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Arrow Sign Company - Insurance Certificate (2018)
/ 1 ® A� o CERTIFICATE OF LIABILITY INS'U'RANCE DATE (MM /DD/YYYY) 1/17/2018 THIS CERTIFICATE IS ISSUED AS A (MATTER OF iINFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE (HOLDER. THIS CERTIFICATE (DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 'INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED (provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require art endorsement. A statement on p Y p Y 4 this certificate does not confer (rights to the certificate holder in lieu of such' endorsements PRODUCER MCGovernl insurance 1625 El Camino (Real Belmont, CA 94002 CONTACT NAME: 'McGovern Insurance PHONE FAX 650- 593 -8216 A/c INo : 650 - 594 -9130 E -MAIL ADDRESS: INSURERS AFFORDING COVERAGE 'NA'IC # www.jemins.com INSURER A: Associated Industries !Insurance CO 'Inc 231140 INSURED Arrow Slgn Co. INSURER B: United' Financial Casualty Company 1!11770 INSURER C: Great American E &S Insurance Company 37532 1051 46th Avenue INSURER D: United Specialty Insurance Company 112537 Oakland CA 94601 -4436 INSURER E: Cypress Insurance Company 110855 AGGREGATE LIMIT APPLIES (PER: POLICY PRO - POLICY V LOC OTHER: INSURER F: $ 2,000,000. PRODUCTS - COMP /OP AGG COVERAGES CERTIFICATE NUMBER: 39932113 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 1 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. ILIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ILTR TYPE OFINSURANCE ADDL SUBR POLICY NUMBER MM POLICY /DD/YYFF MM/DD/YYYY I LIMITS A �/ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE ✓ I' OCCUR ✓ �/ AES1038793 01 5/15/2017 5/15/201$ 1 EACROCCURRENCE $ 1: 000 000. DAMAGE TO 'RENTED PREMISES Ea occurrence $1:00' 000. MED EXP (Any one person) $5,000. PERSONAL & ADV INJURY $1: 000 000. GEN'L ✓ AGGREGATE LIMIT APPLIES (PER: POLICY PRO - POLICY V LOC OTHER: GENERAL AGGREGATE $ 2,000,000. PRODUCTS - COMP /OP AGG $ 2,000,000. $ IB II :D I D AUTOMOBILE!LIABILITY ANY AUTO OWNED ✓ SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Hired Autos O I 'Non -Owned Au ✓ os II nl 04044896 -0 I'EGM- HN02956 -17 7/30/2017 7/30/2017 7/30/2018 7/30/2018 COMBINED SINGLE LIMIT Ea accident $ 1 000 000. BODILY INJURY (Per person) $ BODILY INJURY (Per accident)(( $ V/ PROPERTY DAMAGE 'Per accident $ Combined Sin le Limit $1,000,000. C ✓ UMBRELLA LIAB EXCESS LIAB �/ OCCUR CLAIMS MADE XS4959616 011 ** Follows Form. ** 5/15/20117 5/15/2011$ EACH OCCURRENCE $5,000,000. AGGREGATE $5,000,000. DIED ✓ I RETENTION $ E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y /'N ' ANYPROPRIETOR/PARTNER/EXECUTIVE jOFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe vender DESCRIPTION OF OPERATIONS below N / A' V ARWC919666 1 /1 /201$ 1'' /1 /2019 ,/ STATUTE ERH E.L.'EACH ACCIDENT $ 1 10001000. E.L.'DISEASE - EA EMPLOYEE $ 1 E.L. DISEASE - POLICY LIMIT $1,000,000. 'DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional' Remarks Schedule, may be attached if more space is'required) RE: Work performed @ Wayfi'nding, Gilroy City of Gilroy, its officers, elected or appointed officials, employees, agents and volunteers are named as Additional Insured & Primary Non- Contributory *30' day written 'Notice of Cancellation, except for non -pay of premium) which is 110' days. CERTIFICA"E'HOLDER CANCELLATION! Clt Of Gilroy, its officers, elected or appointed officials, employees, a agents and volunteers %351 Rosanna Street 9 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Gilroy CA 95020 AUTHORIZED REPRESENTATIVE Steve Suissa` ACORD 25 (2016/03) ©11988 -2015 ACORD CORPORATION(. All rights reserved. The ACORD name and logo are registered marks of ACORD 39932113 1 ARROW -1 II 18/19 GL, AU, UMB, WC (BOR) il'MaryAn Worman 1 1/17/2019 5 04:09 PM (PST) I Page 1 of 12 POLICY NUMBER: AES1038793 01 Arrow Sign Co. 1/17/2018 COMMERCIAL GENERAL LIABILITY CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE TREAD IT CAREFULLY. ADD'IIITIONAL IN'SURE'D - OWNERS, LESSEES OR CONTRACTORS AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided 'under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section Ill. Who Is An Insured is amended to include as an additional: insured any person or organization for whom your are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for ",bodily injury", "property damage" or "lpersonall andl advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed::. Name of Organization: B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury ", "'property damage" or ",personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural! or engineering activities. 