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COI - Architectural Resources Group, Inc. - Expires 2022-09-01SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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 an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 8/18/2021 AssuredPartners Design Professionals Insurance Services,LLC 3697 Mt.Diablo Blvd.,Suite 230 Lafayette CA 94549 Nancy Ferrick Nancy.Ferrick@AssuredPartners.com License#:6003745 XL Speciality Insurance Company 37885 ARCHRES-04 Travelers Property Casualty Company of America 25674ArchitecturalResourcesGroup,Inc. Pier 9,The Embarcadero,Suite 107 San Francisco CA 94111 HARTFORD INSURANCE COMPANY 38288 The Travelers Indemnity Company of Connecticut 25682 682243665 D X 2,000,000 X 1,000,000 X Contractual Liab 10,000 Included 2,000,000 4,000,000 X X Y Y 6802H186591 9/1/2021 9/1/2022 4,000,000 D 1,000,000 X X Y Y BA1S985277 9/1/2021 9/1/2022 B X X 5,000,000YCUP7150Y0429/1/2021Y 9/1/2022 5,000,000 X 0 C XY57WEGLP76259/1/2021 9/1/2022 1,000,000 1,000,000 1,000,000 A Professional Liability &Contractors Pollution Legal Liability DPR9982564 8/20/2021 8/20/2022 Per Claim Annual Aggregate $2,000,000 $2,000,000 Umbrella Liability policy is follow-form underlying General Liability/Non-Owned &Hired Auto Liability/&Employers Liability. Re:ARG Project #15185,Gilroy On-Call Historical Evaluations Agreement,Service Agreement.City of Gilroy,its officers,officials and employees are named Additional Insured for General and Auto Liability. 30 Days Notice of Cancellation City of Gilroy,its officers,officials and employees 7351 Rosanna Street Gilroy CA 95020 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B ÐÑÔ×ÝÇÒËÓÞÛÎ COMMERCIAL GENERAL LIABILITY ISSUED DATE: ÌØ×ÍÛÒÜÑÎÍÛÓÛÒÌÝØßÒÙÛÍÌØÛÐÑÔ×ÝÇòÐÔÛßÍÛÎÛßÜ×ÌÝßÎÛÚËÔÔÇò    Ì¸·»²¼±®»³»²¬³±¼·º·»·²«®¿²½»°®±ª·¼»¼«²¼»®¬¸»º±´´±©·²¹æ ÝÑÓÓÛÎÝ×ßÔÙÛÒÛÎßÔÔ×ßÞ×Ô×ÌÇÝÑÊÛÎßÙÛÐßÎÌ    ø×²º±®³¿¬·±²®»¯«·®»¼¬±½±³°´»¬»¬¸·Í½¸»¼«´»ô·º²±¬¸±©²¿¾±ª»ô©·´´¾»¸±©²·²¬¸»Ü»½´¿®¿¬·±²ò÷ Í»½¬·±²×× É¸±×ß²×²«®»¼·¿³»²¼»¼¬±·²ó Ì¸··²«®¿²½»¼±»²±¬¿°°´§¬±þ¾±¼·´§·²¶«®§þ±® ½´«¼»¿¿²¿¼¼·¬·±²¿´·²«®»¼¬¸»°»®±²ø÷±® þ°®±°»®¬§¼¿³¿¹»þ±½½«®®·²¹ô±®°»®±²¿´·²¶«®§Œ ±®¹¿²·¦¿¬·±²ø÷¸±©²·²¬¸»Í½¸»¼«´»ô¾«¬±²´§ ±®¿¼ª»®¬··²¹·²¶«®§Œ¿®··²¹±«¬±º¿²±ºº»²» ©·¬¸®»°»½¬¬±´·¿¾·´·¬§º±®þ¾±¼·´§·²¶«®§þôþ°®±°»®¬§ ½±³³·¬¬»¼ô¿º¬»®æ ¼¿³¿¹»þôþ°»®±²¿´·²¶«®§Œ±®¿¼ª»®¬··²¹·²¶«®§þ ß´´©±®µô·²½´«¼·²¹³¿¬»®·¿´ô°¿®¬±®»¯«·°ó½¿«»¼ô·²©¸±´»±®·²°¿®¬ô¾§æ ³»²¬º«®²·¸»¼·²½±²²»½¬·±²©·¬¸«½¸©±®µô Ç±«®¿½¬±®±³··±²å±®±²¬¸»°®±¶»½¬ø±¬¸»®¬¸¿²»®ª·½»ô³¿·²¬»ó ²¿²½»±®®»°¿·®÷¬±¾»°»®º±®³»¼¾§±®±²Ì¸»¿½¬±®±³··±²±º¬¸±»¿½¬·²¹±²§±«®¾»¸¿´º±º¬¸»¿¼¼·¬·±²¿´·²«®»¼ø÷¿¬¬¸»´±½¿ó¾»¸¿´ºå ¬·±²±º¬¸»½±ª»®»¼±°»®¿¬·±²¸¿¾»»²½±³ó·²¬¸»°»®º±®³¿²½»±º§±«®±²¹±·²¹±°»®¿¬·±²º±®°´»¬»¼å±®¬¸»¿¼¼·¬·±²¿´·²«®»¼ø÷¿¬¬¸»´±½¿¬·±²ø÷¼»·¹ó Ì¸¿¬°±®¬·±²±ºþ§±«®©±®µþ±«¬±º©¸·½¸¬¸»²¿¬»¼¿¾±ª»ò ·²¶«®§±®¼¿³¿¹»¿®·»¸¿¾»»²°«¬¬±·¬·²óÉ·¬¸®»°»½¬¬±¬¸»·²«®¿²½»¿ºº±®¼»¼¬±¬¸»»¬»²¼»¼«»¾§¿²§°»®±²±®±®¹¿²·¦¿¬·±²¿¼¼·¬·±²¿´·²«®»¼ô¬¸»º±´´±©·²¹¿¼¼·¬·±²¿´»¨½´«ó ±¬¸»®¬¸¿²¿²±¬¸»®½±²¬®¿½¬±®±®«¾½±²¬®¿½ó·±²¿°°´§æ ¬±®»²¹¿¹»¼·²°»®º±®³·²¹±°»®¿¬·±²º±®¿ °®·²½·°¿´¿¿°¿®¬±º¬¸»¿³»°®±¶»½¬ò Ý±°§®·¹¸¬îððëÌ¸»Í¬òÐ¿«´Ì®¿ª»´»®Ý±³°¿²·»ô×²½òß´´®·¹¸¬®»»®ª»¼ò Ð¿¹»ï±ºï ×²½´«¼»½±°§®·¹¸¬»¼³¿¬»®·¿´±º×²«®¿²½»Í»®ª·½»Ñºº·½»ô×²½ò©·¬¸·¬°»®³··±²ò Any person or organization that you agree in a written contract, on this Coverage Part, provided that such written contract was signed and executed by you before, and is in effect when the "bodily injury" or "property damage" occurs or the "personal injury" or "advertising injury" offense is committed. Any project to which an applicable written contract with the described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. 