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HomeMy WebLinkAboutAgreement - Island Kids LLC - Recreation Independent Contract InstructorCity of Gilroy Agreement/Contract Tracking Today’s Date: January 27, 2025 Your Name: Adam Henig Contract Type: Other (Non-Standard contracts must be reviewed by the City Administrator prior to initiating) Phone Number: 408-846-0577 Contract Effective Date: (Date contract goes into effect) 1/23/2025 Contract Expiration Date: 12/31/2027 Contractor / Consultant Name: (if an individual’s name, format as last name, first name) Island Kids LLC (dba Challenge Island Bay Area), Contract Subject: (no more than 100 characters) Recreation Independnet Contract Instructor Contract Amount: (Total Amount of contract. If no amount, leave blank) By submitting this form, I confirm this information is complete: Date of Contract Contractor/Consultant name and complete address Terms of the agreement (start date, completion date or “until project completion”, cap of compensation to be paid) Scope of Services, Terms of Payment, Milestone Schedule and exhibit(s) attached Taxpayer ID or Social Security # and Contractors License # if applicable Contractor/Consultant signer’s name and title City Administrator or Department Head Name, City Clerk (Attest), City Attorney (Approved as to Form) Routing Steps for Electronic Signature Risk Manager City Attorney Approval As to Form City Administrator or Department Head City Clerk Attestation Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 706343.2 1 4821-9476-5219v1 CCHU\04706083 CITY OF GILROY RECREATION DIVISION AGREEMENT FOR CONTRACT PROGRAMS INSTRUCTION 1. Parties. The parties to this Agreement are: 1.1 Instructor Island Kids LLC (dba Challenge Island Bay Area), an independent contractor who will provide services to the city as a skilled instructor (“Instructor.”) 1.2 City of Gilroy, a municipal corporation (“City.”) 2. Instructor Services. 2.1 Instruction: Instructor will conduct the program(s) (“Program”) as described below and in the activity guide on behalf of the City’s Recreation Division in accordance with all ordinances, policies, and regulations of the City. 2.2 Program Information: Instructor will submit program information prior to the established deadline for publication in the seasonal Recreation Guide. Failure to submit information in a timely manner may result in either cancellation of the class and/or omission in the Guide. 2.3 Attendance: Instructor will be present and prepared to teach at each scheduled class. Absences must be communicated to a designated Recreation Division staff representative (“Designated Representative”) and must be preceded by not less than 48 hours advance notice. In the event of an absence, Instructor shall try to offer a make-up class (es) at a convenient time. All services are to be provided by Instructor; substitute instructors shall not be utilized without advance written permission from the Designated Representative. If the instructor is unable to make up a class(es) and a refund is offered, the instructor will be responsible for covering the refund payment processing fees as determined by the City of Gilroy. 2.4 Fingerprinting: As a condition of this Agreement and prior to teaching any classes, Instructor shall submit to fingerprinting and a California Division of Justice (DOJ) criminal background check that confirms that Instructor has no criminal convictions. If Instructor has employees, prior to the first day of class, Instructor will provide proof to City that said employees have also been fingerprinted and have passed a DOJ background check. Challenge Island is a Science and STEM organization that offers engaging classes and camps for youth aged 5-12 years old. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 706343.2 2 4821-9476-5219v1 CCHU\04706083 2.5 Customer Service: Instructor will conduct his or her Program in a professional, courteous, helpful, welcoming, and supportive manner. 2.6 Participant Information: Instructor is not permitted to use any participant information, rosters, mailing lists, etc. for any purpose other than authorized City use (for example, class communication and notification of upcoming City classes). 2.7 Communication: Instructor will maintain direct communication with the Designated Representative regarding program information such as class cancellations, inquiries, changes, accidents, incidents and/or any concerns patrons may express. If the Instructor has to cancel class(es), he or she is responsible for notifying all participants by phone, email, note at site, and/or in-person. This is not the responsibility of the Designated Representative. 2.8 Facility/Classroom: Instructor is responsible for securing his or her assigned facility and/or classroom. (a) Indoors: If inside a city facility, all doors must be closed and secured after each class. Instructor is responsible for set-up and clean-up. No storage of instructional materials is allowed, unless approved by the Designated Representative. City is not responsible for any lost or stolen items. Keys: If Instructor is provided keys to a city facility, it is their responsibility for reporting any lost or stolen key(s) within 24 hours to the Designated Representative. A $50 charge for each key lost or stolen will be deducted from Instructor’s next compensation payment. (b) Outdoors: If outside at a city park or other facility, Instructor is responsible, prior to the start of each class/program, for inspecting the grounds to ensure it is safe to use. Any hazards identified need to be rectified before the start of class. If hazard is significant enough that safety cannot be assured, Instructor shall either cancel the class or hold class at an alternate facility approved by the City and determined by Instructor to be safe. 2.9 Insurance: All instructors are required to provide their own liability insurance of $1,000,000 for each occurrence and $1,000,000 annual aggregate covering themselves and naming the City of Gilroy as an additional insured. For activities with greater risk, the city may require a higher level of coverage. If the Instructor has employees, Instructor will provide City proof of Worker’s Compensation insurance, as required by California Labor Code § 3700 et seq. Insurance coverage may vary depending on the program offered. 2.10 Certificate of Occupancy Permit: All contract instructors that operate their own facilities are required to file a copy of their Certificate of Occupancy Permit with the Designated Representative. 2.11 Business License: All contract instructors must obtain and maintain a City of Gilroy Business License. 3. Instructor Warranties. Instructor warrants that: 3.1 He/she is trained, qualified, and experienced to instruct the class in a safe and professional manner. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 706343.2 3 4821-9476-5219v1 CCHU\04706083 3.2 He/she has the requisite qualifications, certifications, experience and/or other requirements, which are conditions precedent of this Agreement, including but not limited to: CPR & First Aid Certified- Challenge Island 3.3 He/she has never been convicted of any offense specified in Penal Code section 11105.3(c). 4. Instructor Acknowledgements. Instructor acknowledges, understands, and agrees to the following: 4.1 Independent Contractor: The instructor will not be an employee of the City but will solely be an independent contractor acting under the terms and conditions specified herein. As an independent contractor, the instructor will be solely responsible for payment of federal and state taxes, will not be an employee of City for worker’s compensation or any other purposes, and will not have unemployment insurance benefits, social security coverage or other employee benefits. Instructor may at instructor’s own expense, employ any person Instructor deems necessary to conduct the Program, subject to the limitations on assignment in section 8, below. Instructor agrees that neither Instructor nor any person employed by Instructor will be in any way an employee of the City as the term is defined in the California Labor Code. 4.2 Instructor Performance: Instructor will have the sole authority to control the means of performing the instructional services required by this Agreement. 4.3 Compliance with Laws: Instructor will comply with all applicable Federal, State, and local laws and regulations in fulfilling his/her obligations under this Agreement. Without limiting the generality of the foregoing, Instructor will comply with the provisions of California Government Code Section 12940, and subject to the exceptions specified in such section, refrain from unlawful, discriminatory employment practices on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, or military and veteran status of any employee. 4.4 Concussion and Other Head Injury; Sudden Cardiac Arrest. Instructor hereby certifies that Instructor is aware of the signs of, and appropriate responses to, concussion and other head injury. Instructor further acknowledges that information and training regarding concussion and other head injuries are available at: https://www.cdc.gov/headsup/index.html. Instructors shall institute appropriate protocols whenever a course participant is suspected of sustaining concussion or other head injury in an athletic activity. At a minimum, Instructor agrees to implement the following protocols: a. An athlete who is suspected of sustaining a concussion or other head injury in an athletic activity, or who has passed out or fainted, shall immediately be removed from the athletic activity for the remainder of the day, and shall not be permitted to return to any athletic activity until the athlete is evaluated by a licensed healthcare provider. b. The athlete shall not be permitted to return to athletic activity until the athlete receives written clearance to return to athletic activity from a licensed healthcare provider. c. If the licensed healthcare provider determines that the athlete sustained a concussion or other head injury, the athlete shall also complete a graduated return-to-play protocol of Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 706343.2 4 4821-9476-5219v1 CCHU\04706083 no less than seven days in duration as recommended by, and under the supervision of, a licensed healthcare provider. d. If the licensed healthcare provider suspects that the athlete has a cardiac condition that puts the athlete at risk for sudden cardiac arrest or other heart-related issues, the athlete shall remain under the care of the licensed healthcare provider to pursue follow-up testing until the athlete is cleared to play. e. If an athlete who is 17 years of age or younger has been removed from athletic activity due to a suspected concussion or due to fainting or a suspected cardiac condition, Instructor shall contact a parent or guardian of the athlete of the time and date of the injury, the symptoms observed, and any treatment provided to that athlete for the injury. f. If any athlete is suspected of sustaining a concussion or other head injury or passes out or faints during an athletic activity, Instructor shall contact City’s Risk Manager as soon as reasonably possible by phone and shall provide a detailed written report within 24 hours describing the incident, including the identity of any witnesses and the steps taken to address the incident. 