ACCEPTED ANY_ALL GL,AL,WC,PROF LIAB 01.01.25-03.31.26.pdf
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- Attached to
- Master Agreement AZ|CTR059565
- Contract number
- CTR059565
- Issued by
- Arizona
About this file
This document is a comprehensive insurance certificate and endorsement package issued by Travelers Insurance for International Cybernetics Company, LP, primarily covering the State of Arizona and its various departments, agencies, boards, commissions, universities, and employees. The insurance policies include Commercial General Liability, Automobile Liability, Umbrella Liability, Workers' Compensation, and Professional Liability coverage. The policies are effective from 03/31/2025 to 03/31/2026, with USI Insurance Services, LLC acting as the insurance producer.
The insurance package provides extensive coverage with various limits, including $2,000,000 for General Aggregate, $1,000,000 for each occurrence in General Liability, $1,000,000 for Automobile Liability, $10,000,000 Umbrella Liability, and $4,000,000 for Professional Liability. The policies include additional insured provisions for the State of Arizona, with primary and non-contributory status as required by written contract. The coverage encompasses protection for bodily injury, property damage, and personal and advertising injury across various operational contexts. Notable endorsements include waivers of subrogation, blanket additional insured provisions, and specific coverage extensions for technology-related risks and business auto operations.
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INSR ADDL SUBR
LTR INSR WVD
DATE (MM/DD/YYYY)
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER
POLICY EFF POLICY EXP
TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY
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
INSURER(S) AFFORDING COVERAGE NAIC #
Y / N
N / A (Mandatory in NH)
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
EACH OCCURRENCE $
DAMAGE TO RENTED
$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
PRO-
OTHER:
LOCJECT
COMBINED SINGLE LIMIT
$(Ea accident)
BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
AUTOS ONLY
HIRED PROPERTY DAMAGE $
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 LIMIT $DESCRIPTION OF OPERATIONS below
POLICY
NON-OWNED
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 any 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.
The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
Travelers Property Cas. Co. of America
Travelers Casualty and Surety Company
Travelers Casualty & Surety Co. of Amer
Travelers Indemnity Co of America
3/26/2025
USI Insurance Services, LLC 2502 N Rocky Point Drive Suite 400 Tampa, FL 33607
Ronnie LACHAPELLE 813 321-7500 813 321-7525 ronnie.lachapelle@usi.com
International Cybernetics Company, LP 10630 75th Street Largo, FL 33777
25674 19038 31194 25666
A X X
X
H6304W201303TIL25 03/31/2025 03/31/2026 2,000,000
1,000,000 15,000 1,000,000 2,000,000 2,000,000
D X
X X
BA2T93976525I3G 03/31/2025 03/31/2026 1,000,000
A X X
X 10,000
CUP2T94245625I3 03/31/2025 03/31/2026 10,000,000
10,000,000
B
N
UB2T94123825I3G 03/31/2025 03/31/2026 X
1,000,000
1,000,000 1,000,000
C Professional Lia 107414121 04/01/2025 04/01/2026 $4,000,000 Ea. Claim $4,000,000 All Claims $25,000 Retention
The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are included as Additional Insureds with respects to General Liability and Auto Liability as required by written contract or agreement. Primary and Non-Contributory applies with respects to General Liability as required by written contracted or agreement. Waiver of Subrogation applies with respects to General Liability, Auto Liability, and Workers Compensation as required by written contract or agreement. 30 Day Notice of cancellation applies. Umbrella follows form.
The State of Arizona 1324 N. 22nd Ave.
Phoenix, AZ 85009
#S48641903/M48631817
INTERCYBClient#: 1501509
SKUZP
Cindy Lewis Accepted
COMM RCI L G NERAL IAB LI YE A E L I T
T IS ENDORSEMENT CHANGES T E POLICY. PL ASE READ IT CAREFULLY.H H E
XTEND ENDORSEMENT FOR TECH OLOGYN
GE ERAL D SCRIP ION O CO ERAGE –N E T F V Thi endorsem nt broadens cov rage. Howev r cov rage fo anys e e e , e r i ju y, dama e o me i al ex ense descri ed in any o the provn r g r d c p s b f i ion o th s e dorseme t mays s f i n n be ex luded orc l m ted by anothe endorsem n to this Cov rage Pa t, and the e i i r e t e r s cov rage broadening prov sions do no ap ly toe i t p the ex en tha cov rage is ex l ded or lim ted by such ant t t e c u i endorsem n . The fo lo ing li ti g i a e t l w s n s general cov rage de cript o only Read al the prov sion o thie s i n . l i s f s endorsem n and the re t o yo r pole t s f u i y ca e ul y toc r f l de erm ne r gh s, dut es, and wha i and i not ov red.t i i t i t s s c e
A. No - wned a e cra t – 75 Feet Long Or Le sn O W t r f s I. Bla ket Addi ional Insured – Mortgagee ,n t s Assi nee , Su ce so s O ece v rsg s c s r r R i eB. Wh I An Insured – Unnam d Subsi ia ieo s e d r s
J. Bla ket Addi ional Insured – Gov rnmen aln t e tC. Wh I An Insured – Em loyee – Supe v soryo s p s r i En it e – Pe m t O utho izat o s Rela i g ot i s r i s r A r i n t n TPo i ionss t Prem sei s
D. Wh I An Insured – Newly Acqui ed O Form do s r r e Lim ted Liabil ty Com aniei i p s K. Bla ket Addi ional Insured – Gov rnmen aln t e t
En it e – Pe m t O utho izat o s Rela i g ot i s r i s r A r i n t n TE. Wh I An Insured – Lia ili y For onduct Ofo s b t C Ope atio sr nUnnam d Partne ship O Jo nt Venturese r s r i
L. Med cal Paym nts – In rea ed Lim ti e c s iF. Bla ket Addi ional Insured – Pe sons Orn t r O ganizat on Fo Your ngoi g pe ations Asr i s r O n O r M. Bla ket Wa v r f Sub ogationn i e O r Re ui ed By ri te Con ra t r greem ntq r W t n t c O A e
N. Co tra tua iabil ty – Rai roadn c l L i l s G. Bla ket Addi ional Insured – Broad Form Vendo sn t r
O. Da a e To Prem se Ren ed o Youm g i s t TH. Bla ket Addi ional Insured – Cont ol i g ntere tn t r l n I s
P O ISIONR V S
i re ponsible fo the use o a wate cra ts s r f r fA NON OWNED WATE CRAFT – 75 FEE L N. - R T O G that yo do not own that i :u sO L SR E S
