2023-11-01_COI.pdf

H o ld e r Id e n ti fi e r

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70424 01332

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70007 07007

C e rt if ic a te N o

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

10/05/2023

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 Services Northeast, Inc.

New York NY Office One Liberty Plaza 165 Broadway, Suite 3201 New York NY 10006 USA

PHONE

(A/C. No. Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

(866) 283-7122

INSURED 22667ACE American Insurance CompanyINSURER A:

43575Indemnity Insurance Co of North AmericaINSURER B:

20702ACE Fire Underwriters Insurance Co.INSURER C:

10172Westchester Surplus Lines Ins CoINSURER D:

INSURER E:

INSURER F:

FAX

(A/C. No.):

(800) 363-0105

CONTACT

NAME:

Laboratory Corporation of America Holdings & Subsidiaries 531 S Spring Street Burlington NC 27215 USA

COVERAGES CERTIFICATE NUMBER: 570102114445 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

GEN'L AGGREGATE LIMIT APPLIES PER:

$1,000,000

$1,000,000

$1,000,000

$2,000,000

$1,000,000

A 11/01/2022 11/01/2023Y Y HDOG72951529

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)

$2,000,000A 11/01/2022 11/01/2023Y Y COMBINED SINGLE LIMIT

(Ea accident)

ISA H25571915

EXCESS LIAB

X OCCUR

CLAIMS-MADE AGGREGATE

EACH OCCURRENCE

DED

$3,000,000

$3,000,000

11/01/2022

UMBRELLA LIAB

D 11/01/2023G27524485009

RETENTION

X

E.L. DISEASE-EA EMPLOYEE

E.L. DISEASE-POLICY LIMIT

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

X OTH-

ER

PER STATUTEB 11/01/2022 11/01/2023

AOS

WLRC68921612A 11/01/2022 11/01/2023

C 11/01/2022 11/01/2023

$1,000,000

Y / N

(Mandatory in NH)

ANY PROPRIETOR / PARTNER / EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / A

Y

N

SCFC6892165A

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

If yes, describe under DESCRIPTION OF OPERATIONS below

$1,000,000

WLRC68921697

Each IncidentHDCG72951566 11/01/2022 11/01/2023 Claims Made $3,000,000Aggregate

E&O - Professional Liability

- Primary

A $1,000,000

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

Policy No. G27524485009 includes Professional Liability coverage on a claims Made basis. Professional Liability SIR applies as follows: $5,000,000 for Genetics and $3,000,000 for all other. The General Liability policy evidenced herein had been endorsed to include Limited Abuse and Molestation Coverage as regards all Arizona locations with a limit of $1M Each occurrence and $2M Aggregate. RE: Contract No. CTR055522. State of Arizona, Arizona Department of Economic security and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are included as Additional Insured in accordance with the policy provisions of the General Liability and Automobile Liability policies. General Liability policy evidenced herein are Primary and Non-Contributory to other insurance available to Additional Insured, but only in accordance

CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVEArizona Dept. of Economic Security c/o myCOI 1075 Broad Ripple Ave., Suite 313 Indianapolis IN 46220 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.

with the policy's provisions. Automobile Liability policy evidenced herein is Primary to other insurance available to Additional Insured, but only in accordance with the policy's provisions. A Waiver of subrogation is granted in favor of State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees in accordance with the policy provisions of the General Liability, Automobile Liability and Workers' compensation policies. umbrella Liability includes professional liability coverage.

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 Services Northeast, Inc.

NAMED INSUREDAGENCY

LOC #:

570000008881 AGENCY CUSTOMER ID:

© 2008 ACORD CORPORATION. All rights reserved.

See Certificate Number:

See Certificate Number:

The ACORD name and logo are registered marks of ACORD

570102114445

570102114445

ACORD 25 Certificate of Liability Insurance

Additional Description of Operations / Locations / Vehicles:

ACORD 101 (2008/01)

ADDITIONAL REMARKS SCHEDULE Page _ of _

Laboratory Corporation of America

ALL-32688 (01/11) Page 1 of 2

NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES

Named Insured Laboratory Corp of America Holdings Endorsement Number

Policy Symbol

HDO

Policy Number

G72951529 Policy Period

11/01/2022 TO 11/01/2023

Effective Date of Endorsement

Issued By (Name of Insurance Company)

ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below (the “Schedule”). You or your representative must provide us with both the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule.

