2023-10-01_Tetra_Tech_CTR056545_GAWP.pdf

H o ld e r

Id e n ti fi e r

C e rt if ic a te

N o

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

10/4/2022

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

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.

PRODUCER

Aon Risk Insurance Services West, Inc.

Los Angeles CA Office 707 Wilshire Boulevard Suite 2600 Los Angeles CA 90017-0460 USA

PHONE

(A/C. No. Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

(866) 283-7122

INSURED 16535Zurich American Ins CoINSURER A:

24319Allied World Surplus Lines Insurance CoINSURER B:

INSURER C:

INSURER D:

INSURER E:

INSURER F:

FAX

(A/C. No.):

(800) 363-0105

CONTACT

NAME:

Tetra Tech, Inc.

45610 Woodland Road, Suite 400 Sterling VA 20166 USA

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. Limits shown are as requested

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

(MM/DD/YYYY)

SUBR

WVD

INSR

LTR

ADDL

INSD POLICY NUMBER TYPE OF INSURANCE LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY LOC

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

X

X

X

X X

GEN'L AGGREGATE LIMIT APPLIES PER:

$1,000,000

$1,000,000

$10,000

$1,000,000

$2,000,000

$2,000,000

X,C,U Coverage

A 10/01/2022 10/01/2023GLO181740604

PRO-

JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

SCHEDULED

AUTOS

HIRED AUTOS

ONLY

NON-OWNED

AUTOS ONLY

BODILY INJURY ( Per person)

PROPERTY DAMAGE

(Per accident)

X

BODILY INJURY (Per accident)

$1,000,000A 10/01/2022 10/01/2023 COMBINED SINGLE LIMIT

(Ea accident)

BAP 1857085 04

EXCESS LIAB

OCCUR

CLAIMS-MADE AGGREGATE

EACH OCCURRENCE

DED

UMBRELLA LIAB

RETENTION

E.L. DISEASE-EA EMPLOYEE

E.L. DISEASE-POLICY LIMIT

E.L. EACH ACCIDENT $1,000,000

X OTH-

ER

PER STATUTEA 10/01/2022 10/01/2023

WC185708704A 10/01/2022 10/01/2023

$1,000,000

Y / N

(Mandatory in NH)

ANY PROPRIETOR / PARTNER / EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / AN

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

If yes, describe under DESCRIPTION OF OPERATIONS below

$1,000,000

WC254061604

Each Claim03120276 10/01/2022 10/01/2023 Professional/Pollution $5,000,000Aggregate

Env Contr ProfB

SIR applies per policy terms & conditions

$5,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

RE: Contract Numbers: CTR060742 - Tanks Services, CTR045160 - ASRAC, CTR056545 - Water Quality Sampling and Monitoring CTR055984 - Assessment & Remediation of Hazardous or Regulated Substances or Materials. The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents and employees are included as Additional Insured in accordance with the policy provisions of the General Liability, Automobile Liability and Pollution Liability policies as required by written contract. General Liability policy evidenced herein is Primary and Non-Contributory to other insurance available to an Additional Insured, but only in accordance with the policy's provisions as required by written contract.

CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVE

Arizona Dept. of Environmental Quality Contracts and Procurement Section Judy A. Junge - CPPB - EV 09 - 0100.

1110 W. Washington St.

Phoenix AZ 85007-2935 USA

ACORD 25 (2016/03)

©1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

POLICY PROVISIONS.

FORM TITLE:FORM NUMBER:

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

ADDITIONAL REMARKS

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

Aon Risk Insurance Services West, Inc.

NAMED INSUREDAGENCY

LOC #:

570000036654AGENCY CUSTOMER ID:

© 2008 ACORD CORPORATION. All rights reserved.

See Certificate Number:

See Certificate Number:

The ACORD name and logo are registered marks of ACORD

ACORD 25 Certificate of Liability Insurance Additional Description of Operations / Locations / Vehicles:

A Waiver of Subrogation is granted in favor of The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents and employees in accordance with the policy provisions of the General Liability, AutomobileLiability and Workers' Compensation policies as required by written contract. Contractual Liability is included under the General Liability policy where required by written contract. Stop Gap Coverage for the following states: OH, ND, WA, WY.

