ACCEPTED ANY_ALL GL,AL,WC 03.15.24-03.01.25.pdf

09/24/2024

House-Chilson & Associates 400 White Spar Road

Prescott AZ 86303

Deann Harguess

(928) 445-4600 deann@housechilson.com

Koehler Enterprises, Inc Titan Landscape Management, Inc

PO BOX 12348

Prescott AZ 86304

Secura Insurance 22543

CL2421921583

A Y Y 3219046 03/15/2024 03/01/2025

1,000,000 500,000 5,000 1,000,000 2,000,000 2,000,000

A Y Y 3219047 03/15/2024 03/01/2025

1,000,000

A 10,000

Y Y 3269552 03/15/2024 03/01/2025 1,000,000 1,000,000

A Y Y 3219048 03/01/2024 03/01/2025 1,000,000 1,000,000 1,000,000

Automatic Additional Insured applies to General Liability, Auto Liability & Umbrella coverages on a Primary & Non-Contributory Basis where required by written contract subject to policy terms, conditions & exclusions. Waiver of Subrogation applies to General Liability, Auto Liability, Workers Compensation & Umbrella coverage where required by written contract subject to policy terms, conditions & exclusions. The coverage extensions referenced on this certificate are achieved through the following forms which are included on the policy & attached to this certificate: CG 20 10 07 04, CG 20 33 07 04, CG 20 37 07 04, CGE 2266 1301, CG 24 04 05 09, CA 04 44 10 13, CAE 0131 1508 & WC 00 03 13 4 84, ILE 550 1101.

The State of Arizona and/or ADOT MD 128A, 206 S. 17th Avenue

Phoenix AZ 85007

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

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

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

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

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

G0171 Accepted

00104123

Shepherd Insurance, LLC.

25 Certificate of Liability Insurance: Notes

"Any and all jobs"

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

ILE 0550 Includes copyrighted materials of Insurance Services Office, Inc., with its permission. Page 1 of 1 1101 © 2011, SECURA Insurance Company

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

NOTICE OF CANCELLATION ENDORSEMENT

This Endorsement modifies insurance provided under the following:

BUSINESSOWNERS POLICY

COMMERCIAL GENERAL LIABILITY COVERAGE PART

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

SCHEDULE

Name and address/contact information 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 this endorsement.)

The following Condition is added:

Notice Of Cancellation – Scheduled Person(s) or Organization(s)

a. If we do not renew or cancel this policy, we will send advance written notice to the person(s) or organization(s) as shown in the SCHEDULE. The notice will be delivered by any method we choose, in the applicable timeframe specified in the policy’s Cancellation Condition, any amendment to that Condition, or any other statutory timeframe requirements.

b. Notice provided on this policy shall also apply as notice for any other Commercial Lines insurance policy or coverage part issued to the Named Insured by us.

c. The notice is intended only to inform the person(s) or organization(s) named in the SCHEDULE in the event of a pending cancellation or non-renewal of coverage. Our failure to provide such advance notification will not:

(1) Change any policy cancellation or non-renewal effective date;

(2) Negate any cancellation or non-renewal of the policy; or

(e) Grant, alter, or extend any rights or obligations under any policy issued by us.

All other terms and conditions of this policy not in conflict with the terms and conditions of this Endorsement shall continue to apply.

POLICY NUMBER: 20-TC-003219046-13

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Deann Harguess Typewriter The State of Arizona and/or ADOT MD 128A, 206 S. 17th Avenue Phoenix AZ 85007

POLICY NUMBER: 20-TC-003219046-13 ILD 0002 1204

SUPPLEMENTAL FORM DECLARATION FOR ILE0550 1101

NOTICE OF CANCELLATION ENDORSEMENT

ILD 0002 1204 SECURA Insurance Company Page 1 of 1

SCHEDULE

Name of Person(s) or Organization(s) Address/contact information of Person(s) or Organization(s)

ASH-Dorn LLC/ASH-DH Homes LLC 600 W Gurley St, Ste 100, Prescott, AZ 86305

Ace Hardware Corporation Vendor #48283 Attn Certfocus

PO Box 140528, Kansas City, MO 64114

Arizona Department of Transportation Procurement Group

1739 W Jackson St, Ste A MP100, Phoenix, AZ 85007

Hometown Pine Lakes MHC LLC 3707 W Pine Lakes Dr, Prescott, AZ 86305

Jones Lang Lasalle Americas Inc Attn Leidos Attn Contracts Manager

11955 Freedom Dr, Reston, VA 20190

Kitchell Development Company 1707 E Highland Ave, Ste 100, Phoenix, AZ 85016

State of Arizona Department of Public Safety

1324 N 22nd Ave, MD 128A, Phoenix, AZ 85009

The Natures Bounty Co Its Parents Affiliates and Subsidiaries

2100 Smithtown Ave, Ronkonkoma, NY 11779

POLICY NUMBER: 20-TC-003219046-13 COMMERCIAL GENERAL LIABILITY

CG 20 10 07 04

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1

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) desig-nated above.