4.5 Indemnification: Instructor, on behalf of itself and its officers, employees, assistants, agents and successors, hereby agrees to release, hold harmless, defend and indemnify the City and its officers, employees, agents, and successors from any liability, loss, damage, expense, claim, cause of action or cost, including attorney’s fees, for injury to persons or property, including death of any person, which relate to the services provided by Instructor as stated herein. 4.6 Emergency Circumstances: The contractor further acknowledges that all City-owned parks and facilities are subject to emergency use by the City, the State of California, and/or another governmental agency (e.g., FEMA). Considering an emergency (such as flooding, earthquake, wildfire, terrorist attack, and/or similar incidents), contractors may experience disruption to their normal programming and will be expected to cooperate in rescheduling and/or relocating classes as necessary to accommodate emergency operati ons without additional compensation. If a suitable location cannot be determined, class(es) may be cancelled, and instructor will not be compensated for loss of income. This decision will be made at the discretion of the City. If the class can be offered, but the instructor chooses to cancel the class(es), the instructor will be responsible for covering the refund payment processing fees as determined by the City of Gilroy. 5. City Duties. 5.1 Publicity: City will publicize Program in the seasonal recreation guide. The City shall inform the instructor of the deadline for submission of class information. Other forms of publicity such as a program flyer(s) will need to be approved by the Designated Representative before distribution. 5.2 Program Fee(s), Classes Offered and Size: With guidance from the Division staff representative, Instructor will determine Program fee(s). Based on facility availability and community interest, the Designated Representative will assist the instructor to determine the number of classes that may be offered in the guide. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 706343.2 5 4821-9476-5219v1 CCHU\04706083 5.3 Program Registration Dates and Participants: The Recreation Division will determine the registration dates and deadlines for classes unless otherwise specified. Programs featured in the Recreation Guide are only available to participants who enroll through the Recreation Division. Any exception to this must have City approval prior to advertisement of Program. 5.4 Registration Fees: City will collect all registration fees. Instructors will not collect payments or allow drop-in registration unless they have received prior permission from the Designated Representative. 5.5 Compensation: City will compensate Instructor for services to be provided hereunder as follows: Instructor will be paid for services rendered under this agreement at Sixty percent (60%) of the registration fees received for the Program conducted by Instructor. Instructor payment shall not include the additional non-resident fee. The remaining Forty percent (40%) of fees for the Program will be retained by the City to offset program costs, including administration, registration, facility, rental, utilities, building maintenance, publicity, activity guide, postage, insurance, and keys. Instructor will be paid in one lump sum, unless otherwise determined by the Designated Representative. Payment amount will be determined by the number of participants registered for your program. (a) If the class does not reach the instructor’s minimum number of participants to operate the program, the city can request renegotiating the compensation rate for the class to continue and avoid being canceled. 6. Termination/Contract Renewal. City may terminate this Agreement immediately upon any breach of performance of this Agreement by Instructor or his or her assistants or any violation of State, Federal or local law, or may cancel this Agreement at any time with or without cause. Contractor may terminate this Agreement without cause upon 20 days written notice to the other party. City reserves the right not to renew an instructor’s contract for any reason. Grounds for immediate termination of a contract include but are not limited to verbal and/or physical abuse, actions which may cause injury to another, and/or being under the influence of drugs or alcohol while teaching. 7. Negligent Or Knowing Misrepresentation. If any of the foregoing is found to be negligently or knowingly misrepresented by Instructor, this Agreement, at the option of City, shall be null and void and of no force and effect, and Instructor shall be liable to City for any damages arising therefrom. 8. Assignment. This Agreement may not be assigned or delegated by either party without prior written consent of the other party, provided further that the Assignee or Delegate agrees to be bound in writing to all the terms of this Agreement. 9. Attorneys’ Fees. In the event of controversy, claim or dispute arising out of or relating to this Agreement or the breach thereof, the prevailing party shall be entitled to recover reasonable attorney’s fees in addition to any other relief to which that party may be entitled. 10. Governing Law and Venue. This Agreement shall be governed by and construed in accordance with the laws of the State of California without regard to the conflict of law’s provisions of any jurisdiction. The exclusive jurisdiction and venue with respect to all disputes arising hereunder shall be in State and Federal courts located in Santa Clara County, California. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 706343.2 6 4821-9476-5219v1 CCHU\04706083 11. No Third Party Beneficiary. This Agreement shall not be construed or deemed to be an agreement for the benefit of any third party or parties, and no third party or parties will have any claim or right of action hereunder for any cause whatsoever. 12. Survival Clause. Instructor’s obligation to release, hold harmless, defend, and indemnify the City, and City’s rights and remedies, as provided in this Agreement, survive the expiration o r any termination of this Agreement, including without limitation, City’s rights and remedies under sections 7 and 9, above. 13. Waiver. Waiver by City of any breach, violation of, or failure to perform any covenant, term, condition or provision of this Agreement, or of the provisions of any applicable ordinance or law, by Instructor, or any City delay in enforcement of the same, will not be deemed to be a waiver of any other term, covenant, condition, provisions, ordinance or law, or of any subsequent breach or violation of the same or of any other term, covenant, condition, provision, ordinance or law, by Instructor. 14. Entire Agreement. This Agreement constitutes the entire agreement between the parties relative to the subject matter thereof. Statements or representations of any kind not embodied herein shall be of no force and effect. This Agreement may be modified only in writing. 15. Agreement Commencement/End. This Agreement will commence upon the date the parties execute this Agreement (if signed on different dates, the later date shall govern.) This Agreement will expire on the ending date of the Program, _December 31, 2027 _, unless terminated earlier as provided herein. Executed on January 23, 2025 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 706343.2 7 4821-9476-5219v1 CCHU\04706083 Contractor Name: Aaska Patel- Owner Contractor’s Address: 39497 Sundale Dr. Fremont, CA 94538 Federal Tax ID/Social Security No. 47-2015119 Business Telephone Number: 510-359-1205 Other Phone Number: __________________________ E-mail Address: apatel@challenge-island.com __ CITY OF GILROY CONTRACTOR LeeAnn McPhillips, Risk Manager Aaska Patel, Owner Jimmy Forbis, City Administrator Date ATTEST: Beth Minor, Interim City Clerk Date Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 2/2/2025 2/3/2025 1/16/2025 Mark Bartlett 39812 Mission Blvd, Ste 101 Fremont CA 94539 Mark Bartlett (510) 573-4745 mbartlett@twfg.com Island Kids LLC 39497 Sundale Dr Fremont CA 94538-1925 Philadelphia Indemnity Insurance Company 18058 Philadelphia Indemnity Insurance Company 18058 Technology Insurance Company 42376 Philadelphia Indemnity Insurance Company 18058 ISLA25011612592447 A Y N PHPK2644618 3/1/2024 3/1/2025 2,000,000 100,000 25,000 2,000,000 4,000,000 4,000,000 C PHUB897084 3/1/2024 3/1/2025 1,000,000 1,000,000 D Y TWC4391099 3/23/2024 3/23/2025 1,000,000 1,000,000 1,000,000 E Assault and Abuse Professional Liability Y N PHPK2644618 3/1/2024 3/1/2025 1,000,000 1,000,000 1,000,000 3,000,000 Confirmation of Coverage. City of Gilroy Recreation 7351 Rosanna Street Gilroy CA 95020 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 TECHNOLOGY INSURANCE COMPANY, INC. [59 Maiden Lane, 43rd Floor New York, NY 10038 ] WORKERS' COMPENSATION and EMPLOYERS’ LIABILITY INSURANCE POLICY In Witness Whereof, we have caused this policy to be executed and attested. [][] [Stephen Ungar, Secretary ][Christopher H. Foy, President ] To obtain information, please contact your agent or Technology Insurance Company, Inc. at 877-528-7878. You may also write Technology Insurance Company, Inc. Consumer Relations at: 800 Superior Avenue East, 21st Floor Cleveland, OH 44114 (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. WC 99 00 00 B Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 PN049902B POLICYHOLDER NOTICE (Ed. 05-02) Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers’ compensation rating laws. CALIFORNIA WORKERS’ COMPENSATION INSURANCE RATING LAWS 1. We establish our own rates for workers’ compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers’ compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. 