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PROOF OF INSURANCE (2017) CLOSEDDATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 0811111201 ..... ..... . 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(les) 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)• NAME" PRODUCER Phone: 310-370-5000 —, PACIFIC UNIFIED INSURANCE PHONE, X P.O. Box 68 Fax: 310-370-5454 A( ITL.F_11� . . . . . . . . . . . . . . . . . . . . AtC 11 _q No. Exh� 'L Lawndale, CA 90260 INA L ADDRESSI . . . ...... . John Huttinger, CIE, CRM 1NSURER(§JAff2RRTG COVERAGE _AIC # INSURER A, Hartford Insurance �Comp�an INSURED South Bav Chllar657s _Healthl 114SURER s: Technology Insurance Cornpan Center Association, Inc. IN$URERC' .... . ..... 410 So. Camino Real Redondo Beach, CA 90277 INSURER IN§VRER F. I --- — ------ — OVERAGES; 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. R Erm — I ...... ;,Mr M WE— ;; —POLIdY 191 LIMITS TYPE OF INSURANCE NAR wvn POLICY NUMBER DOM, 1NWDYL GENERAL LIABILITY EACH OCCURRENCE .. $ 1,000,0 A X COMMIERCIAL GENERAL LIABILITY X 8502SS311218-7 0313112016 0313112017 _DA9%1rT0_R0TR1V_ 2—R&MISLa Sc4wrf8n_J__ EAl $ a CLAIMS-MADE X OCCUR MED EXE_(Any one Person) PERSONAL & ADV INJURY GENERAL AGGREGATE $ 3 SEXUAL —MISCONDT-$ - COMPIOP AGG 3 GEN'L AGGREGATE LIMIT APPLIES PER: El POLICY D Loa M El trnp _PRODUCTS BBen. ESIN _! $ .4 AUTOMOBILE LIABILITY GL I JECOMBINED _A ff__tidJaU__ A —7 ANY AUTO 8502SS311218-7 03/31/2016 0313112017 BODILY INJURY (Per person) $ 7 ALL OWNED SCHEDULED I11 AUTOS AUTOS HIRED AUTOS AUTOS NON-OWNED B DILY INJURY (Per accident) A ME A—acri-iff ML— $ $ A X UMBRELLA LIAB X OCCUR EXCESS LIAR CLAIMsmAvE 4602SS347908-6 0313112016 03/3112017 EAC14 OCCURRENCE AGGREGATE &CSTATU* IOTH- DED X I RETENTION$ 10,000 WORKERS COMPENSATION B A AND EMPLOYERS' LIABILITY YIN ANY PROPMETORIPARTNEWEXECUTIVE OFFICERNEMSER EXCLUDED? (Mandatory In NH) If yes describe under DESCRIPTION OF OPERATIONS below Loc. #I/Repi Cost NIA TWC3517075 8602SS31121847 SPECIAL 12101112016 03/311120116 12/01/2016 03131120117 _?�YQ $ E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT BUILDING $ $ A Loc. #I/Repl Cost 18602SS311218-7 -SPECIAL 03131120' 03131/20117 CONTENTS DESCRIPTION OF OPERATIONS) LOCATIONS I VEHICLES (Attach ACORD 101, AddIflonal Remarks schedule, if niore space is raquired) :ertifioate Holder is included as Additional Insured per the general Liability extension form#ML242 (03/14), • Im Counseling of abused children and :heir families who are referred to the South Bay Youth Project. SZE HOLDER 40TES FOR ADDITIONAL POLICY FORMS & CONDITIONS. CITYOFE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo CDBG Grant ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Tina Gall 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 q'z— Aa't:�' ACORD 25 (2010106) I ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY III MARKEV Markel Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY PLUS ENHANCEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following coverages and extensions are added to this policy as detailed below. As respects any coverage provided by this endorsement, if higher limits are provided on any other schedule, declarations or endorsement attached to this policy, then the limits and coverage provided by this endorsement would not apply for that coverage. SCHEDULE Limited Product Withdrawal Expense $10,000 All Product Withdrawal Expenses Extended Property Damage - Expected Or Intended Included Injury Non -Owned Watercraft Non -Owned Aircraft Property Damage To Borrowed Equipment Property Damage To Customers' Goods Damage To Premises Rented To You Property Damage From Elevator Use Personal And Advertising Injury From Televised Or Videotaped Material Supplementary Payments Bail Bonds Loss Of Earnings Medical Personnel Broadened Definition Of Insured Automatic Additional Insureds When Required By Contract Or Agreement Managers Or Lessors Of Premises Mortgagees, Assignees Or Receivers Vendors Medical Payments Each Location And Each Project Aggregates Duties In The Event Of Occurrence, Offense, Claim Or Suit Unintentional Failure To Disclose All Hazards Waiver Of Transfer Of Rights Of Recovery Against Others To Us Increased To 51 Feet Long If Rented Or Loaned With A Paid Crew $10,000 Each Occurrence $10,000 Each Occurrence Equal To The General Liability Each Occurrence Limit Included Included Up To $5,000 Up To $500 A Day $100,000 Any One Person Included Included Included Included Included $10,000 Any One Person (Unless Excluded) Equal To The General Aggregate Limit Included Included Included Liberalization Included Mental Anguish Resulting From Bodily Injury Included Broadened Definition Of Mobile Equipment Included MGL 1242 0314 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 12 A. LIMITED PRODUCT WITHDRAWAL EXPENSE THIS COVERAGE ONLY PROVIDES REIMBURSEMENT TO YOU FOR EXPENSES INCURRED BECAUSE OF A COVERED "PRODUCT WITHDRAWAL ". THIS COVERAGE DOES NOT PROVIDE ANY LIABILITY COVER- AGE OR COVERAGE FOR THE COST OR EXPENSE OF DEFENDING ANY CLAIM OR "SUIT ". 