Loading...
PROOF OF INSURANCE (2013) CLOSEDKYOCMIT -01 MOREHU CERTIFICATE OF LIABILITY INSURANCE UATE,IIAM, °D /VYYY 2/7/2013 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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). .,..... ........................ _ PRODUCER CONTACT - ------- ----- — ---- .._. . NAME: Wolfs Ohio, Inc. PHONE _. P i � ) 977 945 -7378 ) A Nn ; 998 46 -2378 Century �� ��a): C � .. A 7 P.O. Box 305191 E -MAIL Nashville, TN 37230 -5191 AoD3aI $: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, NSR TYPE OF INSURANCE... PO SUBR - -�.. POLICY EFF POLICY EXP LTR POLICY NUMBER DpIYYYY) LIMITS _ (MMIg01Y,YYX� 1N?IW, ,. GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0 A X COMMERCIAL GENERAL LIABILITY X PKG3101066 4/112012 4/1/2013 DAMAGE TO RFNTE f, PREMISES (Ea occurrence) $ 500,0 CLAIMS -MADE [X OCCUR I MED EXP (Any one person) $ 10,0 _ PERSONAL & ADV INJURY $ 1,000 m GENERAL AGGREGATE $ 2,000 GE N'LAGGREGATELIMITAPPLIESPER PRODUCTS COMP /OPAGG $ 1,000 PRd:k .��.I POLICY � l LCD, �........�t LOC J _ AUTOMOBILE E LIABILITY ...... L',9MI%V6'krU "BivkiaLl° t "Ii4+iIT� $, ANY AUTO BODILY INJURY (Per person) $ ALL OWNED " SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) �,$ NON -OWNED 'PROPERTY ,. DNMAb5. HIREDAUTOS AUTOS (PER � _$. ..... LIAB X UMBRELLA X OCCUR EACH OCCURRENCE $ 5,000 A EXCESS LIAB CLAIMS MADE, UMB r 5000909 4/1/2012 4/1/2013 AGGREGATE DED X RETENTION $ 10"'o 0'0 WORKERS COMPENSATION .. i - -- ......... ......... $ ...... "' 'UVCY LIMIT OTH X TQj�' LIMIT � E_R AND EMPLOYERS LIABILITY YIN B i 3VIIKUB0046L98913 1/1/2013 1/1/2014 , .,. .... ANY PROPRIETORIPARTNER/EXECUTIVE X E L EACH ACCIDENT $ 1,000 OFFICER /MEMBER EXCLUDED? N I I NIA - -- - .. (Mandatory In NH) ` ' "` E L DISEASE - EA EMPLOYEE $ 1,000 If yes, describe under DESCRIPTION OF OPERATIONS below —` _ E DISEASE - POLICY LIMIT $ 1,000 A Property in Transit PKG3101066 �31FJU!300461_99013 4/1/2012 4/1/2013 100 C Worker's Comp. 1/1/2013 1/1/2014 ,See Attached DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of El Segundo with whom the insured has agreed in written contract, is afforded Additional Insured status with respect to the insured's work associated with said written contract. The insured waives any right to recovery that they might have against the City of El Segundo because of payments that maybe made for bodily injury or property damage arising out of the insureds' ongoing operations or work done under a contract with the City of El Segundo. CERTIFICATE HOLDER City of El Segundo Q Attn: City Clerk 350 Main Street El Segundo, CA 90245 -3813 ACORD 25 (2010/05) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved.. The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE ..... - ------ - - - - -- COVERAGE LIMITS .. ...w_ ._ .,...�,� POLICY TYPE: Workers Compensation Workers Compensation — Statutory tort' CARRIER: Travelers Casualty and Surety Company EL -Each Accident: $1,000,000 POLICY TERM: 01/01/2013 — 01/01/2014 EL- Disease — Policy Limit: $1,000,000 POLICY NUMBER: 31FJUB0046L99013 EL- Disease — Each Employee: $1,000,000 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to theterms and conditions of the policy, certain policies may require an endorsement. Astatementon this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER I CONTACT'S INSURED Willis of Ohio, Inc. c/o 26 Century Blvd. P. 0. Box 305191 Nashville, TN 37230 -5191 KYOCERA Document Solutions ,America, Inc. Attn: Shawn O'Malley 225 Sand Road Fairfield, NJ 07004 Rf1VFQAnFC r_F42TIPIr_AT1= IUIIMQr -P- t 792" 'A^ar FAX IN3UH.LIt(S)A1+0RI1NG COVERAGE NAIC# Mitsui Sumitomo Insurance Company of Amer 20362 -002 Mitsui Sumitomo Insurance Company of _�.. ......... .._...... -- Mitsui Sumitomo Amer 20362 -092 Travelers Casualty and Surety Company of 19038-006 Travelers Indemnity Cop m.. ._.. _._,..,_ ....... .w any, The 25658-004 0 r.%1I CAt%k1 r..t..m rRa..o r -101 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 OFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LIS __... _ D' SUB pO._._. PO.... LICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER _ ___ ������� LIMITS • GENERAL LIABILITY PKG3101066 /1/2012 4/1/2013 EACHOCCURRwENCE X COMMERCIAL GENERAL LIABILITY DAMAGE T RENTED P o rencaj b 500.000 mmmmITmm e - CLAIMS -MAUE� OCCUR MED EXP one arson __..�._..{fv,y � � S .� 000._.... .............. �._..... �....,,,............... _,.�� ._ GENERALAGGREGATE ....... GENI AGGREGATE LIMIT APPLIES PER: —1 PRODUCTS- COMP /OPAGG $ 1,,_QQO�OQ0 POLICY PRO- LOC IECI • AUTOMOWLE LIABILITY 000 000,,,,, • X BVR8302208 /1/2012 4/1/2013 1, B ODIBLYINJJURY(Perperson) $ T ........ -. AUTOS ... 