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HomeMy WebLinkAboutSimplexGrinnell - Insurance CertificateACORO® CERTIFICATE OF LIABILITY INSURANCE DATE (NIMMDNYYY) 11/3/2016 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES .BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ,PRODUCER CONTACT - - - NAME: Marsh USA Inc. - 411 E. Wisconsin Avenue Suite 1300 PHONE FAX ' A/C No): ADDRESS: Please see bottom of Acord 101 INSURERS AFFORDING COVERAGE _NAIC# Milwaukee, WI 53202 INSURER A: Old Re ublic Insurance Company 24147 - - -Tf ' _$ , $10,000,000 INSURED INSURER B: ACE Property and Casualty Insurance Company 20699 SimplexGrinnell LP 6952 PRESTON AVENUE INSURER C: - X XCU Included LIVERMORE, CA 94551 INSURER D: GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY FI JE° 7 LOC OTHER: INSURER E: $30,000,000 United States INSURER F: $ COVERAGES CFRTIFICATF NIIMRFR• 1RR7RA9 - A DCVISInM MItMIRCD. 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. ILTR _ _TYPE OF INSURANCE DL IM SU R WV13 POLICY NUMBER (POLICY EFF POLIO EXP LIMBS • X COMMERCIAL GENERAL FV__1 CLAIMS -MADE OCCUR Contractual Liability MWZY 308341 10/1/2016 10/1/2017 EACH OCCURRENCE _ . - - -Tf ' _$ , $10,000,000 DAMAGE TO R5NT515_ PREMISES Ea occurrence) - $ $ 10,000,000 X MED EXP Any one.person), $ $50,000 X XCU Included PERSONAL & ADV INJURY $ $10,000,000' GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY FI JE° 7 LOC OTHER: GENERAL AGGREGATE ..$ $30,000,000 PRODUCTS - COMP /OP AGG $ INC IN GEN AGG $ • A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNED HIRED AUTOS X AUTOS MWTB 308344 Excludes NH ( ) MWTB 308371 (NH) 10/1/2016 1011/2016 .10/112017 10/1/2017 COMBINED SINGLE LIMB Ea accident $ $7,500,000 X BODILY INJURY (Per person) $ BODILY INJURY Per accident ( ) $ X PROPERTY DAMAGE Peraccident $ NEW HAMPSHIRE. CSL _ _ $ $250,000 B A X UMBRELLA LIAB EXCESS LIAB X 1OCCUIR CLAIMS -MADE 628162509,001 MWZX 308372 (NH) 10/1/2016 10/1/2016 10/1/2017 10/1/2017 . EACH OCCURRENCE $- $5,000,000 X AGGREGATE _ �. _$. $5,000;000 DED RETENTION NEW HAMPSHIRE (CSL) $ $Z,250 000 A A AND EMPLOYERS* LIABILITY ND OPR YERSPARBNIERIEXECUTIVE Y� OFFICERIMEMBEREXCLUDED9 N (Mandato ry In NH) If yes, describe under DESCRIPTION OF OPERATIONS below � N/A MWC 308342 0( AOS — See 2 MWXS 308343 OH & WA F9 ) 10/1/2016 10/1/2016 10/1/2017 10/1/2017 X STATUTE -ERµ i E.L. EACH ACCIDENT $ $$,000,000 E.LDISEASE - EAEMPLOYEE $ $5,000,000 iE.L. DISEASE- POLICY LIMIT $ $5,000,000 .DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES ( ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: ALL CALIFORNIA OPERATIONS Please refer to attached ACORD 101 for further remarks. City of Gilroy, its officers, officals and employees 7351 Rosanna Street Gilroy, CA 95020. United States SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i MARSH USA INC, BY: ACORD CORPORATION. All riahts reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC M. ACCM0 ADDITIONAL REMARKS SCHEDULE Page 2 of _2_ L_ AGENCY NAMED INSURED Marsh-USA Inc. SimplexGrinnell LP 6952 PRESTON AVENUE POLICY NUMBER LIVERMORE, CA 94551 United States CARRIER NAIC EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE CERTIFICATE OF LIABILITY INSURANCE WORKERS COMPENSATION: Workers Compensation "AOS" Policy includes coverage for the following states: AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, & WV. PRIMARY COVERAGE: The General Liability and.Automobile Liability policies are primary and not excess of or contributing with other insurance or self - insurance, where required by written lease or written contract. For General Liability, this applies to both ongoing and completed operations. WAIVER OF SUBROGATION: The General Liability, Automobile Liability, Workers Compensation and Employers Liability policies include a waiver of subrogation in favor of the certificate holder and any other person or organization to the extent required by written contract. For Monitoring