner, of material whose first publication took place before the beginning of the policy period. d. Criminal Acts "Personal and advertising injury" arising out of a criminal act committed by or at the direction of the insured. e. Contractual Liability "Personal and advertising injury" for which the insured has assumed liability in a contract or agreement. This exclusion does not apply to liability for damages that the insured would have in the absence of the contract or agreement. f. Breach Of Contract "Personal and advertising injury" arising out of a breach of contract, except an implied contract to use another's advertising idea in your "advertisement ". g. Quality Or Performance Of Goods — Failure To Conform To Statements "Personal and advertising injury" arising out of the failure of goods, products or services to conform with any statement of quality or performance made in your "advertisement ". h. Wrong Description Of Prices "Personal and advertising injury" arising out of the wrong description of the price of goods, products or services stated in your "advertisement ". Page 6 of 16 © Insurance Services Office, Inc., 2012 CG 00 01 0413 i. Infringement Of Copyright, Patent, Trademark Or Trade Secret "Personal and advertising injury" arising out of the infringement of copyright, patent, trademark, trade secret or other intellectual property rights. Under this exclusion, such other intellectual property rights do not include the use of another's advertising idea in your "advertisement ". However, this exclusion does not apply to infringement, in your "advertisement ", of copyright, trade dress or slogan. j. Insureds In Media And Internet Type Businesses "Personal and advertising injury" committed by an insured whose business is: (1) Advertising, broadcasting, publishing or telecasting; (2) Designing or determining content of web sites for others; or (3) An Internet search, access, content or service provider. However, this exclusion does not apply to Paragraphs 14.a., b. and c. of "personal and advertising injury" under the Definitions section. For the purposes of this exclusion, the placing of frames, borders or links, or advertising, for you or others anywhere on the Internet, is not by itself, considered the business of advertising, broadcasting, publishing or telecasting. k. Electronic Chatrooms Or Bulletin Boards "Personal and advertising injury" arising out of an electronic chatroom or bulletin board the insured hosts, owns, or over which the insured exercises control. I. Unauthorized Use Of Another's Name Or Product "Personal and advertising injury" arising out of the unauthorized use of another's name or product in your e-mail address, domain name or metatag, or any other similar tactics to mislead another's potential customers. m. Pollution "Personal and advertising injury" arising out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of "pollutants" at any time. n. Pollution - related Any loss, cost or expense arising out of any: (1) Request, demand, order or statutory or regulatory requirement that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, "pollutants "; or (2) 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 ". o. War "Personal and advertising injury", however caused, arising, directly or indirectly, out of: (1) War, including undeclared or civil war; (2) Warlike action by a military force, including action in hindering or defending against an actual or expected attack, by any government, sovereign or other authority using military personnel or other agents; or (3) Insurrection, rebellion, revolution, usurped power, or action taken by governmental authority in hindering or defending against any of these. p. Recording And Distribution Of Material Or Information In Violation Of Law "Personal and advertising injury" arising directly or indirectly out of any action or omission that violates or is alleged to violate: (1) The Telephone Consumer Protection Act (TCPA), including any amendment of or addition to such law; (2) The CAN -SPAM Act of 2003, including any amendment of or addition to such law; (3) The Fair Credit Reporting Act (FCRA), and any amendment of or addition to such law, including the Fair and Accurate Credit Transactions Act (FACTA); or (4) Any federal, state or local statute, ordinance or regulation, other than the TCPA, CAN -SPAM Act of 2003 or FCRA and their amendments and additions, that addresses, prohibits, or limits the printing, dissemination, disposal, collecting, recording, sending, transmitting, communicating or distribution of material or information. CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 7 of 16 COVERAGE C — MEDICAL PAYMENTS 1. Insuring Agreement a. We will pay medical expenses as described below for "bodily injury" caused by an accident: (1) On premises you own or rent; (2) On ways next to premises you own or rent; or (3) Because of your operations; provided that: (a) The accident takes place in the "coverage territory" and during the policy period; (b) The expenses are incurred and reported to us within one year of the date of the accident; and (c) The injured person submits to examination, at our expense, by physicians of our choice as often as we reasonably require. b. We will make these payments regardless of fault. These payments will not exceed the applicable limit of insurance. We will pay reasonable expenses for: (1) First aid administered at the time of an accident; (2) Necessary medical, surgical, X -ray and dental services, including prosthetic devices; and (3) Necessary ambulance, hospital, professional nursing and funeral services. 2. Exclusions We will not pay expenses for "bodily injury": a. Any Insured To any insured, except "volunteer workers ". b. Hired Person To a person hired to do work for or on behalf of any insured or a tenant of any insured. c. Injury On Normally Occupied Premises To a person injured on that part of premises you own or rent that the person normally occupies. d. Workers' Compensation And Similar Laws To a person, whether or not an "employee" of any insured, if benefits for the "bodily injury" are payable or must be provided under a workers' compensation or disability benefits law or a similar law. e. Athletics Activities To a person injured while practicing, instructing or participating in any physical exercises or games, sports, or athletic contests. f. Products - Completed Operations Hazard Included within the "products- completed operations hazard ". g. Coverage A Exclusions Excluded under Coverage A. SUPPLEMENTARY PAYMENTS — COVERAGES A AND B 1. We will pay, with respect to any claim we investigate or settle, or any "suit" against an insured we defend: a. All expenses we incur. b. Up to $250 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. c. The cost of bonds to release attachments, but only for bond amounts within the applicable limit of insurance. We do not have to furnish these bonds. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit ", including actual loss of earnings up to $250 a day because of time off from work. e. All court costs taxed against the insured in the "suit ". However, these payments do not include attorneys' fees or attorneys' expenses taxed against the insured. f. Prejudgment interest awarded against the insured on that part of the judgment we pay. If we make an offer to pay the applicable limit of insurance, we will not pay any prejudgment interest based on that period of time after the offer. Page 8 of 16 © Insurance Services Office, Inc., 2012 CG 00 01 0413 g. All interest on the full amount of any judgment that accrues after entry of the judgment and before we have paid, offered to pay, or deposited in court the part of the judgment that is within the applicable limit of insurance. These payments will not reduce the limits of insurance. 2. If we defend an insured against a "suit" and an indemnitee of the insured is also named as a party to the "suit ", we will defend that indemnitee if all of the following conditions are met: a. The "suit" against the indemnitee seeks damages for which the insured has assumed the liability of the indemnitee in a contract or agreement that is an "insured contract'; b. This insurance applies to such liability assumed by the insured; c. The obligation to defend, or the cost of the defense of, that indemnitee, has also been assumed by the insured in the same "insured contract "; d. The allegations in the "suit" and the information we know about the "occurrence" are such that no conflict appears to exist between the interests of the insured and the interests of the indemnitee; e. The indemnitee and the insured ask us to conduct and control the defense of that indemnitee against such "suit" and agree that we can assign the same counsel to defend the insured and the indemnitee; and f. The indemnitee: (1) Agrees in writing to: (a) Cooperate with us in the investigation, settlement or defense of the "suit "; (b) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the "suit "; (c) Notify any other insurer whose coverage is available to the indemnitee; and (d) Cooperate with us with respect to coordinating other applicable insurance available to the indemnitee; and (2) Provides us with written authorization to: (a) Obtain records and other information related to the "suit "; and (b) Conduct and control the defense of the indemnitee in such "suit ". So long as the above conditions are met, attorneys' fees incurred by us in the defense of that indemnitee, necessary litigation expenses incurred by us and necessary litigation expenses incurred by the indemnitee at our request will be paid as Supplementary Payments. Notwithstanding the provisions of Paragraph 2.b.(2) of Section I — Coverage A — Bodily Injury And Property Damage Liability, such payments will not be deemed to be damages for "bodily injury" and "property damage" and will not reduce the limits of insurance. Our obligation to defend an insured's indemnitee and to pay for attorneys' fees and necessary litigation expenses as Supplementary Payments ends when we have used up the applicable limit of insurance in the payment of judgments or settlements or the conditions set forth above, or the terms of the agreement described in Paragraph f. above, are no longer met. SECTION II — WHO IS AN INSURED 1. If you are designated in the Declarations as: a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses are also insureds, but only with respect to the conduct of your business. c. A limited liability company, you are an insured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insureds, but only with respect to their duties as your managers. d. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your "executive officers" and directors are insureds, but only with respect to their duties as your officers or directors. Your stockholders are also insureds, but only with respect to their liability as stockholders. e. A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as trustees. CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 9 of 16 2. Each of the following is also an insured: a. Your "volunteer workers" only while performing duties related to the conduct of your business, or your "employees ", other than either your "executive officers" (if you are an organization other than a partnership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these "employees" or "volunteer workers" are insureds for: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co- "employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co-"employee" or "volunteer worker" as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraph (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. (2) "Property damage" to property: (a) Owned, occupied or used by; (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by; you, any of your "employees ", "volunteer workers ", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). b. Any person (other than your "employee" or "volunteer worker "), or any organization while acting as your real estate manager. c. Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of that property; and (2) Until your legal representative has been appointed. d. Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this Coverage Part. 3. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the 90th day after you acquire or form the organization or the end of the policy period, whichever is earlier; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations. SECTION III — LIMITS OF INSURANCE 1. The Limits of Insurance shown in the Declarations and the rules below fix the most we will pay regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits ". 2. The General Aggregate Limit is the most we will pay for the sum of: a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard "; and c. Damages under Coverage B. Page 10 of 16 © Insurance Services Office, Inc., 2012 CG 00 01 0413 3. The Products - Completed Operations Aggregate Limit is the most we will pay under Coverage A for damages because of "bodily injury" and "property damage" included in the "products- completed operations hazard ". 4. Subject to Paragraph 2. above, the Personal And Advertising Injury Limit is the most we will pay under Coverage B for the sum of all damages because of all "personal and advertising injury" sustained by any one person or organization. 5. Subject to Paragraph 2. or 3. above, whichever applies, the Each Occurrence Limit is the most we will pay for the sum of: a. Damages under Coverage A; and b. Medical expenses under Coverage C because of all "bodily injury" and "property damage" arising out of any one "occurrence ". 6. Subject to Paragraph 5. above, the Damage To Premises Rented 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 the case of damage by fire, while rented to you or temporarily occupied by you with permission of the owner. 7. Subject to Paragraph 5. above, the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person. The Limits of Insurance of this Coverage Part apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS 1. Bankruptcy Bankruptcy or insolvency of the insured or of the insured's estate will not relieve us of our obligations under this Coverage Part. 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit a. You must see to it that we are notified as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occurrence" or offense took place; (2) The names and addresses of any injured persons and witnesses; and (3) The nature and location of any injury or damage arising out of the "occurrence" or offense. b. If a claim is made or "suit" is brought against any insured, you must: (1) Immediately record the specifics of the claim or "suit" and the date received; and (2) Notify us as soon as practicable. You must see to it that we receive written notice of the claim or "suit" as soon as practicable. c. You and any other involved insured must: (1) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the claim or "suit "; (2) Authorize us to obtain records and other information; (3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit "; and (4) Assist us, upon our request, in the enforcement of any right against any person or organization which may be liable to the insured because of injury or damage to which this insurance may also apply. d. No insured will, except at that insured's own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent. 3. Legal Action Against Us No person or organization has a right under this Coverage Part: a. To join us as a party or otherwise bring us into a "suit" asking for damages from an insured; or b. To sue us on this Coverage Part unless all of its terms have been fully complied with. A person or organization may sue us to recover on an agreed settlement or on a final judgment against an insured; but we will not be liable for damages that are not payable under the terms of this Coverage Part or that are in excess of the applicable limit of insurance. An agreed settlement means a settlement and release of liability signed by us, the insured and the claimant or the claimant's legal representative. CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 11 of 16 4. Other Insurance If other valid and collectible insurance is available to the insured for a loss we cover under Coverages A or B of this Coverage Part, our obligations are limited as follows: a. Primary Insurance This insurance is primary except when Paragraph b. below applies. If this insurance is primary, our obligations are not affected unless any of the other insurance is also primary. Then, we will share with all that other insurance by the method described in Paragraph c. below. b. Excess Insurance (1) This insurance is excess over: (a) Any of the other insurance, whether primary, excess, contingent or on any other basis: (i) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for "your work "; (ii) That is Fire insurance for premises rented to you or temporarily occupied by you with permission of the owner; (iii) That is insurance purchased by you to cover your liability as a tenant for "property damage" to premises rented to you or temporarily occupied by you with permission of the owner; or (iv) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of Section I — Coverage A — Bodily Injury And Property Damage Liability. (b) Any other primary insurance available to you covering liability for damages arising out of the premises or operations, or the products and completed operations, for which you have been added as an additional insured. (2) When this insurance is excess, we will have no duty under Coverages A or B to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit ". If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. (3) When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (a) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (b) The total of all deductible and self - insured amounts under all that other insurance. (4) We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Method Of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. 5. Premium Audit a. We will compute all premiums for this Coverage Part in accordance with our rules and rates. b. Premium shown in this Coverage Part as advance premium is a deposit premium only. At the close of each audit period we will compute the earned premium for that period and send notice to the first Named Insured. The due date for audit and retrospective premiums is the date shown as the due date on the bill. If the sum of the advance and audit premiums paid for the policy period is greater than the earned premium, we will return the excess to the first Named Insured. c. The first Named Insured must keep records of the information we need for premium computation, and send us copies at such times as we may request. 