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PROOF OF INSURANCE (2018) CLOSED Page 1 of 2
0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD
10/oa/2017o17
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 have ADDITIONAL INSURED provisions or 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„
Willis Insurance Services of California, Inc. PHONE1-877-945-7378 FAX 1-888-467-2378
c/o 26 Century Blvd (AIC.No,Ext: (A/C,190
E-MAIL
P.O. Box 305191 ADDRESS: certificate0willis.Com
E
Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAICN
INSURER A: Travelers Property Casualty Company of Ame 25674
INSURED
Tek, Inc., INSURER
Travelers Casualty Co. 25682
DynN Travelers Indemnity Company of CT
444 Dynteservices, Ina, eric 19046
4440 Von Barman Ave.,. Ste 200 INS, R C Y Of Am
Newport Beach, CA 92660 INSURERD: Travelers Indemnity Company of America 25666
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:W3916725 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 'OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE IANSD YEWVD POLICY NUM .. .... . WD Y EFF F POLI�CX EXPr .. .
������ ��������� NUMBER ¢MMfDO/YYYYy,•,.I_IMMdDDfYYYY&
LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
DAMCLAIMS-MADE � X I OCCUR PREMISES
( a occurrence)
rr 300,000
„PREMISE$,(Ea ocrurrence) � ___
A X Owners & Contractors MED EXP(Any one person) $ 10,000
630 2G970183 10/01/2017 10/01/2018 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000
POLICY V X PRO-
JECT X I LOC PRODUCTS-COMP/OP AGG S
2 000 000
OTHER $
AUTOMOBILE LIABILITY COMBINE`;,DSINGLFUMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED BA 2G970183 10/01/2017 10/01/2018 BODILY INJURY Per accident 5
AUTOS ONLY AUTOS ( )
X AUTOS ONLY X.. NON-OWNED Pi�'OPEi'm oAMAFaQ .. .
HIRED
... AUTOS ONLY (Peracclder4I)_ .,
$
X UMBRELLALIAB X (OCCUR EACH OCCURRENCE $ 5,000,000
EXCESS LIAB (CLAIMS-MADE CUP 9J728180 10/01/2017 10/01/2018 AGGREGATE 5 5,000,000
DED I,,,,,,., I RETENTIONS S
X o �
PER
OFFICER/MEMBER MEMBER EXCLUDED? No EL EACH'STATUTEACCI ENT t7RH-
RSCOMPENSATION NIA UB-6J962558 10/01/2017 10/01/2018 X ® E S 1,000,000
EMPLOYERS'LIABILITY YIN
C OFFICE /MEMB REXC EXCLUDED?
EL DISEASE
(Mandatory inNH EMPLOYEE 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S 1,000,000
D Professional Liability- ZPL 21N55554 10/01/2017 10/01/2018 Per Claim & Agg $5,000,000
Claims Made Deductible $25,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
General Liability policy shall be Primary and Non-contributory with any other insurance in force for or which may be
purchased by Additional Insureds.
Waiver of Subrogation applies in favor of Additional Insureds with respects to General Liability, Auto Liability and
Workers Compensation as permitted by law.
City of E1 Segundo, its parent, subsidiaries and other affiliates, and its directors, officers, employees,
CERTIFICATE HOLDER 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.
City of E1 Segundo AUTHORIZED REPRESENTATIVE
350 Main Street (21v
E1 Segundo, CA �f
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
SR ID: 15144932 BATCH: 466852
AGENCY CUSTOMER ID:
...........
LOC#:
SCHEDULE ADDITIONAL REMARKS
D LE Page 2 of 2
AGENCY NAMED INSURED
Willie Insurance Services of California, Inc. DynTek, Inc., Dyntek Services, Inc,4440 von Karman Ave., Ste 200
POLICY NUMBER Newport Beach, CA 92660
See Page 1
.......................
CARRIER NAIC CODE..................
See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 ...�.�...
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
---..........................................................._.............................. .................................................................
representatives and agents are named Additional Insured with respect to General Liability, but only if require""......... ....ww....w ..
.........�............ by a
written contract with the Named Insured prior to an occurrence, and always subject to the terms and conditions of the
policy.
ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are reqistered marks of ACORD
SR ID: 15144932 BATCH: ®66352 CERT: W3916725
Policy#BA-2G907183 COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage. However, coverage for any
injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover-
age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. BROAD FORM NAMED INSURED H. HIRED AUTO PHYSICAL DAMAGE— LOSS OF
B. BLANKET ADDITIONAL INSURED USE—INCREASED LIMIT
C. EMPLOYEE HIRED AUTO I. PHYSICAL DAMAGE — TRANSPORTATION
EXPENSES—INCREASED LIMIT
D. EMPLOYEES AS INSURED J. PERSONAL PROPERTY
E. SUPPLEMENTARY PAYMENTS — INCREASED K. AIRBAGS
LIMITS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
F. HIRED AUTO — LIMITED WORLDWIDE COV- LOSS
ERAGE—INDEMNITY BASIS M. BLANKET WAIVER OF SUBROGATION
G. WAIVER OF DEDUCTIBLE—GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS
PROVISIONS
A. BROAD FORM NAMED INSURED this insurance applies and only to the extent that
The following is added to Paragraph A.1., Who Is person or organization qualifies as an "insured"
An Insured, of SECTION II—COVERED AUTOS under the Who Is An Insured provision contained
LIABILITY COVERAGE: in Section II.
