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HomeMy WebLinkAboutCOI - Ferma Corporation - Expires 2022-10-01r 5260 uxIw2 A� V CERTIFICATE 4F LIABILITY INSURANCE 09/30/201"'' 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 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 Ileu of such endorsements). PRODUCER LIC #OM77949 1-888-845-2248 McSherry & Hudson, LLC Insurance Services CONTACT NAME: PHONE 408-550-2130 FAX A/C No 408-550-2119 E-MAIL ADDRESS: 160 West Santa Clara Street Suite 715 San Jose, CA 95113 INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: STARR IND & LIAB CO 38318 Charles M. Griswold INSURED INSURERS: Tokio Marine Specialty Insurance Ccmpan3,23850 Parma Corporation INSURER C : INSURER0: 6639 Smith Avenue INSURERE: Newark, CA 94560 INSURER F : COVERAGES CERTIFICATE NUMBER: 63416485 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 INSURANCEADDLSUBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS A GENERAL LIABILITY X X 1000025823211 10/01/2 10/01/22 EACH OCCURRENCE $ 1, 000, 000 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxI OCCUR DAWX PREM T ENTED PREMISES Ea occurrence $ 100, 000 MED EXP (Any one person) $10, 000 PERSONAL & ADV INJURY $ 1, 000, 000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2, 000 , 000 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY X X 1000198707211 10/01/2 10/01/22 COMBINED SINGLE LIMIT Ea accident 1, 000, 000 BODILY INJURY Per ( vex«►) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED X HIRED AUTOS Ix AUTOS PROPERTY DAMAGE Per accident $ $ A LIAB X OCCUR 1000584640211 10/01/2 10/01/22 EACH OCCURRENCE $ 10,000,000 X HEXCESSLIAB CLAIMS -MADE AGGREGATE $ 10, 000,000 RETENTION FOLLOW FORM $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIE.L. ER EXCLUDED? N NIA X 1000004374 10/01/2 10/01/22 X I WCSTATU- I OTH. EACH ACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory In (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1, 000, 000 B Pollution Liability PPR ng a ggregate iomaom B Professional Liability PPK2332747 10/01/2 10/01/22 Single/Aggregate 5M/1014 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) RE: Encroachment Permit. Additional Insured: City of Gilroy. %omm i rrmom i c nVLWCM UANULLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Gilroy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 7351 Rosanna Street AUTHORIZED REPRESENTATIVE Gilroy, CA 95020 I USA 9111e� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD veliasj 63416485 9.2 O N 11526(X)281N12 SUPPLEMENT TO CERTIFICATE OF INSURANCE I DATE 09�3o/aoal NAME OF INSURED: Ferma Corporation Additional Description of Operations/Remarks from Page 1: N x z w Additional Information: Includes: General Liability: Additional Insured per forms attached CG20100413 and CO20370413. Coverage is Primary as required by written contract per from attached 00 107 (04-11). Per Project Aggregate per attached form CG25030509. Waiver of Subrogation as required by written contract per attached form CG24040509. Automobile Liability: Additional Insured per attached form SICA-1016 (0919). Primary and Non -Contributory Wording per attached form SICA-1037 (0919). Waiver of Subrogation per attached form CA04441013. Workers Compensation: Waiver of Subrogation per attached form WC040306 (Ed. 4-84). POLICY NUMBER: 1000025823211 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Where Required by Written Contract Where Required by Written 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" or "property damage" caused, in whole or in part, 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". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. may.. y 0 M CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 1000025823211 COMMERCIAL GENERAL LIABILITY CG 2010 0413 x THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ° ADDITIONAL INSURED - OWNERS, LESSEES OR N CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION z w This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Oroanization(s) I Location(s) Of Covered Operations Where Required by Written Contract Where Required by Written 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, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 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. CG20100413 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 00 z Page 2 of 2 ©insurance Services Office, Inc., 2012 CG 2010 0413 POLICY NUMBER: 1000025823211 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) N GENERAL AGGREGATE LIMIT Z This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Where Required by Written Contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under Section I - Coverage A, and for all medical expenses caused by accidents under Section I - Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each