(1) 75 fee lon o le s; andt g r s1. The fo lowing repla e Pa agraphl c s r (2) of g., Ai craft, Auto O Watercraftr r , (2) No bei g used to arry any pe son ot n c r r i Pa agraphn r 2. of SE TION I –C prope ty o a ha ge.r f r c r
CO ERAGES – CO ERAGE A – BODI YV V L B WH IS AN INSU ED – UNNAMED. O R
INJU Y AND P OP RT DAMAGER R E Y SUBS DIARIEI S
L ABI ITI L Y:
The fol owing is ad ed tol d SE TION II – WHO ISC
(2) A wa er ra t y u do not own t at i :t c f o h s AN INSU EDR :
Any o y u sub idiar e , ot er than a partne shif o r s i s h r p(a) 75 fee lon o le s; andt g r s or joint v nture that is not shown a a Nam de , s e
(b) No bei g used to arry any pe son ot n c r r In ured i the eclara ion i a am d Insured i :s n D t s s N e f prope ty o a ha ge;r f r c r
a. Yo are the so e owner o , o ma ntai anu l f r i n
2. The fo lo ing repla e Pa agraphl w c s r 2.e. of ownership intere t o mo e than 50% in, suchs f r
SE TI N II – WHO I AN INSU EDC O S R : subsidia y on the fi st day o the pol cy pe iodr r f i r ;
ande. Any perso or o gani at on that, wi h yourn r z i t ex re s o im lie conse t, ei her use op s r p d n t s r b. Su h subsidiary i not an in ured undec s s r si ila o her nsuran e.m r t i c
CG 4 17 02 19D © 2017 T e Travelers Indemnity Company. All rights rh eserved. Pa e 1 o 5g f Includes copyrighted material of nsurance Services OfI f ce, Inc. with its permis ion.i s
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Exclusion
POLICY NUMBER: H-630-4W201303-TIL-25
COMM RCI L G NERAL LIA ILI YE A E B T
No such subsidiary i a insured fo "bodily inju y organi ation in wris n r r " z ting to us wit ih n or "property dama e" tha o curred, o "perso al 180 ay a te yog t c r n d s f r u a qui e or o m it;c r f r and a v rt sing i ju y caused by an o fe sed e i n r " f n b. Cov ragee A does not apply to "bodily com i ted:m t i ju y" o "property dama e that o curredn r r g " c
a. Be o e you ma ntai ed an ownership intere t be o e you a qui ed or fof r i n s f r c r rmed the o mo e than 50% i such ub idiary; or organi ation; andf r n s s z
b. Af e the date, i any duri g the poli y periot r f , n c d c. Cov ragee B doe not ap ly to "perso als p n that yo no longer ma ntain a ownershi and adv rti i g injury ariu i n p e s n " sing out o af n i tere t o o e han 50% in such subsidia y. o fe se com i ten s f m r t r f n m t d be o e yo a qui ed of r u c r r fo med the o ganiza io .r r t nFo purpose o Pa agraphr s f r 1. o Se tionf c II – Who Fo t e purpose o Pa ag apr h s f r r h 1. o Se t onf c i IIIs An Insured, ea h such sub idiary will bec s
– Who Is An Insured, each such o ganiza ior t ndeem d to e de ignated in the Declarat on a :e b s i s s wil be deem d to be designated in thel e
a. A im ted l ab l ty company;l i i i i De la ation a :c r s s
b. An o ganizat on o he than a pa tnership, jo ntr i t r r i
a. A im ted l ab l ty company;l i i i i v nture or l m ted liab l ty om any; ore i i i i c p
b. An organiza ion o her than a pa tnership,t , t r
c. A rust;t jo n v nture or lim ted lia ili y com any;i t e i b t p a indi a ed in i s nam o the docum n s tha ors c t t e r e t t gov rn it stru ture.e s c c. A rust;t
C. WH IS AN INSURED – EMP O EES –O L Y a indica ed i its nam or the do um ntss t n e c e S PE VISO Y PO I IO SU R R S T N that gov rn t structure.e i s
The fol o ing is added to Paragraphl w 2.a.(1) of E. WH IS AN INSU ED – L ABIL TY FOO R I I R
SE TI N II – WHO I AN INSUREDC O S : CONDU T O UNNAMED PARTNE SHIP OC F R S R
JO NT VEN UREI T SPa ag aphsr r (1)(a), (b) and (c) abov do not applye to "bodi y injury to a co "em loyee while in thel " - p " The fo lo ing rep a es the la t paragraph ol w l c s f cour e o he co "em loyee s" em loy en by yous f t - p ' p m t SE TI N II – WHO I AN INSU EDC O S R :
ari ing out o work by any o your "em loy e "s f f p e s No person o organi ation is an insured wi hr z t who hol a superv so y po itio .d i r s n re pe t to the con uct o any current o pa ts c d f r s pa tnership o joi t v nture tha i not shown a ar r n e t s sD WH IS AN INSURED – N WLY ACQU RED. O E I Na e Insured in the Thism dO FO MED LIMIT D L ABIL T CO PANIESR R E I I Y M pa agraph doe not apply to any such partne shipr s r
The fo lowing repla e Pa agraphl c s r 3. of SECTI NO or joi t v nture tha ot erwi e qua i ie a an e t h s l f s s n
II – WHO I AN IN U EDS S R :
i sured under ection S n II – Who I An I sured.s n
3. Any o gani at on y u newly a qui e or fo mr z i o c r r , F B ANKET ADDI IONAL IN URED – P RSON. L T S E S ot er than a partnershi or joi t v nture anh p n e , d
O O GANIZATI N FO YOU ON O NR R O S R R G I G
o whi h yo a e the so e owner o in whi hf c u r l r c
OP RATION AS REQUIRED B WRI T NE S Y T E
y u ma nta n an owne ship intere t o m reo i i r s f o
CON RACT R AGRE MENT O E T
than 50%, wi l quali y a a Nam d Insured ifl f s e The fol owing is ad ed tol d SE TION II – WHO ISCthe e i no othe sim lar i surance av ila le tor s r i n a b AN INSU EDR :that organiz tio . owev r:a n H e
Any person or o gani at on tha i no o herwi er z i t s t t sa. Cov rage unde thi prov sion i a fo dede r s i s f r an insured under this Cov rage Pa t and that yoe r uon yl :
hav ag ee in a writ en cont a t o agreem nt toe r d t r c r e
(1) Unt l the 180th day a ter you a quirei f c i clu e as an a ditio al insured on thi Cov ragen d d n s e or fo m the organi ation o the end or z r f Pa t is an in ured, but only wi h re pe t to l abi ityr s t s c i l the pol cy period whi hev r is earl er,i , c e i fo "bodi y i ju y" or "prope ty dama e" thatr l n r r g :
i y u do not report such o ganizat of o r i n
a. Occurs subse uent to the signi g o thatq n fi writ ng to us wi hin 180 days a ten i t f r contra t or ag ee ent; andc r my u a quire o fo m i ; oo c r r t r
b. Is cause , in whole or in part by yo r acts od , u r(2) Unt l the end o the pol cy perio ,i f i d om ssions in the perfo ma ce o yo r ongoini r n f u gwhen that date is late than 180 dayr s a ter y u a qui e or fo m such operatio s to whi h tha contra t f o c r r n c t c or organi ation, i you report suchz f
Pa e 2 o 5g f © 2017 T e Travelers Indemnity Company. All rights rh eserved. CG 4 17 02 19D Includes copyrighted material of nsurance Services OfI f ce, Inc. with its permis ion.i s
Declarations.
