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HomeMy WebLinkAboutJENNIFER BACKHAUS DBA BACKHAUS DANCE (3)INSURANCE ON FILE WORK MAY PROCEED N-2021-250-02 UNTIL INSURANCE EXPIRES (6.3. 106113 CLERK OF COUNCIL DATE: SECOND AMENDMENT TO AGREEMENT WITH JENNIFER BACKHAUS DBA BACKHAUS DANCE FOR PROVISION OF BALLET AND CREATIVE MOVEMENT CLASSES l�'•r f�✓��b.11��1AvM g.� �IMt t F.) (AV)JJHIS SECOND AMENDMENT to the above -referenced agreement is entered into (VDVOMbO'l0, 2022, by J and between Jennifer Backhaus dba Backbaus Dance ("Provider"), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). N c RECITALS U13 A. The parties entered into Agreement No. N-2021-250 ("Agreement") dated December 6, 2021, to retain Provider to provide ballet and creative movement classes in the City's recreation class 0 program. B. On May 31, 2022, the Parties entered into a First Amendment to expand the scope to include Hip - Hop dance classes. The Agreement is current and in -effect through December 31, 2022. C. The parties now wish to amend the Agreement to expand the scope to include Yoga classes and extend the term of the Agreement. The Parties therefore agree: 1. Section 1, Scope of Services, is hereby amended to include Yoga classes as further described in Exhibit A-2, attached hereto and incorporated by reference. 2. Section 3, Term, is hereby amended to extend the term of the Agreement through December 31, 2023. 3. Except as modified by this Second Amendment, all terms and conditions of the Agreement, shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Second Amendment to the Agreement on the date and year first written above. ATTEST 'Clerk of the Council � APPROVED AS TO FORM SONIA R. CARVALHO City Attorney By. Bra n Salvatierra Deputy City Attorney CITY OF SANTA AAA KRISTCINE GE City Manager 12:i1YI I13 DI A Jennifer Backhaus Artistic Director [signatures continued on next page] Page 1 of 2 Parks, Recreation and Community Services Agency Page 2 of 2 EXHIBIT A-2 Exhibit A-2 SCOPE OF SERVICES A. Provider shall teach such or similar classes (1) at the times below at facilities to be designated by the City or (2) on a schedule agreed upon by the parties for each class session or term, including the location, specific days and hours when classes will be held, and holidays to be observed, in accordance with City's needs. YOGA (18-99 yrs) Yoga practice will stretch and strengthen your body and relax your mind. Escape your daily stress and connect your mind, body and spirit on a yoga mat. All levels are welcome. INSTRUCTOR: Backhaus Dance/Chihiro Sano LOCATION: El Salvador Center, 1825 W Civic Center Dr., Santa Ana, (714) 647-6558 • Yoga classes will consist of monthly sessions, held 1 day per week, 1 hour per day. Ages 18-99 years old B. Provider shall provide all materials, supplies, equipment, records and personnel. Provider shall be responsible for clean-up of the facilities and materials and shall ensure the safety and effectiveness of instruction. CLASS SIZE A. Each class must have a minimum of 5 paid students and no more than 20 students. B. No registration will be accepted after the second meeting of classes. C. If the minimum registration has not been reached by the second class, the class shall be canceled. Provider will be under no obligation to provide services for the canceled classes, and the City will have no further obligations to pay Provider compensation for the remaining classes that were canceled in that session. CLASS FEES A. Each participant shall pay class registration fees as established by City. B. Provider may not waive class participation/registration fees. C. Only registered participants may participate in class. D. Any refunds to participants will be made in accordance with City policy. E. Any materials fee shall be established by mutual agreement of City and Provider and shall be payable directly to Provider. COVID-19 REQUIREMENTS A. Instructor and participants shall wear a mask at all times to participate. B. Temperature will be taken at the beginning of the class for instructor and participants. C. Social Distancing should be adhered to at all times. E. State of California COVID-19 regulations shall apply. Digitally signed by Ton Pierson Tori Pierson Date: 2022.011522.15 -0Tp0 -1 5AGKDAN-U1 TP E DATE514l1202 vyv) lzoz2 CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s . PRODUCER CONTACT Maury, Donnell & Parr 24 Commerce St. Baltimore, MD 21202 PHONE FAX Alc, IN Eat): (410) 685-4625 JAIC, Ni 685-3071 E-MAIL SS INSURERS AFFORDING COVERAGE NAIC p INSURER A:Gfeat American Insurance Company# 16691 INSURED INSURER B INSURER C: Backhaus Dance PO BOX 5890 Orange, CA 92863 INSURER 0: INSURER E INSURER F COVERAGES CERTIFICATE NIIMRFR- REVISION NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY UP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X GLP3961460 6/312022 6/312023 EACH OCCURRENCE 1,000,000 DAMAGE I RENTED PREMISES (Ed occurenc,l 1,000,000 NED EXP An one arson 20,00D PERSONAL &ADV INJURY 1,000,00D AGGREGATE LIMIT APPLIES PER: POLICY ❑ °EET LOC GENERALAGGREGATE 2,000,000 GENL X PRODUCTS-COMPIOPAGG 21000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO OWNED SCHEDULED AUTOS ONLY AlC1HEDU BODILY INUURY Per arson BODILY INJURY Per accident) gg PPeOFE tle , Ai AUTOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS -MADE DEO I I RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMWRp EXCLUDED? (Mantlstory In NH) H yes, describe under NIA PER OTH- E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS below A Abuse & Molestation X GLP3967460 61312022 61312023 Each Abuse 1,000,000 A Abuse & Molestation X GLP3961460 61312022 613/2023 Aggregate Limit 2,000,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, maybe attached if more space Is required) The City of Santa Ana, Risk Management, its officers, employees, agents, representatives, and volunteers are additional insured. Coverage is primary and non-contributory. 30 day prior written notice of cancellation is in favor of the City of Santa Ana, Risk Management, its officers, employees, agents, representatives, and volunteers. City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROV""""" . BNke MyesanmaWwt AUTHORIZED REPRESENTATIVE ° T IRMEVVEDL MrRT'®BY: �tf�/�—KJ e, /J7, 7ari P:cuar Rbkh4rugrnmt Um�alAide AUUMU zo ttul olual ©1988-2015 ACORD C( W 11 The ACORD name and logo are registered marks of ACORD S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 2019 GENERAL LIABILITY MULTISTATE ENDORSEMENT REVISION - COMMERCIAL GENERAL LIABILITY ADVISORY NOTICE TO POLICYHOLDERS This is a summary of the potential changes in your policy. No coverage is provided by this summary nor can it be construed to replace any provision of your policy. You should read your policy and review your Declarations page for complete information on the coverages you are provided. If there is any conflict between the policy and this summary, THE PROVISIONS OF THE POLICY SHALL PREVAIL. The major areas within the policy that broaden or reduce coverage, and other changes, are highlighted below. This notice does not reference every editorial change made in your policy. Carefully read your policy, including the endorsements attached to your policy. Please note that not all the forms listed below may be on your policy. This Notice provides information concerning the following new and revised endorsements, which applies to your renewal policy being issued by us: ENDORSEMENTS WITH EITHER BROADENINGS OR REDUCTIONS IN COVERAGE............................................5 CG 04 71 Electronic Data Liability — Limited Bodily Injury Exception Not Included..................................................5 CG 04 72 Electronic Data Liability Coverage (Coverage A) With Access Or Disclosure Of Confidential Or Personal Information Exclusion (Coverage B)...............................................................................................5 CG 2017 Additional Insured— Unit -owners Of Townhouse Or Homeowner Associations. ......... .......... ............. 6 CG 2131 Limited Exclusion— Designated Operations Covered By A Controlled (Wrap-up) Insurance Program.... .... . ..... 