ACORD 101 (2008/01)

ADDITIONAL REMARKS SCHEDULE Page _ of _

Tetra Tech, Inc.

COMMERCIAL AUTO

CA 20481013

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

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 this endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

Name Of Person(s) Or Organization(s):

ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO

PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A

PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN

AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR

AGREEMENT IS PROHIBITED BY LAW.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form.

CA 20481013 © Insurance Services Office, Inc., 2011 Page 1 of 1

POLICY NUMBER: BAP 1857085-04

Blanket Notification to Others of Cancellation or Non-Renewal

Policy No. Eff. Date of Pol. Eff. Date of End. Producer No.

BAP 1857085-04 10/01/2022

Exp. Date of Pol.

10/01/2023 75272000

Add'I. Prem

INCL

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the:

Commercial Automobile Coverage Part

ZURICH

Return Prem.

A. If we cancel or non-renew this Coverage Part by written notice to the first Named Insured, we will mail or deliver notification that such Coverage Part has been cancelled or non-renewed to each person or organization shown in a list provided to us by the first Named Insured if you are required by written contact or written agreement to provide such notification. However, such notification will not be mailed or delivered if a conditional notice of renewal has been sent to the first Named Insured. Such list:

1. Must be provided to us prior to cancellation or non-renewal;

2. Must contain the names and addresses of only the persons or organizations requiring notification that such Coverage Part has been cancelled or non-renewed; and

3. Must be in an electronic format that is acceptable to us.

B. Our notification as described in Paragraph A. of this endorsement will be based on the most recent list in our records as of the date the notice of cancellation or non-renewal is mailed or delivered to the first Named Insured. We will mail or deliver such notification to each person or organization shown in the list:

1. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or

2. At least 30 days prior to the effective date of:

a. Cancellation, if cancelled for any reason other than nonpayment of premium; or

b. Non-renewal, but not including conditional notice of renewal.

C. Our mailing or delivery of notification described in Paragraphs A. and B. of this endorsement is intended as a courtesy only. Our failure to provide such mailing or delivery will not:

1. Extend the Coverage Part cancellation or non-renewal date;

2. Negate the cancellation or non-renewal; or

3. Provide any additional insurance that would not have been provided in the absence of this endorsement.

D. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs A. and B. of this endorsement.

All other terms and conditions of this policy remain unchanged.

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

U-CA-832-A CW (01 / 13)

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

POLICY NUMBER: BAP 1857085-04 COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured: TETRA TECH, INC.

Endorsement Effective Date:

SCHEDULE

Name(s) Of Person(s) Or Organization(s):

ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN

CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE

ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER

THIS POLICY.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the “accident” or the “loss” under a contract with that person or organization.

U-GL-1466-D CW (12-13)

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

Additional Insured – Owners, Lessees Or Contractors – Completed Operations – Scheduled

Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add’l. Prem Return Prem.

GLO 1817406-04 10/01/2022 10/01/2023 75272000 INCL

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the:

Commercial General Liability Coverage Part

SCHEDULE

Name of Person or Organization: Location and Description of Completed Operations:

Additional Premium:

ANY PERSON OR ORGANIZATION TO WHOM

OR TO WHICH YOU ARE REQUIRED TO

PROVIDE ADDITIONAL INSURED STATUS

IN A WRITTEN CONTRACT OR WRITTEN

AGREEMENT EXECUTED PRIOR TO THE

LOSS, EXCEPT WHERE SUCH CONTRACTOR

OR AGREEMENT IS PROHIBITED BY LAW.

ANY LOCATION OR PROJECT, OTHER

THAN A WRAP-UP OR OTHER

CONSOLIDATED INSURANCE PROGRAM

LOCATION OR PROJECT FOR WHICH

INSURANCE IS OTHERWISE SEPARATELY

PROVIDED TO YOU BY A WRAP-UP OR

OTHER CONSOLIDATED INSURANCE

PRGRAM.

