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HomeMy WebLinkAboutCAG2022-119 - Original - L&S Tire Company - 2022 Recycling Events - 03/31/2022Nancy Yoshitake for Tony Donati Public Works 03/31/2022 04/04/2021 N/A 47005245.64110.7910/7940 N/A L&S Tire Company Contract Other 2022 Recycling Events Provide tire recycling services for the city. Other 11/30/2022 $4,000 Original CAG2022-119 4/1/2022 4/4/2022_________ _____ GOODS & SERVICES AGREEMENT - 1 ($20,000 or Less, incl. WSST) GOODS & SERVICES AGREEMENT between the City of Kent and L&S Tire Company THIS AGREEMENT is made by and between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and L&S Tire Company organized under the laws of the State of Washington, located and doing business at 9215 39th Avenue SW, Lakewood, WA 98499, Phone: (253) 582-5556, Contact: Steffeny Wallace-Jacobs (hereinafter the "Vendor"). AGREEMENT I. DESCRIPTION OF WORK. The Vendor shall provide the following goods and materials and/or perform the following services for the City: The Vendor shall provide tire collection services for two City of Kent 2022 Recycling Events. For a description, see the Vendor's Scope of Work which is attached as Exhibit A and incorporated by this reference. The Vendor acknowledges and understands that it is not the City’s exclusive provider of these goods, materials, or services and that the City maintains its unqualified right to obtain these goods, materials, and services through other sources. II. TIME OF COMPLETION. Upon the effective date of this Agreement, the Vendor shall complete the work and provide all goods, materials, and services by November 30, 2022. III. COMPENSATION. The City shall pay the Vendor an amount not to exceed Four Thousand Dollars ($4,000), including applicable Washington State Sales Tax, for the goods, materials, and services contemplated in this Agreement. The City shall pay the Vendor the following amounts according to the following schedule: Vendor shall be paid per recycling event, after submittal of invoice. Card Payment Program. The Vendor may elect to participate in automated credit card payments provided for by the City and its financial institution. This Program is provided as an alternative to payment GOODS & SERVICES AGREEMENT - 2 ($20,000 or Less, including WSST) by check and is available for the convenience of the Vendor. If the Vendor voluntarily participates in this Program, the Vendor will be solely responsible for any fees imposed by financial institutions or credit card companies. The Vendor shall not charge those fees back to the City. If the City objects to all or any portion of an invoice, it shall notify the Vendor and reserves the option to only pay that portion of the invoice not in dispute. In that event, the parties will immediately make every effort to settle the disputed portion. A. Defective or Unauthorized Work. The City reserves its right to withhold payment from the Vendor for any defective or unauthorized goods, materials or services. If the Vendor is unable, for any reason, to complete any part of this Agreement, the City may obtain the goods, materials or services from other sources, and the Vendor shall be liable to the City for any additional costs incurred by the City. "Additional costs" shall mean all reasonable costs, including legal costs and attorney fees, incurred by the City beyond the maximum Agreement price specified above. The City further reserves its right to deduct these additional costs incurred to complete this Agreement with other sources, from any and all amounts due or to become due the Vendor. B. Final Payment: Waiver of Claims. VENDOR’S ACCEPTANCE OF FINAL PAYMENT SHALL CONSTITUTE A WAIVER OF CLAIMS, EXCEPT THOSE PREVIOUSLY AND PROPERLY MADE AND IDENTIFIED BY VENDOR AS UNSETTLED AT THE TIME REQUEST FOR FINAL PAYMENT IS MADE. IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor- Employer Relationship will be created by this Agreement. By their execution of this Agreement, and in accordance with Ch. 51.08 RCW, the parties make the following representations: A. The Vendor has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. B. The Vendor maintains and pays for its own place of business from which the Vendor’s services under this Agreement will be performed. C. The Vendor has an established and independent business that is eligible for a business deduction for federal income tax purposes that existed before the City retained the Vendor’s services, or the Vendor is engaged in an independently established trade, occupation, profession, or business of the same nature as that involved under this Agreement. D. The Vendor is responsible for filing as they become due all necessary tax documents with appropriate federal and state agencies, including the Internal Revenue Service and the state Department of Revenue. E. The Vendor has registered its business and established an account with the state Department of Revenue and other state agencies as may be required by the Vendor’s business, and has obtained a Unified Business Identifier (UBI) number from the State of Washington. F. The Vendor maintains a set of books dedicated to the expenses and earnings of its business. V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party thirty (30) days written notice at its address set forth on the signature block of this Agreement. VI. CHANGES. The City may issue a written amendment for any change in the goods, materials or services to be provided during the performance of this Agreement. If the Vendor determines, for any reason, that an amendment is necessary, the Vendor must submit a written amendment request GOODS & SERVICES AGREEMENT - 3 ($20,000 or Less, including WSST) to the person listed in the notice provision section of this Agreement, Section XV(D), within fourteen (14) calendar days of the date the Vendor knew or should have known of the facts and events giving rise to the requested change. If the City determines that the change increases or decreases the Vendor's costs or time for performance, the City will make an equitable adjustment. The City will attempt, in good faith, to reach agreement with the Vendor on all equitable adjustments. However, if the parties are unable to agree, the City will determine the equitable adjustment as it deems appropriate. The Vendor shall proceed with the amended work upon receiving either a written amendment from the City or an oral order from the City before actually receiving the written amendment. If the Vendor fails to require an amendment within the time allowed, the Vendor waives its right to make any claim or submit subsequent amendment requests for that portion of the contract work. If the Vendor disagrees with the equitable adjustment, the Vendor must complete the amended work; however, the Vendor may elect to protest the adjustment as provided in subsections A through E of Section VIII, Claims, below. The Vendor accepts all requirements of an amendment by: (1) endorsing it, (2) writing a separate acceptance, or (3) not protesting in the way this section provides. An amendment that is accepted by the Vendor as provided in this section shall constitute full payment and final settlement of all claims for contract time and for direct, indirect and consequential costs, including costs of delays related to any work, either covered or affected by the change. VII. FORCE MAJEURE. Neither party shall be liable to the other for breach due to delay or failure in performance resulting from acts of God, acts of war or of the public enemy, riots, pandemic, fire, flood, or other natural disaster or acts of government (“force majeure event”). Performance that is prevented or delayed due to a force majeure event shall not result in liability to the delayed party. Both parties represent to the other that at the time of signing this Agreement, they are able to perform as required and their performance will not be prevented, hindered, or delayed by the current COVID-19 pandemic, any existing state or national declarations of emergency, or any current social distancing restrictions or personal protective equipment requirements that may be required under federal, state, or local law in response to the current pandemic. If any future performance is prevented or delayed by a force majeure event, the party whose performance is prevented or delayed shall promptly notify the other party of the existence and nature of the force majeure event causing the prevention or delay in performance. Any excuse from liability shall be effective only to the extent and duration of the force majeure event causing the prevention or delay in performance and, provided, that the party prevented or delayed has not caused such event to occur and continues to use diligent, good faith efforts to avoid the effects of such event and to perform the obligation. Notwithstanding other provisions of this section, the Vendor shall not be entitled to, and the City shall not be liable for, the payment of any part of the contract price during a force majeure event, or any costs, losses, expenses, damages, or delay costs incurred by the Vendor due to a force majeure event. Performance that is more costly due to a force majeure event is not included within the scope of this Force Majeure provision. If a force majeure event occurs, the City may direct the Vendor to restart any work or performance that may have ceased, to change the work, or to take other action to secure the work or the project site during the force majeure event. The cost to restart, change, or secure the work or project site arising from a direction by the City under this clause will be dealt with as a change order, except to the extent that the loss or damage has been caused or exacerbated by the failure of the Vendor to fulfill its obligations under this Agreement. Except as expressly contemplated by this section, all other costs will be borne by the Vendor. VIII. CLAIMS. If the Vendor disagrees with anything required by an amendment, another written order, or an oral order from the City, including any direction, instruction, interpretation, or determination by the City, the Vendor may file a claim as provided in this section. The Vendor shall give written notice to the City of all claims within fourteen (14) calendar days of the occurrence of the events giving rise to the claims, or within fourteen (14) calendar days of the date the Vendor knew or should have known of the facts or events giving rise to the claim, whichever occurs first. Any claim for damages, additional payment for any reason, or extension of time, whether under this Agreement or otherwise, shall GOODS & SERVICES AGREEMENT - 4 ($20,000 or Less, including WSST) be conclusively deemed to have been waived by the Vendor unless a timely written claim is made in strict accordance with the applicable provisions of this Agreement. At a minimum, a Vendor's written claim shall include the information set forth in subsections A, items 1 through 5 below. FAILURE TO PROVIDE A COMPLETE, WRITTEN NOTIFICATION OF CLAIM WITHIN THE TIME ALLOWED SHALL BE AN ABSOLUTE WAIVER OF ANY CLAIMS ARISING IN ANY WAY FROM THE FACTS OR EVENTS SURROUNDING THAT CLAIM OR CAUSED BY THAT DELAY. A. Notice of Claim. Provide a signed written notice of claim that provides the following information: 1. The date of the Vendor's claim; 2. The nature and circumstances that caused the claim; 3. The provisions in this Agreement that support the claim; 4. The estimated dollar cost, if any, of the claimed work and how that estimate was determined; and 5. An analysis of the progress schedule showing the schedule change or disruption if the Vendor is asserting a schedule change or disruption. B. Records. The Vendor shall keep complete records of extra costs and time incurred as a result of the asserted events giving rise to the claim. The City shall have access to any of the Vendor's records needed for evaluating the protest. The City will evaluate all claims, provided the procedures in this section are followed. If the City determines that a claim is valid, the City will adjust payment for work or time by an equitable adjustment. No adjustment will be made for an invalid protest. C. Vendor's Duty to Complete Protested Work. In spite of any claim, the Vendor shall proceed promptly to provide the goods, materials and services required by the City under this Agreement. D. Failure to Protest Constitutes Waiver. By not protesting as this section provides, the Vendor also waives any additional entitlement and accepts from the City any written or oral order (including directions, instructions, interpretations, and determination). E. Failure to Follow Procedures Constitutes Waiver. By failing to follow the procedures of this section, the Vendor completely waives any claims for protested work and accepts from the City any written or oral order (including directions, instructions, interpretations, and determination). IX. LIMITATION OF ACTIONS. VENDOR MUST, IN ANY EVENT, FILE ANY LAWSUIT ARISING FROM OR CONNECTED WITH THIS AGREEMENT WITHIN 120 CALENDAR DAYS FROM THE DATE THE CONTRACT WORK IS COMPLETE OR VENDOR’S ABILITY TO FILE THAT SUIT SHALL BE FOREVER BARRED. THIS SECTION FURTHER LIMITS ANY APPLICABLE STATUTORY LIMITATIONS PERIOD. X. WARRANTY. The Vendor warrants that it will faithfully and satisfactorily perform all work provided under this Agreement in accordance with the provisions of this Agreement. In addition to any other warranty provided for at law or herein, this Agreement is additionally subject to all warranty provisions established under the Uniform Commercial Code, Title 62A, Revised Code of Washington. The Vendor warrants goods are merchantable, are fit for the particular purpose for which they were obtained, and will perform in accordance with their specifications and the Vendor’s representations to City. The Vendor shall promptly correct all defects in workmanship and materials: (1) when the Vendor knows or should have known of the defect, or (2) upon the Vendor’s receipt of notification from the City of the existence or discovery of the defect. In the event any part of the goods are repaired, only original replacement parts shall be used—rebuilt or used parts will not be acceptable. When defects are corrected, GOODS & SERVICES AGREEMENT - 5 ($20,000 or Less, including WSST) the warranty for that portion of the work shall extend for an additional year beyond the original warranty period applicable to the overall work. The Vendor shall begin to correct any defects within seven (7) calendar days of its receipt of notice from the City of the defect. If the Vendor does not accomplish the corrections within a reasonable time as determined by the City, the City may complete the corrections and the Vendor shall pay all costs incurred by the City in order to accomplish the correction. XI. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any sub-contract, the Vendor, its sub-contractors, or any person acting on behalf of the Vendor or sub-contractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is qualified and available to perform the work to which the employment relates. The Vendor shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement. XII. INDEMNIFICATION. The Vendor shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or in connection with the Vendor's performance of this Agreement, except for that portion of the injuries and damages caused by the City's negligence. The City's inspection or acceptance of any of the Vendor's work when completed shall not be grounds to avoid any of these covenants of indemnification. IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE VENDOR'S WAIVER OF IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER. In the event the Vendor refuses tender of defense in any suit or any claim, if that tender was made pursuant to this indemnification clause, and if that refusal is subsequently determined by a court having jurisdiction (or other agreed tribunal) to have been a wrongful refusal on the Vendor’s part, then the Vendor shall pay all the City’s costs for defense, including all reasonable expert witness fees and reasonable attorneys’ fees, plus the City’s legal costs and fees incurred because there was a wrongful refusal on the Vendor’s part. The provisions of this section shall survive the expiration or termination of this Agreement. XIII. INSURANCE. The Vendor shall procure and maintain for the duration of the Agreement, insurance of the types and in the amounts described in Exhibit B attached and incorporated by this reference. XIV. WORK PERFORMED AT VENDOR'S RISK. The Vendor shall take all necessary precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be done at the Vendor's own risk, and the Vendor shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. XV. MISCELLANEOUS PROVISIONS. A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its contractors and consultants to use recycled and recyclable products whenever practicable. A price preference may be available for any designated recycled product. B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this GOODS & SERVICES AGREEMENT - 6 ($20,000 or Less, including WSST) Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute, difference or claim arising from the parties’ performance of this Agreement, the exclusive means of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or award provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section XII of this Agreement. D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. E. Assignment. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment, the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent. F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding unless in writing and signed by a duly authorized representative of the City and the Vendor. G. Entire Agreement. The written provisions and terms of this Agreement, together with any Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the City, and such statements shall not be effective or be construed as entering into or forming a part of or altering in any manner this Agreement. All of the above documents are hereby made a part of this Agreement. However, should any language in any of the Exhibits to this Agreement conflict with any language contained in this Agreement, the terms of this Agreement shall prevail. H. Compliance with Laws. The Vendor agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable to the Vendor's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those operations. I. Public Records Act. The Vendor acknowledges that the City is a public agency subject to the Public Records Act codified in Chapter 42.56 of the Revised Code of Washington and documents, notes, emails, and other records prepared or gathered by the Consultant in its performance of this Agreement may be subject to public review and disclosure, even if those records are not produced to or possessed by the City of Kent. As such, the Vendor agrees to cooperate fully with the City in satisfying the City’s duties and obligations under the Public Records Act. J. City Business License Required. Prior to commencing the tasks described in Section I, Contractor agrees to provide proof of a current city of Kent business license pursuant to Chapter 5.01 of the Kent City Code. K. Counterparts and Si natu es by Fax or Email. This Agreement may be executed in any number of counterparts, each of which shall constitute an original, and all of which will together constitute this one Agreement. Further, upon exec iting this Agreement, either party may deliver the signature page to the other by fax or email and that si nature shall have the same force and effect as if the Agreement bearing the original signature was receiv d in person. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. All acts consistent with the authority of this Agreement and prior to its effective date are ratified and affirmed, and the terms of the Agreement shall be deemed to have applied. VENDOR: CITY OF KENT: By: By: Vl Print Name: W a UZAA-Print Name: Michael Mactutis, P.E. Its: Q U Its: Environmental Engineering Manager DATE: 3 P7 DATE: 3/31/22 NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: VENDOR: CITY OF KENT: Steffeny Wallace -Jacobs Chad Bieren, P.E. L&S Tire Company City of Kent 9215 39t" Avenue SW 220 Fourth Avenue South Lakewood, WA 98499 Kent, WA 98032 (253) 582-5556 (telephone) (253) 856-5500 (telephone) (253) 588-0809 (facsimile) (253) 856-6500 (facsimile) ATTEST: ff i�.�r ■ ��l.rr[� -. L&5 - Recycling Events 4/0onatl GOODS & SERVICES AGREEMENT - 7 ($20,000 or Less, including WSST) DECLARATION CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically i contractor, subcontractor or supplie response is required on all of the foil If any contractor, subcontractor or si directives outlines, it will be consid determination regarding suspension The questions are as follows: 1. I have read the attached City entify the requirements the City deems necessary for any on this specific Agreement to adhere to. An affirmative ►wing questions for this Agreement to be valid and binding. pplier willfully misrepresents themselves with regard to the red a breach of contract and it will be at the City's sole r termination for all or part of the Agreement; Kent administrative policy number 1.2. 2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability. 3. During the time of this Agreement the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 4. During the time of the Agreement I, the prime contractor, will actively consider hiring and promotion of women and minorities. 5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above. By signing below, I agree to fulfill th� five requirements referenced above. 410 �. 1l � Date: 3 EEO COMPLIANCE DOCUMENTS - 1 of 3 K. Counterparts and Si natures by Fax or Email. This Agreement may be executed in any number of counterparts, each of which shall constitute an original, and all of which will together constitute this one Agreement. Further, upon exec iting this Agreement, either party may deliver the signature page to the other by fax or email and that si nature shall have the same force and effect as if the Agreement bearing the original signature was received in person. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. All acts consistent with the authority of this Agreement and prior to its effective date are ratified and affirmed, and the terms of the Agreement shall be deemed to have applied. VENDOR: By: Print Name Its: M6 DATE: 31I71M NOTICES TO BE SENT TO. VENDOR: Steffeny Wallace -Jacobs L&S Tire Company 9215 39Yf1 Avenue SW Lakewood, WA 98499 (253) 582-5556 (telephone) (253) 588-0809 (facsimile) L&5 - Recycling Events 4/1)onatl CITY OF KENT: By: Print Name: Michael Mactutis, P.E. Its: Environmental Engineering Manager DATE: NOTICES TO BE SENT TO: CITY OF KENT: Chad Bieren, P.E. City of Kent 220 Fourth Avenue South Kent, WA 98032 (253) 856-5500 (telephone) (253) 856-6500 (facsimile) ATTEST: Kent Citv Clerk GOODS & SERVICES AGREEMENT - 7 ($20,000 or Less, including WSST) EEO COMPLIANCE DOCUMENTS - 2 of 3 CITY OF KENT ADMINISTRATIVE POLICY NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998 SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996 CONTRACTORS APPROVED BY Jim White, Mayor POLICY: Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding Agreements with the City amounting to $10,000 or more within any given year, must take the following affirmative steps: 1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 2. Actively consider for promotion and advancement available minorities and women. Any contractor, subcontractor, consultant or supplier who willfully disregards the City’s nondiscrimination and equal opportunity requirements shall be considered in breach of contract and subject to suspension or termination for all or part of the Agreement. Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments. 1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City’s equal employment opportunity policy. 2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines. EEO COMPLIANCE DOCUMENTS - 3 of 3 CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. I, the undersigned, a duly represented agent of Company, hereby acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement known as that was entered into on the (date), between the firm I represent and the City of Kent. I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. By: ___________________________________________ For: __________________________________________ Title: _________________________________________ Date: _________________________________________ EXHIBIT A EXHIBIT B INSURANCE REQUIREMENTS FORSERVICE CONTRACTS Insurance The Contractor shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Contractor, their agents, representatives, employees or subcontractors. A. Minimum Scope of Insurance Contractor shall obtain insurance of the types described below: 1. Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01 and shall cover liability arising from premises, operations, independent contractors, products-completed operations, personal injury and advertising injury, and liability assumed under an insured contract. The City shall be named as an insured under the Contractor’s Commercial General Liability insurance policy with respect to the work performed for the City using ISO additional insured endorsement CG 20 10 11 85 or a substitute endorsement providing equivalent coverage. 2. Automobile Liability insurance covering all owned, non-owned, hired and leased vehicles. Coverage shall be written on Insurance Services Office (ISO) form CA 00 01 or a substitute form providing equivalent liability coverage. If necessary, the policy shall be endorsed to provide contractual liability coverage. 3. Workers’ Compensation coverage as required by the Industrial Insurance laws of the State of Washington. B. Minimum Amounts of Insurance Contractor shall maintain the following insurance limits: 1.Commercial General Liability insurance shall be written with limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate and a $2,000,000 products-completed operations aggregate limit. 2. Automobile Liability insurance with a minimum combined single limit for bodily injury and property damage of $1,000,000 per accident. EXHIBIT B (Continued) C. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions for Automobile Liability and Commercial General Liability insurance: 1. The Contractor’s insurance coverage shall be primary insurance as respect the City. Any Insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Contractor’s insurance and shall not contribute with it. 2. The Contractor’s insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. 3. The City of Kent shall be named as an additional insured on all policies (except Professional Liability) as respects work performed by or on behalf of the contractor and a copy of the endorsement naming the City as additional insured shall be attached to the Certificate of Insurance. The City reserves the right to receive a certified copy of all required insurance policies. The Contractor’s Commercial General Liability insurance shall also contain a clause stating that coverage shall apply separately to each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer’s liability. D. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best rating of not less than A:VII. E. Verification of Coverage Contractor shall furnish the City with original certificates and a copy of the amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Contractor before commencement of the work. F. Subcontractors Contractor shall include all subcontractors as insureds under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the same insurance requirements as stated herein for the Contractor. L&STIRE-01 A� c� CERTIFICATE OF LIABILITY INSURANCE 1 DATE 12/4/20221 I 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 rgahts to the certificate holder in lieu of such endorsement(s). PRODUCER X ' Spokane Office PHONE o Ex . (509) 838-3501 ,No 8fi6) 226-3738 alPnewest Insurance, a Marsh McLennan Agency LLC Company 5N. Rlverp�int Blvd., Ste 403 - Splakane, WA 99202 INS AFFORDING COVERAGE NAIC # INSURER A; Western National Assurance Company 24465 INSURED INSURERB:Western National Mutual Insurance Co 15377 L & S Tire Company INSURERC: 8119 N. Regal, Bldg 5 INSURERD: Spokane, WA 99217 INSURER E INSURER F : rnVxRAfZr__q f`FRTIFIrATK NIIMRFW RFVIRlinM NIIMRFR- 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 ADM SUER POLICY NUMBER POLICY EFF POi.SCY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �X OCCUR X CPP 0013699 19 12/8/2021 12/8/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 100,000 MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PIDLICY F] jpa- LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMPIOPAGG $ 2,000,000 IWA STOP GAP $ 11000,000 13 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS EEpp X AUTOS ONLY X At,ITNLY -- — ICPP 1063215 11 12/8/2021 12/8/2022 _G.91 9ir16AI.-BtI11IL _ g i+000,000 BODuylhuURy Per ersoo $ BODJLYJNJURY Paraccidant $ UMBRELLA LIAB EXCESS LUIB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE. $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY CPPER/MEMggOEER EXCLUDED? ECUTIVE ❑ 4far atory In NH) Iyes, describe under DFSCRIPTION OF OPERATIONS below NIA I'tK TUTE U i H- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE S E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Certificate Holder Is named as Additional Insured as required by contract, performs attached. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Kent THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y ACCORDANCE WITH THE POLICY PROVISIONS. 400 West Gowe St Kent, WA 98032 - AUTHORIZED REPRESENTATIVE (IAI� ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY WN GL 49 07 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU PRIMARY AND NONCONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or or- ganization for whom you are performing opera- tions when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with re- spect to liability for "bodily injury", "property dam- age" or "personal and 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; in the performance of your ongoing operations for the additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are complet- ed. However: 1. The insurance afforded to such additional in- sured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the in- surance afforded to such additional insured will not be broader than that which you are re- quired by the contract or agreement to provide for such additional insured. WN GL 49 07 15 B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sion applies: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the ren- dering of, or the failure to render, any profes- sional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to pre- pare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifica- tions; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against an additional insured allege negli- gence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any profes- sional services by you with respect to your providing engineering, architectural or survey- ing services in your capacity as an engineer, architect or surveyor. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 2 2. 'Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sured(s) at the location of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or or- ganization other than another contractor or subcontractor engaged in performing op- erations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Sec- tion III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is: 1. The minimum amount required by the contract or agreement; or 2. The Limits of Insurance shown in the Declara- tions; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. WN GL 49 07 15 D. The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek any contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERICAL GENERAL LIABILITY WNGL390818 COMMERCIAL GENERAL LIABILITY ENHANCEMENT ENDORSEMENT The Commercial General Liability Enhancement Endorsement is an optional endorsement that provides coverage en- hancements. The following is a summary of broadened coverages provided by this endorsement. No coverage is pro- vided by this summary, refer to following endorsement for changes in your policy. SUMMARY OF COVERAGES PAGE Bodily Injury And Property Damage Liability • Non Owned Watercraft Up To 50 Feet...............................................................................2 Property Damage Liability • Elevators..........................................................................................................................3 ■ Fire, Lightning, Explosion Or Sprinkler Leakage Exception..................................................3 ■ Borrowed Equipment ($25,000 Per Occurrence, $50,000 Aggregate, $2,500 Deductible Per Occurrence.................................................................................3 Supplementary Payments — Amended • Bail Bonds Up To$5,000...................................................................................................4 • Loss of Earnings Up To $500/Day.....................................................................................4 Who Is An Insured Amendments • Employee Bodily Injury To A Co-Employee.........................................................................4 • Newly Formed Or Acquired Organizations For Up To 180 Days...........................................4 • Blanket Additional Insured — Vendors — As Required By Contract........................................4 ■ Blanket Additional Insured — Lessor Of Leased Equipment..................................................6 • Blanket Additional Insured — Managers Or Lessors Of Premises..........................................6 • Blanket Additional Insured — State Or Governmental Agency Or Subdivision Or Political Subdivision — Permits Or Authorizations.........................................................7 ■ Blanket Additional Insured — State Or Governmental Agency Or Subdivision Or Political Subdivision — Permits Or Authorizations Relating To Premises ........................8 Damage To Premises Rented To You —$300,000.........................................................................9 Medical Payments Increased Limit — $10,000 Or Amount Shown on Declarations ...........................9 Conditions • Knowledge of Occurrence, Offense, Claim Or Suit Amended...............................................9 • Unintentional Failure To Disclose Hazards.........................................................................9 • Waiver of Subrogation..................................................................................................... 10 Insured Contract Amended........................................................................................................... 10 Personal And Advertising Injury Redefined • Televised, Videotaped Or Electronic Publication............................................................... 10 WN GL 39 0818 Includes copyrighted material of the Insurance Service Office, Inc.,with its permission. Page 1 of 10 COMMERCIAL GENERAL LIABILITY WNGL390818 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY COMMERCIAL GENERAL LIABILITY ENHANCEMENT ENDORSEMENT This endorsement modifies the insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. The SECTIONS of the Commercial General Liability Coverage Form identified in this endorsement will be amended as shown below. SECTION I —COVERAGES AMENDMENTS COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY A. Non Owned Aircraft Or Watercraft Item 2. Exclusions, Paragraph g. is replaced by the following: g. Aircraft, Auto Or Watercraft "Bodily injury" or "property damage" arising out of the ownership, maintenance, use or entrustment to others of any aircraft, "auto" or watercraft owned or operated by or rented or loaned to any insured. Use includes operation and "loading or unloading". This exclusion applies even if the claims against any insured allege negligence or other wrong- doing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage" involved in the ownership, maintenance, use or entrustment to others of any aircraft, "auto" or watercraft that is owned or operated by or rented or loaned to any insured. This exclusion does not apply to: (1) A watercraft while ashore on premises you own or rent; (2) A watercraft you do not own that is: (a) Less than 50 feet long; and (b) Not being used to cant' persons or prop- erty for a charge; This Subparagraph (2) applies to any person, who with your expressed or implied consent, either uses or is responsible for the use of the watercraft; (3) Parking an "auto" on, or on the ways next to, premises you own or rent, provided the "auto" is not owned by or rented or loaned to you or the insured; (4) Liability assumed under any "insured con- tract" for the ownership, maintenance or use of aircraft or watercraft; or (5) "Bodily injury" or "property damage" arising out of: (a) The operation of machinery or equipment that is attached to, or part of, a land vehicle that would qualify under the definition of "mobile equipment" if it were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where it is licensed or principally garaged; or (b) The operation of any of the machinery or equipment listed in Paragraph f. (2) or f. (3) of the definition of "mobile equip- ment". B. Damage To Property Coverage Extensions Item 2. Exclusions, Paragraph j. is replaced by the following: j. Damage To Property "Property damage" to: (1) Property you own, rent, or occupy, including any costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restora- tion or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property; (2) Premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises; WN GL 39 08 18 Includes copyrighted material of the Insurance Service Office, Inc., with its permission. Page 2 of 10 (3) Property loaned to you; (4) Personal property in the care, custody or con- trol of the insured; (5) That particular part of real property on which you or any contractors or subcontractors working directly or indirectly on your behalf are performing operations, if the "property damage" arises out of those operations; or (6) That particular part of any property that must be restored, repaired or replaced because '.your work" was incorrectly performed on it. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire, lightning, explosion or sprinkler leakage) to premises, including the contents of such premises, rented to you for a period of seven or fewer consecutive days. A separate limit of insurance applies to Damage To Premises Rented To You as described in SECTION III — LIMITS OF INSURANCE. However, the provisions of this paragraph do not apply if coverage for Damage To Premises Rented To You is excluded by endorsement. Paragraph (2) of this exclusion does not apply if the premises are "your work" and were never occupied, rented or held for rental by you. Paragraphs (3) and (4) of this exclusion do not apply to the use of elevators. Paragraphs (3), (4), (5) and (6) of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph (4) of this exclusion does not apply to "property damage" to borrowed equipment while not being used to perform operations at the jobsite. Subject to Paragraph 2. of SECTION III — LIMITS OF INSURANCE, the rules below fix the most we will pay for "property damage" under this provision: (1) $25,000 any one "occurrence", regardless of the number of persons or organizations who sustain damages because of that "occurrence'; (2) $50,000 annual aggregate; and (3) We will pay only for damages in excess of $2,500 as a result of any one "occurrence", regardless of the number of persons or organizations who sustain damages because of that "occurrence". We may, or if required by law, pay all or any part of any deductible amount, if applicable, to effect settlement of any claim or "suit". Upon notice of our payment of a deductible amount, you shall promptly reimburse us for the part of the deductible amount we paid. Paragraph (6) of this exclusion does not apply to "property damage" included in the "products -com- pleted operations hazard". The insurance provided for "property damage" from the use of elevators and for "property damage" to borrowed equipment is excess over any other valid and collectible property insurance (including any de- ductible portion thereof) available to the insured whether primary, excess, contingent or on any other basis. C. Damage To Premises Rented To You Item 2. Exclusions, the last paragraph is replaced by the following: Exclusions c. through In. do not apply to damage by fire, lightning, explosion or sprinkler leakage to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to this coverage as described in Paragraph 6. of SECTION III — LIMITS OF INSURANCE. COVERAGE B — PERSONAL AND ADVERTISING INJURY LIABILITY D. Personal And Advertising Injury Item 2. Exclusions is amended by replacing Sub- paragraphs b. and c. with the following: b. Material Published With Knowledge Of Falsity "Personal and advertising injury" arising out of oral, written, televised, videotaped or electronic publication, in any manner, of material, if done by or at the direction of the insured with knowledge of its falsity. c. Material Published Prior To Policy Period "Personal and advertising injury" arising out of oral, written, televised, videotaped or electronic publication, in any manner, of material whose first publication took place before the beginning of the policy period. SUPPLEMENTARY PAYMENTS —COVERAGES A AND B E. Supplementary Payments— Coverages A and B Item 1. is amended by replacing Subparagraphs b. and d. with the following: b. Up to $5,000 for cost of bail bonds required be- cause of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. WN GL 39 0818 Includes copyrighted material of the Insurance Service Office, Inc., with its permission. Page 3 of 10 SECTION II —WHO IS AN INSURED AMENDMENTS The following are added: A. Employee Bodily Injury To A Co -Employee C. Paragraph 2. a. (1) is replaced by the following: However, none of these "employees" or "volunteer workers" are insureds for "bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co - "employee" 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 the co -"employee" or 'volunteer worker" as a consequence of Paragraph (1)(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 (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. However, if a suit seeking damages for "bodily injury" or "personal and advertising injury" to any co - "employee" or other "volunteer worker" arising out of and in the course of the co -"employee's" or "volunteer worker's" employment or while performing duties related to the conduct of your business, or a suit seeking damages brought by the spouse, child, parent, brother or sister of the co -"employee" or other "volunteer worker", is brought against you or a co - "employee" or a "wlunteer worker", we will reimburse the reasonable costs that you incur in providing a defense to the co"employee" or "volunteer worker" against such matters. Any reimbursement made pursuant to this sub -section will be in addition to the limits of liability set forth in the Declarations. B. Newly Acquired Organizations Paragraph 3. a. is replaced by the following: a. Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; Blanket Additional Insured — Vendors — As Re- quired By Contract 1. Section II — Who Is An Insured is amended to include as an additional insured any person(s) or organization(s) (referred to throughout this endorsement as vendor) with whom you have agreed in a written contract, executed prior to loss, to name as an additional insured, but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business. However, a. The insurance afforded to such vendor only applies to the extent permitted by law; and b. If coverage provided to the vendor is required by a contract or agreement, the insurance afforded to such vendor will not be broader than that which you are required by the contract or agreement to provide for such vendor. 2. With respect to the insurance afforded to these vendors, the following additional exclusions apply: a. The insurance afforded the vendor does not apply to: (1) "Bodily injury" or "property damage" for which the vendor is obligated to pay dam- ages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; (2) Any express warranty unauthorized by you; (3) Any physical or chemical change in the product made intentionally by the vendor; (4) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; WN GL 39 0818 Includes copyrighted material of the Insurance Service Office, Inc., with its permission. Page 4 of 10 (5) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; (6) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; (7) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or (8) "Bodily injury or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (i) The exceptions contained in Subparagraphs (4) or (6); or (ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. 3. This Provision C. does not apply: a. To any insured person or organization from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products; b. To any vendor for which coverage as an addi- tional insured specifically is scheduled by endorsement; or c. When liability included within the "products - completed operations hazard" has been ex- cluded for such product either by the provi- sions of the coverage part or by endorse- ment. 4. With respect to the insurance afforded to these vendors, the following is added to Section III — Limits Of Insurance: If coverage provided to the vendor is required by a contract or agreement, the most we will pay on behalf of the vendor is: a. The minimum amount required by the contract or agreement; or b. The Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 5. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against an additional insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any professional services by you with respect to your providing engineering, architectural or surveying services in your capacity as an engineer, architect or surveyor. WN GL 39 08 18 Includes copyrighted material of the Insurance Service Office, Inc., with its permission. Page 5 of 10 D. Blanket Additional Insured — Lessor Of Leased Equipment 1. Section II — Who Is An Insured is amended to include as an additional insured any person(s) or organization(s) from whom you lease equipment when you and such person(s) or organization(s) have agreed in writing in a contract or agreement, executed prior to loss, that such person(s) or organization(s) be added as an additional insured on your policy. Such person(s) or organization(s) is an insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or organization(s). However, the insurance afforded to such additional insured: a. Only applies to the extent permitted by law; and b. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an addi- tional insured under this endorsement ends when their contract or agreement with you for such leased equipment ends. 2. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after the equipment lease expires. 3. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is: a. The minimum amount required by the contract or agreement; or b. The Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 4. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against an additional insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any professional services by you with respect to your providing engineering, architectural or surveying services in your capacity as an engineer, architect or surveyor. E. Blanket Additional Insured — Managers Or Les- sors Of Premises 1. Section II — Who Is An Insured is amended to include as an additional insured any person(s) or organization(s) with whom you have agreed in a written contract, executed prior to loss, to name as an additional insured, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you, subject to the following additional exclusions: This insurance does not apply to: a. Any "occurrence" which takes place after you cease to be a tenant in that premises. b. Structural alterations, new construction or demolition operations performed by or on behalf of such additional insured. WN GL 39 08 18 Includes copyrighted material of the Insurance Service Office, Inc., with its permission. Page 6 of 10 However: F. Blanket Additional Insured — State Or a. The insurance afforded to such additional Governmental Agency Or Subdivision Or Political insured only applies to the extent permitted Subdivision — Permits Or Authorizations by law; and Section II — Who Is An Insured is amended to in- b. If coverage provided to the additional insured clude as an additional insured any state or is required by a contract or agreement, the governmental agency or subdivision or political insurance afforded to such additional insured subdivision with whom you have agreed in a written will not be broader than that which you are contract, executed prior to loss, to name as an required by the contract or agreement to additional insured, subject to the following provisions: provide for such additional insured. 1. This insurance applies only with respect to op- 2. With respect to the insurance afforded to these erations performed by you or on your behalf for additional insureds, the following is added to which the state or governmental agency or sub - Section III — Limits Of Insurance: division or political subdivision has issued a If coverage provided to the additional insured is permit or authorization. required by a contractor agreement, the most we However: will pay on behalf of the additional insured is: a. The insurance afforded to such additional a. The minimum amount required by the insured only applies to the extent permitted contract or agreement; or by law; and b. The Limits of Insurance shown in the b. If coverage provided to the additional insured Declarations; is required by a contract or agreement, the insurance afforded to such additional insured whichever is less. will not be broader than that which you are This endorsement shall not increase the required by the contract or agreement to applicable Limits of Insurance shown in the provide for such additional insured. Declarations. 2. This insurance does not apply to: 3. With respect to the insurance afforded to these a. "Bodily injury", "property damage" or "per - additional insureds, the following additional sonal and advertising injury" arising out of op - exclusion applies: erations performed for the federal govern - This insurance does not apply to: ment, state or municipality; or a. 'Bodily injury", "property damage" or b. "Bodily injury" or "property damage" included "personal and advertising injury" arising out within the "products -completed operations of the rendering of, or the failure to render, hazard". any professional architectural, engineering or 3. With respect to the insurance afforded to these surveying services, including: additional insureds, the following is added to (1) The preparing, approving, or failing to Section III— Limits Of Insurance: prepare or approve, maps, shop If coverage provided to the additional insured is drawings, opinions, reports, surveys, required by a contract or agreement, the most we field orders, change orders or drawings will pay on behalf of the additional insured is: and specifications; or a. The minimum amount required by the (2) Supervisory, inspection, architectural or contract or agreement; or engineering activities. b. The Limits of Insurance shown in the This exclusion applies even if the claims Declarations; against an additional insured allege negligence or other wrongdoing in the whichever is less. superrision, hiring, employment, training or This endorsement shall not increase the monitoring of others by that insured, if the applicable Limits of Insurance shown in the "occurrence" which caused the "bodily injury" Declarations. or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any professional services by you with respect to your providing engineering, architectural or surveying services in your capacity as an engineer, architect or surveyor. WN GL 39 0818 Includes copyrighted material of the Insurance Service Office, Inc.,w ith its permission. Page 7 of 10 4. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against an additional insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any professional services by you with respect to your providing engineering, architectural or surveying services in your capacity as an engineer, architect or surveyor. G. Blanket Additional Insured — State Or Governmental Agency Or Subdivision Or Political Subdivision — Permits Or Authorizations Relating To Premises Section II — Who Is An Insured is amended to in- clude as an additional insured any state or governmental agency or subdivision or political subdivision with whom you have agreed in a written contract, executed prior to loss, to name as an additional insured, subject to the following provision: 1. This insurance applies only with respect to the fol- lowing hazards for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization in connection with premises you own, rent or control and to which this insurance applies: a. The existence, maintenance, repair, construction, erection or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners or decorations and similar exposures; or b. The construction, erection or removal of elevators; or c. The ownership, maintenance or use of any elevators covered by this insurance. However, a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 2. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is: a. The minimum amount required by the contract or agreement; or b. The Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 3. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. WN GL 39 08 18 Includes copyrighted material of the Insurance Service Office, Inc.,with its permission. Page 8 of 10 This exclusion applies even if the claims against an additional insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury' or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any professional services by you with respect to your providing engineering, architectural or surveying services in your capacity as an engineer, architect or surveyor. SECTION III —LIMITS OF INSURANCE AMENDMENTS A. Damage To Premises Rented To You Paragraph 6. is replaced by the following: 6. Subject to Paragraph 5. above, the most we will pay under Coverage A for damages because of "property damage" to any one premises, while rented to you, or in the case of damage by fire, lightning, explosion or sprinkler leakage, while rented to you or temporarily occupied by you with permission of the owner is the greater of: a. $300,000; or b. The amount shown next to the Damage To Premises Rented To You Limit in the Decla- rations. However, the provisions of this paragraph do not apply if Damage To Premises Rented To You Coverage is excluded by endorsement. B. Medical Expense Limit Paragraph 7. is replaced with the following: 7. Subject to Paragraph 5. above, the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person is the greater of: a. $10,000; or b. The amount shown next to the Medical Ex- pense Limit in the Declarations. This insurance does not apply if coverage for Medical Expenses is excluded either by the pro- visions of the coverage part or by endorsement. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS AMENDMENTS A. Knowledge Of Occurrence Item 2. Duties In The Event Of Occurrence, Of- fense, Claim or Suit is amended by adding the fol- lowing: e. You must give us or our authorized representa- tive prompt notice of an 'occurrence", claim or loss only when the "occurrence", claim or loss is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; (3) An executive officer or insurance manager, if you are a corporation; or (4) A member or manager, if you are a limited liability company. B. Other Insurance Item 4. Other Insurance, b. Excess Insurance (1) (a) (ii) is replaced by the following: (ii) That is fire, lightning, explosion or sprinkler leak- age insurance for premises rented to you or temporarily occupied by you with permission of the owner; C. Unintentional Failure To Disclose Hazards Item 6. Representations is replaced by the following: 6. Representations And Unintentional Failure To Disclose Hazards a. By accepting this policy, you agree: (1) The statements in the Declarations are accurate and complete; (2) Those statements are based upon repre- sentations you made to us; and (3) We have issued this policy in reliance upon your representations. b. If you unintentionally fail to disclose any haz- ards existing at the inception date of your policy, we will not deny coverage under this Coverage Part because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. WN GL 39 0818 Includes copyrighted material of the Insurance Service Office, Inc., with its permission. Page 9 of 10 D. Waiver of Subrogation Item 8. Transfer of Rights of Recovery Against Others to Us is hereby amended by the addition of the following: We waive any right of recovery we may have because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a written contract, executed prior to loss, requiring such waiver with that person or organization and included in the "products -completed operations hazard". However, our rights may only be waived prior to the "occurrence" giving rise to the injury or damage for which we make payment under this Coverage Part. The insured must do nothing after a loss to impair our rights. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce those rights. SECTION V — DEFINITIONS AMENDMENTS A. Insured Contract Amended Paragraph 9. a. is replaced by the following: a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion or sprinkler leakage to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract'; B. Personal And Advertising Injury Redefined Paragraph 14. d. and e. are replaced by the following: d. Oral, written, televised, videotaped or electronic publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or service; e. Oral, written, televised, videotaped or electronic publication of material that violates a person's right of privacy; WN GL 39 08 18 Includes copyrighted material of the Insurance Service Office, Inc.,w ith its permission. Page 10 of 10 WIN CA 27 0616 BUSINESS AUTO ENHANCEMENT ENDORSEMENT The Business Auto Enhancement Endorsement is an optional endorsement that provides coverage enhancements. The following is a summary of broadened coverages provided by this endorsement. No coverage is provided by this summary, refer to following endorsement for changes in your policy. SUMMARY OF COVERAGES PAGE Accidental Airbag Deployment Coverage 4 Auto Loan/Lease Gap Coverage 4 Blanket Additional Insured 2 Blanket Waiver of Subrogation 5 Broadened Definition of Insured includes: • Newly Acquired Organizations for up to 180 Days 2 • Employees as Insureds 2 • Subsidiaries in Which You Own 50% or More 2 Deductible Waiver for Glass Repair 3 Employee Hired Auto 2,5 Fellow Employee Coverage 3 Hired Auto Physical Damage Coverage 4 Knowledge of Accident, Claim, Suit or Loss 5 Loss Of Use Expenses - Amended 3 Personal Effects 3 Rental Reimbursement Coverage 4 Supplementary Payments - Amended: • Bail Bonds up to $5,000 2 • Loss of Earnings up to $500/Day 2 Transportation Expense Limits — Amended 3 Unintentional Failure to Disclose Hazards 5 WN CA 27 06 16 Includes copyrighted material of Insurance Services Office, with its permission Page 1 Of 5 WN CA 27 06 16 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BUSINESS AUTO ENHANCEMENT ENDORSEMENT This endorsement modifies the insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to the coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. The SECTIONS of the Business Auto Coverage Form identified in this endorsement will be amended as shown below. SECTION II — COVERED AUTOS LIABILITY g. Any "employee" of yours is an "insured" while COVERAGE AMENDMENTS operating a covered "auto" hired or rented under A. Who Is An Insured a contract or agreement in the "employee's" name, with your permission, while performing SECTION II — COVERED AUTOS LIABILITY duties related to the conduct of your business. COVERAGE, A. Coverage, 1. Who Is An Insured is amended to add: B. Blanket Additional Insured d. Any legally incorporated subsidiary of yours in which you own more than 50% of the voting stock on the effective date of this coverage form. However, "insured" does not include any subsidiary of yours that is an "insured" under any other automobile liability policy, or would be an "insured" under such policy but for termination of such policy or the exhaustion on such policy's limits of insurance. e. Any organization which is newly acquired or formed by you and over which you maintain majority ownership. However, coverage under this provision: (1) is afforded only for the first 180 days after you acquire or form the organization or until the end of the policy period, whichever comes first; (2) does not apply to "bodily injury" or "property damage" that results from an "accident" that occurred before you formed or acquired the organization; (3) does not apply to any newly acquired or formed organization that is a joint venture or partnership; and (4) does not apply to an "insured" under any other automobile liability policy, or would be an "insured" under such a policy but for ter- mination of such policy or the exhaustion of such policy's limits of insurance. SECTION II — COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, paragraph c. is amended to add the following: Any person or organization who is required under a written contract or agreement between you and that person or organization, that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to be named as an additional insured is an "insured" for Liability Coverage, but only for damages to which this insurance applies and only to the extent that persons or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section II. C. Liability Coverage Extensions — Supplementary Payments SECTION II — COVERED AUTOS LIABILITY COVERAGE, A. Coverage, 2. Coverage Extensions, a. Supplementary Payments is amended by replacing subparagraphs (2) and (4) with the following: (2) Up to $5,000 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work. f. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. WN CA 27 06 16 Includes copyrighted material of Insurance Services Office, with its permission Page 2 of 5 D. Fellow Employee Coverage SECTION II — COVERED AUTOS LIABILITY COVERAGE, B. Exclusions, 5. Fellow Employee, the following is added: Co -Employee Lawsuit Defense Cost Reimbursement If a suit seeking damages for "bodily injury" to any fellow "employee" of the "insured" arising out of and in the course of the fellow "employee's" employment or while performing duties related to the conduct of your business, or a suit seeking damages brought by the spouse, child, parent, brother or sister of that fellow "employee", is brought against you, we will reimburse reasonable costs that you incur in the defense of such matters. Any reimbursement made pursuant to this sub -section will be in addition to the limits of liability set forth in the Declarations. SECTION III — PHYSICAL DAMAGE COVERAGE AMENDMENTS A. Transportation Expense — Limits Amended SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, a. Trans- portation Expenses is amended by replacing $20 per day/$600 maximum limit with $50 per day/$1000 maximum. B. Hired Auto Physical Damage — Loss Of Use Expenses — Limits Amended SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, b. Loss of Use Expenses is amended by replacing the $20 per day/$600 maximum limit with $50 per day/$750 maximum limit. C. Personal Effects Coverage SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions is amended by adding the following: c. Personal Effects We will pay up to $500 for "loss" to personal effects, which are: (1) Owned by an "insured"; and (2) In or on your covered "auto." This coverage applies only in the event of the total theft of your covered "auto." No deductible applies to this coverage D. Glass Repair— Deductible Waiver SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 3. Glass Breakage — Hitting A Bird Or Animal — Falling Objects Or Missiles, is amended by adding the following: No deductible will apply to glass breakage if such glass is repaired, in a manner acceptable to us, rather than replaced. E. Hired Auto Physical Damage SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage is amended by adding the following: 5. Hired Auto Physical Damage If hired "autos" are covered "autos" for Liability Coverage and if Comprehensive, Specified Causes of Loss, or Collision coverages are pro- vided under this coverage form for any "auto" you own, then the Physical Damage Coverages provided are extended to "autos" you hire of like kind and use, subject to the following: a. The most we will pay for any one "loss" is $50,000 or the actual cash value or cost to repair or replace, whichever is less, minus a deductible; b. The deductible will be equal to the largest deductible applicable to any owned "auto" for that coverage. Any Comprehensive deductible does not apply to "loss" caused by fire or lightening; c. Hired Auto Physical Damage coverage is excess over any other collectible insurance; and d. Subject to the above limit, deductible and excess provisions we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own. If a limit for Hired Auto Physical Damage is indicated in the Declarations, then that limit replaces, and is not added to, the $50,000 limit indicated above. WN CA 27 06 16 Includes copyrighted material of Insurance Services Office, with its permission Page 3 of 5 F. Rental Reimbursement SECTION III — PHYSICAL DAMAGE COVERAGE A. Coverage, is amended by adding the following: 6. Rental Reimbursement This coverage applies only to a covered "auto" of the private passenger or light truck type as follows: a. We will pay for rental reimbursement expenses incurred by you for the rental of a private passenger or light truck type "auto" because of "loss" to a covered private pas- senger or light truck type "auto". Payment applies in addition to the otherwise applica- ble amount of each coverage you have on a covered private passenger or light truck type "auto." No deductibles apply to this coverage. b. We will pay only for those expenses incurred during the policy period beginning 24 hours after the "loss" and ending, regardless of the policy's expiration, with the lesser of the fol- lowing number of days: (1) The number of days reasonably re- quired to repair or replace the covered private passenger or light truck type "auto". If "loss" is caused by theft, this number of days is added to the number of days it takes to locate the covered private passenger or light truck type "auto" and return it to you; or (2) 30 days. c. Our payment is limited to the lesser of the following amounts: (1) Necessary and actual expenses incurred, or (2) $50 per day, up to a maximum of $1,000. d. This coverage does not apply while there are spare or reserve private passenger or light truck type "autos" available to you for your operations. e. If "loss" results from the total theft of a covered "auto" of the private passenger or light truck type, we will pay under this cover- age only that amount of your rental reim- bursement expenses which is not already provided for under SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions. For the purposes of this Rental Reimbursement coverage, light truck is defined as a truck with a gross vehicle weight of 10,000 lbs. or less as defined by the manufacturer as the maximum loaded weight the auto is designed to carry. G. Accidental Airbag Deployment Coverage SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage is amended by adding the following: 7. Accidental Airbag Deployment Coverage We will pay to reset or replace factory installed airbag(s) in any covered "auto" for accidental discharge, other than discharge due to a collision loss. This coverage is applicable only if comprehen- sive coverage applies to the covered "auto". This coverage is excess over any other collecti- ble insurance or reimbursement by manufac- turer's warranty. H. Auto Loan/Lease Gap Coverage SECTION III PHYSICAL DAMAGE COVERAGE, Item A., Coverage, is amended by adding the following: 8. Auto Loan/Lease Gap Coverage This coverage applies only to a covered "auto" described or designated in the Schedule or in the Declarations as including physical damage coverage. In the event of a covered total "loss" to a covered "auto" described or designated in the Schedule or in the Declarations, we will pay any unpaid amount due on the lease or loan for a covered "auto" less: a. The amount paid under the Physical Damage Coverage Section on the policy; and b. Any: (1) Overdue lease/loan payments at the time of the "loss"; (2) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; (3) Security deposits not returned by the lessor; (4) Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and (5) Carry-over balances from previous loans or leases. WN CA 27 06 16 Includes copyrighted material of Insurance Services Office, with its permission Page 4 of 5 SECTION IV — BUSINESS AUTO CONDITIONS AMENDMENTS A. Duties In The Event Of Accident, Claim, Suit Or Loss Amended SECTION IV — BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The Event Of Accident, Claim, Suit Or Loss, a. is amended by adding the following: This condition applies only when the "accident" or "loss" is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; (3) An executive officer or insurance manager, if you are a corporation; or (4) A member or manager, if you are a limited liability company. But, this section does not amend the provisions relating to notification of police, protection or exami- nation of the property which was subject to the "loss". B. Blanket Waiver of Subrogation Section IV — BUSINESS AUTO CONDITIONS, A. Loss Conditions, 5. Transfer of Rights of Recovery Against Others to Us, is amended by adding the following exception: However, we waive any right of recovery we may have against any person or organization to the extent required of you by a written contract signed and executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract. C. Unintentional Failure to Disclose Hazards SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 2. Concealment, Misrepre- sentation Or Fraud, is amended by adding the following paragraph: If you unintentionally fail to disclose any hazards existing at the inception date of the policy, or during the policy period in connection with any additional hazards, we will not deny coverage under this Cov- erage Part because of such failure. D. Employee Hired Auto SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, paragraph b. is deleted and replace by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be a covered "autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow. (2) Any covered "auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". WN CA 27 06 16 Includes copyrighted material of Insurance Services Office, with its permission Page 5 of 5 COMMERCIAL LIABILITY UMBRELLA WN CU 114 0715 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WHO IS AN INSURED AMENDED This endorsement modifies insurance provided under the following: COMMERCIAL LIABILITY UMBRELLA COVERAGE PART With respect to SECTION II — WHO IS AN INSURED, Paragraph 3. is replaced by the fol- lowing: 3. Any additional insured under any policy of "underlying insurance" will automati- cally be an insured under this insurance. Subject to Section III — Limits Of In- surance, if coverage provided to the additional insured is required by a con- tract or agreement, the most we will pay on behalf of the additional insured is: WN CU 114 07 15 a. The minimum amount of insurance required by the contract or agree- ment, less any amounts payable by any "underlying insurance; or b. The amount of insurance available under the applicable Limits of Insur- ance shown in the Declarations; whichever is less. Additional insured coverage provided by this insurance will not be broader than coverage provided by the "underlying insurance". Page 1 of 1 Includes copyrighted material of the Insurance Service Office, Inc., with its permission. WESTERN NATIONAL INSURANCE The relationship company 12/03/2021 L & S TIRE COMPANY 8119 N REGAL ST BLDG S SPOKANE WA 99217 Business Insurance Number: 0000203718 Dear Western National Policyholder, Thank you for renewing your insurance policy with Western National — the carrier of choice for outstanding insurance coverage and service since 1901. We sincerely appreciate your business. From our roots as a small insurance company serving Midwestern creameries to our current role as an "A+" rated (A.M. Best) company serving businesses and families throughout the Midwestern and Western U.S., we've always defined success as a measure of the relationships we've built over time. Of course, the most important part of our relationship with you is our promise to pay covered claims. With a customer claim satisfaction rate of 98%, in the event of a covered claim you can be confident that Western National's experienced claim representatives will provide the helpful service and timely payment you need to make your business whole again. Enclosed is the renewal information for your insurance policy. Please note that the enclosed policy contains only your renewal declaration and any policy forms or endorsements that have changed since your last renewal. If you would like to receive a complete copy of your policy with all the forms and endorsements (similar to what you received when your policy was first issued), please contact us us at commercial@wnins.com and include your policy number in the request. You can also contact your Independent Insurance Agent for information or assistance. We look forward to continuing to serve your insurance needs, and we encourage you to visit our website (www.wnins.com) for helpful policy tools including online bill payment, access to free safety videos, and more. You can also download the Western National mobile app (available in the Apple and Google Play app stores) to pay your bill, access your policy information, or report a claim while you're `on the go'. With thanks and best wishes from all of us here at Western National, Stuart C. Henderson, JD, CPCU President and CEO Western National Insurance Group 14700 West 77th Street I Edina, MN 55435 1 (952) 835-5350 or (800) 862-6070 info@wnins.com I www.wnins.com WESTERN NATIONAL MUTUAL I WESTERN NATIONAL ASSURANCE I PIONEER SPECIALTY I UMIALIK I ARIZONA AUTOMOBILE I WESTERN HOME NEVADA GENERAL I MICHIGAN MILLERS (AFFILIATE) COMMERCIAL POLICY SUMMARY PAGE L & S TIRE COMPANY PAYNEWEST INSURANCE 8119 N REGAL ST BLDG 5 501 N RIVERPOINT BLVD, STE 403 SPOKANE WA 99217 SPOKANE, WA 99202-1649 Group # 0000203718 COVERAGE 06023 509-838-3501 Effective Date: DECEMBER 8, 2021 Expiration Date: DECEMBER 8, 2022 12:01 A.M. standard time at the Named Insured's mailing address. Your coverage consists of the following lines of insurance for which a premium is indicated. This premium may be subject to adjustment. Commercial Auto $ 90, 848.00 Commercial Property $ 8,684.00 Commercial General Liability $ 8,726.00 Commercial Inland Marine $ 2,522.00 Commercial Umbrella $ 14, 696.00 Total Estimated Annual Premium $ 125,476.00 These Declarations together with the common policy conditions, coverage part declarations, coverage part form(s), and form(s) and endorsements, if any, issued, complete the above numbered policy. Countersigned: By Authorized Representatives WN IL 21 07 07 INSURED COPY Page 1 of 1 Group #: 0000203718 Date: 12/03/2021 Insured: L & S TIRE COMPANY Address: 8119 N REGAL ST BLDG S SPOKANE WA 99217 Effective Date: DECEMBER 8, 2021 ENCLOSURE — REJECTION OF CERTIFIED TERRORISM INSURANCE I hereby reject the offer of terrorism coverage. I understand that an EXCLUSION of certain terrorism losses will be made a part of this policy. Policyholder Signature Print Name Date PROPERTY COVERAGE ONLY: In this state, a terrorism exclusion makes an exception for (and thereby provides coverage for) fire losses resulting from an act of terrorism. Therefore, if you reject the offer of terrorism coverage, that rejection does not apply to fire losses resulting from an act of terrorism — coverage for such fire losses will continue to be provided in your policy. There will be an additional premium just for such fire coverage. (Not applicable in Alaska, Idaho, Minnesota, Montana, Nevada, North Dakota, South Dakota and Utah) ALASKA AUTO ONLY: In this state, the terrorism exclusion applies above the minimum limits required for Liability, Uninsured and/or Underinsured Motorists Coverage by the state's Financial Responsibility Statutes. Therefore, if you reject the offer of terrorism coverage, that rejection does not apply to losses resulting from an act of terrorism, for limits up to the minimum state compulsory limits of insurance for Liability, Uninsured and/or Underinsured Motorists Coverage. The additional premium just for such coverage up to the Financial Responsibility Statutes is stated in the DISCLOSURE OF PREMIUM. s 0 0 OREGON AUTO ONLY: In this state, the terrorism exclusion applies above the minimum limits required for Liability, Uninsured and/or Underinsured Motorists Coverage and Personal Injury Protection Coverage by the state's Financial Responsibility Statutes. Therefore, if you reject the offer of terrorism coverage, that rejection does not apply to losses resulting from an act of terrorism, for limits up to the minimum state compulsory limits of insurance for Liability, Uninsured and/or Underinsured Motorists, and Personal Injury Protection Coverage. The additional premium just for such coverage up to the Financial Responsibility Statutes is stated in the DISCLOSURE OF PREMIUM. IF YOU CHOOSE TO REJECT THIS OFFER OF TERRORISM COVERAGE, PLEASE SIGN THIS REJECTION STATEMENT AND RETURN IT TO YOUR AGENT AS SOON AS POSSIBLE. IF YOUR SIGNED REJECTION IS NOT RECEIVED BY US WITHIN 30 DAYS OF THE EFFECTIVE DATE OF YOUR POLICY, OR WITHIN 30 DAYS OF THE DATE OF THIS NOTICE, WHICHEVER IS LATER, THE CHARGE FOR TERRORISM WILL NOT BE REMOVED. WN IL 18 01 15 Group #: 0000203718 Date: 12/03/2021 Insured: L & S TIRE COMPANY Address: 8119 N REGAL ST BLDG 5 SPOKANE WA 99217 Effective Date: DECEMBER 8, 2021 POLICYHOLDER DISCLOSURE NOTICE — OFFER OF TERRORISM INSURANCE COVERAGE AND DISCLOSURE OF PREMIUM Under the Terrorism Risk Insurance Act, as amended in 2019, you have a right to purchase insurance coverage for losses resulting from acts of terrorism. As defined in Section 102(1) of the Act: The term "act of terrorism" means any act or acts that are certified by the Secretary of the Treasury — in consultation with the Secretary of Homeland Security, and the Attorney General of the United States — to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; and to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Your decision is needed on this question: do you choose to continue to pay the premium for terrorism coverage stated in this offer of coverage, or do you choose to reject the offer of coverage and not pay the premium? Please consult your agent if you have questions regarding your options. REJECTION OF TERRORISM INSURANCE COVERAGE Your insurance policy has been issued/quoted with Certified Terrorist Acts coverage, and a premium has been included for the applicable lines of insurance. Unless you reject this coverage, you must pay the additional terrorism premium as stated in the DISCLOSURE OF PREMIUM. You may choose to reject the offer of terrorism coverage by signing the enclosed REJECTION STATEMENT; then your policy will be written to exclude the described coverage. DISCLOSURE OF PREMIUM If you continue to accept this offer, the premium for terrorism coverage is $ 241.00 If you reject this offer, a portion of the above premium will be charged due to state law requiring coverage if a "certified act of terrorism" results in a direct loss by fire to covered property. (Not applicable in Alaska, Idaho, Minnesota, Montana, Nevada, North Dakota, South Dakota and Utah). This premium is $ 13 . 00 Alaska only: If you have auto insurance, terrorism coverage up to the minimum limits required for Liability, Uninsured and/or Underinsured Motorists, by the state's Financial Responsibility Statutes applies. The premium for this coverage is $0.00. Oregon only: if you have auto insurance, terrorism coverage up to the minimum limits required for Liability, Uninsured and/or Underinsured Motorists and Personal Injury Protection Coverage, by the state's Financial Responsibility Statutes applies. The premium for this coverage is $0.00. DISCLOSURE OF FEDERAL PARTICIPATION IN PAYMENT OF TERRORISM LOSSES: You should know that where coverage is provided by this policy for losses resulting from certified acts of terrorism, such losses may be partially reimbursed by the United States Government under a formula established by federal law. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear events. Under the formula, the United States Government reimburses 80% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage is shown above and does not include any charges for the portion of the loss that may be covered by the federal government under the Act. CAP ON LOSSES: You should also know that the Terrorism Risk Insurance Act, as amended, contains a $100 billion cap that limits U.S. Government reimbursement as well as insurers' liability for losses resulting from certified acts of terrorism when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced. WNIL1050121 Western National Mutual Insurance Company `� 4700 West 77th Street Edina, MN 55435 WESTERN NATIONAL INSURANCE www.wnins.com BUSINESS AUTO The relationship m Ipamy A Mutual Company DECLARATION Group # 0000203718 Policy Period: From 12/08/2021 To 12/08/2022 Policy # CPP 1063215 11 1 2:01 A.M. standard time at the Named Insured's mailing address. Transaction RENEWAL DECLARATION Insured Name and Address Agent L & S TIRE COMPANY PAYNEWEST INSURANCE 06023 8119 N REGAL ST BLDG 5 501 N RIVERPOINT BLVD, STE 403 SPOKANE WA 99217 SPOKANE, WA 99202-1649 Telephone: 509-838-3501 Business Description Type of Business Audit Period Billing Type TIRE RETREADING CORPORATION ANNUAL DIRECT ITEM TWO: SCHEDULE OF COVERAGES AND COVERED AUTOS This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "autos" shown as covered "autos". "Autos" are shown as covered "autos" for a particular coverage by the entry of one or more of the symbols from the Covered Autos Section of the Business Auto ........ Coverage Form next to the name of the coverage. COVERAGES COVERED LIMIT AUTO THE MOST WE WILL PAY FOR ANY ONE PREMIUM SYMBOLS ACCIDENT OR LOSS COVERED AUTOS LIABILITY 7 8 9 10 $1,000,000 Each Accident minus $56,467.00 Deductible PERSONAL INJURY PROTECTION Separately stated in each PIP endorsement minus (Or equivalent No-fault coverage) ADDED PERSONAL INJURY PROT. (Or equivalent No-fault coverage) Separately stated in each Added PIP endorsement AUTO MEDICAL PAYMENTS 7 $5, 000 Each Insured $262.00 UNINSURED MOTORISTS Included in Underinsured UNDERINSURED MOTORISTS (when not included in Uninsured Motorists 7 $1, 000,000 Each Accident $2, 682.00 Coverage) PHYSICAL DAMAGE Actual Cash Value or Cost Of Repair, whichever is less, minus 7 8 the Deductible stated in the Schedule of Covered Autos for each $2, 440. 00 COMPREHENSIVE covered auto, but no Deductible applies to loss caused by lightning or fire. See ITEM FOUR for hired or borrowed "autos". PHYSICAL DAMAGE SPECIFIED Actual Cash Value or Cost Of Repair, whichever is less, minus CAUSES OF LOSS the Deductible stated in the Schedule of Covered Autos for each covered auto for loss caused by Mischief or Vandalism. See ITEM FOUR for hired or borrowed "autos". PHYSICAL DAMAGE Actual Cash Value or Cost Of Repair, whichever is less, minus 7 B the Deductible stated in the Schedule of Covered Autos for each $13 , 052 . 00 COLLISION covered auto. See ITEM FOUR for hired or borrowed "autos". PHYSICAL DAMAGE TOWING AND LABOR (not available in California) Premium for Endorsements $15, 945.00 Estimated Total Premium • $90 , 848 . 00 "This policy may be subject to final audit =orms and Endorsements applicable to this policy See Forms and Endorsements Schedule Issued Date: 12/03/2021 WN CA 01 06 16 INSURED COPY Page 1 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 www.wnins.com BUSINESS AUTO ITEM THREE: SCHEDULE OF COVERED AUTOS YOU OWN Policy Number: CPP 106321S 11 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY DESCRIPTION LOCATION ZONE PURCHASED Original Stated Unit # Year, Make & Model, Serial No. or Vehicle Identification Number Cost New Amount State Territory ORG.DEST 00032004 PETERBILT TRACTOR 2461 $120,377 WA 002 00041999 KENWORTH TRACTOR 9624 $97,651 WA 002 00052008 GMC/CHEV K23 1GCHK23678F149653 $39,590 WA 002 00062008 CHEV SILVERADO 1054 $28,000 WA 002 00072008GMC/CHEV K23 1527 $39,590 WA 002 CLASSIFICATION Primary Rating Factor Secondary Physical Radius of Size GVW, GCW or Rating Age Unit # Code Operation Business Use Seating Capacity Liability Damage Factor Group 000350499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 6 0004SO499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 6 000501499 Local Service 0-10,000 GVW 1.000 1.000 0.000 6 000601499 Local Service 0-10,000 GVW 1.000 1.000 0.000 6 000701499 Local Service 0-10,000 GVW 1.000 1.000 0.000 6 COVERAGES - PREMIUMS, LIMITS AND DEDUCTIBLES COVERED AUTOS LIABILITY PERSONAL INJURY PROTECTION ADDED PIP UNINSURED MOTORISTS Limit stated in each Limit stated in each PIP Endorsement Added PIP Endorsement minus Deductible Unit # Limit Premium shown below Premium Premium Limit Premium 0003 $1,000,000 $3,434 0004 $1,000,000 $3,434 0005 $1,000,000 $1,001 0006 $1,000,000 $1,001 0007 $1,000,000 $1,001 COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) UNDERINSURED MOTORISTS AUTO MEDICAL PAYMENTS COMPREHENSIVE Limit stated in ITEM TWO minus deductible Unit # Limit Premium Limit Premium shown below Premium 0003 $1,000,000 $149 $5,000 $14 $2,000 $119 0004 $1,000,000 $149 $5,000 $14 $2,000 $107 0005 $1,000,000 $149 $5,000 $14 $1,000 $71 0006 $1,000,000 $149 $5,000 $14 $1,000 $71 0007 $1,000,000 $149 $5,000 $14 $1,000 $71 COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) SPECIFIED CAUSES OF LOSS COLLISION TOWING & LABOR Limit stated in ITEM TWO Limit stated in ITEM TWO Unit # minus Deductible shown below Premium minus Deductible shown below Premium Limit per disablement Premium 0003 $2,000 $559 0004 $2,000 $455 0005 $1,000 $151 0006 $1,000 $151 0007 $1,000 $151 Issued Date: 12/03/2021 WN CA 01 06 16 INSURED COPY Page 2 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 www.wnins.com BUSINESS AUTO ITEM THREE: SCHEDULE OF COVERED AUTOS YOU OWN Policy Number: CPP 1063215 11 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY DESCRIPTION LOCATION ZONE PURCHASED Original Stated Unit # Year, Make & Model, Serial No. or Vehicle Identification Number Cost New Amount State I erritorylORG.DEST 00092000 SEMI TRAILERS 9999 $72,611 WA 002 00111994 GMC BOX TRUCK 1879 $5,000 WA 002 00122005 FREIGHTLINER 1FVACWDC75HN79780 $73,092 WA 002 00152007 INTERNATIONAL 9200I CONV CAB 1HSCDSBNX7C521081 $117,245 WA 002 00162015 FREIGHTLINER X12564ST TRK TRAC 3AKJGED3FSGB6832 $166,250 WA 002 CLASSIFICATION Primary Rating Factor Secondary Physical Radius of Size GVW, GCW or Rating Age Unit # Code Operation Business Use Seating Capacity Liability Damage Factor Group 000967499 Local Semitrailer OVER 2,000 LBS. LOAD 0.100 0.000 0.000 6 001133499 Local Commercial 20,001-45,000 GVW 1.600 0.940 0.000 6 001223499 Local Commercial 10,001-20,000 GVW 1.400 0.850 0.000 6 001533499 Local Commercial 20,001-45,000 GVW 1.600 0.940 0.000 6 001650499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 6 COVERAGES - PREMIUMS, LIMITS AND DEDUCTIBLES COVERED AUTOS LIABILITY PERSONAL INJURY PROTECTION ADDED PIP UNINSURED MOTORISTS Limit stated in each Limit stated in each PIP Endorsement Added PIP Endorsement minus Deductible Unit # Limit Premium shown below Premium Premium Limit Premium 0009 $1,000,000 $101 �0011I$1,000,000 $1,784 0012 $1,000,000 $1,401 0015 $1,000,000 $1,784 0016 $1,000,000 $3,571 COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) UNDERINSURED MOTORISTS AUTO MEDICAL PAYMENTS COMPREHENSIVE Limit stated in ITEM TWO minus deductible Unit # Limit Premium Limit Premium shown below Premium 0009 0011 $1,000,000 $149 $5,000 $14 $2,000 $22 0012 $1,000,000 $149 $5,000 $14 $1,000 $81 0015 $1,000,000 $149 $5,000 $14 $2,000 $92 10016 $1,000,000 $149 $5,000 $14 $2,000 $213 I COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) SPECIFIED CAUSES OF LOSS COLLISION TOWING & LABOR Limit stated in ITEM TWO Limit stated in ITEM TWO minus Deductible minus Deductible Limit per Unit # shown below Premium shown below Premium disablement Premium 0009 0011 $2,000 $9 0012 $1,000 $259 0015 $2,000 $341 0016 $2,000 $1,252 Issued Date: 12/03/2021 WN CA 01 06 16 INSURED COPY Page 3 of 12 Western National Mutual Insurance Company Policy Number: CPP 1063215 11 4700 West 77th Street RENEWAL DECLARATION Edina, MN 55435 Named Insured: www.wnins.com L & S TIRE COMPANY BUSINESS AUTO ITEM THREE: SCHEDULE OF COVERED AUTOS YOU OWN DESCRIPTION LOCATION ZONE PURCHASED Original Stated Unit # Year, Make & Model, Serial No. or Vehicle Identification Number Cost New Amount State Territory ORG.DEST 00172015 FREIGHTLINER X12564ST TRK TRAC3AKJGEDVXFSGB6830 $166,250 WA 002 00182015 FREIGHTLINER TRUCK -TRACTOR 3AKJGEDVlFSGB6831 $166,250 WA 002 00191978 FORD PICKUP TRUCK F25JRBC1107 $12,000 WA 002 00212017 FREIGHTLINER TRUCK 1FVACWDTXHHHS9372 $115,178 WA 002 00222022 INTERNATIONAL TRUCK -TRACTOR 3HSDXTZN9NN17608 $135,392 WA 003 CLASSIFICATION Primary Rating Factor Secondary Radius of Size GVW, GCW or Rating Age Physical Unit # Code Operation Business Use Seating Capacity Liability Damage Factor Group 0017SO499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 6 0018S0499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 6 001901499 Local Service 0-10,000 GVW 1.000 1.000 0.000 6 002123499 Local Commercial 10,001-20,000 GVW 1.400 0.850 0.000 6 0022S0499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 1 COVERAGES - PREMIUMS, LIMITS AND DEDUCTIBLES COVERED AUTOS LIABILITY PERSONAL INJURY PROTECTION ADDED PIP UNINSURED MOTORISTS Limit stated in each Limit stated in each PIP Endorsement Added PIP Endorsement Unit # Limit Premium minus Deductible shown below Premium Premium Limit Premium 0017 $1,000,000 $3,571 0018 $1,000,000 $3,571 0019 $1,000,000 $1,001 0021 $1,000,000 $1,457 0022 $1,000,000 $5,483 COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) UNDERINSURED MOTORISTS AUTO MEDICAL PAYMENTS COMPREHENSIVE Limit stated in ITEM TWO minus deductible Unit # Limit Premium Limit Premium shown below Premium 0017 $1,000,000 $149 $5,000 $14 $2,000 $213 0018 $1,000,000 $149 $5,000 $14 $2,000 $213 0019 $1,000,000 $149 $5,000 $14 0021 $1,000,000 $149 $5,000 $14 $1,000 $144 0022 $1,000,000 $149 $5,000 $16 $2,000 $224 COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) SPECIFIED CAUSES OF LOSS COLLISION TOWING & LABOR Limit stated in ITEM TWO Limit stated in ITEM TWO Unit # minus Deductible shown below Premium minus Deductible shown below Premium Limit per disablement Premium 0017 $2,000 $1,252 0018 $2,000 $1,252 0019 0021 $1,000 $648 0022 $2,000 $1,515 Issued Date: 12/03/2021 WN CA 01 06 16 INSURED COPY Page 4 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 www.wnins.com BUSINESS AUTO ITEM THREE: SCHEDULE OF COVERED AUTOS YOU OWN Policy Number: CPP 106321S 11 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY DESCRIPTION LOCATION ZONE PURCHASED Unit # Year, Make & Model, Serial No. or Vehicle Identification Number State Territory lORG.DEST Original Cost New Stated Amount 