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Insurance - TelePacific Communications - 2012-10-12 � 1 ® ,4�° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) ,0/12/2012 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 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 CONTACT Marsh Risk&Insurance Services PHOE: CA Lic.#0437153 (A/C,No,Ext): (A/C,No): 777 South Figueroa Street E-MAIL Los Angeles,CA 90017-5822 ADDRESS: Attn:Michelle dela Cruz/fax 213-346-5927 INSURER(S)AFFORDING COVERAGE NAIC# 609623-AII'-CAS-2012 INSURER A:Travelers Property Casualty Co.Of America 25674 INSURED INSURER B:Hartford Fire Insurance Co 19682 U.S.TelePacific Holdings Corp. 515 South Flower Street,47th Floor INSURER C:N/A N/A Los Angeles,CA 90017 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: LOS-001526431-01 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY 660 3597R369 07/01/2012 07/01/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY 'r LOC $ B AUTOMOBILE LIABILITY 10UEN NE4706 07/01/2012 07/01/2013 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X x NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) Comp/Coll.Deductible $ 1,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION HJUB 3678M28712 07/01/2012 07/01/2013 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Costa Mesa Sanitary District,its directors,officials,officers,employees,agents and volunteers are Certificate holder is additional insured as respects the General Liability policy,but only with respect to the operations of named insured. Primary and Non-Contributory provision is included in the General Liability policy. Waiver of subrogation with regard to Workers Compensation. CERTIFICATE HOLDER CANCELLATION Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 628 West 19th Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa,CA 92627 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk&Insurance Services Michelle dela Cruz ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Policy No. 6603597R369 Policy Effective Date: 7/1/2012-7/1/2013 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TECHNOLOGY XTEND ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. Reasonable Force Property Damage— Exception J. Blanket Additional Insured — Lessors Of Leased To Expected Or Intended Injury Exclusion Equipment B. Non-Owned Watercraft Less Than 75 Feet K. Blanket Additional Insured — Persons Or Organi- c. Aircraft Chartered With Pilot zations For Your Ongoing Operations As Re- quired By Written Contract Or Agreement D. Damage To Premises Rented To You L. Blanket Additional Insured—Broad Form Vendors E. Increased Supplementary Payments M. Who Is An Insured— Unnamed Subsidiaries F. Who Is An Insured — Employees And Volunteer N. Who Is An Insured— Liability For Conduct Of Un- Workers—First Aid named Partnerships Or Joint Ventures G. Who Is An Insured — Employees — Supervisory O. Contractual Liability—Railroads Positions H. Who Is An Insured — Newly Acquired Or Formed P. Knowledge And Notice Of Occurrence Or Offense Organizations Q. Unintentional Omission I. Blanket Additional Insured — Owners, Managers R. Blanket Waiver Of Subrogation Or Lessors Of Premises PROVISIONS of SECTION I — COVERAGES — COVERAGE A A. REASONABLE FORCE PROPERTY DAMAGE— BODILY INJURY AND PROPERTY DAMAGE EXCEPTION TO EXPECTED OR INTENDED IN- LIABILITY: JURY EXCLUSION (2) A watercraft you do not own that is: The following replaces Exclusion a., Expected Or (a) Less than 75 feet long; and Intended Injury, in Paragraph 2., of SECTION I— (b) Not being used to carry any person or COVERAGES — COVERAGE A BODILY IN- property for a charge. JURY AND PROPERTY DAMAGE LIABILITY: C. AIRCRAFT CHARTERED WITH PILOT a. Expected Or Intended Injury Or Damage The following is added to Exclusion g., Aircraft, "Bodily injury" or"property damage" expected Auto Or Watercraft,in Paragraph 2.of SECTION or intended from the standpoint of the in- I — COVERAGES — COVERAGE A BODILY IN- sured. This exclusion does not apply to "bod- JURY AND PROPERTY DAMAGE LIABILITY: ily injury" or"property damage" resulting from the use of reasonable force to protect any This exclusion does not apply to an aircraft that person or property. Is: B. NON-OWNED WATERCRAFT LESS THAN 75 (a) Chartered with a pilot to any insured; FEET (b) Not owned by any insured; and The following replaces Paragraph(2) of Exclusion (c) Not being used to carry any person or prop- g., Aircraft, Auto Or Watercraft, in Paragraph 2. erty for a charge. CG D4 17 07 08 ®2008 The Travelers Companies,Inc. Page 1 of 6 Includes the copyrighted material of insurance Services Office, Inc.with its permission. COMMERCIAL GENERAL LIABILITY D. DAMAGE TO PREMISES RENTED TO YOU 5. The following is added to the DEFINITIONS 1. The first paragraph of the exceptions in Ex- Section: clusion j., Damage To Property, in Para- "Premises damage" means "property darn- graph 2. of SECTION I — COVERAGES — age"to: COVERAGE A BODILY INJURY AND a. Any premises while rented to you or tern- PROPERTY DAMAGE LIABILITY is deleted. porarily occupied by you with permission 2. The following replaces the last paragraph of of the owner;or Paragraph 2., Exclusions, of SECTION I — b. The contents of any premises while such COVERAGES - COVERAGE A BODILY IN- premises is rented to you, if you rent such JURY AND PROPERTY DAMAGE LIABIL- premises for a period of seven or fewer ITY: consecutive days. Exclusions c., g. and h., and Paragraphs (1), 6. The following replaces Paragraph 4.b.