des- ignated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, ex- cept damages because of "bodily injury" or "property damage" included in the "products - completed operations hazard", and for medi- cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Con- struction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Ag- gregate Limit shown in the Declarations nor shall they reduce any other Designated Con- struction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Decla- rations, such limits will be subject to the appli- cable Designated Construction Project Gen- eral Aggregate Limit. CG 25 03 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 2 0 J 81 :In 91 Z861 AN---[ - M o v,c �� w= o I c "-a -�y QQ Or-03Q. can°' m U oo +. cE o cn � -ma j3 n -a c � c m .0- N�ctsOa�v, cO O '~ U U N +o C C U 'G 5 0 o O '2 � C " � W O ::. c� *0 CL CLca O C 0)N y- CO) QC�U � � N :- m C C- CU m O C N 'p .'-• O .0 �= C E O "a .v3 CM N' O O� O_ N .� vi 0 — t m •-' . 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O' J "O N Q O — 'O .O N L O E 0 O �: d L (D O C U cd Cl R m o O C = p'' t A -0 c0 •� O CL 0);n OL W to C L Cm'p L LO ''' O A N O O O E— c0aOOvUi _ .occ: ��cc•v cn� — LoaZ,,� 0L) co,CO i =W E ora > , r.--.E—ii.'_Eaa)--c`_w0(D `now 0tcc�oou)a)CIS0) w� 000 C -p -p = Q- U f� 0 m '�'' C1 C M O U O O O 'O O CA CA t C— +: 2 m L +� � C U C t CL-5 � cm CA .2 O .w N f- O w 0 C W L= O M to -6 O O t N L �+ C71 N L -0 'C m O '~ U .-. cd N U 0 0 0 U Q L m 0)C� Cl) m • L Q cm M CA O C� p C3f — E�oacupW= �o�Q cam o°)a' c� �C�oJwC �m A0CM000c U Emote �� m 0 CJ- a)Cio LammM U rn(oj�3c� �0'-'�0•� Co m E N Qo CD ?Q n -a V ca L CO = c au E - o L -o -a - ca C-0com n a)oL ch v,o N o v, � C E to }. cci c� UO m CO •0 O :� cxs CO Q C C 0 C2 m 0 0 Om m N �no'a�QVov� Ev�v�CD ao= rX cai Qcm o0 3 CL o �Co N�00.0 cx2 �m � cm U '— '"' �� O Q '0 m O d J co C Cm Omca��mCm U_0L_Ecn3�� r N m CD O W O Cl* O !A N U _j N O CV m Cn W CL Lot 110011 iOZ pi 26012KW2 *Starr Indemnity & Liability Company 0 Dallas, TX 1-866-519-2522 N 00 a Primary and Non -Contributory Condition z Policy Number: 1000025823211 Effective Date: 10/01/2021 Named Insured: Ferma Corporation This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. SECTION IV — CONDITIONS, condition 4.Other Insurance is amended as follows: 1. The following is added to paragraph 4.a. of the Other Insurance condition: This insurance is primary insurance as respects our coverage to the additional insured, where the written contract or written agreement requires that this insurance be primary and non-contributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured on which the additional insured is a Named Insured. ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. Signed for STARR INDEMNITY & LIABILITY COMPANY Steve Blakey, President Nehemiah E. Ginsburg, General Pounsel OG 107 (04/11) Page 1 of 1 Copyright © C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved. Includes copyrighted material of ISO Properties, Inc., used with its permission. PSN.�r�:xcxR POLICY NUMBER: 1000025823211 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE game Of Person Or Organization: Any person or organization to whom you become obligated to waive your rights of recovery against, under any ;ontract or agreement you enter into prior to the occurrence of loss. nformation required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 0 * Starr Indemnity & Liability Company COMMERCIAL AUTO SICA-1016 (0919) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATUS AMENDATORY ENDORSEMENT Policy Number: 1000198707211 Effective Date: 10/1/2021 Named Insured: FERMA CORPORATION This endorsement modifies the insurance coverage form(s) listed below that have been purchased by you and evidenced as such on the Declarations page. Please read the endorsement and respective policy(ies) carefully. AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM It is hereby agreed that SECTION II — COVERED AUTOS LIABILITY COVERAGE, A. COVERAGE, 1. Who Is An Insured of the Business Auto Coverage Form and Motor Carrier Coverage Form, and SECTION I — COVERED AUTOS COVERAGES, D. Covered Autos Liability Coverage, 2. Who Is An Insured of the Auto Dealers Coverage Form are amended to include the following: Any person or organization whom you become obligated to include as an additional insured under this policy, as a result of any written contract or written 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 use of a covered "auto". However, the insurance provided will not exceed the less of: (1) The coverage and/or limits of this policy, or (2) The coverage and/or limits required by such written contract or written agreement. All other terms and conditions of this Policy remain unchanged. SICA-1016 (0919) Copyright© Starr Indemnity & Liability Company. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Pi2W2X1X)2 r_ 3 x n * Starr Indemnity & Liability Company COMMERCIAL AUTO SICA-1037 (0919) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY AMENDATORY ENDORSEMENT Policy Number: 1000198707211 Effective Date: 10/01/2021 Named Insured: FERMA CORPORATION This endorsement modifies the insurance coverage form(s) listed below that have been purchased by you and evidenced as such on the Declarations page. Please read the endorsement and respective policy(ies) carefully. MOTOR CARRIER COVERAGE FORM It is hereby agreed that SECTION V — MOTOR CARRIER CONDITIONS, B. General Conditions, 5. Other Insurance — Primary and Excess Insurance Provisions is deleted in its entirety and replaced by the following: 5. Other Insurance — Primary And Excess Insurance Provisions a. While any covered "auto" is hired or borrowed from you by another "motor carrier", this Coverage Form's Covered Autos Liability Coverage is: (1) Primary and noncontributory if a written agreement between you as the lessor and the other "motor carrier" as the lessee requires you to hold the lessee harmless. (2) Excess over any other collectible insurance if a written agreement between you as the lessor and the other "motor carrier" as the lessee does not require you to hold the lessee harmless. b. While any covered "auto" is hired or borrowed by you from another "motor carrier", this Coverage Form's Covered Autos Liability Coverage is: (1) Primary and noncontributory if a written agreement between the other "motor carrier" as the lessor and you as the lessee does not require the lessor to hold you harmless, and then only while the covered "auto" is used exclusively in your business as a "motor carrier" for hire. (2) Excess over any other collectible insurance if a written agreement between the other "motor carrier" as the lessor and you as the lessee requires the lessor to hold you harmless. c. While a covered "auto" which is a "trailer" is connected to a power unit, this Coverage Form's Covered Autos Liability Coverage is: (1) Provided on the same basis, either primary or excess, as the Covered Autos Liability Coverage provided for the power unit if the power unit is a covered "auto". (2) Excess if the power unit is not a covered "auto". d. Any Trailer Interchange Coverage provided by this Coverage Form is primary for any covered "auto". e. Except as provided in Paragraphs a., b., c. and d. above, this Coverage Form provides primary insurance for any covered "auto" you own and excess insurance for any covered "auto" you don't own. f. For Hired Auto Physical Damage Coverage, any covered "auto" you lease, hire, rent or borrow is deemed SICA-1037 (0919) Copyright© Starr Indemnity & Liability Company. All rights reserved. Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 22 0 N 00 z L' 2021 I1N1I 14117 ^N D j 0 w V Q �O \I 0 0 cc " 5 a 0 90 ID a 0 0 w �c in CD CD m Q. IV N 0 N D 0 CD ch Q. 0 0 a 0 cn 0 3 N 0' CD c c� ID 0 cc CD Q. =r co 00.E r� 0 w Ejw � M- ID n CD CD W ca. 0 N CD n (a0 0 CD CD -0 I'D CD CD w (D N o� m N-00 CD =0 �.< 0 0�3 CD a0io � � ca. w � CO) m -. -.. C O_ N > N -0 > O O(Do :3 0) N � o co 0 r. I � 0 0 m Cl) n Cr� C) c 0cDCD ow cr ?. m mvicfl =r CD o � CO CD O 0 1 _ Z170 " 0 0 3 :3CL 30c90 �'9 o Cr t0_ SD a ,� 0 w SD c N 0 o A.-. < c < (D • =r N Ca d =r 0. 0 r O c V) - < 3' Q.n 2: CD 0 CD CDCD CO N SD 1 Q. - 0N0 :3 =CO CD cD 0 a ti c C) O ^' m 0. CDA N fl. O 5D CD C 0 O o O C "t 1-1 W < a C O Vf0X aQ Q 0 CD N D CO N 0 CDO y ENV 1982 17 OF 18 B POLICY NUMBER: 1000198707211 COMMERCIAL AUTO EM r CA 04 44 10 13 00 0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY N AGAINST OTHERS TO US (WAIVER OF SUBROGATION) a Z This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: FERMA CORPORATION Endorsement Effective Date: 10/01 /2021 SCHEDULE Name(s) Of Person(s) Or Organization(s): Any person or organization to whom you become obligated to waive your rights of recovery against, under any contract or agreement you enter into prior to the occurrence 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 Others 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 "accident" or the "loss" under a contract with that person or organization. CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 Pi261X)2WX)2 ev N WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 • o % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Where required by written contract Any person or organization to whom you become obligated to waive your rights of recovery against, under any contract or agreement you enter into prior to the occurrence of loss. 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: 10/01/2021 Policy No.: 1000004374 Endorsement No.: Insured: Ferma Corporation Premium: Insurance Company: STARR INDEMNITY & LIABILITY CO Countersigned by: WC 04 03 06 (Ed. 04-84) Page 1 of 1