0023 2018 INTERNATIONAL BOX TRUCK-TRAC 1HTMMMML4JH732669 $83,175 WA 003 00242020 FREIGHTLINER BOX TRUCK-TRAC 3HAEUMMLBLL846644 $92,759 WA 003 00252022 INTERNATIONAL TRUCK -TRACTOR 3HCDZTZRONL285712 $135,392 WA 003 00262022 INTERNATIONAL TRUCK -TRACTOR 3HCDZTZR9NL285711 $135,392 WA 003 CLASSIFICATION Primary Rating Factor Secondary Physical Radius of Size GVW, GCW or Rating Age Unit # Code Operation Business Use Seating Capacity Liability Damage Factor Group 0023S0499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 5 002450499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 3 002SS0499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 1 0026S0499 Local Commercial Over 45,000 GCW 2.820 1.200 0.000 1 COVERAGES - PREMIUMS, LIMITS AND DEDUCTIBLES COVERED AUTOS LIABILITY PERSONAL INJURY PROTECTION ADDED PIP UNINSURED MOTORISTS Limit stated in each Limit stated in each PIP Endorsement Added PIP Endorsement minus Deductible Unit # Limit Premium shown below Premium Premium Limit Premium 0023 $1,000,000 $5,483 0024 $1,000,000 $5,483 0025 $1,000,000 $5,483 0026 $1,000,000 $5,483 $55,527 COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) UNDERINSURED MOTORISTS AUTO MEDICAL PAYMENTS COMPREHENSIVE Limit stated in ITEM TWO Unit # Limit Premium Limit Premium minus deductible shown below Premium 0023 $1,000,000 $149 $5,000 $16 $2,000 $165 0024 $1,000,000 $149 $5,000 $16 $2,000 $186 0025 $1,000,000 $149 $5,000 $16 $2,000 $224 0026 $1,000,000 $149 $5,000 $16 $2,000 $224 $2,682 $262 $2,440 COVERAGES - PREMIUM, LIMITS AND DEDUCTIBLES (Cont.) SPECIFIED CAUSES OF LOSS COLLISION TOWING & LABOR Limit stated in ITEM TWO Limit stated in ITEM TWO minus Deductible minus Deductible Limit per Unit # shown below Premium shown below Premium disablement Premium 0023 $2,000 $910 0024 $2,000 $1,042 0025 $2,000 $1,515 0026 $2,000 $1,515 $12,977 Issued Date: 12/03/2021 WN CA 01 06 16 INSURED COPY Page 5 of 12 Western National Mutual Insurance Company Policy Number: CPP 1063215 11 4700 West 77th Street RENEWAL DECLARATION Edina, MN 55435 Named Insured: www.wnins.com L & S TIRE COMPANY BUSINESS AUTO ITEM FOUR: SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS COVERED AUTOS LIABILITY COVERAGE - COST OF HIRE RATING BASIS FOR AUTOS USED IN YOUR MOTOR CARRIER OPERATIONS (OTHER THAN MOBILE OR FARM EQUIPMENT) ESTIMATED ANNUAL COVERED AUTOS LIABILITY COVERAGE COST OF HIRE FOR ALL STATES PREMIUM PRIMARY COVERAGE EXCESS COVERAGE TOTAL HIRED AUTO PREMIUM For "autos" used in your motor carrier operations, cost of hire means: 1. The total dollar amount of costs you incurred for the hire of automobiles (includes "trailers" and semitrailers), and if not included therein, 2. The total remunerations of all operators and drivers' helpers, of hired automobiles whether hired with a driver by lessor or an "employee" of the lessee, or any other third party, and 3. The total dollar amount of any other costs (i.e., repair, maintenance, fuel, etc.) directly associated with operating the hired automobiles whether such costs are absorbed by the "insured", paid to the lessor or owner, or paid to others. COVERED AUTOS LIABILITY COVERAGE - COST OF HIRE RATING BASIS FOR AUTOS NOT USED IN YOUR MOTOR CARRIER OPERATIONS (OTHER THAN MOBILE OR FARM EQUIPMENT) COVERED AUTOS LIABILITY ESTIMATED ANNUAL COVERAGE COST OF HIRE FOR ALL STATES PREMIUM PRIMARY COVERAGE EXCESS COVERAGE If Any $67 TOTAL HIRED AUTO PREMIUM $67 For "autos" NOT used in your motor carrier operations, cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. LIABIITY COVERAGE - RATING BASIS, NUMBER OF DAYS FOR MOBILE OR FARM EQUIPMENT - RENTAL PERIOD BASIS STATE ESTIMATED NUMBER OF DAYS EQUIPMENT WILL BE RENTED BASE PREMIUM FACTOR PREMIUM Total Premium Issued Date: 12/03/2021 WN CA 01 06 16 INSURED COPY Page 6 of 12 Western National Mutual Insurance Company Policy Number: CPP 1063215 11 4700 West 77th Street RENEWAL DECLARATION Edina, MN 55435 Named Insured: www.wnins.com L & S TIRE COMPANY BUSINESS AUTO ITEM FOUR: SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS (CONT'D) PHYSICAL DAMAGE COVERAGES - COST OF HIRE RATING BASIS FOR ALL AUTOS ESTIMATED ANNUAL COST OF HIRE FOR EACH STATE (EXCLUDING AUTOS HIRED COVERAGE LIMIT OF INSURANCE WITH A DRIVER) PREMIUM COMPREHENSIVE Actual Cash Value or Cost of If Any INCL repair, whichever is less, minus $ 500 Deductible for each Covered Auto, but no Deductible applies to Loss Caused by Fire or Lightning SPECIFIED CAUSES Actual Cash Value or Cost of OF LOSS Repair, whichever is less, minus $ Deductible for each Covered Auto for Loss Caused by Mischief or Vandalism COLLISION Actual Cash Value or Cost of If Any $ 7 5 Repair, whichever is less, minus $ 5 0 0 Deductible for each Covered Auto TOTAL HIRED AUTO PREMIUM $75 For Physical Damage Coverages, cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for any "auto" that is leased, hired, rented or borrowed with a driver. ITEM FIVE: SCHEDULE FOR NON -OWNERSHIP COVERED AUTOS LIABILITY NAMED INSURED'S BUSINESS RATING BASIS NUMBER PREMIUM Other Than Garage Service Operations And Number Of Employees 30 $873 Other Than Social Service Agencies Number Of Partners Garage Service Operations Number Of Employees Whose Principal Duty Involves The Operation Of Autos Social Service Agencies Number Of Employees Number of Volunteers Who Regularly Use Autos To Transport Clients TOTAL NON -OWNERSHIP COVERED AUTOS PREMIUM $873 Issued Date: 12/03/2021 WN CA 01 06 16 INSURED COPY Page 7 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 www.wnins.com Policy Number: CPP 106321S 11 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY LOCATION ADDRESS SCHEDULE Prem # 001 Prem # 002 SEE SCHEDULE SEE SCHEDULE SPOKANE, WA 99217 LAKEWOOD, WA 98499 Issued Date: 12/03/2021 WN IL 27 07 07 INSURED COPY Page 8 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, NIN 55435 www.wnins.com Unit/Loc 0003 CA9989 - LOSS PAYABLE WASHINGTON TRUST BANK LOAN SERVICE CENTER PO BOX 2127 SPOKANE WA 99210-2127 Unit/Loc 0004 CA9989 - LOSS PAYABLE WASHINGTON TRUST BANK LOAN SERVICE CENTER PO BOX 2127 SPOKANE WA 99210-2127 Unit/Loc 0005 CA9989 - LOSS PAYABLE WASHINGTON TRUST BANK LOAN SERVICE CENTER PO BOX 2127 SPOKANE WA 99210-2127 Unit/Loc 0006 CA9989 - LOSS PAYABLE 5WASHINGTON TRUST BANK .LOAN SERVICE CENTER 0 'PO BOX 2127 SPOKANE WA 99210-2127 Unit/Loc 0007 CA9989 - LOSS PAYABLE WASHINGTON TRUST BANK LOAN SERVICE CENTER PO BOX 2127 SPOKANE WA 99210-2127 Policy Number: CPP 1063215 it RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY POLICY INTEREST SCHEDULE Issued Date: 12/03/2021 WN IL 27 07 07 INSURED COPY Page 9 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 Unit/Loc 0011 CA9989 - LOSS PAYABLE WASHINGTON TRUST BANK LOAN SERVICE CENTER PO BOX 2127 SPOKANE WA 99210-2127 Unit/Loc 0012 CA9989 - LOSS PAYABLE WASHINGTON TRUST BANK LOAN SERVICE CENTER PO BOX 2127 SPOKANE WA 99210-2127 Unit/Loc 0015 CA9989 - LOSS PAYABLE WASHINGTON TRUST BANK LOAN SERVICE CENTER PO BOX 2127 SPOKANE WA 99210-2127 Unit/Loc 0000 CA9989 - LOSS PAYABLE RE:HIRED AUTOS RYDER TRUCK (REFER TO WNIL02) 6000 WINDWARD PARKWAY ALPHARETTA GA 30005 Unit/Loc 0016 CA2001 - ADD INS & LOSS PAYEE PENSKA TRUCK LEASING CO., LP SEE WNIL02 FOR REST OF NAME PO BOX 563 READING PA 19603 Policy Number: CPP 106321S 11 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY POLICY INTEREST SCHEDULE Issued Date: 12/03/2021 WN IL 27 07 07 Page 10 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 Unit/Loc 0017 CA2001 - ADD INS & LOSS PAYEE PENSKE TRUCK LEASING CO., LP SEE WNIL02 FOR REST OF NAME PO BOX 563 READING PA 19603 Unit/Loc oola CA2001 - ADD INS & LOSS PAYEE PENSKE TRUCK LEASING CO, LP PENSKE LEASING & RENTAL CO PO BOX 563 READING PA 19603 Unit/Loc 0021 CA2001 - ADD INS & LOSS PAYEE PENSKE TRUCK LEASING CO LP PENSKE LEASING & RENTAL CO PO BOX 563 READING PA 19603 Policy Number: CPP 1063215 11 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY POLICY INTEREST SCHEDULE Issued Date: 12/03/2021 WN IL 27 07 07 Pagel 1 of 12 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 www.wnins.com Coverage Line Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Commercial Auto Policy Number: CPP 1063215 11 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY FORMS AND ENDORSEMENTS SCHEDULE Form Number IL0123 IL0146 IL0198 WNIL02 CA0001 CA0135 CA2001 CA2134 CA2392 CA9903 CA9989 MCS90 WNCA11 WNCA27 WNCA43 WNCA72 WNCA73 Ed. Date (11/13) (08/10) (09/08) (07/07) (10/13) (10/13) (10/13) (10/13) (10/13) (10/13) (05/01) (04/00) (07/10) (06/16) (06/16) (12/16) (03/20) Description WA Changes - Defense Costs WA Common Policy Conditions Nuclear Energy Liab Excl Endt Endorsement Business Auto Coverage Form WA Changes Lessor AI & LP Washington Underinsured Motor WA -Exclusion of Terrorism Auto Medical Payments Coverage WA Loss Payable Form Motor Carrier Filing Punitive Damage Exclusion Business Auto Enhancement Endt Abuse Or Molestation Exclusion Exclusion - Asbestos Choice of Law Issued Date: 12/03/2021 WN IL 26 07 07 INSURED COPY Page 12 of 12 WN IL 02 07 07 ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL AUTO - CPP 1063215-10 With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. COMMERCIAL BUSINESS AUTO SCHEDULE UNIT 9 2000 SEMI TRAILERS LIABILITY CHARGE IS FOR FIRST 2000 SEMI TRAILER MISC LIABILITY IS FOR THE 136 ADDITIONAL SEMI TRAILER THIS ENDORSEMENT AMENDS THE POLICY IN REGARDS TO FORM CA 9989 PERSON OR ORGANIZATION (NAME AND ADDRESS) RYDER TRUCK RENTAL INC AND RYDER TRUCK RENTAL LT AND AFFILIATES 6000 WINDWARD PARKWAY ALPHARETTA, GA 3005 WN IL 02 07 07 POLICY NUMBER: CPP 1063215 11 COMMERCIAL AUTO CA 20 01 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LESSOR - ADDITIONAL INSURED AND LOSS PAYEE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is in- dicated below. Named Insured: L & S TIRE COMPANY Endorsement Effective Date: SCHEDULE Insurance Company: Western National Mutual Insurance Company Policy Number: CPP 1063215 11 Effective Date: 12/08/2021 Expiration Date: 12/08/2022 Named Insured: L & S TIRE COMPANY Address: 8119 N REGAL ST BLDG 5 SPOKANE WA 99217 Additional Insured (Lessor): PENSKA TRUCK LEASING CO., LP Address: PO BOX 563 READING PA 19603 Designation Or Description Of "Leased Autos": 2015 FREIGHTLINER X12564ST TRK TRAC 3AKJGED3FSGB6832 CA 20 01 10 13 ° Insurance Services Office, Inc., 2011 Page 1 of 2 Coverages Limit Of Insurance Covered Autos Liability $ 1, o o o, o o o. o o Each "Accident" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Comprehensive $ 2,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Collision $ 2,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Specified Causes Of Loss $ Deductible For Each Covered "Leased Auto" Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 1. Any "leased auto" designated or described in the Schedule will be considered a cov- ered "auto" you own and not a covered "auto" you hire or borrow. 2. For a "leased auto" designated or described in the Schedule, the Who Is An Insured provision under Covered Autos Liability Coverage is changed to include as an "insured" the lessor named in the Sched- ule. However, the lessor is an "insured" only for "bodily injury" or "property dam- age" resulting from the acts or omissions by: a. You; b. Any of your "employees" or agents; or c. Any person, except the lessor or any "employee" or agent of the lessor, op- erating a "leased auto" with the permis- sion of any of the above. 3. The coverages provided under this endorse- ment apply to any "leased auto" described in the Schedule until the expiration date shown in the Schedule, or when the lessor or his or her agent takes possession of the "leased auto", whichever occurs first. B. Loss Payable Clause 1. We will pay, as interest may appear, you and the lessor named in this endorsement for "loss" to a "leased auto". 2. The insurance covers the interest of the lessor unless the "loss" results from fraud- ulent acts or omissions on your part. 3. If we make any payment to the lessor, we will obtain his or her rights against any other party. C. Cancellation 1. If we cancel the policy, we will mail notice to the lessor in accordance with the Can- cellation Common Policy Condition. 2. If you cancel the policy, we will mail notice to the lessor. 3. Cancellation ends this agreement. D. The lessor is not liable for payment of your pre- miums. E. Additional Definition As used in this endorsement: "Leased auto" means an "auto" leased or rented to you, including any substitute, re- placement or extra "auto" needed to meet seasonal or other needs, under a leasing or rental agreement that requires you to provide direct primary insurance for the lessor. Page 2 of 2 ° Insurance Services Office, Inc., 2011 CA 20 01 10 13 POLICY NUMBER: CPP 1063215 11 COMMERCIAL AUTO CA 20 01 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LESSOR - ADDITIONAL INSURED AND LOSS PAYEE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is in- dicated below. Named Insured: L & S TIRE COMPANY Endorsement Effective Date: SCHEDULE Insurance Company: Western National Mutual Insurance Company Policy Number: CPP 1063215 11 Effective Date: 12/08/2021 Expiration Date: 12/08/2022 Named Insured: L & S TIRE COMPANY Address: 8119 N REGAL ST BLDG 5 SPOKANE WA 99217 Additional Insured (Lessor): PENSKE TRUCK LEASING CO., LP Address: PO BOX 563 READING PA 19603 Designation Or Description Of "Leased Autos": 2015 FREIGHTLINER X12564ST TRK TRAC 3AKJGEDVXFSGB6830 CA 20 01 10 13 ° Insurance Services Office, Inc., 2011 Page 1 of 2 Coverages Limit Of Insurance Covered Autos Liability $ 1, o 0 0, o 0 0. 0 0 Each "Accident" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Comprehensive $ 2,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Collision $ 2,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Specified Causes Of Loss $ Deductible For Each Covered "Leased Auto" Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 1. Any "leased auto" designated or described in the Schedule will be considered a cov- ered "auto" you own and not a covered "auto" you hire or borrow. 2. For a "leased auto" designated or described in the Schedule, the Who Is An Insured provision under Covered Autos Liability Coverage is changed to include as an "insured" the lessor named in the Sched- ule. However, the lessor is an "insured" only for "bodily injury" or "property dam- age" resulting from the acts or omissions by: a. You; b. Any of your "employees" or agents; or c. Any person, except the lessor or any "employee" or agent of the lessor, op- erating a "leased auto" with the permis- sion of any of the above. 3. The coverages provided under this endorse- ment apply to any "leased auto" described in the Schedule until the expiration date shown in the Schedule, or when the lessor or his or her agent takes possession of the "leased auto", whichever occurs first. B. Loss Payable Clause 1. We will pay, as interest may appear, you and the lessor named in this endorsement for "loss" to a "leased auto". 2. The insurance covers the interest of the lessor unless the "loss" results from fraud- ulent acts or omissions on your part. 3. If we make any payment to the lessor, we will obtain his or her rights against any other party. C. Cancellation 1. If we cancel the policy, we will mail notice to the lessor in accordance with the Can- cellation Common Policy Condition. 2. If you cancel the policy, we will mail notice to the lessor. 3. Cancellation ends this agreement. D. The lessor is not liable for payment of your pre- miums. E. Additional Definition As used in this endorsement: "Leased auto" means an "auto" leased or rented to you, including any substitute, re- placement or extra "auto" needed to meet seasonal or other needs, under a leasing or rental agreement that requires you to provide direct primary insurance for the lessor. Page 2 of 2 ° Insurance Services Office, Inc., 2011 CA 20 01 10 13 POLICY NUMBER: CPP 1063215 11 COMMERCIAL AUTO CA 20 01 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LESSOR - ADDITIONAL INSURED AND LOSS PAYEE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is in- dicated below. Named Insured: L & S TIRE COMPANY Endorsement Effective Date: SCHEDULE Insurance Company: Western National Mutual Insurance Company Policy Number: CPP 1063215 11 Effective Date: 12/08/2021 Expiration Date: 12/08/2022 Named Insured: L & S TIRE COMPANY Address: 8119 N REGAL ST BLDG 5 SPOKANE WA 99217 Additional Insured (Lessor): PENSKE TRUCK LEASING CO, LP Address: PO BOX 563 READING PA 19603 Designation Or Description Of "Leased Autos": 2015 FREIGHTLINER TRUCK -TRACTOR 3AKJGEDV1 FSGB6831 CA 20 01 10 13 ° Insurance Services Office, Inc., 2011 Page 1 of 2 Coverages Limit Of Insurance Covered Autos Liability $ 1, o o o, o o o. o o Each "Accident" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Comprehensive $ 2,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Collision $ 2,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Specified Causes Of Loss $ Deductible For Each Covered "Leased Auto" Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 1. Any "leased auto" designated or described in the Schedule will be considered a cov- ered "auto" you own and not a covered "auto" you hire or borrow. 2. For a "leased auto" designated or described in the Schedule, the Who Is An Insured provision under Covered Autos Liability Coverage is changed to include as an "insured" the lessor named in the Sched- ule. However, the lessor is an "insured" only for "bodily injury" or "property dam- age" resulting from the acts or omissions by: a. You; b. Any of your "employees" or agents; or c. Any person, except the lessor or any "employee" or agent of the lessor, op- erating a "leased auto" with the permis- sion of any of the above. 3. The coverages provided under this endorse- ment apply to any "leased auto" described in the Schedule until the expiration date shown in the Schedule, or when the lessor or his or her agent takes possession of the "leased auto", whichever occurs first. B. Loss Payable Clause 1. We will pay, as interest may appear, you and the lessor named in this endorsement for "loss" to a "leased auto". 2. The insurance covers the interest of the lessor unless the "loss" results from fraud- ulent acts or omissions on your part. 3. If we make any payment to the lessor, we will obtain his or her rights against any other party. C. Cancellation 1. If we cancel the policy, we will mail notice to the lessor in accordance with the Can- cellation Common Policy Condition. 2. If you cancel the policy, we will mail notice to the lessor. 3. Cancellation ends this agreement. D. The lessor is not liable for payment of your pre- miums. E. Additional Definition As used in this endorsement: "Leased auto" means an "auto" leased or rented to you, including any substitute, re- placement or extra "auto" needed to meet seasonal or other needs, under a leasing or rental agreement that requires you to provide direct primary insurance for the lessor. Page 2 of 2 © Insurance Services Office, Inc., 2011 CA 20 01 10 13 POLICY NUMBER: CPP 1063215 11 COMMERCIAL AUTO CA 20 01 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LESSOR - ADDITIONAL INSURED AND LOSS PAYEE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is in- dicated below. Named Insured: L & S TIRE COMPANY Endorsement Effective Date: SCHEDULE Insurance Company: Western National Mutual Insurance Company Policy Number: CPP 1063215 11 Effective Date: 12/08/2021 Expiration Date: 12/08/2022 Named Insured: L & S TIRE COMPANY Address: 8119 N REGAL ST BLDG 5 SPOKANE WA 99217 Additional Insured (Lessor): PENSKE TRUCK LEASING CO LP Address: PO BOX 563 READING PA 19603 Designation Or Description Of "Leased Autos": 2017 FREIGHTLINER TRUCK 1 FVACWDTXHHHS9372 CA 20 01 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 2 Coverages Limit Of Insurance Covered Autos Liability $ 1, 000, 000. 00 Each "Accident" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Comprehensive $ 1,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Collision $ 1,000.00 Deductible For Each Covered "Leased Auto" Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Specified Causes Of Loss $ Deductible For Each Covered "Leased Auto" Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 1. Any "leased auto" designated or described in the Schedule will be considered a cov- ered "auto" you own and not a covered "auto" you hire or borrow. 2. For a "leased auto" designated or described in the Schedule, the Who Is An Insured provision under Covered Autos Liability Coverage is changed to include as an "insured" the lessor named in the Sched- ule. However, the lessor is an "insured" only for "bodily injury" or "property dam- age" resulting from the acts or omissions by: a. You; b. Any of your "employees" or agents; or c. Any person, except the lessor or any "employee" or agent of the lessor, op- erating a "leased auto" with the permis- sion of any of the above. 3. The coverages provided under this endorse- ment apply to any "leased auto" described in the Schedule until the expiration date shown in the Schedule, or when the lessor or his or her agent takes possession of the "leased auto", whichever occurs first. B. Loss Payable Clause 1. We will pay, as interest may appear, you and the lessor named in this endorsement for "loss" to a "leased auto". 2. The insurance covers the interest of the lessor unless the "loss" results from fraud- ulent acts or omissions on your part. 3. If we make any payment to the lessor, we will obtain his or her rights against any other party. C. Cancellation 1. If we cancel the policy, we will mail notice to the lessor in accordance with the Can- cellation Common Policy Condition. 2. If you cancel the policy, we will mail notice to the lessor. 3. Cancellation ends this agreement. D. The lessor is not liable for payment of your pre- miums. E. Additional Definition As used in this endorsement: "Leased auto" means an "auto" leased or rented to you, including any substitute, re- placement or extra "auto" needed to meet seasonal or other needs, under a leasing or rental agreement that requires you to provide direct primary insurance for the lessor. Page 2 of 2 ° Insurance Services Office, Inc., 2011 CA 20 01 10 13 POLICY NUMBER: CPP 1063215 11 COMMERCIAL AUTO CA21341013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WASHINGTON UNDERINSURED MOTORISTS COVERAGE For a covered "auto" licensed or principally garaged in, or for "auto dealer operations" conducted in, Washington, this endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. Named Insured: L & S TIRE COMPANY Endorsement Effective Date: SCHEDULE "Bodily Injury" And "Property Damage": $ 1,000,000 Each "Accident" Or "Bodily Injury": $ Each "Accident" This endorsement provides "bodily injury" and "property damage" Underinsured Motorists Coverage unless an "X" is entered below: HIf an "X" is entered in this box, this endorsement provides "bodily injury" Underinsured Motorists Coverage only for the following "autos": Description Of "Autos": Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Coverage 1. We will pay all sums the "insured" is legally entitled to recover as compensatory damages from the owner or driver of an "underinsured motor vehicle". The dam- ages must result from "bodily injury" or "property damage" sustained by the "insured" caused by an "accident". The owner's or driver's liability for these damages must result from the ownership, maintenance or use of the "underinsured motor vehicle". B. Who Is An Insured If the Named Insured is designated in the Declarations as: 1. An individual, then the following are "insureds": a. The Named Insured and any "family me mbers". b. Anyone else "occupying" a covered "auto" or a temporary substitute for a covered "auto". The covered "auto" must be out of service because of its breakdown, repair, servicing, "loss" or destruction. CA 21 34 10 13 © Insurance Services Office, Inc., 2012 Page 1 of 5 c. Anyone for damages he or she is entitled to recover because of "bodily injury" sustained by another "insured". 2. A partnership, limited liability company, corporation or any other form of organi- zation, then the following are "insureds": a. Anyone "occupying" a covered "auto" or a temporary substitute for a covered "auto". The covered "auto" must be out of service because of its break- down, repair, servicing, "loss" or de- struction. b. Anyone for damages he or she is entitled to recover because of "bodily injury" sustained by another "insured". c. The Named Insured for "property dam- age" only. C. Exclusions This insurance does not apply to: 1. The benefit of any insurer or self -insurer under any workers' compensation law or any similar disability benefits law. 2. The benefit of any insurer of property. 3. "Bodily injury" sustained by: a. An individual Named Insured while "occupying" any vehicle owned by that Named Insured or made available for that Named Insured's regular use that is not a covered "auto" for Covered Autos Liability Coverage under this Coverage Form; b. Any "family member" while "occu- pying" any vehicle owned by that "family member" or available for that "family member's" regular use that is not a covered "auto" for Covered Autos Liability Coverage under this Coverage Form; or c. Any "family member" while "occu- pying" any vehicle owned by the Named Insured or made available for the Named Insured's regular use that is insured for Liability Coverage on a primary basis under any other Coverage Form or policy. 4. Property contained in or struck by any vehicle owned by or available for the regular use of the Named Insured or any "family member", if the Named Insured is an individual, which is not a covered "auto" for Covered Autos Liability Cover- age under this Coverage Form. 5. The first $300 of the amount of "property damage" to the property of each "insured" as the result of any one "accident" caused by a hit-and-run vehicle as described in Paragraph 5.d. of the definition of "under - insured motor vehicle". In all other cases, this insurance does not apply to the first $100 of the amount of "property damage" to the property of each "insured" as the result of any one "accident". 6. Anyone using a vehicle without a reason- able belief that the person is entitled to do SO. 7. "Bodily injury" or "property damage" to an "insured" while operating or "occupying" a motorcycle or motor driven cycle which is not a covered "auto" for Covered Autos Liability Coverage under this Coverage Form. 8. Punitive or exemplary damages. 9. "Bodily injury" or "property damage" arising directly or indirectly out of: a. War, including undeclared or civil war; b. Warlike action by a military force, including action in hindering or de- fending against an actual or expected attack, by any government, sovereign or other authority using military per- sonnel or other agents; or c. Insurrection, rebellion, revolution, usurped power, or action taken by governmental authority in hindering or defending against any of these. D. Limit Of Insurance 1. Regardless of the number of covered "autos", "insureds", premiums paid, claims made or vehicles involved in the "acci- dent", the most we will pay for all damages resulting from any one "accident" is the limit shown in the Schedule or in the Declarations. 2. No one will be entitled to receive duplicate payments for the same elements of "loss" under this Coverage Form and any Liability Coverage form, Medical Payments Cover- age endorsement or Personal Injury Pro- tection Coverage endorsement attached to this Coverage Part. We will not make a duplicate payment under this coverage for any element of "loss" for which payment has been made by or for anyone who is legally responsible. Page 2 of 5 © Insurance Services Office, Inc., 2012 CA 21 34 10 13 E. Changes In Conditions The Conditions are changed for Washington Underinsured Motorists Coverage as follows: 1. Other Insurance in the Auto Dealers and Business Auto Coverage Forms and Other Insurance - Primary And Excess Insurance Provisions in the Motor Carrier Coverage Form are replaced by the following: If there is other applicable insurance avail- able under one or more policies or provisions of coverage: a. The maximum recovery under all Cov- erage Forms or policies combined may equal but not exceed the highest applicable limit for any one vehicle under any Coverage Form or policy providing coverage on either a primary or excess basis. b. Any insurance we provide with respect to a vehicle the Named Insured does not own shall be excess over any other collectible underinsured motorists insur- ance providing coverage on a primary basis. c. If the coverage under this Coverage Form is provided: (1) On a primary basis, we will pay only our share of the loss that must be paid under insurance providing coverage on a primary basis. Our share is the proportion that our limit of liability bears to the total of all applicable limits of liability for cov- erage on a primary basis. (2) On an excess basis, we will pay only our share of the loss that must be paid under insurance providing coverage on an excess basis. Our share is the proportion that our limit of liability bears to the total of all applicable limits of liability for cov- erage on an excess basis. 2. Duties In The Event Of Accident, Claim, Suit Or Loss in the Business Auto and Motor Carrier Coverage Forms and Duties In The Event Of Accident, Claim, Offense, Suit, Loss Or Acts, Errors Or Omissions in the Auto Dealers Coverage Form are changed by adding the following: a. A person seeking Underinsured Mo- torists Coverage must also promptly notify us in writing of a tentative settlement between the "insured" and the insurer of an "underinsured motor vehicle" and allow us 30 days to advance payment to that "insured" in an amount equal to the tentative settle ment to preserve our rights against the insurer, owner or operator of such "underinsured motor vehicle". How- ever, this provision does not apply if failure to notify us does not prejudice our right to recover payment from the person legally responsible for the "accident". 