6. Representations By accepting this policy, you agree: a. The statements in the Declarations are accurate and complete; Page 12 of 16 © Insurance Services Office, Inc., 2012 CG 00 01 0413 b. Those statements are based upon representations you made to us; and c. We have issued this policy in reliance upon your representations. 7. Separation Of Insureds Except with respect to the Limits of Insurance, and any rights or duties specifically assigned in this Coverage Part to the first Named Insured, this insurance applies: a. As if each Named Insured were the only Named Insured; and b. Separately to each insured against whom claim is made or "suit" is brought. 8. Transfer Of Rights Of Recovery Against Others To Us If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. 9. When We Do Not Renew If we decide not to renew this Coverage Part, we will mail or deliver to the first Named Insured shown in the Declarations written notice of the nonrenewal not less than 30 days before the expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. SECTION V — DEFINITIONS 1. "Advertisement" means a notice that is broadcast or published to the general public or specific market segments about your goods, products or services for the purpose of attracting customers or supporters. For the purposes of this definition: a. Notices that are published include material placed on the Internet or on similar electronic means of communication; and b. Regarding web sites, only that part of a web site that is about your goods, products or services for the purposes of attracting customers or supporters is considered an advertisement. 2. "Auto" means: a. A land motor vehicle, trailer or semitrailer designed for travel on public roads, including any attached machinery or equipment; or b. Any other land vehicle that is subject to a compulsory or financial responsibility law or other motor vehicle insurance law where it is licensed or principally garaged. However, "auto" does not include "mobile equipment ". 3. "Bodily injury" means bodily injury, sickness or disease sustained by a person, including death resulting from any of these at any time. 4. "Coverage territory" means: a. The United States of America (including its territories and possessions), Puerto Rico and Canada; b. International waters or airspace, but only if the injury or damage occurs in the course of travel or transportation between any places included in Paragraph a. above; or c. All other parts of the world if the injury or damage arises out of: (1) Goods or products made or sold by you in the territory described in Paragraph a. above; (2) The activities of a person whose home is in the territory described in Paragraph a. above, but is away for a short time on your business; or (3) "Personal and advertising injury" offenses that take place through the Internet or similar electronic means of communication; provided the insured's responsibility to pay damages is determined in a "suit" on the merits, in the territory described in Paragraph a. above or in a settlement we agree to. 5. "Employee" includes a "leased worker ". "Employee" does not include a "temporary worker ". 6. "Executive officer" means a person holding any of the officer positions created by your charter, constitution, bylaws or any other similar governing document. 7. "Hostile fire" means one which becomes uncontrollable or breaks out from where it was intended to be. 8. "Impaired property" means tangible property, other than "your product" or "your work ", that cannot be used or is less useful because: a. It incorporates "your product" or "your work" that is known or thought to be defective, deficient, inadequate or dangerous; or b. You have failed to fulfill the terms of a contract or agreement; if such property can be restored to use by the repair, replacement, adjustment or removal of "your product" or "your work" or your fulfilling the terms of the contract or agreement. CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 13 of 16 9. "Insured contract" means: a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract "; b. A sidetrack agreement; c. Any easement or license agreement, except in connection with construction or demolition operations on or within 50 feet of a railroad; d. An obligation, as required by ordinance, to indemnify a municipality, except in connection with work for a municipality; e. An elevator maintenance agreement; f. That part of any other contract or agreement pertaining to your business (including an indemnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury" or "property damage" to a third person or organization. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement. Paragraph f. does not include that part of any contract or agreement: (1) That indemnifies a railroad for "bodily injury" or "property damage" arising out of construction or demolition operations, within 50 feet of any railroad property and affecting any railroad bridge or trestle, tracks, road -beds, tunnel, underpass or crossing; (2) That indemnifies an architect, engineer or surveyor for injury or damage arising out of: (a) Preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (b) Giving directions or instructions, or failing to give them, if that is the primary cause of the injury or damage; or (3) Under which the insured, if an architect, engineer or surveyor, assumes liability for an injury or damage arising out of the insured's rendering or failure to render professional services, including those listed in (2) above and supervisory, inspection, architectural or engineering activities. 10. "Leased worker" means a person leased to you by a labor leasing firm under an agreement between you and the labor leasing firm, to perform duties related to the conduct of your business. "Leased worker" does not include a "temporary worker ". 11. "Loading or unloading" means the handling of property: a. After it is moved from the place where it is accepted for movement into or onto an aircraft, watercraft or "auto "; b. While it is in or on an aircraft, watercraft or "auto "; or c. While it is being moved from an aircraft, watercraft or "auto" to the place where it is finally delivered; but "loading or unloading" does not include the movement of property by means of a mechanical device, other than a hand truck, that is not attached to the aircraft, watercraft or "auto ". 12. "Mobile equipment" means any of the following types of land vehicles, including any attached machinery or equipment: a. Bulldozers, farm machinery, forklifts and other vehicles designed for use principally off public roads; b. Vehicles maintained for use solely on or next to premises you own or rent; c. Vehicles that travel on crawler treads; d. Vehicles, whether self - propelled or not, maintained primarily to provide mobility to permanently mounted: (1) Power cranes, shovels, loaders, diggers or drills; or (2) Road construction or resurfacing equipment such as graders, scrapers or rollers; e. Vehicles not described in Paragraph a., b., c. or d. above that are not self - propelled and are maintained primarily to provide mobility to permanently attached equipment of the following types: (1) Air compressors, pumps and generators, including spraying, welding, building cleaning, geophysical exploration, lighting and well servicing equipment; or (2) Cherry pickers and similar devices used to raise or lower workers; f. Vehicles not described in Paragraph a., b., c. or d. above maintained primarily for purposes other than the transportation of persons or cargo. Page 14 of 16 © Insurance Services Office, Inc., 2012 CG 00 01 0413 However, self - propelled vehicles with the following types of permanently attached equipment are not "mobile equipment" but will be considered "autos ": (1) Equipment designed primarily for: (a) Snow removal; (b) Road maintenance, but not construction or resurfacing; or (c) Street cleaning; (2) Cherry pickers and similar devices mounted on automobile or truck chassis and used to raise or lower workers; and (3) Air compressors, pumps and generators, including spraying, welding, building cleaning, geophysical exploration, lighting and well servicing equipment. However, "mobile equipment" does not include any land vehicles that are subject to a compulsory or financial responsibility law or other motor vehicle insurance law where it is licensed or principally garaged. Land vehicles subject to a compulsory or financial responsibility law or other motor vehicle insurance law are considered "autos ". 13. "Occurrence" means an accident, including continuous or repeated exposure to substantially the same general harmful conditions. 14. "Personal and advertising injury" means injury, including consequential "bodily injury", arising out of one or more of the following offenses: a. False arrest, detention or imprisonment; b. Malicious prosecution; c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room, dwelling or premises that a person occupies, committed by or on behalf of its owner, landlord or lessor; d. Oral or written publication, in any manner, of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; e. Oral or written publication, in any manner, of material that violates a person's right of privacy; f. The use of another's advertising idea in your "advertisement "; or 16. "Products- completed operations hazard ": a. Includes all "bodily injury" and "property damage" occurring away from premises you own or rent and arising out of "your product" or "your work" except: (1) Products that are still in your physical possession; or (2) Work that has not yet been completed or abandoned. However, "your work" will be deemed completed at the earliest of the following times: (a) When all of the work called for in your contract has been completed. (b) When all of the work to be done at the job site has been completed if your contract calls for work at more than one job site. (c) When that part of the work done at a job site has been put to its intended use by any person or organization other than another contractor or subcontractor working on the same project. Work that may need service, maintenance, correction, repair or replacement, but which is otherwise complete, will be treated as completed. b. Does not include "bodily injury" or "property damage" arising out of: (1) The transportation of property, unless the injury or damage arises out of a condition in or on a vehicle not owned or operated by you, and that condition was created by the "loading or unloading" of that vehicle by any insured; (2) The existence of tools, uninstalled equipment or abandoned or unused materials; or (3) Products or operations for which the classification, listed in the Declarations or in a policy Schedule, states that products - completed operations are subject to the General Aggregate Limit. 17. "Property damage" means: a. Physical injury to tangible property, including all resulting loss of use of that property. All such loss of use shall be deemed to occur at the time of the physical injury that caused it; or g. Infringing upon another's copyright, trade dress b. Loss of use of tan ible property 9� that is not or slogan in your "advertisement ". physically injured. All such loss of use shall be 15. "Pollutants" mean any solid, liquid, gaseous or deemed to occur at the time of the thermal irritant or contaminant, including smoke, "occurrence" that caused it. vapor, soot, fumes, acids, alkalis, chemicals and For the purposes of this insurance, electronic data waste. Waste includes materials to be recycled, is not tangible property. reconditioned or reclaimed. CG 00 01 0413 © Insurance Services Office, Inc., 2012 Page 15 of 16 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. 18. "Suit" means a civil proceeding in which damages because of "bodily injury", "property damage" or "personal and advertising injury" to which this insurance applies are alleged. "Suit" includes: a. An arbitration proceeding in which such damages are claimed and to which the insured must submit or does submit with our consent; or b. Any other alternative dispute resolution proceeding in which such damages are claimed and to which the insured submits with our consent. 19. "Temporary worker" means a person who is furnished to you to substitute for a permanent "employee" on leave or to meet seasonal or short- term workload conditions. 20. "Volunteer worker" means a person who is not your "employee ", and who donates his or her work and acts at the direction of and within the scope of duties determined by you, and is not paid a fee, salary or other compensation by you or anyone else for their work performed for you. 21. "Your product ": a. Means: (1) Any goods or products, other than real property, manufactured, sold, handled, distributed or disposed of by: (a) You; (b) Others trading under your name; or (c) A person or organization whose business or assets you have acquired; and (2) Containers (other than vehicles), materials, parts or equipment furnished in connection with such goods or products. b. Includes: (1) Warranties or representations made at any time with respect to the fitness, quality, durability, performance or use of "your product "; and (2) The providing of or failure to provide warnings or instructions. c. Does not include vending machines or other property rented to or located for the use of others but not sold. 22. "Your work ": a. Means: (1) Work or operations performed by you or on your behalf; and (2) Materials, parts or equipment furnished in connection with such work or operations. b. Includes: (1) Warranties or representations made at any time with respect to the fitness, quality, durability, performance or use of "your work "; and (2) The providing of or failure to provide warnings or instructions. Page 16 of 16 © Insurance Services Office, Inc., 2012 CG 00 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM A. EMPLOYMENT RELATED PRACTICES (3) Any obligation to defend any claim or suit EXCLUSION against the insured alleging "bodily The following exclusion is added to paragraph 2., injury", "property damage ", "personal and advertising injury" and seeking damages, Exclusions of COVERAGE A — BODILY INJURY if such claim or suit arises from "bodily AND PROPERTY DAMAGE LIABILITY (Section al injury", "property damage ", "personal and I- Coverages) and to paragraph 2., Exclusions of advertising injury" as a result the COVERAGE B — PERSONAL AND manufacture of, mining of, use of, sales ADVERTISING INJURY LIABILITY (Section I- of, installation of, removal of, distribution Coverages): of or exposure to asbestos, asbestos, This insurance does not apply to: asbestos products, asbestos or asbestos "Bodily injury" or "Personal and advertising dust; or injury" to: A person arising out of any: (4) To any loss, cost, expense, fine, or (1) Refusal to employ a person; penalty arising out of any of the foregoing items 1., 2., or 3. (2) Termination of a person's employment; q. Fungus (3) Coercion, demotion, evaluation, This insurance does not apply to "bodily reassignment, discipline, defamation, injury", "property damage ", "personal and harassment, humiliation or advertising injury", or any other loss, cost or discrimination directed at a person; or expense, including, but not limited to losses, costs or expenses related to, arising from or (4) Consequential "bodily injury" or associated with clean -up, remediation, "personal an advertising injury" as a containment, removal or abatement, caused result of (1) through (3) above. directly or indirectly, in whole or in part, by: This exclusion applies: „ , mold(s) ", mildew or (1) (1) Whether the insured may be liable as y east, orngus(i) an employer or in any other capacity; and (2) Any "spore(s)" or toxins created or produced by or emanating from such (2) To any obligation to share damages "fungus(i) ", "mold(s) ", mildew or yeast, or with or repay someone else who must pay damages because of the (3) Any substance, vapor, gas, or other injury. emission or organic or inorganic body or substance produced by or arising out of B. EXCLUSIONS any "fungus(i) ", "mold(s) ", mildew or The following paragraphs are added to Section I — yeast, or Coverage A — 2. Exclusions: (4) Any material, product, building p. Asbestos component, building or structure, or any concentration of moisture, water or other (1) The manufacture of, mining of, use of, liquid within such material, product, sale of, installation of, removal of, building component, building or structure, distribution of or exposure to asbestos, that contains, harbors, nurtures or acts as asbestos products, asbestos fibers or a medium for any "fungus(i) ", "mold(s) ", asbestos dust; mildew, yeast or "spore(s)" or toxins (2) Any obligation of the insured to indemnify emanating therefrom. any party because of damages arising regardless of any other cause, event, out of such "bodily injury", "property material, product and /or building component damage ", "personal and advertising that contributed concurrently or in any injury" as a result of the manufacture of, sequence to that "bodily injury", "property mining of, use of, sale of, installation of, damage ", "personal and advertising injury", removal of, distribution of or exposure to loss, cost or expense. asbestos, asbestos products, fibers or asbestos dust; 8656312/04 .1r For purposes of this exclusion, the following definitions are added to the Policy: (1) "Fungus(i)" includes, but is not limited to, any of the plants or organisms belonging to the major group Fungi, lacking chlorophyll, and including molds, rusts, mildews, smuts, and mushrooms. (2) "Mold(s)" includes, but is not limited to, any superficial growth produced on damp or decaying organic matter or on living organisms, and fungi that produce molds. (3) "Spore(s)" means any dormant or reproductive body produced by or arising or emanating out of any "fungus(i) ", "mold(s) ", mildew, plants, organisms or microorganisms. This exclusion does not apply to any "fungi" or bacteria that are, are on, or are contained in, a good or product intended for bodily consumption. This fungus exclusion DOES NOT apply in the States of Alaska, California, Louisiana, New York or Washington. C. KNOWLEDGE OF OCCURRENCE As respects any loss reporting requirements under this policy, it is understood and agreed that knowledge of an accident or incident by an agent, servant or employee of yours or any other person shall not in itself constitute knowledge by you, unless a corporate officer of yours shall have received notice from said agent, servant, employee or any other person. D. LIBERALIZATION CLAUSE If we adopt a change in our forms or rules which would broaden your coverage without an additional premium charge, your policy will automatically provide the additional coverages as of the date the revision is effective in your state. E. NON -OWNED WATERCRAFT EXCLUSION Paragraph g.