HomeMy WebLinkAboutORANGE COUNTY COUNCIL OF THE SOCIETY OF ST. VINCENT DE PAUL (2) - 2017AP MovrI)
INSURANCE NOT ON FILE N-2097-989
WORK MAY OT PROCEED
CLERK OF COUNCIL LICENSE GRANTING RIGHT OF ENTRY
DATE. X 18 20V
d'• NiGw THIS NONEXCLUSIVE LICENSE ("License") is made and entered into as of April 18th,
,2011 by and between the TI E, CITY OF SANTA ANA, a charter city and municipal
Gi, corporation duly organized and existing under the Constitution and laws of the State of
j California (the "City"), and the ORANGE COUNTY COUNCIL OF TI3E SOCIETY OF ST.
VINCENT DE PAUL, a Section 501(c,)(3) non-profit organization ("SVDP"), with respect to
the following:
RECITALS
A, As part of its Lights On Program ("Program"), SVDP offers interim services during the
evening hours to inmates recently released from the Orange County Jail and the Santa Ana Jail
for a short period of time immediately following their release until they are they are transported
elsewhere„ where such services include providing the released inmates with food, beverage,
and/or telephonic communication to arrange for their transportation.
B. SVDP utilizes a recreational vehicle in operating the Program and desires to park this
vehicle on a portion of the private street owned by the City and located north of Sixth Street and
south of Civic Center Drive, adjacent to the parking structure at 1020 W. Civic Center Drive, and
west of the Santa Ana Municipal Stadium/Eddie West Field located at 602 N. Flower Street,
Santa Ana, California, and identified on the Site Map attached hereto as Exhibit A ("the
Property"), so as to better provide the above mentioned services.
C. The City believes the services offered by SVDP in operating this Program benefit the
community surrounding the Orange County and Santa. Ana Jails, and wishes to accommodate
SVDP's desire to utilize the Property for parking its recreational vehicle for a limited time during
the evening hours by granting a right o[entry to SVDP upon these terms and conditions.
NOW, THEREFORE, for good and valuable consideration, SVDP and City do hereby agree as
follows:
L Right of Entry. Provided that all of the terms and conditions of this License are fully
satisfied, the City hereby grants to SVDP and its employees, agents and contractors the
nonexclusive, nonassignable, personal right to enter upon the Property from 10:00 p.m, to 4:00
a.m., unless otherwise notified by the Santa Ana Police Department Chief of Police or his
designee, for the purpose of parking its recreational vehicle to operate the Program, and for no
other purposes, It is expressly understood that this License does not in any way whatsoever
grant or convey to SVDP any rights of possession, easement or other cognizable property interest
in the Property.
2, Conditions. By execution of this License, SVDP agrees for itself and on the behalf of its
employees, agents, consultants and contractors as follows:
Page 1 of 8
(a) That SVDP shall only be granted the nonexclusive right to enter and occupy the Property
daily from 10:00 p.m. to 4:00 a.m.
(b) That SVDP will not permit any dangerous condition to be created on the Property.
(c) All acts and things done by SVDP on the Property will be done in a careful and
reasonable manner, in accordance with all federal, state and local laws.
(d) SVDP shall not allow and agrees to report to the Santa Ana Police Department any
suspected criminal activity taking place on or around the Property.
(e) SVDP shall ensure that the property is maintained and kept free of litter and debris at all
times, and that no personal belongings or similar items remain after SVVP vacates the property
each day.
(f) SVDP shall enter and occupy the Property entirely at its own cost, risk and expense.
(g) Prior to undertaking performance of any operations or services under this License, SVDP
shall maintain and shall require its contractors and/or subcontractors, if any, to obtain and
maintain insurance as described below in Section 4.
3. Termination, Modification and Suspension
(a) Term. This right of entry shall commence on the date first written above and terminate
five (5) years from that date, unless terminated earlier in accordance with subsection (b) below.
The term of this license may be extended for two (2) additional five-year periods upon written
notification provided by SVDP and a writing executed by the City and SVDP.
(b) Modification and Termination by City without Cause. This right to enter the Property is
subject to immediate temporary termination or modification upon verbal notification by the
Santa Ana Police Department Chief of Police or his designee. Additionally, SVDP understands
and agrees that the City or the Santa Ana Police Department Chief of Police or his designee may
immediately and permanently terminate this license and revol<e the right of entry for whatever
reason, but will make best efforts to give two (2) weeks notice before doing so.
