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HomeMy WebLinkAboutInsurance Certificate: Shea Carr & Jewell PROPEL INSURANCE PAGE 2 OF 13 Client: 116497 SH EACARR YY ACORD. CERTIFICATE OF LIABILITY INSURANCE 6 D/16/2014 6/16/2014 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 NOME: Sandy Kulseth FAX Propel Insurance PHONE 800499-0933 866.577.1326 ac No Eat : No Olympia Commercial Insurance EMAIL -ADDRESS sjk@propolinsurance.com P.O. Box 2007 Olympia, WA 98507 INSURER(S)AFFORDINGCOVERAGE NAIC9 INSURER A: American Casualty Co of Reading INSURED INSURER 8,ContlnentalCasualty Company 20443 Shea, Carr 8 Jewell Inc INSURERC: Beazley Insurance Company, Inc. 8730 Talton Lane NE, Suite 200 INSURERD: Continental Insurance Company Olympia, WA 985116 6 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 CONTRACTOR 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 UBR POLICY SEE POUCY UP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DDM' A GENERAL_LIABD.RY Y Y 2090667295 6/15/2014 06/15/201 EE~AAqCCMHppOEECTCTURRENCE s2'000.000 X COMMERCIALGENERALLIABILITV PREMISES EeEaNCanDenm $300000 CLAIMSMADE F OCCUR MED EXP(my we person) $10000 PERSONAL B ADV INJURY $2000,000 GENERALAGGREGATE s4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $4000000 PoLICV X PRO LOC $ D AUTOMOBILELIABLLIrY Y Y 4012152794 6/15/201406/15/201 COMBINED SINGLE LIMIT 1,000,000 e ecctlenl X ANY AUTO BODILY INJURY (P., person) $ ALL OWNED SCHEDULED AUTOS AIfTD$ BODILY INJURY(Peracddon0 $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Peadden$ $ B X UMBRELLA UAB X OCCUR 4016829451 6/15/2014 06/15/201 EACH OCCURRENCE s3.000.000 EXCESS CLAIMS-MADE AGGREGATE s3,000,000 OED RETENTION $ WORKERS COMPENSATION WA STATE FUND A NA X WC STATU- 07H- _ AND EMPLOYERS' LIABILITY A ANY FROPRIErOR/PARTNER/EXECUTNE Y/N 2090667295 6/15/201406/15/201 E.L.EAOHACCIDENT $1000000 OFFICERIMEMBER EXCLUDED? FAI N/A (Mandatory in NH) (WA STOP GAP) E.L. DISEASE - EA EMPLOYEE $1000000 If yy~e d cri esbe under ā¯‘ESCRIPTION OFOPERATIONS 1*1rn E.L. DISEASE - POLICY LIMIT $1,000,000 C Professional VlOBC2140401 6/17/2014 06117/201 Each Claim: $1,000,000 Liability Aggregate-$2,000,000 Deductible: $50 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Aeach ACORD 101, Additional Rema s Schedule, if more space is inquired) Additional Insureds: The City of Ashland, Oregon and Its elected officials, officers and employees. CERTIFICATE HOLDER CANCELLATION City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 East Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Ashland, OR 97520 AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1429750IM1429261 NMB00 PROPEL INSURANCE PAGE 3 OF 13 This page has been left blank intentionally. PROPEL INSURANCE PAGE 4 OF 13 Shea, Cam& Jewell Inc 2090667295 SB-14 01/06) CNA (Ed. 01/06) IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE ADDITIONAL INSURED IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT. SEE PARAGRAPH C., OF THIS ENDORSEMENT FOR THESE DUTIES. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT WITH PRODUCTS-COMPLETED OPERATIONS COVERAGE 8r, BLANKET WAIVER OF SUBROGATION Architects, Engineers and Surveyors This endorsement modifies insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM BUSINESSOWNERS COMMON POLICY CONDITIONS A. WHO IS AN INSURED (Section C.) of the 4. The insurance provided to the additional insured Businessowners Liability Coverage Form is does not apply to "bodily injury," "property amended to include as an insured any person or damage," "personal and advertising injury" organization whom you are required to add as an arising out of an architect's, engineer's, or additional insured on this policy under a written surveyor's rendering of or failure to render any contract or written agreement; but the written professional services including: contract or written agreement must be: a. The preparing, approving, or failing to 1. Currently in effect or becoming effective during prepare or approve maps, shop drawings, the term of this policy; and opinions, reports, surveys, field orders, 2. Executed prior to the "bodily injury property change orders or drawings and damage," or "personal and advertising injury." specifications by any architect, engineer or surveyor performing services on a project of B. The insurance provided to the additional insured is which you serve as Construction manager; limited as follows: or 1. That person or organization is an additional b. Inspection, supervision, quality control, insured solely for liability due to your negligence engineering or architectural services done specifically resulting from "your work" for the by you on a project of which you serve as additional insured which is the subject of the construction manager. written contract or written agreement. No 5. This insurance does not apply to "bodily injury," coverage applies to liability resulting from the "property damage," or "personal and advertising sole negligence of the additional insured. injury' arising out of: 2. The Limits of Insurance applicable to the a. The construction or demolition work while additional insured are those specified in the you are acting as a construction or written contract or written agreement or