Any organization you newly acquire or form dur- C. EMPLOYEE HIRED AUTO
ing the policy period over which you maintain 1. The following is added to Paragraph A.1.,
50% or more ownership interest and that is not Who Is An Insured, of SECTION II — COV-
separately insured for Business Auto Coverage. ERED AUTOS LIABILITY COVERAGE:
Coverage under this provision is afforded only un- An "employee" of yours is an "insured" while
til the 180th day after you acquire or form the or- operating an "auto" hired or rented under a
ganization or the end of the policy period, which- contract or agreement in an "employee's"
ever is earlier. name, with your permission, while performing
duties related to the conduct of your busi-
B. BLANKET ADDITIONAL INSURED ness.
The following is added to Paragraph c. in A.1., 2. The following replaces Paragraph b. in B.5.,
Who Is An Insured, of SECTION II—COVERED Other Insurance, of SECTION IV — BUSI-
AUTOS LIABILITY COVERAGE: NESS AUTO CONDITIONS:
Any person or organization who is required under b. For Hired Auto Physical Damage Cover-
a written contract or agreement between you and age, the following are deemed to be cov-
that person or organization, that is signed and ered"autos"you own:
executed by you before the "bodily injury" or (1) Any covered "auto" you lease, hire,
"property damage" occurs and that is in effect rent or borrow;and
during the policy period, to be named as an addi- (2) Any covered "auto" hired or rented by
tional insured is an "insured" for Covered Autos your "employee" under a contract in
Liability Coverage, but only for damages to which an "employee's" name, with your
CA T3 53 02 15 b 2015 The Travelers Indemnity Company,All rights reserved. Page 1 of 4
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
COMMERCIAL AUTO
permission, while performing duties (a) With respect to any claim made or "suit"
related to the conduct of your busi- brought outside the United States of
ness. America, the territories and possessions
However, any"auto"that is leased, hired, of the United States of America, Puerto
rented or borrowed with a driver is not a Rico and Canada:
covered"auto". (i) You must arrange to defend the "in-
D. EMPLOYEES AS INSURED sured"against, and investigate or set-
tle any such claim or "suit" and keep
The following is added to Paragraph A.1., Who Is us advised of all proceedings and ac-
An Insured, of SECTION II—COVERED AUTOS tions.
LIABILITY COVERAGE:
(ii) Neither you nor any other involved
Any"employee"of yours is an "insured"while us- "insured" will make any settlement
ing a covered "auto"you don't own, hire or borrow without our consent.
in your business or your personal affairs.
(iii)We may, at our discretion, participate
E. SUPPLEMENTARY PAYMENTS — INCREASED in defending the "insured" against, or
LIMITS in the settlement of, any claim or
1. The following replaces Paragraph A.2.a.(2), "suit".
of SECTION II—COVERED AUTOS LIABIL- (iv)We will reimburse the "insured" for
ITY COVERAGE: sums that the "insured" legally must
(2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily
cluding bonds for related traffic law viola- injury" or"property damage" to which
tions) required because of an "accident" this insurance applies, that the "in-
we cover. We do not have to furnish sured" pays with our consent, but
these bonds. only up to the limit described in Para-
2. The following replaces Paragraph A.2.a.(4), graph C., Limits Of Insurance, of
of SECTION II—COVERED AUTOS LIABIL- SECTION II — COVERED AUTOS
ITY COVERAGE: LIABILITY COVERAGE.
(4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for
"insured" at our request, including actual the reasonable expenses incurred
loss of earnings up to $500 a day be- with our consent for your investiga-
cause of time off from work. tion of such claims and your defense
of the "insured" against any such
F. HIRED AUTO — LIMITED WORLDWIDE COV- "suit", but only up to and included
ERAGE—INDEMNITY BASIS within the limit described in Para-
The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of
graph B.7., Policy Period, Coverage Territory, SECTION II — COVERED AUTOS
of SECTION IV — BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in
TIONS: addition to such limit. Our duty to
(5) Anywhere in the world, except any country or make such payments ends when we
jurisdiction while any trade sanction, em- have used up the applicable limit of
bargo, or similar regulation imposed by the insurance in payments for damages,
United States of America applies to and pro- settlements or defense expenses.
hibits the transaction of business with or (b) This insurance is excess over any valid
within such country or jurisdiction, for Cov- and collectible other insurance available
ered Autos Liability Coverage for any covered to the "insured" whether primary, excess,
"auto" that you lease, hire, rent or borrow contingent or on any other basis.
without a driver for a period of 30 days or less (c) This insurance is not a substitute for re-
and that is not an "auto" you lease, hire, rent quired or compulsory insurance in any
or borrow from any of your "employees", country outside the United States, its ter-
partners (if you are a partnership), members ritories and possessions, Puerto Rico and
(if you are a limited liability company) or Canada.
members of their households.
Page 2 of 4 02015 The Travelers Indemnity Company.All rights reserved. CA T3 53 02 15
Includes copyrighted material of Insurance Services Office,Inc.with its permission,
COMMERCIAL AUTO
You agree to maintain all required or (2) In or on your covered"auto".
compulsory insurance in any such coun- This coverage applies only in the event of a total
try up to the minimum limits required by theft of your covered"auto".
local law. Your failure to comply with No deductibles apply to this Personal Property
compulsory insurance requirements will coverage.
not invalidate the coverage afforded by
this policy, but we will only be liable to the K. AIRBAGS
same extent we would have been liable The following is added to Paragraph B.3., Exclu-
had you complied with the compulsory in- sions, of SECTION III — PHYSICAL DAMAGE
surance requirements. COVERAGE:
(d) It is understood that we are not an admit- Exclusion 3.a. does not apply to 'loss" to one or
ted or authorized insurer outside the more airbags in a covered "auto"you own that in-
United States of America, its territories flate due to a cause other than a cause of 'loss"
and possessions, Puerto Rico and Can- set forth in Paragraphs A.1.b. and A.1.c., but
ada. We assume no responsibility for the only:
furnishing of certificates of insurance, or a. If that"auto" is a covered "auto"for Compre-
for compliance in any way with the laws hensive Coverage under this policy;
of other countries relating to insurance. b. The airbags are not covered under any war-
G. WAIVER OF DEDUCTIBLE—GLASS ranty; and
The following is added to Paragraph D., Deducti- c. The airbags were not intentionally inflated.
ble, of SECTION III — PHYSICAL DAMAGE We will pay up to a maximum of $1,000 for any
COVERAGE: one'loss".