1. The following is added to Section I - Coverages: LIMITED PRODUCT WITHDRAWAL EXPENSE COVERAGE Insuring Agreement a. We will reimburse you for "product withdrawal expenses" incurred by you because of a "product withdraw- al" to which this insurance applies. The amount of such reimbursement is limited as described in Section III - Limits Of Insurance, as amended by this endorsement. No other obligation or liability to pay sums or perform acts or services is covered. b. This insurance applies to a "product withdrawal' only if the "product withdrawal' is initiated in the "coverage territory" during the policy period because: (1) You determine that the "product withdrawal' is necessary; or (2) An authorized government entity has ordered you to conduct a "product withdrawal'. c. We will reimburse "product withdrawal expenses" only if: (1) The expenses are incurred within one year of the date the "product withdrawal' was initiated; (2) The expenses are reported to us within one year of the date the expenses were incurred; and (3) The product that is the subject of the "product withdrawal' was produced during the policy period. d. The initiation of a "product withdrawal' will be deemed to have been made only at the earliest of the follow- ing times: (1) When you first announced, in any manner, to the general public, your vendors or to your "employees" (other than those "employees" directly involved in making the determination) your decision to conduct or participate in a "product withdrawal'. This applies regardless of whether the determination to conduct a "product withdrawal' is made by you or is requested by a third party; or (2) When you first received, either orally or in writing, notification of an order from an authorized govern- ment entity to conduct a "product withdrawal'. e. "Product withdrawal expenses" incurred to withdraw "your products" which contain the same or substantial- ly similar "defects" will be deemed to have arisen out of the same "product withdrawal'. Exclusions This insurance does not apply to "product withdrawal expenses" arising out of: a. Breach Of Warranty And Failure To Conform To Intended Purpose Any "product withdrawal' initiated due to the failure of "your product' to accomplish its intended purpose, in- cluding any breach of warranty of fitness, whether written or implied. This exclusion does not apply if such failure has caused or is reasonably expected to cause "bodily injury" or physical damage to tangible prop- erty other than "your product'. Infringement Of Copyright, Patent, Trade Secret, Trade Dress Or Trademark Any "product withdrawal' initiated due to copyright, patent, trade secret, trade dress or trademark infringe- ments. c. Chemical Transformation, Deterioration Or Decomposition Any "product withdrawal' initiated due to transformation of a chemical nature, deterioration or decomposi- tion of "your product'. This exclusion does not apply if transformation of a chemical nature, deterioration or decomposition is caused by: MGL 1242 0314 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 12 with its permission. (1) An error in manufacturing, design or processing; (2) Transportation of "your product'; or (3) "Product tampering ". d. Goodwill, Market Share, Revenue, Profit Or Redesign The costs of goodwill, market share, revenue or "profit" or the costs of redesigning "your product ". e. Expiration Of Shelf Life Any "product withdrawal" initiated due to expiration of the designated shelf life of "your product ". f. Known Defect A "product withdrawal" initiated because of a "defect" in "your product" known to exist by the Named In- sured or the Named Insured's "executive officers" prior to the policy period or the time "your product" leaves your control or possession. g. Otherwise Excluded Products A recall of any specific products for which "bodily injury" or "property damage" is excluded under Coverage A - Bodily Injury And Property Damage Liability. h. Governmental Ban A recall when "your product" or a component contained within "your product" has been: (1) Banned from the market by an authorized government entity prior to the policy period; or (2) Distributed or sold by you subsequent to any governmental ban. i. Defense Of Claim The defense of a claim or "suit" against you for liability arising out of a "product withdrawal ". j. Third Party Damages, Fines And Penalties Any compensatory damages, fines, penalties, punitive or exemplary or other non - compensatory damages imposed upon the insured. k. Pollution - Related Expenses Any loss, cost, or expense due to any: (1) Request, demand, order, statutory or regulatory requirement that any insured or others test for, moni- tor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to or assess the ef- fects of, "pollutants'; or (2) Claim or "suit" by or on behalf of a governmental authority for damages because of testing for, moni- toring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to or assessing the effects of, "pollutants ". 2. The following is added to Section III - Limits Of Insurance: The most that we will reimburse you for the sum of all "product withdrawal expenses" incurred for all "product withdrawals" initiated during the policy period is the amount shown in the Schedule of this endorsement, re- gardless of the number of: a. Insureds; b. "Product withdrawals" initiated; or c. "Your products" withdrawn. 3. Section IV - Commercial General Liability Conditions is amended as follows: a. Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit is replaced by the following: 2. Duties In The Event Of A Defect Or A Product Withdrawal MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 3 of 12 with its permission. a. You must see to it that we are notified as soon as practicable of any actual, suspected or threat- ened "defect' in "your product ", or any governmental investigation, that may result in a "product withdrawal ". To the extent possible, notice should include: (1) How, when and where the "defect' was discovered; (2) The names and addresses of any injured persons and witnesses; and (3) The nature, location and circumstances of any injury or damage arising out of use or consump- tion of "your product'. Your obligation to notify us as soon as practicable is satisfied if you send us written notice as soon as practicable after any of your "executive officers ", directors, partners, insurance managers or le- gal representatives become aware of or should have become aware of such actual, suspected or threatened "defect' in "your product', or any governmental investigation, that may result in a "prod- uct withdrawal'. b. If a "product withdrawal' is initiated, you must: (1) Immediately record the specifics of the "product withdrawal' and the date where it was initiated; and (2) Notify us as soon as practicable. You must see to it that we receive written notice of the "product withdrawal' as soon as practicable. c. You must promptly take all reasonable steps to mitigate the expenses associated with a "product withdrawal'. Any "profit" that you receive from mitigating the expenses will be deducted from the a- mount of reimbursement that you will receive for "product withdrawal expenses ". d. You and any other involved insured must: (1) Immediately send us copies of pertinent correspondence received in connection with the "prod- uct withdrawal; (2) Authorize us to obtain records and other information; and (3) Cooperate with us in our investigation of the "product withdrawal'. b. The following Conditions are added: Concealment Or Fraud We will not provide "product withdrawal expense" coverage to you or any other insured who, at any time: a. Engaged in fraudulent conduct; or b. Intentionally concealed or misrepresented a material fact concerning a "product withdrawal' or "product withdrawal expenses" incurred by you. Product Tampering Limitation When "product tampering" is known, suspected or threatened, a "product withdrawal' will be limited to those batches of "your product' which are known or suspected to have been tampered with. 4. The following definitions are added: a. "Defect' means a flaw, deficiency or inadequacy that creates a dangerous condition. b. 'Product tampering" means an act of intentional alteration of "your product' which has caused or is rea- sonably expected to cause "bodily injury" or physical injury to tangible property other than "your product'. For purposes of this insurance, electronic data is not tangible property. As used in this definition, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and application software, hard or floppy disks, CD -ROMs, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment. MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 4 of 12 with its permission. c. "Product withdrawal' means the recall or withdrawal: (1) From the market; or (2) From use by any other person or organization; of "your products" or products which contain "your products ", because of known or suspected "defects" in "your product" or known or suspected "product tampering" which has caused or is reasonably expected to cause "bodily injury" or physical injury to tangible property other than "your product ". For purposes of this insurance, electronic data is not tangible property. As used in this definition, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD -ROMs, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment. d. 'Product withdrawal expenses" means those reasonable and necessary extra expenses, listed below, paid and directly related to a "product withdrawal': (1) Costs of notification; (2) Costs of stationery, envelopes, production of announcements and postage or facsimiles; (3) Costs of overtime paid to your regular non -salary "employees" and costs incurred by your "employees ", including costs of transportation and accommodations; (4) Costs of computer time; (5) Costs of hiring independent contractors and other temporary employees; (6) Costs of transportation, shipping or packaging; (7) Costs of warehouse or storage space; or (8) Costs of proper disposal of "your products" or products that contain "your products" that cannot be re- used, not exceeding your purchase price or your costs to produce the products. e. 'Profit' means the positive gain from business operation after subtracting for all expenses. B. EXTENDED PROPERTY DAMAGE - EXPECTED OR INTENDED INJURY Exclusion 2.a. Expected Or Intended Injury under Section I - Coverages, Coverage A - Bodily Injury And Property Damage Liability is replaced by the following: 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" or "property damage" resulting from the use of reasonable force to protect per- sons or property. C. NON -OWNED WATERCRAFT AND NON -OWNED AIRCRAFT Exclusion 2.g. Aircraft, Auto Or Watercraft under Section I - Coverages, Coverage A - Bodily Injury And Property Damage Liability is amended as follows: 1. Paragraph (2) is replaced by the following: (2) A watercraft you do not own that is: (a) Less than 51 feet long; and (b) Not being used to carry persons or property for a charge; 2. The following is added: (6) 'Bodily injury" or "property damage" arising out of any aircraft not owned by any insured that is rented or loaned to you with a paid crew. If other insurance applies to a loss because of "property damage" to non -owned watercraft or aircraft as described in Paragraphs (2) or (6) above, the insurance provided by this Coverage Form does not apply, whether the other in- surance is primary, excess, contingent or issued on any other basis. MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 5 of 12 with its permission. D. PROPERTY DAMAGE TO BORROWED EQUIPMENT 1. The following is added to Exclusion 2.j. Damage To Property under Section I - Coverages, Coverage A - Bodily Injury And Property Damage Liability: Paragraph (4) of this exclusion does not apply to "property damage" to borrowed equipment while that equip- ment is: a. Not being used to perform operations; and b. Away from an insured's premises. 