4. Insurance
(a) Commercial General Liability Insurance. SVDP shall maintain commercial general
liability insurance naming the City of Santa Ana and their respective officers, employees, agents,
volunteers and representatives as additional insured(s) and shall include, but not be limited to,
protection against claims arising from bodily and personal injury, including death resulting
therefrom and damage to property, resulting from any act or occurrence arising out of SVDP's
operations in the performance of this License, including, without limitation, acts involving
vehicles. The amounts of insurance shall be not less than the following: single limit coverage
applying to bodily and personal injury, including death resulting therefrom, and property
Page 2 of 8
damage, in the total amount of $1,000,000.00 per occurrence. SVDP shall supply City with a
fully executed additional insured endorsement in substantially the form attached hereto as
Exhibit B upon execution of this License and shall be approved in form by counsel for the City.
(b) Business automobile liability insurance, or equivalent form, with a combined single limit
of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned,
hired and non -owned automobiles.
(c) In accordance with the provisions of Section 3300 of the Labor Code, SVDP, if SVDP
has any employees, is required to be insured against liability for worker's compensation or to
undertake self-insurance and as such, prior to the commencement of this License, SVDP agrees
to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per
accident.
(d) The following requirements apply to the insurance to be provided by SVDP pursuant to
this section:
• SVDP shall maintain all insurance required above in full force and effect for
the entire period covered by this License.
• Certificates of insurance shall be furnished to the City upon execution of this
License and shall be approved in form by counsel for the City.
• Certificates and policies shall state that the policies shall not be canceled or
reduced in coverage or changed in any other material aspect without thirty
(30) days prior written notice to the City.
(e) if SVDP fails or refuses to produce or maintain the insurance required by this section or
fails or refuses to furnish the City with required proof that insurance has been procured and is in
force and paid for, the City shall have the right, at its election, to forthwith terminate this
License.
5. Indemnity. SVDP hereby agrees to defend, indemnify and hold the City of Santa Ana
and its respective officers, officials, members, employees, agents, volunteers and representatives,
harmless from and against any and all loss, damage, injury, liability, claim, cost or expense
(including, without limitation, reasonable attorneys' fees, expert witness fees, court costs, and
expenses) arising from or attributable to the activities of SVDP or any of its officers, officials,
members, employees, agents, volunteers and representatives upon the Property pursuant to this
License. All use of and entry upon the Property shall be at the sole cost, risk and expense of
SVDP.
6. License Payment. Upon execution of this License SVDP shall pay to City a license fee
of $1.00.
Page 3 of 8
7. Miscellaneous.
(a) Choice of Law. This License is to be governed by, and construed in accordance with, the
laws of the State of California.
(b) Remedies. Either party shall, in addition to all other rights provided herein or as may be
provided by law, be entitled to the remedies of specific performance and injunction to enforce its
rights hereunder, except to the extent expressly provided to the contrary in this License. All
rights and remedies under this License are cumulative and no one of them shall be exclusive of
any other, and each party shall have the right to pursue any one or all of such rights and remedies
or any other remedy which may be provided by law, whether or not stated in this License, except
to the extent expressly provided to the contrary in this License.
(c) Counterparts. This License may be executed in two (2) or more counterparts, each of
which shall be deemed an original but all of which together shall constitute one and the same
instrument.
(d) Non -Liability of Public Officials. No officer, employee, member, agent or representative
of the City shall be personally liable to SVDP, or any successor in interest, in the event of any
default or breach by the City, or for any amount which may become due to SVDP or its
successor, or for any breach of any obligation of the terms of this License.
Page 4 of 8
� � s
IN WITNESS WHEREOF, the parties hereto have entered into this License as of the date first
set forth above.
AT'T'EST
By: ( >.,�
. MARIA D. HUIZAR
Clerk of the Council
APPROVED AS TO FORM:
SONIA R. CARV
CityAttRrney_
Tamak Bogos an
Assistant City Art
APPROV , AS O O ,N'I':
By� . ._
CAR.LOS ROJAS
Chief of Police
CITY OF SANTA ANA
By. zc's�
Cynthia J. Kurtz
Interim City Manager
ORANGE COUNTY COUNCIL OF THE
SOCIETY OF ST. VINCE T DE PAUL
By: i
&y
(NAME) 5n(xQ r F, LjE
(Title) ,. (2e-..4 S k R
EXHIBIT A
SITE MAPS
The above map shows the portion of the private street owned by the City and located north of
Sixth Street and south of Civic Center Drive, adjacent to the parking structure at 1020 W. Civic
Center Drive, and west of the Santa Ana Municipal Stadium/Eddie West Field located at 602 N.