2. "Bodiily injury" or "property damage" occurring after: a. All work, including Imatedals, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured( s) at the location of the covered' operations has been compl'etedi; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any 'person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. City of Gilroy, its officers, elected or appointed officials, employees, agents andl volunteers CG 20 33 07 04 ©'ISO Properties, Inc., 2004 39932113 11 ARROW -1 1' 18/19 GL, AU, 'UMB, WC (BOR) Ii MaryAnn Worman 11 1/17/2018 5-04:09 PM (PST) I Page 2 of 12 Page 11 of 1 POLICY NUMBER: AES1038793 01 COIWIW.ERCIAL GENERAL LIA131LIITY Arrow Sign Co. CG 20 37 07!04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional' Insured Person(s) Or Or anization s : Location And Description Of Completed Operations All persons or organizations where written contract with the Named iInsured (requires completed Opera- Work performed ,@ Wayfinding, Gilroy tions coverage. This form does not apply to your work on "resid'ential property." City of Gilroy, its officers, elected or appointed officials„ employees, agents and volunteers Information required to m l t co e e this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown lin the Schedule, but only with respect to liability for "bodily injury" or "(property dam- age" caused, in whole or in apart, by "your work" at the 'location designated and described iin the sched- ule of this endorsement performed for that additional insured and included lin the "products - completed operations hazard ". CG 20 37 07 04 @ ISO Properties, Inc., 2004 Page 1 of I 39932113 II ARROW -1 11 18/19 GL, AU, UMB, WC (BOR) I MaryAnn Worman 1 1/17/2019 5:'04:09 PM (PST) 11 Page 3 of 12 04044896 -0 Arrow Sign Co. CAUFORRNU AMENDATORY ENDORSEMENT Except as specifically modified in this endorsement, all provisions of the Commercial Auto Policy apply. We agree with you that the insurance provided under your Commercial Auto Policy is modified as follows: GENERAL DEFIN nONS The general definition of "relative" is deleted and replaced by the following: 13. "Relative" means, if the named insured is a natural person, any other person living in the household in which the named insured resides who is related to the named insured by blood, marriage or adoption, including a ward or foster child and including the registered) domestic (partner of the named insured. ALL OTHER TERM, LIMITS AM PROVISIONS OF THE POLICY REMAIN UNCHANGED. Form 4881 CA (12/04) 39932113 1 ARROW -1 1 18/19 GL, AU, UMB, WC (BOR) I MaryAnn Worman 11 1/17/2019 5-04:09 PM (PST) I Page 4 of 12 MEDICAL PAYMENTS COVERAGE ENDORSEMENT Except as specifically modified in this endorsement, all provisions of the Commercial Auto Policy apply. We agree with you that the insurance provided under your Commercial Auto Policy is modified as follows: INSURING AGREEMENT Subject to the Limits of Liability, if you pay the premium for Medical Payments Coverage, we will pay the usual and custom w7 charge for reasonable and necessary expenses, incurred within three (3) years from the date of an accident. for medical and funeral services because of bodily injury: 11. sustained by an insured, 2. caused by an accident; and 3. arising out of the ownership, maintenance or use of a motor vehicle or trailer. Any dispute as to the usual and customary charge will' be resolved between the service provider and us. ADDITIONAL. DEFINITIONS When used in this endorsement, whether in the singular, plural, or possessive: 1. "Insured" means: a. if the named insured shown on the Declarations Page is a natural person: (i) you while occupying any auto, other than an auto ownedby you which is not an insured