No deductible for a covered "auto" will apply to L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
glass damage if the glass is repaired rather than LOSS
replaced. The f'oll'owing is added to Paragraph A.2.a., of
H. HIRED AUTO PHYSICAL DAMAGE— LOSS OF SECTION IV—BUSINESS AUTO CONDITIONS:
USE—INCREASED LIMIT Your duty to give us or our authorized representa-
The following replaces the last sentence of Para- tive prompt notice of the "accident" or "loss" ap-
graph AA.b., Loss Of Use Expenses, of SEC- plies only when the "accident" or'loss" is known
TION III—PHYSICAL DAMAGE COVERAGE: to:
However, the most we will pay for any expenses (a) You(if you are an individual);
for loss of use is $65 per day, to a maximum of (b) A partner(if you are a partnership);
$750 for any one"accident". (c) A member (if you are a limited liability com-
I. PHYSICAL DAMAGE — TRANSPORTATION pany);
EXPENSES—INCREASED LIMIT (d) An executive officer, director or insurance
The following replaces the first sentence in Para- manager(if you are a corporation or other or-
graph AA.a., Transportation Expenses, of ganization); or
SECTION III — PHYSICAL DAMAGE COVER- (e) Any "employee"authorized by you to give no-
AGE: tice of the"accident"or"loss".
We will pay up to $50 per day to a maximum of M. BLANKET WAIVER OF SUBROGATION
$1,500 for temporary transportation expense in- The following replaces Paragraph A.5., Transfer
curred by you because of the total theft of a cov- Of Rights Of Recovery Against Others To Us,
ered"auto"of the private passenger type. of SECTION IV — BUSINESS AUTO CONDI-
J. PERSONAL PROPERTY TIONS:
The following is added to Paragraph AA., Cover- 5. Transfer Of Rights Of Recovery Against
age Extensions, of SECTION III — PHYSICAL Others To Us
DAMAGE COVERAGE: We waive any right of recovery we may have
Personal Property against any person or organization to the ex-
tent required of you by a written contract
We will pay up to $400 for "loss" to wearing ap- signed and executed prior to any "accident'
parel and other personal property which is: or"loss", provided that the"accident'or"loss"
(1) Owned by an"insured"; and arises out of operations contemplated by
CA T3 53 02 15 @2015 The Travelers Indemnity Company.All rights reserved. Page 3 of 4
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
COMMERCIAL AUTO
such contract. The waiver applies only to the The unintentional omission of, or unintentional
person or organization designated in such error in, any information given by you shall not
contract. prejudice your rights under this insurance. How-
N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col-
The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of
cealment, Misrepresentation, Or Fraud, of cancellation or non-renewal.
SECTION IV—BUSINESS AUTO CONDITIONS:
Page 4 of 4 02015 The Travelers Indemnity Company.All rights reserved. CA T3 53 02 15
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
COMMERCIAL GENERAL LIABILITY
Policy#630 2G970183
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
TECHNOLOGY XTEND ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage. However,coverage for any
injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover-
age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. Reasonable Force Property Damage—Ex- K. Blanket Additional Insured—Persons Or Or-
ception To Expected Or Intended Injury Ex- ganizations For Your Ongoing Operations As
clusion Required By Written Contract Or Agreement
B. Non-Owned Watercraft Less Than 75 Feet L. Blanket Additional Insured—Broad Form
C. Aircraft Chartered With Pilot Vendors
D. Damage To Premises Rented To You M. Who Is An Insured—Unnamed Subsidiaries
E. Increased Supplementary Payments N. Who Is An Insured—Liability For Conduct Of
F. Who Is An Insured—Employees And Volun-
Unnamed Partnerships Or Joint Ventures
teer Workers—First Aid O. Medical Payments—Increased Limits
G. Who Is An Insured—Employees—Supervi- P. Contractual Liability—Railroads
sory Positions Q. Knowledge And Notice Of Occurrence Or Of-
H. Who Is An Insured—Newly Acquired Or fense
Formed Organizations R. Unintentional Omission
I. Blanket Additional Insured—Owners, Manag- S. Blanket Waiver Of Subrogation
ers Or Lessors Of Premises
J. Blanket Additional Insured—Lessors Of
Leased Equipment
PROVISIONS B. NON-OWNED WATERCRAFT LESS THAN 75
A. REASONABLE FORCE PROPERTY DAMAGE— FEET
EXCEPTION TO EXPECTED OR INTENDED IN- The following replaces Paragraph (2) of Exclusion
JURY EXCLUSION g., Aircraft, Auto Or Watercraft, in Paragraph 2.
The following replaces Exclusion a., Expected Or of SECTION I — COVERAGES — COVERAGE A
Intended Injury, in Paragraph 2., of SECTION I— BODILY INJURY AND PROPERTY DAMAGE
COVERAGES — COVERAGE A BODILY IN- LIABILITY:
JURY AND PROPERTY DAMAGE LIABILITY: (2) A watercraft you do not own that is:
a. Expected Or Intended Injury Or Damage (a) Less than 75 feet long;and
"Bodily injury" or "property damage" expected or (b) Not being used to carry any person or
intended from the standpoint of the insured. This property for a charge.
exclusion does not apply to "bodily injury" or C. AIRCRAFT CHARTERED WITH PILOT
"property damage" resulting from the use of rea-
sonable force to protect any person or property. The following is added to Exclusion g., Aircraft,
Auto Or Watercraft, in Paragraph 2.of SECTION
CG D4 17 01 12 O 2012 The Travelers Indemnity Company. All rights reserved. Page 1 of 6
Includes copyrighted material of Insurance Services Office,Inc,with its permission.
