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HomeMy WebLinkAboutBEGINNERS EDGE SPORTS TRAINING, LLC (2)INSURANCE ON FILE M,RW MAY PROCEED UNTILIAURANCE EXPIRES 91 2,61 202 `� CITY DATE•'11 2 9 2024 N-2024-130-01 CITY OF SANTA ANA o. pr2csn�) FIRST AMENDMENT TO RECREATION SERVICES AGREEMENT WITH (Corllyn La"tm)"'BEGINNERS EDGE SPORTS TRAINING, LLC, FOR MULTI -SPORT PROGRAMMING THIS FIRST AMENDMENT to the above -referenced agreement is entered into on August 23, 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"). RECITALS A. The parties entered into Agreement No. N-2024-130 ("Agreement") dated March 21, 2024, to retain a qualified provider to provide multi -sport programming in the City's recreation class program. B. The Agreement is in full force and effect through March 31, 2025. C. The parties now wish to amend the Agreement to update the scope of services and facilities, increase compensation, and add two (2) additional extensions for a total of three (3) optional extensions. The Parties therefore agree: 1. Section 1, Scope of Services, is hereby amended to replace Exhibit A of the Agreement with Exhibit A-1 and Exhibit B-1 to this First Amendment. 2. Section 2a, Compensation, is hereby amended to increase the total amount by $24,000 for a "not to exceed" amount of $49,000 for the term of this Agreement, including any extension periods. 3. Section 3, Term, is hereby amended to read: 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 three (3) one-year periods upon a writing executed by the City Manager and City Attorney. 4. Except as modified by this First Amendment all terms and conditions of the Agreement shall remain in full force and effect. [signature page follows/ Page 1 of 2 SIGNATURE PAGE FOR FIRST AMENDMENT TO RECREATION SERVICES AGREEMENT WITH BEGINNERS EDGE SPORTS TRAINING, LLC, FOR MULTI -SPORT PROGRAMMING IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the Agreement on the date and year first written above. I APPROVED AS TO FORM SONIA R. CARVALHO, City Attorney By: Bra Salvatierra Deputy City Attorney RECOMMENDED FOR APPROVAL 2e4r_A= Hawk Smtt (Aug 23, 202409:53 PDT) Hawk Scott Executive Director, Parks, Recreation and Community Services Alvaro Nunez City Manager PROVIDER Mitchell Goldberg Instructor Page 2 of 2 EXHIBIT A-1 Exhibit A-1 SCOPE OF SERVICES Program Overview: This Scope of Services outlines the responsibilities and expectations for a contract class instructor organization that will provide various sports classes for ages 6 months — 99 years with a primary focus on classes for youth at City recreation facilities and parks. The aim is to promote health and wellness in the community by offering affordable recreation opportunities that encourage physical activity and teamwork. A. Instructor Responsibilities: Planning and delivering engaging and age -appropriate sports classes as defined by class curriculum and description to be approved by City staff. Ensuring the safety and well-being of all participants during class sessions. ■ Instructor will immediately report to City staff, by phone or email, any injuries as a result of class participation, damages to the facility that could cause potential injury to a class participant and/ or require facility repairs. Instructor will notify parent/ guardian of minors under the age of 18 and city staff regarding any injuries experienced during class. iii. Submitting seasonal program proposals to City staff for seasonal approval of class descriptions, details, and schedules. Proposals must be submitted in writing by way of the provided City form(s) to City staff for review and approval at least 60 days prior to the start of the new season, unless otherwise specified by City staff. City staff will review and approve written proposals based on community needs, facility availability, and alignment with City goals. iv. Adhering to all City policies and procedures related to the use of facilities and interaction with participants. v. Adhering to all City deadlines for required documentation. vi. The instructor's organization is responsible for fingerprinting, monitoring, and managing all staff that will be instructing. vii. Promotion of class(es) with City approved marketing materials outside of City managed platforms. Publicizing on additional channels and networks outside of City platforms is the sole responsibility of the instructor. viii. Instructor shall provide all materials, supplies, equipment, records and personnel. Instructor shall be responsible for repairing and maintaining all equipment and supplies, and ensuring that it is in good working condition. Instructor shall ensure clean-up of the facilities and materials to ensure the safety and effectiveness of instruction. The City will not responsible for any damage, repairs, misplaced, or stolen supplies or equipment, and will not be responsible for storing supplies or equipment. B. City Responsibilities: City shall manage participant registration and class information through registration software. Instructor shall be granted access to the class roster on the City registration system and is responsible for tracking attendance. City shall collect all enrollment fees through the registration software. Instructor shall not accept enrollment fees directly from a participant, and shall only collect materials fees that are pre -approved by City and published in advance as a part of the program marketing. Such material fees shall be collected by Instructor at the first class meeting. No additional fees shall be collected for materials, uniforms, awards, etc. without written approval and advanced advertising. iii. City shall provide publicity for