auto; (ii) a relative while occupying an insured auto, temporary substitute auto, or non-owned auto; you or any relative when struck by a land motor vehicle of any type, or a trailer, while not occupying a motor vehicle; and (iv) any other person while occupying an Insured auto, temporary substitute auto, or a trailer while attached'; to aninsured auto; or b. if the named' insured shown on the Declarations Page is a corporation, partnership, organization or any other entity that is not a natural, person, any person occupying your insured auto, temporary substitute auto, or a trailer while attached to an insured auto. 2. "No"wned auto" means any auto that is not ownedby you or famished for your regular use and. if the named insured is a natural person, not owned by or furnished for the regular use of the named insured's spouse or a relative. 3. "Owned" means the person: IL holds legal title to the vehicle; b. has legal' possession of the vehicle that is subject to a written security agreement with an original' term of six (6) months or more; or c. has legal possession of the vehicle that is leased to that person under a written agreement for a continuous periDd of six (6) months or more. 39932113 11 ARROW -1 1 18/19 GL, AU, UMB, WC (BOR) I MaryAn-. Worman 1 1/17/2018 5;04:09 P.M (PST) II Page 5 of 12 4. "Owner" means the person who, withi respect to a vehicle: a. hobs legal title to the vehicle; b. has legall possession of the vehicle that is subject to a written security agreement with an original term of six (6) months or more; or c. has legal possession of the vehicle that is leased to that person under a written agreement for a continuous period of six (6) months or more. 5. "Usual and customary charge" meads an amount which we determine represents a customary charge for services in the geographical area in which the service is rendered. We shall determine the usual and customary charge through the use of independent sources of our choice. EXCLUSIONS - READ TIDE FOLLOWING EXCLUSIONS CAREFULLY. IF AN EXCLUSION APPIM9 COVERAGE WILL NOT BE AFFORDED UNDER TM ENDORSEMENT. Coverage under this endorsement does not apply to bodily Injury: 1. sustained while occupying any auto or trailer while being used as a residence or premises; 2. occurring during the course of employment if workers' compensation coverage should apply; 3. arising out of an accident involving an auto or trailer while being used by a person while employed or engaged in the business of selling, leasing, repairing, parking, storing, servicing, delivering, or testing vehicles, unless that business is yours; 4. resulting from any pre - arranged or organized racing, speed or demolition contest, stunting activity, or in ,practice or preparation for any such contest or activity; 5. due to a nuclear reaction or radiation; 6. for which insurance is afforded under a nuclear energy liability insurance coanw; 7. for which the United, States Government is liable under the Federal Tort Claims Act; 8. sustained by any person while occupying an Insured auto, temporary substitute auto, or trailer without the express or implied permission ofyou or, if the named insured is a natural ,person, a relative; 9. sustained by any person while occupying a non-owned vehicle without the express or implied permission ofthe owner, 10. that is intentionally inflicted on an insured at that person's request or self - inflicted; or 11. sustained while occupying any vehicle that has less than four wheels or is not designed for operation principally upon public roads. LIMITS OF LIABILITY Regardless of the number of premiums paid, or the number of insured autos or trailers shown on the Declarations Page, or the number of policies issued by us, or the number of vehicles or Insureds involved in an accident, or the number of claims or lawsuits arising out of an accidont, me will' pay no more than the Limit of Liability shown for Medical Payments Coverage on the Declarations Page. 39932113 1 ARROW -1 I' 18/19 GL, AU, UMB, WC (BOR) I MaryAnn Worman II 1/17/2019 5 04:09 PM (PST) I Page 6 of 12 Any amount payable to an insured, under this endorsement will be reduced by any amount paid or payable for the same expense under Pan I • Liability To Others or any applicable Uninsured/Underinsured Motorist Coverage Endorsement. No one will be entitled to duplicate payments under this policy for the same elements of damages. 