ACORD_Form_20221010-081756.pdf

10/10/2022

Passey-Bond Co., Inc.

28 North Center Street P. O. Box 819 Mesa AZ 85211-0819

Kori L. Moseley, CISR, CPIW (480)969-2291 (480)833-4833 korim@passeybond.com

Kearney Electric, Inc.

3609 E. Superior Ave

Phoenix AZ 85040-1640

Cincinnati Insurance Co. 10677 CopperPoint Western Insurance Co. 13209

A

X

X

X GA472AZ/GA4316AZ/GA233

X CG2001/GA101

X

X Y EPP0098100 10/1/2022 10/1/2023

1,000,000

500,000

10,000

1,000,000

2,000,000

2,000,000

A X

X

X AA288 0620

X

X Y EBA0098100 10/1/2022 10/1/2023

1,000,000

A

X X EPP0098100 10/1/2022 10/1/2023 10,000,000

10,000,000

B N

WC000313 (4/84)

1010035 10/1/2022 10/1/2023

X

1,000,000

1,000,000

1,000,000

Solicitation No. BPM004541 Communications Cabling Systems.

Arizona Department of Administration State Procurement Office (*) 100 N. 15th Avenue Phoenix, AZ 85007

Bill Passey/KORI

Y

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

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

LOCJECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSD

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

OTHER:

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 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:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

(*) State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees

COMMENTS/REMARKS

COPYRIGHT 2000, AMS SERVICES INC.OFREMARK

Includes copyrighted material of Insurance GA 472 AZ 05 20 Services Office, Inc., with its permission. Page 1 of 3

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CONTRACTORS ADDITIONAL INSURED - AUTOMATIC STATUS

AND AUTOMATIC WAIVER OF SUBROGATION

WHEN REQUIRED IN WRITTEN CONTRACT, AGREEMENT,

PERMIT OR AUTHORIZATION - ARIZONA

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. Additional Insured - Owners, Lessees or Contractors - Automatic Status for Other Parties When Required in Written Contract or Agreement With You

1. Section II - Who is an Insured is amended to include as an additional in-sured any person or organization you have agreed in writing in a contract or agreement to add as an additional in-sured on this Coverage Part. Such per-son(s) or organization(s) is an additional insured only with respect to liability for "bodily injury", "property damage" or "per-sonal and advertising injury" caused, in whole or in part, by the performance of your ongoing operations by you or on your behalf, under that written contract or written agreement. Ongoing operations does not apply to "bodily injury" or "prop-erty damage" occurring after:

a. 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 loca-tion 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 subcontractor engaged in performing operations for a principal as a part of the same pro-ject.

2. With respect to the insurance afforded to the additional insureds described in Para-graph A.1., the following additional exclu-sion applies:

This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including:

a. The preparing, approving or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or draw-ings and specifications; or

b. Supervisory, inspection, architectural or engineering activities.

This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hir-ing, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "prop-erty damage", or the offense which caused the "personal and advertising inju-ry", involved the rendering of, or the fail-ure to render, any professional architec-tural, engineering or surveying services.

3. This Paragraph A. does not apply to addi-tional insureds described in Paragraph B.

B. Additional Insured - State or Governmental Agency or Subdivision or Political Subdi-vision - Automatic Status When Required in Written Permits or Authorizations

1. Section II - Who is an Insured is amended to include as an additional in-sured any state or governmental agency or subdivision or political subdivision you have agreed in writing in a permit or au-thorization to add as an additional insured on this Coverage Part. Such state or gov-ernmental agency or subdivision or politi-cal subdivision is an additional insured only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivi-sion or political subdivision has issued, in writing, a permit or authorization.

GA 472 AZ 05 20 Services Office, Inc., with its permission. Page 2 of 3

2. With respect to the insurance afforded to the additional insureds described in Para-graph B.1., the following additional exclu-sions apply:

This insurance does not apply to:

a. "Bodily injury", "property damage" or "personal and advertising injury" aris-ing out of operations performed for the federal government, state or mu-nicipality; or

b. "Bodily injury" or "property damage" included within the "products-completed operations hazard."

C. The insurance afforded to additional insureds described in Paragraphs A. and B.:

1. Only applies to the extent permitted by law; and

2. Will not be broader than that which you are required by the written contract, writ-ten agreement, written permit or written authorization to provide for such addition-al insured; and

3. Does not apply to any person, organiza-tion, state, governmental agency or sub-division or political subdivision specifically named as an additional insured for the same project in the schedule of an en-dorsement added to this Coverage Part.

D. With respect to the insurance afforded to the additional insureds described in Paragraphs A. and B., the following is added to Section III

- Limits of Insurance:

The most we will pay on behalf of the addi-tional insured is the amount of insurance:

1. Required by the written contract, written agreement, written permit or written au-thorization described in Paragraphs A.

and B. For the purpose of determining the required amount of insurance only, we will include the minimum amount of any Um-brella Liability or Excess Liability cover-age required for that additional insured in that written contract, written agreement, written permit or written authorization; or

2. Available under the applicable limits of in-surance;

whichever is less.

