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HomeMy WebLinkAboutSTETSON ENGINEERS, INC. (5)INSURANCE ON FILE WOR MAY PROCEED UNTIL INSURANCE EXPIRES 2,8 Z3 CLEP.K OF COUNCIL DATE: N MAYOR ® Valerie Amezcua N MAYOR PRO TEM Jessie Lopez - -_ COUNCILMEMBERS I rt Phil Bacema Johnathan Ryan Hernandez _ d David Penaloza Thai Viet Phan Benjamin Vazquez CITY OF SANTA ANA PUBLIC WORKS AGENCY ✓ 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 www.santa-ana.orn March 31, 2023 Stetson Engineers, Inc. 861 Village Oaks Drive, Suite 100 Covina, CA 91724 Attn: Stephen B. Johnson, P.E., President N-2021-097-01 CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CITY CLERK Jennifer L. Hall Re: Extension of Agreement (N-2021-097) for Consumer Confidence Report Services Dear Mr. Johnson: Pursuant to Section 3 ("Term") of the above -referenced Agreement, entered into by Stetson Engineers, Inc., and the City of Santa Ana, dated May 1, 2021, the time period of the Agreement is hereby extended for an additional one-year period, from May 1, 2023 through April 30, 2024. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, c Saba, P.E. Executive Director, Public Works Agency CITY OF SANTA ANA ! Kristine Ridge City Manager ATTEST Je ' er L. al erk APPROVED AS TO FORM STETSON ENGWEEI INC. ,J6nathan T. Martine ephen B. Johnson Assistant City Attorney Presidcnt/CEO/CF SANTA ANA CITY COUNCIL VaIe6e N... J afi. Lopez ThaNkl Phan eenymm vacua Phu Ei JGhna9han Ryan Hemandez DzNd Penalpze Mayor Mayor Pm Tam, W.3 W"I hit W.04 Wahl6 Ward6 v rme®zanm.3na nm t"NOWxwsanM ere mwn@sanw.eDa.naJ Vets ®sw,. ^aem ewm sanuada.am Iad611YaY16G��9W9�Od.Pls a aflaioza®sima"awdn I on Fierson �,y,. 0', , „7", Data: zazz.m.os n:0�nl -m'ooSTETS-1 ACORD" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 06/20/2022 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 ro- Rhonda Buck rance Services I Moorpark Avenue, #104 Jose, CA 95117 ro Agents&Brokers Ins Sery Ste. K Allmerica Financial Ins Ins Co#22306 CnvPPAr:FC rFRTIFICATF NI IMRFR- RFVISION NUMRFR- 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 ADOL Wvn SUB R� POLICY NUMBER POLICY EFF POLICY EXP _ LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE occuR OZFD95532203 07/0112022! 07/01/2023 EACH OCCURRENCE 11000,000 DAMAGE TO RENTED $ 300,000 MED EXP An one arson _ S 10,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PE€T LOC OTHER: PERSONAL&ADV INJURY g 1,000,000 GENERAL AGGREGATE $ 2,000,000 _ PRODUCTS - COMPIOP AGG 2,000,000 C AUTOMOBILE LIABILITY X ANY AUTO ED AUTOpSyUyLEOp AUTOOS ONLYN X AUTOS ONLY AUTOS ONLY 'AWFD95530603 07/01/2022 07/01/2023 COMBINED SINGLE LIMIT $ 1,0001000 BODILY INJURY Par arson BODILY INJURY Per aaitlent $ Llaconidenl AMAGE _, $ A UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE OZFD95532203 07101/2022'107101/2023 EACH OCCURRENCE 3,000,000 X AGGREGATE _ $ 3,000,000 DED I X I RETENTION$ O'. D WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY Y/N� ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED] n (Mandatory In NH) I(yes, tlesaibe under DES RIPTI N FOPERATIONSbL_ ! !NIA WDFD92893203 i07/01/2022 07/01/2023 PER OTH- _X:STRTS EL EACH ACCIDENT _ $ 1,000,000 E.L. DISEASE, EA EMPLOYEE $ 1,000,000 E. L. DISEA E -POLICY LIMIT 1,000,000 B Professional Liab. Deductible $50,000 USS2232978 07/01/2022 i 07/01/2023 Ea. Claim Aggregate 2,000,000 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLE$ (ACORD 101, AddlUanal Remarks Schedule, may be attached If more space Is required) SEE ATTACHED ADDENDUM. 30 day notice of cancellation except 10 days when for nonpayment of premium. RE: N-2021-097 CITY-15 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Santa THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ana ACCORDANCE WITH THE POLICY PROVISIONS. Risk Mgmt Division 20 Civic Center Plaza 4th Fir AUTHORIZED REPRESENTATIVE RIAM..g.jduw� Santa Ana, CA 92701 RENEY/ED&AFF\ _ �fC AUUKU Z5 (2U1e/U3) ©1988-2015 ACORD CC -- The ACORD name and logo are registered marks of ACORD NOTEPAD. HOLDER CODE CITY-15 STETS-1 PAGE 2 INSURED'S NAME Stetson Engineers, Inc. OP ID: RB Data 06120=22 City of Santa Ana its officers, employees, agents and representatives are additional insured with primary. coverage and waiver of subrogation as required by written contract with respect to operations of the named insured per form 3911006, 4610478, BP0497 4610478 S 4610155 attached. Waiver of subrogation per attached WC040366. MAM.gg tDiWAm Rrme 6Arrawm Em aakrWa.dye„arcem�iaa� THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESSOWNERS LIABILITY SPECIAL BROADENING ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SUMMARY OF COVERAGES Limits Page 1. Additional Insured by Contract, Agreement or Permit Included 1 2. Additional Insured - Broad Form Vendors Included 2 3. Alienated Premises Included 3 4. Broad Form Property Damage - Borrowed Equipment, Customers Goods and Use of Elevators Included 3 5. Incidental Malpractice (Employed Nurses, EMT's and Paramedics) Included 3 6. Personal and Advertising Injury - Broad Form Included 4 7. Product Recall Expense Included 4 Product Recall Expense Each Occurrence Limit $25.000 Occurrence 5 Product Recall Expense Aggregate Limit $50,000 Aggregate 5 Product Recall Deductible $500 5 B. Unintentional Failure to Disclose Hazards Included 6 9. Unintentional Failure to Notify Included 6 This endorsement amends coverages provided under the Businessowners Coverage Form through new coverages and broader coverage grants. This coverage is subject to the provisions applicable to the Businessowners Coverage Form, except as provided below. The following changes are made to SECTION II - (2) Premises you own, rent, lease or LIABILITY: occupy; or 1. Additional Insured by Contract, Agreement or (3) Your maintenance, operation or use of Permit equipment leased to you. The following is added to SECTION II - b. The insurance afforded to such additional LIABILITY, C. Who Is An Insured: insured described above: Additional Insured by Contract, Agreement or (1) Only applies to the extent permitted by Permit law; and a. Any person or organization with whom you (2) Will not be broader than the insurance agreed in a written contract, written