in the demolition contractor. This exclusion does Declarations of this policy, whichever is less. not apply to work done for or by you at your These Limits of Insurance are inclusive of, and not in addition to, the Limits of Insurance shown premises, in the Declarations. C. BUSINESSOWNERS GENERAL LIABILITY 3. The coverage provided to the additional insured CONDITIONS - Duties In The Event of within this endorsement and section titled Occurrence, Offense, Claim or Suit (Section E.2.) LIABILITY AND MEDICAL EXPENSE of the Businessowners Liability Coverage Form is DEFINITIONS - "Insured Contract" (Section amended to add the following: F.9.) within the Businessowners Liability An additional insured under this endorsement will as Coverage Form, does not apply to "bodily injury" soon as practicable: or "property damage" arising out of the 1. Give written notice of an occurrence or an "products-completed operations hazard" unless required by the written contract or written offense to us which may result in a claim or agreement. "suit" under this insurance; SB-146968-A Page 1 of 2 (Ed. 01/06) PROPEL INSURANCE PAGE 5 OF 13 Shea, Cam & Jewell Inc 01/06) 2osCNA SB-14 (Ed. 01 /O6) 2. Tender the defense and indemnity of any claim insured against that "suit" If no other insurer or "suit" to us for a loss we cover under this defends, we will undertake to do so, but we will Coverage Part; be entitled to the additional insured's rights 3. Tender the defense and indemnity of any claim against all those other insurers. or "suit" to any other insurer which also has When this insurance is excess over other insurance for a loss we cover under this insurance, we will pay only our share of the Coverage Part; and amount of the loss, if any, that exceeds the sum 4. Agree to make available any other insurance of: which the additional insured has for a loss we (a) The total amount that all such other cover under this Coverage Part. insurance would pay for the loss in the We have no duty to defend or indemnify an absence of this insurance; and additional insured under this endorsement until we (b) The total of all deductible and self-insured receive written notice of a claim or "suit" from the amounts under all that other insurance. additional insured. We will share the remaining loss, if any, with D. OTHER INSURANCE (Section H. 2. & 3.) of the any other insurance that is not described in this Businessowners Common Policy Conditions are Excess Insurance provision and was not bought deleted and replaced with the following: specifically to apply in excess of the Limits of 2. This insurance is excess over any other Insurance shown in the Declarations of this Coverage naming the additional insured as an Part. insured whether primary, excess, contingent or E. TRANSFER OF RIGHTS OF RECOVERY on any other basis unless a written contract or AGAINST OTHERS TO US (Section K.2.) of the written agreement specifically requires that this Businessowners Common Policy Conditions is insurance be either primary or primary and deleted and replaced with the following: noncontributing to the additional insured's own 2 We waive any right of recovery we may have coverage. This insurance is excess over any against any person or organization against whom other insurance to which the additional insured you have agreed to waive such right of recovery in a has been added as an additional insured by written contract or agreement because of payments endorsement. we make for injury or damage arising out of your 3. When this insurance is excess, we will have no ongoing operations or "your work" done under a duty under Coverages A or B to defend the contract with that person or organization and additional insured against any "suit" if any other included within the "products-completed operations insurer has a duty to defend the additional hazard." SB-146968-A Page 2 of 2 (Ed.01/O6) PROPEL INSURANCE PAGE 6 OF 13 090667295 ~r~p SB-146932-E CAM (Ed. 06/11) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - LIABILITY EXTENSION This endorsement modifies insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM Coverage afforded under this extension of coverage endorsement does not apply to any person or organization covered as an additional insured on any other endorsement now or hereafter attached to this Policy. 1. ADDITIONAL INSURED -BLANKET VENDORS own acts or omission or those of its employees or anyone else acting on its WHO IS AN INSURED is amended to include as an behalf. However, this exclusion does not additional insured any person or organization (referred apply to: to below as vendor) with whom you agreed, because of a written contract or agreement to provide (1) The exceptions contained in insurance, but only with respect to 'bodily injury' or Subparagraphs d. or f.; or 'property damage' arising out of 'your products' which (2) Such inspections, adjustments, tests or are distributed or sold in the regular course of the servicing as the vendor has agreed to vendor's business, subject to the following additional make or normally undertakes to make in exclusions: the usual course of business, in 1. The insurance afforded the vendor does not apply connection with the distribution or sale of to: the products. a. 