6 CG 2154 Exclusion — Designated Operations Covered By A Controlled (Wrap-up) Insurance Program. _... _....... ......6 CG 22 36 Exclusion — Limited Products And Professional Services— Pharmacists..................................................6 CG22 69 Pharmacists.......................................................................................................................... ..6 CG 23 02 Exclusion — Professional Services— Pharmacists................................................................................7 CG 23 03 Exclusion— Professional Services —Optical And Hearing Aid Establishments...........................................7 CG 40 07 Exclusion — Designated Operations Covered By A Controlled (Wrap-up) Insurance Program — Limited Exception For Additional Insureds......................................................................................................7 CG 40 08 Limited Exclusion — Designated Operations Covered By A Controlled (Wrap-up) Insurance Program —Limited Exception For Additional Insureds........................................................................................7 CG 40 09 Amendment Of Liquor Liability Exclusion — Limited Exception For Bring Your Own Alcohol. ............... ....... _7 ENDORSEMENTS THAT ONLY REFLECT A BROADENING IN COVERAGE..........................................................8 CG 20 39 Additional Insured — Owners, Lessees Or Contractors —Automatic Status When Required In Written Construction Agreement With You (Completed Operations)....................................................................8 CG 20 40 Additional Insured — Owners, Lessees Or Contractors —Automatic Status For 0& Required In Written Construction Agreement (Completed Operations) .............................. kbkMg..dDM1iaai min &AR Br. �- %u >�tCRJOn © Includes copyrighted material of Insurance Services Office, Inc., with its pE �R My 9am4Om lAtl ' SDM-1040 (Ed. 12/19) (Page 1 of 15) 00 S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 20 41 Additional Insured — Owners, Lessees Or Contractors— Completed Operations Subject To The GeneralAggregate...................................................................................................................................8 CG 20 42 Additional Insured —Automatic Status For Designated Operations .......................................... .............8 CG 20 43 Additional Insured —Automatic Status When Required In Written Contract Or Agreement ..................... ... 8 CG 20 44 Additional Insured —Vendors —Automatic Status When Required In Agreement........................................8 CG 24 54Automatic Insured Status For Newly Acquired Or Formed Limited Liability Companies.................................8 CG 25 45 Designated Project(s) Products -Completed Operations Aggregate Limit.................................................9 CG 25 46 Designated Location(s) Products -Completed Operations Aggregate Limit...............................................9 ENDORSEMENTS THAT ONLY REFLECT A REDUCTION IN COVERAGE ............................................... ........ _...9 CG 2011 Additional Insured — Managers Or Lessors Of Premises....................................................................... 9 CG 20 24 Additional Insured —Owners Or Other Interests From Whom Land Has Been Leased..................................9 CG 22 97 Pharmacists — Broadened Coverage................................................................................................9 CG 34 54 Cannabis Exclusion, ................................................................................................... 9 CG 34 55 Cannabis Exclusion With Hemp Exception......................................................................................10 CG 40 01 Genetically Modified Organism Exclusion Endorsements...................................................................10 CG 40 02 Genetically Modified Organism Exclusion For Designated Operations Or Products Endorsements.............10 CG 40 03 Exclusion —Athletic Or Sports Participants —AII Contests Or Exhibitions.................................................10 CG 40 04 Exclusion — Earth Movement......................................................................................................10 CG 40 05 Exclusion — Earth Movement— Completed Operations.......................................................................11 CG 40 06 Earth Movement — Exclusion For Designated Operation(s) Or Project(s).............................................11 CG 4010 Exclusion — Cross Suits Liability...................................................................................................11 CG 40 11 Exclusion — Hired Auto Liability...................................................................................................11 CG 4012 Exclusion —All Hazards In Connection With An Electronic Smoking Device, Its Vapor, Component Parts, Equipment And Accessories.....................................................................................................................11 CG 4013 Exclusion — Health Hazards, Electronic Smoking Device Vapor...........................................................11 CG4014 Cannabis Exclusion...................................................................................................................12 CG 4015 Cannabis Exclusion With Hemp Exception. . ...................................... ............................................. 12 CG 4016 Cannabis Exclusion With Hemp And Lessors Risk Exceptions.............................................................12 ENDORSEMENTS THAT REFLECT A REINFORCEMENT OR NO CHANGE IN COVERAGE.... _ ................... ........13 CG 04 36 Limited Product Withdrawal Expense Endorsement ....................................... <. o .IN I�NEWmfi MrmTm Br © Includes copyrighted material of Insurance Services Office, Inc., wi a" 7ou Pie« SDM-1040 (Ed. 12/19) (Page 2 of 15) S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 20 01 Primary And Noncontributory —Other Insurance Condition ................................ _ ................. ............13 CG 20 03 Additional Insured —Concessionaires Trading Under Your Name.........................................................13 CG 20 05 Additional Insured — Controlling Interest....................................................................... ...........13 CG 20 07 Additional Insured — Engineers, Architects Or Surveyors, ................................................................... 13 CG 2010 Additional Insured —Owners, Lessees Or Contractors —Scheduled Person Or Organization CG 2011 Additional Insured — Managers Or Lessors Of Premises....................................................................13 CG 20 12 Additional Insured — State Or Governmental Agency Or Subdivision Or Political Subdivision — Permits Or Authorizations.......................................................................................................................................13 CG 20 13 Additional Insured — State Or Governmental Agency Or Subdivision Or Political Subdivision — Permits Or Authorizations Relating To Premises..........................................................................................................14 CG 2015 Additional Insured —Vendors... ............................................... - .... ....... .. . .... ....................... 14 CG 2018 Additional Insured — Mortgagee, Assignee Or Receiver......................................................... _ ... _.14 CG 20 23 Additional Insured— Executors, Administrators, Trustees Or Beneficiaries ............................................ 14 CG 20 24 Additional Insured — Owners Or Other Interests From Whom Land Has Been Leased......... 14 CG 20 26 Additional Insured — Designated Person Or Organization .............................................. ..................14 CG 20 27 Additional Insured — Co-owner Of Insured Premises..........................................................................14 CG 20 28 Additional Insured — Lessor Of Leased Equipment.................................................................. .......14 CG 20 29 Additional Insured —Grantor Of Franchise ........................ _.............. ..................................14 CG 20 30 Oil Or Gas Operations— Nonoperating, Working Interests ....... ....... ... . _....... ......... ... ...... ..14 CG 20 31 Additional Insured — Engineers, Architects Or Surveyors .......................... ... _ .. _ ....... ..14 CG 20 32 Additional Insured— Engineers, Architects Or Surveyors Not Engaged By The Named Insured. , ............. ... 14 CG 20 33 Additional Insured — Owners, Lessees Or Contractors — Automatic Status When Required In ConstructionAgreement With You.............................................................................................................14 CG 20 34 Additional Insured — Lessor Of Leased Equipment —Automatic Status When Required In Lease AgreementWith You.............................................................................................................................14 CG 20 35 Additional Insured —Grantor Of Licenses —Automatic Status When Required By Licensor......... _.............14 CG 20 36 Additional Insured —Grantor Of Licenses...................................................................................14 CG 20 37 Additional Insured —Owners, Lessees Or Contractors— Completed Operations.......................................14 CG 20 38 Additional Insured — Owners, Lessees Or Contractors —Automatic Status For Other Parties When Required In Written Construction Agreement...............................................................................................14 A © Includes copyrighted material of Insurance Services Office, Inc., wi SDM-1040 (Ed. 12/19) (Page 3 of 15) S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 2101 Exclusion — Athletic Or Sports Participants ..................................... . ........ ..................................... 14 CG 22 71 Colleges Or Schools (Limited Form) .............................................. . ......................... ................. 14 CG 22 72 Colleges Or Schools .......................................................... .. ..... . . .... . .... ....................... 14 CG 2137 Exclusion — Employees And Volunteer Workers As Insureds ....... ................................................. ..... 15 CG 2166 Exclusion —Volunteer Workers ................................................ .... __ ............... ........................ 15 CG 2141 Exclusion — Intercompany Products Suits .................................................................... .... ............ 15 CG 22 65 Optical And Hearing Aid Establishments .......................................... _ ... ...... — ................................ 15 CG 24 04 WaiverOf Transfer Of Rights Of Recovery Against OthersTo Us (Waiver Of Subrogation).. .... . ....... .. .... 15 CG 24 53 Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) — Automatic............................ ............................ ................................................................................... 15 CG9909 Premium Audit Noncompliance Charge ........... .................................. ............ ............................... 15 RHEWm & Arxw® Br '7 Includes copyrighted material of Insurance Services Office, Inc., wi 6%e SDM-1040 (Ed. 12/19) (Page 4 of 15) r S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 ENDORSEMENTS WITH EITHER BROADENINGS OR REDUCTIONS IN COVERAGE CG 04 71 Electronic Data Liability - Limited Bodily Injury Exception Not Included When this endorsement is attached to your policy, it will generally provide limited coverage with respect to loss of computerized or electronically stored data or software which results from physical injury to tangible property, subject to a Loss Of Electronic Data Limit. It excludes access or disclosure of confidential or personal information and data -related liability under Coverage A and Coverage B and will not provide a limited bodily injury exception included under Coverage A. If the attachment of this endorsement replaces CG 21 06 Exclusion - Access Or Disclosure Of Confidential Or Personal Information And Data -related Liability - With Limited Bodily Injury Exception or CG 2107 Exclusion - Access Or Disclosure Of Confidential Or Personal Information And Data -related Liability - Limited Bodily Injury Exception Not Included, then coverage is broadened. If the attachment of this endorsement replaces CG 21 08 Exclusion - Access Or Disclosure Of Confidential Or Personal Information (Coverage B Only), then: - Coverage is broadened for data -related liability in Coverage A; Coverage is reduced for access or disclosure of confidential or personal information in Coverage A; and - There is no coverage impact in Coverage B. If the attachment of this endorsement replaces CG 04 37 Electronic Data Liability, then: - Coverage is broadened for data -related liability in Coverage A; - Coverage is reduced with respect to bodily injury in Coverage A; and Coverage is reduced in Coverage B. CG 04 72 Electronic Data Liability Coverage (Coverage A) With Access Or Disclosure Of Confidential Or Personal Information Exclusion (Coverage B) When this endorsement is attached to your policy, it will generally provide limited coverage with respect to loss of computerized or electronically stored data or software which results from physical injury to tangible property, subject to a Loss Of Electronic Data Limit. It excludes access or disclosure of confidential or personal information from Coverage B only. If the attachment of this endorsement: - Replaces CG 2106 Exclusion -Access Or Disclosure Of Confidential Or Personal Information And Data- related Liability - With Limited Bodily Injury Exception, CG 21 07 Exclusion - Access Or Disclosure Of Confidential Or Personal Information And Data -related Liability - Limited Bodily Injury Exception Not Included or CG 21 08 Exclusion - Access Or Disclosure Of Confidential Or Personal Information (Coverage B Only), coverage is broadened. - Replaces CG 04 37 Electronic Data Liability, coverage is broadened in Coverage A and coverage is reduced in Coverage B. qy s. rr kMo Sr. IIENEwEn4 MAiW®r. © Includes copyrighted material of Insurance Services Office, Inc., wi y �t° �° F0" SDM-1040 (Ed. 12119) (Page 5 of 15) S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 20 17 Additional Insured - Unit -owners Of Townhouse Or Homeowner Associations This endorsement is revised to include unit -owners of homeowner associations. In addition, a provision is added to address restriction of coverage to the unit -owner for liability arising out of maintenance, use or repair of a portion of the premises (common area) that is reserved for the unit -owner's exclusive use or occupancy, e.g., assigned parking area, garden plot, storage closets or lockers. With respect to unit owners of homeowner associations, this represents a broadening of coverage. With respect to unit - owners of townhouse associations, the provision restricting additional insured status for a unit- owner's liability arising out of the ownership, maintenance, use or repair of that portion of the premises which is reserved for the unit -owner's exclusive use or occupancy may be a reduction in coverage. CG 21 31 Limited Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program This endorsement is revised to add a definition of "controlled (wrap-up) insurance program" and revise Paragraph A. to emphasize the application of the exclusion to bodily injury and property damage arising out of ongoing operations as well as included within the products -completed operations hazard at the location(s) described in the Schedule. The attachment of this endorsement may result in a reduction of coverage, unless: If this endorsement replaces the previous version of CG 21 31 on a policy, it may result in a broadening of coverage. If this endorsement replaces CG 21 54 Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program on a policy, it will result in a broadening of coverage. CG 21 54 Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program This endorsement is revised to add a definition of "controlled (wrap-up) insurance program" and revise Paragraph A. to emphasize the application of the exclusion to bodily injury