3. Legal Action Against Us is replaced by the following: Legal Action Against Us a. No one may bring a legal action against us under this Coverage Form until there has been full compliance with all the terms of this Coverage Form. b. Any legal action against us under this Coverage Form must be brought within one year after the date on which the cause of action accrues. If this action is brought pursuant to Sec. 3 of RCW 48.30, then 20 days prior to filing such an action, you are required to provide written notice of the basis for the cause of action to us and the Office of the Insurance Commissioner. Such notice may be sent by regular mail, registered mail or certified mail with return receipt requested. CA 21 34 10 13 © Insurance Services Office, Inc., 2012 Page 3 of 5 4. Transfer Of Rights Of Recovery Against Others To Us is changed by adding the following: If we make any payment and the "insured" recovers from another party, the "insured" shall hold the proceeds in trust for us and pay us back the amount we have paid. We shall be entitled to recovery only after the "insured" has been fully compensated for damages. Our rights do not apply under this provision with respect to damages caused by an "accident" with an "underinsured motor vehicle" if we: a. Have been given prompt notice of a tentative settlement between an "in- sured" and the insurer of an "underinsured motor vehicle"; and b. Fail to advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification. If we advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification: (1) That payment will be separate from any amount the "insured" is entitled to recover under the pro- visions of Underinsured Motorists Coverage; and (2) We also have a right to recover the advanced payment. 5. The following condition is added: Arbitration a. If we and an "insured" disagree whether the "insured" is legally entitled to recover damages from the owner or driver of an "underinsured motor vehicle" or do not agree as to the amount of damages that are recover- able by that "insured", then the matter may be arbitrated. However, disputes concerning coverage under this en- dorsement may not be arbitrated. Both parties must agree to arbitration. If so agreed, each party will select an arbitrator. The two arbitrators will se lect a third. If they cannot agree within 30 days, either may request that selection be made by a judge of a court having jurisdiction. We will pay all arbitration expenses. Arbitration ex- penses will not include the "insured's" attorney's fees or any expenses in- curred in producing evidence or wit- nesses. b. Unless both parties agree otherwise, arbitration will take place in the county in which the "insured" lives. Local rules of law as to arbitration procedure and evidence will apply. A decision agreed to by two of the arbitrators will be binding. F. Additional Definitions As used in this endorsement: 1. "Property damage" means injury to or destruction of the property of an "insured". 2. "Family member" means a person related to an individual Named Insured by blood, marriage or adoption, who is a resident of such Named Insured's household, including a ward or foster child. 3. "Occupying" means in, upon, getting in, on, out or off. 4. "Suit" means a civil proceeding in which: a. Damages because of "bodily injury" or "property damage"; or b. A "covered pollution cost or expense" to which this insurance applies, are alleged. "Suit" includes: (1) An arbitration proceeding in which such damages or "covered pollution costs or expenses" are claimed; or (2) Any other alternative dispute res- olution proceeding in which such damages or "covered pollution costs or expenses" are claimed. 5. "Underinsured motor vehicle" means a land motor vehicle or "trailer": a. For which no liability bond or policy applies at the time of an "accident"; or b. For which liability bonds or policies apply at the time of the "accident", but the amount paid under all of the bonds or policies to an "insured" is not enough to pay the full amount an "insured" is legally entitled to recover as damages caused by the "accident"; or c. For which all insuring or bonding com- panies deny coverage or are or become insolvent; or d. That is a hit-and-run vehicle and neither the driver nor owner can be identified. The vehicle must either: (1) Hit an "insured", a covered "auto" or a vehicle an "insured" is "occu- pying"; or Page 4 of 5 ° Insurance Services Office, Inc., 2012 CA 21 34 10 13 (2) Cause "bodily injury" or "property damage" with no physical contact with the "insured" or the vehicle the "insured" was "occupying" at the time of the "accident", pro- vided: (a) The facts of the "accident" can be corroborated by competent evidence other than the testi- mony of any person having an underinsured motorists cover- age claim as a result of such "accident"; and (b) Someone reports the "accident" to the police within 72 hours of the "accident". However, "underinsured motor vehicle" does not include any vehicle: (1) For which the Covered Autos Liability Coverage of this Coverage Form applies. However, if the Named Insured is an individual and that Named Insured or any "family member" sustains damages while "occupying", or when struck by, an "auto" which is a covered "auto" for Covered Autos Liability Cover- age under this Coverage Form, this exception to this definition of an "underinsured motor vehicle" does not apply to that Named Insured or any such "family member". (2) Owned by a governmental unit or agency. This provision does not apply if the governmental unit or agency is unable to pay damages because of financial inability or in- solvency. 6. Whenever the terms "uninsured motorists coverage" or "uninsured motor vehicle" appear in the Coverage Form or any endorsements attached to the Coverage Form, they are replaced by the terms "underinsured motorists coverage" and "underinsured motor vehicle" for covered "autos" licensed in, or "auto dealer oper- ations" conducted in, Washington. CA 21 34 10 13 © Insurance Services Office, Inc., 2012 Page 5 of 5 POLICY NUMBER: CPP 1063215 11 COMMERCIAL AUTO CA99890501 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WASHINGTON LOSS PAYABLE FORM REG-335 This endorsement reflects the text of the form promulgated in Washington State Insurance Commissioner's Regulation No. 335, as reproduced in Section 284-21-990 of the Washington Administrative Code. SCHEDULE Insurance Company Policy Number CPP 1063215 11 Endorsement Effective Date Issued To WASHINGTON TRUST BANK LOAN SERVICE CENTER Secured Party PO BOX 2127 Address SPOKANE WA 99210-2127 Additional Secured Party Address By Agent A. Loss or damage, if any, under this policy shall be payable first to the loss payee or mortgagee (hereinafter called secured party), and, second, to the insured, as their interests may appear; pro- vided, that, upon demand for separate settlement by the secured party, the amount of said loss shall be paid directly to the secured party to the extent of its interest. B. This insurance as to the interest of the secured party shall not be invalidated by any act or neg- lect of the insured named in said policy or his a- gents, employees or representatives, nor by any change in the title or ownership of the insured property: provided, however, that, the conver- sion, embezzlement or secretion by the named in- sured or his agents, employees or representatives is not covered under said policy unless specific- ally insured against and premiums paid therefor. C. In applying the pro rata provisions of the policy, the amount payable to the secured party shall be reduced only to the extent of pro rata payments receivable by the secured party under other poli- cies. D. The company reserves the right to cancel the policy at any time as provided by its terms, but in such case the company shall mail to the secured party a notice stating when such cancellation shall become effective as to the interest of said secured party. The amount and form of such no- tice shall not be less than that required to be given the named insured, by law or by the policy provisions, whichever is more favorable to the se- cured party. E. If the insured fails to render proof of loss within the time granted in the policy conditions, such secured party shall do so within sixty days after having knowledge of a loss, in form and manner as provided by the policy, and, further, shall be subject to the provisions of the policy relating to appraisal and the time of payment and bringing suit. F. Whenever the company shall pay the secured party any sum for loss or damage under policy and shall claim that, as to the insured, no liability exists, the company shall, to the extent of such payment, be thereupon legally subrogated to all the rights of the party to whom such payment shall be made, under all collateral held to secure the debt, or may, at its option, pay to the secured party the whole principal due or to grow due on the mortgage or other security agreement, with interest, and shall thereupon receive a full assign- ment and transfer of the mortgage or other se- curity agreement and of all collateral held to se- cure it; but no subrogation shall impair the right of the secured party to recover the full amount due it. G. All terms and conditions of the policy remain un- changed except as herein specifically provided. H. All notices sent to the secured party shall be sent to its last reported address, which must be stated in the policy or in this endorsement. CA 99 89 05 01 Copyright, ISO Properties, Inc., 2000 Page 1 of 1 POLICY NUMBER: CPP 1063215 11 COMMERCIAL AUTO CA 99 89 05 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WASHINGTON LOSS PAYABLE FORM REG-335 This endorsement reflects the text of the form promulgated in Washington State Insurance Commissioner's Regulation No. 335, as reproduced in Section 284-21-990 of the Washington Administrative Code. SCHEDULE Insurance Company Policy Number CPP 1063215 11 Endorsement Effective Date Issued To REHIRED AUTOS RYDER TRUCK (REFER TO WNIL02) Secured Party 6000 WINDWARD PARKWAY Address ALPHARETTA GA 30005 Additional Secured Party Address By Agent A. Loss or damage, if any, under this policy shall be payable first to the loss payee or mortgagee (hereinafter called secured party), and, second, to the insured, as their interests may appear; pro- vided, that, upon demand for separate settlement by the secured party, the amount of said loss shall be paid directly to the secured party to the extent of its interest. B. This insurance as to the interest of the secured party shall not be invalidated by any act or neg- lect of the insured named in said policy or his a- gents, employees or representatives, nor by any change in the title or ownership of the insured property: provided, however, that, the conver- sion, embezzlement or secretion by the named in- sured or his agents, employees or representatives is not covered under said policy unless specific- ally insured against and premiums paid therefor. C. In applying the pro rata provisions of the policy, the amount payable to the secured party shall be reduced only to the extent of pro rata payments receivable by the secured party under other poli- cies. D. The company reserves the right to cancel the policy at any time as provided by its terms, but in such case the company shall mail to the secured party a notice stating when such cancellation shall become effective as to the interest of said secured party. The amount and form of such no- tice shall not be less than that required to be given the named insured, by law or by the policy provisions, whichever is more favorable to the se- cured party. E. If the insured fails to render proof of loss within the time granted in the policy conditions, such secured party shall do so within sixty days after having knowledge of a loss, in form and manner as provided by the policy, and, further, shall be subject to the provisions of the policy relating to appraisal and the time of payment and bringing suit. F. Whenever the company shall pay the secured party any sum for loss or damage under policy and shall claim that, as to the insured, no liability exists, the company shall, to the extent of such payment, be thereupon legally subrogated to all the rights of the party to whom such payment shall be made, under all collateral held to secure the debt, or may, at its option, pay to the secured party the whole principal due or to grow due on the mortgage or other security agreement, with interest, and shall thereupon receive a full assign- ment and transfer of the mortgage or other se- curity agreement and of all collateral held to se- cure it; but no subrogation shall impair the right of the secured party to recover the full amount due it. G. All terms and conditions of the policy remain un- changed except as herein specifically provided. H. All notices sent to the secured party shall be sent to its last reported address, which must be stated in the policy or in this endorsement. CA 99 89 05 01 Copyright, ISO Properties, Inc., 2000 Page 1 of 1 2 U.S. Department of Transportation ENDORSEMENT FOR Form Approved: Federal Motnr Carrier MOTOR CARRIER POLICIES OF INSURANCE FOR PUBLIC LIABILITY OMB No.: 2126-0008 safe" Administration UNDER SECTIONS 29 AND 30 OF THE MOTOR CARRIER ACT OF 1980 Issued to L & S TIRE COMPANY of WA Dated at 12:00 NOON this 03 day of DECEMBER 20 21 Amending Policy No. CPP 1063215 11 Effective Date 12/08/2021 Name of Insurance Company Western National Mutual Insurance Company Countersigned by paf Authorized Company Representative The policy to which this endorsement is attached provides primary or excess insurance, as indicated by "[XI," for the limits shown: [x] This insurance is primary and the company shall not be liable for amounts in excess of $1, 000, 000 for each accident. [ ] This insurance is excess and the company shall not be liable for amounts in excess of $ for each accident in excess of the underlying limit of $ for each accident. Whenever required by the Federal Motor Carrier Safety Administration (FMCSA), the company agrees to furnish the FMCSA a duplicate of said policy and all its endorsements. The company also agrees, upon telephone request by an authorized representative of the FMCSA, to verify that the policy is in force as of a particular date. The telephone number to call is: 952-835-5350 Cancellation of this endorsement may be effected by the company of the insured by giving (11 thirty-five (35) days notice in writing to the other party (said 35 days notice to commence from the date the notice is mailed, proof of mailing shall be sufficient proof of notice), and (2) if the insured is subject to the FMCSA's registration requirements under 49 U.S.C. 13901, by providing thirty (30) days notice to the FMCSA (said 30 days notice to commence from the date the notice is received by the FMCSA at its office in Washington, D.C.). DEFINITIONS AS USED IN THIS ENDORSEMENT Property Damage means damage to or loss of use of tangible property. Accident includes continuous or repeated exposure to conditions or Environmental Restoration means restitution for the loss, damage, which results in bodily injury, property damage, or environmental or destruction of natural resources arising out of the accidental damage which the insured neither expected nor intended. discharge, dispersal, release or escape into or upon the land, Motor Vehicle means a land vehicle, machine, truck, tractor, trailer, or atmosphere, watercourse, or body of water, of any commodity semitrailer propelled or drawn by mechanical power and used on a transported by a motor carrier. This shall include the cost of highway for transporting property, or any combination thereof. removal and the cost of necessary measures taken to minimize or Bodily Injury means injury to the body, sickness, or disease to any mitigate damage to human health, the natural environment, fish, person, including death resulting from any of these. shellfish, and wildlife. Public Liability means liability for bodily injury, property damage, and environmental restoration The insurance policy to which this endorsement is attached provides judgment, within the limits of liability herein described, irrespective automobile liability insurance and is amended to assure compliance by of the financial condition, insolvency or bankruptcy of the insured. the insured, within the limits stated herein, as a motor carrier of However, all terms, conditions, and limitations in the policy to Sproperty, with Sections 29 and 30 of the Motor Carrier Act of 1980 which the endorsement is attached shall remain in full force and S and the rules and regulations of the Federal Motor Carrier Safety effect as binding between the insured and the company. The Administration (FMCSA). insured agrees to reimburse the company for any payment made by the company on account of any accident, claim, or suit In consideration of the premium stated in the policy to which this involving a breach of the terms of the policy, and for any payment endorsement is attached, the insurer (the company) agrees to pay, that the company would not have been obligated to make under within the limits of liability described herein, any final judgment the provisions of the policy except for the agreement contained in recovered against the insured for public liability resulting from this endorsement. negligence in the operation, maintenance or use of motor vehicles subject to the financial responsibility requirements of Sections 29 and It is further understood and agreed that, upon failure of the 30 of the Motor Carrier Act of 1980 regardless of whether or not each company to pay any final judgment recovered against the insured motor vehicle is specifically described in the policy and whether or not as provided herein, the judgment creditor may maintain an action such negligence occurs on any route or in any territory authorized to be in any court of competent jurisdiction against the company to served by the insured or elsewhere. Such insurance as is afforded, for compel such payment. public liability, does not apply to injury to or death of the insured's employees while engaged in the course of their employment, or The limits of the company's liability for the amounts prescribed in property transported by the insured, designated as cargo. It is this endorsement apply separately to each accident and any understood and agreed that no condition, provision, stipulation, or payment under the policy because of any one accident shall not limitation contained in the policy, this endorsement, or any other operate to reduce the liability of the company for the payment of endorsement thereon, or violation thereof, shall relieve the company final judgments resulting from any other accident. from liability or from the payment of any final THE SCHEDULE OF LIMITS SHOWN ON THE REVERSE SIDE DOES NOT PROVIDE COVERAGE. The limits shown in the schedule are for information purposes only. MC 1622p (0 1 -07) Form MCS-90 (4/2000) SCHEDULE OF LIMITS PUBLIC LIABILITY Type of carriage Commodity transported Jan. 1, 1985 (1) For -hire (In interstate or foreign Property (nonhazardous) $ 750,000 commerce, with a gross vehicle weight rating of 10,000 or more pounds). (2) For -hire and Private (In interstate, Hazardous substances, as defined in 49 $5,000,000 foreign, or intrastate commerce, with CFR 171.8, transported in cargo tanks, a gross vehicle weight rating of portable tanks, or hopper -type vehicles 10,000 or more pounds). with capacities in excess of 3,500 water gallons; or in bulk Divisions 1.1, 1 .2, and 1.3 materials, Division 2.3, Hazard Zone A, or Division 6.1, Packing Group 1, Hazard Zone A material; in bulk Division 2.1 or 2.2; or highway route controlled quantities of a Class 7 material, as defined in 49 CFR 173.403. (3) For -hire and Private (In interstate or Oil listed in 49 CFR 172.101; hazardous $1,000,000 foreign commerce, in any quantity; or waste, hazardous materials, and hazardous in intrastate commerce, in bulk only; substances defined in 49 CFR 171.8 and with a gross vehicle weight rating of listed in 49 CFR 172.101, but not 10,000 or more pounds). mentioned in (2) above or (4) below. (4) For -hire and Private (In interstate or Any quantity of Division 1.1, 1 .2, or 1.3 $5,000,000 foreign commerce, with a gross material; any quantity of a Division 2.3, vehicle weight rating of less than Hazard Zone A, or Division 6.1 , Packing 10,000 pounds). Group 1, Hazard Zone A material; or highway route controlled quantities of a Class 7 material as defined in 49 CFR 173.403. Form MCS-90 (4/2000) MC 1622p (01 /07) Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 www.wnins.com A Mutual Company COMMERCIAL LIABILITY UMBRELLA DECLARATION W WESTERN NATIONAL INSURANCE The relationship company Group # 0000203718 Policy Period: From DECEMBER 8, 2021 To DECEMBER 8, 2022 Policy # UMB 3.044772 02 12:01 A.M. standard time at the Named Insured's mailing address. Transaction RENEWAL DECLARATION Insured Name and Address Agent L & S TIRE COMPANY PAYNEWEST INSURANCE 06023 8119 N REGAL ST BLDG 5 501 N RIVERPOINT BLVD, STE 403 SPOKANE WA 99217 SPOKANE, WA 99202-1649 Telephone: 509-838-3501 Business Description Type of Business Audit Period Billing Type TIRE RETREADING CORPORATION NONE DIRECT IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. LIMITS OF INSURANCE COVERAGES Aggregate Limit Liability Coverage - except with respect to covered autos Coverage A Bodily Injury and Property Damage Liability Coverage B Personal and Advertising Injury Liability Retained Limit Self Insured Retention PREMIUM Annual Premium LIMITS OF LIABILITY $3,000,000 $3,000,000 each occurrence $3, 000, 000 any one person or organization subject to the Aggregate Limit of Liability $10, 000 any one occurrence or offense $14,696 DISCLOSURE OF PREMIUM: The portion of your annual premium attributable to coverage for certified acts of terrorism is $ 14S.00 Forms and Endorsements Applicable to this Policy See Forms and Endorsements Schedule I hese Declarations together with the common policy conditions, coverage part declarations, coverage form(s), and form(s) and endorsements, if any, issued, complete the above numbered policy. Issued Date: 12/03/2021 WN CU 02 07 07 INSURED COPY Page 1 of 3 Western National Mutual Insurance Company Policy Number: UMB 1044772 02 4700 West 77th Street RENEWAL DECLARATION Edina, MN 55435 Named Insured: www.wnins.com L & S TIRE COMPANY COMMERCIAL LIABILITY UMBRELLA SCHEDULE OF UNDERLYING INSURANCE POLICY NUMBER, CARRIER TYPE OF LIMITS OF INSURANCE and POLICY PERIOD POLICY CPP 1063215 Commercial Auto Liability WESTERN NATIONAL MUTUAL INS CO 12/08/2021 to 12/08/2022 CPP 0013699 Bodily Injury Liability Each Person Each Accident Property Damage Liability Each Accident Commercial General Liability 1 WESTERN NATIONAL ASSURANCE CO 12/08/2021 to 12/08/2022 CPP 0013699 1 WESTERN NATIONAL ASSURANCE CO 12/08/2021 to 12/08/2022 Combined Single Limit $1,000,000 $2, 000, 000 General Aggregate (other than Products - Completed Operations) $2, 000, 000 Products -Completed Operations Aggregate $1, 000, 000 Personal and Advertising Injury $1, 000, 000 Each Occurrence Stop Gap Bodily Injury by Accident Liability $1, 000, o o o Each Accident Bodily Injury by Disease $1, 000, o o o Policy Limit Bodily Injury by Disease $1, 000, o o o Each Employee Issued Date: 12/03/2021 WN CU 02 07 07 INSURED COPY Page 2 of 3 Western National Mutual Insurance Company 4700 West 77th Street Edina, MN 55435 www.wnins.com Policy Number: UMB 1044772 02 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY FORMS AND ENDORSEMENTS SCHEDULE Coverage Line Form Number Ed. Date Description Commercial Umbrella IL0123 (11/13) WA Changes - Defense Costs Commercial Umbrella IL0146 (08/10) WA Common Policy Conditions Commercial Umbrella IL0198 (09/08) Nuclear Energy Liab Excl Endt Commercial Umbrella CU0001 (04/13) Comm Liab Umbrella Cvg Form Commercial Umbrella CU0121 (09/00) WA Changes Commercial Umbrella CU0186 (01/15) WA Cond Excl of Terrorism Commercial Umbrella CU2118 (09/00) Excl-Yr 2000 Computer Commercial Umbrella CU2124 (06/15) Excl-Non-Owned Aircraft Commercial Umbrella CU2131 (01/15) Excl Oth Acts Terr Outside US Commercial Umbrella CU2136 (01/15) Excl of Punitive Damages Relat Commercial Umbrella CU2142 (12/04) Excl-Exterior Insulation Commercial Umbrella CU2150 (03/05) Silica or Silica Related Dust Commercial Umbrella CU2155 (06/08) Amended Terrorism Coverage Commercial Umbrella CU2171 (06/15) Exclusion -Unmanned Aircraft Commercial Umbrella CU2186 (05/14) Excl-Acc. or Disc of Confident Commercial Umbrella CU2430 (04/13) Amendment of Insured Contract Commercial Umbrella CU2677 (12/04) WA -Fungi or Bacteria Excl Commercial Umbrella WNCU11 (07/14) Abuse or Molestation Excl Commercial Umbrella WNCU114 (07/15) Who is an Insured Amended Commercial Umbrella WNCU47 (07/14) Occupational Disease Exclusion Commercial Umbrella WNCU79 (07/15) Total Liquor Liability Excl Commercial Umbrella WNCU91 (07/10) Excl-Punitive Damages Commercial Umbrella WNCU92 (01/04) Excl-Lead Liability Commercial Umbrella WNCU93 (12/16) Excl-Asbestos Issued Date: 12/03/2021 WN IL 26 07 07 INSURED COPY Page 3 of 3 COMMERCIAL UMBRELLA LIABILITY COVERAGE FORM QUICK REFERENCE READ YOUR POLICY CAREFULLY The Commercial Umbrella Liability Coverage policy consists of Declarations, a Commercial Umbrella Liability Coverage Form (CU 00 01), Common Policy Conditions and Endorsements, if applicable. Following is a Quick Reference indexing of the principal provisions contained in each of the components making up the Coverage Part, listed in sequential order. DECLARATIONS Policy Period Named Insured Limits Of Insurance Premium Applicable Endorsements SCHEDULE OF UNDERLYING INSURANCE Schedule Of Underlying Policies SECTION I — COVERAGES Coverage A — Bodily Injury And Property Damage Liability Insuring Agreement Exclusions Coverage B — Personal And Advertising Injury Liability Insuring Agreement Exclusions Supplementary Payments — Coverages A and B SECTION II — WHO IS AN INSURED SECTION III — LIMITS OF INSURANCE SECTION IV —CONDITIONS Appeals Bankruptcy Duties In The Event Of Occurrence, Offense, Claim Or Suit Legal Action Against Us Other Insurance Premium Audit Representations Or Fraud Separation Of Insureds Transfer Of Rights Of Recovery Against Others To Us When We Do Not Renew Loss Payable Transfer Of Defense Maintenance Of/Changes To Underlying Insurance Expanded Coverage Territory SECTION V — DEFINITIONS IMPORTANT: This Quick Reference is not part of your Umbrella Policy and does not provide coverage. Refer to your Commercial Umbrella Liability Policy for actual contractual provisions. WN CU 75 07 15 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com A Stock Company COMMERCIAL PROPERTY DECLARATION W WESTERN NATIONAL I-RANCE The r•elanonship rnmpany Group # 0000203718 Policy Period: From DECEMBER 8, 2021 To DECEMBER 8, 2022 Policy # CPP 0013699 19 12:01 A.M. standard time at the Named Insured's mailing address. Transaction RENEWAL DECLARATION Insured Name and Address Agent L & S TIRE COMPANY PAYNEWEST INSURANCE 06023 8119 N REGAL ST BLDG 5 501 N RIVERPOINT BLVD, STE 403 SPOKANE WA 99217 SPOKANE, WA 99202-1649 Telephone: 509-838-3501 Business Description Type of Business Audit Period Billing Type TIRE SHREDDING & BALING CORPORATION ANNUAL DIRECT IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE ........ WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. DESCRIPTION OF PREMISES Refer to attached schedule. COVERAGES PROVIDED Refer to attached schedule, if any. OPTIONAL COVERAGES Refer to attached schedule, if any. MORTGAGEES AND ADDITIONAL INTERESTS Refer to attached schedule, if any. PREMIUM FOR THIS COVERAGE PART DISCLOSURE OF PREMIUM: The portion of your annual premium attributable to coverage for certified acts of terrorism is rorms ana tnaorsemenis Appncame to finis roucy See Forms and Endorsements Schedule $ 8,684.00 $ 21.00 Issued Date: 12/03/2021 WN CP 02 07 07 INSURED COPY Page 1 of 12 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Policy Number: CPP 0013699 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY COMMERCIAL PROPERTY DESCRIPTION OF PREMISES Prem. Bldg. Prot. No. No. Occupancy Construction Class Terr 001 001 BLDG 5 - TIRE RECAPPING Non -Combustible 04 320:::: 001 002 BLDG 6 - TIRE RECYCLING Non -Combustible 03 320 002 001 TIRE RECYCLING Frame 03 270 Issued Date: 12/03/2021 WN CP 02 07 07 INSURED COPY Page 2 of 12 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Policy Number: CPP 0013699 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY COMMERCIAL PROPERTY DESCRIPTION OF COVERAGES PROVIDED Insurance At The Described Premises Applies Only For Coverages For Which A Limit Of Insurance Is Shown PREM. BLDG. LIMIT OF BLANKET COVERED NO. NO. COVERAGE INSURANCE COVERAGE CAUSES OF COINSURANCEt DIED. LOSS 000 000 Property Enhancement 001 001 Business Income $350,000 SPECIAL 90 With Extra Expense Including Rental Value 001 001 Personal Property of Insured $140,000 SPECIAL 90 $1000 001 002 Personal Property of Insured $550,000 SPECIAL 90 $1000 002 001 Business Income $530,000 SPECIAL 90 With Extra Expense Including Rental Value 002 001 Personal Property of Insured $495,000 SPECIAL 90 $1000 t IF EXTRA EXPENSE COVERAGE, LIMIT ON LOSS PAYMENT Issued Date: 12/03/2021 WN CP 02 07 07 Page 3 of 12 Western National Assurance Company Policy Number: CPP 0013699 19 9706 4th Avenue NE, Ste 200 RENEWAL DECLARATION Seattle, WA 981 15-2162 Named Insured: www.wnins.com L & S TIRE COMPANY COMMERCIAL PROPERTY DESCRIPTION OF OPTIONAL COVERAGES PROVIDED (Applicable Only When Entries Are Made In The Section Below) Replacement Costt Inflation Grd Monthly" Maximum` Extended ` Agreed Pers Incl Pers Limit of Period of Period of Coverage Effective Date Expiration Date Value Bldg Prop "Stock" Bldg Prop Indemnity Indemnity Indemnity Business Income RC Personal Property of Insured RC Personal Property of Insured Business Income RC Personal Property of Insured * Applies to Business Income only t RC = Replacement Cost FRC = Functional Replacement Cost ACV = Actual Cash Value Issued Date:12/03/2021 WN CP 02 07 07 INSURED COPY Page 4 of 12 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 981 15-2162 www.wnins.com PREMIUM FOR THIS COVERAGE FORM $ Policy Number: CPP 0013699 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY 1,770 * Included in property premium COMMERCIAL PROPERTY EQUIPMENT BREAKDOWN COVERAGE SCHEDULE Equipment Breakdown is subject to the Limit of Insurance shown in the Commercial Property Coverage Part Declarations except as specifically shown below. These coverages apply to all locations covered on the policy, unless otherwise specified. COVERAGES Equipment Breakdown Business Income Extra Expense Data Restoration Expediting Expenses "Fungus", Wet Rot, Dry Rot and Bacteria Hazardous Substances Off Premises Equipment Breakdown Public Relations Service Interruption Spoilage DIRECT COVERAGES DEDUCTIBLES OTHER CONDITIONS LIMITS FOLLOWS PROPERTY POLICY LIMIT FOLLOWS PROPERTY IF COVERED FOLLOWS PROPERTY IF COVERED $0 $0 $0 $0 $0 $0 FOLLOWS EQ BRKDOWN COV ENDORSEMENT $0 o Coinsurance $5,000 COVERED EQUIPMENT 25 YEARS OR OLDER WILL BE VALUED AT ACTUAL CASH VALUE. COVERED EQUIPMENT DOES NOT INCLUDE CONVEYORS, CRANES OR HOISTS BUT DOES INCLUDE ELECTRICAL EQUIPMENT MOUNTED ON OR USED WITH A CONVEYOR, CRANE OR HOIST. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COVERED PROPERTY DOES NOT INCLUDE ANY HAMMER MILLS, DEFABRICATORS, IMPACT MILLS, BALER/BAILERS, CRUSHERS, SHEARS AND THEIR DRIVE MOTORS, ENGINES, SHAFTS, GEAR SETS OR CLUTCHES. IN ADDITION, COVERED PROPERTY DOES NOT INCLUDE EQUIPMENT SCHEDULED UNDER ANY INLAND MARINE AND/OR EQUIPMENT FLOATER POLICY. WN CP 10 10 16 INSURED COPY Page 5 of 12 Western National Assurance Company `�` 9706 4thAvenue NE, Ste 200 A� Seattle, WA 981 15-2162 WESTERN NATIONAL INSURANCE www.wnins.com COMMERCIAL GENERAL LIABILITY ne,W°r°"ship..,,,p<,,,Y. A Stock Company COVERAGE PART Group # 0000203718 Policy Period: From DECEMBER 8, 2021 To DECEMBER 8, 2022 Policy # CPP 0013699 19 12:01 A.M. standard time at the Named Insured's mailing address. Transaction RENEWAL DECLARATION Insured Name and Address Agent L & S TIRE COMPANY PAYNEWEST INSURANCE 06023 8119 N REGAL ST BLDG 5 501 N RIVERPOINT BLVD, STE 403 SPOKANE WA 99217 SPOKANE, WA 99202-1649 Telephone: 509-838-3501 Business Description Type of Business Audit Period Billing Type TIRE SHREDDING & BALING CORPORATION ANNUAL DIRECT IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. LIMITS OF INSURANCE General Aggregate Limit (Other than Products -Completed Operations) Products - Completed Operations Aggregate Limit Each Occurrence Limit Personal and Advertising Injury Limit, any one person or organization Medical Expense Limit, any one person Damage to Premises Rented to you, any one premises LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY s Refer to attached schedule. 0 0 0 CLASSIFICATIONS Refer to attached schedule. $ 2,000,000 $ 2,000,000 $ 1,000,000 $ 1,000,000 $ 5,000 $ 100,000 PREMIUM FOR THIS COVERAGE PART $ 8,726.00 DISCLOSURE OF PREMIUM: The portion of your annual premium attributable to coverage for certified acts of terrorism is $ 32.00 Forms and Endorsements Applicable to this Policy See Forms and Endorsements Schedule Issued Date: 12/03/2021 WN GL 06 07 07 INSURED COPY Page 6 of 12 Western National Assurance Company Policy Number:CPP 0013699 19 9706 4th Avenue NE, Ste 200 RENEWAL DECLARATION Seattle, WA 981 15-2162 Named Insured: www.wnins.com L & S TIRE COMPANY COMMERCIAL GENERAL LIABILITY EXTENSION OF DECLARATIONS LOCATION OF PREMISES Location of All Premises You Own, Rent or Occupy: 001 002 8119 N REGAL ST 9215 39TH AVE SW SPOKANE WA 99217 LAKEWOOD WA 98499 PREMIUM Premium Rate Advance Premium Location Classification Code No. Exposure Base* Prem.Ops. Prod/Comp Prem/Ops. Prod/Comp Ops. Ops. 001 49239 If Any S 0.425 TIRE -RETREADING OR RECAPPING 001 47146 $2,300,000 S 3.245 INCL $7,464 INCL RECYCLING COLLECTION CENTERS -OTHER THAN NOT -FOR -PROFIT "Products - completed operations are subject to the General Aggregate Limit" 001 49239 If Any S 1.517 TIRE -RETREADING OR RECAPPING * - A = Area * - C = Total Cost * - E = Each * - M = Admissions * - O = Total Operating Expenses * - P = Payroll * -S = Gross Sales * - T = See Classification Notes * - U = Units Extension of Declarations --Total Advance Annual Premium $7, 464 Issued Date: 12/03/2021 WN GL 06 07 07 INSURED COPY Page 7 of 12 Western National Assurance Company Policy Number: CPP 0013699 19 9706 4th Avenue NE, Ste 200 RENEWAL DECLARATION Seattle, WA 981 15-2162 Named Insured: www.wnins.com L & S TIRE COMPANY COMMERCIAL GENERAL LIABILITY CLASSIFICATION SCHEDULE Loc St Terr Code Premium Base Exposure Rate Per Cov Premium Classification Description 000 WA 502 92100 EMPLOYEE BENEFITS LIABILITY 4 000 WA 44444 GENERAL LIABILITY ENHANCEMENT WNGL39 - GENERAL LIABILITY ENHANCEMENT ENDORSEMENT 001 WA 502 49950 ADDITIONAL INTERESTS CLASS CODE WNGL49 - ADDITIONAL INSURED 001 WA 502 49239 GROSS SALES TIRE -RETREADING OR RECAPPING CG0442 - STOP GAP -EMPLOYERS LIABILITY 001 WA 502 47146 GROSS SALES 2,300,000 RECYCLING COLLECTION CENTERS -OTHER THAN NOT -FOR -PROFIT CG0442 - STOP GAP -EMPLOYERS LIABILITY Each EBL $525 N/A GLENH $288 N/A ADDINS $250 1000 EMPLL $0 1000 EMPLL $167 Issued Date: 12/03/2021 WN GL 06 07 07 INSURED COPY Page 8 of 12 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Policy Number: CPP 0013699 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY LOCATION ADDRESS SCHEDULE Prem # 001 Prem # 002 8119 N REGAL ST 9215 39TH AVE SW SPOKANE, WA 99217 LAKEWOOD, WA 98499 Issued Date: 12/03/2021 WN IL 27 07 07 INSURED COPY Page 9 of 12 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Policy Number: CPP 0013699 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY SUB -LOCATION ADDRESS SCHEDULE Prem # ool Bldg # ool Prem # 001 Bldg # 002 BLDG 5 - TIRE RECAPPING BLDG 6 - TIRE RECYCLING Prem # 002 Bldg # ool TIRE RECYCLING IIssued Date: 12/03/2021 WN IL 28 07 07 INSURED COPY Pagel 0 of 12 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Unit/Loc 0001 CP1220 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 Unit/Loc 0002 CP1220 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 Policy Number: CPP 0013699 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY POLICY INTEREST SCHEDULE Issued Date: 12/03/2021 WN IL 29 07 07 INSURED COPY Pagel 1 of 12 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Coverage Line Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire Commercial Fire General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability General Liability Policy Number: CPP 0013699 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY FORMS AND ENDORSEMENTS SCHEDULE Form Number IL0123 IL0146 IL0157 IL0935 IL0952 IL0983 IL0995 CP0010 CP0030 CP0090 CP0126 CP0140 CP0160 CP0179 CP1030 CP1220 WNCP01 WNCP08 WNCP10 WNCP15 IL0123 IL0146 IL0198 CG0001 CGO197 CG0435 CG0442 CG0450 CG2106 CG2109 CG2116 CG2160 CG2171 CG2176 CG2186 CG2426 CG2677 CG3220 WNGL02 WNGL10 WNGL15 WNGL21 WNGL39 WNGL49 Ed. Date (11/13) (08/10) (07/02) (07/02) (01/15) (01/08) (01/07) (10/12) (10/12) (07/88) (10/12) (07/06) (12/98) (10/12) (10/12) (10/12) (08/19) (10/16) (10/16) (10/16) (11/13) (08/10) (09/08) (04/13) (12/07) (12/07) (11/03) (05/08) (05/14) (06/15) (04/13) (09/98) (01/15) (01/15) (12/04) (04/13) (12/04) (01/15) (07/10) (01/04) (12/16) (07/14) (08/18) (07/15) Description WA Changes - Defense Costs WA Common Policy Conditions WA Changes Actual Cash Value Excl of Certain Computer Relat Cap on Losses from CAT WA Amendment of Terrorism Excl Conditional Excl of Terrorism Bldg and Pers Prop Cvg Form Business Income Cvg Form (&EE) Commercial Property Conditions WA Changes Excl Loss due to Virus or Bact WA Chgs-Domestic Abuse WA Changes-Excl Causes of Loss Cause of Loss - Special Form Loss Payable Provisions - WA Property Enhancement Endt Equipment Breakdown Coverage Equipment Breakdown Schedule WA Amendatory Endorsement WA Changes - Defense Costs WA Common Policy Conditions Nuclear Energy Liab Excl Endt Comml Gen Liab Coverage Form WA Chgs-Empl-Related Practices Employee Benefits Liab Co Stop Gap -Employers Liab-WA WA Changes - Who Is An Insured Excl-Access or Disclosure Exclusion -Unmanned Aircraft Excl-Designated Prof Service Excl-Yr 2000 Computer Rel & Ot Excl Oth Acts Terr Outside US Excl Punitive Damages Excl-Exterior Insul & Fin Sys Amendment of Ins. Contract Def WA -Fungi or Bacteria Exclusion WA -fond Excl of Terrorism Punitive Damages Exclusion Excl-Lead Liability Endt Exclusion -Asbestos Abuse or Molestation Excl Comm Gen Liab Enhancement Endt Addl Insd-Own, Less, Cont-Auto Issued Date: 12/03/2021 WN IL 26 07 07 INSURED COPY Page 12 of 12 POLICY NUMBER:CPP 0013699 19 IL 09 95 01 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONDITIONAL EXCLUSION OF TERRORISM (RELATING TO DISPOSITION OF FEDERAL TERRORISM RISK INSURANCE ACT) This endorsement modifies insurance provided under the following: BOILER AND MACHINERY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART EQUIPMENT BREAKDOWN PROTECTION COVERAGE FORM FARM COVERAGE PART STANDARD PROPERTY POLICY SCHEDULE The Exception Covering Certain Fire Losses (Paragraph D.) applies to property located in the following state(s), if covered under the indicated Coverage Form, Coverage Part or Policy: State(s) Cove -rage Form, Coverage Part Or Policy WASHINGTON Commercial Property Coverage Part Information required to complete this Schedule, if not shown above will be shown in the Declarations A. Applicability Of The Provisions Of This En- dorsement 1. The provisions of this endorsement become applicable commencing on the date when any one or more of the following first oc- curs. But if your policy (meaning the policy period in which this endorsement applies) begins after such date, then the provisions of this endorsement become applicable on the date your policy begins. a. The federal Terrorism Risk Insurance Program ("Program"), established by the Terrorism Risk Insurance Act, has terminated with respect to the type of insurance provided under this Coverage Form, Coverage Part or Policy; or b. A renewal, extension or replacement of the Program has become effective with- out a requirement to make terrorism coverage available to you and with revi- sions that: (1) Increase our statutory percentage deductible under the Program for terrorism losses. (That deductible determines the amount of all certi- fied terrorism losses we must pay in a calendar year, before the fed- eral government shares in subse- quent payment of certified terrorism losses.); or (2) Decrease the federal government's statutory percentage share in po- tential terrorism losses above such deductible; or (3) Redefine terrorism or make insur- ance coverage for terrorism subject to provisions or requirements that differ from those that apply to other types of events or occurrences un- der this policy. 2. If the provisions of this endorsement be- come applicable, such provisions: a. Supersede any terrorism endorsement already endorsed to this policy that ad- dresses "certified acts of terrorism" and/or "other acts of terrorism", but only with respect to loss or damage from an incident(s) of terrorism (how- ever defined) that occurs on or after the date when the provisions of this en- dorsement become applicable; and IL 09 95 01 07 Copyright, ISO Properties, Inc., 2005 Page 1 of 3 b. Remain applicable unless we notify you 3. The "terrorism" is carried out by means of of changes in these provisions, in re- the dispersal or application of pathogenic or sponse to federal law. poisonous biological or chemical materials; 3. If the provisions of this endorsement do or NOT become applicable, any terrorism en- 4. Pathogenic or poisonous biological or dorsement already endorsed to this policy, chemical materials are released, and it ap- that addresses "certified acts of terrorism" pears that one purpose of the "terrorism" and/or "other acts of terrorism", will con- was to release such materials; or tinue in effect unless we notify you of 5. The total of insured damage to all types of changes to that endorsement in response property in the United States, its territories to federal law. and possessions, Puerto Rico and Canada B. The following definition is added and applies exceeds $25,000,000. In determining under this endorsement wherever the term ter- whether the $25,000,000 threshold is ex- rorism is enclosed in quotation marks. ceeded, we will include all insured damage "Terrorism" means activities against persons, sustained by property of all persons and organizations or property of any nature: entities affected by the "terrorism" and business interruption losses sustained by 1. That involve the following or preparation owners or occupants of the damaged prop - for the following: erty. For the purpose of this provision, in - a. Use or threat of force or violence; or sured damage means damage that is cov- b. Commission or threat of a dangerous ered by any insurance plus damage that would be covered by any insurance but for act; or the application of any terrorism exclusions. c. Commission or threat of an act that in- Multiple incidents of "terrorism" which oc- terferes with or disrupts an electronic, cur within a 72-hour period and appear to communication, information, or me- be carried out in concert or to have a relat- chanical system; and ed purpose or common leadership will be 2. When one or both of the following applies: deemed to be one incident, for the purpose of determining whether the threshold is ex - a. The effect is to intimidate or coerce a ceeded. government or the civilian population or any segment thereof, or to disrupt any With respect to this Item C.S., the immedi- segment of the economy; or ately preceding paragraph describes the b. It appears that the intent is to intimi- threshold used to measure the magnitude of an incident of "terrorism" and the cir- date or coerce a government, or to fur- cumstances in which the threshold will ap- ther political, ideological, religious, soci- ply, for the purpose of determining whether al or economic objectives or to express this Exclusion will apply to that incident. (or express opposition to) a philosophy When the Exclusion applies to an incident or ideology. of "terrorism", there is no coverage under C. The following exclusion is added: this Coverage Form, Coverage Part or Poli- EXCLUSION OF TERRORISM cv. We will not pay for loss or damage caused di- rectly or indirectly by "terrorism", including ac- tion in hindering or defending against an actual or expected incident of "terrorism". Such loss or damage is excluded regardless of any other cause or event that contributes concurrently or in any sequence to the loss. But this exclusion applies only when one or more of the following are attributed to an incident of "terrorism": 1. The "terrorism" is carried out by means of the dispersal or application of radioactive material, or through the use of a nuclear weapon or device that involves or produces a nuclear reaction, nuclear radiation or radi- oactive contamination; or 2. Radioactive material is released, and it ap- pears that one purpose of the "terrorism" was to release such material; or D. Exception Covering Certain Fire Losses The following exception to the Exclusion Of Terrorism applies only if indicated and as indi- cated in the Schedule of this endorsement. If "terrorism" results in fire, we will pay for the loss or damage caused by that fire, subject to all applicable policy provisions including the Limit of Insurance on the affected property. Such coverage for fire applies only to direct loss or damage by fire to Covered Property. Therefore, for example, the coverage does not apply to insurance provided under Business In- come and/or Extra Expense coverage forms or endorsements that apply to those coverage forms, or to the Legal Liability Coverage Form or the Leasehold Interest Coverage Form. Page 2 of 3 Copyright, ISO Properties, Inc., 2005 IL 09 95 01 07 E. Application Of Other Exclusions 1. When the Exclusion Of Terrorism applies in accordance with the terms of C.1. or C.2., such exclusion applies without regard to the Nuclear Hazard Exclusion in this Cover- age Form, Coverage Part or Policy. 2. The terms and limitations of any terrorism exclusion, or the inapplicability or omission of a terrorism exclusion, do not serve to create coverage for any loss or damage which would otherwise be excluded under this Coverage Form, Coverage Part or Poli- cy, such as losses excluded by the Nuclear Hazard Exclusion or the War And Military Action Exclusion. IL 09 95 01 07 Copyright, ISO Properties, Inc., 2005 Page 3 of 3 POLICY NUMBER: CPP 0013699 19 COMMERCIAL PROPERTY CP12201012 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOSS PAYABLE PROVISIONS - WASHINGTON This endorsement modifies insurance provided under the following: BUILDING AND PERSONAL PROPERTY COVERAGE FORM BUILDERS' RISK COVERAGE FORM CONDOMINIUM ASSOCIATION COVERAGE FORM CONDOMINIUM COMMERCIAL UNIT -OWNERS COVERAGE FORM STANDARD PROPERTY POLICY SCHEDULE Premises Number: 1 Building Number: 1 Applicable Clause C.1. (Enter C.1., C.2. or C.3.): Description Of Property: Loss Payee Name: WASHINGTON TRUST BANK PO BOX 2127 Loss Payee Address: SPOKANE WA 99210 Premises Number: 2 Building Number: 1 Applicable Clause C.1. (Enter C.1., C.2. or C.3.): Description Of Property: Loss Payee Name: WASHINGTON TRUST BANK PO BOX 2127 Loss Payee Address: SPOKANE WA 99210 Premises Number: Building Number: Applicable Clause (Enter C.1., C.2. or C.3.): Description Of Property: Loss Payee Name: Loss Payee Address: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CP 12 20 10 12 ° Insurance Services Office, Inc., 2013 Page 1 of 2 A. When this endorsement is attached to the Standard Property Policy CP 00 99, the term Coverage Part in this endorsement is replaced by the term Policy. B. Nothing in this endorsement increases the applicable Limit of Insurance. We will not pay any Loss Payee more than their financial interest in the Covered Property, and we will not pay more than the applicable Limit of Insurance on the Covered Property. C. The following is added to the Loss Payment Loss Condition, as indicated in the Declarations or in the Schedule: 1. Loss Payable Clause For Covered Property in which both you and a Loss Payee shown in the Schedule or in the Declarations have an insurable interest, we will: a. Adjust losses with you; and b. Pay any claim for loss or damage jointly to you and the Loss Payee, as interests may appear. 2. Contract Of Sale Clause a. The Loss Payee shown in the Schedule or in the Declarations is a person or organization you have entered into a contract with for the sale of Covered Property. b. For Covered Property in which both you and the Loss Payee have an insurable interest, we will: (1) Adjust losses with you; and (2) Pay any claim for loss or damage jointly to you and the Loss Payee, as interests may appear. c. The following is added to the Other Insurance Condition: For Covered Property that is the subject of a contract of sale, the word "you" includes the Loss Payee. 3. Building Owner Loss Payable Clause a. The Loss Payee shown in the Schedule or in the Declarations is the owner of the described building, in which you are a tenant. b. We will adjust losses to the described building with the Loss Payee. Any loss payment made to the Loss Payee will satisfy your claims against us for the owner's property. c. We will adjust losses to tenants' improvements and betterments with you, unless the lease provides otherwise. Page 2 of 2 ° Insurance Services Office, Inc., 2013 CP 12 20 10 12 COMMERCIAL GENERAL LIABILITY COVERAGE FORM QUICK REFERENCE READ YOUR POLICY CAREFULLY The Commercial General Liability Coverage part in your policy consists of Declarations, a Commercial General Liability Coverage Form (CG 00 01), Common Policy Conditions and Endorsements, if applicable. Following is a Quick Reference indexing of the principal provisions contained in each of the components making up the Coverage Part, listed in sequential order. DECLARATIONS Named Insured And Mailing Address Policy Period Coverages And Limits Of Insurance Forms And Endorsements Applying To The Coverage Part At The Time Of Issue COVERAGE FORM (CG 00 01) SECTION 1 - COVERAGES Coverage A - Bodily Injury And Property Damage Liability Insuring Agreement Exclusions Coverage B - Personal And Advertising Injury Liability Insuring Agreement Exclusions Coverage C - Medical Payments Insuring Agreement Exclusions Supplementary Payments - Coverages A and B SECTION II - WHO IS AN INSURED SECTION III - LIMITS OF INSURANCE SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS Bankruptcy s Duties In The Event Of Occurrence, Offense, Claim Or Suit Legal Action Against Us Other Insurance Premium Audit Representations Separations Of Insureds Transfer Of Rights Of Recovery Against Others To Us When We Do Not Renew SECTION V - DEFINITIONS COMMON POLICY CONDITIONS A. Cancellation B. Changes C. Examinations Of Your Books And Records D. Inspections And Surveys E. Premiums F. Transfer Of Your Rights And Duties Under This Policy ENDORSEMENTS (If Any) IMPORTANT: This Quick Reference is not part of your Commercial General Liability Policy and does not provide coverage. Refer to your Commercial General Liability Policy for actual contractual provisions. POLICY NUMBER: CPP 0013699 19 COMMERCIAL GENERAL LIABILITY CG 04 35 12 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EMPLOYEE BENEFITS LIABILITY COVERAGE THIS ENDORSEMENT PROVIDES CLAIMS -MADE COVERAGE. PLEASE READ THE ENTIRE ENDORSEMENT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Each Employee Coverage Limit Of Insurance Deductible Premium Employee Benefits $ 1,000,000 each employee $ 1,000 Programs $ 2,000,000 a re ate $ 525 Retroactive Date: 12/08/2004 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. The following is added to Section I - Cover- ages: COVERAGE - EMPLOYEE BENEFITS LIABILITY 1. Insuring Agreement a. We will pay those sums that the in- sured becomes legally obligated to pay as damages because of any act, error or omission, of the insured, or of any other person for whose acts the in- sured is legally liable, to which this in- surance 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 de- fend the insured against any "suit" seeking damages to which this insur- ance does not apply. We may, at our discretion, investigate any report of an act, error or omission and settle any "claim" or "suit" that may result. But: (1) The amount we will pay for dam- ages is limited as described in Para- graph D. (Section III - Limits Of In- surance); and (2) Our right and duty to defend ends when we have used up the applica- ble limit of insurance in the pay- ment of judgments or settlements. 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 damages only if: (1) The act, error or omission, is negli- gently committed in the "admin- istration" of your "employee benefit program"; (2) The act, error or omission, did not take place before the Retroactive Date, if any, shown in the Schedule nor after the end of the policy peri- od; and (3) A "claim" for damages, because of an act, error or omission, is first made against any insured, in accor- dance with Paragraph c. below, during the policy period or an Ex- tended Reporting Period we provide under Paragraph F. of this endorse- ment. c. A "claim" seeking damages will be deemed to have been made at the ear- lier of the following times: (1) When notice of such "claim" is re- ceived and recorded by any insured or by us, whichever comes first; or (2) When we make settlement in accor- dance with Paragraph a. above. A "claim" received and recorded by the insured within 60 days after the end of the policy period will be considered to have been received within the policy period, if no subsequent policy is avail- able to cover the claim. d. All "claims" for damages made by an "employee" because of any act, error or omission, or a series of related acts, CG 04 35 12 07 Copyright, ISO Properties, Inc., 2006 Page 1 of 6 errors or omissions, including damages claimed by such "employee's" depen- dents and beneficiaries, will be deemed to have been made at the time the first of those "claims" is made against any insured. 2. Exclusions This insurance does not apply to: a. Dishonest, Fraudulent, Criminal Or Ma- licious Act Damages arising out of any intentional, dishonest, fraudulent, criminal or mali- cious act, error or omission, committed by any insured, including the willful or reckless violation of any statute. b. Bodily Injury, Property Damage, Or Per- sonal And Advertising Injury "Bodily injury", "property damage" or "personal and advertising injury". c. Failure To Perform A Contract Damages arising out of failure of per- formance of contract by any insurer. d. Insufficiency Of Funds Damages arising out of an insufficiency of funds to meet any obligations under any plan included in the "employee benefit program". e. Inadequacy Of Performance Of Invest- ment/Advice Given With Respect To Participation Any "claim" based upon: (1) Failure of any investment to per- form; (2) Errors in providing information on past performance of investment ve- hicles; or (3) Advice given to any person with re- spect to that person's decision to participate or not to participate in any plan included in the "employee benefit program". f. Workers' Compensation And Similar Laws Any "claim" arising out of your failure to comply with the mandatory provi- sions of any workers' compensation, unemployment compensation insur- ance, social security or disability bene- fits law or any similar law. g. ERISA Damages for which any insured is liable because of liability imposed on a fiduci- ary by the Employee Retirement Income Security Act of 1974, as now or here- after amended, or by any similar feder- al, state or local laws. h. Available Benefits Any "claim" for benefits to the extent that such benefits are available, with reasonable effort and cooperation of the insured, from the applicable funds accrued or other collectible insurance. i. Taxes, Fines Or Penalties Taxes, fines or penalties, including those imposed under the Internal Rev- enue Code or any similar state or local law. j. Employment -Related Practices Damages arising out of wrongful ter- mination of employment, discrimina- tion, or other employment -related prac- tices. B. For the purposes of the coverage provided by this endorsement: 1. All references to Supplementary Payments - Coverages A and B are replaced by Sup- plementary Payments - Coverages A, B and Employee Benefits Liability. 2. Paragraphs 1.b. and 2. of the Supplemen- tary Payments provision do not apply. C. For the purposes of the coverage provided by this endorsement, Paragraphs 2. and 3. of Sec- tion II - Who Is An Insured are replaced by the following: 2. Each of the following is also an insured: a. Each of your "employees" who is or was authorized to administer your "em- ployee benefit program". b. Any persons, organizations or "employ- ees" having proper temporary authori- zation to administer your "employee benefit program" if you die, but only until your legal representative is ap- pointed. c. Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this Endorse- ment. 3. Any organization you newly acquire or form, other than a partnership, joint ven- ture or limited liability company, and over which you maintain ownership or majority interest, will qualify as a Named Insured if no other similar insurance applies to that organization. However: Page 2 of 6 Copyright, ISO Properties, Inc., 2006 CG 04 35 12 07 LC a. Coverage under this provision is af- forded only until the 90th day after you acquire or form the organization or the end of the policy period, whichever is earlier. b. Coverage under this provision does not apply to any act, error or omission that was committed before you acquired or formed the organization. For the purposes of the coverage provided by this endorsement, Section III - Limits Of Insur- ance is replaced by the following: 1. Limits Of Insurance a. The Limits of Insurance shown in the Schedule and the rules below fix the most we will pay regardless of the number of: (1) Insureds; (2) "Claims" made or "suits" brought; (3) Persons or organizations making "claims" or bringing "suits"; (4) Acts, errors or omissions; or (5) Benefits included in your "employee benefit program". b. The Aggregate Limit is the most we will pay for all damages because of acts, errors or omissions negligently com- mitted in the "administration" of your "employee benefit program". c. Subject to the Aggregate Limit, the Each Employee Limit is the most we will pay for all damages sustained by any one "employee", including damag- es sustained by such "employee's" de- pendents and beneficiaries, as a result of: (1) An act, error or omission; or (2) A series of related acts, errors or omissions negligently committed in the "adminis- tration" of your "employee benefit pro- gram". However, the amount paid under this endorsement shall not exceed, and will be subject to, the limits and restrictions that apply to the payment of benefits in any plan included in the "employee benefit program". The Limits of Insurance of this endorse- ment 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 of the policy to which this en- dorsement is attached, unless the policy period is extended after issuance for an ad- ditional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits Of Insurance. 2. Deductible a. Our obligation to pay damages on be- half of the insured applies only to the amount of damages in excess of the deductible amount stated in the Sched- ule as applicable to Each Employee. The limits of insurance shall not be re- duced by the amount of this deductible. b. The deductible amount stated in the Schedule applies to all damages sus- tained by any one "employee", includ- ing such "employee's" dependents and beneficiaries, because of all acts, errors or omissions to which this insurance applies. c. The terms of this insurance, including those with respect to: (1) Our right and duty to defend any "suits" seeking those damages; and (2) Your duties, and the duties of any other involved insured, in the event of an act, error or omission, or "claim" apply irrespective of the application of the deductible amount. d. We may pay any part or all of the de- ductible amount to effect settlement of any "claim" or "suit" and, upon notifi- cation of the action taken, you shall promptly reimburse us for such part of the deductible amount as we have paid. E. For the purposes of the coverage provided by this endorsement, Conditions 2. and 4. of Sec- tion IV - Commercial General Liability Condi- tions are replaced by the following: 2. Duties In The Event Of An Act, Error Or Omission, Or "Claim" Or "Suit" a. You must see to it that we are notified as soon as practicable of an act, error or omission which may result in a "claim". To the extent possible, notice should include: (1) What the act, error or omission was and when it occurred; and (2) The names and addresses of any- one who may suffer damages as a result of the act, error or omission. b. If a "claim" is made or "suit" is brought against any insured, you must: CG 04 35 12 07 Copyright, ISO Properties, Inc., 2006 Page 3 of 6 (1) Immediately 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 writ- ten notice of the "claim" or "suit" as soon as practicable. c. You and any other involved insured must: (1) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the "claim" or "suit"; (2) Authorize us to obtain records and other information; (3) Cooperate with us in the investiga- tion 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 be- cause of an act, error or omission 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 ex- pense without our consent. 