2. The following is added to Section III - Limits Of Insurance: Subject to the General Aggregate limit, the most we will pay for "property damage" to borrowed equipment is the amount shown in the Schedule of this endorsement for each "occurrence ". 3. The insurance afforded by Paragraph 1. above is excess over any valid and collectible property insurance (in- cluding any deductible) available to the insured, whether primary, excess, contingent or issued on any other basis. E. PROPERTY DAMAGE TO CUSTOMERS' GOODS 1. The following is added to Exclusion 2.j. Damage To Property under Section I - Coverages, Coverage A - Bodily Injury And Property Damage Liability: Paragraphs (3), (4) and (6) of this exclusion do not apply to "property damage" to "customers' goods" while on your premises. 2. The following is added to Section III - Limits Of Insurance: Subject to the General Aggregate limit, the most we will pay for "property damage" to "customers' goods" is the amount shown in the Schedule of this endorsement for each "occurrence ". 3. The insurance afforded by Paragraph 1. above is excess over any valid and collectible property insurance (in- cluding any deductible) available to the insured, whether primary, excess, contingent or issued on any other basis. 4. The following definition is added: "Customers' goods" means tangible personal property belonging to your customers and left with you for stor- age, service or repair. "Customers' goods" does not include: a. Accounts, bills, currency, deeds, food stamps or other evidences of debt, money, notes or securities. Lottery tickets held for sale are not securities; b. Animals; c. Contraband, or property in the course of illegal transportation or trade; d. Personal property while airborne or waterborne; e. Property that is covered under another coverage form of this or any other policy in which it is more specific- ally described, except for the excess of the amount due (whether you can collect on it or not) from that oth- er insurance; f. Vehicles or self - propelled machines that are licensed for use on public roads; aircraft; or watercraft; This paragraph does not apply to: (1) Vehicles or self - propelled machines, other than "autos ", you hold for sale; or (2) Rowboats or canoes out of water at your premises; or g. The following property while outside of buildings: (1) Grain, hay, straw or other crops; (2) Fences, radio or television antennas (including satellite dishes) and their lead -in wiring, masts or tow- ers, trees, shrubs or plants (other than trees, shrubs or plants held for sale). MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 6 of 12 with its permission. F. DAMAGE TO PREMISES RENTED TO YOU The following applies only if Damage To Premises Rented To You is not excluded from the policy to which this en- dorsement is attached: 1. The first paragraph following Paragraph (6) of Exclusion 2.j. Damage To Property under Section I - Coverages, Coverage A - Bodily Injury And Property Damage Liability is replaced by the following: 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. A separate limit of insurance applies to Dam- age To Premises Rented To You as described in Section III - Limits Of Insurance. 2. The final paragraph of Paragraph 2. Exclusions under Section I - Coverages, Coverage A - Bodily Injury And Property Damage Liability is replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke or sprinkler leakage 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. 3. Paragraph 6. under Section III - Limits Of Insurance is replaced by the following: 6. Subject to Paragraph 5. above, 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, explosion, smoke or sprinkler leakage, while rented to you or temporarily occupied by you with permission of the own- er, is equal to the Each Occurrence limit shown in the Declarations. 4. Paragraph 4.b.(1)(a)(ii) of the Commercial General Liability Coverage Form, and Paragraph 4.b.(1)(a)(iii) of the Commercial General Liability Coverage Form (Claims -Made Version) under Section IV - Commercial General Liability Conditions are replaced by the following: That is fire, lightning, explosion, smoke or sprinkler leakage insurance for premises rented to you or temporarily occupied by you with permission of the owner; 5. Paragraph a. of Definition 9. "insured contract' 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 in- demnifies any person or organization for damage by fire, lightning, explosion, smoke or sprinkler leakage to premises while rented to you or temporarily occupied by you with permission of the owner is not an "in- sured contract'; G. PROPERTY DAMAGE FROM ELEVATOR USE 1. The following is added to Exclusion 2.j. Damage To Property under Section I - Coverages, Coverage A - Bodily Injury And Property Damage Liability: Paragraphs (3), (4) and (6) of this exclusion do not apply if such "property damage" arises out of the use of ele- vators at premises you own, rent, lease or occupy. 