and property damage arising out of ongoing operations as well as included within the products -completed operations hazard at the location(s) described in the Schedule. The attachment of this endorsement may result in a reduction of coverage, unless if this endorsement replaces the previous version of CG 21 54 on a policy, it may result in a broadening of coverage. CG 22 36 Exclusion - Limited Products And Professional Services — Pharmacists This endorsement has been revised to limit the products/completed operations hazard exclusion to apply only to bodily injury or property damage arising out of the insured's products dispensed or sold in connection with the pharmacist's services, e.g., prescription drugs. If the attachment of this endorsement replaces the prior version of CG 22 36, it may result in a broadening of coverage. The attachment of this endorsement to a policy not containing the prior version of CG 22 36 results in a reduction of coverage. CG 22 69 Pharmacists This endorsement is revised to: - Generally address state or federal laws affecting the professional services provided by pharmacists; - Amend the exclusion for willful violation of a penal statute or ordinance to apply to the willful violation of applicable state or federal laws governing pharmacists, not just sales of pharmaceuticals; - Amend the exclusion for certain specific services performed by a pharmacist to apply to all tests, not just blood tests, Remove managing drug therapy from the exclusion for certain specific services and w.k D� !" min &APPRO/m Br ?i © Includes copyrighted material of Insurance Services Office, Inc., wi°u �0 SDM-1040 (Ed.12/19) (Page 6 of 15) S9 ` 04/11/2022 " GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY 'D/B" 072977484 262428 Other editorial changes. With respect to removal of managing drug therapy from the exclusion of certain specified services, this change may be considered a broadening in coverage. With respect to the amendment to the willful violation exclusion and the amendment to the exclusion for certain specified services related to tests, these changes may result in a reduction of coverage. Other changes have no impact on coverage. CG 23 02 Exclusion - Professional Services - Pharmacists When this endorsement is attached to your policy, it will exclude bodily injury and property damage arising out of rendering of or failure to render professional health care services as a pharmacist, but this exclusion does not apply to bodily injury or property damage included within the products -completed operations hazard. If the attachment of this endorsement replaces CG 22 36 Exclusion - Limited Products And Professional Services - Pharmacists, it may result in a broadening of coverage. The attachment of this endorsement to a policy not containing CG 22 36 results in a reduction of coverage. CG 23 03 Exclusion - Professional Services - Optical And Hearing Aid Establishments When this endorsement is attached to your policy, it excludes bodily injury and property damage arising out of rendering of or failure to render professional health care services, including services in connection with optical goods and hearing aid establishments, such as the prescribing or fitting of ophthalmic lenses or hearing aid devices, but will not exclude bodily injury and property damage arising out of the products -completed operations hazard. If attachment of this endorsement replaces CG 22 37 Exclusion - Products And Professional Services (Optical And Hearing Aid Establishments), it may result in a broadening of coverage. The attachment of this endorsement to a policy not previously containing CG 22 37 results in a reduction of coverage. CG 40 07 Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program - Limited Exception For Additional Insureds When this endorsement is attached to your policy, it will exclude coverage for designated operations covered by a controlled (wrap-up) insurance program but contains a limited exception for additional insureds who are not enrolled in a controlled (wrap-up) insurance program with respect to the location described in the Schedule of the endorsement. The attachment of this endorsement may result in a reduction of coverage, unless if this endorsement replaces CG 21 54 Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program on a policy, it will result in a broadening of coverage. CG 40 08 Limited Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program - Limited Exception For Additional Insureds When this endorsement is attached to your policy, it will exclude coverage for designated operations covered by a controlled (wrap-up) insurance program unless the wrap-up program covering operations designated in the Schedule has been cancelled, nonrenewed or otherwise no longer applies for reasons other than exhaustion of available limits. This endorsement also contains a limited exception for any person or organization as an additional insured who is not enrolled in a wrap-up insurance program with respect to the location described in the Schedule of the endorsement. The attachment of this endorsement may result in a reduction of coverage, unless if this endorsement replaces CG 21 54 Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program or CG 21 31 Limited Exclusion - Designated Operations Covered By A Controlled (Wrap-up) Insurance Program on a policy, it will result in a broadening of coverage. CG 40 09 Amendment Of Liquor Liability Exclusion - Limited Exception For Bring Your Own Alcohol When this endorsement is attached to your policy, it will replace the liquor liability exclusion currently in your policy. It applies the exclusion if you manufacture, sell or distribute alcoholic beverages, and more ge if you serve or furnish alcoholic beverages whether or not a charge is made or a license is r+" p' RENEWID6 NPliw®Br: 0 Includes copyrighted material of Insurance Services Office, Inc., wi `r`f 0°u `0 SDM-1040 (Ed.12H9) (Page 7 of 15) � ft=_7agmmtOmo Atl S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 exception for liability resulting from the intoxication of any person because alcoholic beverages were permitted on your premises, for consumption on your premises. If the attachment of this endorsement replaces Endorsements CG 21 50 Amendment Of Liquor Liability Exclusion or CG 21 51 Amendment Of Liquor Liability Exclusion - Exception For Scheduled Premises Or Activities, it may result in a broadening of coverage. The attachment of this endorsement to a policy not containing endorsements CG 21 50 or CG 21 51 results in a reduction of coverage. ENDORSEMENTS THAT ONLY REFLECT A BROADENING IN COVERAGE CG 20 39 Additional Insured - Owners, Lessees Or Contractors - Automatic Status When Required In Written Construction Agreement With You (Completed Operations) When this endorsement is attached to your policy, coverage is broadened to generally provide automatic additional insured status with respect to completed operations to anyone you have performed operations for and has agreed in writing in a contract or agreement that such person be added as an additional insured. CG 20 40 Additional Insured - Owners, Lessees Or Contractors -Automatic Status For Other Parties When Required In Written Construction Agreement (Completed Operations) When this endorsement is attached to your policy, coverage is broadened to generally provide automatic additional insured status with respect to completed operations to anyone you have performed operations for and have agreed in writing in a contract or agreement that such person be added as an additional insured and anyone that the additional insured is also required by a written contract or agreement to add as an additional insured. CG 20 41 Additional Insured - Owners, Lessees Or Contractors - Completed Operations Subject To The General Aggregate When this endorsement is attached to your policy, coverage is broadened to generally provide an additional insured with insured status for both Premises Operations and Products -Completed Operations and is designed for use with the "Products -Completed Operations Included"/plus sign (+) classifications found in the ISO General Liability manual. CG 20 42 