No preview available
PROOF OF INSURANCE (2016) CLOSED (2)Client #: 12965 ANDERPART ACORD. CERTIFICATE OF LIABILITY II SURAI CE =015 D/YYYY) 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. --.. ,,,.w,,........M. ,a.a.a.,, -... ,ae ................ ................................... ............................... --- - - - - -- IMPORTANT. If the certiflcate holder is an ADDI'f"IONAL INSURED, the pollcy(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 Dealey, Renton & Associates ' HOkt 714 427 -6810 FAX 714 427 6818 vyp No. Ertl: -� (A/C„ No): License #0020739 E-MAIL ' ` P. O. Box 10550 AnDRess" Santa Ana, CA 92711 -0550 __ _ _ INSURER(S) Indemnity DING COVERAGE NAIC1 INSURER A : Travelers demnl Co. of Conn 25682 ---- INSURED INSURER B Travelers Property Ciasualty C. ....o 61 1 AndersonPenna Partners, Inc. M.... ............................. 3737 Birch Street Suite 250 INSURER c :Everest National Insurance Comp 10120 Newport Beach, CA 92660 INSURER D INSURER E INS_ URER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. MA, TYPE OF INSURANCE gRA W ,' WNW POLICY NUMBER (M D fYYYY) ' IMMIO lYYYY) LIMITS A GENERAL LIABILITY 68030521_77A 8/01/2015 08/01/2016 EACH OCCURRENCE $1.000.000 X COMMERCIAL GENERAL LIABILITY General Liab. °AMnAnFS i1 R ��TED �rwl $1.000.000 CLAIMS -MADE X OCCUR excludes claims MED EX _ P (Any one person) $10,000 _ arising out of PERSONAL & ADV INJURY .................. $11,000,000 the performance GENERAL AGGREGATE s2.000.000 . ....... GEN'L AGGREGATE LIMIT APPLIES PER: of professional PRODUCTS COMP /OP AGG $2 OOO OOO POLICY X L.. LOC services $ B AUTOMOBILE LIABILITY BA30531_556 8/01/2015 08/01/201 COMBINED SINGLE LIMIT (Ep a; PI#n1) 1,000000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED X X PROPERTY D_ AMPG_ $ HIRED AUTOS AUTOS (Pgraccddenk) B - _ U..MB- REIr4AUAB �. _.. X OCCUR ..., .... CVP6874Y728 ......... 8/01/2015 08/01/201 �'AGGREGATE CCURREN EACH O CE $1 OOO OOO EXCESS LIAB LAIMS -MADE $1.000.000 WORKERS COMPENSATION WC STATU OTH- B U63708T659 8/01/2015 08/01/201 X TORY,LIMITS ER AND EMPLOYERS' LIABILITY Y / f4 ANY PROPRIETOR/PARTNER/EXECUTIVE EL. EACH ACCIDENT $1,000.000 OFFICER/MEMBER EXCLUDED? N, N/A -- (Mandatory in NH) E-1 SEASE EA EMPLOYEE $1.000.000 If yes, describe under ----- -- ------ ------- --- ------------- _..... -- -- -. - - - -- --- - - - - -- ............... ........... 000 DESCRIPTION OF OPERATIONS below L DISEASE- POLICY LIMIT $1.000 C Professional PLSE000154151 8/01/2015 08/01/2016 1, 00,000 per claim Liability "'' 00,000 annl aggr. Claims Made 0.000 Ded. Der claim DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Excess Liability Coverage Excludes Professional Liability 30 Day Notice of Cancellation /10 Day notice for Non - Payment of Prem Re: All operations as performed by the named Insured. City of El Segundo, its officials and employees are additional insured as respects to General Liability as required by written contract. Primary and Non - Contributing coverage applies to GL as required by written contract. City of El Segundo - Public Works, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Lifan Xu, P.E, ACCORDANCE WITH THE POLICY PROVISIONS. Principal Civil Engineer 350 Main St. AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1408648/M1408624 RLL AndersonPenna Partners, Inc. 6803052L77A 08/01/2015 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to WHO IS AN INSURED (Section II): Any person or organization that you agree in a "contract or agreement requiring insurance" to in- clude as an additional insured on this Coverage Part, but only with respect to liability for "bodily in- jury", "property damage" or "personal injury" caused, in whole or in part, by your acts or omis- sions or the acts or omissions of those acting on your behalf: a. In the performance of your ongoing opera- tions; b. In connection with premises owned by or rented to you; or c. In connection with "your work" and included within the "products - completed operations hazard ". Such person or organization does not qualify as an additional insured for "bodily injury ", "property damage" or "personal injury" for which that per- son or organization has assumed liability in a con- tract or agreement. INSURANCE (Section III) for this Coverage Part. B. The following is added to Paragraph a. of 4. Other Insurance in COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV): However, if you specifically agree in a "contract or agreement requiring insurance" that the insurance provided to an additional insured under this Cov- erage Part must apply on a primary basis, or a primary and