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Insurance - Utility Systems Science and Software, Inc. - 2024-05-06ACOR"" CERTIFICATE OF LIABILITY INSURANCE `,� DATE(MM/DDYYYY) 5/6/2024 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). PRODUCER GMGS Risk Management & Insurance Services 6201 Oak Canyon, Suite 100 Irvine, CA 92618 CONTACT NAME: Certificate Request Team PHONE Ext: 949 559-6700 ac No: 949 559-6703 E-MAIL ADDRESS: certre uests m s.com INSURER(S) AFFORDING COVERAGE NAIC p 3/28/2024 INSURERA: Navigators Specialty Insurance Company 36056 www.gmgs.com OB84519 INSURED INSURER B: AmGUARD Insurance Company 42390 Utility Systems Science and Software, Inc. 601 N. Parkcenter Drive, Suite 209 INSURER C: Ohio Security Insurance Company 24082 INSURER D: Santa Ana CA 92705 INSURER E: $ INSURER F : AUTOMOBILE VIANYAUTO ✓ COVERAGES CERTIFICATE NUMBER: 7QRRR914 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER EFF MWDDPOLICY/YYYY LICY EXP M M/DD1YYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Iv]OCCUR LA24CGLZOGDZ41C 3/28/2024 3/28/2025 EACH OCCURRENCE $1 000,000 DAMAGE REN PREM SESOEa occu ante $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F—] PRO- ❑ JECT LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OPAGG $2,000,000 $ B AUTOMOBILE VIANYAUTO ✓ LIABILITY OWNED SCHEDULED AUTOS ONLY ✓ AUTOS HIRED NON -OWNED AUTOS ONLY ✓ AUTOS ONLY UTAU522921 3/28/2024 3/28/2025 (CEOMBIN $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLALIAB EXCESS LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ $ DED I I RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A XWS(24)58258345 7/6/2023 7/6/2024I/SPER TATUTE OERH _ E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - Ems, EMPLOYEE $11.000.000 E.L. DISEASE -POLICY LIMIT 1 $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) All operations of the named insured subject to the terms and conditions of the policies. This certificate may be relied upon only if the certificate addendum referred to herein is attached hereto. CERTIFICATE HOLDER CANCELLATION All operations SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 290 Paularino Ave. ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa CA 92626 �I0[�-Lt AUTHORIZED REPRESENTATIVE Griff Griffith © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 79868214 1 24-25 A/G/U/E&O/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) 1 Page 1 of 13 AGENCY CUSTOMER ID: LOC #: ACO ® ADDITIONAL REMARKS SCHEDULE Page of AGENCY GMGS Risk Management & Insurance Services NAMED INSURED Utility Systems Science and Software, Inc. 601 N. Parkcenter Drive, Suite 209 Santa Ana CA 92705 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (03/16) HOLDER: Costa Mesa Sanitary District ADDRESS: 290 Paularino Ave. Costa Mesa CA 92626 All operations of the named insured subject to the terms and conditions of the policies. As respects General Liability coverage, Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees listed are added as Additional Insureds per CG20100413 and CG20370704 attached and this insurance is primary per CG20010413 attached. As respects General Liability coverage, 30 -day written notice of cancellation (10 days for non-payment of premium) applies per IL00171198 attached. As respects Automobile Liability coverage, Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees listed are added as Additional Insured, per BA99040618 attached. As respects Automobile Liability coverage, 30 -day written notice of cancellation (10 days for non-payment of premium) applies per IL00171198 attached. As respects Workers' Compensation coverage, a Waiver of Subrogation is hereby included per WC990679(B) attached. As respects Workers' Compensation coverage, 30 -day written notice of cancellation (10 days for non-payment of premium) applies per WC040601B attached. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 79868214 1 24-25 A/G/U/E&0/A&L/WC I Dani Aembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 2 of 13 POLICY NUMBER: LA24CGLZOGDZ4IC COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Any person or organization for whom you are performing operations during the policy period when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy; and any other person or organization you are required to add as an additional insured under the contract or agreement described above. 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the CG 20 10 04 13 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © Insurance Services Office, Inc., 2012 79868214 1 24-25 A/G/U/E&0/R&L/WC I Dani Rembleski I 5/6/2024 10:50:49 AM (PDT) I Page 3 of 13 Page 1 of 2 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. C. With respect to the insurance afforded to these 2. Available under the applicable Limits of Insurance additional insureds, the following is added to shown in the Declarations; Section III - Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the applicable required by a contract or agreement, the most we Limits of Insurance shown in the Declarations. will pay on behalf of the additional insured is the amount of insurance: 1.Required by the contract or agreement; or CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 79868214 1 24-25 A/G/U/E&O/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 4 of 13 POLICY NUMBER: LA24CGLZOGDZ4IC COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Any person or organization for whom you have performed operations during the policy period when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy; and any other person or organization you are required to add as an additional insured under the contract or agreement described above. 