Policy#630 2G970183
COMMERCIAL GENERAL LIABILITY
I — COVERAGES — COVERAGE A BODILY IN- 4. The following replaces Paragraph a. of the
JURY AND PROPERTY DAMAGE LIABILITY: definition of"insured contract" in the DEFINI-
This exclusion does not apply to an aircraft that TIONS Section:
is: a. A contract for a lease of premises. How-
(a) Chartered with a pilot to any insured; ever, that portion of the contract for a
lease of premises that indemnifies any
(b) Not owned by any insured;and person or organization for "premises
(c) Not being used to carry any person or prop- damage" is not an"insured contract";
erty for a charge. 5. The following is added to the DEFINITIONS
D. DAMAGE TO PREMISES RENTED TO YOU Section:
1. The first paragraph of the exceptions in Ex- "Premises damage" means "property dam-
clusion j., Damage To Property, in Para- age"to:
graph 2. of SECTION I — COVERAGES — a. Any premises while rented to you or tem-
COVERAGE A BODILY INJURY AND porarily occupied by you with permission
PROPERTY DAMAGE LIABILITY is deleted. of the owner;or
2. The following replaces the last paragraph of b. The contents of any premises while such
Paragraph 2., Exclusions, of SECTION I — premises is rented to you, if you rent such
COVERAGES — COVERAGE A BODILY IN- premises for a period of seven or fewer
JURY AND PROPERTY DAMAGE LIABIL- consecutive days.
ITY:
6. The following replaces Paragraph 4.b.(1)(b)
Exclusions c., g. and h., and Paragraphs (1), of SECTION IV— COMMERCIAL GENERAL
(3) and (4) of Exclusion j., do not apply to LIABILITY CONDITIONS:
"premises damage". Exclusion f.(1)(a) does
not apply to "premises damage" caused by (b) That is insurance for "premises damage";
fire unless Exclusion f. of Section I — Cover- or
age A — Bodily Injury And Property Damage 7. Paragraph 4.b.(1)(c) of SECTION IV —
Liability is replaced by another endorsement COMMERCIAL GENERAL LIABILITY CON-
to this Coverage Part that has Exclusion -All DITIONS is deleted.
Pollution Injury Or Damage or Total Pollution E. INCREASED SUPPLEMENTARY PAYMENTS
Exclusion in its title. A separate limit of insur-
ance applies to "premises damage" as de- 1. The following replaces Paragraph 1.b. of
scribed in Paragraph 6. of Section III —Limits SUPPLEMENTARY PAYMENTS — COVER-
Of Insurance. AGES A AND B of SECTION I — COVER-
AGES:
3. The following replaces Paragraph 6. of SEC-
TION III—LIMITS OF INSURANCE: b. Up to $2,500 for cost of bail bonds re-
quired because of accidents or traffic law
6. Subject to 5. above, the Damage To violations arising out of the use of any
Premises Rented To You Limit is the vehicle to which the Bodily Injury Liability
most we will pay under Coverage A for Coverage applies. We do not have to fur-
damages because of"premises damage" nish these bonds.
to any one premises.
2. The following replaces Paragraph 1.d. of
The Damage To Premises Rented To SUPPLEMENTARY PAYMENTS — COVER-
You Limit will be: AGES A AND B of SECTION I — COVER-
a. The amount shown for the Damage AGES:
To Premises Rented To You Limit on d. All reasonable expenses incurred by the
the Declarations of this Coverage insured at our request to assist us in the
Part;or investigation or defense of the claim or
b. $300,000 if no amount is shown for "suit", including actual loss of earnings up
the Damage To Premises Rented To to $500 a day because of time off from
You Limit on the Declarations of this work.
Coverage Part.
Page 2 of 6 O 2012 The Travelers Indemnity Company. All rights reserved. CG D4 17 01 12
Includes copyrighted material of Insurance Services Office,Inc.with its permission,
Policy#630 2G970183
COMMERCIAL GENERAL LIABILITY
F. WHO IS AN INSURED — EMPLOYEES AND your "employees" who hold a supervisory posi-
VOLUNTEER WORKERS—FIRST AID tion.
1. The following is added to the definition of"oc- H. WHO IS AN INSURED — NEWLY ACQUIRED
currence" in the DEFINITIONS Section: OR FORMED ORGANIZATIONS
Unless you are in the business or occupation The following replaces Paragraph 4. of SECTION
of providing professional health care services, II — WHO IS AN INSURED of the Commercial
"occurrence" also means an act or omission General Liability Coverage Form, and Paragraph
committed by any of your "employees" or 3. of SECTION II—WHO IS AN INSURED of the
"volunteer workers", other than an employed Global Companion Commercial General Liability
or volunteer doctor, in providing or failing to Coverage Form, to the extent such coverage
provide first aid or"Good Samaritan services" forms are part of your policy:
to a person. Any organization you newly acquire or form, other
2. The following is added to Paragraph 2.a.(1)of than a partnership or joint venture, of which you
SECTION II—WHO IS AN INSURED: are the sole owner or in which you maintain the
majority ownership interest, will qualify as a
Unless you are in the business or occupation Named Insured if there is no other insurance
of providing professional health care services, which provides similar coverage to that organiza-
Paragraphs (1 )(a), (b), (c) and (d) above do tion. However:
not apply to "bodily injury" arising out of pro- a. Coverage under this provision is afforded
viding or failing to provide first aid or "Good
Samaritan services" by any of your "employ-
ees" or "volunteer workers", other than an (1) Until the 180th day after you acquire or
employed or volunteer doctor. Any of your form the organization or the end of the
"employees" or "volunteer workers" providing policy period, whichever is earlier, if you
or failing to provide first aid or"Good Samari- do not report such organization in writing
tan services" during their work hours for you to us within 180 days after you acquire or
form it; or
will be deemed to be acting within the scope
of their employment by you or performing du- (2) Until the end of the policy period, when
ties related to the conduct of your business. that date is later than 180 days after you
acquire or form such organization, if you
3. The following is added to Paragraph S. of report such organization in writing to us
SECTION III—LIMITS OF INSURANCE: within 180 days after you acquire or form
For the purposes of determining the applica- it, and we agree in writing that it will con-
ble Each Occurrence Limit, all related acts or tinue to be a Named Insured until the end
omissions committed by any of your"employ- of the policy period;
ees" or "volunteer workers" in providing or b. Coverage A does not apply to "bodily injury"
failing to provide first aid or"Good Samaritan or "property damage" that occurred before
services"to any one person will be deemed to you acquired or formed the organization; and
be one"occurrence". c. Coverage B does not apply to "personal in-
4. The following is added to the DEFINITIONS jury" or "advertising injury" arising out of an
Section: offense committed before you acquired or
"Good Samaritan services" means any emer-
formed the organization.