3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner’s approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. 5. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. California Workers’ Compensation Insurance Notice of Nonrenewal Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. 1 of 2 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 PN049902B (Ed. 05-02) We are not required to provide you with a notice of nonrenewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. 2 of 2 (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, “premium rate” means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 PN049904 POLICYHOLDER NOTICE (Ed. 12-04) Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged, “CA Surcharge” or “CA Surcharge (CIGA Surcharge)” with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 PN 04 99 01 I (Ed.02-22) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I.Information Available to You A.Information Available from Us - (1)General questions regarding your policy should be directed to: 800 Superior Ave.E.,21st Floor Cleveland,OH 44114 (877)528-7878 www.amtrustfinancial.com (2)Dividend Calculation.If this is a participating policy (a policy on which a dividend may be paid),upon payment or non¬ payment of a dividend,we shall provide a written explanation to you that sets forth the basis of the dividend calculation.The explanation will be in clear,understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3)Claims Information.Pursuant to Sections 3761 and 3762 of the California Labor Code,you are entitled to receive information in our claim files that affects your premium.Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy,we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers’Compensation Insurance Rating Bureau of California (WCIRB)no later than twenty months after the policy becomes effective.The cost of any settled claims will also be reported at that time.At twelve-month intervals thereafter,we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim.The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B.Information Available from the Workers’Compensation Insurance Rating Bureau of California (1)The WCIRB is a licensed rating organization and the California Insurance Commissioner’s designated statistical agent.As such,the WCIRB is responsible for administering the California Workers’Compensation Uniform Statistical Reporting Plan— 7995 (USRP)and the California Workers’Compensation Experience Rating Plan—7995 (ERP).WCIRB contact information is: WCIRB,1901 Harrison Street,17th Floor,Oakland,CA 94612,Attn:Customer Service;888.229.2472 (phone);415.778.7272 (fax);and customerservice@wcirb.com (email).The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2)Policyholder Information.Pursuant to California Insurance Code (CIC)Section 11752.6,upon written request,you are entitled to information relating to loss experience,claims,classification assignments,and policy contracts as well as rating plans,rating systems,manual rules,or other information impacting your premium that is maintained in the records of the WCIRB.Complaints and Requests for Action requesting policyholder information should be forwarded to:WCIRB,1901 Harrison Street,17th Floor,Oakland,CA 94612,Attn:Custodian of Records.The Custodian of Records can be reached at 415.777.0777 (phone)and 415.778.7272 (fax). (3)Experience Rating Form.Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet.The Experience Rating Form/Worksheet will include a Loss-Free Rating,which is the experience modification that would have been calculated if $0 (zero)actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II.Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A.Our Dispute Resolution Process. If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium,or by the application of our rating system to your workers’compensation insurance,you may dispute these matters with us.If you are dissatisfied with the outcome of the initial dispute with us,you may send us a written Complaint and Request for Action as outlined below. You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you.Written Complaints and Requests for Action should be forwarded to:AmTrust North America,Inc.,17771 Cowan,Suite 100,Irvine,CA 92614,or Telephone:(877)528-7878 or by email at:regulatorycompliance@amtrustgroup.com. After you send your Complaint and Request for Action,we have 30 days to send you a written notice indicating whether your written request will be reviewed.If we agree to review your request,we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review.If we decline to review your PN 04 99 01 I (Ed.02-22) 1 of 2 Technology Insurance Company, Inc. Technology Insurance Company, Inc. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 800 Superior Avenue E • 21st Floor • Cleveland, OH 44114 (p) 866.203.3037 • (f) 800.487.9654 • www.amtrustnorthamerica.com Dear Policyholder, In an effort to continue to provide AmTrust customers with a variety of billing options, we have updated our fee structure to help customers meet payment due dates, ensure that valid and properly funded payments are submitted, and provide an incentive for paid-in-full options. Our updated fee structure is as follows: Fee Title Fee Amount Description Returned Payment Fee $25 A returned payment fee applied to any returned payment. Late Fee $20 Late fee applied if payment not received on or before payment due date. Installment Fee $15 A “paper” billing fee that is assessed for each mailed installment invoice. Excludes down payment and annual payment plans. Fee is billed at the account level. Reinstatement Fee $50 Fee applied upon reinstatement of a non-payment cancellation. EFT Fee $3 An “electronic” billing fee that is assessed for each ACH Direct Debit transaction. Fee is billed at the account level. *Fee amount may vary by state and program of business For policyholders who choose to pay their annual premium on installments, we plan to implement an installment fee, which will be displayed on your renewal invoice. Thank you for your attention to this fee structure change. If you have any questions, feel free to contact our Customer Service Department at 877.528.7878. We value you as a policyholder and appreciate the opportunity to serve you. Sincerely, AmTrust North America Customer Service Department January 31, 2024 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 AmTrust Claims Kit FAQs © 2022, AmTrust Financial Services, Inc. 59 Maiden Lane, New York, NY 10038 I 877.528.7878 I www.amtrustfinancial.com AmTrust is AmTrust Financial Services, Inc., located at 59 Maiden Lane, New York, NY 10038. Coverages are provided by its affiliated property and casualty insurance companies. Consult the applicable policy for specific terms, conditions, limits and exclusions to coverage. For full legal disclaimer information, including Texas and Washington writing companies, visit: www.amtrustfinancial.com/about-us/legal-disclaimer. MKT5948 02/22 Thank you for placing your Workers’ Compensation Coverage with AmTrust. For your convenience, we now offer electronic versions of our Claims Kits. Please see the instructions and FAQs below for more information. I have a question about a claim or injured worker, who do I contact? Customer Service can direct you to the appropriate person. Please contact them at 888-239-3909. Where’s my claims kit? All the States’ Claims Kits are online for insured to download which contains all the necessary WC notices. Visit the Talispoint Direct Link at www.talispoint.com/amtrust/external/ • Click State Rules/Kits, choose corresponding state and open the PDF link to view and print. I have an injured worker, how do I find a doctor? We will provide completed Panel of Physicians for the 4 states that require a panel to be posted (CO, GA, PA & TN). We offer our online physician search for all other states. There are 3 ways to access this information: 1. Visit the Talispoint Direct Link at www.talispoint.com/amtrust/external/ 2. California MPN: www.talispoint.com/amtrust/campn/ 3. Visit the AmTrust Financial Website at www.amtrustfinancial.com • Click Claims • Click Provider Directory or California MPN under “Find a Provider” • State specific laws for directing medical treatment are listed on the State Rules Tab • Search for physicians by Name, Address or Region Where are my posting notices? All states claim kits are available online, including applicable postings. There are 4 states (CO, CT, FL & MD) we cannot place online. For these states, we will mail additional posting notices to the main address on the policy. I have a question about my claims kit, posting notice, panel or accessing the website’s physician searches, who do I contact? You may send an email to clientservices@amtrustgroup.com. Please make sure to include your policy number along with your request. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 24/7 Toll Free Claim Reporting for All States Information Required for All Claims Reported (888)239-3909 WorkersCompClaimReport@AmTrustgroup.com www.amtrustfinancial.com © 2023, AmTrust Financial Services, Inc. 877.528.7878 I www.amtrustfinancial.com This material is for informational purposes only and is not legal or business advice. Neither AmTrust Financial Services, Inc. nor any of its subsidiaries or affiliates represents or warrants that the information contained herein is appropriate or suitable for any specific business or legal purpose. Readers seeking resolution of specific questions should consult their business and/or legal advisors. Coverages may vary by location. Contact your local RSM for more information. MKT6310 06/23 Timely Reporting When a work-related injury occurs, it is important to act immediately. Timely reporting of a new claim helps to provide a smooth and successful claim process for both you and your injured worker. We’re Here To Help After your claim has been filed, we may be in touch to obtain additional information. Our goal is to offer a smooth and hassle-free experience – from your first contact to the claims conclusion. Feel free to also call us with any questions. We’re here to help. Relax And Stay Positive You have the assurance of our knowledge, expertise, and understanding of the claim process. We’re with you all the way. 1. Name of the insured and policy number 2. Name and contact information of injured worker 3. Date, time and place of accident 4. Description of accident or incident 5. Name, phone, and/or email of person making the report 6. Any information on the injured workers lost time Workers’ Compensation Claim Reporting Information How do I help my injured worker find a doctor? • We offer an online physician search for all states, www.talispoint.com/amtrust/external • For California, www-lv.talispoint.com/amtrust/campn • For CO, GA, PA & TN, please refer to the panel provided by AmTrust via mail or email How does my injured employee receive prescription medications related to the accident/injury? • Refer to the claims kit for your state at www.talispoint.com/amtrust/external for a First Fill card for your injured employee to use at the pharmacy to cover the cost of approved medication. Early claim reporting is essential to a better claim outcome. Don’t delay reporting if you do not have all the details. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 California Short-Rate Cancellation Disclosure Notice IMPORTANT INFORMATION REGARDING YOUR POLICY The policy for which you have applied contains a cancellation provision that permits us to refund premium on a basis other than pro rata when you cancel the policy. Under the policy for which you have applied, if you cancel the policy, your final premium will be calculated based on the time your policy was in force with us, using the percentage specified in the short-rate cancellation table listed below. SHORT RATE CANCELLATION TABLE FOR A TERM OF ONE YEAR Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Technology Insurance Company, Inc. A Stock Insurance Company WORKERS COMPENSATION WC 99 00 01 E AND EMPLOYERS LIABILITY 1 of 5 INSURANCE POLICY INFORMATION PAGE Ncci Code: 39071 1.Insured: Island Kids LLC 39497 Sundale Dr Fremont, CA 94538 Other workplaces not shown above: See Extension of Information Page Producer: TWFG Insurance Services, LLC at 1201 Lake Woodlands Dr. Ste. 4020 The Woodlands, TX 77380 Policy Number:TWC4391099 Individual Partnership Corporation or X LLC Federal Tax ID:472015119 Risk Id: Renewal of:TWC4224298 2.The policy period is from 3/23/2024 to 3/23/2025 12:01 a.m. at the insured's mailing address. 3.A.Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: California B.Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $1,000,000 each accident $1,000,000 policy limit $1,000,000 each employee C.Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and State(s) Designated in Item 3.A D.This policy includes these endorsements and schedules: See Extension of Information Page 4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM 500 STATE ASSESSMENT 31 TOTAL ESTIMATED COST 531 Minimum Premium 500 Deposit Premium 531 Issue Date: 1/31/2024 Countersigned by: Authorized Representative Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Technology Insurance Company, Inc.WC 99 00 01 E 2 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Island Kids LLC Policy Number: TWC4391099 EXTENSION OF INFORMATION PAGE FOR ITEM #1 ITEM 1: NAMED INSURED and WORKPLACES NAMED INSURED:Island Kids LLC Fein: 472015119 WORKPLACES:Location Number 1. 39497 Sundale Dr. Fremont, CA 94538 NAMED INSURED:Island Kids LLC Fein: 472015119 WORKPLACES:Location Number 2. 39497 Sundale Dr Fremont, CA 94538 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Technology Insurance Company, Inc.WC 99 00 01 E 3 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Island Kids LLC Policy Number: TWC4391099 EXTENSION OF INFORMATION PAGE FOR ITEM #3.D ITEM 3.D: ENDORSEMENT SCHEDULE State Form Number Description WC990001E DECLARATIONS PAGE CA 34-2005 1008 CA Important Notice WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000406A PREMIUM DISCOUNT ENDORSEMENT WC000419 PREMIUM DUE DATE ENDORSEMENT WC000421F CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT CA WC040301D POLICY AMENDATORY ENDORSEMENT CALIFORNIA CA WC040306 CA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CA WC040310 CA DUTY TO DEFEND CA WC040318C LIMITED LIABILITY COMPANY COVERAGE/EXCLUSION - CALIFORNIA CA WC040360B EMPLOYERS’ LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA CA WC040421 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT CA WC040601B CALIFORNIA CANCELATION ENDORSEMENT CA WC040604A Covid-19 Reporting Requirement Endorsement-California Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Technology Insurance Company, Inc.WC 99 00 01 E 4 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Island Kids LLC Policy Number: TWC4391099 EXTENSION OF INFORMATION PAGE FOR ITEM #4 ITEM 4: SCHEDULE OF PREMIUMS Classifications # of Emps Code No. Premium Basis Total Estimated Annual Remuneration Rate Per $100 of Remun. Estimated Annual Premium California Colleges or Schools — private — academic professionals 5 8868 10,609 0.79 84 Manual Premium 84 Total Manual Premium 84 Blanket Waiver 2% ($250 Minimum)0930 250 Total Premium Subject To Experience Modification 334 Experience Modification N/A 334 Terrorism 3%9740 3 Catastrophe (other than Terrorism) 1%9741 1 Balance to Minimum Premium 0990 62 Expense Constant 0900 100 Total CA Premium 500 WCARF 2.4604%9999 12 UEBTF 0.1505%9999 1 SIBTF 1.5891%9999 8 OSHAF 0.7266%9999 4 LECF 0.7109%9999 4 FRAUD 0.4122%9999 2 Total CA Cost 531 TOTAL ESTIMATED ANNUAL PREMIUM 500 STATE ASSESSMENT 31 TOTAL COST 531 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Technology Insurance Company, Inc.WC 99 00 01 E 5 of 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Island Kids LLC Policy Number: TWC4391099 PAYMENT SCHEDULE Printed: 1/31/2024 Statement Closing Date Payment Due Date Description Amount Due 3/23/2024 Annual Premium Due $531.00 Total Cost $531.00 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 IMPORTANT NOTICE CALIFORNIA WORKERS COMPENSATION REGARDING YOUR INSURANCE POLICY This policy, including all endorsements or riders forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in the policy or in such endorsement or rider shall affect such contract or any rights, duties, or privileges arising therefrom. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Infor- mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor- mation Page) and us (the insurer named on the In- formation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an em- ployer of the partnership’s employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen’s compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen’s compensation law, any fed- eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such workplaces. PART ONE WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in- vestigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6  Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reser ved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du- ties under this insurance after an injury occurs. 3. We are directly and primarily liable to any per- son entitled to the benefits payable by this in- surance. Those persons may enforce our duties; so may an agency authorized by law. Enforc e- ment may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or oth- er special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your du- ties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee’s employment by you. 2. The employment must be necessary or inci- dental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by ac- cident or by disease must be brought in the United States of America, its territories or pos- sessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employ- ees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permit- ted by law, include damages: 1. For which you are liable to a third party by rea- son of a claim or suit against you by that third party to recover the damages claimed against 2 of 6  Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) such third party as a result of injury to your em- ployee; 2. For care and loss of services; and 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em- ployee; provided that these damages are the di- rect consequence of bodily injury that arises out of and in the course of the injured employee’s employment by you; and 4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclu- sion does not apply to a warranty that your work will be done in a workmanlike manner; 2. Punitive or exemplary damages because of bodi- ly injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive offic- ers; 4. Any obligation imposed by a workers compensa- tion, occupational disease, unemployment com- pensation, or disability benefits law, or any sim i- lar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, de- motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina- tion against or termination of any employee, or any personnel practices, policies, acts or omis- sions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers’ Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonap- propriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651–1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901– 944), any other federal workers or workmen’s compensation law or other federal occupational disease law, or any amendments to these laws; 9. Bodily injury to any person in work subject to the Federal Employers’ Liability Act (45 U.S.C. Sec- tions 51 et seq.), any other federal laws obligat- ing an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10. Bodily injury to a master or member of the crew of any vessel, and does not cover punitive dam- ages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11. Fines or penalties imposed for violation of federal or state law; and 12. Damages payable under the Migrant and Sea- sonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our ex- pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed- ings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our request, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgment as required by law until we offer the amount due under this insurance; and 5. Expenses we incur. 