APPROVED CTR059124 GL, AL,WC 04.01.23 - 04.01.24.Pdf

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

05/02/2023 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 SUBROGATIONIS 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).

PRODUCER

LOCKTON COMPANIES LLC/PHS

34340808 The Hartford Business Service Center 3600 Wiseman Blvd San Antonio, TX 78251

CONTACT

NAME:

PHONE

(A/C, No, Ext):

(866) 467-8730 FAX

(A/C, No):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

INSURED

KEEN INDEPENDENT RESEARCH LLC

100 FILLMORE ST FL 5

DENVER CO 80206-4916

INSURER A : Sentinel Insurance Company Ltd. 11000

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR

LTR

TYPE OF INSURANCE ADDL

INSR

SUBR

WVD

POLICY NUMBER POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/Y YYY)

LIMITS

A

COMMERCIAL GENERAL LIABILITY

X X 34 SBA PJ4296 04/01/2023 04/01/2024

EACH OCCURRENCE $2,000,000

CLAIMS-MADE X OCCUR DAMAGE TO RENTED

PREMISES (Ea occurrence) $1,000,000

X General Liability MED EXP (Any one person) $10,000

PERSONAL & ADV INJURY $2,000,000

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000

POLICY X PRO-

JECT

LOC PRODUCTS - COMP/OP AGG $4,000,000

OTHER:

A

AUTOMOBILE LIABILITY

X 34 SBA PJ4296 04/01/2023 04/01/2024

COMBINED SINGLE LIMIT

(Ea accident)

$2,000,000 ANY AUTO BODILY INJURY (Per person)

ALL OWNED

AUTOS

SCHEDULED

AUTOS BODILY INJURY (Per accident)

X HIRED

AUTOS X NON-OWNED

AUTOS

PROPERTY DAMAGE

(Per accident)

A

X UMBRELLA LIAB

EXCESS LIAB

X OCCUR

CLAIMS-

MADE 34 SBA PJ4296 04/01/2023 04/01/2024

EACH OCCURRENCE $2,000,000

AGGREGATE $2,000,000

DED X RETENTION $ 10,000

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY

PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

N/ A

PER

STATUTE

OTH-

ER

Y/N E.L. EACH ACCIDENT

E.L. DISEASE -EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

A EMPLOYMENT PRACTICES

LIABILITY

34 SBA PJ4296 04/01/2023 04/01/2024 Each Claim Limit Aggregate Limit

$10,000 $10,000

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

Those usual to the Insured's Operations.

CERTIFICATE HOLDER CANCELLATION

ADOT Procurement Group Mail Drop 100P

1739 W JACKSON ST STE A

PHOENIX AZ 85007-3218

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED

BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED

IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD e6906 Accepted

ACORD 101 (2014/01) © 2014 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

AGENCY CUSTOMER ID:

LOC# :

ADDITIONAL REMARKS SCHEDULE Page 2 of 2

AGENCY

LOCKTON COMPANIES LLC/PHS

NAMED INSURED

KEEN INDEPENDENT RESEARCH LLC

100 FILLMORE ST FL 5

DENVER CO 80206-4916

POLICY NUMBER

SEE ACORD 25

CARRIER

SEE ACORD 25

NAIC CODE

EFFECTIVE DATE: SEE ACORD 25

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM

FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE

Notice of Cancellation will be provided in accordance with Form SS1223, attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy.State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees additional insured per the Business Liability Coverage Form SS0008, attached to this policy. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008 and the Hired Auto and Non Owned Auto Endorsement SS0438, attached to this policy. Coverage is primary and noncontributory per the Business Liability Coverage Form SS0008, attached to this policy.

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

INSURER(S) AFFORDING COVERAGE NAIC #

PRODUCER

INSURED

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

COVERAGES

TYPE OF INSURANCE POLICY NUMBER LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

LOCPOLICY

OTHER:

EACH OCCURRENCE

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

AUTOMOBILE LIABILITY

ANY AUTO

OCCUR

CLAIMS-MADE

DED RETENTION $

EACH OCCURRENCE

AGGREGATE

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

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

CERTIFICATE HOLDER CANCELLATION

Y/N

CONTACT

NAME:

PHONE

(A/C, No, Ext):

E-MAIL

ADDRESS:

FAX

(A/C, No):

CERTIFICATE NUMBER: REVISION NUMBER:

UMBRELLA LIAB

EXCESS LIAB

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

INSURER F :

N/A

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

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.

