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HomeMy WebLinkAboutCOI - CSG Consultants, Inc. - Expires 2021-12-04ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 2/8/2021 25674 CSG Consultants, Inc. 550 Pilgrim Drive Foster City, CA 94404 25666 11150 A 1,000,000 X 660-5R143841-TIL-20 12/4/2020 12/4/2021 1,000,000 10,000 1,000,000 2,000,000 2,000,000 1,000,000A X 810-5R143576-20-43-G 12/4/2020 12/4/2021 APD Owned Autos Only Comp/Coll Ded.2,000 1,000,000B ZUP-61N34906-20-NF 12/4/2020 12/4/2021 1,000,000 A X UB-5R147157-20-43-G 12/4/2020 12/4/2021 1,000,000 N 1,000,000 1,000,000 C Professional Liab.PAAEP0008805 12/4/2020 $5,000,000 Agg; Ded:50,000 re: all operations. The City of Gilroy, its employees, officers, officials and volunteers are named as additional insureds on GL with 30 Day Notice of Cancellation and included as additional insured on Auto per attached endorsements. Waiver of Subrogation on WC per attached endorsement. 30 Day Notice of Cancellation per attached endorsement. Sixty (60) Months Optional Extended Claims Reporting Period on Professional. 30 Day Notice of Cancellation on WC is not available. City of Gilroy Attn: Ogarita / City of Gilroy 7351 Rosanna Street Gilroy, CA 95202 CSGCONS-01 MHILL Alliant Insurance Services, Inc. 575 Market St Ste 3600 San Francisco, CA 94105 Melissa Hill Melissa.Hill@alliant.com Travelers Property Casualty Company of America Travelers Indemnity Company of America Arch Insurance Company X 12/4/2021 X X X X X X X DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 City of Gilroy, its officers, officials, and employees 7351 Rosanna St. Gilroy, CA 95020 12 04 20660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - WRITTEN CONTRACTS (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. The following is added to SECTION II - WHO IS AN INSURED: Any person or organization that you agree in a "written contract requiring insurance" to include as an additional insured on this Coverage Part, but: a. Only with respect to liability for "bodily injury", "property damage" or "personal injury"; and b. If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies. The person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. The insurance provided to such additional insured is limited as follows: c. In the event that the Limits of Insurance of this Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the in- surance provided to the additional insured shall be limited to the limits of liability required by that "written contract requiring insurance". This endorsement shall not increase the limits of insurance described in Section Ill - Limits Of Insurance. d. This insurance does not apply to the render- ing of or failure to render any "professional services" or construction management errors or omissions. e. This insurance does not apply to "bodily in- jury" or "property damage" caused by "your work" and included in the "products- completed operations hazard" unless the "written contract requiring insurance" specifi- cally requires you to provide such coverage for that additional insured, and then the insur- ance provided to the additional insured ap- plies only to such "bodily injury" or "property damage" that occurs before the end of the pe- riod of time for which the "written contract re- quiring insurance" requires you to provide such coverage or the end of the policy period, whichever is earlier. 2. The following is added to Paragraph 4.a. of SEC- TION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS: The insurance provided to the additional insured is excess over any valid and collectible "other in- surance", whether primary, excess, contingent or on any other basis, that is available to the addi- tional insured for a loss we cover. However, if you specifically agree in the "written contract requiring insurance" that this insurance provided to the ad- ditional insured under this Coverage Part must apply on a primary basis or a primary and non- contributory basis, this insurance is primary to "other insurance" available to the additional in- sured which covers that person or organization as a named insured for such loss, and we will not share with that "other insurance". But this insur- ance provided to the additional insured still is ex- cess over any valid and collectible "other insur- ance", whether primary, excess, contingent or on any other basis, that is available to the additional insured when that person or organization is an additional insured under any "other insurance". 