3 of 6  Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other in- surance or self-insurance. Subject to any limits of li- ability that apply, all shares will be equal until the loss is paid. If any insurance or self -insurance is ex- hausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid . G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for “bodily injury by accident—each accident” is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for “bodily injury by disease—policy limit” is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis- ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for “bodily injury by disease—each em- ployee” is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include dis- ease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability un- der this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this poli- cy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to deter- mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga- tions under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor- mation Page. 2. If you begin work in any one of those states after the effective date of this policy and are not in- sured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this pol- icy in any state not listed in Item 3.A. of the In- formation Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other ser- vices required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal 4 of 6  Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may re- quest, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would in- terfere with our right to recover from others. 6. Do not voluntarily make payments, assume obli- gations or incur expenses, except at your own cost. PART FIVE PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classific a- tions. We may change our manuals and apply the changes to this policy if authorized by law or a gov- ernmental agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifi- cations. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remu- neration is the most common premium basis. This premium basis includes payroll and all other rem u- neration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com- pensation Insurance) of this policy. If you do not have payroll records for these persons, the con- tract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the em- ployers of these persons lawfully secured their workers compensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensa- tion law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premi- um basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the bal- ance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be de- termined in the following way unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short-rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to com- pute premium. You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledg- ers, journals, registers, vouchers, contracts, tax re- ports, payroll and disbursement records, and pro- grams for storing and retrieving data. We may con- duct the audits during regular business hours during the policy period and within three years after the pol- icy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. 5 of 6  Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) PART SIX CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurabil- ity of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organiza- tions have the same rights we have under this provision. B. Long Term Policy If the policy period is longer than one year and six- teen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days af- ter your death, we will cover your legal representa- tive as insured. D. Cancelation 1. You may cancel this policy. You must mail or de- liver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or de- liver to you not less than ten days advance writ- ten notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com- ply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. 6 of 6  Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. Schedule WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 06 A (Ed. 7-95) 1.State Estimated Eligible Premium First Next Next $5,000 $95,000 $400,000 Balance California 0%3.5%5%7% 2.Average percentage discount:0 % 3.Other policies: 4.If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by WC 00 04 06 A (Ed. 7-95) Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95  2000 National Council on Compensation Insurance, Inc. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed. 1-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D.Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Policy No. Endorsement No. Premium Insurance Company Countersigned by ___________________________________________ WC 00 04 19 (Ed. 1-01) 3/23/2024 TWC4391099 Island Kids LLC $500 Technology Insurance Company, Inc. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement This endorsement is notification that we are charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). Coverage for such losses is subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement attached to this policy. For purposes of this endorsement, Catastrophe (Other Than Certified Acts of Terrorism) is defined as: A single event or peril resulting in a group of claims with aggregate workers compensation losses in excess of $50 million. This $50 million threshold applies per occurrence, across all states for which claims arise from a single event or peril. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) Schedule State Rate Premium CA 0.010 $1.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by WC 00 04 21 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) © Copyright 2021 National Council on Compensation Insurance, Inc. All rights reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-21) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act Of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a.The act is an act of terrorism. b.The act is violent or dangerous to human life, property, or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1.Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2.Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3.The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. WC 00 04 22 C (Ed. 01-21) © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-21) Schedule State Rate Premium CA 0.03 $3.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by WC 00 04 22 C (Ed. 01-21) © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 02-18) 1 of 2 POLICY AMENDATORY ENDORSEMENT–CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed – Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages – Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment – Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Department of Insurance. 4. Application of Policy. Part One, “Workers Compensation Insurance”, A, “How This Insurance Applies”, is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee’s exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6. Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. 8. Part Five, “Premium”, E, “Final Premium”, is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: a. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short-rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 02-18) 2 of 2 It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company Countersigned By 3/23/2024 TWC4391099 Island Kids LLC Countersigned by Technology Insurance Company, Inc. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 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% of the California workers' compensation premium otherwise due on such remuneration. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) Schedule Person or Organization Job Description Any person or organization as required by written contract. 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 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by WC 04 03 06 (Ed. 04-84) Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 10 (Ed. 01-95) DUTY TO DEFEND-CALIFORNIA The insurance afforded by Part One, Section C,"We Will Defend", is hereby deleted and replaced with the following: WE WILL DEFEND We have the right and duty to defend at our expense any claim or proceeding against you before the California Workers' Compensation Appeals Board or its equivalent in any other state (and any appeal of a decision therefrom) for the benefits payable by this workers’ compensation insurance. We have the right to investigate and settle these claims or proceedings. We have no duty to defend a claim, proceeding, or suit that is not covered by this insurance. Nothing contained in this Section shall amend, modify, restrict, or otherwise alter any obligations or conditions under Part Two – Employer’s Liability Insurance of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by WC 04 03 10 (Ed. 01-95) Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE LIMITED LIABILITY COMPANY COVERAGE / EXCLUSION-CALIFORNIA If the employer named in Item 1 of the Information Page is a limited liability company, this policy applies to all working members receiving wages irrespective of profits from the limited liability company, as employees, except those managing members excluded below. The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 18 C (Ed. 07-18) Managing Members/Trustees Excluded Title Aaska Patel Managing Member Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements or limitations in this endorsement. It is further agreed that "remuneration" when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Insurance Company Technology Insurance Company, Inc. Countersigned by WC 04 03 18 C (Ed. 07-18) Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 A. 1. 2. 3. 4. 5. E. 1. 1. 2. 3. 7. 4. 1. 2. 