'Bodily injury' or 'property damage' for which 2. This insurance does not apply to any insured the vendor is obligated to pay damages by person or organization, from whom you have reason of the assumption of liability in a acquired such products, or any ingredient, part or contract or agreement. This exclusion does container, entering into, accompanying or not apply to liability for damages that the containing such products. vendor would have in the absence of the 3. This provision 2. does not apply to any vendor contract or agreement; included as an insured by an endorsement issued b. Any express warranty unauthorized by you; by us and made a part of this Policy. c. Any physical or chemical change in the 4. This provision 2. does not apply if 'bodily injury' or product made intentionally by the vendor; 'property damage' included within the 'products- completed operations hazard' is excluded either d. Repackaging, except when unpacked solely by the provisions of the Policy or by endorsement. for the purpose of Inspection, demonstration, testing, or the substitution of parts under 2. MISCELLANEOUS ADDITIONAL INSUREDS instructions from the manufacturer, and then WHO IS AN INSURED is amended to include as an repackaged in the original container; insured any person or organization (called additional e. Any failure to make such inspections, insured) described in paragraphs 2.a. through 2.11h. adjustments, tests or servicing as the vendor below whom you are required to add as an additional has agreed to make or normally undertakes to insured on this policy under a written contract or make in the usual course of business, in agreement but the written contract or agreement must connection with the distribution or sale of the be: products; 1. Currently in effect or becoming effective during the f. Demonstration, installation, servicing or repair term of this policy; and operations, except such operations performed 2. Executed prior to the 'bodily injury,' 'property at the vendor's premises in connection with damage' or 'personal and advertising injury,' but the sale of the product; Only the following persons or organizations are g. Products which, after distribution or sale by additional insureds under this endorsement and you, have been labeled or relabeled or used coverage provided to such additional insureds is as a container, part or Ingredient of any other limited as provided herein: thing or substance by or for the vendor; or a. Additional Insured -Your Work h. 'Bodily injury' or 'properly damage' arising out of the sole negligence of the vendor for its. That person or organization for whom you do work is an additional insured solely for liability S13-146932-E Page 1 of 5 (Ed. 06/11) PROPEL INSURANCE PAGE 7 OF 13 090667296 SB-146932-E (Ed. 06/11) due to your negligence specifically resulting This insurance does not apply to 'bodily from your work for the additional insured injury,' 'property damage' or 'personal and which is the subject of the written contract or advertising injury' arising out of operations written agreement. No coverage applies to performed for the state or municipality. liability resulting from the sole negligence of the additional insured c. Controlling Interest . The insurance provided to the additional Any persons or organizations with a insured is limited as follows: controlling interest in you but only with respect to their liability arising out of: (1) The Limits of Insurance applicable to the additional insured are those specified in (1) Their financial control of you; or the written contract or written agreement (2) Premises they own, maintain or control or in the Declarations of this policy, while you lease or occupy these whichever is less. These Limits of Premises, Insurance are inclusive of, and not in addition to, the Limits of Insurance shown This insurance does not apply to structural in the Declarations, alterations, new construction and demolition operations performed by or for such additional (2) The coverage provided to the additional insured. insured by this endorsement and d. Managers or Lessors of Premises paragraph F.9. of the definition of 'insured contract' under Liability and Medical A manager or lessor of premises but only with Expenses Definitions do not apply to respect to liability arising out of the ownership, 'bodily Injury' or 'property damage' maintenance or use of that specific part of the arising out of the 'products-completed premises leased to you and subject to the operations hazard' unless required by the following additional exclusions: written contract or written agreement. (3) The insurance provided to the additional This insurance does not apply to: insured does not apply to 'bodily injury,' (1) Any 'occurrence' which takes place after 'property damage,' or 'personal and you cease to be a tenant in that premises; advertising injury' arising out of the or rendering or failure to render any (2) Structural alterations, new construction or professional services. demolition operations performed by or on b. State or Political Subdivisions behalf of such additional insured. A state or political subdivision subject to the e. Mortgagee, Assignee or Receiver following provisions: A