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HomeMy WebLinkAboutInsurance Certificate: DOWL, LLC (2) DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 4/30/2026 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 CONTACT Parker Smith & Feek Insurance LLC PHONE IMA Certificate Team FAX 10400 NE 4th St A/c No EXt: 'C,NO): E-MSuite 900 ADDRESS: certificates@imacorp.com Bellevue WA 98004-5174 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:The Charter Oak Fire Insurance Company 25615 INSURED DOWLLLC-01 INSURERB:The Travelers Indemnity Company 25658 DOWL, LLC 5015 Business Park Blvd, Suite 4000 INsuRERc:Travelers Property Casualty Company of America 25674 Anchorage AK 99503 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570032308 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 EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY Y Y 6305W32478000F26 5/1/2026 5/1/2027 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR PREMISES DAMAGE TO PREMISES Ea occurrence) ccurrence $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y Y 8105W3264352643G 5/1/2026 5/1/2027 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED FIR ER DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident L $ C UMBRELLALIAB X OCCUR Y Y CUP5W3305772543 5/1/2026 5/1/2027 EACH OCCURRENCE $1,000,000 X EXCESS LAB CLAIMS-MADE AGGREGATE $1,000,000 DED X RETENTION$1 n nnn $ A WORKERS COMPENSATION Y UBB37971682643G 5/1/2026 5/1/2027 X PER X OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER WA&WY Stop Gap ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) RE: Project#2072.001304.01, Project Name: IFE City of Ashland Airport Pavmnt Rehab. Certificate Holder and all other parties required by the contract are included as Additional Insured on the General Liability,Automobile Liability and Excess Liability Policies, if required by written contract or agreement,subject to the policy terms and conditions. This Insurance is Primary& Non-Contributory on the General Liability,Automobile Liability and Excess Liability Policies,if required by written contract or agreement,subject to the policy terms and conditions. A Waiver of Subrogation is provided in favor of Certificate Holder and all other parties required by the contract on the General Liability,Automobile Liability, Excess Liability and Workers Compensation Policies, if required by written contract or agreement,subject to the policy terms and conditions. General Liability,Automobile Liability, Excess Liability and Workers Compensation Coverages includes 30 day notice of cancellation,subject to the terms and conditions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Ashland 51 Winburn Way AUTHORIZED REPRESENTATIVE Ashland OR 97520 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - WRITTEN CONTRACTS (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. The following is added to SECTION II — WHO IS plies only to such "bodily injury" or "property AN INSURED: damage" that occurs before the end of the pe- Any person or organization that you agree in a riod of time for which the "written contract re- written contract requiring insurance" to include as quiring insurance" requires you to provide an additional insured on this Coverage Part, but: such coverage or the end of the policy period, whichever is earlier. a. Only with respect to liability for "bodily injury", "property damage" or"personal injury"; and 2. The following is added to Paragraph 4.a. of SEC- TION IV— COMMERCIAL GENERAL LIABILITY b. If, and only to the extent that, the injury or CONDITIONS: damage is caused by acts or omissions of you or your subcontractor in the performance The insurance provided to the additional insured of "your work" to which the "written contract is excess over any valid and collectible "other in- requiring insurance" applies. The person or surance", whether primary, excess, contingent or organization does not qualify as an additional on any other basis, that is available to the addi- insured with respect to the independent acts tional insured for a loss we cover. However, if you or omissions of such person or organization. specifically agree in the "written contract requiring insurance" that this insurance provided to the ad- The insurance provided to such additional insured ditional insured under this Coverage Part must is limited as follows: apply on a primary basis or a primary and non- c. In the event that the Limits of Insurance of contributory basis, this insurance is primary to this Coverage Part shown in the Declarations "other insurance" available to the additional in- exceed the limits of liability required by the sured which covers that person or organization as "written contract requiring insurance", the in- a named insured for such loss, and we will not surance provided to the additional insured share with that "other insurance". But this insur- shall be limited to the limits of liability required ance provided to the additional insured still is ex- by that "written contract requiring insurance". cess over any valid and collectible "other insur- This endorsement shall not increase the limits ance", whether primary, excess, contingent or on of insurance described in Section III — Limits any other basis, that is available to the additional Of Insurance. insured when that person or organization is an d. This insurance does not apply to the render- additional insured under any "other insurance". ing of or failure to render any "professional 3. The following is added to SECTION IV — COM- services" or construction management errors MERCIAL GENERAL LIABILITY CONDITIONS: or omissions. Duties Of An Additional Insured e. This insurance does not apply to "bodily in- As a condition of coverage provided to the addi- jury" or "property damage" caused by "your tional insured: work" and included in the "products- completed operations hazard" unless the a. The additional insured must give us written "written contract requiring insurance" specifi- notice as soon as practicable of an "occur- cally requires you to provide such coverage rence" or an offense which may result in a for that additional insured, and then the insur- claim. To the extent possible, such notice ance provided to the additional