which you are required by the contract, agreement or permit to add such person or agreement or permit to provide for such organization as an additional insured on additional insured. your policy is an additional insured only with (3) Applies on a primary basis if that is respect to liability for 'bodily injury", required by the written contract, written property damage", or 'personal and agreement or permit. advertising injury' caused, in whole or in part, by your acts or omissions, or the acts (4) Will not be broader than coverage or omissions of those acting on your behalf, provided to any other insured. but only with respect to: (5) Does not apply if the "bodily injury", (1) "Your work" for the additional insured(s) "property damage" or "personal and designated in the contract, agreement or advertising injuryis otherwise excluded permit; from coverage unc' including any endc /�■ ��. Ren 6 A P m Br. I 391-1006 as 16 Includes copyrighted materials of Insurance Services Offices, Inc., with its permissi pukMn,genen aauiaae c. This provision does not apply: (1) Unless the written contract or written agreement was executed or permit was issued prior to the "bodily injury", "property damage", or "personal injury and advertising injury'. (2) To any person or organization included as an insured by another endorsement issued by us and made part of this Coverage Part. (3) To any lessor of equipment: (a) After the equipment lease expires; or (b) If the "bodily injury', "property 2. damage", "personal and advertising Injury' arises out of sole negligence of the lessor. (4) To any: (a) Owners or other interests from whom land has been leased if the "occurrence" takes place or the offense is committed after the lease for the land expires; or (b) Managers or lessors of premises if: (1) The "occurrence" takes place or the offense is committed after you cease to be a tenant in that premises; or (II) The "bodily injury', "property damage", "personal injury" or "advertising injury" arises out of structural alterations, new construction or demolition operations performed by or on behalf of the manager or lessor. (5) To "bodily injury', "property damage" or "personal and advertising injury" arising out of the rendering of or the failure to render any professional services. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage" or the offense which caused the "personal and advertising injury" involved the rendering of or failure to render any professional services by or for you. d. With respect to the insurance afforded to these additional insureds, the following is added to SECTION II - LIABILITY, D. Liability and Medical Expense Limits of Insurance: 4 Hanover Insurance Group_ OZF D955322 5701761 The most we will pay on behalf of the additional insured for a covered claim is the lesser of the amount of insurance: 1. Required by the contract, agreement or permit described in Paragraph a.; or 2. Available under the applicable Limits of Insurance shown in the Declarations. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations 6. All other insuring agreements, exclusions, and conditions of the policy apply. Additional Insured - Broad Form Vendors The following is added to SECTION 11 - LIABILITY, C. Who Is An Insured: Additional Insured - Broad Form Vendors a. Any person or organization that is a vendor with whom you agreed in a written contract or written agreement to include as an additional insured under this Coverage Part is an insured, but only with respect to liability for "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. b. The insurance afforded to such vendor described above: (1) Only applies to the extent permitted by law; (2) Will not be broader than the insurance which you are required by the contract or agreement to provide for such vendor; (3) Will not be broader than coverage provided to any other insured; and (4) Does not apply if the "bodily injury", "property damage" or "personal and advertising injury" is otherwise excluded from coverage under this Coverage Part, including any endorsements thereto c. With respect to insurance afforded to such vendors, the following additional exclusions apply: The insurance afforded to the vendor does not apply to: (1) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reasons of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the insured would have in the absence of the contract or agreement; (2) Any express warranty unauthorized by you; RukMmgq tD� Rene &A,PPRwm BY. 391-1006 08 16 Includes copyrighted materials of Insurance Services Offices, Inc., with its permiss R'. aee, tCl ,4,iade (3) Any physical or chemical change in the product made intentionally by the vendor; (4) Repackaging, unless unpacked solely for the purpose of Inspection, demonstration, testing, or the substitution of parts under instruction from the manufacturer, and then repackaged in the original container; (5) Any failure to make such inspection, 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 sale of the product; (6) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; (7) 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; (8) "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to -- (a) The exceptions contained within the exclusion in subparagraphs (4) or (6) above; or (b) 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. The most we will pay on behalf of the vendor for a covered claim is the lesser of the amount of insurance: 1. Required by the contract or agreement described in Paragraph a.; or 2. Available under the applicable Limits of Insurance shown in the Declarations; This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 3. Alienated Premises SECTION II - LIABILITY, B. Exclusions, 1. Applicable To Business Liability Coverage k. Damage to Property, paragraph (2) is replaced by the following: (2) Premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises and occurred from hazards that were known by you, or should have reasonably been known by you, at the time the property was transferred or abandoned. 