gency medical services for which no compen- I. BLANKET ADDITIONAL INSURED —OWNERS,
sation is demanded or received. MANAGERS OR LESSORS OF PREMISES
G. WHO IS AN INSURED — EMPLOYEES — SU- The following is added to SECTION II —WHO IS
PERVISORY POSITIONS AN INSURED:
The following is added to Paragraph 2.a.(1) of Any person or organization that is a premises
SECTION II—WHO IS AN INSURED: owner, manager or lessor is an insured, but only
with respect to liability arising out of the owner-
Paragraphs (1)(a), (b) and (c) above do not apply ship, maintenance or use of that part of any prem-
to "bodily injury" or "personal injury" to a co- ises leased to you.
"employee" in the course of the co-"employee's" The insurance provided to such premises owner,
employment by you arising out of work by any of manager or lessor does not apply to:
CG D4 17 01 12 02012 The Travelers Indemnity Company. All rights reserved, Page 3 of 6
Includes copyrighted material of Insurance Services Office,Inc,with its permission.
Policy#630 2G970183
COMMERCIAL GENERAL LIABILITY
a. Any "bodily injury" or "property damage" L. BLANKET ADDITIONAL INSURED — BROAD
caused by an "occurrence" that takes place, FORM VENDORS
or "personal injury" or "advertising injury" The following is added to SECTION II —WHO IS
caused by an offense that is committed, after AN INSURED:
you cease to be a tenant in that premises;or
bAny person or organization that is a vendor and
. Structural alterations, new construction or
that you have agreed in a written contract or
demolition operations performed by or on be- agreement to include as an additional insured on
half of such premises owner, manager or les- this Coverage Part is an insured, but only with re-
sor. spect to liability for "bodily injury" or "property
J. BLANKET ADDITIONAL INSURED— LESSORS damage"that:
OF LEASED EQUIPMENT a. Is caused by an"occurrence"that takes place
The following is added to SECTION II —WHO IS after you have signed and executed that con-
AN INSURED: tract or agreement; and
Any person or organization that is an equipment b. Arises out of "your products" which are dis-
lessor is an insured, but only with respect to liabil- tributed or sold in the regular course of such
ity for "bodily injury", "property damage", "per- vendor's business.
sonal injury" or "advertising injury" caused, in The insurance provided to such vendor is subject
whole or in part, by your acts or omissions in the to the following provisions:
maintenance, operation or use by you of equip-
ment leased to you by such equipment lessor. a. The limits of insurance provided to such ven-
The insurance provided to such equipment lessor dor will be the limits which you agreed to pro-
does nota I to an "bodily ' "property vide in the written contract or agreement, or
apply y injury" or ro p p y the limits shown in the Declarations, which-
damage" caused by an "occurrence" that takes ever are less.
place, or "personal injury" or "advertising injury"
caused by an offense that is committed, after the b. The insurance provided to such vendor does
equipment lease expires. not apply to:
K. BLANKET ADDITIONAL INSURED— PERSONS (1) Any express warranty not authorized by
OR ORGANIZATIONS FOR YOUR ONGOING you;
OPERATIONS AS REQUIRED BY WRITTEN (2) Any change in"your products"made by
CONTRACT OR AGREEMENT such vendor;
The following is added to SECTION II —WHO IS
AN INSURED: (3) Repackaging, unless unpacked solely for
the purpose of inspection,demonstration,
Any person or organization that is not otherwise testing,or the substitution of parts under
an insured under this Coverage Part and that you instructions from the manufacturer, and
have agreed in a written contract or agreement to then repackaged in the original container;
include as an additional insured on this Coverage
Part is an insured, but only with respect to liability (4) Any failure to make such inspections,
for"bodily injury"or"property damage"that: agree to o p tests or servicing as vendors
agree perform or normally undertake to
a. Is caused by an "occurrence"that takes place perform in the regular course of business,
after you have signed and executed that con- in connection with the distribution or sale
tract or agreement; and of"your products";
b. Is caused, in whole or in part, by your acts or (5) Demonstration, installation, servicing or
omissions in the performance of your ongoing repair operations, except such operations
operations to which that contract or agree- performed at such vendor's premises in
ment applies or the acts or omissions of any connection with the sale of"your prod-
person or organization performing such op- ucts";or
erations on your behalf.
(6) "Your products"which, after distribution
The limits of insurance provided to such insured or sale by you, have been labeled or re-
will be the limits which you agreed to provide in labeled or used as a container, part or in-
the written contract or agreement, or the limits gredient of any other thing or substance
shown in the Declarations,whichever are less. by or on behalf of such vendor.