insured ap- should include: CG D4 14 04 08 0 2008 The Travelers Companies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY i. How, when and where the 'occurrence" any provider of other insurance which would or offense took place; cover the additional insured for a loss we ii. The names and addresses of any injured cover. However, this condition does not affect persons and witnesses; and whether this insurance provided to the addi- iii. The nature and location of any injury or tional insured is primary to that other insur- damage arising out of the 'occurrence" or ance available to the additional insured which offense. covers that person or organization as a named insured. b. If a claim is made or "suit" is brought against Sec- the additional insured, the additional insured 4. The following is added to the DEFINITIONS Sec- m tion: must: i. Immediately record the specifics of the "Written contract requiring insurance" means that claim or"suit" and the date received; and part of any written contract or agreement under which you are required to include a person or or- ganization as an additional insured on this Cover- The additional insured must see to it that we age Part, provided that the "bodily injury" and receive written notice of the claim or "suit" as "property damage" occurs and the "personal in- soon as practicable. jury" is caused by an offense committed: c. The additional insured must immediately send a. After the signing and execution of the contract us copies of all legal papers received in con- or agreement by you; nection with the claim or"suit", cooperate with b. While that part of the contract or agreement is us in the investigation or settlement of the in effect; and claim or defense against the "suit", and oth- erwise comply with all policy conditions. c. Before the end of the policy period. d. The additional insured must tender the de- fense and indemnity of any claim or "suit" to Page 2 of 2 0 2008 The Travelers Companies, Inc. CG D4 14 04 08 UMBRELLA 2. We have no duty to defend any insured applicable limit of insurance. If we do not against any "suit": pay part of the judgment for any reason a. Seeking damages to which this insurance other than it is more than the applicable does not apply; or limit of insurance, we will not pay any pp y' interest that accrues on that portion of the b. If any other insurer has a duty to defend. judgment. 3. When we have the duty to defend,we may, at With respect to a claim we investigate or our discretion, investigate and settle any claim settle, or "suit" against an insured we defend or "suit". In all other cases, we may, at our under COVERAGE A — EXCESS FOLLOW- discretion, participate in the investigation, FORM LIABILITY, these payments will not defense and settlement of any claim or "suit" reduce the applicable limits of insurance, but for damages to which this insurance may only if the applicable "underlying insurance" apply. If we exercise such right to participate, provides for such payments in addition to its all expenses we incur in doing so will not limits of insurance. With respect to a claim we reduce the applicable limits of insurance. investigate or settle, or "suit" against an 4. Our duty to defend ends when we have used insured we defend under COVERAGE B — up the applicable limit of insurance in the UMBRELLA LIABILITY, these payments will payment of judgments or settlements, or not reduce the applicable limits of insurance. defense expenses if such expenses are within SECTION II—WHO IS AN INSURED the limits of insurance of this policy. A. COVERAGE A — EXCESS FOLLOW-FORM 5. We will pay, with respect to a claim we LIABILITY investigate or settle, or "suit" against an insured we defend: With respect to Coverage A, the following persons a. All expenses we incur. and organizations qualify as insureds: b. The cost of: 1. The Named Insured shown in the Declarations; and (1) Bail bonds required because of accidents or traffic law violations 2. Any other person or organization qualifying as arising out of the use of any vehicle to an insured in the "underlying insurance". If which this insurance applies; or you have agreed to provide insurance for that person or organization in a written contract or (2) Appeal bonds and bonds to release agreement: attachments; a. The limits of insurance afforded to such but only for bond amounts within the person or organization will be: applicable limit of insurance. We do not have to furnish these bonds. (1) The amount by which the minimum limits of insurance you agreed to c. All reasonable expenses incurred by the provide such person or organization insured at our request to assist us in the in that written contract or agreement investigation or defense of such claim or exceed the total limits of insurance of "suit", including actual loss of earnings up all applicable "underlying insurance"; to $1,000 a day because of time off from or work. d. All court costs taxed against the insured (2) The limits of insurance of this policy; in the "suit". However, these payments do whichever is less; and not include attorneys' fees or attorneys' b. Coverage under this policy does not apply expenses taxed against the insured. to such person or organization if the e. Prejudgment interest awarded against the minimum limits of insurance you agreed insured on that part of the judgment we to provide such person or organization in pay. If we make an offer to pay the that written contract or agreement are applicable limit of insurance, we will not wholly within the total limits of insurance pay any prejudgment interest based on of all available applicable "underlying that period of time after the offer. insurance". f. All interest that accrues on the full amount B. COVERAGE B— UMBRELLA LIABILITY of any judgment after entry of the With respect to Coverage B: judgment and before we have paid, offered to pay or deposited in court the 1. The Named Insured shown in the part of the judgment that is within the Declarations is an insured. 