This endorsement shall not increase the appli-cable limits of insurance.

E. Section IV - Commercial General Liability Conditions is amended to add the following:

Automatic Additional Insured Provision

This insurance applies only if the "bodily inju-ry" or "property damage" occurs, or the "per-sonal and advertising injury" offense is com-mitted:

1. During the policy period; and

2. Subsequent to your execution of the writ-ten contract or written agreement, or the issuance of a written permit or written au-thorization, described in Paragraphs A.

and B.

F. Except when G. below applies, the following is added to Section IV - Commercial General Liability Conditions, Other Insurance, and supersedes any provision to the contrary:

When Other Additional Insured Coverage Applies on an Excess Basis

This insurance is primary to other insurance available to the additional insured described in Paragraphs A. and B. except:

1. As otherwise provided in Section IV - Commercial General Liability Condi-tions, Other Insurance, b. Excess In-surance; or

2. For any other valid and collectible insur-ance available to the additional insured as an additional insured on another insur-ance policy that is written on an excess basis. In such case, this insurance is also excess.

G. The following is added to Section IV - Com-mercial General Liability Conditions, Other Insurance, and supersedes any provision to the contrary:

Primary Insurance When Required by Writ-ten Contract, Agreement, Permit or Author-ization

Except when wrap-up insurance applies to the claim or "suit" on behalf of the additional in-sured, this insurance is primary to any other insurance available to the additional insured described in Paragraphs A. and B. provided that:

1. The additional insured is a Named In-sured under such other insurance; and

2. You have agreed in writing in a contract, agreement, permit or authorization de-scribed in Paragraph A. or B. that this in-surance would be primary to any other in-surance available to the additional in-sured.

As used in this endorsement, wrap-up insur-ance means a centralized insurance program under which one party has secured either in-surance or self-insurance covering some or all

GA 472 AZ 05 20 Services Office, Inc., with its permission. Page 3 of 3 of the contractors or subcontractors perform-ing work on one or more specific project(s).

Primary and Noncontributory Insurance When Required by Written Contract, Agreement, Permit or Authorization

Except when wrap-up insurance applies to the claim or "suit" on behalf of the additional in-sured, this insurance is primary to and will not seek contribution from any other insurance available to the additional insured described in Paragraphs A. and B. provided that:

1. The additional insured is a Named In-sured under such other insurance; and

2. You have agreed in writing in a contract, agreement, permit or authorization de-scribed in Paragraph A. or B. that this in-surance would be primary and would not seek contribution from any other insur-ance available to the additional insured.

As used in this endorsement, wrap-up insur-ance means a centralized insurance program under which one party has secured either in-surance or self-insurance covering some or all of the contractors or subcontractors perform-ing work on one or more specific projects(s).

H. Section IV - Commercial General Liability Conditions, Transfer of Rights of Recovery Against Others to Us is amended by the ad-dition of the following:

Waiver of Subrogation

We waive any right of recovery against any additional insured under this endorsement, because of any payment we make under this endorsement, to whom the insured has waived its right of recovery in a written con-tract, written agreement, written permit or writ-ten authorization. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such additional in-sured prior to loss.

GA 4316 AZ 05 20 Services Office, Inc., with its permission. Page 1 of 3

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CONTRACTORS ADDITIONAL INSURED - AUTOMATIC STATUS

AND AUTOMATIC WAIVER OF SUBROGATION

WHEN REQUIRED IN WRITTEN CONSTRUCTION AGREEMENT -

(COMPLETED OPERATIONS) - ARIZONA

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. Additional Insured - Owners, Lessees Or Contractors - Automatic Status For Other Parties When Required In Written Con-struction Agreement (Completed Opera-tions)

1. Section II - Who Is An Insured is amended to include as an additional in-sured any person or organization you have agreed in writing in a contract or agreement to add as an additional in-sured on this Coverage Part. Such per-son(s) or organization(s) is an additional insured only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" performed under that written contract or written agreement and included in the "products-completed operations hazard", but only if:

a. The Coverage Part to which this en-dorsement is attached provides cov-erage for "bodily injury" or "property damage" included within the "prod-ucts-completed operations hazard";

and

b. The written contract or written agreement requires you to provide additional insured coverage included within the "products-completed oper-ations hazard" for that person or or-ganization.

If the written contract or written agree-ment requires you to provide additional insured coverage included within the "products-completed operations hazard" for a specified length of time for that per-son or organization, the "bodily injury" or "property damage" must occur prior to the expiration of that period of time in order for this insurance to apply.

If the written contract or written agree-ment requires you to provide additional insured coverage for a person or organi-zation per only ISO additional insured en-dorsement form number CG 20 10, with-out specifying an edition date, and without specifically requiring additional insured coverage included within the “products-completed operations hazard”, coverage does not apply to that person or organiza-tion.