6802H186591 8/18/2021 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B ÐÑÔ×ÝÇÒËÓÞÛÎæ COMMERCIAL GENERAL LIABILITY ISSUED DATE: ÌØ×ÍÛÒÜÑÎÍÛÓÛÒÌÝØßÒÙÛÍÌØÛÐÑÔ×ÝÇòÐÔÛßÍÛÎÛßÜ×ÌÝßÎÛÚËÔÔÇò   Ì¸·»²¼±®»³»²¬³±¼·º·»·²«®¿²½»°®±ª·¼»¼«²¼»®¬¸»º±´´±©·²¹æ ÝÑÓÓÛÎÝ×ßÔÙÛÒÛÎßÔÔ×ßÞ×Ô×ÌÇÝÑÊÛÎßÙÛÐßÎÌ    ×²º±®³¿¬·±²®»¯«·®»¼¬±½±³°´»¬»¬¸·Í½¸»¼«´»ô·º²±¬¸±©²¿¾±ª»ô©·´´¾»¸±©²·²¬¸»Ü»½´¿®¿¬·±²ò ·¿³»²¼»¼¬±·²ó ´±½¿¬·±²¼»·¹²¿¬»¼¿²¼¼»½®·¾»¼·²¬¸»½¸»¼«´»±º ½´«¼»¿¿²¿¼¼·¬·±²¿´·²«®»¼¬¸»°»®±²ø÷±®±®ó ¬¸·»²¼±®»³»²¬°»®º±®³»¼º±®¬¸¿¬¿¼¼·¬·±²¿´·²ó ¹¿²·¦¿¬·±²ø÷¸±©²·²¬¸»Í½¸»¼«´»ô¾«¬±²´§©·¬¸ «®»¼¿²¼·²½´«¼»¼·²¬¸»þ°®±¼«½¬ó½±³°´»¬»¼±°»®¿ó ®»°»½¬¬±´·¿¾·´·¬§º±®þ¾±¼·´§·²¶«®§þ±®þ°®±°»®¬§¼¿³ó ¬·±²¸¿¦¿®¼þò ¿¹»þ½¿«»¼ô·²©¸±´»±®·²°¿®¬ô¾§þ§±«®©±®µþ¿¬¬¸» ×ÍÑÐ®±°»®¬·»ô×²½òôîððì Ð¿¹»ï±ºï Any person or organization that you agree in a written contract to include as an additional insured on this Coverage Part for "bodily injury" or "property damage" included in the "products- completed operations hazard", provided that such contract was signed and executed by you before, and is in effect when, the bodily injury or property damage occurs. Any project to which an applicable contract described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. 8/18/20216802H186591 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B COMMERCIAL GENERAL LIABILITY c. Method Of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this methoo, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. d. Primary And Non-Contributory Insurance If Required By Written Contract If you specifically agree in a written contract or agreement that the insurance afforded to an insured under this Coverage Part must apply on a primary basis, or a primary and non- contributory basis. this insurance is primary to other insurance that is available to such insured which covers such insured as a named insured, and we will not share with that other insurance, provided that: (1) The "bodily injury'' or "property damage" for which coverage is sought occurs; and (2) The "personal and advertising injury" for which coverage is sought is caused by an offense that is committed; subsequent to the signing of that contract or agreement by you. 5. Premium Audit a. We will compute all premiums for this Coverage Part in accordance with our rules and rates. b. Premium shown in this Coverage Part as advance premium is a deposit premium only. At the close of each audit perioo we will compute the earned premium for that period and send notice to the first Named Insured. The due date for audit and retrospective premiums is the date shown as the due date on the bill. If the sum of the advance and audit premiums paid for the policy period is greater than the earned premium, we will return the excess to the first Named Insured. c. The first Named Insured must keep records of the information we need for premium computation , and send us copies at such times as we may request. 6. Representations By accepting this policy, you agree: a. The statements in the Declarations are accurate and complete; b. Those statements are based upon representations you made to us; and c. We have issued this policy in reliance upon your representations. The unintentional omission of, or unintentional error in, any information provided by you which we relied upon in issuing this policy will not prejudice your rights under this insurance. However, this provision does not affect our right to collect additional premium or to exercise our rights of cancellation or nonrenewal in accordance with applicable insurance laws or regulations. 7. Separation Of Insureds Except with respect to the Limits of Insurance, and any rights or duties specifically assigned in this Coverage Part to the first Named Insured, this insurance applies: a. As if each Named Insured were the only Named Insured; and b. Separately to each insured against whom claim is made or "suit" is brought. 8. Transfer Of Rights Of Recovery Against Others To Us If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. 