2. If you are: Page 4 of 22 ©2016 The Travelers Indemnity Company.All rights reserved. EU 00 01 07 16 Policy #CUP5W3305772643 UMBRELLA b. You have paid all premiums due for this b. To sue us on this insurance unless all of policy at the time you make such request; its terms have been fully complied with. c. You promptly pay the additional premium 2. A person or organization may sue us to we charge for the Extended Reporting recover on an agreed settlement or on a final Period endorsement for this insurance judgment against an insured. We will not be when due. We will determine that liable for damages that: additional premium after we have received your request for the Extended a. Are not payable under the terms of this Reporting Period endorsement for this insurance; or insurance. That additional premium is not b. Are in excess of the applicable limit of subject to any limitation stated in the insurance. "underlying insurance" on the amount or An agreed settlement means a settlement percentage of additional premium that and release of liability signed by us, the may be charged for the "extended insured and the claimant or the claimant's reporting period" in such "underlying legal representative. insurance"; and d. That Extended Reporting L. MAINTENANCE OF UNDERLYING INSURANCE Periodendorsement is issued by us and 1. The insurance afforded by each policy of made a part of this policy. "underlying insurance" will be maintained for 3. Any Extended Reporting Period endorsement the full policy period of this Excess Follow- for this insurance will not reinstate or increase provision does not apply to the reduction or the Limits of Insurance or extend the policy exhaustion of the aggregate limit or limits of period. such "underlying insurance" solely by 4. Except with respect to any provisions to the payments as permitted in Paragraphs 4.a.(1), contrary contained in Paragraphs 1., 2. or 3. (2) and (3) of COVERAGE A — EXCESS above, all provisions of any option to FOLLOW-FORM LIABILITY of SECTION I — purchase an "extended reporting period" COVERAGES. As such policies expire, you granted to you in the "underlying insurance" will renew them at limits and with coverage at apply to this insurance. least equal to the expiring limits of insurance. J. INSPECTIONS AND SURVEYS If you fail to comply with the above requirements, Coverage A is not invalidated. 1. We have the right but are not obligated to: However, in the event of a loss, we will pay a. Make inspections and surveys at any only to the extent that we would have paid had time; you complied with the above requirements. b. Give you reports on the conditions we 2. The first Named Insured shown in the find; and Declarations must give us written notice of c. Recommend changes. any change in the "underlying insurance" as respects: 2. Any inspections, surveys, reports or recommendations relate only to insurability a. Coverage; and the premiums to be charged. We do not b. Limits of insurance; make safety inspections. We do not c. Termination of any coverage; or undertake to perform the duty of any person or organization to provide for the health or d. Exhaustion of aggregate limits. safety of workers or the public. We do not 3. If you are unable to recover from any warrant that conditions: "underlying insurer" because you fail to a. Are safe or healthful; or comply with any term or condition of the b. Comply with laws, regulations, codes or "underlying insurance", Coverage A is not standards. invalidated. However, we will pay for any loss only to the extent that we would have paid had K. LEGAL ACTION AGAINST US you complied with that term or condition in 1. No person or organization has a right under that"underlying insurance". this insurance: M. OTHER INSURANCE a. To join us as a party or otherwise bring us This insurance is excess over any valid and into a "suit" asking for damages from an collectible "other insurance" whether such "other insured; or insurance" is stated to be primary, contributing, Page 14 of 22 ©2016 The Travelers Indemnity Company.All rights reserved. EU 00 01 07 16 UMBRELLA excess, contingent or otherwise. This provision P. PROHIBITED COVERAGE — UNLICENSED does not apply to a policy bought specifically to INSURANCE apply as excess of this insurance. 1. With respect to loss sustained by any insured However, if you specifically agree in a written in a country or jurisdiction in which we are not contract or agreement that the insurance provided licensed to provide this insurance, this to any person or organization that qualifies as an insurance does not apply to the extent that insured under this insurance must apply on a insuring such loss would violate the laws or primary basis, or a primary and non-contributory regulations of such country orjurisdiction. basis, then insurance provided under Coverage A 2. We do not assume responsibility for: is subject to the following provisions: 1. This insurance will apply before any "other a. The payment of any fine, fee, penalty or other charge that may be imposed on any insurance" that is available to such additional person or organization in any country or insured which covers that person or jurisdiction because we are not licensed organization as a named insured, and we will to provide insurance in such country or not share with that "other insurance", provided jurisdiction; or that the injury or damage for which coverage is sought is caused by an "event" that takes b. The furnishing of certificates or other place or is committed subsequent to the evidence of insurance in any country or signing of that contract or agreement by you. jurisdiction in which we are not licensed to 2. This insurance is still excess over any valid provide insurance. and collectible "other insurance", whether Q. PROHIBITED COVERAGE — TRADE OR primary, excess, contingent or otherwise, ECONOMIC SANCTIONS which covers that person or organization as We will provide coverage for any loss, or an additional insured or as any other insured otherwise will provide any benefit, only to the that does not qualify as a named insured. extent that providing such coverage or benefit N. PREMIUM does not expose us or any of our affiliated or parent companies to: 1. The first Named Insured shown in the 1. Any trade or economic sanction under any law Declarations is responsible for the payment of or regulation of the United States of America; all premiums and will be the payee for any return premiums. or 2. If the premium is a flat charge, it is not subject 2. Any other applicable trade or economic to adjustment except as provided in sanction, prohibition or restriction. Paragraph 4. below. R. REPRESENTATIONS 3. If the premium is other than a flat charge, it is By accepting this insurance, you agree: an advance premium only. The earned 1. The statements in the Declarations and any premium will be computed at the end of the subsequent notice relating to "underlying policy period, or at the end of each year of the insurance" are accurate and complete; policy period if the policy period is two years 2. Those statements are based upon or longer, at the rate shown in the representations you made to us; and Declarations, subject to the Minimum Premium. 