2. With respect to the insurance afforded to the additional insureds described in Para-graph A.1., the following additional exclu-sions apply:

This insurance does not apply to

a. "Bodily injury" or "property damage" arising out of the rendering of, or the failure to render, any professional ar-chitectural, engineering or surveying services, including:

(1) The preparing, approving or fail-ing to prepare or approve, maps, shop drawings, opinions, re-ports, surveys, field orders, change orders or drawings and specifications; or

(2) Supervisory, inspection, archi-tectural or engineering activities.

This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage" involved the ren-dering of, or the failure to render, any professional architectural, engineer-ing or surveying services.

b. "Bodily injury" or "property damage" arising out of "residential" construc-tion.

B. The insurance afforded to additional insureds described in Paragraph A.:

GA 4316 AZ 05 20 Services Office, Inc., with its permission. Page 2 of 3

1. Only applies to the extent permitted by law; and

2. Will not be broader than that which you are required by the written contract or written agreement to provide for such ad-ditional insured; and

3. Does not apply to any person or organiza-tion specifically named as an additional insured for the same project in the sched-ule of an endorsement added to this Cov-erage Part.

C. With respect to the insurance afforded to the additional insureds described in Paragraph A., the following is added to Section III - Limits Of Insurance:

The most we will pay on behalf of the addi-tional insured is the amount of insurance:

1. Required by the written contract or written agreement described in Paragraph A. For the purpose of determining the required amount of insurance only, we will include the minimum amount of any Umbrella Li-ability or Excess Liability coverage re-quired for that additional insured in that written contract or written agreement; or

2. Available under the applicable limits of in-surance;

whichever is less.

This endorsement shall not increase the appli-cable limits of insurance.

D. Section IV - Commercial General Liability Conditions is amended to add the following:

Automatic Additional Insured Provision

This insurance applies only if the "bodily inju-ry" or "property damage" occurs:

1. During the policy period; and

2. Subsequent to your execution of the writ-ten contract or written agreement de-scribed in Paragraph A.

E. Except when F. below applies, the following is added to Section IV - Commercial General Liability Conditions, Other Insurance, and supersedes any provision to the contrary:

When Other Additional Insured Coverage Applies On An Excess Basis

This insurance is primary to other insurance available to the additional insured described in Paragraph A. except:

1. As otherwise provided in Section IV - Commercial General Liability Condi-tions, Other Insurance, b. Excess In-surance; or

2. For any other valid and collectible insur-ance available to the additional insured as an additional insured on another insur-ance policy that is written on an excess basis. In such case, this insurance is also excess.

F. The following is added to Section IV - Com-mercial General Liability Conditions, Other Insurance, and supersedes any provision to the contrary:

Primary Insurance When Required By Writ-ten Contract Or Agreement

Except when wrap-up insurance applies to the claim or "suit" on behalf of the additional in-sured, this insurance is primary to any other insurance available to the additional insured described in Paragraph A. provided that:

1. The additional insured is a Named In-sured under such other insurance; and

2. You have agreed in writing in a contract or agreement described in Paragraph A.

that this insurance would be primary to any other insurance available to the addi-tional insured.

As used in this endorsement, wrap-up insur-ance means a centralized insurance program under which one party has secured either in-surance or self-insurance covering some or all of the contractors or subcontractors perform-ing work on one or more specific projects(s).

Primary And Noncontributory Insurance When Required By Written Contract Or Agreement

Except when wrap-up insurance applies to the claim or "suit" on behalf of the additional in-sured, this insurance is primary to and will not seek contribution from any other insurance available to the additional insured described in Paragraph A. provided that:

1. The additional insured is a Named In-sured under such other insurance; and

2. You have agreed in writing in a contract or agreement described in Paragraph A.

that this insurance would be primary and would not seek contribution from any oth-er insurance available to the additional in-sured.

As used in this endorsement, wrap-up insur-ance means a centralized insurance program under which one party has secured either in-surance or self-insurance covering some or all of the contractors or subcontractors perform-ing work on one or more specific projects(s).

GA 4316 AZ 05 20 Services Office, Inc., with its permission. Page 3 of 3

G. Section IV – Commercial General Liability Conditions, Transfer Of Rights Of Recov-ery Against Others To Us is amended by the addition of the following:

Waiver of Subrogation

We waive any right of recovery against any additional insured under this endorsement, because of any payment we make under this endorsement, to whom the insured has waived its right of recovery in a written con-tract or written agreement. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such addi-tional insured prior to loss.

