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HomeMy WebLinkAboutBEGINNERS EDGE SPORTS TRAINING, LLCINSURANCE ON FILE WORK MAY PROCEED UNTIL INS, EXPIRES EXPIRES CITY CLERK DATE: APR 0 9 2024 CITY OF SANTA ANA N-2024-130 b : ? fLCS P 0 RECREATION SERVICES AGREEMENT WITH BEGINNERS EDGE SPORTS CQ�d1i f� )iA TRAINING, LLC, FOR MULTI -SPORT PROGRAMMING S . THIS AGREEMENT is made and entered into on this 21st day of March 2024, by and between Beginners Edge Sports Training, LLC, a California limited liability company ("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"). City and Provider are also referred to as "the Parties." RECITALS A. The City desires to retain a recreation service provider having special skills, resources and knowledge to provide multi -sport programming in its recreation class program. B. Provider represents that it is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that it is knowledgeable in its field and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. D. The Parties acknowledge that the City intends to provide recreational activities to the public but must balance the need to comply with all COVID-19 guidance and restrictions. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES a. Provider shall perform those services as set forth in Exhibit A to this Agreement. b. All classes operated pursuant to this Agreement for conducting recreation classes at City facilities, including parks, will comply with all applicable guidance and public health orders, including those from the Centers for Disease Control ("CDC"), California Department of Public Health ("CDPH"), the Orange County Health Care Agency ("OCHCA") and the City itself for as long as those orders and guidance remain in place. Provider will remind participants of these guidelines. To the extent that Provider needs assistance with enforcing any rules or requirements, Provider will contact a City Parks' employee or City security for assistance. c. Provider shall not attend a class or teach any class if Provider is sick or has any symptom(s) associated with COVID-19 including but not limited to, fever above 100.4, chills, cough, shortness of breath loss of taste or smell, nausea, muscle or body aches, vomiting, headache, sore throat or diarrhea. Page 1 of 10 d. Provider will not attend class or teach a class if Provider or any member of Provider's household has been asked to quarantine or self -isolate due to symptoms of COVID-19 or a positive test result for COVID-19. e. Provider acknowledges that, to the extent that City is able to and chooses to conduct classes indoors, this Agreement will also cover classes conducted at one of City's recreational centers during the term of this Agreement. f City reserves the right to change the location(s) at which the services contemplated by this Agreement are provided. g. Provider shall comply with the City's recreation classes policy manual and any other City rules and regulations regarding the operation of recreation classes. 2. COMPENSATION a. In consideration for the provision of the programs set forth in Exhibit A, City agrees to pay, and Provider agrees to accept as total payment for their services for the City, seventy percent (70%) of all gross revenue received from program participants. Total annual revenue to Provider shall not exceed Twenty -Five Thousand Dollars and Zero cents ($25,000). b. Payment to Provider shall be made monthly within thirty (30) days following completion of the last class taught by Provider the prior month, subject to City accounting procedures. City and Provider agree that all payments due and owing under this Agreement shall be made through Automated Clearing House (ACH) transfers. Provider agrees to execute the City's standard ACH Vendor Payment Authorization and provide required documentation. Upon verification of the data provided, the City will be authorized to deposit payments directly into Provider's account(s) with financial institutions. Payment need not be made for work that fails to meet the standards of performance set forth in the Recital that may reasonably be expected by the City. c. City shall be responsible for collecting all fees from program participants. Provider shall not collect fees but will refer all interested participants to City for registration information. d. Provider agrees that City shall retain thirty percent (30%) of all gross revenue received from program participants as an administrative fee. 3. TERM This Agreement shall commence on April 4, 2024 and end on March 31, 2025 unless terminated earlier in accordance with Section 14 below. The term of this Agreement may be extended for up to one (1) one-year period upon a writing executed by the City Manager and City Attorney. Page 2 of 10 4. INDEPENDENT CONTRACTOR Provider shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require subcontractors, if any, to obtain and maintain insurance, as described below, for the entire term of this Agreement, against claims for injuries to persons or damage to property which may arise from or in connection with services, products and materials supplied. Total cost of such insurance shall be borne by Provider. a. Minimum Scope and Limit of Insurance (1) Commercial General Liability (CGL). Insurance Services Office ("ISO") Forrn CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence and $2,000,000 aggregate. (2) Automobile Liability. Insurance Services Office (ISO) Form CA 00 01 covering Code 1 (any auto), with limits of no less than $1,000,000 per accident for bodily injury and property damage. In the event Provider does not maintain commercial automobile liability insurance, City will accept evidence of personal automobile insurance as compliance with this requirement. (3) Workers' Compensation. As required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. (4) Sexual Abuse or Molestation Liability (SAML). If the work will include contact with minors, and the CGL policy referenced above is not endorsed to include affirmative coverage for sexual abuse or molestation, Provider shall obtain and maintain a policy covering Sexual Abuse and Molestation with a limit of no less than $1,000,000 per occurrence or claim. (5) Broader Coverage. If the Provider maintains broader coverage and/or higher limits than the minimums shown above, the City requires and shall be entitled Page 3 of 10 to the broader coverage and/or the higher limits maintained by the Provider. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City. b. Other Insurance Provisions The above required insurance policies are to contain or be endorsed to contain the following provisions: (1) Additional Insured Status. The City, its officers, officials, employees, and volunteers are to be covered as additional insureds on the CGL policy, with respect to liability arising out of work or operations performed by or on behalf of the Provider including materials, parts, or equipment furnished in connection with such work or operations. (2) Waiver of Subrogation. Provider's insurance company(ies) agree(s) to waive all rights of subrogation against City, its City Council, its officers, officials, employees, agents, and volunteers for losses paid under the terms of any policy which arise from work performed by Provider under this Agreement. (3) Primary Coverage. For any claims related to this Agreement, Provider's insurance coverage shall be primary and any insurance maintained by City, its City Council, its officers, officials, employees, agents, or volunteers shall not contribute to it. (4) Severability. A severability of interest provision must apply for all the additional insureds, ensuring that Provider's insurance shall apply separately to each insured against whom a claim is made or suit is brought, except with respect to the Provider's limits of liability. (5) Cancellation. Insurance policy(ies) herein shall provide that coverage shall not be canceled, suspended, voided, reduced in coverage or in limits, non -renewed by the carrier, or materially changed except after thirty (30) days prior written notice has been given to City. Ten (10) days prior written notice shall be provided to City for policy cancellation or non -renewal due to non-payment. (6) Certificate Holder. The certificate holder on each evidence of insurance certificate shall be: City of Santa Ana, 20 Civic Center Plaza, Santa Ana, CA 92701. C. Acceptability of Insurers. Insurance is to be placed with insurers authorized to conduct business in the state with a current A.M. Best's rating of no less than A:VII, unless otherwise acceptable to the City. d. Verification of Coverage. Provider shall furnish the City with original Certificates of Insurance including all required amendatory endorsements (or copies of the applicable policy language effecting coverage requiredby this clause) and a copy of Page 4 of 10 the Declarations and Endorsement Page of the CGL policy listing all policy endorsements to City before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive the Provider's obligation to provide them. The City reserves the right to require complete, certified copies of all required insurance policies,including endorsements required by these specifications, at any time. e. Special Events Coverage. Special events coverage is available and can be purchased by Provider. Use this link to learn more: www.2sparta.com. £ Special Risks or Circumstances. City reserves the right to modify these requirements, including limits, based on the nature of therisk, prior experience, insurer, coverage, or other special circumstances. 6. INDEMNIFICATION Provider agrees to defend, and shall indemnify and hold harmless the City, its officers, agents, employees, Providers, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Provider or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement, to the extent that the injury, damages, just compensation, restitution, judicial or equitable relief is caused by the negligence of the Provider. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. In no case will Provider be required to indemnify or hold harmless the City from injury, damages, just compensation, restitution, judicial or equitable relief caused by the negligence of the City. 7. CONFIDENTIALITY If Provider receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Provider agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information, including but not limited to student records. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and Page 5 of 10 nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Provider disclosed in a publicly available source; (c) is in rightful possession of the Provider without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Provider without reference to information disclosed by the City. 8. COVID-19 ASSUMPTION OF RISI{ AND WAIVER Provider acknowledges that Provider could be exposed to persons that may have COVID- 19 providing services pursuant to this Agreement. Provider understands that interacting with any person currently comes with the inherent risk of exposure to COVID-19 and that COVID-19 is highly contagious. Provider assumes the risks associated with providing services pursuant to this Agreement, namely potential exposure to COVID-19. Provider acknowledges that while some people have no symptoms or mild symptoms from COVID-191 some people have become seriously ill requiring hospitalization and that some people have died from COVID-19. Provider acknowledges that persons over the age of 65 and persons with underlying health conditions are at greater risk of contracting COVID-19 and are potentially risking serious injury or death. Provider is agreeing to provide classes pursuant to this Agreement and does so of Provider's own free will. Provider intends to be legally bound by this assumption of risk, release and waiver and to bind Provider's heirs, personal representatives, next of kin and anyone who may make a claim on Provider's behalf. Provider knowingly releases and waives any and all claims that Provider may have or could have in the future and includes any claims resulting from potential exposure or actual exposure to COVID-19, this includes claims for personal injury, transmittal of COVID-19 to others, and/or wrongful death. Provider agrees to hold harmless, defend and indemnify the City, its public officials, officers, employees, volunteers, and agents from any and all claims for liability or damages, including those for exposure to or diagnosis with COVID-19 as a result of providing services pursuant to this Agreement. 9. CONFLICT OF INTEREST Provider covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 10. BACKGROUND CHECK Provider shall ensure that all employees, subcontractors, and any volunteers are fingerprinted and background checked prior to conducting any work pursuant to this Agreement. Provider shall not assign any employee, agent, subcontractor, volunteer or the Provider personally to provide services pursuant to this Agreement, if that employee, agent, subcontractor, volunteer, or the Provider personally are required to register as a sex offender under California Penal Code Section 290 et seq, have a conviction for any crime of moral turpitude, have a conviction for a sexual based crime, have a conviction for a violent felony as defined in California Penal Code Section 667.5(c), or has a conviction for a serious felony as defined in California Penal Code Section 1192.7(c). Disqualifying convictions include but are not limited to, violations of California Page 6 of 10 Penal Code Sections 37, 128, 136.1 with Section 186.22, 187, 190-190.4 and 192(a), 205, 206, 207-209.5, 211, 212, 212.5, 213, 214, 215, 218-219, 220, 236.1(b) or 236.1(c), 243.4, 261, 261.5, 273.5, 262, 264.1, 266, 266c, 266h, 266i, 266j, 267, 269, 272, 273a, 273ab, 273d, 285, 286, 288, 288a, 288.2, 288.3, 288.4, 288.5, 288.7, 289, 290, 311.1, 311.2, 311.3, 311.4, 311.10, 311.11, 314, 347(a), 368, 417(b), 451(a),518 with 186.22, 647.6, 653f(c), 664 and 187, 667.5(c), 18745, 18750, or 18755, 12022.53, 11418(b)(1) or (b)(2); Business and Professions Code Section 729. 11. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax (714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Fax (714) 571-4211 To Provider: Beginners Edge Sports Training Attn: Mitchell Goldberg 24654 N. Lake Pleasant Pkwy., Suite 103-405 Peoria, AZ 85383 mitch@best-snorts-usa. com A party may change its address by giving notice in writing to the other parry. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 12. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider regarding the subject matter herein, and supersedes any and all other agreements, oral or Page 7 of 10 written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Provider. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Provider or the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 13. ASSIGNMENT The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to enter into this Agreement. Therefore, Provider may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. 14. TERMINATION a. This Agreement may be terminated by the City immediately pursuant to any federal, state, county or local health order related to or regarding COVID-19 making it impossible to hold classes. For any other reason, this Agreement may be terminated by City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. b. Termination or cancellation of classes by the Provider outside of Section 14.a. must be given to the City at least thirty (30) days prior to termination/cancellation. Failure to provide adequate cancellation notice to the City may put future contracting of business with the City at risk and will result in the City's retention of ten (10%) percent of the final payment to Provider. 15. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. 16. RECORDS Provider shall use attendance sheets generated and supplied by the City to record attendance in each class. Provider shall keep these and any other records in connection with the work to be performed under this Agreement and shall permit City, upon request, to review such records for a period of three (3) years from the date of final payment to Provider under this Agreement. Page 8 of 10 17. NON-DISCRIMINATION Provider shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, gender identity, gender expression, gender, medical conditions, genetic information, or military and veteran status, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement. Provider affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 18. JURISDICTION —VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 19. LICENSES Provider shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. 20. SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by validjudgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. 21. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 22. AUTHORITY The person(s) executing this Agreement on behalf of the patties hereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that by so executing this Agreement, the patties hereto are formally bound to the provisions of this Agreement. Page 9 of 10 N-2024-130 SIGNATURE PAGE FOR RECREATION SERVICES AGREEMENT WITH EDGE SPORTS TRAINING, LLC, FOR MULTI -SPORT PROGRAMMING IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By: Br'an�alvatierra Deputy City Attorney RECOMMENDED FOR APPROVAL: X�bq� Hawk Scott (Mar 23, 2024 08:38 PDT) Hawk Scott Executive Director of Parks, Recreation and Community Services Agency CITY OF SANTA ANA Alvaro Nunez Acting City Manager Mitchell Goldberg Instructor Page 10 of 10 EXHIBIT A Exhibit A SCOPE OF SERVICES A. Provider shall conduct VARIOUS SPORTS classes for ages 2yrs — 10yrs. B. 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. Soccer Skills Training with BEST Sports Our industry -leading weekly soccer class will teach your kids the skills of soccer by offering activities such as: dribbling, kicking, throw-ins, goalie skills, and more! Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. Please bring an age appropriate soccer ball with your child's name on it and a water bottle. Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ Baseball & Softball Training with BEST Sports Our industry -leading weekly program will teach your kids the skills of baseball & softball by offering activities such as: fielding, throwing, hitting, base recognition, and more! Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. A glove is not mandatory for kids under 4. Please provide your own baseball hitting tee & bat Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ 2-Sport Multi Sport by BEST SPORTS (Soccer, Baseball/Softball) Our industry -leading 2-Sport program brings you multiple weeks of 2 fantastic sports: Soccer & Baseball/Softball. We will teach your player how to kick and control a soccer ball, how to hit, catch, throw and run the bases, and so much more! Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. Please bring an age -appropriate soccer ball for the first week. A hitting tee/bat is needed later in the session. Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ 3-Sport Multi Sport by BEST SPORTS (Soccer, Baseball/Softball, Basketbafl) Our industry -leading 3-Sport program brings you multiple weeks of 3 fantastic sports: Soccer, Baseball/Softball, & Basketball. We will teach your player how to kick and control a soccer ball, how to hit, catch, throw and run the bases, shoot and dribble a basketball and building strength + endurance. Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. Please bring an age -appropriate soccer ball for the first week. A hitting tee/bat and a basketball is needed later in the session. Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ 3-Sport Multi Sport by BEST SPORTS (Soccer, Baseball/Softball, Track d Field) Our industry -leading 3-Sport program brings you multiple weeks of 3 fantastic sports: Soccer, Baseball/Softball & Track. We will teach your player how to kick and control a soccer ball, how to hit, catch, throw and run the bases, run, jump and building strength + endurance in our Track & Field program. Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. Please bring an age -appropriate soccer ball for the first week. A hitting tee/bat will be needed later in the session. Copy this link to learn more about your B.E.S.T. Class: https✓/best-sports-usa.com/welcome/ 4-Sport Multi Sport by BEST SPORTS (Soccer, Baseball/Softball, Basketball, Track & Field) Our industry -leading 4-Sport program brings you multiple weeks of 4 fantastic sports: Soccer, Baseball/Softball, Basketball & Track. We will teach your player how to kick and control a soccer ball, how to hit, catch, throw, and run the bases, shoot and dribble a basketball and running, jumping and building strength + endurance in our Track & Field program. Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. Please bring an age -appropriate soccer ball for the first week. A hitting tee/bat and a basketball is needed later in the session. Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ Basketball Skills and Drills by BEST SPORTS Our industry -leading basketball skills and drills clinics introduce and advance your players ability for ball handling, dribbling, defense, jumping, passing, shooting and the triple threat position. Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. This is an extremely active, endurance -based class. Please bring your child's favorite basketball with their name on it. Copy this link to learn more about your B.E.S.T. Class: https://best-sports- usa. com/welcome/ Volleyball Skills and Drills by BEST Sports Our industry -leading Volleyball skills and drills clinics will teach Volleyball terminology, good sportsmanship, passing, serving under and overhand, bumping, setting, spiking, digging and more. Our goal and focus is to maintain an energetic and highly active program that will allow your player to enjoy and learn the joy of the game that will teach, encourage and advance your young players regardless of their skill level. Soft -Touch Volleyballs are provided, bringing your own knee and elbow pads are recommended. Fitness, Agility, Speed and Track Training by BEST Sports Our F.A.S.T.T. program will have your kids running and getting in shape. We will have your kids running, jumping, sprinting, relays, doing long jump, hurdles, discuss, shotput, long distance running, agility courses and of course obstacle courses. Our goal and focus is to maintain an energetic and highly active program that will allow your player to enjoy time in class. High energy Children are definitely welcome! Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ Football Skills and Training with BEST Sports Welcome to B.E.S.T.'s Blitz'Em Football, your child's non-league introduction to Gridiron skills. We provide your children with the B.E.S.T. way to learn touch & flag football without getting sacked. We will coach your children to learn: football terminology, good sportsmanship, passing, receiving, agility, cradling, kicking/punting, flag/touch, blocking, and defense/offense skills. Please bring a Football! Click the welcome link at the bottom of this description to learn more about your classll B.E.S.T. PICKLEBALL SKILLS & DRILLS Welcome to the BEST Pickleball Class, where young athletes can experience the excitement of one of the fastest -growing sports in the world! Pickleball is a fun and inclusive game that combines elements of tennis, badminton, and ping pong, making it an excellent choice for kids. We will teach kids proper grip, stance, and swing techniques, serving, volleying, and groundstrokes. Children will learn the rules of pickleball, such as scoring, boundaries, and how to play both singles and doubles. The class promotes physical fitness through fun and engaging drills and games, helping children stay active while enjoying themselves. Please bring your favorite paddle and a water bottle. Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ B.E.S.T. TENNIS SKILLS & DRILLS Welcome to the BEST Tennis Class, where young athletes can embark on a thrilling journey into the world of tennis, a sport rich in tradition and excitement. Kids will learn the basics, including proper grip, footwork, and stroke techniques for forehands, backhands, volleys, and serves. Our Tennis Class is open to kids of all skill levels, from complete beginners to those with some tennis experience. Whether your child dreams of becoming a tennis pro or simply wants to enjoy a new and exciting sport, this class is the perfect place to start. Come prepared with your favorite tennis racket, and we'll take care of the rest, guiding your child toward a future of fun and achievement on the tennis court. Copy this link to learn more about your B.E.S.T. Class: https://best-sports-usa.com/welcome/ THE FOLLOWING ARE ALL OUR OTHER PROGRAMS WE CAN OFFER. 1) The ages are the span we offer. We do age split as the others are demonstrated above. 2) We also can run these on Saturday or Sunday. 3) All Programs are priced at 6 week @ $99. Depending on the time of year the # of weeks can change. 4) All below are: INSTRUCTOR: B.E.ST (Beginners Edge Sports Training) Staff LOCATION: Jerome Center, 726 S. Center St. Santa Ana, CA. (714) 647-6559 • Baseball/Softball will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun- Age: 2-10yrs old), price $99 per session • Soccer will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun -Age: (Walking to 10 yrs old), price $99 per session • Track and Field will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun- Age: 3-10yrs old), price $99 per session • Volleyball will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun - Age: 5-12 yrs old), price $99 per session • Pickleball will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun - Age: 5-12 yrs old), price $99 per session • Basketball will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun - Age: 3-15yrs old), price $99 per session • Football will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun- Age: 3-15yrs old), price $99 per session • 4-Sport Multi (will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun - Age: 3-15yrs old), price $99 per session • Tennis will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun- Age: 3-15yrs old), price $129 per session (min-max(6/10) • 4-Sport Multi (Soccer, Baseball/Softball, Track, Basketball) will consist of 6-week session, held 1 day per week, 45 minutes (Sat or Sun- Age: 3-15yrs old), price $99 per session INSTRUCTOR: B.E.ST (Beginners Edge Sports Training) Staff LOCATION: Jerome Center, 726 S. Center St. Santa Ana, CA. (714) 647-6559 • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sat- Age: 2-3yrs old), price $99 per session • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sat- Age: 3-5yrs old), price $99 per session • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sat- Age: 6-8yrs old), price $99 per session • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sat- Age: 8-10yrs old), price $99 per session INSTRUCTOR: B.E.ST (Beginners Edge Sports Training) Staff LOCATION: Jerome Center, 726 S. Center St. Santa Ana, CA. (714) 647-6559 • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sun- Age: 2-3yrs old), price $99 per session • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sun -Age: 3-5yrs old), price $99 per session • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sun - Age: 6-8yrs old), price $99 per session • Soccer, Baseball/Softball & Track will consist of 6-week session, held 1 day per week, 45 minutes (Sun - Age: 7-10yrs old), price $99 per session C. 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 8 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 cancelled. Provider will be under no obligation to provide services for the cancelled classes, and the City will have no further obligations to pay Provider compensation for the remaining classes that were cancelled 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. Hoang, Julie From: City of Santa Ana <certificate-request@ctrax.jdidata.com> Sent: Wednesday, March 27, 2024 3:59 PM To: Hoang, Julie; Moorman, Kristin; mitch@best-sports-usa.com; Baird, Sarah Subject: Internal Notice of Compliance Attention: This email of 1 indLml tier , u:,i& of C its of Santa .pia. Use caution \1.11e1 NOTICE OF COMPLIANCE ci ri STAFF: PRINT THIS PAGE AND INCLUDE NN ITH AGREEVI ENT TO THE CLERK OF THE C'OUNC'IL Contractor Beginners Edge Sports Training, LLC B.E.S.T. Mitch Goldeburg Name: Project N-2023-213 Number: Project Recreation Services Agreement With Beginners Edge Sports Training, Name: LLC, For Multi -Sport Programming The Certificate of Insurance (COI) submitted indicates that the coverages comply with the insurance requirements. The compliant coverage(s) are: TYPE OF INSURANCE AUTOMOBILE LIABILITY GENERAL LIABILITY GENERAL LIABILITY POLICY EXPIRATION COI DATE NUMBER DATE WAIVER 03/20/2025 03/27/2024 8502AHO 110303 8502AH0110303 11/05/2024 11/05/2024 10/20/2023 10/20/2023 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 76WEGAZ6AMU 09/26/2024 02/27/2024 No further action is required at this time. Thank you, FILE NAME WAIVER- Auto Liability (Non - Use Agreement) Request_fillable Anaheim.pdf Santa Ana l.pdf Santa Ana 1.pdf New 2023 - 2024 Workers Comp Policy AZ CA TX.pdf (Policy Provisions:WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER:SEE ATTACHED ENDORSEMENT 20621 NCCI Company Number: Company Code:9 Ejhjubmmz!tjhofe!cz!Bohjf!Bdfwfep! Bohjf!Bdfwfep Ebuf;!3135/21/12!25;36;51!.18(11( Suffix LARSRENEWAL 76WEGAZ6AMU2 POLICY NUMBER: 76 WEG AZ6AMU Previous Policy Number: BEGINNERS EDGE SPORTS TRAINING 1.Named Insured and Mailing Address: 7432 E TIERRA BUENA LN (No., Street, Town, State, Zip Code) SCOTTSDALE AZ85260 FEIN Number:26-2932264 Refer to the EXTENSION OF THE INFORMATION PAGE – WC990365. State Identification Number(s): The Named Insured is:LLC Business of Named Insured:Fitness and Recreational Sports Centers Other workplaces not shown above:See Endorsement - WC990366 2.Policy Period:From09/26/24To09/26/25ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer’s Name:PAYCHEX INSURANCE AGENCY INC/PHS 225 KENNETH DR STE 110 ROCHESTER NY 14623 Producer’s Code:76210690 THE HARTFORD BUSINESS SERVICE CENTER Issuing Office: 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 287-1312 $2,133 Total Estimated Annual Premium: Deposit Premium: $600CA (Includes Increased Limit Min. Prem.) Policy Minimum Premium: Installment Term: Audit Period:ANNUAL The policy is not binding unless countersigned by our authorized representative. 08/17/24 Countersigned by Authorized RepresentativeDate Form WC 00 00 01 A(1)Printed in U.S.A.Page 1(Continued on next page) Process Date:08/17/24Policy Expiration Date:09/26/25 INFORMATION PAGE (Continued) Policy Number:76 WEG AZ6AMU 3.A. Workers Compensation Insurance:Part one of the policy applies to the Workers Compensation Law of the states listed here:CASEE ENDORSEMENT - WC 99 03 67 B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident$1,000,000each accident Bodily injury by Disease$1,000,000policy limit Bodily injury by Disease$1,000,000each employee C. Other States Insurance:Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT-WC 99 03 68 4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.All information required below is subject to verification and change by audit. Premium Basis ClassificationsTotal EstimatedRates PerEstimated Code Number andAnnual$100 ofAnnual DescriptionRemunerationRemunerationPremium Total Standard Premium$1,817 Expense Constant$200 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement$26 Catastrophe (Other Than Certified Acts Of Terrorism)$16 Estimated Annual Premium (before Surcharges)$2,059 Total Estimated Surcharges$74 *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium:$2,133 Deposit Premium: Policy Minimum Premium: $600CA (Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number:Refer to Schedule of Operations NAICS: 713940 Labor Contractors Policy Number:SIC:7991 Form WC 00 00 01 A(1)Printed in U.S.A.Page 2 Process Date:08/17/24Policy Expiration Date:09/26/25 EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Item 1 of the Information Page is completed to include other workplaces of the named insured: 7432 E TIERRA BUENA LN, SCOTTSDALE, AZ 85260 5900 Balcones Dr., Austin, TX 78731 LOCATION MAY VARY, COSTA MESA, CA 92626 Form WC 99 03 66Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Item 3.A. of the Information Page is completed to include the following states: CaliforniaCA TexasTX ArizonaAZ Form WC 99 03 67Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Item 3.D. of the Information Page is completed to include the following endorsements: G-4119-0POLICYHOLDER NOTICE-PAYROLL BILLING PN049901IPOLICYHOLDER NOTICE - YOUR RIGHT TO RATING AND DIVIDEND INFORMATION WC000000CWORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000001A.1INFORMATION PAGE WC000001A.2INFORMATION PAGE WC000313WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC000403EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC000414A90-DAY REPORTING REQUIREMENT- NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC000419APART FIVE - PREMIUM AMENDATORY ENDORSEMENT WC000421FCATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC000422CTERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC000424AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC020401CARIZONA ALCOHOL AND DRUG-FREE WORKPLACE PREMIUM CREDIT ENDORSEMENT WC020601CArizona Cancellation and Nonrenewal Endorsement WC020603AARIZONA AMENDATORY ENDORSEMENT WC040301BBPOLICY AMENDATORY ENDORSEMENT - CALIFORNIA WC040306WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Form WC 99 03 68Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Item 3.D. of the Information Page is completed to include the following endorsements: WC040360BEMPLOYERS LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA WC040421OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA WC040422CALIFORNIA SHORT-RATE CANCELLATION ENDORSEMENT WC040601BCALIFORNIA CANCELATION ENDORSEMENT WC420301LTEXAS AMENDATORY ENDORSEMENT WC550011DEmployees Claim for Workers compensation Benefits WC550022ANOTICE TO WORKERS' COMPENSATION POLICYHOLDERS IN TEXAS LETTER WC880400INotice to Employees - Injuries Caused By Work (TITLE IN SPANISH) WC880401INotice to Employees - Injuries Caused By Work WC990001KSignature/Copyright WC990002WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE POLICY WC990005SCHEDULE OF OPERATIONS WC990302BWORKERS COMPENSATION BROAD FORM ENDORSEMENT WC990358BAMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT - EMPLOYERS LIABILITY STOP GAP COVERAGE WC990366EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES WC990367EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED WC990368EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS Form WC 99 03 68Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Item 3.D. of the Information Page is completed to include the following endorsements: WC990371AARIZONA COUNTERSIGNATURE EXCLUSION ENDORSEMENT WC990375CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT WC990689GOODS AND SERVICES ENDORSEMENT WC990694GOODS AND SERVICES ENDORSEMENT Form WC 99 03 68Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 POLICY INSURER LIST BY JURISDICTION INSURERNAICJURISDICTION Hartford Casualty Insurance Company29424CA ONE HARTFORD PLAZA HARTFORD CT 06155 Hartford Insurance Company of the Southeast38261AZ ONE HARTFORD PLAZA HARTFORD CT 06155 Hartford Insurance Company of Illinois38288TX ONE HARTFORD PLAZA HARTFORD CT 06155 THECOVERAGEPROVIDEDINEACHJURISDICTIONISWITHRESPECTTOTHELOCATIONSOFTHENAMED INSUREDINTHATJURISDICTIONINACCORDANCEWITHTHEWORKERS’COMPENSATIONLAWOFTHAT JURISDICTION.ASUSEDINTHISPOLICY,“COMPANY”,“WE”,“US”AND“OURS”MEANTHEMEMBERINSURANCE COMPANIES OF THE HARTFORD INSURANCE GROUP COLLECTIVELY PROVIDING THIS INSURANCE. Nothingherein,containedshallbeheldtovary,waive,alterorextendanyoftheterms,conditions,agreementsor information of the policy, other than as herein stated. Form WC 66 04 40Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER:HARTFORD INSURANCE COMPANY OF THE SOUTHEAST Company Code:J Policy Number:76WEGAZ6AMUSchedule Number:01-02-01 Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALE AZ 85260 NAICS: 713940 FEIN:26-2932264SIC: 7991NO. OF EMPL: 5 4.ThepremiumforthispolicywillbedeterminedbyourManualsofRules,Classifications,RatesandRating Plans.All information required below is subject to verification and change by audit. Premium Basis ClassificationsTotal EstimatedRates PerEstimated Code Number andAnnual$100 ofAnnual DescriptionRemunerationRemunerationPremium 9063157,100.000.300000471 HEALTH OR EXERCISE INSTITUTE & CLERICAL Total State Summary Total Class Premium471 Waiver of Subrogation250 Emp liab increased limits0.0110005 Total Estimated Annual Standard Premium726 Terrorism Risk Insurance Program Reauthorization Act157,100.000.01000016 Disclosure Endorsement Catastrophe (other than certified acts of terrorism)157,100.000.01000016 Total Estimated Annual Premium758 Countersigned by Authorized Representative Form WC 99 00 05(1) Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER:HARTFORD CASUALTY INSURANCE COMPANY Company Code:3 Policy Number:76WEGAZ6AMUSchedule Number:01-04-03 Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: Beginners Edge Sports Training LOCATION MAY VARY COSTA MESA CA 92626 NAICS: 713940 FEIN:26-2932264SIC: 7991NO. OF EMPL: 2 4.ThepremiumforthispolicywillbedeterminedbyourManualsofRules,Classifications,RatesandRating Plans.All information required below is subject to verification and change by audit. Premium Basis ClassificationsTotal EstimatedRates PerEstimated Code Number andAnnual$100 ofAnnual DescriptionRemunerationRemunerationPremium 887052,400.001.570000823 FITNESS INSTRUCTION PROGRAMS OR STUDIOS - ALL EMPLOYEES - INCLUDING RECEPTIONISTS Total State Summary Total Class Premium823 CA Territorial Differential1.03500029 Waiver of Subrogation500 Small Policy Credit25-338 Total Estimated Annual Standard Premium1,014 Expense constant200 Terrorism Risk Insurance Program Reauthorization Act52,400.000.02000010 Disclosure Endorsement CA User Fund2.46040030 CA Fraud0.4122005 CA Uninsured Employers Benefit Trust Fund0.1505002 CA Subsequent Injuries Benefit Trust Fund Assessments1.58910019 CA Occupational Safety & Health Fund0.7266009 CA Labor Enforcement & Compliance Fund0.7109009 Total Estimated Annual Premium1,298 Countersigned by Authorized Representative Form WC 99 00 05(1) Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER:HARTFORD INSURANCE COMPANY OF ILLINOIS Company Code:F Policy Number:76WEGAZ6AMUSchedule Number:01-42-02 Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: Beginners Edge Sports Training 5900 Balcones Dr. Austin TX 78731 NAICS: 713940 FEIN:26-2932264SIC: 7991NO. OF EMPL: 1 4.ThepremiumforthispolicywillbedeterminedbyourManualsofRules,Classifications,RatesandRating Plans.All information required below is subject to verification and change by audit. Premium Basis ClassificationsTotal EstimatedRates PerEstimated Code Number andAnnual$100 ofAnnual DescriptionRemunerationRemunerationPremium 90633,100.000.2100007 HEALTH OR EXERCISE INSTITUTE & DRIVERS Total State Summary Total Class Premium7 Employer Liability Increase Limits balance to Minimum145 Premium Premium Incentive For Small Employers0.850000-23 Schedule Rating Factor0.600000-52 Total Estimated Annual Standard Premium77 Terrorism Risk Insurance Program Reauthorization Act3,100.000.0050000 Disclosure Endorsement Catastrophe (other than certified acts of terrorism)3,100.000 Total Estimated Annual Premium77 Countersigned by Authorized Representative Form WC 99 00 05(1) Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 Texas Regional Office THIS LETTER CONTAINS IMPORTANT INFORMATION. 