2. The insurance afforded by Paragraph 1. above is excess overy any other valid and collectible insurance which applies to a loss because of "property damage" arising out of the use of elevators, whether such other insur- ance is primary, excess, contingent or issued on any other basis. H. PERSONAL AND ADVERTISING INJURY FROM TELEVISED OR VIDEOTAPED MATERIAL 1. Exclusions 2.b. and 2.c. under Section I - Coverages, Coverage B - Personal And Advertising Injury Liability are replaced by the following: b. Material Published With Knowledge Of Falsity "Personal and advertising injury" arising out of oral, written or professionally produced televised or video- taped 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, written or professionally produced televised or video- taped publication, in any manner, of material whose first publication took place before the beginning of the policy period. MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 7 of 12 with its permission. 2. Paragraphs d. and e. of the definition of "personal and advertising injury" are replaced by the following: d. Oral, written or professionally produced televised or videotaped 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, written or professionally produced televised or videotaped publication, in any manner, of material that violates a person's right to privacy; I. SUPPLEMENTARY PAYMENTS - BAIL BONDS AND LOSS OF EARNINGS Paragraphs 1.b. and 1.d. under Section I - Coverages, Supplementary Payments - Coverages A And B are re- placed by the following: b. Up to the amount shown in the Schedule of this endorsement for cost of bail bonds required because of ac- cidents or traffic law violations arising out of the use of any vehicle to which Bodily Injury Liability Coverage ap- plies. 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 the amount shown in the Schedule of this endorse- ment because of time off from work; J. MEDICAL PERSONNEL The following applies only if no other similar coverage is included on or added to the policy to which this endorse- ment is attached: 1. Paragraph 2.a.(1)(d) under Section II - Who Is An Insured does not apply to any registered nurse, licensed practical nurse, certified emergency medical technician or certified paramedic who is employed by you to pro- vide professional health care services, but only while acting within the scope and course of their duties as such. 2. The following is added to Section III - Limits Of Insurance: Subject to the General Aggregate limit, the most we will pay under Medical Personnel Coverage is the amount shown in the Schedule of this endorsement for all loss sustained by any one person from professional health services. K. BROADENED DEFINITION OF INSURED Section II - Who Is An Insured is amended as follows: 1. The following is added to Paragraph 2.a.: Paragraph (1) does not apply to managers at the supervisory level or above. 2. Paragraph 2. is amended to include the following as insureds: Any legally incorporated entity of which you own at least 51% of the voting stock on the inception date of this Coverage Form and on the date of any covered "occurrence ", claim or "suit ". This insurance shall not apply to any entity that is already insured under any other insurance provided by any company or that would be an insured but for the exhaustion of its limits of insurance. 3. Paragraph 3.a. is replaced by the following: a. Coverage for your newly acquired or formed organization shall be: (1) Effective on the date of acquisition or formation; and (2) Afforded until the end of the policy period of this Coverage Form. L. AUTOMATIC ADDITIONAL INSUREDS The following paragraphs are added to Section II - Who Is An Insured: 1. The following are also insureds under this policy, subject to the following provisions: a. When Required By Contract Or Agreement Any person or organization to whom you are required by written contract, agreement, permit or authoriza- tion to provide insurance, but only if the contract, agreement, permit or authorization is in effect during the policy period shown in the Declarations and was executed prior to the "bodily injury", "property damage" or "personal and advertising injury". However: MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 8 of 12 with its permission. (1) The person or organization is an insured only to the extent you are held liable due to: (a) The ownership, maintenance or use of that part of premises you own, rent, lease or occupy, sub- ject to the following additional provisions: (i) This insurance does not apply to any "occurrence" which takes place after you cease to be a tenant in any premises leased to or rented to you; and (ii) This insurance does not apply to any structural alterations, new construction or demolition op- erations performed by or on behalf of the person or organization; (b) Your ongoing operations for that insured, whether the work is performed by you or for you; (c) The maintenance, operation or use by you of equipment leased to you by such person or organiza- tion, subject to the following additional provisions: (i) This insurance does not apply to any "occurrence" which takes place after the equipment lease expires or you cease to lease that equipment; and (ii) This insurance does not apply to "bodily injury" or "property damage" arising out of the sole negligence of such person or organization; (d) Permits or authorizations issued by any state or political subdivision with respect to operations per- formed by you or on your behalf, subject to the following additional provision: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising in- jury" arising out of operations performed for that state or municipality. (2) The insurance with respect to any architect, engineer or surveyor