Flower Street, Santa Ana, California.
The red arrow on the above map indicates the area where the vehicle shall be parked and
permitted to operate, which is in the widened area of the roadway on the west side of the street
north o[' 6"' Sweet and south of the entrance to the parking structure.
Page 7 of 8
EXIIIBIT B
ADDITIONAL INSURED ENDORSEMENT
FOR. COMMERCIAL GENERAL LIABILITY POLICY
Insurance Company
This endorsement modifies such insurance as is afforded by the provisions of Policy
relating to the following:
1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its
officers, employees, agents, volunteers and representatives are named as additional insureds
("additional insureds") with regard to liability and defense of suits arising from the operations
and uses performed by or on behalf of the named insured.
2. With respect to claims arising out of the operations and uses performed by or on
behalf of the named insured, such insurance as is afforded by this policy is primary and is not
additional to or contributing with any other insurance carried by or for the benefit of the
additional insureds.
3. This insurance applies separately to each insured against whom claim is made or
suit is brought except with respect to the company's limits of liability. The inclusion of any
person or organization as an insured shall not affect any right which such person or organization
would have as a claimant if not so included.
4. With respect to the additional insureds, this insurance shall not be cancelled, or
materially reduced in coverage or limits except after thirty (30) days written notice has been
given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701.
(Completion of the following, including countersignature, is required to make this endorsement
effective.)
Effective
Policy #
Issued to
Page 8 of 8
this endorsement form as a part of
Named Insured
Coturtersigned by
Authorized Representative
AE L1 CERTIFICATE OF LIABILITY INSURANCE DATE
)
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 DY 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(los)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER "COISTwpm, CandyCindy Anderson
Leavitt Pacific Insurance Brokers, Ines .AN¢No.EMh (408)288-6262 PAC.Non(4owxdd-7saa
License #0D79674 lamoindy-andersonOleavitt.com
N1330 S Bascom Ave '-020/7m It a INSURER(S)APFORDINa COVERAGE NAICM
San Jose CA 95128 NSURERA:Oak River Insurance Company 34630
INSURED INSURERS:
Council of Orange County INSURER0:
8014 Marine Way MOM D:
Society of St. Vincent De Paul INSURER e:
Irvine CA 92618 INSURERP:
COVERAGES CERTIFICATE NUMBER:2017-2018 St. Vincent De REVISION NUMBER:
THIS IS TO CERTIPY 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.
TNSR ADM BUM PaLICYEFF POLICY ESP
TR TYPE OF INSURANCE 0/80 MID POLICY NUMBER IIAMMOMMI IMMNDIYVYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE a OCCUR DAMAGETO RENTED
PREMISES(Ea NTED os) $
MED EXP(My one person) $
PERSONAL&ADV INJURY $
GENL AGGREGATE LIMITAPPUES PER: GENERAL AGGREGATE $
POLICY jECT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE IJARILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
AUTOS
LL NED ,.._ SCHEDULED BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS Por occldentl $ _
•
UMBRELLA UAB _OCCUR EACH OCCURRENCE I
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTIONS $
WORKERS COMPENSATION XSTATUTEcH•
ET
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE 1 E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N/A
A
Mandatory NH) SON0815604 1/1/2017 1/1/2018 E.L.DISEASE-EA EMPLOYEE $ 1,000,000
PYyon,dooCdbo Under
DESCRIPTION OFOPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 401,Addlfonel Ramada Schedule,may be attached N more apace Is requlnd)
Evidence of current workers compensation insurance
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Santa Ana Police Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Sgt. Matt Wharton ACCORDANCE WITH THE POLICY PROVISIONS.
60 Civic Center Plaza
Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE
Fred Stafford/COSSEX •�•#".....Iz-%'' r —
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORDlogo are re le red marks of ACORD
INS025(201401) ' Gir��
•
•
CC7Rre CERTIFICATE OF LIABILITY INSURANCE 24/20MIDDA Y)
la DATEA
�` 5124/2017
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 pollcy(Iss)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
thls certificate does not confer rights to the certificate holder Intros of such 9n%Qrsenlent(s).