3. We have issued this insurance in reliance upon 4. Additional premium may become payable your representations. when coverage is provided for additional S. SEPARATION OF INSUREDS insureds under the provisions of SECTION II Except with respect to the Limits of Insurance, —WHO IS AN INSURED. and any rights or duties specifically assigned in O. PREMIUM AUDIT this policy to the first Named Insured shown in the Declarations, this insurance applies: The premium for this policy is the amount stated 1. As if each Named Insured were the only in Item 5. of the Declarations. The premium is a Named Insured; and flat charge unless it is specified in the Declarations as adjustable. 2. Separately to each insured against whom claim is made or"suit" is brought. EU 00 01 07 16 ©2016 The Travelers Indemnity Company.All rights reserved. Page 15 of 22 Policy Number: CUP5W3305772643 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED PERSON OR ORGANIZATION - NOTICE OF CANCELLATION PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice: 30 PERSON OR ORGANIZATION: ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: 1. YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OF THIS POLICY; AND 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS SCHEDULE. ADDRESS: THE ADDRESS FOR THAT PERSON OR ORGANIZ- ATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US. PROVISIONS If we cancel this policy for any legally permitted reason other than nonpayment of premium, and a number of days is shown for Cancellation in the Schedule above. we will mail notice of cancellation to the person or organization shown in such Schedule. We will mail such notice to the address shown to the Schedule above at least the number of days shown for Cancellation in such Schedule before the effective date of cancellation. IL T4 05 05 19 �)2019 The Travelers Indemnity Company All rights reserved Page 1 of 1 Policy #CUP5W3305772643 UMBRELLA b. You have paid all premiums due for this b. To sue us on this insurance unless all of policy at the time you make such request; its terms have been fully complied with. c. You promptly pay the additional premium 2. A person or organization may sue us to we charge for the Extended Reporting recover on an agreed settlement or on a final Period endorsement for this insurance judgment against an insured. We will not be when due. We will determine that liable for damages that: additional premium after we have received your request for the Extended a. Are not payable under the terms of this Reporting Period endorsement for this insurance; or insurance. That additional premium is not b. Are in excess of the applicable limit of subject to any limitation stated in the insurance. "underlying insurance" on the amount or An agreed settlement means a settlement percentage of additional premium that and release of liability signed by us, the may be charged for the "extended insured and the claimant or the claimant's reporting period" in such "underlying legal representative. insurance"; and d. That Extended Reporting L. MAINTENANCE OF UNDERLYING INSURANCE Periodendorsement is issued by us and 1. The insurance afforded by each policy of made a part of this policy. "underlying insurance" will be maintained for 3. Any Extended Reporting Period endorsement the full policy period of this Excess Follow- for this insurance will not reinstate or increase provision does not apply to the reduction or the Limits of Insurance or extend the policy exhaustion of the aggregate limit or limits of period. such "underlying insurance" solely by 4. Except with respect to any provisions to the payments as permitted in Paragraphs 4.a.(1), contrary contained in Paragraphs 1., 2. or 3. (2) and (3) of COVERAGE A — EXCESS above, all provisions of any option to FOLLOW-FORM LIABILITY of SECTION I — purchase an "extended reporting period" COVERAGES. As such policies expire, you granted to you in the "underlying insurance" will renew them at limits and with coverage at apply to this insurance. least equal to the expiring limits of insurance. J. INSPECTIONS AND SURVEYS If you fail to comply with the above requirements, Coverage A is not invalidated. 1. We have the right but are not obligated to: However, in the event of a loss, we will pay a. Make inspections and surveys at any only to the extent that we would have paid had time; you complied with the above requirements. b. Give you reports on the conditions we 2. The first Named Insured shown in the find; and Declarations must give us written notice of c. Recommend changes. any change in the "underlying insurance" as respects: 2. Any inspections, surveys, reports or recommendations relate only to insurability a. Coverage; and the premiums to be charged. We do not b. Limits of insurance; make safety inspections. We do not c. Termination of any coverage; or undertake to perform the duty of any person or organization to provide for the health or d. Exhaustion of aggregate limits. safety of workers or the public. We do not 3. If you are unable to recover from any warrant that conditions: "underlying insurer" because you fail to a. Are safe or healthful; or comply with any term or condition of the b. Comply with laws, regulations, codes or "underlying insurance", Coverage A is not standards. invalidated. However, we will pay for any loss only to the extent that we would have paid had K. LEGAL ACTION AGAINST US you complied with that term or condition in 1. No person or organization has a right under that"underlying insurance". this insurance: M. OTHER INSURANCE a. To join us as a party or otherwise bring us This insurance is excess over any valid and into a "suit" asking for damages from an collectible "other insurance" whether such "other insured; or insurance" is stated to be primary, contributing, Page 14 of 22 ©2016 The Travelers Indemnity Company.All rights reserved. EU 00 01 07 16 UMBRELLA excess, contingent or otherwise. This provision P. PROHIBITED COVERAGE — UNLICENSED does not apply to a policy bought specifically to INSURANCE apply as excess of this insurance. 