4. Other Insurance If other valid and collectible insurance is available to the insured for a loss we cover under this endorsement, our obligations are limited as follows: a. Primary Insurance This insurance is primary except when Paragraph b. below applies. If this in- surance is primary, our obligations are not affected unless any of the other in- surance is also primary. Then, we will share with all that other insurance by the method described in Paragraph c. below. b. Excess Insurance (1) This insurance is excess over any of the other insurance, whether pri- mary, excess, contingent or on any other basis that is effective prior to the beginning of the policy period shown in the Schedule of this in- surance and that applies to an act, error or omission on other than a claims -made basis, if: (a) No Retroactive Date is shown in the Schedule of this insurance; or (b) The other insurance has a poli- cy period which continues after the Retroactive Date shown in the Schedule of this insurance. (2) When this insurance is excess, we will have no duty to defend the in- sured against any "suit" if any oth- er insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will un- dertake to do so, but we will be en- titled 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 the total amount that all such other insurance would pay for the loss in absence of this insurance; and 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 In- surance provision and was not bought specifically to apply in ex- cess of the Limits of Insurance shown in the Schedule of this en- dorsement. c. Method Of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this ap- proach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If 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 limits of in- surance to the total applicable limits of insurance of all insurers. F. For the purposes of the coverage provided by this endorsement, the following Extended Re- porting Period provisions are added, or, if this endorsement is attached to a claims -made Cov- erage Part, replaces any similar Section in that Coverage Part: EXTENDED REPORTING PERIOD 1. You will have the right to purchase an Ex- tended Reporting Period, as described be- low, if: a. This endorsement is canceled or not re- newed; or Page 4 of 6 Copyright, ISO Properties, Inc., 2006 CG 04 35 12 07 b. We renew or replace this endorsement with insurance that: (1) Has a Retroactive Date later than the date shown in the Schedule of this endorsement; or (2) Does not apply to an act, error or omission on a claims -made basis. 2. The Extended Reporting Period does not extend the policy period or change the scope of coverage provided. It applies only to "claims" for acts, errors or omissions that were first committed before the end of the policy period but not before the Retro- active Date, if any, shown in the Schedule. Once in effect, the Extended Reporting Pe- riod may not be canceled. 3. An Extended Reporting Period of five years is available, but only by an endorsement and for an extra charge. You must give us a written request for the endorsement within 60 days after the end of the policy period. The Extended Report- ing Period will not go into effect unless you pay the additional premium promptly when due. We will determine the additional premium in accordance with our rules and rates. In doing so, we may take into account the fol- lowing: a. The "employee benefit programs" in- sured; b. Previous types and amounts of insur- ance; c. Limits of insurance available under this endorsement for future payment of damages; and d. Other related factors. The additional premium will not exceed 100% of the annual premium for this en- dorsement. The Extended Reporting Period endorse- ment applicable to this coverage shall set forth the terms, not inconsistent with this Section, applicable to the Extended Report- ing Period, including a provision to the ef- fect that the insurance afforded for "claims" first received during such period is excess over any other valid and collectible insurance available under policies in force after the Extended Reporting Period starts. 4. If the Extended Reporting Period is in ef- fect, we will provide an extended reporting period aggregate limit of insurance de- scribed below, but only for claims first re- ceived and recorded during the Extended Reporting Period. The extended reporting period aggregate limit of insurance will be equal to the dollar amount shown in the Schedule of this en- dorsement under Limits of Insurance. Paragraph D.1.b. of this endorsement will be amended accordingly. The Each Employ- ee Limit shown in the Schedule will then continue to apply as set forth in Paragraph D.1.c. G. For the purposes of the coverage provided by this endorsement, the following definitions are added to the Definitions Section: 1. "Administration" means: a. Providing information to "employees", including their dependents and benefici- aries, with respect to eligibility for or scope of "employee benefit programs"; b. Handling records in connection with the "employee benefit program"; or c. Effecting, continuing or terminating any "employee's" participation in any bene- fit included in the "employee benefit program". However, "administration" does not include handling payroll deductions. 2. "Cafeteria plans" means plans authorized by applicable law to allow employees to elect to pay for certain benefits with pre- tax dollars. 3. "Claim" means any demand, or "suit", made by an "employee" or an "employ- ee's" dependents and beneficiaries, for damages as the result of an act, error or omission. 4. "Employee benefit program" means a pro- gram providing some or all of the following benefits to "employees", whether provided through a "cafeteria plan" or otherwise: a. Group life insurance, group accident or health insurance, dental, vision and hearing plans, and flexible spending ac- counts, provided that no one other than an "employee" may subscribe to such benefits and such benefits are made generally available to those "employ- ees" who satisfy the plan's eligibility requirements; b. Profit sharing plans, employee savings plans, employee stock ownership plans, pension plans and stock subscription plans, provided that no one other than an "employee" may subscribe to such benefits and such benefits are made generally available to all "employees" who are eligible under the plan for such benefits; CG 04 35 12 07 Copyright, ISO Properties, Inc., 2006 Page 5 of 6 H c. Unemployment insurance, social securi- ty benefits, workers' compensation and disability benefits; d. Vacation plans, including buy and sell programs; leave of absence programs, including military, maternity, family, and civil leave; tuition assistance plans; transportation and health club subsid- ies; and e. Any other similar benefits designated in the Schedule or added thereto by en- dorsement. For the purposes of the coverage provided by this endorsement, Definitions 5. and 18. in the Definitions Section are replaced by the follow- ing: 5. "Employee" means a person actively em- ployed, formerly employed, on leave of ab- sence or disabled, or retired. "Employee" includes a "leased worker". "Employee" does not include a "temporary worker". 18. "Suit" means a civil proceeding in which damages because of an act, error or omis- sion to which this insurance applies are al- leged. "Suit" includes: a. An arbitration proceeding in which such damages are claimed and to which the insured must submit or does submit with our consent; or b. Any other alternative dispute resolution proceeding in which such damages are claimed and to which the insured sub- mits with our consent. Page 6 of 6 Copyright, ISO Properties, Inc., 2006 CG 04 35 12 07 POLICY NUMBER: CPP 0013699 19 COMMERCIAL GENERAL LIABILITY CG 04 42 11 03 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. STOP GAP - EMPLOYERS LIABILITY COVERAGE ENDORSEMENT - WASHINGTON This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Limits Of Insurance Bodily Injury By Accident $ 1, 000, 000 Each Accident Bodily Injury By Disease $ 1,000,000 Aggregate Limit Bodily Injury By Disease $ 1, 000, 000 Each Employee (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. The following is added to Section I - Cover- b. This insurance applies to "bodily injury ages: by accident" or "bodily injury by dis- COVERAGE - STOP GAP - EMPLOYERS LIABIL- ease" only if: ITY (1) The: 1. Insuring Agreement (a) "Bodily injury by accident" or a. We will pay those sums that the in- "bodily injury by disease" takes sured becomes legally obligated by place in the "coverage terri- Washington Law to pay as damages tory"; because of "bodily injury by accident" (b) "Bodily injury by accident" or or "bodily injury by disease" to your "bodily injury by disease" arises "employee" to which this insurance ap- out of and in the course of the plies. We will have the right and duty injured "employee's" employ - to defend the insured against any "suit" ment by you; and seeking those damages. However, we (c) "Employee", at the time of the will have no duty to defend the insured "suit" injury, was covered under a against any seeking damages to worker's compensation policy I which this insurance does not apply. y' and subject to a "workers com- We may, at our discretion, investigate pensation law" of Washington; any accident and settle any claim or and "suit" that may result. But: (2) The: (1) The amount we will pay for dam- ages is limited as described in Sec- (a) "Bodily injury by accident" is tion III - Limits Of Insurance; and caused by an accident that oc- (2) Our right and duty to defend end curs during the policy period; or when we have used up the appli- (b) "Bodily injury by disease" is cable limit of insurance in the pay- caused by or aggravated by ment of judgments or settlements conditions of employment by under this coverage. you and the injured "employ - No other obligation or liability to pay ee's" last day of last exposure sums or perform acts or services is to the conditions causing or ag- "bodily covered unless explicitly provided for gravating such injury by disease" occurs during the poli- cy period. CG 04 42 11 03 Copyright, ISO Properties, Inc., 2003 Page 1 of 4 c. The damages we will pay, where recov ery is permitted by law, include dam- ages: (1) For: (a) Which you are liable to a third party by reason of a claim or "suit" against you by that third party to recover the damages claimed against such third party as a result of injury to your "employee"; (b) Care and loss of services; and (c) Consequential "bodily injury by accident" or "bodily injury by disease" to a spouse, child, par- ent, brother or sister of the in- jured "employee"; provided that these damages are the direct consequence of "bodily injury by accident" or "bodily injury by disease" that arises out of and in the course of the injured "em- ployee's" employment by you; and (2) Because of "bodily injury by acci- dent" or "bodily injury by disease" to your "employee" that arises out of and in the course of employ- ment, claimed against you in a capacity other than as employer. 2. Exclusions This insurance does not apply to: a. Intentional Injury "Bodily injury by accident" or "bodily injury by disease" intentionally caused or aggravated by you, or "bodily injury by accident" or "bodily injury by dis- ease" resulting from an act which is determined to have been committed by you if it was reasonable to believe that an injury is substantially certain to oc- cur. b. Fines Or Penalties Any assessment, penalty, or fine levied by any regulatory inspection agency or authority. c. Statutory Obligations Any obligation of the insured under a workers' compensation, disability bene- fits or unemployment compensation law or any similar law. d. Contractual Liability Liability assumed by you under any contract or agreement. e. Violation Of Law "Bodily injury by accident" or "bodily injury by disease" suffered or caused by any employee while employed in vi- olation of law with your actual knowl- edge or the actual knowledge of any of your "executive officers". f. Termination, Coercion Or Discrimination Damages arising out of coercion, criti- cism, demotion, evaluation, reassign- ment, discipline, defamation, harass- ment, humiliation, discrimination against or termination of any "employ- ee", or arising out of other employment or personnel decisions concerning the insured. g. Failure To Comply With "Workers Com- pensation Law" "Bodily injury by accident" or "bodily injury by disease" to an "employee" when you are: (1) Deprived of common law defenses; or (2) Otherwise subject to penalty; because of your failure to secure your obligations or other failure to comply with any "workers compensation law". h. Violation Of Age Laws Or Employment Of Minors "Bodily injury by accident" or "bodily injury by disease" suffered or caused by any person: (1) Knowingly employed by you in vio- lation of any law as to age; or (2) Under the age of 14 years, regard- less of any such law. L Federal Laws Any premium, assessment, penalty, fine, benefit, liability or other obligation imposed by or granted pursuant to: (1) The Federal Employer's Liability Act (45 USC Section 51-60); (2) The Non -appropriated Fund Instru- mentalities Act (5 USC Sections 8171-8173); (3) The Longshore and Harbor Work- ers' Compensation Act (33 USC Sections 910-950); (4) The Outer Continental Shelf Lands Act (43 USC Section 1331-1356); (5) The Defense Base Act (42 USC Sections 1651-1654); Page 2 of 4 Copyright, ISO Properties, Inc., 2003 CG 04 42 11 03 (6) The Federal Coal Mine Health and Safety Act of 1969 (30 USC Sec- tions 901-942); (7) The Migrant and Seasonal Agricul- tural Worker Protection Act (29 USC Sections 1801-1872); (8) Any other workers compensation, unemployment compensation or disability laws or any similar law; or (9) Any subsequent amendments to the laws listed above. Punitive Damages Multiple, exemplary or punitive dam- ages. k. Crew Members "Bodily injury by accident" or "bodily injury by disease" to a master or mem- ber of the crew of any vessel or any member of the flying crew of an air- craft. B. The Supplementary Payments provisions apply to Coverage - Stop Gap Employers Liability as well as to Coverages A and B. C. For the purposes of this endorsement, Section II - Who Is An Insured, is replaced by the fol- lowing: If you are designated in the Declarations as: 1. An individual, you and your spouse are in- sureds, but only with respect to the con- duct of a business of which you are the sole owner. D. For the purposes of this endorsement, Section III - Limits Of Insurance, is replaced by the fol- lowing: 1. The Limits of Insurance shown in the Schedule of this endorsement and the rules below fix the most we will pay regardless of the number of: a. Insureds; 2. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses are also insureds, but only with respect to the conduct of your busi- ness. 3. A limited liability company, you are an in- sured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insureds, but E only with respect to their duties as your managers. 4. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your "executive of- ficers" and directors are insureds, but only with respect to their duties as your officers or directors. Your stockholders are also in- sureds, but only with respect to their lia- bility as stockholders. b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 2. The "Bodily Injury By Accident" - Each Ac- cident Limit shown in the Schedule of this endorsement is the most we will pay for all damages covered by this insurance be- cause of "bodily injury by accident" to one or more "employees" in any one accident. 3. The "Bodily Injury By Disease" - Aggregate Limit shown in the Schedule of this en- dorsement is the most we will pay for all damages covered by this insurance and arising out of "bodily injury by disease", re- gardless of the number of "employees" who sustain "bodily injury by disease". 4. Subject to Paragraph D.3. of this endorse- ment, the "Bodily Injury By Disease" - Each "Employee" Limit shown in the Schedule of this endorsement is the most we will pay for all damages because of "bodily injury by disease" to any one "employee". The limits of the coverage apply separately to each consecutive annual period and to any re- maining 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. In that case, the addi- tional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. For the purposes of this endorsement, Con- dition 2. - Duties In The Event Of Occurrence, Claim Or Suit of the Conditions Section IV is deleted and replaced by the following: 2. Duties In The Event Of Injury, Claim Or Suit a. You must see to it that we or our agent are notified as soon as practicable of a "bodily injury by accident" or "bodily injury by disease" which may result in a claim. To the extent possible, notice should include: No person or organization is an insured (1) How, when and where the "bodily with respect to the conduct of any current injury by accident" or "bodily injury or past partnership, joint venture or limited by disease" took place; liability company that is not shown as a (2) The names and addresses of any in - Named Insured in the Declarations. jured persons and witnesses; and CG 04 42 11 03 Copyright, ISO Properties, Inc., 2003 Page 3 of 4 (3) The nature and location of any in- jury. b. If a claim is made or "suit" is brought against any insured, you must: (1) Immediately record the specifics of the claim or "suit" and the date re- ceived; and (2) Notify us as soon as practicable. You must see to it that we receive writ- ten notice of the claim or "suit" as soon as practicable. c. You and any other involved insured must: (1) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the injury, claim, proceeding or "suit"; (2) Authorize us to obtain records and other information; (3) Cooperate with us and assist us, as we may request, in the investiga- tion or settlement of the claim or defense against the "suit"; (4) Assist us, upon our request, in the enforcement of any right against any person or organization which may be liable to the insured be- cause of injury to which this insur- ance may also apply; and (5) Do nothing after an injury occurs that would interfere with our right to recover from others. d. No insured will, except at that insured's own cost, voluntarily make a payment, assume any obligation, or incur any ex- pense, other than for first aid, without our consent. F. For the purposes of this endorsement, Para- graph 4. of the Definitions Section is replaced by the following: 4. "Coverage territory" means: a. The United States of America (including its territories and possessions), Puerto Rico and Canada; b. International waters or airspace, but only if the injury or damage occurs in the course of travel or transportation between any places included in a. above; or c. All other parts of the world if the injury or damage arises out of the activities of a person whose home is in the territory described in a. above, but who is away for a short time on your business; provided the insured's responsibility to pay damages is determined in the United States (including its territories and possessions), Puerto Rico, or Canada, in a suit on the merits according to the substantive law in such territory, or in a settlement we agree to. G. The following are added to the Definitions Sec- tion: 1. "Workers Compensation Law" means the Workers Compensation Law and any Occu- pational Disease Law of Washington. This does not include provisions of any law pro- viding non -occupational disability benefits. 2. "Bodily injury by accident" means bodily in- jury, sickness or disease sustained by a person, including death, resulting from an accident. A disease is not "bodily injury by accident" unless it results directly from "bodily injury by accident". 3. "Bodily injury by disease" means a disease sustained by a person, including death. "Bodily injury by disease" does not include a disease that results directly from an acci- dent. H. For the purposes of this endorsement, the defi- nition of "bodily injury" does not apply. Page 4 of 4 Copyright, ISO Properties, Inc., 2003 CG 04 42 11 03 POLICY NUMBER: CPP 0013699 19 COMMERCIAL GENERAL LIABILITY CG 21 16 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - DESIGNATED PROFESSIONAL SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Description Of Professional Services 1. ALL PROFESSIONAL SERVICES 2. 3. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. With respect to any professional services shown in the Schedule, the following exclusion is added to Paragraph 2. Exclusions of Section I — Coverage A — Bodily Injury And Property Damage Liability and Paragraph 2. Exclusions of Section I — Coverage B — Personal And Advertising Injury Liability: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" due to the rendering of or failure to render any professional service. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occur- rence" which caused the "bodily injury" or "prop- erty damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any professional service. CG 21 16 04 13 ° Insurance Services Office, Inc., 2012 Page 1 of 1 Western National Assurance Company `� 9706 4th Avenue NE, Ste 200 Seattle, WA 981 15-2162 WESTERN NATIONAL ....ANC. www.wnins.com 7Re r•e(annnship mmny A Stock Company INLAND MARINE DECLARATIONS Group #0000203718 Policy Period: From DECEMBER 8, 2021 To DECEMBER 8, 2022 Policy # CPP 0013730 19 12:01 A.M. standard time at the Named Insured's mailing address. Transaction RENEWAL DECLARATION Insured Name and Address Agent L & S TIRE COMPANY PAYNEWEST INSURANCE 06023 8119 N REGAL ST BLDG 5 501 N RIVERPOINT BLVD, STE 403 SPOKANE WA 99217 SPOKANE, WA 99202-1649 Telephone: 509-838-3501 Business Description Type of Business Audit Period Billing Type TIRE SHREDDING & BALING CORPORATION ANNUAL DIRECT IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. COVERAGES PREMIUM CONTRACTORS' EQUIPMENT $2,479.00 PREMIUM FOR THIS COVERAGE PART $ 2,S22.00 DISCLOSURE OF PREMIUM: The portion of your annual premium attributable to coverage for certified acts of terrorism is $ 43 .00 Forms and Endorsements Applicable to this Policy See Forms and Endorsements Schedule Issued Date: 12/03/2021 WN IM 03 07 07 INSURED COPY Page 1 of 9 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Policy Number: CPP 0013730 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY SCHEDULE OF COVERAGES CONTRACTORS' EQUIPMENT COVERAGE I PREMIUM FOR THIS COVERAGE FORM $ 2,479 PROPERTY COVERED ❑x Scheduled Equipment REFER TO CONTRACTORS' EQUIPMENT SCHEDULE ❑ Schedule On File Catastrophe Limit - The most "we" pay for loss in any one occurrence is: I COVERAGE EXTENSIONS Additional Debris Removal Expense SUPPLEMENTAL COVERAGES Employee Tools Equipment Leased or Rented From Others Newly Purchased Equipment (check one) ❑ Percentage of Catastrophe Limit ❑X Dollar Limit Pollutant Cleanup and Removal Rental Reimbursement - Reimbursement Limit - Waiting Period Spare Parts and Fuel COINSURANCE (check one) X❑ 80% ❑ 90% ❑ 100% ❑Other REPORTING CONDITIONS (check if applicable) ❑ Equipment Leased or Rented From Others - Reporting Rate - Deposit Premium - Minimum Premium VALUATION (check if applicable) X❑ Actual Cash Value ❑ Replacement Cost Limit of Insurance $ 301,375 $ 5,000 $ 5,000 $ 100,000 $ 50,000 $ 25,000 $ 5,000 72 Hours $ 5,000 ❑ Indicated On Contractors' Equipment Schedule IM 7005 04 04 INSURED COPY Page 2 of 9 Includes Copyrighted Material With Permission of American Association of Insurance Services DEDUCTIBLE (check one) 0 Flat Deductible Amount Per Occurrence (other than Coverage Extensions and Supplemental Coverages) $ 1,000 ❑ Flat Deductible Amount Per Item Indicated On Contractors' Equipment Schedule ❑ Percentage Deductible Maximum Deductible Amount $ Minimum Deductible Amount $ In addition to deductible option checked above, this per occurrence deductible applies to Coverage Extensions and Supplemental Coverages $ Soo OPTIONAL COVERAGES AND ENDORSEMENTS See Forms and Endorsements Schedule IM 7005 04 04 INSURED COPY Page 3 of 9 Includes Copyrighted Material With Permission of American Association of Insurance Services EQUIPMENT SCHEDULE CONTRACTORS' EQUIPMENT (The entries required to complete this schedule will be shown below or on the "schedule of coverages".) EQUIPMENT SCHEDULE Schedule 001 Item No Description of Equipment 001 YARD GOAT TIRE HAULER 1 003 2007 SKIDSTEER 006 2008 CATERPILLAR SKID STEER LOADER 262C #MST02143 007 2006 KOMATSU PC138 EXCAVATOR MST02143 008 HOTSIE STEAM CLEANER 009 CAT FORKLIFT 1 010 CAT FORKLIFT 1 013 BOBCAT S175 SKIDSTER *ACV=Actual Cash Value RP=Replacement Value AA=Agreed Amount WN IM 20 07 07 Rate Limit Valuation* Deductible 0.640 $20,000 ACV 0.640 $25,000 ACV 0.640 $30,000 ACV 0.640 $95,000 ACV 0.640 $5,000 ACV 0.640 $8,000 ACV 0.640 $8,000 ACV 0.640 $17,000 ACV WN IM 20 07 07 Page 4 of 9 WN IM 20 07 07 EQUIPMENT SCHEDULE CONTRACTORS' EQUIPMENT (The entries required to complete this schedule will be shown below or on the "schedule of coverages".) EQUIPMENT SCHEDULE 014 BOBCAT SKIDSTER 0.640 $17,000 ACV 015 1998 SPUDNICK CONVEYOR 0.640 $25,000 ACV 017 KUBOTA SVL75-2W 0.640 $51,375 ACV S# KBCZOS2CHL1J53246 *ACV=Actual Cash Value RP=Replacement Value AA=Agreed Amount Page 5 of 9 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Unit/Loc 000l CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0003 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0006 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0007 CL0465 - LOSS PAYABLE A WASHINGTON TRUST BANK .PO BOX 2127 0 'SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0008 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Policy Number: CPP 0013730 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY POLICY INTEREST SCHEDULE Issued Date: 12/03/2021 WN IM 03 07 07 INSURED COPY Page 6 of 9 Western National Assurance Company Policy Number: CPP 0013730 19 9706 4th Avenue NE, Ste 200 RENEWAL DECLARATION Seattle, WA 981 15-2162 Named Insured: L & S TIRE COMPANY POLICY INTEREST SCHEDULE Unit/Loc 0009 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0010 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0013 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0014 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Unit/Loc 0015 CL0465 - LOSS PAYABLE WASHINGTON TRUST BANK PO BOX 2127 SPOKANE WA 99210 ALL SCHEDULED EQUIPMENT Issued Date: 12/03/2021 WN IM 03 07 07 Page 7 of 9 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 Unit/Loc 0006 CL0465 - LOSS PAYABLE CATERPILLAR FINANCIAL SVC CORP 2120 WEST END AVE NASHVILLE TN 37203 6. 2008 CAT LOADER #MST02143 Unit/Loc 0000 CL0465 - LOSS PAYABLE WESTERN STATES CAT 4625 E TRENT AVE SPOKANE WA 99212 Unit/Loc 0017 CL0465 - LOSS KUBOTA CREDIT PO BOX 2046 GRAPEVINE TX PAYABLE CORP. U.S.A. 76099 Policy Number: CPP 0013730 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY POLICY INTEREST SCHEDULE Issued Date: 12/03/2021 WN IM 03 07 07 Page 8 of 9 Western National Assurance Company 9706 4th Avenue NE, Ste 200 Seattle, WA 98115-2162 www.wnins.com Policy Number: CPP 0013730 19 RENEWAL DECLARATION Named Insured: L & S TIRE COMPANY FORMS AND ENDORSEMENTS SCHEDULE Coverage Line Form Number Ed. Date Inland Marine CLO103 Inland Marine CL046S Inland Marine CL0600 Inland Marine CL0700 Inland Marine CL1630 Inland Marine IM2097 Inland Marine IM7000 Inland Marine IM7005 Inland Marine IM7016 Inland Marine IM7017 Inland Marine IM7034 Inland Marine WNIM14 Inland Marine WNIM20 Inland Marine WNIM21 Description (03/10) Common Policy Conditions -WA (01/01) Loss Payable Endt WA (01/15) Certified Terrorism Loss (10/06) Virus or Bacteria Exclusion (08/06) Conditional Terrorism Excl (01/13) Amendatory Endt-WA (04/04) Contractors Equipment (04/04) Sch Of Cov Contractors Equip (04/04) Boom Restriction (06/04) Weight of Load Exclusion (06/04) Tools Endorsement (01/02) Amendator Endt Prem Due Date (07/07) Equipment Sch Contractors' Eqp (07/07) Cont Equip Amend of Ded Endt Issued Date: 12/03/2021 WN IL 26 07 07 INSURED COPY Page 9 of 9 COMMERCIAL INLAND MARINE POLICY QUICK REFERENCE READ YOUR POLICY CAREFULLY The Commercial Inland Marine Coverage policy consists of Declarations, Schedule of Coverages, Coverage Form(s), Common Policy Conditions and Endorsements, if applicable. Following is a Quick Reference indexing of the principal provisions contained in each of the components making up the Coverage Part, listed in sequential order. DECLARATIONS Named Insured And Mailing Address Policy Period Coverages Forms And Endorsements Applying To The Coverage Part At The Time Of Issue SCHEDULE OF COVERAGES Coverages and Limits Deductible COVERAGE FORMS The individual Inland Marine coverage forms that are part of this policy determine the type of coverage provided. On these forms you will find provisions dealing with: Agreement Definitions Property Covered Property Not Covered Perils Covered Perils Excluded What Must Be Done In Case Of Loss Valuation How Much We Pay Loss Payment Other Conditions Other terms that apply to the specific coverage COMMON POLICY CONDITIONS Assignment Cancellation Changes, Modifications or Waiver of Policy Terms Inspections Examinations of Books and Records ENDORSEMENTS (If Any) IMPORTANT: This Quick Reference is not part of your Commercial Inland Marine Policy and does not provide coverage. Refer to your Commercial Inland Marine Policy for actual contractual provisions. AAIS This endorsement changes CL 0465 01 01 the policy Paqe 1 of 2 -- PLEASE READ THIS CAREFULLY -- LOSS PAYABLE ENDORSEMENT WASHINGTON (The entries required to complete this endorsement will be shown below or on the "declarations" or "schedule of coverages".) This form is identical to that promulgated in Washington State Insurance Commissioner's Regulation No. 335, pursuant to section 1, Chapter 12, Laws of 1967, ex. sess., State of Washington. 1 . Loss or damage, if any, under this policy shall be payable first to the loss payee or mortgagee (hereinafter called secured party), and, second, to the insured, as their interests may appear; PROVIDED, That, upon demand for separate settlement by the secured party, the amount of said loss shall be paid directly to the secured party to the extent of its interest. 2. This insurance as to the interest of the secured party shall not be invalidated by any act or neglect of the insured named in said policy or his agents, employees or representatives, nor by any change in the title or ownership of the insured property: Provided, however, That, the conversion, embezzlement or secretion by the named insured or his agents, employees or representatives is not covered under said policy unless specifically insured against and premiums paid therefor. 3. In applying the pro rata provisions of the policy, the amount payable to the secured party shall be reduced only to the extent of pro rata payments receivable by the secured party under other policies. 