non - contributory basis, this insurance is primary to other insurance that is available to such additional insured which covers such addi- tional insured as a named insured, and we will not share with the other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal injury" for which coverage is sought arises out of an offense committed; The insurance provided to such additional insured is limited as follows: d. This insurance does not apply on any basis to any person or organization for which cover- C. age as an additional insured specifically is added by another endorsement to this Cover- age Part. e. This insurance does not apply to the render- ing of or failure to render any "professional services ". f. The limits of insurance afforded to the addi- tional insured shall be the limits which you agreed in that "contract or agreement requir- ing insurance" to provide for that additional insured, or the limits shown in the Declara- tions for this Coverage Part, whichever are less. This endorsement does not increase the limits of insurance stated in the LIMITS OF after you have entered into that "contract or agreement requiring insurance ". But this insur- ance still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the insured when the insured is an additional insured under any other insurance. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us in COMMERCIAL GENERAL LIABILITY COW DITIONS (Section IV): We waive any rights of recovery we may have against any person or organization because of payments we make for "bodily injury", "property damage" or "personal injury" arising out of "your work" performed by you, or on your behalf, under a "contract or agreement requiring insurance" with that person or organization. We waive these rights only where you have agreed to do so as part of the "contract or agreement requiring insur- ance" with such person or organization entered into by you before, and in effect when, the "bodily CG D3 81 09 07 © 2007 The Travelers Companies, Inc. Page 1 of 2 Includes the coovriahted material of Insurance Services Office. Inc.. with its permission COMMERCIAL GENERAL LIABILITY injury" or "property damage" occurs, or the "per- sonal injury" offense is committed. D. The following definition is added to DEFINITIONS (Section V): "Contract or agreement requiring insurance" means that part of any contract or agreement un- der which you are required to include a person or organization as an additional insured on this Cov- erage Part, provided that the "bodily injury" and "property damage" occurs, and the "personal in- jury" is caused by an offense committed: a. After you have entered into that contract or agreement; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 © 2007 The Travelers Companies, Inc. CG D3 8109 07 Includes the coovriahted material of Insurance Services Office. Inc.. with its permission TRAVELE AW � WORKERS COMPENSATION R AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 99 03 76 ( A) — 001 POLICY NUMBER: (XJUB- 3708T65 -9 -15) 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 03.00 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER.I� 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 Policy No. Endorsement No. Insured Premium Insurance Company Countersigned by DATE OF ISSUE: 08 -05 -15 ST ASSIGN: Page 1 of 1 TRAVELERSJ WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 99 (00) POLICY NUMBER: (XJUB- 3708T65 -9 -15) CALIFORNIA WORKERS' COMPENSATION NOTICE OF NON - RENEWAL Section 11664 of the California Insurance Code which becomes operative November 30, 1994 requires us in most instances to provide you with a notice of non - renewal. Except as specified in paragraphs 1 through 6 below, if we elect to non -renew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the non - renewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of non - renewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you at least 30 days, but not more than 120 days, prior to the end of the policy period to renew the policy at a changed premium rate. DATE OF ISSUE: 08 -05 -15 ST ASSIGN: Page 1 of 1 TRAVELERS Report Claims Immediately by Calling* 1- 800 - 238 -6225 Speak directly with a claim professional 24 hours a day, 365 days a year *Unless Your Policy Requires Written Notice or Reporting WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY A Custom Insurance Policy Prepared for: ANDERSONPENNA PARTNERS, INC. 3737 BIRCH STIR #250 NEWPORT BEACH CA 92660 POLICYHOLDER NOTICE SHORT RATE CANCELATION CALIFORNIA INSURANCE CODE SECTION 481 CA Insurance Code Section 481 requires that where an insurance