8 OSUL.E�D BVR8302050 4/1/2012 4/1/2013 B0DILYINJURY(Peraoddent) $ ..... _....... .. .X.._ B HIRED AUTOS X NON-OWNED BVPi8803008 /1/2012 14/l/2013 I .—H —h l7ufA t (perawident $ A X UMBRELLALIAB X OCCUR U14B5000903 /1/2012 4/1/2013 EACHOCCURRENCE $ j Q, QQQ AP Q EXCESS LIAR CLAIMS -MADE —00 AGGREGATE .. $ �Q..r��,.... DED X RETENTION $ 10 r 0 $ C WORKERS COMPENSATION 31FMM0046L99012 1/1/2012 1/1/2013 SIAI X O i.lMITS AND EMPLOYERS'LIABILITY Y/N D ECUTIVEO NIA 3VIIKUB0046L98912 1 1 2012 / / 1 1/2013 / EL ACCIDE NT 1,000,000 OFFICEOPR[ BEREXCLUDR/ (Mandatory In NH) E.L. DISEASE EA EMPLOYEE � 1.� Q.... +..a.fl ff yes, describe under DESCRIPTI ON OF OPERATIONS below _. ...... ........ E.L. DISEASE - POLICY LIMIT - .... ',$ 1,000,000 A Commercial Prop PK03101066 1 2012 4/1/2013 Building See Policy Limits Personal Property See Policy Limits BI with EE See Policy Limits DESCRI PTO N OFOPERATIONW LOCATIONS I VE1 IVCLE.S (Attach Acord'101, AddHonaU Remarka ScNaraoIs, if more space W requirad) �......... %.YcmI Ir'II mIm nuL.ur—m 9,ANA„rtLLA I IVN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN r, ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Coverage CoZ1:3683901 TA1:1427426 Cert::' 637336 © 7988 -2010 CORD CORPORATION_ All riahtcracarvarf ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ii THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ IT CAREFULLY. ENHANCED COMMERCIAL GENERAL LIABILITY COVERAGE FORM ENDORSEMENT This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMON POLICY CONDITIONS This endorsement modifies coverage and provides increased limits of insurance to enhance your insurance program. The Limits of Insurance stated below are granted by us as enhancements to your insurance program and are subject to the terms and conditions of this endorsement and the COMMERCIAL GENERAL LIABILITY COVERAGE FORM and COMMON POLICY CONDITIONS_ If these Limits of Insurance are not sufficient, you may purchase additional Limits of Insurance. The premium charge will be based on the additional Limits of Insurance you purchase. When you purchase additional Limits of Insurance for any coverage, the Limit of Insurance stated in the Declarations will be in addition to any Limit of Insurance we have granted below. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 16. 19. 20. Summary Of Coverage Broad Form Named Insured Non owned Watercraft Property Damage — Property Loaned To You Property Damage Liability - Elevators Damage To Premises Rented To You Personal and Advertising Injury Assumed By Contract Medical Payments- Increased Period Supplementary Payments- Increased Limits Cost of Bail Bonds Lass of Earnings Automatic Additional Insureds By Contract, Agreement Or Permit Who Is An Insured Redefined - Fellow Employee Coverage and Incidental Medical Malpractice Duties In The Event Of Occurrence, Claim Or Suit Redefined Unintentional Failure To Disclose All Hazards Waiver Of Transfer Of Rights Of Recovery Against Others To Us Liberalization Bodily Injury Redefined Insured Contract Redefined 3 Years Up To $2,500 Up To $500 Per Day Mobile Equipment Redefined ( This provision is not applicable in New York or Virginia) Personal and Advertising Injury Redefined Additional Definitions Cancellation Condition 90 Days The following OPTIONAL COVERAGE applies only if a YES is indicated next to the coverage below. YES ! Additional Insured — Broad Form Vendors MS 6401 01 10 Pagel of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) AGENTS COPY r X a. The second paragraph of the preamble of this Coverage Form is replaced by the following: Throughout this policy the words "you" and 'your" refer to the Named Insured shown in the Declarations, any other person or organization qualifying as a Named Insured under this policy, and any "controlled business entity ". The words 'We ", "us" and "our" refer to the company providing this insurance. - As used in this endorsement, the term "controlled business entity" means any business entity in which the Named Insured owns an interest of more than 50 percent during the policy period and for which similar coverage is not otherwise more specifically provided. However, we will not pay any sums such a "controlled business entity" must pay as damages because of "bodily injury" or "property damage" to which this insurance applies caused by an "occurrence" that occurred before the Named Insured acquired or formed the "controlled business entity ", or because of "personal and advertising injury" to which this insurance applies caused by an offense committed before the Named Insured acquired or formed the "controlled business entity." Notwithstanding the foregoing, we will not pay any sums or perform any acts or services on behalf of any person or organization for which coverage is specifically excluded by endorsement. b. Paragraph 3. of Section II —Who Is An Insured of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is deleted in its entirety. 