(1)(b) (3) and (4) of Exclusion j., do not apply to of SECTION IV — COMMERCIAL GENERAL "premises damage". Exclusion f.(1)(a) does LIABILITY CONDITIONS: not apply to "premises damage" caused by fire unless Exclusion f. of Section I — Cover (b) That is Insurance for "premises damage": age A — Bodily Injury And Property Damage or Liability is replaced by another endorsement 7. Paragraph 4.b.(1)(c) of SECTION IV — to this Coverage Part that has Exclusion—All COMMERCIAL GENERAL LIABILITY CON- Pollution Injury Or Damage or Total Pollution DITIONS is deleted. Exclusion in its title. A separate limit of insur- E. INCREASED SUPPLEMENTARY PAYMENTS ance applies to "premises damage" as de- scribed in Paragraph 6. of Section III — Limits 1. The following replaces Paragraph 1.b. of Of Insurance. SUPPLEMENTARY PAYMENTS — COVER- AGES A AND B of SECTION I — COVER- 3. The following replaces Paragraph 6. of SEC- AGES: TION III—LIMITS OF INSURANCE: b. Up to $2,500 for cost of bail bonds re- 6. Subject to 5. above, the Damage To quired because of accidents or traffic law Premises Rented To You Limit is the violations arising out of the use of any most we will pay under Coverage A for vehicle to which the Bodily Injury Liability damages because of "premises damage" Coverage applies. We do not have to fur- to any one premises. nish these bonds. The Damage To Premises Rented To 2. The following replaces Paragraph 1.d. of You Limit will be: SUPPLEMENTARY PAYMENTS — COVER- a. The amount shown for the Damage AGES A AND B of SECTION I — COVER- To Premises Rented To You Limit on AGES: the Declarations of this Coverage d. All reasonable expenses incurred by the Part; or insured at our request to assist us in the b. $100,000 if no amount is shown for investigation or defense of the claim or the Damage To Premises Rented To "suit", including actual loss of earnings up You Limit on the Declarations of this to $500 a day because of time off from Coverage Part. work. 4. The following replaces Paragraph a. of the F. WHO IS AN INSURED — EMPLOYEES AND definition of "insured contract" in the DEFINI- VOLUNTEER WORKERS—FIRST AID TIONS Section: 1. The following is added to the definition of"oc- a. A contract for a lease of premises. How- currence" in the DEFINITIONS Section: ever, that portion of the contract for a Unless you are in the business or occupation lease of premises that indemnifies any of providing professional health care services, person or organization for "premises "occurrence" also means an act or omission damage"is not an "insured contract"; committed by any of your "employees" or "volunteer workers", other than an employed Page 2 of 6 ©2008 The Travelers Companies. Inc. CG D4 17 07 08 includes the copyrighted material of Insurance Services Office. Inc_with its permission. COMMERCIAL GENERAL LIABILITY or volunteer doctor, in providing or failing to or in which you maintain the majority provide first aid or"Good Samaritan services" ownership interest, will qualify as a to a person. Named Insured if there is no other insur- 2. The following is added to Paragraph 2.a.(1) of ante which provides similar coverage to SECTION II—WHO IS AN INSURED: that organization. However: Unless you are in the business or occupation a. Coverage under this provision is of of providing professional health care services, forded only: Paragraphs (1 )(a). (b), (c) and (d) above do (1) Until the 180th day after you ac- not apply to "bodily injury" arising out of pro- quire or form the organization or viding or failing to provide first aid or "Good the end of the policy period, Samaritan services" by any of your "employ- whichever is earlier, if you do not ees" or "volunteer workers", other than an report such organization in writing employed or volunteer doctor. Any of your to us within 180 days after you "employees" or "volunteer workers" providing acquire or form it; or or failing to provide first aid or "Good Samari- (2) Until the end of the policy period, tan services" during their work hours for you when that date is later than 180 will be deemed to