policy includes a provision to refund premium on anything other than a pro rata basis, including the assessment of cancellation fees, the insurer must disclose that fact to the policyholder in writing prior to, or concurrent with, the proposal or quote prior to each renewal. The disclosure must include the actual or maximum fees or penalties to be applied. The WCIRB also created a Short Rate Cancelation Endorsement which complements the disclosure requirement. This requirement applies to in- surance policies issued or renewed on or after January 1, 2012. In order to respond to this insurance code requirement we have created this Policyholder Notice to disclose our use of short rate calculations as described in the California Short Rate Cancelation Endorsement included in the policy. W04N2H12 Page 1 of 1 TRAVELERS ONE TOWER SQUARE HARTFORD, CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 04 03 17 (00) POLICY NUMBER: (XJUB- 3708T65 -9 -15) ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Employee Insured by General Employer Excluded The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE; NO LIABILITY FOR Any liability you may have as the special employer of an employee who is not EMPLOYEE INSURED BY on your payroll at the time of injury, based upon your representation that: (1) GENERAL EMPLOYER you have entered into a valid and enforceable agreement pursuant to Labor Code Section 3602 (d) with the employee's general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers' compensation coverage for the employee. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). By signature below, you affirm that, with respect to any employee who is also the employee of a general employer, (1) you have entered into a valid and enforceable agreement pursuant to Labor Code Section 3602(d) with the employee's general employer under which the general employer agrees to secure the payment of compensation for such employee and (2) the general employer has obtained workers' compensation coverage for the employee. Countersigned By 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 Policy No. Endorsement No. Insured Insurance Company Countersigned by Important Notice to Policy Holders in California Your policy contains the following form: WC 04 03 17 00 — Employee Insured by General Employer If, in the conduct of your business in California, you have employees provided to you pursuant to an agreement with another employer (the "General Employer "), this endorsement is intended to prevent your workers' compen- sation policy from responding to work related injuries to such employees in the event the General Employer's workers' compensation carrier becomes insolvent. Such an agreement may exist, for example, if you hire temporary employees through an agency, or contract with an employee leasing company. In order for exclusion WC 04 03 17 00 to be effective, you must countersign the form. Sign and return the form if you want to avoid this exposure under your policy, if you have a valid and enforceable agreement with the General Employer in which the General Employer has agreed to obtain workers' compensation coverage for the employees, and if the General Employer has obtained such workers' compensation coverage. With this exclusion in place on your policy, an injured employee you hired through a temporary agency or under contract with an employee leasing company would submit the claim to the California Insurance Guarantee Association (CIGA) in the event the temporary agency's or employee leasing company's workers' compensation carrier becomes insolvent. Without the signed exclusion, CIGA may not pay such claims, resulting in increased exposure under your policy. Signed forms should be sent to your agent or broker. WUNNIB08 Page 1 of 1 TRAVEL�;R� WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (XJUB- 3708T65 -9 -15) RENEWAL OF (XJUB- 3708T65 -9 -14) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1. INSURED: ANDERSONPENNA PARTNERS, INC. 3737 BIRCH STR #250 NEWPORT BEACH CA 92660 Insured is A CORPORATION NCCI CO CODE: 13579 PRODUCER: DEALEY RENTON & ASSOC PO BOX 10550 SANTA ANA CA 92711 -0550 Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08 -01 -15 to 08 -01 -16 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: CA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit Bodily Injury by Disease: $ 1000000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 08 -05 -15 LP OFFICE: A &E RETAIL 20V PRODUCER: DEALEY RENTON & ASSOC CGW74 DIRECT BILL Apok TR VL LER'S J ONE TOWER SQUARE HARTFORD, CT 06183 CLASSIFICATION SCHEDULE. CLASSIFICATIONS