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+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/3/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Marla Johnson USI Insurance Services, Inc. PHONE FAX 601 Union Street Suite 1000 (A/C, No Ext): (360) 787-9827 (A/C, No): E-MAIL Seattle, WA 98101 ADDRESS: marla.johnson@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Fire Ins Co INSURED INSURER B: Allied World Nat'l Assurance Co. State of Utah Department of Transportation INSURER C: Liberty Insurance Corporation 4501 South 2700 West PO Box 148430 INSURER D: Ironshore Indemnity Inc. Salt Lake City, Utah 84114 INSURER E: Ohio Casualty Insuance Company INSURER F: Great American Ins. Co. of NY COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 A X CIP Utah Department of Trans TB2-631-510584-027 5/15/2019 3/6/2022 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 B X EXCESS LIAB CLAIMS-MADE 0310-5858 5/15/2019 3/6/2022 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? WA7-63D-510713- C 3/6/2020 3/6/2022 (Mandatory in NH) 830 E.L. EACH ACCIDENT $ 2,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 2,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 2,000,000 EACH OCCURRENCE AGGREGATE D 2nd Layer Excess 3087900 5/15/2019 3/6/2022 $25,000,000 $25,000,000 E 3rd Layer Excess ECO (22) 57828762 5/15/2019 3/6/2022 $25,000,000 $25,000,000 F 4th Layer Excess EXC 1552478 5/15/2019 3/6/2022 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is enrolled in the Utah Department of Transportation Owner Controlled Insurance Program and listed as Additional Insured for General Liability, Excess Liability, Builder's Risk and Contractor's Pollution in accordance with the terms and conditions of the policy. General Liability, Excess Liability, Builder's Risk and Contractor's Pollution limits and aggregates are shared by all enrolled contractors on this project. F-115-7(328)332 Layton; I-15; SR-232 to I-84 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, Hark Drilling, Inc. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12225 W Peoria Avenue Suite A AUTHORIZED REPRESENTATIVE El Mirage, AZ 85335 C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/7/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Irene Ambrosio USI Insurance Services, LLC. PHONE FAX (A/C, No. Ext): (516) 419-4013 333 Earle Ovington Blvd. (A/C. No): (610) 362-8856 E-MAIL Suite 800 ADDRESS: Irene.Ambrosio@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Star Indemnity & Liability Co INSURED INSURER B: Star Indemnity & Liability Company A & S Steel Contractors, Ltd. INSURER C: Starr Indemnity & Liability Company 38318 4 Claudet Way Eastchester, NY 10709 INSURER D: Navigator's Insurance Company INSURER E: Philadelphia Indemnity Ins Co. INSURER F: Allied World Assurance Co COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A CIP Lettire CCIP II Caton 1000025679191 6/21/2019 1/3/2022 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE 1000584879171 6/21/2019 1/3/2022 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N C OFFICER/MEMBER EXCLUDED? 900 0081009 1/3/2020 1/3/2021 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE D 2nd Layer Excess IS19EXCZ00VW3IV 6/21/2019 1/3/2022 $10,000,000 $10,000,000 E 3rd Layer Excess PHUB660781 6/21/2019 1/3/2022 $10,000,000 $10,000,000 F 4th Layer Excess 03116766 6/21/2019 1/3/2022 $25,000,000 $25,000,000 G 5th Layer Excess USL00177319 6/21/2019 1/3/2022 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS/ VEHICLES (ACORD 101. Additional Remarks Schedule may be attached if more space is required) Coverage is limited to work performed at the Lettire Construction Caton Flats Project at 800 Flatbush Ave, Brooklyn, NY 11226, Job #CAT-FLA. The General and Umbrella limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A & S Steel Contractors, Ltd. 4 Claudet Way AUTHORIZED REPRESENTATIVE Eastchester, NY 10709 gamichPivce 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/5/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Marla Johnson USI Insurance Services, Inc. PHONE FAX 601 Union Street Suite 1000 (A/C, No. Ext): (360) 787-9827 (A/C, No): E-MAIL Seattle, WA 98101 ADDRESS: marla.johnson@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Fire Ins Co INSURED INSURER B: Allied World Nat'l Assurance Co. State of Utah Department of Transportation INSURER C: Liberty Insurance Corporation 4501 South 2700 West PO Box 148430 INSURER D: Ironshore Indemnity Inc. Salt Lake City, Utah 84114 INSURER E: Ohio Casualty Insuance Company INSURER F: Great American Ins. Co. of NY COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 A X CIP Utah Department of Trans TB2-631-510584-027 6/5/2020 3/6/2022 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 B X EXCESS LIAB CLAIMS-MADE 0310-5858 6/5/2020 3/6/2022 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? WA7-63D-510747- C 6/5/2020 3/6/2022 (Mandatory in NH) 290 E.L. EACH ACCIDENT $ 2,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 2,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 2,000,000 EACH OCCURRENCE AGGREGATE D 2nd Layer Excess 3087900 6/5/2020 3/6/2022 $25,000,000 $25,000,000 E 3rd Layer Excess ECO (22) 57828762 6/5/2020 3/6/2022 $25,000,000 $25,000,000 F 4th Layer Excess EXC 1552478 6/5/2020 3/6/2022 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is enrolled in the Utah Department of Transportation Owner Controlled Insurance Program and listed as Additional Insured for General Liability, Excess Liability, Builder's Risk and Contractor's Pollution in accordance with the terms and conditions of the policy. General Liability, Excess Liability, Builder's Risk and Contractor's Pollution limits and aggregates are shared by all enrolled contractors on this project. F-115-7(328)332 Layton; I-15; SR-232 to I-84 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Premier Group 600 South Broadway AUTHORIZED REPRESENTATIVE Denver, CO 80209 C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/7/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Irene Ambrosio USI Insurance Services, LLC. PHONE FAX (A/C, No. Ext): (516) 419-4013 333 Earle Ovington Blvd. (A/C, No): (610) 362-8856 E-MAIL Suite 800 ADDRESS: Irene.Ambrosio@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Star Indemnity & Liability Co INSURED INSURER B: Star Indemnity & Liability Company Metropolitan Sewer Inc. INSURER C: Starr Indemnity & Liability Company 38318 1324 Herschell Street Bronx, NY 10461 INSURER D: Navigator's Insurance Company INSURER E: Philadelphia Indemnity Ins Co. INSURER F: Allied World Assurance Co COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A X CIP Lettire CCIP II Caton 1000025679191 10/7/2019 1/3/2022 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAB CLAIMS-MADE 1000584879171 10/7/2019 1/3/2022 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N C OFFICER/MEMBER EXCLUDED? 9000081022 1/3/2020 1/3/2021 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE D 2nd Layer Excess IS19EXCZ00VW3IV 10/7/2019 1/3/2022 $10,000,000 $10,000,000 E 3rd Layer Excess PHUB660781 10/7/2019 1/3/2022 $10,000,000 $10,000,000 F 4th Layer Excess 03116766 10/7/2019 1/3/2022 $25,000,000 $25,000,000 G 5th Layer Excess USL00177319 10/7/2019 1/3/2022 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101. Additional Remarks Schedule. may be attached if more space is required) Coverage is limited to work performed at the Lettire Construction Caton Flats Project at 800 Flatbush Ave, Brooklyn, NY 11226, Job #CAT-FLA. The General and Umbrella limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Metropolitan Sewer Inc. 1324 Herschell Street AUTHORIZED REPRESENTATIVE Bronx, NY 10461 gamichPince 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/14/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Ashley Viets USI Insurance Services, LLC. PHONE FAX 308 North 21st Street (A/C, No Ext): (A/C, No): E-MAIL St. Louis, Missouri 63103 ADDRES$: Ashley.Viets@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: First Mercury Ins Company INSURED INSURER B: Navigator Specialty Ins Co Kiley Owner, LLC 140 Q. Street NE Washington, DC 20002 INSURER C: Endurance American Specialty Ins Comapny INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ EXCLUDED MED EXP (Any one person) $ EXCLUDED A X OCIP The Kiley NY-CGL-0000079811-01 3/14/2019 8/29/2021 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS-MADE NY-EX-0000079815-01 8/29/2018 8/29/2021 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE GENERAL AGGREGATE B 2nd Layer Excess NY18EXC936693IC 8/29/2018 8/29/2021 $15,000,000 $15,000,000 C 3rd Layer Excess ELD30000761100 8/29/2018 8/29/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is enrolled in the Kiley Project. This coverage inly applies onsite. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, R.B. Hinkle Construction, Inc. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 21595 Cedar Lane Unit 6 AUTHORIZED REPRESENTATIVE Sterling, VA 20166 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 2/19/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Evan Thomas USI Insurance Services, LLC. PHONE FAX 308 North 21st Street (A/C, No Ext): (202) 424-2732 (A/C, No): E-MAIL St. Louis, Missouri 63103 ADDRESS: Evan.Thomas@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Fire Insurance Company INSURED INSURER B: Allied World Assurance Company Morrow-Meadows Corporation INSURER C: Liberty Insurance Underwriters Inc 1050 Bing Street San Carlos, CA 94070 INSURER D: Starr Idemnity & Liability Company INSURER E: Lloyds of London INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 A OCIP Silicon Valley Clean Wa Y Y TB2-661-067164-028 7/20/2018 7/20/2023 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 25,000,000 B EXCESS LIAB CLAIMS-MADE 0311-4521 7/20/2018 7/20/2023 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? Y WA2-66D-067164-199 2/19/2019 7/20/2023 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE GENERAL AGGREGATE C 2nd Layer Excess 1000304849-01 7/20/2018 7/20/2023 $25,000,000 $25,000,000 D 3rd Layer Excess 1000585256181 7/20/2018 7/20/2023 $25,000,000 $25,000,000 E 4th Layer Excess B0901LB1834447000 7/20/2018 7/20/2023 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Silicon Valley Clean Water RESCU ProjectsFront of Plant Certificate holder is enrolled and is a Named Insured as it relates to General Liability and Workers Compensation in the Owner Controlled Insurance Program for work performed on the Silicon Valley Clean Water Front of Plant project. Coverage evidenced is for on-site operations only. This certificate of insurance supersedes all previously provided certificates. Enrollment Effective:2/19/2019 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Morrow-Meadows Corporation 1050 Bing Street AUTHORIZED REPRESENTATIVE San Carlos, CA 94070 Jambal © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 6/24/2020 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 EPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Dulce Castaneda Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C. No Ext): 2007 (A/C, No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: dcastaneda@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: LIBERTY MUTUAL INSURANCE COMPANY 23043 Atascadero Glass, Inc. 8730 El Camino Real INSURER C: EVEREST INDEMNITY INSURANCE COMPANY 10851 Atascadero, CA 93422 INSURER D: COLONY INSURANCE COMPANY 39993 INSURER E: ASPEN INSURANCE UK LIMITED AA1120337 ENDURANCE AMERICAN SPECIALTY SURANCE INSURER F: COMPANY 41718 COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Included MED EXP (Any one person) $ Included A OCIP 2017-2019 (Phase VII) B0595XN5203017 9/1/2019 5/31/2020 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XN5204017 9/1/2019 5/31/2020 AGGREGATE $ 20,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N B OFFICER/MEMBER EXCLUDED? WC5-661-067240-329 9/1/2019 11/14/2019 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE C 2nd Layer Excess XC1EX00018-171 9/1/2019 5/31/2020 $10,000,000 $20,000,000 D 3rd Layer Excess AR6460840 9/1/2019 5/31/2020 $15,000,000 $30,000,000 E 4th Layer Excess K0A8HTC17A0Q 9/1/2019 5/31/2020 $15,000,000 $30,000,000 F 5th Layer Excess ELD30000471400 9/1/2019 5/31/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. West Hills Community College District District Administration Building 275 Phelps Avenue, Coalinga, CA 93210 Site Code: 0174-02-0453652-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Atascadero Glass, Inc. 8730 El Camino Real AUTHORIZED REPRESENTATIVE Atascadero, CA 93422 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 2/4/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Tiffany Kratt Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX 2012 (310) 787-8838 (A/C, No. Ext): (A/C. No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: TMinor-Kratt@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ARCH INSURANCE COMPANY 11150 INSURED INSURER B: AXIS SURPLUS INSURANCE COMPANY 26620 Control Air Conditioning Service Corporation 5200 E. La Palma Avenue INSURER C: Anaheim, CA 92807 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 5,000 A X OCIP Phase VI 71GPP8930100 2/1/2018 8/31/2018 PERSONAL & ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 6,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 6,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 B X EXCESS LIAB CLAIMS-MADE ELU789740/01/2015 2/1/2018 8/31/2018 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPEN SATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? 71WCI0648401 2/1/2018 10/1/2018 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE GENERAL AGGREGATE DESCRIPTION OF OPERATIONS /LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only Palomar Community College District South Education Center 11111 Rancho Bernardo Rd., San Diego, CA, 92127 204213A45 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Control Air Conditioning Service Corporation 5200 E. La Palma Avenue AUTHORIZED REPRESENTATIVE Anaheim, CA 92807 c 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/30/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Irene Ambrosio USI Insurance Services LLC. PHONE FAX 333 Earle Ovington Blvd. (A/C, No Ext): (516) 419-4013 (A/C, No): (610) 362-8856 E-MAIL Suite 800 ADDRESS: Irene.Ambrosio@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Starr Indemnity INSURED INSURER B: Navigator's Insurance Company Martinsulate Inc. INSURER C: Endurance American Ins. Co. 115 Warwick Street Brooklyn, NY 11207 INSURER D: Philadelphia Indemnity Ins Co. INSURER E: Allied World Assurance (US) Inc INSURER F: Allianz Global Risk US Insurance Co. COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A X CIP Lettire CCIP II Phipps 1000025726191 7/7/2020 6/3/2022 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE 1000584879171 7/7/2020 6/3/2022 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N 9000100037 7/7/2020 6/3/2021 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess IS19EXCZ00Y52IV 7/7/2020 6/3/2022 $10,000,000 $10,000,000 C 3rd Layer Excess EXC30001103300 7/7/2020 6/3/2022 $10,000,000 $10,000,000 D 4th Layer Excess PHUB677942 7/7/2020 6/3/2022 $25,000,000 $25,000,000 E 5th Layer Excess 03118732 7/7/2020 6/3/2022 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule may be attached if more space is required) Coverage is limited to work performed at the Lettire Construction Phipps Far Rockaway Project at 1720 Village Lane & 1725 Village Lane (Block 15537, part of Lot 1), Far Rockaway, NY 11691, Job #FAR-PH1 (Building B), and Job #FAR-P1C (Building C). The General and Umbrella Liability limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled subcontractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Martinsulate Inc. 115 Warwick Street AUTHORIZED REPRESENTATIVE Brooklyn, NY 11207 gamichPince 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 9/29/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Irene Ambrosio USI Insurance Services LLC. PHONE FAX (A/C, No Ext): (516) 419-4013 333 Earle Ovington Blvd. (A/C, No): (610) 362-8856 E-MAIL Suite 800 ADDRESS: Irene.Ambrosio@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Starr Indemnity INSURED INSURER B: Navigator's Insurance Company Sigma Electric, Inc. INSURER C: Endurance American Ins. Co. 65/21 Grand Avenue Maspeth, NY 11378 INSURER D: Philadelphia Indemnity Ins Co. INSURER E: Allied World Assurance (US) Inc INSURER F: Allianz Global Risk US Insurance Co. COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A CIP Lettire CCIP II Phipps 1000025726191 6/7/2019 8/22/2020 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE 1000584879171 6/7/2019 8/22/2020 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N 900 0100008 6/3/2020 8/22/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess IS19EXCZ00Y52IV 6/7/2019 8/22/2020 $10,000,000 $10,000,000 C 3rd Layer Excess EXC30001103300 6/7/2019 8/22/2020 $10,000,000 $10,000,000 D 4th Layer Excess PHUB677942 6/7/2019 8/22/2020 $25,000,000 $25,000,000 E 5th Layer Excess 03118732 6/7/2019 8/22/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is limited to work performed at the Lettire Construction Phipps Far Rockaway Project at 1720 Village Lane & 1725 Village Lane (Block 15537, part of Lot 1), Far Rockaway, NY 11691, Job #FAR-PH1 (Building B), and Job #FAR-P1C (Building C). The General and Umbrella Liability limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled subcontractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Sigma Electric, Inc. 65/21 Grand Avenue AUTHORIZED REPRESENTATIVE Maspeth, NY 11378 gamichPince © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 5/1/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Yarden Bleicher USI Insurance Services, LLC. PHONE FAX (A/C, No. Ext): (516) 419-4068 333 Earle Ovington Blvd. (A/C, No): E-MAIL Suite 800 ADDRESS: Yarden.Bleicher@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Company INSURED INSURER B: Starr Indemnity & Liability Company Door Control Inc. INSURER C: ACE Property & Casualty Insurance Co 8 Delta Dr Unit D Londonderry, NH 03053 INSURER D: Allied World Assurance Company INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 10,000 A X OCIP Maine Medical Center Ex GLO015612200 10/10/2019 10/9/2023 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 A EXCESS LIAB CLAIMS-MADE SXS015613300 10/10/2019 10/9/2023 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? WC760199701 4/9/2020 4/9/2021 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess 1000585056181 10/10/2019 10/9/2023 $25,000,000 $25,000,000 C 3rd Layer Excess XCQG71115689001 10/10/2019 10/9/2023 $25,000,000 $25,000,000 D 4th Layer Excess 03112845 10/10/2019 10/9/2023 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is limited to work performed at the Maine Medical Center (MMC) Expansion - Consigli Garage Addition worksite. The General and Umbrella Liability limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled contractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Door Control Inc. 8 Delta Dr Unit D AUTHORIZED REPRESENTATIVE Londonderry, NH 03053 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/3/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Evan Thomas USI Insurance Services National, Inc PHONE FAX 601 13th Street NW (A/C. No Ext): (202) 424-2732 (A/C, No): E-MAIL 9th Floor North ADDRESS: Evan.Thomas@usi.com Washington, DC 20005 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Arch Specialty Insurance INSURED INSURER B: Axis Surplus Insurance Company 26620 Sparkle Painting Co., Inc INSURER C: The Hartford Insurance Company 7962 Conell Court N/A INSURER D: Gemini Insurance Company 10833 Lorton, VA 22079 INSURER E: Starr Surplus Lines Insurance Company INSURER F: First Mercury Insurance Company COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE DAMAGE TO RENTED OCCUR PREMISES (Ea occurrence) $ 0 MED EXP (Any one person) $ 0 A X CIP Meridian Group Holdings, DPC1007801-00 12/1/2017 8/1/2020 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PROJECT LOC PRODUCTS COMP/ OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000 B X EXCESS LIAB CLAIMS-MADE ELU796169012016 12/1/2017 8/1/2020 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N C OFFICER/MEMBER EXCLUDED? N 84 WN OV4455 8/1/2018 4/1/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE D 2nd Layer Excess CEX09602373-00 12/1/2017 8/1/2020 $15,000,000 $15,000,000 E 3rd Layer Excess 1000022973 12/1/2017 8/1/2020 $25,000,000 $25,000,000 F 4th Layer Excess NY-EX-0000066446-01 12/1/2017 8/1/2020 $25,000,000 $25,000,000 G 5th Layer Excess EXC 4100423 12/1/2017 8/1/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is a Named Insured on the Workers Compensation Policy and Named Insured as specified on the Master General Liability Policy per the following: All contractors and /or subcontractors/consultantsand/or subconsultants for whom the owner or owners agent are responsible to arrange insurance to the extent of their respective rights and interests with respects to the construction at The Meridian Group OCIP Project. Please Note: Coverages are site specific for all program enrollees. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, Sparkle Painting Co., Inc NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 7962 Conell Court N/A AUTHORIZED REPRESENTATIVE Lorton, VA 22079 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/14/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: James Hite USI Insurance Services PHONE FAX 190 River Road 1st Floor (A/C, No. Ext): (A/C, No): E-MAIL Summit, NJ 07901-1444 ADDRESS: james.hite@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Endurance American Specialty Insurance Company 41718 INSURED INSURER B: Everest National Insurance Company 10120 RB Stamford Associates LLC & URL Stamford Owner LLC INSURER C: TOKIO MARINE SPECIALTY INS c/o Ironstate Development 50 Washington Street INSURER D: Hoboken, NJ 07030 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded A X CIP URL Stamford Project PGL10011788200 9/22/2017 3/22/2021 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 25,000,000 B EXCESS LIAB CLAIMS-MADE XC5EX00252-171 9/22/2017 3/22/2021 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE GENERAL AGGREGATE C 2nd Layer Excess PUB600992 9/22/2017 3/22/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is confirmed as enrolled in the RB Stamford Associates LLC Owner Controlled Insurance Program. General Liability and Excess Liability coverage applies to On-Site exposure only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, Quality Pro Painters NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 50 Harrison Street Suite 206 AUTHORIZED REPRESENTATIVE Hoboken, NJ 07030 Jambal 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/31/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Dulce Castaneda Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C, No Ext): 2007 (A/C, No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: dcastaneda@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: LIBERTY MUTUAL INSURANCE COMPANY 23043 CTG Construction Inc. 433 Lecouvreur Avenue INSURER C: EVEREST INDEMNITY SURANCE COMPANY 10851 Wilmington, CA 90744 INSURER D: COLONY INSURANCE COMPANY 39993 INSURER E: ASPEN INSURANCE UK LIMITED AA1120337 ENDURANCE AMERICAN SPECIALTY INSURANCE INSURER F: COMPANY 41718 COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Included MED EXP (Any one person) $ Included A X OCIP 2017-2019 (Phase VII) B0595XN5203017 7/1/2019 8/1/2020 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XN5204017 7/1/2019 8/1/2020 AGGREGATE $ 20,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N B OFFICER/MEMBER EXCLUDED? WC5-661-067217-349 7/1/2019 10/1/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE C 2nd Layer Excess XC1EX00018-171 7/1/2019 8/1/2020 $10,000,000 $20,000,000 D 3rd Layer Excess AR6460840 7/1/2019 8/1/2020 $15,000,000 $30,000,000 E 4th Layer Excess K0A8HTC17A0Q 7/1/2019 8/1/2020 $15,000,000 $30,000,000 F 5th Layer Excess ELD30000471400 7/1/2019 8/1/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Menifee Union School DistrictHarvest Hill STEAM Academy Addition New Building29775 Haun Road Menifee, California 925845 Code/Contract #: 1044-11-0635916-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CTG Construction Inc. 433 Lecouvreur Avenue AUTHORIZED REPRESENTATIVE Wilmington, CA 90744 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 6/22/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Irene Ambrosio USI Insurance Services LLC. PHONE FAX 333 Earle Ovington Blvd. (A/C, No. Ext): (516) 419-4013 (A/C, No): (610) 362-8856 E-MAIL Suite 800 ADDRESS: Irene.Ambrosio@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Starr Indemnity & Liability Company INSURED INSURER B: Navigators Insurance Company Rockledge Scaffold Corp INSURER C: Endurance American Insurance Company 808 Nepperhan Ave Yonkers, NY 10703 INSURER D: Ohio Casualty Insurance Company INSURER E: Allied World Assurance (US) Inc INSURER F: Allianz Global Risks US Insurance Co COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A CIP Lettire CCIP II Chestn 1000025775191 6/3/2020 12/23/2022 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE 1000584879171 6/3/2020 12/23/2022 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N 9000124008 6/3/2020 12/23/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess IS19EXCZ03HQRIV 6/3/2020 12/23/2022 $10,000,000 $10,000,000 C 3rd Layer Excess EXN30001428000 6/3/2020 12/23/2022 $10,000,000 $10,000,000 D 4th Layer Excess ECO(22)60701137 6/3/2020 12/23/2022 $25,000,000 $25,000,000 E 5th Layer Excess 03121644 6/3/2020 12/23/2022 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is limited to work performed at the Lettire Construction Chestnut Commons CCIP Project at 110 Dinsmore Place, Brooklyn, NY 11208, Job #CHE-020. The General and Umbrella Liability limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled subcontractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Rockledge Scaffold Corp 808 Nepperhan Ave AUTHORIZED REPRESENTATIVE Yonkers, NY 10703 gamichPince 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 9/18/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Tiffany Kratt Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C, No. Ext): 2012 (A/C. No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: TMinor-Kratt@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: EVEREST INDEMNITY IN SURANCE COMPANY 10851 Impact Sign EF X 8250 Calvine Rd., Unit C220 INSURER C: COLONY INSURANCE COMPANY 39993 Sacramento, CA 95828 INSURER D: ASPEN INSURANCE UK LIMITED AA1120337 ENDURANCE AMERICAN SPECIALTY INSURANCE INSURER E: COMPANY 41718 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Included MED EXP (Any one person) $ Included A X OCIP 2017-2019 (Phase VII) B0595XN5203017 9/1/2019 5/7/2020 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XN5204017 9/1/2019 5/7/2020 AGGREGATE $ 20,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE B 2nd Layer Excess XC1EX00018-171 9/1/2019 5/7/2020 $10,000,000 $20,000,000 C 3rd Layer Excess AR6460840 9/1/2019 5/7/2020 $15,000,000 $30,000,000 D 4th Layer Excess K0A8HTC17A0Q 9/1/2019 5/7/2020 $15,000,000 $30,000,000 E 5th Layer Excess ELD30000471400 9/1/2019 5/7/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Liberty Union High School District Freedom High School Maintenance Facility 1050 Neroly Road, Oakley, California 94513 Site Code: 0848-04-0924383-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Impact Sign E X 8250 Calvine Rd., Unit C220 AUTHORIZED REPRESENTATIVE Sacramento, CA 95828 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/13/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Jake Russell USI Insurance Services LLC PHONE FAX 261 Madison Ave (A/C, No. Ext): (516) 419-4024 (A/C, No): E-MAIL New York, NY 10016 ADDRESS: Jake.Russell@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Aspen Specialty Insurance Company INSURED INSURER B: Evanston Insurance Company 75 Park Lane, LLC & 2 Shore Drive North, LLC INSURER C: Navigator Specialty Ins Co 5 Bryant Park (aka 1065 Avenue of the Americas) 7th Floor INSURER D: Gemini Insurance Company 10833 New York, NY 10018 INSURER E: First Mercury Ins Company INSURER F: Endurance American Specialty Ins Comapny COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded A X CIP Newport OCIP CR004NR16 9/12/2016 4/30/2020 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS LIAB CLAIMS-MADE MKLV2EUL100452 9/12/2016 4/30/2020 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess NY16FXS877159IC 9/12/2016 4/30/2020 $15,000,000 $15,000,000 D 3rd Layer Excess CEX03602408-00 9/12/2016 4/30/2020 $25,000,000 $25,000,000 E 4th Layer Excess NY-EX-0000067480-01 9/12/2016 4/30/2020 $25,000,000 $25,000,000 F 5th Layer Excess ELD30000175600 9/12/2016 4/30/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is enrolled and is a Named Insured in the 75 Park Lane, LLC Owner Controlled Insurance Program for work performed on the 75 Park Lane South project located at 75 Park Lane South, Jersey City, NJ 07310.Coverage applies to on-site exposure only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All Craft Fabricators, Inc. 150 Wireless Blvd. AUTHORIZED REPRESENTATIVE Hauppauge, NY 11788 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/8/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Dulce Castaneda Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C, No. Ext): 2007 (A/C. No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: dcastaneda@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ARCH INSURANCE COMPANY 11150 INSURED INSURER B: AXIS SURPLUS INSURANCE COMPANY 26620 Simmons & Wood, Inc. INSURER C: 8737 Wintergardens Blvd. Lakeside, CA 92040 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 5,000 A X OCIP - 2015-2017 (Phase VI) 71GPP8930100 6/1/2017 6/30/2018 PERSONAL & ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 6,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 6,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 B X EXCESS LIAB CLAIMS-MADE ELU789740/01/2015 6/1/2017 6/30/2018 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPEN SATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? 71WCI0648702 10/1/2017 4/26/2018 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Moreno Valley Unified School District Edgemont Elementary School Increment 2 21790 Eucalyptus Avenue, Moreno Valley, California 92553 Site Code: 00707S CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Simmons & Wood, Inc. 8737 Wintergardens Blvd. AUTHORIZED REPRESENTATIVE Lakeside, CA 92040 C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 5/1/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Sara Mirza Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C, No. Ext): 2020 (A/C, No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: SMirza@keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: LIBERTY MUTUAL NSURANCE COMPANY 23043 Robles Engineering Constructors 29227 Rangewood Road INSURER C: EVEREST INDEMNITY SURANCE COMPANY 10851 Castaic, CA 91384 INSURER D: COLONY INSURANCE COMPANY 39993 INSURER E: ASPEN INSURANCE UK LIMITED AA1120337 ENDURANCE AMERICAN SPECIALTY INSURANCE INSURER F: COMPANY 41718 COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ A X OCIP 2017-2019 (Phase VII) B0595XN5203017 4/16/2018 8/17/2018 PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XN5204017 4/16/2018 6/1/2018 AGGREGATE $ 20,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N B OFFICER/MEMBER EXCLUDED? WC5-661-067123-608 4/16/2018 10/1/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE C 2nd Layer Excess XC1EX00018-171 4/16/2018 6/1/2018 $10,000,000 $20,000,000 D 3rd Layer Excess AR6460840 4/16/2018 6/1/2018 $15,000,000 $30,000,000 E 4th Layer Excess K0A8HTC17A0Q 4/16/2018 6/1/2018 $15,000,000 $30,000,000 F 5th Layer Excess ELD30000471400 4/16/2018 6/1/2018 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only Long Beach Community College District Water Conservation Landscape (PCC) 1305 E Pacific Coast y,Long Beach,California,9080 0628-37-1000839-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Robles Engineering Constructors 29227 Rangewood Road AUTHORIZED REPRESENTATIVE Castaic, CA 91384 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/5/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Jake Russell Hays Companies c/o PHONE FAX USI Insurance Services, LLC. (A/C, No Ext): (516) 419-4024 (A/C, No): E-MAIL 333 Earle Ovington Blvd, Suite 800 ADDRESS: Jake.Russell@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: XL Insurance America, Inc INSURED INSURER B: Starr Surplus Lines Insurance Company Performance Contracting Inc. (PCI) INSURER C: Navigators Insurance Company 1203 Main Street Grandview, MO 64030 INSURER D: Arch Insurance Company INSURER E: Endurance American Specialty Insurance Company 41718 INSURER F: Crum & Forster Ins. Co. COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 10,000 A X OCIP Cerner Innovations GDR7442566 10/31/2019 6/30/2020 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 A EXCESS LIAB CLAIMS-MADE US00068567LI14A 10/31/2019 6/30/2020 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER AND EMPLOYERS' LIABILITY X OTHER STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N WDR7453805 10/31/2019 10/31/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess 1000021366 10/31/2019 6/30/2020 $25,000,000 $25,000,000 C 3rd Layer Excess GA14EXC823583IC 10/31/2019 6/30/2020 $25,000,000 $25,000,000 D 4th Layer Excess UFP005777600 10/31/2019 6/30/2020 $25,000,000 $25,000,000 E 5th Layer Excess ELD10005891500 10/31/2019 6/30/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Cerner Innovations, formerly known as Trails Campus, Phases 3 & 4 The Certificate Holder is a Named Insured on the Workers Compensation Policy and Named Insured as specified on the Master General Liability Policy per the following: All contractors and/or subcontractors/consultants and/or subconsultants for whom the owner or owners agent are responsible to arrange insurance to the extent of their respective rights and interests with respects to the construction at the Innovations, formerly known as Trails Campus Phases 3 & 4 Please Note: Coverages are site specific for all program enrollees. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Performance Contracting Inc. (PCI) 1203 Main Street AUTHORIZED REPRESENTATIVE Grandview, MO 64030 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 2/19/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Louise Bell USI Insurance Services National, Inc PHONE FAX 601 13th Steet NW, 9th Floor North (A/C, No. Ext): (A/C, No): E-MAIL Washington, DC 2005 ADDRESS: Louise@questinsurance.us INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: HDI Specialty Insurance Company INSURED INSURER B: See attached schedule Metropolitan Washington Airports Authority INSURER C: PO Box 15608 Arlington VA 22215 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ NA MED EXP (Any one person) $ NA A X CIP MWAA AVIATION OCIP CWD5488400S 6/1/2018 6/1/2023 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 400,000,000 SEE ATTACHED B EXCESS LIAB CLAIMS-MADE 6/1/2018 6/1/2023 SCHEDULE AGGREGATE $ 400,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Contractor is enrolled in the Metropolitan Washington Airports Authority Aviation OCIP CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. JBL Contractors LLC 5500 Duchaine Dr AUTHORIZED REPRESENTATIVE Lanham, MD 20706 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 2/29/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Peggy Ray USI Insurance Services PHONE FAX 601 Union Street Suite 1000 (A/C. No Ext): (A/C, No): E-MAIL Seattle, WA 98101 ADDRES$: Peggy.Ray@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Endurance American Specialty Insurance Company 41718 INSURED INSURER B: Star Indemnity & Liability Company Kandle I, LP; Wolff Kandle Development Company, LLC INSURER C: Ironshore Specialty Insurance Co. and KIW Revel Pima Venture, LLC 6710 E Camelback Road, Suite 100 INSURER D: Scottsdale, AZ 85251 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded A X OCIP Kandle I LP: Wolff Kand PCL 10013086500 1/6/2020 7/6/2021 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 B X EXCESS LIAB CLAIMS-MADE 1000024105 1/6/2020 7/6/2021 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess 003604500 1/6/2020 7/6/2021 $15,000,000 $15,000,000 A 3rd Layer Excess ELD30000669000 1/6/2020 7/6/2021 $15,000,000 $15,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is a Named Insured as specified on the Master General Liability and Excess Liability Policies. This applies to all enrolled contractors or subcontractors of any tier working on behalf of the First Named Insured and performing work on The Revel Legacy project and intended by the First Named Insured to be enrolled within these policies, excluding vendors and suppliers of goods and materials. These policies apply only to operations related to The Revel Palm Desert Project and operations necessary or incidental thereto but limited to the designated Project site and such other locations as agreed to by underwriter (s) by written confirmation. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, Arizona Fire Protection, Inc. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 8550 N 91st Ave 25 AUTHORIZED REPRESENTATIVE Peoria, AZ 85345 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/19/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Courtney Evans USI Insurance Services LLC PHONE FAX 3190 Fairview Park Drive, Suite 400 (A/C, No. Ext): (A/C, No): E-MAIL Falls Church, VA 22042 ADDRESS: Courtney.Evans@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Endurance American Specialty Ins CO INSURED INSURER B: Navigators Speciality Ins Co The Greenery Inc INSURER C: 93 Arrow Road Hilton Head Island, SC 29928 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded A X OCIP Liberty Place by Hilton PGL10014587300 8/30/2019 5/1/2021 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 8,000,000 A X EXCESS LIAB CLAIMS-MADE ELD30001091000 8/30/2019 5/21/2021 AGGREGATE $ 8,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE B 2nd Layer Excess SF19FXSZ01XTQIC 8/30/2019 5/21/2021 $15,000,000 $15,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Liberty Plant: Certificate holder is enrolled and is a Named Insured as it relates to General Liability and Excess Liability policies on the Owner Controlled Insurance Program for work performed on the Liberty Place project. Coverage evidenced is for on-site operations only. This certificate of insurance supersedes all previously provided certificates. Enrollment Effective: 8/30/2019 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Jambal 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 5/3/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Yarden Bleicher USI Insurance Services, LLC. PHONE FAX (A/C, No Ext): (516) 419-4068 333 Earle Ovington Blvd. (A/C, No): E-MAIL Suite 800 ADDRESS: Yarden.Bleicher@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Company INSURED INSURER B: Starr Indemnity & Liability Company T.J. McCartney, Inc. INSURER C: ACE Property & Casualty Insurance Co 3 Capitol Street Unit 1 INSURER D: Allied World Assurance Company Nashua, NH 03063 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 10,000 A X OCIP Maine Medical Center Ex GLO015612200 11/5/2018 10/9/2023 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 A EXCESS LIAB CLAIMS-MADE SXS015613300 11/5/2018 10/9/2023 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? WC014902201 4/9/2019 4/9/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess 1000585056181 11/5/2018 10/9/2023 $25,000,000 $25,000,000 C 3rd Layer Excess XCQG71115689001 11/5/2018 10/9/2023 $25,000,000 $25,000,000 D 4th Layer Excess 03112845 11/5/2018 10/9/2023 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is limited to work performed at the Maine Medical Center (MMC) Expansion, Phase 1 at 22 Bramhall Street, Portland, ME 04102, Project #180082. The General and Umbrella Liability limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled contractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, T.J. McCartney, Inc. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 3 Capitol Street Unit 1 AUTHORIZED REPRESENTATIVE Nashua, NH 03063 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/5/2020 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 SUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Tommy Lawrence USI Insurance Services National, Inc PHONE FAX 601 13th Steet NW, 9th Floor North (A/C, No. Ext): (A/C. No): E-MAIL Washington, DC 2005 ADDRESS: tommy.lawrence@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Westchester Fire Insurance Company INSURED INSURER B: ACE Property and Casualty Insurance Co. DPR Construction INSURER C: Great American Insurance Co. of New York 22136 315 2nd Ave S Ste 200 INSURER D: Seattle, WA 98104 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Excluded MED EXP (Any one person) $ Excluded A X OCIP RagingWire Data G7116617A 001 8/8/2018 8/8/2021 Centers PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 25,000,000 B EXCESS LIAB CLAIMS-MADE XCQ G7116603A 001 8/8/2018 8/8/2021 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess EXC2619572 8/8/2018 8/8/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RagingWire Data Centers -HI1: Certificate Holder is enrolled and is a Named Insured as it relates to the General Liability and Excess Liability policies on the Owner Controlled Insurance Program for work performed on the RagingWire Data Centers HI1 project. Coverage evidenced is for on-site operaitons only. Enrollment Effective: 1/7/2020 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, DPR Construction NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 315 2nd Ave S Ste 200 AUTHORIZED REPRESENTATIVE Seattle, WA 98104 Jamesas 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/1/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: James Hite USI Insurance Services PHONE FAX 190 River Road 1st Floor (A/C, No. Ext): (A/C, No): E-MAIL Summit, NJ 07901-1444 ADDRESS: james.hite@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Endurance American Specialty Insurance Company 41718 INSURED INSURER B: Everest National Insurance Company 10120 RB Stamford Associates LLC & URL Stamford Owner LLC INSURER C: TOKIO MARINE SPECIALTY INS c/o Ironstate Development 50 Washington Street INSURER D: Hoboken, NJ 07030 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded A X CIP URL Stamford Project PGL10011788200 9/22/2017 3/22/2021 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 25,000,000 B EXCESS LIAB CLAIMS-MADE XC5EX00252-171 9/22/2017 3/22/2021 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE GENERAL AGGREGATE C 2nd Layer Excess PUB600992 9/22/2017 3/22/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is confirmed as enrolled in the RB Stamford Associates LLC Owner Controlled Insurance Program. General Liability and Excess Liability coverage applies to On-Site exposure only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Craftline Cabinet Corp 10 Walnut Street AUTHORIZED REPRESENTATIVE Clifton, NJ 07013 Jambal 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 6/26/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Irene Ambrosio USI Insurance Services, LLC. PHONE FAX 333 Earle Ovington Blvd. (A/C, No Ext): (516) 419-4013 (A/C, No): (610) 362-8856 E-MAIL Suite 800 ADDRESS: Irene.Ambrosio@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Starr Indemnity & Liability Company INSURED INSURER B: Navigators Insurance Company Imperiex Construction Inc. INSURER C: Liberty Insurance Underwriters, Inc. 1185 Randall Avenue Bronx, NY 10474 INSURER D: Berkshire Hathaway Specialty Ins Co INSURER E: Westchester Fire Insurance Company INSURER F: Endurance American Insurance Company COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A CIP Lettire CCIP II Archer 1000025593171 3/4/2020 7/2/2021 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 1000584879171 3/4/2020 7/2/2021 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N 9000051048 7/2/2020 7/2/2021 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess NY18EXC921427IV 3/4/2020 7/2/2021 $10,000,000 $10,000,000 C 3rd Layer Excess 100028316801 3/4/2020 7/2/2021 $10,000,000 $10,000,000 D 4th Layer Excess 47XSF30563401 3/4/2020 7/2/2021 $25,000,000 $25,000,000 E 5th Layer Excess G71153538001 3/4/2020 7/2/2021 $25M/ p/o $50M $25M/ p/o $50M X $50M X $50M DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) Coverage is limited to work performed at the Lettire Construction Archer Green Project at 92-23 168th Street, Jamaica, NY 11433, Job #ARC-018. The General and Umbrella limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled contractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Imperiex Construction Inc. 1185 Randall Avenue AUTHORIZED REPRESENTATIVE Bronx, NY 10474 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/7/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Kristin Bonilla USI Insurance Services LLC. PHONE FAX (A/C, No Ext): (866) 410-4045 333 Earle Ovington Blvd. (A/C, No): E-MAIL Suite 800 ADDRESS: NCPRPADMIN@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Illinois Union Insurance Co INSURED INSURER B: Illinois Union Insurance Co. Shook Construction Company INSURER C: ACE Property & Casualty Insurance Company 2000 W Dorothy Lane Moraine, OH 45439 INSURER D: The Ohio Casualty Insurance Company INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Excluded MED EXP (Any one person) $ Excluded A X CIP - Tissue Center CCIP G71188073 001 10/1/2020 1/1/2021 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 B EXCESS LIAB CLAIMS-MADE G71188103 001 10/1/2020 1/1/2021 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess XCQ G71188048 001 10/1/2020 1/1/2021 $15,000,000 $15,000,000 D 3rd Layer Excess ECO (20) 59 19 65 12 10/1/2020 1/1/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is enrolled in the Shook Construction Company CCIP for on-site exposure CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ohio Concrete Sawing and Drilling 314 Conover Dr AUTHORIZED REPRESENTATIVE Franklin, OH 45005 James © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/3/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Tommy Lawrence USI Insurance Services, Inc. PHONE FAX 601 Union Street Suite 1000 (A/C, No. Ext): (A/C, No): E-MAIL Seattle, WA 98101 ADDRESS: tommy.lawrence@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Fire Ins Co INSURED INSURER B: Allied World Nat'l Assurance Co. State of Utah Department of Transportation INSURER C: Liberty Insurance Corporation 4501 South 2700 West PO Box 148430 INSURER D: Ironshore Indemnity Inc. Salt Lake City, Utah 84114 INSURER E: Ohio Casualty Insuance Company INSURER F: Great American Ins. Co. of NY COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 A CIP Utah Department of Trans TB2-631-510584-027 4/3/2019 3/6/2022 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 B X EXCESS LIAB CLAIMS-MADE 0310-5858 4/3/2019 3/6/2022 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? WA7-63D-510713- C 3/6/2020 3/6/2023 (Mandatory in NH) 840 E.L. EACH ACCIDENT $ 2,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 2,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 2,000,000 EACH OCCURRENCE AGGREGATE D 2nd Layer Excess 3087900 4/3/2019 3/6/2022 $25,000,000 $25,000,000 E 3rd Layer Excess ECO (22) 57828762 4/3/2019 3/6/2022 $25,000,000 $25,000,000 F 4th Layer Excess EXC 1552478 4/3/2019 3/6/2022 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is enrolled in the Utah Department of Transportation Owner Controlled Insurance Program and listed as Additional Insured for General Liability, Excess Liability, Builder's Risk and Contractor's Pollution in accordance with the terms and conditions of the policy. General Liability, Excess Liability, Builder's Risk and Contractor's Pollution limits and aggregates are shared by all enrolled contractors on this project. Mountain View Corridor / MVC; 4100 South to SR-201; Project No. S-0085(9) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Coughlin Company 809 E Commerce Drive Street AUTHORIZED REPRESENTATIVE St George, UT 84790 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/24/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Kristin Bonilla USI Insurance Services PHONE FAX 601 Union Street Suite 1000 (A/C, No Ext): (866) 410-4045 (A/C, No): E-MAIL Seattle, WA 98101 ADDRESS: USI@nourtek.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Endurance American Specialty Insurance Company 41718 INSURED INSURER B: Star Indemnity & Liability Company Kandle I, LP; Wolff Kandle Development Company, LLC INSURER C: Ironshore Speciatly Insurance Company and KIW Grand Prairie Venture, LLC 6710 E Camelback Road, Suite 100 INSURER D: Scottsdale, AZ 85251 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded A OCIP - Grand Prairie Phase I PGL10013086500 11/2/2020 5/29/2023 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 2,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000 B X EXCESS LIAB CLAIMS-MADE 1000024105 11/2/2020 5/29/2023 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess 003604500 11/2/2020 5/29/2023 $15,000,000 $15,000,000 A 3rd Layer Excess ELD3000669000 11/2/2020 5/29/2023 $15,000,000 $15,000,000 DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is a Named Insured as specified on the Master General Liability and Excess Liability Policies. This applies to all enrolled contractors or subcontractors of any tier working on behalf of the First Named Insured and performing work on The Grand Prairie Phase I project and intended by the First Named Insured to be enrolled within these policies, excluding vendors and suppliers of goods and materials. These policies apply only to operations related to The Grand Prairie Phase I Project and operations necessary or incidental thereto but limited to the designated Project site and such other locations as agreed to by underwriter (s) by written confirmation. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cody Pools, Inc. 5117 S IH35 AUTHORIZED REPRESENTATIVE Georgetown, TX 78626 James 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/28/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Irene Ambrosio USI Insurance Services LLC. PHONE FAX (A/C, No. Ext): (516) 419-4013 333 Earle Ovington Blvd. (A/C, No): (610) 362-8856 E-MAIL Suite 800 ADDRESS: Irene.Ambrosio@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Starr Indemnity & Liability Company INSURED INSURER B: Navigators Insurance Company Schindler Elevator INSURER C: Endurance American Insurance Company 6950 W. Jefferson Ave. Suite 210 Lakewood, CO 80235 INSURER D: Ohio Casualty Insurance Company INSURER E: Allied World Assurance (US) Inc INSURER F: Allianz Global Risks US Insurance Co COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A CIP Lettire CCIP II Chestn 1000025775191 6/9/2020 8/22/2020 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE 1000584879171 6/9/2020 8/22/2020 AGGREGATE $ 5,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N 9000124100 6/9/2020 8/22/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE B 2nd Layer Excess IS19EXCZ03HQRIV 6/9/2020 8/22/2020 $10,000,000 $10,000,000 C 3rd Layer Excess EXN30001428000 6/9/2020 8/22/2020 $10,000,000 $10,000,000 D 4th Layer Excess ECO(22)60701137 6/9/2020 8/22/2020 $25,000,000 $25,000,000 E 5th Layer Excess 03121644 6/9/2020 8/22/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is limited to work performed at the Lettire Construction Chestnut Commons CCIP Project at 110 Dinsmore Place, Brooklyn, NY 11208, Job #CHE-020. The General and Umbrella Liability limits and aggregates are shared by all enrolled contractors on this project. An individual Workers Compensation policy will be issued in the name of the enrolled subcontractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Schindler Elevator 6950 W. Jefferson Ave. Suite 210 AUTHORIZED REPRESENTATIVE Lakewood, CO 80235 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8/18/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Tommy Lawrence USI Insurance Services National, Inc PHONE FAX 601 13th Steet NW, 9th Floor North (A/C, No. Ext): (A/C. No): E-MAIL Washington, DC 2005 ADDRESS: tommy.lawrence@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Westchester Fire Insurance Company INSURED INSURER B: ACE Property and Casualty Insurance Co. C.H. Reynolds Electric, Inc. INSURER C: Great American Insurance Co. of New York 22136 1281 Wayne Avenue San Jose, CA 95131 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Excluded MED EXP (Any one person) $ Excluded A OCIP RagingWire Data G7116617A 001 8/8/2018 8/8/2021 Centers PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 25,000,000 B EXCESS LIAB CLAIMS-MADE XCQ G7116603A 001 8/8/2018 8/8/2021 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess EXC2619572 8/8/2018 8/8/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RagingWire Data Centers -SV1: Certificate Holder is enrolled and is a Named Insured as it relates to the General Liability and Excess Liability policies on the Owner Controlled Insurance Program for work performed on the RagingWire Data Centers SV1 project. Coverage evidenced is for on-site operaitons only. Enrollment Effective: 5/11/2020 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. C.H. Reynolds Electric, Inc. 1281 Wayne Avenue AUTHORIZED REPRESENTATIVE San Jose, CA 95131 Jambal © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/17/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Jason Colasante USI Insurance Services, LLC. PHONE FAX 333 Earle Ovington Blvd. (A/C, No. Ext): (A/C, No): E-MAIL Suite 800 ADDRESS: jason.colasante@usi.com Uniondale, NY 11553 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Company INSURED INSURER B: B&G Installation Services 140 Lincoln PL 2nd FL INSURER C: Irvington, NJ 07111 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N WC648026100 4/22/2019 7/17/2019 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule may be attached if more space is required) Coverage is limited to work performed at the Triton Construction CCIP Project at 98 Front Street, Brooklyn, NY 11201, Job #1224. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, New York State Insurance Fund NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 199 Church Street Attn: Audit Department AUTHORIZED REPRESENTATIVE New York, NY 10007-1100 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/29/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Dulce Castaneda Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C, No. Ext): 2007 (A/C, No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: dcastaneda@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: LIBERTY MUTUAL INSURANCE COMPANY 23043 Cutting Edge Excavation, Inc. 19510 Van Buren Blvd. #292 INSURER C: EVEREST INDEMNITY SURANCE COMPANY 10851 Riverside, CA 92508 INSURER D: COLONY INSURANCE COMPANY 39993 INSURER E: ASPEN INSURANCE UK LIMITED AA1120337 ENDURANCE AMERICAN SPECIALTY INSURANCE INSURER F: COMPANY 41718 COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Included MED EXP (Any one person) $ Included A X OCIP 2017-2019 (Phase VII) B0595XN5203017 7/1/2019 6/1/2020 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XN5204017 7/1/2019 6/1/2020 AGGREGATE $ 20,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N B OFFICER/MEMBER EXCLUDED? WC5-661-067071-057 7/1/2019 10/1/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE C 2nd Layer Excess XC1EX00018-171 7/1/2019 6/1/2020 $10,000,000 $20,000,000 D 3rd Layer Excess AR6460840 7/1/2019 6/1/2020 $15,000,000 $30,000,000 E 4th Layer Excess K0A8HTC17A0Q 7/1/2019 6/1/2020 $15,000,000 $30,000,000 F 5th Layer Excess ELD30000471400 7/1/2019 6/1/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Riverside Unified School DistrictHighgrove Elementary School New Building and Modernization690 Center Street Riverside, California 92507 Site Code/Contract #: 0779-01-0839679-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cutting Edge Excavation, Inc. 19510 Van Buren Blvd. #292 AUTHORIZED REPRESENTATIVE Riverside, CA 92508 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/10/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Adriana Ramirez USI Insurance Services National, Inc PHONE FAX 601 13th Street NW (A/C, No. Ext): (202) 424-2743 (A/C, No): E-MAIL 9th Floor North ADDRES$: adriana.ramirez@usi.com Washington, DC 20005 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: The Hartford Insurance Company INSURED INSURER B: CBF Construction, LLC 3702 Cordell Ave INSURER C: 3702 Cordell Ave INSURER D: woodbridge, VA 22172 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N A OFFICER/MEMBER EXCLUDED? N 84 WN OV4596 10/10/2018 2/1/2019 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE GENERAL AGGREGATE DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101. Additional Remarks Schedule. may be attached if more space is required) The Certificate Holder is a Named Insured on the Workers Compensation Policy and Named Insured as specified on the Master General Liability Policy per the following: All contractors and /or subcontractors/consultantsand/or subconsultants for whom the owner or owners agent are responsible to arrange insurance to the extent of their respective rights and interests with respects to the construction at The Meridian Gorup OCIP Project. Please Note: Coverages are site specific for all program enrollees. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, New York State Insurance Fund NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 199 Church Street Attn: Audit Department AUTHORIZED REPRESENTATIVE New York, NY 10007-1100 James 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/10/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Louise Bell USI Insurance Services National, Inc PHONE FAX 601 13th Steet NW, 9th Floor North (A/C, No. Ext): (A/C, No): E-MAIL Washington, DC 2005 ADDRESS: Louise@questinsurance.us INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: HDI Specialty Insurance Company INSURED INSURER B: See attached schedule Metropolitan Washington Airports Authority INSURER C: PO Box 15608 Arlington VA 22215 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ NA MED EXP (Any one person) $ NA A X CIP MWAA AVIATION OCIP CWD5488400S 6/1/2018 6/1/2023 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 400,000,000 SEE ATTACHED B EXCESS LIAB CLAIMS-MADE 6/1/2018 6/1/2023 $ SCHEDULE AGGREGATE 400,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS LIABILITY STATUTE ANY ROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) Contractor is enrolled in the Metropolitan Washington Airports Authority Aviation OCIP CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Netcom Technologies, Inc 7616 Standish Place AUTHORIZED REPRESENTATIVE Rockville, MD 20855 Jambal 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/1/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Dulce Castaneda Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C, No. Ext): 2007 (A/C. No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: dcastaneda@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: LIBERTY MUTUAL INSURANCE COMPANY 23043 Angus Asphalt, Inc. 9959 Prospect Avenue INSURER C: EVEREST INDEMNITY NSURANCE COMPANY 10851 Santee, CA 92072 INSURER D: COLONY INSURANCE COMPANY 39993 INSURER E: ASPEN INSURANCE UK LIMITED AA1120337 ENDURANCE AMERICAN SPECIALTY INSURANCE INSURER F: COMPANY 41718 COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Included MED EXP (Any one person) $ Included A X OCIP 2017-2019 (Phase VII) B0595XN5203017 8/1/2020 6/30/2021 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XN5204017 8/1/2020 6/30/2021 AGGREGATE $ 20,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N B OFFICER/MEMBER EXCLUDED? WC5-661-067265-700 8/1/2020 8/6/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE C 2nd Layer Excess XC1EX00018-171 8/1/2020 6/30/2021 $10,000,000 $20,000,000 D 3rd Layer Excess AR6460840 8/1/2020 6/30/2021 $15,000,000 $30,000,000 E 4th Layer Excess K0A8HTC17A0Q 8/1/2020 6/30/2021 $15,000,000 $30,000,000 F 5th Layer Excess ELD30000471400 8/1/2020 6/30/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule. may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Mt. San Jacinto Community College District Temecula Valley Campus Renovation 41888 Motorcar Parkway, Temecula, CA 92591 Site Code: 0710-01-0523300-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Angus Asphalt, Inc. 9959 Prospect Avenue AUTHORIZED REPRESENTATIVE Santee, CA 92072 c 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/6/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Kristin Bonilla USI Insurance Services PHONE FAX 601 Union Street Suite 1000 (A/C, No. Ext): (866) 410-4045 (A/C, No): E-MAIL Seattle, WA 98101 ADDRESS: USI@nourtek.