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HomeMy WebLinkAboutCOI (endorsement) - Gilroy Golf Course, Inc. - Expires 2025-05-10SEQUOIA INSURANCE COMPANY 17771 Cowan Avenue Suite 100 Irvine, CA 92694 1 WORKERS' COMPENSATION and EMPLOYERS' LIABILITY INSURANCE POLICY In Witness Whereof, we have caused this policy to be executed and attested. Stephen Ungar, Secretary (iy Barry Dov Zyskind, President To obtain information, please contact your agent or Sequoia Insurance Company at 877- 528-7878. You may also write Sequoia Insurance Company Consumer Relations at: 800 Superior Avenue East, 21 st Floor Cleveland, OH 44114 WC99DODO B (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Endorsement No. 0 Premium $ 4428 PN049902B (Ed. 05-02) POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. 1. We establish our own rates for workers' compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20'3/0 or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. 3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. 5. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. California Workers' Compensation Insurance Notice of Nonrenewal Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. 1 of 2 PN049902B (Ed. 05-02) We are not required to provide you with a notice of nonrenewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of Tess than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate" means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. 2 of 2 P N049904 (Ed. 12-04) POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent. the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged. "CA Surcharge" or "CA Surcharge (CIGA Surcharge)" with an amount will be displayed ❑n your premium notice. This notice does not change the policy to which it is attached. PN 04 99 01 (Ed. 02-22) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION Information Available to You A. Information Available from Us — Sequoia Insurance Company (1) General questions regarding your policy should be directed to: Sequoia Insurance Company 800 Superior Ave. E., 21st Floor Cleveland, OH 44114 (877) 528-7878 www.amtrustfi nanciaicom (2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non-. payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan- 7995 (USRP) and the California Workers' Compensation Experience Rating Plan-7995 (ERP). WCIRB contact information is: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 (fax); and customerserviceoa wcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating FormlWorksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.comlratesheet. The Experience Rating FormfWorksheet will include a Loss -Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below. You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: AmTrust North America, Inc., 1 Park Plaza, Suite 800, Irvine, CA 92614, or Telephone: (877) 528-7878 or by email at: amtrustcomplaints@amtrustgroup.com After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your PN049901I (Ed. 02-22) 1 of 2 PN049901I (Ed. 02-22) request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice(diwcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1901 Harrison Street, 17th Floor, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerserviceOwcirb.com (email). C. California Department of Insurance — Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Mailroom Oakland, CA 94612 415.538.4243 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1901 Harrison Street, 17th Floor, Oakland. CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (fax) and ombudsman@wcirb.com (email). B. California Department of Insurance — Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. PN 04 99 01 I (Ed. 02-22) 2 of 2 Sequoia Insurance Company An AmTrust Financial Company California Short -Rate Cancellation Disclosure Notice IMPORTANT INFORMATION REGARDING YOUR POLICY The policy for which you have applied contains a cancellation provision that permits us to refund premium on a basis other than pro rata when you cancel the policy. Under the policy for which you have applied, if you cancel the policy, your final premium will be calculated based on the time your policy was in force with us, using the percentage specified in the short -rate cancellation table listed below. SHORT RATE CANCELLATION TABLE FOR A TERM OF ONE YEAR Percent Percent Percent Days of Days of Days of Policy One Year Policy One Year Policy One Year In Force Premirn In Force Premirn In Force Premtrn 1 5% 95— 98 3T% 219-223 E.9% 2 6 99-102 38 224-228 70 3— 4 7 103-105 39 229-232 71 5— 6 8 106-109 40 233-237 72 7— 8 9 110-113 41 238-241 73 9-10 10 114-116 42 242-246 (8 mos) 74 11-12 11 117-120 .. 43 247-250 75 13-14 12 121-124 (4 m0s.) 44 251-255 76 15-16 13 125-127 45 256-260 77 17-18 14 128-131 46 261-264 78 19-20 15 132-135 47 265-269 79 21-22 16 136-138 48 270-273 (9 m08) 80 23-25 17 139-142 49 274-278 81 26-29 18 143-146 50 279-282 82 30-32 (1 mo.) 19 147-149 51 283-287 83 33-36 20 150-153 (5 m0s.) 52 288-291 84 37-40 21 154-156 53 292-296 85 41-43 22 157-160 54 297-301 86 44-47 23 161-164 55 302-305 (10 mos.)... 