class(es) seasonally in the City's recreation magazine (published seasonally). City shall have the sole discretion to decide what information will be included in the recreation magazine about the class and Instructor. Publicity may also include flyers created by City. Instructor created flyers are encouraged, but must be finalized by City to include use of City logos before distribution. iv. City shall provide a location for the class(es). Instructor will request dates and times for the class(es) seasonally in writing. The City will confirm the class(es) schedule seasonally. Location selection is based on need, size of class, type of activity and availability, and is reserved at the discretion of the City. City shall provide refunds to participants when: • The participant formally requests to drop the class before the second class meeting. ■ The class is canceled by City or Instructor. C. Program and Class Offerings: Seasonal programs and class offerings may include, but are not limited to the following class options: i. Soccer Skills Training with BEST Sports ii. Baseball & Softball Training with BEST Sports iii. 2-Sport Multi Sport by BEST SPORTS iv. 3-Sport Multi Sport by BEST SPORTS v. 3-Sport Multi Sport by BEST SPORTS vi. 4-Sport Multi Sport by BEST SPORTS vii. Basketball Skills and Drills by BEST SPORTS viii. Volleyball Skills and Drills by BEST Sports ix. Fitness, Agility, Speed and Track Training by BEST Sports x. Football Skills and Training with BEST Sports A. B.E.S.T. Pickleball Skills & Drills xii. B.E.S.T. Tennis Skills & Drills b. Instructor shall teach such or similar classes at facilities to be designated by the City, as listed in Exhibit B-1, 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. c. Class Size i. At the City's discretion and upon mutual agreement, the minimum and maximum number of participants required for each class will be determined to ensure the quality and safety of the class participants. ii. Class ratio of participants to instructor(s) will be set for each class to ensure effective instruction and safety based on statewide standards. iii. If the minimum registration has not been reached by the second class, it is up to the discretion of the City upon mutual agreement with Instructor, that the class shall be cancelled. Instructor will be under no obligation to provide services for the cancelled classes, and the City will have no further obligations to pay Instructor compensation for the remaining classes that were cancelled in that session. d. Class Fees i. Class pricing is dependent on session length per season and subject to City staff approval. Class pricing is limited to no more than a 5% increase annually. Each participant shall pay class registration fees as established by City. Instructor may not waive class participation/registration fees. Only registered participants paid in full may participate in class. iii. Any refunds to participants will be made in accordance with City policy. EXHIBIT B-1 Exhibit B-1 Recreation Facilities — Community Centers El Salvador Community Center 1825 W. Civic Center Drive Garfield Community Center 501 N. Lacy Street Jerome Community Center 726 S. Center Street Roosevelt -Walker Community Center 816 E. Chestnut Ave Salgado Community Center 706 N. Newhope St. Recreation Facilities -Senior Centers Santa Ana Senior Center 424 W. 3rd St. Southwest Senior Center 2201 W. McFadden Ave. Parks Locations Adams Park 2302 S. Raitt St. Angels Community Park 300 N. Flower St. Birch Park 400 W. 311 St. Bomo Koral Park 900 W. MacArthur Blvd. Cabrillo Park 1820 E. Fruit Street Carl Thornton Park 1801 W. Segerstorm Ave. Centennial Park 3000 W. Edinger Ave. Cesar Chavez Campesino Park 3311 W. 511 St. Chepa's Park 1009 N. Custer St. Delhi Park 2314 S. Halladay St. Ed Caruthers Park 423 S. Raitt St. Edna Park 2140 W. Edna Dr. Eldridge Park 2933 N. Fallbrook Dr. El Salvador Park 1825 W. Civic Center Dr. Fairview Triangle Park Santa Ana River Trail Fisher Park 2501 N. Flower St, French Park 901 N. French St. Friendship Park 2210 W. Myrtle St. Garfield Exercise Park 902 N. Brown St. Griset Park 2400 W MacArthur Blvd. Heritage Park 4812 W. Camille St. Jerome Park 2115 W McFadden Ave. King Street Project- Not the official name. 1000 N. King Street Lillie King Park 500 W. Alton Ave. Mabury Park 1801 E. Fruit St. Madison Park 1528 S. Standard Ave. Maple and Occidental Park Corner of Maple and Occidental Street Mariposa Park 720 E. 611 SA McFadden Triangle Park 630 S. Susan St. Memorial Park 2102 S. Flower St. Memory Lane Park 1560 W. Memory Ln. Morrison Park 2801 N. Westwood Ave. Pacific Electric Park 329 McFadden Ave. Plaza Calle Cuatro 325 E. Fourth St. Portola Park 1700 E. Santa Clara Ave. Prentice Park 1801 E. Chestnut Ave. Riverview Park 1817 W. 21't St. Rosita Park 706 N. Newhope St. Saddleback View Park 631 N. Patricia Ln. Sandpointe Park 3700 S. Birch St. Santa Anita Park 300 S. Figueroa St. Santiago Park 600 E. Memory Ln. Sasscer Park 600 W. Santa Ana Blvd. Segerstorm Triangle Park 1000 W. Hemlock Wy. Windsor Park 2915 W. La Verne Ave. 171h Street Triangle Park Santa Ana River Trail and 171h Street Sarah May Downie Herb Garden 2405 N. Flower St. 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 lAttentimc liiis email on uri::.1 1- ' -- i i C .._i A:,i 1. _e catmon = hen opnin_ at:-i _ NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH .AGREERIEN'r TO THE CLERK OF THE COUNCIL 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 l.pdf New 2023 - 2024 Workers Comp Policy AZ CA TX.pdf 1 City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 3/27/2024 6:58 PM (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