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Liberty Surplus Insurance Corporation 10725 INSURED INSURER B: Houston Casualty Company BFG Gainesville PropCo IV, LLC INSURER C: 228 N. Park Avenue, Suite A Winter Park, FL 32789 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5,000 A X OCIP - Bourne Financial Group Y Y 1000037591001 12/1/2020 11/4/2022 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000 B X EXCESS LIAB CLAIMS-MADE H19XC5114300 12/1/2020 11/4/2022 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Fieldstone Silverdale: Certificate Holder is Enrolled and is a Named Insured as it relates to the General Liability and Excess Liability policies on the Owner Controlled Insurance Program for work performed on the Fieldstone Silverdale Project. Coverage is for on-site operations only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, A and R Solar SPC dba A&R Solar NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DBA A&R Solar 3211 Martin Luther King Jr Way S, Suite B AUTHORIZED REPRESENTATIVE Seattle, WA 98144 Jambal © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 2/6/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Dulce Castaneda Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C. No. Ext): 2007 (A/C, No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: dcastaneda@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: LIBERTY MUTUAL INSURANCE COMPANY 23043 Rite-Way Roof Corporation 15425 Arrow Route INSURER C: AXIS SPECIALTY INSURANCE COMPANY 15610 Fontana, CA 92335 INSURER D: COLONY INSURANCE COMPANY 39993 INSURER E: IRONSHORE SPECIALTY INSURANCE COMPANY 25445 ENDURANCE AMERICAN SPECIALTY INSURANCE INSURER F: COMPANY 41718 COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Included MED EXP (Any one person) $ Included A OCIP Phase VIII B0595XR6009019 1/6/2020 3/10/2021 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 15,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XR6010019 1/6/2020 3/10/2021 AGGREGATE $ 15,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N B OFFICER/MEMBER EXCLUDED? WC5-661-067258-110 1/6/2020 10/1/2022 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE C 2nd Layer Excess P-001-000188686-01 1/6/2020 3/10/2021 $10,000,000 $20,000,000 D 3rd Layer Excess AR6461177 1/6/2020 3/10/2021 $15,000,000 $20,000,000 E 4th Layer Excess 4193000 1/6/2020 3/10/2021 $20,000,000 $40,000,000 F 5th Layer Excess ELD30001227100 1/6/2020 3/10/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Coachella Valley Unified School District Palm View ES Modernization and Reconstruction Phase 3 P. O. Box 847 Thermal, California 92274 Site Code/Contract #: 0170-12-0661941-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Rite-Way Roof Corporation 15425 Arrow Route AUTHORIZED REPRESENTATIVE Fontana, CA 92335 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Adriana Ramirez USI Insurance Services National, Inc PHONE FAX 190 River Road 1st Floor (A/C, No. Ext): (202) 416-2556 (A/C, No): E-MAIL Summit, NJ 07901-1444 ADDRES$: adriana.ramirez@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Houston Casualty Company INSURED INSURER B: Everest Indemity Insurance Co. 100 Monitor Holdings, LLC Etal INSURER C: Tokio Marine America Insurance Company 10945 c/o Ironstate Development 50 Washington Street INSURER D: Hoboken, NJ 07030 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 0 A X CIP 100 Monitor H18PC30935-00 1/26/2018 1/26/2020 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 B EXCESS LIAB CLAIMS-MADE XC5EX00337181 1/26/2018 1/26/2020 AGGREGATE $ 25,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess PUB616396 1/26/2018 1/26/2020 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is enrolled and is a Named Insured in the 100 Monitor Street Project Owner Controlled Insurance Program. Coverage applies to on-site exposure only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NJ Granite & Marble Inc 1435 51st Street Unit 1B AUTHORIZED REPRESENTATIVE North Bergen, NJ 07047 James C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 8/29/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Tiffany Kratt Keenan and Associates (310) 212-0363 Ext 2355 Crenshaw Blvd. PHONE FAX (A/C, No. Ext): 2012 (A/C. No): Suite 200 E-MAIL Torrance, CA 90501 ADDRESS: TMinor-Kratt@Keenan.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: UNDERWRITERS AT LLOYDS LONDON (ILLINOIS) 15792 INSURED INSURER B: LIBERTY MUTUAL INSURANCE COMPANY 23043 CCD Inc 10235 Systems Parkway Ste B INSURER C: EVEREST INDEMNITY INSURANCE COMPANY 10851 Sacramento, CA 95827 INSURER D: COLONY INSURANCE COMPANY 39993 INSURER E: ASPEN INSURANCE UK LIMITED AA1120337 ENDURANCE AMERICAN SPECIALTY INSURANCE INSURER F: COMPANY 41718 COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 5,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ Included MED EXP (Any one person) $ Included A X OCIP 2017-2019 (Phase VII) B0595XN5203017 9/1/2019 12/16/2019 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 20,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 5,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE B0595XN5204017 9/1/2019 12/16/2019 AGGREGATE $ 20,000,000 DED RETENTION $ WORKERS COMPENSATION PER X OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N B OFFICER/MEMBER EXCLUDED? WC5-661-067217-869 9/1/2019 10/1/2020 (Mandatory in NH) E.L. EACH ACCIDENT $ 1,000,000 If yes, describe under E.L. DISEASE EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ 1,000,000 EACH OCCURRENCE AGGREGATE C 2nd Layer Excess XC1EX00018-171 9/1/2019 12/16/2019 $10,000,000 $20,000,000 D 3rd Layer Excess AR6460840 9/1/2019 12/16/2019 $15,000,000 $30,000,000 E 4th Layer Excess K0A8HTC17A0Q 9/1/2019 12/16/2019 $15,000,000 $30,000,000 F 5th Layer Excess ELD30000471400 9/1/2019 12/16/2019 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Liberty Union High School District Heritage High School Culinary Arts 101 American Avenue Brentwood, California 94513 Site Code: 0848-06-0722434-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CCDS Inc 10235 Systems Parkway Ste B AUTHORIZED REPRESENTATIVE Sacramento, CA 95827 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+acord25,"ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 7/18/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Marla Johnson USI Insurance Services PHONE FAX (A/C, No Ext): (360) 787-9827 601 Union St, Suite 1000 (A/C, No): E-MAIL Seattle, WA 98101 ADDRESS: marla.johnson@usi.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Navigaotrs Specialty Ins. Co. INSURED INSURER B: AXIS Surplus Ins. Co. Expedia Group, Inc. INSURER C: First Mercury Ins Company 333 108th Ave NE Bellevue, WA 98004 INSURER D: Great American Insurance Companies INSURER E: Endurance American Specialty Ins co INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded A X OCIP Expedia Cruise Projec GA18CGL231040IC 1/2/2018 7/21/2021 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY PROJECT LOC PRODUCTS COMP/ OP AGG $ 4,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per AUTOS ONLY AUTO accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000 B X EXCESS LIAB CLAIMS-MADE ELU627847/01/2018 1/2/2018 7/1/2021 AGGREGATE $ 10,000,000 DED RETENTION $ WORKERS COMPENSATION PER OTHER AND EMPLOYERS' LIABILITY STATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. EACH ACCIDENT $ If yes, describe under E.L. DISEASE EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE EA EMPLOYEE $ EACH OCCURRENCE AGGREGATE C 2nd Layer Excess CA-EX-0000076349-01 1/2/2018 7/1/2021 $15,000,000 $15,000,000 A 3rd Layer Excess SE17FXS913425IC 1/2/2018 7/1/2021 $25,000,000 $25,000,000 D 4th Layer Excess EXC 2068856 1/2/2018 7/1/2021 $25,000,000 $25,000,000 E 5th Layer Excess ELD30000554200 1/2/2018 7/1/2021 $25,000,000 $25,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Expedia OCIP - Project Cruise: 1201 Amgen Court West, Seattle, WA 98119 Certificate Holder is enrolled in the Expedia/Cruise OCIP for General Liability and Excess Liability in accordance with the terms and conditions of the policy. Excess Liability follows form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Insulation Contractors, Inc. 22706 58th Place South AUTHORIZED REPRESENTATIVE Kent, WA 98032 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD"
+declaration,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number E.E. BISS HEATING & COOLING INC. 1144 MAPLE DRIVE Policy Number FREDERICKSBURG PA 17026 Symbol: RWC Number: C58581872 Policy Period Effective Date of Endorsement 04-17-2020 TO 12-01-2020 04-17-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 000001A CONTRACT INFORMATION PAGE WC 000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC 000115 NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 WC 000201B MARITIME COVERAGE ENDORSEMENT WC 000203 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT WC 000301A ALTERNATE EMPLOYER ENDORSEMENT WC 000302 DESIGNATED WORKPLACES EXCLUSION ENDORSEMENT WC 000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT WC 000311A VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC 000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC 000414A 90-DAY REPORTING REQUIREMENT-NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC 000419 PREMIUM DUE DATE ENDORSEMENT WC 000421D CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC 000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 08020261 CIVIL UNIONS OR DOMESTIC PARTNERSHIPS WC 990302D VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN WC 990334 CONTROLLED INSURANCE PROGRAM - AMENDATORY ENDORSEMENT WC 990355 UNINTENTIONAL ERRORS AND OMISSIONS WC 990391A TWO OR MORE POLICIES ISSUED BY US WC 990409 NOTIFICATION OF PREMIUM ADJUSTMENT (Authorized Representative) WC 99 99 99D INSURED COPY"
+declaration,Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number E.E. BISS HEATING & COOLING INC. 1144 MAPLE DRIVE Policy Number FREDERICKSBURG PA 17026 Symbol: RWC Number: C58581872 Policy Period Effective Date of Endorsement 04-17-2020 TO 12-01-2020 04-17-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 990697 EARLIER NOTICE OF CANCELLATION AND NON-RENEWAL ENDORSEMENT WC 990773 TRADE OR ECONOMIC SANCTIONS ENDORSEMENT WC 999999D SCHEDULE OF FORMS AND ENDORSEMENTS WC 900379 ND NORTH DAKOTA AMENDATORY ENDORSEMENT WC 990303C ND EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 900380 OH OHIO CANCELLATION AND NONRENEWAL ENDORSEMENT WC 990442 OH STOP GAP COVERAGE - OHIO WC 370401 PA PENNSYLVANIA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC 370402 PA PENNSYLVANIA CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT ENDORSEMENT WC 370601 PA SPECIAL PENNSYLVANIA ENDORSEMENT - INSPECTION OF MANUALS WC 370602 PA PENNSYLVANIA NOTICE (INSURANCE CONSULTATION SERVICES EXEMPTION ACT) WC 370603A PA PENNSYLVANIA ACT 86 - 1986 ENDORSEMENT WC 900341 PA EARLIER NOTICE OF NON-RENEWAL ENDORSEMENT - PENNSYLVANIA WC 990303C WA EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 490301 WY WYOMING AMENDATORY ENDORSEMENT WC 990303C WY EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) (Authorized Representative) WC 99 99 99D INSURED COPY
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 81 87 2 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation NORTH DAKOTA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/05/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58581872 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation OHIO Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/05/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY Workers' Compensation ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE and Employers Liability 12165 Insurance Policy Information Page POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 81 87 2 PREVIOUS POLICY NO. Individual Partnership Association Symbol: Number: Corporation Joint Venture Other Legal Entity Item 1. E.E. BISS HEATING & COOLING INC. Inter/Intrastate ID No.: Named 1144 MAPLE DRIVE Insured FREDERICKSBURG PA 17026 Federal Employer ID No.: 260506660 Mailing Address Employer's ID No.: PIIC CODE: 5411 For other named insured see Extension of Information Page - Schedule of Named Insured, WC 99 99 A For other workplaces see Extension of Information Page Schedule of Other Workplaces, WC 99 99 99 B Item 2. Policy period: From 04-17-2020 To 12-01-2020 12:01 A.M., standard time at the named insured's mailing address. Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: PA Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND,OH,WA,WY, AND STATES DESIGNATED IN ITEM 3.A Item 3D. This Policy includes these endorsements and schedules: See schedule of Forms and Endorsements WC999999D Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE -CLASSIFICATIONS If indicated here, interim adjustments of premium will be made: Minimum Premium collected in PA $ 516. Semi-Annually Quarterly Monthly Total Estimated Premium $ 1205. Deposit Premium $ PRODUCER NAME AND MAILING ADDRESS WILLIS TOWERS WATSON SOUTHEAST INC 214 NORTH TRYON STREET SUITE 2500 CHARLOTTE NC 28202 PRODUCER CODE: 132685 62-1404453 DWU MARKETING OFFICE: DALLAS CON. WRAP-UP ISSUE DATE: 05/05/2020 972 Authorized Representative WC 00 00 01A (05/88) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58581872 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation PENNSYLVANIA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS HARRISBURG, PA # LHW - IF ANY BASIS 664 F IF ANY 5.16 0. HEATING, VENTILATING OR AIR CONDITIONING 664 IF ANY 3.21 0. CONTRACTOR HEATING, VENTILATING OR AIR CONDITIONING 664 IF ANY 3.21 0. CONTRACTOR SPECIAL** CLASS DESC 0 516. ESTIMATED STANDARD POLICY PREMIUM 516. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .020 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR CATASTROPHE (OTHER 9741 .010 0. THAN CERTIFIED ACTS OF TERRORISM) PA EMPLOYERS ASSESSMENT SURCHARGE 0938 .020 4. EXPENSE CONSTANT 0900 210. TOTAL 730. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 730. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/05/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58581872 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WASHINGTON Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - FLAT 9139 25. CHARGE ESTIMATED STANDARD POLICY PREMIUM 25. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 25. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 25. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/05/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58581872 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WYOMING Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/05/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 81 87 2 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total Per $100 of No. Premium Remuneration Remuneration FOREIGN VOLUNTARY 0. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 0. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/05/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number UNION COUNTY CONSTRUCTION GROUP, INC. 638 CHERRY STREET Policy Number GLOUCESTER CITY NJ 08030 Symbol: RWC Number: C58582542 Policy Period Effective Date of Endorsement 04-29-2020 TO 12-01-2020 04-29-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 000001A CONTRACT INFORMATION PAGE WC 000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC 000115 NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 WC 000201B MARITIME COVERAGE ENDORSEMENT WC 000203 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT WC 000301A ALTERNATE EMPLOYER ENDORSEMENT WC 000302 DESIGNATED WORKPLACES EXCLUSION ENDORSEMENT WC 000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT WC 000311A VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC 000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC 000414A 90-DAY REPORTING REQUIREMENT-NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC 000419 PREMIUM DUE DATE ENDORSEMENT WC 000421D CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC 000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 08020261 CIVIL UNIONS OR DOMESTIC PARTNERSHIPS WC 990302D VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN WC 990334 CONTROLLED INSURANCE PROGRAM - AMENDATORY ENDORSEMENT WC 990355 UNINTENTIONAL ERRORS AND OMISSIONS WC 990391A TWO OR MORE POLICIES ISSUED BY US WC 990409 NOTIFICATION OF PREMIUM ADJUSTMENT (Authorized Representative) WC 99 99 99D INSURED COPY"
+declaration,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number UNION COUNTY CONSTRUCTION GROUP, INC. 638 CHERRY STREET Policy Number GLOUCESTER CITY NJ 08030 Symbol: RWC Number: C58582542 Policy Period Effective Date of Endorsement 04-29-2020 TO 12-01-2020 04-29-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 990697 EARLIER NOTICE OF CANCELLATION AND NON-RENEWAL ENDORSEMENT WC 990773 TRADE OR ECONOMIC SANCTIONS ENDORSEMENT WC 999999D SCHEDULE OF FORMS AND ENDORSEMENTS WC 900379 ND NORTH DAKOTA AMENDATORY ENDORSEMENT WC 990303C ND EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 900380 OH OHIO CANCELLATION AND NONRENEWAL ENDORSEMENT WC 990442 OH STOP GAP COVERAGE - OHIO WC 370401 PA PENNSYLVANIA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC 370402 PA PENNSYLVANIA CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT ENDORSEMENT WC 370601 PA SPECIAL PENNSYLVANIA ENDORSEMENT - INSPECTION OF MANUALS WC 370602 PA PENNSYLVANIA NOTICE (INSURANCE CONSULTATION SERVICES EXEMPTION ACT) WC 370603A PA PENNSYLVANIA ACT 86 - 1986 ENDORSEMENT WC 900341 PA EARLIER NOTICE OF NON-RENEWAL ENDORSEMENT - PENNSYLVANIA WC 990303C WA EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 490301 WY WYOMING AMENDATORY ENDORSEMENT WC 990303C WY EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) 472 (Authorized Representative) WC 99 99 99D INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 54 2 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation NORTH DAKOTA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58582542 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation OHIO Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY Workers' Compensation ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE and Employers Liability 12165 Insurance Policy Information Page POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 54 2 PREVIOUS POLICY NO. Individual Partnership Association Symbol: Number: Corporation Joint Venture Other Legal Entity Item 1. UNION COUNTY CONSTRUCTION GROUP, INC. Inter/Intrastate ID No.: Named 638 CHERRY STREET Insured GLOUCESTER CITY NJ 08030 Federal Employer ID No.: 223339296 Mailing Address Employer's ID No.: PIIC CODE: 5411 For other named insured see Extension of Information Page - Schedule of Named Insured, WC 99 99 99 A For other workplaces see Extension of Information Page Schedule of Other Workplaces, WC 99 99 99 B Item 2. Policy period: From 04-29-2020 To 12-01-2020 12:01 A.M., standard time at the named insured's mailing address. Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: PA Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY, AND STATES DESIGNATED IN ITEM 3.A Item 3D. This Policy includes these endorsements and schedules: See schedule of Forms and Endorsements WC999999D Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE -CLASSIFICATIONS If indicated here, interim adjustments of premium will be made: Minimum Premium collected in PA $ 956. Semi-Annually Quarterly Monthly Total Estimated Premium $ 1645. Deposit Premium $ PRODUCER NAME AND MAILING ADDRESS WILLIS TOWERS WATSON SOUTHEAST INC 214 NORTH TRYON STREET SUITE 2500 CHARLOTTE NC 28202 PRODUCER CODE: 132685 62-1404453 DWU MARKETING OFFICE: DALLAS CON. WRAP-UP ISSUE DATE: 05/08/2020 972 Authorized Representative WC 00 00 01A (05/88) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 54 2 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation PENNSYLVANIA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS RIVWEWALK, PA #6561 LHW - IF ANY BASIS 645 F IF ANY 9.56 0. WALLBOARD INSTALLATION - WITHIN BUILDINGS 645 IF ANY 5.95 0. CEILING INSTALLATION, SUSPENDED ACOUSTICAL GRID 649 IF ANY 3.90 0. TYPE CARPENTRY - COMMERCIAL STRUCTURES 651 IF ANY 5.28 0. CARPENTRY - COMMERCIAL STRUCTURES 651 IF ANY 5.28 0. SPECIAL** CLASS DESC 0 956. ESTIMATED STANDARD POLICY PREMIUM 956. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .020 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR CATASTROPHE (OTHER 9741 .010 0. THAN CERTIFIED ACTS OF TERRORISM) PA EMPLOYERS ASSESSMENT SURCHARGE 0938 .020 4. EXPENSE CONSTANT 0900 210. TOTAL 1170. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 1170. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58582542 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WASHINGTON Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - FLAT 9139 25. CHARGE ESTIMATED STANDARD POLICY PREMIUM 25. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 25. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 25. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58582542 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WYOMING Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 54 2 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total Per $100 of No. Premium Remuneration Remuneration FOREIGN VOLUNTARY 0. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 0. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 63 3 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation NORTH DAKOTA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 63 3 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation OHIO Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58582633 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation PENNSYLVANIA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS RIVERWALK, PA #6561 LHW - IF ANY BASIS 608 F IF ANY 8.93 0. FLAT CEMENT WORK 608 IF ANY 5.56 0. EXCAVATION 609 IF ANY 3.48 0. CONCRETE CONSTRUCTION 654 IF ANY 6.74 0. SPECIAL** CLASS DESC 0 893. ESTIMATED STANDARD POLICY PREMIUM 893. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .020 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR CATASTROPHE (OTHER 9741 .010 0. THAN CERTIFIED ACTS OF TERRORISM) PA EMPLOYERS ASSESSMENT SURCHARGE 0938 .020 4. EXPENSE CONSTANT 0900 210. TOTAL 1107. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 1107. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 63 3 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WASHINGTON Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - FLAT 9139 25. CHARGE ESTIMATED STANDARD POLICY PREMIUM 25. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 25. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 25. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 63 3 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WYOMING Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 150. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($210.00 COLLECTED IN PA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 82 63 3 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total Per $100 of No. Premium Remuneration Remuneration FOREIGN VOLUNTARY 0. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 0. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/08/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number NAUTILUS COMMERCIAL 1417 WEST MAIN ST. Policy Number YADKINVILLE NC 27055 Symbol: RWC Number: C58586080 Policy Period Effective Date of Endorsement 05-03-2020 TO 12-01-2020 05-03-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 000001A CONTRACT INFORMATION PAGE WC 000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC 000115 NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 WC 000201B MARITIME COVERAGE ENDORSEMENT WC 000203 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT WC 000301A ALTERNATE EMPLOYER ENDORSEMENT WC 000302 DESIGNATED WORKPLACES EXCLUSION ENDORSEMENT WC 000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT WC 000311A VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC 000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC 000414A 90-DAY REPORTING REQUIREMENT-NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC 000419 PREMIUM DUE DATE ENDORSEMENT WC 000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC 000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC 000425 EXPERIENCE RATING MODIFICATION FACTOR REVISION ENDORSEMENT 08020261 CIVIL UNIONS OR DOMESTIC PARTNERSHIPS WC 990302D VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN WC 990334 CONTROLLED INSURANCE PROGRAM - AMENDATORY ENDORSEMENT WC 990355 UNINTENTIONAL ERRORS AND OMISSIONS WC 990391A TWO OR MORE POLICIES ISSUED BY US (Authorized Representative) WC 99 99 99D INSURED COPY"