9. When We Do Not Renew If we decide not to renew this Coverage Part, we will mail or deliver to the first Named Insured shown in the Declarations written not ice of the nonrenewal not less than 30 days before the expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. SECTION V -DEFINITIONS 1. "Advertisement" means a notice that is broadcast or published to the general public or specific market segments about your goods, products or services for the purpose of attracting customers or supporters. For the purposes of this definition: a. Notices that are published include material placed on the Internet or on similar electronic means of communication; and b. Regarding websites, only that part of a website that is about your goods, prooucts or services for the purposes of attracting customers or supporters is considered an advertisement. Page 16 of 21 © 2017 The Travelers Indemnity Company. All rights reserved. CG T1000219 Includes copyrighted material of Insurance Services Office, Inc. with its permiss ion. Policy #6802H186591 6802H1865916802H186591 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B COMMERCIAL GENERAL LIABILITY that is available to any of your "employees"occupational therapist or occupational for "bodily injury" that arises out of providingtherapy assistant, physical therapist or or failing to provide "incidental medicalspeech-language pathologist; or services" to any person to the extent not(b)First aid or "Good Samaritan services"subject to Paragraph 2.a.(1)of Section II –by any of your "employees" or "volunteer Who Is An Insured.workers", other than an employed or volunteer doctor. Any such "employees"K. MEDICAL PAYMENTS – INCREASED LIMIT or "volunteer workers" providing or failing The following replaces Paragraph 7.ofto provide first aid or "Good Samaritan SECTION III – LIMITS OF INSURANCE:services" during their work hours for you 7.Subject to Paragraph 5.above, the Medicalwill be deemed to be acting within the scope of their employment by you or Expense Limit is the most we will pay under performing duties related to the conduct Coverage C for all medical expenses of your business.because of "bodily injury" sustained by any one person, and will be the higher of:3.The following replaces the last sentence of Paragraph 5.of SECTION III – LIMITS OF a.$10,000; orINSURANCE: b.The amount shown in the Declarations ofFor the purposes of determining the this Coverage Part for Medical Expenseapplicable Each Occurrence Limit, all related Limit.acts or omissions committed in providing or failing to provide "incidental medical L. AMENDMENT OF EXCESS INSURANCE services", first aid or "Good Samaritan CONDITION – PROFESSIONAL LIABILITYservices" to any one person will be deemed The following is added to Paragraph 4.b.,to be one "occurrence".Excess Insurance, of SECTION IV –4.The following exclusion is added to COMMERCIAL GENERAL LIABILITYParagraph2.,Exclusions, of SECTION I –CONDITIONS: COVERAGES – COVERAGE A – BODILY This insurance is excess over any of the otherINJURY AND PROPERTY DAMAGE insurance, whether primary, excess, contingentLIABILITY:or on any other basis, that is ProfessionalSale Of Pharmaceuticals Liability or similar coverage, to the extent the "Bodily injury" or "property damage" arising loss is not subject to the professional services out of the violation of a penal statute or exclusion of Coverage A or Coverage B. ordinance relating to the sale of M. BLANKET WAIVER OF SUBROGATION –pharmaceuticals committed by, or with the WHEN REQUIRED BY WRITTEN CONTRACTknowledge or consent of the insured.OR AGREEMENT5.The following is added to the DEFINITIONS The following is added to Paragraph 8.,TransferSection: Of Rights Of Recovery Against Others To Us,"Incidental medical services" means:of SECTION IV – COMMERCIAL GENERAL