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HomeMy WebLinkAboutInsurance Certificate:: Rubenstein's Contract Carpet LLCClient#: 1785091 RUBENCON ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1 9/09/2024 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Alexandra Goodspeed USI Insurance Services NW PHONE 503 224-8390 FAX 610 362-8130 MA Lo, Ext : (A/C, No): 825 NE Multnomah Suite 1500 ADDRESS: alexandra.goodspeed@usi.com Portland, OR 97232 INSURER(S) AFFORDING COVERAGE NAIC # 503 226-3801 Middlesex Insurance Company INSURER A: P y 23434 INSURED INSURER B : SAIF Corporation 36196 Rubenstein's Contract Carpet LLC 160 Cleveland Street INSURER C Eugene OR 97402 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 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 LTR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY A0148707004 03/15/2024 03/15/2025 EACH OCCURRENCE $1 ,000,000 CLAIMS -MADE [* OCCUR PREMI6ESOEa oNcurrDence $1 ,000,000 MED EXP (Any one person) $15,000 PERSONAL & ADV INJURY $1 ,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 PRO - POLICY X JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 $ OTHER: A AUTOMOBILE LIABILITY A0148707001 03/15/2024 03/15/202 COEaMBINED identSINGLE LIMIT acc 1 r 000r 000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ X HIRED NON -OWNED AUTOS ONLY X AUTOS ONLY A X UMBRELLA LIAB X OCCUR A0148707005 03/15/2024 03/15/2025 EACH OCCURRENCE $1 U 00U 000 AGGREGATE $1 O 00O 000 EXCESS LIAB CLAIMS -MADE DED I X RETENTION $0 $ B WORKERS COMPENSATION EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A 794537 10/01/2024 10/01/202 X PER OTH- STATUTE ERAND E.L. EACH ACCIDENT $1 ,000,000 E.L. DISEASE - EA EMPLOYEE $1 ,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1 ,000,000 A Installation: A0148707003 03/15/2024 03/15/2025 Limit $1,000,000 Temp Storage/ Limit $500,000 Transit Deductibles $1,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ** Workers Comp Information ** Proprietors/Partners/Executive Officers/Members Excluded: Randall Rubenstein, Member Re: All Projects When Required by Written Contract The City of Ashland and its elected officials, officers (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION City of Ashland 20 East Main Street Ashland, OR 97520-0000 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 ACORD 25 (2016/03) 1 of 2 #S46140806/M46138553 Y © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHPZR DESCRIPTIONS (Continued from Page 1) and employees are included as additional insureds with primary and non-contributory wording and waiver of subrogation when required by written contract. SAGITTA 25.3 (2016/03) 2 of 2 #S46140806/M46138553 A0148707004 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 This page has been left blank intentionally. POLICY NUMBER: A0148707005 COMMERCIAL EXCESS / UMBRELLA EU 70 91 05 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies the coverage provided under the following: CK� as] /e1Naxe] *•&00]r•1:3all: IIW KOIT a el: a.7e1:09 With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. SCHEDULE Name Of Person Or Organization: Any Additional Insured as required by written contract or written agreement executed prior to loss (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The following is added to Paragraph H. Other (4) Affords indemnification and/or defense of Insurance of Section IV - Conditions: the designated person or organization to 1. This insurance is primary to and will not seek the extent permitted by law. contribution from any other insurance available 2. This condition does not apply to: to the person or organization shown in the a. Other insurance, not included in Paragraph 1. Schedule above, provided that such designated above, that may be available to the person or organization: designated person or organization outside of a. Is identified as an additional insured in the your written contract or agreement; or "underlying insurance"; b. Liability which: b. Is a Named Insured under such other (1) May attach to the designated person or insurance; and organization and is not assumed by your c. Has agreed with you in a written contract or written contract or agreement; or agreement that: (2) Is assumed by the designated person or (1) Is signed and effective prior to an organization under any other written "occurrence" to which this insurance contract assuming the obligations of applies; another. (2) This insurance would be primary and would not seek contribution from such other insurance identified in Paragraphs 1.a. and 1.b. above; (3) Agrees to indemnify or defend the designated person or organization for liability and damages covered by the "underlying insurance"; and EU 70 91 05 15 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 A0148707 with its permission. 04/27/2020 Middlesex Insurance Company 00001 0000000000 20118 0 N 4051e411-42de-4b29-a2f6-5ded6242c814 This page has been left blank intentionally. POLICY NUMBER: A0148707001 COMMERCIAL AUTO CA 76 01 06 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MOM.,: 1 • This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated. Named Insured: Endorsement Effective Date: SCHEDULE Name Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Each person or organization shown in the B Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in: (1) Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms; or (2) Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other auto insurance issued to the person or organization in the schedule under your policy provided that: (1) The person or organization is a Named Insured under such other insurance; and (2) Prior to the "accident' 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 person or organization. CA 76 01 06 15 A0148707 Middlesex Insurance Company 00001 0000000000 23073 0 N Includes copyrighted material of Insurance Services Office, Inc., with its permission. 