H. Section V – Definitions is amended to in-clude:

1. "Residential" means:

a. A structure used, or intended, in whole or in part, for the purpose of human habitation, and includes, but is not limited to, single-family hous-ing, multi-family housing, tract homes, condominiums, cooperatives, townhomes, townhouses, planned-unit developments and timeshares;

b. A structure converted, or being con-verted, in whole or in part, into con-dominiums or cooperatives; and

c. Common areas and grounds, appur-tenant structures and facilities, of the structures described in H.1.a. and b.

above, except a public street, public road, public right of way, or public utility easement located on or near such common areas and grounds.

"Residential" does not include:

a. Hospitals, jails or prisons; and

b. Provided there is no individual own-ership of units and that such was not, in whole or in part, at any time, mar-keted, sold, occupied or used as sin-gle-family housing, multi-family hous-ing, or as a condominium, coopera-tive, townhouse, townhome or timeshare:

(1) Government housing on military bases;

(2) College/university dormitories;

(3) Apartments;

(4) Long-term care facilities;

(5) Assisted-living facilities;

(6) Nursing homes; and

(7) Hotels or motels.

CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

COMMERCIAL GENERAL LIABILITY

CG 20 01 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRIMARY AND NONCONTRIBUTORY -

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

The following is added to the Other Insurance Condi-tion and supersedes any provision to the contrary:

Primary And Noncontributory Insurance

This insurance is primary to and will not seek con-tribution 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.

GA 233 09 17 Services Office, Inc., with its permission. Page 1 of 17

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CONTRACTORS' COMMERCIAL GENERAL LIABILITY

BROADENED ENDORSEMENT

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. Endorsement - Table of Contents:

Coverage: Begins on Page:

1. Employee Benefit Liability Coverage

2. Unintentional Failure To Disclose Hazards

3. Damage To Premises Rented To You

4. Supplementary Payments

5. Medical Payments

6. 180 Day Coverage For Newly Formed Or Acquired Organizations

7. Waiver Of Subrogation

8. Automatic Additional Insured - Specified Relationships:

• Managers Or Lessors Of Premises;

• Lessor Of Leased Equipment;

• Vendors;

• State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits

Or Authorizations Relating To Premises; and

• Mortgagee, Assignee Or Receiver

9. Property Damage To Borrowed Equipment

10. Employees As Insureds - Specified Health Care Services And Good Samaritan

Services

11. Broadened Notice Of Occurrence

12. Nonowned Aircraft

13. Bodily Injury Redefined

14. Expected Or Intended Injury Redefined

15. Former Employees As Insureds

16. Voluntary Property Damage Coverage And Care, Custody Or Control Liability

Coverage

17. Broadened Contractual Liability - Work Within 50' Of Railroad Property

18. Alienated Premises

B. Limits Of Insurance:

The Commercial General Liability Limits of Insurance apply to the insurance provided by this endorse-ment, except as provided below:

1. Employee Benefit Liability Coverage

Each Employee Limit: $1,000,000 Aggregate Limit: $3,000,000 Deductible Amount: $ 1,000

3. Damage To Premises Rented To You

The lesser of:

a. The Each Occurrence Limit shown in the Declarations; or

b. $500,000 unless otherwise stated $

4. Supplementary Payments

a. Bail Bonds: $ 2,500

GA 233 09 17 Services Office, Inc., with its permission. Page 2 of 17

b. Loss Of Earnings: $ 500

5. Medical Payments

Medical Expense Limit: $ 10,000

9. Property Damage To Borrowed Equipment

Each Occurrence Limit: $10,000 Deductible Amount: $ 250

16. Voluntary Property Damage Coverage (Coverage a.) And Care, Custody Or Control Liability Coverage (Coverage b.)

Limits Of Insurance Coverage a.

$1,000 Each Occurrence $5,000 Aggregate Coverage b. $5,000 Each Occurrence unless otherwise stated $

Deductible Amount (Each Occurrence) Coverage a. $250 Coverage b. $250 unless otherwise stated $

COVERAGE

PREMIUM BASIS

(a) Area

(b) Payroll

(c) Gross Sales

(d) Units

(e) Other

RATE

(For Limits in Excess of $5,000)

ADVANCE PREMIUM

(For Limits in Excess of $5,000)

b. Care, Custody Or Control $

TOTAL ANNUAL PREMIUM $

GA 233 09 17 Services Office, Inc., with its permission. Page 3 of 17

C. Coverages

1. Employee Benefit Liability Coverage

a. The following is added to Section I - Coverages:

Employee Benefit Liability Cover-age

(1) Insuring Agreement

(a) We will pay those sums that the insured becomes legally obligated to pay as damag-es caused by any act, error or omission of the insured, or of any other person for whose acts the insured is legally liable, to which this insurance applies. We will have the right and duty to defend the insured against any "suit" seeking those damages. However, we will have no duty to defend against any "suit" seeking damages to which this in-surance does not apply. We may, at our discretion, in-vestigate any report of an act, error or omission and settle any claim or "suit" that may result. But:

1) The amount we will pay for damages is limited as described in Section III - Limits Of Insur-ance; and

2) Our right and duty to defend ends when we have used up the appli-cable limit of insurance in the payment of judg-ments or settlements.