SIC -CODE: 8711 CODE NO WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (XM- 3708T65 -9 -15) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) NAICS: 541330 STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 32857 PREMIUM DISCOUNT 986 0900 -04 EXPENSE CONSTANT 185 TERRORISM 1326 TOTAL ESTIMATED PREMIUM 33382 TAXES AND SURCHARGES 1092 DEPOSIT AMOUNT DUE 34474 Minimum Premium: $ 815 OTHER MINIMUMS ARE INDICATED ON THE APPLICABLE SCHEDULE(S) DATE OF ISSUE: 08 -05 -15 LP OFFICE: A &E RETAIL 20V PRODUCER: DEALEY RENTON & ASSOC CGW74 COUNTERSIGNED -AGENT TRAVELERS WORKERS COMPENSATION AND ONE TOWER SQUARE HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE - SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (XJUB- 370BT65 -9 -15) INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 095 13579 -CA INSURED'S NAME: ANDERSONPENNA PARTNERS, INC. RATE BUREAU ID: 5782151 PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 FEIN 203110850 ENTITY CD 001 ANDERSONPENNA PARTNERS, INC. 3737 BIRCH STR #250 NEWPORT BEACH, CA 92660 SIC CODE: 8711 NAICS: 541330 BLANKET WAIVER SEE ENDT. WC 99 03 76 ( A) 001 WAIVER CALCULATION IS BASED ON 0930 38902 ,03 1167 ENGINEERS-CONSULTING- MECHANICAL, CIVIL, ELECTRICAL AND MINING ENGINEERS AND ARCHITECTS -NOT ENGAGED IN ACTUAL CONSTRUCTION OR OPERATION- INCLUDING OUTSIDE SALESPERSONS AND CLERICAL OFFICE EMPLOYEES. 8601 4420714 .88 38902 DATE OF ISSUE: 08 -05 -15 LP SCHEDULE NO: 1 OF MORE TRAVELERV WORKERS COMPENSATION AND ONE TOWER SQUARE HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE - SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (XJUB- 3708T65 -9 -15) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 (CONT'D) ENGINEERS-CONSULTING- MECHANICAL, CIVIL, ELECTRICAL AND MINING ENGINEERS AND ARCHITECTS -NOT ENGAGED IN ACTUAL CONSTRUCTION OR OPERATION- INCLUDING OUTSIDE SALESPERSONS AND CLERICAL OFFICE EMPLOYEES. 8601U IF ANY 1.76 USL HW -SEE ENDT WC 99 01 01 MANRATE .8800 LOCATION 002 01 FEIN 203110850 ENTITY CD 001 ANDERSONPENNA PARTNERS, INC. 1225 W 190TH STR STE 255 GARDENA, CA 90248 SIC CODE: 8711 NAICS: 541330 DATE OF ISSUE: 08 -05 -15 LP SCHEDULE NO: 2 OF MORE TRAVELERS WORKERS COMPENSATION AND ONE TOWER SQUARE HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY EXTENSION OF INFO PAGE - SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: (XJUB- 3708T65 -9 -15) PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 002 01 (CONT'D) ENGINEERS-CONSULTING- MECHANICAL, CIVIL, ELECTRICAL AND MINING ENGINEERS AND ARCHITECTS -NOT ENGAGED IN ACTUAL CONSTRUCTION OR OPERATION- INCLUDING OUTSIDE SALESPERSONS AND CLERICAL OFFICE EMPLOYEES. 8601 IF ANY .88 CA MANUAL PREMIUM $ 38902 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION $ EXPERIENCE MODIFICATION: .82 MODIFIED PREMIUM TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 3.00% PREMIUM DISCOUNT(0064) EXPENSE CONSTANT(0900) TERRORISM (9740) 1.83% CIGA SURCHARGE 1.44% USER / FRAUD / UEBT / SIBT / OSH / LEC TOTAL ESTIMATED PREMIUM DEPOSIT AMOUNT DUE 40069 32857 32857 986 185 1326 611 481 34474 34474 DATE OF ISSUE: 08 -05 -15 LP SCHEDULE NO: 3 OF LAST TRAVELERS WORKERS COMPENSATION AND ONE TOWER SQUARE HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 00 01 (A) POLICY NUMBER: (XTUB- 3708T65 -9 -15) LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date. WC 00 00 01 A - 001 INFORMATION PAGE WC 00 00 01 A - 001 INFORMATION PAGE 2 WC 00 00 01 A - 001 EXTENSION OF INFORMATION PAGE - SCHEDULE WC 00 00 01 A - 001 ENDORSEMENT LISTING WC 04 03 17 00 - 001 ENDT AGRMNT LIMITING & RESTRICTING INS WC 00 04 22 B - 001 TERRORISM RISK INS PROG REAUTH ACT ENDT WC 99 01 01 00 - 001 STATE WC COMP LAWS AND USL & H WC ACT WC 99 03 F3 00 - 001 CA LIMITS OF LIABILITY ENDT WC 99 03 76 A -- 001 WAIVER OF OUR RIGHTS TO RECOVER -CA WC 99 03 99 00 - 001 CA WORKERS' COMP NOTICE OF NON- RENEWAL WC 99 06 F4 00 - 001 MANAGED CARE PROGRAM ENDORSEMENT WC 99 06 R3 00 - 001 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN WC 99 06 R3 00 - 002 NOTICE OF CAN TO DESIGN PERSONS OR ORGAN WC 00 04 21 D - 001 CATASTROPHE (0 /T CERT ACTS OF TERR) ENDT WC 99 04 08 00 - 001 PREMIUM DISCOUNT ENDORSEMENT WC 04 01 01 A - 001 LONGSHORE & HARBOR WC ACT ENDT - CA WC 04 03 01 B - 001 POLICY AMENDATORY ENDORSEMENT- CALIFORNIA WC 04 03 03 01 - 001 OFFICERS & DIRECTORS COV /EXCLUSION ENDT. WC 04 03 05 00 - 001 VOL COMP & EMPLOYERS LIAB COV ENDT. WC 04 03 60 B - 001 EMPLOYERS' LIAB COV AMENDATORY ENDT -CA WC 04 04 22 00 001 CALIFORNIA SHORT -RATE CANCELATION ENDT WC 04 06 01 A 001 CA CANCELATION ENDT DATE OF ISSUE: 08 -05 -15 STASSIGN: Page 1 of LAST