HomeMy WebLinkAboutCAG2020-165 - Amendment - #1 - KPG, P.S. - West Hill Reservoir Landscape Design Services - 12/15/2020KENT
Agreement Routing Form
For Approvals, Signatures and Records Management
This form combines & replaces the Request for Mayor's Signature and Contract Cover Sheet forms.
(Print on pink or cheny colored paper)WasHtNGToN
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Originator:
Nancy Yoshitake for Drew Holcomb
Department:
Public Works
Date Sent:
12t16t20
Date Required
12t21t20
Authorized to Sign:
E Director or Designee E Mayor
Date of Council Approval
N/A
Budget Account Number:
\^/20054
Budget? EYes EINo
Grant? EYes ENo
Type:
c
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Vendor Name:
KPG, P.S.
Category:
Contract
Vendor Number:Sub-Category:
Amendment 1
Project Name: West Hill Reservoir
Project oetails:Extend the time of completion to Decembet 31,2021
Agreement Amount: $0
Srarr Dare: 12115120
Basis for Selection of Contractor:
Termination Date: 12131121
Local Business? E Yes El No*
*lf meets requirements per KCC 3.70.100, please complete "Vendor Purchase-Local Exceptions" form on Cftyspace.
Notice required prior to disclosure?
EYes ENo
Contract Number:
cAG2020-165
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Date Received by city Attorney:Comments:
Date Routed to the Mayor's Office
Date Routed to the City Clerk's Office:
adccwl237l 1 10 Visit Documents.KentwA.gov to obtain copies of all agreements
KENT
WasHrNcroN
AMENDMENT NO. 1
NAME OF CONSULTANT OR VENDOR:KPG. P.S.
CONTRACT NAME & PROJECT NUMBER West Hill Reservoir
ORIGINAL AGREEMENT DATE :June 8, 2O2O
This Amendment is made between the City and the above-referenced Consultant or
Vendor and amends the original Agreement and all prior Amendments. All other provisions of
the original Agreement or prior Amendments not inconsistent with this Amendment shall remain
in full force and effect. For valuable consideration and by mutual consent of the parties,
Consultant or Vendor's work is modified as follows:
1. Section I of the Agreement, entitled "Description of Work," is hereby modified to
add additional work or revise existing work as follows:
In addition to work required under the original Agreement and any
prior Amendments, the Consultant or Vendor shall:
No change to the scope of work, however an amendment is
needed to extend the time of completion to December 3Lr 2O2L
due to the project will not be completed by the time of contract
completion.
2. The contract amount and time for performance provisions of Section II "Time of
Completion," and Section III, "Compensation," are modified as follows:
Original Contract Sum,
includ ing a ppl icable WSST
$27,014
Net Change by Previous Amendments
includ ing applicable WSST
$o
Current Contract Amount
including all previous amendments
$27,014
Current Amendment Sum $o
Applicable WSST Tax on this
Amendment
$o
Revised Contract Sum $27,014
AMENDMENT-1OF2
Original Time for Completion
(insert date)
t2t3u20
Revised Time for Completion under
prior Amendments
(insert date)
nla
Add'l Days Required (+) for this
Amendment
365 calendar days
Revised Time for Completion
(insert date)
t2t3u2l
The Consultant or Vendor accepts all requirements of this Amendment by signing below,
by its signature waives any protest or claim it may have regarding this Amendment, and
acknowledges and accepts that this Amendment constitutes full payment and final settlement of
all claims of any kind or nature arising from or connected with any work either covered or
affected by this Amendment, including, without limitation, claims related to contract time,
contract acceleration, onsite or home office overhead, or lost profits. This Amendment, unless
otherwise provided, does not relieve the Consultant or Vendor from strict compliance with the
guarantee and warranty provisions of the original Agreement.
All acts consistent with the authority of the Agreement, previous Amendments (if any),
and this Amendment, prior to the effective date of this Amendment, are hereby ratified and
affirmed, and the terms of the Agreement, previous Amendments (if any), and this Amendment
shall be deemed to have applied.
The parties whose names appear below swear under penalty of perjury that they are
authorized to enter into this Amendment, which is binding on the parties of this contract,
IN WITNESS, the pafties below have executed this Amendment, which will
become effective on the last date written below.
coNSULTANT/VENDOR:
By Etrztube+{o Qtbwn
(signature)
Pfint Namg. Elizabeth Gibson, PLA
115 Urban Design Manager
(title)
DATE: 12t14t20
crw KENT:
By:
Print Name:
Its
DATE:
ATTEST:
U* &^roda
Kent City Clerk
APPROVED AS TO FORM:
(applicable if Mayor's signature required)
Kent Law Department
KPG - W Hlll Reseruolr Amd l/Holcomb
AMENDMENT-2OF2
Clienf#: 1487397 KPGPSACORD* CERTIFIGATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
6t03t2020
THIS CERTIFIGATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE OOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTTUTE A CONTRACT BETWEEN THE rSSUtNc TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
lf SUBROGATION lS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsemenl. A statement on
this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
USI lnsurance Services NW PR
601 Union Street, Suite 1000
Seattle, WA 98101
fiRtll" Tracy Miyake
206 441-6300
r.com
610-362-8530
INSURER(S) AFFORDING COVERAGE NAIC #
tNsuRER A: Travelers lndemnity Go of America 25666
INSURED
KPG, P.S. fka KPG, lnc.
3131 Elliott Avenue, Suite 400
Seattle, WA 98121
tNsuRER s. Berkley lnsurance Company 32603
;NSuRER c . Charter Oak Fire lnsurance Company 25615
INSURER D;
INSURER E
INSTJRER F:
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD
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.
LTR TYPE OF INSURANCE NSp POLICY NUMBER
6809M677855
LIMITS
A X COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
"or,.r i i* !$oi
OTHER:
LOC
x
X x
X
011O112020 0110112021 EACH OCCURRENCE $ 1,000,000
91,000,oqq
$5.000
DAMAGE TO RENTED
eBEllEEs (Ea ocscrelq9)
MED EXP (Anv one person)
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE s2,000,000
PRODUCTS - COMP/OP AGG s2,000,000
$
c AUTOMOBILE LIABIL'TY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON.OWNED
AUTOS ONLYX
x 8A9M680558
cuP9M682435
)1lo'v2020 olto'U2021
0'110112021
s1.000.000
BODILY INJURY (Per person)$
BODILY INJURY (Per accident)$
$
$
A x UMBRELLA LIAB
EXCESS LIAB
x OCCUR
CLAIMS-MADE
x x 0110112020 EACH OCCURRENCE $1.000.000
AGGREGATE $1.000.000
DFN x nprrurrom *1 0-000 $
A WORKERS COMPENSATION
AND EMPLOYERS'LrABrLtTy YrNANYPROPRIETOFyPARTNEFyEXECUTIVE I
OFFICERYMEMBER EXCLUDED? N
(Mandatory in NH)
lf yes, describe under
DESCRIPTION OF OPFRATIoNS hclow
NIA
x 6809M677855
(WA Stop Gap)
0'U0112020 01t01t2021 PERQIATI ITE x OTH.rD
E.L. EACH ACCIDENT $1.000.000
E,L. DISEASE - EA EMPLOYEE $1.000.000
E,L. DISEASE. POLICY LIMIT s1.000.000
B Professional
Liability
lncl: Pollution
x AEC903396102 0110112020 01t01t2021 $2,000,000 per claim
$2,000,000 annl aggr
DESCRIPTION OF OPERATIONS / LOCATIONS MHICLES (ACORD 101, Additional Remarks Schedule, may bo aftached if more space is required)
RE: KPG PN 20052 - West Hill Reservoir Landscaping.
The General Liability and Automobile Liability policies include an automatic Additional lnsured endorsement
that provides Additional Insured status to City of Kent, only when there is a written contract that
requires such status, and only with regard to work performed on behalf of the named insured. The General
Liability policy includes Separation of lnsureds Provision. The General Liability ineludes per project
(See Attached Descriptions)
CERTIFICATE
AcoRD 25 (2016103) 1 ot 2
#s289 4827 0 I M27 627',t 1 I
@ 1988-2015 ACORD CORPORATION. All rights reserved.
The AGORD name and logo are registered marks of ACORD
PXPZP
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE wlTH THE POLICY PROVISIONS,
Gity of Kent
Aftn: Nancy Yosh
220 Fourth Avenue South
Kent, WA 98032
Q.*a, ltr*,-
AUTHORIZED REPRESENIATIVE
DESCRIPTIONS (Continued from Page 1)
aggregate limits. The General Liability and Automobile Liability policies include an endorsement providing
that 30 days notice of cancellation will be given to the Certificate Holder by the lnsurance Carrier.
SAGITTA 25.3 (2016103) 2 ot 2
#s289482701M27627119
Berkley lnsurance Gompany Page 1 of 1
Notice of Gancellation to Certificate Holder(s) Endorsement
ln consideration of the premium paid for this Policy, it is understood and agreed that Section Vll, Conditions, H. Notice of Cancellation,
is amended by adding the following provision:
ln the event this Policy is to be cancelled by you or by us, we agree to give thirty (30) days prior notice to the certificate
holder(s) with mailing addresses on file with the agent of record.