3. EMPLOYERS’ LIABILITY COVERAGE AMENDATORY ENDORSEMENT-CALIFORNIA The insurance afforded by Part Two (Employers’ Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: How This Insurance Applies This employers’ liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including resulting death. The bodily injury must arise out of and in the course of the injured employee’s employment by you. The employment must be necessary or incidental to your work in California. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): Exclusion 1 is amended to read as follows: liability assumed under a contract. Exclusion 2 is deleted. Exclusion 7 is amended to read as follows: damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, termination of employment, or any personnel practices, policies, acts or omissions. The following exclusions are added: bodily injury to any member of the flying crew of any aircraft. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers’ compensation law(s) applicable to you or otherwise fail to comply with that law. liability arising from California Labor Code Section 2810.3 which relates to labor contracting. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B (Ed. 1-15) 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 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Insurance Company Technology Insurance Company, Inc. Countersigned by WC 04 03 60 B (Ed. 1-15) © Copyright 2015 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Comensation Insurance Forms Manual © 2001. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 OPTIONAL PREMIUM INCREASE ENDORSEMENT – CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verification audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified, return-receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 (Ed. 1-08) 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 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by WC 04 04 21 (Ed. 1-08) © Copyright 2007 National Council on Compensation Insurance, Inc. All Rights Reserved. Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 1. 2. a. b. c. d. e. f. g. h. i. j. k. 3. 4. 5. CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: Cancelation You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. We may cancel this policy for one or more of the following reasons: Non-payment of premium; Failure to report payroll; Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; Material misrepresentation made by you or your agent; Failure to cooperate with us in the investigation of a claim; Material failure to comply with federal or state safety orders or written recommendations of our designated loss control representatives; The occurrence of a material change in the ownership of your business; The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) through (k), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. If we mail the notice to you, the stated periods of notice and your right to remedy the condition will be extended by 5 days if the place of mailing and your mailing address is within California, 10 days if the place of mailing or your mailing address is outside of California and 20 days if the place of mailing or your mailing address is outside of the United States. The policy period will end on the day and hour stated in the cancelation notice. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 B (Ed. 01-22) 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 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by WC 04 06 01 B (Ed. 01-22) Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 04 A (Ed. 01-23) COVID-19 REPORTING REQUIREMENT ENDORSEMENT - CALIFORNIA In addition to the requirements under Part 4, "Your Duties If Injury Occurs" of your policy, If you have five or more employees and an employee that is not described in California Labor Code section 3212.87 tests positive for COVID-19, you are required to report the following information as provided below. Pursuant to California Labor Code Section 3212.88(i), when you know, or reasonably should know, that an employee has tested positive for COVID-19 between September 17, 2020 and January 1, 2024, you must report to your claims administrator in writing via electronic mail or facsimile within 3 business days all of the following: (1)An employee has tested positive. For purposes of this reporting, do not provide any personally identifiable information regarding the employee who tested positive for COVID-19 unless the employee asserts the infection is work related or has filed a claim form pursuant to California Labor Code Section 5401. (2)The date that the employee tests positive, which is the date the specimen was collected for testing. (3)The specific address or addresses of the employee’s specific place of employment during the 14-day period preceding the date of the employee’s positive test. (4)The highest number of employees who reported to work at the employee’s specific place of employment in the 45-day period preceding the last day the employee worked at each specific place of employment. Labor Code Section 3212.88(j) states that the intentional submission of false or misleading information or the failure to report the above information as required may subject you to a civil penalty in the amount of up to $10,000 to be assessed by the Labor Commissioner. For the purposes of these reporting requirements, California Labor Code Section 3212.88(m) provides the following: (1)"COVID-19" means the 2019 novel coronavirus disease. (2)"Test" or "testing" means a PCR (Polymerase Chain Reaction) test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA. "Test" or "testing" does not include serologic testing, also known as antibody testing. "Test" or "testing" may include any other viral culture test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA which has the same or higher sensitivity and specificity as the PCR test. (3)"A specific place of employment" means the building, store, facility, or agricultural field where an employee performs work at the employer’s direction. "A specific place of employment" does not include the employee’s home or residence, unless the employee provides home health care services to another individual at the employee’s home or residence. 2 1 of WC 04 06 04 A (Ed. 01-23) Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 04 A (Ed. 01-23) 24/7 Toll-Free COVID-19 Claim Reporting for all AmTrust carriers: Phone: (888) 239-3909 Email: WorkersCompClaimReport@AmTrustgroup.com OR Visit this webpage: amtrustfinancial.com/sb1159 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/23/2024 Policy No.TWC4391099 Endorsement No.0 Insured Island Kids LLC Premium $500 Insurance Company Technology Insurance Company, Inc. Countersigned by 2 2 of WC 04 06 04 A (Ed. 01-23) Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL LIABILITY DELUXE ENDORSEMENT SCHOOLS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE It is understood and agreed that the following extensions only apply in the event that no other specific coverage for the indicated loss exposure is provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits of Insurance and additional coverages provided by this endorsement. For complete details on specific coverages, consult the policy contract wording. Coverage Applicable Limit of Insurance Page# Damage to Premises Rented to You $300,000 2 Extended Property Damage included 2 Non-Owned Watercraft Less than 58 feet 2 Supplementary Payments -Bail Bonds $2,500 2 Supplementary Payment -Loss of Earnings $500 per day 2 Medical Payments $15,000 3 Medical Payments -Extended Reporting Period 3 years 3 Employee Indemnification Defense Coverage for Employee $25,000 3 Additional Insured -Medical Directors and Administrators Included 3 Additional Insured -Managers and Supervisors Included 3 Additional Insured -Broadened Named Insured Included 3 Additional Insured -Funding Source Included 3 Additional Insured -Managers or Lessors of Premises Included 4 Additional Insured -By Contract, Agreement or Permit Included 4 Additional Insured -Broad Form Vendors Included 4 General Aggregate -Per Campus Included 5 Duties in the Event of Occurrence, Claim or Suit Included 6 Other Insurance-Primary Additional Insured Included 6 Other Insurance-You Are An Additional Insured On Included 7 Another Person's Or Oroanization's Policv Unintentional Failure to Disclose Hazards Included 8 Liberalization Included 8 Bodily Injury -includes Mental Anguish Included 8 Personal and Advertising Injury -includes Abuse of Included 8 Process, Discrimination Transfer of Rights of Recovery Against Others To Us Clarification 9 Science Laboratory "Occurrence" $50,000 9 Medical Incident Liability-Nurse and Athletic Trainer Included 9 Pl-GLD-VS (05/17) Page 1 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) A. Damage to Premises Rented to You 1. If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the word "fire" is changed to "fire, lightning, explosion, smoke, or leakage from automatic fire protective systems" where it appears in: a. The last paragraph of SECTION I -COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions; b. SECTION Ill -LIMITS OF INSURANCE, Paragraph 6.; c. SECTION V -DEFINITIONS, Paragraph 9.a. 2. If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the words "Fire insurance" are changed to "insurance for fire, lightning, explosion, smoke, or leakage from automatic fire protective systems" where it appears in: a. SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4. Other Insurance, Paragraph b. Excess Insurance 3. The Damage To Premises Rented To You Limit section of the Declarations is amended to the greater of: a. $300,000; or b. The amount shown in the Declarations as the Damage to Premises Rented to You Limit. This is the most we will pay for all damage proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems or any combination thereof. B. Extended "Property Damage" SECTION I -COVERAGES. COVERAGE A, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph a. is deleted and replaced by the following: a. Expected or Intended Injury "Bodily Injury'' or "Property Damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury'' or "property damage" resulting from the use of reasonable force to protect persons or property. C. Non-Owned Watercraft SECTION 1-COVERAGES, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph g. (2) is amended to read as follows: (2) A watercraft you do not own that is: (a) Less than 58 feet long; and (b) Not being used