1. With respect to loss sustained by any insured However, if you specifically agree in a written in a country or jurisdiction in which we are not contract or agreement that the insurance provided licensed to provide this insurance, this to any person or organization that qualifies as an insurance does not apply to the extent that insured under this insurance must apply on a insuring such loss would violate the laws or primary basis, or a primary and non-contributory regulations of such country orjurisdiction. basis, then insurance provided under Coverage A 2. We do not assume responsibility for: is subject to the following provisions: 1. This insurance will apply before any "other a. The payment of any fine, fee, penalty or other charge that may be imposed on any insurance" that is available to such additional person or organization in any country or insured which covers that person or jurisdiction because we are not licensed organization as a named insured, and we will to provide insurance in such country or not share with that "other insurance", provided jurisdiction; or that the injury or damage for which coverage is sought is caused by an "event" that takes b. The furnishing of certificates or other place or is committed subsequent to the evidence of insurance in any country or signing of that contract or agreement by you. jurisdiction in which we are not licensed to 2. This insurance is still excess over any valid provide insurance. and collectible "other insurance", whether Q. PROHIBITED COVERAGE — TRADE OR primary, excess, contingent or otherwise, ECONOMIC SANCTIONS which covers that person or organization as We will provide coverage for any loss, or an additional insured or as any other insured otherwise will provide any benefit, only to the that does not qualify as a named insured. extent that providing such coverage or benefit N. PREMIUM does not expose us or any of our affiliated or parent companies to: 1. The first Named Insured shown in the 1. Any trade or economic sanction under any law Declarations is responsible for the payment of or regulation of the United States of America; all premiums and will be the payee for any return premiums. or 2. If the premium is a flat charge, it is not subject 2. Any other applicable trade or economic to adjustment except as provided in sanction, prohibition or restriction. Paragraph 4. below. R. REPRESENTATIONS 3. If the premium is other than a flat charge, it is By accepting this insurance, you agree: an advance premium only. The earned 1. The statements in the Declarations and any premium will be computed at the end of the subsequent notice relating to "underlying policy period, or at the end of each year of the insurance" are accurate and complete; policy period if the policy period is two years 2. Those statements are based upon or longer, at the rate shown in the representations you made to us; and Declarations, subject to the Minimum Premium. 3. We have issued this insurance in reliance upon 4. Additional premium may become payable your representations. when coverage is provided for additional S. SEPARATION OF INSUREDS insureds under the provisions of SECTION II Except with respect to the Limits of Insurance, —WHO IS AN INSURED. and any rights or duties specifically assigned in O. PREMIUM AUDIT this policy to the first Named Insured shown in the Declarations, this insurance applies: The premium for this policy is the amount stated 1. As if each Named Insured were the only in Item 5. of the Declarations. The premium is a Named Insured; and flat charge unless it is specified in the Declarations as adjustable. 2. Separately to each insured against whom claim is made or"suit" is brought. EU 00 01 07 16 ©2016 The Travelers Indemnity Company.All rights reserved. Page 15 of 22 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. 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 the 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 coverage description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. BROAD FORM NAMED INSURED H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF B. BLANKET ADDITIONAL INSURED USE—INCREASED LIMIT I. PHYSICAL DAMAGE — TRANSPORTATION C. EMPLOYEE HIRED AUTO EXPENSES—INCREASED LIMIT D. EMPLOYEES AS INSURED J. PERSONAL EFFECTS E. SUPPLEMENTARY PAYMENTS — INCREASED K. AIRBAGS LIMITS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR F. HIRED AUTO — LIMITED WORLDWIDE LOSS COVERAGE—INDEMNITY BASIS M. BLANKET WAIVER OF SUBROGATION G.WAIVER OF DEDUCTIBLE—GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS PROVISIONS A. BROAD FORM NAMED INSURED as an additional insured for Liability Coverage, The following is added to Paragraph A.1., Who Is but only for damages to which this insurance An Insured, of SECTION II — LIABILITY applies and only to the extent of that person's or COVERAGE: organization's liability for the conduct of another "insured". Any organization you newly acquire or form during the policy period over which you maintain C. EMPLOYEE HIRED AUTO 50% or more ownership interest and that is not 1. The following is added to Paragraph A.1., separately insured for Business Auto Coverage. Who Is An Insured, of SECTION II — Coverage under this provision is afforded only LIABILITY COVERAGE: until the 180th day after you acquire or form the organization or the end of the policy period, An "employee" of yours is an "insured" while whichever is earlier. operating an "auto" hired or rented under a contract or agreement in that "employee's" B. BLANKET ADDITIONAL INSURED name, with your permission, while performing The following is added to Paragraph c. in A.1., duties related to the conduct of your Who Is