This provision does not apply if cancellation is due to nonpayment of premiums to us or to a finance company authorized to
cancel this Policy.
Any notification rights provided by this endorsement apply only to active certificate holder{s) who were issued a certificate of
insurance applicable to the Policy Period stated in Declarations, ltem 2^
Failure to provide such notice to the certificate holder(s) will not amend or extend the date the cancellation becomes effective,
nor will it negate cancellation of the policy. Failure to send notice shall impose no liability of any kind upon us or our agents or
representatives.
Whenever prinied in this Endorsement, the boldface type terms shall have the same meanings as indicated in the Policy Form. All other provisions of
the Policy remain unchanged.
lnsured
KPG PS dba KPG, lnc.
Policy Number
AEC-9033961-02
Effective Date of This Endorsement
0110112020
Authorized Representative
3 - 8DP0713130 (07-13)26963-9033961 -721 04 Policy Form: 8DP0417001 (04-17)
This page has been left blank intentionally
Berkley lnsurance Company Page 1 of 1
Amendatory Endorsement - Washington
ln consideration of the premium paid for this Policy, it is understood and agreed that Section Vll. Conditions is amended as follows:
H. Notice of Cancellation and Nonrenewal is deleted and replaced with the following:
H. Notice of Cancellation and Nonrenewal
This Policy may be canceled by the Named Insured identified in the Declarations, by notifying us or our authorized
representaiive in one of the following ways:
1. surrender of the Policy;
2. written notice by mail, fax or email; or
3. verbal notice.
Upon receipt of such notice, we will cancel this Policy effective on the later of:
1. the date on which notice is received or the Policy is surrendered, or
2. the date of cancellation requested by the lnsured.
We will not cancel this Policy except for nonpayment of premium, fraud or material misrepresentation in procuring
this insurance or in relation to any Claim, or changes in law affecting this Policy. lf we cancel this Policy, we will
mail or deliver written notice of cancellation to the flrst Named lnsured, as well as any other lnsured, person or
entity endorsed onto the Policy as having an interest in any Claim or Circumstance. The notice will include the
reason for cancellation. We will provide you at least ten (10) days-notice before the effective date of cancellation if
we cancel for nonpayment of premium. lf we cancel for any other reason, we will provide at least sixty (60) days-
notice before the effective date of cancellation.
lf this Policy is canceled, we will send the first Named Insured any premium refund due. The refund will be pro
rata. The cancellation will be effective even if we have not made or offered a refund.
We will give the first Named Insured and any other lnsured endorsed onto the Policy written notice sixty (60) days
prior to the expiration of this Policy if we do not intend to renew this insurance subject to any state requirements.
The notice will include our reason for nonrenewal. Proof of mailing will be sufficient proof of notice.
J. Subrogation is deleted and replaced with the following:
J. Subrogation
ln the event of any payment under this Policy, we shall be subrogated to all of your rights of recovery against any
person or organization. You must do everything reasonably necessary to secure such rights and must do nothing
after a Glaim is made to jeopardize them. We hereby waive our subrogation rights against a client of yours to the
extent that you had, prior to a Claim or Circumstance, entered into a written agreement to waive such rights. Any
recovery shall first be paid to you to the extent of any Damages or Glaim Expenses paid by you and the balance
shall be paid to us. We will be entitled to recovery only after you have been fully compensated for the loss
sustained, including your deductible. Our right of subrogation will not exceed the amount of our payment for
Damages or Claim Expenses.
3.K. First Named lnsured as Sole Agent is deleted and replaced with the following:
K. First Named lnsured as Sole Agent
The first Named lnsured in ltem 1 of the Declarations will be the sole agent and will act on behalf of all lnsureds
for the payment or return of premium, receipt and acceptance of any endorsements, notices or provisions of this
Policy, giving notice of cancellation io us or our authorized representative, the payment of any deductibles, and to
exercise the rights provided in Section Q Extended Reporting Period Option.
Whenever prinled in this Endorsement, the boldface type terms shall have ihe same meanings as indicated in the Policy Form. All other provisions of
the Policy remain unchanged.
2.
lnsured
KPG PS dba KPG, lnc.
Policy Number
AEC-9033961-02
Effective Date of This Endorsement
0110112020
Authorized Representative
4 - 8DP0713257 (07-13)27052-903396 1-72104 Policy Form: 8DP0417001 (04-17)
This page has been left blank intentionally.
Rig
co
5.
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF SUBROGATION
This endorsement modifies insurance provided under the following
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
The required of you by a written contract executed
prior to any "accident" or "loss", provided that the
"accident" or "loss" arises out of the operations
contemplated by such contract. The waiver ap-
plies only to the person or organization desig-
nated in such contract.
O 2015 The Travelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission.
following replaces Paragraph A.5., Transfer of
hts Of Recovery Against Others To Us, of the
NDITIONS Section:
Transfer Of Rights Of Recovery Against Oth-
ers To Us
We waive any right of recovery we may have
against any person or organization to the extent
cAT3 40421s Page 1 of 1
This page has been left blank intentionally.
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLAN KET ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
The following is added to Paragraph c. in A.1., Who
ls An lnsured, of SECTION ll - COVERED AUTOS
LIABILITY COVERAGE in the BUSINESS AUTO
COVERAGE FORM and Paragraph e. in A.1., Who ls
An lnsured, of SEGTION ll - COVERED AUTOS
LIABILITY COVERAGE in the MOTOR CARRIER
COVERAGE FORM, whichever Coverage Form is
part of your policy:
This includes any person or organization who you are
required under a written contract or agreement
between you and that person or organization, that is
signed by you before the "bodily injury" or "property
damage" occurs and that is in effect during the policy
period, to name as an additional insured for Covered
Autos Liability Coverage, but only for damages to
which this insurance applies and only to the extent of
that person's or organization's liability for the conduct
of another "insurgd".
@ 2016 The Travelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
cA T4 37 02 16 Page 1 of 1
This page has been left blank intentionally
COMMERCIAL AUTO
8A9M680558
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
1. The following is added to Paragraph A.1.c., Who
ls An lnsured, of SECTION ll - COVERED
AUTOS LIABILITY COVERAGE:
This includes any person or organization who you
are required under a written contract or
agreement between you and that person or
organization, that is signed by you before the
"bodily injury" or "property damage" occurs and
that is in effect during the policy period, to name
as an additional insured for Covered Autos
Liability Coverage, but only for damages to which
this insurance applies and only to the extent of
that person's or organization's liability for the
conduct of another "insured".
2. The following is added to Paragraph 8.5., Other
Insurance of SECTION lV - BUSINESS AUTO
CONDITIONS:
Regardless of the provisions of paragraph a. and
paragraph d. of this part 5. Other lnsurance, this
insurance is primary 1o and non-contributory with
applicable other insurance under which an
additional insured person or organization is the
first named insured when the written contract or
agreement between you and that person or
organization, that is signed by you before the
"bodily injury" or "property damage" occurs and
that is in effect during the policy period, requires
this insurance to be primary and non-contributory.
@ 2016 The Travelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
cA T4 740216 Page 1 ol 1
This page has been left blank intentionally.
COMMERCIAI AUTO POLICY
ENDORSEMENT - CA T8 04 OL 20
POIICY NI'MBER BA-9M680558-20-GRP
** THIS ENDORSEMENT CHANGES THE POLICY. PI,E.ASE READ IT CAREFULIY. **
NOTICE OF CAI{CELI,ATION
IT IS AGREED THAT
THIS ENDORSE!,IENT CI{AT.IGES THE POLICY.
PLE.ASE REJAD IT CAREEULTY.
DESIGNATED ENTITY - NOTICE OF
CAIICELI.AIION PROVIDED BY US
THIS ENDORSEMENT MODIFIES INSUR,AT.ICE PROVIDED
I'NDER TIIE FOLLOWING:
ALL COVERAGE PARTS INCLUDED IN THIS POLICY
SCHEDULE
CAI{CEI,I,ATION: NUMBER OF DAYS NOTICE OF CN{CEII,ATION: 30
PERSON OR ORGNIIZATION:
ANY PERSON OR ORGAI{IZATION TO !{HOM YOU HA\IE AGREED IN A
IIRITTEN CONTRACT THAT NOTICE OF CA}TCELTATION OE THIS
POLICY WIIL BE GMN, BUT ONLY IF:1. YOU SEND US A WRTTTEN REQUEST TO PROVTDE SUCH NOTTCE,
INCLUDING THE NAI{E A![D ADDRESS OF SUCH PERSON OR
oRGAIIIZATION. AI'TER THE FrRST NNdED INSURED SHOI{N rN TIIE
DECLARIMIONS RECEII/ES NOTICE FROM US OF THE CAI.ICELI"ATION
OF THIS POLICY; AI{D2. WE RECETVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE
THE BEGINNING OF THE APPI.ICABI.E NT'IIBER OF DAYS SHOTVN IN
THIS SCHEDULE.