071EER INSURANCE If there is other applicable auto medical payments insurance, vm will pay only our sham of the medical and funeral services. Our share is the proportion that our limit of liability bears to the total of all applicable limits. However, any insurance we provide for an insured occupying 1. an auto, other than an insured auto or temporary substitute auto; or 2. a trallez other than a trailer while connected to an insured auto; will be excess over any other auto or trailer insurance providing payments for medical or funeral expenses. ALL OTHER TERMS, LEWTS AND PROVISIONS OF THE POLICY REMAIN UNCHANGED. Form No. 4757 (03/05) 39932113 1 ARROW -1 1' 18/19 GL, AU, UMB, WC (BOR) 11 MaryAnn Worman 1 1/17/2018 5-04:09 P.M (PST) 11 Page 7 of 12 �_i r it Except as specifically modified in this endorsement, all' provisions of the Commercial Auto Policy apply We agree with you that the insurance provided under your• Commercial Auto Policy is modified as follows: PART I - LIABILITY TO OTHERS ADDITIONAL DEFINITIONS USED IN THIS PART ONLY is modified as follows: B. When used in PART I - LIABILITY TO OTHERS, Insured auto also includes: 1. Trailers, with a load capacity of 2,000 pounds or less and designed primarily for travel on public roads, while connected to your insured auto that is a power unit; 2. Mobile equipment while being carried or towed by an insured auto; 3. Any temporary substitute auto; and 4. Any mobile equipment owned by you, or if you have purchased Hired Auto or Non -owned Auto coverage, leased, or hired by you, when subject to a compulsory or financial responsibility law or other motor vehicle insurance law in the state or province where it is licensed or principally garaged'. This does not change the effect of exclusion 13 conceming the operation of mobfie equipment. MEDICAL PAYNIENTS COVERAGE If you pay the premium for Medical Payments Coverage, that endorsement is modified as follows: ADDI'T'IONAL DEFINITIONS' The definition of "Insured" is deleted and replaced by: 1. "Insured" means: a. if the named 'insured shown on the Declarations Page is a naturals person: (i) you while occupying any auto, other than an auto ownedby you which is not an insured auto; (ii) a relative while occupying an insured auto, temporary substitute auto, or no"wnedauto; you or any relative when smack by a land motor vehicle of any type, or a trailer, while not occupying a motor vehicle; and (iv) any other person while occupying an insured auto, temporary substitute auto, or a trailer whileattachedl to an insured auto; or b. if the named insured shown on the Declaration Page is a corporation, partnership, organization or any other entity that is not a natural', person, any 39932113 1' ARROW -1 1 18/19 GL, AU, 'UMB, WC (BOR) h MaryAnn Worman II 1/17/2019 5:04:09 PM (PST) I Page 8 of 12 person occupying, your insured auto, temporary substitute auto, or a trailer while attached to annsured auto. For purposes of this definition, insured auto includes mobile equipment ownedby you, or if you have purchased Fred Auto or Non-owned Auto coverage, leased, or hired by you, when it is subject to a compulsory or financial responsibility law or other motor vehicle insurance law in the state or province where it is licensed or principally garaged. UNINSURED MOTORIST AND UNDERINSURED MOTORIST COVERAGES If you pay the premium for Uninsured Motorist Coverage and/or Underinsured Motorist Coverage, that endorsement is modified as follows: ADDITIONALDEFINITIONS The definition of "Insured" is deleted and replaced by: 1. "Insured" means: a. if the named insured shown on the Declarations Page is a natural' person: (i) you or a relative; (ii) any person occupying your insured: auto or a temporary substitute auto; and (iii) any person who is entitled' to recover damages covered by this endorsement because of bodily injury sustained by a person described in (i) or (ii) above; or b. if the named insured shown on the Declarations