to carry persons or property for a charge; This provision applies to any person, who with your consent, either uses or is responsible for the use of a watercraft. This insurance is excess over any other valid and collectible insurance available to the insured whether primary, excess or contingent. D. Supplementary Payments Under the SUPPLEMENTARY PAYMENTS -COVERAGE AAND B provision, Items 1.b. and 1.d. Pl-GLD-VS (05/17) Page 2 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) are amended as follows: 1. The limit for the cost of bail bonds is changed from $250 to $2,500; and 2. The limit for loss of earnings is changed from $250 a day to $500 a day. E. Medical Payments -Limit Increased to $15,000, Extended Reporting Period If COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part: 1. The Medical Expense Limit is changed subject to all of the terms of SECTION Ill -LIMITS OF INSURANCE to the greater of: a. $15,000; or b. The Medical Expense Limit shown in the Declarations of this Coverage Part. 2. SECTION I-COVERAGE, COVERAGE C MEDICAL PAYMENTS, Subsection 1. Insuring Agreement, the second part of Paragraph a. is amended to read: provided that: (2) The expenses are incurred and reported to us within three years of the date of the accident; F. Employee Indemnification Defense Coverage Under the SUPPLEMENTARY PAYMENTS -COVERAGES A AND B provision, the following is added: 3. We will pay, on your behalf, defense costs incurred by an "employee" in a criminal proceeding. The most we will pay for any "employee" who is alleged to be directly involved in a criminal proceeding is $25,000 regardless of the numbers of "employees", claims or "suits" brought or persons or organizations making claims or bringing "suits". G. SECTION II -WHO IS AN INSURED is amended as follows: 1. If coverage for newly acquired or formed organizations is not otherwise excluded from this Coverage Part, Paragraph 3.a. is changed to read: a. Coverage under this provision is afforded until the end of the policy period. 2. Each of the following is also an insured: a. Medical Directors and Administrators -Your medical directors and administrators, but only while acting within the scope of and during the course of their duties as such. b. Managers and Supervisors -If you are an organization other than a partnership or joint venture, your managers and supervisors are also insureds, but only with respect to their duties as your managers and supervisors. c. Broadened Named Insured -Any organization and subsidiary thereof which you control and actively manage on the effective date of this Coverage Part. However, coverage does not apply to any organization or subsidiary not named in the Declarations as Named Insured, if they are also insured under another similar policy, but for its termination or the exhaustion of its limits of insurance. d. Funding Source -Any person or organization with respect to their liability arising out of: (1) Their financial control of you; or Pl-GLD-VS (05/17) Page 3 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) (2) Premises they own, maintain or control while you lease or occupy these premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. e. Managers or Lessors of Premises -Any person or organization with respect to their liability arising out of the ownership, maintenance or use of that part of the premises leased to you subject to the following additional exclusions: This insurance does not apply to: (1) Any "occurrence" which takes place after you cease to be a tenant in that premises. (2) Structural alterations, new construction or demolition operations performed by or on behalf of that person or organization. f. By Contract, Agreement or Permit -Any person or organization with whom you agreed, because of a written contract or agreement or permit, to provide insurance such as is afforded under this policy, but only with respect to your operations, "your work" or facilities owned or used by you. (1) This provision does not apply: (a) Unless the written contract or agreement has been executed or permit has been issued prior to the "bodily injury," "property damage," "personal and advertising injury'': (b) To any person or organization included as an insured under g. Broad Form Vendors below; or (c) To any person or organization included as an insured by an endorsement issued by us and made a part of this Coverage Part. (2) When an engineer, architect or surveyor becomes an insured under this Coverage Part, the following additional exclusion applies: (a) "Bodily injury'', "property damage", "personal and advertising injury'' arising out of the rendering of or the failure to render any professional services by or for you, including: (i) The preparing, approving, or failing to approve maps, drawings, opinions, reports, surveys, change orders, designs or specifications; and (ii) Supervisory, inspection, or engineering services. (3) When a lessor of leased equipment becomes an insured under this Coverage Part, the following additional exclusions apply: (a) To any "occurrence" which takes place after the equipment lease expires; or {b) To "bodily injury'' or "property damage" arising out of the sole negligence of the lessor. (4) When owners or other interests from whom land has been leased become an insured under this Coverage Part, the following additional exclusions apply: (a) Any "occurrence" which takes place after you cease to lease that land; or {b) Structural alterations, new construction or demolition operations performed by or on behalf of the owners or other interests from whom land has been leased. g. Broad Form Vendors -Any person or organization with whom you agreed, because of a written contract or agreement to provide insurance, but only with respect to "bodily injury'' or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions. (1) The insurance afforded the vendor does not apply to: (a) "Bodily injury'' or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; {b) Any express warranty unauthorized by you; (c) Any physical or chemical change in the product made intentionally by the vendor; {d) Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing or substitution of parts under instructions from the manufacturer, and then repackaged in the original container; Pl-GLD-VS (05/17) Page 4 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) (e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; (f) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with sale of the product; (g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor. (2) This provision does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. (3) This provision does not apply to any vendor included as an insured by an endorsement issued by us and made a part of this Coverage Part. (4) This provision does not apply if "bodily injury'' or "property damage" included within the "products-completed operations hazard" is excluded either by the provisions of the Coverage Part or by endorsement. H. Per Campus -General Aggregate SECTION Ill -LIMITS OF INSURANCE is amended to include the following provisions: 1. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under SECTION I -COVERAGE, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, and for all medical expenses caused by accidents under SECTION I -COVERAGE, COVERAGE C MEDICAL PAYMENTS which can be attributed only to operations at a single designated "campus" shown in the Declarations: a. A separate Per Campus General Aggregate Limit is applicable to each single designated "campus" shown in the Declarations and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. b. The Per Campus General Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except damages because of "bodily injury'' or "property damage" included in the "products-completed operations hazard," and for medical expenses under COVERAGE C regardless of the number of: (1) Insureds; (2) Claims made or "suits" brought; or (3) Persons or organizations making claims or bringing "suits." c. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Per Campus General Aggregate Limit for that designated "campus." Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Per Campus General Aggregate Limit for any other designated "campus" shown in the Declarations. d. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Per Campus General Aggregate Limit. Pl-GLD-VS (05/17) Page 5 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) 2. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under SECTION I -COVERAGE, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABIITY, and for all medical expenses caused by accidents under SECTION I -COVERAGE, COVERAGE C MEDICAL PAYMENTS which cannot be attributed only to operations at a single designated "campus" shown in the Declarations: a. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-Completed Operations Aggregate Limit, whichever is applicable; and b. Such payments shall not reduce any separate designated "campus" General Aggregate Limit. 3. When coverage for liability arising out of the "products-completed operations hazard" is provided, any payment for damages because of "bodily injury'' or "property damage" included in the "products-completed operations hazard" will reduce the Products-Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Per Campus General Aggregate Limit. 4. SECTION V -DEFINITIONS is amended by adding the following: "Campus" is defined as premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. 5. The provisions of SECTION Ill -LIMITS OF INSURANCE not otherwise modified by the above shall continue to apply as stipulated. I. Duties in the Event of Occurrence, Claim or Suit 1. The requirement in Paragraph 2.a. of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS that you must see to it that we are notified as soon as practicable of an "occurrence" or an offense, applies only when the "occurrence" or offense is known to: a. You, if you are an individual; b. A partner, if you are a partnership; or c. An executive officer or insurance manager, if you are a corporation. 