ADDRESS:
THE ADDRESS FOR THAT PERSON OR ORGAI{IZATION INCLUDED IN
sucH WRTTTEN REQUEST FROM yOU TO US.
PROVISTONS:
A. IF WE CAI{CEL THIS POTICY FOR A}IY STATUTORILY PERMITIED
REASON OTHER TIIN{ NONPAYMENT OF' PREMIUU WE
WILL MAIL NOTICE OF CAIICET],ATION TO THE PERSON OR
ORGANIZATION SHOttN IN THE SCHEDUTE ABOVE. t'[E WILL
IIAIL SUCH NOTICE TO THE ADDRESS SHOWN IN THE SCHEDULE
ABO\IE AT LEASE THE NUMBER OT DAYS SHOWN FOR
CAI{CETI,ATION IN THE SCHEDUTE ABO\TE BEFORE THE
EFFECTI\TE DATE OF CN{CELI.ATION.B. IF IIE DECIDE TO NOT RENEW THIS POLICY FOR Al{Y
S?ATUTORILY PERMITTED RBASON, AlilD A NUDTBER OF DAYSIS SHOI{N FOR NONRENE!{AL IN THE SCITEDULE ABOVE/ WE
WILL MAIL NOTICE OF THE NONRENEWAI TO THE PERSON OR
ORGAIIIZATION SHOMI IN THE SCHEDULE ABOVE. WE I{ILL
MAIL SUCH NOTICE TO TIIE N)DRESS SHOVIN IN THE SCHEDULE
ABOVE AT LEAST THE NT'MBER OF DAYS SHOI{N FOR
NONRENEWAI, IN THE SCHEDULE ABOVE BEFORE
THE EXPIRATION DATE.
EFFECTIVE DATE 01-01-20
PAGE OOO1 DATE OF ISSUE
EXPIR,ATION DATE 01-01-21
L2-3L-L9
Tlris page lras been left blank intcntionally
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS
AND SURVEYORS
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILIry COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE - This endorsement broadens coverage. However, coverage for
any injury, damage or medical expenses described in any of the provisions of this endorsement may be
excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions
do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a
general coverage description only. 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. Non-Owned Watercraft - 75 Feet Long Or Less
B. Who ls An lnsured - Unnamed Subsidiaries
C. Who ls An lnsured - Retired Partners, Members,
Directors And Employees
D. Who ls An lnsured - Employees And Volunteer
Workers - Bodily lnjury To Co-Employees, Co-
Volunteer Workers And Retired Partners,
Members, Directors And Employees
E. Who ls An lnsured - Newly Acquired Or Formed
Limited Liability Companies
F. Blanket Additional lnsured - Controlling lnterest
G. Blanket Additional lnsured Mortgagees,
Assignees, Successors Or Receivers
PROVISIONS
A. NON.OWNED WATERCRAFT 75 FEET
LONG OR LESS
1. The following replaces Paragraph (2) of
Exclusion 9., Aircraft, Auto Or Watercraft,
in Paragraph 2. of SECTION I -
COVERAGES - COVERAGE A - BODILY
INJURY AND PROPERTY DAMAGE
LIABILITY:
(2) A watercraft you do not own that is:
(a) 75 feet long or less; and
(b) Not being used to carry any person
or property for a charge;
2. The following replaces Paragraph 2.e. of
SECTION II- WHO IS AN INSURED:
e. Any person or organization that, with
your express or implied consent, either
H. Blanket Additional lnsured Governmental
Entities - Permits Or Authorizations Relating To
Premises
l. Blanket Additional lnsured Governmental
Entities - Permits Or Authorizations Relating To
Operations
J. lncidental Medical Malpractice
K. Medical Payments - lncreased Limit
L. Amendment Of Excess lnsurance Condition -
Professional Liability
M. Blanket Waiver Of Subrogation * When Required
By Written Contract Or Agreement
N. Contractual Liability - Railroads
uses or is responsible for the use of a
watercraft that you do not own that is:
(1) 75 feet long or less; and
(2) Not being used to carry any person
or property for a charge;
B. WHO IS AN INSURED UNNAMED
SUBSIDIARIES
The following is added to SECTION ll - WHO lS
AN INSURED:
Any of your subsidiaries, other than a partnership
or joint venture, that is not shown as a Named
lnsured in the Declarations is a Named lnsured
if:
a. You are the sole owner of, or maintain an
ownership interest of more than 50% in, such
subsidiary on the first day of the policy
period; and
@ 2017 The Travelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission.
cG D3 79 02 19 Page 1 of 6
COMMERCIAL GENERAL LIABILIry
b. Such subsidiary is not an insured under
similar other insurance.
No such subsidiary is an insured for "bodily
injury" or "property damage" that occurred, or
"personal and advertising injury" caused by an
offense committed:
a. Before you maintained an ownership interest
of more than 50% in such subsidiary; or
b. After the date, if any, during the policy period
that you no longer maintain an ownership
interest of more than 500/o in such subsidiary.
For purposes of Paragraph 1. of Section ll - Who
ls An lnsured, each such subsidiary will be
deemed to be designated in the Declarations as:
a. A limited liability company;
b. An organization other than a partnership,
joint venture or limited liability company; or
c. A trust;
as indicated in its name or the documents that
govern its structure.
C. WHO IS AN INSURED _ RETIRED PARTNERS,
MEMBERS, DIRECTORS AND EMPLOYEES
The following is added to Paragraph 2. of
SECTION II- WHO IS AN INSURED:
Any person who is your retired partner, member,
director or "employee" that is performing services
for you under your direct supervision, but only for
acts within the scope of their employment by you
or while performing duties related to the conduct
of your business. However, no such retired
partner, member, director or "employee" is an
insured for:
(1) "Bodily injury":
(a) To you, to your current partners or
members (if you are a partnership or
joint venture), to your current members
(if you are a limited liability company) or
to your current directors;
(b) To the spouse, child, parent, brother or
sister of that current partner, member or
director as a consequence of Paragraph
(1Xa) above;
(c) For which there is any obligation to
share damages with or repay someone
else who must pay damages because of
the injury described in Paragraph (1Xa)
or (b) above; or
(d) Arising out of his or her providing or
failing to provide professional health care
services,
Unless you are in the business or occupationof providing professional health care
services, Paragraphs (1)(a), (b), (c) and (d)
above do not apply to "bodily injuryr" arising
out of providing or failing to provide first aid
or "Good Samaritan services" by any of your
retired partners, members, directors or
"employees", other than a doctor. Any such
retired partners, members, directors or
"employees" providing or failing to provide
first aid or "Good Samaritan services" during
their work hours for you will be deemed to be
acting within the scope of their employment
by you or performing duties related to the
conduct of your business.
(2) "Personal injury":
(a) To you, to your current or retired
partners or members (if you are a
partnership or joint venture), to your
current or retired members (if you are a
limited liability company), to your other
current or retired directors or
"employees" while in the course of his or
her employment or performing duties
related to the conduct of your business,
or to your other "volunteer workers"
while performing duties related to the
conduct of your business;
(b) To the spouse, child, parent, brother or
sister of that current or retired partner,
member, director, "employee" or
"volunteer worker" as a consequence of
Paragraph (2)(a) above;
(c) For which there is any obligation to
share damages with or repay someone
else who must pay damages because of
the injury described in Paragraph (2)(a)
or (b) above; or
(d) Arising out of his or her providing or
failing to provide professional health care
services.
(3) "Property damage" to property:
(a) Owned, occupied or used by; or
(b) Rented to, in the care, custody or control
of, or over which physical control is
being exercised for any purpose by;
you, any of your retired partners, membersor directors, your current or retired
"employees" or "volunteer workers", any
current partner or member (if you are a
partnership or joint venture), or any current
member (if you are a limited liability
company) or current director.
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Page 2 of 6 cG D3 79 02 19
D. WHO IS AN INSURED _ EMPLOYEES AND
VOLUNTEER WORKERS _ BODILY INJURY
TO CO-EMPLOYEES, CO.VOLUNTEER
WORKERS AND RETIRED PARTNERS,
MEMBERS, DIRECTORS AND EMPLOYEES
The following is added to Paragraph 2.a.(1) of
SECTION II - WHO IS AN INSURED:
Paragraphs (lXa), (b) and (c) above do not
apply to "bodily injury" to a current or retired co-
"employee" while in the course of the co-
"employee's" employment by you or performing
duties related to the conduct of your business, orto "bodily injury" to your other "volunteer
workers" or retired partners, members or
directors while per-forming duties related to the
conduct of your business.