a.Medical, surgical, dental, laboratory, x-LIABILITY CONDITIONS: ray or nursing service or treatment,If the insured has agreed in a written contract oradvice or instruction, or the related agreement to waive that insured's right offurnishing of food or beverages; or recovery against any person or organization, we b.The furnishing or dispensing of drugs or waive our right of recovery against such personmedical, dental, or surgical supplies or or organization, but only for payments we makeappliances.because of: 6.The following is added to Paragraph 4.b.,a."Bodily injury" or "property damage" thatExcess Insurance, of SECTION IV –occurs; orCOMMERCIAL GENERAL LIABILITY b."Personal and advertising injury" caused byCONDITIONS: an offense that is committed;This insurance is excess over any valid and subsequent to the signing of that contract orcollectible other insurance, whether primary, excess, contingent or on any other basis,agreement. CG D3 79 02 19 ú 2017 The Travelers Indemnity Company. All rights reserved.Page 5 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy #6802H186591 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B COMM RCI L AUTOE A T IS ENDORSEMENT CHANGES T E POLICY.PL ASE READ IT CAREFULLY.H H E BLANKET ADDITIONAL INSURED Thi e dorseme t m d fie i surance prov ded under he f l o ing:s n n o i s n i t o l w BUS NE S A TO OV RAGE F RMI S U C E O M TO CA RI R COV RA E F RMO R R E E G O The fo lo ing i added to Parag aphl w s r c.in A.1.,Who be ween you and that pe son or organiza ion,that istrt Is An Insu edr,of SECTION II CO E ED AU OV R T S si ned by yo be o e the "bodi y injury or "prope tyg u f r l " r L ABI I Y CO E AGEI L T V R in the BUSIN SS AUTE O dam ge occur and that is in ef e t during the pol cya " s f c i CO ERAGE FO MVR and Pa agraphr e.in A.1.,Who Is pe iod,to nam as an addi ional insured fo Cov redretr e An Insu edr,of SECT ON II CO ERED AU OIV T S Auto Liabil ty Cov rage,but o ly fo dam ges tos i e n r a L ABI I Y CO ERAGEI L T V in the MOT R CARRIEOR whi h this insurance applie an only to the ex ent ocs d t f CO ERAGE FO MVR,whichev r Co erage Form i that perso 's o o ganizat o 'se v s n r r i n lia il ty fo the co ductb i r n pa t o y ur poli y o anot er "in ured".r f o c :f h s Thi i cl de any perso or organi ation who you ares n u s n z re ui ed unde a written cont a t o ag ee entq r r r c r r m CA 4 37 2 16T 0 ©2016 The Travelers Indemnity Company.All rights reserved.Page 1 of 1 Includes copyrighted material of nsurance Services OfIf ce,Inc.with its permis ion.i s Policy:BA1S985277 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following replaces Paragraph A.5.,Transfer of required of you by a written contract executed Rights Of Recovery Against Others To Us,of the prior to any "accident"or "loss",provided that the CONDITIONS Section:"accident"or "loss"arises out of the operations 5.Transfer Of Rights Of Recovery Against Oth-contemplated by such contract.The waiver ap- ers To Us plies only to the person or organization desig- nated in such contract.We waive any right of recovery we may have against any person or organization to the extent CA T3 40 02 15 ©2015 The Travelers Indemnity Company.All rights reserved.Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.with its permission. Policy #BA1S985277 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B FormWC990301B Printed in U.S.A. (Ed. 8/00) Process Date: Endorsement Number: Effective hour is the same as stated on the Information Page of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WORKERS’ COMPENSATION BROAD FORM ENDORSEMENT EXTENDED OPTIONS Policy Number: Effective Date: Named Insured and Address: Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section III of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: INDEX SUBJECT