450 Gears Road, Suite 500 PLEASE READ CAREFULLY AND RETAIN THIS LETTER Houston, TX 77067-4585 P.O. Box 4611 FOR FUTURE USE. Houston, TX 77210-4611 Telephone (281) 874-9600 TO:WORKERS' COMPENSATION POLICYHOLDERS IN TEXAS ThankyouforchoosingTheHartfordasyourworkers'compensationcarrier.Weaskthatyoutakeaminutetofamiliarize yourself with the forms and reporting requirements for the State of Texas which we have included in this packet. 1.Eachemployershouldmaintainarecordofallinjuriesreportedormadeknowntotheemployer.TheTexas Department of Insurance, Division of Workers’ Compensation (DWC) may at times request these records for review. 2.IftheinjurycausesanemployeetobeoffworkmorethanonedayORinvolveaclaimforanoccupationaldiseaseyou must immediately report the loss. 3.Please refer to Form WC 66 02 51 for LossConnect loss reporting instructions. 4.LossConnect will file all necessary state reports. 5.THECLAIMMUSTBEREPORTEDNOLATERTHANTHEEIGHTHDAYAFTERTHELOSSOFONEDAYOF WORKORTHEFIRSTNOTICEOFANOCCUPATIONALDISEASE.FAILURETOCOMPLYMAYRESULTINAN ADMINISTRATIVE VIOLATION WHICH COULD INCLUDE UP TO A $500.00 FINE. 6.TheFROImustbefiledevenonadoubtfulordisputedclaim.Yourlackofknowledgeoftheclaimdetailsshouldbe reflected on the report. COMPLETIONOFAFROIISNOTCONSIDEREDANADMISSIONOFOREVIDENCEOFACOMPENSABLEINJURY IF THE FACTS CONTAINED THEREIN ARE LATER CONTRADICTED. 7.TheEmployer'sWageStatement(DWC-3)shouldbeprovidedtothecarrier,employee,andDWCifyouknowor expect 8 days of disability. 8.TheSupplementalReportofInjury(DWC-6)shouldbefiledwiththecarrierwheneveryou(astheemployer)are aware of any change in work status or earnings due to the injury.DO NOT SEND TO THE DWC. We,asthecarrier,cannotactquicklyandefficientlyinyourinterestunlessimmediatenoticeofaninjuryisreceived.Your cooperation is imperative and we stand to assist you in any way we can. The Hartford Insurance Group Form WC 55 00 22 APrinted in U.S.A. Hartford Fire Insurance Company and its Affiliates Hartford Plaza, Hartford, Connecticut 06115 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BeginningBeginning on Pageon Page INFORMATION PAGEPART TWO - Continued 1G.Limits of Liability..............................................4 General Section..............................................................1H.Recovery From Others.....................................4 A.The Policy...............................................................1I.Actions Against Us...........................................4 B.Who Is Insured.......................................................1 C.Workers Compensation Law..................................1PART THREE - OTHER STATES INSURANCE4 D.State.......................................................................1A.How This Insurance Applies.............................4 E.Locations................................................................1B.Notice...............................................................5 PARTONE- WORKERSCOMPENSATIONINSURANCE...1PART FOUR - YOUR DUTIES IF INJURY OCCURS.....5 A.How This Insurance Applies...................................1 B.We Will Pay............................................................1PART FIVE - PREMIUM...............................................5 C.We Will Defend.......................................................1A.Our Manuals.....................................................5 D.We Will Also Pay....................................................1B.Classifications..................................................5 E.Other Insurance......................................................2C.Remuneration...................................................5 F.Payments You Must Make......................................2D.Premium Payments..........................................5 G.Recovery From Others...........................................2E.Final Premium..................................................5 H.Statutory Provisions................................................2F.Records............................................................6 G.Audit.................................................................6 PART TWO - EMPLOYERS LIABILITY INSURANCE......2 A.How This Insurance Applies...................................2PART SIX - CONDITIONS.......................................6 B.We will Pay.............................................................3A.Inspection.........................................................6 C.Exclusions..............................................................3B.Long Term Policy.............................................6 D.We Will Defend.......................................................3C.Transfer of Your Rights and Duties..................6 E.We Will Also Pay....................................................4D.Cancellation.....................................................6 F.Other Insurance......................................................4E.Sole Representative.........................................6 IMPORTANT:ThisQuickReferenceisnotpartoftheWorkersCompensationandEmployersLiabilityPolicyanddoes notprovidecoverage.RefertotheWorkersCompensationandEmployersLiabilityPolicyitselffor actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY. Form WC 66 01 56 BPrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A.The PolicylawofeachstateorterritorynamedinItem3.A.ofthe InformationPage.Itincludesanyamendmentsto Thispolicyincludesatitseffectivedatethe thatlawwhichareineffectduringthepolicyperiod.It InformationPageandallendorsementsandschedules doesnotincludeanyfederalworkersorworkmen's listedthere.Itisacontractofinsurancebetweenyou compensationlaw,anyfederaloccupationaldisease (theemployernamedinItem1oftheInformation lawortheprovisionsofanylawthatprovide Page)andus(theinsurernamedontheInformation nonoccupational disability benefits. Page).Theonlyagreementsrelatingtothisinsurance arestatedinthispolicy.ThetermsofthispolicymayD.State notbechangedorwaivedexceptbyendorsement StatemeansanystateoftheUnitedStatesof issued by us to be part of this policy. America, and the District of Columbia. B.Who Is Insured E.Locations YouareinsuredifyouareanemployernamedinItem Thispolicycoversallofyourworkplaceslistedin 1oftheInformationPage.Ifthatemployerisa Items1or4oftheInformationPage;anditcoversall partnership,andifyouareoneofitspartners,youare otherworkplacesinItem3.A.statesunlessyouhave insured,butonlyinyourcapacityasanemployerof otherinsuranceorareself-insuredforsuch the partnership's employees. workplaces. C.Workers Compensation Law WorkersCompensationLawmeanstheworkersor workmen's compensation law and occupational disease PART ONE - WORKERS COMPENSATION INSURANCE A.How This Insurance AppliesC.We Will Defend ThisworkerscompensationinsuranceappliestoWehavetherightanddutytodefendatourexpense bodilyinjurybyaccidentorbodilyinjurybydisease.anyclaim,proceedingorsuitagainstyouforbenefits Bodily injury includes resulting death.payablebythisinsurance.Wehavetherightto investigateandsettletheseclaims,proceedingsor 1.Bodilyinjurybyaccidentmustoccurduringthe suits. policy period. Wehavenodutytodefendaclaim,proceedingor 2.Bodilyinjurybydiseasemustbecausedor suit that is not covered by this insurance. aggravatedbytheconditionsofyouremployment. Theemployee'slastdayoflastexposuretotheD.We Will Also Pay conditionscausingoraggravatingsuchbodily Wewillalsopaythesecosts,inadditiontoother injurybydiseasemustoccurduringthepolicy amountspayableunderthisinsurance,aspartofany period. claim, proceeding or suit we defend: B.We Will Pay 1.reasonableexpensesincurredatourrequest,but Wewillpaypromptlywhenduethebenefitsrequirednot loss of earnings; of you by the workers compensation law. Form WC 00 00 00 CPrinted in U.S.A.Page1 of6 Process Date: 08/17/24Policy Expiration Date: 09/26/25 2.premiumsforbondstoreleaseattachmentsandYouwilldoeverythingnecessarytoprotectthose forappealbondsinbondamountsuptotherights for us and to help us enforce them. amount payable under this insurance; H.Statutory Provisions 3.litigation costs taxed against you; Thesestatementsapplywheretheyarerequiredby 4.interestonajudgmentasrequiredbylawuntilwelaw. offer the amount due under this insurance; and 1.Asbetweenaninjuredworkerandus,wehave 5.expenses we incur.notice of the injury when you have notice. E.Other Insurance2.Yourdefaultorthebankruptcyorinsolvencyof youoryourestatewillnotrelieveusofourduties Wewillnotpaymorethanourshareofbenefitsand under this insurance after an injury occurs. costscoveredbythisinsuranceandotherinsurance orself-insurance.Subjecttoanylimitsofliabilitythat3.Wearedirectlyandprimarilyliabletoanyperson mayapply,allshareswillbeequaluntilthelossisentitledtothebenefitspayablebythisinsurance. paid.Ifanyinsuranceorself-insuranceisexhausted,Thosepersonsmayenforceourduties;somay thesharesofallremaininginsurancewillbeequalanagencyauthorizedbylaw.Enforcementmay until the loss is paid.be against you and us. F.Payments You Must Make4.Jurisdictionoveryouisjurisdictionoverusfor purposesoftheworkerscompensationlaw.We Youareresponsibleforanypaymentsinexcessofthe areboundbydecisionsagainstyouunderthat benefitsregularlyprovidedbytheworkers law,subjecttotheprovisionsofthispolicythat compensation law including those required because: are not in conflict with that law. 1.of your serious and willful misconduct; 5.Thisinsuranceconformstothepartsofthe 2.youknowinglyemployanemployeeinviolationof workers compensation law that apply to: law; a.benefits payable by this insurance; 3.youfailtocomplywithahealthorsafetylawor b.specialtaxes,paymentsintosecurityorother regulation; or specialfunds,andassessmentspayableby 4.youdischarge,coerceorotherwisediscriminate us under that law. againstanyemployeeinviolationoftheworkers 6.Termsofthisinsurancethatconflictwiththe compensation law. workerscompensationlawarechangedbythis Ifwemakeanypaymentsinexcessofthebenefits statement to conform to that law. regularlyprovidedbytheworkerscompensationlaw Nothingintheseparagraphsrelievesyouofyourduties on your behalf, you will reimburse us promptly. under this policy. G.Recovery From Others Wehaveyourrights,andtherightsofpersonsentitled tothebenefitsofthisinsurance,torecoverour payments from anyone liable for the injury. PART TWO - EMPLOYERS LIABILITY INSURANCE A.How This Insurance Applies2.Theemploymentmustbenecessaryorincidental toyourworkinastateorterritorylistedinItem Thisemployersliabilityinsuranceappliestobodily 3.A. of the Information Page. injurybyaccidentorbodilyinjurybydisease.Bodily injury includes resulting death.3.Bodilyinjurybyaccidentmustoccurduringthe policy period. 1.Thebodilyinjurymustariseoutofandinthe courseoftheinjuredemployee'semploymentby4.Bodilyinjurybydiseasemustbecausedor you.aggravatedbytheconditionsofyour employment. Theemployee's lastdayoflast Form WC 00 00 00 CPrinted in U.S.A.Page2 of6 exposuretotheconditionscausingoraggravatingThisexclusiondoesnotapplytobodilyinjurytoa suchbodilyinjurybydiseasemustoccurduringcitizenorresidentoftheUnitedStatesofAmerica the policy period.orCanadawhoistemporarilyoutsidethese countries; 5.Ifyouaresued,theoriginalsuitandanyrelated legalactionsfordamagesforbodilyinjuryby7.Damagesarisingoutofcoercion,criticism, accidentorbydiseasemustbebroughtinthedemotion,evaluation,reassignment,discipline, UnitedStatesofAmerica,itsterritoriesordefamation,harassment,humiliation,dis- possessions, or Canada.criminationagainstorterminationofany employee,oranypersonnelpractices,policies, B.We Will Pay acts or omissions; Wewillpayallsumsthatyoulegallymustpayas 8.Bodilyinjurytoanypersoninworksubjecttothe damagesbecauseofbodilyinjurytoyouremployees, LongshoreandHarborWorkers'Compensation providedthebodilyinjuryiscoveredbythisEmployers Act(33U.S.C.Sections901etseq.),the Liability Insurance. NoappropriatedFundInstrumentalitiesAct(5 Thedamageswewillpay,whererecoveryispermitted U.S.C.Sections8171etseq.),theOuter by law, include damages: ContinentalShelfLandsAct(43U.S.C.Sections 1.Forwhichyouareliabletoathirdpartybyreason 1331etseq.),theDefenseBaseAct(42U.S.C. ofaclaimorsuitagainstyoubythatthirdpartyto Sections1651-1654),theFederalMineSafety recoverthedamagesclaimedagainstsuchthird andHealthAct(30U.S.C.Sections801etseq. party as a result of injury to your employee; and901-944)anyotherfederalworkersor workmen'scompensationlaworotherfederal 2.For care and loss of services; and occupationaldiseaselaw,oranyamendmentsto 3.Forconsequentialbodilyinjurytoaspouse,child, these laws; parent,brotherorsisteroftheinjuredemployee; 9.Bodilyinjurytoanypersoninworksubjecttothe providedthatthesedamagesarethedirect FederalEmployers'LiabilityAct(45U.S.C. consequenceofbodilyinjurythatarisesoutofand Sections51etseq.),anyotherfederallaws inthecourseoftheinjuredemployee's obligatinganemployertopaydamagestoan employment by you; and employeeduetobodilyinjuryarisingoutoforin 4.Becauseofbodilyinjurytoyouremployeethat thecourseofemployment,oranyamendments arisesoutofandinthecourseofemployment, to those laws; claimedagainstyouinacapacityotherthanas 10.Bodilyinjurytoamasterormemberofthecrew employer. ofanyvessel,anddoesnotcoverpunitive C.Exclusions damagesrelatedtoyourdutyorobligationto This insurance does not cover: providetransportation,wages,maintenance,and cure under any applicable maritime law; 1.Liabilityassumedunderacontract.Thisexclusion doesnotapplytoawarrantythatyourworkwillbe 11.Finesorpenaltiesimposedforviolationoffederal done in a workmanlike manner; or state law; and 2.Punitiveorexemplarydamagesbecauseofbodily 12.DamagespayableundertheMigrantand injury to an employee employed in violation of law; SeasonalAgriculturalWorkerProtectionAct(29 U.S.C.Sections1801etseq.)andunderany 3.Bodilyinjurytoanemployeewhileemployedin otherfederallawawardingdamagesforviolation violationoflawwithyouractualknowledgeorthe ofthoselawsorregulationsissuedthereunder, actual knowledge of any of your executive officers; and any amendments to those laws. 4.Anyobligationimposedbyaworkerscom- D.We Will Defend pensation,occupationaldisease,unemployment compensation,ordisabilitybenefitslaw,orany Wehavetherightanddutytodefend,atourexpense, similar law; anyclaim,proceedingorsuitagainstyoufordamages payablebythisinsurance.Wehavetherightto 5.Bodilyinjuryintentionallycausedoraggravatedby investigateandsettletheseclaims,proceedingsand you; suits. 6.BodilyinjuryoccurringoutsidetheUnitedStatesof America, its territories or possessions, and Canada. Form WC 00 00 00 CPrinted in U.S.A.Page3 of6 Wehavenodutytodefendaclaim,proceedingorsuitAdiseaseisnotbodilyinjurybyaccidentunlessit thatisnotcoveredbythisinsurance.Wehavenoresults directly from bodily injury by accident. dutytodefendorcontinuedefendingafterwehave 2.BodilyInjurybyDisease.Thelimitshownfor paidourapplicablelimitofliabilityunderthis ''bodilyinjurybydiseasepolicylimit''isthemost insurance. wewillpayforalldamagescoveredbythis E.We Will Also Payinsuranceandarisingoutofbodilyinjuryby disease,regardlessofthenumberofemployees Wewillalsopaythesecosts,inadditiontoother whosustainbodilyinjurybydisease.Thelimit amountspayableunderthisinsurance,aspartofany shownfor''bodilyinjurybydiseaseeach claim, proceeding or suit we defend: employee''isthemostwewillpayforall 1.Reasonableexpensesincurredatourrequest,but damagesbecauseofbodilyinjurybydiseaseto not loss of earnings; any one employee. 2.Premiumsforbondstoreleaseattachmentsand Bodilyinjurybydiseasedoesnotincludedisease forappealbondsinbondamountsuptothelimit thatresultsdirectlyfromabodilyinjuryby of our liability under this insurance; accident. 3.Litigation costs taxed against you; 3.Wewillnotpayanyclaimsfordamagesafterwe 4.Interestonajudgmentasrequiredbylawuntilwe havepaidtheapplicablelimitofourliabilityunder offer the amount due under this insurance; and this insurance. 5.Expenses we incur. H.Recovery From Others F.Other Insurance Wehaveyourrightstorecoverourpaymentfrom anyoneliableforaninjurycoveredbythisinsurance. Wewillnotpaymorethanourshareofdamagesand Youwilldoeverythingnecessarytoprotectthose costscoveredbythisinsuranceandotherinsurance rights for us and to help us enforce them. orself-insurance.Subjecttoanylimitsofliabilitythat apply,allshareswillbeequaluntilthelossispaid.If I.Actions Against Us anyinsuranceorself-insuranceisexhausted,the Therewillbenorightofactionagainstusunderthis sharesofallremaininginsuranceandself-insurance insurance unless: will be equal until the loss is paid. 1.Youhavecompliedwithallthetermsofthis G.Limits of Liability policy; and Ourliabilitytopayfordamagesislimited.Ourlimitsof 2.Theamountyouowehasbeendeterminedwith liabilityareshowninItem3.B.oftheInformationPage. our consent or by actual trial and final judgment. They apply as explained below. Thisinsurancedoesnotgiveanyonetherighttoadd 1.BodilyInjurybyAccident.Thelimitshownfor usasadefendantinanactionagainstyouto ''bodilyinjurybyaccidenteachaccident''isthe determineyourliability.Thebankruptcyor mostwewillpayforalldamagescoveredbythis insolvencyofyouoryourestatewillnotrelieveusof insurancebecauseofbodilyinjurytooneormore our obligations under this Part. employees in any one accident. PART THREE - OTHER STATES INSURANCE A.How This Insurance Applieslisted in Item 3.A. of the Information Page. 1.Thisotherstatesinsuranceappliesonlyifoneor3.Wewillreimburseyouforthebenefitsrequiredby morestatesareshowninItem3.C.ofthetheworkerscompensationlawofthatstateifwe Information Page.arenotpermittedtopaythebenefitsdirectlyto persons entitled to them. 2.Ifyoubeginworkinanyoneofthosestatesafter theeffectivedateofthispolicyandarenotinsured4.Ifyouhaveworkontheeffectivedateofthis orarenotself-insuredforsuchwork,allprovisionspolicy in any state not listed in Item 3.A. ofthe of the policy will apply as though that state were Form WC 00 00 00 CPrinted in U.S.A.Page4 of6 InformationPage,coveragewillnotbeaffordedforB.Notice that state unless we are notified within thirty days. Tellusatonceifyoubeginworkinanystatelistedin Item 3.C. of the Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tellusatonceifinjuryoccursthatmaybecoveredby4.Cooperatewithusandassistus,aswemay this policy.Your other duties are listed here.request,intheinvestigation,settlementor defense of any claim, proceeding or suit. 1.Provideforimmediatemedicalandotherservices required by the workers compensation law.5.Donothingafteraninjuryoccursthatwould interfere with our right to recover from others. 