E. WHO rS AN TNSURED - NEWLY ACQUTRED
OR FORMED LIMITED LIABILITY COMPANIES
The following replaces Paragraph 3. of
SECTION II - WHO IS AN INSURED:
3. Any organization you newly acquire or form,
other than a partnership or joint venture, and
of which you are the sole owner or in which
you maintain an ownership interest of more
than 50%, will qualify as a Named lnsured if
there is no other similar insurance available
to that organization. However:
a. Coverage under this provision is
afforded only:
(1) Until the 180th day after you acquire
or form the organization or the end ofthe policy period, whichever is
earlier, if you do not report such
organization in writing to us within
180 days after you acquire or form it;
or
(2) Until the end of the policy period,
when that date is later than 180 days
after you acquire or form such
organization, if you report such
organization in writing to us within
180 days after you acquire or form it;
b. Coverage A does not apply to "bodily
injury" or "property damage" that
occurred before you acquired or formed
the organization; and
c. Coverage B does not apply to "personal
and advertising injury" arising out of an
offense committed before you acquired
or formed the organization.
For the purposes of Paragraph 1. of Sectionll - Who ls An lnsured, each such
COMMERCIAL GENERAL LIABILITY
organization will be deemed to be
designated in the Declarations as:
a. A limited liability company;
b. An organization other than a partnership,
joint venture or limited liability company;
or
c. A trust;
as indicated in its name or the documents
that govern its structure.
F. BLANKET ADDITIONAL INSURED
CONTROLLING INTEREST
1. The following is added to SECTION ll -
WHO IS AN INSURED:
Any person or organization that has financial
control of you is an insured with respect to
liability for "bodily injury", "property damage"
or "personal and advertising injury" that
arises out of:
a. Such financial control; or
b. Such person's or organization's
ownership, maintenance or use of
premises leased to or occupied by you.
The insurance provided to such person or
organization does not apply to structural
alterations, new construction or demolition
operations performed by or on behalf of such
person or organization.
2. The following is added to Paragraph 4. of
SECTIO N II - WHO IS AN INSURED:
This paragraph does not apply to any
premises owner, manager or lessor that has
financial control of you.
G. BLANKET ADDITIONAL INSURED
MORTGAGEES, ASSIGNEES, SUCCESSORS
OR RECEIVERS
The following is added to SECTION ll - WHO lS
AN INSURED:
Any person or organization that is a mortgagee,
assignee, successor or receiver and that you
have agreed in a written contract or agreement
to include as an additional insured on this
Coverage Part is an insured, but only with
respect to its liability as mortgagee, assignee,
successor or receiver for "bodily injury", "property
damage" or "personal and advertising injury"
that:
a. ls "bodily injury" or "property damage" that
occurs, or is "personal and advertising injury"
caused by an offense that is committed,
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cG D3 79 02 19 Page 3 of 6
COMMERCIAL GENERAL LIABILIry
subsequent to the signing of that contract or
agreement; and
b. Arises out of the ownership, maintenance or
use of the premises for which that
mortgagee, assignee, successor or receiver
is required under that contract or agreement
to be included as an additional insured on
this Coverage Part.
The insurance provided to such mortgagee,
assignee, successor or receiver is subject to the
following provisions:
a. The limits of insurance provided to such
mortgagee, assignee, successor or receiver
will be the minimum limits that you agreed to
provide in the written contract or agreement,
or the limits shown in the Declarations,
whichever are less.
b. The insurance provided to such person or
organization does not apply to:
(1) Any "bodily injury" or "property damage"
that occurs, or any "personal and
advertising injury" caused by an offense
that is committed, after such contract or
agreement is no longer in effect; or
(2) Any "bodily injury", "property damage" or
"personal and advertising injury" arising
out of any structural alterations, new
construction or demolition operations
performed by or on behalf of such
mortgagee, assignee, successor or
receiver.
H. BLANKET ADDITIONAL INSURED
GOVERNMENTAL ENTITIES _ PERMITS OR
AUTHORIZATIONS RELATING TO PREMISES
The following is added to SECTION ll - WHO lS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to premises owned
or occupied by, or rented or loaned to, you and
that you are required by any ordinance, law,
building code or written contract or agreement to
include as an additional insured on this
Coverage Part is an insured, but only with
respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
arising out of the existence, ownership, use,
maintenance, repair, construction, erection or
removal of any of the following for which that
governmental entity has issued such permit or
authorization: advertising signs, awnings,
canopies, cellar entrances, coal holes,
driveways, manholes, marquees, hoist away
openings, sidewalk vaults, elevators, street
banners or decorations.
I. BLANKET ADDITIONAL INSURED
GOVERNMENTAL ENTITIES PERMITS
OR AUTHORIZATIONS RELATING TO
OPERATIONS
The following is added to SECTION ll - WHO lS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to operations
performed by you or on your behalf and that you
are required by any ordinance, law, building code
or written contract or agreement to include as an
additional insured on this Coverage Part is an
insured, but only with respect to liability for
"bodily injury", "property damage" or "personal
and advertising injury" arising out of such
operations.
The insurance provided to such governmental
entity does not apply to:
a. Any "bodily injury", "property damage" or
"personal and advertising injury" arising outof operations performed for the
governmental entity; or
b. Any "bodily injury" or "property damage"
included in the "products-completed
operations hazard".
J. INCIDENTAL MEDICAL MALPRACTICE
1. The following replaces Paragraph b. of the
definition of "occurrence" in the
DEFINITIONS Section:
b. An act or omission committed in
providing or failing to provide "incidental
medical services", first aid or "Good
Samaritan seryices" to a person, unless
you are in the business or occupation of
providing professional health care
services.
2. The following replaces the last paragraph of
Paragraph 2.a.(1) of SECTION ll - WHO lS
AN INSURED:
Unless you are in the business or occupationof providing professional health care
services, Paragraphs (1Xa), (b), (c) and (d)
above do not apply to "bodily injury" arising
out of providing or failing to provide:
(a) "lncidental medical services" by any of
your "employees" who is a nurse,
nurse assistant, emergency medical
technician, paramedic, athletic trainer,
audiologist, dietician, nutritionist,
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lncludes copyrighted material of lnsurance Services Office, lnc. with its permission.
Page 4 of 6 cG D3 79 02 19
occupational therapist or occupational
therapy assistant, physical therapist or
speech-language pathologist; or
(b) First aid or "Good Samaritan services"
by any of your "employees" or "volunteer
workers", other than an employed or
volunteer doctor. Any such "employees"
or "volunteer workers" providing or failing
to provide first aid or "Good Samaritan
services" during their work hours for you
will be deemed to be acting within the
scope of their employment by you or
performing duties related to the conduct
of your business.
3. The following replaces the last sentence of
Paragraph 5. of SECTION lll - LIMITS OF
INSURANCE:
For the purposes of determining the
applicable Each Occurrence Limit, all related
acts or omissions committed in providing or
failing to provide "incidental medical
services", first aid or "Good Samaritan
services" to any one person will be deemed
to be one "occurrence".
4. The following exclusion is added to
Paragraph 2., Exclusions, of SECTION I -
COVERAGES - COVERAGE A - BODILY
INJURY AND PROPERTY DAMAGE
LIABILITY:
Sale Of Pharmaceuticals
"Bodily injury" or "property damage" arising
out of the violation of a penal statute or
ordinance relating to the sale of
pharmaceuticals committed by, or with the
knowledge or consent of the insured.
5. The following is added to the DEFINITIONS
Section:
"lncidental medical services" means:
a. Medical, surgical, dental, laboratory, x-
ray or nursing service or treatment,
advice or instruction, or the related
furnishing of food or beverages; or
b. The furnishing or dispensing of drugs or
medical, dental, or surgical supplies or
appliances.
6. The following is added to Paragraph 4.b.,
Excess lnsurance, of SECTION lV
COMMERCIAL GENERAL LIABILITY
CONDITIONS:
This insurance is excess over any valid and
collectible other insurance, whether primary,
excess, contingent or on any other basis,
COMMERCIAL GENERAL LIABILITY
that is available to any of your "employees"
for "bodily injury" that arises out of providing
or failing to provide "incidental medical
seryices" to any person to the extent not
subject to Paragraph 2.a.(1) of Section ll -
Who ls An lnsured.
K. MEDICAL PAYMENTS _ INCREASED LIMIT
The following replaces Paragraph 7. of
SECTION III _ LIMITS OF INSURANCE:
7, Subject to Paragraph 5. above, the Medical
Expense Limit is the most we will pay under
Coverage C for all medical expenses
because of "bodily injury" sustained by any
one person, and will be the higher of:
a. $10,000: or
b. The amount shown in the Declarations of
this Coverage Part for Medical Expense
Limit.
L. AMENDMENT OF EXCESS INSURANCE
CONDITION - PROFESSIONAL LIABILITY
The following is added to Paragraph 4.b.,
Excess Insurance, of SECTION lV
COMMERCIAL GENERAL LIABILIW
CONDITIONS:
This insurance is excess over any of the other
insurance, whether primary, excess, contingent
or on any other basis, that is Professional
Liability or similar coverage, to the extent the
loss is not subject to the professional services
exclusion of Coverage A or Coverage B.