POLICY NUMBER: H-630-4W201303-TIL-25
Highlight pe fo med a such v ndor' prem se inr r t e s i sagreement applies or the acts or omissions of connect on with the sale o "y ui f o rany pe son o organi at on pe fo m ng suchr r z i r r i product "; orso eratio s on your behal .p n f
The lim t o in urance prov ded to such insuredi s f s i (6) "Yo r product " that a te di tri ution ou s , f r s b r wil be the m nim m lim t that you ag ee to sale by you, hl i u i s r d av bee labeled oe n r prov de i the wri ten cont act or agreem nt, oi n t r e r re abeled or used a a containe , part ol s r r the lim t shown in the Declaratio s, whi hev ri s n c e i gredien o any o her thing or substancen t f t are le s.s by or on behal o uch v ndor.f f s e
G B ANKET ADDIT ONAL IN URED – B OAD. L I S R Cov rage under thi p ov sion doe not apply toe s r i s :
F RM VENDO SO R
a. Any pe son o o ganizat on from whom yor r r i u The fol owing is ad ed tol d SE TION II – WHO ISC hav acqui ed "y ur produ ts", or anye r o c AN INSU EDR : i gredie t, part or containe enterin in o,n n r g t Any perso o organ zat on that i a v ndor an a com ann r i i s e d c p y ng o contain ng such product ;i r i s orthat you have agreed in a written contract or ag ee ent to in lude a an addi ional insured onr m c s t b. Any v ndo fo whi h cov rage a ane r r c e s th s Cov rage Part i a in ured, but only wi hi e s n s t addi ional insured spe if ca ly i sche ule byt c i l s d d re pe t to lia il ty fo "bodily injury or "prope tys c b i r " r endo sem nt.r e dama e thatg " :
H B ANKET ADD T ONAL INSURED –. L I I
a. Occurs subse uent to the signi g o thatq n f
CON RO L NG IN ERE TT L I T S
co tra t or agreem nt; andn c e
1. The fo lo ing is added tol w SE TI N II – WHOC O
b. Ari e out o "y ur products" that ares s f o
IS AN INSURED:
di tr buted o so d in the regula cou se os i r l r r f
Any pe son or o gan zat on that ha fi ancialr r i i s nsuch v ndor s busine s.e ' s cont ol o yo is an i sured wi h re pe t tor f u n t s c
The insura ce prov ded to such v ndor is subje tn i e c l ab l ty fo "bodily inj ry , "property dam gei i i r u " a "to the o lowing pro v sion :f l i s or "pe sonal a d adv rti ing i ju y that a i er n e s n r " r s s
a. The lim t o in urance prov ded to suchi s f s i ou o :t f v ndor wil be the m nim m li i s tha y ue l i u m t t o
a. Su h i an ial cont ol orc f n c r ;
ag ee to prov de in the writ en cont a t or d i t r c r
b. Su h person's or o ganizat on'c r i sag ee ent, o the lim t shown in ther m r i s ownership, ma ntenance or use ofi prem se lea ed o or o cupied by y u.i s s t c o
b. The in urance prov ded to such v ndor does i e s The i surance prov ded to such person on i rno ap ly o:t p t organi ation does not apply to structuralz
(1) Any ex ress warranty no authorized byp t al erat on , new con tru tion or dem li iot i s s c o t n y u or any di tribut on or sa e fo ao s i l r operatio s pe fo me by or on behal o suchn r r d f f pu po e not authorized by yo ;r s u pe son or organizationr .
(2) Any change i "y u products" m de byn o r a 2. The fo lowing is ad ed to Paragraphl d 4. of such v ndor;e SE TI N II – WHO I AN INSU EDC O S R :
(3) Re a kagi g, unle s unpa ked so ely fop c n s c l r Thi pa agraph does not apply to anys r the purpo e o i spectio , dem n tratio ,s f n n o s n prem se owner, manager or le sor tha hai s s t s te tin , o the sub tit tion o part undes g r s u f s r fi a cial o trol o yo .n n c n f u i struction fro the man fa ture , ann s m u c r d
I. B ANKET ADD T ONAL INSURED –L I I
then repackaged in the orig nal containe ;i r
MO T A E S ASSIGN ES, SU CES O SR G G E , E C S R
(4) Any fai ure to ma e such in pect on ,l k s i s O ECEI ERSR R V a justme t , te ts or se v cing ad n s s r i s The fol owing i added tol s SE TION II – WHO ISC v ndors agree to perfo m or no ma lye r r l AN INSU EDR :
unde take to pe fo m in the regular r r r
Any pe son o o ganiza io tha is a mo tgagee,r r r t n t rcour e o bu ine s, in connectio wi h thes f s s n t a signee succe so or re eiv r and tha yos , s r c e t udi trib tio or sale o "y ur p oduct ";s u n f o r s hav agreed i a writ en cont a t o agreem nt toe n t r c r e
(5) De o stra ion instal a ion, se v ci g om n t , l t r i n r i clu e as an a ditio al insured on thi Cov ragen d d n s e re ai operatio s, ex ept such o e ationp r n c p r s Pa t is an insured, but on y with re pe t to itsr l s c
CG 4 17 02 19D © 2017 T e Travelers Indemnity Company. All rights rh eserved. Pa e 3 o 5g f Includes copyrighted material of Insurance Services Of ice, Inc. with its permis ion.f s
Declarations, whichever are less.