Additional Insured - Automatic Status For Designated Operations When this endorsement is attached to your policy, coverage is broadened to provide automatic additional insured status in relation to a designated operation. CG 20 43 Additional Insured -Automatic Status When Required In Written Contract Or Agreement When this endorsement is attached to your policy, coverage is broadened to provide automatic additional insured status when there is a written contract or agreement that such additional insured be added to the Policy. CG 20 44 Additional Insured - Vendors - Automatic Status When Required In Agreement When this endorsement is attached to your policy, coverage is broadened to generally provide additional insured status to those persons or organizations for whom you are obligated in writing in a contract or agreement to name as an additional insured under your policy with respect to distribution or sale of any of your products in the regular course of the vendor's business. CG 24 54 Automatic Insured Status For Newly Acquired Or Formed Limited Liability Companies When this endorsement is attached to your policy, coverage is broadened to generally include limited liability companies you newly acquire or form, and over which you maintain ownership or majority interest, if there is no other similar insurance available to that limited liability company. I © Includes copyrighted material of Insurance Services Office, Inc., wi°up�SDM-1040 (Ed. 12/19) (Page 8 of 15) S9 * 04/1112022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 25 45 Designated Project(s) Products -Completed Operations Aggregate Limit When this endorsement is attached to your policy, a separate Designated Project Products -Completed Operations Aggregate Limit applies to each project designated in the Schedule of the endorsement. This is a broadening of coverage. CG 25 46 Designated Location(s) Products -Completed Operations Aggregate Limit When this endorsement is attached to your policy, a separate Designated Location Products -Completed Operations Aggregate Limit applies to each location designated in the Schedule of the endorsement. This is a broadening of coverage. ENDORSEMENTS THAT ONLY REFLECT A REDUCTION IN COVERAGE CG 20 11 Additional Insured - Managers Or Lessors Of Premises CG 20 24 Additional Insured - Owners Or Other Interests From Whom Land Has Been Leased These endorsements have been revised to delete "arising out of and add specific language that provides an additional insured with coverage for their vicarious or contributory negligence only. When these endorsements are attached to your policy, there may be a reduction in coverage for those states in which: Named insureds are permitted to contractually hold harmless an additional insured for that additional insured's sole negligence; and Courts have enabled coverage for the sole negligence of the additional insured. CG 22 97 Pharmacists - Broadened Coverage This endorsement is revised to: Generally address state or federal laws affecting the professional services provided by pharmacists; Amend the exclusion for willful violation of a penal statute or ordinance to apply to the willful violation of applicable state or federal laws governing pharmacists, not just sales of pharmaceuticals; - Add negligent supervision -related language; and - Other editorial changes. There is no impact on coverage. However, the negligent supervision provision may result in a reduction in coverage in states where courts have ruled professional services exclusions to be inapplicable to negligent supervision claims and other similar types of claims. CG 34 54 Cannabis Exclusion When this endorsement is attached in conjunction with the Limited Product Withdrawal Expense Endorsement CG 04 36 to your policy, it generally excludes "product withdrawal expenses" -related exposures associated with cannabis. To the extent that an exposure exists with respect to the cannabis -related activity or events addressed in this endorsement, attachment of this endorsement will result in a reduction in coverage. Howevf Rhh Mvgv Dom, 3 { RE4¢V/m g NrNwmB.: © Includes copyrighted material of Insurance Services Office, Inc., wi 7ou Pao« SDM-1040 (Ed. 12/19) (Page 9 of 15) S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 in the endorsement, the attachment of this endorsement will not result in a reduction of coverage for product withdrawal expenses arising out of the actual, alleged, threatened or suspected inhalation, ingestion, absorption or consumption of, or contact with cannabis by an insured or any other person for whom you are legally responsible, but only if the product withdrawal expense does not arise out of your selling, serving or furnishing of cannabis to any such person. CG 34 55 Cannabis Exclusion With Hemp Exception When this endorsement is attached in conjunction with the Limited Product Withdrawal Expense Endorsement CG 04 36 to your policy, it generally excludes product withdrawal expenses -related exposures associated with cannabis while also containing an exception addressing product withdrawal expenses arising out of goods or products containing or derived from hemp or damage to such goods or products. To the extent that an exposure exists with respect to the cannabis -related activity or events addressed in this endorsement, attachment of this endorsement will result in a reduction in coverage. However, due to related exceptions in the endorsement, the attachment of this endorsement will not result in a reduction of coverage for: Product withdrawal expenses arising out of the actual, alleged, threatened or suspected inhalation, ingestion, absorption or consumption of, or contact with cannabis by an insured or any other person for whom you are legally responsible, but only if the product withdrawal expense does not arise out of your selling, serving or furnishing of cannabis to any such person; and - Product withdrawal expenses arising out of goods or products containing or derived from hemp, including, but not limited to: (i) seeds, (ii) food, (iii) clothing, (iv) lotions, oils or extracts, (v) building materials, or (vi) paper, and, product withdrawal expenses incurred by you because of property damage to any such goods or products, unless, and to the extent, any such goods or products are prohibited under an applicable state or local statute, regulation or ordinance in the state wherein your products involved in the product withdrawal are located or were located at the time the injury or damage occurred. CG 40 01 Genetically Modified Organism Exclusion Endorsement When this endorsement is attached to your policy, "bodily injury," "property damage" and "personal and advertising injury" arising out of genetic modification, whether by design or accident, will be excluded. To the extent that current policy exclusions do not limit liability arising out of genetically modified products, attachment of this endorsement to your policy will result in a reduction of coverage. CG 40 02 Genetically Modified Organism Exclusion For Designated Operations Or Products Endorsement When this endorsement is attached to your policy, "bodily injury," "property damage" and "personal and advertising injury" arising out of genetic modification, whether by design or accident, will be excluded but only with respect to operations or products listed in the Schedule of the endorsement. To the extent that current policy exclusions do not limit liability arising out of genetically modified products, attachment of this endorsement to your policy will result in a reduction of coverage. CG 40 03 Exclusion - Athletic Or Sports Participants - All Contests Or Exhibitions When this endorsement is attached to your policy, it will expressly exclude coverage under Coverage A, with respect to operations described in the Schedule of the endorsement, for bodily injury to any person while practicing for or participating in any sports or athletic contest or exhibition. If this endorsement is attached as a replacement for CG 21 01 Exclusion -Athletic Or Sports Participants, it may result in a restriction in coverage with respect to events the insured does not sponsor. If this endorsement is newly attached to the Policy, it may result in a restriction in coverage. CG 40 04 Exclusion - Earth Movement When this endorsement is attached to your policy, it will exclude coverage for "bodily injury" and "property damage" that arises out of earth movement that is caused by or alleged to have been caused by, in whole or in part; or aggravated by or alleged to have been aggravated by various operations related to "your work" as defii ,• .. �inEv,ID6AreRo.