B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy.

C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy.

D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement.

E. We may arrange with your representative to send such notice in the event of any such cancellation.

F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and physical address of the persons or organizations listed in the Schedule.

G. This endorsement does not apply in the event that you cancel the Policy.

SCHEDULE

Name of Certificate Holder E-Mail Address Physical Address

Arizona Dept. of Economic Security Division of Child Support Enforcement

P.O. Box 40458 Phoenix, AZ 85081

ALL-32688 (01/11) Page 2 of 2

Name of Certificate Holder E-Mail Address Physical Address

All other terms and conditions of this Policy remain unchanged.

Authorized Representative

PUBLIC ENTITY ADDITIONAL INSURED ENDORSEMENT

ALL-22422 (05/07) Page 1 of 1

Named Insured Laboratory Corp of America Holdings Endorsement Number

Policy Symbol

HDO

Policy Number

G72951529 Policy Period

11/01/2022 TO 11/01/2023

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

EXCESS COMMERCIAL GENERAL LIABILITY POLICY

BUSINESS AUTO COVERAGE FORM

(name and address of additional insured)

The State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents and employees.

ADDITIONAL INSURED

It is agreed that the entity shown in the Schedule, its Officers, Employees, and Agents are named as Additional Insureds with respect to the operations and activities of the Named Insured.

PRIMARY INSURANCE

Insurance provided by this policy shall be primary insurance and no other insurance or self insured retention carried or held by the Scheduled Entity shall be called upon to contribute to a loss covered by insurance for the named insured.

CANCELLATION CLAUSE

Thirty (30) days written notice shall be given to the Scheduled Entity in the event of cancellation and/or reduction in limits or coverage.

SEVERABILITY OF INTEREST

This insurance shall apply separately to each insured against whom claim is made or suit is brought except with respect to the limits of liability of the insuring company.

Except as stated above and not in conflict with this endorsement, nothing contained herein shall be held to waive, alter or extend any of the limits, agreements, or exclusions of the policy(ies) to which this endorsement applies.

All other terms and conditions of this policy remain the same.

Authorized Agent

CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

POLICY NUMBER: HDO G72951529 Endorsement Number: 90

COMMERCIAL GENERAL LIABILITY

CG 20 26 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – DESIGNATED

PERSON OR ORGANIZATION

COMMERCIAL GENERAL LIABILITY COVERAGE PART

Name Of Additional Insured Person(s) Or Organization(s): The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees shall be named as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor

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

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

1. In the performance of your ongoing operations;

or

2. In connection with your premises owned by or rented to you.

However:

1. The insurance afforded to such additional insured 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 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.

B. 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 the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable limits of insurance;

whichever is less.

This endorsement shall not increase the applicable limits of insurance.

CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

POLICY NUMBER: HDO G72951529 Endorsement Number: 123

COMMERCIAL GENERAL LIABILITY

CG 24 04 12 19

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

COMMERCIAL GENERAL LIABILITY COVERAGE PART

ELECTRONIC DATA LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES

POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

RAILROAD PROTECTIVE LIABILITY COVERAGE PART

UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS

Name Of Person(s) Or Organization(s):The State of Arizona, and departments, agencies, boards, commissions, universities, officers, agents, and employees for losses arising from work performed by or on behalf of the Contractor

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 against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above.

LD-25238 (12/08) Page 1 of 3

ABUSE AND MOLESTATION EXCLUSION AND LIMITED COVERAGE ENDORSEMENT

Named Insured

Laboratory Corp of America Holdings Endorsement Number

Policy Symbol

HDO

Policy Number

G72951529 Policy Period

11/01/2022 to 11/01/2023 Effective Date of Endorsement

Issued By (Name of Insurance Company)

ACE American Insurance Company

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

COMMERCIAL GENERAL LIABILITY POLICY

THIS ENDORSEMENT PROVIDES CLAIMS MADE AND REPORTED COVERAGE

This Endorsement is written on a Claims Made and Reported basis and provides “Limited Abuse and Molestation Coverage” as set forth below that takes place subsequent to the Retroactive Date and before the end of the policy period, which are first made against you and reported to us during the policy period. No coverage exists for claims first made against you or reported to us after the end of the policy period.

