2024-04-25 Legend Technical Services PP.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT

OTHER: $

COMBINED SINGLE LIMIT

$(Ea accident)

ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED

BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE

$AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE

CLAIMS-MADE AGGREGATE $

DED RETENTION $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N N / A

(Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

4/24/2023

License # 20443386

(651) 288-5128 (651) 286-0539

24414

Legend Technical Services Of AZ Inc & Wabe Sabe, LLC 17631 N 25th Ave Phoenix, AZ 85023

24449 22322

A 1,000,000

X X BPK0005688 7/8/2022 7/8/2023 100,000

5,000

1,000,000 2,000,000 2,000,000

1,000,000B

X X BCA0003323 7/8/2022 7/8/2023

3,000,000A

BUM0007186 7/8/2022 7/8/2023 3,000,000

10,000 A

X BWC0002945 7/8/2022 7/8/2023 1,000,000

1,000,000 1,000,000

C Professional Liab PEC000256323 4/25/2023 Each Claim 2,000,000 C Including Pollution PEC000256323 4/25/2023 4/25/2024 Aggregate 2,000,000

RE: Contract #CTR061675 / State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees / Refer to attached endorsements for Additional Insured & Waiver of Subrogation status / 30 Day Notice of Cancellation

Arizona Department of Environmental Quality Contracts & Procurement 1110 W Washington St Phoenix, AZ 85007

LEGETEC-02 KREYNOLDS1

HUB International Great Plains, LLC 245 E. Roselawn Avenue Suite 31 Saint Paul, MN 55117-1940

Kris Reynolds kristine.reynolds@hubinternational.com

General Casualty Company of Wisconsin Regent Insurance Company Greenwich Insurance Company

X

4/25/2024

X X

X

X

X

X

© Insurance Services Office, Inc., 2018 Page 1 of 5CG 20 10 12 19

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 10 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations

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:

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(s) at the location(s) designated above.

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 additional exclusions apply:

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 location 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.

Coverage Provided as Provided by Written Contract or Agreement 1789 W Jefferson St Site Code 8057 Phoenix, AZ 85007-3202

17631 N 25th Ave Maricopa Phoenix, AZ 85023-2114

BPK0005688-03

© Insurance Services Office, Inc., 2018 CG 20 10 12 19Page 2 of 5

C. 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.

© Insurance Services Office, Inc., 2018 Page 3 of 5CG 20 10 12 19

CG 20 10 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations

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:

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(s) at the location(s) designated above.

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 additional exclusions apply:

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 location 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.

See Schedule in Pages to Follow See Schedule in Pages to Follow

© Insurance Services Office, Inc., 2018 CG 20 10 12 19Page 4 of 5

C. 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.

© Insurance Services Office, Inc., 2018 Page 5 of 5CG 20 10 12 19

SCHEDULE

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

1789 W Jefferson St Site Code 8057

Phoenix, AZ 85007-3202

Location(s) Of Covered Operations 17631 N 25th Ave Maricopa Phoenix, AZ 85023-2114

Name Of Additional Insured Person(s) Or Organization(s)

© Insurance Services Office, Inc., 2018 Page 1 of 2CG 20 37 12 19

CG 20 37 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations

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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".

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.

See schedule in pages to follow

© Insurance Services Office, Inc., 2018 CG 20 37 12 19Page 2 of 2

SCHEDULE

Location And Description Of Completed Operations 17631 N 25th Ave Maricopa Phoenix, AZ 85023-2114

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

Name Of Additional Insured Person(s) Or Organization(s)

CG 24 04 05 09

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.

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

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor

1 1

COMMERCIAL GENERAL LIABILITY

AH CG 8623 09 17

AH CG 8623 09 17

Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 6

PREMIER GENERAL LIABILITY COVERAGE

EXTENSION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

A. REASONABLE FORCE

Paragraph 2.a. Expected or Intended Injury under COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY of SECTION I

— COVERAGES within the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by:

a. Expected or Intended Injury

"Bodily injury" or "property damage" expected or intended from the standpoint of the in-sured. This exclusion does not apply to "bodi-ly injury" or "property damage" resulting from the use of reasonable force to protect any person or property.