COMM RCI L G NERAL LIA ILI YE A E B T
l ab l ty a m rtgagee, a signee succe so o constru tion, erei i i s o s , s r r c ction or remov l o any o thea f f re e v r fo "bodi y i ju y , "property dam ge" o fo lowi g fo wc i e r l n r " a r l n r hi h that gov rnme tal enti y hac e n t s "pe sonal and adv rti ing i ju y" that i sue such perm t o aur e s n r : s d i r thorizat o : adv rti ingi n e s si n , awni gs, canopie , cel ar entrance , coalg s n s l sa. Is "bo ily inju y or "prope ty dama e" thatd r " r g ho es, driv way , ma holes, marquees, hoi tl e s n so curs, o i "pe sonal an adv rti ing inju yc r s r d e s r " away open ng , sidewalk v ults, e ev tor , streeti s a l a scaused by an o f n e that is com it ed,f e s m t banners o de orat on .r c i ssubsequent to the si ning o that co tra t og f n c r ag ee ent; andr m K. B ANKET ADD T ONAL INSURED –L I I GO E N ENT L EN IT ES – P RMIT OV R M A T I E S Rb. Ari e out o the ownership, m in enance os s f a t r AU HO I ATI N RELATIN TO OP R-T R Z O S G Euse o the prem se fo whi h that mo tgagee,f i s r c r ATIONSa signee succe so o re eiv r is requi eds , s r r c e r unde that cont act o agreem nt to be The fol owing is ad ed tor r r e l d SE TION II – WHO ISC i clu ed a an a dit onal insured on thisn d s d i AN INSU EDR :
Cov rage Parte . Any gov r men al enti y tha ha issued a perm te n t t t s i
The insurance prov ded to such mo tgagee, or authoriza ion wit ri r t h e pe t to ope ationss c r a signee succe so o re eiv r is subje t to the pes , s r r c e c rfo med by y u or on your behal and that yor o f u fo lowi g prov sions: are required by any o dinance, law, buil ing cl n i r d ode or written cont act or agreement to incl de a anr u sa. The lim t o in urance prov ded to suchi s f s i addi ional i sured on thi Cov rage Pa t is at n s e r nm rtgagee, a signee, succe so o re eiv ro s s r r c e i sured, but only wi h re pe t to liabi i y fo "bodilyn t s c l t rwil be the m n m m l m t tha y u agreed tol i i u i i s t o i ju y", "prope ty dam ge" or "perso al andn r r a nprov de in the writ en con ra t or agreem nt,i t t c e adv rti ing inj ry" ari ing ou o uch operatio s.e s u s t f s n whi hev r are e s. The in uran e prov ded to such gov rnmen alc e l s s c i e t en ity doe not apply o:t s tb. The i surance prov ded to such person on i r organi ation oe not apply to:z d s a. Any "bodi y inju y , "property dama e ol r " g " r "pe sonal and adv rti ing injury" a i ing o t or e s r s u f(1) Any "bodily inj ry or "property dam geu " a " operatio s perfo m d fo the gov r men aln r e r e n tthat occurs, or any "pe sonal andr en ity ort ;adv rti ing inju y ca sed by an o fe see s r " u f n that is com it ed, a ter such con ra t om t f t c r b. Any "bodily inj ry or "property dam geu " a " ag ee ent s no lon er in e fe t; o i clu ed in the "products-co plr m i g f c r n d m eted operatio s hazard".n(2) Any "bodi y inju y , "property dama e ol r " g " r "pe sonal and adv rti ing i ju y ari ingr e s n r " s L MED CAL PAYMEN S – INCREASED LI IT. I T M ou o any structural al eratio s, newt f t n The fo lowing repla e Pa agraphl c s r 7. of SECTI NO constru tion o dem li ion ope ationsc r o t r II – L MIT F INSURANCEI I S O :
pe fo med by or on behal o suchr r f f
7. Su je t to Paragraphb c 5. abov , the Medicae lm rtgagee, assignee, succe so oo s r r Ex ense Lim t is the mo t we will pay undep i s rre e v r.c i e Cov ragee C fo al me ical ex enser l d p s
J B ANKET ADD T ONAL INSURED –. L I I be ause o "bod ly i ju y sustained by anyc f i n r " GO E N ENT L EN IT ES – P RMIT OV R M A T I E S R one erson, and will be he ighe o :p t h r f
AU HO I ATI N RELAT N O P E IS ST R Z O S I G T R M E
a. $10, 00; or0 The fol owing is ad ed tol d SE TION II – WHO ISC
b. The am unt shown i the oo n fAN INSU EDR :
th s Cov rage Part fo Medi al Ex ensei e r c p
Any gov r men al enti y tha ha issued a perm te n t t t s i Lim t.i or aut orizat o wit respe t to prem se ownedh i n h c i s
M. B ANKET WAIVER O SUB O ATIONL F R Gor o cupied by, o rented o loa ed to, y u anc r r n o d that yo a e requi ed by any ordi ance, law,u r r n The fo lowing is a ded to Parag aphl d r 8., Tra sfen r
O Righ s O Rec very Against O hers To Uf t f o t sbuilding code or written contract or agreement to , i clu e as an a ditio al insured on thi Cov ragen d d n s e of SE TION IV – CO MERCIAL GENERALC M Pa t is an insured, but on y with re pe t to lia il tyr l s c b i L AB LIT CO D TIONI I Y N I S:
fo "bodi y inj ry , "prope ty dam ge or "perso alr l u " r a " n If the insured has a ree in a cont act og d r r and adv rti ing inj ry arising out o thee s u " f ag ee ent to waiv that i sured' righ or m e n s t f ex stence owne ship, use mai tenance repai ,i , r , n , r re ov ry against any per on o o ganiza io , wec e s r r t n
Pa e 4 o 5g f © 2017 T e Travelers Indemnity Company. All rights rh eserved. CG 4 17 02 19D Includes copyrighted material of nsurance Services OfI f ce, Inc. with its permis ion.i s or the limits shown in the Declarations, Declarations