�Br. © Includes copyrighted material of Insurance Services Office, Inc., wi 7cu 7�c oK SDM-1040 (Ed.12119) (Page 10 of 15) �"" S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 To the extent there is an exposure for liability arising out of earth movement, as defined within the endorsement, that may be caused by, alleged to be caused by or aggravated by or alleged to be aggravated by that which is described in the endorsement may result in a restriction of coverage. CG 40 05 Exclusion - Earth Movement - Completed Operations When this endorsement is attached to your policy, it will exclude coverage for "bodily injury" and "property damage" that arises out of earth movement that is caused by or alleged to have been caused by, in whole or in part; or aggravated by or alleged to have been aggravated by various operations related to "your work' (as defined in the Policy) and that is included in the "products -completed operations hazard" (also as defined in the Policy). To the extent there is an exposure for liability arising out of earth movement, as defined within the endorsement, that may be caused by, alleged to be caused by or aggravated by or alleged to be aggravated by that which is described in the endorsement may result in a restriction of coverage. CG 40 06 Earth Movement - Exclusion For Designated Operation(s) Or Project(s) When this endorsement is attached to your policy, it will exclude coverage for "bodily injury" and "property damage" that arises out of earth movement that is caused by or alleged to have been caused by, in whole or in part, or aggravated by or alleged to have been aggravated by various operations but only with respect to operations or projects described in the Schedule of the endorsement and as those operations or projects relates to "your work" as defined within the Policy. To the extent there is an exposure for liability arising out of earth movement, as defined within the endorsement, that may be caused by, alleged to be caused by or aggravated by or alleged to be aggravated by that which is described in the endorsement may result in a restriction of coverage. CG 40 10 Exclusion - Cross Suits Liability When this endorsement is attached to your policy, any claim or suit for damages that are brought by any Named Insured against another Named Insured will be excluded. To the extent that an exposure exists with respect to cross suits being brought between Named Insureds, the attachment of this endorsement will result in a reduction in bodily injury, property damage or personal and advertising injury coverage with respect to such exposure related to cross suits liability. CG 40 11 Exclusion - Hired Auto Liability When this endorsement is attached to a policy, this endorsement will exclude liability arising out of a hired auto. To the extent that: An exposure exists with respect to any hired auto; or - Liability is assumed under any insured contract for the maintenance, use or entrustment of any hired auto; the attachment of this endorsement will result in a reduction in bodily injury and property damage liability coverage with respect to such exposures related to any hired auto. CG 40 12 Exclusion - All Hazards In Connection With An Electronic Smoking Device, Its Vapor, Component Parts, Equipment And Accessories When this endorsement is attached to your policy, it will generally exclude all bodily injury, property damage or personal and advertising injury with respect to an electronic smoking device. To the extent that an exposure exists with respect to an electronic smoking device, its vapor, component parts, equipment and accessories, attachment of this endorsement will result in a reduction in coverage. CG 40 13 Exclusion - Health Hazards, Electronic Smoking Device Vapor w_ Rb4Mmga,mtDivitl RFn 6/Nrxwm Or. © Includes copyrighted material of Insurance Services Office, Inc., wi SDM-1040 (Ed. 12/19) (Page 11 of 15) �R°"" gevt°"�1Atle S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 When this endorsement is attached to your policy, it will generally exclude bodily injury with respect to vapor delivered from an electronic smoking device. To the extent that an exposure exists with respect to the actual, alleged, threatened or suspected inhalation of, contact with, exposure to, existence of, or presence of, vapor delivered from an electronic smoking device; or, any component part of, or equipment or accessory designed for use with, an electronic smoking device in connection with the actual, alleged, threatened or suspected inhalation of, contact with, exposure to, existence of, or presence of, vapor delivered from an electronic smoking device not otherwise excluded, the attachment of this endorsement will result in a reduction in bodily injury coverage. However, such reduction in coverage does not apply to coverage for bodily injury arising out of the explosion, bursting, or rupturing, of an electronic smoking device or any component part, equipment or accessory, designed for use with an electronic smoking device for any reason due to a related exception in the endorsement. CG 40 14 Cannabis Exclusion When this endorsement is attached to your policy, it generally excludes bodily injury, property damage and personal and advertising injury -related exposures associated with cannabis. To the extent that an exposure exists with respect to the cannabis -related activity or events addressed in this endorsement, attachment of this endorsement will result in a reduction in coverage. However, due to related exceptions in the endorsement, the attachment of this endorsement will not result in a reduction of coverage for: - Bodily injury or property damage arising out of the actual, alleged, threatened or suspected inhalation, ingestion, absorption or consumption of, or contact with cannabis by an insured or any other person for whom you are legally responsible, but only if the bodily injury or property damages does not arise out of your selling, serving or furnishing of cannabis to any such person, and - Personal and advertising injury arising out of the offenses addressing, in part, (i) false arrest, detention or imprisonment and (ii) wrongful eviction. CG 40 15 Cannabis Exclusion With Hemp Exception When this endorsement is attached to your policy, it generally excludes bodily injury, property damage and personal and advertising injury -related exposures associated with cannabis while also containing an exception generally addressing injury or damage arising out of goods or products containing or derived from hemp or damage to such goods or products. To the extent that an exposure exists with respect to the cannabis -related activity or events addressed in this endorsement, attachment of this endorsement will result in a reduction in coverage. However, due to related exceptions in the endorsement, the attachment of this endorsement will not result in a reduction of coverage for: - Bodily injury or property damage arising out of the actual, alleged, threatened or suspected inhalation, ingestion, absorption or consumption of, or contact with cannabis by an insured or any other person for whom you are legally responsible, but only if the bodily injury or property damages does not arise out of your selling, serving or furnishing of cannabis to any such person; - Personal and advertising injury arising out of the offenses addressing, in part, (i) false arrest, detention or imprisonment and (ii) wrongful eviction; and Bodily injury, property damage or personal and advertising injury arising out of goods or products containing or derived from hemp, including, but not limited to: (i) seeds, (ii) food, (iii) clothing, (iv) lotions, oils or extracts, (v) building materials, or (vi) paper, and property damage to any such