Page is a corporation, partnership, organization or any other entity that is not a natural person: (i) any person occupying your insured auto or a temporary substitute auto; and (ii) any person who is entitled to recover damages covered by this endorsement because of ibodily injury sustained by a person described in (i) above. For purposes of this definition, insured auto includes mobile equipment owne d by you, or if you have purchased Hired Auto or Non - owned Auto coverage, leased, or hired by you, when it is subject to a compulsory or financial responsibility law or other motor vehicle insurance law in the state or province where it is licensed' or principally garaged. ALL OTHER TERMS, LIMITS AND PROVISIONS OF THE POLICY REMAIN UNCHANGED. Form 2228 (07105) 39932113 1 ARROW -1 11 18/19 GL, AU, UMB, WC (BOR) iI MaryAnn Worman 1 1/'17/2018 5 09:09 PM (PST), 11 Page 9 of 12 POLICY NUMBER: AES'11038793 01 Arrow Sign Co. COMMERCIAL GENERAL UAWLITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NOWCONTRIIBUTING INSURANCE • . (THIRD-PARTY) This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY 'COVERAGE PART SCHEDULE Third Party: As required by written contract City of Gilroy, its officers, elected or appointed officials, employees, agents and, volunteers (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contactual agreement with any Third Party for whom you are performing work.) . Paragraph 4. of SECTION 'IV. COMMERCIAL GENERAL. iuABILITY CONDITIONS is replaced by the following: 4. Other'Insurance: With respect to the Third Party shown above, this Insurance is ,primary and non - contributing. Any and all other valid and collectable insurance available to such Third Party In respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall In no Instance be considered as primary, co- Insurance, or contributing insurance. Rather, any such other !Insurance shall be considered eoocess over and above the insurance provided by this policy. NX GL 009 08 -09 Page 1 of 9 Includes copyrighted material of insurance Services Office, Inc., with Its permission 39932113 11 ARROW -1 II 18/19 GL, AU, UMB, WC ('BOR) 11 MaryAnn Worman p, 1/17/2019 5-04!09 PM (PST) 11 Page 10 of 12 Arrow Sign Co. POLICY NUMBER: AES1038793 01 4/17/2018 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERSI OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GiENERALLIABILITY COVERAGE iPART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE J; Name Of Person Or Organization: ANY PERSON ORORGANIZATION WITH WHOM THE INSURED HAS AGREED TO WAIVE RIGHTS OF RECOVERY, PROVIDED SUCH AGREEMENT IS MADE IN WRITING AND PRIOR TO THE LOSS Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To lUs of Section IV - Conditions: We waive any right of recovery we may have against the person or organization shown In the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "prod ucts- completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. City of Gilroy, its officers, elected or appointed officials, employees, agents ands volunteers CGi 24 04 05 09 Copyright, Insurance Services Office, lnc., 2008 39932113 li ARROW -1 li 18/19 GL—AU, UMB, WC (BOR) 11 MaryAnn Worman '.I 1/17/2018 5-04:09 PM (PST) I Page 11 of 12 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY !INSURANCE 'PO'LICY WC 99 04108 (Ed. 9 -14) WAIVER OF OUR RIGHT TO'RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA BLANKET BASIS WP have the right to recnver our payments from anyone linhlP for an injury covPrad by this policy. WP will not Pnforce 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 anyone not named in the Schedule. SCHEDULE BLANKET WAIVER Person /Orga ilzation Blanket Waiver — Any person or organization for whom the Named Insured has agreed by written contract to furnish, this waiver. Job Description This endorsement changes the ipolicy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 1/1/2018 Policy No- ARWC919666 Insured Arrow Sign Co. Insurance Company Cypress Insurance Company Countersigned by WC 99 04108 (Ed. 9 -14) 39932113 11 ARROW -1 1 18/19 GL, AU., UMB„ WC (BOR) I MaryAnn Worman 1 ' 1/17/2018 5-04:09 PM (PST) 11 Page 12 of 12 Endorsement No. Premium $