4. Broad Form Property Damage - Borrowed Equipment, Customers Goods, Use of Elevators a. The following is added to SECTION II - LIABILITY, B. Exclusions, 1. Applicable To Business Liability Coverage, k. Damage to Property: Paragraph (4) does not apply to "property damage" to borrowed equipment while at a jobsite and not being used to perform operations. Paragraph (3), (4) and (6) do not apply to "property damage" to "customers goods" while on your premises nor to the use of elevators. b. For the purposes of this endorsement, the following definition is added to SECTION II - LIABILITY, F. Liability and Medical Expenses Definitions: (9) "Bodily injury" or "property damage" 1. "Customers goods" means property of arising out of an "occurrence" that took your customer on your premises for the place before you have signed the purpose of being: contract or agreement with the vendor. a. Worked on; or (10)To any person or organization included b. Used in your manufacturing process, as an insured by another endorsement c. The insurance afforded under this provision is issued by us and made part of this excess over any other valid and collectible Coverage Part. property insurance (including deductible) (11)Any insured person or organization, available to the insured whether primary, from whom you have acquired such excess, contingent or on any other basis. products, or any ingredient, part or container, entering into, accompanying 5. Incidental Malpractice - Employed Nurses, EMT's or containing such products. and Paramedics d. With respect to the insurance afforded to SECTION II - LIABILITY, C. Who Is An Insured these vendors, the following is added to paragraph 2.a.(1)(d) does not apply to a nurse, SECTION II - LIABILITY, D. Liability and Medical Expense Limits of Insurance: RukM mga tw.;,im `./ ■ , �;. REv 6APVBw07 By. Tau 391-1006 08 16 Includes copyrighted materials of Insurance Services Offices, Inc., with its permissi rsmkn �e rza� naae Hanover Insurance Group_ OZF D955322 5701761 emergency medical technician or paramedic o. Recall of Products, Wont or Impaired employed by you if you are not engaged in the Property is replaced by the following: business or occupation of providing medical, o. Recall of Products, Work or Impaired paramedical, surgical, dental, x-ray or nursing Property services. 6. Personal Injury -Broad Form Inju Damages claimed for any loss, cost or expense incurred byyou or others for a. SECTION II - LIABILITY, B. Exclusions, 2. the loss of use, withdrawal, recall, Additional Exclusions Applicable only to inspection, repair, replacement, "Personal and Advertising Injury`, paragraph adjustment, removal or disposal of: e. is deleted. ( "Your product"; b. SECTION II - LIABILITY, F. Liability and (22) ) "Your work"; or Medical Expenses Definitions, 14. "Personal and advertising injury", paragraph b. is (3) "Impaired property"; replaced by the following: If such product, work or property is b. Malicious prosecution or abuse of withdrawn or recalled from the market or process. from use by any person or organization c. The following is added to SECTION II - because of a known or suspected defect, LIABILITY, F. Liability and Medical Expenses deficiency, inadequacy or dangerous Definitions, Definition 14. "Personal and condition in it, but this exclusion does advertising injury": not apply to "product recall expenses" that you incur for the "covered recall" of "Discrimination" (unless insurance thereof is "your product". prohibited by law) that results in injury to the However, the exception to the exclusion feelings or reputation of a natural person, "discrimination" does not apply to "product recall but only if such is: expenses" resulting from: (1) Not done intentionally by or at the (4) Failure of any products to accomplish direction of: their intended purpose; (a) The insured; (5) Breach of warranties of fitness, (b) Any officer of the corporation, quality, durability or performance; director, stockholder, partner or member of the insured; and (6) Loss of customer approval, or any cost incurred to regain customer (2) Not directly or indirectly related to an approval; employee", not to the employment, (7) Redistribution or replacement of prospective employment or termination your product" which has been of any person or persons by an insured. recalled by like products or d. For purposes of this endorsement, the substitutes; following definition is added to SECTION It - (6) Caprice or whim of the insured; LIABILITY, F. Liability and Medical Expenses Definitions: (9) A condition likely to cause loss of 1. "Discrimination" means the unlawful which any insured knew or had treatment of individuals based upon race, reason to know at the inception of color, ethnic origin, gender, religion, age, this insurance; or sexual preference. "Discrimination" (10)Asbestos, including loss, damage or does not include the unlawful treatment clean up resulting from asbestos or of individuals based upon developmental, asbestos containing materials; or physical, cognitive, mental, sensory or (11)Recall of "your products" that have emotional impairment or any no known or suspected defect solely combination of these. because a known or suspected e. This coverage does not apply if liability defect in another of "your products" coverage for "personal and advertising has been found. injury" is excluded either by the provisions of b. The following is added to SECTION II - the Coverage Form or any endorsement LIABILITY, C. Who Is An Insured, paragraph thereto. 