M. BLANKET WAIVER OF SUBROGATION
WHEN REQUIRED BY WRITTEN CONTRACT
OR AGREEMENT
The following is added to Paragraph 8., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV - COMMERCIAL GENERAL
LIABILITY CONDITIONS:
lf the insured has agreed in a written contract or
agreement to waive that insured's right of
recovery against any person or organization, we
waive our right of recovery against such person
or organization, but only for payments we make
because of:
a. "Bodily injury" or "property damage" that
occurs; or
b. "Personal and advertising injury" caused by
an offense that is committed;
subseguent to the signing of that contract or
agreement.
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lncludes copyrighted material of lnsurance Services Office, lnc. with its permission.
cG D3 79 02 19 Page 5 of 6
COMMERCIAL GENERAL LIABILIry
N. CONTRACTUAL LIABILITY. RAILROADS
1. The following replaces Paragraph c. of the
definition of "insured contract" in the
DEFINITIONS Section:
c. Any easement or license agreement;
2. Paragraph f.(1) of the definition of "insured
contract" in the DEFINITIONS Section is
deleted.
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Page 6 of 6 cG D3 79 0219
POLICY NUMBER; 580 - 9M6778s5 -20 -47
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
TOTAL AGGREGATE LIMIT OTHER THAN PROJECTS
AND DESIGNATED PROJECT AND LOCATION
AGGREGATE LIMITS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE - LIMITS OF INSURANCE AND DESIGNATED PROJECTS AND LOCATIONS
LIMITS OF INSURANCE
TotalAggregateLimit $ 8,000,000
(Other Than Projects and Products-Completed Operations)
Designated Location Aggregate Limit $ 2, 000 ' 000
(Other Than Products-Completed Operations)
DesignatedProjectAggregateLimit $ 2,000'000
(Other Than Products-Completed Operations)
General Aggregate Limit $ 2 ' 000, 000
(Other Than Products-Completed Operations)
Designated Projects:
Each I'projec!" for which you have agreed, in a written contracts which
iE in effect during this policy period, !o Provide a seParate General
Aggregate Limit, provided that the conlract ie signed by you before
the ttbodily injury'r or rrproperty da.nagerr occura.
Designated Locations:
A11 Locatsions lieted in lten 3. of the Comnon Policy Declarations or
in any Mast,er Pac Accoun! Exposure EndorEemen! included in this
policy.
PROVISIONS
1. The General Aggregate Limit (Other Than
Products-Completed Operations) shown in the
Declarations is replaced by the Limits of
lnsurance shown in the Schedule - Limits Of
lnsurance And Designated Projects And
Locations.
2. The following replaces Paragraph 1. of SECTION
III - LIMITS OF INSURANCE:
COMMERCIAL GENERAL LIABILITY
ISSUE DATE:L2/3L/2oLg
1. The Limits of lnsurance shown in the
Declarations or the Schedule - Limits Of
Insurance And Designated Projects And
Locations, whichever apply, and the rules
below fix the most we will pay regardless of
the number of:
a. lnsureds;
b. Claims made or "suits" brought;
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lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
cG D4 69 02 19 Page 1 of 3
3
COMMERCIAL GENERAL LIABILIry
c. Persons or organizations making claims
or bringing "suits"; or
d. "Projects" or "locations".
The following replaces Paragraph 2. of SECTION
III - LIMITS OF INSURANCE:
2. a. The Total Aggregate Limit shown in the
Schedule - Limits Of lnsurance And
Designated Projects And Locations is the
most we will pay for the sum of all
amounts under the Designated Location
Aggregate Limit and all amounts under
the General Aggregate Limit. This
includes:
(1) Damages under Coverage A, except
damages because of "bodily injury" or
"property damage" included in
the "products-completed operations
hazard";
(2) Damages under Coverage B; and
(3) Medical expenses under Coverage C.
b. The Designated Project Aggregate Limit
shown in the Schedule Limits Of
lnsurance And Designated Projects And
Locations applies and is further subject to
all of the following provisions:
(1) The Designated Project Aggregate
Limit is the most we will pay for the
sum of:
(a) Damages under Coverage A
because of "bodily injury" and
"property damage" caused by
"occurrences"; and
(b) Medical expenses under
Coverage C for "bodily injury"
caused by accidents;
that can be attributed only to
operations at a single "project".
(2) The Designated Project Aggregate
Limit applies separately to each
"project".
(3) The Designated Project Aggregate
Limit does not apply to damages
because of "bodily injury" or "property
damage" included in the "products-
completed operations hazard".
lnstead, the Products-Completed
Operations Aggregate Limit
described in Paragraph 3. below
applies to such damages.
(4) The Designated Project Aggregate
Limit does not apply to damages
@2017 Thelravelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
under Coverage B. lnstead, the
General Aggregate Limit described in
Paragraph 2.d. below applies to such
damages.
(5) Any payments made for damages or
medical expenses to which the
Designated Project Aggregate Limit
applies will reduce the Designated
Project Aggregate Limit for the
applicable "project". Such payments
will not reduce the Total Aggregate
Limit, the General Aggregate Limit
described in Paragraph 2.d. below,
the Designated Project Aggregate
Limit for any other "project" or the
Designated Location Aggregate Limit,
Subject to the Total Aggregate Limit
described in Paragraph 2.a. above, the
Designated Location Aggregate Limit
shown in the Schedule Limits Of
lnsurance And Designated Projects And
Locations applies and is further subject to
all of the following provisions:
(1) The Designated Location Aggregate
Limit is the most we will pay for the
sum of:
(a) Damages under Coverage A
because of "bodily injury" and
"property damage" caused by
"occurrences"; and
(b) Medical expenses under
Coverage C for "bodily injury"
caused by accidents;
that can be attributed only to
operations at a single "location".
(2) The Designated Location Aggregate
Limit applies separately to each
"location".
(3) The Designated Location Aggregate
Limit does not apply to damages
because of "bodily injury" or "property
damage" included in the "products-
completed operations hazard".
lnstead, the Products-Completed
Operations Aggregate Limit
described in Paragraph 3. below
applies to such damages.
(4) The Designated Location Aggregate
Limit does not apply to damages
under Coverage B. lnstead, the
General Aggregate Limit described in
c
Page 2 of 3 cG D4 69 02 19
Paragraph 2.d. below applies to such
damages.
(5) Any payments made for damages or
medical expenses to which the
Designated Location Aggregate Limit
applies will reduce:
(a) The TotalAggregate Limit; and
(b) The Designated Location
Aggregate Limit for the applicable
"location".
Such payments will not reduce the
General Aggregate Limit described in
Paragraph 2.d. below, the
Designated Project Aggregate Limitor the Designated Location
Aggregate Limit for any other
"location".
d. Subject to the Total Aggregate Limit
described in Paragraph 2.a. above, the
General Aggregate Limit shown in the
Schedule - Limits Of lnsurance And
Designated Projects And Locations
applies and is further subject to all of the
following provisions:
(1) The General Aggregate Limit is the
most we will pay for the sum of:
(a) Damages under Coverage A
because of "bodily injury" and
"property damage" caused by
"occurrences", and medical
expenses under Coverage C for
"bodily injury" caused by
accidents, that cannot be
attributed only to operations at a
single "project" or a single
"location"; and
(b) Damages under Coverage B.
(2) The General Aggregate Limit does
not apply to damages for "bodily
injury" or "property damage" includedin the "products-completed oper-ations hazard". lnstead, the
Products-Completed Operations
Aggregate Limit described in
Paragraph 3. below applies to such
damages.
(3) Any payments made for damages or
medical expenses to which the
COMMERCIAL GENERAL LIABI LITY
General Aggregate Limit applies will
reduce:
(a) The Total Aggregate Limit; and
(b) The GeneralAggregate Limit.
Such payments will not reduce the
Designated Project Aggregate Limit
for any "project" or the Designated
Location Aggregate Limit for any
"location".
4, The following replaces Paragraph 3. of SECTION
III- LIMITS OF INSURANCE:
3. The Products-Completed Operations Aggre-
gate Limit shown in the Declarations is the
most we will pay under Coverage A for
damages because of "bodily injury" or
"property damage" included in the "products-
completed operations hazard". Any payments
made for such damages will not reduce the
TotalAggregate Limit, the General Aggregate
Limit, the Designated Project Aggregate Limit
for any "project" or the Designated Location
Aggregate Limit for any "location".
5. The following is added to the DEFINITIONS
Section:
"Location" means any designated location shown
in the Schedule - Limits Of lnsurance And
Designated Projects and Locations that is owned
by or rented to you. For the purposes of
determining the applicable aggregate limit of
insurance, each "location" that includes a
premises involving the same or connecting lots,
or premises whose connection is interrupted only
by a street, roadway or waterway, or by a right-of-
way of a railroad, will be considered a single
"location",
"Project" means any designated project shown in
the Schedule Limits Of lnsurance And
Designated Projects And Locations that is away
from premises owned by or rented to you and at
which you are performing operations pursuant to
a contract or agreement. For the purposes of
determining the applicable aggregate limit of
insurance, each "project" that includes a premises
involving the same or connecting lots, or
premises whose connection is interrupted only by
a street, roadway or waterway, or by a right-of-
way of a railroad, will be considered a single
"project".