does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or failure to ren- der any professional services by or for you, including: (a) The preparing, approving or failure to prepare or approve maps, drawings, opinions, reports, sur- veys, change orders, designs or specifications; and (b) Supervisory, inspection or engineering services. (3) This insurance does not apply to "bodily injury" or "property damage" included within the "products - completed operations hazard ". (4) This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or failure to render any professional services. (5) This insurance does not apply to any insured person or organization if the loss, cost, injury or damage is otherwise excluded from coverage under this insurance, including any endorsements made a part of this policy. (6) A person's or organization's status as an insured under this endorsement ends when your operations for that insured are completed. (7) This insurance does not apply to any person or organization included as an insured by an endorsement issued by us or otherwise made part of this insurance. (8) No coverage will be provided if, in the absence of this endorsement, no liability will be imposed by law on you. Coverage will be limited to the extent of your negligence or fault according to the applicable principles of comparative fault. This Additional Insured provision does not apply to managers or lessors of premises; mortgagees, assign- ees or receivers; or vendors. b. Managers Or Lessors Of Premises Any person or organization who leases to you or manages property you rent or lease, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf in connection with that part of the premises leased or rented to you and shown on the Declarations. The following additional exclusions apply to such managers or lessors of premises: This insurance does not apply to: MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 9 of 12 with its permission. (1) Any "occurrence" which takes place after you cease to be a tenant in that premises. (2) Structural alterations, new construction or demolition operations performed by or on behalf of the per - son(s) or organization(s) who leases to you or manages property you rent or lease. c. Mortgagees, Assignees Or Receivers Any person or organization with respect to their liability as mortgagee, assignee or receiver and arising out of the ownership, maintenance or use of premises by you. However, this insurance does not apply to structural alterations, new construction or demolition operations performed by or for that person or organi- zation. d. Vendors Any vendor with whom you have agreed in a written contract or agreement to provide insurance, but only if the contract or agreement is in effect during the policy period shown in the Declarations and was executed prior to the "bodily injury" or "property damage ", and only with respect to "bodily injury" or "property dam- age" arising out of "your products" which are distributed or sold in the regular course of the vendor's busi- ness. (1) The following additional exclusions apply to such vendors: This insurance does not apply to: (a) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; (b) Any express warranty unauthorized by you; (c) Any physical or chemical change in the product made intentionally by the vendor; (d) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing or the substitution of parts under instructions from the manufacturer, and then repackaged in the origi- nal 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 the usual course of business, in connection with the distri- bution or sale of the products; (f) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; (g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a con- tainer, part or ingredient of any other thing or substance by or for the vendor; (h) Any failure to maintain the product in a merchantable condition; or (1) "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: (i) The exceptions contained in subparagraphs (d) or (f); or (ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normal- ly undertakes to make in the usual course of business, in connection with the distribution or sale of the products. (2) This insurance does not apply to any insured person or organization from whom you have acquired such products, or any ingredient, part or container entering into, accompanying or containing such products. (3) This insurance does not apply to any vendor included as an insured by an endorsement issued by us or otherwise made a part of this insurance. (4) This insurance does not apply if "bodily injury" or "property damage" included in the "products -com- pleted operations hazard" is excluded either by the provisions of this insurance or by endorsement. MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 10 of 12 with its permission. 2. The insurance provided to such automatic additional insureds: a. Only applies to the extent permitted by law; and b. Will not be broader than that which you are required by the contract or agreement to provide for such addi- tional insureds. 