An Insured, of SECTION II — LIABILITY business. COVERAGE: 2. The following replaces Paragraph b. in B.5., This includes any person or organization who you Other Insurance, of SECTION IV — are required under a written contract or BUSINESS AUTO CONDITIONS: agreement between you and that person or organization, that is signed by you before the b. For Hired Auto Physical Damage "bodily injury" or "property damage" occurs and Coverage,the following are deemed to be that is in effect during the policy period, to name covered "autos"you own: CA T3 53 08 17 ©2016 The Travelers Indemnity Company.All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc.with its permission COMMERCIAL AUTO territories and possessions, Puerto Rico Personal Effects and Canada. We will pay up to $400 for "loss" to wearing You agree to maintain all required or apparel and other personal effects which are: compulsory insurance in any such (1) Owned by an "insured"; and country up to the minimum limits required by local law. Your failure to comply with (2) In or on your covered"auto". compulsory insurance requirements will This coverage applies only in the event of a total not invalidate the coverage afforded by theft of your covered"auto". this policy, but we will only be liable to the No deductibles apply to this Personal Effects same extent we would have been liable coverage. had you complied with the compulsory insurance requirements. K. AIRBAGS (4) It is understood that we are not an The following is added to Paragraph B.3., admitted or authorized insurer outside the Exclusions, of SECTION III — PHYSICAL United States of America, its territories DAMAGE COVERAGE: and possessions, Puerto Rico and Exclusion 3.a. does not apply to "loss" to one or Canada. We assume no responsibility for more airbags in a covered "auto" you own that the furnishing of certificates of insurance, inflate due to a cause other than a cause of"loss" or for compliance in any way with the set forth in Paragraphs A.1.b. and A.1.c., but laws of other countries relating to only: insurance. G. WAIVER OF DEDUCTIBLE—GLASS a. If that "auto" is a covered "auto" for Comprehensive Coverage under this policy; The following is added to Paragraph D., b. The airbags are not covered under any Deductible, of SECTION III — PHYSICAL warranty; and DAMAGE COVERAGE: No deductible for a covered "auto" will apply to c. The airbags were not intentionally inflated. glass damage if the glass is repaired rather than We will pay up to a maximum of $1,000 for any replaced. one"loss". H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF L. NOTICE AND KNOWLEDGE OF ACCIDENT OR USE—INCREASED LIMIT LOSS The following replaces the last sentence of The following is added to Paragraph A.2.a., of Paragraph AA.b., Loss Of Use Expenses, of SECTION IV—BUSINESS AUTO CONDITIONS: SECTION III — PHYSICAL DAMAGE Your duty to give us or our authorized COVERAGE: representative prompt notice of the "accident" or However, the most we will pay for any expenses "loss" applies only when the"accident" or"loss" is for loss of use is $65 per day, to a maximum of known to: $750 for any one"accident". (a) You (if you are an individual); I. PHYSICAL DAMAGE — TRANSPORTATION (b) A partner(if you are a partnership); EXPENSES—INCREASED LIMIT (c) A member (if you are a limited liability The following replaces the first sentence in company); Paragraph A.4.a., Transportation Expenses, of (d) An executive officer, director or insurance SECTION III — PHYSICAL DAMAGE manager (if you are a corporation or other COVERAGE: organization); or We will pay up to $50 per day to a maximum of (e) Any "employee" authorized by you to give $1,500 for temporary transportation expense notice of the"accident" or"loss". incurred by you because of the total theft of a covered "auto" of the private passenger type. M. BLANKET WAIVER OF SUBROGATION J. PERSONAL EFFECTS The following replaces Paragraph A.5., Transfer The following is added to Paragraph A.4. Of Rights Of Recovery Against Others To Us, , of SECTION IV — BUSINESS AUTO Coverage Extensions, of SECTION III — CONDITIONS: PHYSICAL DAMAGE COVERAGE: CA T3 53 08 17 ©2016 The Travelers Indemnity Company.All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc.with its permission COMMERCIAL AUTO 5. Transfer Of Rights Of Recovery Against N. UNINTENTIONAL ERRORS OR OMISSIONS Others To Us The following is added to Paragraph B.2., We waive any right of recovery we may have Concealment, Misrepresentation, Or Fraud, of against any person or organization to the SECTION IV—BUSINESS AUTO CONDITIONS: extent required of you by a written contract The unintentional omission of, or unintentional signed and executed prior to any "accident" error in, any information given by you shall not or"loss", provided that the"accident" or"loss" prejudice your rights under this insurance. arises out of operations contemplated by However this provision does not affect our right to such contract. The waiver applies only to the collect additional premium or exercise our right of person or organization designated in such cancellation or non-renewal. contract. Page 4 of 4 ©2016 The Travelers Indemnity Company.All rights reserved. CA T3 53 08 17 Includes copyrighted material of Insurance Services Office, Inc.with its permission Policy Number: 8105W3264352643G ISSUE DATE: 05/01/2026 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED PERSON OR ORGANIZATION - NOTICE OF CANCELLATION PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice: 30 PERSON OR ORGANIZATION: ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN, BUT ONLY IF: 1. YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OF THIS POLICY; AND 2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS SCHEDULE. ADDRESS: THE ADDRESS FOR THAT PERSON OR ORGANIZ- ATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US. PROVISIONS If we cancel this policy for any legally permitted reason other than nonpayment of premium, and a number of days is shown for Cancellation in the Schedule above, we will mail notice of cancellation to the person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for Cancellation in such Schedule before the effective date of cancellation. IL T4 05 05 19 O 2019 The Travelers