PAGE SUBJECT PAGE SECTION I 2 B. Part One Does Not Apply 3 2 C. Application of Coverage 3PARTS ONE and TWO 2 D. Additional Exclusions 301 We Will Also Pay 2 E. West Virginia 3PART - THREE 2 EXTENDED OPTIONS 402 How This Insurance Works 2401 Employers’ Liability InsurancePART - SIX 2402 Unintentional Failure to Disclose03 Transfer of Your Rights and Duties 2 Hazards04 Cancellation 2403 Waiver of Our Right to Recover from05 Liberalization 2 OthersSECTION II 2404 Foreign Voluntary CompensationVOLUNTARY COMPENSATION INSURANCE 4A. How This Reimbursement Applies06 Voluntary Compensation Insurance 24B. We Will ReimburseA. How This Insurance Applies 24C. ExclusionsB. We Will Pay 35D. Before We PayC. Exclusions 35E. Recovery From OthersD. Before We Pay 35F. Reimbursement For Actual LossE. Recovery From Others 3 SustainedF. Employers’ Liability Insurance 35G. RepatriationEMPLOYERS’ LIABILITY STOP GAP 35H. Endemic DiseaseENDORSEMENT 505 Longshore and Harbor Workers’07 Employers’ Liability Stop Gap 3 Compensation Act CoverageCoverageEndorsementA. Stop Gap Coverage Limited to 36SECTION IIIMontana, North Dakota, Ohio,601 Schedule of Covered StatesWashington, West Virginia and Wyoming Page 1 of 6 Policy Expiration Date: ______ _______________ _______________ © 2000, The Hartford 57WEGLP7625 09/01/2021 Architectural Resources Pier 9,The Embarcadero, San Francisco CA 94111 DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B SECTION I PARTS ONE and TWO the Information Page, coverage will not be afforded for that state unless we are notified1. WE WILL ALSO PAY sixtywithin days.D. We Will Also Pay Part Oneof (WORKERS’ COMPENSATION INSURANCE); and PART SIX E. We Will Also Pay Part Twoof (EMPLOYERS’3. Transfer Of Your Rights and DutiesLIABILITY INSURANCE) is replaced by the C. Transfer Of Your Rights and Duties Part 6offollowing: (Conditions) is replaced by the following:We Will Also Pay Your rights or duties under this policy may notWe will also pay these costs, in addition to be transferred without our written consent.other amounts payable under this insurance, sixtyIf you die and we receive notice withinas part of any claim, proceeding, or suit we days after your death, we will cover your legaldefend: representative as insured.1. reasonable expenses incurred at our 4. CancellationINCLUDINGrequest, loss of earnings; 2. D. Cancellation Part 6Paragraph of of2. premiums for bonds to release (Conditions) is replaced by the following:attachments and for appeal bonds in bond amounts up to the limit of our liability 2. We may cancel this policy. We must mail or under this insurance;15deliver to you not less than days advance written notice stating when the cancellation is3. litigation costs taxed against you; to take effect. Mailing that notice to you at4. interest on a judgment as required by law your mailing address shown in Item 1 of theuntil we offer the amount due under this Information Page will be sufficient to provelaw; and notice.5. expenses we incur.5. Liberalization If we adopt a change in this form that wouldPART THREE broaden the coverage of this form without extra2. How This Insurance Applies charge, the broader coverage will apply to this 4. A. How This Insurance AppliesParagraph of policy. It will apply when the change becomes Part 3of (Other States Insurance) is replaced by effective in your state. the following: 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS’ 2. The bodily injury must arise out of and in the course of employment or incidental toLIABILITY COVERAGE work in a state shown in Item 3.A. of the6. Voluntary Compensation Insurance Information Page. A. How This Insurance Applies 3. The bodily injury must occur in the United This insurance applies to bodily injury by States of America, its territories or accident or bodily