+declaration,Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number NAUTILUS COMMERCIAL 1417 WEST MAIN ST. Policy Number YADKINVILLE NC 27055 Symbol: RWC Number: C58586080 Policy Period Effective Date of Endorsement 05-03-2020 TO 12-01-2020 05-03-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 990409 NOTIFICATION OF PREMIUM ADJUSTMENT WC 990697 EARLIER NOTICE OF CANCELLATION AND NON-RENEWAL ENDORSEMENT WC 990773 TRADE OR ECONOMIC SANCTIONS ENDORSEMENT WC 999999D SCHEDULE OF FORMS AND ENDORSEMENTS WC 900379 ND NORTH DAKOTA AMENDATORY ENDORSEMENT WC 990303C ND EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 900380 OH OHIO CANCELLATION AND NONRENEWAL ENDORSEMENT WC 990442 OH STOP GAP COVERAGE - OHIO WC 450602 VA VIRGINIA AMENDATORY ENDORSEMENT WC 450604 VA VIRGINIA CONTRACTING CLASIFICATION PREMIUM ADJUSTMENT PROGRAM ENDORSEMENT WC 990303C WA EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 490301 WY WYOMING AMENDATORY ENDORSEMENT WC 990303C WY EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) 472 (Authorized Representative) WC 99 99 99D INSURED COPY
+declaration,"CHUBB ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 86 08 0 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation NORTH DAKOTA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 84. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($240.00 COLLECTED IN VA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/19/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 86 08 0 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation OHIO Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 84. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($240.00 COLLECTED IN VA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/19/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY Workers' Compensation ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE and Employers Liability 12165 Insurance Policy Information Page POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 86 08 0 PREVIOUS POLICY NO. Individual Partnership Association Symbol: Number: Corporation Joint Venture Other Legal Entity Item 1. NAUTILUS COMMERCIAL Inter/Intrastate ID No.: 914382483 Named 1417 WEST MAIN ST. Insured YADKINVILLE NC 27055 Federal Employer ID No.: 472801618 Mailing Address Employer's ID No.: PIIC CODE: 5411 For other named insured see Extension of Information Page - Schedule of Named Insured, WC 99 99 99 A For other workplaces see Extension of Information Page Schedule of Other Workplaces, WC 99 99 99 B Item 2. Policy period: From 05-03-2020 To 12-01-2020 12:01 A.M., standard time at the named insured's mailing address. Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: VA Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND,OH,WA,WY, AND STATES DESIGNATED IN ITEM 3.A Item 3D. This Policy includes these endorsements and schedules: See schedule of Forms and Endorsements WC999999D Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE -CLASSIFICATIONS If indicated here, interim adjustments of premium will be made: Minimum Premium collected in VA $ 973. Semi-Annually Quarterly Monthly Total Estimated Premium $ 1448. Deposit Premium $ PRODUCER NAME AND MAILING ADDRESS WILLIS TOWERS WATSON SOUTHEAST INC 214 NORTH TRYON STREET SUITE 2500 CHARLOTTE NC 28202 PRODUCER CODE: 132685 62-1404453 DWU MARKETING OFFICE: DALLAS CON. WRAP-UP ISSUE DATE: 05/19/2020 972 Authorized Representative WC 00 00 01A (05/88) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 86 08 0 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation VIRGINIA Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS SPRINGFIELD, VA #2745 LHW - IF ANY BASIS 5146F IF ANY 6.24 0. FIXTURES OR FURNITURE INSTALLATION NOC 5146 IF ANY 4.73 0. EMPLOYERS' LIABILITY INCREASED LIMITS, 9848 120. ADDITIONAL PREMIUM TO BALANCE TO MINIMUM PREMIUM PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 120. APPLICABLE EXPERIENCE MODIFICATION .840 PREMIUM ADJUSTED BY EXPERIENCE MODIFICATION 101. PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 0. APPLICABLE EXPERIENCE MODIFICATION .830 PREMIUM ADJUSTED BY EXPERIENCE MODIFICATION 0. TO EQUAL MINIMUM PREMIUM 0990 632. ESTIMATED STANDARD POLICY PREMIUM 101. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT 0900 240. TOTAL 973. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 973. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/19/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 86 08 0 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WASHINGTON Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - FLAT 9139 25. CHARGE ESTIMATED STANDARD POLICY PREMIUM 14. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($240.00 COLLECTED IN VA) TOTAL 25. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 25. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/19/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 86 08 0 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation WYOMING Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total No. Per $100 of Premium Remuneration Remuneration AHOLD AMERICAS HOLDINGS EMPLOYERS' LIABILITY - STOPGAP COVERAGE - 9139 .19 150. PAYROLL ESTIMATED STANDARD POLICY PREMIUM 84. CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM CATASTROPHE PROVISIONS FOR TERRORISM - NOT PART 9740 .000 0. OF STANDARD PREMIUM EXPENSE CONSTANT ($240.00 COLLECTED IN VA) TOTAL 150. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 150. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/19/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"CHUBB R ISSUING COMPANY EXTENSION OF INFORMATION ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE PAGE-CLASSIFICATION 12165 POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C5 85 86 08 0 PREVIOUS POLICY NO. Individual Partnership Symbol: Number: Corporation Complete Item 4. of the Information Page Premium Basis Rate Code Estimated Classifications Estimated Total Per $100 of No. Premium Remuneration Remuneration FOREIGN VOLUNTARY 0. Minimum, Estimated and Deposit Premiums are shown on the Information Page. Total State Premium 0. FOR PERIOD INDICATED IN POLICY INFORMATION PAGE THIS EXTENSION OF INFORMATION PAGE IS EFFECTIVE FOR THE POLICY PERIOD INDICATED ON THE POLICY INFORMATION PAGE UNLESS OTHERWISE STATED. ISSUE DATE: 05/19/2020 (PAGE 1 LAST PAGE) WC 99 04 18 (12/05) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+declaration,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number COLD TECHNOLOGY, INC 203 OWER LANDING ROAD Policy Number BLACKWOOD NJ 08012 Symbol: RWC Number: C58582529 Policy Period Effective Date of Endorsement 03-03-2020 TO 12-01-2020 03-03-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 000001A CONTRACT INFORMATION PAGE WC 000106A LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT WC 000115 NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 WC 000201B MARITIME COVERAGE ENDORSEMENT WC 000203 VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT WC 000301A ALTERNATE EMPLOYER ENDORSEMENT WC 000302 DESIGNATED WORKPLACES EXCLUSION ENDORSEMENT WC 000310 SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT WC 000311A VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT WC 000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC 000414A 90-DAY REPORTING REQUIREMENT-NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT WC 000419 PREMIUM DUE DATE ENDORSEMENT WC 000421D CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC 000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT 08020261 CIVIL UNIONS OR DOMESTIC PARTNERSHIPS WC 990302D VOLUNTARY COMPENSATION ENDORSEMENT FOREIGN WC 990334 CONTROLLED INSURANCE PROGRAM - AMENDATORY ENDORSEMENT WC 990355 UNINTENTIONAL ERRORS AND OMISSIONS WC 990391A TWO OR MORE POLICIES ISSUED BY US WC 990409 NOTIFICATION OF PREMIUM ADJUSTMENT (Authorized Representative) WC 99 99 99D INSURED COPY"
+declaration,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number COLD TECHNOLOGY, INC 203 OWER LANDING ROAD Policy Number BLACKWOOD NJ 08012 Symbol: RWC Number: C58582529 Policy Period Effective Date of Endorsement 03-03-2020 TO 12-01-2020 03-03-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. FORM AND ENDORSEMENT SCHEDULE WC 990697 EARLIER NOTICE OF CANCELLATION AND NON-RENEWAL ENDORSEMENT WC 990773 TRADE OR ECONOMIC SANCTIONS ENDORSEMENT WC 999999D SCHEDULE OF FORMS AND ENDORSEMENTS WC 900379 ND NORTH DAKOTA AMENDATORY ENDORSEMENT WC 990303C ND EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 900380 OH OHIO CANCELLATION AND NONRENEWAL ENDORSEMENT WC 990442 OH STOP GAP COVERAGE - OHIO WC 370401 PA PENNSYLVANIA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC 370402 PA PENNSYLVANIA CONSTRUCTION CLASSIFICATION PREMIUM ADJUSTMENT ENDORSEMENT WC 370601 PA SPECIAL PENNSYLVANIA ENDORSEMENT - INSPECTION OF MANUALS WC 370602 PA PENNSYLVANIA NOTICE (INSURANCE CONSULTATION SERVICES EXEMPTION ACT) WC 370603A PA PENNSYLVANIA ACT 86 - 1986 ENDORSEMENT WC 900341 PA EARLIER NOTICE OF NON-RENEWAL ENDORSEMENT - PENNSYLVANIA WC 990303C WA EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) WC 490301 WY WYOMING AMENDATORY ENDORSEMENT WC 990303C WY EMPLOYERS LIABILITY ENDORSEMENT (STOP-GAP COVERAGE) (Authorized Representative) WC 99 99 99D INSURED COPY"
+declaration,"CHUBB ISSUING COMPANY Workers' Compensation ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE and Employers Liability 12165 Insurance Policy Information Page POLICY NUMBER New Renewal Rewrite Symbol: RWC Number: C58582529 PREVIOUS POLICY NO. Individual Partnership Association Symbol: Number: Corporation Joint Venture Other Legal Entity Item 1. COLD TECHNOLOGY, INC Inter/Intrastate ID No.: Named 203 OWER LANDING ROAD Insured BLACKWOOD NJ 08012 Federal Employer ID No.: 222642162 Mailing Address Employer's ID No.: PIIC CODE: 5411 For other named insured see Extension of Information Page - Schedule of Named Insured, WC 99 99 99 A For other workplaces see Extension of Information Page Schedule of Other Workplaces, WC 99 99 99 B Item 2. Policy period: From 03-03-2020 To 12-01-2020 12:01 A.M., standard time at the named insured's mailing address. Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: PA Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY, AND STATES DESIGNATED IN ITEM 3.A Item 3D. This Policy includes these endorsements and schedules: See schedule of Forms and Endorsements WC999999D Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE -CLASSIFICATIONS If indicated here, interim adjustments of premium will be made: Minimum Premium collected in PA $ 956. Semi-Annually Quarterly Monthly Total Estimated Premium $ 1645. Deposit Premium $ PRODUCER NAME AND MAILING ADDRESS WILLIS TOWERS WATSON SOUTHEAST INC 214 NORTH TRYON STREET SUITE 2500 CHARLOTTE NC 28202 PRODUCER CODE: 132685 62-1404453 DWU MARKETING OFFICE: DALLAS CON. WRAP-UP ISSUE DATE: 05/08/2020 972 Authorized Representative WC 00 00 01A (05/88) Copyright 1987 National Council on Compensation Insurance INSURED COPY"
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number BROCK SERVICES, LLC 10343 SAM HOUSTON PARK DRIVE Policy Number SUITE 200 Symbol: WLR Number: C58593709 Policy Period Effective Date of Endorsement 06-01-2020 TO 06-01-2021 06-01-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 82 Authorized Agent WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number MOODY SPRINKLER COMPANY, INC. 5434 FORT HENRY DRIVE Policy Number KINGSPORT TN 37663 Symbol: WLR Number: C58593734 Policy Period Effective Date of Endorsement 06-01-2020 TO 06-01-2021 06-01-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. Authorized Agent WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number PARTNER INDUSTRIAL, L.P. 8901 GAYLORD DRIVE Policy Number SUITE 230 Symbol: WLR Number: C58593746 Policy Period Effective Date of Endorsement 06-01-2020 TO 06-01-2021 06-01-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. X Authorized Agent WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number PARTNER INDUSTRIAL, L.P. 8901 GAYLORD DRIVE Policy Number SUITE 230 Symbol: WLR Number: C58678478 Policy Period Effective Date of Endorsement 06-01-2021 TO 06-01-2022 06-01-2021 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 24 Authorized Agent WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number INDUSTRIAL ROOFING & CONSTRUCTION, LLC 1128 HIGHWAY 2 Policy Number STERLINGTON LA 71280 Symbol: WLR Number: C56855336 Policy Period Effective Date of Endorsement 01-01-2022 TO 01-01-2023 01-01-2022 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. WE WILL NOT ATTEMPT TO ASSERT ANY RIGHT OF SUBROGATION WITH RESPECT TO, OR ANY LIEN UPON, PAYMENTS MADE BY OR ON BEHALF OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE TO ANY INJURED EMPLOYEE OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 922 Authorized Agent WC 00 03 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number AUSTIN MAINTENANCE & CONSTRUCTION, INC. 201 EAST 13TH STREET Policy Number LA PORTE TX 77571 Symbol: WLR Number: C58645588 Policy Period Effective Date of Endorsement 01-01-2021 TO 01-01-2022 01-01-2021 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. WE WILL NOT ATTEMPT TO ASSERT ANY RIGHT OF SUBROGATION WITH RESPECT TO, OR ANY LIEN UPON, PAYMENTS MADE BY OR ON BEHALF OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE TO ANY INJURED EMPLOYEE OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 87.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. Authorized Agent WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/30/2014 forms a part of Policy No. WC 034-15-7226 Issued to TRADESMEN INTERNATIONAL, INC By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. The premium charge for the endorsement is INCLUDED This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by Invradable (Ed. 04/84) Authorized Representative"
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number RWB CONTRACTING CORP 19-29 DITMARS BLVD. Policy Number ASTORIA NY 11105 Symbol: RWC Number: C58606406 Policy Period Effective Date of Endorsement 06-18-2020 TO 12-01-2020 06-18-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule BLANKET AS REQUIRED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 472 Authorized Agent WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number WC FINISHER CORP 150 SOUTH 6TH AVENUE Policy Number MOUNT VERNON NY 10550 Symbol: RWC Number: C58594568 Policy Period Effective Date of Endorsement 06-02-2020 TO 12-01-2020 06-02-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule BLANKET AS REQUIRED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 472 Authorized Agent WC 00 03 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number EASTERN REFRIGERATION CO. 275 OLD HARTFORD RD. Policy Number COLCHESTER CT 06415 Symbol: RWC Number: C58585956 Policy Period Effective Date of Endorsement 05-06-2020 TO 12-01-2020 05-06-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule BLANKET AS REQUIRED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 872 Authorized Agent WC 00 03 13 (11/05) C Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"POLICY NUMBER: FWC0000030940900 COMMERCIAL GENERAL LIABILITY CG 20 11 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): Name Of Person(s) Or Organization(s) (Additional Insured): ANY PERSON OR ORGANIZATION TO WHOM YOU ARE OBLIGATED BY VALID WRITTEN CONTRACT TO PROVIDE SUCH COVERAGE. Additional Premium: 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 2. If coverage provided to the additional insured is include as an additional insured the person(s) or required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured with respect to liability arising out of the ownership, will not be broader than that which you are maintenance or use of that part of the premises required by the contract or agreement to leased to you and shown in the Schedule and provide for such additional insured. subject to the following additional exclusions: B. With respect to the insurance afforded to these This insurance does not apply to: additional insureds, the following is added to Section III - Limits Of Insurance: 1. Any ""occurrence"" which takes place after you cease to be a tenant in that premises. If coverage provided to the additional insured is 2. Structural alterations, new construction or required by a contract or agreement, the most we demolition operations performed by or on behalf will pay on behalf of the additional insured is the amount of insurance: of the person(s) or organization(s) shown in the Schedule. 1. Required by the contract or agreement; or However: 2. Available under the applicable Limits of 1. The insurance afforded to such additional Insurance shown in the Declarations; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 11 04 13 Insurance Services Office, Inc., 2012 Page 1 of 1"
+endorsement,"POLICY NUMBER: FWC0000030940900 COMMERCIAL GENERAL LIABILITY CG 20 12 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: ANY PERSON OR ORGANIZATION TO WHOM YOU ARE OBLIGATED BY VALID WRITTEN CONTRACT TO PROVIDE SUCH COVERAGE. 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 2. This insurance does not apply to: include as an additional insured any state or governmental agency or subdivision or political a. ""Bodily injury"", ""property damage"" or subdivision shown in the Schedule, subject to the ""personal and advertising injury"" arising out of following provisions: operations performed for the federal government, state or municipality; or 1. This insurance applies only with respect to operations performed by you or on your behalf b. ""Bodily injury"" or ""property damage"" included for which the state or governmental agency or within the ""products-completed operations hazard"". subdivision or political subdivision has issued a permit or authorization. B. With respect to the insurance afforded to these However: additional insureds, the following is added to Section III - Limits Of Insurance: a. The insurance afforded to such additional insured only applies to the extent permitted If coverage provided to the additional insured is by law; and required by a contract or agreement, the most we will pay on behalf of the additional insured is the b. If coverage provided to the additional insured amount of insurance: is required by a contract or agreement, the insurance afforded to such additional insured 1. Required by the contract or agreement; or will not be broader than that which you are 2. Available under the applicable Limits of required by the contract or agreement to Insurance shown in the Declarations; provide for such additional insured. whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 12 04 13 Insurance Services Office, Inc., 2012 Page 1 of 1"