Indemnity Company.All rights reserved. Page 1 of 1 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY WITH OTHER INSURANCE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM PROVISIONS 2. The following is added to Paragraph B.5., Other 1. The following is added to Paragraph A.1.c., Who Insurance of SECTION IV — BUSINESS AUTO Is An Insured, of SECTION II — LIABILITY CONDITIONS: COVERAGE: Regardless of the provisions of paragraph a. and This includes any person or organization who you paragraph d. of this part 5. Other Insurance, this are required under a written contract or insurance is primary to and non-contributory with agreement between you and that person or applicable other insurance under which an organization, that is signed by you before the additional insured person or organization is the "bodily injury" or "property damage" occurs and first named insured when the written contract or that is in effect during the policy period, to name agreement between you and that person or as an additional insured for Liability Coverage, organization, that is signed by you before the but only for damages to which this insurance "bodily injury" or "property damage" occurs and applies and only to the extent of that person's or that is in effect during the policy period, requires organization's liability for the conduct of another this insurance to be primary and non-contributory. "insured". CA T4 74 08 17 ©2016 The Travelers Indemnity Company.All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.with its permission. COMMERCIAL GENERAL LIABILITY occupational therapist or occupational that is available to any of your "employees" therapy assistant, physical therapist or for "bodily injury" that arises out of providing speech-language pathologist; or or failing to provide "incidental medical (b) First aid or "Good Samaritan services" services" to any person to the extent not by any of your"employees" or"volunteer subject to Paragraph 2.a.(1) of Section II — workers", other than an employed or Who Is An Insured. volunteer doctor. Any such "employees" K. MEDICAL PAYMENTS—INCREASED LIMIT or"volunteer workers" providing or failing The following replaces Paragraph 7. of to provide first aid or "Good Samaritan services" during their work hours for you SECTION III—LIMITS OF INSURANCE: will be deemed to be acting within the 7. Subject to Paragraph 5. above, the Medical scope of their employment by you or Expense Limit is the most we will pay under performing duties related to the conduct Coverage C for all medical expenses of your business. because of "bodily injury" sustained by any 3. The following replaces the last sentence of one person, and will be the higher of: Paragraph 5. of SECTION III — LIMITS OF a. $10,000; or INSURANCE: For the purposes of determining the b. The amount shown in the Declarations of applicable Each Occurrence Limit, all related this Coverage Part for Medical Expense acts or omissions committed in providing or Limit. failing to provide "incidental medical L. AMENDMENT OF EXCESS INSURANCE services", first aid or "Good Samaritan CONDITION — PROFESSIONAL LIABILITY services" to any one person will be deemed The following is added to Paragraph 4.b., to be one "occurrence". Excess Insurance, of SECTION IV — 4. The following exclusion is added to COMMERCIAL GENERAL LIABILITY Paragraph 2., Exclusions, of SECTION I — CONDITIONS: COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE This insurance is excess over any of the other LIABILITY: insurance, whether primary, excess, contingent Sale Of Pharmaceuticals or on any other basis, that is Professional Liability or similar coverage, to the extent the "Bodily injury" or "property damage" arising loss is not subject to the professional services out of the violation of a penal statute or exclusion of Coverage A or Coverage B. ordinance relating to the sale of M. BLANKET WAIVER OF SUBROGATION — pharmaceuticals committed by, or with the WHEN REQUIRED BY WRITTEN CONTRACT knowledge or consent of the insured. OR AGREEMENT 5. The following is added to the DEFINITIONS Section: The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, "Incidental medical services" means: of SECTION IV — COMMERCIAL GENERAL a. Medical, surgical, dental, laboratory, x LIABILITY CONDITIONS: ray or nursing service or treatment, If the insured has agreed in a written contract or advice or instruction, or the related agreement to waive that insured's right of furnishing of food or beverages; or recovery against any person or organization, we b. The furnishing or dispensing of drugs or waive our right of recovery against such person medical, dental, or surgical supplies or or organization, but only for payments we make appliances. because of: 6. The following is added to Paragraph 4.b., a. "Bodily injury" or "property damage" that Excess Insurance, of SECTION IV — COMMERCIAL GENERAL LIABILITY occurs; or CONDITIONS: b. "Personal and advertising injury" caused by This insurance is excess over any valid and an offense that is committed; collectible other insurance, whether primary, subsequent to the signing of that contract or excess, contingent or on any other basis, agreement. CG D3 79 02 19 ©2017 The Travelers Indemnity Company.All rights reserved. Page 5 of 6 Includes copyrighted material of Insurance Services Office, Inc.with its permission. POLICY NUMBER: ISSUE DATE: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION OR NONRENEWAL PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice: 60 WHEN WE DO NOT RENEW(Nonrenewal): Number of Days Notice: 60 PROVISIONS B. If we do not renew this policy for any legally A. If we cancel this policy for any legally permitted permitted reason other than nonpayment of reason other than nonpayment of premium, and a premium, and a number of days is shown for number of days is shown for Cancellation in the When We Do Not Renew (Nonrenewal) in the Schedule above, we will mail notice of Schedule above, we will mail notice of cancellation at least the number of days shown nonrenewal at least the number of days shown for for Cancellation in such Schedule before the When We Do Not Renew (Nonrenewal) in such effective date of cancellation. Schedule before the effective date of