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POLICY NUMBER: 70 t 5145362 <br />COMMERCIAL AUTO <br />CA 20 48 02 99 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />DESIGNATED INSURED <br />This endorsement modifies insurance provided under the following: <br />BUSINESS AUTO COVERAGE FORM <br />GARAGE COVERAGE FORM <br />MOTOR CARRIER COVERAGE FORM <br />TRUCKERS COVERAGE FORM <br />With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless <br />modified by this endorsement. <br />This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured <br />Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage <br />Form. <br />This endorsement changes the policy effective on the inception date of the policy unless another date is <br />indicated below. <br />Endorsement Effective: 06/20/21 <br />Countersigned By: <br />Named Insured: Ware Malcomb <br />Authorized Representative <br />SCHEDULE <br />Name of Person(s) or Organization(s): <br />Any person or organization that the Named Insured is obligated to provide Insurance where required by a <br />written contract or agreement is an insured, but only with respect to legal responsibility for acts or <br />omissions of a person for whom Liability Coverage is afforded under this policy. <br />(If no entry appears above, information required to complete this endorsement will be shown in the <br />Declarations as applicable to the endorsement.) <br />Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the <br />extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision <br />contained in Section II of the Coverage Form. <br />CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 <br />R19kMRMgM0dokVWl <br />REME & APP BY: <br />P" V CL�wf <br />�' Risk Management Mabyt <br />