88dOd581-bc9d4fa6-9f77-b4c54dde6509 Page 1 of 1 03/14/2023 POLICY NUMBER: A0148707001 COMMERCIAL AUTO CA 04 44 10 13 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: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER 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: Rubenstein's Contract Carpet LLC Endorsement Effective Date: 03/15/2023 SCHEDULE Name(s) Of Person(s) Or Organization(s): Any person or organization you are required to add as an additional insured under a written contract or written agreement in effect prior to any loss or damage. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others 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 10 13 A0148707 Middlesex Insurance Company 1 00001 0000000000 22073 0 N © Insurance Services Office, Inc., 2011 d990c3d1-51594312-830d-28213592bd4f Page 1 of 1 03/14/2022 POLICY NUMBER: A0148707001 ADDITIONAL INTEREST SUPPLEMENTAL DECLARATIONS The following additional interests apply to this policy. Any person or organization you are required to add as an additional insured under a written contract or written agreement in effect prior to any loss or damage PO Box 80544 Seattle, WA 98108-0544 CA 76 01 06 15 Designated Insured - Primary and Noncontributory - Covered Autos Liability Coverage CA 89 04 10 14 Page 1 of 1 A0148707 03/14/2023 Middlesex Insurance Company 1 00001 0000000000 23073 0 N 1db45c6a-f8204804-9fbc-7858fadb21d6 This page has been left blank intentionally. A0148707004 COMMERCIAL GENERAL LIABILITY CG 71 18 06 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EACH CONSTRUCTION PROJECT GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policy Maximum Each Construction Project General Aggregate Limit: Not Applicable Designated Construction Project(s): All construction projects away from premises owned by or rented by insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A, and for all medical expenses caused by accidents under Section I - Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Subject to Paragraph 2. below, a separate Each Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. If shown in the Schedule, the Policy Maximum Each Construction Project General Aggregate Limit is the most we will pay for the sum of all damages paid under all Each Construction Project General Aggregate Limits included in this policy. 3. Subject to Paragraph 2. above, the Each Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard", and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 4. Subject to Paragraph 2. above, any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Each Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Each Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 5. Subject to Paragraph 2. above, the limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Each Construction Project General Aggregate Limit. CG 71 18 06 20 A0148707 Middlesex Insurance Company 00001 0000000000 23073 0 N Includes copyrighted material of Insurance Services Office, Inc., with its permission. b615be40-23ad-4e3f-86cf-9c9222789cc3 Pagel of 2 03/14/2023 B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A, and for all medical expenses caused by accidents under Section I - Coverage C, which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products -completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Each Construction Project General Aggregate Limit provided under this policy. C. When coverage for liability arising out of the "products -completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor any Each Construction Project General Aggregate Limit provided under this policy. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Section III - Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., CG 71 18 06 20 A0148707 with Its permission. 03/14/2023 Middlesex Insurance Company A0148707004 COMMERCIAL GENERAL LIABILITY CG 71 24 06 22 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. -4 Iki • • *01:11L ffzew: • • This endorsement modifies the coverage provided under the following Coverage Form(s): COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Coverage enhancements are listed below. For details of each coverage, please read the corresponding policy provisions in the body of this endorsement. 1. Additional Insureds - Automatic Status for 12 Additional Insured Types A. Automatic Status When Required In Written Contract Or Agreement (for Acts or Omissions In The Performance of Your Operations) B. Lessor of Leased Equipment C. Owners or Other Interests From Whom Land Has Been Leased D. Manager or Lessor of Premise E. Mortgagee, Assignee, or Receiver F. Controlling Interest G. Co-owner Of Insured Premises H. Executors, Administrators, Trustees Or Beneficiaries I. State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits Or Authorizations Relating To Premises J. Any Person Or Organization You Are Performing Work For K. Vendors L. Grantor of Franchise 2. Primary and Noncontributory - Other Insurance Condition 3. Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) - Automatic With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. 