be acting within the scope days after you acquire or form of their employment by you or performing du- such organization, if you report ties related to the conduct of your business. such organization in writing to us 3. The following is added to Paragraph 5. of within 180 days after you acquire SECTION III—LIMITS OF INSURANCE: or form it, and we agree in writing For the purposes of determining the applica that it will continue to be a ble Each Occurrence Limit, all related acts or Named Insured until the end of omissions committed by any of your "employ—the policy period; ees" or "volunteer workers" in providing or b. Coverage A does not apply to "bodily failing to provide first aid or"Good Samaritan injury" or "property damage" that oc- services"to any one person will be deemed to curred before you acquired or formed be one"occurrence". the organization; and 4. The following is added to the DEFINITIONS c. Coverage B does not apply to "per- Section: sonal injury" or "advertising injury" "Good Samaritan services" means any emer- arising out of an offense committed gency medical services for which no compen- before you acquired or formed the sation is demanded or received. organization. I. BLANKET ADDITIONAL INSURED—OWNERS, G. WHO IS AN INSURED — EMPLOYEES — SU- PERVISORY POSITIONS MANAGERS OR LESSORS OF PREMISES The following is added to Paragraph 2.a.(1) of The following is added to SECTION II —WHO IS SECTION II—WHO IS AN INSURED: AN INSURED: Paragraphs(1)(a), (b) and (c) above do not apply Any person or organization that is a premises to "bodily injury" or "personal injury" to a co- owner, manager or lessor is an insured, but only "employee" in the course of the co-"employee's" with respect to liability arising out of the owner employment by you arising out of work by any of ship, maintenance or use of that part of any prem your "employees" who hold a supervisory posi ises leased to you. tion. The insurance provided to such premises owner, H. WHO IS AN INSURED — NEWLY ACQUIRED manager or lessor does not apply to: OR FORMED ORGANIZATIONS a. Any "bodily injury" or "property damage" The following replaces Paragraph 4. of SECTION caused by an "occurrence" that takes place, II—WHO IS AN INSURED: or "personal injury" or "advertising injury" caused by an offense that is committed, after 4. Any organization you newly acquire or you cease to be a tenant in that premises; or form, other than a partnership or joint venture, of which you are the sole owner CG D4 17 07 08 ©2008 The Travelers Companies, inc. Page 3 of 6 Includes the copyrighted material of insurance Services Office, Inc.with its permission. COMMERCIAL GENERAL LIABILITY b. Structural alterations, new construction or Any person or organization that is a vendor and demolition operations performed by or on be- that you have agreed in a written contract or half of such premises owner, manager or les- agreement to include as an additional insured on sor. this Coverage Part is an insured, but only with re- J. BLANKET ADDITIONAL INSURED — LESSORS spect to liability for "bodily injury" or "property OF LEASED EQUIPMENT damage" that: The following is added to SECTION II— WHO IS a. Is caused by an "occurrence" that takes place AN INSURED: after you have signed and executed that con- tract or agreement; and Any person or organization that is an equipment lessor is an insured, but only with respect to liabil b. Arises out of "your products" which are dis ity for "bodily injury", "property damage", "per- tributed or sold in the regular course of such sonal injury" or "advertising injury" caused, in vendors business. whole or in part, by your acts or omissions in the The insurance provided to such vendor is subject maintenance, operation or use by you of equip- to the following provisions: ment leased to you by such equipment lessor, a. The limits of insurance provided to such ven- The insurance provided to such equipment lessor dor will be the limits which you agreed to pro- does not apply to any "bodily injury" or "property vide in the written contract or agreement, or damage" caused by an "occurrence" that takes the limits shown in the Declarations, which- place, or "personal injury" or "advertising injury" ever are less. caused by an offense that is committed, after the b. The insurance provided to such vendor does equipment lease expires. not apply to: K. BLANKET ADDITIONAL INSURED— PERSONS (1) Any express warranty not authorized by OR ORGANIZATIONS FOR YOUR ONGOING you; OPERATIONS AS REQUIRED BY WRITTEN CONTRACT OR AGREEMENT (2) Any change in "your products" made by such vendor; The following is added to SECTION II — WHO IS AN INSURED: (3) Repackaging, unless unpacked solely for the purpose of inspection, demonstration, Any person or organization that is not otherwise