3. With respect to the insurance afforded to such automatic 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: a. Required by the contract or agreement; or b. Available under the applicable limits of insurance shown in the Declarations, whichever is less. The insurance afforded to the additional insured does not increase the applicable limits of insurance shown in the Declarations. M. MEDICAL PAYMENTS The following applies only if Medical Payments Coverage is not excluded from the policy to which this endorsement is attached: Paragraph 7. under Section III - Limits Of Insurance is replaced by the following: 7. Subject to Paragraph 5. above, the Medical Expense limit is equal to the Medical Expense limit stated in the Declarations or the amount shown in the Schedule of this endorsement, whichever is greater, and is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person. N. EACH LOCATION AND EACH PROJECT AGGREGATES The following is added to Section III - Limits Of Insurance: 1. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Coverage A, and for all medical expenses caused by accidents under Coverage C, which can be attributed on- ly to operations at a single designated covered "location" or covered construction project: a. A separate Each Location or Each Project Aggregate limit applies to each covered "location" or covered construction project, and that limit is equal to the General Aggregate limit shown in the Declarations. b. The Each Location or Each Project Aggregate limit is the most we will pay for the sum of all damages un- der Coverage A, except damages because of "bodily injury" or "property damage" included in the "prod- ucts- completed operations hazard ", and for medical expenses under Coverage C, regardless of the number of: (1) Insureds; (2) Claims made or "suits" brought; or (3) Persons or organizations making claims or bringing "suits ". c. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall re- duce the Each Location or Each Project Aggregate limit for each covered "location" or covered project for which payment is made. Such payments shall not reduce the General Aggregate limit shown in the Decla- rations nor shall they reduce any other covered "location" or covered project's general aggregate. d. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medi- cal Expense continue to apply. However, instead of being subject to the General Aggregate limit shown in the Declarations, such limits will be subject to the applicable Each Location or Each Project Aggregate lim- it. 2. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Coverage A, and for all medical expenses caused by accidents under Coverage C, which cannot be attributed only to ongoing operations at a covered "location" or covered project: a. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall re- duce the amount available under the General Aggregate limit or the Products - Completed Operations Ag- gregate limit, whichever is applicable; and MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 11 of 12 with its permission. b. Such payments shall not reduce any Each Location or Each Project Aggregate limit. 3. When coverage for liability arising out of the "products- completed operations hazard" is provided, any pay- ments for damages because of "bodily injury" or "property damage" included in the "products- completed opera- tions hazard" will reduce the Products - Completed Operations Aggregate limit, and not reduce the General Ag- gregate limit nor the Each Location or Each Project Aggregate limit. 4. If the applicable covered construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. 5. For the purposes of this section of this endorsement, 'location" means premises involving the same or con- necting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right -of -way of a railroad. 6. The provisions of Section III - Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. O. DUTIES IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit under Section IV - Commercial General Liability Conditions: Your obligation to notify us as soon as practicable of an 'occurrence ", offense, claim or "suit" is satisfied if you send us written notice as soon as practicable after any of your "executive officers ", directors, partners, insurance man- agers or legal representatives become aware of or should have become aware of such 'occurrence ", offense, claim or "suit'. P. UNINTENTIONAL FAILURE TO DISCLOSE ALL HAZARDS The following is added to Condition 6. Representations under Section IV - Commercial General Liability Conditions: If you unintentionally fail to disclose all hazards prior to the beginning of the policy period of the Coverage Form, we shall not deny coverage under this Coverage Form because of such failure. Q. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US The following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us under Section IV - Commercial General Liability Conditions: We waive any right of recovery we may have against any 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 or- ganization and included in the "products- completed operations hazard ". This waiver applies only to the person or organization with whom you have agreed in a written contract prior to an 'occurrence" to waive such rights. R. LIBERALIZATION The following is added to Section IV - Commercial General Liability Conditions: Liberalization Clause If we adopt any revision that would broaden coverage under this Coverage Form without additional premium, the broadened coverage will immediately apply to this Coverage Form as of the day the revision is effective in your state. S. MENTAL ANGUISH RESULTING FROM BODILY INJURY Definition 3. "bodily injury" is replaced by the following: 3. 'Bodily injury" means: a. Bodily injury, sickness or disease sustained by a person, including mental anguish or emotional distress re- sulting from any of these; and b. Death resulting from bodily injury, sickness or disease. T. BROADENED DEFINITION OF MOBILE EQUIPMENT The following is added to Paragraph f.