nonrenewal. IL T3 20 05 19 02019 The Travelers Indemnity Company.All rights reserved. Page 1 of 1 COMMERCIAL GENERAL LIABILITY c. Method Of Sharing a. The statements in the Declarations are If all of the other insurance permits contribution accurate and complete; by equal shares, we will follow this method also. b. Those statements are based upon Under this approach each insurer contributes representations you made to us; and equal amounts until it has paid its applicable c. We have issued this policy in reliance upon limit of insurance or none of the loss remains, your representations. whichever comes first. The unintentional omission of, or unintentional error If any of the other insurance does not permit in, any information provided by you which we relied contribution by equal shares, we will contribute upon in issuing this policy will not prejudice your by limits. Under this method, each insurer's rights under this insurance. However, this provision share is based on the ratio of its applicable limit does not affect our right to collect additional of insurance to the total applicable limits of premium or to exercise our rights of cancellation or insurance of all insurers. nonrenewal in accordance with applicable insurance d. Primary And Non-Contributory Insurance If laws or regulations. Required By Written Contract 7. Separation Of Insureds If you specifically agree in a written contract or Except with respect to the Limits of Insurance, and agreement that the insurance afforded to an any rights or duties specifically assigned in this insured under this Coverage Part must apply on Coverage Part to the first Named Insured, this a primary basis, or a primary and non- insurance applies: contributory basis, this insurance is primary to a. As if each Named Insured were the only other insurance that is available to such insured Named Insured; and which covers such insured as a named insured, and we will not share with that other insurance, b. Separately to each insured against whom claim provided that: is made or"suit" is brought. (1) The "bodily injury" or"property damage"for 8. Transfer Of Rights Of Recovery Against Others which coverage is sought occurs; and To Us (2) The "personal and advertising injury" for If the insured has rights to recover all or part of any which coverage is sought is caused by an payment we have made under this Coverage Part, offense that is committed; those rights are transferred to us. The insured must do nothing after loss to impair them.At our request, subsequent to the signing of that contract or the insured will bring "suit" or transfer those rights agreement by you. to us and help us enforce them. 5. Premium Audit 9. When We Do Not Renew a. We will compute all premiums for this Coverage If we decide not to renew this Coverage Part, we will Part in accordance with our rules and rates. mail or deliver to the first Named Insured shown in b. Premium shown in this Coverage Part as the Declarations written notice of the nonrenewal advance premium is a deposit premium only.At not less than 30 days before the expiration date. the close of each audit period we will compute If notice is mailed, proof of mailing will be sufficient the earned premium for that period and send notice to the first Named Insured. The due date proof of notice. for audit and retrospective premiums is the date SECTION V—DEFINITIONS shown as the due date on the bill. If the sum of 1. "Advertisement" means a notice that is broadcast or the advance and audit premiums paid for the published to the general public or specific market policy period is greater than the earned segments about your goods, products or services premium, we will return the excess to the first for the purpose of attracting customers or Named Insured. supporters. For the purposes of this definition: c. The first Named Insured must keep records of a. Notices that are published include material the information we need for premium placed on the Internet or on similar electronic computation, and send us copies at such times means of communication; and as we may request. b. Regarding websites, only that part of a website 6. Representations that is about your goods, products or services By accepting this policy, you agree: for the purposes of attracting customers or supporters is considered an advertisement. Page 16 of 21 ©2017 The Travelers Indemnity Company.All rights reserved. CG T1 00 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. TRAVELERS J� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 03 13 (00)- POLICY NUMBER:UBB37971682543G 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: Any Person or Organization for which the Insured has agreed by written contract executed prior to loss to furnish this waiver DESIGNATED ORGANIZATION: DATE OF ISSUE: - - ST ASSIGN. TRAVELERS , WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 99 06 R3 (00) - 001 POLICY NUMBER: UBB37971682543G NOTICE OF CANCELLATION TO DESIGNATED PERSONS OR ORGANIZATIONS The following is added to PART SIX—CONDITIONS : Notice Of Cancellation To Designated Persons Or Organizations If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organiza- tion before the cancellation is to take effect. You are responsible for providing us with the information necessary to accurately complete the Schedule below. If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail,deliver or otherwise notify such designated person or organization of the cancellation. SCHEDULE Name and Address of Designated Persons or Organizations: Number of Days Notice "ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF 30 THIS POLICY WILL BE GIVEN, BUT ONLY IF: 1. YOU SEE TO IT THAT WE RECEIVE A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDING THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION, AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE CANCELLATION OF THIS POLICY; AND 2.WE RECEIVE SUCH A WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN THIS ENDORSEMENT. " "THE ADDRESS FOR THAT PERSON OR ORGANIZATION INCLUDED IN SUCH WRITTEN REQUEST FROM YOU TO US." All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned by DATE OF ISSUE: ST ASSIGN: Page 1 of 1 ©2013 The Travelers Indemnity Company.All rights reserved.