3.b.: 7. Product Recall Expense "Product recall expense" arising out of any a. SECTION II - LIABILITY, B. Exclusions, 1. withdrawal or recall that occurred before you Applicable To Business Liability Coverage, acquired or formed the organization. wd, MArag.1 D,� �S( 1L7ou au,_a" 391-100666 16 Includes copyrighted materials of Insurance Services Offices, Inc., with its permissi rs xmaoa9ere,.a� iaae c. The following is added to SECTION II - of a deductible amount, you shall LIABILITY, D. Liability and Medical Expenses promptly reimburse us for the part of the Limits of Insurance: deductible amount we paid. Product Recall Expense Limits of Insurance The Product Recall Expense Limits of a. The Limits of Insurance shown in the Insurance apply separately to each SUMMARY OF COVERAGES of this consecutive annual period and to any endorsement and the rules stated below remaining period of less than 12 months, fix the most that we will pay under this starting with the beginning of the policy Product Recall Expense Coverage period shown in the Declarations, unless the regardless of the number of: policy period is extended after issuance for an additional period of less than 12 months. (1) Insureds; In that case, the additional period will be (2) "Covered Recalls" initiated; or deemed part of the last preceding period for (3) Number of "your products" the purposes of determining the Limits of withdrawn. Insurance. b. The e Product Recall Expense Aggregate d. The following is added to SECTION II - is the most that we will reimburse LIABILITY, E. Liability and Medical Expense you for the sum of all "product recall General Conditions, 2. Duties in the Event of expenses" incurred for all "covered Occurrence, Offense, Claim or Suit: recalls" initiated during the policy period. You must see to it that the following are c. The Product Recall Each Occurrence done in the event of an actual or anticipated Limit is the most we will pay in covered recall" that may result in "product connection with any one defect or recall expense : deficiency. (1) Give us prompt notice of any discovery d. All "product recall expenses" in or notification that "your product" must connection with substantially the same be withdrawn recalled. Includeour "your general harmful condition will be description product" and the deemed to arise out of the same defect reason for thea withdrawal or recall; or deficiency and considered one (2) Cease any further release, shipment, "occurrence". consignment or any other method of e. Any amount reimbursed for "product distribution of like or similar products recall expenses" in connection with any until it has been determined that all one "occurrence" will reduce the amount such products are free from defects that of the Product Recall Expense Aggregate could be a cause of loss under this Limit available for reimbursement of insurance. "product recall expenses" in connection e. For the purposs of this endorsement, the with any other defect or deficiency. following definitions are added to SECTION f. If the Product Recall Expense Aggregate II - LIABILITY, F. Liability and Medical Limit has been reduced by Expenses Definitions: reimbursement of "product recall 1. "Covered recall" means a recall made expenses" to an amount that is less than necessary because you or a government the Product Recall Expense Each body has determined that a known or Occurrence Limit, the remaining suspected defect, deficiency, Aggregate Limit is the most that will be inadequacy, or dangerous condition in available for reimbursement of "product "your product' has resulted or will result recall expenses" in connection with any in "bodily injury" or "property damage". other defect or deficiency. 2. "Product recall expense(s)" means: g. Product Recall Deductible a. Necessary and reasonable expenses We will only pay for the amount of for: "product recall expenses" which are in (1) Communications, including radio excess of the $500 Product Recall or television announcements or Deductible. The Product Recall printed advertisements including Deductible applies separately to each stationary, envelopes and "covered recall". The limits of insurance postage; will not be reduced by the amount of this deductible. We may, or will if required by law, pay all or any part of any deductible amount, if applicable. Upon notice of our payment Rw to Rsnt &AmcB By. 391-1006 08 16 Includes copyrighted materials of Insurance Services Offices, Inc., with its permissi --�— rs�xr�oage,,,.,ear�iane (2) Shipping the recalled products from any purchaser, distributor or user to the place or places designated by you; (3) Remuneration paid to your regular "employees" for necessary overtime; (4) Hiring additional persons, other than your regular "employees"; (5) Expenses incurred by"employees" including transportation and accommodations; (6) Expenses to rent additional warehouse or storage space; (7) Disposal of "your product, but only to the extent that specific methods of destruction other than those employed for trash discarding or disposal are required to avoid "bodily injury" or "property damage" as a result of such disposal, you incur exclusively for the purpose of recalling "your product"; and b. Your lost profit resulting from such "covered recall". f. This Product Recall Expense Coverage does not apply: me Hanover Insurance Group - OZF D955322 5701761 (1) If the "products - completed operations hazard" is excluded from coverage under this Coverage Part including any endorsement thereto; or (2) To "product recall expense" arising out of any of "your products" that are otherwise excluded from coverage under this Coverage Part including endorsements thereto. S. Unintentional Failure to Disclose Hazards The following is added to SECTION II - LIABILITY, E. Liability and Medical Expenses General Conditions: Representations We will not disclaim coverage under this Coverage Part if you fail to disclose all hazards existing as of the inception date of the policy provided such failure is not intentional. 9. Unintentional Failure to Notify The following is added to SECTION II - LIABILITY, E. Liability and Medical Expenses General Conditions, 2. Duties in the Event of Occurrence, Offense, Claim or Suit: Your rights afforded under this Coverage Part shall not be prejudiced if you fail to give us notice of an "occurrence", offense, claim or "suit", solely due to your reasonable and documented belief that the "bodily injury", "property damage" or "personal and advertising injury" is not covered under this Policy. ALL OTHER TERMS, CONDITIONS, AND EXCLUSIONS REMAIN UNCHANGED. 