PROMISE Mitt r
Artex Risk Solutions,Inc.(CB) NAMN ,800-ien Brothers Services PAX
2860 Golf Road,5th Floor Natoll*--(19a�Fae,sal,800-807.0300 (Arc.Nm,630.378-2508
Rolling Meadows IL 60008.4060 � A be's,
INSURERJSJ APEORDING COVERAOS NAIL k
INSURER A;Pennsylvania Manufacturers Assoc In 12262
INBUREM CHRIBRO-14 INSURER a IOld Republic Insurance Company ,,24147
Brothers of the Christian Schools&Affiliates INSURER c:
Loc#1134066 COUNCIL OF 00 SOCIETY SVDP INSURER a;
1206 Windham Parkway
Rameovllle IL 60446.1679 INSURERS;
INSURER P: _
COVERAGES CERTIFICATE NUMBER.978871424 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 OP 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,
pP} EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
/ Ily't'1(p, TYPE OP INSURANCE EN AINSOL MO POLICY NUMISR LIMITS
V A X COMMERCIAL GENERAL LIABILITY Y 821709 0578617 6116/2017 0116/2019 EACH OCCURRENCE $2,000,000
CLAIM&dAAOE X OCCUR
PREMISES(�Es�orcuresoel $IRaluded
MED EXP(Any one person) $16,000
_ PERSONAL Si ADV INJURY $Included
OEM AGGREGATE GATELIMIT APPLIES PER, GENERAL AGGREGATE $NIA _
Li
X POLICY p�p7 C LOC PRODUCTS.COMP/CP AGO $Included
OTI-ER: $
f D AUTOMU(fILE LIABILITY - Y MWTE 21543 6/15/2017 6/1512018 —r�a dnn0 INtfLELIMII' $1,000,000
X ANY AUTO BODILYINJURY(Per person) $
�1R11P D gUINIJJE.ppDWWUrLED
FIDDLY INJURY(PerBcokiers) $
X Ata ONLY X AAU7000Y
NO N D npRife TYDAMAGE
(Paracclden0 $ _
$
UMGRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR OLAIMS•MADE AGGREGATE $
DED RETENTION$ ,$
WORKERS COMPENSATIONPfR DTH•
AND EMPLOYERS'LIABILITY Y/N S7ATU,jF, ER
ANY PROPRIETOWPARTNEUXECUTIVE I P.A..EACH ACCIDENT .$
DPPICEWMEMBEREXOLUDEDP NIA
(Mandatory In NH) E.L.DISEASE•EA EMPLOYEE$
If yea,describe under
DESCRIPTION OP OPERATIONS below E.L.DISEASE.POLICY LIMIT $
DESORPTION OP OPSRATIOND/LOCATIONS/VEHICLES (AC ORS ib1,Additional Remarks Schedule,maybe atteohed If mare space[enquired)
Only the General Liability Coverage will apply on a Primary and Nan-Contributory basis(per attached endorsement)If required by fully
executed written contract.Certificate Holder Is added as Additional Insured(per attached endorsement)for General Liability and Automobile
coverages solely,strictly and specifically with regards to;
Use of Parking Lot at 1020 W Civic Center Drive.City of Santa Ana,Its officers officials members employees agents
volunteers and representatives are Included as additional insured.
CERTIFICATE HOLDER CANCELLATION '
SHOULD ANYOP THE MOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SO Civic Center Plaza PD/M-193 ACCORDANCE WITH THE POLICY PROVISIONS.
USanta
SA Ana CA92702
AUTHORIZED REPRESENTATIVE
.i^T
I
.CtwCe b'eFOder 47_,...
,...
321988.2016 ACORD CORPORATION, All rights reserved.
ACORD 25(2018/08) The ACORD name and logo are registered marks of ACORD
Per
PENNSYLVANIA MANUFACTURERS'
ASSOCIATION INSURANCE COMPANY
Attaching to end forming part of Policy No. 621700 0678917
Named Insured; THE RELIGIOUS AND CHARITABLE RISK POOLING TRUST OF THE BROTHERS OF THE
CHRISTIAN SCHOOLS AND AFFILIATES
Effective date of this endorsement Is Juno 18,2017
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED
SCHEDULED PERSON OR ORGANIZATION
This endorsement modules Insurance provided under SECTION H INSURING AGREEMENT C,GENERAL LIABILITY
COVERAGE defined within the Coverage Agreement
SECTION 1.:Schedule
Name of Additional insured Romanis) Designated Lecarlea(s) Of Covered
Or Organizatton(s): Operations
ANY PERSON OR ORGANIZATION WHEN
YOU HAVE AGREED IN A WRITTEN
CONTRACT FOR THAT PERSON OR
ORGANIZATION TO BE ADDED AS AN
ADDITIONAL INSURED ON YOUR POLICY.