2. The requirement in Paragraph 2.b. of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS that you must see to it that we receive notice of a claim or "suit" as soon as practicable will not be considered breached unless the breach occurs after such claim or "suit" is known to: a. You, if you are an individual; b. A partner, if you are a partnership; or c. An executive officer or insurance manager, if you are a corporation. J. Other Insurance -Primary Additional Insured 1. If the written contract or agreement or permit requires this insurance to be primary for any person or organization with whom you agree to include in SECTION II -WHO IS AN INSURED, then SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4. Other Insurance is replaced by the following: If other valid and collectible insurance is available for a loss we cover under COVERAGE A of this Coverage Part, our obligations are limited as follows: a. Primary Insurance -This insurance is primary. We will not seek contributions from other Pl-GLD-VS (05/17) Page 6 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) insurance available to the person or organization with whom you agree to include in SECTION II -WHO IS AN INSURED, except when 2. below applies. b. Excess Insurance -This insurance is excess over any of the other insurance whether primary, excess, contingent or any other basis: (1) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for "your work"; (2) That is Fire, lightning or explosion insurance for premises rented to you; or temporarily occupied by you with permission of the owner; or (3) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to SECTION I -COVERAGE, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph g. When this insurance is excess, we will have no duty under Coverages A or B to defend any claim or "suit" that any other insurer has a duty to defend. If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (2) The total of all deductible and self-insured amounts under all other insurance. We will share the remaining loss, if any, with any other insurance that is not described in this excess insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Method of Sharing -If all the other insurance permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any or the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's contribution is based on the ratio of its applicable limits of insurance of all insurers. 2. This provision only applies with respect to your operations, "your work" or facilities owned or used by you. K. Other Insurance -You Are An Additional Insured On Another Person's Or Organization's Policy If you are an insured under SECTION II -WHO IS AN INSURED, then SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4. OTHER INSURANCE, Paragraph b. Excess Insurance is replaced by the following: This insurance is excess over any other insurance, whether primary, excess, contingent or on any other basis: 1. That is Fire, Extended Coverage, Builders Risk, Installation Risk or similar coverage for "your work"; 2. That is Fire, lightning or explosion insurance for premises rented to you or temporarily occupied by you with permission of the owner; Pl-GLD-VS (05/17) Page 7 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) 3. If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to SECTION I -COVERAGE, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph g.; or 4. When any of the Named Insureds, under this Coverage Part, are additional insureds under a commercial general liability policy or similar insurance of another party. When this insurance is excess, we will have no duty under Coverages A or B to defend any claim or "suit" that any other insurer has a duty to defend. If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insureds. When this insurance is excess or other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: 1. The total amount that all such other insurance would pay for the loss in the absence of this insurance; and 2. The total of all deductible and self-insured amounts under all that other insurance. We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. L. Unintentional Failure To Disclose Hazards It is agreed that, based on our reliance on your representations as to existing hazards, if you should unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this Coverage Part, we shall not deny coverage under this Coverage Part because of such failure. M. Liberalization If we revise this endorsement to provide more coverage without additional premium charge, we will automatically provide the additional coverage to all endorsement holders as of the day the revision is effective in your state. N. Bodily Injury -Mental Anguish SECTION V -DEFINITIONS, Paragraph 3. is changed to read: "Bodily Injury'': a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish resulting from any of these; and b. Except for mental anguish, includes death resulting from the foregoing (item a. above) at any time. 0. Personal and Advertising Injury -Abuse of Process, Discrimination If COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is not otherwise excluded from this Coverage Part, the definition of "personal and advertising injury" is amended as follows: 1. SECTION V -DEFINITIONS, Paragraph 14. b. is revised to read: b. Malicious prosecution or abuse of process: 2. SECTION V -DEFINITIONS, Paragraph 14. is amended to include the following: Pl-GLD-VS (05/17) Page 8 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Philadelphia Indemnity Insurance Company Pl-GLD-VS (05/17) "Personal Injury'' also means discrimination based on race, color, religion, sex, age or national origin, except when: a. Done intentionally by or at the direction of, or with the knowledge or consent of: (1) Any insured; or (2) Any executive officer, director, stockholder, partner or member of the insured; or b. Directly or indirectly related to the employment, former or prospective employment, termination of employment, or application for employment of any person or persons by an insured; or c. Directly or indirectly related to the sale, rental, lease or sublease or prospective sales, rental, lease or sub-lease of any room, dwelling or premises by or at the direction of any insured; or d. Insurance for such discrimination is prohibited by or held in violation of law, public policy, legislation, court decision or administrative ruling. The above does not apply to fines or penalties imposed because of discrimination. P. Transfer of Rights of Recovery Against Others To Us As a clarification, the following is added to SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 8. Transfer of Rights of Recovery Against Others To Us: Therefore, the insured can waive the insurer's Rights of Recovery prior to the occurrence of a loss, provided the waiver is made in a written contract. Q. Science Laboratory "Occurrence" SECTION I -COVERAGE, COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Subsection 2. Exclusions, Paragraph f. does not apply to any "bodily injury'' or "physical damage" arising out of a fire or "occurrence" in any of your science laboratories while teaching is being conducted in that laboratory, subject to a $50,000 per policy limit. R. Medical Incident Liability-Nurse and Athletic Trainer 1. SECTION II-WHO IS AN INSURED, Subparagraph 2.a. (1) (d) is deleted and replaced by the following: (d) Arising out of his or her providing or failing to provide professional medical services. This paragraph does not apply to a registered or practical nurse or athletic trainer, while acting within the scope of his or her duties for the Named Insured and arising out of a "medical incident". 2. SECTION V-DEFINITIONS, 13. is deleted and replaced by the following: "Occurrence" means an accident, including continuous or repeated exposure to substantially the same general harmful conditions, and "medical incident". 3. The following definition is added to SECTION V -DEFINITIONS: "Medical Incident" means any act or omission in the furnishing or failure to furnish professional medical services by the insured or any person acting under the personal direction, control, or supervision of the insured. Any such act or omission together with all related acts or omissions in the furnishing of such services to any one person shall be considered one "medical incident". "Medical incident" does not include any actual, alleged or threatened emotional, physical, or sexual abuse of any patient or professional medical services recipient. Pl-GLD-VS (05/17) Page 9 of 9 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number: PHPK2644618Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95 Form W-9 (Rev. March 2024) Request for Taxpayer Identification Number and Certification Department of the Treasury Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information. Give form to the requester. Do not send to the IRS. Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.Print or type. See Specific Instructions on page 3.1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.) 2 Business name/disregarded entity name, if different from above. 3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes. Individual/sole proprietor C corporation S corporation Partnership Trust/estate LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . . Note: Check the “LLC” box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner. Other (see instructions) 3b If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . . . . 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any) (Applies to accounts maintained outside the United States.) 5 Address (number, street, and apt. or suite no.). See instructions. 6 City, state, and ZIP code Requester’s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number –– or Employer identification number – Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of U.S. person Date General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. What’s New Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the “LLC” box and enter its appropriate tax classification. New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow-through entity in which it has an ownership interest. This change is intended to provide a flow-through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065). Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they Cat. No. 10231X Form W-9 (Rev. 3-2024) January 24 2025 Challenge Island Bay Area Island Kids LLC 4 2450 Peralta Blvd Suite 112 Fremont CA 94536 4 7 2 0 1 5 1 1 9 Docusign Envelope ID: 59BF6BCC-1D8C-476F-826F-93928EF17F95