87 48-51 24 165-167 56 306-310 88 52-54 25 168-171 57 311-314 89 55-58 26 172-175 58 315-319 90 59-62 (2 m0s) 27 176-178 59 320-323 91 63-65 28 179-182 (6 m0s.) 60 324-328 92 66-69 .. 29 183-187 61 329-332 93 70-73 30 188-191 62 333-337 (11 mos.),.. 94 74-76 31 192-196 63 338-342 95 77-80 32 197-200 64 343-348 96 81-83 33 201-205 65 347-351 97 84-87 34 206-209 66 352-355 98 88-91 (3 m08.) 35 210-214 (7 m08.) 67 356-360 99 92-94 36 215-218 68 361-365 (12 mos.)... 100 '► AmTrust INSURANCE Workers' Compensation Claim Reporting Information 24/7 Toll Free Claim Reporting for All States Q5; (888)239-3909 WorkersCompClaimReport@AmTrustgroup.com Information Required for All Claims Reported 1. Name of the insured and policy number 2. Name and contact information of injured worker 3. Date, time and place of accident www.anntrustfinancial.com 4. Description of accident or incident 5. Name, phone, and/or email of person making the report 6. Any information on the injured workers lost time Early claim reporting is essential to a better claim outcome. Don't delay reporting if you do not have all the details. How do I help my injured worker find a doctor? • We offer an online physician search for all states, www.talispoint.com/amtrust/external • For California,www-lvtalispoint.comlamtrusticampn • For CO, GA, PA & TN, please refer to the panel provided by AmTrust via mail or email How does my injured employee receive prescription medications related to the accident/injury? • Refer to the claims kit for your state at www.talispoint.com/amtrust/external for a First Fill card for your injured employee to use at the pharmacy to cover the cost of approved medication. Timely Reporting When a work -related injury occurs, it is important to act immediately. Timely reporting of a new claim helps to provide a smooth and successful claim process for both you and your injured worker. We're Here To Help After your claim has been filed, we may be in touch to obtain additional information. Our goal is to offer a smooth and hassle -free experience - from your first contact to the claims conclusion. Feel free to also callus with any questions. We're hereto help. Relax And Stay Positive You have the assurance of our knowledge, expertise, and understanding of the claim process. We're with you all the way. 877.528.7878 I www.amtrustfinancial.com This material is for informational purposes only and is not legal or business advice. Neither AmTrust Financial Services, Inc. nor any of its subsidiaries or affiliates represents or warrants that the information contained herein is appropriate or suitable for any specific business or legal purpose. Readers seeking resolution of specific questions should consult their business and/or legal advisors. Coverages may vary by location. Contact your local RSM for more information. AmTrust FA Ma INSURANCE MKT6310 06/23 2023,AmTrust Financial Services, Inc. AmTrust Claims Kit FAQs Thank you for placing your Workers' Compensation Coverage with AmTrust. For your convenience, we now offer electronic versions of our Claims Kits. Please see the instructions and FAQs below for more information. �1 O Where's my claims kit? ALE the States' Claims Kits are online for insured to download which contains all the necessary WC notices. Visitthe Talispoint Direct Link at www.talispoint.com/amtrust/external/ • Click State Rules/Kits, choose corresponding state and open the PDF link to view and print. have an injured worker, how do I find a doctor? We will provide completed Panel of Physicians for the 4 states that require a panel to be posted (CO, GA, PA & TN). We offer our online physician search for all other states. There are 3 ways to access this information: 1. Visit the Talispoint Direct Link at www.taiispoint.com/amtrustiexternai/ 2. California MPN: www.talispoint.com/amtrust/campn/ 3. Visit the AmTrust Financial Website atwww.amtrustfinanciaLcom Click Claims Click Provider Directory or California MPN under "Find a Provider" • State specific laws for directing medical treatment are listed on the State Rules Tab • Search for physicians by Name, Address or Region Where are my posting notices? All states claim kits are available online, including applicable postings. There are 4 states (CO, CT, FL & MD) we cannot place online. For these states, we will mail additional posting notices to the main address on the policy. have a question about my claims kit, posting notice, panel or accessing the website's physician searches, who do I contact? You may send an email to dientservices@amtrustgroup.com. Please make sure to include your policy number along with your request. have a question about a claim or injured worker, who do I contact? Customer Service can directyou to the appropriate person. Please contact them at888-239-3909. AmTrust 59 Maiden Lane, New York, NY 10038 1877.528.7878 I www.amtrustfinancial.com FINANC 1 AL Am I rust is Am ]rust Financial Services, .n c, located at 59 Maiden Lane, New York, NY 19938. Coverages are provided by its affiliated property and casualty in su ra sCe Cornpa n ies. to nsu It the applicable policy for specific terms, conditions, limits and exclusions to coverage. For full legal disclaimer information, including Texas and Washington writing companies, visit: vwrm.amtru stF na