I. Abuse and Molestation Exclusion

The following exclusion is added to Paragraph 2. Exclusions of SECTION I – COVERAGE A –Bodily Injury And Property Damage Liability and to 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” directly or indirectly from or arising out of “abuse or molestation”.

II. Limited Abuse and Molestation Coverage

Limits of Insurance:

Each Person Limit: $1,000,000 Each Occurrence Limit: $1,000,000 Aggregate Limit: $2,000,000

Deductible: $1,000,000 Locations: All Arizona locations of the Named Insured Entity: The Department of Economic Security in Arizona Retroactive Date: 6/1/2006

A. In consideration of an additional premium, we provide “Limited Abuse and Molestation Coverage” for the locations shown in the Schedule and only for the benefit of the entities shown in the Schedule, which is described as follows, and is subject to the terms, conditions and exclusions set out below:

Subject to the Limits of Insurance listed in the Schedule and to the Exclusions below, we will pay under this endorsement the “ultimate net loss” that the insured becomes legally obligated to pay as damages for “bodily injury”, “property damage” or “personal and advertising injury” arising out of “abuse or molestation”, only if a claim for damages is first made against any insured during the policy period, and the insured had no knowledge, or reasonably should not have been expected to know, of the “abuse or molestation” prior to the inception date of the policy.

No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Paragraph B. Defense, Investigation, Settlement, Legal Expenses, and Interest on Judgments.

But the amount we will pay for the “ultimate net loss” because of damages is limited as described in the Limits of Insurance listed in the schedule.

LD-25238 (12/08) Page 2 of 3

B. Defense, Investigation, Settlement, Legal Expenses and Interest on Judgments

The insurance provided under this endorsement does not apply to defense, investigation, settlement or legal expenses, or to prejudgment interest arising out of any “occurrence” or offense. However, we shall have the right and opportunity to assume from the insured the defense and control of any claim or “suit”, including any appeal from a judgment, seeking payment of damages covered under this endorsement. In such event, we and the insured shall cooperate fully.

We shall pay interest only on that amount of any judgment we pay that accrues as post-judgment interest after entry of the judgment and before we have paid, offered to pay, or deposited in court that part of the judgment that is within the applicable limit of insurance shown in the Schedule.

C. Exclusions

The insurance for “Limited Abuse and Molestation Coverage” provided by this endorsement does not apply to:

1. Claims or damages for “abuse or molestation” that occurred before the Retroactive Date shown above or which occur after the end of the policy period;

2. Any insured who is alleged to have personally participated in committing any “abuse or molestation”;

3. Any insured who is alleged to have remained passive after having personal knowledge, or under circumstances in which the insured should reasonably have known, of any “abuse or molestation”;

4. Any “abuse or molestation” of a person if the first incident of “abuse or molestation” of that person by the same, or allegedly the same, individual or individuals occurred prior to the effective date of this endorsement.

D. Limits of Insurance and Deductible

The Limits shown in the Schedule of this endorsement and the rules below fix the most we will pay for the “Limited Abuse and Molestation Coverage” provided for herein, regardless of the number of:

1. Insureds;

2. Claims made or “suits” brought; or

3. Persons or organizations making claims or bringing “suits”.

The Each Person Limit is the most we will pay for all damages sustained resulting from “abuse or molestation” to any one person regardless of the number of incidents of “abuse or molestation”.

The Each Occurrence Limit is, subject to the Each Person Limit, the most we will pay for the sum of all “bodily injury”, “property damage” and “personal and advertising injury” arising out of any one “occurrence”.

The Aggregate Limit is, subject to the Each Person Limit and the Each Occurrence Limit, the most we will pay for all damages regardless of the number of a) insureds, b) claims made or "suits" brought, or c) persons or organizations making claims or bringing suits. The Aggregate Limit is included in, and is not in addition to, the General Aggregate Limit.

Coverage under this endorsement is subject to the Deductible amount shown in the Schedule above. We will pay up to the applicable limit for Each Person or Each Occurrence and you will reimburse us up to the Deductible amount.