mortgagee, assignee or receiver but only (1) This insurance applies only with respect with respect to their liability as mortgagee. $ to the following hazards for which the assignee, or receiver and arising out of the state or political subdivision has Issued a ownership, maintenance, or use of a premises permit in connection with premises you by you. own, rent, or control and to which this This insurance does not apply to structural insurance applies: alterations, new construction or demolition (a) The existence, maintenance, repair, operations performed by or for such additional construction, erection, or removal of insured. advertising signs, awnings, canopies, I. Owners/Other Interests - Lath is Leased cellar entrances, coal holes, driveways, manholes, marquees, An owner or other interest from whom land hoistaway openings, sidewalk vaults, has been leased by you but only with respect street banners, or decorations and to liability arising out of the ownership, similar exposures; or maintenance or use of that specific part of the (b) The construction, erection, or land leased to you and subject to the following additional exclusions: removal of elevators; or (2) This insurance applies only with respect This insurance does not apply to: to operations performed by you or on your (1) Any 'occurrence' which takes place behalf for which the state or political after you cease to lease that land; or subdivision has issued a permit. SB-146932-E Page 2 of 5 (Ed. 06/11) PROPEL INSURANCE PAGE 8 OF 13 090667295 CAM SB-146932-E (Ed. 06111) (2) Structural alterations, new Damage To Property, is replaced by the construction or demolition operations following: performed by or on behalf of such k Damage To Property additional insured. g. Co-owner of Insured Premises 'Property damage' to; A co-owner of a premises co-owned by you 1. Property you own, rent or occupy, and covered under this insurance but only including any costs or expenses with respect to the co-owners liability as co- incurred by you, or any other person, owner of such premises. organization or entity, for repair, replacement, enhancement, h. Lessor of Equipment restoration or maintenance of such Any person or organization from whom you property for any reason, including prevention of Injury to a person or lease equipment. Such person or organization damage to anther's property; are insureds only with respect to their liability arising out of the maintenance, operation or 2. Premises you sell, give away or use by you of equipment leased to you by abandon, if the 'property damage' such person or organization. A person's or arises out of any part of those organization's status as an insured under this premises; endorsement ends when their written contract or agreement with you for such leased 3. Property loaned to you; equipment ends. 4. Personal property in the care, With respect to the insurance afforded these custody or control of the insured; additional insureds, the following additional 5. That particular part of any real exclusions apply; property on which you or any This insurance does not apply: contractors or subcontractors working directly or indirectly in your behalf are (1) To any 'occurrence' which takes place performing operations, if the 'property after the equipment lease expires; or damage' arises out of those (2) To 'bodily injury; 'property damage' or operations; or 'personal and advertising injury' arising 6. That particular part of any property out of the sole negligence of such that must be restored, repaired or additional insured. replaced because your work' was Any insurance provided to an additional insured incorrectly performed on it. designated under paragraphs b. through h. above Paragraph 2 of this exclusion does not does not apply to 'bodily injury' or 'property apply if the premises are your work' and damage' included within the 'products-completed were never occupied, rented or hold for operations hazard.' rental by you. 3. The following is added to Paragraph H. of the Paragraphs 1, 3, and 4, of this exclusion BUSINESSOWNERS COMMON POLICY do not apply to 'property damage' (other CONDITIONS: than damage by fire or explosion) to premises: H. Other Insurance 4. This insurance is excess over any other (1) rented to you: insurance naming the additional insured (2) temporarily occupied by you with the as an insured whether primary, excess, permission of the owner, or contingent or on any other basis unless a (3) to the contents of premises rented to written contract or written agreement you for a period of 7 or fewer specifically requires that this Insurance be consecutive days. either primary or primary and. noncontributing. A separate limit of insurance applies to Damage To Premises Rented To You as 4. LEGAL LIABILITY -DAMAGE TO PREMISES described In Section D - Liability and A. Under B. Exclusions, t. Applicable to Medical Expenses Limits of Insurance. Business Liability Coverage, Exclusion k. SB-146932-E Page 3 of 5 (Ed. 06111) PROPEL INSURANCE PAGE 9 OF 13 090667295 q SB-146932-E CN!