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lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
cG D4 69 02 19 Page 3 of 3
This page has been left blank intentionally.
COMMERCIAL GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Various provisions in this policy restrict coverage. Read
the entire policy carefully to determine rights, duties and
what is and is not covered.
Throughout this policy the words "you" and "your" refer
to the Named lnsured shown in the Declarations, and
any other person or organization qualifying as a Named
lnsured under this policy. The words "we", "us" and
"our" refer to the company providing this insurance.
The word "insured" means any person or organization
qualifying as such under Section ll - Who ls An
lnsured.
Other words and phrases that appear in quotation
marks have special meaning. Refer to Section V -
Definitions.
SECTION I - COVERAGES
COVERAGE A - BODILY INJURY AND PROPERTY
DAMAGE LIABILITY
1. Insuring Agreement
a. We will pay those sums that the insured
becomes legally obligated to pay as damages
because of "bodily injury" or "property damage"
to which this insurance applies. We will have
the right and duty to defend the insured against
any "suit" seeking those damages. However,
we will have no duty to defend the insured
against any "suit" seeking damages for "bodily
injury" or "property damage" to which this
insurance does not apply. We may, at our
discretion, investigate any "occurrence" and
settle any claim or "suit" that may result. But:
(1) The amount we will pay for damages is
limited as described in Section lll - Limits
Of lnsurance; and
(2) Our right and duty to defend end when we
have used up the applicable limit of
insurance in the payment of judgments or
settlements under Coverages A or B or
medical expenses under Coverage C.
No other obligation or liability to pay sums or
perform acts or services is covered unless
explicitly provided for under Supplementary
Payments.
b. This insurance applies to "bodily injury" and
"property damage" only if:
(1) The "bodily injury" or "property damage" is
caused by an "occurrence" that takes place
in the "coverage territory"'
(2) The "bodily injury" or "propefty damage"
occurs during the policy period; and
(3) Prior to the policy period, no insured listed
under Paragraph 1. of Section ll - Who ls
An lnsured and no "employee" authorized
by you to give or receive notice of an
"occurrence" or claim knew that the "bodily
injury" or "property damage" had occurred,
in whole or in part. lf such a listed insured
or authorized "employee" knew, prior to the
policy period, that the "bodily injury" or
"property damage" occurred, then any
continuation, change or resumption of such
"bodily injury" or "property damage" during
or after the policy period will be deemed to
have been known prior to the policy period.
c. "Bodily injury" or "property damage" which
occurs during the policy period and was not,
prior to the policy period, known to have
occurred by any insured listed under Paragraph
1. of Section ll - Who ls An lnsured or any
"employee" authorized by you to give or receive
notice of an "occurrence" or claim, includes any
continuation, change or resumption of that
"bodily injury" or "property damage" after the
end of the policy period.
d, "Bodily injury" or "property damage" will be
deemed to have been known to have occurred
at the earliest time when any insured listed
under Paragraph 1. of Section ll - Who ls An
lnsured or any "employee" authorized by you to
give or receive notice of an "occurrence" or
claim:
(1) Reports all, or any part, of the "bodily
injury" or "property damage" to us or any
other insurer;
(2) Receives a written or verbal demand or
claim for damages because of the "bodily
injury" or "property damage", or
(3) Becomes aware by any other means that
"bodily injury" or "property damage" has
occurred or has begun to occur.
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Includes copyrighted material of lnsurance Services Office, lnc. wlth its permission
cG T1 00 02 19 Page 1 of 21
venture or limited liability company that is not shown as
a Named lnsured in the Declarations. This paragraph
does not apply to any such partnership, joint venture or
limited liability company that otherwise qualifies as an
insured under Section ll - Who ls An lnsured.
SECTION III- LIMITS OF INSURANCE
1. The Limits of lnsurance shown in the Declarations
and the rules below fix the most we will pay
regardless of the number of:
a. lnsureds;
b. Claims made or "suits" brought; or
c. Persons or organizations making claims or
bringing "suits".
2. The General Aggregate Limit is the most we will pay
for the sum of:
a. Medical expenses under Coverage C;
b. Damages under Coverage A, except damages
because of "bodily injury" or "property damage"
included in the "products-completed operations
hazard"; and
c. Damages under Coverage B.
3. The Products-Completed Operations Aggregate
Limit is the most we will pay under Coverage A for
damages because of "bodily injury" and "property
damage" included in the "products-completed
operations hazard".
4. Subject to Paragraph 2. above, the Personal And
Advertising lnjury Limit is the most we will pay
under Coverage B for the sum of all damages
because of all "personal injury" and "advertising
injury" sustained by any one person or organization.
5. Subject to Paragraph 2. or 3. above, whichever
applies, the Each Occurrence Limit is the most we
will pay for the sum of:
a. Damages under Coverage A; and
b. Medical expenses under Coverage C;
because of all "bodily injury" and "property damage"
arising out of any one "occurrence".
For the purposes of determining the applicable
Each Occurrence Limit, all related acts or
omissions committed in providing or failing to
provide first aid or "Good Samaritan services" to
any one person will be deemed to be one
"occurrencg".
6. Subject to Paragraph 5. above, the Damage To
Premises Rented To You Limit is the most we will
pay under Coverage A for damages because of
"premises damage" to any one premises. The
Damage To Premises Rented To You Limit will be:
COMMERCIAL GENERAL LIABILITY
a. The amount shown for the Damage To
Premises Rented To You Limit in the
Declarations of this Coverage Part; or
b. $300,000 if no amount is shown for the
Damage To Premises Rented To You Limit in
the Declarations of this Coverage Part.
7. Subject to Paragraph 5. above, the Medical
Expense Limit is the most we will pay under
Coverage C for all medical expenses because of
"bodily injury" sustained by any one person.
The Limits of lnsurance of this Coverage Part apply
separately to each consecutive annual period and to any
remaining period of less than 12 months, starting with
the beginning of the policy period shown in the
Declarations, unless the policy period is extended after
issuance for an additional period of less than 12
months. ln that case, the additional period will be
deemed part of the last preceding period for purposes of
determining the Limits of lnsurance.
SECTION IV _ COMMERCIAL GENERAL LIABILITY
CONDITIONS
1. Bankruptcy
Bankruptcy or insolvency of the insured or of the
insured's estate will not relieve us of our obligations
under this Coverage Part.
2. Duties ln The Event Of Occurrence, Offense,
Claim Or Suit
a. You must see to it that we are notified as soon
as practicable of an "occurrence" or an offense
which may result in a claim. To the extent
possible, notice should include:
(1) How, when and where the "occurrence" or
offense took place;
(2) The names and addresses of any injured
persons and witnesses; and
(3) The nature and location of any injury or
damage arising out of the "occurrence" or
offense.
b. lf a claim is made or "suit" is brought against
any insured, you must:
(1) lmmediately record the specifics of the
claim or "suit" and the date received; and
(2) Notify us as soon as practicable.
You must see to it that we receive written notice
of the claim or "suit" as soon as practicable.
c. You and any other involved insured must:
(1) lmmediately send us copies of any
demands, notices, summonses or legal
papers received in connection with the
claim or "suit";
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lncludes copyrighted material of lnsurance Services Office, lnc. with its permission.
Page 13 of 21cG T1 00 02 19
COMMERCIAL GENERAL LIABILIry
(2) Authorize us to obtain records and other
information;
(3) Cooperate with us in the investigation or
settlement of the claim or defense against
the "suit"; and
(4) Assist us, upon our request, in the
enforcement of any right against any
person or organization which may be liable
to the insured because of injury or damage
to which this insurance may also apply.
d. No insured will, except at that insured's own
cost, voluntarily make a payment, assume any
obligation, or incur any expense, other than for
first aid, without our consent.
e. The following provisions apply to Paragraph a.
above, but only for purposes of the insurance
provided under this Coverage Part to you or any
insured listed in Paragraph 1. or 2. of Section ll
- Who ls An lnsured:
(1) Notice to us of such "occurrence" or
offense must be given as soon as
practicable only after the "occurrence" or
offense is known to you (if you are an
individual), any of your partners or
members who is an individual (if you are a
partnership or joint venture), any of your
managers who is an individual (if you are a
limited liability company), any of your
"executive officers" or directors (if you are
an organization other than a partnership,
joint venture, or limited liability company),
any of your trustees who is an individual (if
you are a trust) or any "employee" 3.
authorized by you to give notice of an
"occurrence" or offense.
(2) lf you are a partnership, joint venture,
limited liability company or trust, and none
of your partners, joint venture members,
managers or trustees are individuals, notice
to us of such "occurrence" or offense must
be given as soon as practicable only after
the "occurrence" or offense is known by:
(a) Any individualwho is:
(i) A partner or member of any
partnership or joint venture;
(ii) A manager of any limited liability
company;
(iii) An executive officer or director of
any other organization; or
(iv) A trustee of any trust;
that is your partner, joint venture
member, manager or trustee; or
(b) Any employee authorized by such
partnership, joint venture, limited
liability company, trust or other
organization to give notice of an
"occurrence" or offense.