E. Definitions

For the purposes of this endorsement only:

1. "Abuse or molestation" means:

a. The actual or threatened abuse or molestation by anyone of any person while in the care, custody or control of any insured, including but not limited to “physical abuse”, “sexual misconduct”, mental abuse, harassment, and any other type of abuse or molestation, or

LD-25238 (12/08) Page 3 of 3

b. The actual or alleged negligent:

i. Employment;

ii. Investigation;

iii. Supervision;

iv. Reporting to the proper authorities, or failure to so report; or

v. Retention of a person for whom any insured is or ever was legally responsible and whose conduct would be excluded by sub-paragraph a. above.

2. “Bodily injury” includes mental anguish resulting from “physical abuse” or “sexual misconduct” of the person injured.

3. “Physical abuse” means actual, alleged, or threatened physical mistreatment.

4. “Sexual misconduct” means any conduct, whether actual, alleged, or threatened, of a sexual nature.

5. “Ultimate net loss” means the total amount which the insured is legally obligated to pay as damages due to an “occurrence” or offense arising out of covered claims or “suits” either by an adjudication or a settlement to which we agree in writing and includes interest that accrues after entry of the judgment and deductions for recoveries and salvages which have been or will be paid. "Ultimate net loss” does not include any of the expenses incurred by the insured or us in connection with defending the claim or “suit”.

DA-13115a (06/14) Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS

Named Insured Laboratory Corporation of America Holdings Endorsement Number

Policy Symbol

ISA

Policy Number

H25571915 Policy Period

11/01/2022 TO 11/01/2023

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

This Endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIERS COVERAGE FORM

AUTO DEALERS COVERAGE FORM

We waive any right of recovery we may have against the person or organization shown in the Schedule below because of payments we make for injury or damage arising out of the use of a covered auto. The waiver applies only to the person or organization shown in the SCHEDULE.

Magellan Health Services of Arizona, Inc.

DA-9U74c (03/16) Page 1 of 1

ADDITIONAL INSURED –

DESIGNATED PERSONS OR ORGANIZATIONS

Named Insured Laboratory Corporation of America Holdings Endorsement Number

Policy Symbol

ISA

Policy Number

H25571915 Policy Period

11/01/2022 TO 11/01/2023

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

BUSINESS AUTO COVERAGE FORM

AUTO DEALERS COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

EXCESS BUSINESS AUTO COVERAGE FORM

Additional Insured(s): The State of Arizona, and its departments agencies, boards, commissions universities, officers, officials, agents and employees shall be named as additional insureds with respect to liability arising out of the activities performed by, or on behalf of, the Contractor, involving automobiles owned, leased, hired or borrowed by the Contractor

A. For a covered “auto,” Who Is Insured is amended to include as an “insured,” the persons or organizations named in this endorsement. However, these persons or organizations are an “insured” only for “bodily injury” or “property damage” resulting from acts or omissions of:

1. You.

2. Any of your “employees” or agents.

3. Any person operating a covered “auto” with permission from you, any of your “employees” or agents.

B. The persons or organizations named in this endorsement are not liable for payment of your premium.

Workers' Compensation and Employers' Liability Policy

WC 00 03 13 (11/05) © Copyright 1983–2017 National Council on Compensation Insurance, Inc. All Rights Reserved.

Named Insured

LABORATORY CORP OF AMERICA HOLDINGS

531 SOUTH SPRING STREET 2ND FLOOR

BURLINGTON NC 27215

Endorsement Number

Policy Number

Symbol: WLR Number: C68921697 Policy Period

11-01-2022 TO 11-01-2023

Effective Date of Endorsement 11-01-2022

Issued By (Name of Insurance Company)

INDEMNITY INS. CO. OF NORTH AMERICA

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

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

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

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

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

Schedule

IN FAVOR OF THE STATE OF ARIZONA, AND ITS DEPARTMENT, AGENCIES, BOARDS,

COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES

FOR LOSSES ARISING FROM WORK PERFORMED BY OR ON BEHALF OF THE

CONTRACTOR

For the states of CA, UT, TX, refer to state specific endorsements.

This endorsement is not applicable in KY, NH, and NJ.

The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications.

For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A..

16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program.