If no entry appears above,information required to complete this endorsement will be shown In the Certificate of Coverage
as applicable to:this endorsement,
Section II Insuring Agreement C•Nene of Insured Amended
A. Who le An Insured defined in the General Insurance Agreement Is amended to include as an Additional Insured
the person(e)or orgenlzation(a)shown In the Schedule above,but only with respect to liability in the performance of
the Named Insured's ongoing operation's for the Additional Insured(s)at the Locetlon(s)designated in the Schedule
shove for"bodily injury"or"properly damage",caused In whole or in part,by the Named insured's acts or omissions
Mich lakes place after the execution of a written agreement with the Additional Insured(s).
B. For the coverage provided by tie endorsement;the following paragraph Is added to Section IV—General
Conditions,Section II,Insuring Agreement C-General Liability.
This Insurance is primary insurance as respects to this coverage to the additional insured person or organization,
where the written c itract or written agreement requires that this Insurance be primary and noncontributory.In tat
event,we will not seek contribution from any other Insurance policy available to the additional Insured on which the
additional insured person or organization is a Named insured
C. Who Is An Insured is also amended to Include as an additional Insured the parsons)or organization(s)shown in
the Schedule, with respect to liability for"bodily Injury" or"property damage'caused, in whole or in part, by the
"Named insured's work"at the location designated and described in the schedule of this endorsement performed far
that additional insured and Included In the"products-completed operations hazard".
The mast we will pay Is the amount of insurance required by the written contract or the amount of applicable limits of
insurance under this policy;whichever le loss.
This Insurance does not apply to any claims or sults seeking damages, including defense, arising out of, directly or
Indirectly,torn nny actual or alleged participation In any act of sexual misconduct,sexual harassment,sexual molestation,
sexual abuse or any claim sexual In nature,physical or mental,of any person.
Except as amended In this endorsement, this Insurance Is subjeot to all coverage terms, clauses and conditions in the
policy to which this endorsement Is attached arta only applies to the extent permitted by law.
Ay, Z;
THIS FORM APPLIES iN STATES WHICH USE:CA 00 01 (031 D)
IL 10 (12!06) OLD REPUBLIC INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY,PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
This endorsement modifies Insurance provided under the following;
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
SCHEDULE
Name of Person(s) or Organization(s):
All persons or organizations as required by contract or agreement
•
With respect to LIABILITY COVERAGE,Who is An Insured is changed with the addition of the following:
Each person or organization shown in the Schedule for whom you are doing work is en "Insured". But
only for "bodily Injury" or"property damage" that results from The ownership, maintenance or use of a
covered"auto"by:
1. You;
2. an"employee" of yours; or
S. anyone who drives a covered "auto"with your permission or with the permission of one of your
"employees".
However, the insurance afforded to the person or organization shown In the Schedule shall not exceed
the scope of coverage and/or limits of this policy. Not withstanding the foregoing sentence, In no event
shall the Insurance provided by this policy exceed the scope of coverage and/or limits required by the
contract or agreement.
PCA 001 03 06
MW76 21043 ReRgrow;and charitable Risk Pooling Trost 08/15/2017.06/18/2010
/1p2P,e0Ver, at-z--v-' 2 Prat'
THIS FORM APPLIES IN STATES WHICH USE:CA 00 01 (10.13)
IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
This endorsement modifies Insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
SCHEDULE
Name of Person(s)or Organizatlon(s):
All persona or organizations as required by contract or agreement
With respect to COVERED AUTOS LIABILITY COVERAGE, Who Is An Insured Is changed with the
addition of the following:
Each person or organization shown In the Schedule for whom you are doing work la an "insured". But
only for "bodily injury" or "property damage" that results from the ownership, maintenance or use of a
covered"auto"by:
1. You;
2. an"employee" of yours;or
3. anyone Who drives a covered "auto"with your permission or with the permission of one of your
"employees".
However, the Insurance afforded to the person or organization shown In the Schedule shall not exceed
the scope of ooverage and/or limns of this policy, Not withstanding the foregoing sentence, In no event
shall the insurance provided by this policy exceed the scope of coverage and/or limits required by the
contract or agreement.
PCA 001 10 13
MWTB 21543 Relryloua and Chaftable Risk Pooling Trust 00/16/2017.06/18/2018