POLICY NUMBER: H-630-4W201303-TIL-25
waiv our right o e ov ry against such pe son oe f r c e r r 2. Pa ag aphr r f. 1)( o the de init on o "i suredf f i f n organi a ion, but only fo pay ents we make cont a t" i thez t r m r c n D FIN TIONE I S Se tion isc be ause o : de eted.c f l
a. "Bo ily i ju y o "property dam ge" thatd n r " r a O DAMAGE TO P EMISE EN ED TO YOU. R S R T o curs; oc r The fol owing repla e the de i ition o "prem sel c s f n f i s
b. "Pe so al and adv rti ing inj ry ca sed byr n e s u " u dama e in heg " t DEF NIT ONSI I Se tionc :
an o fe se hat i comm ttedf n t s i ;
"Pre i e dama e m a s "property damage to:m s s g " e n " subsequent to the ex cu ion o the cont a t oe t f r c r
a. Any prem se whi e rented to y u oi s l o r ag e ment.r e tem ora ily o cupied by you wi h pe m ssionp r c t r i N CON RACTUAL IABILIT – RAIL OAD. T L Y R S o he owne ; orf t r
1. The fol o ing repla e Pa agraphl w c s r c. o thef b. The co tent o any premi e whi e suchn s f s s l de i i ion o "insured cont act" i thef n t f r n prem se i rented to yo , i y u rent suchi s s u f o D FIN TIONE I S Se tion:c prem se fo a period o sev n or fewei s r f e r
c. Any ea em nt or l cense agreem nt;s e i e conse utiv day .c e s
CG 4 17 02 19D © 2017 T e Travelers Indemnity Company. All rights rh eserved. Pa e 5 o 5g f Includes copyrighted material of Insurance Services Of ice, Inc. with its permis ion.f s
COMM RCIAL E ERAL IAB LITYE G N L I
c. Meth d O h rin a.o f S a g The sta e e t in th a et m n s e r a cura e a d co p e ec t n m l t ;If a l o the o he i sura ce pe m t co t i ut ol f t r n n r i s n r b i n by e u l sha e , w i l fo l w t i m t o l oq a r s e w l l o h s e h d a s . b. Tho e sta e e ts a e ba e upos t m n r s d n Und r th s e ch in ure co t i ut s re re e t ti n y ue i a s r n r b e p s n a o s o a e to us; nm d a d e ua a o n s unt l it ha pa d it a pl ca lq l m u t i s i s p i b e c. We ha e i sue th s po i y i re i n e up nv s d i l c n l a c o l m t o in ura ce o no e o th l ss re a ns,i i f s n r n f e o m i y ur e re e ta i ns.o r p s n t o
The uni te ti n l o i sio o , o uni t n i na e ron n o a m s n f r n e t o l r r If a y o th o h r i sura ce do s no pe m tn f e t e n n e t r i i , a y i f rm ti n pro i e by y u whi h we re i dn n n o a o vd d o c l e co tr bu i n by e u l sha e , we wi l co t i utn i t o q a r s l n r b e up n i issui g th s po i y wi l no pre u i e y uo n n i l c l t j d c o r by l m t . Und r th s m t o , e ch i sure 'si i s e i e h d a n r ri ht unde th s in ura ce Ho e e , thi pro i i ng s r i s n . w v r s v s o sha e is ba e o the ra i o i s a p i a l i ir s d n t o f t p l c b e l m t do s no a f ct o r ri h to co l ct a di i n le t f e u g t l e d t o a o in ura ce to th to a a pl ca l li i s of s n e t l p i b e m t f pre i m o to e e ci e o r rig t o ca ce l t o om u r x r s u h s f n l a i n r i sura ce o l nsure s.n n f a l i r no re e a i cco d nce w t pp i a l n ura cen n w l n a r a i h a l c b e i s n d P i a y And No -Co trib t ry In u an e If. r m r n n u o s r c l ws o e ul t o s.a r r g a i n Req i ed B Wri te o tracu r y t n C n t 7. Se arat o f n u edp i n O I s r s If y u spe i i a l a re i a wri t n co t a t oo c f c l y g e n t e n r c r Ex e t wi h re pe t to the Li i s o In ura ce a dc p t s c m t f s n , n a re m nt tha the i sura ce a fo d d to ag e e t n n f r e n a y ri h s o du i s a sig e i th sn g t r t e s n d n i i sure un e hi Co e a e Pa t m st p l nn d d r t s v r g r u a p y o Co e a e Pa t to the fi st Na e Insure , th sv r g r r m d d i a pri a y ba i , o a pri a y a d no -m r s s r m r n n i sura ce a pl e :n n p i s co tr bu o y ba is, th s i sura ce is pri a y ton i t r s i n n m r
a. As i e ch Na e In ure we e the o lf a m d s d r n y o h r in ura ce th t i a a l bl ot e s n a s v i a e t
Na e n ure ; ndm d I s d a whi h o e s such n ure a a n m d i sure ,c c v r i s d s a e n d
b. Se a a e y to e ch in ure a a n t who cl ip r t l a s d g i s m a ma d we wil no sha e wi h th t o h r in ura cen l t r t a t e s n , i m d o "sui " i b o g ts a e r t s r u h .pro i e ha :vd d t t
8. Tra sfe O i h s O e o ery Ag i s t ersn r f R g t f R c v a n t O h(1) The "bo i y i j ry o "pro e ty da a e fod l n u " r p r m g " r To Uswhi h co e a e i so gh o cur ; ndc v r g s u t c s a If the i sure ha ri h s to re o e a l o pa t o a yn d s g t c v r l r r f n(2) The "pe so a a d a v rt sin i j ry for n l n d e i g n u " r pa m n we ha e m d unde thi Co e a e Pa ty e t v a e r s v r g r ,whi h co e a e is so gh i ca se by ac v r g u t s u d n th se ri ht a e tra sfe re t us. he i sure usto g s r n r d o T n d mo fe se t a i co m t e ;f n h t s m i t d do no h ng a te l ss to i p i th m At o r re u st,t i f r o m a r e . u q e subse u nt to the si n ng o tha co tr ct oq e g i f t n a r th i sure wi l bri g "sui " o tra sfe tho e ri h se n d l n t r n r s g t a re m nt by y ug e e o .