+endorsement,"POLICY NUMBER: FWC0000030940900 COMMERCIAL GENERAL LIABILITY CG 20 18 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MORTGAGEE, ASSIGNEE OR RECEIVER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Person(s) Or Organization(s) Designation Of Premises ANY PERSON OR ORGANIZATION TO WHOM YOU ARE OBLIGATED BY VALID WRITTEN CONTRACT TO PROVIDE SUCH COVERAGE. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A Section Il - Who Is An Insured is amended to C. 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 with Section III - Limits Of Insurance: respect to their liability as mortgagee, assignee, or If coverage provided to the additional insured is receiver and arising out of the ownership, required by a contract or agreement, the most we maintenance, or use of the premises by you and will pay on behalf of the additional insured is the shown in the Schedule. amount of insurance: However: 1. Required by the contract or agreement; or 1. The insurance afforded to such additional 2. Available under the applicable Limits of insured only applies to the extent permitted by Insurance shown in the Declarations; law; and whichever is less. 2. If coverage provided to the additional insured is This endorsement shall not increase the applicable required by a contract or agreement, the Limits of Insurance shown in the Declarations. 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. B. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. CG 20 18 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1"
+endorsement,"POLICY NUMBER: FWC0000030940900 COMMERCIAL GENERAL LIABILITY CG 20 24 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS OR OTHER INTERESTS FROM WHOMLAND HAS BEEN LEASED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises Name Of Person(s) Or Organization(s) (Part Leased To You) ANY PERSON OR ORGANIZATION TO WHOM YOU ARE OBLIGATED BY VALID WRITTEN CONTRACT TO PROVIDE SUCH COVERAGE. 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 1. Any ""occurrence"" which takes place after you include as an additional insured the person(s) or cease to lease that land; organization(s) shown in the Schedule, but only 2. Structural alterations, new construction or with respect to liability arising out of the ownership, maintenance or use of that part of the land leased demolition operations performed by or on behalf to you and shown in the Schedule. of the person(s) or organization(s) shown in the Schedule. However: C. With respect to the insurance afforded to these 1. The insurance afforded to such additional additional insureds, the following is added to insured only applies to the extent permitted by Section III - Limits Of Insurance: law; and If coverage provided to the additional insured is 2. If coverage provided to the additional insured is required by a contract or agreement, the most we required by a contract or agreement, the will pay on behalf of the additional insured is the insurance afforded to such additional insured amount of insurance: will not be broader than that which you are required by the contract or agreement to provide 1. Required by the contract or agreement; or for such additional insured. 2. Available under the applicable Limits of B. With respect to the insurance afforded to these Insurance shown in the Declarations; additional insureds, the following additional whichever is less. exclusions apply: This endorsement shall not increase the applicable This insurance does not apply to: Limits of Insurance shown in the Declarations. CG 20 24 04 13 Insurance Services Office, Inc., 2012 Page 1 of 1"
+endorsement,"POLICY NUMBER: FWC0000030940900 COMMERCIAL GENERAL LIABILITY CG 20 28 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-LESSOR OF LEASED EQUIPMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION TO WHOM YOU ARE OBLIGATED BY VALID WRITTEN CONTRACT TO PROVIDE SUCH COVERAGE 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, this insurance does not apply to organization(s) shown in the Schedule, but only with any ""occurrence"" which takes place after the respect to liability for ""bodily injury"", ""property equipment lease expires. damage"" or ""personal and advertising injury"" C. With respect to the insurance afforded to these caused, in whole or in part, by your maintenance, additional insureds, the following is added to operation or use of equipment leased to you by such Section III - Limits Of Insurance: person(s) or organization(s). If coverage provided to the additional insured is However: required by a contract or agreement, the most we 1. The insurance afforded to such additional will pay on behalf of the additional insured is the insured only applies to the extent permitted by amount of insurance: law; and 1. Required by the contract or agreement; or 2. If coverage provided to the additional insured is 2. Available under the applicable Limits of required by a contract or agreement, the Insurance shown in the Declarations; insurance afforded to such additional insured will not be broader than that which you are required whichever is less. by the contract or agreement to provide for such This endorsement shall not increase the applicable additional insured. Limits of Insurance shown in the Declarations. CG 28 04 13 Insurance Services Office, Inc., 2012 Page 1 of 1"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01/02/2014 forms a part of Policy No. WC 049-34-2319 Issued to SOC LLC By NEW HAMPSHIRE INSURANCE COMPANY Premium INCLUDED 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY, OR 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by forgradule (Ed. 04/84) Authorized Representative"
+endorsement,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION - CERTIFICA ATE HOLDERS (SPECIFIED DAYS) The person(s) or organization(s) listed or described in the Schedule below have requested that they receive written notice of cancellation when this policy is cancelled by us. We will mail or deliver to the Person(s) or Organization(s) listed or described in the Schedule a copy of the written notice of cancellation that we sent to you. If possible, such copies of the notice will be mailed at least 30 days, except for cancellation for non-payment of premium which will be mailed 10 days, prior to the effective date of the cancellation, to the address or addresses of certificate holders as provided by your broker or agent. Schedule Person(s) or Organization(s) including mailing address: All certificate holders where written notice of the cancellation of this policy is required by written contract, permit or agreement with the Named Insured and whose names and addresses will be provided by the broker or agent listed in the Declarations Page of this policy for the purposes of complying with such request. This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s) or organization(s) shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule above to any benefit, rights or protection under this policy. Any provision of this endorsement that is in conflict with a statute or rule is hereby amended to conform to that statute or rule. All other terms and conditions of this policy remain unchanged. Endorsement Number: Policy Number: 41WCI1655600 Named Insured: G&A BORING DIRECTIONAL, LLC This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 07-13-20 00 ML0087 00 11 10 Page 1 of 1"
+endorsement,"WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EARLIER NOTICE OF CANCELLATION PROVIDED BY US ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following ""attached clause"" is to be completed only when this endorsement is issued subsequent to prepara- tion of the policy.) This endorsement, effective on 07/13/2020 at 12:01 A.M. standard time, forms a part of Policy No.41WCI1655600 of the Insurance Company Issued to G&A BORING DIRECTIONAL, LLC (Named Insured) Authorized Representative For any statutorily permitted reason other than nonpayment of premium, the number of days required for notice of cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy Condition or as amended by an applicable state cancellation endorsement, is increased to the number of days shown in the Schedule be- low. All the terms and conditions of the Policy which are not inconsistent with this endorsement continue to apply. SCHEDULE Number of Days' Notice: 120 00 WC004 00 11 03 Page 1 of 1"
+endorsement,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION - CERTIFICA ATE HOLDERS (SPECIFIED DAYS) The person(s) or organization(s) listed or described in the Schedule below have requested that they receive written notice of cancellation when this policy is cancelled by us. We will mail or deliver to the Person(s) or Organization(s) listed or described in the Schedule a copy of the written notice of cancellation that we sent to you. If possible, such copies of the notice will be mailed at least 30 days, except for cancellation for non-payment of premium which will be mailed 10 days, prior to the effective date of the cancellation, to the address or addresses of certificate holders as provided by your broker or agent. Schedule Person(s) or Organization(s) including mailing address: All certificate holders where written notice of the cancellation of this policy is required by written contract, permit or agreement with the Named Insured and whose names and addresses will be provided by the broker or agent listed in the Declarations Page of this policy for the purposes of complying with such request. This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s) or organization(s) shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule above to any benefit, rights or protection under this policy. Any provision of this endorsement that is in conflict with a statute or rule is hereby amended to conform to that statute or rule. All other terms and conditions of this policy remain unchanged. Endorsement Number: Policy Number: 41WCI1655300 Named Insured: JOHNSON BROTHERS SERVICE, INC. This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 05-06-20 00 ML0087 00 11 10 Page 1 of 1"
+endorsement,"WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EARLIER NOTICE OF CANCELLATION PROVIDED BY US ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following ""attached clause"" is to be completed only when this endorsement is issued subsequent to prepara- tion of the policy.) This endorsement, effective on 05/06/2020 at 12:01 A.M. standard time, forms a part of Policy No.41WCI1655300 of the Insurance Company Issued to JOHNSON BROTHERS SERVICE, INC. (Named Insured) Authorized Representative For any statutorily permitted reason other than nonpayment of premium, the number of days required for notice of cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy Condition or as amended by an applicable state cancellation endorsement, is increased to the number of days shown in the Schedule be- low. All the terms and conditions of the Policy which are not inconsistent with this endorsement continue to apply. SCHEDULE Number of Days' Notice: 120 00 WC004 00 11 03 Page 1 of 1"
+endorsement,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION - CERTIFICATE HOLDERS (SPECIFIED DAYS) The person(s) or organization(s) listed or described in the Schedule below have requested that they receive written notice of cancellation when this policy is cancelled by us. We will mail or deliver to the Person(s) or Organization(s) listed or described in the Schedule a copy of the written notice of cancellation that we sent to you. If possible, such copies of the notice will be mailed at least 30 days, except for cancellation for non-payment of premium which will be mailed 10 days, prior to the effective date of the cancellation, to the address or addresses of certificate holders as provided by your broker or agent. Schedule Person(s) or Organization(s) including mailing address: All certificate holders where written notice of the cancellation of this policy is required by written contract, permit or agreement with the Named Insured and whose names and addresses will be provided by the broker or agent listed in the Declarations Page of this policy for the purposes of complying with such request. This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such notification to the person(s) or organization(s) shown in the Schedule will not extend any policy cancellation date nor impact or negate any cancellation of the policy. This endorsement does not entitle the person(s) or organization(s) listed or described in the Schedule above to any benefit, rights or protection under this policy. Any provision of this endorsement that is in conflict with a statute or rule is hereby amended to conform to that statute or rule. All other terms and conditions of this policy remain unchanged. Endorsement Number: Policy Number: 41WCI1655900 Named Insured: NORTH TEXAS CORING, INC. This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 07-22-20 00 ML0087 00 11 10 Page 1 of 1"
+endorsement,"WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EARLIER NOTICE OF CANCELLATION PROVIDED BY US ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following ""attached clause"" is to be completed only when this endorsement is issued subsequent to prepara- tion of the policy.) This endorsement, effective on 07/22/2020 at 12:01 A.M. standard time, forms a part of Policy No.41WCI1655900 of the Insurance Company Issued to NORTH TEXAS CORING, INC. (Named Insured) Authorized Representative For any statutorily permitted reason other than nonpayment of premium, the number of days required for notice of cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy Condition or as amended by an applicable state cancellation endorsement, is increased to the number of days shown in the Schedule be- low. All the terms and conditions of the Policy which are not inconsistent with this endorsement continue to apply. SCHEDULE Number of Days' Notice: 120 00 WC004 00 11 03 Page 1 of 1"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/01/2014 forms a part of Policy No. WC 066-45-5790 Issued to ELYRIA FOUNDRY HOLDINGS, LLC By COMMERCE AND INDUSTRY INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION TO WHOM YOU BECOME OBLIGATED TO WAIVE YOUR RIGHTS OF RECOVERY AGAINST, UNDER ANY CONTRACT OR AGREEMENT YOU ENTER INTO PRIOR TO THE OCCURRENCE OF LOSS. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by finient Catagano (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/27/2017 forms a part of Policy No. WC 065-43-7485 Issued to LIBERTY LABOR, LLC By GRANITE STATE INSURANCE COMPANY 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 in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, Texas, or Utah. This form is not applicable in Missouri when there is a construction code on the policy and there is Missouri premium or exposure. WC 00 03 13 Countersigned by (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. This endorsement, effective 12:01 AM 01/01/2021 forms a part of Policy No. WC 012-32-6659 Issued to PARSONS CORPORATION By A I U INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in Kansas for private construction contracts as defined in K.S.A. 16-1801 through K.S.A 16-1807 or public construction contracts as defined in K.S.A. 16-1901 through 16-1908, except where permitted by statute or other applicable law, such as for use in wrap-up insurance programs. Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, Texas, or Utah. DEPHMEDY WC 00 03 13 Countersigned by (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/01/2015 forms a part of Policy No. WC 017-73-1498 Issued to APOGEE ENTERPRISES, INC. By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION TO WHOM YOU BECOME OBLIGATED TO WAIVE YOUR RIGHTS OF RECOVERY AGAINST, UNDER ANY CONTRACT OR AGREEMENT YOU ENTER INTO PRIOR TO THE OCCURRENCE OF LOSS. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. This form is not applicable in Missouri when there is a construction code on the policy and there is Missouri premium or exposure. WC 00 03 13 Countersigned by forgradule (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/30/2014 forms a part of Policy No. WC 034-15-7233 Issued to TRADESMEN INTERNATIONAL, INC By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by forgradale (Ed. 04/84) Authorized Representative"
+endorsement,"NOTICE OF CANCELLATION AND NON-RENEWAL TO CERTIFICATE HOLDER This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 03/01/2015 forms a part of Policy No. WC 017-73-1500 Issued to APOGEE ENTERPRISES, INC. By NEW HAMPSHIRE INSURANCE COMPANY This endorsement, modifies Insurance provided under the following: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY We shall provide written notice in accordance with state law in the event this policy is cancelled or nonrenewed, for any reason other than non payment of premium, to those entities set out in the schedule below. Schedule Notice will be mailed to: CERTIFICATE HOLDER ON FILE WITH COMPANY. To the attention of: Contract, Permit or Job Number: forgradule WC 99 00 4 45 Countersigned by (Ed. 07/03) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - TENNESSEE This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/30/2014 forms a part of Policy No. WC 034-15-7226 Issued to TRADESMEN INTERNATIONAL, INC By NEW HAMPSHIRE INSURANCE COMPANY 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 ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. progradals WC 99 41 02 Countersigned by (Ed. 07/04) 0 1983 National Council on Compensation Insurance. Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 08/01/2014 forms a part of Policy No. WC 037-08-3155 Issued to VERSO PAPER HOLDINGS LLC By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by forgradule (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 08/01/2014 forms a part of Policy No. WC 037-08-3154 Issued to VERSO PAPER HOLDINGS LLC By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED IN TO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PERSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by forgradale (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 12/10/2017 forms a part of Policy No. WC 031-13-2171 Issued to WOLF CREEK NUCLEAR OPERATING CORPORATION By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, Texas, or Utah. This form is not applicable in Missouri when there is a construction code on the policy and there is Missouri premium or exposure. July WC 00 03 13 Countersigned by (Ed. 04/84) Authorized Representative"
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number RWB CONTRACTING CORP 19-29 DITMARS BLVD. Policy Number ASTORIA NY 11105 Symbol: RWC Number: C58606406 Policy Period Effective Date of Endorsement 06-18-2020 TO 12-01-2020 06-18-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule BLANKET AS REQUIRED BY WRITTEN CONTRACT EXECUTED PRIOR LOSS For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 472 Authorized Agent WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number WC FINISHER CORP 150 SOUTH 6TH AVENUE Policy Number MOUNT VERNON NY 10550 Symbol: RWC Number: C58594568 Policy Period Effective Date of Endorsement 06-02-2020 TO 12-01-2020 06-02-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 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 any one not named in the Schedule. Schedule BLANKET AS REQUIRED BY WRITTEN CONTRACT EXECUTED PRIOR LOSS For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 472 Authorized Agent WC 00 03 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 07/01/2014 forms a part of Policy No. WC 067-71-2693 Issued to THE DAY & ZIMMERMANN GROUP INC By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by forgradade (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/26/2013 forms a part of Policy No. WC 025-05-2571 Issued to STAFFING SOLUTIONS HOLDINGS, INC By NEW HAMPSHIRE INSURANCE COMPANY Premium INCLUDED 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by forgradule (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/30/2014 forms a part of Policy No. WC 034-15-7230 Issued to TRADESMEN INTERNATIONAL, INC. By NEW HAMPSHIRE INSURANCE COMPANY 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE ENTERED INTO A CONTRACT, A CONDITION OF WHICH REQUIRES YOU TO OBTAIN THIS WAIVER FROM US. THIS ENDORSEMENT DOES NOT APPLY TO BENEFITS OR DAMAGES PAID OR CLAIMED: 1. PURSUANT TO THE WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY LAWS OF KENTUCKY, NEW HAMPSHIRE, OR NEW JERSEY; OR, 2. BECAUSE OF INJURY OCCURRING BEFORE YOU ENTERED INTO SUCH A CONTRACT. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, North Dakota, Ohio, Tennessee, Texas, Utah, or Washington. WC 00 03 13 Countersigned by forgradade (Ed. 04/84) Authorized Representative"
+endorsement,"WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT--CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 04/26/2013 forms a part of Policy No. WC 025-05-2575 Issued to STAFFING SOLUTIONS HOLDINGS, INC By NEW HAMPSHIRE INSURANCE COMPANY Premium I INCLUDED We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WC 04 03 06 Countersigned by forgradals (Ed. 04/84) Authorized Representative"