2.Giveusorouragentthenamesandaddressesof theinjuredpersonsandofwitnesses,andother6.Donotvoluntarilymakepayments,assume information we may need.obligationsorincurexpenses,exceptatyourown cost. 3.Promptlygiveusallnotices,demandsandlegal papersrelatedtotheinjury,claim,proceedingor suit. PART FIVE - PREMIUM A.Our Manuals2.allotherpersonsengagedinworkthatcould makeusliableunderPartOne(Workers Allpremiumforthispolicywillbedeterminedbyour CompensationInsurance)ofthispolicy.Ifyoudo manualsofrules,rates,ratingplansand nothavepayrollrecordsforthesepersons,the classifications.Wemaychangeourmanualsand contractpricefortheirservicesandmaterials applythechangestothispolicyifauthorizedbylawor maybeusedasthepremiumbasis.This a governmental agency regulating this insurance. paragraph2willnotapplyifyougiveusproof B.Classifications thattheemployersofthesepersonslawfully Item4oftheInformationPageshowstherateand secured their workers compensation obligations. premiumbasisforcertainbusinessorwork D.Premium Payments classifications.Theseclassificationswereassigned Youwillpayallpremiumwhendue.Youwillpaythe basedonanestimateoftheexposuresyouwould premiumevenifpartorallofaworkers haveduringthepolicyperiod.Ifyouractual compensation law is not valid. exposuresarenotproperlydescribedbythose classifications,wewillassignproperclassifications,E.Final Premium ratesandpremiumbasisbyendorsementtothis ThepremiumshownontheInformationPage, policy. schedules,andendorsementsisanestimate.The C.Remunerationfinalpremiumwillbedeterminedafterthispolicyends byusingtheactual,nottheestimated,premiumbasis Premiumforeachworkclassificationisdeterminedby andtheproperclassificationsandratesthatlawfully multiplyingaratetimesapremiumbasis. applytothebusinessandworkcoveredbythis Remuneration is the most common premium basis. policy.Ifthefinalpremiumismorethanthepremium Thispremiumbasisincludespayrollandallother youpaidtous,youmustpayusthebalance.Ifitis remunerationpaidorpayableduringthepolicyperiod less,wewillrefundthebalancetoyou.Thefinal for the services of: premiumwillnotbelessthanthehighestminimum 1.Allyourofficersandemployeesengagedinwork premium for the classifications covered by this policy. covered by this policy; and Form WC 00 00 00 CPrinted in U.S.A.Page5 of6 Ifthispolicyiscancelled,finalpremiumwillbeG.Audit determinedinthefollowingwayunlessourmanuals Youwillletusexamineandauditallyourrecordsthat provide otherwise: relatetothispolicy.Theserecordsincludeledgers, 1.Ifwecancel,finalpremiumwillbecalculatedprojournals,registers,vouchers,contracts,taxreports, ratabasedonthetimethispolicywasinforce.payrollanddisbursementrecords,andprogramsfor Finalpremiumwillnotbelessthantheproratastoringandretrievingdata.Wemayconductthe share of the minimum premium.auditsduringregularbusinesshoursduringthepolicy periodandwithinthreeyearsafterthepolicyperiod 2.Ifyoucancel,finalpremiumwillbemorethanpro ends.Informationdevelopedbyauditwillbeusedto rata;itwillbebasedonthetimethispolicywasin determinefinalpremium.Insurancerateservice force,andincreasedbyourshortratecancellation organizationshavethesamerightswehaveunder tableandprocedure.Finalpremiumwillnotbe this provision. less than the minimum premium. F.Records Youwillkeeprecordsofinformationneededto computepremium.Youwillprovideuswithcopiesof those records when we ask for them. PART SIX - CONDITIONS A.InspectionD.Cancellation Wehavetheright,butarenotobligatedtoinspect1.Youmaycancelthispolicy.Youmustmailor yourworkplacesatanytime.Ourinspectionsarenotdeliveradvancewrittennoticetousstatingwhen safetyinspections.Theyrelateonlytotheinsurabilitythe cancellation is to take effect. oftheworkplacesandthepremiumstobecharged. 2.Wemaycancelthispolicy.Wemustmailor Wemaygiveyoureportsontheconditionswefind. delivertoyounotlessthantendaysadvance Wemayalsorecommendchanges.Whiletheymay writtennoticestatingwhenthecancellationisto helpreducelosses,wedonotundertaketoperform takeeffect.Mailingthatnoticetoyouatyour thedutyofanypersontoprovideforthehealthor mailingaddressshowninItem1ofthe safetyofyouremployeesorthepublic.Wedonot InformationPagewillbesufficienttoprove warrantthatyourworkplacesaresafeorhealthfulor notice. thattheycomplywithlaws,regulations,codesor 3.Thepolicyperiodwillendonthedayandhour standards.Insurancerateserviceorganizationshave stated in the cancellation notice. the same rights we have under this provision. 4.Anyoftheseprovisionsthatconflictwithalaw B.Long Term Policy thatcontrolsthecancellationoftheinsurancein Ifthepolicyperiodislongerthanoneyearandsixteen thispolicyischangedbythisstatementtocomply days,allprovisionsofthispolicywillapplyasthougha with that law. newpolicywereissuedoneachannualanniversary E.Sole Representative that this policy is in force. TheinsuredfirstnamedinItem1oftheInformation C.Transfer of Your Rights and Duties Pagewillactonbehalfofallinsuredstochangethis Yourrightsordutiesunderthispolicymaynotbe policy,receivereturnpremium,andgiveorreceive transferred without our written consent. notice of cancellation. Ifyoudieandwereceivenoticewithinthirtydaysafter yourdeath,wewillcoveryourlegalrepresentativeas insured. Form WC 00 00 00 CPrinted in U.S.A.Page6 of6 POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS PursuanttoSection11752.8oftheCaliforniaInsurancepremiumtoreflectyourclaimhistory.Abetterclaim Code,weareprovidingyouwithanexplanationofthehistorygenerallyresultsinalowerexperiencerating California workers' compensation rating laws.modification;moreclaims,ormoreexpensive claims,generallyresultinahigherexperiencerating modification.Theuniformexperienceratingplan, 1.Weestablishourownratesforworkers’ whichisdevelopedbytheinsurancerating compensation.Ourrates,ratingplans,andrelated organizationdesignatedbytheinsurance informationarefiledwiththeinsurance commissioner,issubjecttoapprovalbythe commissioner and are open for public inspection. insurance commissioner. 2.Theinsurancecommissionercandisapproveour 5.Astandardclassificationsystem,developedbythe rates,ratingplans,orclassificationsonlyifheorshe insuranceratingorganizationdesignatedbythe hasdeterminedafterpublichearingthatourrates insurancecommissioner,issubjecttoapprovalby mightjeopardizeourabilitytopayclaimsorcreatea theinsurancecommissioner.Thestandard monopolyinthemarket.Amonopolyisdefinedby classificationsystemisamethodofrecognizingand lawasamarketwhereoneinsurerwrites20%or separatingpolicyholdersintoindustryor moreofthatpartoftheCaliforniaworkers' occupationalgroupsaccordingtotheirsimilarities compensationinsurancethatisnotwrittenbythe and/ordifferences.Wecanadoptandapplythe StateCompensationInsuranceFund.Ifthe standardclassificationsystemordevelopandapply insurancecommissionerdisapprovesourrates, ourownclassificationsystem,providedwecan ratingplans,orclassifications,heorshemayorder reportthepayroll,expenses,andothercostsof anincreaseintheratesapplicabletooutstanding claimsinawaythatisconsistentwiththeuniform policies. statistical plan or the standard classification system. 3.Ratingorganizationsmaydeveloppurepremium 6.Ourratesandclassificationsmaynotviolatethe ratesthataresubjecttotheinsurance Unruh Civil Rights Act or be unfairly discriminatory. commissioner'sapproval.Apurepremiumrate reflectstheanticipatedcostandexpensesofclaims per$100ofpayrollforagivenclassification.Pure7.Wewillprovideanappealprocessforyoutoappeal premiumratesareadvisoryonly,aswearenotthewaywerateyourinsurancepolicy.Theprocess requiredtousethepurepremiumratesdevelopedbyrequiresustorespondtoyourwrittenappealwithin any rating organization in establishing our own rates.30days.Ifyouarenotsatisfiedwiththeresultof yourappeal,youmayappealourdecisiontothe insurance commissioner. 4.Wemustadheretoasingle,uniformexperience ratingplan.Ifyouareeligibleforexperiencerating under the plan, we will berequired toadjust your Form PN 04 99 02 B (Ed. 5-02)Printed in U.S.A.Page1 of2 CALIFORNIA WORKERS’ COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section11664oftheCaliforniaInsuranceCoderequires4.Thepolicyisforaperiodofnomorethan60days us,inmostinstances,toprovideyouwithanoticeofandyouwerenotifiedatthetimeofissuancethatit nonrenewal.Exceptasspecifiedinparagraphs1may not be renewed. through6below,ifweelecttononrenewyourpolicy,we5.Yourequestedachangeinthetermsorconditions arerequiredtodeliverormailtoyouawrittennoticeorriskscoveredbythepolicywithin60dayspriorto statingthereasonorreasonsforthenonrenewalofthethe end of the policy period. policy.Thenoticeisrequiredtobesenttoyouno earlierthan120daysbeforetheendofthepolicyperiod6.Wemadeawrittenoffertoyoutorenewthepolicy andnolaterthan30daysbeforetheendofthepolicyat a premium rate increase of less than 25 percent. period.Ifwefailtoprovideyoutherequirednotice,we arerequiredtocontinuethecoverageunderthepolicy(A)Ifthepremiumrateinyourgoverning withnochangeinthepremiumrateuntil60daysafterclassificationistobeincreased25percentor we provide you with the required notice.greaterandweintendtorenewthepolicy,we shallprovideawrittennoticeofarenewaloffer Wearenotrequiredtoprovideyouwithanoticeofnotlessthan30dayspriortothepolicyrenewal nonrenewal in any of the following situations:date.Thegoverningclassificationshallbe determinedbytherulesandregulations 1.YourpolicywastransferredorrenewedwithoutaestablishedinaccordancewithCalifornia changeinitstermsorconditionsortherateonInsurance Code 11750.3(c). whichthepremiumisbasedtoanotherinsureror otherinsurerswhoaremembersofthesame(B)ForpurposesofthisNotice,“premiumrate” insurance group as us.meansthecostofinsuranceperunitof exposurepriortotheapplicationofindividual 2.Thepolicywasextendedfor90daysorlessandtheriskvariationsbasedonlossorexpense required notice was given prior to the extension.considerationssuchasscheduledratingand experience rating. 3.Youobtainedreplacementcoverageoragreed,in writing,within60daysoftheterminationoftheThisnoticedoesnotchangethepolicytowhichitis policy, to obtain that coverage.attached. Form PN 04 99 02 B (Ed. 5-02)Printed in U.S.A.Page2 of2 POLICY HOLDER NOTICE - PAYROLL BILLING ThankyouforchoosingTheHartford.Yourpolicyisonourpayrollbillingmethod.Thepayrollbillingmethodusesactual payrollsreceivedthroughoutthepolicyperiodandablendedrate(s)todeterminepremiumsdueduringthepolicyperiod. Tolearnmoreabouthowyourpremiumiscalculatedonthepayrollbillingmethodpleasevisit: https://www.thehartford.com/blended Below are the blended rate(s) being used for each state and classification code on your policy: StateClass CodeBlended RateEffective 3: LOCATION MAY VARY,88702.10000009/26/2024 COSTA MESA, CA 2: 5900 Balcones Dr., Austin,90632.32000009/26/2024 TX 1: 7432 E TIERRA BUENA90630.48000009/26/2024 LN, SCOTTSDALE, AZ Form G-4119-0Printed in U.S.A. © 2017, The Hartford POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I.Information Available to You A.Information Available from Us -Hartford Casualty Insurance Company (1)General questions regarding your policy should be directed toyour Hartford Agent or Hartford Casualty Insurance Company 3600 Wiseman Blvd San Antonio, TX 78251 Telephone:(877) 287-1312 agency.services@thehartford.com www.thehartford.com (2)DividendCalculation.Ifthisisaparticipatingpolicy(apolicyonwhichadividendmaybepaid),upon paymentornon-paymentofadividend,weshallprovideawrittenexplanationtoyouthatsetsforththe basisofthedividendcalculation.Theexplanationwillbeinclear,understandablelanguageandwill expressthedividendasadollaramountandasapercentageoftheearnedpremiumforthepolicyyear on which the dividend is calculated. (3)ClaimsInformation.PursuanttoSections3761and3762oftheCaliforniaLaborCode,youareentitled toreceiveinformationinourclaimfilesthataffectsyourpremium.Copiesofdocumentswillbesuppliedat your expense during reasonable business hours. Forclaimscoveredunderthispolicy,wewillestimatetheultimatecostofunsettledclaimsforstatistical purposeseighteenmonthsafterthepolicybecomeseffectiveandwillreportthoseestimatestothe Workers'CompensationInsuranceRatingBureauofCalifornia(WCIRB)nolaterthantwentymonthsafter thepolicybecomeseffective.Thecostofanysettledclaimswillalsobereportedatthattime.Attwelve- monthintervalsthereafter,wewillupdateandreporttotheWCIRBtheestimatedcostofanyunsettled claimsandtheactualfinalcostofanyclaimssettledintheinterim.Theamountswereportwillbeusedby the WCIRB to compute your experience modification if you are eligible for experience rating. B.Information Available from the Workers' Compensation Insurance Rating Bureau of California (1)TheWCIRBisalicensedratingorganizationandtheCaliforniaInsuranceCommissioner'sdesignated statisticalagent.Assuch,theWCIRBisresponsibleforadministeringtheCaliforniaWorkers' CompensationUniformStatisticalReportingPlan—1995(USRP)andtheCaliforniaWorkers' CompensationExperienceRatingPlan—1995(ERP).WCIRBcontactinformationis:WCIRB,1901 th HarrisonStreet,17Floor,Oakland,CA94612,Attn:CustomerService;888.229.2472(phone); 415.778.7272(fax);andcustomerservice@wcirb.com(email).TheregulationscontainedintheUSRP and ERP are available for public viewing through the WCIRB's website atwcirb.com. (2)PolicyholderInformation.PursuanttoCaliforniaInsuranceCode(CIC)Section11752.6,uponwritten request,youareentitledtoinformationrelatingtolossexperience,claims,classificationassignments,and policycontractsaswellasratingplans,ratingsystems,manualrules,orotherinformationimpactingyour premiumthatismaintainedintherecordsoftheWCIRB.ComplaintsandRequestsforActionrequesting th policyholderinformationshouldbeforwardedto:WCIRB,1901HarrisonStreet,17Floor,Oakland,CA 94612,Attn:CustodianofRecords.TheCustodianofRecordscanbereachedat415.777.0777(phone) and 415.778.7272 (fax). Form PN 04 99 01 I (02/22)Printed in U.S.A.Page1 of3 Process Date: 08/17/24Policy Expiration Date:09/26/25 (3)ExperienceRatingForm.EachexperienceratedriskmayreceiveasinglecopyofitscurrentExperience RatingForm/WorksheetfreeofchargebycompletingaPolicyholderExperienceRatingWorksheet RequestFormontheWCIRB'swebsiteatwcirb.com/ratesheet.TheExperienceRatingForm/Worksheet willincludeaLoss-FreeRating,whichistheexperiencemodificationthatwouldhavebeencalculatedif $0(zero)actuallosseswereincurredduringtheexperienceperiod.Thishypotheticalratingcalculationis provided for informational purposes only. II.Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A.Our Dispute Resolution Process. YoumaysendusawrittenComplaintandRequestforActionrequestingthatwereconsiderachangeina classificationassignmentthatresultsinanincreasedpremiumand/orrequestingthatwereviewthemannerin whichourratingsystemhasbeenappliedinconnectionwiththeinsuranceaffordedorofferedyou.Written Complaints and Requests for Action should be forwarded to: Hartford Casualty Insurance Company One Pointe Drive, Suite 200, Brea, CA 92821; Telephone (800) 451-6944; Fax (860) 723-4289. AfteryousendyourComplaintandRequestforAction,wehave30daystosendyouawrittennotice indicatingwhetheryourwrittenrequestwillbereviewed.Ifweagreetoreviewyourrequest,wemustconduct thereviewandissueadecisiongrantingorrejectingyourrequestwithin60daysaftersendingyouthewritten noticegrantingreview.Ifwedeclinetoreviewyourrequest,ifyouaredissatisfiedwiththedecisionupon review,orifwefailtograntorrejectyourrequestorissueadecisionuponreview,youmayappealtothe Insurance Commissioner as described in paragraph II.C., below. B.DisputingtheActionsoftheWCIRB.Ifyouhavebeenaggrievedbyanydecision,action,oromissiontoact oftheWCIRB,youmayrequest,inwriting,thattheWCIRBreconsideritsdecision,action,oromissiontoact. Youmayalsorequest,inwriting,thattheWCIRBreviewthemannerinwhichitsratingsystemhasbeen appliedinconnectionwiththeinsuranceaffordedorofferedyou.Forrequestsrelatedtoclassification disputes,thereportingofexperience,orcoverageissues,yourinitialrequestforreviewmustbereceivedby theWCIRBwithin12monthsaftertheexpirationdateofthepolicytowhichtherequestforreviewpertains, exceptiftherequestinvolvestheapplicationoftheRevisionofLossesrule.Forrequestsrelatedtoyour experiencemodification,yourinitialrequestforreviewmustbereceivedbytheWCIRBwithin6monthsafter theissuance,or12monthsaftertheexpirationdate,oftheexperiencemodificationtowhichtherequestfor reviewpertains,whicheverislater,exceptiftherequestforreviewinvolvestheapplicationoftheRevisionof Lossesrule.IftherequestinvolvestheRevisionofLossesrule,thetimetostateyourappealmaybelonger. (See Section VI, Rule 7 of the ERP). YoumaycommencethereviewprocessbysendingtheWCIRBawrittenInquiry.WrittenInquiriesshouldbe th sentto:WCIRB,1901HarrisonStreet,17Floor,Oakland,CA94612,Attn:CustomerService. CustomerServicecanbereachedat888.229.2472(phone),415.778.7272(fax)and customerservice@wcirb.com (email). IfyouaredissatisfiedwiththeWCIRB'sdecisionuponanInquiry,oriftheWCIRBfailstorespondwithin90 daysafterreceiptoftheInquiry,youmaypursuethesubjectoftheInquirybysendingtheWCIRBawritten ComplaintandRequestforAction.AfteryousendyourComplaintandRequestforAction,theWCIRBhas30 daystosendyouwrittennoticeindicatingwhetheryourwrittenrequestwillbereviewed.IftheWCIRBagrees toreviewyourrequest,itmustconductthereviewandissueadecisiongrantingorrejectingyourrequest within60daysaftersendingyouthewrittennoticegrantingreview.IftheWCIRBdeclinestoreviewyour request,ifyouaredissatisfiedwiththedecisionuponreview,oriftheWCIRBfailstograntorrejectyour requestorissueadecisionuponreview,youmayappealtotheInsuranceCommissionerasdescribedin paragraphII.C.,below.WrittenComplaintsandRequestsforActionshouldbeforwardedto:WCIRB,1901 th HarrisonStreet,17Floor,Oakland,CA94612,Attn:ComplaintsandReconsideration.TheWCIRB's contactinformationis888.229.2472(phone),415.371.5204(fax)andcustomerservice@wcirb.com (email). Form PN 04 99 01 I (02/22)Printed in U.S.A.Page2 of3 C.CaliforniaDepartmentofInsurance–AppealstotheInsuranceCommissioner.Afteryoufollowthe appropriatedisputeresolutionprocessdescribedabove,if(1)weortheWCIRBdeclinetoreviewyour request,(2)youaredissatisfiedwiththedecisionuponreview,or(3)weortheWCIRBfailtograntorreject yourrequestorissueadecisionuponreview,youmayappealtotheInsuranceCommissionerpursuantto CICSections11737,11752.6,11753.1andTitle10,CaliforniaCodeofRegulations,Section2509.40etseq. Youmustfileyourappealwithin30daysafterweortheWCIRBsendyouthenoticerejectingreviewofyour ComplaintandRequestforActionorthedecisionuponyourComplaintandRequestforAction.Ifnowritten decisionregardingyourComplaintandRequestforActionissent,yourappealmustbefiledwithin120days afteryousentyourComplaintandRequestforActiontousortotheWCIRB.Thefilingaddressforallappeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Mailroom Oakland, CA 94612 415.538.4243 YouhavetherighttoahearingbeforetheInsuranceCommissioner,andouraction,ortheactionofthe WCIRB, may be affirmed, modified or reversed. III.Resources Available to You in Obtaining Information and Pursuing Disputes A.PolicyholderOmbudsman.PursuanttoCaliforniaInsuranceCodeSection11752.6,apolicyholder ombudsmanisavailableattheWCIRBtoassistyouinobtainingandevaluatingtherating,policy,andclaims informationreferencedinI.A.andI.B.,above.Theombudsmanmayadviseyouonanydisputewithus,the WCIRB,oronanappealtotheInsuranceCommissionerpursuanttoSection11737oftheInsuranceCode. th TheaddressofthepolicyholderombudsmanisWCIRB,1901HarrisonStreet,17Floor,Oakland,CA94612, Attn:PolicyholderOmbudsman.Thepolicyholderombudsmancanbereachedat415.778.7159(phone), 415.371.5288 (fax) andombudsman@wcirb.com (email). B.CaliforniaDepartmentofInsurance-InformationandAssistance.Informationandassistanceonpolicy questionscanbeobtainedfromtheDepartmentofInsuranceConsumerHOTLINE,800.927.HELP(4357)or insurance.ca.gov.ForquestionsandcorrespondenceregardingappealstotheAdministrativeHearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. Form PN 04 99 01 I (02/22)Printed in U.S.A.Page3 of3 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnotenforceour right against the person or organization named in the Schedule. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE City of Scottsdale, 9191 E SAN SALVADOR DR,1 SCOTTSDALE, AZ, 85258 Countersigned by Authorized Representative Form WC 00 03 13Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Thepremiumforthepolicywillbeadjustedbyanexperienceratingmodificationfactor.Thefactorwasnotavailablewhen thepolicywasissued.Thefactor,ifany,shownontheInformationPageisanestimate.Wewillissueanendorsementto show the proper factor, if different from the factor shown, when it is calculated. Countersigned by Authorized Representative Form WC 00 04 03Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. 90-DAY REPORTING REQUIREMENT - NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Youmustreportanychangeinownershiptousinwritingwithin90daysofthedateofthechange.Changeinownership includessales,purchases,othertransfers,mergers,consolidations,dissolutions,formationsofanewentityandother changesprovidedforintheapplicableexperienceratingplan.Experienceratingismandatoryforalleligibleinsureds.The experienceratingmodificationfactor,ifany,applicabletothispolicy,maychangeifthereisachangeinyourownershipor in that of one or more of the entities eligible to be combined with you for experience rating purposes. Failuretoreportanychangeinownership,regardlessofwhetherthechangeisreportedwithin90daysofsuchchange, may result in revision of the experience rating modification factor used to determine your premium. Thisreportingrequirementappliesregardlessofwhetheranexperienceratingmodificationiscurrentlyapplicabletothis policy. Form WC 00 04 14 APrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. PART FIVE - PREMIUM AMENDATORY ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 This endorsement amends Part Five - Premium of the policy as follows: Part Five - Premium, Section A. (Our Manuals) is replaced by the following provision: A.Our Manuals Allpremiumforthispolicywillbedeterminedbyourmanualsofrules,ratesandlosscosts(asapplicable),rating plans,forms,endorsements,andclassifications,andsuchmanualsareexpresslyincorporatedbyreferenceinto,and applyto,thispolicyandanyrenewals(ourmanuals).Asusedinthispolicyandanyrenewals,ourmanualsmeans manuals that have been: 1.Developedinanyformatandfiledbythestate-designatedworkerscompensationratingoradvisoryorganization on our behalf with the appropriate state insurance regulatory authority; or 2.Developedinanyformatandfiledbytherespectivestateratingbureauonourbehalfwiththeappropriatestate insurance regulatory authority; or 3.Developed in any format and filed by us with the appropriate state insurance regulatory authority; and 4.Foreachoranyofthethreescenariosabove,themanualsalsomustbeapprovedforusebytheappropriate state insurance regulatory authority, or as otherwise authorized by law as applicable. Wemaychangeourmanualsandapplythechangestothispolicyandanyrenewalsifsuchmanualchangesare approvedforusebytheappropriatestateinsuranceregulatoryauthority,oranotherwiseauthorizedbylawas applicable. Part Five - Premium, Section D. (Premium Payments) is replaced by the following provision: D.Premium Payments Youwillpayallpremiumwhendue.Youwillpaythepremiumevenifpartorallofaworkerscompensationlawisnot valid. The due date for audit and retrospective premiums is the due date specified in the billing for the policy. Form WC 00 04 19 APrinted in U.S.A. Process Date:08/17/2024Policy Expiration Date:09/26/2025 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 ThisendorsementisnotificationthatwearechargingForpurposesofthisendorsement,Catastrophe(Other premiumtocoverthelossesthatmayoccurintheThanCertifiedActsofTerrorism)isdefinedas:Asingle eventofaCatastrophe(OtherThanCertifiedActsofeventorperilresultinginagroupofclaimswith Terrorism)asthattermisdefinedbelow.Yourpolicyaggregateworkerscompensationlossesinexcessof providescoverageforworkerscompensationlosses$50million.This$50millionthresholdappliesper causedbyaCatastrophe(OtherThanCertifiedActsoccurrence,acrossallstatesforwhichclaimsarisefrom ofTerrorism).Coverageforsuchlossesissubjecttoa single event or peril. allterms,definitions,exclusions,andconditionsin yourpolicy,andanyapplicablefederaland/orstate Thepremiumchargeforthecoverageyourpolicy laws,rules,orregulations.Thispremiumchargedoes providesforworkerscompensationlossescausedbya notprovidefundingforCertifiedActsofTerrorism Catastrophe(OtherThanCertifiedActsofTerrorism)is contemplatedundertheTerrorismRiskInsurance showninItem4oftheInformationPageorinthe ProgramReauthorizationActDisclosureEndorsement Schedule below. attached to this policy. Schedule StateRatePremium See Attached Schedule Form WC 00 04 21 FPrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 PartFive-Premium,SectionG.(Audit)oftheWorkersCompensationandEmployersLiabilityInsurancePolicyisrevised by adding the following: Ifyoudonotallowustoexamineandauditallofyourrecordsthatrelatetothispolicy,and/ordonotprovideaudit informationasrequested,wemayapplyanAuditNoncomplianceCharge.ThemethodfordeterminingtheAudit Noncompliance Charge by state, where applicable, is shown in the Schedule below. IfyouallowustoexamineandauditallofyourrecordsafterwehaveappliedanAuditNoncomplianceCharge,wewill revise your premium in accordance with our manuals and Part 5 - Premium, E. (Final Premium) of this policy. Failuretocooperatewiththispolicyprovisionmayresultinthecancellationofyourinsurancecoverage,asspecified under the policy. Schedule Basis of Audit NoncomplianceMaximum Audit Noncompliance State(s) ChargeCharge Multiplier AL,AR,CO,CT,DC,DE,GA,IA,ID,Estimated Annual PremiumUp to two times IL,KY,MD,ME,MI,MN,MS,NE,NJ, NM,OR,RI,SC,SD,TN,UT,VA,VT, WV AZ, HI, KS, OKEstimated Annual PremiumTwo times NCEstimated Annual PremiumUp to three times NVEstimated Annual PremiumUp to one times WIEstimated Annual PremiumOne time Form WC 00 04 24Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ARIZONA ALCOHOL- AND DRUG-FREE WORKPLACE PREMIUM CREDIT ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Thisendorsementappliesonlytotheinsuranceprovidedc.Complywiththealcoholanddrugtestingpolicy bythepolicybecauseArizonaisshowninItem3.A.ofrequirementsinaccordancewithTitle23, the Policy Information Page.Chapter 2, Article 14. Thisendorsementprovidesnoticethatpremiumforyourd.Conductalcoholanddrugtestingofprospective policymaybeaffectedbytheArizonaAlcohol-andDrug-employees. Free Workplace Premium Credit Program. e.Conductalcoholanddrugtestingofan Youmayqualifyfora5%premiumcreditifyouhaveemployee after the employee has been injured. establishedandmaintainaqualifyingalcohol-anddrug- f.Allowustohaveaccesstothealcoholanddrug freeworkplaceprograminaccordancewithTitle23, testing results under d. and e. above. Chapter 2, Article 14 of Arizona Statutes. 3.Thedeterminationthatyouhaveestablishedand Wewilldetermineyoureligibilityforthispremiumcredit maintainaqualifyingprogrammustbemadeduring aftertotalpremiumhasbeenpaidforthepolicyperiod eachpolicytermthatyoureceivethepremium andmayberevisedatthetimeyourfinalpremiumaudit credit. is processed. 4.Yourcertificationandanyotherinformationrelied Thedeterminationthatyouhaveaqualifyingprogram uponbytheinsureringrantingthepremiumcredit mustbemadeeachyearthatyoureceivethepremium mustbekeptintheinsurer’sunderwritingfilesand credit.Toimplementapremiumcreditprogram,the madeavailabletotheDepartmentofInsuranceupon following guidelines must be established: request. 1.Insurersofferingthepremiumcreditprogrammay 5.Thepremiumcreditmaybeappliedaftertotal apply a 5% premium credit to qualifying employers. premiumhasbeenpaidforthepolicyperiodand 2.To receive the premium credit, you must:mayberevisedatfinalaudittotheemployer’s policy.Thecreditisapplicableasasupplementto a.Provideawrittenstatementtotheinsurerprior deviatedratesandisappliedinamultiplicative toorwithin30daysafterthebeginningofthe manner,aftertheapplicationoftheexperience policyeffectivedateeachyear,certifyingthat modification,andbeforetheapplicationofthe thebusinesshasimplementedaprogram premium discount and expense constant. meetingtherequirementsofTitle23,Chapter2, Article 14.6.Youmustreimbursethepremiumcreditifitis determinedthatyouwerenotincompliancewiththe b.Atanytimeduringthetermofthepolicy,provide provisions of the program. additionalinformationtotheinsurer,asrequired, toconfirmthataqualifyingprogramhasbeen7.Minimumpremiumpoliciesareeligibleforthis established and is being maintained.premium credit. 8.Residualmarketemployersareeligibletoapplyfor this premium credit. Form WC 02 04 01 CPrinted in U.S.A Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ARIZONA CANCELLATION AND NONRENEWAL ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 This endorsement applies because Arizona is shown in Item 3.A. of the Information Page. Part Six - Conditions, Section D. (Cancellation) of the policy is replaced by the following: D.Cancellation and Nonrenewal 1.Youmaycancelthispolicy.Youmustmailordeliveradvancewrittennoticetousstatingwhenthecancellationis to take effect. 2.If you cancel or fail to renew this policy, we must promptly notify the Industrial Commission of Arizona. 3.Wemaycancelthispolicyifyoufailtopaypremiumwhendue,orwhenoneorbothofthepartiestoa professional employer agreement terminate the agreement. oIfwecancelornonrenewthispolicy,wemustprovidetoyouandtheIndustrialCommissionofArizonaat least 30 days' notice of the cancellation or nonrenewal. oNotice to you may be sent via mail or delivered by electronic means as follows: oMailingthatnoticetoyouatyourlast-knownmailingaddressonfilewithuswillbesufficientproofof notice. oDelivery to an email address at which you have consented to receive notices or documents. oPostingonaportal,securewebsite,electronicnetworkorsiteaccessibleviatheInternetoramobile application,computer,mobiledevice,tablet,orotherelectronicdevice,togetherwithaseparatenotice thatincludesadescriptionofthedocumentornoticethatwaspostedandthatwasprovidedbyemailto theemailaddressatwhichyouconsentedtoreceivenotice,orbyanyotherdeliverymethodtowhichyou consented. oIfyouconsentedtohavethenoticeemailedinaccordancewithArizonalaw,emailingthatnoticetoyouat your last-known email address as provided by you to us will be sufficient proof of notice. oIftheemailnoticeis:(1)rejectedfordelivery;(2)returnedtous;or(3)webecomeawarethatthe emailaddressprovidedbyyouisnolongervalid,thenwewillalsomailthatnoticetoyoubyUS PostalServicecertifiedmail,certificateofmailing,orfirst-classmailusingintelligentmailbarcode,or another similar tracking method used or approved by the US Postal Service. oIfwenonrenewthispolicyandfailtogiveyounoticeofnonrenewal,coveragewillnotextendbeyond the policy period. 4.The policy period will end on the date and time stated in the cancellation or nonrenewal notice. 5.Anyoftheseprovisionsthatconflictwithalawthatcontrolsthecancellationoftheinsuranceinthispolicyis changed by this statement to comply with the law. Form WC 02 06 01 CPrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. POLICY AMENDATORY ENDORSEMENT - CALIFORNIA Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Itisagreedthat,anythinginthepolicytothecontraryandwillreimburseusforanyincreaseinindemnity notwithstanding,suchinsuranceasisaffordedbythispaymentnotcoveredunderthepolicywhenthe policybyreasonofthedesignationofCaliforniainItemaggregatetotalamountofthereimbursement 3oftheInformationPageissubjecttothefollowingpaymentspaidinapolicyyearexceedsone provisions:hundred dollars ($100). Ifwenotifyyouinwriting,within30daysofthe payment,thatyouareobligatedtoreimburseus,we 1.MinorsIllegallyEmployed-NotInsured.This willbillyoufortheamountofincreaseinindemnity policydoesnotcoverliabilityforadditional paymentandcollectitnolaterthanthefinalaudit. compensationimposedonyouunderSection4557, Youwillhave60days,followingnoticeofthe DivisionIV,LaborCodeoftheStateofCalifornia, obligationtoreimburse,toappealthedecisionofthe byreasonofinjurytoanemployeeundersixteen insurer to the Department of Insurance. yearsofageandillegallyemployedatthetimeof injury.4.ApplicationofPolicy.PartOne,"Workers CompensationInsurance",A,"HowThisInsurance 2.PunitiveorExemplaryDamages-Uninsurable. Applies", is amended to read as follows: Thispolicydoesnotcoverpunitiveorexemplary damageswhereinsuranceofliabilitythereforisThisworkerscompensationinsuranceappliesto prohibited by law or contrary to public policy.bodilyinjurybyaccidentordisease,includingdeath resultingtherefrom.Bodilyinjurybyaccidentmust 3.IncreaseinIndemnityPayment- occurduringthepolicyperiod.Bodilyinjuryby Reimbursement.Youareobligatedtoreimburse diseasemustbecausedoraggravatedbythe usfortheamountofincreaseinindemnity conditionsofyouremployment.Youremployee's paymentsmadepursuanttoSubdivision(d)of exposuretothoseconditionscausingoraggravating Section4650oftheCaliforniaLaborCode,ifthe suchbodilyinjurybydiseasemustoccurduringthe lateindemnitypaymentwhichgivesrisetothe policy period. increaseintheamountofpaymentisdueless thanseven(7)daysafterwereceivethe5.RateChanges.Thepremiumandrateswith completedclaimformfromyou.Youarerespecttotheinsuranceprovidedbythis obligatedtoreimburseusforanyincreaseinpolicy by reason of the designation ofCalifornia in indemnity payments not covered under this policy Form WC 04 03 01 BBPrinted in U.S.A.Page1 of2 Process Date:08/17/24Policy Expiration Date:09/26/25 Item3oftheInformationPagearesubjecttocoveredbythispolicy.Ifthefinalpremiumismore changeiforderedbytheInsuranceCommissionerthanthepremiumyoupaidtous,youmustpayus oftheStateofCaliforniapursuanttoSection11737thebalance.Ifitisless,wewillrefundthebalance of the California Insurance Code.toyou.Thefinalpremiumwillnotbelessthanthe highestminimumpremiumfortheclassifications 6.LongTermPolicy.Ifthispolicyiswrittenfora covered by this policy. periodlongerthanoneyear,alltheprovisionsof thispolicyshallapplyseparatelytoeachIfthispolicyiscanceled,finalpremiumwillbe consecutivetwelve-monthperiodor,ifthefirstordeterminedinthefollowingwayunlessourmanuals lastconsecutiveperiodislessthantwelvemonths,provide otherwise: tosuchperiodoflessthantwelvemonths,inthe a.Ifwecancel,finalpremiumwillbecalculatedpro samemannerasifaseparatepolicyhadbeen ratabasedonthetimethispolicywasinforce. written for each consecutive period. Finalpremiumwillnotbelessthantheprorata 7.StatutoryProvision.Youremployeehasafirstshare of the minimum premium. lienuponanyamountwhichbecomesowingtoyoub.Ifyoucancel,finalpremiummaybemorethan byusonaccountofthispolicy,andinthecaseofprorata;itwillbebasedonthetimethispolicy yourlegalincapacityorinabilitytoreceivethewasinforce,andmaybeincreasedbyour moneyandpayittotheclaimant,wewillpayitshort-ratecancelationtableandprocedure. directly to the claimant.Finalpremiumwillnotbelessthantheprorata share of the minimum premium. 8.PartFive,"Premium",E,"FinalPremium",is amended to read as follows: Itisfurtheragreedthatthispolicy,includingall endorsementsformingapartthereof,constitutesthe ThepremiumshownontheInformationPage, entirecontractofinsurance.Nocondition,provision, schedules,andendorsementsisanestimate.The agreement,orunderstandingnotsetforthinthispolicyor finalpremiumwillbedeterminedafterthispolicy suchendorsementsshallaffectsuchcontractorany endsbyusingtheactual,nottheestimated, rights, duties, or privileges arising therefrom. premiumbasisandtheproperclassificationsand rates that lawfully apply to the business and work Form WC 04 03 01 BBPrinted in U.S.A.Page2 of2 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. WAIVER OF OURRIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnotenforceour rightagainstthepersonororganizationnamedintheSchedule.(Thisagreementappliesonlytotheextentthatyou perform work under a written contract that requires you to obtain this agreement from us.) Youmustmaintainpayrollrecordsaccuratelysegregatingtheremunerationofyouremployeeswhileengagedinthework described in the Schedule. Theadditionalpremiumforthisendorsementshallbe5%oftheCaliforniaworkers'compensationpremiumotherwisedue on such remuneration. SCHEDULE Person or OrganizationJob Description Beginners Edge Sports Training, LLC7432 East Tierra02 Buena Suite 102 Scottsdale AZ 8526 Countersigned by Authorized Representative Form WC 04 03 06(1) Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. WAIVER OF OURRIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Wehavetherighttorecoverourpaymentsfromanyoneliableforaninjurycoveredbythispolicy.Wewillnotenforceour rightagainstthepersonororganizationnamedintheSchedule.(Thisagreementappliesonlytotheextentthatyou perform work under a written contract that requires you to obtain this agreement from us.) Youmustmaintainpayrollrecordsaccuratelysegregatingtheremunerationofyouremployeeswhileengagedinthework described in the Schedule. Theadditionalpremiumforthisendorsementshallbe5%oftheCaliforniaworkers'compensationpremiumotherwisedue on such remuneration. SCHEDULE Person or OrganizationJob Description City of Riverside, 3900 Main St Riverside, CA 925222 Countersigned by Authorized Representative Form WC 04 03 06(1) Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ARIZONA AMENDATORY ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 This endorsement applies because Arizona is shown in Item 3.A. of the Information Page. Item 2. of the Information Page is replaced by the following: 2.Thepolicyperiodisfrom09/26/24to09/26/2512:01a.m.inthetimezoneoftheinsured’smailingaddress.For endorsementsissuedduringthepolicyperiod,theeffectivedateisinthetimezoneoftheinsured’smailing address. Form WC 02 06 03 APrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 TheinsuranceaffordedbyPartTwo(Employers'LiabilityC.The“Exclusions”sectionismodifiedasfollows(all Insurance)byreasonofdesignationofCaliforniainItem3otherexclusionsinthe“Exclusions”sectionremain oftheInformationPageissubjecttothefollowingas is): provisions: 1.Exclusion 1 is amended to read as follows: 1.liability assumed under a contract. A.“HowThisInsuranceApplies,”isamendedtoread 2.Exclusion 2 is deleted. as follows: 3.Exclusion 7 is amended to read as follows: A.How This Insurance Applies 7.damagesarisingoutofcoercion,criticism, Thisemployers'liabilityinsuranceappliestobodily demotion,evaluation,reassignment, injurybyaccidentorbodilyinjurybydisease. discipline,defamation,harassment, Bodilyinjurymeansaphysicalinjury,including humiliation,discriminationagainstor resulting death. terminationofanyemployee,terminationof 1.Thebodilyinjurymustariseoutofandinthe employment,oranypersonnelpractices, courseoftheinjuredemployee'semployment policies, acts or omissions. by you. 4.The following exclusions are added: 2.Theemploymentmustbenecessaryor 1.bodilyinjurytoanymemberoftheflyingcrew incidental to your work in California. of any aircraft. 3.Bodilyinjurybyaccidentmustoccurduring 2.bodilyinjurytoanemployeewhenyouare the policy period. deprivedofstatutoryorcommonlaw 4.Bodilyinjurybydiseasemustbecausedor defensesoraresubjecttopenaltybecause aggravatedbytheconditionsofyour ofyourfailuretosecureyourobligations employment.Theemployee'slastdayoflast undertheworkers’compensationlaw(s) exposuretotheconditionscausingor applicabletoyouorotherwisefailtocomply aggravatingsuchbodilyinjurybydisease with that law. must occur during the policy period. 