3. The following is added to SECTION IV - COM- MERCIAL GENERAL LIABILITY CONDITIONS: Duties Of An Additional Insured As a condition of coverage provided to the addi- tional insured: a. The additional insured must give us written notice as soon as practicable of an "occur- rence" or an offense which may result in a claim. To the extent possible, such notice should include: CG D4 14 04 08 © 2008 The Travelers Companies, Inc. Page 1 of 2 Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY i. How, when and where the "occurrence" or offense took place; ii. The names and addresses of any injured persons and witnesses; and iii. The nature and location of any injury or damage arising out of the "occurrence" or offense. b. If a claim is made or "suit" is brought against the additional insured, the additional insured must: i. Immediately record the specifics of the claim or "suit" and the date received; and ii. Notify us as soon as practicable. The additional insured must see to it that we receive written notice of the claim or "suit" as soon as practicable. c. The additional insured must immediately send us copies of all legal papers received in con- nection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit", and oth- erwise comply with all policy conditions. d. The additional insured must tender the de- fense and indemnity of any claim or "suit" to any provider of other insurance which would cover the additional insured for a loss we cover. However, this condition does not affect whether this insurance provided to the addi- tional insured is primary to that other insur- ance available to the additional insured which covers that person or organization as a named insured. 4. The following is added to the DEFINITIONS Sec- tion: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or or- ganization as an additional insured on this Cover- age Part, provided that the "bodily injury" and "property damage" occurs and the "personal in- jury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 © 2008 The Travelers Companies, Inc. CG D4 14 04 08 Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS AND SURVEYORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE – This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A.Non-Owned Watercraft – 75 Feet Long Or Less H.Blanket Additional Insured – Governmental Entities – Permits Or Authorizations Relating ToB.Who Is An Insured – Unnamed Subsidiaries PremisesC.Who Is An Insured – Retired Partners, Members, I.Blanket Additional Insured – GovernmentalDirectors And Employees Entities – Permits Or Authorizations Relating ToD.Who Is An Insured – Employees And Volunteer OperationsWorkers – Bodily Injury To Co-Employees, Co- J.Incidental Medical MalpracticeVolunteer Workers And Retired Partners, Members, Directors And Employees K.Medical Payments – Increased Limit E.Who Is An Insured – Newly Acquired Or Formed L.Amendment Of Excess Insurance Condition – Limited Liability Companies Professional Liability F.Blanket Additional Insured – Controlling Interest M.Blanket Waiver Of Subrogation – When Required By Written Contract Or AgreementG.Blanket Additional Insured – Mortgagees, Assignees, Successors Or Receivers N.Contractual Liability – Railroads PROVISIONS uses or is responsible for the use of a watercraft that you do not own that is:A. NON-OWNED WATERCRAFT – 75 FEET (1)75 feet long or less; andLONG OR LESS (2)Not being used to carry any person1.The following replaces Paragraph (2)of or property for a charge;Exclusion g.,Aircraft, Auto Or Watercraft, in Paragraph 2.of SECTION I –B. WHO IS AN INSURED – UNNAMED COVERAGES – COVERAGE A – BODILY SUBSIDIARIES INJURY AND PROPERTY DAMAGE The following is added to SECTION II – WHO ISLIABILITY:AN INSURED: (2)A watercraft you do not own that is:Any of your subsidiaries, other than a partnership(a)75 feet long or less; and or joint venture, that is not shown as a Named (b)Not being used to carry any person Insured in the Declarations is a Named Insured or property for a charge;if: 2.The following replaces Paragraph 2.e.of a.You are the sole owner of, or maintain an SECTION II – WHO IS AN INSURED:ownership interest of more than 50% in, such subsidiary on the first day of the policye.Any person or organization that, with period; andyour express or implied consent, either CG D3 79 02 19 ú 2017 The Travelers Indemnity Company. All rights reserved.Page 1 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY Unless you are in the business or occupationb.Such subsidiary is not an insured under of providing professional health caresimilar other insurance. services, Paragraphs (1)(a),(b),(c)and (d)No such subsidiary is an insured for "bodily above do not apply to "bodily injury" arisinginjury" or "property damage" that occurred, or out of providing or failing to provide first aid"personal and advertising injury" caused by an or "Good Samaritan services" by any of youroffense committed:retired partners, members, directors or a.Before you maintained an ownership interest "employees", other than a doctor. Any such of more than 50% in such subsidiary; or retired partners, members, directors or "employees" providing or failing to provideb.After the date, if any, during the policy period first aid or "Good Samaritan services" duringthat you no longer maintain an ownership their work hours for you will be deemed to beinterest of more than 50% in such subsidiary.acting within the scope of their employmentFor purposes of Paragraph 1.of Section II – Who by you or performing duties related to theIs An Insured, each such subsidiary will be conduct of your business.deemed to be designated in the Declarations as:(2)"Personal injury": a.A limited liability company;(a)To you, to your current or retired b.An organization other than a partnership,partners or members (if you are ajoint venture or limited liability company; or partnership or joint venture), to your current or retired members (if you are ac.A trust; limited liability company), to your otheras indicated in its name or the documents that current or retired directors orgovern its structure."employees" while in the course of his or her employment or performing dutiesC. WHO IS AN INSURED – RETIRED PARTNERS, related to the conduct of your business,MEMBERS, DIRECTORS AND EMPLOYEES or to your other "volunteer workers"The following is added to Paragraph 2.of while performing duties related to theSECTION II – WHO IS AN INSURED:conduct of your business; Any person who is your retired partner, member,(b)To the spouse, child, parent, brother or director or "employee" that is performing services sister of that current or retired partner, for you under your direct supervision, but only for member, director, "employee" or "volunteer worker" as a consequence ofacts within the scope of their employment by you Paragraph (2)(a)above;or while performing duties related to the conduct of your business. However, no such retired (c)For which there is any obligation to partner, member, director or "employee" is an share damages with or repay someone else who must pay damages because ofinsured for: the injury described in Paragraph (2)(a) (1)"Bodily injury":or (b)above; or (a)To you, to your current partners or (d)Arising out of his or her providing ormembers (if you are a partnership or failing to provide professional health carejoint venture), to your current members services.(if you are a limited liability company) or (3)"Property damage" to property:to your current directors; (a)Owned, occupied or used by; or(b)To the spouse, child, parent, brother or sister of that current partner, member or (b)Rented to, in the care, custody or controldirector as a consequence of Paragraph of, or over which physical control is(1)(a)above;being exercised for any purpose by; (c)For which there is any obligation to you, any of your retired partners, membersshare damages with or repay someone or directors, your current or retiredelse who must pay damages because of "employees" or "volunteer workers", anythe injury described in Paragraph (1)(a) current partner or member (if you are aor(b)above; or partnership or joint venture), or any current(d)Arising out of his or her providing or member (if you are a limited liabilityfailing to provide professional health care company) or current director.services. Page 2 of 6 ú 2017 The Travelers Indemnity Company. All rights reserved.CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY D. WHO IS AN INSURED – EMPLOYEES AND organization will be deemed to be VOLUNTEER WORKERS – BODILY INJURY designated in the Declarations as: TO CO-EMPLOYEES, CO-VOLUNTEER a.A limited liability company;WORKERS AND RETIRED PARTNERS, b.An organization other than a partnership,MEMBERS, DIRECTORS AND EMPLOYEES joint venture or limited liability company;The following is added to Paragraph 2.a.