391-1006 08 16 Includes copyrighted materials of Insurance Services Offices, Inc., with its permissi o'\ y M...galrnl Dtvieion RtnE�wfm&ApmP BY: Riau /OTC P,M-o4 Ruk Manage,rcvn ClcTical Aide OTHER INSURANCE - PRIMARY AND NON-CONTRIBUTORY (ADDITIONAL INSURED) ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM The following is added to SECTION III — COMMON POLICY CONDITIONS: M. Other Insurance 1. Additional Insureds If you agree in a written contract, written agreement or permit that the insurance provided to any person or organization included as an Additional Insured under SECTION II - LIABILITY, Part C — Who is An Insured, is primary and non-contributory, the following applies: If other valid and collectible insurance is available to the Additional Insured for a loss we cover under SECTION II — LIABILITY, Part A. Coverages, Paragraph 1., Business Liability our obligations are limited as follows: a. Primary Insurance This insurance is primary to other insurance that is available to the Additional Insured which covers the Additional Insured as a Named Insured. We will not seek contribution from any other insurance available to the Additional Insured except: (1) For the sole negligence of the Additional Insured; (2) When the Additional Insured is an Additional Insured under another primary liability policy; or (3) When b.(2) below applies. If this insurance is primary, our obligations are not affected unless any of the other insurance is also primary. Then, we will share with all that other insurance by the method described in b.(3) below. b. Excess Insurance This insurance is excess over: (1) Any of the other insurance, whether primary, excess, contingent or on any other basis: (a) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for "your work'; (b) That is Fire insurance for premises rented to the Additional Insured or temporarily occupied by the Additional Insured with permission of the owner; (c) That is insurance purchased by the Additional Insured to cover the Additional Insured's liability as a tenant for "property damage" to premises rented to the Additional Insured or temporarily occupied by the Additional Insured with permission of the owner; or (d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of SECTION II — LIABILITY, Part A. Coverages, 1. Business Liability. When this insurance is excess, we will have no duty under SECTION II — LIABILITY, Part A. Coverages, 1. Business Liability to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". 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: (2) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (3) 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 thi provision and was to apply in excess c Rb4Mv.gowtt Ad 391-1331 06 09 Includes copyrighted material of Insurance Services Offices, Inc., with its permissior Dmdm _ RE`AEW<D6 MPRaVeJ BY: •� ai. lll 111��'Ruk ' %asi �rca.en - Ma,ugemm[CImmlAitle 01 Insurance shown in the Declarations of this Coverage Part. c. Method Of Sharing If all of 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 of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. Ridt7Wrugorint on+vcn �&ne�os MraoJEn Br +.. ' 7au raitz.eu �. 391-1331 06 09 Includes copyrighted material of Insurance services Offices, Inc., with its permission THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE" Name Of Person Or Organization: AS REQUIRED BY WRITTEN CONTRACT Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Paragraph K. Transfer Of Rights Of Recovery Against Others To Us in Section III - Common Pol- icy Conditions is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing op- erations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. BP 04 97 07 02 Copyright, ISO Properties, Inc., 2001 mk Muugm[m,t DitBian Rnt�wfm&A"Rw Br. DMISM �Rizk Nljivgemm[Clmral Aitle Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART A. The following is added to SECTION II - LIABILITY COVERAGE, Paragraph A.1. Who Is An Insured: Additional Insured if Required by Contract If you agree in a written contract, written agreement or written permit that a person or organization be added as an additional "Insured" under this Coverage Part, such person or organization is an "insured"; but only to the extent that such person or organization qualifies as an "insured" under paragraph A.1.c. of this Section. If you agree in a written contract, written agreement or written permit that a person or organization be added as an additional "insured" under this Coverage Part, the most we will pay on behalf of such additional "insured" is the lesser of: (1) The Limits of Insurance for liability coverage specified in the written contract, written agreement or written permit; or (2) The Limits of Insurance for Liability Coverage shown in the Declarations applicable to this Coverage Part. Such amount shall be part of and not in addition to the Limits of Insurance shown in the Declarations applicable to this Coverage Part. Regardless of the number of covered "autos", "Insureds", premiums paid, claims made or vehicles involved in the "accident", the most we will pay for the total of all damages and "covered pollution cost or expense" combined resulting from any one "accident" is the Limit of Insurance for Liability Coverage shown in the Declarations. B. The following is added to SECTION IV - BUSINESS AUTO CONDITIONS, Paragraph B. General Conditions, subparagraph 5. Other Insurance: Primary and Non -Contributory If you agree in a written contract, written agreement or written permit that the insurance provided to a person or organization who qualifies as an additional "insured" under SECTION II - LIABILITY COVERAGE, Paragraph A.I. Who Is An Insured, subparagraph Additional Insured if Required by Contract is primary and non-contributory, the following applies: The liability coverage provided by this Coverage Part is primary to any other insurance available to the additional "insured" as a Named Insured. We will not seek contribution from any other insurance available to the additional "insured" except: (1) For the sole negligence of the additional "Insured": or (2) For negligence arising out of the ownership, maintenance or use of any "auto" not owned by the additional "insured" or by you, unless that "auto" is a "trailer" connected to an "auto" owned by the additional "insured" or by you; or (3) When the additional "insured" is also an additional "insured" under another liability policy. C. This endorsement will apply only if the "accident" occurs: 1. During the policy period; 2. Subsequent to the execution of the written contract or written agreement or the issuance of the written permit; and 3. Prior to the expiration of the period of time that the written contract, written agreement or written permit requires such insurance to be provided to the additional "insured". D. Coverage provided to an additional "insured" will not be broader than coverage provided to any other "insured" under this Coverage Part. ALL OTHER TERMS, CONDITIONS, AND EXCLUSIONS REMAIN UNCHANGED. 