ncia I.co m/about-u s/legal-disclaimer. MKT5949 D2/22 e2022,AmTrust Financial Services, InC. AmTrust North America An AmTrust Financial Company April 2, 2025 Dear Policyholder, In an effort to continue to provide AmTrust customers with a variety of billing options, we have updated our fee structure to help customers meet payment due dates, ensure that valid and properly funded payments are submitted, and provide an incentive for paid -in -full options. Our updated fee structure is as follows: Fee Title Fee Amount Description Retumed Payment Fee $25 A returned payment fee applied to any returned payment. Late Fee $20 Late fee applied if payment not received on or before payment due date. Installment Fee $15 A "paper" billing fee that is assessed for each mailed installment invoice. Excludes down payment and annual payment plans. Fee is billed at the account level. Reinstatement Fee $50 Fee applied upon reinstatement of a non-payment cancellation. EFT Fee $3 An "electronic" billing fee that is assessed for each ACH Direct Debit transaction. Fee is billed at the account level. *Fee amount may vary by state and program of business For policyholders who choose to pay their annual premium on installments, we plan to implement an installment fee, which will be displayed on your renewal invoice. Thank you for your attention to this fee structure change. If you have any questions, feel free to contact our Customer Service Department at 877.528.7878. We value you as a policyholder and appreciate the opportunity to serve you. Sincerely, AmTrust North America Customer Service Department 800 Superior Avenue E • 21st Floor • Cleveland, OH 44114 (p) 866.203.3037 • (f) 800.487.9654 • www.amtrustnorthamerica.com Sequoia Insurance Company A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC990001 B 1 of 5 INFORMATION PAGE Ncci Code: 19755 1 Insured: Gilroy Golf Course, Inc. DBA: Gilroy Golf Course 2695 Hecker Pass Hwy Gilroy, CA 95020 Other workplaces not shown above: None Producer: Glow Insurance Services, LLC 548 Market St. San Francisco, CA 94104-5401 Policy Number: Individual X Corporation or Federal Tax ID: Risk Id: Renewal of: QWC1455617 Partnership 770530937 QWC 1364826 2. The policy period is from 5/10/2025 to 5/10/2026 12:01 a.m. at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: California B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $1 000,000 each accident $1,000moo policy limit C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and State(s) Designated in Item 3.A D. This policy includes these endorsements and schedules: See Extension of Information Page $1,000moo each employee 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM STATE ASSESSMENT TOTAL ESTIMATED COST Minimum Premium Deposit Premium Issue Date: 4/2/2025 Countersigned by: Authorized Representative 4,428 223 4,651 500 664 Sequoia Insurance Company WC 99 00 01 B 2of5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Gilroy Golf Course, Inc. Policy Number: QWC1455617 EXTENSION OF INFORMATION PAGE FOR ITEM #1 ITEM 1: NAME❑ INSURED and WORKPLACES NAMED INSURED: WORKPLACES: Gilroy Golf Course, Inc. DBA: Gilroy Golf Course Location Number 1. 2695 Hecker Pass Hwy Gilroy, CA 95020 Fein: 770530937 Sequoia Insurance Company WC 99 00 01 B 3 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Insured: Gilroy Golf Course, Inc. EXTENSION OF INFORMATION PAGE FOR ITEM #3.❑ ITEM 3.D: ENDORSEMENT SCHEDULE INFORMATION PAGE Policy Number: QWC1455617 State Form Number WC990001B CA 34-20051008 wc000000C WC000406A WC000419 WC000421F CA CA CA CA WC000422C WC040301 D WC040303C WC040310 WC040360B CA WC040421 CA WC040601 B CA WC040604A Description ❑ECLARATIONS PAGE CA Important Notice WORKERS COMPENSATION AN❑ EMPLOYERS LIABILITY INSURANCE POLICY PREMIUM ❑ISCOUNT ENDORSEMENT PREMIUM ❑UE DATE ENDORSEMENT CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ❑ISCLOSURE ENDORSEMENT POLICY AMENDATORY ENDORSEMENT CALIFORNIA OFFICERS AN❑ ❑IRECTORS COVERAGE/EXCLUSION CALIFORNIA CA DUTY TO ❑EFEND EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA CA OPTIONAL PREMIUM INCREASE ENDORSEMENT CALIFORNIA CANCELATION ENDORSEMENT Covid-19 Reporting Requirement Endorsement -California Sequoia Insurance Company WC 99 00 01 B 4 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Gilroy Golf Course, Inc. Policy Number: QWC1455617 EXTENSION OF INFORMATION PAGE FOR ITEM #4 ITEM 4: SCHEDULE OF PREMIUMS Classifications Premium Basis Total Estimated Rate Per Estimated # of Code Annual $100 of Annual Emps No. Remuneration Remun. Premium California Clubs — country or golf 13 9060 248,218 3.92 9,730 Manual Premium 9,730 Total Manual Premium 9,730 Premium for Increased Limits Part Two: 0% (1000/1000/1000) 9812 0 Total Premium Subject To Experience Modification 9,730 Experience Modification (0.82) Credit 9898 7,979 Schedule Rating Plan Modification Credit 47% 9887 -3,750 Terrorism 3% 9740 74 Catastrophe (other than Terrorism) 1% 9741 25 Minimum Premium Adjustment 0990 0 Expense Constant 0900 100 Total CA Premium 4,428 WCARF 1.237% 9999 55 UEBTF 0.0818% 9999 4 SIBTF 3.0148% 9999 133 OSHAF 0.1885% 9999 8 LECF 0.1058°I❑ 9999 5 FRAUD 0.4096% 9999 18 Total CA Cost 4,651 TOTAL ESTIMATED