(1)of orSECTION II – WHO IS AN INSURED: c.A trust;Paragraphs (1)(a),(b)and (c)above do not as indicated in its name or the documentsapply to "bodily injury" to a current or retired co-that govern its structure."employee" while in the course of the co- "employee's" employment by you or performing F. BLANKET ADDITIONAL INSURED – duties related to the conduct of your business, or CONTROLLING INTEREST to "bodily injury" to your other "volunteer 1.The following is added to SECTION II –workers" or retired partners, members or WHO IS AN INSURED:directors while performing duties related to the Any person or organization that has financialconduct of your business.control of you is an insured with respect toE. WHO IS AN INSURED – NEWLY ACQUIRED liability for "bodily injury", "property damage"OR FORMED LIMITED LIABILITY COMPANIES or "personal and advertising injury" that The following replaces Paragraph 3.of arises out of: SECTION II – WHO IS AN INSURED:a.Such financial control; or 3.Any organization you newly acquire or form,b.Such person's or organization'sother than a partnership or joint venture, and ownership, maintenance or use ofof which you are the sole owner or in which premises leased to or occupied by you.you maintain an ownership interest of more The insurance provided to such person orthan 50%, will qualify as a Named Insured if organization does not apply to structuralthere is no other similar insurance available alterations, new construction or demolitionto that organization. However:operations performed by or on behalf of sucha.Coverage under this provision is person or organization.afforded only: 2.The following is added to Paragraph 4.of(1)Until the 180th day after you acquire SECTION II – WHO IS AN INSURED:or form the organization or the end This paragraph does not apply to anyof the policy period, whichever is premises owner, manager or lessor that hasearlier, if you do not report such financial control of you.organization in writing to us within 180 days after you acquire or form it;G. BLANKET ADDITIONAL INSURED – or MORTGAGEES, ASSIGNEES, SUCCESSORS OR RECEIVERS(2)Until the end of the policy period, when that date is later than 180 days The following is added to SECTION II – WHO ISafter you acquire or form such AN INSURED:organization, if you report such Any person or organization that is a mortgagee,organization in writing to us within assignee, successor or receiver and that you180 days after you acquire or form it; have agreed in a written contract or agreementb.Coverage A does not apply to "bodily to include as an additional insured on thisinjury" or "property damage" that Coverage Part is an insured, but only withoccurred before you acquired or formed respect to its liability as mortgagee, assignee,the organization; and successor or receiver for "bodily injury", "property c.Coverage B does not apply to "personal damage" or "personal and advertising injury" and advertising injury" arising out of an that: offense committed before you acquired a.Is "bodily injury" or "property damage" thator formed the organization.occurs, or is "personal and advertising injury" For the purposes of Paragraph 1.of Section caused by an offense that is committed, II – Who Is An Insured, each such CG D3 79 02 19 ú 2017 The Travelers Indemnity Company. All rights reserved.Page 3 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY subsequent to the signing of that contract or openings, sidewalk vaults, elevators, street agreement; and banners or decorations. b.Arises out of the ownership, maintenance or I. BLANKET ADDITIONAL INSURED – use of the premises for which that GOVERNMENTAL ENTITIES – PERMITS mortgagee, assignee, successor or receiver OR AUTHORIZATIONS RELATING TO is required under that contract or agreement OPERATIONS to be included as an additional insured on The following is added to SECTION II – WHO ISthis Coverage Part.AN INSURED: The insurance provided to such mortgagee,Any governmental entity that has issued a permitassignee, successor or receiver is subject to the or authorization with respect to operationsfollowing provisions:performed by you or on your behalf and that you a.The limits of insurance provided to such are required by any ordinance, law, building code mortgagee, assignee, successor or receiver or written contract or agreement to include as an will be the minimum limits that you agreed to additional insured on this Coverage Part is an provide in the written contract or agreement, insured, but only with respect to liability for or the limits shown in the Declarations, "bodily injury", "property damage" or "personal whichever are less.and advertising injury" arising out of such operations.b.The insurance provided to such person or organization does not apply to:The insurance provided to such governmental entity does not apply to:(1)Any "bodily injury" or "property damage" that occurs, or any "personal and a.Any "bodily injury", "property