1. Additional Insureds - Automatic Status for 12 Additional Insured Types Section II - Who Is An Insured is amended to include the following as additional insureds when you have agreed to add that person or organization as an Additional Insured on your policy in a written contract or written agreement with that person or organization, or because of a permit issued by a state or political subdivision; provided the injury or damage occurs subsequent to the execution of the contract or agreement or issuance of the permit and while the contract, agreement or permit remains in effect. A. Automatic Status When Required In Written Contract Or Agreement (for Acts or Omissions In The Performance of Your Operations) 1) A person or organization with respect to liability for: a. "Bodily injury" or "property damage" not included in the "products - completed operations hazard"; or b. "Personal and advertising injury"; caused by, in whole or in part, your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your operations. CG 71 24 06 22 A0148707 Middlesex Insurance Company 00003 0000000000 23073 0 N Includes copyrighted material of Insurance Services Office, Inc., with its permission. f57abl56-d968-405e-93dc-923c80fa5036 Page 1 of 5 03/14/2023 2) With respect to insurance afforded to This exclusion applies even if the claims these additional insureds, the following against any insured allege negligence or additional exclusion applies: other wrongdoing in the supervision, This insurance does not apply to "bodily hiring, employment, training or injury", "property damage" or "personal monitoring of others by that insured, if and advertising injury" due to rendering of the "occurrence" which caused the or failure to render any professional "bodily injury" or "property damage", or service. This includes but is not limited to: the offense which caused the "personal a. Legal, accounting or advertising and advertising injury", involved the services; rendering of or failure to render any professional service. b. Preparing, approving, or failing to prepare or approve, maps, shop B. Lessor of Leased Equipment drawings, opinions, reports, surveys, 1) Any person(s) or organization(s) with field orders, change orders or drawings respect to liability for "bodily injury", or specifications; "property damage" or "personal and c. Inspection, supervision, quality control, advertising injury" caused, in whole or in architectural or engineering activities part, by your maintenance, operation or done by or for you on a project on use of equipment leased to you by such which you serve as construction person(s) or organization(s). manager; 2) With respect to the insurance afforded to d. Engineering services, including related these additional insureds, this insurance supervisory or inspection services; does not apply to any "occurrence" which e. Medical, surgical, dental, X-ray or takes place after the equipment lease nursing services treatment, advice or expires. instruction; C. Owners or Other Interests From Whom f. Any health or therapeutic service Land Has Been Leased treatment, advice or instruction; 1) Any person(s) or organization(s) with g. Any service, treatment, advice or respect to liability for "bodily injury", instruction for the purpose of "property damage" or "personal and appearance or skin enhancement, hair advertising injury" caused, in whole or in removal or replacement, or personal part, by you or those acting on your behalf grooming or therapy; in connection with the ownership, h. Any service, treatment, advice or maintenance or use of that part of the land instruction relating to physical fitness, leased to you by the additional insured including service, treatment, advice or person(s) or organization(s). instruction in connection with diet, cardiovascular fitness, bodybuilding or 2) With respect to the insurance afforded to physical training programs; these additional insureds, the following additional exclusions apply: i. Optometry or optical or hearing aid services including the prescribing, This insurance does not apply to: preparation, fitting, demonstration or a. Any "occurrence" which takes place distribution of ophthalmic lenses and after you cease to lease that land; similar products or hearing aid devices; b. Structural alterations, new construction j. Body piercing services; or demolition operations performed by k. Services in the practice of pharmacy; or on behalf of the additional insured I. Law enforcement or firefighting person(s) or organization(s). services; and m. Handling, embalming, disposal, burial, cremation or disinterment of dead bodies. Page 2 of 5 Includes copyrighted material of Insurance Services Office, Inc., CG 71 24 06 22 A0148707 with Its permission. 03/14/2023 Middlesex Insurance Company D. Manager or Lessor of Premise Any person(s) or organization(s) with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by you or those acting on your behalf in connection with the ownership, maintenance or use of that part of the premises leased to you by the additional insured person(s) or organization(s), subject to the following additional exclusions: This insurance does not apply to: 1) Any "occurrence" which takes place after you cease to be a tenant in that premises. 2) Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. E. Mortgagee, Assignee, or Receiver Any person(s) or organization(s) with respect to their liability as mortgagee, assignee or receiver and arising out of the ownership, maintenance or use of a premises by you. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for such additional insured person(s) or organization(s). F. Controlling Interest 1) Any person(s) or organization(s) with respect to their liability arising out of: a. Their financial control of you; or b. Premises they own, maintain or control while you lease or occupy these premises. 