3.liabilityarisingfromCaliforniaLaborCode 5.Ifyouaresued,theoriginalsuitandany Section2810.3whichrelatestolabor relatedlegalactionsfordamagesforbodily contracting. injurybyaccidentorbydiseasemustbe broughtintheUnitedStatesofAmerica,its territories or possessions, or Canada. Countersigned by Authorized Representative Form WC 04 03 60 BPrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Youmustprovideus,orourauthorizedrepresentative,Wewillnotifyyouofyourfailuretoprovideaccessby accesstorecordsnecessarytoperformapayrollmailingacertified,return-receiptdocumentstatingthe verificationaudit.Ifyoufailtoprovideaccesswithin90increasedpremiumandthetotalamountofourcosts daysafterexpirationofthepolicy,youareliabletopayaincurredinourattempt(s)toperformanaudit.Inaddition totalpremiumequalto3timesourcurrentestimateoftoanyotherobligationsunderthiscontract,30days theannualpremiumforyourpolicy.Inaddition,ifyoufailafteryoureceivethenotification,youwillbeobligatedto toprovideaccessafterourthirdrequestwithina90daypaythetotalpremiumandcostsreferencedabove.If, orlongerperiod,youarealsoliableforourcostsinthereafter,youprovideaccesstoyourrecordswithin attemptingtoperformtheauditunlessyouprovideathreeyearsafterthepolicyexpires,orwithinanother compelling business reason for your failure.mutuallyagreedupontime,andwesucceedin performingtheaudittooursatisfaction,wewillrevise yourtotalpremiumandthecostsduetoreflectthe Wewillcontactyoutoscheduleappointmentsduring results of the audit. normal business hours. Form WC 04 04 21Printed in U.S.A.Page1 of1 Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. CALIFORNIA SHORT-RATE CANCELATION ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Itisagreedthat,anythinginthepolicytothecontrarynotwithstanding,suchinsuranceasisaffordedbythispolicyby reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: IfyoucancelthepolicyandadisclosurewasprovidedinaccordancewithSection481(c)oftheCaliforniaInsurance Code,finalpremiumwillbebasedonthetimethispolicywasinforceandincreasedbytheshort-ratecancelationtable below: ExtendedPercentofExtendedPercentofExtendedPercentof NumberofFullPolicyNumberofFullPolicyNumberofFullPolicy DaysPremiumDaysPremiumDaysPremium 1..........5%95-98..........37%219-223..........69% 2..........6%99-102..........38%224-228..........70% 3-4..........7%103-105..........39%229-232..........71% 5-6..........8%106-109..........40%233-237..........72% 7-8..........9%110-113..........41%238-241..........73% 9-10..........10%114-116..........42%242-246(8 mos.)74% 11-12..........11%117-120..........43%247-250..........75% 13-14..........12%121-124(4 mos.)44%251-255..........76% 15-16..........13%125-127..........45%256-260..........77% 17-18..........14%128-131..........46%261-264..........78% 19-20..........15%132-135..........47%265-269..........79% 21-22..........16%136-138..........48%270-273(9 mos.)80% 23-25..........17%139-142..........49%274-278..........81% 26-29..........18%143-146..........50%279-282..........82% 30-32(1 mo.)19%147-149..........51%283-287..........83% 33-36..........20%150-153(5 mos.)52%288-291..........84% 37-40..........21%154-156..........53%292-296..........85% 41-43..........22%157-160..........54%297-301..........86% 44-47..........23%161-164..........55%302-305(10 mos.)87% 48-51..........24%165-167..........56%306-310..........88% 52-54..........25%168-171..........57%311-314..........89% 55-58..........26%172-175..........58%315-319..........90% 59-62(2 mos.)27%176-178..........59%320-323..........91% 63-65..........28%179-182(6 mos.)60%324-328..........92% 66-69..........29%183-187..........61%329-332..........93% 70-73..........30%188-191..........62%333-337(11 mos.)94% 74-76..........31%192-196..........63%338-342..........95% 77-80..........32%197-200..........64%343-346..........96% 81-83..........33%201-205..........65%347-351..........97% 84-87..........34%206-209..........66%352-355..........98% 88-91(3 mos.)35%210-214(7 mos.)67%356-360..........99% 92-94..........36%215-218..........68%361-365(12 mos.)100% Form WC 04 04 22Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. CALIFORNIA CANCELATION ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Name of California Insurer:Hartford Casualty Insurance Company Thisendorsementappliesonlytotheinsuranceprovidedj.Theoccurrenceofanychangeinyourbusiness bythepolicybecauseCaliforniaisshowninItem3.A.oforoperationthatrequiresadditionalordifferent the Information Page.classification for premium calculation; ThecancelationconditioninPartSix(Conditions)ofthek.Theoccurrenceofanychangeinyourbusiness policy is replaced by these conditions:oroperationwhichcontemplatesanactivity excluded by our reinsurance treaties. Cancelation 3.Ifwecancelyourpolicyforanyofthereasonslisted 1.Youmaycancelthispolicy.Youmustmailordeliver in(a)through(f),wewillgiveyou10daysadvance advancewrittennoticetousstatingwhenthe writtennotice,statingwhenthecancelationistotake cancelation is to take effect. effect.Mailingthatnoticetoyouatyourmailing 2.Wemaycancelthispolicyforoneormoreofthe addressshowninItem1oftheInformationPagewill following reasons: besufficienttoprovenotice.Ifwecancelyourpolicy a.Non-payment of premium; foranyofthereasonslistedinItems(g)through(k), wewillgiveyou30daysadvancewrittennotice; b.Failure to report payroll; however,weagreethatintheeventofcancelation c.Failuretopermitustoauditpayrollasrequired andreissuanceofapolicyeffectiveuponamaterial bythetermsofthispolicyorofapreviouspolicy changeinownershiporoperations,noticewillnotbe issued by us; provided. d.Failuretopayanyadditionalpremiumresulting 4.Ifwemailthenoticetoyou,thestatedperiodsof fromanauditofpayrollrequiredbythetermsof noticeandyourrighttoremedytheconditionwillbe this policy or any previous policy issued by us; extendedby5daysiftheplaceofmailingandyour e.Materialmisrepresentationmadebyyouoryour mailingaddressiswithinCalifornia,10daysifthe agent; placeofmailingoryourmailingaddressisoutsideof f.Failuretocooperatewithusintheinvestigation Californiaand20daysiftheplaceofmailingoryour of a claim; mailing address is outside of the United States. g.Materialfailuretocomplywithfederalorstate 5.Thepolicyperiodwillendonthedayandhour safetyordersorwrittenrecommendationsofour stated in the cancelation notice. designated loss control representatives; h.Theoccurrenceofamaterialchangeinthe ownership of your business; i.Theoccurrenceofanychangeinyourbusiness oroperationsthatmateriallyincreasesthe hazard for frequency or severity of loss; Form WC 04 06 01 B (01/22)Printed in U.S.A. Process Date: 08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TEXAS AMENDATORY ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 ThisendorsementappliesonlytotheinsuranceprovidedbythepolicybecauseTexasisshowninItem3.A.ofthe Information Page. GENERAL SECTION B.Who Is Insured is amended to read: YouareinsuredifyouareanemployernamedinItem1oftheInformationPage.Ifthatemployerisapartnershipor jointventure,andifyouareoneofitspartnersormembers,youareinsured,butonlyinyourcapacityasanemployer of the partnership's or joint venture's employees. D.State is amended to read: State means any state or territory of the United States of America, and the District of Columbia. PART ONE - WORKERS COMPENSATION INSURANCE E.Other Insurance is amended by adding this sentence: This Section only applies if you have other insurance or are self-insured for the same loss. F.Payments You Must Make This Section is amended by deleting the words "workers compensation" from number 4. H.Statutory Provisions This Section is amended by deleting the words "after an injury occurs" from number 2. PART TWO - EMPLOYERS LIABILITY INSURANCE C.Exclusions Sections 2 and 3 are amended to add: This exclusion does not apply unless the violation of law caused or contributed to the bodily injury. Section 6 is amended to read: 6.bodilyinjuryoccurringoutsidetheUnitedStatesofAmerica,itsterritoriesorpossessions,andCanada.This exclusiondoesnotapplytobodilyinjurytoacitizenorresidentoftheUnitedStatesofAmerica,Mexicoor Canada who is temporarily outside these countries. D.We Will Defend This Section is amended by deleting the last sentence. PART FOUR - YOUR DUTIES IF INJURY OCCURS Number 6 of this part is amended to read: 6.Texaslawallowsyoutomakeweeklypaymentstoaninjuredemployeeincertaininstances.Unlessauthorized by law, do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. Form WC 42 03 01 LPrinted in U.S.A.Page1 of3 Process Date: 08/17/24Policy Expiration Date: 09/26/25 PART FIVE - PREMIUM A.Our Manuals is amended by adding this sentence: In this part, "our manuals" means manuals approved or prescribed by the Texas Department of Insurance. C.Remuneration Number 2 is amended to read: 2.AllotherpersonsengagedinworkthatwouldmakeusliableunderPartOne(WorkersCompensationInsurance) ofthispolicy.Thisparagraph2willnotapplyifyougiveusproofthattheemployersofthesepersonslawfully secured workers compensation insurance. D.Premium Payments is amended by adding this sentence: The billing statement or invoice for audit additional premiums and/or retrospective additional premiums establishes the date the premium is due. E.Final Premium Number 2 is amended to read: 2.Ifyoucancel,finalpremiumwillbecalculatedproratabasedonthetimethispolicywasinforce.Finalpremium will not be less than the pro rata share of the minimum premium. PART SIX - CONDITIONS A.Inspection is amended by adding this sentence: Your failure to comply with the safety recommendations made as a result of an inspection may cause the policy to be canceled by us. C.Transfer of Your Rights and Duties is amended to read: Yourrightsanddutiesunderthispolicymaynotbetransferredwithoutourwrittenconsent.Ifyoudie,coveragewill beprovidedforyoursurvivingspouseoryourlegalrepresentative.Thisappliesonlywithrespecttotheiractinginthe capacity as an employer and only for the workplaces listed in Items 1 and 4 on the Information Page. D.Cancellation is amended to read: 1.Youmaycancelthispolicy.Youmustmailordeliveradvancenoticetousstatingwhenthecancellationistotake effect. 2.Wemaycancelthispolicy.Wemayalsodeclinetorenewit.Wemustgiveyouwrittennoticeofcancellationor nonrenewal.Thatnoticewillbesentcertifiedmailordeliveredtoyouinperson.Acopyofthewrittennoticewill be sent to the Texas Department of Insurance-Division of Workers' Compensation. 3.Noticeofcancellationornonrenewalmustbesenttoyounotlaterthanthe30thdaybeforethedateonwhichthe cancellationornonrenewalbecomeseffective,exceptthatwemaysendthenoticenotlaterthanthe10thday beforethedateonwhichthecancellationornonrenewalbecomeseffectiveifwecancelordonotrenewbecause of: a.Fraud in obtaining coverage; b.Misrepresentation of the amount of payroll for purposes of premium calculation; c.Failure to pay a premium when payment was due; d.Anincreaseinthehazardforwhichyouseekcoveragethatresultsfromanactionoromissionandthatwould produceanincreaseintherate,includinganincreasebecauseoffailuretocomplywithreasonable recommendationsforlosscontrolortocomplywithinareasonableperiodwithrecommendationsdesignedto reduce a hazard that is under your control; e.AdeterminationbytheCommissionerofInsurancethatthecontinuationofthepolicywouldplaceusin violation of the law, or would be hazardous to the interests of subscribers, creditors, or the general public. 4.IfanotherinsurancecompanynotifiestheTexasDepartmentofInsurance-DivisionofWorkers'Compensationthat itisinsuringyouasanemployer,suchnoticemustbeacancellationofthispolicyeffectivewhentheotherpolicy starts. Add the following to the policy: PART SEVEN - OUR DUTY TO YOU FOR CLAIM NOTIFICATION A.Claims Notification Wearerequiredtonotifyyouofanyclaimthatisfiledagainstyourpolicy.Thereafterwemustnotifyyouofany proposaltosettleaclaimor,onreceiptofawrittenrequestfromyou,ofanyadministrativeorjudicialproceeding relatingtotheresolutionofaclaim,includingabenefitreviewconferenceconductedbytheTexasDepartmentof Insurance-Division of Workers' Compensation.You may, in writing, elect to waive this notification requirement. Wemust,onthewrittenrequestfromyou,provideyouwithalistofclaimschargedagainstyourpolicy,payments madeandreservesestablishedoneachclaim,andastatementexplainingtheeffectofclaimsonyourpremiumrates. Wemustfurnishtherequestedinformationtoyouinwritingnolaterthanthe30thdayafterthedatewereceiveyour request.TheinformationisconsideredtobeprovidedonthedatetheinformationisreceivedbytheUnitedStates Postal Service or is personally delivered. Form WC 42 03 01 LPrinted in U.S.A.Page2 of3 COMPLAINT NOTICE: DISPUTE RESOLUTION SERVICES NCCI’S DISPUTE RESOLUTION PROCESS DOES NOT APPLY TO WORKERS COMPENSATION CLAIMS. Forworkerscompensationclaimdisputes,see“CLAIMCOMPLAINT”below.Forissuesrelatedtoaviolationof law related to your policy, see “VIOLATIONS OF LAW” below. ImportantNote:ThedisputeresolutionservicesprovidedthroughtheDisputeResolutionProcess(Process)ofthe NationalCouncilonCompensationInsurance(NCCI)arevoluntary.TheProcessisnotanadministrativeremedythat mustbeexhaustedbeforeyoupursuereliefincourt.UsingtheProcessdoesnotpreventyouorthecarrierthatissued the policy from pursuing any available legal remedies at any time. NCCI can assist in the resolution of a dispute regarding your policy that is related to any of the following matters: oTheapplicationorinterpretationofrulescontainedinthevariousNCCImanuals(including,butnotlimitedto, classification codes and experience rating modifications) oRating programs oEndorsements oForms Contactthecarrierthatissuedthepolicyandattempttoresolvethedisputedirectly.Ifyouandthecarriercannotagree, thencontactNCCItoaskforassistance.NCCI'sBasicManualrule,DisputeResolutionProcess,addressesdisputes. Youmayobtaindisputeresolutionservicesonlyafteryouhavemadeareasonableattempttofirstresolvethedispute directly with the carrier and after you have paid any undisputed premium due to the carrier. SendyourrequestforassistancebymailtoNCCI,DisputeResolutionServices,901PeninsulaCorporateCircle,Boca Raton, FL 33487-1362; or by fax to 561-893-5043; or by email to disputeresolution@ncci.com. THISNOTICEOFTHEDISPUTERESOLUTIONPROCESSISFORINFORMATIONONLYANDDOESNOTBECOME A PART, TERM, OR CONDITION OF THIS POLICY. VIOLATIONS OF LAW: Ifyoubelievetherehasbeenaviolationoflawrelatedtoyourpolicy,fileacomplaintwiththeTexasDepartmentof Insurance: Phone: 1-800-252-3439Online: tdi.texas.gov Email: ConsumerProtection@tdi.texas.govMail: MC CO-CP, PO Box 12030, Austin, TX 78711-2030 CLAIM COMPLAINT: Ifthereisaworkerscompensationclaimcomplaintinvolvingoneofyouremployees,thencontacttheTexasDepartment ofInsurance-DivisionofWorkers'Compensation,ComplianceandInvestigationsbymailtoMC:CI,POBox12050, Austin, TX 78711-2050; or by fax to 512-490-1030; or by email to DWCCOMPLAINTS@tdi.texas.gov. THISNOTICEISFORINFORMATIONONLYANDDOESNOTBECOMEAPART,TERM,ORCONDITIONOFTHIS POLICY. Form WC 42 03 01 LPrinted in U.S.A.Page3 of3 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. WORKERS’ COMPENSATION BROAD FORM ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section III of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: INDEX SUBJECTPAGE SECTION I2 PARTS ONE and TWO2 01We Will Also Pay2 PART - THREE2 02How This Insurance Works2 PART - SIX2 03Transfer of Your Rights and Duties2 04Liberalization2 SECTION II2 VOLUNTARY COMPENSATION INSURANCE2 05Voluntary Compensation Insurance2 A.How This Insurance Applies2 B.We will Pay3 C.Exclusions3 D.Before We Pay3 E.Recovery From Others3 F.Employers’ Liability Insurance3 EMPLOYERS’ LIABILITY STOP GAP COVERAGE3 06Employers’ Liability Stop Gap Coverage3 A.Stop Gap Coverage Limited Montana, North Dakota, Ohio, Washington, West3 Virginia and Wyoming B.Part One does not Apply3 C.Application of Coverage3 D.Additional Exclusions3 E.West Virginia3 SECTION III4 07Schedule of Covered States4 Form WC 99 03 02 BPrinted in U.S.A. (Ed. 8/00)Page 1 of 4 Process Date:08/17/24Policy Expiration Date:09/26/25 © 2000, The Hartford SECTION I PARTS ONE and TWOPART THREE 1.WE WILL ALSO PAY2.How This Insurance Applies D.WeWillAlsoPayofPartOne(WORKERS’Paragraph4. ofA.How This Insurance COMPENSATION INSURANCE); and AppliesofPart3(OtherStatesInsurance)is E.WeWillAlsoPayofPartTworeplaced by the following: (EMPLOYERS’LIABILITYINSURANCE)is 4.Ifyouhaveworkontheeffectivedateofthis replaced by the following: policyinanystatenotlistedinItem3.A.ofthe We Will Also PayInformationPage,coveragewillnotbeafforded forthatstateunlesswearenotifiedwithinsixty Wewillalsopaythesecosts,inadditionto days. otheramountspayableunderthisinsurance, aspartofanyclaim,proceeding,orsuitwe PART SIX defend: 3.Transfer Of Your Rights and Duties 1.reasonableexpensesincurredatour request,INCLUDING loss of earnings; C.TransferOfYourRightsandDutiesofPart6 (Conditions) is replaced by the following: 2.premiumsforbondstorelease attachmentsandforappealbondsin Yourrightsordutiesunderthispolicymaynotbe bondamountsuptothelimitofour transferred without our written consent. liability under this insurance; Ifyoudieandwereceivenoticewithinsixty 3.litigation costs taxed against you; daysafteryourdeath,wewillcoveryourlegal representative as insured. 4.interestonajudgmentasrequiredby lawuntilweoffertheamountdueunder 4.Liberalization this law; and Ifweadoptachangeinthisformthatwouldbroaden 5.expenses we incur. thecoverageofthisformwithoutextracharge,the broadercoveragewillapplytothispolicy.Itwill applywhenthechangebecomeseffectiveinyour state. SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS’toworkinastateshowninItem3.A.ofthe LIABILITY COVERAGEInformation Page. 5.Voluntary Compensation Insurance3.ThebodilyinjurymustoccurintheUnited StatesofAmerica,itsterritoriesor A.How This Insurance Applies possessions,orCanada,andmayoccur Thisinsuranceappliestobodilyinjuryby elsewhereiftheemployeeisaUnitedStates accidentorbodilyinjurybydisease.Bodily orCanadiancitizen,orotherwiselegal injury includes resulting death. resident,andlegallyemployed,intheUnited 1.Thebodilyinjurymustbesustainedby StatesorCanadaandtemporarilyawayfrom anyofficeroremployeenotsubjectto those places. theworkers’compensationlawofany 4.Bodilyinjurybyaccidentmustoccurduring stateshowninItem3.A.ofthe the policy period. Information Page. 5.Bodilyinjurybydiseasemustbecausedor 2.Thebodilyinjurymustariseoutofandin aggravatedbytheconditionsoftheofficer’s the course of employment or incidental or employee’s employment. Form WC 99 03 02 BPrinted in U.S.A. (Ed. 8/00)Page 2 of 4 Theofficer’soremployee’slastdayofIfthepersonsentitledtothebenefitsofthis lastexposuretotheconditionscausinginsurancemakearecoveryfromothers,they oraggravatingsuchbodilyinjurybymust reimburse us for the benefits we paid them. diseasemustoccurduringthepolicy F.Employers’ Liability Insurance period. PartTwo(Employers’LiabilityInsurance)applies B.We Will Pay tobodilyinjurycoveredbythisendorsementas WewillpayanamountequaltothebenefitsthoughtheStateofEmploymentwasshownin thatwouldberequiredofyouasifyouandItem 3.A. of the Information Page. youremployeesweresubjecttotheworkers’ Thisprovision5.doesnotapplyinNewJerseyor compensationlawofanystateshowninItem Wisconsin. 3.A.oftheInformationPage.Wewillpay EMPLOYERS’ LIABILITY STOP GAP COVERAGE thoseamountstothepersonswhowouldbe 6.Employers’ Liability Stop Gap Coverage entitled to them under the law. A.ThiscoverageonlyappliesinMontana,North C.Exclusion Dakota,Ohio,Washington,WestVirginiaand This insurance does not cover: Wyoming. 1.anyobligationimposedbyworkers’ B.PartOne(Workers’CompensationInsurance) compensationoroccupationaldisease doesnotapplytoworkinstatesshownin law or any similar law. Paragraph A above. 2.bodilyinjuryintentionallycausedor C.PartTwo(Employers’LiabilityInsurance)applies aggravated by you. inthestates,showninParagraphA.,asthough 3.officersoremployeeswhohaveelected theywereshowninItem3.A.oftheInformation nottobesubjecttothestateworkers’ Page. compensation law. D.PartTwo,SectionC.Exclusionsischangedby 4.partnersorsoleproprietorsnotcovered adding these exclusions. undertheStandardSoleProprietors, This insurance does not cover; Partners,OfficersandOthersCoverage 5.bodilyinjuryintentionallycausedor Endorsement. aggravatedbyyouorinOhiobodilyinjury D.Before We Pay resultingfromanactwhichisdeterminedby Beforewepaybenefitstothepersons anOhiocourtoflawtohavebeencommitted entitled to them, they must: byyouwiththebeliefthananinjuryis 1.Releaseyouandus,inwriting,ofallsubstantiallycertaintooccur.However,the responsibility for the injury or death.costofdefendingsuchclaimsorsuitsinOhio is covered. 