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acord25
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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
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acord25
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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
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acord25
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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
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acord25
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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
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acord25
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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
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acord25
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 $25,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Riverside Unified School DistrictHighgrove Elementary School New Building and Modernization690 Center Street Riverside, California 92507 Site Code/Contract #: 0779-01-0839679-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cutting Edge Excavation, Inc. 19510 Van Buren Blvd. #292 AUTHORIZED REPRESENTATIVE Riverside, CA 92508 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/10/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Adriana Ramirez USI Insurance Services National, Inc PHONE FAX 601 13th Street NW (A/C, No. Ext): (202) 424-2743 (A/C, No): E-MAIL 9th Floor North ADDRES$: 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
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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
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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
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acord25
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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
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acord25
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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 $25,000,000 DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Wrap-Up Insurance Program: Statewide Educational Wrap Up Program (SEWUP). Insurance evidenced above is limited to the project site only. Coachella Valley Unified School District Palm View ES Modernization and Reconstruction Phase 3 P. O. Box 847 Thermal, California 92274 Site Code/Contract #: 0170-12-0661941-01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Rite-Way Roof Corporation 15425 Arrow Route AUTHORIZED REPRESENTATIVE Fontana, CA 92335 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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acord25
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ACORD DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Adriana Ramirez USI Insurance Services National, Inc PHONE FAX 190 River Road 1st Floor (A/C, No. Ext): (202) 416-2556 (A/C, No): E-MAIL Summit, NJ 07901-1444 ADDRES$: 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
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acord25
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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
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acord25
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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
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declaration
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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
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declaration
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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
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declaration
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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declaration
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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
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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
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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
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declaration
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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
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declaration
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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
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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
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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
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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
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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
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endorsement
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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.
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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.
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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.
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endorsement
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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endorsement
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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
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