4. The company reserves the right to cancel the policy at any time as provided by its terms, but in such case the company shall mail to the secured party a notice stating when such cancellation shall become effective as to the interest of said secured party. The amount and form of such notice shall be not less than that required to be given the named insured, by law or by the policy provisions, whichever is more favorable to the secured party. 5. If the insured fails to render proof of loss within the time granted in the policy conditions, such secured party shall do so within sixty days after having knowledge of a loss, in form and manner as provided by the policy, and, further, shall be subject to the provisions of the policy relating to appraisal and the time of payment and bringing suit. 6. Whenever the company shall pay the secured party any sum for loss or damage under policy and shall claim that, as to the insured, no liability exists, the company shall, to the extent of such payment, be thereupon legally subrogated to all the rights of the party to whom such payment shall be made, under all collateral held to secure the debt, or may, at its option, pay to the secured party the whole principal due or to grow due on the mortgage or other security agreement, with interest, and shall thereupon receive a full assignment and transfer of the mortgage or other security agreement and of all collateral held to secure it; but no subrogation shall impair the right of the secured party to recover the full amount due it. 7. All terms and conditions of the policy remain unchanged except as herein specifically provided. 8. All notices sent to the secured party shall be sent to its last reported address, which must be stated in the policy or in this endorsement below. AAIS CL 0465 01 01 Page 2 of 2 9. The following item shall be completed if this endorsement is not referred to by number in the policy to which this endorsement is attached: The foregoing is attached to and forms a part of Policy No. CPP 0013730 19 of Western National Assurance Insurance Company, issued to T. F, S TTRR rnMPANY Endorsement effective date 10. If the secured party and its address is not designated in the policy to which this endorsement is attached, the following line(s) shall be completed: Secured Party WASHINGTON TRUST BANK Address: PO BOX 2127 SPOKANE WA 99210 Secured Party Address: In Agent PAYNEWEST INSURANCE Form REG.-335 CL 0465 01 01 Copyright, American Association of Insurance Services, 2001 AAIS This endorsement changes CL 0465 01 01 the policy Page 1 of 2 -- PLEASE READ THIS CAREFULLY -- LOSS PAYABLE ENDORSEMENT WASHINGTON (The entries required to complete this endorsement will be shown below or on the "declarations" or "schedule of coverages".) This form is identical to that promulgated in Washington State Insurance Commissioner's Regulation No. 335, pursuant to section 1, Chapter 12, Laws of 1967, ex. sess., State of Washington. 1 . Loss or damage, if any, under this policy shall be payable first to the loss payee or mortgagee (hereinafter called secured party), and, second, to the insured, as their interests may appear; PROVIDED, That, upon demand for separate settlement by the secured party, the amount of said loss shall be paid directly to the secured party to the extent of its interest. 2. This insurance as to the interest of the secured party shall not be invalidated by any act or neglect of the insured named in said policy or his agents, employees or representatives, nor by any change in the title or ownership of the insured property: Provided, however, That, the conversion, embezzlement or secretion by the named insured or his agents, employees or representatives is not covered under said policy unless specifically insured against and premiums paid therefor. 3. In applying the pro rata provisions of the policy, the amount payable to the secured party shall be reduced only to the extent of pro rata payments receivable by the secured party under other policies. 4. The company reserves the right to cancel the policy at any time as provided by its terms, but in such case the company shall mail to the secured party a notice stating when such cancellation shall become effective as to the interest of said secured party. The amount and form of such notice shall be not less than that required to be given the named insured, by law or by the policy provisions, whichever is more favorable to the secured party. 5. If the insured fails to render proof of loss within the time granted in the policy conditions, such secured party shall do so within sixty days after having knowledge of a loss, in form and manner as provided by the policy, and, further, shall be subject to the provisions of the policy relating to appraisal and the time of payment and bringing suit. 6. Whenever the company shall pay the secured party any sum for loss or damage under policy and shall claim that, as to the insured, no liability exists, the company shall, to the extent of such payment, be thereupon legally subrogated to all the rights of the party to whom such payment shall be made, under all collateral held to secure the debt, or may, at its option, pay to the secured party the whole principal due or to grow due on the mortgage or other security agreement, with interest, and shall thereupon receive a full assignment and transfer of the mortgage or other security agreement and of all collateral held to secure it; but no subrogation shall impair the right of the secured party to recover the full amount due it. 7. All terms and conditions of the policy remain unchanged except as herein specifically provided. 8. All notices sent to the secured party shall be sent to its last reported address, which must be stated in the policy or in this endorsement below. AAIS CL 0465 01 01 Paae 2 of 2 9. The following item shall be completed if this endorsement is not referred to by number in the policy to which this endorsement is attached: The foregoing is attached to and forms a part of Policy No. CPP 0013730 19 of Western National Assurance Insurance Company, issued to T, & S TIRE COMPANY Endorsement effective date 10. If the secured party and its address is not designated in the policy to which this endorsement is attached, the following line(s) shall be completed: Secured Party CATERPILLAR FINANCIAL SVC CORP Address: 2120 WEST END AVE NASHVILLE TN 37203 Secured Party Address: 0 Agent PAYNEWEST INSURANCE CL 0465 01 01 Copyright, American Association of Insurance Services, 2001 AAIS This endorsement changes CL 0465 01 01 the policy Page 1 of 2 -- PLEASE READ THIS CAREFULLY -- LOSS PAYABLE ENDORSEMENT WASHINGTON (The entries required to complete this endorsement will be shown below or on the "declarations" or "schedule of coverages".) This form is identical to that promulgated in Washington State Insurance Commissioner's Regulation No. 335, pursuant to section 1, Chapter 12, Laws of 1967, ex. sess., State of Washington. 1. Loss or damage, if any, under this policy shall be payable first to the loss payee or mortgagee (hereinafter called secured party), and, second, to the insured, as their interests may appear; PROVIDED, That, upon demand for separate settlement by the secured party, the amount of said loss shall be paid directly to the secured party to the extent of its interest. 2. This insurance as to the interest of the secured party shall not be invalidated by any act or neglect of the insured named in said policy or his agents, employees or representatives, nor by any change in the title or ownership of the insured property: Provided, however, That, the conversion, embezzlement or secretion by the named insured or his agents, employees or representatives is not covered under said policy unless specifically insured against and premiums paid therefor. 3. In applying the pro rata provisions of the policy, the amount payable to the secured party shall be reduced only to the extent of pro rata payments receivable by the secured party under other policies. 4. The company reserves the right to cancel the policy at any time as provided by its terms, but in such case the company shall mail to the secured party a notice stating when such cancellation shall become effective as to the interest of said secured party. The amount and form of such notice shall be not less than that required to be given the named insured, by law or by the policy provisions, whichever is more favorable to the secured party. 5. If the insured fails to render proof of loss within the time granted in the policy conditions, such secured party shall do so within sixty days after having knowledge of a loss, in form and manner as provided by the policy, and, further, shall be subject to the provisions of the policy relating to appraisal and the time of payment and bringing suit. 6. Whenever the company shall pay the secured party any sum for loss or damage under policy and shall claim that, as to the insured, no liability exists, the company shall, to the extent of such payment, be thereupon legally subrogated to all the rights of the party to whom such payment shall be made, under all collateral held to secure the debt, or may, at its option, pay to the secured party the whole principal due or to grow due on the mortgage or other security agreement, with interest, and shall thereupon receive a full assignment and transfer of the mortgage or other security agreement and of all collateral held to secure it; but no subrogation shall impair the right of the secured party to recover the full amount due it. 7. All terms and conditions of the policy remain unchanged except as herein specifically provided. 8. All notices sent to the secured party shall be sent to its last reported address, which must be stated in the policy or in this endorsement below. AAIS CL 0465 01 01 Paqe 2 of 2 9. The following item shall be completed if this endorsement is not referred to by number in the policy to which this endorsement is attached: The foregoing is attached to and forms a part of Policy No. CPP 0013730 19 of Western National Assurance Insurance Company, issued to L & S TIRE COMPANY Endorsement effective date 10. If the secured party and its address is not designated in the policy to which this endorsement is attached, the following line(s) shall be completed: Secured Party WESTERN STATES CAT Address: 462S E TRENT AVE SPOKANE WA 99212 Secured Party Address: By Agent PAYNEWEST INSURANCE CL 0465 01 01 Copyright, American Association of Insurance Services, 2001 AAIS This endorsement changes CL 0465 01 01 the policy Page 1 of 2 -- PLEASE READ THIS CAREFULLY -- LOSS PAYABLE ENDORSEMENT WASHINGTON (The entries required to complete this endorsement will be shown below or on the "declarations" or "schedule of coverages".) This form is identical to that promulgated in Washington State Insurance Commissioner's Regulation No. 335, pursuant to section 1, Chapter 12, Laws of 1967, ex. sess., State of Washington. 1 . Loss or damage, if any, under this policy shall be payable first to the loss payee or mortgagee (hereinafter called secured party), and, second, to the insured, as their interests may appear; PROVIDED, That, upon demand for separate settlement by the secured party, the amount of said loss shall be paid directly to the secured party to the extent of its interest. 2. This insurance as to the interest of the secured party shall not be invalidated by any act or neglect of the insured named in said policy or his agents, employees or representatives, nor by any change in the title or ownership of the insured property: Provided, however, That, the conversion, embezzlement or secretion by the named insured or his agents, employees or representatives is not covered under said policy unless specifically insured against and premiums paid therefor. 3. In applying the pro rata provisions of the policy, the amount payable to the secured party shall be reduced only to the extent of pro rata payments receivable by the secured party under other policies. 4. The company reserves the right to cancel the policy at any time as provided by its terms, but in such case the company shall mail to the secured party a notice stating when such cancellation shall become effective as to the interest of said secured party. The amount and form of such notice shall be not less than that required to be given the named insured, by law or by the policy provisions, whichever is more favorable to the secured party. 5. If the insured fails to render proof of loss within the time granted in the policy conditions, such secured party shall do so within sixty days after having knowledge of a loss, in form and manner as provided by the policy, and, further, shall be subject to the provisions of the policy relating to appraisal and the time of payment and bringing suit. 6. Whenever the company shall pay the secured party any sum for loss or damage under policy and shall claim that, as to the insured, no liability exists, the company shall, to the extent of such payment, be thereupon legally subrogated to all the rights of the party to whom such payment shall be made, under all collateral held to secure the debt, or may, at its option, pay to the secured party the whole principal due or to grow due on the mortgage or other security agreement, with interest, and shall thereupon receive a full assignment and transfer of the mortgage or other security agreement and of all collateral held to secure it; but no subrogation shall impair the right of the secured party to recover the full amount due it. 7. All terms and conditions of the policy remain unchanged except as herein specifically provided. 8. All notices sent to the secured party shall be sent to its last reported address, which must be stated in the policy or in this endorsement below. AAIS CL 0465 01 01 Page 2 of 2 9. The following item shall be completed if this endorsement is not referred to by number in the policy to which this endorsement is attached: The foregoing is attached to and forms a part of Policy No. CPP 0013730 19 of Western National Assurance Insurance Company, issued to L & S TIRE COMPANY Endorsement effective date 10. If the secured party and its address is not designated in the policy to which this endorsement is attached, the following line(s) shall be completed: Secured Party KUBOTA CREDIT CORP. U.S.A. Address: PO BOX 2046 GRAPEVINE TX 76099 Secured Party Address: Agent PAYNEWEST INSURANCE Form REG.-335 CL 0465 01 01 Copyright, American Association of Insurance Services, 2001 AAIS This endorsement changes the IM 7034 06 04 Contractors' Equipment Coverage Page 1 of 1 -- PLEASE READ THIS CAREFULLY -- TOOLS ENDORSEMENT (The entries required to complete this endorsement will be on the "schedule of coverages".) Limit 1. Your Tools -- a. The most "we" pay for loss to any one "tool" is: $ 1,000 b. The most "we" pay in any one occurrence for loss to "your" "tools" is: $ 5,000 Deductible Deductible Amount $ 500 "Tools" means equipment, and tools of a mobile nature that "you" use in "your" contracting, installation, erection, repair, or moving operations or projects. 1. Your Tools -- "We" cover direct physical loss caused by a covered peril to "your" "tools". Tools Deductible -- "We" pay only that part of "your" loss over the deductible amount indicated for "tools". IM 7034 06 04 Copyright, American Association of Insurance Services, Inc., 2004 WESTERN NATIONAL INSURANCE GROUP* MINNEAPOLIS, MINNESOTA PRIVACY POLICY WESTERN NATIONAL INSURANCE GROUP VALUES THE TRUST YOU HAVE PLACED IN US. IN RETURN, WE TAKE SERIOUSLY THE PROTECTION OF YOUR NON-PUBLIC PERSONAL INFORMATION. THIS NOTICE DE- SCRIBES HOW WESTERN NATIONAL USES AND SAFEGUARDS YOUR INFORMATION. INFORMATION WE MAY COLLECT Western National Insurance Group may collect certain information about you in the operation of its business. This information falls generally within three categories: 1) Information necessary to properly underwrite risks and charge a fair premium. This may include infor- mation you provided on the application for insur- ance, motor vehicle reports, credit reports, or past claims information. 2) Information necessary to fairly evaluate claims. This may include information you provided on loss reports, information maintained by governmental agencies such as police and fire departments, motor vehicle information, medical records, em- ployment records, wage and salary verification, credit reports, information from other insurers, in- formation about past claims, and other information necessary to evaluate claims. 3) Finance information related to premium payments. This may include credit card numbers, bank ac- count information, or other financial information. DISCLOSURE OF INFORMATION Western National does not sell your private informa- tion. We do not make available your private informa- tion to nonaffiliated companies for marketing pur- poses. Western National only shares information when it is necessary to conduct our insurance busi- ness. Information may be disclosed to insurance sup- port groups that provide data for underwriting and claims purposes. In addition, information may be shared with adjusters, attorneys, auditors, agents or others that Western National retains to work on your or its behalf or by individuals that you retain, such as body shops or contractors, to work on your behalf. Western National may disclose claim information to other insurers or other parties during the handling of claims, during litigation surrounding those claims, or after claims have been resolved to the extent permit- ted by law. PROTECTING YOUR INFORMATION Western National maintains physical and electronic safeguards to prevent access to your information by people other than Western National employees. West- ern National continually assesses new technology for protecting information and upgrades its systems when appropriate. * This privacy policy applies to all companies within Western National Insurance Group: American Freedom Insurance Company Arizona Automobile Insurance Company Nevada General Insurance Company Pioneer Specialty Insurance Company Umialik Insurance Company Western Home Insurance Company Western National Assurance Company Western National Finance Company Western National Mutual Insurance Company WN GR 01 01 17 WN IL 13 05 14 WESTERN NATIONAL MUTUAL INSURANCE COMPANY EDINA, MINNESOTA MUTUAL POLICY CONDITIONS This policy is issued by a Mutual Company having special regulations lawfully applicable to its organization, membership, policies or contracts of insurance, of which the following shall apply to and form a part of this policy. This policy is nonassessable. The policyholder is a member of the company and shall participate, to the extent and upon the conditions fixed and determined by the Board of Directors of the Company in accordance with the provisions of law, in the distribution of dividends so fixed and determined. The insured is hereby notified that by virtue of this policy they are a member of the Western National Mutual Insurance Company, and that the annual meetings of the company are held at its home office in the city of Edina, Minnesota on the second Tuesday in June in each year, at 1:30 p.m. The insured is entitled to vote either in person or by proxy at any and all meetings of said company. In Witness Whereof, we have caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by our authorized representative, if applicable in your state. 4 President & CEO Secretary WN IL 13 05 14 WN IL 30 05 14 WESTERN NATIONAL ASSURANCE COMPANY EDINA, MINNESOTA In Witness Whereof, we have caused this policy to be executed and attested, but this policy shall not be valid unless countersigned by our authorized representative, if applicable in your state. President & CEO Secretary WN IL 30 05 14 W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE Western National Mutual Insurance Company MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW Vie relationship company- Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Year Make/Model 2004 PETERBILT TRACTOR Fold Here) Vehicle ID Number 2461 W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1. Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE The relationshipcompany Western National Mutual Insurance Company MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Year Make/Model 1999 KENWORTH TRACTOR (Fold Here) Vehicle ID Number 9624 W WESTERN NATIONAL IN THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1. Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE P y Western National Mutual Insurance Company MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship com an Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Year Make/Model 2008 GMC/CHEV K23 Fold Here) Vehicle ID Number 1GCHK23678F149653 W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Vehicle Description Vehicle ID Number Year Make/Model 1054 Agency 2008 CHEV SILVERADO PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 (Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Heel Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Year Make/Model 2008 GMC/CHEV K23 (Fold Here) Vehicle ID Number 1527 W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (5091838-3501 What To Do In Case of An Accident 1. Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW Therelationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Vehicle Description Vehicle ID Number Year Make/Model 9999 Agency 2000 SEMI TRAILERS PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 (Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: 18551921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE 15091838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? WVehicle Insurance Identification Card WESTERN NATIONAL INSURANCE The relationship company Western National Mutual Insurance Company Insured L & S TIRE COMPANY Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES THE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW Policy Number 01 CPP 106321511 Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Vehicle Description Year Make/Model 1994 GMC BOX TRUCK Here) Vehicle ID Number 1879 W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. N a 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN `� WESTERN NATIONAL VEHICLE AT ALL TIMES THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW Therelationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Vehicle Description Vehicle ID Number Year Make/Model 1FVACWDC75HN79780 Agency 2005 FREIGHTLINER PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 (Fold W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model 1HSCDSBNX7C521081 2007 INTERNATIONAL 9200I CONV CAB Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Heel Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE n MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationsh' com anv Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model 3AKJGED3FSG86832 2015 FREIGHTLINER X12564ST TRK TRAC (Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company, 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Heel Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model 3AKJGEDVXFSGB6330 2015 FREIGHTLINER X12564ST TRK TRAC (Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN `� WESTERN NATIONAL VEHICLE AT ALL TIMES THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW Therelationshipcompany, Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model 3AKJGEDVlFSGB6831 2015 FREIGHTLINER TRUCK -TRACTOR Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company, 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE Western National Mutual Insurance Company MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model P25JRBC1107 1978 FORD PICKUP TRUCK Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN `� WESTERN NATIONAL VEHICLE AT ALL TIMES THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company, Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Year Make/Model 2017 FREIGHTLINER TRUCK (Fold Here) Vehicle ID Number 1FVACWDTXHHHS9372 W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company, 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN `� WESTERN NATIONAL VEHICLE AT ALL TIMES THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model 3HSDXTZN9NN17608 2022 INTERNATIONAL TRUCK -TRACTOR (Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN '`� WESTERN NATIONAL VEHICLE AT ALL TIMES THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company, Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 Y�i%II �CI:IICICS��iI Vehicle Description Vehicle ID Number Year Make/Model 1HTMMMML4JH732669 2018 INTERNATIONAL BOX TRUCK-TRAC (Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company, 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321S11 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model 3HAEUMMLBLL846644 2020 FREIGHTLINER BOX TRUCK-TRAC (Fold Here) W WESTERN NATIONAL IN THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW The relationship company Western National Mutual Insurance Company Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 IDM-I91=1 VIIII Vehicle Description Vehicle ID Number Year Make/Model 3HCDZTZRONL285712 2022 INTERNATIONAL TRUCK -TRACTOR (Fold Here) W WESTERN NATIONAL /N THE EVENT OF AN ACC/DENT, PLEASE FOLLOW THESE STEPS: INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. S. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (855)921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (509)838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W Vehicle Insurance Identification Card LAW REQUIRES ID CARD TO BE CARRIED IN VEHICLE AT ALL TIMES WESTERN NATIONAL THE COVERAGE PROVIDED BY THIS POLICY MEETS THE INSURANCE Therelationshipcompony Western National Mutual Insurance Company MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW Insured Policy Number 01 CPP 106321511 L & S TIRE COMPANY Effective Date Expiration Date DECEMBER 8, 2021 DECEMBER 8, 2022 Agency PAYNEWEST INSURANCE 501 N RIVERPOINT BLVD, STE 403 SPOKANE, WA 99202-1649 509-838-3501 Vehicle Description Vehicle ID Number Year Make/Model 3HCDZTZR9NL285711 2022 INTERNATIONAL TRUCK -TRACTOR (Fold Here) W WESTERN NATIONAL/N THE EVENT OF AN ACC/DENT PLEASE FOLLOW THESE S TEP S. INSURANCE The relationship company 1. Remain Calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 911. 3. Do not leave the scene of an accident. 4. Always notify law enforcement. They will let you know if an officer needs to be present at the scene. 5. Do not admit fault or make any comment or statement regarding the accident except to the police or an identified representative of Western National. 6. Complete the back portion of this form. Get the full names, complete addresses, license numbers and phone numbers of each driver, passenger, and witness as well as license plate numbers of all involved vehicles. 7. Promptly notify your agent or Western National of all accidents, regardless of fault and even if damage is minor. TO REPORT A CLAIM: Call: (8551921-3164 Online: www.wnins.com Agent: PAYNEWEST INSURANCE (5091838-3501 What To Do In Case of An Accident 1 . Remain calm. Protect your family members or passengers and your property. 2. If someone is injured, obtain first aid by calling 91 1 . 3. Get the full names, complete addresses, license numbers, and phone numbers of each driver, passenger and witness as well as license plate numbers of involved vehicles. 4. Obtain the name of the Insurance Company and policy number for each vehicle involved. 5. Do not admit fault or make any comments or statement regarding the accident except to the police or an identified representative of Western National. 6. Promptly notify your agent or Western National of all accidents, regardless of fault and even if the damage is minor. Claims: (855)921-3164 Policy Services: (800)352-2772 (Fold Here) Date of Accident and Time: Location of Accident: (City/State, Street Names) Description of Accident: Insured Vehicle: Year Make Model Western National Policy Number 01 CPP 106321511 Driver's Name Address: Residence Phone: Cell Phone: Business Phone: Describe Damage to Insured Vehicle: Property Damage: Describe Property: (If auto: year, make, model, plate #) Other Insurance Carrier (Address and Phone) Policy Number: Other Driver's Name and Address: Residence Phone: Cell Phone: Business Phone: Describe Damage: WITNESSES OR PASSENGERS Name and Address Phone Insured Vehicle Other Vehicle Injured? W* WESTERN NATIONAL INSURANCE The relationship company A Special Message from Stuart Henderson, President and CEO of Western National A company mission statement provides the opportunity to tell people what you stand for, and what you are working to achieve. Ideally, a mission statement will reinforce the values that guide the behavior and work efforts of our employees on a daily basis. At Western National, we understand the importance of having a brief, yet memorable mission to guide us today and into the future. The folks at Western National recently developed the following mission statement: Our Mission To act with integrity in the service of others. We will achieve this mission by maintaining financial strength, and by establishing lasting relationships with people and businesses who share these attributes with us: A passion for business and life A desire to serve others in need Adaptability to a changing world A strong sense of humility and humor As with our slogan "The Relationship Company", this Mission comes to us because it is already what we believe, and how we act in our lives - it's not a temporary and catchy marketing campaign. Integrity may be intermittent in some corporate circles, but not 0 here. Serving others has been most recently embodied by Western National's commitment to contribute 1 % of prior year's income to charity, and by giving our employees paid time off for community service. We will continue that tone in the design of product offerings (such as a new benefit for all homeowners that pays a policyholder wage loss for time they miss taking care of a sick child) and in the dissemination of information to policyholders (such as the Teen Safe Driver Booklet for auto insureds sent to all youthful drivers and their parents). The importance of good values seems to be making a welcome resurgence recently in the business world. For us it's "business as usual". Our Mission Statement will serve to endorse our past, and to provide guideposts for the future. On behalf of all the employees at Western National, we appreciate the opportunity to serve you now and for many years to come. WN GR 02 08 11 Western National Insurance Group 14700 West 77th Street I Edina, MN 55435 1 (952) 835-5350 or (800) 862-6070 info@wnins.com I www.wnins.com OUR COMPANIES: ARIZONA AUTOMOBILE I PIONEER SPECIALTY I UMIALIK I WESTERN HOME I WESTERN NATIONAL ASSURANCE WESTERN NATIONAL MUTUAL I WISCONSIN AMERICAN MUTUAL