services, Waiver of Subrogation does not apply. ADDITIONAL INSURED – AUTOMOBILE LIABILITY: The Automobile Liability policy,, if required by written contract, includes coverage for Additional Insureds as required by such written contract. ADDITIONAL INSURED – GENERAL LIABILITY: For General Liability, if required by written contract, the following are included as additional insureds, as required pursuant to a written contract with a named insured, per attached Policy Endorsements A2 and A2A: THE CERTIFICATE HOLDER LISTED ON THIS CERTIFICATE OF LIABILITY INSURANCE, AND EACH OTHER PERSON OR ORGANIZATION REQUIRED TO BE INCLUDED AS AN ADDITIONAL INSURED PURSUANT TO A WRITTEN CONTRACT WITH THE NAMED INSURED. LIMIT OF LIABILITY: The Liability Limit that applies is the amount indicated on the face of this Certificate of Liability Insurance, or the minimum Liability limit that, is required by the written contract, whichever is less. If there is no contract then the Liability Limit is limited to $1,000,000. LIMIT OF UMBRELLAIEXCESS LIABILITY: If the primary insurance policies noted on the face of this Certificate of Liability Insurance satisfy the combination of minimum primary limits and minimum Umbrella/Excess Liability limits required by the written contract, the Umbrella/Excess Liability limits shown on the face of this Certificate of Liability Insurance do not- apply. NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS: This endorsement modes the notice of cancellation of insurance provided hereunder: Should any of the above described policies be cancelled, other than for non - payment, before the expiration date thereof, 30 days advice of cancellation will be delivered to certificate holders in accordance with the policy endorsements. Additional Insureds:City of Gilroy, its officers, officials and employees FOR QUESTIONS REGARDING THIS CERTIFICATE OF INSURANCE CONTACT: mathew rosecrans (Email: mrosecransQsimplexgrinnell.com Phone.: 925- 273 -0100 ext.122) ------------------------------------------------------------------------------------------------------------ -------- -------- ----- __ —__��� THIS CERTIFICATE OF INSURANCE WAS GENERATED AND DELIVERED BY EXIGIS RiskWorks® rm.Certiflcates® Business Process Automation for Risk Management, Insurance, and Trade Finance To learn what EXIGIS can do for your business visit exi gis.com or call 800.928.1963 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION - ENDORSEMENT A2 Named Insured Endorsement Number Johnson Controls, Inc., Tyco International Holding S.a.r.l. Policy Prefix . Policy Number Policy-Period Effective Date of Endorsement MWZY 308341 10/01/16 to 10/01/17 Issued By Old Republic Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): If required by contract, the person or organization listed on the certificate of insurance as additional insured, and each other person or organization required to be included as an additional insured pursuant to a contract with a named insured. Location(s) Of Covered Operations: As required by contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused solely by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. GL 289 001 1012 MWZY 308341 Johnson Controls, Inc. 1010112016 - 1010112017 IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS - ENDORSEMENT A2A Named Insured Endorsement Number Johnson Controls, Inc., Tyco International Holding S.a.r.l. Policy Prefix Policy Number 1 Policy Period 110/01/16 Effective Date of Endorsement MWZY 308341 to 10/01/17 Issued By Old Republic Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modes insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): If required by contract, the person or organization listed on the certificate of insurance as additional insured, and each other person or organization required to be included as an additional insured pursuant to a contract with a named insured. Location And Description Of Completed Operations: As required by contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused solely by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard ". GL 289 002 1012 MWZY 308341 Johnson Controls, Inc. 1010112016 - 10/01/2017 AC ORl7® CERTIFICATE OF LIABILITY INSURANCE DATE (MMroD/YYYIf) 09/23/2016 "THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Mandl USA Inc. 411 East Wisconsin Avenue Suite 1300 Milwaukee, WI 53202 CONTACT NAME: PHONE' FAX A/C No): EppI , INSURER(S) AFFORDING COVERAGE NAIC # INSURER A Old Republic Insurance Company 24147 CN101230596- Tyco-GAWU &16-17 INSURED Johnson Controls, Inc. Tyco International Holding S.a.r.l. INSURER B: ACE Property and Casualty Insurance Company 20699 INSURER C : Factory Mutual Insurance Company 21482 INSURER D: $ 50,000 (and see allMed) 5757 North Green Bay Avenue Milwaukee, WI 53209 INSURER E: PERSONAL & ADV INJURY $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: N LOCPOLICY JEO - OTHER: GENERAL AGGREGATE . _ INSURER F: PRODUCTS - COMP /OP AGG nnv�nwr_o� rc0711=I41AT= wrMRFD. CHWn6793257 -01 REVISION NHMRER-0 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 SHOW_ N MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SU13R POLICY NUMBER POLICY EFF IM MIDD POLICY EXP MMIDDlYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR Corltralttlrei Liability MWZY 306341 10/0112016 10/01%2017 EACH OCCURRENCE $ 10,000,000 DAMAGE RENTED P EMISEST Ea oxu".. $ 10,000,000 X MED EXP (Any one person) $ 50,000 X XCU Included PERSONAL & ADV INJURY $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: N LOCPOLICY JEO - OTHER: GENERAL AGGREGATE . _ _ $ 30,000,000 PRODUCTS - COMP /OP AGG $ INC IN_GEN AGG $ A A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS MWTB 308344 (Excludes NH) MWiB 308371 (NH) 10/01/2016 10/0112016 10/01/2017 10/01/2017 COMBINED SINGLE LIMIT E. $ 7,500,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY AMAGE e P $ New Hampshire (CSL) $ 250,000 B A X UMBRELLA UAB �EESS LIAB X OCCUR CLAIMS -MADE G281625M 001 MW1-X 308372 (NH) 10/01/2016 10/01/2016 10101/2017 10/01/2017 EACH OCCURRENCE $ 5,000,000 rX AGGREGATE $ 5,000,000 RETENTION' New Hampshire (CSL) $ 7,250,000 A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N OFFICER/MEMBER EXCLUDED? F (Mandatory in NH) M yes, describe under DESCRIPTION OF.OPERATIONS below NIA MWC 308342 00 (AOS - see page 2) MWXS 308343 (OH & WA) 10/01/2016 10/01/2016 10/01/2017 10/01/2017 X IPER oTH- STATUTE E E. L. EACH ACCIDENT $ 5,000,000 E. L. DISEASE - EA EMPLOYEE $ 5,000,000 E. L. DISEASE -POLICY LIMIT 5,000,000 $ _ _ C Builders Risk (see Acord 101) 1018231 10/01/2016 10/0112017 See Acord 101 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) CITY OF GILROY is /are included as additional insured per the attached. See attached Acord 101 for additional information including Additional Insured, Primary/Non- contributory, Waiver of Subrogation and Notice of Cancellation provisions. CFRTIFICATF MIDI r1FR CANCELLATION CITY OF GILROY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 7351 ROSANNA STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GILROY,, CA 95020 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhelee „Ma%A ft0U. ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (M4101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101230596 LOC #: Chicago ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED Marsh USA Inc. Johnson Controls, Inc. Tyco International Holding S.a.d. POLICY NUMBER (and see attached) 5757 North Green Bay Avenue Milwaukee, Wl 53209 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A. SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Ins WORKERS COMPENSATION: Workers Compensation "AOS" Policy includes coverage for the following states: AK, AL, AR, AZ, CA, CO, CT, DC, DE, EL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WI, & WV. PRIMARY COVERAGE: The General Liability and Automobile Liability policies are primary and not excess of or contributing