to us a d h l s e f rce t e .n e p u n o h m
5. P e i m Au ir m u d t
9. Wh n We D N t en we o o R e
a. We wi l co p t a l p e i m f r h s Co e a el m u e l r m u s o t i v r g If we d ci e n t o r n w h s Co e a e P rt e wi le d o t e e t i v r g a , w l
Pa t i cco d nce w t ur u e a d a e .r n a r a i h o r l s n r t s m i o de i e to th fi st Na e In ure sho n ina l r l v r e r m d s d w
b. Pre i m sho n in th s Co e a e Pa t am u w i v r g r s th De l ra i n wri te no i e o the no r n wae c a t o s t n t c f n e e l a v nce pre i m i a de o i pr m um o l . Ad a m u s p s t e i n y t no l ss th n 0 da s be o e t e e pi a i n da et e a 3 y f r h x r t o t .
th clo e o e ch a d t pe i d we wi l co p te s f a u i r o l m u e
If no i e is m i e , pro f o m i i g wi l be suffi i nt c a l d o f a l n l c e t th e rn d pre i m fo th t pe i d a d se de a e m u r a r o n n pro f f o i eo o n t c .
no i e t th fi st Na e I sure . The du da et c o e r m d n d e t
SE TI N V – D F N T O SC O E I I I Nfo a di a d re ro pe ti e p e i m i t e d tr u t n t s c v r m u s s h a e
1. "shown as the due date on the bill. If the sum of Ad e t se e t" m a s a no i e th t s br a ca t ov r i m n e n t c a i o d s r pu l she to the ge e a pub i o spe i i m rb i d n r l l c r c f c athe advance and audit premiums paid for the k te po i y pe i d is gre te tha the e rn dl c r o a r n a e se m nt a o t y ur go ds, pro u ts o ser i eg e s b u o o d c r v c s fo th purp se o a t a g custo e s or e o f t r m r rpremium, we will return the excess to the first Na e nsure . supp rt r . o h p r o e o hi de i i i nm d I d o e s F r t e u p s s f t s f n t o :
c. The fi st Na e In ure m st k e re o d or m d s d u e p c r s f a. No i e th t a e publ she i cl de m t r at c s a r i d n u a e i l th in o m t o we ne d fo pre i m pl ce o the Int rn t o oe f r a i n e r m u a d n e e r n sim l r i a co p t ti n a d se d us co i s a such t m sm u a o , n n p e t i e m a s o co m ni a i n; a de n f m u c t o n a we m y re u st.s a q e b. Re a di g we sit s, o l tha pa t o a we si eg r n b e n y t r f b t
6. Rep es n ati nr e t o s th t is a o t y u go d , pro u ts o se v cea b u o r o s d c r r i s fo th pur o e o a t a custo e s or e p s s f t r m r rBy ti g t i p l cy o gre :p n h s o i , y u a e supp rt r i co si e e a a v rt se e to e s s n d r d n d e i m n .
Pa e 16 o 21g f CG 1 0 02 1T 0 9© 2017 The Travelers Indemnity Company. All rights reserved.
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
approach specifically ctin cting electronic acce whichever comes first.
Declarations such insured samantha.bendig Highlight samantha.bendig
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXTENSION ENDORSEMENT – FLORIDA
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GENERAL DESCRIPTION OF COVERAGE – This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
CA F2 19 03 21 © 2021 The Travelers Indemnity Company. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission
COMMERCIAL AUTO
A. BROAD FORM NAMED INSURED
B. BLANKET ADDITIONAL INSURED
C. EMPLOYEE HIRED AUTO
D. EMPLOYEES AS INSURED
E. SUPPLEMENTARY PAYMENTS –
INCREASED LIMITS
F. HIRED AUTO – LIMITED WORLDWIDE
COVERAGE – INDEMNITY BASIS
G. WAIVER OF DEDUCTIBLE – GLASS
H. HIRED AUTO PHYSICAL DAMAGE – LOSS OF
USE – INCREASED LIMIT
I. PHYSICAL DAMAGE – TRANSPORTATION
EXPENSES – INCREASED LIMIT
J. PERSONAL PROPERTY
K. AIRBAGS
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
M. BLANKET WAIVER OF SUBROGATION
N. UNINTENTIONAL ERRORS OR OMISSIONS
PROVISIONS
A. BROAD FORM NAMED INSURED
The following is added to Paragraph A.1., Who Is An Insured, of SECTION II – COVERED AUTOS
LIABILITY COVERAGE:
Any organization you newly acquire or form during the policy period over which you maintain 50% or more ownership interest and that is not separately insured for Business Auto Coverage.
Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier.
B. BLANKET ADDITIONAL INSURED
The following is added to Paragraph c. in A.1., Who Is An Insured, of SECTION II – COVERED
AUTOS LIABILITY COVERAGE:
Any person or organization who is required under a written contract or agreement between you and that person or organization, that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to be named as an additional insured is an "insured" for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section II.
C. EMPLOYEE HIRED AUTO
1. The following is added to Paragraph A.1., Who Is An Insured, of SECTION II –
COVERED AUTOS LIABILITY COVERAGE:
An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in an "employee's" name, with your permission, while performing duties related to the conduct of your business.
2. The following replaces Paragraph b. in B.5., Other Insurance, of SECTION IV –
BUSINESS AUTO CONDITIONS:
b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own:
(1) Any covered "auto" you lease, hire, rent or borrow; and
(2) Any covered "auto" hired or rented by your "employee" under a contract in an "employee's" name, with your permission, while performing duties related to the conduct of your business.
However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto".
D. EMPLOYEES AS INSURED
The following is added to Paragraph A.1., Who Is An Insured, of SECTION II – COVERED AUTOS
LIABILITY COVERAGE:
Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs.
E. SUPPLEMENTARY PAYMENTS – INCREASED
LIMITS
1. The following replaces Paragraph A.2.a.(2), of SECTION II – COVERED AUTOS
LIABILITY COVERAGE:
(2) Up to $3,000 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We do not have to furnish these bonds.
2. The following replaces Paragraph A.2.a.(4), of SECTION II – COVERED AUTOS
LIABILITY COVERAGE:
(4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work.