B. CONTRACTUAL LIABILITY

Paragraph 2.b. Contractual Liability under

COVERAGE A — BODILY INJURY AND

PROPERTY DAMAGE LIABILITY of SECTION I

— COVERAGES within the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by:

b. Contractual Liability

"Bodily injury" or "property damage" for which the insured is obligated to pay damages by reason of the assumption of liability in a con-tract or agreement. This exclusion does not apply to liability for damages:

(1) That the insured would have had in the absence of the contract or agreement; or

(2) Assumed in a contract or agreement that is an "insured contract", provided the "bodily injury" or "property damage" oc-curs subsequent to the execution of the contract or agreement.

C. NON OWNED WATERCRAFT

Paragraph 2.g.(2) in the Aircraft, Auto Or Wa-tercraft exclusion under COVERAGE A —

BODILY INJURY AND PROPERTY DAMAGE

LIABILITY of SECTION I — COVERAGES within the COMMERCIAL GENERAL LIABILITY COV- ERAGE FORM is replaced by:

(2) A watercraft you do not own that is:

(a) less than 75 feet long; and

(b) Not being used to carry persons or prop-erty for a charge.

D. ELECTRONIC DATA LIABILITY

1. Paragraph 2.p. Electronic Data under COV-

ERAGE A — BODILY INJURY AND PROP-

ERTY DAMAGE LIABILITY of SECTION I — COVERAGES within the COMMERCIAL GENERAL LIABILITY COVERAGE FORM is replaced by:

p. Electronic Data

Damages arising out of the loss of, loss of use of, damage to, corruption of, inability to access, or inability to manipulate "elec-tronic data" that does not result from physical injury to tangible property.

However, this exclusion does not apply to liability for damages because of "bodily injury".

2. The following definition is added to SEC-

TION V — DEFINITIONS:

"Electronic data" means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD-ROMs, tapes, drives, cells, data processing devices or any other media which are used with electronically con-trolled equipment.

3. For purposes of the coverage provided for "Electronic Data", Paragraph 17. in SEC- TION V — DEFINITIONS is replaced by:

17. "Property damage" means:

a. Physical injury to tangible property, including all resulting loss of use of that property. All such loss of use shall be deemed to occur at the time of the physical injury that caused it; or

BPK0005688

INTERLINE FORM

AH IL 8590 09 17

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

AMENDMENT — NOTICE TO OTHERS OF CANCELLATION

SCHEDULE*

Name and Address of Person or Organization Number of Days Notice

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

The following is added to the policy:

A. If we cancel the policy by notice to the first Named Insured, for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the person(s) or or-ganization(s) shown in the Schedule above.

B. Any copy of notice per paragraph A. above will be mailed or delivered:

1. To the address corresponding to each person or organization indicated in the Schedule above; and

2. At least the number of days set forth in the Schedule prior to the cancellation date appli-cable to the policy, as advised in our notice to the first Named Insured.

C. If notice per paragraph A. is mailed, proof of mail-ing will be sufficient proof of notice.

D. Written notices mailed or delivered by us pursuant to the terms of this endorsement are intended only to be an advance notification to the person(s) or organization(s) named in the Schedule of this en-dorsement in the event of a pending cancellation and shall not operate or be deemed to benefit, di-rectly or indirectly, any person or organization not named in the Schedule above.

All other terms and conditions of the policy remain unchanged.

POLICY NUMBER: BPK0005688-03

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

COMMERCIAL GENERAL LIABILITY

CG 20 01 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1

PRIMARY AND NONCONTRIBUTORY –

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

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 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.

BPK0005688

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

COMMERCIAL AUTO

CA 20 48 10 13

POLICY NUMBER: BCA0003323-03

© Insurance Services Office, Inc., 2011 Page 1 of 2CA 20 48 10 13

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.

