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HomeMy WebLinkAboutUSA SHADE & FABRIC STRUCTURES (SHADE STRUCTURES, INC.) (2) Docusign Envelope ID:55838BBF-74B7-444A-BCF7-3F9F5AA589BC A-2024-144-01 MAYOR CITY MANAGER Valerie Amezcua Alvaro Nunez MAYOR PRO TEM yr. ,,�7 CITY ATTORNEY Benjamin Vazquez A— Sonia R.Carvalho COUNCILMEMBERS CITY CLERK Phil Bacerra Jennifer L.Hall Johnathan Ryan Hernandez _;', ; Jessie Lopez David Penaloza Thai Viet Phan CITY OF SANTA ANA INSURANCE NOT ON FILE WORM MAY NOT PROCEED LIBRARY SERVICES AGENCY CITY CLER�4 20 Civic Center Plaza a P.O.Box 1988 DATDEC1 2�2 Santa Ana,California 92702 E: www.santa-ana.orit UbrUlrL (61) () 1ImA qiV(pz) December 12,2025 Shade Structures, Inc. dba USA Shade& Fabric Structures Attn: Rob Blaktey, Senior Vice President PO Box 3467 Coppel TX 75019 Re: Extension of Agreement#A-2024-144 for Purchase and Installation of a Shade Structure at the Newhove Library Pursuant to Section 3 ("Tenn")of the above-referenced Agreement, entered into by Shade Structures, Inc. dba USA Shade& Fabric Structures and the City of Santa Ana, dated September 17, 2024,the time period of the Agreement is hereby extended for an additional one-year period through December 31, 2026. Any insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, Brian Sternberg Executive Director, Library Services Agency CITY OF S A ANA ATTEST - , A varo Nudez Jennifer H 11 City Manager City Cler APPROVED AS TO FORM: USA SHADE& FABRIC STRUCTURES SONIA R. CARVALHO City Attorney DgwSi9ned by: Jonathan Martinez Rob Blakley Assistant City Attorney Senior Vice President SANTA ANA CITY COUNCIL Valerie Amezcua Benjamin Vazquez Thai Viet Phan Jessie Lopez Phil Bacena Johnalhan Ryan Remandez David Penalom Mayor Mayor Pro Tem,Wald 2 W aid 1 Ward 3 Ward 4 Ward 5 Ward 6 vamezcuafiksan ana.oro bvazauezasanta-ana-org tohank4 ianla-ana.orq lessielope:b:anm-ana.Qm obacena�santa-ana.um in.,'anhernanpe4g santa-ana.om dDeA8Wza0=1a-ana.om ACORO® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/04/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain w� p y, policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 'a NAME: Aon Risk Services Central, Inc. PHONE FAX St. Louis MO Office (A/C.No.Ezt): (866) 283-7122 (A/C.No.): (800) 363-0105 'a 4220 Duncan Avenue E-MAIL 2 Suite 401 ADDRESS: St Louis Mo 63110 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Pennsylvania Manufacturers' Assoc Ins Co 12262 shade Structures, Inc. INSURERB: Allied World Assurance Company (US) Inc 19489 USA SHADE & FABRIC STRUCTURES 2580 Esters Blvd., Suite 100 INSURERC: James River Insurance Company 12203 DFW Airport, TX 75261 USA INSURERD: Columbia Casualty Company 31127 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570116964701 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDNYYY) LIMITS C X COMMERCIAL GENERAL LIABILITY Y Y 000959656 10 01 2025 10 01 2026 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR P REVISES (Eaoccurrence) $300,000 X XCU not excl MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 P'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY FTPEO �LOC PRODUCTS-COMP/OPAGG $2,000,000CID OTHER: o r A AUTOMOBILE LIABILITY y Y 152500 0652321 10/01/2025 10/01/2026 COMBINED SINGLE LIMIT $1'000,000 uD (Ea accident) )( ANYAUTO BODILY INJURY(Per person) 0 O OWNED SCHEDULED BODILY INJURY(Per accident) Z AUTOS ONLY AUTOS N HIREDAUTOS NON-OWNED PROPERTY DAMAGE 2 ONLY AUTOS ONLY (Per accident) N B X UMBRELLA LAB X OCCUR 03140086 10/01/2025 10/01/2026 EACH OCCURRENCE $5,000,000 U EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED I X RETENTION $10,000 A WORKERS COMPENSATION AND Y 2025750652321 10/01/2025 10/01/2026 X I PERSTATUTE 0TTH- EMPLOYERS'LIABILITY Y/N JER A PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ENN/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 UID SCes, un der $1,000,000 RIPTION OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Project Name: Newhope Library, Quote No. CA0623PA06712. The per location aggregate is subject to a policy cap of $10,000,000. The General Liability (on oing & Completed Operations) and Automobile Liability include a blanket Additional Insured endorsement in favor of City of Santa Ana, its City Council, its officers, officials, employees, agents, and volunteer are to be covered that provides this feature only when there is a written contract with the named insured that requires such status. General Liability insurance is primary and non-contributory. The General Liability, Automobile Liability and Workers' Compensation policies include a blanket Waiver of Subrogation endorsement in favor of City of Santa Ana, its City Council, its officers, officials, employees, agents, and volunteers are to be covered that provides this feature only when there is a CERTIFICATE HOLDER APPROVED CANCELLATION By Tu Tran Nguyen at 12:14 pm,Dec 10,2025 