damage" oradvertising injury" caused by an offense "personal and advertising injury" arising outthat is committed, after such contract or of operations performed for theagreement is no longer in effect; or governmental entity; or (2)Any "bodily injury", "property damage" or b.Any "bodily injury" or "property damage""personal and advertising injury" arising included in the "products-completedout of any structural alterations, new operations hazard".construction or demolition operations J. INCIDENTAL MEDICAL MALPRACTICEperformed by or on behalf of such 1.The following replaces Paragraph b.of themortgagee, assignee, successor or definition of "occurrence" in thereceiver. DEFINITIONS Section:H. BLANKET ADDITIONAL INSURED – b.An act or omission committed inGOVERNMENTAL ENTITIES – PERMITS OR providing or failing to provide "incidentalAUTHORIZATIONS RELATING TO PREMISES medical services", first aid or "GoodThe following is added to SECTION II – WHO IS Samaritan services" to a person, unlessAN INSURED:you are in the business or occupation of providing professional health careAny governmental entity that has issued a permit services.or authorization with respect to premises owned or occupied by, or rented or loaned to, you and 2.The following replaces the last paragraph of that you are required by any ordinance, law,Paragraph 2.a.(1)of SECTION II – WHO IS building code or written contract or agreement to AN INSURED: include as an additional insured on this Unless you are in the business or occupationCoverage Part is an insured, but only with of providing professional health carerespect to liability for "bodily injury", "property services, Paragraphs (1)(a),(b),(c)and (d)damage" or "personal and advertising injury"above do not apply to "bodily injury" arisingarising out of the existence, ownership, use,out of providing or failing to provide: maintenance, repair, construction, erection or (a)"Incidental medical services" by any ofremoval of any of the following for which that your "employees" who is a nurse,governmental entity has issued such permit or nurse assistant, emergency medicalauthorization: advertising signs, awnings,technician, paramedic, athletic trainer,canopies, cellar entrances, coal holes,audiologist, dietician, nutritionist,driveways, manholes, marquees, hoist away Page 4 of 6 ú 2017 The Travelers Indemnity Company. All rights reserved.CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY that is available to any of your "employees"occupational therapist or occupational for "bodily injury" that arises out of providingtherapy assistant, physical therapist or or failing to provide "incidental medicalspeech-language pathologist; or services" to any person to the extent not(b)First aid or "Good Samaritan services"subject to Paragraph 2.a.(1)of Section II –by any of your "employees" or "volunteer Who Is An Insured.workers", other than an employed or volunteer doctor. Any such "employees"K. MEDICAL PAYMENTS – INCREASED LIMIT or "volunteer workers" providing or failing The following replaces Paragraph 7.ofto provide first aid or "Good Samaritan SECTION III – LIMITS OF INSURANCE:services" during their work hours for you 7.Subject to Paragraph 5.above, the Medicalwill be deemed to be acting within the scope of their employment by you or Expense Limit is the most we will pay under performing duties related to the conduct Coverage C for all medical expenses of your business.because of "bodily injury" sustained by any one person, and will be the higher of:3.The following replaces the last sentence of Paragraph 5.of SECTION III – LIMITS OF a.$10,000; orINSURANCE: b.The amount shown in the Declarations ofFor the purposes of determining the this Coverage Part for Medical Expenseapplicable Each Occurrence Limit, all related Limit.acts or omissions committed in providing or failing to provide "incidental medical L. AMENDMENT OF EXCESS INSURANCE services", first aid or "Good Samaritan CONDITION – PROFESSIONAL LIABILITYservices" to any one person will be deemed The following is added to Paragraph 4.b.,to be one "occurrence".Excess Insurance, of SECTION IV –4.The following exclusion is added to COMMERCIAL GENERAL LIABILITYParagraph2.,Exclusions, of SECTION I –CONDITIONS: COVERAGES – COVERAGE A – BODILY This insurance is excess over any of the otherINJURY AND PROPERTY DAMAGE insurance, whether primary, excess, contingentLIABILITY:or on any other basis, that is ProfessionalSale Of Pharmaceuticals Liability or similar coverage, to the extent the "Bodily injury" or "property damage" arising loss is not subject to the