testing, or the substitution of parts under an insured under this Coverage Part and that you instructions from the manufacturer, and have agreed in a written contract or agreement to then repackaged in the original container; include as an additional insured on this Coverage Part is an insured, but only with respect to liability (4) Any failure to make such inspections, ad for"bodily injury"or"property damage"that: justments, tests or servicing as vendors agree to perform or normally undertake to a. Is caused by an "occurrence" that takes place perform in the regular course of business, after you have signed and executed that con- in connection with the distribution or sale tract or agreement; and of"your products"; b. Is caused, in whole or in part, by your acts or (5) Demonstration, installation, servicing or omissions in the performance of your ongoing repair operations, except such operations operations to which that contract or agree- performed at such vendor's premises in ment applies or the acts or omissions of any connection with the sale of "your prod- person or organization performing such op- ucts"; or erations on your behalf. (6) "Your products" which, after distribution The limits of insurance provided to such insured or sale by you, have been labeled or re- will be the limits which you agreed to provide in labeled or used as a container, part or in- the written contract or agreement, or the limits gredient of any other thing or substance shown in the Declarations, whichever are less, by or on behalf of such vendor. L. BLANKET ADDITIONAL INSURED — BROAD Coverage under this provision does not apply to: FORM VENDORS a. Any person or organization from whom you The following is added to SECTION II — WHO IS have acquired "your products", or any ingre- AN INSURED: Page 4 of 6 ((I':2008 The Travelers Companies,Inc. CG D4 17 07 08 Includes the copyrighted material of Insurance Services Office. Inc.with its permission. COMMERCIAL GENERAL LIABILITY dient, part or container entering into, accom- P. KNOWLEDGE AND NOTICE OF OCCUR- panying or containing such products; or RENCE OR OFFENSE b. Any vendor for which coverage as an addi- The following is added to Paragraph 2., Duties In tional insured specifically is scheduled by en- The Event of Occurrence, Offense, Claim or dorsement. Suit, of SECTION IV — COMMERCIAL GEN- M. WHO IS AN INSURED — UNNAMED SUBSIDI- ERAL LIABILITY CONDITIONS: ARIES e. The following provisions apply to Paragraph The following is added to SECTION II — WHO IS a. above, but only for the purposes of the in- AN INSURED: surance provided under this Coverage Part to you or any insured listed in Paragraph 1. or 2. Any of your subsidiaries, other than a partnership of Section II—Who Is An Insured: or joint venture, that is not shown as a Named In- sured in the Declarations is a Named Insured if: (1) Notice to us of such "occurrence" or of fense must be given as soon as practica- a. You maintain an ownership interest of more ble only after the "occurrence" or offense than 50% in such subsidiary on the first day is known to you (if you are an individual), of the policy period; and any of your partners or members who is b. Such subsidiary is not an insured under Simi- an individual (if you are a partnership or lar other insurance. joint venture), any of your managers who No such subsidiary is an insured for"bodily injury" is an individual (if you are a limited liability or "property damage" that occurred, or "personal company), any of your trustees who is an injury" or "advertising injury" caused by an of individual (if you are a trust), any of your fense committed: "executive officers" or directors (if you are an organization other than a partnership, a. Before you maintained an ownership interest joint venture, limited liability company or of more than 50% in such subsidiary; or trust) or any "employee" authorized by b. After the date, if any, during the policy period you to give notice of an "occurrence" or that you no longer maintain an ownership in- offense. terest of more than 50% in such subsidiary. (2) If you are partnership,y p p,joint venture, lim- N. WHO IS AN INSURED — LIABILITY FOR CON- ited liability company or trust, and none of DUCT OF UNNAMED PARTNERSHIPS OR your partners, joint venture members, JOINT VENTURES managers or trustees are individuals, no- The following replaces the last paragraph of tice to us of such "occurrence" or offense SECTION It—WHO IS AN INSURED: must be given as soon as practicable only after the"occurrence" or offense is known No person or organization is an insured with re- by: spect to the conduct of any current or past part- nership or joint venture that is not shown as a (a) Any individual who is: Named Insured in the Declarations. This para- (i) A partner or member of any part- graph does not apply to any such partnership or nership or joint venture; joint venture that otherwise qualifies as an in- (ii) A manager of any limited liability sured under Section II—Who Is An Insured, company; O. CONTRACTUAL LIABILITY—RAILROADS (iii) A trustee of any trust; or 1. The following replaces Paragraph c. of the (iv)An executive officer or director of definition of "insured contract" in the DEFINI- any other organization; TIONS Section: that is your partner, joint venture c. Any easement or license agreement; member, manager or trustee; or 2. Paragraph f.