goods or products, unless, and to the extent, any such goods or products are prohibited under an applicable state or local statute, regulation or ordinance in the state wherein the (i) bodily injury or property damage occurs, (ii) occurrence which caused the bodily injury or property damage takes place, or (iii) the offense which caused the personal and advertising injury was committed. CG 40 16 Cannabis Exclusion With Hemp And Lessors Risk Exceptions When this endorsement is attached to your policy, it generally excludes bodily injury, property damage and personal and advertising injury -related exposures associated with cannabis while also containing an or damage arising out of goods or products containing or derived from hemp or damage tc REN 6 A m Or. © Includes copyrighted material of Insurance Services Office, Inc., wi SDM-1040 (Ed. 12/19) (Page 12 of 15) S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 also contains an explicit exception addressing bodily injury, property damage or personal and advertising injury arising out of the ownership, maintenance or use of a premises leased to others by you. To the extent that an exposure exists with respect to the cannabis -related activity or events addressed in this endorsement, attachment of this endorsement will result in a reduction in coverage. However, due to related exceptions in the endorsement, the attachment of this endorsement will not result in a reduction of coverage for: - Bodily injury or property damage arising out of the actual, alleged, threatened or suspected inhalation, ingestion, absorption or consumption of, or contact with cannabis by an insured or any other person for whom you are legally responsible, but only if the bodily injury or property damages does not arise out of your selling, serving or furnishing of cannabis to any such person; Personal and advertising injury arising out of the offenses addressing, in part, (i) false arrest, detention or imprisonment and (ii) wrongful eviction, due to related exceptions in the endorsement; Bodily injury, property damage or personal and advertising injury arising out of goods or products containing or derived from hemp, including, but not limited to: (1) seeds, (ii) food, (iii) clothing, (iv) lotions, oils or extracts, (v) building materials, or (vi) paper, and property damage to any such goods or products, unless, and to the extent, any such goods or products are prohibited under an applicable state or local statute, regulation or ordinance in the state wherein the (i) bodily injury or property damage occurs, (ii) occurrence which caused the bodily injury or property damage takes place, or (III) the offense which caused the personal and advertising injury was committed; and - Bodily injury, property damage or personal and advertising injury arising out of the ownership, maintenance or use of a premises leased to others by you. ENDORSEMENTS THAT REFLECT A REINFORCEMENT OR NO CHANGE IN COVERAGE CG 04 36 Limited Product Withdrawal Expense Endorsement This endorsement is revised to delete the second paragraph under Paragraph B.3.a. under the Limits Of Insurance section relating to the insured's reimbursement to the insurer of any payment of all or part of any deductible amount that the insurer is required to pay by law. As this endorsement only relates to reimbursement for product withdrawal expenses incurred by you and not product withdrawal expenses that you become legally obligated to pay as damages, there is no impact on coverage. CG 20 01 Primary And Noncontributory - Other Insurance Condition This endorsement is revised to reflect its availability for use with the Liquor Liability Coverage Part. There is no impact on coverage. CG 20 03 Additional Insured - Concessionaires Trading Under Your Name CG 20 05 Additional Insured - Controlling Interest CG 20 07 Additional Insured - Engineers, Architects Or Surveyors CG 20 10 Additional Insured - Owners, Lessees Or Contractors - Scheduled Person Or Organization CG 20 11 Additional Insured - Managers Or Lessors Of Premises CG 20 12 Additional Insured - State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits Or Authorizations R.k Draw, ` IR� 6 APrRw®8� 6 %au i�u:r.er © Includes copyrighted material of Insurance Services Office, Inc., wi ftek AMru9errmc dmgl h J. SDM-1040 (Ed. 12/19) (Page 13 of 15) S9 « 04/11/2022 ` GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY 'D/B` 072977484 262428 CG 20 13 Additional Insured - State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits Or Authorizations Relating To Premises CG 20 15 Additional Insured - Vendors CG 20 18 Additional Insured - Mortgagee, Assignee Or Receiver CG 20 23 Additional Insured - Executors, Administrators, Trustees Or Beneficiaries CG 20 24 Additional Insured - Owners Or Other Interests From Whom Land Has Been Leased CG 20 26 Additional Insured - Designated Person Or Organization CG 20 27 Additional Insured - Co-owner Of Insured Premises CG 20 28 Additional Insured - Lessor Of Leased Equipment CG 20 29 Additional Insured - Grantor Of Franchise CG 20 30 Oil Or Gas Operations - Nonoperating, Working Interests CG 20 31 Additional Insured - Engineers, Architects Or Surveyors CG 20 32 Additional Insured - Engineers, Architects Or Surveyors Not Engaged By The Named Insured CG 20 33 Additional Insured - Owners, Lessees Or Contractors -Automatic Status When Required In Construction Agreement With You CG 20 34 Additional Insured - Lessor Of Leased Equipment -Automatic Status When Required In Lease Agreement With You CG 20 35 Additional Insured - Grantor Of Licenses - Automatic Status When Required By Licensor CG 20 36 Additional Insured - Grantor Of Licenses CG 20 37 Additional Insured - Owners, Lessees Or Contractors - Completed Operations CG 20 38 Additional Insured - Owners, Lessees Or Contractors - Automatic Status For Other Parties When Required In Written Construction Agreement These endorsements are revised to remove the phrase "shown in the Declarations" in order to account for limits of insurance that may be available under an endorsement attached to the Policy. Some endorsements include other minor editorial revisions. These changes result in no impact on coverage. CG 21 01 Exclusion - Athletic Or Sports Participants CG 22 71 Colleges Or Schools (Limited Form) CG 22 72 Colleges Or Schools These endorsements are revised: So that negligent supervision -related language will apply to the participation or practicing of any sports or athletic contests, and To replace "while" with "arising out of in relation to the phrase "practicing for or participatinc can be revealed at a time later than the related practice or participation. w.k rM� _ riEV1EV.Ep6 MCRW®ar. © Includes copyrighted material of Insurance Services Office, Inc., wi SDM-1040 (Ed. 12119) (Page 14 of 15) """" 9e tO 1Ntle S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 These revisions are a reinforcement of original coverage intent and have no impact on coverage. CG 21 37 Exclusion - Employees And Volunteer Workers As Insureds CG 21 66 Exclusion - Volunteer Workers These endorsements are revised to provide for consistency with wording in other forms and are a clarification of coverage intent. CG 21 41 Exclusion - Intercompany Products Suits This endorsement is revised to include the term "suit" within the endorsement, for consistency with language used in the new cross suits liability exclusion endorsements and is a clarification of coverage intent. CG 22 65 Optical And Hearing Aid Establishments This endorsement is revised to replace "including" with "the following" in the Insuring Agreement provision and other editorial revisions. This is a reinforcement of coverage intent and has no impact on coverage. CG 24 04 Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) This endorsement is revised to address various situations where the insured has agreed to waive its right of recovery against another person or organization and adds a provision to reinforce that the waiver of the insurer applies only to the extent that the insured has waived its right of recovery, and that the insured's waiver occurred prior to loss. Other editorial revisions have also been made. These changes have no impact on coverage. CG 24 53 Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) - Automatic When this endorsement is attached to your policy, it will automatically waive the insurer's right of recovery on a blanket basis to the extent the insured has waived its right of recovery in a written contract or agreement. Attachment of this endorsement does not impact coverage. CG 99 09 Premium Audit Noncompliance Charge When this endorsement is attached to your policy, it may apply a premium audit noncompliance charge and/or a reassessment charge if you do not cooperate with a premium audit at the end of the policy period as provided in the Premium Audit Condition in your policy. Attachment of this endorsement does not impact coverage, but this may incur additional charges if you fail to cooperate with a premium audit. Rik Afvgeeod0iolm Ink _ NenEwID6/rrxw®B'" ©includes copyrighted material of Insurance Services Office, Inc., wi _ p dO SDM-1040 (Ed.12/19) (Page 15 of 15) S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 82 82 (Ed. 12/09) Policy No. GLP 3961460 01 ABUSE OR MOLESTATION COVERAGE FORM DECLARATIONS PAGE NAMED INSURED: BACKHAUS DANCE POLICY PERIOD: 06/03/2022 to 06/03/2023 LIMITS OF INSURANCE: Aggregate Limit $ 2,000,000 DESCRIPTION OF BUSINESS: Form of Business CORPORATION Each Abuse Limit $ 1,000,000 READ YOUR POLICY CAREFULLY, OPTIONAL COVERAGES ARE PROVIDED BY PREMIUM INSERTION. Abuse or Molestation Coverage Premium shown is payable: $ Premium $ 788 TOTAL ADVANCE PREMIUM $ 788 at inception; FORMS AND ENDORSEMENTS Applicable to this Coverage Part and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule CG 88 01 (11/85). fr<, R�6M�Sr. CG 82 82 (Ed. 12/09) (Page 1 of 1) * S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 90 83 (Ed. 06117) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - ABUSE, MOLESTATION, HARASSMENT OR SEXUAL CONDUCT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to the Exclusions section of the policy: This insurance does not apply to "bodily injury," "property damage," or "personal and advertising injury" arising out of: (a) the actual, threatened or alleged "abuse", molestation, harassment or sexual conduct by anyone of any person; or (b) the negligent: (i) employment; (ii) investigation; (iii) supervision; (iv) reporting to the proper authorities, (v) or failure to so report; (vi) retention; or (vii) referral of a person for whom any insured is or ever was legally responsible and whose conduct would be excluded by a. above. For the purpose of this endorsement: "Abuse" means: a. any actual, threatened, or alleged act, error, omission, conduct, or misconduct, that a claim or "suit" alleges to be, or to constitute, any form of abuse (including, but not limited to, elder abuse, child abuse, patient abuse, or abuse of a dependent person) under any applicable state or federal statute or regulation; and b. any actual, threatened, or alleged act, error, omission, conduct, or misconduct, of one or more of the following kinds: (1) sexual behavior, sexual conduct or misconduct, sexual assault, sexual ba sexual molestation, of or directed at a person; RWk".'g.0^1m" IRNE & APPRovID By' • Yi %au ;VM " 2uN M1Uu9ertem ClmalNde Includes copyrighted material of Insurance Services Office, Inc., with its permission. CG 90 83 (Ed. 06/17) (Page 1 of 2) S9 * 04/11/2022 * GLP 3961460 01 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (2) non -sexual assault, non -sexual battery, or non -sexual abuse, of or directed at a person; and (3) any: (i) employment; (ii) investigation; (iii) supervision; (iv) reporting to proper authorities, or failure to so report; or (v) retention in employment; of any person committing conduct or misconduct described in b.(1) or b.(2); or (vi) referral of a patient, student, parishioner, client, or person, to any other person whose conduct or misconduct is described in a., b.(1), or b.(2). Conduct or misconduct described in b.(1) through b.(3) constitutes "abuse" within the meaning of this definition regardless of whether or not it is alleged to be negligent, reckless, knowing, intentional, fraudulent, oppressive, malicious, or otherwise. This endorsement does not change any other provision of the policy. Includes copyrighted material of Insurance Services Office CG 90 83 (Ed. 06117) (Page 2 of 2) 19�kMegalmto�.alo� _ IRnrwmsnmao.�®sr '� ei� %au Prcwa« R,sk NNna9emmtClttirlle4,le Inc., with its permission. backhausdance I May 28, 2022 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 Re: Auto Insurance Requirement Dear City of Santa Ana Risk Management Division Backhausdance has intent to enter into an agreement with the City of Santa Ana. Throughout the course of this agreement, Backhausdance attests to the following: 1.Backhausdance, will not use/drive any vehicle during the course and scope of the services provided in the agreement/contract. 2. Backhausdance will not use any owned/rented/leased vehicles during the course and scope of the services provided in the agreement/contract. 3. Backhausdance consultants/independent contractors/employees utilize their personal vehicles/non-company owned, borrowed, or rented/leased vehicles for transportation to and from work and if applicable carry their own automobile insurance. By signing below, I attest that I possess the legal authority to enter into an agreement with the City of Santa Ana as well as the legal authority to attest to the statements above. If at any time it is found that Backhausdance is not adhering to any/all statements in this document and has not provided the minimum Auto liability insurance coverage of $1 million per occurrence, the contract will be considered null and void and the company will be held fully liable for any and all damages. Sincerely, Jennifer Backhaus, Artistic Director Jenny@backhausdance.org PO Box 5890, Orange, CA 92863 1 mobile: 562.335.2442 1 backhaus 1, "4aLLU<l` R � TA�� 7ou r(LTJOK Rekhti,uger,mtUmcilNtle ACOR& CERTIFICATE OF LIABILITY INSURANCE `/ DATE(MMIODIYYYY) 1 05/28/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Automatic Data Processing Insurance Agency, Inc. Automatic Data Processing Insurance Agency, Inc. AICNN 1-800-524-7024 NC No), EMAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC4 1 Adp Boulevard INSURER A: SIRIUS AMERICA INSURANCE COMPANY 36776 Roseland NJ 07068 INSURED BACKHAUS DANCE INSURER e INSURER C : INSURER D : 4365 JOHANNA AVE INSURER E : LAKEWOOD CA 90713 INSURER F: COVERAGES CERTIFICATE NUMBER: 2476103 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR INSD MD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYVY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ PREMISES Ea ocmmmme $ MED EXP(My one person) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jEO F I LOC OTHER: GENERALAGGREGATE $ PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person( $ BODILY INJURY (Par acci) tlent $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY OFFICERIMEM ER EXCLUDED?ECUTIVE YIN (Mandatory in NH) gym. deembe under DESCRIPTION OF OPERATIONS below NIA N WC8094600 09/07/2021 09/07/2022 OTH- STATUTE ER EL EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Santa Ana, Attn: Risk Management Division 20 Civic Center Plaza, 4th floor Santa Ana CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4�,d„o Wale Mro�gewdDlvYcn �%icarex ©1988.2015 ACORD C(R"""""'9e"""ae"�A'"� ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD v `0 NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Backhaus Dance Name: Project N-2021-250-02 Number: Second Amendment To Agreement With Jennifer Backhaus Project DBA Backhaus Dance For Provision Of Ballet And Creative Name: Movement Classes The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE ABUSE & MOLESTATION GLP3961460 06/03/2024 05/03/2023 Backhaus- Santa Ana.pdf Auto Liability (Non-Use Agreement) AUTOMOBILE LIABILITY WAIVER 05/31/2024 06/02/2023 Request for Waiver_Fillable (2).pdf GENERAL LIABILITY GLP3961460 06/03/2024 05/03/2023 Backhaus- Santa Ana.pdf WORKERS COMPENSATION AND WC8094601 09/07/2023 05/31/2023 Certificate_WC8094601_3041136.pdf EMPLOYERS' LIABILITY Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 6/2/2023 5:38 PM