No other obligation or liabil-ity to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments.

(b) This insurance applies to damages only if the act, er-ror or omission, is negligent-ly committed in the "admin-istration" of your "employee benefit program"; and

1) Occurs during the policy period; or

2) Occurred prior to the "first effective date" of this endorsement pro-vided:

a) You did not have knowledge of a claim or "suit" on or before the "first ef-fective date" of this endorsement.

You will be deemed to have knowledge of a claim or "suit" when any "author-ized representa-tive";

i) Reports all, or any part, of the act, error or omission to us or any other insurer;

ii) Receives a written or ver-bal demand or claim for dam-ages because of the act, er-ror or omis-sion; and

b) There is no other applicable insur-ance.

(2) Exclusions

This insurance does not apply to:

(a) Bodily Injury, Property Damage Or Personal And Advertising Injury

"Bodily injury", "property damage" or "personal and advertising injury".

(b) Dishonest, Fraudulent, Criminal Or Malicious Act

Damages arising out of any intentional, dishonest, fraudulent, criminal or mali-cious act, error or omission, committed by any insured, including the willful or reck-less violation of any statute.

(c) Failure To Perform A Con-tract

Damages arising out of fail-ure of performance of con-tract by any insurer.

GA 233 09 17 Services Office, Inc., with its permission. Page 4 of 17

(d) Insufficiency Of Funds

Damages arising out of an insufficiency of funds to meet any obligations under any plan included in the "employee benefit program".

(e) Inadequacy Of Perfor-mance Of Invest-ment/Advice Given With Respect To Participation

Any claim based upon:

1) Failure of any invest-ment to perform;

2) Errors in providing in-formation on past per-formance of investment vehicles; or

3) Advice given to any person with respect to that person's decision to participate or not to par-ticipate in any plan in-cluded in the "employee benefit program".

(f) Workers' Compensation And Similar Laws

Any claim arising out of your failure to comply with the mandatory provisions of any workers' compensation, un-employment compensation insurance, social security or disability benefits law or any similar law.

(g) ERISA

Damages for which any in-sured is liable because of li-ability imposed on a fiduci-ary by the Employee Re-tirement Income Security Act of 1974, as now or hereafter amended, or by any similar federal, state or local laws.

(h) Available Benefits

Any claim for benefits to the extent that such benefits are available, with reasonable effort and cooperation of the insured, from the applicable funds accrued or other col-lectible insurance.

(i) Taxes, Fines Or Penalties

Taxes, fines or penalties, in-cluding those imposed un-der the Internal Revenue Code or any similar state or local law.

(j) Employment-Related Prac-tices

Any liability arising out of any:

(1) Refusal to employ;

(2) Termination of employ-ment;

(3) Coercion, demotion, evaluation, reassign-ment, discipline, defa-mation, harassment, humiliation, discrimina-tion or other employ-ment - related practices, acts or omissions; or

(4) Consequential liability as a result of (1), (2) or

(3) above.

This exclusion applies whether the insured may be held liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the in-jury.

(3) Supplementary Payments

Section I - Coverages, Sup-plementary Payments - Cover-ages A And B also apply to this Coverage.

b. Who Is An Insured

As respects Employee Benefit Lia-bility Coverage, Section II - Who Is An Insured is replaced by the follow-ing:

(1) If you are designated in the Dec-larations as:

(a) An individual, you and your spouse are insureds, but on-ly with respect to the con-duct of a business of which you are the sole owner.

(b) A partnership or joint ven-ture, you are an insured.

Your members, your part-

GA 233 09 17 Services Office, Inc., with its permission. Page 5 of 17 ners, and their spouses are also insureds but only with respect to the conduct of your business.

(c) A limited liability company, you are an insured. Your members are also insureds, but only with respect to the conduct of your business.

Your managers are in-sureds, but only with respect to their duties as your man-agers.

(d) An organization other than a partnership, joint venture or limited liability company, you are an insured. Your "execu-tive officers" and directors are insureds, but only with respect to their duties as your officers or directors.

Your stockholders are also insureds, but only with re-spect to their liability as stockholders.

(e) A trust, you are an insured.

Your trustees are also in-sureds, but only with respect to their duties as trustees.

(2) Each of the following is also an insured:

(a) Each of your "employees" who is or was authorized to administer your "employee benefit program";

(b) Any persons, organizations or "employees" having prop-er temporary authorization to administer your "employ-ee benefit program" if you die, but only until your legal representative is appointed;

or

(c) Your legal representative if you die, but only with re-spect to duties as such. That representative will have all your rights and duties under this Coverage Part.