(2) of Section I — Coverage A — 2. Exclusions is deleted and replaced by the following: (2) A watercraft you do not own that is: (a) Less than 52 feet long; and (b) Not being used to carry persons or property for a charge. F. NOTICE OF OCCURRENCE Your failure to give first report of a claim to us shall not invalidate coverage under this policy if the loss was inadvertently reported to another Insurer. However, you shall report any such 8656312/04 "Occurrence" to us within a reasonable time once you become aware of such error. G. SUPPLEMENTARY PAYMENTS 1. Paragraph 1. b. of SUPPLEMENTARY PAYMENTS — COVERAGES A and B (SECTION 1) is deleted and replaced by the following: b. Up to $2,500 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 2. Paragraph 1. d. of SUPPLEMENTARY PAYMENTS — COVERAGES A and B (SECTION 1) is deleted and replaced by the following: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit," including actual loss of earnings up to $350 a day because of time off from work. H. TOTAL POLLUTION EXCLUSION WITH A HOSTILE FIRE EXCEPTION Exclusion f. under Paragraph 2., Exclusions of Section I — Coverage A is deleted and replaced by the following: f. Pollution (1) "Bodily injury" or "property damage" which would not have occurred in whole or part but for the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of "pollutants" at any time. This exclusion does not apply to "bodily injury" or "property damage" arising out of heat, smoke or fumes from a "hostile fire" unless that "hostile fire" occurred or originated: (a) At any premises, site or location which is or was at any time used by or for any insured or others for the handling, storage, disposal, processing or treatment of waste; or (b) At any premises, site or location on which any insured or any contractors or subcontractors working directly or indirectly on any insured's behalf are performing operations to test for, monitor, clean up, remove, contain, treat, detoxify, neutralize or in any -2- way respond to, or assess the effects of, "pollutants ". (2) Any loss, cost or expense arising out of any: (a) Request, demand, order or statutory or regulatory requirement that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of "pollutants "; or (b) Claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying for neutralizing, or in any way responding to, or assessing the effects of, "pollutants ". I. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS The following is added to paragraph 6., Representations of Section IV — Commercial General Liability Conditions: Your failure to disclose all hazards existing as of the inception date of the policy shall not prejudice you with respect to the coverage afforded by this policy provided such failure or any omission is not intentional. 8656312/04 .3.. COMMERCIAL GENERAL LIABILITY CG 2146 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ABUSE OR MOLESTATION EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following exclusion is added to Paragraph 2., Exclusions of Section I — Coverage A — Bodily Injury And Property Damage Liability and Para- graph 2., Exclusions of Section I — Coverage B — Personal And Advertising Injury Liability: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of: 1. The actual or threatened abuse or molestation by anyone of any person while in the care, custody or control of any insured, or 2. The negligent: a. Employment; b. Investigation; c. Supervision; d. Reporting to the proper authorities, or failure to so report; or e. Retention; of a person for whom any insured is or ever was legally responsible and whose conduct would be excluded by Paragraph 1. above. CG 2146 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 13 ENDORSEMENT This endorsement, effective 12:01 A.M. Oct 01, 2013 forms a part of policy No. 83331455 issued to Dayton Borders by New Hampshire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ASBESTOS AND SILICA EXCLUSION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Section I. - COVERAGES, COVERAGE A. - BODILY INJURY and PROPERTY DAMAGE LIABILITY, 2. - Exclusions, is amended to add the following exclusions: Asbestos "Bodily injury" or "Property damage" arising out of the manufacture of, mining of, use of, sale of, installation of, removal of, distribution of, or exposure to asbestos products, asbestos fibers or asbestos dust, or to any obligation of the insured to indemnify any party because of "bodily injury" or "property damage" arising out of the manufacture of, mining of, use of, sale of, installation of, removal of, distribution of, or exposure to asbestos products, asbestos fibers or asbestos dust. Silica "Bodily injury" or "property damage" or any other loss, cost or expense arising out of the presence, ingestion, inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form, or to any obligation of the insured to indemnify any party because of "bodily injury" or "property damage" arising out of the presence, ingestion, inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form. Section I. - COVERAGES, COVERAGE B. - PERSONAL and ADVERTISING INJURY LIABILITY, 2. - Exclusions is amended to add the following exclusions: Asbestos "Personal and Advertising Injury" arising out of the manufacture of, mining of, use of, sale of, installation of, removal of, distribution of, or exposure to asbestos products, asbestos fibers or asbestos dust, or to any obligation of the insured to indemnify any party because of "personal and advertising injury" arising out of the manufacture of, mining of, use of, sale of, installation of, removal of, distribution of, or exposure to asbestos products, asbestos fibers or asbestos dust. Silica "Personal and Advertising Injury" or any other loss, cost or expense arising out of the presence, ingestion, inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form, or to any obligation of the insured to indemnify any party because of "personal and advertising injury" arising out of the presence, ingestion, 82540 (8/07) Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form. All other terms, conditions and exclusions of the policy shall remain unchanged. Authorized Representative or Countersignature (in States Where Applicable) 82540 (8/07) Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 12:01 a.m. Oct 01, 2013 forms a part of Policy No. 83331455 issued to Dayton Borders by New Hampshire Insurance Company ASSAULT AND BATTERY EXCLUSION This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following exclusion is added to Paragraph 2. Exclusions of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES) and Paragraph 2. Exclusions of COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY (SECTION I — COVERAGES): This Policy shall not apply to "bodily injury, pr operty damage ", or "personal injury and advertising injury", arising out of assault and /or battery or out of any act or omission in connection with the prevention or suppression of such assault and /or battery. All other terms and conditions of the policy remain the same. Authorized Representative 101145409 ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 12:01 a.m. Oct 01, 2013 forms a part of Policy No.83331455 issued to Dayton Borders by New Hampshire Insurance Company ATTENDANCE LIMITATION EXCLUSION ENDORSEMENT This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Number of Admissions: 500 Per Day The following exclusion is added to both Paragraph 2. Exclusions of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES) and Paragraph 2. Exclusions of COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY (SECTION I — COVERAGES): This insurance does not apply to "bodily injury", "property damage ", or "personal and advertising injury" arising out of any event in which the attendance or capacity of the designated venue for such event exceeds the Number of Admissions shown in the Schedule to this Attendance Limitation Exclusion Endorsement. However, this exclusion does not apply if the attendance or capacity of the designated venue for such event is otherwise approved by us in writing. All other terms and conditions of the policy remain the same. Authorized Representative 100461 309 Page 1 of 1 THIS ENDORSEMENT EFFECTIVE: 12:01 A.M. Oct 01, 2013 FORMS A PART OF POLICY NO.: 83331455 ISSUED TO: Dayton Borders By: New Hampshire Insurance Company FIELD OF ENTERTAINMENT EXCLUSION This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART In consideration of the premium charged, it is hereby agreed that with respect to Coverage B. Personal and Advertising Injury Liability: 1w This policy does not apply to the following offenses arising out of the business of the Insured in the Field of Entertainment: A. Invasion of the right of privacy; B. Infringement of copyright, whether under statutory or common law; C. Libel, slander or other forms of defamation; D. Unauthorized uses of titles, formats, ideas, characters, plots or other program material; and E. Infringement of copyright or common law property rights, in literary or musical material, plagiarism, unfair competition or piracy. 2. "The Business of the Insured in the Field of Entertainment" means: A. The production, pre - production, post - production, distribution, exploitation and exhibition of motion pictures, television programs, commercial film, photograph records, electrical transcriptions, sheet music or other similar properties. B. The conduct of any players, entertainers or musicians in any show, theatrical performance or exhibition. C. The ownership, operation, maintenance or use of merchandising programs, advertising or publicity material, characters or ideas; whether or not on, premises of the Insured or in possession of the Insured at the time of the alleged offense. D. The ownership, operation, maintenance or use of theaters and similar exhibition media. All other terms, conditions and exclusions remain the same. v Authorized Representative 603685 ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.. This endorsement, effective at 12:01 A.M. Oct 01, 2013 forms a part of Policy No. 83331455 Issued to: Dayton Borders By: New Hampshire Insurance Company FIREWORKS, EXPLOSIVES, PYROTECHNIC DEVICES, OR INCENDIARY DEVICE EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following exclusion is added to Paragraph 2., Exclusions of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES) and Paragraph 2., Exclusions of COVERAGE B. PERSONAL AND ADVERTISING INJURY LIABILITY (SECTION I — COVERAGES) as follows: This insurance does not apply to "bodily injury", "property damage" and "personal advertising injury" caused by, arising out of, or resulting directly or indirectly, in whole or in part from fireworks, explosives, pyrotechnic devices, or any incendiary device. However, this exclusion does not apply to "flashboxes ". As used in this endorsement, "flashbox(es)" means a device used to create a visual effect along with an explosive noise and is induced electronically in a cylinder with no projectile, wadding, or wrapping. All other terms, conditions and exclusions remain unchanged. NJ Authorized Representative 96725 1207 Page 1 of 1 ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 12:01 a.m. Oct 01, 2013 forms a part of Policy NO.83331455 issued to Dayton Borders by New Hampshire Insurance Company LIMITED EVENT COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE TY F EVi -See- Attacteri -Endorserne DATE OF EVENT LOCATION LIMITS PREMIUM Paragraph 1. Insuring Agreement of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY and Paragraph 1. Insuring Agreement of COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY are amended to include the following: This insurance applies only to "bodily injury", "property damage" or "personal and advertising injury" arising out of an "occurrence" or offense which takes pl ace during an event shown in the Schedule to thi s Limited Event Coverage Endorsement (hereinafter the "Schedule "). Notwithstanding the Date of Event shown in the Schedule, those activities that are part of the setup and teardown required for the event are considered part of the event. The following is added to SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If any of the events sh own in the Schedul a are p ostponed by you, we may amend the Date(s) of Event in the Schedule to the dates) you tell u s. You must promptly notify us in writing of the postponement on or prior to th e Date(s) of Event in the Schedule and prior to the revised Date(s) of Event. If any of the events in the Schedule are cancelled by you, we may refund to you the premium for the cancelled events if you cancel the event(s) prior to the sch eduled start date (s). You must pr omptly notify us in writi ng of th e cancellation prior to the scheduled start date(s). All other terms and conditions shall remain unchanged, Authorized Signature 100472 (3/09) Page 1 of 1 This Addendum forms a part of the LIMITED EVENT COVERAGE ENDORSEMENT 100472 (3/09) part of the Policy No: 83331455 Issued To: Dayton Borders By: New Hampshire Insurance Company SCHEDULE Event Name: El Segundo Halloween Frolic Event Dates: 10/31/2013 - 10/31/2013 Max Daily Attendance: 500 Venue Location: Streets of El Segundo El Segundo CA, 90245 Limits & Premium: * Classification: Festival Advance Premium: 50 * Limits & Premium as per Commercial General Liability Coverage Part Declarations JDL 190 (2) -X -A (1 -95) INTERLINE IL 00 21 05 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (Broad Form) This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART PROFESSIONAL LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART 1. The insurance does not apply: A. Under any Liability Coverage, to "bodily injury" or "property damage ": (1) With respect to which an "insured" under the policy is also an insured under a nu- clear energy liability policy issued by Nu- clear Energy Liability Insurance Associa- tion, Mutual Atomic Energy Liability Under- writers, Nuclear Insurance Association of Canada or any of their successors, or would be an insured under any such policy but for its termination upon exhaustion of its limit of liability; or (2) Resulting from the "hazardous properties" of "nuclear material' and with respect to which (a) any person or organization is re- quired to maintain financial protection pur- suant to the Atomic Energy Act of 1954, or any law amendatory thereof, or (b) the "in- sured" is, or had this policy not been issued would be, entitled to indemnity from the United States of America, or any agency thereof, under any agreement entered into by the United States of America, or any agency thereof, with any person or organi- zation. B. Under any Medical Payments coverage, to expenses incurred with respect to "bodily in- jury" resulting from the "hazardous properties" of "nuclear material' and arising out of the op- eration of a "nuclear facility" by any person or organization. C. Under any Liability Coverage, to "bodily injury" or "property damage" resulting from "hazard- ous properties" of "nuclear material', if: (1) The "nuclear material' (a) is at any "nuclear facility" owned by, or operated by or on be- half of, an "insured" or (b) has been dis- charged or dispersed therefrom; (2) The "nuclear material' is contained in "spent fuel" or "waste" at any time pos- sessed, handled, used, processed, stored, transported or disposed of, by or on behalf of an "insured "; or (3) The "bodily injury" or "property damage" arises out of the furnishing by an "insured" of services, materials, parts or equipment in connection with the planning, construction, maintenance, operation or use of any "nu- clear facility ", but if such facility is located within the United States of America, its terri- tories or possessions or Canada, this ex- clusion (3) applies only to "property dam- age" to such "nuclear facility" and any property thereat. IL 00 21 05 04 © ISO Properties, Inc., 2001 Page 1 of 2 ❑ 2. As used in this endorsement: "Hazardous properties" includes radioactive, toxic or explosive properties; "Nuclear material" means "source material', "Spe- cial nuclear material' or "by- product material'; "Source material", "special nuclear material," and "by- product material" have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof; "Spent fuel" means any fuel element or fuel com- ponent, solid or liquid, which has been used or exposed to radiation in a "nuclear reactor "; "Waste" means any waste material (a) containing "by- product material" other than the tailings or wastes produced by the extraction or concentra- tion of uranium or thorium from any ore processed primarily for its "source material' content, and (b) resulting from the operation by any person or or- ganization of any "nuclear facility" included under the first two paragraphs of the definition of "nu- clear facility ". "Nuclear facility" means: (a) Any "nuclear reactor "; (b) Any equipment or device designed or used for (1) separating the isotopes of uranium or plutonium, (2) processing or utilizing "spent fuel', or (3) handling, processing or packag- ing "waste "; (c) Any equipment or device used for the proc- essing, fabricating or alloying of "special nuclear material" if at any time the total amount of such material in the custody of the "insured" at the premises where such equipment or device is located consists of or contains more than 25 grams of pluto- nium or uranium 233 or any combination thereof, or more than 250 grams of uranium 235; (d) Any structure, basin, excavation, premises or place prepared or used for the storage or disposal of "waste "; and includes the site on which any of the forego- ing is located, all operations conducted on such site and all premises used for such