461-0478 12 12 Includes copyrighted material of ISO Insurance Services Office, Inc., with its permissio uil wJ Mwga Dfw(m Rene &A"Rwm6Y: 11 I l' unnatim 767e Peevoo _o_R,,k �ge, Famoiwde m� Hanover Jnsura! , Group_ AWFD955306 5701761 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE BROADENING ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. 1. CANCELLATION EXTENSION Paragraph A. CANCELLATION 2. b. of the COMMON POLICY CONDITIONS is replaced with the following: b. 60 days before the effective date of cancellation if we cancel for any other reason. SECTION I - COVERED AUTOS 2. EMPLOYEE HIRED "AUTOS" Description Of Covered Auto Designation Symbols; Symbol 8 is replaced by the following: 8 = Hired "Autos" Only - Only those "autos" you lease, hire, rent or borrow: including "autos" your employee hires at your direction, for the purpose of conducting your business. This does not include any "auto" you lease, hire, rent, or borrow from any of your "employees" or partners or members of their households. SECTION II - LIABILITY COVERAGE 3. BROADENED NAMED INSURED The following is added to the SECTION II - LIABILITY COVERAGE, Paragraph 1. Who Is An Insured provision: d. Any business entity for which you have a financial interest greater than 50% of the voting stock or otherwise have a controlling interest after the effective date of this policy or that is newly acquired or formed by you during the term of this policy. The coverage provided by this provision is afforded until expiration or termination of this policy, whichever occurs earlier. The coverage provided by this provision does not apply to any business entity described in d. above that qualifies as an insured under any other automobile liability policy issued to that business entity as a named insured or would have been an insured except for the exhaustion of the policy limits or the insolvency of the insurer. The coverage provided by this provision does not apply to "bodily injury" nor "property damage" arising from an accident that occurred prior to your acquiring or forming the business entity described in d. above. Risk MawganmtOM1i . Rent 6 Apvq By. Includes copyrighted material of Insurance Services Office, Inc. with its ps `( 7cz<P coo Copyright, Insurance Services Office, Inc., 1996 461-0155 (9-97) 4. EMPLOYEES AS INSUREDS The following is added to the SECTION II - LIABILITY COVERAGE, Paragraph 1. Who Is An Insured provision: e. Any employee of yours is an "insured" while using a covered "auto" you do not own, hire or borrow in your business or your personal affairs. 5. SUPPLEMENTARY PAYMENTS The following amends SECTION II - LIABILITY COVERAGE, Paragraph 2. Coverage Extensions provision: Paragraph (2) is replaced by the following: (2) Up to $2500 for cost of bail bonds (including bonds for related traffic law violations) required because Of an "accident" we cover. We do not have to furnish these bonds. Paragraph (4) is replaced by the following: (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work. 6. AMENDED FELLOW EMPLOYEE EXCLUSION The following is added to the SECTION II - LIABILITY COVERAGE, B. Exclusions Paragraph 5. Fellow Employee exclusion: This exclusion does not apply if the "bodily injury" arises from the use of a covered "auto" you own or hire. This coverage is excess over any other collectible insurance SECTION III - PHYSICAL DAMAGE COVERAGE. 7. EXPENSE OF RETURNING A STOLEN "AUTO" and SIGN COVERAGE The following is added to SECTION III - PHYSICAL DAMAGE COVERAGE, A.1. COVERAGE: d. Expense Of Returning A Stolen "Auto" We will pay for the expense of returning a covered "auto" to you. e. Sign Coverage We will pay for loss to signs, murals, paintings or graphics, as part of equipment, which are displayed on a covered "auto". The most we will pay for "loss" in any one "accident" is the lesser of: 1. The actual cash value of the property as of the time of the "loss"; or 2. The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality; or 3. $2,000. 8. GLASS BREAKAGE DEDUCTIBLE The following is added to SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE paragraph 3. Glass Breakage - Hitting a Bird or Animal - Falling Objects or Missiles: Any deductible shown in the Declarations as applicable to the Includes copyrighted material of Insurance Services Office, Inc. with its pe �&Amo Copyright, Insurance Services Office, Inc., 1996 461-0155(9-97) �ftkMn,,e ,Cfe.lPde ` The Hanover Insurance Group_ AWFD955306 5701761 covered "auto" will not apply to glass direction, for the purpose of breakage if such glass is repaired, conducting your business, for a rather than replaced. period of 30 days or less, of like kind and use as the "autos" you 9. TRANSPORTATION EXPENSE own, subject to the following: Paragraph 4. Coverage Extension. of The most we will pay for any one SECTION III - PHYSICAL DAMAGE loss is the lesser of the following: COVERAGE, A. COVERAGE is replaced with the following: a. $50.000 per accident, or b. cash value, or 4. Coverage Extension c. the cost of repair, We will pay up to $50 per day to a minus the deductible equal to the maximum of $1500 for temporary lowest deductible applicable to transportation expense incurred any owned "auto" for that by you because of the total theft of coverage. Any deductible shown a covered "auto" of the private in the Declarations does not apply passenger type. We will pay only to "loss" caused by fire or for those covered "autos" for lightning. Subject to the limit and which you carry either deductible stated above, we will Comprehensive or Specified provide coverage equal to the Causes of Loss Coverage. We will broadest coverage provided to pay for temporary transportation any covered "auto" you own, that expenses incurred during the is applicable to the loss. period beginning 24 hours after the theft and ending, regardless of If the loss arises from an accident the policy s expiration, when the for which you are legally liable covered "auto" is returned to use and the lessor incurs an actual or we pay for its "loss". financial loss from that accident, we will cover the lessor s actual 10. HIRED AUTO PHYSICAL DAMAGE financial loss of use of the hired "auto" for a period of up to seven The following is added to SECTION III - consecutive days from the date of PHYSICAL DAMAGE COVERAGE, A. the accident, subject to a limit of COVERAGE: $1,000 per accident. S. Hired Auto Physical Damage 11. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE If hired "autos" are covered "autos" for Liability Coverage and The following is added to SECTION III - if Physical Damage Coverage of PHYSICAL DAMAGE COVERAGE, A. Comprehensive, Specified Causes COVERAGE: of Loss, or Collision is provided under this Coverage Form for any 6. Audio, Visual and Data Electronic "auto" you own, then the Physical Equipment Coverage Damage Coverage(s) provided is extended to "autos" you hire We will pay for "loss" to any without a driver or your employee electronic equipment that receives hires, without a driver, at your M.regenmt o.w,� Includes copyrighted material of Insurance Services Office, Inc, with its pc ae�Ewma�r�ovme+: Copyright, Insurance Services Office, Inc., 1996 ui 7cu P&wo.r 461-0155 (9-97) a k „age ,a iaae or transmits audio, visual or data equipment is permanently signals and that is not designed installed in the covered solely for the reproduction of "auto", and sound. This coverage applies b. Permanently installed only if the equipment is in the opening of the dash permanently installed in the or console normally used covered "auto" at the time of the by the manufacturer for "loss" or the equipment is the installation of a radio. removable from a housing unit which is permanently installed in With respect to coverage herein, the covered auto at the time of the LIMIT OF INSURANCE the "loss", and such equipment is provision of PHYSICAL DAMAGE designed to be solely operated by COVERAGE is replaced by the use of the power from the "auto s" following: electrical system, in or upon the covered "auto", including its 1. The most we will pay for all antennas and other accessories. "loss" to audio, visual or data However , this does not include electronic equipment and any tapes, records or discs. accessories used with this equipment as a result of any The exclusions that apply to one "accident" is the lesser of PHYSICAL DAMAGE COVERAGE, except for the exclusion relating to a. The actual cash value of Audio, Visual and Data Electronic the damaged or stolen Equipment, also apply to coverage property as of the time of provided herein. In addition, the the "loss"; or following exclusions apply: b. The cost of repairing or replacing the damaged or We will not pay , under this stolen property with other coverage, for either any electronic property of like kind and equipment or accessories used quality; or with such electronic equipment c. $500. that is: 2. An adjustment for 1. Necessary for the normal depreciation and physical operation of the covered condition will be made in "auto" or the monitoring of determining actual cash value the covered "auto s" at the time of the "loss". operating system; or 3. Deductibles applicable to 2. Both: PHYSICAL DAMAGE COVERAGE, do not apply a. An integral part of the to this Audio, Visual and Data same unit housing any Electronic Equipment sound reproducing Coverage. equipment designed solely for the If there is other coverage provided reproduction of sound if by this policy for audio, visual and the sound reproducing data electronic equipment, the coverage provided herein is w.tM.&App awe Includes copyrighted material of Insurance Services Office, Inc. with its pe ,�6�,�By. Copyright, Insurance Services Office, Inc., 1996 7074 p4mw. 461-0155 (9-97) W Riskgent tCfM[ IAde excess. However, you may elect to apply the limit or any portion thereof of coverage provided herein to pay any deductible that is applicable under the provisions of the other coverage. 12. RENTAL REIMBURSEMENT and MATERIAL TRANSFER EXPENSE The following is added to SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE: 7. Rental Reimbursement and Material Transfer Expense This coverage provides only those Physical Damage Coverages where a premium is shown in the Declarations. It applies only to a covered "auto" described or designated to which the Physical Damage Coverages apply. We will pay for auto rental expenses and the expenses, incurred by you because of "loss" to a covered "auto", to remove and transfer your materials and equipment from the covered "auto' . Payment applies in addition to the otherwise applicable amount of each coverage you have on a covered "auto". No deductibles apply to this coverage. We will pay only for those auto rental expenses incurred during the policy period beginning 24 hours after the "loss" and ending, regardless of the policy s expiration, with the lesser of the following number of days: 1. The number of days reasonably required to repair or replace the rn� Hanover Insurance Group_ AWFD955306 5701761 covered"auto".If loss is caused by theft, this number of days is added to the number of days it takes to locate the covered "auto" and transport it to a repair shop. 2. 60 days. Our payment is limited to the lesser of the following amounts: 1. Necessary and actual expenses incurred, including loss of use. m, irr This auto rental expense coverage does not apply while there are spare or reserve "autos" available to you for your operations. If "loss" results from the total theft of a covered "auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided for under the SECTION III - PHYSICAL DAMAGE COVERAGE, A. 4. Coverage Extension. 13. AIRBAG COVERAGE The following is added to SECTION III - PHYSICAL DAMAGE COVERAGE, B. Exclusions, paragraph 3. The portion of this exclusion relating to mechanical or electrical breakdown does not apply to the accidental discharge of an airbag. This coverage is excess of other collectible insurance or warranty. No deductible applies to this Airbag Coverage. rs�tm.