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HomeMy WebLinkAboutInsurance Certificate: Hukills, Inc ` � DATE(MM/DD/YYYY) '`�"' CERTIFICATE OF LIABILITY INSURANCE 1 1/0412 0 2 5 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 NAME: CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY AND ITS AFFILIATES PHONE FCLUDING PRIMARY SOURCE INSURANCE AGENCY (AIC,No,Ext):888-333-4949 INC,A/ No):507-446-4664 121 E. PARK SQUARE E-MAIL OWATONNA,MN 55060 ADDRESS:CLIENTCONTACTCENTER@FEDINS.COM INSURERS AFFORDING COVERAGE NAIC# INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED Lnom CERTAIN UNDERWRITERS AT LLOYDS 15792 HUKILL'S,INC. INSURER c:FEDERATED RESERVE INSURANCE COMPANY 16024 3310 LACKLAND RD FORT WORTH,TX 76116-7140 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:433 REVISION NUMBER:0 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YVYV MM/DD/YYYV X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES $100,000 (Ea occurrence) MED EXP(Any one person) EXCLUDED A Y Y 9816391 04/01/2025 04/01/2026 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY QPECT ❑LOC PRODUCTS&COMP/OP ACC $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 (Ea accident) JANYAUTC BODILY INJURY(Per Person) AOWNED AUTOS ONLY gUTESULED Y Y 1833617 04/01/2025 04/01/2026 BODILY INJURY(Per Accident) HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE AUTOS ONLY (Per Accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $5,000,000 A EXCESS LIAR CLAIMS-MADE Y Y 9816395 04/01/2025 04/01/2026 AGGREGATE $5,000,000 DED I RETENTION WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X PER STATUTE OTHER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $2,000,000 C OF EXCLUDED? N/A Y 1835186 04/01/2025 04/01/2026 (Mandatory in NH) E.L DISEASE EA EMPLOYEE $2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE POLICY LIMIT $2,000,000 CONTRACTORS POLLUTION LIABILITY Y Y CPLI00278001 07/01/2025 07/01/2026 EACH LIMIT $1,000,000 BAGGREGATE $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) SEE ATTACHED PAGE CERTIFICATE HOLDER CANCELLATION CITY OF ASHLAND PUBLIC WORKS 4330 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 90 N MOUNTAIN AVE ASHLAND,OR 97520-2014 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I n © 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: AC "� LOC#: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMEDINSURED FEDERATED MUTUAL INSURANCE COMPANY AND ITS AFFILIATES HUKILL'S,INC. 3310 LACKLAND RD INCLUDING PRIMARY SOURCE INSURANCE AGENCY FORT WORTH,TX 76116-7140 POLICY NUMBER SEE CERTIFICATE#433.0 CARRIER NAIC CODE EFFECTIVE DATE:SEE CERTIFICATE#433.0 SEE CERTIFICATE#433.0 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE SECONDARY POLICY(S) Business Auto Y Y 9816391 04/01/2025 04/01/2026 COMB SINGLE LIM-EA ACC 51,000,000 THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN A WRITTEN CONSTRUCTION AGREEMENT WITH YOU ENDORSEMENT FOR GENERAL LIABILITY. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED BY CONTRACT ENDORSEMENT FOR BUSINESS AUTO LIABILITY. INSURANCE PROVIDED BY THE GENERAL LIABILITY COVERAGE IS PRIMARY AND NONCONTRIBUTORY OVER OTHER INSURANCE SUBJECT TO THE CONDITIONS OF THE PRIMARY AND NONCONTRIBUTORY CLAUSE- OTHER INSURANCE CONDITION. INSURANCE PROVIDED BY THE BUSINESS AUTO LIABILITY IS PRIMARY AND NONCONTRIBUTORY OVER OTHER INSURANCE SUBJECT TO THE CONDITIONS OF THE PRIMARY AND NONCONTRIBUTORY CLAUSE- OTHER INSURANCE CONDITION. GENERAL LIABILITY CONTAINS A WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) - AUTOMATIC ENDORSEMENT BUSINESS AUTO LIABILITY CONTAINS A WAIVER OF SUBROGATION IN FAVOR OF THE CERTIFICATE HOLDER SUBJECT TO THE CONDITIONS OF THE BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY ENDORSEMENT. WORKERS COMPENSATION CONTAINS A WAIVER OF SUBROGATION IN FAVOR OF THE CERTIFICATE HOLDER WHERE PERMITTED BY STATE STATUTE SUBJECT TO THE CONDITIONS OF THE TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT. GENERAL LIABILITY COVERAGE CONTAINS CG 25 03 DESIGNATED CONSTRUCTION GENERAL AGGREGATE LIMIT ENDORSEMENT APPLICABLE TO EACH CONSTRUCTION PROJECT AS REQUIRED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT. COMMERCIAL UMBRELLA FOLLOWS FORM ACCORDING TO THE TERMS, CONDITIONS, AND ENDORSEMENTS FOUND IN THE COMMERCIAL UMBRELLA POLICY. FOR REASONS OTHER THAN NON-PAYMENT OF PREMIUM, 30 DAYS NOTICE WILL BE PROVIDED TO THE CERTIFICATE HOLDER IN THE EVENT THAT THE ISSUING COMPANY CANCELS THE POLICY BEFORE THE EXPIRATION DATE OF THE POLICY. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - BLANKET ENDORSEMENT FOR CONTRACTORS POLLUTION LIABILITY. THE CONTRACTORS POLLUTION LIABILITY COVERAGE CONTAINS A WAIVER OF SUBROGATION IN FAVOR OF THE CERTIFICATE HOLDER SUBJECT TO THE CONDITIONS OF THE WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US. INSURANCE PROVIDED BY THE CONTRACTORS POLLUTION LIABILITY IS PRIMARY AND NONCONTRIBUTORY OVER OTHER INSURANCE. ACORD 101 (2008/01) O 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL AUTO CA 04 49 11 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION 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. A. The following is added to the Other Insurance B. The following is added to the Other Insurance Condition in the Business Auto Coverage Form Condition in the Auto Dealers Coverage Form