ANNUAL PREMIUM 4,428 STATE ASSESSMENT 223 TOTAL COST 4,651 Sequoia Insurance Company WC 99 00 01 B 5 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Gilroy Golf Course, Inc. Policy Number: QWC1455617 PAYMENT SCHEDULE Statement Payment Closing Date Due Date Description Amount Due 5/10/2025 Down payment 6/10/2025 Installment 1 of 9 7/10/2025 Installment 2 of 9 8/10/2025 Installment 3 of 9 9/10/2025 Installment 4 of 9 10/10/2025 Installment 5 of 9 11/10/2025 Installment 6 of 9 12/10/2025 Installment 7 of 9 1/10/2026 Installment 8 of 9 2/10/2026 Installment 9 of 9 $664.00 $443.00 $443.00 $443.00 $443.00 $443.00 $443.00 $443.00 $443.00 $443.00 Total Cost $4,651.00 Printed: 4/2/2025 IMPORTANT NOTICE CALIFORNIA WORKERS COMPENSATION REGARDING YOUR INSURANCE POLICY This policy, including all endorsements or riders forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in the policy or in such endorsement or rider shall affect such contract or any rights, duties, or privileges arising therefrom. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Infor- mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor- mation Page) and us (the insurer named on the In- formation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an em- ployer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any fed- eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self -insured for such workplaces. PART ONE WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in- vestigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du- ties under this insurance after an injury occurs. 3. We are directly and primarily liable to any per- son entitled to the benefits payable by this in- surance. Those persons may enforce our duties; so may an agency authorized by law. Enforce- ment may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or oth- er special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your du- ties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or inci- dental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by ac- cident or by disease must be brought in the United States of America, its territories or pos- sessions, or Canada. 2 of 6 B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employ- ees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permit- ted by law, include damages: 1. For which you are liable to a third party by rea- son of a claim or suit against you by that third party to recover the damages claimed against © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) such third party as a result of injury to your em- ployee; 2. For care and loss of services; and 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em- ployee; provided that these damages are the di- rect consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclu- sion does not apply to a warranty that your work will be done in a workmanlike manner; 2. Punitive or exemplary damages because of bodi- ly injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive offic- ers; 4. Any obligation imposed by a workers compensa- tion, occupational disease, unemployment com- pensation, or disability benefits law, or any simi- lar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, de- motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina- tion against or termination of any employee, or any personnel practices, policies, acts or omis- sions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonap- propriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901- 944), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 3 of 6 9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sec- tions 51 et seq.), any other federal laws obligat- ing an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10.Bodily injury to a master or member of the crew of any vessel, and does not cover punitive dam- ages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11.Fines or penalties imposed for violation of federal or state law; and 12.Damages payable under the Migrant and Sea- sonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our ex- pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed- ings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our request, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgment as required by law until we offer the amount due under this insurance; and 5. Expenses we incur. © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other in- surance or self-insurance. Subject to any limits of li- ability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is ex- hausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident —each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease —policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis- ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease —each em- ployee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include dis- ease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability un- der this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this poli- cy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to deter- mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga- tions under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor- mation Page. 2. If you begin work in any one of those states after the effective date of this policy and are not in- sured or are not self -insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this pol- icy in any state not listed in Item 3.A. of the In- formation Page, coverage will not be afforded for that state unless we are notified within thirty days. 4 of 6 B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other ser- vices required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may re- quest, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would in- terfere with our right to recover from others. 