2.Transfertoustheirrighttorecoverfrom otherswhomayberesponsibleforthe13.bodilyinjurysustainedbyanymemberofthe injury or death.flying crew of any aircraft. 3.Cooperatewithusanddoeverything14.anyclaimforbodilyinjurywithrespectto necessarytoenableustoenforcethewhichyouaredeprivedofanydefenseor right to recover from others.defensesorareotherwisesubjecttopenalty becauseofdefaultinpremiumunderthe Ifthepersonsentitledtothebenefitsofthis provisionsoftheworkers’compensationlaw insurancefailtodothosethings,ourdutyto or laws of a state shown in Paragraph A. payendsatonce.Iftheyclaimdamages fromyouorfromusfortheinjuryordeath,E.Thisinsuranceappliestodamagesforwhichyou our duty to pay ends at once.areliableunderWestVirginiaCodeAnnot.S23- 4-2. E.Recovery From Others Ifwemakearecoveryfromothers,wewill keepanamountequaltoourexpensesof recoveryandthebenefitswepaid.Wewill pay the balance to the persons entitled to it. Form WC 99 03 02 BPrinted in U.S.A. (Ed. 8/00)Page 3 of 4 SECTION III 7.SCHEDULE OF COVERED STATESB.Ifastate,showninItem3.A.oftheInformation Page,approvesthisendorsementafterthe A.Thisendorsementonlyappliesinthestates effectivedateofthispolicy,thisendorsementwill listed in this Schedule of Covered States. applytothispolicy.Thecoveragewillapplyin thenewstateontheeffectivedateofthestate approval. C.Schedule of Covered States: CA Countersigned by Authorized Representative Form WC 99 03 02 BPrinted in U.S.A. (Ed. 8/00)Page 4 of 4 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. AMENDMENT TO WORKERS’ COMPENSATION BROAD FORM ENDORSEMENT- EMPLOYERS’ LIABILITY STOP GAP COVERAGE Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 ThisendorsementchangestheWorkers’A.ThiscoverageonlyappliesinNorthDakota, CompensationBroadFormEndorsement–Ohio, Washington, and Wyoming Employers’LiabilityStopGapCoverage E.This paragraph is removed. 6.Employers’LiabilityStopGapCoverage Form WC 99 03 58 BPrinted in U.S.A (Ed. 7/08) Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ARIZONA COUNTERSIGNATURE EXCLUSION ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Thisendorsementappliesonlytotheinsurance"Thisendorsementshallnotbebindingunless providedbythepolicybecauseArizonaisshownincountersignedbyadulyauthorizedagentofthe Item 3.A. of the Information Page.company,providedthatifthisendorsementtakeseffect asoftheeffectivedateofthepolicyand,atissueof Thefollowingwording,asmaybecontainedinthis saidpolicy,formsapartthereof,countersignedonthe policy, does not apply in Arizona: InformationPageofsaidpolicybyadulyauthorized "Thispolicyisnotbindingunlesscountersigned Agentofthecompanyshallconstitutevalid by our authorized representative." countersignature of this endorsement." Form WC 99 03 71 APrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Thisendorsementappliesonlytotheinsuranceprovidedwhenyourpremiumispaidininstallments.Theservice becauseCaliforniaisshowninItem3.A.ofthefeeis$5.00perwithdrawalwhenyouselectan Information Page.electronicfundtransferpaymentplan.Theservicefee willbeaddedtothepremiumamountshownonyour Aservice fee of $7.00 ischargedforeachinstallment premium billing statement. Form WC 99 03 75Printed in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. GOODS AND SERVICES ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Name of Insurer:Hartford Casualty Insurance Company This endorsement modifies insurance provided under all Coverage Parts of this Policy. Wemayofferormake“goodsorservices”availabletoyouthroughthisunderwritingcompany,anon-insurer subsidiary,orunaffiliatedthirdpartiesasapartofthispolicy.The“goodsorservices”maybeprovidedforacharge, atadiscount,onasubsidizedbasis,orfreeofcharge.Insomecases,wemayreceiveafeefromtheunaffiliated thirdpartiesthatprovide“goodsorservices”.Wedonotwarrantorguaranteethe“goodsorservices”providedby thirdparties,andsuchthirdpartiesshallbesolelyliableandresponsibleforthe“goodsorservices”theyprovide.The “goods or services” offered or made available by us may be modified or discontinued at any time. “Goodsorservices”meansgoods,productsorservices,includingbutnotlimitedtoriskmitigation,safety,and/orloss prevention services or equipment. Form WC 99 06 89 (02/21)Printed in U.S.A.Page1 of1 Process Date:08/17/24Policy Expiration Date:09/26/25 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. GOODS AND SERVICES ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Name of Insurer:Hartford Insurance Company of Illinois Wemayofferormake“goodsorservices”availabletoyouthroughthisunderwritingcompany,anon-insurer subsidiary,orunaffiliatedthirdpartiesasapartofthispolicy.The“goodsorservices”areoptionalandmaybe providedforacharge,atadiscount,onasubsidizedbasis,orfreeofcharge.Insomecases,wemayreceiveafee fromtheunaffiliatedthirdpartiesthatprovide“goodsorservices”.Wedonotwarrantorguaranteethe“goodsor services”providedbythirdparties,andsuchthirdpartiesshallbesolelyliableandresponsibleforthe“goodsor services”theyprovide.The“goodsorservices”offeredormadeavailablebyusmaybemodifiedordiscontinuedat any time. “Goods or services” means risk mitigation, safety, and/or loss prevention goods, products, services or equipment. Form WC 99 06 94 (06/21)Printed in U.S.A.Page1 of1 Process Date:08/17/24Policy Expiration Date:09/26/25 MAINTAINING YOUR RECORDS FOR AUDIT PURPOSES WHAT IS A PREMIUM ADJUSTMENT?Remuneration does not include: a.Employercontributionstoagroupinsuranceor WhenyourWorkers'Compensationpolicywasissuedyoupension plan other than statutory plans of insurance. paidadepositpremiumbasedonthenatureofyourb.Specialawardsforindividualinventionsor businessandestimatesofyourpayroll.Attheendofthediscoveries. policyperiod,weconductanaudittocomparethec.Overtime.* estimatesagainsttheactualfiguresandoperations. Basedonthiscomparisonanadjustmentismade.IftheSubcontractors.Intheabsenceofotherinsurance,most actualpremiumislessthanwhatyoualreadyhavepaid,astatelawsholdacontractorresponsibleforinjuriesto refundwillbemade.Ifit'smore,youwillbebilledfortheemployeesofsubcontractors.Atthetimeofaudit difference.TheseadjustmentsaresubjecttoanyminimumCertificatesofInsurancemustbeavailablefor premiums that apply.subcontractorswithemployees,inordertoavoidpayment of premium. HOW WILL THE PREMIUM ADJUSTMENT BE MADE? IndependentContractors,withoutemployees,whose Onsmaller,lesscomplexoperationswemaye-mailyou,dutiescloselyresemblethoseofanemployee,willbe callyou,ormailyouarequesttoaskyoutoprovidetheconsideredyouremployeewiththeappropriatepremium informationviaouronlineweb-basedportal,mailorcharged. telephone.Ifwerequirethisinformation,wewillprovide anelectroniclinkto,orapapercopyof,thenecessaryTheactualworkingrelationshipbetweenyouandthe forms for you to complete.IndependentContractorisexamined.Itemssuchas,but notlimitedto:whethertheworkperformedisanintegral Onlarger,morecomplexoperationsoneofourPremiumpartofyouroperations,whetheryouhavetherightto Auditorswillcontactyouforanappointment.Youwillbecontrolthedetailsofthework,themethodofpayment, contactedeitherbye-mail,telephoneormail.Ifdirected,whosuppliedthematerialsused,doestheperson theauditorwillcontactyouraccountanttoobtainasmuchregularlyworkforothers,whoseregulatoryauthoritydid informationaspossibleandcontactyouatalatertimeforpersonoperateunder,whetherthepersonisinvolvedina additional information that may be needed.separateanddistinctbusinessofferingthesameservices to the public. BASIS OF PREMIUM RECORDS Remuneration (Payroll) in most states, includes: Aspartofthepolicyconditions,weareallowedto Payment of:Wages,bonuses,commissions, examineyourfinancialbooksandrecordstodetermine overtime,*sickpay,vacationpay,*tool actualexposuresandoperations.Wewouldappreciate allowances,contributionstoindividual yourcooperationinmakingtheneededrecordsavailable retirementaccounts,employee for the auditor's inspection. contributions to employee benefit plans. Payments on What Records Will Be Needed? basis of:Piece work, incentive plans, profit sharing. Therecordsneededwillvary.Inmostcases,thePremium The value of:Housingfurnishedtoemployees,*meals Auditorwillbeabletoobtainthenecessaryauditdata furnishedtoemployees,*storecertificates, fromtwoormoreofthefollowingrecords:Journals, merchandise and other dollar substitutes. Ledgers,StateandFederalTaxReports,Individual Earning Cards, Checkbooks and Contracts. Form 98456 5th Rev. 12-13Printed in U.S.A.Page1 of2 How You Should Keep Your Recordscomputationofpremium.Theirremunerationisassigned Bymaintainingyourpayrollrecordsinaccordancewiththewithoutdivisiontotheactualoperationinwhichtheyare followingguidelines,youmightreduceyourinsuranceengaged.Iftheirdutiesarethesameasthoseofa costs.worker,foremanorsuperintendent,theirpayrollis assignedtotheclassificationthatdevelopsthehighest Overtime.Inmoststates,theamountpaidinexcessofpayroll.Minimumandmaximumpayrollsapplyto straighttimepaycanbedeductedifitcanbeverifiedinexecutive officers. yourrecords.Youmustmaintainyourrecordstoshow payseparatelybyemployeeandinsummarybyAutomatedRecords.Ifyourrecordsareautomatedor classification of work.youplantoautomateinthenearfutureyoucanobtain maximumbenefitsbysettingupyourrecordstoinclude *Divisionofanemployee'spayrolltomorethanoneinsurancerequirements.OurPremiumAuditorwillbe classification is not allowed in most states.pleasedtoassistyouinsettingupyourrecords.Contact yourHartfordRepresentativeifyouwouldlikethis Exception:Forconstruction,erectionorstevedoringassistance. operationsthepayrollofanemployeemaybeallocatedto eachtypeofworkperformedifproperrecordsarekept.NOTE:Thecontentsofthispublicationarenotintended Yourrecordsmustshowthenumberofhoursandamounttosupersedeanydefinitionsorconditionsofyourpolicy, ofpayrollforeachtypeofwork.Ifyoudonotkeepsuchathe Workers' Compensation Law or any legal rulings. breakdown,thefullsalarymustbechargedtothehighest rated classification to which the employee is exposed.*Yourstatemayhavespecificrulesorexceptions. PleasecontactyourHartfordRepresentativefordetails ExecutiveOfficersin moststates are consideredthat may apply and answer questions you may have. employeesoftheircorporationandincludedinthe Form 98456 5th Rev. 12-13Printed in U.S.A.Page2 of2 Customer Privacy Notice The Hartford Financial Services Group, Inc. and Affiliates (herein called “we, our, and us”) This Privacy Policy applies to our United States Operations Wevalueyourtrust.Wearecommittedtothec)insurance companies; responsible: d)administrators; and e)service providers; a)management; who help us serveYou and service our business. b)use; and c)protection; Whenallowedbylaw,wemaysharecertainPersonal ofPersonal Information. FinancialInformationwithotherunaffiliatedthirdparties whoassistusbyperformingservicesorfunctionssuch Thisnoticedescribeshowwecollect,disclose,and as: protectPersonal Information. a)taking surveys; We collectPersonal Information to: b)marketing our products or services; or a)service yourTransactions with us; and c)offeringfinancialproductsorservicesunderajoint b)support our business functions. agreementbetweenusandoneormorefinancial institutions. We may obtainPersonal Information from: We,andthirdpartieswepartnerwith,maytracksomeof a)You; the pagesYou visit through the use of: b)yourTransactions with us; and c)third parties such as a consumer-reporting agency.a)cookies; b)pixel tagging; or BasedonthetypeofproductorserviceYouapplyforor c)other technologies; get from us,Personal Information such as: andcurrentlydonotprocessorcomplywithanyweb a)your name; browser’s“donottrack”signalorothersimilar b)your address; mechanismthatindicatesarequesttodisableonline c)your income; trackingofindividualuserswhovisitourwebsitesoruse our services. d)your payment; or e)your credit history; Formoreinformation,ourOnlinePrivacyPolicy,which maybegatheredfromsourcessuchasapplications, governsinformationwecollectonourwebsiteandour Transactions, and consumer reports. affiliatewebsites,isavailableat https://www.thehartford.com/online-privacy-policy. ToserveYouandserviceourbusiness,wemayshare certainPersonalInformation.WewillsharePersonal WewillnotsellorshareyourPersonalFinancial Information,onlyasallowedbylaw,withaffiliatessuch Informationwithanyoneforpurposesunrelatedtoour as: businessfunctionswithoutofferingYoutheopportunity a)our insurance companies; to: b)our employee agents; a)“opt-out;” or c)our brokerage firms; and b)“opt-in;” d)our administrators. as required by law. Asallowedbylaw,wemaysharePersonalFinancial We only disclosePersonal Health Information with: Information with our affiliates to: a)your authorization; or a)market our products; or b)as otherwise allowed or required by law. b)market our services; OuremployeeshaveaccesstoPersonalInformationin toYouwithoutprovidingYouwithanoptiontoprevent the course of doing their jobs, such as: these disclosures. a)underwriting policies; WemayalsosharePersonalInformation,onlyas b)paying claims; allowed by law, with unaffiliated third parties including: c)developing new products; or a)independent agents; d)advising customers of our products and services. b)brokerage firms; Form WC 66 03 30 QPrinted in U.S.A.Page1 of2 Weusemanualandelectronicsecurityprocedurestoa)credit history; maintain: b)income; c)financial benefits; or a)the confidentiality; and d)policy or claim information. b)the integrity of; PersonalInformationthatwehave.Weusethese PersonalFinancialInformationmayincludeSocial procedures to guard against unauthorized access. SecurityNumbers,Driver’slicensenumbers,orother government-issuedidentificationnumbers,orcredit,debit SometechniquesweusetoprotectPersonal card, or bank account numbers. Information include: a)secured files; PersonalHealthInformationmeanshealthinformation such as: b)user authentication; c)encryption; a)your medical records; or d)firewall technology; and b)information about your illness, disability or injury. e)the use of detection software. PersonalInformationmeansinformationthatidentifies We are responsible for and must: Youpersonallyandisnototherwiseavailabletothe public. It includes: a)identify information to be protected; a)Personal Financial Information; and b)provide an adequate level of protection for that data; b)Personal Health Information. and c)grantaccesstoprotecteddataonlytothosepeople Transactionmeansyourbusinessdealingswithus,such whomustuseitintheperformanceoftheirjob- as: related duties. a)yourApplication; Employeeswhoviolateourprivacypoliciesand b)your request for us to pay a claim; and proceduresmaybesubjecttodiscipline,whichmay c)your request for us to take an action on your account. include termination of their employment with us. YoumeansanindividualwhohasgivenusPersonal Information in conjunction with: WewillcontinuetofollowourPrivacyPolicyregarding PersonalInformationevenwhenabusiness a)asking about; relationship no longer exists between us. b)applying for; or c)obtaining; As used in this Privacy Notice: afinancialproductorservicefromusiftheproductor Applicationmeansyourrequestforourproductor serviceisusedmainlyforpersonal,family,orhousehold service. purposes. PersonalFinancialInformationmeansfinancial information such as: Ifyouhaveanyquestionsorcommentsaboutthisprivacynotice,pleasefeelfreetocontactusatTheHartford-ConsumerRightsandPrivacy Compliance Unit, One Hartford Plaza, Mail Drop: HO1-09, Hartford, CT 06155, or at ConsumerPrivacyInquiriesMailbox@thehartford.com. ThisCustomerPrivacyNoticeisbeingprovidedonbehalfofTheHartfordFinancialServicesGroup,Inc.anditsaffiliates(includingthefollowingasof February 2024), to the extent required by the Gramm-Leach-Bliley Act and implementing regulations: 1stAGChoice,Inc.;AccessCoverageCorp,Inc.;AccessCoverageCorpTechnologies,Inc.;BusinessManagementGroup,Inc.;CervusClaimSolutions, LLC;FirstStateInsuranceCompany;FTCResolutionCompanyLLC;HartReGroupL.L.C.;HartfordAccidentandIndemnityCompany;Hartford AdministrativeServicesCompany;Hartford(Asia)Limited;HartfordCasualtyGeneralAgency,Inc.;HartfordCasualtyInsuranceCompany;Hartford CorporateUnderwritersLimited;HartfordFireGeneralAgency,Inc.;HartfordFireInsuranceCompany;HartfordFundsDistributors,LLC;HartfordFunds ManagementCompany,LLC;HartfordFundsManagementGroup,Inc.;HartfordHoldings,Inc.;HartfordInsuranceCompanyofIllinois;Hartford InsuranceCompanyoftheMidwest;HartfordInsuranceCompanyoftheSoutheast;HartfordInsurance,Ltd.;HartfordIntegratedTechnologies,Inc.; HartfordInvestmentManagementCompany;HartfordLifeandAccidentInsuranceCompany;HartfordLloyd’sCorporation;HartfordLloyd’sInsurance Company;HartfordManagement,Ltd.;HartfordManagement(UK)Limited;HartfordProductivityServicesLLC;HartfordoftheSoutheastGeneral Agency,Inc.;HartfordofTexasGeneralAgency,Inc.;HartfordResidualMarket,L.C.C.;HartfordSpecialtyInsuranceServicesofTexas,LLC;Hartford STAGVenturesLLC;HartfordStrategicInvestments,LLC;HartfordUnderwritersGeneralAgency,Inc.;HartfordUnderwritersInsuranceCompany; HartfordUnderwritingAgencyLimited;HeritageHoldings,Inc.;HeritageReinsuranceCompany,Ltd.;HLALLC;HorizonManagementGroup,LLC;HRA BrokerageServices,Inc.;LatticeStrategiesLLC;MaxumCasualtyInsuranceCompany;MaxumIndemnityCompany;MaxumSpecialtyServices Corporation;MillenniumUnderwritingLimited;MPCResolutionCompanyLLC;NavigatorsHoldings(UK)Limited;NavigatorsInsuranceCompany; NavigatorsManagementCompany,Inc.;NavigatorsSpecialtyInsuranceCompany;NavigatorsUnderwritingLimited;NewEnglandInsuranceCompany; NewEnglandReinsuranceCorporation;NewOceanInsuranceCo.,Ltd.;NICInvestments(Chile)SpA;NutmegInsuranceAgency,Inc.;Nutmeg InsuranceCompany;PacificInsuranceCompany,Limited;PropertyandCasualtyInsuranceCompanyofHartford;SentinelInsuranceCompany,Ltd.; The Navigators Group, Inc.; Trumbull Flood Management, L.L.C.; Trumbull Insurance Company; Twin City Fire Insurance Company; Y-Risk, LLC. Form WC 66 03 30 QPrinted in U.S.A.Page2 of2 POLICYHOLDER NOTICE PAYROLL RECORD AND AUDIT REQUIREMENTS FOR DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Yourpolicyincludesoneormoreconstructionorerectionclassifications.Dualwageclassificationsarepairsof classificationsthatdescribethesameconstructionorerectionoperationyetareassignedbaseduponwhetherthe employee'shourlywageisaboveorbelowaspecifiedthreshold.Eachpairofdualwageclassificationscontainsone"high wage"classificationthatisassignabletopayrollsearnedbyemployeeswhoseregularhourlywageequalsorexceedsa specifiedwagethresholdandone"lowwage"classificationthatisassignabletopayrollsearnedbyemployeeswhose regular hourly wage is less than the specified threshold. Payroll Record Requirements Theassignmentofahighwageclassificationiscontingentonverifyingthattheemployee'shourlywageequalsor exceedsthespecifiedwagethreshold.Thedeterminationoftheregularhourlywageforanynon-salariedemployeemust be supported by one of the following sources: o Originaltimecardsortimebookentriesforeachemployee.Originalrecordsmustincludetheoperations performed,thetotalhoursworkedeachdayandthetimestheemployeestartedandendedeachworkperiod throughouttheworkday.Atjoblocationswherealloftheemployer'soperationsceaseforauniformunpaid meal period, recording the start and stop times of the uniform break period is not required. o Avalidcollectivebargainingagreementthatshowstheregularhourlywageratebyjobclassificationofa worker.Ifusingacollectivebargainingagreement,therecordsmustincludeanemployeerosterbyjob classificationthatpermitsthereconciliationofindividualemployeestothejobclassificationssetforthinthe collective bargaining agreement. Thenon-salariedemployee'sregularhourlywageshallbedeterminedbydividingthatemployee'stotalremunerationby