(3) Notice to us of such "occurrence" or
offense will be deemed to be given as soon
as practicable if it is given in good faith as
soon as practicable to your workers'
compensation insurer. This applies only if
you subsequently give notice to us of the
"occurrence" or offense as soon as
practicable after any of the persons
described in Paragraph e.(1) or (2) above
discovers that the "occurrence" or offense
may result in sums to which the insurance
provided under this Coverage Part may
apply.
However, if this policy includes an endorsement
that provides limited coverage for "bodily injury"
or "property damage" or pollution costs arising
out of a discharge, release or escape of
"pollutants" which contains a requirement that
the discharge, release or escape of "pollutants"
must be reported to us within a specific number
of days after its abrupt commencement, this
Paragraph e. does not affect that requirement.
Legal Action Against Us
No person or organization has a right under this
Coverage Part:
a. To join us as a party or otherwise bring us into
a "suit" asking for damages from an insured; or
b. To sue us on this Coverage Part unless all of
its terms have been fully complied with.
A person or organization may sue us to recover on
an agreed settlement or on a finaljudgment against
an insured; but we will not be liable for damages
that are not payable under the terms of this
Coverage Part or that are in excess of the
applicable limit of insurance. An agreed settlement
means a settlement and release of liability signed by
us, the insured, and the claimant or the claimant's
legal representative.
@ 2017 The Travelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission.
Page 14 of 21 cG T1 00 02 19
4. Other Insurance
lf valid and collectible other insurance is available to
the insured for a loss we cover under Coverages A
or B of this Coverage Part, our obligations are
limited as described in Paragraphs a. and b. below.
As used anywhere in this Coverage Part, other
insurance means insurance, or the funding of
losses, that is provided by, through or on behalf of:
(i) Another insurance companyl
(ii) Us or any of our affiliated insurance companies,
except when the Non cumulation of Each
Occurrence Limit provision of Paragraph 5. of
Section lll - Limits Of lnsurance or the Non
cumulation of Personal and Advertising lnjury
Limit provision of Paragraph 4. of Section lll -Limits of lnsurance applies because the
Amendment Non Cumulation Of Each
Occurrence Limit Of Liability And Non
Cumulation Of Personal And Advertising lnjury
Limit endorsement is included in this policy;
(iii) Any risk retention group; or
(iv)Any self-insurance method or program, in
which case the insured will be deemed to be
the provider of other insurance.
Other insurance does not include umbrella
insurance, or excess insurance, that was bought
specifically to apply in excess of the Limits of
lnsurance shown in the Declarations of this
Coverage Part.
As used anywhere in this Coverage Part, other
insurer means a provider of other insurance. As
used in Paragraph c. below, insurer means a
provider of insurance.
a. Primary lnsurance
This insurance is primary except when
Paragraph b. below applies. lf this insurance is
primary, our obligations are not affected unless
any of the other insurance is also primary.
Then, we will share with all that other insurance
by the method described in Paragraph c. below,
except when Paragraph d. below applies.
b. Excess lnsurance
(1) This insurance is excess over:
(a) Any of the other insurance, whether
primary, excess, contingent or on any
other basis:
(i) That is Fire, Extended Coverage,
Builder's Risk, lnstallation Risk or
similar coverage for "your work";
@ 2017 fhe Travelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission.
COMMERCIAL GENERAL LIABI LITY
(ii) That is insurance for "premises
damage";
(iii) lf the loss arises out of the
maintenance or use of aircraft,
"autos" or watercraft to the extent
not subject to any exclusion in this
Coverage Part that applies to
aircraft, "autos" or watercraft;
(iv) That is insurance available to a
premises owner, manager or
lessor that qualifies as an insured
under Paragraph 4. of Section ll -
Who ls An lnsured, except when
Paragraph d. below applies; or
(v) That is insurance available to an
equipment lessor that qualifies as
an insured under Paragraph 5. of
Section ll - Who ls An lnsured,
except when Paragraph d. below
applies.
(b) Any of the other insurance, whether
primary, excess, contingent or on any
other basis, that is available to the
insured when the insured is an
additional insured, or is any other
insured that does not qualify as a
named insured, under such other
insurance.
(2) When this insurance is excess, we will
have no duty under Coverages A or B to
defend the insured against any "suit" if any
other insurer has a duty to defend the
insured against that "suit". lf no other
insurer defends, we will undertake to do so,
but we will be entitled to the insured's rights
against all those other insurers.
(3) When this insurance is excess over other
insurance, we will pay only our share of the
amount of the loss, if any, that exceeds the
sum of:
(a) The total amount that all such other
insurance would pay for the loss in the
absence of this insurance; and
(b) The total of all deductible and self-
insured amounts under all that other
insurance.
(4) We will share the remaining loss, if any,
with any other insurance that is not
described in this Excess lnsurance
provision and was not bought specifically to
apply in excess of the Limits of lnsurance
shown in the Declarations of this Coverage
Part.
cG T1 00 02 19 Page 15 of 21
COMMERCIAL GENERAL LIABILITY
c. Method Of Sharing
lf all of the other insurance permits contribution
by equal shares, we willfollow this method also.
Under this approach each insurer contributes
equal amounts until it has paid its applicable
limit of insurance or none of the loss remains,
whichever comes first.
lf any of the other insurance does not permit
contribution by equal shares, we will contribute
by limits. Under this method, each insurer's
share is based on the ratio of its applicable limit
of insurance to the total applicable limits of
insurance of all insurers.
d. Primary And Non-Contributory lnsurance lf
Required By Written Contract
lf you specifically agree in a written contract or
agreement that the insurance afforded to an
insured under this Coverage Part must apply ona primary basis. or a primary and non-
contributory basis, this insurance is primary to
other insurance that is available to such insured
which covers such insured as a named insured,
and we will not share with that other insurance,
provided that:
(1) The "bodily injury" or "property damage" for
which coverage is sought occurs; and
(2) The "personal and advertising injury" for
which coverage is sought is caused by an
offense that is committed;
subsequent to the signing of that contract or
agreement by you.
5. Premium Audit
a. We will compute all premiums for this Coverage
Part in accordance with our rules and rates.
b. Premium shown in this Coverage Part as
advance premium is a deposit premium only. At
the close of each audit period we will compute
the earned premium for that period and send
notice to the first Named lnsured. The due date
for audit and retrospective premiums is the date
shown as the due date on the bill. lf the sum of
the advance and audit premiums paid for the
policy period is greater than the earned
premium, we will return the excess to the first
Named lnsured.
c. The first Named lnsured must keep records ofthe information we need for premium
computation, and send us copies at such times
as we may request.
6. Representations
By accepting this policy, you agree:
a. The statements in the Declarations are
accurate and complete;
b. Those statements are based upon
representations you made to us; and
c. We have issued this policy in reliance upon
your representations.
The unintentional omission of, or unintentional error
in, any information provided by you which we relied
upon in issuing this policy will not prejudice your
rights under this insurance. However, this provision
does not affect our right to collect additional
premium or to exercise our rights of cancellation or
nonrenewal in accordance with applicable insurance
laws or regulations.
7. Separation Of lnsureds
Except with respect to the Limits of lnsurance, and
any rights or duties specifically assigned in this
Coverage Part to the first Named lnsured, this
insurance applies:
a. As if each Named lnsured were the only
Named lnsured; and
b. Separately to each insured against whom claim
is made or "suit" is brought.
8. Transfer Of Rights Of Recovery Against Others
To Us
lf the insured has rights to recover all or part of any
payment we have made under this Coverage Part,
those rights are transferred to us. The insured must
do nothing after loss to impair them. At our request,
the insured will bring "suit" or transfer those rights
to us and help us enforce them.
9. When We Do Not Renew
lf we decide not to renew this Coverage Part, we will
mail or deliver to the first Named lnsured shown in
the Declarations written notice of the nonrenewal
not less than 30 days before the expiration date.
lf notice is mailed, proof of mailing will be sufficient
proof of notice.
SECTION V - DEFINITIONS
1. "Advertisement" means a notice that is broadcast or
published to the general public or specific market
segments about your goods, products or servicesfor the purpose of attracting customers or
supporters. For the purposes of this definition:
a. Notices that are published include material
placed on the lnternet or on similar electronic
means of communication; and
b. Regarding websites, only that part of a website
that is about your goods, products or services
for the purposes of attracting customers or
supporters is considered an advertisement.
@2017 The Travelers lndemnity Company. All rights reserved.
lncludes copyrighted material of lnsurance Services Office, lnc. with its permission
Page 16 of 21 cG T1 00 02 19
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GENERALPURPOSEENDORSEMENT POLICYNUMBER: 580-eM5778ss-20-47
OFFTCE PAC ISSUE DATE: L2/3L/20T9
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
cGD3 6 1
This endorsement modifies insurance provided under the following:
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
NAMES OF ADDTTTONAL TNSURED PERSON(S) OR ORGANTZATTON(S):
Any person or organization that you agree in a written contract to include as
an additional insured on this Coverage Part, provided that such written
contract was signed by you before,and is in effect when, the "bodily injury"
or "property damage" occurs or the "personal injury" or "advertising injury"
offense is committed.