(1) of Definition 12. "mobile equipment': This shall not apply to self - propelled vehicles of less than 1,000 pounds gross vehicle weight. All other terms and conditions remain unchanged. MGL 1242 03 14 Includes copyrighted material of Insurance Services Office, Inc., Page 12 of 12 with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 2of6 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs, covered by this insurance and other insurance or self- insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss Is paid. If any Insurance or self - insurance Is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 3 of 6 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. We Will Pay We will pay all sums you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. for which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2. for care and loss of services; and 3. for consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. bodily Injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. bodily injury intentionally caused or aggravated by you; 6. bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901 -950), the Non - appropriated Fund Instrumentalities Act (5 USC Sections 8171- 8173), the Outer Continental Shelf Lands Act (43 USC Sections 1331 - 135.6), the Defense Base Act (42 USC Sections 1651 - 1654), the Federal Coal Mine Health and Safety Act of 1969 (30 USC Sections 901 -942), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. bodily injury to any person in work subject to the Federal Employers' Liability Act (45 USC Sections 51 -60), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10. bodily injury to a master or member of the crew of any vessel; 11. fines or penalties imposed for violation of federal or state law; and 12. damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 USC Sections 1801 -1872) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 4of6 D. We Will Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against your for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self - insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self- insurance is exhausted, the shares of all remaining insurance and self - insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.6. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident —each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "'bodily Injury by disease— policy limiVis the most we will pay for all damages covered by this Insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease.. The limit shown for "bodily injury by disease --each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in anyone of those states after the effective date of this policy and are not insured or are not self- insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 5 of 6 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE — PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of. 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 A 6of6 classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance, If Ills less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy, If thls policy is canceled, final premium will be determined In the following way unless our manuals provide otherwise; 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. if you cancel, final premium will be more than pro rata, It will be based on the time this policy was in force, and increased by our short -rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G, Audit You will let us examine and audit all your records that relate to this policy, These records include ledgers, journals, registers, vouchers, contracts tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends, Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. PART SIX — CONDITIONS A. Inspection We have the right, but are not obliged to Inspect your workplaces at any tune. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give YOU reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public, We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as Insured. D. Cancellation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to comply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. Includes copyright materlal of the National Council on Compensation Insurance, Inc. used with Its permission. Technology Insurance Company A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ncci Code: 39071 Insured: South Bay Children's Health Center Association, Inc 410 Camino Real Redondo Beach, CA 90277 Other workplaces not shown above: See Extension of Information Page Producer: AmTrust North America, Inc. c/o 'I'nternational 'Facilities North Insurance Services PO Box 101320 Pasadena, CA 91189 WC 99 00 01 E 1 of 5 INFORMATION PAGE Policy Number: TWC3517075 _Individual _Partnership _Corporation X Other Federal Tax ID: 956000395 Risk Id: Renewal of: New 2. The policy period is from 12/1/2015 to 12/1/2016 12:01 a.m. at the insured's tilai ling address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states 'listed here: California 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: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $1,000,000 each accident $1,000,000 policy limit $I,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and State(s) Designated in Item 3A. D. This policy includes these endorsements and schedules: See Extension of Information Rage 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM 19,905 STATE ASSESSMENT 653 TOTAL ESTIMATED COST 20,558 Minimum Premium 500 Deposit Premium 2,639 Issue Date: 12/23/2015 Countersigned by: Authorized Representative