6. Do not voluntarily make payments, assume obli- gations or incur expenses, except at your own cost. PART FIVE PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifica- tions. We may change our manuals and apply the changes to this policy if authorized by law or a gov- ernmental agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifi- cations. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remu- neration is the most common premium basis. This premium basis includes payroll and all other remu- neration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com- pensation Insurance) of this policy. If you do not have payroll records for these persons, the con- tract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the em- ployers of these persons lawfully secured their workers compensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensa- tion law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premi- um basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the bal- ance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be de- termined in the following way unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short -rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to com- pute premium. You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledg- ers, journals, registers, vouchers, contracts, tax re- ports, payroll and disbursement records, and pro- grams for storing and retrieving data. We may con- duct the audits during regular business hours during the policy period and within three years after the pol- icy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. 5 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) PART SIX CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurabil- ity of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organiza- tions have the same rights we have under this provision. B. Long Term Policy If the policy period is longer than one year and six- teen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days af- ter your death, we will cover your legal representa- tive as insured. D. Cancelation 1. You may cancel this policy. You must mail or de- liver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or de- liver to you not less than ten days advance writ- ten notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com- ply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. 6 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 A (Ed. 7-95) PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule 1. State Estimated Eligible Premium California First Next Next $5,000 $100,000 $500,000 Balance 0% 3.5°I° 5% 7% 2. Average percentage discount: 0 % 3. Other policies: 4. If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium ❑iscount Endorsement attached to your policy number: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by Endorsement No. 0 Premium $ 4,428 WC 00 04 06 A (Ed. 7-95) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed. 1-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM ❑. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company WC 00 04 19 (Ed. 1-01) © 2000 National Council on Compensation Insurance, Inc. Policy No. QWC1455617 Endorsement No. Premium $4,428 Countersigned by WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement This endorsement is notification that we are charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). Coverage for such losses is subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement attached to this policy. For purposes of this endorsement, Catastrophe (Other Than Certified Acts of Terrorism) is defined as: A single event or peril resulting in a group of claims with aggregate workers compensation losses in excess of $50 million. This $50 million threshold applies per occurrence, across all states for which claims arise from a single event or peril. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page ❑r in the Schedule below. Schedule State Rate Premium CA 0.010 $25.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by Endorsement No. 0 Premium $ 4,428 WC 00 04 21 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) © Copyright 2021 National Council on Compensation Insurance, Inc. All rights reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-21) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act Of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property, or infrastructure. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United c. States missions or certain air carriers or vessels. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United d. States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any Toss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. WC 00 04 22 C (Ed. 01-21) © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-21) Schedule State Rate Premium CA 0.03 $74.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by WC 00 04 22 C (Ed. 01-21) Endorsement No. 0 Premium $ 4,428 © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 02-18) POLICY AMENDATORY ENDORSEMENT—CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed — Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages — Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment — Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Department of Insurance. 4. Application of Policy. Part One, "Workers Compensation Insurance", A, "How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6. Long Term Policy. If this policy is written fora period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. 8. Part Five, "Premium", E, "Final Premium", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: a. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short -rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. 1 of 2 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 02-18) It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Endorsement No. Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by 2 of 2 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 03 C (Ed. 07-18) ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE OFFICERS AND DIRECTORS COVERAGE / EXCLUSION CALIFORNIA If the employer named in Item 1 of the Information Page is a quasi -public or private corporation, this policy applies to all officers and members of boards of directors while rendering actual service for the corporation for pay, as employees, except those excluded below who 1. individually own at least 10 percent of the corporation's issued and outstanding stock, or 2. individually own at least 1 percent of the corporation's issued and outstanding stock if that officer's or member's parent, grandparent, sibling, spouse, or child owns at least 10 percent of the corporation's issued and outstanding stock and that officer or member is covered by a health insurance policy or a health care service plan, or 3. are officers or members of the board of directors of a cooperative corporation organized pursuant to the Cooperative Corporation Law (Corporations Code, Sections 12200 - 12704) who state that he or she is covered by both a health care service plan or health insurance policy, and a disability insurance policy that is comparable in scope and coverage, as determined by the Insurance Commissioner, to a workers' compensation policy. If the employer named in Item 1 of the Information Page is a private corporation, or a private cooperative corporation organized pursuant to the Cooperative Corporation Law, this policy applies to an officer or director who is the sole shareholder of the corporation, as an employee, except if excluded below. The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: Officers, Directors and Trustees Excluded Title Nancy Torres Cfo John Torres Ceo Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that "remuneration" when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by Endorsement No. 0 WC 04 03 03 C (Ed. 07-18) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC040310 (Ed. 01-95) DUTY TO DEFEND-CALIFORNIA The insurance afforded by Part One, Section C,"We Will Defend", is hereby deleted and replaced with the following: WE WILL DEFEND We have the right and duty to defend at our expense any claim or proceeding against you before the California Workers' Compensation Appeals Board or its equivalent in any other state (and any appeal of a decision therefrom) for the benefits payable by this workers' compensation insurance. We have the right to investigate and settle these claims or proceedings. We have no duty to defend a claim, proceeding, or suit that is not covered by this insurance. Nothing contained in this Section shall amend, modify, restrict, or otherwise alter any obligations or conditions under Part Two — Employer's Liability Insurance of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by Endorsement No. 0 Premium $ 4,428 WC040310 (Ed. 01-95) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B (Ed. 1-15) EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT-CALIFORNIA The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: A. How This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in California. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. E. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): 1. Exclusion 1 is amended to read as follows: 1. liability assumed under a contract. 2. Exclusion 2 is deleted. 3. Exclusion 7 is amended to read as follows: 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, termination of employment, or any personnel practices, policies, acts or omissions. 4. The following exclusions are added: 1. bodily injury to any member of the flying crew of any aircraft. 2. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s) applicable to you or otherwise fail to comply with that law. 3. liability arising from California Labor Code Section 2810.3 which relates to labor contracting. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by WC 04 03 60 B (Ed. 1-15) Endorsement No. 0 © Copyright 2015 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Comensation Insurance Forms Manual © 2001. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 (Ed. 1-08) OPTIONAL PREMIUM INCREASE ENDORSEMENT—CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verification audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified, return -receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by WC 04 04 21 (Ed. 1-08) Endorsement No. 0 Premium $ 4,428 © Copyright 2007 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 B (Ed. 01-22) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: Cancelation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Material failure to comply with federal or state safety orders or written recommendations of our designated loss control representatives; h. The occurrence of a material change in the ownership of your business; i. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; j. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; k. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties 3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) through (k), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. If we mail the notice to you, the stated periods of notice and your right to remedy the condition will be extended by 5 days if the place of mailing and your mailing address is within California, 10 days if the place of mailing or your mailing address is outside of California and 20 days if the place of mailing or your mailing address is outside of the United States. 5. The policy period will end on the day and hour stated in the cancelation notice. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by Endorsement No. 0 Premium $ 4,428 WC 04 06 01 B (Ed. 01-22) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 04 A (Ed. 01-23) COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA In addition to the requirements under Part 4, "Your Duties If Injury Occurs" of your policy, If you have five or more employees and an employee that is not described in California Labor Code section 3212.87 tests positive for COVID-19, you are required to report the following information as provided below. Pursuant to California Labor Code Section 3212.88(i), when you know, or reasonably should know, that an employee has tested positive for COVID-19 between September 17, 2020 and January 1, 2024, you must report to your claims administrator in writing via electronic mail or facsimile within 3 business days all of the following: (1) An employee has tested positive. For purposes of this reporting, do not provide any personally identifiable information regarding the employee who tested positive for COVID-19 unless the employee asserts the infection is work related or has filed a claim form pursuant to California Labor Code Section 5401. (2) The date that the employee tests positive, which is the date the specimen was collected for testing. (3) The specific address or addresses of the employee's specific place of employment during the 14-day period preceding the date of the employee's positive test. (4) The highest number of employees who reported to work at the employee's specific place of employment in the 45-day period preceding the last day the employee worked at each specific place of employment. Labor Code Section 3212.88(') states that the intentional submission of false or misleading information or the failure to report the above information as required may subject you to a civil penalty in the amount of up to $10,000 to be assessed by the Labor Commissioner. For the purposes of these reporting requirements, California Labor Code Section 3212.88(m) provides the following: (1) "COVID-19" means the 2019 novel coronavirus disease. (2) "Test" or "testing" means a PCR (Polymerise Chain Reaction) test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA. "Test" or "testing" does not include serologic testing, also known as antibody testing. "Test" or "testing" may include any other viral culture test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA which has the same or higher sensitivity and specificity as the PCR test. "A specific place of employment" means the building, store, facility, or agricultural field where an employee performs work at the employer's direction. "A specific place of employment" does not include the employee's home or residence, unless the employee provides home health care services to another individual at the employee's home or residence. (3) 1 of 2 WC 04 06 04 A (Ed. 01-23) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 04 A (Ed. 01-23) 24/7 Toll -Free COVID-19 Claim Reporting for all AmTrust carriers: Phone: (888) 239-3909 Email: WorkersCompClaimReport©AmTrustgroup.com OR Visit this webpage: amtrusffinancial.com/sb1159 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 5/10/2025 Policy No. QWC1455617 Insured Gilroy Golf Course, Inc. Insurance Company Sequoia Insurance Company Countersigned by 2 of 2 Endorsement No. 0 Premium $ 4,428 WC 04 06 04 A (Ed. 01-23)