Page 4 of 6 ©2012 The Travelers Indemnity Company. All rights reserved. CG D4 17 0112
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
Policy#630 2G970183
COMMERCIAL GENERAL LIABILITY
Coverage under this provision does not apply to: (b) The amount shown on the Declarations of
a. Any person or organization from whom you this Coverage Part for Medical Expense
have acquired "your products", or any ingre- Limit.
dient, part or container entering into, accom- P. CONTRACTUAL LIABILITY—RAILROADS
panying or containing such products; or 1. The following replaces Paragraph c. of the
b. Any vendor for which coverage as an addi- definition of"insured contract" in the DEFINI-
tional insured specifically is scheduled by en- TIONS Section:
dorsement. c. Any easement or license agreement;
M. WHO IS AN INSURED — UNNAMED SUBSIDI- 2. Paragraph f.(1) of the definition of "insured
ARIES contract" in the DEFINITIONS Section is de-
The following is added to SECTION II—WHO IS leted.
AN INSURED: Q. KNOWLEDGE AND NOTICE OF OCCUR-
Any of your subsidiaries, other than a partnership RENCE OR OFFENSE
or joint venture, that is not shown as a Named In- The following is added to Paragraph 2., Duties In
sured in the Declarations is a Named Insured if: The Event of Occurrence, Offense, Claim or
a. You maintain an ownership interest of more Suit, of SECTION IV — COMMERCIAL GEN-
than 50% in such subsidiary on the first day ERAL LIABILITY CONDITIONS:
of the policy period; and e. The following provisions apply to Paragraph
b. Such subsidiary is not an insured under simi- a. above, but only for the purposes of the in-
lar other insurance. surance provided under this Coverage Part to
No such subsidiary is an insured for"bodily injury" you or any insured listed in Paragraph 1.or 2.of Section II—Who Is An Insured:
or "property damage" that occurred, or "personal
injury" or "advertising injury" caused by an of- (1) Notice to us of such "occurrence" or of-
fense committed: fense must be given as soon as practica-
a. Before you maintained an ownership interest ble only after the "occurrence" or offense
of more than 50% in such subsidiary; is known to you (if you are an individual),
or any of your partners or members who is
b. After the date, if any, during the policy period an individual (if you are a partnership or
that you no longer maintain an ownership in- joint venture), any of your managers who
terest of more than 50% in such subsidiary. is an individual (if you are a limited liability
N. WHO IS AN INSURED — LIABILITY FOR CON- company), any of your trustees who is an
DUCT OF UNNAMED PARTNERSHIPS OR individual (if you are a trust), any of your
JOINT VENTURES "executive officers" or directors (if you are
The following replaces the last paragraph of an organization other than a partnership,
joint venture, limited liability company or
SECTION II—WHO IS AN INSURED: trust) or any "employee" authorized by
No person or organization is an insured with re- you to give notice of an "occurrence" or
spect to the conduct of any current or past part- offense.
nership or joint venture that is not shown as a
Named Insured in the Declarations. This para- (2) If you are a partnership,joint venture, lim-
ited liability company or trust, and none of
graph does not apply to any such partnership or your partners, joint venture members,
joint venture that otherwise qualifies as an in- managers or trustees are individuals, no-
sured under Section II—Who Is An Insured. tice to us of such "occurrence" or offense
O. MEDICAL PAYMENTS—INCREASED LIMITS must be given as soon as practicable only
The following replaces Paragraph 7. of SECTION after the"occurrence"or offense is known
III—LIMITS OF INSURANCE: by:
7. Subject to 5. above, the Medical Expense (a) Any individual who is:
Limit is the most we will pay under Coverage
C for all medical expenses because of"bodily (i) partner member any part
-
C joint venture;
injury" sustained by any one person, and will ership or o
be the higher of: (ii) A manager of any limited liability
(a) $10,000; or company;
CG D4 17 01 12 O 2012 The Travelers Indemnity Company. All rights reserved. Page 5 of 6
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
Policy#630 2G970183
COMMERCIAL GENERAL LIABILITY
(iii)A trustee of any trust;or abrupt commencement, this Paragraph e.
(iv)An executive officer or director of does not affect that requirement.
any other organization; R. UNINTENTIONAL OMISSION
that is your partner, joint venture The following is added to Paragraph 6., Repre-
member, manager or trustee;or sentations, of SECTION IV — COMMERCIAL
(b) Any "employee" authorized by such GENERAL LIABILITY CONDITIONS:
partnership, joint venture, limited li- The unintentional omission of, or unintentional ar-
ability company, trust or other organi- ror in, any information provided by you which we
zation to give notice of an "occur- relied upon in issuing this policy will not prejudice
rence"or offense. your rights under this insurance. However, this
(3) Notice to us of such "occurrence" or of- provision does not affect our right to collect addi-
fense will be deemed to be given as soon tional premium or to exercise our rights of cancel-
as practicable if it is given in good faith aslation or nonrenewal in accordance with applica-
soon as practicable to your workers' ble insurance laws or regulations.
compensation insurer. This applies only if S. BLANKET WAIVER OF SUBROGATION
you subsequently give notice to us of the The following is added to Paragraph 8., Transfer
occurrence" or offense as soon as prac- Of Rights Of Recovery Against Others To Us,
ticable after any of the persons described of SECTION IV— COMMERCIAL GENERAL LI-
in Paragraphs e. (1) or(2) above discov- ABILITY CONDITIONS:
ers that the "occurrence" or offense may
result in sums to which the insurance If the insured has agreed in a contract or agree-
provided under this Coverage Part may ment to waive that insured's right of recovery
apply. against any person or organization, we waive our
right of recovery against such person or organiza-
ment that provides limited coverage for "bod-
However, if this policy includes an endorse- tion, but only for payments we make because of:
ily injury" or "property damage" or pollution a. "Bodily injury" or "property damage" caused
costs arising out of a discharge, release or by an "occurrence"that takes place; or
escape of "pollutants" which contains a re- b. "Personal injury" or "advertising injury"
quirement that the discharge, release or es- caused by an offense that is committed;
cape of "pollutants" must be reported to us subsequent to the execution of the contract or
within a specific number of days after its agreement.
Page 6 of 6 ©2012 The Travelers Indemnity Company, All rights reserved. CG D4 17 01 12
includes copyrighted material of Insurance Services Office,Inc.with its permission.