operations; "Nuclear reactor" means any apparatus designed or used to sustain nuclear fission in a self - supporting chain reaction or to contain a critical mass of fissionable material; "Property damage" includes all forms of radioac- tive contamination of property. Page 2 of 2 © ISO Properties, Inc., 2001 IL 00 21 05 04 ❑ ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective at 12:01 A.M. Oct 01, 2013 forms a part of Policy No. 83331455 Issued to: Dayton Borders By: New Hampshire Insurance Company PROFESSIONAL LIABILITY EXCLUSION This endorsement modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM It is agreed that this policy shall not apply to liability arising out of the rendering of or failure to render professional services, or any error or omission, malpractice or mistake of a professional nature committed by or on behalf of the "Insured" in the conduct of any of the "Insured's" business activities. However, this exclusion shall not apply to an insured included under ADDITIONAL INSURED — MEDICAL PERSONNEL endorsement #97019 if applicable to this policy. All other terms, conditions and exclusions remain unchanged. AUTHORIZED Representative OR Countersignature (In states where applicable) 97020208 POLICY NUMBER: 83331455 COMMERCIAL GENERAL LIABILITY CG 21 35 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - COVERAGE C - MEDICAL PAYMENTS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ption And Location Of Premises Or Classification: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) With respect to any premises or classification shown 2. The following is added to Section I — Supple - in the Schedule: mentary Payments: 1. Section I — Coverage C — Medical Payments h. Expenses incurred by the insured for first does not apply and none of the references to it aid administered to others at the time of an in the Coverage Part apply: and accident for "bodily injury" to which this in- surance applies. CG 21 3510 01 © ISO Properties, Inc., 2000 Page 1 of 1 ❑ THIS ENDORSEMENT EFFECTIVE: 12:01 A.M. Oct 01, 2013 FORMS A PART OF POLICY NO.: 83331455 ISSUED TO: Dayton Borders BY: New Hampshire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ CAREFULLY. SECURITIES AND FINANCIAL INTEREST EXCLUSION This endorsement modifies insurance under the following: COMMERCIAL LIABILITY COVERAGE PART It is agreed that this insurance does not apply to any "bodily injury" and property damage" arising out of or by reason of: The purchase, or sale, or offer of sale, or solicitation of any security, debt, bank deposit of financial interest or instrument. Any representative made at any time in relation to the price or value of any security, debt, bank deposit or financial interest or instrument; or Any depreciation or decline in price or value of any security, debt, bank deposit or financial interest or instrument. It is furthermore agreed that we have no obligations to defend or pay for the defense of any claim that may allege any of the foregoing. All other terms and condition remain the same. Authorized Representative 73003499 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ENDORSEMENT This endorsement, effective 12:01 A.M. Oct 01, 2013 forms a part of Policy No. 83331455 issued to Dayton Borders by New Hampshire Insurance Company SILICOSIS EXCLUSION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Section I. - Coverages, Coverage A.- Bodily Injury and Property Damage Liability, 2. - Exclusions, is amended to add: "Bodily injury" or "property damage ", or any other loss, cost or expense arising out of the presence, ingestion, inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form, or to any obligation of the insured to indemnify any party because of damages arising out of the presence, ingestion, inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form. Section I. - Coverages, Coverage B.- Personal and Advertising Injury Liability, 2. - Exclusions, is amended to add: Or any other loss, cost or expense arising out of the presence, ingestion, inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form, or to any obligation of the insured to indemnify any party because of damages arising out of the presence, ingestion, inhalation or absorption of or exposure to silica products, silica fibers, silica dust or silica in any form. AUTHORIZED REPRESENTATIVE MIIINVIIS ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective at 12:01 A.M. Oct 01, 2013 forms a part of Policy No. 83331455 Issued to: Dayton Borders By: New Hampshire Insurance Company EXCLUSION -- SPORTS /LEISURE /ENTERTAINMENT ACTIVITIES AND DEVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following exclusions are added to Paragraph 2. Exclusions of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES) and Paragraph 2. Exclusions of COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY (SECTION I — COVERAGES) if an X is indicated to the left of such exclusion.:. This insurance does not apply to "bodily injury", "property damage ", "personal and advertising injury" Inverted Aerial Maneuver Arising out of the attempt to perform or performanc a of any inverted aerial maneuver by a skier from a jump: 1. Built by you or on your behalf; or 2. Built on your premises with your permission or knowledge. X Amusement Device Arising out of the ownership, operation, maintenance or use of any "amusement device ". For purposes of this exclusion, "amusement dev ice" means any device or equipment a person rides for enjoyment, including, but not limited to, any mec hanical or non - mechanical ride, slide, water slide (including any ski or tow when used in connection with a water slide), moonwalk or moon bounce, bungee operation or equipment. "Amusement device" does not include any video arcade or computer game. Bungee Arising out of the ownership, operation, main tenance or use of any bungee operation or equipment whether owned, operated, maintained or used by you, any other insured or any other person or entity. Animals Arising out of injury or death to any animal. Object Propelled Arising out of any object propelled, whether intentionally or unintentionally, into the crowd by or at the direction of a "participant' or insured. X "Participant' Arising out of the involvement of a participant in any activity, event or exhibition, including, but not limited to, any contest, physical training, sport, event, athletic activity, martial arts or stunt. Rodeo Arising out of any rodeo activity, including, but not limited to, bronco or bull riding, steer roping, team roping, barrel racing or horseback riding. 100456309 Page 1 of 2 Concert Arising out of a concert, show, or theatrical event. X Performer Arising out of the involvement of any performer duri ng any activity, event or exhibition, including, but not limited to any stunt, concert, show or theatrical event. DEFINITION OF PARTICIPANT For purposes of this endorsement, "participant" means any person while instructing, supervising, training or practicing for, participating in or while otherwise involved in any sports or athletic activi ty, contest, or exhibition. "Participant" does not include any spectator. All other terms, conditions and exclusions remain unchanged.. NJ Authorized Representative 100456309 Page 2 of 2 THIS ENDORSEMENT EFFECTIVE: 12:01 A.M. Oct 01, 2013 FORMS A PART OF POLICY NO.: 83331455 ISSUED TO: Dayton Borders BY: New Hampshire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ CAREFULLY. STUNT EXCLUSION ENDORSEMENT This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART In consideration of the premium charged, it is hereby agreed that all stunting activity or any practice or preparation of any such stunt is excluded from all coverage under this policy. "Stunting Activity ", means any feat or activity requiring special strength, skill, equipment, device or daring. All other terms and conditions remain the same. � Authorized Representative 72981 499 ENDORSEMENT This endorsement, effective 12:01 A.M. Oct 01, 2013 forms a part of Policy No. 83331455 issued to Dayton Borders By. New Hampshire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ CAREFULLY TOTAL LEAD EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL UMBRELLA LIABILITY This insurance does not apply to any "bodily injury", "property damage ", "personal injury", or "advertising injury", or any other loss, cost or expense arising out of the presence, ingestion, inhalation, or absorption of or exposure to lead in any form or products containing lead. ICZN AUTHORIZED REPRESENTATIVE 58332 793 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 12:01 A. M. Oct 01, 2013 forms part of Policy No.83331455 issued to Dayton Borders by New Hampshire Insurance Company EXCLUSION - VIOLATION OF STATUTES IN CONNECTION WITH SENDING, TRANSMITTING OR COMMUNICATING ANY MATERIAL OR INFORMATION This insurance does not apply to any loss, injury, damage, claim, suit, cost or expense arising out of or resulting from, caused directly or indirectly, in whole or in part by, any act that violates any statute, ordinance or regulation of any federal, state or local government, including any amendment of or addition to such laws, that includes, addresses or applies to the sending, transmitting or communicating of any material or information, by any means whatsoever. To the extent any coverage may otherwise be available under this Policy , the provisions of this Exclusion shall supercede the same and exclude such coverage. All other terms and conditions of the policy are the same. 87295105 Countersignature, if required by law Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 00 63 12 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAR LIABILITY EXCLUSION This endorsement modifies insurance provided under the following: OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART The War Exclusion under Paragraph 2., Exclusions of Section I — Bodily Injury And Property Damage Liability is replaced by the following: 2. Exclusions This insurance does not apply to: WAR "Bodily injury" or "property damage ", however caused, arising, directly or indirectly, out of: a. War, including undeclared or civil war; or b. Warlike action by a military force, including action in hindering or defending against an actual or expected attack, by any govern- ment, sovereign or other authority using military personnel or other agents; or c. Insurrection, rebellion, revolution, usurped power, or action taken by governmental au- thority in hindering or defending against any of these. CG 00 6312 02 © ISO Properties, Inc., 2002 Page 1 of 1 ❑ POLICY NUMBER: 83331455 COMMERCIAL GENERAL LIABILITY CG 20 11 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART '.43:L41111? Designation Of Premises (Part Leased To You): City of El Segundo, 350 Main Street, El Segundo, CA, 90245 Name Of Person(s) Or Organization(s) (Additional Insured):. City of El Segundo, 350 Main Street, El Segundo, CA, 90245 Additional Premium: Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to 2. If coverage provided to the additional insured include as an additional insured the person(s) or is required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured with respect to liability arising out of the will not be broader than that which you are ownership, maintenance or use of that part of the required by the contract or agreement to premises leased to you and shown in the provide for such additional insured. Schedule and subject to the following additional B. With respect to the insurance afforded to these exclusions: additional insureds, the following is added to This insurance does not apply to: Section III — Limits Of Insurance: 1. Any 'occurrence" which takes place after you If coverage provided to the additional insured is cease to be a tenant in that premises. required by a contract or agreement, the most we 2. Structural alterations, new construction or will pay on behalf of the additional insured is the demolition operations performed by or on amount of insurance: behalf of the person(s) or organization(s) 1. Required by the contract or agreement; or shown in the Schedule. 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the by law; and applicable Limits of Insurance shown in the Declarations. CG 20 11 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 83331455 COMMERCIAL GENERAL LIABILITY CG 20 12 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Political Subdivision: As submitted to company and required by written contract. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II — Who Is An Insured is amended to 2. This insurance does not apply to: include as an insured any state or political subdivi- a. "Bodily injury," "property damage" or "personal sion shown in the Schedule, subject to the following and advertising injury arising out of opera - provisions: tions performed for the state or municipality; 1. This insurance applies only with respect to opera- tions performed by you or on your behalf for which the state or political subdivision has issued a permit. or b. 'Bodily injury" or "property damage" included within the "products- completed operations hazard ". CG 20 12 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ POLICY NUMBER: 83331455 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): As submitted to company and required by written contract. Information required to com fete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 21 50 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.. AMENDMENT OF LIQUOR LIABILITY EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following replaces Exclusion c. under Paragraph (b) Providing or failing to provide 2. Exclusions of Section I — Coverage A — Bodily transportation with respect to any Injury And Property Damage Liability: person that may be under the influence 2. Exclusions of alcohol; This insurance does not apply to: c. Liquor Liability "Bodily injury" or "property damage" for which any insured may be held liable by reason of: (1) Causing or contributing to the intoxication of any person, including causing or contributing to the intoxication of any person because alcoholic beverages were permitted to be brought on your premises, for consumption on your premises; (2) The furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol; or (3) Any statute, ordinance or regulation relating to the sale, gift, distribution or use of alcoholic beverages. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in: (a) The supervision, hiring, employment, training or monitoring of others by that insured; or if the 'occurrence" which caused the "bodily injury" or "property damage ", involved that which is described in Paragraph (1), (2) or (3) above. This exclusion applies only if you: (1) Manufacture, sell or distribute alcoholic beverages; (2) Serve or furnish alcoholic beverages for a charge whether or not such activity: (a) Requires a license; (b) Is for the purpose of financial gain or livelihood; (3) Serve or furnish alcoholic beverages without a charge, if a license is required for such activity; or (4) Permit any person to bring any alcoholic beverages on your premises, for consumption on your premises. CG 21 50 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE (COVERAGE INCLUDED) Coverage for acts of terrorism is included in your policy. You are hereby notified that under the Terrorism Risk Insurance Act, as amended, that you have a right to purchase insurance coverage for losses resulting from acts of terrorism, as defined in Section 102(1) of the Act: The term "act of terrorism" means any act that is certified by the Secretary of the Treasury —in concurrence with the Secretary of State, and the Attorney General of the United States —to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; and to have 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. Under your coverage, any losses resulting from certified acts of terrorism may be partially reimbursed by the United States Government under a formula established by the Terrorism Risk Insurance Act, as amended. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear events. Under the formula, the United States Government generally reimburses 85% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The Terrorism Risk Insurance Act, as amended, contains a $100 billion cap that limits U.S. Government reimbursement as well as insurers' liability for losses resulting from certified acts of terrorism when the amount of such losses exceeds $100 billion in any one calendar year. If the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced. The portion of your annual premium that is attributable to coverage for acts of terrorism is $ $1.00 , and does not include any charges for the portion of losses covered by the United States government under the Act. 96556 (2/08) 0 2007 National Association of Insurance Commissioners Chartis U.S. Privacy and Data Security Notice Your Privacy In the course of conducting business, we collect information about you in order to properly service the products we sell to you. Accordingly, Chartis U.S. has established practices, procedures and system protections that are designed to help protect the privacy and security of your information. About This Notice The term "Personal Information," as used in this Privacy and Data Security Notice, means information that identifies you, our Customer, personally. Examples of Personal Information include a first and last name, a home or other physical address, an email address, a credit card number, a driver's license number, or information on your physical condition or health status. This Privacy and Data Security Notice outlines how we collect, handle, and disclose Personal Information about you. It applies only to your Personal Information obtained by the Companies listed at the end of this Notice, in connection with products or services with which you received this Notice which are primarily for personal, family, or household purposes in the United States. Information Collection We may collect Personal Information about you from applications, enrollment forms, your other interactions with us, our Affiliates, and when we process claims or other transactions in connection with the underwriting process. We may also collect Personal Information about you from credit reporting agencies and other third parties in connection with the sale of our products to you. We will collect Personal Information about you only in accordance with applicable laws or regulations or in response to your request for a product or service from us. Information Sharing We may share your Personal Information with Affiliates and Non - Affiliates as described below. With our Affiliates: We may share customer information with our Affiliates. Our Affiliates may include other insurance companies, insurance holding companies, insurance agents and agencies, claims administrators, marketing companies, e- commerce service providers, and companies providing administrative services. • We may share your Personal Information with our Affiliates that assist us in servicing your insurance policies. Examples are administration (billing and collections), risk management, underwriting, and claims handling. We may also share your Personal Information with our Affiliates for the purpose of detecting and preventing fraud, as directed or authorized by you, or as otherwise permitted or required by law. • We will not share your Personal Information that is of a financial nature with our Affiliates for marketing purposes without first providing you an opportunity to direct that such information not be shared. • We will not share your Personal Information that is of a health nature with our Affiliates except as directed or authorized by you. 78052 (Rev. 12/1/09) With Non - Affiliates: We may also share customer information with Non - Affiliated companies 1. We may share your Personal Information with Non - Affiliates that assist us in servicing your insurance policies. Examples are administration (billing and collections), risk management, underwriting, and claims handling. We may also share your Personal Information with Non - Affiliates for the purpose of detecting and preventing fraud, as directed or authorized by you, or as otherwise permitted or required by law. 2. We may enter into joint marketing agreements with Non - Affiliates to share your non - health Personal Information as permitted by law. These Non - Affiliates may include providers of financial products or services such as insurance companies, financial institutions, and securities firms. Because we do not share customer information in any other way, there is no need for an opt -out process in our privacy procedures. For California and Vermont Residents: If it becomes necessary to share your Personal Information with Non - Affiliates other than as specifically allowed by law, we will not do so without first obtaining your permission. Information Protection We maintain physical, electronic, and procedural safeguards designed to protect your Personal Information. Only authorized employees, insurance agents and administrators are permitted to have access to that information. We expect any Non - Affiliates that serve our Customers on our behalf to adhere to our privacy policy. Those non - affiliates are legally bound to use your Personal Information received from us only for the purposes for which it was provided and to not disclose it or use it in any other way. These Non - Affiliates are also subject to and governed by federal and state privacy laws and regulations. We are not responsible for their misuse of information. To help prevent unwarranted disclosure of your Personal Information and secure it from theft, we utilize secure computer networks. Access is restricted to those individuals who need to use your Personal Information to provide products or services to you. III. Maintaining Information We also maintain procedures to ensure that the information we collect is accurate, up -to -date, and as complete as possible. If you believe the information we have about you in our records or files is incomplete or inaccurate, you may request that we make additions or corrections, or if it is feasible, that we delete this information from our files. You may make this request in writing to (include your name, address and policy number): Chief Privacy Officer Chartis U.S. 175 Water Street, 17th Floor New York, NY 10038 Fax: 212 458 -7081 E -Mail: ClPrivacy(cDchartisinsurance.com Special Notice: You can obtain access to any non - public Personal Information we have about you if you properly identify yourself and submit a written request to the address above describing the information you want to review. We will also tell you the identity, if recorded, of persons to whom we have disclosed your non - public Personal Information within the preceding two years. You may request that we correct, amend or delete any information about you. If we do so, we will notify organizations that provided us with that information and, at your request, persons who received that information from us within the preceding two years. If we refuse to correct, amend or delete the information, you may give us a written statement of the reasons you disagree, which we will place in your file and give to the same parties who would have been notified of the requested change. 78052 (Rev. 12/1/09) Our Customers Can Depend on Us We are committed to maintaining our trusted relationship with our Customers. We consider it our privilege to serve our Customers' insurance and financial needs and we value the trust they have placed in us. Our Customers' privacy is a top priority with us and thus we will continue to monitor our privacy practices in order to protect and respect that privacy and will comply with state privacy laws that require more restrictive practices than those set out in this notice. Important Information Concerning the Applicabillily Applicability and Future Changes to this Privacy and Data Security Notice Although we may change this Privacy and Data Security Notice at any time, you will be notified of any changes as required by law. American Home Assurance Company; Audubon Indemnity Company; Audubon Insurance Company; Chartis Casualty Company; Chartis Property Casualty Company; Chartis Select Insurance Company; Chartis Specialty Insurance Company; Commerce and Industry Insurance Company; Granite State Insurance Company; Illinois National Insurance Co.; Landmark Insurance Company; Lexington Insurance Company; National Union Fire Insurance Company of Pittsburgh, Pa.; National Union Fire Insurance Company of Vermont; New Hampshire Insurance Company; The Insurance Company of the State of Pennsylvania; other member companies of Chartis U.S., and American International Life Assurance Company of New York and AIG Life Insurance Company. 78052 (Rev. 12/1/09) POLICYHOLDER NOTICE Thank you for purchasing insurance from the Chartis companies. Chartis insurance companies generally pay compensation to brokers and independent agents, and may have paid compensation in connection with your policy. You can review and obtain information about the nature and range of compensation paid by Chartis insurance companies to brokers and independent agents in the United States by visiting our website at www. chartisinsurance .com/producercompensation or by calling 1- 800 - 706 -3102. 91222(12/09) ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT EFFECTIVE: 12:01 A.M., Oct 01, 2013 FORMS A PART OF POLICY NO.: 83331455 ISSUED TO: Dayton Borders BY: New Hampshire Insurance Company ENTERTAINERS PROMOTIONAL ACTIVITIES LIMITATION ENDORSEMENT This endorsement modifies insurance under the following:. COMMERCIAL GENERAL LIABILITY COVERAGE FORM Subparagraph f.(4) is added to Paragraph 9. of SECTION V DEFINITIONS as follows: (4) under which you assume liability for an injury or damage arising out of the leasing of any arenas, halls, theaters and or other places for theatrical productions. However, this Subparagraph (4) does not apply if such part of contract or agreement is specifically included as an "insured contract" in an endorsement to this policy for a specified arena, hall, theater or other place for theatrical productions. All other terms and conditions of the policy remain the same. Authorized Representative 100466 (3/09) 2 -14141 Page 1 of 1 ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 4:08 PM CST Oct 01, 2013 forms a part of Policy No.: 83331455 Issued to: Dayton Borders By: New Hampshire Insurance Company AMENDMENT OF POLICY PERIOD This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART The Policy Period as shown in the Declarations Page of this policy is deleted in its entirety and replaced with the following: From 4:08 PM CST Oct 01, 2013 to 12:01 A.M. Nov 01, 2013 standard time at your mailing address shown above. This insurance does not apply to any "bodily injury", "property damage" or "personal and advertising injury" that occurs prior to the Policy Period as stated above. All other terms and conditions of the policy remain the same. C:��: -, CZL,. Authorized Representative 102215 (7/10) Page 1 of 1 ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective 12:01 A.M. Oct 01, 2013 To Nov 01, 2013 12:01 A.M. forms a part of Policy No.: 83331455 Issued to: Dayton Borders By: New Hampshire Insurance Company COVERAGE TERRITORY ENDORSEMENT This endorsement modifies insurance provided under the following: Payment of loss under this policy shall only be made in full compliance with all United States of America economic or trade sanction laws or regulations, including, but not limited to, sanctions, laws and regulations administered and enforced by the U.S. Treasury Department's Office of Foreign Assets Control ( "OFAC "). AUTHORIZED REPRESENTATIVE 89644 (7/05) UNITED STATES FIRE INSURANCE COMPANY Administrative Offices: 5 Christopher Way - 3rd Floor - Eatontown, NJ 07724 BLANKET BENEFITS -ACCIDENTS ONLY CERTIFICATE This Certificate contains the terms under which the United States Fire Insurance Company agrees to insure certain persons and pay benefits. This Certificate is a part of, and is governed by, a Group Policy that has been issued in the state of CALIFORNIA and shall be governed by its laws. Coverage under this Certificate is provided in consideration of payment of the initial premium, continued payment of premiums when due, and completion of an Application. This Certificate is a part of, and is governed by, a Group Policy, The Group Policy has been issued to, and is the contract between, the Group Policyholder and The United States Fire Insurance Company. The Group Policy is held by the Group Policyholder and may be inspected upon request at any reasonable time. The name of the Group Policyholder is shown in the Schedule. This Certificate has been issued to you, the Certificateholder, as a Participant under the Group Policy, in accordance with the terms, conditions, and limitations of the Group Policy. 10 DAY RIGHT TO RETURN THIS CERTIFICATE: If for any reason, you are not satisfied with this Certificate, you may return it to us within 10 -days after receiving it. Upon its return, we will refund any premium paid and this Certificate will be deemed void, just as though it had never been issued. NOTICE THIS NOTICE IS TO ADVISE YOU THAT SHOULD YOU HAVE ANY QUESTIONS OR COMPLAINTS REGARDING THIS CERTIFICATE, YOU MAY CONTACT UNITED STATES FIRE INSURANCE COMPANY AT 5 CHRISTOPHER WAY EATONTOWN, NEW JERSEY 07724 or CALL (732) 676 -9800 ALSO AVAILABLE IS THE CONSUMER SERVICES DIVISION OF THE CALIFORNIA DEPARTMENT OF INSURANCE, WHICH MAY BE CONTACTED AS FOLLOWS: CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION; 300 SPRING STREET, SOUTH TOWER LOS ANGELES, CALIFORNIA 90013 or call 1- 800 -927- HELP or 1- 800 - 927 -4357 THE DEPARTMENT OF INSURANCE SHOULD BE CONTACTED ONLY AFTER DISCUSSIONS WITH THE INSURANCE COMPANY OR ITS REPRESENTATIVES HAVE FAILED TO PRODUCE A SATISFACTORY RESOLUTION TO THE PROBLEM. Required Disclosure under California Insurance Code § 10270.3: Please note that all benefits payable under this Certificate may be subject to reduction, to the extent provided in this Certificate, to the extent that you are entitled to benefits, whether on an indemnity basis or on a provision -of- service basis, for hospital, medical, dental, or surgical expenses under any other valid and collectible individual, group, or blanket insurance policy or contract, hospital or medical service program, or group - practice prepayment plan, except for automobile medical payments insurance. THIS IS ACCIDENT ONLY COVERAGE. READ IT CAREFULLY. BENEFITS ARE NOT PAYABLE FOR LOSS DUE TO SICKNESS. THIS CERTIFICATE PAYS BENEFITS FOR SPECIFIC LOSSES FROM ACCIDENTS ONLY. THIS CERTIFICATE IS NOT RENEWABLE. Signed for The United States Fire Insurance Company By: Signature Signature A L L�� Douglas M. Libby Chairman and CEO GAC26932 -CA James Kraus Secretary TABLE OF CONTENTS The following provisions appear within this Certificate in the following order: Schedule of Benefits Definitions Scope of Coverage Description of Hazards Description of Benefits Exclusions Additional Exclusions Limitations Premium Provisions General Provisions Claim Provisions GAC26932 -CA 2 SCHEDULE OF BENEFITS COVERAGE IS PROVIDED UNDER GROUP POLICY NUMBER: AH- GA26932 -002 ISSUED TO GROUP POLICYHOLDER: The Group and Blanket Accident & Health Insurance Trust CERTIFICATEHOLDER: Dayton Borders CERTIFICATE NUMBER: US000111988 CERTIFICATE EFFECTIVE DATE: Oct 01, 2013 CERTIFICATE EXPIRATION DATE: Nov 01, 2013 CLASSES OF ELIGIBLE PERSONS: A person may be covered only under one Class of Eligible Persons even though He or She may be eligible under more than one class. See Application HAZARDS INSURED AGAINST: Class Hazard # Description of Hazard See Application Policyholder Functions BENEFIT PERIOD: Provided treatment begins within 30 days from the date of Injury, Benefits are payable for 52 weeks from the date of an Injury. The Injury must occur after the Effective Date and prior to the Expiration Date and care must be Medically Necessary. DEDUCTIBLE AMOUNT: See Below COINSURANCE PERCENTAGE: 100% URC (Usual, Reasonable & Customary) Up to the Policy Maximum MAXIMUM BENEFIT AMOUNT: See Below MEDICAL EXPENSE BENEFIT Hospital Room & Board Daily Maximum Benefit Amount: URC Intensive Care Room & Board Daily Maximum Benefit: URC Hospital Miscellaneous Maximum Benefit Amount: URC Outpatient Pre - Admission Testing Benefit Amount: URC Outpatient Hospital Emergency Room Treatment Maximum Benefit Amount: URC Surgical Benefits: Primary Surgeons Maximum Benefit Amount: URC Assistant Surgeon, Second Surgical Opinion, Consultation Maximum Benefit: URC Anesthesia Maximum Benefit: URC Surgical Facility Maximum Benefit per Operating Session: URC GAC26932 -CA 3 Doctor's Visits In- Hospital Maximum Benefit: URC Office Visits Maximum Benefit: URC Maximum for All In- Hospital and Office Doctor's Visits: URC X -ray and Laboratory Maximum Benefit Amount: URC Nursing Maximum Benefit Amount: URC Physiotherapy Benefit Maximum Benefit Amount (Hospital Inpatient): URC Maximum Benefit Amount (Outpatient): URC Maximum for All Physiotherapy Combined (Inpatient & Outpatient): URC Ambulance Maximum Benefit Amount: URC Medical Equipment Rental Charges Maximum Benefit Amount: URC Medical Services and Supplies Maximum Benefit Amount (Blood, Blood Transfusions, Oxygen): URC Dental Treatment For Injury Only Maximum Benefit Amount: See Below Out - Patient Prescription Drug Benefit Maximum Benefit Amount: URC Accidental Death, Dismemberment, Loss of Sight, Speech, Hearing, Or Paralysis Principal Sum: See Below Aggregate Limit per Accident for AD &D only See Below Class I: All active spectators and /or ticketholders who are attending an Insured Group's sponsored, scheduled and supervised short-term event, for whom premium has been paid. Option 1 Limits; $5,000 Accidental Death & Accidental Dismemberment Benefit $5,000 Accident Medical Expense Benefit (Excess Basis) $100 Corridor Deductible (per incident per person) $250 Dental Maximum (per Tooth per Accident) $50,000 Aggregate Limit per Accident for AD &D only GAC26932 -CA 4 DEFINITIONS The terms shown below shall have the meaning given in this section whenever they appear in this Certificate. Additional terms may be defined within the provision to which they apply. "Accident" means a sudden, unforeseeable external event which causes Injury to one or more Covered Persons. "Benefit Period" means the period of time from the date of Injury, as shown in the Schedule of Benefits. "Covered Person" means an Insured Person eligible for coverage as identified in the Enrollment/Application][who is a U.S citizen residing in the United States, or if not a U.S. citizen, resides permanently in the United States],for whom proper premium payment has been made when due, and who is therefore insured under the Policy and this Certificate. "Deductible" means the amount of Eligible Expenses which must be paid by the Covered Person before benefits are payable under this Certificate. It applies separately to each Covered Person. "Eligible Expenses" means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Covered Person for the Medically Necessary treatment of an Injury. Eligible Expenses must be incurred while this Certificate is in force. "He ", "his" and "him" includes "she ", "her" and "hers." "Health Care Plan" means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under: (1) Group or blanket insurance, whether on an insured or self- funded basis; (2) Hospital or medical service organizations on a group basis; (3) Health Maintenance Organizations on a group basis. (4) Group labor management plans; (5) Employee benefit organization plan; (6) Professional association plans on a group basis; or (7) Any other group employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 as amended. "Hospital" means an institution which: (1) Is operated pursuant to law; (2) Is primarily and continuously engaged in providing medical care and treatment to sick and injured persons on an inpatient basis; (3) Is under the supervision of a staff of Physicians; (4) Provides 24 -hour nursing service by or under the supervision of a graduate registered nurse, (R.N.); (5) Has medical, diagnostic and treatment facilities, with major surgical facilities; (a) On its premises; or (b) Available to it on a prearranged basis; and (6) Charges for its services. "Hospital" does not include: (1) A clinic or facility for: (a) Convalescent, custodial, educational or nursing care; (b) The aged, drug addicts or alcoholics; or (c) Rehabilitation; or (2) A military or veterans hospital or a hospital contracted for or operated by a national government or its agency unless: (a) The services are rendered on an emergency basis; and (b) A legal liability exists for the charges made to the individual for the services given in the absence of insurance. "Hospital