2. Nonowned Watercraft Paragraph g.(2) of 2. Exclusions of Section I — Coverage A Bodily Injury And Property Dan-age Liability of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by the following: (2) A watercraft you do not own that is: (a) Less than 75 feet long; and (b) Not being used to carry persons or property for a charge; 3. Property Damage —Property Loaned To You Paragraph j.(3) of 2. Exclusions of Section I — Coverage A Bodily Injury And Property Damage Liability of the COMMERCIAL GENERAL LIABILITY COVERAGE FORMis amended by adding the following: This exclusion j.(3) does not apply to property loaned to you, which is not being used by you to perform'your work ". Our obligation to pay for damages because of such "property damage" is excess over any valid and collectible insurance (including any deductible), whether primary, excess, contingent or on any other basis. 4. Property Damage Liability - Elevators Exclusions j. and k. of Section I — Coverage A Bodily Injury And Property Damage Liability of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM are amended as follows: a. Exclusion j. is amended to add the following: Paragraphs (3), (4) and (6) of this exclusion J. do not apply to "property damage" arising out of the use of an elevator at premises you own, rent or occu py. L Exclusion k. is amended to add the following: This exclusion k. does not apply to: (1) The use of elevators; or (2) Liability assumed under a sidetrack agreement. MS 6401 01 10 Page 2 of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) AGENTS COPY MSIG �41 . I Our obligation to pay sums for damages because of such "property damage" is excess over any other valid and collectible insurance (including any deductible), whether primary, excess, contingent or on any other basis. 5. Damage To Premises Rented To You Paragraph 6. of Section III — Limits Of Insurance of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by the following: a. 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, lightning, or "explosion ", while rented to you or temporarily occupied by you with permission of the owner. U The most we will pay for Damage To Premises Rented To You will be the greater of: (1) $300,000, or (2) The amount shown in the Declarations. 6. Personal and Advertising Injury Assumed by Contract Paragraph e. Contractual Liability of 2. Exclusions of Section I — Coverage B Personal And Advertising Injury Liability of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by the following: "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: (1) That the insured would have in the absence of the contract or agreement; or (2) Assumed in an "insured contract ", provided the "personal and advertising injury" arises out of an offense committed subsequent to the execution of the "insured contract ". Solely for the purpose of liability assumed in an "insured contract ", where the "personal and advertising injury" arises out of an offense committed subsequent to the execution of the "insured contract ", reasonable attorney fees and necessary litigation expenses incurred by or for a party other than an insured are deemed to be damages because of "personal and advertising injury ", provided that: (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 attorney 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. 7; Medical Payments - Increased Period Paragraph a. of 1. Insuring Agreement of Section 1 — C overage C Medical Payments of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by the following: 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 three years of the date of the accident; and MS 6401 01 10 Page 3 of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) AGENTS COPY (c) The injured person submits to "property damage" or "personal and examination, at our expense, by advertising injury "; physicians of our choice as often as (2) To any person or organization we reasonably require. included as an insured by any other endorsement issued by us and 8. Supplementary Payments - Increased Limits made part of this Coverage Form; Paragraphs 1.b. and 1.d. of Section I — (3) To any lessor of equipment: Supplementary Payments — Coverages A failing to prepare or approve and B of the COMMERCIAL GENERAL (a) After the equipment lease LIABILITY COVEAGE FORM are replaced by expires; or the following: change orders, or drawings and LIABILITY