thehoursworkedduringthepayperiod,irrespectiveofwhethertheemployeeispaidonanhourly,piecework,production or commission basis. Thepayrollearnedbyanynon-salariedemployeesforwhomtherecordsspecifiedabovearenotmaintainedand/ormade available will be assigned to the low wage classification that describes the operations performed. Theregularhourlywageofsalariedemployeesisdeterminedbydividingthetotalannualremunerationby2000hours.If anemployeeissalariedforlessthan12months,theregularhourlywageforthesalariedperiodiscalculatedona prorated basis. Audit Requirements IfyourpolicyhasaneffectivedateonorafterJanuary1,2020andproducesafinalpremiumof$10,500ormore,a physicalauditisrequiredatleastonceayear;ifitproducesafinalpremiumoflessthan$10,500anddevelopspayrollina highwageclassification,aphysicalauditofthepolicyisrequiredunlessthepolicyisarenewalandaphysicalauditwas completedforoneofthetwoimmediatelyprecedingpolicyperiods.A"physicalaudit"isdefinedasanauditofpayroll, whetherconductedatthepolicyholder'slocationorataremotesite,thatisbaseduponanauditor'sexaminationofthe policyholder'sbooksofaccountsandoriginalpayrollrecords(ineitherelectronicorhardcopyform)asnecessaryto determine and verify the exposure amounts by classification. IfyouholdaC-39RoofingContractorlicensefromtheCaliforniaContractorsStateLicenseBoard,aphysicalauditis requiredonthecompletepolicyperiodofeachpolicyregardlessoftheamountoffinalpremium.SeeCaliforniaInsurance Code Section 11665(a) for additional requirements regarding the audit of C-39 license holders. Form PN 04 99 06 D Printed in U.S.A. POLICYHOLDER NOTICE OF SHORT RATE CANCELLATION PROVISIONS Ifthepolicyiscancelledbytheinsuredbeforetheendofthepolicyterm,exceptifthereasonforcancellationis permanentclosureorsaleofthebusiness,TheHartfordwillapplyashortratecancellationfee.Thismeansthatthefinal premiumwillbemorethanprorata,asitwillbeincreasedbyashortratecancellationfee.Theamountofthefeewillvary dependingonhowearlythepolicyiscancelledorwhetheryourpolicyissubjecttoanannualminimumpremium.The rangeofthefeeis5%to100%ofthefullpremium,andthefinalpremiumwillnotbelessthantheminimumpremium.The methodfordeterminingtheshortratecancellationfeecanvarybystate;contactyouragentorbrokerifmoreinformation is required. (Note: the Short Rate Cancellation rules do not apply in the state of TX.) Form WC 66 04 51 Printed in U.S.A.Page1 of1 PRODUCER COMPENSATION NOTICE YoucanreviewandobtaininformationonTheHartford’sproducercompensationpracticesat www.TheHartford.com or at 1-800-592-5717. Form G-3418-0 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT Policy Number:76WEGAZ6AMUEndorsement Number: Effective Date:09/26/24Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:Beginners Edge Sports Training 7432 E TIERRA BUENA LN SCOTTSDALEAZ85260 Name of California Insurer: Thisendorsementaddressestherequirementsofthe"ActofTerrorism"meansanyactthatiscertifiedbythe TerrorismRiskInsuranceActof2002asamendedandSecretaryoftheTreasury,inconsultationwiththe extendedbytheTerrorismRiskInsuranceProgramSecretaryofHomelandSecurity,andtheAttorney ReauthorizationActof2019.ItservestonotifyyouofGeneraloftheUnitedStatesasmeetingallofthe certainlimitationsundertheAct,andthatyourinsurancefollowing requirements: carrierischargingpremiumforlossesthatmayoccurin a.The act is an act of terrorism. the event of an Act of Terrorism. b.Theactisviolentordangeroustohumanlife, Yourpolicyprovidescoverageforworkerscompensation property or infrastructure. lossescausedbyActsofTerrorism,includingworkers c.TheactresultedindamagewithintheUnitedStates, compensationbenefitobligationsdictatedbystatelaw. oroutsideoftheUnitedStatesinthecaseofthe Coverageforsuchlossesisstillsubjecttoallterms, premisesofUnitedStatesmissionsorcertainair definitions,exclusions,andconditionsinyourpolicy,and carriers or vessels. anyapplicablefederaland/orstatelaws,rules,or d.Theacthasbeencommittedbyanindividualor regulations. individualsaspartofanefforttocoercethecivilian Definitions populationoftheUnitedStatesortoinfluencethe Thedefinitionsprovidedinthisendorsementarebased policyoraffecttheconductoftheUnitedStates onandhavethesamemeaningasthedefinitionsinthe Government by coercion. Act.Ifwordsorphrasesnotdefinedinthisendorsement "InsuredLoss"meansanylossresultingfromanactof aredefinedintheAct,thedefinitionsintheActwill terrorism(and,exceptforPennsylvania,includinganact apply. ofwar,inthecaseofworkerscompensation)thatis "Act"meanstheTerrorismRiskInsuranceActof2002, coveredbyprimaryorexcesspropertyandcasualty whichtookeffectonNovember26,2002,andany insuranceissuedbyaninsurerifthelossoccursinthe amendmentsthereto,includinganyamendments UnitedStatesoratthepremisesofUnitedStates resultingfromtheTerrorismRiskInsuranceProgram missions or to certain air carriers or vessels. Reauthorization Act of 2019. "InsurerDeductible"means,fortheperiodbeginningon January1,2021,andendingonDecember31,2027,an amountequalto20%ofourdirectearnedpremiums during the immediately preceding calendar year. Form WC 00 04 22 C (01/21)Printed in U.S.A.Page 1 of 2 Process Date:08/17/24Policy Expiration Date:09/26/25 Limitation of Liability TheActlimitsourliabilitytoyouunderthispolicy.If2.Notwithstandingitem1above,theUnitedStates aggregateInsuredLossesexceed$100,000,000,000inGovernmentwillnotmakeanypaymentunderthe acalendaryearandifwehavemetourInsurerActforanyportionofInsuredLossesthatexceed Deductible,wearenotliableforthepaymentofany$100,000,000,000. portionoftheamountofInsuredLossesthatexceeds 3.Thepremiumchargeforthecoverageyourpolicy $100,000,000,000;andforaggregateInsuredLossesup providesforInsuredLossesisincludedinthe to$100,000,000,000,wewillpayonlyaproratashareof amountshowninItem4oftheInformationPageor suchInsuredLossesasdeterminedbytheSecretaryof in the Schedule below. the Treasury. Policyholder Disclosure Notice 1.InsuredLosseswouldbepartiallyreimbursedbythe UnitedStatesGovernment.Iftheaggregateindustry InsuredLossesoccurringinanycalendaryear exceed$200,000,000,theUnitedStates Governmentwouldpay80%ofourInsuredLosses that exceed our Insurer Deductible. Schedule StateRatePremium See Attached Schedule Form WC 00 04 22 C (01/21)Printed in U.S.A.Page 2 of 2 ARIZONA NOTICE INDEPENDENT CONTRACTORS Section23-902oftheArizonastatutesstatesthatacontractorisdeemedanemployeeofthe"employer"forwhichthey are working if: O The employer retains supervision or control over the contractor and O Theworkisongoing,regular,ordinary,orroutineinyouroperationandisroutinelydonebyyourown employees If the above conditions are met, we will treat the contractor as an employee and make the appropriate premium charge. Section23-964,SectionLoftheArizonastatutesallowsacontractorwhoisasoleproprietortowaiverightstoWorkers Compensationcoverage.Noadditionalpremiumchargewillbemade,ifthesoleproprietorcompletesformWC660235 "Arizona Sole Proprietor Waiver". For further information, please contact your agent or broker. Form WC 66 02 48 Printed in U.S.A. CALIFORNIA NOTICE CALIFORNIALABORCODE3551PROVIDESTHATEVERYEMPLOYERSUBJECTTOTHECOMPENSATION PROVISIONSOFTHISCODE,EXCEPTEMPLOYERSOFEMPLOYEESDEFINEDINSUBDIVISION(d)OFSECTION 3351,SHALLGIVEEVERYNEWEMPLOYEE,EITHERATTHETIMEOFHIRE,ORBYTHEENDOFTHEFIRSTPAY PERIOD, WRITTEN NOTICE OF THE INFORMATION CONTAINED IN SECTION 3550. CALIFORNIALABORCODE3550PROVIDESTHATEVERYEMPLOYERSUBJECTTOTHECOMPENSATION PROVISIONSOFTHISDIVISIONSHALLPOSTANDKEEPPOSTEDINACONSPICUOUSLOCATIONFREQUENTED BYEMPLOYEES,ANDWHERETHENOTICEMAYBEEASILYREADBYEMPLOYEESDURINGTHEHOURSOF THEWORKDAY,ANOTICEWHICHSHALLSTATETHENAMEOFTHECURRENTCOMPENSATIONINSURANCE CARRIEROFTHEEMPLOYER,ORWHENSUCHISTHEFACT,THATTHEEMPLOYERISSELF-INSURED,AND WHO IS RESPONSIBLE FOR CLAIMS ADJUSTMENT. Form WC 66 00 15 APrinted in U.S.A. NOTICE TO POLICYHOLDER CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS PursuanttoSection11752.8oftheCaliforniaInsuranceCode,weareprovidingyouwithanexplanationofthe Californiaworkers'compensationratinglawsapplicabletonewandrenewalpolicieswithpolicyeffectivedatesonand after January 1, 1995. 1.Thelawsrequiringallinsurerstochargethesameminimumrateuniformlytoallemployerswithinagiven classificationhasbeenrepealed.BeginningJanuary1,1995,wewillestablishourownratesforworkers' compensation.Ourrateswillnotbeapplicablepriortothefirstnormalpolicyeffectivedateofapolicyinceptingonor afterJanuary1,1995.Ourrates,ratingplansandrelatedinformationarefiledwiththeInsuranceCommissionerand are open for public inspection. 2.TheInsuranceCommissionercandisapproveourrates,ratingplansorclassificationsonlyifhehasdeterminedafter publichearingthatourratesmightjeopardizeourabilitytopayclaimsorcreateamonopolyinthemarket.A monopolyisdefinedbylawasamarketwhereoneinsurerwrites20%ormoreofthatpartoftheCaliforniaworkers' compensationinsurancethatisnotwrittenbytheStateCompensationInsuranceFund.Iftheinsurance Commissionerdisapprovesourrates,ratingplansorclassification,hemayorderanincreaseintheratesapplicable to outstanding policies. 3.RatingorganizationsmaydeveloppurepremiumrateswhicharesubjecttotheInsuranceCommissioner'sapproval. Apurepremiumratereflectstheanticipatedcostandexpensesofclaimsper$100ofpayrollforagiven classification.Purepremiumratesareadvisoryonly,aswearenotrequiredtosuethepurepremiumrates developed by any rating organization in establishing our own rates. 4.Wemustadheretoasingle,uniformexperienceratingplan.Ifyouareeligibleforexperienceratingundertheplan, wewillberequiredtoadjustyourpremiumtoreflectyourclaimhistory.Abetterclaimhistorygenerallyresultsina lowerexperienceratingmodification;moreclaims,ormoreexpensiveclaims,generallyresultinahigherexperience ratingmodification.Theuniformexperienceratingplandevelopedbytheinsuranceratingorganizationdesignatedby the Insurance commissioner is subject to the approval of the Insurance Commissioner. 5.AstandardclassificationsystemdevelopedbytheinsuranceratingorganizationdesignatedbytheInsurance CommissionerissubjecttoapprovaloftheInsuranceCommissioner.Thestandardclassificationsystemisamethod ofrecognizingandseparatingpolicyholdersintoindustryoroccupationalgroupsaccordingtotheirsimilaritiesand/or differences.Wecanadoptandapplythestandardclassificationsystemordevelopandapplyourownclassification system,providedthatwecanreportthepayroll,expensesandothercostsofclaimsinawaywhichisconsistentwith the standard classification system. 6.Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7.Wewillprovideanappealprocessforyoutoappealthewaywerateyourinsurancepolicy.Theprocesswillrequire ustorespondtoyourwrittenappealwithin30days.Ifyouarenotsatisfiedwiththeresultofyourappeal,youmay appeal our decision to the Insurance Commissioner. Form WC 66 02 05 APrinted in U.S.A. DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS COMPENSATION BENEFITS TexaslawpermitsanemployertoobtainWorkers'Compensationinsurancewithadeductible.Thedeductibleappliesto benefitspayableunderTexasWorkers'CompensationLaw.Theinsuranceappliesonlytobenefitsinexcessofthe deductibleamount.Thedeductibleappliesseparatelytoeachaccidentordiseaseregardlessofthenumberofpeople whosustaininjurybysuchaccidentordiseaseorclaimormedical-onlyclaim.Thedeductibleplanshavebeenexplained tome.Premiumreductionsaredeterminedbasedonthedeductibleselected,andthehazardgroup.Thehazardgroupis determined by the classification that produces the largest amount of estimated Texas standard premium. Youarenotrequiredtochooseadeductible.Ifyoudochooseone,yourinsurancecompanywillpaythedeductible amountforyou,butyoumustreimbursetheinsurancecompanywithin30daysaftertheysendyounoticethatpaymentis due.Ifyoufailtoreimbursethecompany,theymaycancelthepolicy,upontendayswrittennotice,andanyresulting premium may be applied to the deductible amount owed. If a deductible amount is desired, please indicate below. ()Yes, I want a deductible of:(select only one) 1$per accident 2.$per claim 3.$per medical-only claim appliedtobenefitspayableundertheTexasWorkers'CompensationLaw.Iunderstandthatthecompanywillpay the deductible amount and seek reimbursement (monthly, quarterly or other) ()No, I do not want a deductible applied to benefits payable under the Texas Workers' Compensation Law ()Yes, I do want a deductible policy, but am unable to obtain for the following reason: Beginners Edge Sports Training Employer Name (print or type)Date 76WEGAZ6AMU Signature and TitlePolicy Number WC 66 01 25 APrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 POLICY NUMBER:76WEGAZ6AMU NAME OF INSURER:Hartford Casualty Insurance Company OurPresidentandSecretaryhavesignedthispolicy.Whererequiredbylaw,theInformationPagehasbeen countersigned by our duly authorized representative. Kevin Barnett, SecretaryM. Ross Fisher, President Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. ©2000 National Council on Compensation Insurance, Inc. All Rights Reserved. DELAWARE: Delaware forms have been copyrighted by the Delaware Compensation Rating Bureau Inc. NEW YORK: Includes copyrighted material of the New York Compensation Insurance Rating Board, used with its permission. © 2021 New York Compensation Insurance Rating Board, all rights reserved. NORTH CAROLINA: Includes copyrighted material of the North Carolina Rate Bureau, used with its permission. PENNSYLVANIA: Pennsylvania forms have been copyrighted by the Pennsylvania Compensation Rating Bureau. Form WC 99 00 01 KPrinted in U.S.A.Page 1 of 1 Process Date:08/17/24Policy Expiration Date:09/26/25 INSTRUCTIONS EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS AsofJanuary1,1990,Californiaemployersarerequiredbylawtofurnishaclaimformtoaninjuredworkerwithinone workingdayofknowledgeofawork-relatedinjuryorillness(otherthanFirstAid).Whileitismandatoryfortheemployer to furnish the claim form to the employee,it is not mandatory for the employee to complete it. Theemployershouldcompletesections9-17,withtheexceptionofsection13(whichreads,"Dateemployer receivedclaimform").Thisistobecompletedaftertheclaimanthascompletedhisorherportionoftheclaim form and returned it to you, at which time section 13 should beimmediatelyfilled out or date stamped. PenaltiescanbeinvokedifemployersfailtoprovideaninjuredemployeeanEMPLOYEE’SCLAIMFOR COMPENSATIONBENEFITSformorifemployersfailtoreporttheclaimtotheworkers’compensation insurance carrier. DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: WhetherornottheemployeecompletestheEMPLOYEE’SCLAIMFORWORKER’SCOMPENSATION BENEFITS,pleasecontactTheHartford’sLossConnect(1-800-327-3636)toreporteveryoccupationalinjuryor illness which results in lost time beyond the date of the incident or requires medical treatment beyond First Aid. Form WC 55 00 11 D Printed in U.S.A. Immediately Report All Work-Related Injuries Through Hartford LossConnect 1)Get the facts regarding the injury. 2)Obtain employee personnel file, whenever possible. 3)Gather information listed below to expedite your call. 4)Call 24 hours a day, 365 days a year at 1-877-383-7022. What Information To Gather Before Placing Your Call DuringyourHartfordLossConnectcall,youwillbeaskedquestionssimilartothoseontheFirstReportofInjury,suchas thoselistedbelow.Themoreinformationyouhaveathand,thelesstimethecallwilltakeandthelessneedforfollow-up. Phone reports take only 10 minutes, and speed the information to open the claim. Employer Account Number or Company Tax ID Number Location Code or Policy Number Injured WorkerInjury Name And Address of the WorkerWhen/Where/How Injury Occurred Social Security NumberType of Injury (cut, burn, etc.) Age/Sex/Marital StatusExact Part of Body Injured Number of DependentsNames of Witnesses Date of Hire/Years in Current PositionName/Address of Physician/Hospital Wage InformationAnticipated Return to Work Date How Hartford LossConnect Will Speed the Process oGathersallnecessaryinformationoverthephone-eliminating the need for you to complete and submit any claim forms. oTriggersanyrequiredFirstReportofInjurynoticeaccordingto state guidelines. oForwardsFirstReportofInjurytothestate,yourcompany,and the appropriate Hartford Claim Office. WC 66 03 09 C Printed in U.S.A. DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS COMPENSATION BENEFITS TexaslawpermitsanemployertoobtainWorkers'Compensationinsurancewithadeductible.Thedeductibleappliesto benefitspayableunderTexasWorkers'CompensationLaw.Theinsuranceappliesonlytobenefitsinexcessofthe deductibleamount.Thedeductibleappliesseparatelytoeachaccidentordiseaseregardlessofthenumberofpeople whosustaininjurybysuchaccidentordiseaseorclaimormedical-onlyclaim.Thedeductibleplanshavebeenexplained tome.Premiumreductionsaredeterminedbasedonthedeductibleselected,andthehazardgroup.Thehazardgroupis determined by the classification that produces the largest amount of estimated Texas standard premium. Youarenotrequiredtochooseadeductible.Ifyoudochooseone,yourinsurancecompanywillpaythedeductible amountforyou,butyoumustreimbursetheinsurancecompanywithin30daysaftertheysendyounoticethatpaymentis due.Ifyoufailtoreimbursethecompany,theymaycancelthepolicy,upontendayswrittennotice,andanyresulting premium may be applied to the deductible amount owed. If a deductible amount is desired, please indicate below. ()Yes, I want a deductible of:(select only one) 1$per accident 2.$per claim 3.$per medical-only claim appliedtobenefitspayableundertheTexasWorkers'CompensationLaw.Iunderstandthatthecompanywillpay the deductible amount and seek reimbursement (monthly, quarterly or other) ()No, I do not want a deductible applied to benefits payable under the Texas Workers' Compensation Law ()Yes, I do want a deductible policy, but am unable to obtain for the following reason: Beginners Edge Sports Training Employer Name (print or type)Date 76WEGAZ6AMU Signature and TitlePolicy Number WC 66 01 25 APrinted in U.S.A. Process Date:08/17/24Policy Expiration Date:09/26/25 CzUvUsboOhvzfobu4;42qn-Nbs23-3136 Ejhjubmmz!tjhofe! cz!Uv!Usbo! Uv!Usbo! Ohvzfo! Ebuf;! Ohvzfo 3136/14/23! 26;42;47!.18(11( 303203136 Date 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: has intent to enter into an agreement with the City of Santa Ana. Throughout the course of this agreement, attests to the following: 1.will not use/drive any vehicle during the course and scope of the services provided in the agreement/contract. 2. will not use any owned/rented/leased vehicles during the course and scope of the services provided in the agreement/contract. 3. 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 asthe legal authority to attest to the statements above. If at any time it is found that 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. Name: Job Title: Company Name: Contact Phone: Email Address: 8502AH011930-4 CityofSantaAna 20CivicCenterPlaza SantaAnaCA,92702 QPMJDZOVNCFS;DPNNFSDJBMHFOFSBMMJBCJMJUZ 8502AH011930-4 DH3515161: UIJTFOEPSTFNFOUDIBOHFTUIFQPMJDZ/QMFBTFSFBEJUDBSFGVMMZ/ XBJWFSPGUSBOTGFSPGSJHIUTPGSFDPWFSZ BHBJOTUPUIFSTUPVT Uijtfoepstfnfounpejgjftjotvsbodfqspwjefevoefsuifgpmmpxjoh; DPNNFSDJBMHFOFSBMMJBCJMJUZDPWFSBHFQBSU QSPEVDUT0DPNQMFUFEPQFSBUJPOTMJBCJMJUZDPWFSBHFQBSU TDIFEVMF ObnfPgQfstpoPsPshboj{bujpo; CityofSantaAna 20CivicCenterPlaza SantaAnaCA,92702 JogpsnbujposfrvjsfeupdpnqmfufuijtTdifevmf-jgoputipxobcpwf-xjmmcftipxojouifEfdmbsbujpot/ UifgpmmpxjohjtbeefeupQbsbhsbqi 9/UsbotgfsPg SjhiutPgSfdpwfszBhbjotuPuifstUpVt pg Tfd. ujpoJW.Dpoejujpot; Xfxbjwfbozsjhiupgsfdpwfszxfnbzibwf bhbjotuuifqfstpopspshboj{bujpotipxojouif Tdifevmfbcpwfcfdbvtfpgqbznfoutxfnblfgps jokvszpsebnbhfbsjtjohpvupgzpvspohpjoh pqfsbujpotps#zpvsxpsl#epofvoefsbdpousbdu xjuiuibuqfstpopspshboj{bujpoboejodmvefejo uif#qspevdut.dpnqmfufepqfsbujpotib{bse#/Uijt xbjwfsbqqmjftpomzupuifqfstpopspshboj{bujpo tipxojouifTdifevmfbcpwf/ DH3515161:Dpqzsjhiu-JotvsbodfTfswjdftPggjdf-Jod/-3119 Qbhf2pg2