2) This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. G. Co-owner Of Insured Premises Any person(s) or organization(s) with respect to their liability as co-owner of a premises coowned by you and covered under this insurance. H. Executors, Administrators, Trustees Or Beneficiaries Any executor, administrator, trustee or beneficiary of your estate or living trust while acting within the scope of their duties as such. I. State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits Or Authorizations Relating To Premises Any state or governmental agency or subdivision or political subdivision, subject to the following additional provision: This insurance applies only with respect to the following hazards for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization in connection with premises you own, rent or control and to which this insurance applies: 1) The existence, maintenance, repair, construction, erection or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; or 2) The construction, erection or removal of elevators; or 3) The ownership, maintenance or use of any elevators covered by this insurance. J. Any Person Or Organization You Are Performing Work For Any person(s) or organization(s) with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1) In the performance of your ongoing operations; or 2) In connection with your premises owned by or rented to you. K. Vendors 1) Any person(s)or organization(s) (referred to throughout this endorsement as vendor), but only with respect to liability for "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. However: a. The insurance afforded to such vendor only applies to the extent permitted by law; and CG 71 24 06 22 A0148707 Middlesex Insurance Company 00003 0000000000 23073 0 N Includes copyrighted material of Insurance Services Office, Inc., with its permission. f57abl56-d968-405e-93dc-923c80fa5036 Page 3 of 5 03/14/2023 b. If coverage provided to the vendor is required by a contract or agreement, the insurance afforded to such vendor will not be broader than that which you are required by the contract or agreement to provide for such vendor. 2) With respect to the insurance afforded to these vendors, the following additional exclusions apply: a. The insurance afforded the vendor does not apply to: 1) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; 2) Any express warranty unauthorized by you; 3) Any physical or chemical change in the product made intentionally by the vendor; 4) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; 5) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; 6) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; 7) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or 8) "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in Subparagraphs d. or f.; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. b. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. L. Grantor of Franchise Any person(s) or organization(s) with respect to their liability as grantor of a franchise to you. However: 1. The insurance afforded to such additional insureds 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 will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 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; whichever is less. This endorsement shall not increase the applicable limits of insurance. If there is any difference in coverage afforded to an additional insured in this endorsement and Page 4 of 5 Includes copyrighted material of Insurance Services Office, Inc., CG 71 24 06 22 A0148707 with Its permission. 03/14/2023 Middlesex Insurance Company that provided under another additional insured endorsement attached to this policy, the broader coverage will apply to that additional insured. 3 2. Primary And Noncontributory Insurance The following is added to the Other Insurance Condition and supersedes any provision to the contrary: 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. Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) - Automatic 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 against any person or organization, because of any payment we make under this Coverage Part, to whom the insured has waived its right of recovery in a written contract or agreement. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person or organization prior to loss. CG 71 24 06 22 A0148707 Middlesex Insurance Company 00003 0000000000 23073 0 N Includes copyrighted material of Insurance Services Office, Inc., with its permission. f57abl56-d968-405e-93dc-923c80fa5036 Page 5 of 5 03/14/2023 This page has been left blank intentionally. POLICY NUMBER: A0148707004 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 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: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization to whom you are required to waive your right to recover by a written contract or agreement executed prior to loss 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 against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 A0148707 Middlesex Insurance Company 1 00001 0000000000 23073 0 N © Insurance Services Office, Inc., 2018 fOf79f98449945ed-a01 f-602 b9f00febd Page 1 of 1 03/14/2023 This page has been left blank intentionally. www.saif.com ®I ik. fe. sailfOregon. Carrier no: 20001 SAIF policy: 794537 Rubensteins Contract Carpet LLC Endorsement no: WC000313 (Ed. 430B) 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 shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Description: ALL OPERATIONS Contractor name: Persons and/or organizations with whom the insured -employer is required by written contract to waive subrogation rights. This endorsement does not alter the rights of an injured worker to pursue recovery from another party or SAIF to receive a statutory share of recoveries by an injured worker, even from the party listed in the schedule. The premium charge for this endorsement is based on one (1) percent of your manual premium. Effective date: October 01, 2024 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. WC000313 (Ed. 430B) Countersigned August 27, 2024 at Salem, Oregon r' Chip Terhune President and Chief Executive Officer 400 High Street SE Salem, OR 97312 P: 800.285.8525 F: 503.373.8020 Pol_PC1_E430B This page has been left blank intentionally.