INSR

LTR

ADDL

INSD

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

PRO-

JECT

DAMAGE TO RENTED

PREMISES (Ea occurrence)

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident)

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

PER

STATUTE

OTH-

ER

SUBR

WVD

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

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

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

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

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

05/01/2023

AUTOMATIC DATA PROCESSING INSURANCE AGCY INC

1 ADP BLVD MS 625

ROSELAND, NJ 07068

(877) 677-0428

(877) 677-0428 (877) 677-0430 spcbicadp@travelers.com

KEEN INDEPENDENT RESEARCH LLC

100 FILLMORE ST. 5TH FL.

DENVER, CO 80206

THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT

320033558181121

A X UB-9M740535-23 04/08/2023 04/08/2024 X

1,000,000 1,000,000 1,000,000

AS RESPECTS TO WORKERS COMPENSATION COVERAGE, WC 00 03 13 00 - WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS HAS BEEN ATTACHED TO THE POLICY. AN ENDORSEMENT HAS BEEN ADDED TO THE POLICY (OR POLICIES) THAT PROVIDES 30 DAY EARLIER NOTICE

OF CANCELLATION, SUBJECT TO THE TERMS OF THAT ENDORSEMENT.

ADOT PROCUREMENT GROUP

MAIL DROP 100P

1739 W JACKSON ST. SUITE A

PHOENIX, AZ 85007

3600 WISEMAN BLVD.

SAN ANTONIO TX 78251

(866) 467-8730

(866) 467-8730

SERVICE.TX@THEHARTFORD.COM

(866) 467-8730

(866) 467-8730

LOCKTON COMPANIES LLC/PHS

The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza, Hartford, Connecticut 06155

Select Customer Insurance Center

Policyholder, please call us at:

Agent, please call us at:

INSURANCE ENDORSEMENT

ATTACHED

*** PLEASE REVIEW THE CHANGE ***

Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes:

Policyholder, please call us at:

Agent, please call us at: between 7 A.M. and 7 P.M. CST .

The premium billing will be mailed to you separately. You can expect to receive it soon.

Thank you for allowing us to service your business needs.

THE HARTFORD SELECT CUSTOMER INSURANCE CENTER

001 (CONTINUED ON NEXT PAGE)

05/01/23 04/01/23

04/01/24

34 SBA PJ4296 DX

KEEN INDEPENDENT RESEARCH LLC

100 FILMORE STREET 5TH FL

DENVER CO 80206

04/21/23

LOCKTON COMPANIES LLC/PHS

340808

SENTINEL INSURANCE COMPANY, LIMITED

ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING

STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK

ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS.

THIS IS NOT A BILL.

NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE

PROPERTY OPTIONAL COVERAGES APPLICABLE TO ALL LOCATIONS ARE ADDED

COMPUTERS AND MEDIA COVERAGE

FORM SS 04 41

DEDUCTIBLE: $ 1,000

FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE:

IH12001185 WAIVER OF SUBROGATION

PRO RATA FACTOR: 0.948

THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN.

Form SS 12 11 04 05 T Page Process Date: Policy Effective Date:

Policy Expiration Date:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

POLICY CHANGE

This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below:

Policy Number:

Named Insured and Mailing Address;

Policy Change Effective Date: Effective hour is the same as stated in the Declarations Page of the Policy.