F. HIRED AUTO – LIMITED WORLDWIDE
COVERAGE – INDEMNITY BASIS
The following replaces Subparagraph (5) in Paragraph B.7., Policy Period, Coverage Territory, of SECTION IV – BUSINESS AUTO
CONDITIONS:
(5) Anywhere in the world, except any country or jurisdiction while any trade sanction, embargo, or similar regulation imposed by the United States of America applies to and prohibits the transaction of business with or within such country or jurisdiction, for Covered Autos Liability Coverage for any covered "auto" that you lease, hire, rent or borrow without a driver for a period of 30 days or less and that is not an "auto" you lease, hire, rent or borrow from any of your "employees", partners (if you are a partnership), members (if you are a limited liability company) or members of their households.
(a) With respect to any claim made or "suit" brought outside the United States of America, the territories and possessions of the United States of America, Puerto Rico and Canada:
(i) You must arrange to defend the "insured" against, and investigate or settle any such claim or "suit" and keep us advised of all proceedings and actions.
(ii) Neither you nor any other involved "insured" will make any settlement without our consent.
(iii) We may, at our discretion, participate in defending the "insured" against, or in the settlement of, any claim or "suit".
(iv) We will reimburse the "insured" for sums that the "insured" legally must pay as damages because of "bodily injury" or "property damage" to which this insurance applies, that the "insured" pays with our consent, but only up to the limit described in Paragraph C., Limits Of Insurance, of
SECTION II – COVERED AUTOS
LIABILITY COVERAGE.
(v) We will reimburse the "insured" for the reasonable expenses incurred with our consent for your investigation of such claims and your defense of the "insured" against any such "suit", but only up to and included within the limit described in Paragraph C., Limits Of Insurance, of
SECTION II – COVERED AUTOS
LIABILITY COVERAGE, and not in addition to such limit. Our duty to make such payments ends when we have used up the applicable limit of insurance in payments for damages, settlements or defense expenses.
(b) This insurance is excess over any valid and collectible other insurance available to the "insured" whether primary, excess contingent or on any other basis.
Page 2 of 4 © 2021 The Travelers Indemnity Company. All rights reserved. CA F2 19 03 21 Includes copyrighted material of Insurance Services Office, Inc. with its permission
COMMERCIAL AUTO
(c) This insurance is not a substitute for required or compulsory insurance in any country outside the United States, its territories and possessions, Puerto Rico and Canada.
You agree to maintain all required or compulsory insurance in any such country up to the minimum limits required by local law. Your failure to comply with compulsory insurance requirements will not invalidate the coverage afforded by this policy, but we will only be liable to the same extent we would have been liable had you complied with the compulsory insurance requirements.
(d) It is understood that we are not an admitted or authorized insurer outside the United States of America, its territories and possessions, Puerto Rico and Canada. We assume no responsibility for the furnishing of certificates of insurance, or for compliance in any way with the laws of other countries relating to insurance.
G. WAIVER OF DEDUCTIBLE – GLASS
The following is added to Paragraph D., Deductible, of SECTION III – PHYSICAL
DAMAGE COVERAGE:
No deductible applies under Specified Causes of Loss or Comprehensive coverage for "loss" to glass used in the windshield.
H. HIRED AUTO PHYSICAL DAMAGE – LOSS OF
USE – INCREASED LIMIT
The following replaces the last sentence of Paragraph A.4.b., Loss Of Use Expenses, of
SECTION III – PHYSICAL DAMAGE
COVERAGE:
However, the most we will pay for any expenses for loss of use is $65 per day, to a maximum of $750 for any one "accident".
I. PHYSICAL DAMAGE – TRANSPORTATION
EXPENSES – INCREASED LIMIT
The following replaces the first sentence in Paragraph A.4.a., Transportation Expenses, of
SECTION III – PHYSICAL DAMAGE
COVERAGE:
We will pay up to $50 per day to a maximum of $1,500 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type.
J. PERSONAL PROPERTY
The following is added to Paragraph A.4., Coverage Extensions, of SECTION III –
PHYSICAL DAMAGE COVERAGE:
Personal Property
We will pay up to $400 for "loss" to wearing apparel and other personal property which is:
(1) Owned by an "insured"; and
(2) In or on your covered "auto".
This coverage applies only in the event of a total theft of your covered "auto".
No deductibles apply to this Personal Property coverage.
K. AIRBAGS
The following is added to Paragraph B.3., Exclusions, of SECTION III – PHYSICAL
DAMAGE COVERAGE:
Exclusion 3.a. does not apply to "loss" to one or more airbags in a covered "auto" you own that inflate due to a cause other than a cause of "loss" set forth in Paragraphs A.1.b. and A.1.c., but only:
a. If that "auto" is a covered "auto" for Comprehensive Coverage under this policy;
b. The airbags are not covered under any warranty; and
c. The airbags were not intentionally inflated.
We will pay up to a maximum of $1,000 for any one "loss".
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
The following is added to Paragraph A.2.a., of
SECTION IV – BUSINESS AUTO CONDITIONS:
Your duty to give us or our authorized representative prompt notice of the "accident" or "loss" applies only when the "accident" or "loss" is known to:
(a) You (if you are an individual);
(b) A partner (if you are a partnership);
(c) A member (if you are a limited liability company);
(d) An executive officer, director or insurance manager (if you are a corporation or other organization); or
(e) Any "employee" authorized by you to give notice of the "accident" or "loss".
CA F2 19 03 21 © 2021 The Travelers Indemnity Company. All rights reserved. Page 3 of 4
M. BLANKET WAIVER OF SUBROGATION
The following replaces Paragraph A.5., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV – BUSINESS AUTO
CONDITIONS:
5. Transfer Of Rights Of Recovery Against Others To Us
We waive any right of recovery we may have against any person or organization to the extent required of you by a written contract signed and executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract.
N. UNINTENTIONAL ERRORS OR OMISSIONS
The following is added to Paragraph B.2., Concealment, Misrepresentation, Or Fraud, of
SECTION IV – BUSINESS AUTO CONDITIONS:
The unintentional omission of, or unintentional error in, any information given by you shall not prejudice your rights under this insurance.
However this provision does not affect our right to collect additional premium or exercise our right of cancellation or non–renewal.