SCHEDULE

Legend Technical Services of Arizona Inc

07/08/2022

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

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

the state of Arizona and per amendatory form 17631 N 25th Ave

Phoenix, AZ 85023

Endorsement Effective Date:

Named Insured:

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.

POLICY NUMBER:

Authorized Representative Signature

Amendatory form for Complete Named Insured for additional Insured

Complete Named Insured for form: CA 2048 - Designated Insured

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor.

BCA0003323-03

POLICY NUMBER: COMMERCIAL AUTO

AH CA 85 97 09 17

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

AH CA 85 97 09 17 Includes copyrighted material of Insurance Services Office, Inc., with its permission

DESIGNATED INSURED — PRIMARY AND

NON-CONTRIBUTORY

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

AUTO DEALERS COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi-sion 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.

Endorsement Effective: Countersigned By:

Named Insured:

(Authorized Representative)

SCHEDULE

Name of Person(s) or Organization(s):

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.)

1. Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision con-tained in Section II of the Coverage Form.

2. This insurance is primary to and non-contributory with any other insurance for each person or organiza-tion shown in the schedule, when required by written contract or agreement that is in effect during the pol-icy period and is signed and executed before any damage or “loss” occurs.

BCA0003331-03

07/08/2022

Blanket Per Contract

Legend Technical Services I d B i LLC

POLICY NUMBER: 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:

Endorsement Effective Date:

SCHEDULE

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

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.

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

BCA0003323-03

07/08/2022

Legend Technical Services of Arizona Inc

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor 17361 N 25th Ave Phoenix, AZ 85023

POLICY NUMBER: INTERLINE FORM

AH IL 8590 09 17

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

AH IL 8590 09 17 Page 1 of 1

AMENDMENT — NOTICE TO OTHERS OF CANCELLATION

SCHEDULE*

Name and Address of Person or Organization Number of Days Notice

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

The following is added to the policy:

A. If we cancel the policy by notice to the first Named Insured, for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the person(s) or or-ganization(s) shown in the Schedule above.

B. Any copy of notice per paragraph A. above will be mailed or delivered:

1. To the address corresponding to each person or organization indicated in the Schedule above; and

2. At least the number of days set forth in the Schedule prior to the cancellation date appli-cable to the policy, as advised in our notice to the first Named Insured.

C. If notice per paragraph A. is mailed, proof of mail-ing will be sufficient proof of notice.

D. Written notices mailed or delivered by us pursuant to the terms of this endorsement are intended only to be an advance notification to the person(s) or organization(s) named in the Schedule of this en-dorsement in the event of a pending cancellation and shall not operate or be deemed to benefit, di-rectly or indirectly, any person or organization not named in the Schedule above.

All other terms and conditions of the policy remain unchanged.

BCA0003323-03

the state of Arizona and per amendatory form 17361 N 25th Ave Phoenix, AZ 85023

POLICY NUMBER:

Authorized Representative Signature

Amendatory form for Complete Named Insured for NOC

Complete Named Insured for Form AH IL 8590- Amendment - Notice to Others Of Cancellation

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor.

BCA0003323-03

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

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

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

Endorsement Effective Policy No. Endorsement No.

Insured Premium

Insurance Company Countersigned by __________________________________________

WC 00 03 13

(Ed. 4-84)

07/08/2022 Legend Technical Services of Arizona Inc

General Casualty Company of Wisconsin

BWC0002945-03

Blanket as required by contract.

Policy Endorsement

Page of

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

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

Endorsement No.Endorsement Effective Date: Policy No.

Carrier Name / Code:

Policy Effective Date: to Premium $

Insured:

DBA:

Countersigned by

The Organization Listed on WC 000313 is Completed to Read:

The Organization Listed on WC 000313 is Completed to Read:

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

BWC0002945-03

General Casualty Company of Wisconsin

Legend Technical Services of Arizona Inc

07/08/2022

07/08/2022 07/08/2023

1 1