Stay" means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital. GAC26932 -CA 5 "Injury" means bodily harm of which an Accident is the proximate cause. All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury. "Medically Necessary" or "Medical Necessity" means a treatment, service or supply that is: (1) required to treat an Injury; (2) prescribed or ordered by a Physician or furnished by a Hospital; (3) performed in a setting required by the condition; (4) consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. The purchasing or renting air conditioners; air purifiers, motorized transportation equipment, escalators or elevators in private homes, swimming pools or supplies for them; and general exercise equipment are not considered Medically Necessary. The fact that a Physician may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Group Policy. "Nurse" means either a professional, licensed, graduate registered nurse (R.N.) or a professional, licensed practical nurse (L.P.N.). "Physician" means a person who is a doctor of medicine, osteopathy, psychology or other legally qualified practitioner of a healing art that is required by law to be licensed and is acting within the scope of his /her license under the laws in the state in which he /she practices and providing only those medical services which are within the scope of his /her license or certificate. It does not include an Insured, an Insured's Spouse, Domestic Partner, son, daughter, father, mother, brother or sister or other relative; "Supervised or Sponsored Activity" means a Certificateholder or School authorized function: (1) In which the Covered Person participates; (2) Which is organized by or under its auspices; which is within the scope of customary activities for such entity and is shown on the Schedule of Benefits. "Usual, Reasonable and Customary means the amount that is the normal payment range for a specific medical procedure performed within a given geographic area. If the charges submitted are higher than what is considered normal for the covered services, then We may not allow the full amount charged. SCOPE OF COVERAGE We will provide the benefits described in this Certificate to all Covered Persons who suffer a covered loss which: (1) Is within the scope of the DESCRIPTION OF BENEFITS PROVISIONS and is the proximate result of disease or bodily infirmity, from an Injury which is suffered in an Accident; (2) Occurs while the person is a Covered Person under this Certificate; and (3) Is within the scope of the risks set forth in the DESCRIPTION OF HAZARDS provisions. Full Excess Medical Expense: If an Injury to the Covered Person results in his incurring Eligible Expenses for any of the services in the SCHEDULE OF BENEFITS, we will pay the Eligible Expenses incurred, subject to the Deductible Amount and Coinsurance Percentage (if any), that are in excess of Expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan. The Covered Person must be under the care of a Physician when the Eligible Expenses are incurred. The Expense must be incurred solely for the treatment of a covered Injury: (1) While the person is insured under this Certificate; or (2) During the Benefit Period stated on the SCHEDULE OF BENEFITS. The first Expense must be incurred within the time frame shown on the SCHEDULE OF BENEFITS. GAC26932 -CA 6 The total of all medical benefits payable under this Certificate is shown on the SCHEDULE OF BENEFITS: and (1) Subject to the specific maximums shown on the SCHEDULE OF BENEFITS; and (2) Subject to compliance with the requirement, set forth in the Limitations section of this Certificate. PROVISIONS CONCERNING COVERED PERSONS Eligibility: Persons eligible to be insured under this Certificate are those persons described as an ELIGIBLE CLASS on the Application. This includes anyone who may become eligible while this Certificate is in force. Effective Dates: A Covered Person will become an insured under this Certificate, provided proper premium payment is made, on the latest of: (1) The Effective Date of this Certificate; or (2) The day he becomes eligible according to the referenced date shown in the Application. Termination: Insurance for a Covered Person will end on the earliest of: (1) The date he is no longer in an Eligible Class. (2) The date he reports for active duty in any Armed Forces, according to the referenced date shown in the Application. We will refund, upon receipt of proof of service, any premium paid, calculated from the date active duty begins until the earlier of: (a) The date the premium is fully earned; or (b) The Expiration Date of this Certificate. This does not include Reserve or National Guard duty for training; (3) The end of the period for which the last premium contribution is made; or (4) The date the Group Policy is terminated. DESCRIPTION OF HAZARDS HAZARD: POLICYHOLDER FUNCTIONS Subject to all other provisions of this Certificate, coverage is provided for a Covered Person while he is: (1) Attending or participating in a Supervised or Sponsored Activity; or (2) Attending a Policyholder function. The activity has to be an event or activity sponsored by and part of the operations of the policyholder. The Covered Person must be: (1) On the premises of the Policyholder: (a) During its normal hours; (b) During scheduled functions; or (c) During other periods if he is attending or participating in a Supervised or Sponsored Activity; (2) Not on Policyholder: premises and attending or participating in a Supervised or Sponsored Activity; (3) Traveling directly, without interruption: (a) Between his home and the Policyholder premises for participation in a Supervised or Sponsored Activity; (b) Between the site of the Supervised or Sponsored Activity and his home or the Policyholder: premises. (c) In a vehicle which is: (i) Designated or furnished by the Policyholder:; (ii) Operated by a properly licensed adult driver; and (iii) Under the direct supervision of the Policyholder; or (d) In a vehicle other than that described in (3)(c) when: (i) Operated by a properly licensed driver; and (ii) Travel time does not exceed an hour each way. GAC26932 -CA 7 Travel time includes the time: (i) To or from home, the Certificateholder's address and the Supervised or Sponsored Activity; (ii) Before the appointed time; and (iii) After the Supervised or Sponsored Activity is completed. Unless otherwise stated, we will pay benefits for a covered loss, only once, even if coverage was provided under more than one Description of Hazards. DESCRIPTION OF BENEFITS BENEFIT A,: BENEFITS FOR ACCIDENTAL DEATH, DISMEMBERMENT, LOSS OF SIGHT, SPEECH AND HEARING; OR PARALYSIS If, within 1 -year from the date of an Accident covered by this Certificate, Injury from such Accident, results in Loss listed below, we will pay the percentage of the Principal Sum set opposite the loss in the table below. If the Covered Person sustains more than one such Loss as the result of one Accident, we will pay only one amount, the largest to which he is entitled. This amount will not exceed the Principal Sum which applies for the Covered Person. Loss Loss of Life Loss of Both Hands Loss of Both Feet Loss of Entire Sight of Both Eyes Loss of One Hand and One Foot Loss of One Hand and Entire Sight of One Eye Loss of One Foot and Entire Sight of One Eye Loss of Speech and Hearing (both ears) Quadriplegia (total Paralysis of both upper and lower limbs) Paraplegia (total Paralysis of both lower limbs Loss of One Hand Loss of One Foot Loss of Entire Sight of One Eye Loss of Speech Loss of Hearing (both ears) Hemiplegia (total Paralysis of upper and lower limbs on one side of body) Loss of Thumb and Index Finger of the Same Hand Percentage of Principal Sum 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 50% 50% 50% 50% 50% 50% 25% Loss of a hand or foot means complete Severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. Loss of speech means total, permanent and irrecoverable loss of audible communication. Loss of hearing means total and permanent loss of hearing in both ears which cannot be corrected by any means. Loss of a thumb and index finger means complete Severance through or above the metacarpophalangeal joints (the joints between the fingers and the hand). In California, loss of a thumb and index finger means loss by complete Severance of at least one whole phalanx of each. "Severance" means the complete separation and dismemberment of the part from the body. "Paralysis" means loss of use, without Severance, of a limb. This loss must be determined by a Physician to be complete and not reversible. GAC26932 -CA 8 BENEFIT - MEDICAL EXPENSE We will pay, Eligible Expenses for a Covered Person's Injury, subject to the Deductible Amount and Coinsurance Percentage, if any, shown in the Schedule of Benefits. Eligible Expenses are those incurred for: (1) Hospital Room and Board — charges for a semi - private daily room rate for each day of the Hospital Stay, up to the Maximum Daily Benefit Amount shown in the Schedule of Benefits for Hospital Room and Board. (2) Intensive Care Room and Board - charges for each day of Intensive Care Unit confinement, up to the Daily Maximum Benefit Amount shown in the Schedule of Benefits for the Intensive Care Room and Board benefit. This payment is in lieu of payment for the Hospital Room and Board charges for those days. (3) Hospital Miscellaneous - charges during a Hospital Stay, up to the Maximum Daily Benefit Amount shown in the Schedule of Benefits for the Hospital Miscellaneous benefit. Miscellaneous charges do not include charges for telephone, radio or television, extra beds or cots, meals for guests, take home items, or other convenience items. (4) Outpatient Hospital Expenses - charges by a Hospital for: (a) Pre - admission testing (confinement must occur within 7 days of the testing); or (b) Emergency room treatment, up to the Maximum Benefit Amount per emergency shown in the Schedule of Benefits for the Outpatient Emergency Room Treatment benefit. (5) Surgical Benefits - charges for: (a) A Physician, for primary performance of a surgical procedure, up to the Maximum Benefit Amount shown in the Schedule of Benefits per procedure. Two or more surgical procedures through the same incision will be considered as one procedure. However, we will pay up to 1.57 times the surgical procedure charge when more than one surgical procedure through different operating fields are performed during the same surgical session. (b) A Physician, for: (i) assistant surgeon duties; (ii) a second surgical opinion; or (iii) consultation, up to the Maximum Benefit shown in the Schedule of Benefits for an Assistant Surgeon, Second Surgical Opinion, and Consultation. (c) Anesthesia and its administration, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Anesthesia benefit. (d) Use of surgical facilities, up to the Maximum Benefit Amount per operating session, as shown in the Schedule of Benefits for the Surgical Facility benefit. (6) Physician's Visits - charges by a Physician for other than pre- or post- operative care: (a) For in- Hospital visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Physician's Visit — In- Hospital. (b) For office visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Physician's Office Visits. Total visits per Injury will not exceed the combined Maximum shown in the Schedule of Benefits for All In- Hospital and Office Physician's Visits. (7) X -Ray and Laboratory - charges for X -ray and laboratory tests, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the X -ray & Laboratory benefit. (8) Nursing Services - Charges for nursing services (other than routine Hospital care) by or under the supervision of a licensed graduate registered nurse, up to the Maximum Benefit Amount shown on the Schedule of Benefits for the Nursing benefit. (9) Physiotherapy - Charges for physiotherapy: (a) While Hospital confined, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Hospital Inpatient Physiotherapy benefit; (b) As an outpatient, up to the Maximum Benefit Amount shown on the Schedule of Benefits for the Outpatient Physiotherapy benefit. Physiotherapy includes: GAC26932 -CA 9 (a) Heat treatment; (b) Diathermy; (c) Microtherm; (d) Ultrasonic; (e) Adjustment; (f) Manipulation; (g) Massage therapy and (h) Acupuncture. Total treatment per Injury will not exceed the Maximum Benefit Amounts for Physiotherapy shown in the Schedule of Benefits. (10) Ambulance - from the place where the Injury occurred to the Hospital, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Ambulance benefit. (11) Medical Equipment Rental - charges for medical equipment for: (a) A wheelchair; (b) An iron lung; or (c) Other medical equipment for which prior approval by us has been given; up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Medical Equipment Rental benefit. (12) Medical Services and Supplies - Charges for medical services and supplies for: (a) Oxygen and its administration; (b) Blood and blood transfusions; up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Medical Service & Supply benefit. (13) Dental Treatment - Charges for dental treatment for Injury to a tooth which was sound and natural at the time of Injury, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Dental Treatment benefit. The amounts payable under this Medical Expense benefit could be greatly reduced if the Covered Person does not comply with the requirements in the Limitations section of this Certificate. BENEFIT - OUT - PATIENT PRESCRIPTION DRUG BENEFIT We will pay the Eligible Expenses, subject to the Deductible Amount and Coinsurance Percentage shown in the Schedule of Benefits, if any; for a Prescription Drug or medication when prescribed by a Physician on an outpatient basis. Prescription Drug means a drug which: (1) Under Federal law may only be dispensed by written prescription; and (2) Is utilized for the specific purpose approved for general use by the Food and Drug Administration. The Prescription Drug must be dispensed for the out - patient use by the Covered Person:. (1) On or after the Covered Person's Effective Date; and (2) By a licensed pharmacy provider. Benefits are payable up to the Maximum Benefit Amount shown on the Schedule of Benefits. The amount payable under this benefit could be greatly reduced if the Covered Person does not comply with the requirements in the Limitations section of this Certificate. GAC26932 -CA 10 EXCLUSIONS Benefits will not be paid for a Covered Person's loss which: (1) Is proximately caused by the Covered Person's own: (a) Intentionally self- inflicted Injury, suicide or any attempt thereat. (In Missouri this applies only while sane.); (b) Voluntary self- administration of any drug or chemical substance not prescribed by, and taken according to the directions of, a doctor (Accidental ingestion of a poisonous substance is not excluded.); (c) Commission or attempt to commit a felony; (d) Participation in a riot or insurrection; (e) [Injury caused by, contributed to or resulting from the Covered Person's use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person's Physician. (2) Is proximately caused by: (a) Declared or undeclared war or act of war; (b) Aviation, except as specifically provided in this Certificate; (c) Sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. ADDITIONAL EXCLUSIONS Benefits will not be paid for: 1. Normal health checkups; 2. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident while the Covered Person is covered under this Certificate, and rendered within 6 months of the Accident; 3. Services or treatment rendered by a doctor, nurse or any other person who is: (a) Employed or retained by the Certificateholder; or (b) Who is the Covered Person or a member of his immediate family; 4. Charges which: (a) The Covered Person would not have to pay if he did not have insurance; or (b) Are in excess of Usual, Reasonable and Customary charges. 5. An Injury that is caused by flight in: (a) An aircraft, except as a fare - paying passenger; (b) A space craft or any craft designed for navigation above or beyond the earth's atmosphere; or (c) An ultra light, hang - gliding, parachuting or bungi -cord jumping; 6. Travel in or upon: (a) A snowmobile; (b) Any two or three wheeled motor vehicle; (c) Any off -road motorized vehicle not requiring licensing as a motor vehicle; 7. Any Accident where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator's license; 8. That part of medical expense arising out of a motor vehicle accident to the extent such benefits are payable by any automobile insurance Certificate without regard to fault. (Does not apply in any state where prohibited); 9. Injury that is: (a) The result of the Covered Person being Intoxicated. ( "Intoxicated" will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs); or (b) Caused by any narcotic, drug, poison, gas or fumes voluntarily taken, administered, absorbed or inhaled, unless prescribed by a doctor; 10. Any Sickness, except infection which occurs directly from an Accidental cut or wound or diagnostic tests or treatment, or ingestion of contaminated food; 11. Blood or Blood plasma, except for charges by a Hospital for the processing or administration of blood; 12. Elective treatment or surgery, health treatment, or examination where no Injury is involved; 13. Injury sustained while in the service of the armed forces of any country. When the Covered Person enters the armed forces of any country, we will refund the unearned pro rata premium upon request; 14. Eyeglasses, contact lenses, hearing aids, braces, appliances, or examinations or prescriptions therefore; GAC26932 -CA 11 15. Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay; 16. Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy; 17. Cosmetic surgery, except for reconstructive surgery on a diseased or injured part of the body; 18. Benefits will not be provided for services or injuries or diseases related to your job to the extent you are covered or are required to be covered by the Workers' Compensation law. If you enter into a settlement giving up your right to recover future medical benefits under a Workers' Compensation law, this policy will not pay those medical benefits that would have been payable in absence of that settlement; 19. The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; 20. Rest cures or custodial care; 21. The repair or replacement of existing dentures, partial dentures, braces or fixed or removable bridges; 22. Expenses incurred for an Accident after the Benefit Period shown in the Schedule of Benefits; 23. Orthopedic appliances which are used mainly to protect an Injury so that a covered student can take part in interscholastic or intercollegiate sports; 24. Hernia of any kind; or any bacterial infection that was not caused by an Accidental cut or wound; 25. Prescription medicines unless specifically provided for under this Certificate. 