Policy Change Number:

Agent Name:

Code:

POLICY CHANGES:

05/01/23 04/01/23

04/01/24

34 SBA PJ4296

IH12001185 ADDITIONAL INSURED DESIGNATED PERSON OR

ORGANIZATION

FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE:

IH12001185 PRIMARY AND NONCONTRIBUTORY

IH12001185 30 DAY NOTICE OF CANCELLATION

IH12001185 HIRED AND NON-OWNED AUTO LIABILITY

ADDITIONALLY INSURED

IH12001185 CONTRACTUAL LIABILITY

Form SS 12 11 04 05 T Page Process Date: Policy Effective Date:

Policy Expiration Date:

POLICY CHANGE (Continued)

Policy Number:

Policy Change Number:

34 SBA PJ4296

WAIVER OF SUBROGATION

THE STATE OF ARIZONA, AND ITS DEPARTMENTS, AGENCIES, BOARDS,

COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS, AND

EMPLOYEES

1324 N 22ND AVE

PHOENIX AZ 85009

CLARK COUNTY SCHOOL DISTRICT

ATTN: PURCHASING DEPARTMENT

4212 EUCALYPTUS AVE BLDG 7

LAS VEGAS NV 89121

CITY OF BOSTON

OFFICE OF ECONOMIC

OPPORTUNITY AND INCLUSION

THE CITY OF BOSTON, ITS OFFICIALS, EMPLOYEES AND VOLUNTEERS

1 CITY HALL SQUARE

BOSTON, MA 02201

THE ORANGE COUNTY TRANSPORTATION

AUTHORITY, ITS OFFICERS, DIRECTORS,

EMPLOYEES AND AGENTS

PO BOX 60840

LAS VEGAS NV 89160-0840

ADOT PROCUREMENT GROUP

STATE OF ARIZONA, ANDITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS,

UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES

1739 W JACKSON ST STE A

PHOENIX AZ 85007-3218

CITY OF SPRINGFIELD

DIVISION OF PURCHASES

218 E CENTRAL ST

SPRINGFIELD MO 65802

004 001

05/01/23 04/01/24

POLICY NUMBER:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Form IH 12 00 11 85 T SEQ. NO. Printed in U.S.A. Page

Process Date: Expiration Date:

E02574 062016 ed. Page 1 of 1

Effective date of this Endorsement: 05/01/2023 This Endorsement is attached to and forms a part of Policy Number: V11DHU23PNPM

Beazley Insurance Company Inc. referred to in this endorsement as either the “Insurer” or the “Underwriters”

AMEND NOTICE OF CANCELLATION

This endorsement modifies insurance provided under the following:

MPL SECURE®

MISCELLANEOUS PROFESSIONAL, INFORMATION SECURITY & PRIVACY, PERSONAL INJURY

AND WEBSITE MEDIA CONTENT LIABILITY INSURANCE POLICY

In consideration of the premium charged for the Policy, it is hereby understood and agreed that notwithstanding any provision regarding cancellation by the Underwriters for non-payment in Clause XV.

CANCELLATION to the contrary, in the event the Underwriters cancel this Policy for non-payment of premium, the Underwriters shall notify ADOT Procurement Group Mail Drop 100P, 1739 W Jackson Street, Suite A, Phoenix AZ 85007 and the cancellation of this Policy shall become effective 30 days thereafter.

All other terms and conditions of this Policy remain unchanged.