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 630-2G970183 ISSUE DATE: 10-01-17
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
TOTAL AGGREGATE LIMIT AND DESIGNATED PROJECT
AND LOCATION AGGREGATE LIMITS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
The Limits of Insurance shown in the Declarations are replaced by the following:
LIMITS OF INSURANCE
Total Aggregate Limit $ 2,000,000
(Other Than Products-Completed Operations)
Designated Project Aggregate Limit $ 2,000,000
(Other Than Products-Completed Operations)
Designated Location Aggregate Limit $ 2,000,000
(Other Than Products-Completed Operations)
General Aggregate Limit $ 2,000,000
(Other Than Products-Completed Operations)
Products-Completed Operations Aggregate Limit $ 2,000,000
Personal and Advertising Injury Limit $ 1,000,000
Each Occurrence Limit $ 1,000,000
Damage To Premises Rented to You Limit $ 300,000
Any One Premises
Medical Expense Limit $ 10,000
Any One Person
Designated Projects:
Designated Locations:
PROVISIONS (4) Designated "projects" or "locations"
A. The following replaces SECTION III-LIMITS OF shown in the Schedule above.
INSURANCE: b. The Total Aggregate Limit shown in the
1. a. The Limits of Insurance shown in the Schedule above is the most we will pay
Schedule above and the rules below fix for the sum of all amounts under the Des-
the most we will pay regardless of the ignated Project Aggregate Limit, all
number of: amounts under the Designated Location
Aggregate Limit and all amounts under
(1) Insureds; the General Aggregate Limit. This in-
(2) Claims made or"suits" brought; cludes:
(3) Persons or organizations making (1) Damages under Coverage A, except
claims or bringing"suits";or damages because of"bodily injury"or
CG D4 68 01 09 O 2009 The Travelers Companies,Inc, Page 1 of 4
COMMERCIAL GENERAL LIABILITY
"property damage" included in the shown in the Schedule above and
"products-completed operations haz- described in 2. below,the Designated
and"; Project Aggregate Limit for any other
(2) Damages under Coverage B;and designated "project" shown in the
(3) Medical expenses under Coverage C. Schedule above or the DesignatedLocation Aggregate Limit shown in
c. Subject to the Total Aggregate Limit the Schedule above.
shown in the Schedule above and de- d. Subject to the Total Aggregate Limit
scribed in b. above, a Designated Project shown in the Schedule above and de-
Aggregate Limit is provided and is also scribed in b. above, a Designated Loca-
shown in the Schedule above. The Des- tion Aggregate Limit is provided and is
ignated Project Aggregate Limit is subject also shown in the Schedule above. The
to all of the following provisions: Designated Location Aggregate Limit is
(1) The Designated Project Aggregate subject to all of the following provisions:
Limit is the most we will pay for the (1) The Designated Location Aggregate
sum of: Limit is the most we will pay for the
(a) Damages under Coverage A be- sum of:
cause of "bodily injury" and (a) Damages under Coverage A be-
"property damage" caused by cause of "bodily injury" and
"occurrences"and "property damage" caused by
(b) Medical expenses under Cover- "occurrences"and
age C for "bodily injury" caused (b) Medical expenses under Cover-
by accidents; age C for "bodily injury" caused
which can be attributed only to opera- by accidents;
tions at a single designated "project" which can be attributed only to opera-
shown in the Schedule above. tions at a single designated "location"
(2) The Designated Project Aggregate shown in the Schedule above.
Limit applies separately to each des- (2) The Designated Location Aggregate
ignated"project". Limit applies separately to each des-
(3) The Designated Project Aggregate ignated"location".
Limit does not apply to damages be- (3) The Designated Location Aggregate
cause of "bodily injury" or "property Limit does not apply to damages be-
damage" included in the "products- cause of "bodily injury" or "property
completed operations hazard." In- damage" included in the "products-
stead, the Products-Completed Op- completed operations hazard." In-
erations Aggregate Limit shown in the stead, the Products-Completed Op-
Schedule above and described in 3. erations Aggregate Limit shown in the
below applies to such damages. Schedule above and described in 3.
(4) The Designated Project Aggregate below applies to such damages.
Limit does not apply to damages un- (4) The Designated Location Aggregate
der Coverage B. Instead,the General Limit does not apply to damages un-
Aggregate Limit shown in the Sched- der Coverage B. Instead,the General
ule above and described in 2. below Aggregate Limit shown in the Sched-
applies to such damages. ule above and described in 2. below
(5) Any payments made for damages or applies to such damages.
medical expenses to which the Des- (5) Any payments made for damages or
ignated Project Aggregate Limit ap- medical expenses to which the Des-
plies shall reduce both the Total Ag- ignated Location Aggregate Limit ap-
gregate Limit shown in the Schedule plies shall reduce both the Total Ag-
above and the Designated Project gregate Limit shown in the Schedule
Aggregate Limit for that designated above and the Designated Location
"project". Such payments shall not Aggregate Limit for that designated
reduce the General Aggregate Limit "location". Such payments shall not
Page 2 of 4 O 2009 The Travelers Companies,Inc. CG D4 68 01 09
COMMERCIAL GENERAL LIABILITY
reduce the General Aggregate Limit completed operations hazard". Any payments
shown in the Schedule above and made for such damages shall reduce the
described in 2. below,the Designated Products-Completed Operations Aggregate
Project Aggregate Limit shown in the Limit shown in the Schedule above. Such
Schedule above or the Designated payments shall not reduce the Total Aggre-
Location Aggregate Limit for any gate Limit shown in the Schedule above, the
other designated "location" shown in General Aggregate Limit shown in the
the Schedule above. Schedule above, the Designated Project Ag-
2. Subject to the Total Aggregate Limit shown in gregate Limit for any designated "project"
the Schedule above and described in 1.b. shown in the Schedule above or the Desig-
above, a General Aggregate Limit is provided nated Location Aggregate Limit for any des-
and is also shown in the Schedule above. ignated "location" shown in the Schedule
The General Aggregate Limit is subject to all above.