(3) Any organization you newly ac-quire or form, other than a part-nership, joint venture or limited liability company, and over which you maintain ownership or major-ity interest, will qualify as a Named Insured if no other similar insurance applies to that organi-zation. However, coverage under this provision:

(a) Is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; and

(b) Does not apply to any act, error or omission that was committed before you ac-quired or formed the organi-zation.

c. Limits Of Insurance

As respects Employee Benefit Lia-bility Coverage, Section III - Limits Of Insurance is replaced by the fol-lowing:

(1) The Limits of Insurance shown in Section B. Limits Of Insurance,

1. Employee Benefit Liability Coverage and the rules below fix the most we will pay regardless of the number of:

(a) Insureds;

(b) Claims made or "suits" brought;

(c) Persons or organizations making claims or bringing "suits";

(d) Acts, errors or omissions; or

(e) Benefits included in your "employee benefit program".

(2) The Aggregate Limit shown in Section B. Limits Of Insurance,

1. Employee Benefit Liability Coverage of this endorsement is the most we will pay for all dam-ages because of acts, errors or omissions negligently committed in the "administration" of your "employee benefit program".

(3) Subject to the limit described in

(2) above, the Each Employee Limit shown in Section B. Limits Of Insurance, 1. Employee Benefit Liability Coverage of this endorsement is the most we will pay for all damages sus-tained by any one "employee", including damages sustained by such "employee's" dependents and beneficiaries, as a result of:

(a) An act, error or omission; or

GA 233 09 17 Services Office, Inc., with its permission. Page 6 of 17

(b) A series of related acts, er-rors or omissions, regard-less of the amount of time that lapses between such acts, errors or omissions;

negligently committed in the "administration" of your "employ-ee benefit program".

However, the amount paid under this endorsement shall not ex-ceed, and will be subject to the limits and restrictions that apply to the payment of benefits in any plan included in the "employee benefit program."

(4) Deductible Amount

(a) Our obligation to pay dam-ages on behalf of the in-sured applies only to the amount of damages in ex-cess of the Deductible Amount stated in the Decla-rations as applicable to Each Employee. The limits of insurance shall not be re-duced by the amount of this deductible.

(b) The Deductible Amount stated in the Declarations applies to all damages sus-tained by any one "employ-ee", including such "employ-ee's" dependents and bene-ficiaries, because of all acts, errors or omissions to which this insurance applies.

(c) The terms of this insurance, including those with respect to:

1) Our right and duty to defend the insured against any "suits" seeking those damag-es; and

2) Your duties, and the du-ties of any other in-volved insured, in the event of an act, error or omission, or claim;

apply irrespective of the ap-plication of the Deductible Amount.

(d) We may pay any part or all of the Deductible Amount to effect settlement of any claim or "suit" and, upon no-tification of the action taken, you shall promptly reim-burse us for such part of the Deductible Amount as we have paid.

d. Additional Conditions

As respects Employee Benefit Lia-bility Coverage, Section IV - Com-mercial General Liability Condi-tions is amended as follows:

(1) Item 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit is replaced by the following:

2. Duties In The Event Of An Act, Error Or Omission, Or Claim Or Suit

a. You must see to it that we are notified as soon as practicable of an act, error or omission which may result in a claim.

To the extent possible, notice should include:

(1) What the act, error or omission was and when it oc-curred; and

(2) The names and addresses of any-one who may suf-fer damages as a result of the act, error or omission.

b. If a claim is made or "suit" is brought against any insured, you must:

(1) Immediately record the specifics of the claim or "suit" and the date received;

and

(2) Notify us as soon as practicable.

You must see to it that we receive written no-tice of the claim or "suit" as soon as practicable.

c. You and any other in-volved insured must:

(1) Immediately send us copies of any demands, notices, summonses or le-gal papers re-

GA 233 09 17 Services Office, Inc., with its permission. Page 7 of 17 ceived in connec-tion with the claim or "suit";

(2) Authorize us to ob-tain records and other information;

(3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit";

and

(4) Assist us, upon our request, in the en-forcement of any right against any person or organi-zation which may be liable to the in-sured because of an act, error or omission to which this insurance may also apply.

d. No insured will, except at that insured's own cost, voluntarily make a payment, assume any obligation, or incur any expense without our consent.

(2) Item 5. Other Insurance is re-placed by the following:

5. Other Insurance

If other valid and collectible insurance is available to the insured for a loss we cover under this Coverage Part, our obligations are limited as follows:

a. Primary Insurance

This insurance is prima-ry except when c. below applies. If this insurance is primary, our obliga-tions are not affected unless any of the other insurance is also prima-

ry. Then, we will share with all that other insur-ance by the method de-scribed in b. below.

b. Method Of Sharing

If all of the other insur-ance permits contribu-tion by equal shares, we will follow this meth-od also. Under this ap-proach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first.