Authorized Representative

ADDITIONAL INSURED DESIGNATED PERSON OR

ORGANIZATION

COUNTY OF SANTA CLARA

PARKS AND RECREATION DEPARTMENT

298 GARDEN HILL DR

LOS GATOS, CA 95032

CITY OF SPRINGFIELD

DIVISION OF PURCHASES

218 E CENTRAL ST

SPRINGFIELD MO 65802

CITY OF BOSTON

OFFICE OF ECONOMIC

OPPORTUNITY AND INCLUSION

THE CITY OF BOSTON, ITS OFFICIALS, EMPLOYEES AND VOLUNTEERS

1 CITY HALL SQUARE

BOSTON, MA 02201

ADOT PROCUREMENT GROUP

MAIL DROP 100P

1739 W JACKSON ST STE A

PHOENIX AZ 85007-3218

THE ORANGE COUNTY TRANSPORTATION

AUTHORITY, ITS OFFICERS, DIRECTORS,

EMPLOYEES AND AGENTS

PO BOX 60840

LAS VEGAS NV 89160-0840

CLARK COUNTY SCHOOL DISTRICT

ATTN: PURCHASING DEPARTMENT

4212 EUCALYPTUS AVE BLDG 7

LAS VEGAS NV 89121

005 001

05/01/23 04/01/24

POLICY NUMBER:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRIMARY AND NONCONTRIBUTORY

CITY OF SPRINGFIELD

DIVISION OF PURCHASES

218 E CENTRAL ST

SPRINGFIELD MO 65802

ADOT PROCUREMENT GROUP

MAIL DROP 100P

1739 W JACKSON ST STE A

PHOENIX AZ 85007-3218

THE ORANGE COUNTY TRANSPORTATION

AUTHORITY, ITS OFFICERS, DIRECTORS,

EMPLOYEES AND AGENTS

PO BOX 60840

LAS VEGAS NV 89160-0840

CLARK COUNTY SCHOOL DISTRICT

ATTN: PURCHASING DEPARTMENT

4212 EUCALYPTUS AVE BLDG 7

LAS VEGAS NV 89121

006 001

05/01/23 04/01/24

POLICY NUMBER:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

30 DAY NOTICE OF CANCELLATION

CLARK COUNTY SCHOOL DISTRICT

ATTN: PURCHASING DEPARTMENT

4212 EUCALYPTUS AVE BLDG 7

LAS VEGAS NV 89121

THE ORANGE COUNTY TRANSPORTATION

AUTHORITY, ITS OFFICERS, DIRECTORS,

EMPLOYEES AND AGENTS

PO BOX 60840

LAS VEGAS NV 89160-0840

ADOT PROCUREMENT GROUP

MAIL DROP 100P

1739 W JACKSON ST STE A

PHOENIX AZ 85007-3218

CITY OF SPRINGFIELD

DIVISION OF PURCHASES

218 E CENTRAL ST

SPRINGFIELD MO 65802

007 001

05/01/23 04/01/24

POLICY NUMBER:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Endorsement Effective

Countersigned by

Policy No.

Premium $Insured

Insurance Company

Endorsement No.

All other terms and conditions of this policy remain unchanged.

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

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

TO DESIGNATED PERSONS OR ORGANIZATIONS

NOTICE OF CANCELLATION

POLICY NUMBER:

ENDORSEMENT WC 99 06 R3 (00) -

EMPLOYERS LIABILITY POLICY

AND

WORKERS COMPENSATION

Notice Of Cancellation To Designated Persons Or Organizations

Name and Address of Designated Persons or Organizations: Number of Days Notice

The following is added to PART SIX – CONDITIONS :

SCHEDULE

If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organiza-tion before the cancellation is to take effect.

You are responsible for providing us with the information necessary to accurately complete the Schedule below.

If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation.

ONE TOWER SQUARE

UB-9M740535-23-42-G

HARTFORD CT 06183 014

MAIL DROP 100P

1739 W JACKSON ST. SUITE A

PHOENIX AZ 85007

ADOT PROCUREMENT GROUP

Page ofDATE OF ISSUE: ST ASSIGN:

© 2013 The Travelers Indemnity Company. All rights reserved.

04-27-23 11

HIRED AND NON-OWNED AUTO LIABILITY

ADDITIONALLY INSURED

CITY OF SPRINGFIELD

DIVISION OF PURCHASES

218 E CENTRAL ST

SPRINGFIELD MO 65802

ADOT PROCUREMENT GROUP

MAIL DROP 100P

1739 W JACKSON ST STE A

PHOENIX AZ 85007-3218

THE ORANGE COUNTY TRANSPORTATION

AUTHORITY, ITS OFFICERS, DIRECTORS,

EMPLOYEES AND AGENTS

PO BOX 60840

LAS VEGAS NV 89160-0840

CLARK COUNTY SCHOOL DISTRICT

ATTN: PURCHASING DEPARTMENT

4212 EUCALYPTUS AVE BLDG 7

LAS VEGAS NV 89121

008 001

05/01/23 04/01/24

POLICY NUMBER:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CONTRACTUAL LIABILITY

CITY OF SPRINGFIELD

DIVISION OF PURCHASES

218 E CENTRAL ST

SPRINGFIELD MO 65802

009 001

05/01/23 04/01/24

POLICY NUMBER:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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-9M740535-23-42-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:

CITY OF CELINA, TX, ITS OFFICIALS, EMPLOYEES AND OFFICERS

DATE OF ISSUE: PAGEST ASSIGN: OF02-10-23 1 1