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AGENCY CUSTOMER ID: <br />NEW YORK CONSTRUCTION <br />DATE(MMIDDIYYYY) <br />CERTIFICATE OF LIABILITY INSURANCE ADDENDUM 10/11/2017 <br />THIS ADDENDUM SUMMARIZES SOME OF THE POLICY PROVISIONS IN THE REFERENCED INSURANCE POLICIES AND IS ISSUED AS A <br />MATTER OF INFORMATION ONLY; IT CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. ALL TERMS, EXCLUSIONS AND CONDITIONS <br />IN THE ACTUAL POLICY SHOULD BE CONSULTED FOR A MORE DETAILED ANALYSIS OF COVERAGE, AS THIS ADDENDUM DOES NOT <br />AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES. <br />AGENCY NAMED INSURED(S) <br />Insurance & Surety Services, LLC Foddrill Construction Corporation <br />POLICY NUMBER EFFECTIVE DATE CARRIER NAIC CODE <br />muuCIVu U IY111VrumntA 11VIV u mm I IrriA I C IVuivim=m: leru iv 11Y KCVIWUN NU1VI5CK: <br />A. Insurer <br />❑ Admitted / authorized <br />ElExcess line or free trade zone <br />B. General Liability (GL) policy form <br />ISO / ISO modified <br />Other <br />C. Specific operations excluded or restricted (GL policy) <br />Location: <br />Type of construction: <br />Building height: <br />Classifications [see attached declarations / endorsement] <br />Designated work [see attached endorsement] <br />D, Additional insured endorsement (GL policy) <br />CG 20 10 <br />Other: <br />❑ CG 20 26 ❑ CG 20 32 ❑ CG 20 33 ❑ CG 20 37 [::] CG 20 38 <br />Title: <br />E. According to the terms of this GL policy, the additional insured has primary and noncontributory coverage <br />❑ Yes ❑ No and ❑ no other option is available with this insurer <br />F. Additional insured will receive advance notice if insurer cancels (GL policy) <br />❑ Yes ❑ No and ❑ no other option is available with this insurer <br />G. Blanket contractual liability located in the "insured contract" definition (Section V, Number 9, Item f. in the ISO CGL polM1s removed or <br />restricted e % q <br />Yes and E:1 no other option is available with this insurer No changes made <br />� <br />H. "Insured contract" exception to the employers liability exclusion is removed or modified (GL policy) <br />Yes and no other option is available with this insurer No changes made c,,`�`r`, <br />v 6 ff ,, <br />1. GL policy (including endorsements) does not cover the additional insured for claims involving injury, employe��Fyfhe named insured or <br />subcontractors (not workers' compensation) <br />Yes and E] no other option is available with this insurer No changes made <br />ACORD 855 NY (2014/051 Attach to ACORD 25 02014 ACOR❑ CORPORATION_ All rinhts rnserv, <br />The ACORD name and logo are registered marks of ACORD <br />Page 2 of 3 <br />