injury by disease. Bodily possessions, or Canada, and may occur injury includes resulting death.elsewhere if the employee is a United States or Canadian citizen, or otherwise1. The bodily injury must be sustained by any legal resident, and legally employed, in theofficer or employee not subject to the United States or Canada and temporarilyworkers’ compensation law of any state away from those places.shown in Item 3.A. of the Information Page. FormWC990301B Page 2 of 6Printed in U.S.A. (Ed. 8/00) DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B 4. Bodily injury by accident must occur keep an amount equal to our expenses of during the policy period. recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If5. Bodily injury by disease must be caused the persons entitled to the benefits of thisor aggravated by the conditions of the insurance make a recovery from others, theyofficer’s or employee’s employment. The must reimburse us for the benefits we paidofficer’s or employee’s last day of last them.exposure to the conditions causing or aggravating such bodily injury by disease F. Employers’ Liability Insurance must occur during the policy period.Part Two (Employers’ Liability Insurance) B. We Will Pay applies to bodily injury covered by this endorsement as though the State ofWe will pay an amount equal to the benefits Employment was shown in Item 3.A. of thethat would be required of you as if you and Information Page.your employees were subject to the workers’ compensation law of any state shown in Item This provision 6. does not apply in New Jersey or 3.A. of the Information Page. We will pay Wisconsin. those amounts to the persons who would be EMPLOYERS’ LIABILITY STOP GAP COVERAGEentitled to them under the law.7. Employers’ Liability Stop Gap CoverageC. Exclusion A. This coverage only applies in Montana, NorthThis insurance does not cover:Dakota, Ohio, Washington, West Virginia and 1. any obligation imposed by workers’Wyoming. compensation or occupational disease law B. Part One (Workers’ Compensation Insurance)or any similar law.does not apply to work in states shown in 2. bodily injury intentionally caused or Paragraph A above. aggravated by you.C. Part Two (Employers’ Liability Insurance) 3. officers or employees who have elected applies in the states, shown in Paragraph A., not to be subject to the state workers’as though they were shown in Item 3.A. of the compensation law.Information Page. 4. partners or sole proprietors not covered ExclusionsD. Part Two, Section C. is changed under the Standard Sole Proprietors,by adding these exclusions. Partners, Officers and Others Coverage This insurance does not cover;Endorsement.5. bodily injury intentionally caused orD. Before We Pay aggravated by you or in Ohio bodily injury Before we pay benefits to the persons entitled resulting from an act which is determined to them, they must:by an Ohio court of law to have been committed by you with the belief than an1. Release you and us, in writing, of all injury is substantially certain to occur.responsibility for the injury or death. However, the cost of defending such2. Transfer to us their right to recover from claims or suits in Ohio is covered.others who may be responsible for the 13. bodily injury sustained by any member ofinjury or death. the flying crew of any aircraft.3. Cooperate with us and do everything 14. any claim for bodily injury with respect tonecessary to enable us to enforce the right which you are deprived of any defense orto recover from others. defenses or are otherwise subject toIf the persons entitled to the benefits of this penalty because of default in premiuminsurance fail to do those things, our duty to under the provisions of the workers’pay ends at once. If they claim damages from compensation law or laws of a stateyou or from us for the injury or death, our duty shown in Paragraph A.to pay ends at once. E. This insurance applies to damages for whichE. Recovery From Others you are liable under West Virginia Code Annot. If we make a recovery from others, we will S 23-4-2. FormWC990301B Page 3 of 6Printed in U.S.A. (Ed. 8/00) DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B EXTENDED OPTIONS 1. Employers’ Liability Insurance 4. Foreign Voluntary Compensation and Employers’ Liability ReimbursementItem 3.B. Information Pageof the is replaced by the following:A. How This Reimbursement Applies B. Employers’ Liability Insurance:This reimbursement provision applies to bodily injury by accident or bodily injury by disease.Part Two1. of the policy applies to work in Bodily injury includes resulting death.each state listed in Item 3.A. 1. The bodily injury must be sustained by an officer or employee.The Limits of Liability under Part Two are 2. The bodily injury must occur in the coursethe higher of: of employment necessary or incidental to work in a country not listed in ExclusionBodily Injury C.1. of this provision.$500,000 Each Accidentby Accident 3. Bodily injury by accident must occur during the policy period.Bodily Injury $500,000 Policy Limitby Disease 4. Bodily injury by disease must be caused or aggravated by the conditions of your Bodily Injury employment. The officer or employee’s $500,000 Each Employee last exposure to those conditions of yourby Disease employment must occur during the policy period.OR B. We Will Reimburse 2. The amount shown in the Information We will reimburse you for all amounts paid by Page.you whether such amounts are: EXTENDED OPTIONSThis provision 1 of does not 1. voluntary payments for the benefits that apply in New York because the Limits Of Our would be required of you if you and your Liability are unlimited.officers or employees were subject to any workers’ compensation law of the state ofIn this provision the limits are changed from hire of the individual employee.$500,000 $1,000,000to in California. 2. sums to which Part Two (Employers’2. Unintentional Failure to Disclose Hazards Liability Insurance) would apply if theIf you unintentionally should fail to disclose all Country of Employment were shown inexisting hazards at the inception date of your Item 3.A. of the Information Page.policy, we shall not deny coverage under this C. Exclusionspolicy because of such failure. This insurance does not cover:3. Waiver of Our Right To Recover From Others 1. any occurrences in the United States,A. We have the right to recover our payments Canada, and any country or jurisdictionfrom anyone liable for an injury covered by this which is the subject of trade or economicpolicy. We will not enforce our right against sanctions imposed by the laws orany person or organization for whom you regulations of the United States ofperform work under a written contract that America in effect as of the inception daterequires you to obtain this agreement from us. of this policy.This agreement shall not operate directly or 2. any obligation imposed by a workers’indirectly to benefit anyone not named in the compensation or occupational diseaseagreement. law, or similar law.B. This provision 3. does not apply in the states 3. bodily injury intentionally caused orof Pennsylvania and Utah. aggravated by you. FormWC990301B Page 4 of 6Printed in U.S.A. (Ed. 8/00) DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B 4. liability for any consequence, whether of America necessarily incurred as a direct direct or indirect, of war, invasion, act of result of bodily injury. Foreign enemy, hostilities (whether war be Our reimbursement shall be limited as follows:declared or not), civil war, rebellion,1. to the amount by which such