of the following provisions: 4. Subject to the Total Aggregate Limit and the
a. The General Aggregate Limit is the most General Aggregate Limit shown in the
we will pay for the sum of: Schedule above and described in 1.b. and 2.
above, the Personal and Advertising Injury
(1) Damages under Coverage A be- Limit is the most we will pay under Coverage
cause of"bodily injury" and "property B for the sum of all damages because of all
damage" caused by "occurrences", "personal injury" and all "advertising injury"
and medical expenses under Cover- sustained by any one person or organization.
age C for "bodily injury" caused by
accidents, which cannot be attributed 5. Subject to the Total Aggregate Limit and ei-
only to operations at a single desig- ther the Designated Project Aggregate Limit,
nated "project" or"location" shown in the Designated Location Aggregate Limit or
the Schedule above;and the General Aggregate Limit, or subject to the
Products-Completed Operations Aggregate
(2) Damages under Coverage B. Limit, shown in the Schedule above and de-
b. The General Aggregate Limit does not scribed in 1.b., 1.c., 1.d., 2. and 3. above,
apply to damages for "bodily injury" or whichever apply or applies, the Each Occur-
"property damage" included in the "prod- rence Limit is the most we will pay for the
ucts-completed operations hazard." In- sum of:
stead, the Products-Completed Opera- a. Damages under Coverage A; and
tions Aggregate Limit shown in the
Schedule above and described in 3. be- b. Medical expenses under Coverage C
low applies to such damages. because of all "bodily injury" and "property
c. Any payments made for damages or damage"arising out of any one"occurrence".
medical expenses to which the General 6. Subject to the Each Occurrence Limit shown
Aggregate Limit applies shall reduce both in the Schedule above and described in 5.
the Total Aggregate Limit shown in the above, the Damage To Premises Rented To
Schedule above and the General Aggre- You Limit is the most we will pay under Cov-
gate Limit shown in the Schedule above. erage A for damages because of "property
Such payments shall not reduce the Des- damage"to any one premises,while rented to
ignated Project Aggregate Limit for any you, or in the case of damage by fire, while
designated "project" shown in the Sched- rented to you or temporarily occupied by you
ule above or the Designated Location with permission of the owner.
Aggregate Limit for any designated "loca- 7, Subject to the Each Occurrence Limit shown
tion" shown in the Schedule above. in the Schedule above and described in 5.
3. If coverage for liability arising out of the above, the Medical Expense Limit is the most
"products-completed operations hazard" is we will pay under Coverage C for all medical
provided,the Products-Completed Operations expenses because of"bodily injury" sustained
Aggregate Limit shown in the Schedule above by any one person.
is the most we will pay under Coverage A for The Limits of Insurance of this Coverage Part ap-
damages because of "bodily injury" or "prop- ply separately to each consecutive annual period
erty damage" included in the "products- and to any remaining period of less than 12
CG D4 68 01 09 ©2009 The Travelers Companies,Inc. Page 3 of 4
COMMERCIAL GENERAL LIABILITY
months, starting with the beginning of the policy rupted only by a street, roadway or waterway, or
period shown in the Declarations, unless the pol- by a right-of-way of a railroad, shall be considered
icy period is extended after issuance for an addi- a single"location".
tional period of less than 12 months. In that case, "Project" means any area, away from premises
the additional period will be deemed part of the owned by or rented to you, shown in the schedule
last preceding period for purposes of determining above at which you are performing operations
the Limits of Insurance. pursuant to a contract or agreement. For the pur-
B. The following is added to the DEFINITIONS Sec- poses of determining the applicable aggregate
tion: limit of insurance, each "project" that includes a
premises involving the same or connecting lots,
"Location" means any premises owned by or
rented to you shown in the Schedule above. For or premises whose connection is interrupted only
the purposes of determining the applicable ag- by a street, roadway or waterway,or by a right-of-
gregate limit of insurance, each "location" that in- way of a railroad, shall be considered a single
cludes a premises involving the same or connect- "project".
ing lots, or premises whose connection is inter-
Page 4 of 4 ©2009 The Travelers Companies,Inc. CG D4 68 01 09
COMMERCIAL GENERAL LIABILITY
Policy#630 2G970183
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
OTHER INSURANCE - ADDITIONAL INSUREDS -
PRIMARY AND NON-CONTRIBUTORY WITH RESPECT TO
CERTAIN OTHER INSURANCE
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The following is added to Paragraph 4. a., Primary (1) The"bodily injury"or"property damage"for which
Insurance, of SECTION IV — COMMERCIAL GEN- coverage is sought is caused by an 'occurrence"
ERAL LIABILITY CONDITIONS: that takes place; and
However, if you specifically agree in a written contract (2) The "personal injury" or "advertising injury" for
or agreement that the insurance afforded to an addi- which coverage is sought arises out of an offense
tional insured under this Coverage Part must apply on that is committed;
a primary basis, or a primary and non-contributory
basis,this insurance is primary to other insurance that subsequent to the signing and execution of that con-
is available to such additional insured which covers tract or agreement by you.
such additional insured as a named insured, and we
will not share with that other insurance, provided that:
CG D4 25 07 08 O 2008 The Travelers Companies,Inc. Page 1 of 1
TRAVELERSJ WORKERS COMPENSATION
AND
ONE TOWER SQUARE
HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 03 13(00)-01
POLICY NUMBER: UB-6J962558
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
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. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule,
SCHEDULE
DESIGNATED PERSON:
a
m—
alp.
a�
DESIGNATED ORGANIZATION:
ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS
AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO
FURNISH THIS WAIVER.
0=
h�
O
ot=
DATE OF ISSUE: 10-01-17 ST ASSIGN:
008484