professional services out of the violation of a penal statute or exclusion of Coverage A or Coverage B. ordinance relating to the sale of M. BLANKET WAIVER OF SUBROGATION –pharmaceuticals committed by, or with the WHEN REQUIRED BY WRITTEN CONTRACTknowledge or consent of the insured.OR AGREEMENT5.The following is added to the DEFINITIONS The following is added to Paragraph 8.,TransferSection: Of Rights Of Recovery Against Others To Us,"Incidental medical services" means:of SECTION IV – COMMERCIAL GENERAL a.Medical, surgical, dental, laboratory, x-LIABILITY CONDITIONS: ray or nursing service or treatment,If the insured has agreed in a written contract oradvice or instruction, or the related agreement to waive that insured's right offurnishing of food or beverages; or recovery against any person or organization, we b.The furnishing or dispensing of drugs or waive our right of recovery against such personmedical, dental, or surgical supplies or or organization, but only for payments we makeappliances.because of: 6.The following is added to Paragraph 4.b.,a."Bodily injury" or "property damage" thatExcess Insurance, of SECTION IV –occurs; orCOMMERCIAL GENERAL LIABILITY b."Personal and advertising injury" caused byCONDITIONS: an offense that is committed;This insurance is excess over any valid and subsequent to the signing of that contract orcollectible other insurance, whether primary, excess, contingent or on any other basis,agreement. CG D3 79 02 19 ú 2017 The Travelers Indemnity Company. All rights reserved.Page 5 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL GENERAL LIABILITY N. CONTRACTUAL LIABILITY – RAILROADS 1.The following replaces Paragraph c.of the definition of "insured contract" in the DEFINITIONS Section: c.Any easement or license agreement; 2.Paragraph f.(1)of the definition of "insured contract" in the DEFINITIONS Section is deleted. Page 6 of 6 ú 2017 The Travelers Indemnity Company. All rights reserved.CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Policy # 660-5R143841-TIL-20 DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. GENERAL DESCRIPTION OF COVERAGE – This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. BROAD FORM NAMED INSURED H. HIRED AUTO PHYSICAL DAMAGE – LOSS OF USE – INCREASED LIMITB. BLANKET ADDITIONAL INSURED I. PHYSICAL DAMAGE – TRANSPORTATIONC. EMPLOYEE HIRED AUTO EXPENSES – INCREASED LIMIT D. EMPLOYEES AS INSURED J. PERSONAL EFFECTS K. AIRBAGSE. SUPPLEMENTARY PAYMENTS – INCREASED LIMITS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSSF. HIRED AUTO – LIMITED WORLDWIDE COVERAGE – INDEMNITY BASIS M. BLANKET WAIVER OF SUBROGATION G. WAIVER OF DEDUCTIBLE – GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS PROVISIONS A. BROAD FORM NAMED INSURED as an additional insured for Liability Coverage, but only for damages to which this insuranceThe following is added to Paragraph A.1., Who Is applies and only to the extent of that person's orAn Insured, of SECTION II – LIABILITY organization's liability for the conduct of anotherCOVERAGE:"insured".Any organization you newly acquire or form C. EMPLOYEE HIRED AUTOduring the policy period over which you maintain 50% or more ownership interest and that is not 1.The following is added to Paragraph A.1., separately insured for Business Auto Coverage.Who Is An Insured, of SECTION II – Coverage under this provision is afforded only LIABILITY COVERAGE: until the 180th day after you acquire or form the An "employee" of yours is an "insured" whileorganization or the end of the policy period,operating an "auto" hired or rented under awhichever is earlier.contract or agreement in that "employee's"B. BLANKET ADDITIONAL INSURED name, with your permission, while performing The following is added to Paragraph c. in A.1.,duties related to the conduct of your Who Is An Insured, of SECTION II – LIABILITY business. COVERAGE:2.The following replaces Paragraph b. in B.5., This includes any person or organization who you Other Insurance, of SECTION IV – are required under a written contract or BUSINESS AUTO CONDITIONS: agreement between you and that person or b.For Hired Auto Physical Damageorganization, that is signed by you before the Coverage, the following are deemed to be"bodily injury" or "property damage" occurs and covered "autos" you own:that is in effect during the policy period, to name CA T3 53 08 17 ú 2016 The Travelers Indemnity Company. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission Policy # 810-5R143576-20-43-G DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL AUTO (1)Any covered "auto" you lease, hire,liability company) or members of their rent or borrow; and households. (2)Any covered "auto" hired or rented by (1)With respect to any claim made or "suit" your "employee" under a contract in brought outside the United States of that individual "employee's" name,America, the territories and possessions with your permission, while of the United States of America, Puerto performing duties related to the Rico and Canada: conduct of your business.(a)You must arrange to defend the However, any "auto" that is leased, hired,"insured" against, and investigate or rented or borrowed with a driver is not a settle any such claim or "suit" and covered "auto".keep us advised of all proceedings and actions.D. EMPLOYEES AS INSURED (b)Neither you nor any other involvedThe following is added to Paragraph A.1., Who Is "insured" will make any settlementAn Insured, of SECTION II – LIABILITY without our consent.COVERAGE: (c)We may, at our discretion, participateAny "employee" of yours is an "insured" while in defending the "insured" against, orusing a covered "auto" you don't own, hire or in the settlement of, any claim orborrow in your business or your personal affairs. "suit".E. SUPPLEMENTARY PAYMENTS – INCREASED (d)We will reimburse the "insured":LIMITS (i)For sums that the "insured"1.The following replaces Paragraph A.2.a.(2), legally must pay as damagesofSECTION II – LIABILITY COVERAGE: because of "bodily injury" or(2)Up to $3,000 for cost of bail bonds "property damage" to which this(including bonds for related traffic law insurance applies, that theviolations) required because of an "insured" pays with our consent,"accident" we cover. We do not have to but only up to the limit describedfurnish these bonds.in Paragraph C., Limit Of Insurance, of SECTION II –2.The following replaces Paragraph A.2.a.(4), LIABILITY COVERAGE;of SECTION II – LIABILITY COVERAGE: (ii)For the reasonable expenses(4)All reasonable expenses incurred by the "insured" at our request, including actual incurred with our consent for your loss of earnings up to $500 a day investigation of such claims and because of time off from work.your defense of the "insured" F. HIRED AUTO – LIMITED WORLDWIDE against any such "suit", but only COVERAGE – INDEMNITY BASIS up to and included within the limit described in Paragraph C., LimitThe following replaces Subparagraph e. in Of Insurance, of SECTION II –Paragraph B.7., Policy Term, Coverage LIABILITY COVERAGE, and notTerritory, of SECTION IV – BUSINESS AUTO CONDITIONS:in addition to such limit. Our duty to make such payments endse.Anywhere in the world, except any country or when we have used up thejurisdiction while any trade sanction, applicable limit of insurance inembargo, or similar regulation imposed by the payments for damages,United States of America applies to and settlements or defense expenses.prohibits the transaction of business with or within such country or jurisdiction, for Liability (2)This insurance is excess over any valid Coverage for any covered "auto" that you and collectible other insurance available lease, hire, rent or borrow without a driver for to the "insured" whether primary, excess a period of 30 days or less and that is not an contingent or on any other basis. "auto" you lease, hire, rent or borrow from (3)This insurance is not a substitute forany of your "employees", partners (if you are required or compulsory insurance in anya partnership), members (if you are a limited country outside the United States, its Page 2 of 4 ú 2016 The Travelers Indemnity Company. All rights reserved. CA T3 53 08 17 Includes copyrighted material of Insurance Services Office, Inc. with its permission Policy # 810-5R143576-20-43-G DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL AUTO territories and possessions, Puerto Rico Personal Effects and Canada.We will pay up to $400 for "loss" to wearing You agree to maintain all required or apparel and other personal effects which are: compulsory insurance in any such (1)Owned by an "insured"; andcountry up to the minimum limits required (2)In or on your covered "auto".by local law. Your failure to comply with compulsory insurance requirements will This coverage applies only in the event of a total not invalidate the coverage afforded by theft of your covered "auto". this policy, but we will only be liable to the No deductibles apply to this Personal Effectssame extent we would have been liable coverage.had you complied with the compulsory K. AIRBAGSinsurance requirements. (4)It is understood that we are not an The following is