+a (Ed. 06/11) Paragraphs 3, 4, 5, and 6 of this (2) Any partner, if you or an additional exclusion do not apply to liability insured is a partnership; assumed under a sidetrack agreement. (3) Any manager, if you or an additional Paragraph 6 of this exclusion does not insured Is a limited liability company; apply to 'property damage' included in the 'products-completed operations (4) Any 'executive officer' or insurance hazard.' manager, if you or an additional Insured is a corporation; B. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the last (5) Any trustee, if you or an additional paragraph of 2. Exclusions is deleted and insured is a trust; or replaced by the following: (6) Any elected or appointed official, if you or Exclusions c, d, e, f, g, h, I, k, 1, m, n, and o, an additional insured is a political do not apply to damage by fire to premises subdivision or public entity. while rented to you or temporarily occupied by This paragraph e. applies separately to you you with permission of the owner or to the and any additional insured. contents of premises rented to you for a period of 7 or fewer consecutive days. A 7 Bodily Injury separate limit of insurance applies to this Section F. Liability and Medical Expenses coverage as described in Section D. Liability Definitions, item 3. 'Bodily Injury' is deleted and And Medical Expenses Limits Of replaced with the following: Insurance. °Bodily Injury' means bodily injury, sickness or C. The first Paragraph under item 5. Damage To disease sustained by a person, including death, Premises Rented To You Limit of Section humiliation, shock, mental anguish or mental 0. Liability And Medical Expenses Limits injury by that person at any time which results as Of Insurance is replaced by the following: a consequence of the bodily injury, sickness or The most we will pay under Business Liability disease. for damages because of "properly damage' 6, Expanded Personal and Advertising Injury 8 to any one premises, while rented to you, or Definition temporarily occupied by you, with the permission of the owner, including contents of a. The following is added to Section F. Liability such premises rented to you for a period of 7 and Medical Expenses Definitions, item 14. or fewer consecutive days, is the Damage to Personal and Advertising Injury, In the Premises Rented to You limit shown in the Businessowners General Liability Declaration. Coverage Form: 5. Blanket Waiver of Subrogation h. Discrimination or humiliation that results in injury to the feelings or reputation of a natural We waive any right of recovery we may have person, but only if such discrimination or against: humiliation is: a. Any person or organization with whom you 1. Not done intentionally by or at the have a written contract that requires such a direction of: waiver. 6. Broad Knowledge of Occurrence a. The insured; or b. Any 'executive officer,' director, The following items are added to E. stockholder, partner, member or Businessowners General Liability Conditions manager (if you are a limited liability in the Businessowners Liability Coverage company) of the insured; and Form: 2. Not directly or indirectly related to the e. Paragraphs e. and b. apply to you or to any employment, prospective employment, additional Insured only when such past employment or termination of 'occurrence; offense, claim or 'suit' is known employment of any person or person by ° to: any insured. (1) You or any additional insured that is an b. The following is added to Exclusions, Section Individual; B SB-146932-E Page 4 of 5 (Ed. 06/11) PROPEL INSURANCE PAGE 10 OF 13 090667295 OVp SB-146932-E 9~ (Ed. 06/11) (15) Discrimination Relating to Room, Personal and Advertising Injury Liability is Dwelling or Promises excluded either by the provisions of the Policy Caused by discrimination directly or or by endorsement. Indirectly related to the sale, rental, lease 9. Personal and Advertising Injury Re-defined or sub-lease or prospective sale, rental, Section F. Liability and Medical Expenses lease or sub-lease of any room, dwelling Definitions, item 1ity Personal Advertising Injury, premises by or at the direction of any Paragraph c. is replaced by the following: Insured. (16)Flnes or Penalties c, The wrongful eviction from, wrongful entry into, or invasion of the right of private Fines or penalties levied or imposed by a occupancy of a room dwelling or premises governmental entity because of that a person or organization occupies discrimination. committed by or on behalf of its owner, c. This provision (Expanded Personal and landlord or lessor. Advertising injury) does not apply if SS-146932-E Page 5 of 5 (Ed. 06111) PROPEL INSURANCE PAGE 11 OF 13 _T A A O C x w d d L d OA cs 0. N F PROPEL INSURANCE PAGE 12 OF 13 Shea, Can, 8 Jewell Inc POLICY NUMBER: 4012152794 COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Endorsement Effective Date: SCHEDULE Name(s) Of Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION FOR WHOM OR WHICH YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER FROM US. YOU MUST AGREE TO THAT d REQUIREMENT PRIOR TO LOSS. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. a The Transfer Of Rights Of Recovery Against Others R To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 04 44 03 10 Copyright, Insurance Services Office, Inc., 2009 Page 1 of 1 PROPEL INSURANCE PAGE 13 OF 13 This page has been left blank intentionally.