B. With respect to the insurance afforded to these additional insureds, the following additional exclu-sions apply:

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

1. All work, including materials, parts or equip-ment 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 in-tended use by any person or organization other than another contractor or subcontractor en-gaged in performing operations for a principal as a part of the same project.

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Deann Harguess Typewriter The State of Arizona and/or ADOT MD 128A, 206 S. 17th Avenue Phoenix AZ 85007

Deann Harguess Typewriter

SUPPLEMENTAL FORM DECLARATION FOR CG2010 0704

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

ILD 0002 1204 SECURA Insurance Company Page 1 of 1

SCHEDULE

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

ASH-Dorn LLC/ASH-DH Homes LLC

600 W Gurley St, Ste 100, Prescott, AZ 86305

Kitchell Development Company, SD Ranch LLC & YK Commercial Realty LLC

1707 E Highland Ave, Ste 100, Phoenix, AZ 85016 Sun State Builders

1050 W Washington St, Ste 214, Tempe, AZ 85281

Titan Landscaping Doing Business As

Additional Named Insureds

Other Named Insureds

OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC

CG 20 37 07 04

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

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

Any entity required to be added as Addi-tional Insured in a written agreement signed prior to a loss

All commercial jobs completed on or af-ter the inception date of this policy.

This endorsement does not apply to any "residential construction" jobs as de-fined in ILE 0502 or ILE 0522, whichever form is attached to your policy, whether completed before, on or after the incep-tion date of this policy.

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

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

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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:

Blanket as required by written contract

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.

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CGE 2266 Includes copyrighted material of Insurance Services Offices, Inc., with its permission. Page 1 of 1 1301 © 2013 SECURA Insurance Company

THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ IT CAREFULLY.

PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

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

Schedule Designated Additional Insured: Any person or organization when required in a written agreement between you and such person or organization

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

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 the Designated Additional Insured shown in the Schedule provided that:

1. The Designated Additional Insured is a Named Insured under such other insurance; and

2. You have agreed in a written agreement that this insurance would be primary and would not seek contribution from any other insurance available to the Designated Additional Insured.

All other terms and conditions of this policy not in conflict with the terms and conditions of this Endorsement shall continue to apply.

POLICY NUMBER: 20-TC-003219046-13

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ILE 0550 Includes copyrighted materials of Insurance Services Office, Inc., with its permission. Page 1 of 1 1101 © 2011, SECURA Insurance Company

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

NOTICE OF CANCELLATION ENDORSEMENT

This Endorsement modifies insurance provided under the following:

BUSINESSOWNERS POLICY

COMMERCIAL GENERAL LIABILITY COVERAGE PART

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

SCHEDULE

Name and address/contact information 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 this endorsement.)

The following Condition is added:

Notice Of Cancellation – Scheduled Person(s) or Organization(s)

a. If we do not renew or cancel this policy, we will send advance written notice to the person(s) or organization(s) as shown in the SCHEDULE. The notice will be delivered by any method we choose, in the applicable timeframe specified in the policy’s Cancellation Condition, any amendment to that Condition, or any other statutory timeframe requirements.

b. Notice provided on this policy shall also apply as notice for any other Commercial Lines insurance policy or coverage part issued to the Named Insured by us.

c. The notice is intended only to inform the person(s) or organization(s) named in the SCHEDULE in the event of a pending cancellation or non-renewal of coverage. Our failure to provide such advance notification will not:

(1) Change any policy cancellation or non-renewal effective date;

(2) Negate any cancellation or non-renewal of the policy; or

(e) Grant, alter, or extend any rights or obligations under any policy issued by us.

All other terms and conditions of this policy not in conflict with the terms and conditions of this Endorsement shall continue to apply.

POLICY NUMBER: 20-TC-003219046-13

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SUPPLEMENTAL FORM DECLARATION FOR ILE0550 1101

NOTICE OF CANCELLATION ENDORSEMENT

ILD 0002 1204 SECURA Insurance Company Page 1 of 1

SCHEDULE

Name of Person(s) or Organization(s) Address/contact information of Person(s) or Organization(s)

ASH-Dorn LLC/ASH-DH Homes LLC 600 W Gurley St, Ste 100, Prescott, AZ 86305

Ace Hardware Corporation Vendor #48283 Attn Certfocus

PO Box 140528, Kansas City, MO 64114

Arizona Department of Transportation Procurement Group

1739 W Jackson St, Ste A MP100, Phoenix, AZ 85007

Hometown Pine Lakes MHC LLC 3707 W Pine Lakes Dr, Prescott, AZ 86305

Jones Lang Lasalle Americas Inc Attn Leidos Attn Contracts Manager

11955 Freedom Dr, Reston, VA 20190

Kitchell Development Company 1707 E Highland Ave, Ste 100, Phoenix, AZ 85016

State of Arizona Department of Public Safety

1324 N 22nd Ave, MD 128A, Phoenix, AZ 85009

The Natures Bounty Co Its Parents Affiliates and Subsidiaries

2100 Smithtown Ave, Ronkonkoma, NY 11779

COMMERCIAL GENERAL LIABILITY

CG 20 33 07 04

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 33 07 04 © ISO Properties, Inc., 2004 Page 1 of 1

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – AUTOMATIC STATUS WHEN

REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU

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 operations 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 addi-tional insured on your policy. Such person or or-ganization 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 com-pleted.