&Apn rm . Includes copyrighted material of Insurance Services Office, Inc. with its pE aEwEwFn6 nvvxavm sr: Copyright, Insurance Services Office, Inc., 199E�Ii' 7ou Pcaaoe 461-0155 (9-97) nkn aye nay lane 14. AUTO LOAN PHYSICAL DAMAGE EXTENSION The following is added to SECTION III - PHYSICAL DAMAGE COVERAGE, C. Limit Of Insurance provision: When a "loss" results in a total loss to a covered auto you own for which a Loss Payee is designated in this policy, the most we will pay for "loss" in any one "accident" is the greater of: 1. The actual cash value of the damaged or stolen property as of the time of the "loss": or 2. The outstanding balance of the initial loan, less any amounts for taxes, overdue payments, overdue payment charges, penalties, interest , any charges for early termination of the loan, costs for Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan, and carry-over balances from previous loans. 15. AUTO LEASE PHYSICAL DAMAGE EXTENSION The following is added to SECTION III - PHYSICAL DAMAGE COVERAGE, C. Limit Of Insurance provision: If, because of damage, destruction or theft of a covered "auto', which is a long-term leased "auto", the lease agreement between you and the lessor is terminated, "we" will pay the difference between the amount paid under paragraph C. LIMIT OF INSURANCE 1. or 2. and the amount due at the time of "loss" under the terms of the lease agreement applicable to the leased "auto" which you are required to pay: less any fees to dispose of the auto; any overdue payments; financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; security deposits not refunded by the lessor; cost for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan; and carry over balances from previous leases. This coverage applies only to the initial lease for the covered "auto" which has not previously been leased. This coverage is excess over all other collectible insurance. SECTION IV - CONDITIONS 16. DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS The following is added to SECTION IV - BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The Event Of Accident, Claim, Suit Or Loss: d. Knowledge of any "accident", claim, "suit" or "loss" will be deemed knowledge by you when notice of such "accident", claim, "suit" or "loss" has been received by: (1) You, if you are an individual; (2) Any partner or insurance manager if you are a partnership; or (3) An executive officer or insurance manager if you are a corporation. 17. BLANKET WAIVER OF SUBROGATION Paragraph 5. Transfer Of Rights Of Recovery Against Others To Us, SECTION IV - BUSINESS AUTO CONDITIONS, A. Loss Conditions is replaced by the following: Risk A4&App Division Includes copyrighted material of Insurance Services Office, Inc. with Its pE R�nex�m6 MVRwmer: Copyright, Insurance Services Office, Inc., 1996 nasz ; 7oiiP&:o„ 461 0155 (9 97) '� Risl<Managenm,ClencalAide 5. Transfer Of Rights Of Recovery Against Others To Us If any person or organization to or for whom we make payment under this Coverage Form has rights to recover damages from another, which have not been waived through the execution of an "insured contract", written agreement, or permit, prior to the "accident" or "loss" giving rise to the payment, those rights to recover damages from another are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after the "accident" or "loss" to impair them. 18. UNINTENTIONAL FAILURE TO DISCLOSE INFORMATION The following is added to SECTION IV BUSINESS AUTO CONDITIONS. B. General Conditions, paragraph 2. Concealment, Misrepresentation Or Fraud: Your unintentional error in disclosing, or failure to disclose, any material fact existing after the effective date of this Coverage Form shall not prejudice your rights under this Coverage Form. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or nonrenewal. m� Hanover Insurance Group_ AWFD965306 5701761 19. HIRED AUTO - WORLDWIDE COVERAGE The following is added to SECTION IV - Business Auto Conditions, B. General Conditions, paragraph 7. Policy Period, Coverage Territory provision: e. Outside the coverage territory described in a., b., c., and d. above for an "accident" or "loss" resulting from the use of a covered "auto" you hire, without a driver, or your employee hires without a driver, at your direction, for the purpose of conducting your business, for a period of 30 days or less, provided the suit is brought within The United States of America or its territories or possessions. SECTION V - DEFINITIONS 20. MENTAL ANGUISH Paragraph C. "Bodily injury", SECTION V - DEFINITIONS is replaced by the following: C. "Bodily injury" means bodily injury, sickness or disease sustained by a person including death or mental anguish resulting from any of these. Includes copyrighted material of Insurance Services Office, Inc. with its Copyright, Insurance Services Office, Inc., 19% 461-0155 (9-97) Ruk Mm.q ioiWlon pE 1}/� Rcvte %6APPRO BY: F�����li ic pwv&, l aisRM.�na9ennn am4,iaae 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 % due on such remuneration. of the California workers' compensation premium otherwise Schedule Person or Organization Job Description APPLIES AS BLANKET WAIVER FOR THOSE HAVING A WRITTEN CONTRACT WITH THE POLICY- HOLDER REQUIRING WOS FOR WC POLICYHOLDER EMPLOYEES. 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 7/1/2022 Polley No. W➢F-D928932-03 Endorsement No, Insured Stetson Engineers Inc. Insurance Company MASSACHUSETTS BAY INSURANCE COMP Countersigned ray WC 04 03 06 (Ed 04.84) Rid ev: Renmnt Divre e&M n�nrRovm Risk fvUnagerm.t Clenczl Ntle NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Stetson Engineers, inc. Name: Project N-2021-097-01 Number: Project Extension of Agreement (N-2021-097) for Consumer Confidence Report Name: Services 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 AUTOMOBILE LIABILITY AWFD955306 07/01/2024 05/26/2023 Sta Ana COI.pdf GENERAL LIABILITY OZFD955322 07/01/2024 05/26/2023 Sta Ana COI.pdf PROFESSIONAL LIABILITY US52333835 07/01/2024 05/26/2023 Sta Ana COI.pdf WORKERS COMPENSATION AND WDFD928932 07/01/2024 05/26/2023 Sta Ana COI.pdf EMPLOYERS' LIABILITY Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 8/3/2023 11:44 AM