If any of the other in-surance does not permit contribution by equal shares, we will contrib-ute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insur-ers.

c. No Coverage

This insurance shall not cover any loss for which the insured is entitled to recovery under any other insurance in force previous to the effective date of this Coverage Part.

e. Additional Definitions

As respects Employee Benefit Lia-bility Coverage, Section V - Defini-tions is amended as follows:

(1) The following definitions are added:

1. "Administration" means:

a. Providing information to "employees", including their dependents and beneficiaries, with re-spect to eligibility for or scope of "employee benefit programs";

b. Interpreting the "em-ployee benefit pro-grams";

c. Handling records in connection with the "employee benefit pro-grams"; or

d. Effecting, continuing or terminating any "em-ployee's" participation in

GA 233 09 17 Services Office, Inc., with its permission. Page 8 of 17 any benefit included in the "employee benefit program".

However, "administration" does not include:

a. Handling payroll deduc-tions; or

b. The failure to effect or maintain any insurance or adequate limits of coverage of insurance, including but not limited to unemployment insur-ance, social security benefits, workers' com-pensation and disability benefits.

2. "Cafeteria plans" means plans authorized by applica-ble law to allow "employees" to elect to pay for certain benefits with pre-tax dollars.

3. "Employee benefit pro-grams" means a program providing some of all of the following benefits to "em-ployees", whether provided through a "cafeteria plan" or otherwise:

a. Group life insurance;

group accident or health insurance; dental, vision and hearing plans; and flexible spending ac-counts; provided that no one other than an "em-ployee" may subscribe to such benefits and such benefits are made generally available to those "employees" who satisfy the plan's eligibil-ity requirements;

b. Profit sharing plans, employee savings plans, employee stock ownership plans, pen-sion plans and stock subscription plans, pro-vided that no one other than an "employee" may subscribe to such benefits and such bene-fits are made generally available to all "employ-ees" who are eligible under the plan for such benefits;

c. Unemployment insur-ance, social security benefits, workers' com-pensation and disability benefits; and

d. Vacation plans, includ-ing buy and sell pro-grams; leave of ab-sence programs, includ-ing military, maternity, family, and civil leave;

tuition assistance plans;

transportation and health club subsidies.

4. "First effective date" means the date upon which cover-age was first effected in a series of uninterrupted re-newals of insurance cover-age.

(2) The following definitions are de-leted in their entirety and re-placed by the following:

8. "Employee" means a person actively employed, formerly employed, on leave of ab-sence or disabled, or retired.

"Employee" includes a "leased worker". "Employee" does not include a "tempo-rary worker".

21. "Suit" means a civil proceed-ing in which money damag-es because of an act, error or omission to which this in-surance applies are alleged.

"Suit" includes:

a. An arbitration proceed-ing in which such dam-ages are claimed and to which the insured must submit or does submit with our consent;

b. Any other alternative dispute resolution pro-ceeding in which such damages are claimed and to which the in-sured submits with our consent; or

c. An appeal of a civil pro-ceeding.

GA 233 09 17 Services Office, Inc., with its permission. Page 9 of 17

2. Unintentional Failure To Disclose Haz-ards

Section IV - Commercial General Liabil-ity Conditions, 7. Representations is amended by the addition of the following:

Based on our dependence upon your rep-resentations as to existing hazards, if un-intentionally you should fail to disclose all such hazards at the inception date of your policy, we will not reject coverage under this Coverage Part based solely on such failure.

3. Damage To Premises Rented To You

a. The last Paragraph of 2. Exclusions under Section I - Coverage A - Bod-ily Injury And Property Damage Li-ability is replaced by the following:

Exclusions c. through q. do not apply to "property damage" by fire, explo-sion, lightning, smoke or soot to premises while rented to you or tem-porarily occupied by you with permis-sion of the owner, for which the amount we will pay is limited to the Damage To Premises Rented To You Limit as described in Section III

- Limits Of Insurance.

b. The insurance provided under Sec-tion I - Coverage A - Bodily Injury And Property Damage Liability ap-plies to "property damage" arising out of water damage to premises that are both rented to and occupied by you.

(1) As respects Water Damage Le-gal Liability, as provided in Para-graph 3.b. above:

The exclusions under Section I - Coverage A - Bodily Injury And Property Damage Liability, 2.

Exclusions, other than i. War and the Nuclear Energy Liabil-ity Exclusion (Broad Form), are deleted and the following are added:

This insurance does not apply to:

(a) "Property damage":

(i) Assumed in any con-tract or agreement; or

(ii) Caused by or resulting from any of the follow-ing:

1) Wear and tear;

2) Rust or other cor-rosion, decay, de-terioration, hidden or latent defect or any quality in property that caus-es it to damage or destroy itself;

3) Smog;

4) Mechanical break-down, including rupture or bursting caused by centrif-ugal force;

5) Settling, cracking, shrinking or ex-pansion;

6) Nesting or infesta-tion, or discharge or release of waste products or secre-tions, by insects, birds, rodents or other animals; or

7) Presence, growth, proliferation, spread or any ac-tivity of fungus, in-cluding mold or mildew, and any mycotoxins, spores, scents or byproducts pro-duced or released by fungi.