N/A

U-GL-1466-D CW (12-13)

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

Section II – Who Is An Insured is amended to include as an insured any person or organization shown in the Schedule of this endorsement, but only with respect to liability arising out of "your work" at or from the corresponding location designated and described in the Schedule performed for that insured and included in the "products-completed operations hazard".

However, if you have entered into a construction contract with an additional insured person or organization shown in the Schedule of this endorsement, the insurance afforded to such additional insured only applies to the extent permitted by law.

All other terms and conditions of this policy remain unchanged.

U-GL-1465-D CW (12-13)

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

Additional Insured – Owners, Lessees Or Contractors – Ongoing Operations – Scheduled

Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add’l. Prem Return Prem.

GLO 1817406-04 10/01/2022 10/01/2023 75272000 INCL

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the:

Commercial General Liability Coverage Part

SCHEDULE

Name of Person or Organization: Location and Description of Ongoing Operations:

Additional Premium:

ANY PERSON OR ORGANIZATION TO WHOM

OR TO WHICH YOU ARE REQUIRED TO

PROVIDE ADDITIONAL INSURED STATUS

IN A WRITTEN CONTRACT OR WRITTEN

AGREEMENT EXECUTED PRIOR TO THE

LOSS, EXCEPT WHERE SUCH CONTRACTOR

OR AGREEMENT IS PROHIBITED BY LAW.

ANY LOCATION OR PROJECT, OTHER

THAN A WRAP-UP OR OTHER

CONSOLIDATED INSURANCE PROGRAM

LOCATION OR PROJECT FOR WHICH

INSURANCE IS OTHERWISE SEPARATELY

PROVIDED TO YOU BY A WRAP-UP OR

OTHER CONSOLIDATED INSURANCE

PRGRAM.

N/A

U-GL-1465-D CW (12-13)

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

A. Section II – Who Is An Insured is amended to include as an insured any person or organization shown in the Schedule of this endorsement, but only with respect to liability arising out of your ongoing operations performed for that insured at or from the corresponding location designated and described in the Schedule.

However, if you have entered into a construction contract with an additional insured person or organization shown in the Schedule of this endorsement, the insurance afforded to such additional insured only applies to the extent permitted by law.

B. With respect to the insurance afforded to any additional insured shown in the Schedule of this endorsement, the following additional exclusion applies:

This insurance does not apply to "bodily injury" or "property damage" occurring after:

1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or

2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.

U-GL-1521-B CW (01/19)

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

Blanket Notification to Others of Cancellation or Non-Renewal

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Policy No. GLO 1817406-04 Effective Date: 10/01/2022

This endorsement applies to insurance provided under the:

Commercial General Liability Coverage Part

A. If we cancel or non-renew this Coverage Part by written notice to the first Named Insured, we will mail or deliver notification that such Coverage Part has been cancelled or non-renewed to each person or organization shown in a list provided to us by the first Named Insured if you are required by written contact or written agreement to provide such notification. Such list:

1. Must be provided to us prior to cancellation or non-renewal;

2. Must contain the names and addresses of only the persons or organizations requiring notification that such Coverage Part has been cancelled or non-renewed; and

3. Must be in an electronic format that is acceptable to us.

B. Our notification as described in Paragraph A. of this endorsement will be based on the most recent list in our records as of the date the notice of cancellation or non-renewal is mailed or delivered to the first Named Insured. We will mail or deliver such notification to each person or organization shown in the list:

1. Within 10 days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or

2. At least 30 days prior to the effective date of:

a. Cancellation, if cancelled for any reason other than nonpayment of premium; or

b. Non-renewal, but not including conditional notice of renewal, unless a greater number of days is shown in the Schedule of this endorsement for the mailing or delivering of such notification with respect to Paragraph B.1. or Paragraph B.2. above.