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number HOIST & CRANE SERVICE 4920 JEFFERSON HIGHWAY Policy Number JEFFERSON LA 70121 Symbol: WLR Number: C56855312 Policy Period Effective Date of Endorsement 01-01-2022 TO 01-01-2023 01-01-2022 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. WE WILL NOT ATTEMPT TO ASSERT ANY RIGHT OF SUBROGATION WITH RESPECT TO, OR ANY LIEN UPON, PAYMENTS MADE BY OR ON BEHALF OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE TO ANY INJURED EMPLOYEE OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 872 Authorized Agent WC 00 03 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number COATING SERVICES, INC 10405 BOUDREAUX ROAD Policy Number GONZALES LA 70737 Symbol: WLR Number: C56855282 Policy Period Effective Date of Endorsement 01-01-2022 TO 01-01-2023 01-01-2022 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. WE WILL NOT ATTEMPT TO ASSERT ANY RIGHT OF SUBROGATION WITH RESPECT TO, OR ANY LIEN UPON, PAYMENTS MADE BY OR ON BEHALF OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE TO ANY INJURED EMPLOYEE OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 872 Authorized Agent WC 00 03 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+endorsement,"UTAH WAIVER OF SUBROGATION ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following ""attaching clause"" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 07/01/2014 forms a part of Policy No. WC 067-71-2693 Issued to THE DAY & ZIMMERMANN GROUP INC By NEW HAMPSHIRE INSURANCE COMPANY This endorsement applies only to the insurance provided by the policy because Utah is shown in Item 3.A. of the Information Page. 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. Our waiver of rights does not release your employees' rights against third parties and does not release our authority as trustee of claims against third parties. Schedule ANY PERSON OR ORGANIZATION TO WHOM YOU BECOME OBLIGATED TO WAIVE YOUR RIGHTS OF RECOVERY AGAINST UNDER ANY CONTRACT OR AGREEMENT YOU ENTER INTO PRIOR TO OCCURRENCE OF LOSS. WC 43 03 05 Countersigned by progradate (Ed. 07/00) © 2000 National Council on Compensation Insurance, Inc. Authorized Representative"
+endorsement,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number SOUTHERN ERECTORS, INC. 6540 W, NINE MILE ROAD Policy Number PENSACOLA FL 32526 Symbol: WLR Number: C56855427 Policy Period Effective Date of Endorsement 01-01-2022 TO 01-01-2023 01-01-2022 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. 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 any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. WE WILL NOT ATTEMPT TO ASSERT ANY RIGHT OF SUBROGATION WITH RESPECT TO, OR ANY LIEN UPON, PAYMENTS MADE BY OR ON BEHALF OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE TO ANY INJURED EMPLOYEE OF ANY PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. 922 Authorized Agent WC 00 03 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+others,SCHEDULE PERSONS (continued) STATE Form WC 00 03 10 Printed in U.S.A Page 2 of 2
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 This endorsement is being sent to you with respect Your policy provides coverage for workers to your workers compensation and employers liability compensation losses caused by acts of terrorism or insurance policy. This endorsement does not replace war, including workers compensation benefit the separate Terrorism Risk Insurance Program obligations dictated by state law, except in Reauthorization Act Disclosure Endorsement (WC Pennsylvania where injuries or deaths resulting from 00 04 22 A) that is attached to your current policy certain war-related activities are excluded from and which remains in effect as applicable. workers compensation coverage. Coverage for such losses is still subject to all terms, definitions, The Terrorism Risk Insurance Act of 2002 (TRIA) as exclusions, and conditions in your policy. previously amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007 The premium charge for the coverage your (TRIPRA), provides for a program under which the policy provides for terrorism or war losses is federal government will share in the payment of shown in Item 4 of the Information Page or the insured losses caused by certain acts of terrorism. In Schedule in the Terrorism Risk Insurance the absence of affirmative US Congressional action Program Reauthorization Act Disclosure to extend, update, or otherwise reauthorize TRIPRA, Endorsement (WC 00 04 22 A) that is attached to in whole or in part, TRIPRA is scheduled to expire your policy, and this amount may continue or December 31, 2014. change for new, renewal, and in-force policies in effect on or after December 31, 2014 in the event Since the timetable for any further Congressional of TRIPRA's expiration, subject to regulatory action respecting TRIPRA is unknown at this time, review in accordance with applicable state law. and exposure to acts of terrorism remains, we are providing our policyholders with relevant information You need not do anything further at this time. concerning their workers compensation policies in effect on or after January 1, 2014 in the event of TRIPRA's expiration. Form WC 00 01 14 Printed in U.S.A. Page 1 of 1 Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 This endorsement is notification that your insurance Insurance Act of 2002 (as amended) but that meets carrier is charging premium to cover the losses that all of the following criteria: may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined a. It is an act that is violent or dangerous to below. Your policy provides coverage for workers human life, property, or infrastructure; compensation losses caused by a Catastrophe b. The act results in damage within the (other than Certified Acts of Terrorism). This United States, or outside of the United premium charge does not provide funding for States in the case of the premises of Certified Acts of Terrorism contemplated under the United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 A), Terrorism Risk Insurance Act of 2002 (as amended); and attached to this policy. C. It is an act that has been committed by an For purposes of this endorsement, the following individual or individuals as part of an definitions apply: effort to coerce the civilian population of the United States or to influence the o Catastrophe (other than Certified Acts of policy or affect the conduct of the United Terrorism): Any single event, resulting from an States Government by coercion. Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in Catastrophic Industrial Accident: A chemical aggregate workers compensation losses in release, large explosion, or small blast that is excess of $50 million. localized in nature and affects workers in a small perimeter the size of a building. Earthquake: The shaking and vibration at the surface of the earth resulting from underground The premium charge for the coverage your policy movement along a fault plane or from volcanic provides for workers compensation losses caused activity. by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information o Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary Page or in the Schedule below. of Treasury pursuant to the Terrorism Risk Schedule State Rate Premium Form WC 00 04 21 C Printed in U.S.A. Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, M.D., , P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 This endorsement addresses the requirements of the ""Act of Terrorism"" means any act that is certified by Terrorism Risk Insurance Act of 2002 as amended the Secretary of the Treasury, in concurrence with and extended by the Terrorism Risk Insurance the Secretary of State, and the Attorney General of Program Reauthorization Act of 2007. It serves to the United States as meeting all of the following notify you of certain limitations under the Act, and requirements: that your insurance carrier is charging premium for a. The act is an act of terrorism. losses that may occur in the event of an Act of Terrorism. b. The act is violent or dangerous to human life, property or infrastructure. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, C. The act resulted in damage within the United including workers compensation benefit obligations States, or outside of the United States in the dictated by state law. Coverage for such losses is case of the premises of United States missions or certain air carriers or vessels. still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal d. The act has been committed by an individual or and/or state laws, rules, or regulations. individuals as part of an effort to coerce the civilian population of the United States or to Definitions influence the policy or affect the conduct of the The definitions provided in this endorsement are United States Government by coercion. based on and have the same meaning as the ""Insured Loss"" means any loss resulting from an act definitions in the Act. If words or phrases not defined of terrorism (and, except for Pennsylvania, including in this endorsement are defined in the Act, the an act of war, in the case of workers compensation) definitions in the Act will apply. that is covered by primary or excess property and ""Act"" means the Terrorism Risk Insurance Act of casualty insurance issued by an insurer if the loss 2002, which took effect on November 26, 2002, and occurs in the United States or at the premises of United States missions or to certain air carriers or any amendments thereto resulting from the vessels. Terrorism Risk Insurance Program Reauthorization Act of 2007. ""Insurer Deductible"" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applicable Program Year. Form WC 00 04 22 A Printed in U.S.A. Page 1 of 2 Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PREMIUM DUE DATE ENDORSEMENT Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, M.D., P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 Section D of Part Five of the policy is replaced by this provision: PART FIVE PREMIUM D. Premium is amended to read: compensation law is not valid. The due date for You will pay all premium when due. You will pay audit and retrospective premiums is the date of the premium even if part or all of a workers the billing. Countersigned by Authorized Representative Form WC 00 04 19 Printed in U.S.A. Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, M.D., , P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. Countersigned by Authorized Representative Form WC 00 04 14 Printed in U.S.A. Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MINNESOTA AMENDATORY ENDORSEMENT Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, M.D. , P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 This endorsement applies only to the insurance by this insurance does not apply if that other provided because Minnesota is shown in Item 3.A. person is insured for the same loss by us. This of the Information Page. limitation applies only if the loss was caused by PART TWO - EMPLOYERS LIABILITY the nonintentional acts of the person against INSURANCE whom subrogation is sought. PART FIVE - PREMIUM E. We will Also Pay is amended to read: We will also pay these costs, in addition to other G. Audit is amended to read: amounts payable under this insurance, as part You will let us examine and audit all your of any claim, proceeding, or suit we defend: records that relate to this policy. These records 1. reasonable expenses incurred at our include ledgers, journals, registers, vouchers, request, but not loss of earnings; contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving 2. premiums for bonds to release attachments data. and for appeal bonds in bond amounts up to the limit of our liability under this insurance; We may conduct the audits during regular business hours during the policy period and 3. litigation costs taxed against you; within three years after the policy period ends, 4. your share of pre-or postjudgment interest except as it pertains to Part Two - Employers' assuming that the principal amount of that Liability Insurance which shall be one year. judgment is within the applicable policy Information developed by audit will be used to limits under this insurance; and determine final premium. Insurance rate 5. expenses we incur. service organizations have the same rights we have under this provision. H. Recovery From Others is amended to read: DEFINITIONS Our ability to exercise your rights to recover our payment from anyone liable for an injury covered As used in this policy "" rate service organization"" shall mean the Minnesota Workers' Compensation Insurers Association, Inc. Countersigned by Authorized Representative Form WC 22 00 00 A Printed in U.S.A. Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MINNESOTA CANCELLATION AND NONRENEWAL ENDORSEMENT Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 This endorsement applies only to the insurance commerce and that the commissioner will render a provided because Minnesota is shown in Item 3.A. of decision as to whether the cancellation is justified the Information Page. because of the loss of reinsurance within 30 Cancellation of a New Policy business days after receipt of the appeal; If this policy is a new policy and has been in effect for 7. A determination by the commissioner that the fewer than 90 days, we may cancel for any reason by continuation of the policy could place us in giving you notice at least 60 days before the effective violation of the Minnesota insurance laws; or date of cancellation. 8. Nonpayment of dues to an association or Cancellation of Other Policies organization, other than an insurance association or organization, where payment of dues is a If this policy has been in effect for 90 days or more, or prerequisite to your obtaining or continuing this if it is a renewal of a policy we issued, we may cancel policy. This item shall not apply to persons who for one or more of the following reasons: are retired at 62 years of age or older or who are 1. Nonpayment of premium; disabled according to Social Security standards. 2. Misrepresentation or fraud made by you or with If we cancel your policy for any of the reasons listed in your knowledge in obtaining the policy or in (2) through (8), we will give notice at least 60 days pursuing a claim under the policy; before the effective date of cancellation. 3. An act or omission by you that substantially Notice of Cancellation increases or changes the risk insured; Any notice of cancellation under this endorsement 4. Refusal by you to eliminate known conditions that shall be in writing and shall be sent by first class mail increase the potential for loss after notification by or delivered to you and any agent, to the last mailing us that the condition must be removed; addresses known to us. A cancellation notice for 5. Substantial change in the risk assumed, except to nonpayment of premium must be sent at least 30 days the extent that we should reasonably have before the actual date of cancellation and shall state foreseen the change or contemplated the risk in the amount of premium due and the due date, and writing this policy; shall state the effect of nonpayment by the due date. Cancellation shall not be effective if payment of the 6. Loss of reinsurance by us which provided amount due is made prior to the effective date of coverage to us for a significant amount of the cancellation in the notice. A cancellation notice for underlying risk insured. Any notice of cancellation some other reason shall state the specific reason for pursuant to this item shall advise you that you cancellation and shall state the effective date of have 10 days from the date of receipt of the notice cancellation. The policy will end on that date. to appeal the cancellation to the commissioner of Form WC 22 06 01 D Printed in U.S.A. Page 1 of 2 Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE Beginning Beginning on Page on Page INFORMATION PAGE PART TWO - Continued 1 G. Limits of Liability 4 General Section 1 H. Recovery From Others 4 A. The Policy 1 I. Actions Against Us 4 B. Who Is Insured 1 C. Workers Compensation Law 1 PART THREE - OTHER STATES INSURANCE 4 D. State 1 A. How This Insurance Applies 4 E. Locations 1 B. Notice 5 PART ONE - WORKERS COMPENSATION INSURANCE 1 PART FOUR-YOUR - DUTIES IF INJURY OCCURS 5 A. How This Insurance Applies 1 B. We Will Pay 1 PART FIVE - PREMIUM 5 C. We Will Defend 1 A. Our Manuals 5 D. We Will Also Pay 1 B. Classifications 5 E. Other Insurance 2 C. Remuneration 5 F. Payments You Must Make 2 D. Premium Payments 5 G. Recovery From Others 2 E. Final Premium 5 H. Statutory Provisions 2 F. Records 6 G. Audit 6 PART TWO - EMPLOYERS LIABILITY INSURANCE 2 A. How This Insurance Applies 2 PART SIX - CONDITIONS 6 B. We will Pay 3 A. Inspection 6 C. Exclusions 3 B. Long Term Policy 6 D. We Will Defend 3 C. Transfer of Your Rights and Duties 6 E. We Will Also Pay 4 D. Cancellation 6 F. Other Insurance 4 E. Sole Representative 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY. Form WC 66 01 56 B Printed in U.S.A. Process Date: 09/27/14 Policy Expiration Date: 11/12/15
+others,"THIS BROCHURE IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT INTENDED TO BE A SUBSTITUTE FOR A COMPLETE ON-SITE SAFETY INSPECTION CONDUCTED BY A QUALIFIED LOSS CONTROL SPECIALIST. READERS ARE ENCOURAGED TO HAVE SUCH AN INSPECTION CONDUCTED BOTH TO PROMOTE WORKPLACE SAFETY AND TO COMPLY WITH APPLICABLE LAW. FOR ADDITIONAL INFORMATION OR ASSISTANCE, EITHER TELEPHONE OR MAIL THIS FORM TO YOUR HARTFORD AGENT OR NEAREST OFFICE OF The HARTFORD NOTICE TO ARKANSAS POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain accident prevention services at no additional cost as required by ARK. Code Ann. 11-9-409(D) and Rule 32. If you would like more information, call The Hartford's Loss Control Department, One Hartford Plaza, HO-GL-19-1, Hartford, CT 06155 at 1-860-547-7761. If you have any questions about this requirement, call the Health and Safety Division, Arkansas Workers' Compensation Commission at 1-800-622-4472. NOTICE TO CALIFORNIA POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain occupational safety and health loss control consultation services as required by the California Labor Code, $6354.5, at no additional charge. If you would like more information call The Hartford's Loss Control Division at 1-860-547-7761 for occupational safety and health loss control consultation services. California Workers Compensation insurance policyholders may register comments about the insurer's loss control consultation service by writing to: State of California Department of Industrial Relations Division of Occupational Safety and Health P.O. Box 420603 San Francisco, California 94142 NOTICE TO PENNSYLVANIA POLICYHOLDERS The Hartford maintains and provides accident and illness prevention services as required by the nature of the policyholder's business or its operation, in accordance with the Pennsylvania Workers' Compensation Act. For more information about these services contact your Hartford Agent or nearest office of The Hartford. Form 97485 14th Rev. Printed in U.S.A. Page 4 of 6"
+others,Workers' Compensation and Employers' Liability Business Insurance Policy THE HARTFORD Form WC 99 00 02 (03/14) Page 1 of 1
+others,"THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT Policy Number: 41 WEC BT1357 Endorsement Number: Effective Date: 11/12/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: KRISTEN M. ZELLER, M.D., P.A. 1185 TOWN CENTRE DR. SUITE 100 EAGAN, MN 55123 An election was made by or on behalf of each person described in the Schedule to be subject to the workers compensation law of the state named in the Schedule. The premium basis for the policy includes the remuneration on such persons. SCHEDULE Persons State Sole Proprietor: Partners: Officers: KRISTEN M. ZELLER MN Others: Countersigned by Authorized Representative Form WC 00 03 10 Printed in U.S.A. Page 1 of 2 Process Date: 09/27/14 Policy Expiration Date: 11/12/15"
+others,"CHUBB CHUBB GROUP CENTRALIZED OPERATIONS 1 BEAVER VALLEY ROAD WILMINGTON, DE 19803 AHOLD AMERICAS HOLDINGS B. PIETRINI & SONS DWP 111 EAST CHRUCH ROAD KING OF PRUSSIA PA 19406 OFFICE 61760 132685 DWP 20200508 SO.TYP C58582633 BEGINNING OF POLICY OFFICE 61760 132685 DWP 20200508 SO.TYP C58582633"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. ALTERNATE EMPLOYER ENDORSEMENT This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be canceled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Schedule 1. Alternate Employer Address IF ANY DOES NOT APPLY TO ALASKA, OR TO ANY EMPLOYEE LEASE CONTRACT/ARRANGEMENT 2. State of Special or Temporary Employment CT, DC, DE, IL, MA, MD, NJ, NY, PA, VA, WV 3. Contract or Project This endorsement is not applicable in the states of AK, HI, MI, OK and TX. Authorized Representative WC 00 03 01A (Ed. 2-89) © Copyright 1984, 1988 National Council on Compensation Insurance, Inc. All Rights Reserved."