26. Injuries, which result over a period of time (such as blisters, tennis elbow, etc.) are not covered. LIMITATIONS Any benefits payable under this Certificate will be limited to the following: (1) The medical benefits otherwise payable under this Certificate will be reduced by 50% if: (a) Excess insurance is provided under this Certificate; and (b) The Covered Person has coverage under another plan providing medical expense benefits; and (c) The other plan is an HMO, PPO or similar arrangement ( "PPO- Preferred Provider Organization" means an Organization offering health care services through designated health care providers who agree to perform these services at rates lower than nonpreferred providers.); and (d) The Covered Person does not use the facilities or services of the HMO, PPO or similar arrangement for the provision of benefits. The Covered Person's limitation does not apply to emergency treatment required within 24 hours after an Accident which occurred outside the geographic area serviced by the HMO, PPO or similar arrangement. (2) Costs that exceed the Usual, Reasonable and Customary charges in the area where the services are furnished or supplies provided. Services, supplies and equipment must be: a) Medically necessary for the care or treatment of a covered Injury; b) Received while coverage is in force under this Certificate; and c) Rendered and /or prescribed by a licensed Physician other than the Covered Person (or a member of his household or immediate family) in accordance with current medical standards and practices. (3) The application of the Coordination of Benefits or Non - Duplication of Benefits provision. (4) If the Covered Person is admitted into the Hospital on a Friday or a Saturday on a non - emergency basis and the procedure for which he is admitted is not performed on the day of or the day after admission, we will not pay the Hospital charges for room and board or miscellaneous Hospital charges for the initial Friday or Saturday preceding the procedure. MEDICAL REVIEW REQUIREMENTS A Covered Person may request an independent medical review ( "IMR ") of disputed health care services from the California Department of Insurance if he or she believes that we have improperly denied, modified, or delayed health care services. A disputed health care service is any health care service eligible for coverage and payment under the Covered Person's coverage that has been denied, modified, or delayed by us, in whole or in part because the service is not Medically Necessary. GAC26932 -CA 12 The IMR process is in addition to any other procedures or remedies that may be available. There is no application or processing fee of any kind for an IMR. The Covered Person has the right to provide information in support of the request for an IMR. We must provide the Covered Person with an IMR application form together with any grievance disposition letter that denies, modifies, or delays health care services. A decision not to participate in the IMR process may cause a Covered Person to forfeit any California statutory right to pursue legal action against us regarding the disputed health care service. It should be noted that we do not believe any such California statutory right exists which is applicable to it. For more information regarding the IMR process, or to request an application form, please contact us. Eligibility. The California Department of Insurance will review the Covered Person's application for an IMR to confirm that: 1. a. The provider has recommended a health care service as Medically Necessary. The Covered Person has received urgent care or emergency services that a provider determined was Medically Necessary; or c. The Covered Person has been seen by a provider for the diagnosis or treatment of the medical condition for which he or she seeks independent review. 2. The disputed health care service has been denied, modified, or delayed by us based in whole or in part on a decision that the health care service is not Medically Necessary; and 3. The Covered Person filed a grievance with us and the disputed decision is upheld or the grievance remains unresolved after 30 days. If the grievance requires expedited review, the Covered Person may bring it immediately to the attention of the California Department of Insurance. It may waive the requirement that the Covered Person follow the plan's grievance process in extraordinary and compelling cases. If a case is eligible for an IMR, the dispute will be submitted to a medical specialist who will make an independent determination as to whether or not the care is Medically Necessary. The Covered Person will receive a copy of the assessment made. If the IMR determines the service is Medically Necessary, we will provide benefits for the health care service. For non - urgent cases, the IMR organization designated by the California Department of Insurance must provide its determination within 30 days of receipt of the Covered Person's application and supporting documents. For urgent cases involving an imminent and serious threat to a Covered Person's health, including, but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of the Covered Person's health, the IMR organization must provide its determination within three business days. PREMIUM PROVISIONS GRACE PERIOD: Unless not less than five days prior to the premium due date we have delivered to the Insured or have mailed to the Insured's last address as shown by our records written notice of our intention not to renew this Policy beyond the period for which the premium has been accepted, a grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force (subject to the right of the insurer to cancel in accordance with the cancellation provision hereof). PREMIUMS: Premium due dates are the first of every month. Premium payment made in advance or for more than a one month period will not affect any provisions of this Certificate with regard to change. Failure by the Certificateholder to pay premiums within the grace period shall be deemed notice to us to terminate coverage at the end of the period for which premium was paid. CHANGES IN RATES: We have the right to change the premium rates on any premium due date: (1) After the first 12 months insurance is in effect; (2) Coinciding with a change in the coverage provided or classes eligible; or GAC26932 -CA 13 (3) Coinciding with a change in the risks we have assumed. We will give 31 days written notice of any change under (1) above. Notice will be sent to the Certificateholder's most recent address in our records. GENERAL PROVISIONS ENTIRE CONTRACT; CHANGES: This Certificate, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by one of our executive officers and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this Certificate or to waive any of its provisions. All statements made by the Policyholder or by a Covered Person in the absence of fraud, be deemed a representation and not a warranty. No such statement shall (avoid the insurance or reduce the benefits under the Policy or) be used in defense to a claim hereunder unless it is contained in a written application, nor shall any such statement of the Policyholder or Covered Person, except a fraudulent misstatement, be used at all to void the Policy or this Certificate after it has been in force for three years from the date of its issue, nor shall any such statement of any person eligible for coverage under the Policy, except a fraudulent misstatement, be used at all in defense to a claim for loss incurred or disability (as defined in the policy) commencing after the insurance coverage with respect to which claim is made has been in effect for three years from the date it became effective. WORKERS' COMPENSATION INSURANCE: This Certificate is not in lieu of and does not affect any requirement for coverage under any Workers' Compensation Insurance. CONFORMITY WITH STATE STATUTES: Any provision of this Certificate in conflict, on the Effective Date of this Certificate, with the laws of the state where it is delivered, is amended to conform to the minimum requirements of such laws. CLAIM PROVISIONS NOTICE OF CLAIM: Written notice of claim must be given to us within 20 days after the occurrence or commencement of any loss covered by this Certificate policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Insured or Covered Person to us at our administrative office listed on the cover -page of this Certificate, or to our authorized agent, with information sufficient to identify the Insured or Covered Person, shall be deemed notice to us. CLAIM FORMS: Upon our receipt of a notice of claim, we will furnish to the claimant such forms as are usually furnished by us for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this Certificate as to proof of loss upon submitting, within the time fixed in this Certificate for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. PROOF OF LOSS: Written proof of loss must be furnished to us in the case of a claim for loss for which this Certificate provides periodic payment contingent upon continuing loss within 90 days after the end of the period for which we are liable. Written proof that the loss continues must be furnished to us at intervals required by us. In case of claim for any other loss, proof must be furnished within 90 days after the date of such loss. If that is not reasonably possible, we will not deny or reduce any claim if proof is furnished as soon as reasonably possible. Proof must, in any case, be furnished not more than a year later, except for lack of legal capacity. GAC26932 -CA 14 TIME OF PAYMENT OF CLAIMS: Benefits payable under this Certificate for any loss other than loss for which this Certificate provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid Monthly and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof. PAYMENT OF CLAIMS: Benefits for a Covered Person's loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such benefit shall be payable to the estate of the Covered Person. Any other accrued benefits unpaid at the Covered Person's death may, at our option, be paid either to such beneficiary or to such estate. All other Benefits will be payable to the Covered Person. If any benefits under this policy shall be payable to the estate of a Covered Person, or to a Cover Person or beneficiary who is a minor or otherwise not competent to give a valid release, we may pay such Benefit, up to an amount not exceeding $1,000, to any relative by blood or connection by marriage of the Covered Person or beneficiary who is deemed by us to be equitably entitled thereto. Any payment made by us in good faith pursuant to this provision shall fully discharge us to the extent of such payment. Subject to any written direction of a Covered Person in the application or otherwise all or a portion of any benefits provided by this certificate on account of hospital, nursing, medical, or surgical services may, at our option and unless the Covered Person requests otherwise in writing not later than the time of filing proofs of that loss, be paid directly to the person or persons having paid for the hospitalization or medical or surgical aid, or to the hospital or person rendering those services; but it is not required that the service be rendered by a particular hospital or person. PAYMENT OF CLAIMS: OTHER BENEFITS: All other benefits will be paid to the Covered Person, if he is living, if not, we will pay his beneficiary or his estate, PHYSICAL EXAMINATION: We, at our own expense, shall have the right and opportunity to examine the person of the Covered Person when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law. TIME LIMIT ON CERTAIN DEFENSES: After the Policy has been in force for a period of three years, no statements of the Policyholder contained in the application, and no statement relating to insurability made by any Covered Persons eligible for coverage under the Policy shall be used to deny a claim or in contesting the validity of the insurance with respect to which such statement was made after the insurance has been in force prior to the contest for a period of three years during the lifetime of the person with respect to whom any such statement was made. No claim for loss incurred after three years from the effective date of the insurance coverage with respect to which the claim is made shall be reduced or denied on the ground that a disease or physical condition, not excluded from coverage by name or specific description effective on the date of loss, had existed prior to the effective date of the coverage with respect to which the claim is made: LEGAL ACTIONS: No action at law or in equity shall be brought to recover benefits under this Certificate less than 60 days after written proof of loss has been furnished as required by this Certificate. No such action shall be brought more than 3 years after the time written proof of loss is required to be furnished. GAC26932 -CA 15 California Guaranty Notice NOTICE OF PROTECTION PROVIDED BY THE CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION This notice provides a brief summary regarding the protection provided to policyholders by the California Life and Health Insurance Guarantee Association ( "the Association). The purpose of this Association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. Insurance Companies licensed in California to sell life insurance, health insurance, annuities and structured settlement annuities are members of the Association. The valuable extra protection provided through the Association is not unlimited and is not a substitute for consumers' care in selecting insurers. This protection was created under California law, which determines who and what is covered and he amounts of coverage. Below is a brief summary of the coverages, exclusions, and limit provided by the Association. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the rights or obligations of the Association. COVERAGE • Persons Covered Generally, an individual is covered by the California Life and Health Insurance Guarantee Association if the insurer was a member of the Association and the individual lives in California at the time the insurer is determined by a court to be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, whether or not they live in California. • Amounts of Coverage The basic coverage protections provided by the Association are as follows: Life Insurance, Annuities and Structured Settlement Annuity Benefits For life insurance policies, annuities and structured settlement annuities, the Association will provide the following: Life Insurance 80% of death benefits but not to exceed $300,000 80% of cash surrender or withdrawal values but not to exceed $100,000 + Annuities and Structured Settlement Annuities 80% of the present value of annuity benefits, including net cash withdrawal and net cash surrender values but not to exceed $250,000. The maximum amount of protection provided by the Association to an individual, for all life insurance, annuities and structured settlement annuities is $300,000, regardless of the number of polices or contracts covering the individual. Guaranty Notice (California) 07/2011 • Health Insurance The maximum amount of protection provided by the Association to an individual, as of April 1, 2011, is $470,125. This amount will increase or decrease based upon changes in the health care cost component of the consumer price index to the date on which an insurer becomes an insolvent insurer. COVERAGE LIMITATIONS AND EXCLUSIONS FROM COVERAGE The California Life and Health Insurance Guarantee Association may not provide coverage for this policy. Coverage by the Association generally requires residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. The following policies and persons are among those that are excluded from Association coverage: • A policy or contract issued by an insurer that was not authorized to do business in California when it issued the policy or contract; • A policy issued by a health care service plan (HMO), a hospital or medical service organization, a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society; • If the person is provided coverage by the guaranty association of another state; • Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which do not guaranty annuity benefits to an individual; • Employer and association plans, to the extent they are self - funded or uninsured; • A policy or contract providing any health care benefits under Medicare Part C or Part D; • An annuity issued by an organization that is only licensed to issue charitable gift annuities; • Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as certain investment elements of a variable life insurance policy or a variable annuity contract; • Any policy of reinsurance unless an assumption certificate was issued; • Interest rate yields (including implied yields) that exceed limits that are specified in Insurance Code Section 1607.02(b) (C) NOTICES Insurance companies or their agents are required by law to give or send you this notice. Policyholders with additional questions should first contact their insurer or agent. To learn more about coverages provided by the Association please visit the Association's website at www.califega.org, or contact either of the following: California Life and Health Insurance or Consumer Service Division Guarantee Association California Department of Insurance P.O. Box 16860 300 South Spring Street Beverly Hills, CA 90209 -3319 Los Angeles, CA 90013 (323) 782 -0182 (800) 927 -4357 or (213) 897 -8921 Insurance companies and their agents are not allowed by California law to use the existence of the Guarantee Association or its coverage to solicit, induce or encourage you to purchase any form of insurance policy. When selecting an insurance company, you should not rely on Association coverage. If there is an inconsistency between this notice and California law, then California law will control. Guaranty