added to Paragraph B.3., admitted or authorized insurer outside the Exclusions, of SECTION III – PHYSICAL United States of America, its territories DAMAGE COVERAGE: and possessions, Puerto Rico and Exclusion 3.a. does not apply to "loss" to one orCanada. We assume no responsibility for more airbags in a covered "auto" you own thatthe furnishing of certificates of insurance,inflate due to a cause other than a cause of "loss"or for compliance in any way with the set forth in Paragraphs A.1.b.and A.1.c., butlaws of other countries relating to only:insurance. a.If that "auto" is a covered "auto" forG. WAIVER OF DEDUCTIBLE – GLASS Comprehensive Coverage under this policy; The following is added to Paragraph D.,b.The airbags are not covered under anyDeductible, of SECTION III – PHYSICAL warranty; andDAMAGE COVERAGE: c.The airbags were not intentionally inflated.No deductible for a covered "auto" will apply to We will pay up to a maximum of $1,000 for anyglass damage if the glass is repaired rather than one "loss".replaced. L. NOTICE AND KNOWLEDGE OF ACCIDENT ORH. HIRED AUTO PHYSICAL DAMAGE – LOSS OF LOSSUSE – INCREASED LIMIT The following is added to Paragraph A.2.a., ofThe following replaces the last sentence of SECTION IV – BUSINESS AUTO CONDITIONS:Paragraph A.4.b.,Loss Of Use Expenses, of SECTION III – PHYSICAL DAMAGE Your duty to give us or our authorized COVERAGE:representative prompt notice of the "accident" or "loss" applies only when the "accident" or "loss" isHowever, the most we will pay for any expenses known to:for loss of use is $65 per day, to a maximum of $750 for any one "accident".(a)You (if you are an individual); I. PHYSICAL DAMAGE – TRANSPORTATION (b)A partner (if you are a partnership); EXPENSES – INCREASED LIMIT (c)A member (if you are a limited liability The following replaces the first sentence in company); Paragraph A.4.a.,Transportation Expenses, of (d)An executive officer, director or insuranceSECTION III – PHYSICAL DAMAGE manager (if you are a corporation or otherCOVERAGE:organization); or We will pay up to $50 per day to a maximum of (e)Any "employee" authorized by you to give$1,500 for temporary transportation expense notice of the "accident" or "loss".incurred by you because of the total theft of a M. BLANKET WAIVER OF SUBROGATIONcovered "auto" of the private passenger type. The following replaces Paragraph A.5., TransferJ. PERSONAL EFFECTS Of Rights Of Recovery Against Others To Us,The following is added to Paragraph A.4.,of SECTION IV – BUSINESS AUTOCoverage Extensions, of SECTION III –CONDITIONS:PHYSICAL DAMAGE COVERAGE: CA T3 53 08 17 ú 2016 The Travelers Indemnity Company. All rights reserved.Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission Policy # 810-5R143576-20-43-G DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 COMMERCIAL AUTO 5. Transfer Of Rights Of Recovery Against N. UNINTENTIONAL ERRORS OR OMISSIONS Others To Us The following is added to Paragraph B.2., We waive any right of recovery we may have Concealment, Misrepresentation, Or Fraud, of against any person or organization to the SECTION IV – BUSINESS AUTO CONDITIONS: extent required of you by a written contract The unintentional omission of, or unintentionalsigned and executed prior to any "accident"error in, any information given by you shall notor "loss", provided that the "accident" or "loss"prejudice your rights under this insurance.arises out of operations contemplated by However this provision does not affect our right tosuch contract. The waiver applies only to the collect additional premium or exercise our right ofperson or organization designated in such cancellation or non-renewal.contract. Page 4 of 4 ú 2016 The Travelers Indemnity Company. All rights reserved.CA T3 53 08 17 Includes copyrighted material of Insurance Services Office, Inc. with its permission Policy # 810-5R143576-20-43-G DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54 ..... TRAVELERSJ WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A) - POLICY NUMBER: WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be mium. Schedule Person or Organization % of the California workers' compensation pre- Job Description 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 Insured Insurance Company DATE OF ISSUE: Policy No. ST ASSIGN: Endorsement No. Premium Page 1 of 1 Countersigned by _ ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. UB-5R147157-20-43-G12/04/2020 UB-5R147157-20-43-G DocuSign Envelope ID: 9E7878CC-38FC-4E96-9472-64492429D99CDocuSign Envelope ID: 0D661DDD-C7D9-4277-9C4D-4FC173755D54