and and the Other Insurance - Primary And Excess supersedes any provision to the contrary: Insurance Provisions in the Motor Carrier This Coverage Form's Covered Autos Liability Coverage Form and supersedes any provision to Coverage and General Liability Coverages are the contrary: primary to and will not seek contribution from any This Coverage Form's Covered Autos Liability other insurance available to an "insured" under Coverage is primary to and will not seek your policy provided that: contribution from any other insurance available to 1. Such "insured" is a Named Insured under an "insured" under your policy provided that: such other insurance; and 1. Such "insured" is a Named Insured under 2• You have agreed in writing in a contract or such other insurance; and agreement that this insurance would be 2. You have agreed in writing in a contract or primary and would not seek contribution from agreement that this insurance would be any other insurance available to such"insured". primary and would not seek contribution from any other insurance available to such "insured". © Insurance Services Office, Inc., 2016 Page 1 of 1 CA 04 49 11 16 Policy Number: 1833617 Transaction Effective Date: 04/01/2025 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED BY CONTRACT ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. WHO IS AN INSURED for "bodily injury" and "property damage" liability is amended to include: Any person or organization other than a joint venture, for which you have agreed by written contract to procure bodily injury or property damage "auto" liability insurance arising out of operation of a covered "auto" with your permission. However, this additional insurance does not apply to: (1) The owner or anyone else from whom you hire or borrow a covered "auto". This exception does not apply if the covered "auto" is a "trailer" connected to a covered "auto" you own. (2) Your "employee" if the covered "auto" is owned by that "employee" or a member of his or her household. (3) Someone using a covered "auto" while he or she is working in a business of selling, servicing, repairing, parking or storing "autos" unless that business is yours. (4) Anyone other than your "employees", partners (if you are a partnership), members (if you are a limited liability company), or a lessee or borrower or any of their "employees", while moving property to or from a covered "auto". (5) A partner (if you are a partnership), or a member (if you are a limited liability company) for a covered "auto" owned by him or her or a member of his or her household. B. The coverage extended to any additional insured by this endorsement is limited to, and subject to all terms, conditions, and exclusions of the Coverage Part to which this endorsement is attached. In addition, coverage shall not exceed the terms and conditions that are required by the terms of the written agreement to add any insured, or to procure insurance. C. The limits of insurance applicable to such insurance shall be the lesser of the limits required by the agreement between the parties, or the limits provided by this policy. D. Additional exclusions. The insurance afforded to any person or organization as an insured under this endorsement does not apply: 1. To "loss" which occurs prior to the date of your contract with such person or organization; 2. To "loss" arising out of the sole negligence of any person or organization that would not be an insured except for this endorsement. 3. To "loss" for any leased or rented "auto" when the lessor or his or her agent takes possession of the leased or rented "auto" or the policy period ends, whichever occurs first. Includes copyrighted material of Insurance Services Office, Inc. with its permission. CA-F-127 (03-03) Policy Number: 1833617 Transaction Effective Date: 04/01/2025 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. In the event of any payment for a loss under this Business Auto Coverage Part arising out of your ongoing operations, we agree to waive our rights under the TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US condition against any person or organization, its subsidiaries, directors, agents or employees, for which you have agreed by written contract, prior to the occurrence of any loss, to waive such rights, except when the payment results from the sole negligence of that person or organization, its subsidiaries, directors, agents or employees. Includes copyrighted material of Insurance Services Office, Inc. with its permission. CA-F-128 (03-03) Policy Number: 1833617 Transaction Effective Date: 04/01/2025 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 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 LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract Condition and supersedes any provision to the or agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured. 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 © Insurance Services Office, Inc., 2018 Page 1 of 1 CG 20 01 12 19 Policy Number: 9816391 Transaction Effective Date: 04/01/2025 COMMERCIAL GENERAL LIABILITY CG 20 33 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN A WRITTEN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or additional insureds, the following additional organization for whom you are performing exclusions apply: operations when you and such person or This insurance does not apply to: organization have agreed in writing in a contract or agreement that such person or organization be 1. "Bodily injury", "property damage" or added as an additional insured on your policy. "personal and advertising injury" arising out of Such person or organization is an additional the rendering of, or the failure to render, any insured only with respect to liability for "bodily professional architectural, engineering or surveying services, including: injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: a. The preparing, approving, or failing to 1. Your acts or omissions; or prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, 2. The acts or omissions of those acting on your change orders or drawings and behalf; specifications; or in the performance of your ongoing operations for b. Supervisory, inspection, architectural or the additional insured. engineering activities. However, the insurance afforded to such This exclusion applies even if the claims additional insured: against any insured allege negligence or other 1. Only applies to the extent permitted by law; wrongdoing in the supervision, hiring, and employment, training or monitoring of others 2. Will not be broader than that which you are by that insured, if the "occurrence" which required by the contract or agreement to caused the "bodily injury" or "property provide for such additional insured. damage", or the offense which caused the A person's or organization's status as an "personal and advertising injury", involved the additional insured under this endorsement ends rendering of or the failure to render any when your operations for that additional insured professional architectural, engineering or are completed. surveying services. © Insurance Services Office, Inc., 2018 Page 1 of 2 CG 20 33 12 19 Policy Number: 9816391 Transaction Effective Date: 04/01/2025 2. 'Bodily injury" or "property damage" C. With respect to the insurance afforded to these occurring after: additional insureds, the following is added to a. All work, including materials, parts or Section III - Limits Of Insurance: equipment furnished in connection with The most we will pay on behalf of the additional such work, on the project (other than insured is the amount of insurance: service, maintenance or repairs) to be 1. Required by the contract or agreement you performed by or on behalf of the additional have entered into with the additional insured; insured(s) at the location of the covered or operations has been completed; or 2. Available under the applicable limits of b. That portion of "your work" out of which insurance; the injury or damage arises has been put to its intended use by any person or whichever is less. organization other than another contractor This endorsement shall not increase the or subcontractor engaged in performing applicable limits of insurance. operations for a principal as a part of the same project. Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 20 33 12 19 Policy Number: 9816391 Transaction Effective Date: 04/01/2025 COMMERCIAL GENERAL LIABILITY CG24531219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) - AUTOMATIC 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 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. © Insurance Services Office, Inc., 2018 Page 1 of 1 CG 24 53 12 19 Policy Number: 9816391 Transaction Effective Date: 04/01/2025 POLICY NUMBER: 9816391 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Each construction project as required by written contract or written agreement. 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 3. Any payments made under Coverage A for obligated to pay as damages caused by damages or under Coverage C for medical "occurrences" under Section I - Coverage A, and expenses shall reduce the Designated for all medical expenses caused by accidents Construction Project General Aggregate Limit under Section I - Coverage C, which can be for that designated construction project. Such attributed only to ongoing operations at a single payments shall not reduce the General designated construction project shown in the Aggregate Limit shown in the Declarations nor Schedule above: shall they reduce any other Designated 1. A separate Designated Construction Project Construction Project General Aggregate Limit General Aggregate Limit applies to each for any other designated construction project designated construction project, and that limit shown in the Schedule above. is equal to the amount of the General 4. The limits shown in the Declarations for Each Aggregate Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, except General Aggregate Limit shown in the damages because of "bodily injury" or Declarations, such limits will be subject to the "property damage" included in the "products- applicable Designated Construction Project completed operations hazard", and for medical General Aggregate Limit. 