COVERAGE FORM is (b) If the "bodily injury ", "property b. Up to $2,500 for the cost of bail bonds damage" or "personal and required because of accidents or traffic advertising injury" arises out of law violations arising out of the use of the sole negligence of the any vehicle to which the Bodily Injury lessor. Liability Coverage applies. We do not have to furnish these bonds. (4) To any engineer, architect or Coverage Form, but only with respect to 'your surveyor if the "bodily injury ", d. All reasonable expenses incurred by the "property damage" or "personal and insured at our request to assist us in the advertising injury" arises out of the investigation or defense of the claim or rendering or the failure to render "suit ", including actual loss of earnings professional architectural, u p to $500 a day because of time off engineering or surveying services from work. by or for you, including: 9. Automatic Additional Insureds By Contract, (a) The preparing, approving or Agreement Or Permit failing to prepare or approve maps, shop drawings, opinions, a. Paragraph 2. of Section II —Who Is An reports, surveys, field orders, Insured of the COMMERCIAL GENERAL change orders, or drawings and LIABILITY COVERAGE FORM is specifications; and amended by adding the following: (b) Supervisory, inspection, Any person or organization with whom architectural or engineering you agreed, in a written contract, activities. agreement or permit, to provide insurance such as is afforded under this (5) To any: Coverage Form, but only with respect to 'your (a) Owners or other interests from your operations, work" or facilities owned or occupied by, or rented or whom land has been leased; or loaned to you. (b) Managers or lessors of premises b. The following additional exclusions If (1) The "occurrence" takes apply to the insurance afforded by place after you cease to be a Paragraph a. above. tenant of such land or premises; This insurance does not apply: or (ii) The "bodily injury ", (1) Unless the written contract, "property damage" or "personal agreement or permit has been and advertising injury arises issued prior to the "bodily injury ", out of structural alterations, new MS 640101 10 Page 4 of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) AGENTS COPY *� ��Iljl S:[G construction or demolition operations performed by or on behalf of the owner, manager or lessor. 10. Who Is An Insured Redefined - Fellow Employee Coverage and Incidental Medical Malpractice Paragraph 2.a.(1) of Section II —Who Is An Insured of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by the following: (1) "Bodily injury" or "personal and advertising injury ": (a) To you, to your partners or members (if you are a partnership or joint venture) or to your members (if you are a limited liability company); (b) For which there is an obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraph (1)(a) above; or (c) Arising out of his or her providing or failing to provide professional health care services. However, this exclusion does not apply to nurses, emergency medical technicians or paramedics who are employed by you to provide medical or paramedical services. 11. Duties In The Event Of Occurrence, Offense, Claim or Suit Redefined Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim or Suit of Section IV — Commercial General Liability Conditions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is amended by adding the following:: e. With respect to an "occurrence ", offense, claim or "suit ": (1) Knowledge of an "occurrence ", offense, claim or "suit" by an agent, servant or "employee" of any insured, and receipt of any demand, notice, summons or other legal paper in connection with a claim or "suit" by any agent, servant or "employee" of any insured, shall not in itself constitute knowledge or receipt of such information by you or by an involved insured, unless and until you, or an "executive officer ", in -house or outside counsel, risk manager or "employee" assigned to the risk management, insurance or safety department (other than clerical staff), or any other agent or "employee" designated to receive or handle notices of an "occurrence" or offense which may result in a claim or "suit" shall have such knowledge or shall have received such demand, notice, summons or legal paper from the agent, servant or "employee." (2) Failure of any agent, servant or "employee" of any insured to notify us of a known "occurrence ", offense, claim or "suit" shall not prejudice coverage afforded by this policy, provided that we are notified of the "occurrence ", offense, claim or "suit" once it is known to you, or to an "executive officer ", in -house or outside counsel, risk manager, or "employee" assigned to the risk management, insurance or safety department (other than clerical staff) or any other agent or "employee" designated to receive or handle notices of an "occurrence" or offense which may result in a claim or "suit." 12. Unintentional Failure To Disclose All Hazards Paragraph 6. Representations of Section IV — Commercial General Liability Conditions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is amended by adding the following: Your failure to disclose hazards existing as of the inception date of this policy shall not prejudice you with respect to the insurance MS 640101 10 Page 5 of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) provided by this Coverage Form, provided such failure or omission was not intentional. However, this provision does not affect our right to collect additional premium for any such hazard or to exercise our right of cancellation or nonrenewal 13. Waiver Of Transfer Of Rights Of Recovery Against Others To Us Paragraph 8. Transfer Of Fights Of Recovery Against Others To Us of Section IV— Conditions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORMis amended by adding the following: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or 'your work" done under a contract with that person or organization and included in the "products- completed operations hazard ", if: a. The waiver of such rights is required in a written contract or agreement with that person or organization; and b. You have assumed the liability of that person or organization in that same contract, and it is an "insured contract "; but, these provisions only apply to the person or organization addressed in a. and b. above, and only if the injury or damage occurs after the execution of the written contract of agreement. 14. Liberalization Section IV — Commercial General Liability Conditions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is amended by adding the following: Liberalization If we adopt a change in the insurance provided by this policy that would broaden the scope of insurance afforded to you without additional premium charge, then the broader insurance will apply. It will apply when the change becomes effective in your state. 15. Bodily Injury Redefined The definition of "bodily injury" in Paragraph 3. of Section V — Definitions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by the following: 3. "Bodily injury" means bodily injury, sickness, disease or "incidental medical malpractice" sustained by a person, including mental anguish or injury, humiliation, embarrassment, or death resulting from any of these at any time. 16. Insured Contract Redefined The definition of " insured contract" in Paragraph 9. of Section V — Definitions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is amended as follows: Paragraph a. is replaced by the following: 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 water, fire, lightning, explosion, or smoke to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract "; Paragraph c. is replaced by the following: c. Any easement or license agreement; Paragraph f. is replaced by the following: 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," "property damage" or "personal and advertising injury" to a third person or organization. Tort liability means a MS 640101 10 Page 6 of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) AGENTS COPY 4 � N1 S liability that would be imposed by law in the absence of any contract or h. Discrimination or humiliation that results agreement. in injury to the feelings or reputation of a natural person, but only if such Paragraph f. does not include that part discrimination or humiliation is: of any contract or agreement: (1) Not done intentionally by or at the direction of; (1) That indemnifies an architect, engineer or surveyor for injury or (a) An insured; or damage arising out of: (b) Any "executive officer ", director, (a) Preparing, approving, or failing stockholder, partner or member to prepare or approve, maps, of the insured; and shop drawings, opinions, reports, surveys, field orders, (2) Not directly or indirectly related to change orders or drawings and the employment, prospective specifications; or employment or termination of (b) Giving directions or employment of any person or instructions, or failing to give persons by any insured. them, if that is the primary cause 19. Additional Definition of the injury or damage; or (2) Under which the insured, if an Section V — Definitions of the COMMERCIAL GENERAL LIABILITY architect, engineer or surveyor, COVERAGE FORM is amended by adding assumes liability