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured CG 20 37 04 13 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 79868214 1 24-25 A/G/U/E&0/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 5 of 13 Page 1 of 2 will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 2 of 2 79868214 1 24-25 A/G/U/E&0/R&L/WC j Dani Rembl—ki 1 5/6/2024 10:50:49 AM (PDT) I Page 6 of 13 LA24CGLZOGDZ4IC Utility Systems Science and Software, Inc. COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 79868214 1 24-25 A/G/U/E&O/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 7 of 13 POLICY NUMBER: LA24CGLZOGDZ41C COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization when you and such person or organization have agreed in writing in a contract or agreement that you will waive any right of recovery against such person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or '.your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 79868214 1 24-25 A/G/U/E&O/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 8 of 13 Page 1 of 1 UTAU522921 Utility Systems Science and Software, Inc. COMMERCIAL AUTO BA 99 04 06 18 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED WHEN REQUIRED BY CONTRACT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This provision does not apply in regard to any ownership, maintenance or use of the additional insured's "autos." Additional Insured When Required by Contract (1) Paragraph A.1. — WHO IS AN INSURED — of Section II — Liability Coverage is amended to add: d. When you have agreed, in a written contract or written agreement, that a person or organization be added as an additional insured on your business auto policy, such person or organization is an "insured", but only to the extent such person or organization is liable for "bodily injury" or "property damage" caused by the conduct of an "insured" under paragraphs a. or b. of Who Is An Insured with regard to the ownership, maintenance or use of a covered "auto." The insurance afforded to any such additional insured applies only if the "bodily injury" or "property damage" occurs: (1) During the policy period, and (2) Subsequent to the execution of such written contract, and (3) Prior to the expiration of the period of time that the written contract requires such insurance be provided to the additional insured. (2) How Limits Apply If you have agreed in a written contract or written agreement that another person or organization be added as an additional insured on your policy, the most we will pay on behalf of such additional insured is the lesser of: (a) The limits of insurance specified in the written contract or written agreement; or (b) The Limits of Insurance shown in the Declarations. Such amount shall be a part of and not in addition to Limits of Insurance shown in the Declarations and described in this Section. (3) Additional Insureds Other Insurance If we cover a claim or "suit" under this Coverage Part that may also be covered by other insurance available to an additional insured, such additional insured must submit such claim or "suit" to the other insurer for defense and indemnity. However, this provision does not apply to the extent that you have agreed in a written contract or written agreement that the insurance is primary and non- contributory with the additional insured's own insurance. (4) Duties in The Event Of Accident, Claim, Suit or Loss If another person or organization is added as an additional insured on your policy, the additional insured shall be required to comply with the provisions in A. Loss Conditions 2. — Duties In The Event Of Accident, Claim, Suit Or Loss — of SECTION IV — BUSINESS AUTO CONDITIONS, in the same manner as the Named Insured. BA 99 04 06 18 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 79868214 1 24-25 A/G/U/E&O/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 9 of 13 LA24CGLZOGDZ4IC Utility Systems Science and Software, Inc. COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions. A. Cancellation 1. The first Named Insured shown in the Declara- tions may cancel this policy by mailing or de- livering to us advance written notice of cancel- lation. 2. We may cancel this policy by mailing or deliv- ering to the first Named Insured written notice of cancellation at least: a. 10 days before the effective date of cancel- lation if we cancel for nonpayment of pre- mium; or b. 30 days before the effective date of cancel- lation if we cancel for any other reason. 3. We will mail or deliver our notice to the first Named Insured's last mailing address known to us. 4. Notice of cancellation will state the effective date of cancellation. The policy period will end on that date. 5. If this policy is cancelled, we will send the first Named Insured any premium refund due. If we cancel, the refund will be pro rata. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will be ef- fective even if we have not made or offered a refund. 6. If notice is mailed, proof of mailing will be suf- ficient proof of notice. B. Changes This policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in the Declara- tions is authorized to make changes in the terms of this policy with our consent. This policy's terms can be amended or waived only by endorsement issued by us and made a part of this policy. C. Examination Of Your Books And Records We may examine and audit your books and re- cords as they relate to this policy at any time dur- ing the policy period and up to three years after- ward. D. Inspections And Surveys 1. We have the right to: a. Make inspections and surveys at any time; IL 00 17 11 98 b. Give you reports on the conditions we find; and c. Recommend changes. 2. We are not obligated to make any inspections, surveys, reports or recommendations and any such actions we do undertake relate only to in- surability and the premiums to be charged. We do not make safety inspections. We do not un- dertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions: a. Are safe or healthful; or b. Comply with laws, regulations, codes or standards. 3. Paragraphs 1. and 2. of this condition apply not only to us, but also to any rating, advisory, rate service or similar organization which makes insurance inspections, surveys, reports or recommendations. 4. Paragraph 2. of this condition does not apply to any inspections, surveys, reports or recom- mendations we may make relative to certifica- tion, under state or municipal statutes, ordi- nances or regulations, of boilers, pressure ves- sels or elevators. E. Premiums The first Named Insured shown in the Declara- tions.- 1. eclara- tions:1. Is responsible for the payment of all premiums; and 2. Will be the payee for any return premiums we pay. F. Transfer Of Your Rights And Duties Under This Policy Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual named in- sured. If you die, your rights and duties will be trans- ferred to your legal representative but only while acting within the scope of duties as your legal rep- resentative. Until your legal representative is ap- pointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. IL 00 17 11 98 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ 79868214 1 24-25 A/G/U/E&0/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) � Page 10 of 13 t WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 79 (Ed. 01-13) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while en- gaged in the work described in the Schedule. The additional premium for this endorsement is $ 250 Schedule Person or Organization AS REQUIRED BY WRITTEN CONTRACT Job Description This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Endorsement No. Policy Effective 07/06/2023 Premium State CA Policy No. XWS(24)58258345 Insured Utility Systems Science and Software, Inc. Insurance Company Ohio Security Insurance Company 19291 Countersigned by WC 99 06 79 (Ed. 01-13) © 2013 Liberty Mutual Insurance Includes copyrighted material of WCIRB,with its permission. 79868214 1 24-25 A/G/U/E&O/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 11 of 13 FORM: WC Policy Number 1 XWS(24)58258345 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 B (Ed. 01-22) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: Cancelation: 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Material failure to comply with federal or state safety orders or written recommendations of our designated loss control representatives; h. The occurrence of a material change in the ownership of your business; i. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; j. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; k. The occurrence of any change in your business or operation which contemplates an activity ex- cluded by our reinsurance treaties. 3. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) through (k), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. If we mail the notice to you, the stated periods of notice and your right to remedy the condition will be extended by 5 days if the place of mailing and your mailing address is within California, 10 days if the place of mailing or your mailing address is outside of California and 20 days if the place of mailing or your mailing address is outside of the United States. 5. The policy period will end on the day and hour stated in the cancelation notice. WC 04 06 01 B (Ed. 01-22) 79868214 124-25 A/G/U/E&0/R&L/WC I Dani Rembleski 15/6/2024 10:50:49 AM (PDT) I Page 12 of 13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 B (Ed. 01-22) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Endorsement No. 0008 Policy Effective 07/06/2023 Premium State Policy No. XWS (24) 58 25 83 45 Insured UTILITY SYSTEMS SCIENCE AND SOFTWARE INC., DBA: U.S. CUBED Insurance Company Ohio Security Insurance Company 19291 Countersigned by WC 04 06 01 B (Ed. 01-22) 79868214 1 24-25 A/G/U/E&C/R&L/WC I Dani Rembleski 1 5/6/2024 10:50:49 AM (PDT) I Page 13 of 13