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. DESIGNATED WORKPLACES EXCLUSION ENDORSEMENT The policy does not cover work conducted at or from: ANY LOCATION EXCEPT: AHOLD AMERICAS HOLDINGS, INC. LOCATIONS IN THE STATES OF CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, ILLINOIS, MARYLAND, MASSACHUSETTS, NEW JERSEY, NEW YORK, RHODE ISLAND, AND VIRGINIA WHERE CAPITAL CONSTRUCTION PROJECTS WILL BE PERFORMED BY CONTRACTORS ENROLLED IN THE ROLLING OWNER CONTROLLED INSURANCE PROGRAM. ALSO, INCLUDES OFF-SITE LOCATIONS WHERE CONSTRUCTION ACTIVITIES ARE CONTRACTUALLY REQUIRED OF AHOLD AMERICAS HOLDINGS, INC. THAT WILL BE PERFORMED BY CONTRACTORS ENROLLED IN THE PROGRAM. INVOLVES NEW CONSTRUCTION, RENOVATION, AND MAINTENANCE OF SUCH FACILITIES, AS WELL AS RELATED NEW CONSTRUCTION, RENOVATION, AND INCIDENTAL OPERATIONS THERETO, PROVIDING SUCH NECESSARY OR INCIDENTAL OPERATIONS SHALL NOT INCLUDE OPERATIONS AT THE INSURED'S REGULARLY ESTABLISHED WORKPLACE, PLANT, FACTORY, OFFICE, SHOP, WAREHOUSE, YARD, OR OTHER PROPERTY EVEN IF SUCH OPERATIONS ARE FOR THE FABRICATION OF MATERIALS TO BE USED AT A JOBSITE. This endorsement is not applicable in the states of CA, ND, OH, PA, WA and WY. Authorized Representative WC 00 03 02 (4/84) Copyright 1983, National Council on Compensation Insurance CKE-3N14"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. SOLE PROPRIETORS, PARTNERS, OFFICERS AND OTHERS COVERAGE ENDORSEMENT An election was made by or on behalf of each person described in the Schedule to be subject to the workers compensation law of the state named in the Schedule. The premium basis for the policy includes the remuneration of such persons. Schedule Persons State SOLE PROPRIETORS PARTNERS OFFICERS OTHERS This endorsement is not applicable in: CA, NJ, NY and TX. 42 Authorized Representative WC 00 03 10 (04/84) Copyright 1983, National Council on Compensation Insurance CKE-2B07"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement adds Voluntary Compensation Insurance to the policy. A. How This Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included in the group of employees described in the Schedule. 2. The bodily injury must arise out of and in the course of employment necessary or incidental to work in a state listed in the Schedule. 3. The bodily injury must occur in the United States of America, its territories or possessions or Canada and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown in the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. Exclusions This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. WC 00 03 11A (08/91) Page 1 of 2"
+others,"F. Employers Liability Insurance Part Two (Employers Liability Insurance) applies to bodily injury covered by this endorsement as though the State of Employment shown in the Schedule were shown in Item 3.A. of the Information Page. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Schedule Employee ANY EMPLOYEE EXEMPT FROM THE WORKERS COMPENSATION LAW: NJ & WI ARE EXCLUDED. State of Employment ALL STATES LISTED UNDER ITEM 3.A. OF THE INFORMATION PAGE EXCEPT NJ & WI. Designated Workers Compensation Law ALL STATES LISTED UNDER ITEM 3.A. OF THE INFORMATION PAGE EXCEPT NJ & WI. This endorsement is not applicable in the states of CA, HI, and NJ. 472 Authorized Representative WC 00 03 11A (08/91) © Copyright 1991 National Council on Compensation Insurance, Inc. Page 2 of 2"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. 90-DAY REPORTING REQUIREMENT-NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT You must report any change in ownership to us in writing within 90 days of the date of the change. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity, and other changes provided for in the applicable experience rating plan. Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Failure to report any change in ownership, regardless of whether the change is reported within 90 days of such change, may result in revision of the experience rating modification factor used to determine your premium. This reporting requirement applies regardless of whether an experience rating modification is currently applicable to this policy. Authorized Representative WC 00 04 14 A (01/19) © Copyright 2017 National Council on Compensation Insurance, Inc. All Rights Reserved."
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. For the states of MA, OR, refer to state specific endorsement. This endorsement is not applicable in AZ, MI and TX. 42 Authorized Representative WC 00 04 19(01/01) Copyright 2000 National Council on Compensation Insurance"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B), attached to this policy. For purposes of this endorsement, the following definitions apply: Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and C. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. WC 00 04 21D (01/15) © Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 2"
+others,"CHUBB ACE AMERICAN INSURANCE COMPANY 436 Walnut Street P.O. Box 1000 Philadelphia, PA 19106 - 3703 B. PIETRINI & SONS STANDARD 111 EAST CHRUCH ROAD WORKERS COMPENSATION AND KING OF PRUSSIA PA 19406 EMPLOYERS LIABILITY POLICY (A stock insurance company) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE BEGINNING ON Page Information Page i General Section 1 A. The Policy 1 B. Who is Insured 1 C. Workers Compensation Law 1 D. State 1 E. Locations 1 PART ONE - WORKERS COMPENSATION INSURANCE 1 A. How This Insurance Applies 1 B. We Will Pay 1 C. We Will Defend 1 D. We Will Also Pay 1 E. Other Insurance 2 F. Payments You Must Make 2 G. Recovery From Others 2 H. Statutory Provisions 2 PART TWO - EMPLOYERS LIABILITY INSURANCE 2 A. How This Insurance Applies 2 B. We Will Pay 3 C. Exclusions 3 D. We Will Defend 3 E. We Will Also 4 F. Other Insurance 4 G. Limits of Liability 4 H. Recovery From Others 4 I. Actions Against Us 4 WC 00 00 00 C (01/15) Copyright 2013 National Council on Compensation Insurance, Inc."
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. ""Act"" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2015. ""Act of Terrorism"" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. C. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. ""Insured Loss"" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. ""Insurer Deductible"" means, for the period beginning on January 1, 2015, and ending on December 31, 2020, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year. WC 00 04 22 B (01/15) © Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 3"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CIVIL UNIONS OR DOMESTIC PARTNERSHIPS Civil Unions or Domestic Partnerships: All references in the policy to ""spouse"" include a party to a civil union or domestic partnership recognized under the applicable law of the jurisdiction having authority. All other terms and conditions remain unchanged. 472 Authorized Representative 08 02 0261 (Ed. 3-12)"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CONTROLLED INSURANCE PROGRAM - AMENDATORY ENDORSEMENT This endorsement applies because the policy is providing workers compensation coverage as part of a Controlled Insurance Program. The Project Sponsor of this Controlled Insurance Program is: AHOLD USA, INC. (""Project Sponsor""). This policy is amended to reflect the following changes and/or additions to clarify the policy provisions as they apply to the operations of Controlled Insurance Programs. General Section, Item E. Location is replaced with the following: E. Locations This policy covers operations conducted at the workplace defined in the Designated Workplace Exclusion. Part Five - Premium, Item D. is replaced with the following: D. Premium Payments The Project Sponsor will pay all premium when due. The Project Sponsor will pay the premium even if part or all of a workers compensation law is not valid. Part Five - Premium, Item E. is replaced with the following: E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the Project Sponsor paid to us, the Project Sponsor must pay us the balance. If it is less, we will refund the balance to the Project Sponsor. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. WC 99 03 34 (7/06) Page 1 of 2"
+others,"Part Six - Conditions, Item E. Sole Representative is replaced with the following: E. Sole Representative The Project Sponsor will act on behalf of the insured named in Item I of the Information Page with respect to changes in this policy, premium payments, receiving return premiums, giving or receiving notice of cancellation, claim payments, claim information and claim settlement agreements. F. Deductible Endorsement The deductible endorsement attached to and made part of this policy applies solely with respect to the Project Sponsor. The duty to reimburse the insurance company and to provide collateral to secure the obligation to reimburse is solely the duties of the Project Sponsor. All other terms, conditions and exclusions of this Policy remain unchanged. State Exceptions: California General Section, Item E. Location is amended to read: E. Locations This policy covers operations conducted at the workplace shown in Item I. of the Information Page. Illinois Part Six - Conditions, Item E. Sole Representative is amended to read: E. Sole Representative The Project Sponsor will act on behalf of the insured named in Item I of the Information Page with respect to changes in this policy, premium payments, receiving return premiums, claim payments, claim information and claim settlement agreements. Indiana General Section, Item E. Location is amended to read: E. Locations This policy covers operations conducted at the workplace shown in Item I. of the Information Page. This endorsement is not applicable in the states of CT, FL, NC, ND, NJ, NY, OH, TN, WA, WI or WY. 472 Authorized Representative WC 99 03 34 (7/06) Page 2 of 2"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. UNINTENTIONAL ERRORS AND OMISSIONS PART SIX - CONDITIONS is amended by the addition of the following: F. Unintentional errors or omissions in representations made to us or our agent by you or any other insured before the inception of this policy will not impair your rights under this policy. This endorsement is not applicable in the states of CT, MI, MN, NC, NJ, TN and WI. This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. 972 Authorized Representative WC 99 03 55 (12/08)"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. TWO OR MORE POLICIES ISSUED BY US The following paragraph is added to G. Limits of Liability under PART TWO - EMPLOYERS LIABILITY: 4. If this policy and any other policy issued to you by us, or any company affiliated with us, apply to the same accident or disease, the maximum limit of liability under all applicable policies for such accident or disease shall not be greater than the highest applicable limit of liability under any one such policy for Bodily Injury by Accident or Bodily Injury by Disease. This provision does not apply to any policy we, or any company affiliated with us, issue to an insured that by its terms specifically provides coverage that is excess over other applicable insurance. This endorsement is not applicable in the states of AK, AZ, CT, FL, NJ, NY, NC, TN and WI. 472 Authorized Representative WC 99 03 91A (08/13) ©Chubb. 2016. All rights reserved. Page 1 of 1"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. NOTIFICATION OF PREMIUM ADJUSTMENT For the states and lines of business in which regulatory approval has been granted for the NCCI Large Risk Alternative Rating Option, the ISO Large Risk Alternative Rating Option, or the independently filed Chubb Large Risk Rating Plan, the premiums for this policy will be adjusted in accordance with the Notice of Election, signed by you. This endorsement is not applicable in the states of CA, FL, NJ, TX, and WI. 472 Authorized Representative WC 99 04 09 (03/05)"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. TRADE OR ECONOMIC SANCTIONS ENDORSEMENT This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims. All other terms and conditions of policy remain unchanged. This endorsement is not applicable in: AZ, FL, MN, NJ, TN, WI. 42 Authorized Agent WC 99 07 73 (11/06)"
+others,CHUBB ® PREMIUM EXPOSURE SUMMARY INSURED UNDERWRITING OFFICE AUDIT TYPE RETRO B. PIETRINI & SONS DWU INT FIN YES X NO AUDIT FRQUENCY POLICY NUMBER E M Q SA A NON POLICY COMPANY ADT TOTAL SYMBOL CODE C5 85 82 63 3 X 1582 RWC AAI CONCURRENT POLICIES TOTAL ESTIMATED ANNUAL PREMIUM 1582 ADV. COMM. CALC (1) (2) (3) (4) (5) (6) (7) (8) (9) PREMIUM SUBJECT TO DISCO COMMIS- STATE EXPOSURE PREMIUM DISCOUNT/ DISCOUNT AMOUNT DEDUCTIBLE AMOUNT PREMIUM UNT % COMMISSION $ SION % HIGH DEDUCTIBLE ND 0 150 150 0.00 OH 0 150 150 0.00 PA 0 0 0 0.00 WA 0 25 25 0.00 WY 0 150 150 0.00 Total 0 FOR VOL 0 N/C EXP CON 210 N/C MIN PREM 893 N ND TRIA 0 O OH TRIA 0 N PA SURG 4 N/C PA TRIA 0 PA DTEC 0 S WA TRIA U 0 B WY TRIA 0 J E C T Policy Totals 1582 0.00 Less Prev./Adj. Balance: Final CK-2Z74 PTD. IN U.S.A. DOC 6178 05-08-2020 DWU
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. LONGSHORE AND HARBOR WORKERS' COMPENSATION ACT COVERAGE ENDORSEMENT This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in Item 3.A. of the Information Page. General Section C. Workers' Compensation Law is replaced by the following: C. Workers' Compensation Law Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusion 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule Longshore and Harbor Workers' State Compensation Act Coverage Percentage PENNSYLVANIA 1.606 The rates for classifications with code numbers not followed by the letter ""F"" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Act Coverage Percentage shown in the Schedule. Authorized Agent CKE-3N11a (4/92) Ptd. in U.S.A. Copyright 1983, 1991, National Council on Compensation Insurance. WC 00 01 06A"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 This endorsement is being attached to your workers compensation and employers liability insurance policy. This endorsement does not replace the separate Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B) that is attached to your current policy and which remains in effect as applicable. The Terrorism Risk Insurance Act of 2002 (TRIA), as previously amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015 (TRIPRA 2015), provides for a program under which the federal government will share in the payment of insured losses caused by certain acts of terrorism. In the absence of affirmative US Congressional action to extend, update, or otherwise reauthorize TRIPRA 2015, in whole or in part, TRIPRA 2015 is scheduled to expire on December 31, 2020. Since the timetable for any further Congressional action regarding TRIPRA 2015 is presently unknown, and exposure to acts of terrorism remains, we are providing policyholders with relevant information concerning their workers compensation policies in the event of the TRIPRA 2015's expiration. Your policy provides coverage for workers compensation losses caused by acts of terrorism, including workers compensation benefit obligations dictated by state law, except in Pennsylvania, where injuries or deaths resulting from certain war-related activities are excluded from workers compensation coverage. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy. The premium charge for the coverage that your policy provides for terrorism losses is shown in Item 4 of the policy Information Page or the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B) Schedule that is attached to your policy. This amount may continue or change for new, renewal, and in-force policies in effect on or after December 31, 2020, in the event of TRIPRA 2015's expiration, subject to regulatory review in accordance with applicable state law. You need not do anything further at this time. Authorized Representative WC 00 01 15 (01/20) Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved."
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. MARITIME COVERAGE ENDORSEMENT This endorsement changes how insurance provided by Part Two (Employers Liability Insurance) applies to bodily injury to a master or member of the crew of any vessel. A. How This Insurance Applies is replaced by the following: A. How This Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to work described in Item 1 of the Schedule of the Maritime Coverage Endorsement. 3. The bodily injury must occur in the territorial limits of, or in the operation of a vessel sailing directly between the ports of, the continental United States of America, Alaska, Hawaii or Canada. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 6. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C. Exclusions is changed by removing exclusion 10 and by adding exclusions 13 and 14. This insurance does not cover: 13. Bodily injury covered by a Protection and Indemnity Policy or similar policy issued to you or for your benefit. This exclusion applies even if the other policy does not apply because of another insurance clause, deductible or limitation of liability clause, or any similar clause. 14. Your duty or obligation to provide transportation, wages, maintenance, and cure. This exclusion does not apply if a premium entry is shown in Item 2 of the Schedule, except that punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law are excluded even if a premium is paid for transportation, wages, maintenance, and cure coverage. D. We Will Defend is changed by adding the following statement: We will treat a suit or other action in rem against a vessel owned or chartered by you as a suit against you. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in the Schedule. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for ""bodily injury by accident-each accident"" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for ""bodily injury by disease-aggregate"" is the most we will pay for all damages covered by this insurance because of bodily injury by disease to one or more employees. The limit applies separately to bodily injury by disease arising out of work in each state shown in Item 3.A. of the Information Page. Bodily injury by disease will be deemed to occur in the state of the vessel's home port. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. WC B (01/15) © 1983-2013 National Council on Compensation Insurance, Inc. All Rights Reserved Page 1 of 2"
+others,"Schedule 1. Description of work: IF ANY 2. Transportation, Wages, Maintenance, and Cure Premium $ INCLUDED Exclusion: This insurance does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law even if a premium is paid for transportation, wages, maintenance, and cure coverage. 3. Limits of Liability Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 aggregate 472 Authorized Representative WC 00 02 01 B (01/15) © 1983-2013 National Council on Compensation Insurance, Inc. All Rights Reserved Page 2 of 2"
+others,"Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number B. PIETRINI & SONS 111 EAST CHRUCH ROAD Policy Number KING OF PRUSSIA PA 19406 Symbol: RWC Number: C58582633 Policy Period Effective Date of Endorsement 05-05-2020 TO 12-01-2020 05-05-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. VOLUNTARY COMPENSATION MARITIME COVERAGE ENDORSEMENT This endorsement adds Voluntary Compensation Maritime Insurance to the Policy. A. How This Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury including resulting death. 1. The bodily injury must be sustained by an employee who is a master or member of the crew of a vessel described in the Schedule. 2. The bodily injury must occur in employment that is necessary or incidental to work described in item 2 of the Schedule. 3. The bodily injury must occur in the territorial limits of, or in the operation of a vessel sailing directly between the ports of, the continental United States of America, Alaska, Hawaii or Canada. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The em- ployee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay an amount equal to the benefits that would be required of you if you and your employees described in item 1 of the Schedule were subject to the workers' compensation law shown in item 1 of the Schedule. We will pay those amounts to the persons who would be entitled to them under that law. C. Exclusions This insurance does not cover: 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the injury or death. 2. Transfer to us their right to recover from others who may be responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. WC 00 02 03 (4/84) Copyright 1982-83, National Council on Compensation Insurance Page 1 of 2"