C. Our mailing or delivery of notification described in Paragraphs A. and B. of this endorsement is intended as a courtesy only. Our failure to provide such mailing or delivery will not:

1. Extend the Coverage Part cancellation or non-renewal date;

2. Negate the cancellation or non-renewal; or

3. Provide any additional insurance that would not have been provided in the absence of this endorsement.

U-GL-1521-B CW (01/19)

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

D. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs A. and B. of this endorsement.

SCHEDULE

The total number of days for mailing or delivering with respect to Paragraph B.1. of this endorsement is amended to indicate the following number of days:

The total number of days for mailing or delivering with respect to Paragraph B.2. of this endorsement is amended to indicate the following number of days:

* If a number is not shown here, 10 days continues to apply.

** If a number is not shown here, 30 days continues to apply.

Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add’l. Prem Return Prem.

GLO 1817406-04 10/01/2022 10/01/2023 75272000 INCL

Other Insurance Amendment – Primary And Non- Contributory

U-GL-1327-B CW (04/13)

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Named Insured:

Address (including ZIP Code):

This endorsement modifies insurance provided under the:

Commercial General Liability Coverage Part

1. The following paragraph is added to the Other Insurance Condition of Section IV – Commercial General Liability Conditions:

This insurance is primary insurance to and will not seek contribution from any other insurance available to an additional insured under this policy provided that:

a. The additional insured is a Named Insured under such other insurance; and

b. You are required by a written contract or written agreement that this insurance would be primary and would not seek contribution from any any other insurance available to the additional insured.

2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV – Commercial

General Liability Conditions:

This insurance is excess over:

Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis.

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 24 04 05 09

CG 24 04 05 09 Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV ---- Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

GLO 1817406-04

ANY PERSON OR ORGANIZATION THAT REQUIRES YOU TO WAIVE YOUR RIGHTS OF

RECOVERY, IN A WRITTEN CONTRACT OR AGREEMENT WITH THE NAMED INSURED

THAT IS EXECUTED PRIOR TO THE ACCIDENT OR LOSS.

WC 99 06 43 Page 1 of 1 (Ed. 01-13) Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission.

2012 Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 43

BLANKET NOTIFICATION TO OTHERS OF CANCELLATION OR NONRENEWAL ENDORSEMENT

This endorsement adds the following to Part Six of the policy.

PART SIX

CONDITIONS

Blanket Notification to Others of Cancellation or Nonrenewal

1. If we cancel or non-renew this policy by written notice to you, we will mail or deliver notification that such policy has been cancelled or non-renewed to each person or organization shown in a list provided to us by you if you are required by written contract or written agreement to provide such notification. However, such notification will not be mailed or delivered if a conditional notice of renewal has been sent to you. Such list:

a. Must be provided to us prior to cancellation or non-renewal;

b. Must contain the names and addresses of only the persons or organizations requiring notification that such policy has been cancelled or non-renewed; and

c. Must be in an electronic format that is acceptable to us.

2. Our notification as described in Paragraph 1. above will be based on the most recent list in our records as of the date the notice of cancellation or non-renewal is mailed or delivered to you. We will mail or deliver such notification to each person or organization shown in the list:

a. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or

b. At least 30 days prior to the effective date of:

(1) Cancellation, if cancelled for any reason other than nonpayment of premium; or

(2) Non-renewal, but not including conditional notice of renewal.

3. Our mailing or delivery of notification described in Paragraphs 1. and 2. above is intended as a courtesy only.

Our failure to provide such mailing or delivery will not:

a. Extend the policy cancellation or non-renewal date;

b. Negate the cancellation or non-renewal; or

c. Provide any additional insurance that would not have been provided in the absence of this endorsement.

4. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs 1. and 2. above.

All other terms and conditions of this policy remain unchanged.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No.

Insured Premium $

Insurance Company

POLICY NUMBER: WC 2540616-04

WC 00 03 13

(Ed. 4-84) 1983 National Council on Compensation Insurance.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN

CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE

ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS

POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION.

POLICY NUMBER: WC 2540616-04