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana AUTHORIZED REPRESENTATIVE all� Attn: Library Services, Dylan Dario 20 Civic Center Plaza, M-42 Santa Ana CA 92701 USA igitall yned Tu Tran byrurranD sigNq =_ Nguyen ■. Date:2025.12.10 121519-0800' ©1988-2015 ACORD CORPORATION.All rights reserved ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000052633 LOC#: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk services Central , Inc. shade structures, Inc. POLICY NUMBER See Certificate Number: 570116964701 CARRIER I NAIC CODE See Certificate Number: 570116964701 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY LNSR ADDL SUBR POLICY NUNIBER LIMITS FIR TYPE OF LNSURANCE L\SD R'{'D EFFECTIVE EXPIRATION DATE DATE (MM/DD/YYYY) MM/DD/YYYY EXCESS LIABILITY D 7040440664 10/01/2025 10/01/2026 Aggregate $5,000,000 01 Excess $5M x $5M Each $5,000,000 Occurrence ACORD 101(2008101) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000052633 LOC#: A o ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk services Central , Inc. shade structures, Inc. POLICY NUMBER see certificate Number: 570116964701 CARRIER NAIC CODE see certificate Number: 570116964701 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Additional Description of Operations/Locations/Vehicles: written contract with the named insured that requires such status. umbrella Liability policy follows form. ACORD 101(2008101) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000052633 LOC#: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk services Central , Inc. shade structures, Inc. POLICY NUMBER See Certificate Number: 570116964701 CARRIER NAIC CODE See Certificate Number: 570116964701 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Companies Affording coverage LINE OF BUSINESS DESCRIPTION POLICY NUMBER POLICY POLICY COMPANY NAIC PRIMARY PERCENTAGE EFFECTIVEDATE EXPIRATION (V/N) OF (MM/I)D/YYYY/ DATE FLAG RISK MMND/YYYY General Liability 000959656 10/1/2025 10/1/2026 James River Insurance 12203 Y 100 Coverage Company Umbrella Liability 03140086 10/1/2025 10/1/2026 Allied World Assurance 19489 Y 100 company (us) Inc Business Auto 152500 0652321 10/1/2025 10/1/2026 Pennsylvania Manufacturers' 12262 Y 100 Coverage Assoc Ins Co Workers compensation 2025750652321 10/1/2025 10/1/2026 Pennsylvania Manufacturers' 12262 Y 100 Assoc Ins Co Excess Liability 7040440664 10/1/2025 10/1/2026 Columbia casualty company 31127 Y 100 coverage The Subscribing insurers' obligations under contracts of insurance to which they subscribe are several and not joint and are limited solely to the extent of their individual subscriptions. The subscribing insurers are not responsible for the subscription of any co-subscribing insurer wF for anv reason does not satisfy all or part of its obligations. ACORD 101(2008/01) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 00095965-6 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Where required by written contract or written All operations of the Named Insured agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III —Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the "products-completed operations 1. Required by the contract or agreement; or hazard". 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the applicable by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 POLICY NUMBER: 00095965-6 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Where required by written contract or written agreement. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III — Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage or personal and advertising injury required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the Declarations. insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 00095965-6 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Where required by written contract or written agreement All operations of the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodilyinjury" or damage" or "personal and advertising injury" pp y property damage occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III— Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: 00095965-6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Name Of Additional Insured Person(s) Or Organization(s): Where required by written contract or written agreement If no entry appears above, this endorsement applies to all Additional Insureds covered under this policy. Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5031 US O4-10 Page 1 of 1 POLICY NUMBER: 00095965-6 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Where required by written contract or written agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of We waive any right of recovery we may have against Rights Of Recovery Against Others To Us of the person or organization shown in the Schedule Section IV—Conditions: above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ POLICY NUMBER: 00095965-6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY LIMITATION - AMENDED AGGREGATE LIMITS OF INSURANCE PER LOCATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION III —LIMITS OF INSURANCE-The General Aggregate Limit applies separately to each "Location" of the Named Insured. Notwithstanding the application of the General Aggregate Limit to each "Location" of the Named Insured, under no circumstances will we pay more than $10,000,000 for all claims under this policy that are subject to the General Aggregate limit. For the purpose of this endorsement, the following definition is added: "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5011 US 12-03 Page 1 of 1 POLICY NUMBER: 00095965-6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY LIMITATION - AMENDED AGGREGATE LIMITS OF INSURANCE PER PROJECT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS COMBINED LIABILITY POLICY SECTION III —LIMITS OF INSURANCE-The General Aggregate Limit applies separately to each "Project" of the Named Insured. Notwithstanding the application of the General Aggregate Limit to each "Project" of the Named Insured, under no circumstances will we pay more than $10,000,000 for all claims under this policy that are subject to the General Aggregate limit. For the purpose of this endorsement, the following definition is added: "Project" means all work done by you or on your behalf, away from premises owned or rented to you,to complete an individual bid or negotiated contract to provide services for a specified period of time. Multiple jobs, work orders, purchase orders, or work done at multiple "locations" under one contract are not separate "projects"within the meaning of this coverage. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5012US 12-03 Page 1 of 1 POLICY NUMBER: 152500 0652321 COMMERCIAL AUTO CA 04 49 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. The following is added to the Other Insurance B. The following is added to the Other Insurance Condition in the Business Auto Coverage Form Condition in the Auto Dealers Coverage Form and and the Other Insurance— Primary And Excess supersedes any provision to the contrary: Insurance Provisions in the Motor Carrier This Coverage Form's Covered Autos Liability Coverage Form and supersedes any provision to Coverage and General Liability Coverages are the contrary: primary to and will not seek contribution from any This Coverage Form's Covered Autos Liability other insurance available to an "insured" under Coverage is primary to and will not seek your policy provided that: contribution from any other insurance available to 1. Such "insured" is a Named Insured under such an "insured" under your policy provided that: other insurance; and 1. Such "insured" is a Named Insured under such 2. You have agreed in writing in a contract or other insurance; and agreement that this insurance would be 2. You have agreed in writing in a contract or primary and would not seek contribution from agreement that this insurance would be any other insurance available to such primary and would not seek contribution from "insured". any other insurance available to such "insured". CA 04 49 11 16 © Insurance Services Office, Inc., 2016 Page 1 of 1 INSURED COPY POLICY NUMBER: 152500 0652321 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: PLAYPOWER, INC. Endorsement Effective Date: 10/1/2 02 5 SCHEDULE Name Of Person(s) Or Organization(s): AS REQUIRED BY WRITTEN CONTRACT Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured"for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 4810 13 ©Insurance Services Office, Inc., 2011 Page 1 of 1 AGENT POLICY NUMBER: 152500 0652321 COMMERCIAL AUTO PICA 05 04 04 14 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF RECOVERY RIGHTS This endorsement modifies coverage provided under the following: BUSINESS AUTO COVERAGE FORM AUTO DEALERS COVERAGE FORM MOTOR CARRIER COVERAGE FORM We waive any right of recovery that we may have agreement with that person or organization, if such against the person or organization shown in the contract or agreement is made and dated prior to the SCHEDULE because of payments we make for injury or loss, and if such written contract or injury or damage arising out of the operation of an agreement requires a waiver of recovery rights. This insured "auto", but such waiver is only effective if the waiver applies only to the person or organization Named Insured has entered into a written contract or shown in the SCHEDULE below. SCHEDULE Name of Person or Organization: AS REQUIRED BY WRITTEN CONTRACT . PICA 05 04 04 14 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission The PMA Insurance Group, 2014 INSURED COPY POLICY NUMBER: 202575 0652321 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE AS REQUIRED BY WRITTEN CONTRACT EXECUTED PRIOR TO THE DATE OF LOSS . 1983 National Council on Compensation Insurance. INSURED COPY