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". CG 25 03 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 2 B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by "products-completed operations hazard" is "occurrences" under Section I - Coverage A, and provided, any payments for damages because of for all medical expenses caused by accidents "bodily injury" or "property damage" included in under Section I - Coverage C, which cannot be the "products-completed operations hazard" will attributed only to ongoing operations at a single reduce the Products-completed Operations designated construction project shown in the Aggregate Limit, and not reduce the General Schedule above: Aggregate Limit nor the Designated Construction 1. Any payments made under Coverage A for Project General Aggregate Limit. damages or under Coverage C for medical D. If the applicable designated construction project expenses shall reduce the amount available has been abandoned, delayed, or abandoned and under the General Aggregate Limit or the then restarted, or if the authorized contracting Products-completed Operations Aggregate parties deviate from plans, blueprints, designs, Limit, whichever is applicable; and specifications or timetables, the project will still 2. Such payments shall not reduce any be deemed to be the same construction project. Designated Construction Project General E. The provisions of Section III - Limits Of Insurance Aggregate Limit. not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 © Insurance Services Office, Inc., 2008 CG 25 03 05 09 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement, effective on 04/01/2025 at 12:01 A.M. standard time, forms a part of Policy No. 1835186 Issued to Hukills, Inc. Issued by Federated Reserve Insurance Company Endorsement No. 1 Authorized Representative This endorsement applies only to the insurance provided by the policy because Texas is shown in item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the Schedule. Schedule 1. Specific Waiver Name of person or organization: QX Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be percent of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Advance Premium: Included © Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 42 03 04 B (06-14) Issue Date: 03/27/2025 ADDITIONAL INSURED-BLANKET This endorsement,effective 12:01 a.m.,7/1/2025 forms a part of Policy No.CPLI0027800i issued by Certain Underwriters at Lloyd's,London. THIS ENDORSEMENT CHANGES THE POLICY—PLEASE READ IT CAREFULLY In consideration of the premium charged,the insured and the Company agree to the following Policy change(s): It is hereby understood and agreed that Section III.WHO IS AN INSURED of the above referenced Policy is amended to include the following person(s)or entity(ies): Any person(s)or entity(ies)for ✓hom you are performing operations when you and such Person(s)or entity(ies) have agreed in writing in a contract or agreement that such person(s)or entity(ies)be added as an additional insured on your policy;and any other person(s)or entity(ies)you are required to add as an additional insured under such contract or agreement.Such written:contract or written agreement must have been executed and in effect prior to a LOSS to which this insurance applies. But solely as respects their liability arising out of YOUR WORK performed during the policy period to which this insurance applies.The coverage provided to the additional insureds)listed above does not apply to a CLAIM, DAMAGES or liability arising out of the sole negligence or acts,errors or omissions of the entity(ies)listed above ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED CPL AlBLKT 07 24 1)U C P M Page 1 of 1 PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement,effective 12:01 a.m.,7/1/2025 forms a part of Policy No.CPLI0027800i issued by Certain Underwriters at Lloyd's,London THIS ENDORSEMENT CHANGES THE POLICY—PLEASE READ IT CAREFULLY In consideration of the premium charged,the insured and the Company agree to the following Policy change(s): Section VII.CONDITIONS of the above policy is amended by the following addition to Paragraph N.OTHER INSURANCE: This policy shall be considered primary and non-contributing to any valid and collectible insurance available to third parties in respect to work performed for them by you under any written contractual agreement which requires that you provide primary insurance ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED CPL PNC 06 22 1)U C P M Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement,effective 12:01 a.m.,7/1/2025 forms a part of Policy No.C131100278001 issued by Certain Underwriters at Lloyd's,London THIS ENDORSEMENT CHANGES THE POLICY—PLEASE READ IT CAREFULLY In consideration of the premium charged,the insured and the Company agree to the following Policy changes}; Schedule Name of Person(s)or Organ ization(s): Blanket as required by written contract and/or agreement Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section VII. CONDITIONS of the above policy is amended by the following addition to Paragraph Q.TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US: We waive any right of recovery against the person(s)or organization(s)shown in the above Schedule because of payments we make for injury or damage arising out of your ongoing operations or YOUR WORK done under a written contract with that person or organization and included in the PRODUCTS-COMPETED OPERATIONS HAZARD. This waiver applies only to the person(s)or organization(s)shown in the above Schedule. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED CPL WOS22 10 23 1)U C P M Page 1 of 1