LOCATION OF COVERED OPERATIONS:
Any project to which a written contract with the Additional lnsured Person(s)
or Organization(s) in the Schedule applies.
(INFORMATION REQUIRED TO COMPLETE THIS SCHEDULE, IF NOT SHOWN ABOVE, WILL BE
sHowN rN THE DECLARATTONS.)
A. SECTION II- WHO IS AN INSURED IS AMENDED TO INCLUDE AS AN ADDITIONAL
INSURED THE PERSON(S) OR ORGANTZATTON(S) SHOWN tN THE SCHEDULE, BUT ONLYW|TH
RESPECT TO LIABILITY FOR "BODILY INJURY", "PROPERTY DAMAGE",PERSONAL INJURY OR
'ADVERTISING INJURY" CAUSED, IN WHOLE OR IN PART, BY:
1. YOUR ACTS OR OMISSIONS; OR
2. THE ACTS OR OMISSIONS OF THOSE ACTING ON YOUR BEHALF;
lN THE PERFORMANCE OF YOUR ONGOING OPERATTONS FOR THE ADDTTTONALTNSURED(S) AT
THE LOCATTON(S) DESTGNATED ABOVE.
B. WITH RESPECT TO THE INSURANCE AFFORDED TO THESE ADDITIONAL INSURED, THE
FOLLOWING ADDITIONAL EXCLUSIONS APPLY:
This insurance does not apply to "bodily injury" or "property damage"
occurring, or "personal injury" or "advertising injury" arising out of an
offense committed, after:
1. ALL WORK, INCLUDING MATERIALS, PARTS OR EQUIPMENT FURNISHED INCONNECTION
wlTH sucH woRK, oN THE PROJECT (OTHER THAN SERVTCE, MATNTENANCEOR REPA|RS) TO
BE PERFORMED BY OR ON BEHALF OF THE ADDTTTONAL TNSURED(S)AT THE LOCATTON OF
THE COVERED OPERATIONS HAS BEEN COMPLETED; OR
2. THAT PORTION OF'YOUR WORK" OUT OF WHICH THE INJURY OR DAMAGE ARISESHAS
cG T8 01 01 20 Page 1- of 2
GENERALPURPOSEENDORSEMENT POLICYNUMBER: 680-eM67?8s5-20-47
OFFICE PAC ISSUE DATE: L2/3L/20I9
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ccD351
This endorsement modifies insurance provided under the following:
BEEN PUT TO ITS INTENDED USE BY ANY PERSON OR ORGANIZATION OTHER THANANOTHER
CONTRACTOR OR SUBCONTRACTOR ENGAGED IN PERFORMING OPERATIONS FOR APRINCIPAL AS
A PART OF THE SAME PROJECT.
cG D3 61 03 05
Copyright 2OO5 The St. Paul Travelers Companies, lnc- All rights reserved
lncludes copyrighted material of lnsurance Services Office, lnc. with its
permission.
cG T8 01 0L 20 Page 2 of 2
GENERAL PURPOSE ENDORSEMENT
OFFICE PAC
POLICY NUMBER: 580-eM57785s -20 -47
ISSUE DATE: 12/3L/20I9
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ce2037
This endorsement modifies insurance provided under the following:
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
NAMES OF ADDTTTONAL TNSURED PERSON(S) OR ORGANTZATTON(S):
Any person or organization that you agree in a written contract to include as
an additional insured on this Coverage Part for "bodily injury" or "property
damage" included in the products-completed operations hazard, provided that
such contract was signed by you before, and is in effect when, the "bodily
injury or "property damage" occurs.
LOCATION AND DESCRIPTION OF COMPLETED OPERATIONS:Any project to which a
written contract with the Additional lnsured Person(s)or Organization(s) in
the Schedule applies.
(TNFORMATION REQUTRED TO COMPLETE TH|S SCHEDULE, tF NOT SHOWN ABOVE, WILL BE
sHowN tN THE DECLARATTONS.)
A. SECTION II - WHO IS AN INSURED IS AMENDED TO INCLUDE AS AN ADDITIONAL
rNsuRED THE PERSON(S) OR ORGANTZATTON(S) SHOWN rN THE SCHEDULE, BUT ONLWVITH
RESPECT TO LIABILITY FOR'BODILY INJURY", "PROPERTY DAMAGE" CAUSED, IN WHOLE
OR IN PART, BY'YOUR WORK'AT THE LOCATION DESIGNATED ANDDESCRIBED IN THE
SCHEDULE OF THIS ENDORSEMENT PERFORMED FOR THATADDITIONAL INSURED AND INCLUDED
IN THE "PRODUCTS-COMPLETED OPERATIONS HMARD".
cG 20 37 07 04
Copyright ISO Properties, lnc- 2OO4
ec 18 02 0t 20 Page 1 of 1
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POLICY NUMBER: cup- eMFB2 43s -20 - 47
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SGHEDULE OF UNDERLYING INSURANCE
This endorsement modifies insurance provided under the following:
EXCESS FOLLOW-FORM AND UMBRELLA LIABILITY INSURANCE
Employere Liability
CaTTieTTHE CHARTER OAK FIRE TNSI'R3I{CE
COMPANY
Policy Number 680 - 00 9M57785s -20
Policy Period
From: aL/oL/2020
to: 07/oL/202L
Connercial- General Liability
Carrier TIIE cHARTER oAK FrRE rNsuRANcE
coMPArirv
Policy Number 580 - 009M57?85s-20
Policy Period
From: 01-l0L/2020
lo: oll0L/202L
Automobile Lj-ability
CarrierTIIE TRAVELERS INDEMNITY
COMPAIiTY
Limits Of Liability
BodiLy Injury By Accident
Each Accident
Bodil-y InJury By Disease
Policy Limit
Bodily Injury By Dieease
Each EmpJ.oyee
Limits Of Liability
General Aggregate
UMBRELLA
ISSUE DATE: L2/32/2oLe
$1, 000, 000
$1, 000, 000
$1,000,000
$2,000,000
ProduetE-Completed
Operations Aggregate $2 , 000, 000
Personal and
Advertieing Injury $1, 000, 000
Each Occurrence $1, ooo, ooo
Limits Of Liability
Bodily Injury And Property $1,000,000
Damage Conbined Single
Liurit
Policy Number BA- 9!d58oss8 - 2 o
Policy Period
From: 0L/0]-/2020
to: 0L/0L/202L
PRODUCER:USI KIBBLE & PRENTICE OFFICE:PLANA& E 2OV
EU 00 03 08 18 @ 2018 The Travelers lndemnity Company, All rights reserved.Page 1 of 1
This page has been left blank intentionally
POLICY NUMBER: cup - 9M082 43s - z0 - 47 ISSUE DATE: L2I3L/20L9
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED ENTITY - NOTICE OF
CANCELLATION/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 of Cancellation: 30
NONRENEWAL: Number of Days Notice of Nonrenewal: 30
PERSON OR
ORGANIZATION:
AI{':T PERSON OR ORGAI{IZATION TO WIIOM YOU
HAVE AGREED IN A WRITTEN CONTRACT THAT
NOTICE OF CANCEIJ''ATTON OR NONRENEWAL OF THIS POLICY
WII.I. BE GIVEN, BIIT ONITY IF:
1. YOU SEND US A WRITTEN REQUEST TO
PROVTDE SUCH NOTICE, INCIJUDING THE
NAITIE A.I{D ADDRESS OF SUCH PERSON OR
ORGN.IIZATION, AFTER THE FIRST NAI.TED
INSURED RECEIVES NOTICE FROM US OF
THE CAI{CETLATION OR NONRENEWAIJ OF THIS POLICY; AtlD
2. WE RECEIVE SUCH WRITTEN REQI'EST AT
IJEAST 14 DAYS BEFORE THE BEGINNING OF
THE APPIJICABLE NI'UBER OF DAYS SHOVIN
IN THIS SCHEDUI,E.
ADDRESS:
THE ADDRESS FOR TIIAT PERSON OR ORGA}TIZ-
ATION INCIJI'DED IN SUCH WRTTTEN REQUEST
FROM YOU TO US.
PROVISIONS:
A. lf we cancel this policy for any statutorily permit-
ted reason other than nonpayment of premium,
and a number of days is shown for cancellation in
the schedule above, we will mail notice of cancel-
lation to the person or organization shown in the
schedule above. We will mail such notice to the
address shown in the schedule above at least the
number of days shown for cancellation in the
schedule above before the effective date of can-
cellation.
B. lf we decide to not renew this policy for any statu-
torily permitted reason, and a number of days is
shown for nonrenewal in the schedule above, we
will mail notice of the nonrenewal to the person or
organization shown in the schedule above. We
will mail such notice to the address shown in the
schedule above at least the number of days
shown for nonrenewal in the schedule above be-
fore the expiration date.
rL T4 00 12 09 @ 2009 The Travelers lndemnity Company Page 1 of 1
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