with other insurance or self- insurance, where.required by written lease or written contract For General Liability, this applies to both ongoing and completed operations. WAIVER OF SUBROGATION: The General.liability, Automobile Liability, Workers Compensation and Employers Liability policies include a waiver of subrogation in favor of the certificate.holder and any other person or organization to the extent required by written contract. ADDITIONAL INSURED - AUTOMOBILE LIABILITY: The Automobile Liability policy, if required by written contract, includes coverage for Additional Insureds as required by such written contract ADDITIONAL INSURED - GENERAL LIABILITY: For General Liability, if required by written contract, the following are included as additional insureds, as required pursuant to a written contract with a named insured, per attached Policy Endorsements A2 and A2A: THE CERTIFICATE HOLDER LISTED ON THIS CERTIFICATE OF LIABILITY INSURANCE, AND EACH OTHER PERSON' OR ORGANIZATION REQUIRED TO BE INCLUDED AS AN ADDITIONAL INSURED PURSUANT TO A WRITTEN CONTRACT WITH THE NAMED INSURED. LIMIT OF LIABILITY: The Liability Limit that applies is the amount indicated on the face of this Certificate of Liability Insurance, or the minimum Liability limit that is required by the written contract, whichever is less. If there is no contract then the Liability Limit is limited to $1,000,000. LIMIT OF UMBRELLAIEXCESS UABIITY: If the primary insurance policies noted on the face of this Certificate of Liability Insurance satisfy the combination of minimum primary limits and minimum Umbrefla/Excess Liability limits required by the written contract, the Umbrella/Excess Liability limits shown on the face of this Certificate of Liability Insurance do not apply. BUILDERS RISK INSURANCE COVERAGE: Policy Number: 1018231 Insurer: Factory Mutual Insurance Company Policy Period: 10/01/2016 - 1010112017 Builder's Risk I Installation 1 Contract Works, $1,000,000 per jobsite Rental' Equipments Contractor's Equipment, $1,000,000 per jobsite Blanket Transit•, $1,000,000 per conveyance Deductibles may apply as per policy terms and conditions. NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS: This endorsement modifies the notice of cancellation of insurance provided hereunder: Should any of the above described policies be cancelled, other than for non-payment. before the expiration date thereof, 30 days advice of cancellation will be delivered to certificate holders in accordance with the policy endorsements. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. rho ACORD name and logo are reglsterea marks or A%.urw AGENCY CUSTOMER ID: CN101230596 LOC #: Chicago .'►coR ADDITIONAL REMARKS SCHEDULE L i Page 3 of 3 AGENCY NAMED INSURED Marsh USA Inc. Johnson Controls, Inc. Tyco International Holding S.a.r.l. (and see attached) POLICY NUMBER 5757 North Green Bay Avenue Milwaukee, WI 53209 CARRIER TAIC CODE EFFECTIVE DATE: annITInKIA1 RFMAPW-q THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance NAMED INSURED: Insureds include: Tyco International Management Company, LLC, Tyco Carter Brothers, LLC, CEM Access Systems, Inc., Central CPVC Corporation, Central Sprinkler LLC, Chagrin H.Q. Venture Ltd., Chagrin Highlands Inc., Chagrin Highlands Ltd., Chemguard, Inc., Connect 24 Wireless Communications Inc., Detcon, Inc., Digital Security Controls, Inc., Elpas, Inc., Exacq Technologies, Inc., G-1 Great Lakes, A Series of Greenleeds LLC, GI Mid Atlantic, A Series of Greenleeds LLC, G -1 MidWest, A Series of Greenleeds LLC, G -1 New York, A Series of Greenleeds LLC, G-1 Other Risk Centers, A Series of Greenleeds LLC, Green Meadow Insurance Corp., Greenleeds LLC, Grinnell LLC, Grinnell Pacific, A Series of Greenleeds LLC, GSF Management Co, LLC, Haz-Tank Fabricators, Inc., Infrared Systems Group, LLC, Integrated Systems and Power, Inc., Master Protection, LP, Presidia (International) Insurance Company, Presidia (US) Insurance Company, Presidia Insurance Company, Qolsys, Inc., Retail Expert, Inc., Scott Figgie LLC, Scott Technologies, Inc., Senelco Iberia, Inc., Sensormatic Asia/Pacific, Inc., Sensormatic Electronics (Puerto Rico) LLC, Sensormatic Electronics, LLC, Sensormatic International, Inc., ShopperTrak International Investment LLC, ShopperTrak RCT Corporation, Shurjoint America, Inc., SimplexGrinnell LP, STI Licensing Corporation, STI Properties, Inc., STI Properties, Ltd., STI Risk Management Co., Tyco Cares Foundation, Tyco Fire & Security LLC, Tyco Fire Products LP, Tyco Integrated Security LLC, Visonic Inc., and WillFire HC, LLC. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION - ENDORSEMENT A2 Named Insured Endorsement Number Johnson Controls, Inc., Tyco International Holding S.a.r.l. Policy Prefix ploy Policy Number 308341 Policy Period 110/01116 to 10/01/17 Effective Date of Endorsement Issued By Old Republic Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): If required by contract, the person or organization listed on the certificate of insurances as additional insured, and each other person or organization required to be included as an additional insured pursuant to a contract with a named insured. Location(s) Of Covered Operations: As required by contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 - Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused solely by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment fumished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. GL 289 001 1012 IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS ENDORSEMENT A2A Named Insured Endorsement Number Johnson Controls, Ina, Tyco International Holding S.a.r.l. Policy Prefix Policy Number 1 Policy Period 110/01/16 Effective Date of Endorsement MWZY 308341 to 10/01/17 Issued By Old Republic Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): If required by contract, the person or organization listed on the certificate of insurance as additional insured, and each other person or organization required to be included as an additional insured pursuant to a contract with a named insured. Location And Description Of Completed Operations: As required by contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Who is An Insured is amended th include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused solely by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard ". GL 289 002 1012 September 2016 Marsh USA Inc. 411 East Wisconsin Avenue Suite 1300 Milwaukee, WI 53202 JC I.CertReauestCaMarsh. cam Johnson Controls, Inc. & Tyco International Holding S.a.r.l. Certificate of Insurance Dear Certholder: If you need this certificate to be renewed next year, please email a copy of it (or at a minimum send us the Certificate Number - located under the Insured and Insurer boxes) to us at ici.certrequest@marsh.com and indicate the email address for future use. If this certificate of insurance does not meet your needs, please email the details of the deficiencies along with a copy of the certificate (or the Certificate Number) to us at.ici.certrequest@marsh.com Please note that we will only be distributing these certificates via email in the future. CERTIFICATE OF LIABILITY INSURANCE DATE (mwoo/YY 12/16/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ,AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, 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). Marsh USA Inc. 1166 Avenue of the Americas New York, NY 10036 SimplexGrinnell LP 6952 PRESTON AVENUE LIVERMORE, CA 94551 United States Cindy Stathos, Michael Stastny or Terryn Castanon [XW,ESs. Please see bottom of 2nd page I I INSURERfSI AFFORDING COVERAGE I NAIC # I INSURER A: ACE American Insurance Company 22667 INSURER B: ACE Fire Underwriters Insurance Company 20702 INSURER C: Indemnity Insurance Company of North America 143575 COVERAGES CERTIFICATE NUMBER: 1523664 -A REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR - - TYPE OF INSURANCE ADDL INSO SUBR VJVQ POLICY NUMBER POLICY.EFF MM/DO nnrM .POLICY EXP (MMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR X HDOG27400358 1011/2015 10/1/2016 EACH OCCURRENCE $ $1,000,000.00 DAMAGE TO RENTED' PREMISES Ea occurrence $ $1,000.000.00 MED EXP (Any one person) $ $10,000.00 OWNER5 & CONTRACTOR'S PROT PERSONAL& ADV INJURY $ $1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ $2,000,000.00 X POLICY F] JEa F LOC PRODUCTS - COMP /OP AGG $ $2,000;000.00 $ OTHER: A AUTOMOBILE LIABILITY X ISA H08859905 (Excludes NH) accident n SINGLE LIMIT $ $1,000,000.00 A ISA H08859917 (NH) 10/1/2015 10/1/2016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED ALROS AUTOS JANYAUTO BODILY INJURY (Per accident) $ PROPERTYDAMAGE a accident $ HIREDAUTOS X NON-OWNED NEW HAMPSHIRE (CSL) $ $250,000.00 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE PRODUCTS - $ EXCESS LIAB CLAIMS -MADE DIED I I RETENTION NEW HAMPSHIRE (CSL) $ A B C AND WORKERS EMPLO YERS' LIABILITY A ILIT AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE YIN OFFICERIMEMBEREXCLUDED? N (Mandatory in NH) N/A WLR 048592284 (AZ, CA, MA) SCF C4W02296 (WI) WLR 048592272 (All Other States) 10/1/2015 10/1/2015 10/1/2015 10/1/2016 10/1/2016 10/1/2016 X ST TUTE ER`* E.L. EACH ACCIDENT $ $2,000,000.00 E.L. DISEASE - EA EMPLOYEE $ $2,000,000.00 If yes, describe under DESCRIPTION OF OPERATIONS below E.L.'DISEASE - POLICY LIMIT $ $2,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: Old City Hall 7400 Monterey Street, City Hall 7351 Rosanna Street and City Hall Annex 7370 Rosanna Street, ilroy, CA Please refer to attached ACORD 101 for further remarks. GtK I II-IGA I l- flULUr-K CITY OF GILROY 7351 ROSANNA STREET GILROY,, CA 95020 United States ACORD 25 (2014/01) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE MARSH USA INC, BY: ©1988 -2014 ACORD The ACORD name and logo are registered marks of ACORD reserved. AGENCY CUSTOMER ID: ,� ■� LOC #: A�oRD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. SimplexGrinnell LP 6952 PRESTON AVENUE LIVERMORE, CA 94551 POLICY NUMBER United States CARRIER NAIC EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS: is endorsement modifies the notice of cancellation of insurance provided hereunder: ould any of the above described policies be cancelled, other than for non - payment of premium, before the piration date thereof, 30 days advice of cancellation will be delivered to certificate holders in cordance.with the policy endorsements. 1 other terms and conditions of this policy remain unchanged. 3ARDING ADDITIONAL INSURED STATUS: accordance with the policy provisions, CITY OF GILROY is included as an additional insured under this licy, as a result of any contract or agreement entered into by the named insured and CITY OF GILROY. In accordance with the policy provisions, coverage afforded to an additional insured will apply as primary insurance where required by contract entered into by the named insured and the CITY OF GILROY. Any other insurance issued to such additional insured shall apply as excess and noncontributory insurance. r Additional Insureds: The City, its officers and employees FOR QUESTIONS REGARDING THIS CERTIFICATE OF INSURANCE CONTACT: mathew rosecrans (Email: mrosecrans @simplexgrinnell.com Phone: 925 - 273 -0100 ext.122) THIS CERTIFICATE OF INSURANCE WAS GENERATED AND DELIVERED BY EXIGIS RiskWorks® rm.CertificatesO Business Process Automation for Rlsk Management, Insurance, and Trade Finance . To learn what EXIGIS can do for vour business visit ezicis.com or call 800.928.1963 © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED WHERE REQUIRED UNDER CONTRACT OR AGREEMENT Named Insured Tyco International Management Company, LLC Endorsement Number 5 Policy Symbol Policy Number Policy Period Effective Date of Endorsement HDO G27400358 110/01/2015 TO 10/01/2016 Issued By (Name of Insurance Company) ACE American Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION II - WHO IS AN INSMIED, is amended to include as an additional insured: Any.person or organization to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of your operations, completed operations, or premises owned by or rented to you. However, the insurance provided will not exceed the lesser of: • The coverage and /or limits of this policy, or • The coverage and /or limits required by said contract or agreement. Authorized Agent MS 24411 10/13 Copyright 2011 12 Page 1 of 1 POLICY NUMBER: ISA H08859905 1 Endorsement Number: 1 COMMERCIAL AUTO CA 04 44 0310 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY , AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE. COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated' below. Named Insured: Tyco International Management Company, LLC Endorsement Effective Date: SCHEDULE Names Of Persons Or Organization (s): Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. Information required to complete this Schedule, if not shown above, will be shown in the. Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident" or the "loss" under .a contract with that person or organization. CA 04 44 0310 © Insurance Services Office, Inc., 2009 Page 1 of 1 0 ` ACORO® DATE- .(MM/DDNYYY) � J CERTIFICATE OF LIABILITY INSURANCE 7/1/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Cindy Stathos, Michael Stastny or Ter ryn CdStanon Marsh USA Inc. 1166 Avenue of the Americas New York, NY 10036 INSURED SimpiexGrinnell LP 6952 PRESTON AVENUE LIVERMORE, CA 94551 United States r-nVFRAGFS GFRTIFIr_ATF MI IMRCI?• 14Add47 - A cevicinki Admicco. THIS 18 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 &M S• Please see bottom of 2nd page EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY _PAID CLAIMS._ INSURERS AFFORDING COVERAGE NAIC # INSURER A: ACE American Insurance Company 22667 INSURER B: ACE Fire Underwriters Insurance Company 20702 INSURER C: Indemnity Insurance Company of North America 43575 r-nVFRAGFS GFRTIFIr_ATF MI IMRCI?• 14Add47 - A cevicinki Admicco. THIS 18 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._ INSR LTR TYPE ADDL S B POLICY NUMBER POLICY EFF M DD/YYYY POLICY EXP M D LIMITS _ A X COMMERCIAL GENERAL LIABILITY CLAIMS =MADE � OCCUR X HDOG27337818 10/1/2014 10/1/2015 EACH.00CURRENCE $ $1,000,000.00 PREMISES Eaoccurrenca $ $1,000,000.00 MED EXP (Any one person) $ $10,000.00 OWNER'S 8 CONTRACTOR'S PROT PERSONAL BADVINJURY $ $1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY F-1 JEa LOC GENERAL AGGREGATE $ $2,000,000.00 PRODUCTS - COMP /OP AGG $ $2,000,000.00 $ OTHER: A AUTOMOBILELUIBILITY X ISA H08828362 All Other States ( ) 10/1/2014 10/1/2015 COMBINED SINGLE LIMIT Ea accident $ $1,000,000.00 %( BODILY INJURY (Per person) $ A ANY AUTO ISA H08828374 (NH) 10/1/2014 10/1/2015 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X PROPERTY AMAGE Per accident D $ NON -OWNED 'HIRED AUTOS X. AUTOS NEW HAMPSHIRE (CSL) $ $250;000.00 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE PRODUCTS- $ EXCESS LIAB DED I I RETENTION$ NEW HAMPSHIRE (CSL) $ B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE Y / N OFFICER/MEMBEREXCLUE FN (Mandatory ImNH) NIA WLR C480187 9 (WI) CA, MA) SCF 048018749 (WI) WLR 048018725 (All Other States) 10/1/2014 10/112014 10/1/2014 10/1/2015 10/1/2015 10/1/2015 X STATUTE ER STATUTE E.L. EACH ACCIDENT $ $2,000,000.00 E.L. DISEASE - EA EMPLOYEE $ $2,000,000.00 If yyes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ $2,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ( ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: Old City Hall 7400 Monterey Street, City Hall 7351 Rosanna Street and City Hall Annex 7370 Rosanna Street, ilroy, CA Please refer to attached ACORD 101 for further remarks. CITY OF GILROY 7351 ROSANNA STREET GILROY,, CA 95020 United States SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ,-644z--;0 Gale MARSH USA INC, BY: ©1 ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: _ LOC #: .4 CC>REY ADDITIONAL REMARKS SCHEDULE Page 2 of 2 .AGENCY NAMED INSURED Marsh USA Inc. SimplexGrinnell LP 6952 PRESTON AVENUE LIVERMORE, CA 94551 POCKY NUMBER United States CARRIER NAIC EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS: is endorsement modifies the notice of cancellation of insurance provided hereunder: ould any of the above described policies be cancelled, other than for non- payment of premium, before the piration date thereof, 30 days advice of cancellation will be delivered to certificate holders in cordance with the policy endorsements. 1 other terms and conditions of this policy remain unchanged. GARDING ADDITIONAL INSURED STATUS: accordance with the policy provisions, CITY OF GILROY is included as an additional insured under this licy, as a result of any contract or agreement entered into by the named insured and CITY OF GILROY. In accordance with the policy provisions, coverage afforded to an additional insured will apply as primary insurance where required by contract entered into by the named insured and the CITY OF GILROY. Any other insurance issued to such additional insured shall apply as excess and noncontributory insurance. r Additional Insureds: The City, its officers and employees FOR QUESTIONS REGARDING THIS CERTIFICATE OF INSURANCE CONTACT: mathew rosecrans (Email: mrosecrans @simplexgrinnell.com Phone: 925 -273 -0100 ext.122) THIS CERTIFICATE OF INSURANCE WAS GENERATED AND DELIVERED BY EXIGIS RIskWorks® rm.Certlfloates@ Business Process Automation for Risk Management, Insurance, and Trade Finance To learn what EXIGIS can do for your business visit exigis.dom or call 800.928.1963 ACORD 101 (2008101) © 2008 ACORD CORPORATION_ All riahts reserved: The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED - WHERE REQUIRED UNDER CONTRACT OR AGREEMENT Named Insured Tyco Intemadonal Management Company, LLC . Endorsement Number 4 Pollay Symbol Pallcy Number Polloy Pedod E,ffecOve'Date of Endorsement HDO 027337818 10/01/2014 TO 10101/2015 Imed By (Name of Insurance Company) ACE Amedoan insurance Company THIS ENDORSEMENT CHANGES THE POLICY, PLEASE RM IT CAREFULLY, THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION 11 - WHO IS AN INSUM, is amended to include as an additional insured, Any person or organization to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy, but only with respect to liability arising out of your operations, completed operations, or premises owned by or rented to you. However, the insurance provided will not exceed the lesser of: The coverage and /or limits of this policy, or • The coverage and /or limits required by said contract or agreement. AJ i .44 U" 14., Authorized Agent MS 24411 10/13 Copyright 2011101 Page 1 of 1 POLICY NUMBER: ISA H08828362 Endorsement Number: 1 COMMERCIAL AUTO CA 04 44 0310 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. _ This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Tyco Intemational Management Company, LLC Endorsement Effective Date: SCHEDULE. Names Of Persons Or Or anization s : Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss, Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident" or the "loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34 (Ed. &W) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). The additional premium for this endorsement shall be 3 % of the total California Workers' Compensation premium otherwise due. Schedule Person or Organization ANY PERSON OR ORG FOR WHOM THIS NAIVER IS REQUIRED Job Description ALL CALIFORNIA OPERATIONS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The kftmadon bebw Is required only when the endorsement is Issued went to preparation of the policy.) Endorsement Effective 04 -30 -14 Policy No. WSD 5026438 00 Endorsement No. Insured FUCHS, HANS ERIC (AN Premium $ INCL. Insurance Company INSURANCE COMPANY OF THE NEST Countersigned By WC 99 06 34 (Ed. 8-00) INSURED