(b) "Property damage" caused directly or indirectly by any of the following:

(i) Earthquake, volcanic eruption, landslide or any other earth move-ment;

(ii) Water that backs up or overflows or is other-wise discharged from a sewer, drain, sump, sump pump or related equipment;

(iii) Water under the ground surface pressing on, or flowing or seeping through:

1) Foundations, walls, floors or paved surfaces;

GA 233 09 17 Services Office, Inc., with its permission. Page 10 of 17

2) Basements, whether paved or not; or

3) Doors, windows or other openings.

(c) "Property damage" caused by or resulting from water that leaks or flows from plumbing, heating, air condi-tioning, fire protection sys-tems, or other equipment, caused by or resulting from freezing, unless:

(i) You did your best to maintain heat in the building or structure; or

(ii) You drained the equip-ment and shut off the water supply if the heat was not maintained.

(d) "Property damage" to:

(i) Plumbing, heating, air conditioning, fire protec-tion systems, or other equipment or applianc-es; or

(ii) The interior of any building or structure, or to personal property in the building or structure, caused by or resulting from rain, snow, sleet or ice, whether driven by wind or not.

c. Limit Of Insurance

With respect to the insurance afford-ed in Paragraphs 3.a. and 3.b. above, the Damage To Premises Rented To You Limit as shown in the Decla-rations is amended as follows:

(1) Paragraph 6. of Section III - Limits Of Insurance is replaced by the following:

6. Subject to Paragraph 5.

above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A - Bodily Injury And Property Dam-age Liability for damages because of "property dam-age" to any one premises:

a. While rented to you, or temporarily occupied by you with permission of the owner;

b. In the case of damage by fire, explosion, light-ning, smoke or soot, while rented to you; or

c. In the case of damage by water, while rented to and occupied by you.

(2) The most we will pay is limited as described in Section B. Limits Of Insurance, 3. Damage To Premises Rented To You of this endorsement.

4. Supplementary Payments

Under Section I - Supplementary Pay-ments - Coverages A And B:

a. Paragraph 2. is replaced by the fol-lowing:

Up to the limit shown in Section B.

Limits Of Insurance, 4.a. Bail Bonds of this endorsement for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage ap-plies. We do not have to furnish these bonds.

b. Paragraph 4. is replaced by the fol-lowing:

All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to the limit shown in Sec-tion B. Limits Of Insurance, 4.b.

Loss Of Earnings of this endorsement per day because of time off from work.

5. Medical Payments

The Medical Expense Limit of Any One Person as stated in the Declarations is amended to the limit shown in Section B.

Limits Of Insurance, 5. Medical Pay-ments of this endorsement.

6. 180 Day Coverage For Newly Formed Or Acquired Organizations

Section II - Who Is An Insured is amended as follows:

Subparagraph a. of Paragraph 3. is re-placed by the following:

a. Insurance under this provision is af-forded only until the 180th day after

GA 233 09 17 Services Office, Inc., with its permission. Page 11 of 17 you acquire or form the organization or the end of the policy period, whichever is earlier;

7. Waiver Of Subrogation

Section IV - Commercial General Liabil-ity Conditions, 9. Transfer Of Rights Of Recovery Against Others To Us is amended by the addition of the following:

We waive any right of recovery we may have against any person or organization against whom you have agreed to waive such right of recovery in a written contract or agreement because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a written contract or agree-ment with that person or organization and included in the "products-completed oper-ations hazard". However, our rights may only be waived prior to the "occurrence" giving rise to the injury or damage for which we make payment under this Cov-erage Part. The insured must do nothing after a loss to impair our rights. At our re-quest, the insured will bring "suit" or trans-fer those rights to us and help us enforce those rights.

8. Automatic Additional Insured - Speci-fied Relationships

a. The following is added to Section II - Who Is An Insured:

(1) Any person(s) or organization(s) described in Paragraph 8.a.(2) of this endorsement (hereinafter re-ferred to as additional insured) whom you are required to add as an additional insured under this Coverage Part by reason of a written contract, written agree-ment, written permit or written authorization.

(2) Only the following persons or or-ganizations are additional in-sureds under this endorsement, and insurance coverage provided to such additional insureds is lim-ited as provided herein:

(a) Managers Or Lessors Of Premises

The manager or lessor of a premises leased to you with whom you have agreed per Paragraph 8.a.(1) of this en-dorsement to provide insur-ance, but only with respect to liability arising out of the ownership, maintenance or use of that part of the prem-ises leased to you, subject to the following additional exclusions:

This insurance does not ap-ply to:

(i) Any "occurrence" which takes place after you cease to be a tenant in that premises;

(ii) Structural alterations, new construction or demolition operations performed by or on be-half of such additional insured.

(b) Lessor Of Leased Equip-ment

Any person or organization from whom you lease equipment…