Notice (California) 07/2011 When used throughout this document "Company ", "Our ", "We ", or "Us" means: ❑ United States Fire Insurance Company ❑ The North River Insurance Company GRIEVANCE PROCEDURES When you submit a claim and that claim is denied, we will provide a written statement containing the reasons for the Adverse Determination. You have the right to request a review of any Company decision or action pertaining to our contractual relationship and to appeal any adverse claim determination we've made by filing a Grievance. These procedures have been developed to ensure a full investigation of a Grievance through a formal process. A "Grievance" is a written complaint requesting a change to a previous claim decision, claims payment, the handling or reimbursement of health care services, or other matters pertaining to your coverage and our contractual relationship. An "Adverse Determination" is a determination by the Company or its designated utilization review organization that (i) a service, treatment, drug, or device, is experimental, investigational, specifically limited or excluded by your coverage; or (ii) a facility admission, the availability of care, continued stay or other health care services proposed or furnished have been reviewed and, based upon the information provided, does not meet the contractual requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness and therefore, the benefit coverage is denied, reduced or terminated in whole or in part. INFORMAL GRIEVANCE PROCEDURE You, your authorized representative, or a provider acting on your behalf may submit an oral complaint to us within 60 -days after an event that causes a dispute. Telephoning allows you to discuss your complaint or concerns and gives us the opportunity to immediately resolve the problem. If we don't have all the information necessary to review your complaint, we will request any additional information within 5 business days of receiving your complaint. After we receive all the necessary information, we will provide you, your authorized representative, or a provider acting on your behalf with our written decision within 30 -days after receiving the complaint and all necessary information. If the problem cannot be resolved in this manner, you still have the right to submit a written request for the complaint to be reviewed through the Formal Grievance Procedure, as outlined below. FORMAL GRIEVANCE PROCEDURE A formal Grievance may be submitted by you, your authorized representative, or in the event of an Adverse Determination, by a provider acting on your behalf. If you file a formal Grievance, you will have the opportunity to submit written comments, documents, records and other information you feel are relevant to the Grievance, regardless of whether those materials were considered in the initial Adverse Determination. First Level Review Within 3 working business days after receiving the Grievance, we must acknowledge the Grievance and provide you, your authorized representative or a provider with the name, address, and telephone number of the coordinator handling the Grievance and information on how to submit written material. The person(s) who reviews the Grievance will not be the same person(s) who made the initial Adverse Determination. During the review, all information, documents, and other materials submitted relating to the claim will be considered, regardless of whether they were considered in making the previous claim decision. The Insured will not be allowed to attend, or have a representative attend, a First Level Review. The Insured may, however, submit written material for consideration by the reviewer(s). Grievance When the Grievance is based in whole or in part on a medical judgment, the review will be conducted by, or in consultation with, a medical doctor with appropriate training and expertise to evaluate the matter. Following our review of your Grievance, we must issue a written decision to you and, if applicable, to your representative or provider, within 20 -days after receiving the Grievance. The written decision must include: (1) The name(s), title(s) and professional qualifications of any person(s) participating in the First Level Review process. (2) A statement of the reviewers understanding of the Grievance. (3) The specific reason(s) for the reviewer's decision in clear terms and the contractual basis or medical rationale used as the basis for the decision in sufficient detail for the Insured to respond further to our position. (4) A reference to the evidence or documentation used as the basis for the decision. (5) If the claim denial is based on medical necessity, experimental treatment or similar exclusion, instructions for requesting an explanation of the scientific or clinical rationale used to make the determination. (6) A statement advising you of your right to request a Second Level Review, if applicable, and a description of the procedure and timeframes for requesting a Second Level Review. Second Level Review The Second Level Review process is available if you are not satisfied with the outcome of the First level Review for an Adverse Determination. Within ten business days after receiving a request for a Second Level Review, we will advise you of the following: (1) the name, address, and telephone number of a person designated to coordinate the Grievance review for the Company; (2) a statement of your rights, including the right to: • attend the Second Level Review • present his /her case to the review panel; • submit supporting materials before and at the review meeting; • ask questions of any member of the review panel; • be assisted or represented by a person of his /her choice, including a provider, family member, employer representative, or attorney. • request and receive from us free of charge, copies of all relevant documents, records and other information that is not confidential or privileged that were considered in making the Adverse Determination. We must convene a review panel and hold a review meeting within 45 -days after receiving a request for a Second Level Review. We will notify you in writing of the meeting date at least 15 -days prior to the date. The review meeting will be held during regular business hours at a location reasonable accessible to you. In cases where a face -to -face meeting is not practical for geographic reasons, we will offer you the opportunity to communicate with the review panel at our expense by conference call or other appropriate technology. Your right to a full review may not be conditioned on whether or not you appear at the meeting. If you choose to be represented by an attorney, we may also be represented by an attorney. If we choose to have an attorney present to represent our interests, we will notify you at least 15 working days in advance of the review that an attorney will be present and that you may wish to obtain legal representation of your own. The panel must be comprised of persons who: (1) were not previously involved in any matter giving rise to the Second Level Review; (2) are not employees of the Company or Utilization Review Organization; and (3) do not have a financial interest in the outcome of the review. A person previously involved in the Grievance may appear before the panel to present information or answer questions. All persons reviewing a Second Level Grievance involving a Utilization Review non - certification or a clinical issue will be providers who have appropriate expertise, including at least one clinical peer. If we use a clinical peer on an appeal of a Utilization Review non - certification or on a First Level Review, we may use one of our employees on the Second Level Review panel if the panel is comprised of 3 or more persons. Grievance We must issue a written decision to you and, if applicable, to your representative or provider, within 10 business days after completing the review meeting. The decision must include: (1) the name(s), title(s) and qualifying credentials of the members of the review panel; (2) a statement of the review panel's understanding of the nature of the Grievance and all pertinent facts; (3) the review panel's recommendation to the Company and the rationale behind the recommendation; (4) a description of, or reference to, the evidence or documentation considered by the review panel in making the recommendation; (5) in the review of a Utilization Review non - certification or other clinical matter, a written statement of the clinical rationale, including the clinical review criteria, that was used by the review panel to make the determination; (6) the rationale for the Company's decision if it differs from the review panel's recommendation; (7) a statement that the decision is the Company's final determination in the matter; (8) notice of the availability of the Commissioner's office for assistance, including the telephone number and address of the Commissioner's office. EXPEDITED REVIEW You are eligible for an expedited review when the timeframes for an Informal, formal First Level review or Second Level review would reasonably appear to seriously jeopardize your life or health, or your ability to regain maximum function. An expedited review is also available for all Grievances concerning an admission, availability of care, continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility. A request for an expedited review may be submitted orally or in writing. An expedited review must be evaluated by an appropriate clinical peer in the same or similar specialty as would typically manage the case being reviewed. If we don't have the information necessary to decide an appeal, we will send you notification of precisely what is required within 24 -hours of our receipt of your Grievance. All necessary information, including our decision, will be transmitted by telephone, facsimile, or the most expeditious method available. Provided we have enough information to make a decision, you, your authorized representative, or a provider acting on your behalf will be notified of the determination as expeditiously as the medical condition requires, but in no event more than 72 -hours after the review has commenced. Written confirmation of our decision will be provided within 2 working business days of the decision and will contain the same items described in the written decision requirements for First Level reviews. If the expedited review does not resolve the situation, you, your representative or a provider acting on your behalf may submit a written Grievance. We will not provide an expedited review for retrospective reviews of Adverse Determinations. Grievance UNITED STATES FIRE INSURANCE COMPANY Administrative Offices: 5 Christopher Way • Eatontown, NJ 07724 PARTICIPATING ORGANIZATION ENDORSEMENT This Endorsement is attached to and made part of the Certificate as of the Certificate Effective Date. It applies only to Accidents and losses of life that occur on or after that date. It is subject to all of the provisions, limitations and exclusions of the Certificate except as they are specifically modified by this Endorsement. 1. The following definition is added to the Definitions section of the Certificate: Participating Organization — means an organization: 1) Which elects to offer coverage under the Group Policy by completing a Participation Organization Application that has been accepted by the Company; 2) Which completes a participation agreement with the Company; 3) Which remits the required premium when due; if applicable, and 4) While coverage through the Participating Organization is available under the Certificate. 2. The following section is added to the Certificate: PARTICIPATING ORGANIZATION EFFECTIVE AND TERMINATION DATES Effective Date. A Participating Organization's coverage under the Certificate begins on the later of: 1) Participating Organization Effective Date shown in the Participating Organization Application at 12:01 AM Standard Time at the address of the Participating Organization shown in the Participating Organization Application; or 2) the Certificate Effective Date. Termination Date. We may terminate coverage on or after the anniversary of any premium due date. Written notice must be given at least 31 days prior to such premium due date. The Participating Organization may terminate the coverage on any premium due date. Failure by the Participating Organization to pay premium when due or within any applicable grace period shall be deemed notice to us to terminate coverage at the end of the period for which premium was paid. 3. The references in the Certificate to "Certificateholder," where applicable, mean "Participating Organization," respectively. 4. The following language applies to each Rider attached to the Certificate: Any Riders attached to the Certificate apply only with respect to Accidents and losses of life that occur on or after the later of: 1) The effective date of each Rider; or 2) The effective date of the Participating Organization's coverage under each Rider. Each Rider applies with respect to a Participating Organization's coverage under the Certificate only if the Participating Organization has elected the coverage described in each Rider, as indicated in the Participating Organization Application. Signed for United States Fire Insurance Company By: Signature Signature 46, A L� Z� IAA Douglas M. Libby James Kraus Chairman and CEO Secretary When used throughout this document "The Company ", "Our', "We ", or "Us" means: ❑ United States Fire Insurance Company ❑ The North River Insurance Company ❑ Crum & Forster Indemnity Company PRIVACY POLICY AND PRACTICES The Company values your business and your trust. In order to administer insurance policies and provide you with effective customer service, we must collect certain information about our customers. We want you to know that we are committed to protecting your private information and we will comply with all federal and state privacy laws. Below is a Privacy Notice describing our policy regarding the collection and disclosure of personal information. Please review this Notice and keep a copy of it with your records. Your Privacy is Our Concern When you apply to The Company for insurance or make a claim against a policy written by The Company, you disclose information about yourself to us. There are legal requirements governing the collection, use, and disclosure of such information. The Company maintains physical, electronic, and procedural safeguards that comply with state and federal regulations to guard your personal information. We also limit employee access to personally identifiable information to those with a business reason for knowing such information. The Company instructs our employees as to the importance of the confidentiality of personal information, and takes measures to enforce employee privacy responsibilities. What kind of information do we collect about you and from whom? We obtain most of our information from you. The application or claim form you complete, as well as any additional information you provide, generally gives us most of the information we need to know. Sometimes we may contact you by phone or mail to obtain additional information. We may use information about you from other transactions with us, our affiliates, or others. Depending on the nature of your insurance transaction, we may need additional information about you or other individuals proposed for coverage. We may obtain the additional information we need from third parties, such as other insurance companies or agents, government agencies, medical personnel, the state motor vehicle department, information clearinghouses, credit reporting agencies, courts, or public records. A report from a consumer reporting agency may contain information as to creditworthiness, credit standing, credit capacity, character, general reputation, hobbies, occupation, personal characteristics, or mode of living. What do we do with the information collected about you? If coverage is declined or the charge for coverage is increased because of information contained in a consumer report we obtained, we will inform you, as required by state law or the federal Fair Credit Reporting Act. We will also give you the name and address of the consumer reporting agency making the report. We may retain information about our former customers and may disclose that information to affiliates and non - affiliates only as described in this notice. To whom do we disclose information about you? We may disclose all the information that we collect about you, as described above. We may disclose such information about you to our affiliated companies, such as: • Insurance companies; • Insurance agencies; • Third party administrators; • Medical bill review companies; and • Reinsurance companies. We may also disclose nonpublic personal information about you to affiliated and nonaffiliated third parties as permitted by law. You have a right to access and correct the personal information we collect, maintain, and disclose about you. How to contact Us You may obtain a more detailed description of the information practices prescribed by law by contacting us at the address below. Remember to include your name, address, policy number, and daytime phone number. Privacy Policy Coordinator Fairmont Speciality 5 Christopher Way, 3' Floor Eatontown, New Jersey 07724 APPLICATION is made to UNITED STATES FIRE INSURANCE COMPANY Administrative Office: 5 Christopher Way, Eatontown, NJ 07724 Policy Number: US000111988 Policyholder: Dayton Borders Address: Dayton Borders 531 Main St. #527 El Segundo, CA 90245 The Policyholder hereby applies to United States Fire Insurance Company for the group special risk coverage provided by the Policy as described in the Attachment No. 1. The Policyholder approves and accepts the Policy by the signature shown below. The Policy takes effect on the date specified on the face page of the Policy. DATED AT: El Segundo, CA on: Oct 01, 2013 SIGNED FOR THE POLICYHOLDER: By: „On File (Signature and Title) Agent's Name: (Must be a Resident Licensed Agent where required by law) GA27037 ATTACHMENT # 1 Dayton Borders Requested Effective Date: Oct 01, 2013 1) Event Name and Location: El Segundo Halloween Frolic Streets of El Segundo Holly and Main St. El Segundo, CA 90245 Event Date: Oct 31, 2013 Class and Option: Class 1, Option 1 Rate: 8.00 % of primary GL premium (no minimum premium) Premium: $8.00 GA27037 Attachment