for an injury or thefollowing definitions: damage arising out of the insured's rendering or failure to render professional services, including 'Incidental medical malpractice" means injury those listed in Paragraph (1) above arising out of the negligent rendering of, or and supervisory, inspection, failure to render medical or paramedical services to persons by any physician, architectural or engineering activities. dentist, nurse, emergency medical technician or paramedic who is employed by you to 17. Mobile Equipment Redefined - This provide such services provided you are not engaged in the business or occupation of provision is not applicable in New York p providing any services referred to in this or Virginia. definition. Paragraph f.(1) of the definition of "Mobile Equipment" in Paragraph 12. of Section V— Definitions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM does not apply to self - propelled vehicles of less than 1,000 pounds gross vehicle weight, designed for use principally off highways. 18. Personal and Advertising Injury Redefined The definition of 'Personal and Advertising Injury" in Paragraph 14. of Section V — Definitions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is amended by adding the following: "Explosion" means a sudden release of expanding pressure accompanied by a noise, a bursting forth of material and evidence of the scattering of debris to locations further than would have resulted by gravity alone. "Explosion" does not include any of the following: a. Artificially generated electrical current including electrical arcing, that disturbs electrical devices, appliances or wires; b. Rupture or bursting of water pipes; MS 640101 10 Page 7 of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) w 5 c. Explosion of steam boilers, steam pipes, steam engines or steam turbines owned or leased by you, or operated under your control; or d. Rupture or bursting caused by centrifugal force. 20. Cancellation Condition Paragraph 2.b. of Section A Cancellation of the COMMON POLICY CONDITIONS is replaced by the following: a. 90 days before the effective date of cancellation if we cancel for any other reason. OPTIONAL COVERAGE The COMMERCIAL GENERAL LIABILITY COVERAGE FORM is amended to provide the following Optional Coverage only if aYES is indicated next to Additional Insured —Broad Form Vendors on the first page of this endorsement. Additional Insured - Broad Form Vendors 1. Section II — Who Is An Insured is amended to include as an additional insured any person(s) or organization(s) (referred to below as vendor) with whom you have agreed, in a written contract or written agreement to provide insurance, but only with respect to "bodily injury" or "property damage" arising out of 'your product" which is distributed or sold in the regular course of the vendor's business. 2. The insurance afforded by this paragraph does not apply to: a. "Bodily Injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change in "your product" made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution or parts under instructions from the manufacturer, and then repackaged in the original container; e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in connection with the sale of 'your product "; f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of "your product "; or g. "Your product" which, after distribution or sale by you, has been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or h. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its "employees" or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in Paragraphs d. or f. above; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in connection with the sale of 'your product." 3. This insurance does not apply to any insured person or organization, from whom you have acquired such products or any ingredient, part or container, entering into, accompanying or containing such products. All other terms and conditions remain unchanged. MS 640101 10 Page 8 of 8 (Includes copyrighted material of Insurance Services Offices, Inc. with its permission) TRAVELERS WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 99 03 76 ( A) — 001 POLICY NUMBER: (3IFJUB- 004GL99 -0 -12) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. The additional premium for this endorsement shall be 0 % of the California workers' compensation pre- mium. Schedule Person or Organization ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TQ FURNISH THIS WAIVER Job Description This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company Policy No. Countersigned by Endorsement No. Premium DATE OF ISSUE: 01 -04 -12 ST ASSIGN: Page 1 of 1