B. With respect to the insurance afforded to these additional insureds, the following additional exclu-sions apply:

This insurance does not apply to:

1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the render-ing of, or the failure to render, any professional architectural, engineering or surveying ser-vices, 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 en-gineering activities.

2. "Bodily injury" or "property damage" occurring after:

a. All work, including materials, parts or equip-ment 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

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 organization other than another contractor or subcon-tractor engaged in performing operations for a principal as a part of the same project.

POLICY NUMBER: 20-TC-003219046-13

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CG 20 10 07 04

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1

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) desig-nated above.

B. With respect to the insurance afforded to these additional insureds, the following additional exclu-sions apply:

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

1. All work, including materials, parts or equip-ment 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 in-tended use by any person or organization other than another contractor or subcontractor en-gaged in performing operations for a principal as a part of the same project.

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SUPPLEMENTAL FORM DECLARATION FOR CG2010 0704

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

ILD 0002 1204 SECURA Insurance Company Page 1 of 1

SCHEDULE

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

ASH-Dorn LLC/ASH-DH Homes LLC

600 W Gurley St, Ste 100, Prescott, AZ 86305

Kitchell Development Company, SD Ranch LLC & YK Commercial Realty LLC

1707 E Highland Ave, Ste 100, Phoenix, AZ 85016 Sun State Builders

1050 W Washington St, Ste 214, Tempe, AZ 85281

CAE 0131 Includes copyrighted material of Insurance Services Offices, Inc., with its permission. Page 1 of 2 1508 © 2015, SECURA Insurance Company

THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ IT CAREFULLY.

AUTO ADDITIONAL INSURED WRAP

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

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

A. AUTOMATIC ADDITIONAL INSURED – PRIMARY AND NONCONTRIBUTORY

SECTION II – COVERED AUTOS LIABILITY COVERAGE, subsection A. Coverage, paragraph 1. Who Is An Insured is amended to add:

d. (1) Automatic Additional Insured – Primary And Noncontributory

Any person or organization is an additional insured when you and such person or organization have agreed in writing prior to a loss that such person or organization be added as additional insured on your policy. Such person or organization is an additional insured only with respect to liability for “bodily injury” or “property damage” resulting from the ownership, maintenance or use of a covered “auto”, provided the “bodily injury” or “property damage” is caused, in whole or in part, by you or by those acting on your behalf. This insurance is primary and is not contributing with any other insurance carried by the additional insured.

(2) Blanket Lessor Additional Insured Provisions

If the additional Insured is a lessor of a “leased auto”;

(a) Coverage

i. Any “leased auto” that is a covered “auto” will be considered a covered “auto” you own and not a covered “auto” you hire or borrow.

For a covered “auto” that is a “leased auto” Who Is An Insured is changed to include as an “Insured” the lessor.

ii. The coverages provided under this endorsement apply to any “leased auto” until the policy expiration date, or when the lessor or his or her agent takes possession of the “leased auto”, whichever occurs first.

(b) Loss Payable Clause

i. We will pay, as interest may appear, you and the lessor for “loss” to a “leased auto”.

ii. The insurance covers the interest of the lessor unless the “loss” results from fraudulent acts or omissions on your part.

iii. If we make any payment to the lessor, we will obtain his or her rights against any other party.

(c) The lessor is not liable for payment of your premiums.

(d) Additional Definition

As used in this endorsement:

“Leased auto” means an “auto” leased or rented to you including any substitute, replacement or extra “auto” needed to meet seasonal or other needs, under a leasing or rental agreement that required you to provide direct primary insurance for the lessor.

POLICY NUMBER: 20-A-003219047-13

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CAE 0131 Includes copyrighted material of Insurance Services Offices, Inc., with its permission. Page 2 of 2 1508 © 2015, SECURA Insurance Company

B. WAIVER -- TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US

SECTION IV – BUSINESS AUTO CONDITIONS, subsection A. Loss Conditions, paragraph 5. Transfer Of Rights Of Recovery Against Others To Us is amended to add:

We waive any right of recovery we may have against any person or organization when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be waived from recovery because of payments we make for injury or damage arising out of an "accident" and resulting from the ownership, maintenance or use of a covered "auto". However, our rights may only be waived prior to the “accident” for which we make payment under this Coverage Part. The insured must do nothing after a loss to impair our rights.

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 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 03/01/2023 Policy

No.

20-WC-003219048-13 Endorsement No. 000

Insured Koehler Enterprises Inc Premium $ Insurance Company Countersigned by ____________________

SECURA Insurance Company

WC 00 03 13

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

State Entity Name Contract or Project Number Description of Work

Waiver Premium Waiver Type

AZ Blanket Waiver of Subrogation

Any Person or organization for whom the Named Insured has agreed by written contract to furnish this waiver

$1,238 BLANKET

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