Page 4 of 4 © 2021 The Travelers Indemnity Company. All rights reserved. CA F2 19 03 21
ENDORSEMENT WC 00 03 13 (00) -
POLICY NUMBER:
EMPLOYERS LIABILITY POLICY
AND
WORKERS COMPENSATION
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
ONE TOWER SQUARE
HARTFORD CT 06183
UB-2T941238-25-I3-G
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
DESIGNATED ORGANIZATION:
DESIGNATED PERSON:
ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED
BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS
WAIVER.
INCLUDING:
PREFERRED MATERIALS INC. ITS AFFILIATES, SUBSIDIARIES AND
EMPLOYEES 5701 E HILLSBOROUGH AVE. STE 1122 TAMPA, FL 33610
DATE OF ISSUE: PAGEST ASSIGN: OF
Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual.
04-16-25 1 1
| Job 1: AECOM |
| Job 2: Ajax Paving Industries of |
| Job 3: Ajax Paving Industries of |
| Job 4: Ajax Paving Industries of |
| Job 5: American Civil Constructors West |
| Job 6: American Engineering Testing |
| Job 7: APWA |
| Job 8: Association of Equipment Manufacturers |
| Job 9: Boh Bros Construction Co. LLC |
| Job 10: Chastain & Associates LLC |
| Job 11: Chastain & Associates, LLC |
| Job 12: City of Bradenton |
| Job 13: City of Elmhurst |
| Job 14: City of Kennewick |
| Job 15: Columbus Consolidated Government |
| Job 16: County of Kitsap |
| Job 17: County of Volisia |
| Job 18: CW Roberts Contracting Inc. |
| Job 19: Dallas Fort Worth International |
| Job 20: Data Transfer Solutions, LLC |
| Job 21: DeAngelo Contracting Services, |
| Job 22: DeAngelo Contracting Services, LLC |
| Job 23: DeAngelo Contracting Services, LLC |
| Job 24: Delaware Department of |
| Job 25: Detroit Building Authority |
| Job 26: Engineering Enterprises, Inc. |
| Job 27: ESP Associates, Inc |
| Job 28: Florida Highway Safety and Motor |
| Job 29: For Informational Purposes Only |
| Job 30: General Caulking & Coatings Co., |
| Job 31: Georgia Department of Transportation |
| Job 32: Gilchrist Construction |
| Job 33: Global Sustainable Solutions, |
| Job 34: HDR Engineering, Inc |
| Job 35: HDR Engineering, Inc. |
| Job 36: Honeycutt Realty of Florida, LLC |
| Job 37: International Cybernetics Canada |
| Job 38: International Cybernetics |
| Job 39: Johnson, Mirmiran & Thompson, Inc. |
| Job 40: Kimley-Horn and Associates, Inc. |
| Job 41: Kimley-Horn and Associates, Inc. |
| Job 42: Kisinger Campo and Associates |
| Job 43: Lake County Illinois Division of |
| Job 44: Lidar Alliance Leasing, LLC |
| Job 45: LTG, Inc. |
| Job 46: M & J Construction |
| Job 47: Maricopa County c/o of Risk |
| Job 48: Marlin Engineering Inc. |
| Job 49: Mission Support and Test |
| Job 50: NDOT |
| Job 51: New York City Department of |
| Job 52: O'Connell & Lawrence, Inc. Attn: |
| Job 53: Oklahoma County |
| Job 54: Oklahoma Department of |
| Job 55: Preferred Materials Inc. |
| Job 56: Preferred Materials, Inc. |
| Job 57: Proof of Insurance |
| Job 58: Purchasing Department |
| Job 59: RAM Construction Services |
| Job 60: RAM Construction Services |
| Job 61: RAM Construction Services |
| Job 62: RAM Construction Services of |
| Job 63: RetroTekUSA Inc |
| Job 64: RMS Properties, Inc. |
| Job 65: Routt County, Board of County |
| Job 66: Santa Fe County |
| Job 67: Skidabrader Group LLC |
| Job 68: State of New Jersey Department |
| Job 69: State of Tennessee, Risk Manager |
| Job 70: Sumter Co Board of Commissioners |
| Job 71: Synovus Bank |
| Job 72: Synovus Bank |
| Job 73: Synovus Bank |
| Job 74: Taffy Event Strategies |
| Job 75: Taffy Events/APWA |
| Job 76: Tetra Tech |
| Job 77: Texas Department of |
| Job 78: The National Academies of |
| Job 79: The Port of Authority of New |
| Job 80: The State of Arizona |
| Job 81: The State of Arizona, and its |
| Job 82: The Truesdell Corporation |
| Job 83: The Truesdell Corporation |
| Job 84: The Truesdell Corporation |
| Job 85: The Truesdell Corporation |
| Job 86: The Truesdell Corporation |
| Job 87: The Truesdell Corporation |
| Job 88: The Truesdell Corporation |
| Job 89: The Truesdell Corporation |
| Job 90: The Truesdell Corporation |
| Job 91: Town of Eaton |
| Job 92: Town of Jupiter |
| Job 93: Town of Smithtown |
| Job 94: Town of Vienna |
| Job 95: Township of Livingston |
| Job 96: Transportation Research Center |
| Job 97: Triborough Bridge and Tunnel |
| Job 98: Truesdell Corporation |
| Job 99: Truesdell Corporation |
| Job 100: Truesdell Corporation |
| Job 101: Truesdell Corporation |
| Job 102: Truesdell Corporation. |
| Job 103: University of North Florida |
| Job 104: University of North Florida Board of Trustees |
| Job 105: US Army Corps of Engineers |
| Job 106: US Bank Equipment Finance |
| Job 107: Venture Construction Inc. |
| Job 108: Village of Addison |
| Job 109: Village of Arlington Heights |
| Job 110: Village of Johnsburg |
| Job 111: Village of Richmond |
| Job 112: Village of South Barrington |
| Job 113: W.W. Clyde & Co. |
| Job 114: Walt Disney Parks and Resorts |
| Job 115: West Virginia Department of Transportation |
| Job 116: Weston & Sampson |
| Job 117: WSP USA Environment & |
| Job 118: WSP USA Environment & Infrastructure Inc. |
| Job 119: WSP USA Environment & |
| Job 120: WSP USA Inc. and affiliates |
| Job 121: Yuma County |
| Job 122: ZB, N.A. dba National Bank of |
File details come from the government source that posted it. Updated .