expensesrevolution, insurrection or military or exceed the normal cost of returning theusurped power. No endorsement now or officer or employee if in good health, orsubsequently attached to this policy shall 2. in the event of death, to the amount bybe construed as overriding or waiving this which such expenses exceed the normallimitation unless specific reference is cost of returning the officer or employee ifmade thereto. alive and in good health.D. Before We Pay In no event shall our reimbursement exceedBefore we reimburse you for the benefits to the the bodily injury by accident limit shown inpersons entitled to them, you must have them:Item 3.B. of the Information Page as respects 1. release you and us, in writing, of all any one such officer or employee whether responsibility for the injury or death,dead or alive. 2. transfer to us their right to recover from H. Endemic Diseaseothers who may be responsible for their The word “disease” includes any endemicinjury or death,diseases.3. cooperate with us and do everything The coverage applies as if endemic diseasesnecessary to enable us to enforce the right were included in the provisions of the workers’to recover from others.compensation law.If the persons entitled to the benefits paid fail 5. Longshore and Harbor Workers’ Compensationto do these things, our duty to reimburse ends Act Coverageat once. If they claim damages from us for the injury or death, our duty to reimburse ends at General Section C. Workers’ Compensation once.Law is replaced by the following: E. Recovery From Others C. Workers’ Compensation Law If we make a recovery from others, we will Workers’ Compensation Law means the keep an amount equal to our expenses of workers or workers’ compensation law and recovery and the benefits we reimbursed. We occupational disease law of each state or will pay the balance to the persons entitled to territory named in Item 3.A. of the Information it. If persons entitled to the benefits make a Page and the Longshore and Harbor Workers’ recovery from others, they must repay us for Compensation Act (33 USC Sections 901- the amounts that we have reimbursed you.950). It includes any amendments to those laws that are in effect during the policy period.F. Reimbursement for Actual Loss Sustained It does not include any other federal workersThis endorsement provides only for or workers’ compensation law, other federalreimbursement for the loss you actually occupational disease law or the provisions ofsustain. In order for you to recover loss or any law that provide nonoccupational disabilityexpenses under this reimbursement you must:benefits. 1. actually sustain and pay the loss or Part Two (Employers’ Liability Insurance), C.expense in money after trial, or Exclusions, exclusion 8, does not apply to 2. secure our consent for the payment of the work subject to the Longshore and Harbor loss or expense.Workers’ Compensation Act. G. Repatriation This coverage does not apply to work subject to the Defense Base Act, the OuterOur reimbursement includes the additional Continental Shelf Lands Act, or theexpenses of repatriation to the United States Nonappropriated Fund Instrumentalities Act. FormWC990301B Page 5 of 6Printed in U.S.A. (Ed. 8/00) DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B SECTION III 1. SCHEDULE OF COVERED STATES B. If a state, shown in Item 3.A. of the Information Page, approves this endorsement after theA. This endorsement only applies in the states effective date of this policy, this endorsementlisted in this Schedule of Covered States.will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. C. Schedule of Covered States: Countersigned by Authorized Representative FormWC990301B Page 6 of 6Printed in U.S.A. (Ed. 8/00) DocuSign Envelope ID: 42B535C1-7364-46C0-AA12-AE780D17971B