(1) of the definition of "insured (b) Any "employee" authorized by such contract" in the DEFINITIONS Section is de- partnership, joint venture, limited li- leted. ability company, trust or other organi- zation to give notice of an "occur- rence"or offense. CG D4 17 07 08 .2008 The Travelers Companies,Inc. Page 5 of 6 includes the copyrighted material of insurance Services Office, !nc.with its permission. COMMERCIAL GENERAL LIABILITY (3) Notice to us of such "occurrence" or of- The unintentional omission of, or unintentional fense will be deemed to be given as soon error in, any information provided by you which as practicable if it is given in good faith as we relied upon in issuing this policy will not preju- soon as practicable to your workers' dice your rights under this insurance. However, compensation insurer. This applies only if this provision does not affect our right to collect you subsequently give notice to us of the additional premium or to exercise our rights of "occurrence" or offense as soon as prac- cancellation or nonrenewal in accordance with ticabie after any of the persons described applicable insurance laws or regulations. in Paragraphs e. (1) or (2) above discov- R. BLANKET WAIVER OF SUBROGATION ers that the "occurrence" or offense may result in sums to which the insurance The following is added to Paragraph B., Transfer provided under this Coverage Part may Of Rights Of Recovery Against Others To Us, apply. of SECTION IV — COMMERCIAL GENERAL LI- ABILITY CONDITIONS: However, if this policy includes an endorse- ment that provides limited coverage for "bod If the insured has agreed in a contract or agree- ily injury" or "property damage" or pollution ment to waive that insured's right of recovery costs arising out of a discharge, release or against any person or organization, we waive our escape of "pollutants" which contains a re- right of recovery against such person or organiza- quirement that the discharge, release or es tion, but only for payments we make because of: cape of "pollutants" must be reported to us a. "Bodily injury" or "property damage" caused within a specific number of days after its by an "occurrence"that takes place; or abrupt commencement, this Paragraph e. b. "Personal injury" or "advertising injury" does not affect that requirement. caused by an offense that is committed; Q. UNINTENTIONAL OMISSION subsequent to the execution of the contract or The following is added to Paragraph 6., Repre- agreement. sentations, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: Page 6 of 6 z-;,)2008 The Travelers Companies,Inc. CG D4 17 07 08 Includes the copyrighted material of Insurance Services Office, Inc.with its permission_ Policy No. 6603597R369 Policy Effective Date: 711/2012-7/1/2013 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE - ADDITIONAL INSUREDS - PRIMARY AND NON-CONTRIBUTORY WITH RESPECT TO CERTAIN OTHER INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to Paragraph 4. a., Primary (1) The "bodily injury" or"property damage"for which Insurance, of SECTION IV — COMMERCIAL GEN- coverage is sought is caused by an "occurrence" ERAL LIABILITY CONDITIONS: that takes place; and However, if you specifically agree in a written contract (2) The "personal injury" or "advertising injury" for or agreement that the insurance afforded to an addi- which coverage is sought arises out of an offense tional insured under this Coverage Part must apply on that is committed; a primary basis, or a primary and non-contributory basis, this insurance is primary to other insurance that subsequent to the signing and execution of that con- is available to such additional insured which covers tract or agreement by you. such additional insured as a named insured, and we will not share with that other insurance, provided that: CG D4 25 07 08 ©2008 The Travelers Companies,inc. Page 1 of 1 Aosw TRAVELERS J WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 00 03 13 (00)-01 POLICY NUMBER: (HUUB-3678M28-7-12) 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 DESIGNATED PERSON: DESIGNATED ORGANIZATION: ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER . DATE OF ISSUE: 07-06-12 ST ASSIGN: