CTR056092_-_COI_and_Endorsements.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

PRODUCER CONTACT

NAME:

FAXPHONE

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

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

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

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

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

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT

OTHER: $

COMBINED SINGLE LIMIT

$(Ea accident)

ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED

BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE

$AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE

CLAIMS-MADE AGGREGATE $

DED RETENTION $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N N / A

(Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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

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

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

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

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

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

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

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

The ACORD name and logo are registered marks of ACORD

11/14/2023

(480) 305-8218 (480) 924-1211

18058

Graham County Rehabilitation Center Inc PO Box 870 Safford, AZ 85548

13210

A 1,000,000

X X PHPK2516867 2/6/2023 2/6/2024 100,000

5,000

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

SEXUAL ABUSE OR 1,000,000

1,000,000A

X X PHPK2516867 2/6/2023 2/6/2024

4,000,000A

PHUB850867 2/6/2023 2/6/2024

10,000 4,000,000 B

X 1009754 1/1/2023 1/1/2024 1,000,000 Y 1,000,000

1,000,000 A Abuse PHPK2516867 2/6/2023 Includes Molestation 1,000,000 A Prof Liab Agrr PHPK2516867 2/6/2023 2/6/2024 1,000,000 Ea Claim 2,000,000

RE: Division Name : ADES. - Contract ID: CTR0506092 The State of Arizona and Dept. of Economic Security and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees, are named as Additional Insured with respect to liability arising out of the activities performed by or on behalf of the Qualified Vendor. Auto Liability: The State of Arizona, the Dept of Economic Security and the SEAGO AAA shall be named as Additional Insureds with respect to liability arising out of activities performed by or on behalf of the contractor, including those involving auto owned, leased, hired or borrowed. Professional Liability falls under the Umbrella coverage to meet the required Each Claim $2,000,000 limit Coverage and is on a claims made basis with 4/22/1994 retro date. 30 Days Notice of Cancellation. Officers excluded from WC coverage are as follows: John O'Smith, Shari Elkins, Don Smith, David Bell, Marion Hastings who all visit the job site.

Subject to policy terms, conditions, limitations and exclusions.

The State of Arizona and Dept of Economic Security C/O myCOI 1075 Broad Ripple Ave, Suite 313 Indianapolis, IN 46220

GRAHCOU-03 MIRTI1

Southwest Risk Management, LLC 4801 E McKellips Mesa, AZ 85215

Tina Miranda tmiranda@southwestrisk.com

Philadelphia Indemnity Insurance Company CopperPoint Casualty Insurance Co

X

2/6/2024

X X

X

X

X

X

X

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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

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

01/01/2023Endorsement Effective 1009754Policy No. 15Endorsement No.

Graham County Rehabilitation Center IncInsured 100 Premium $

MountainPoint Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

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

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us).

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule State Blanket/Schedule/State

AZ STATE

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 26 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page of

ADDITIONAL INSURED – DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

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

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

1. In the performance of your ongoing operations;

or

2. In connection with your premises owned by or rented to you.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of

Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

PHPK

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

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent

3 3

CG 24 04 05 09

CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

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

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

PHPK

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

POLICY NUMBER: COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

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

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

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

PHPK

02/06/202

Graham County Rehabilitation Center

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

1 1

POLICY NUMBER: COMMERCIAL AUTO

CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

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

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

Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II – Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I – Covered Autos Coverages of the Auto Dealers Coverage Form.

PHPK

02/06/202

Graham County Rehabilitation Center

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

The following is added as additional insured CA2048 and CA0444-Waiver of

Subrogation:

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

Addl Insured-The State of Arizona

PI-HS-004D (07/04)

Includes copyright material of the Insurance Services Office, Inc. used with its permission.

PHILADELPHIA INDEMNITY INSURANCE COMPANY

HUMAN SERVICES ORGANIZATION PROFESSIONAL LIABILITY COVERAGE PART

DECLARATIONS

CLAIMS MADE COVERAGE

POLICY NO. Effective date:

12:01 A.M. Standard Time

LIMITS OF INSURANCE

AGGREGATE LIMIT $

EACH PROFESSIONAL INCIDENT LIMIT $

RETROACTIVE DATE

This Insurance Does Not Apply to “Damages” Resulting from a “Professional Incident” Which Occurred Before the Retroactive Date, If Any, Shown Here

(Enter Date or “None” if No Retroactive Date Applies)

BUSINESS DESCRIPTION

Form of Business:

Business Description:

PREMIUM:

FORMS AND ENDORSEMENTS (Other than Applicable Forms and Endorsements Shown Elsewhere in the Policy)

Forms and Endorsements Applying to this Coverage Part and Made Part of this Policy at Time of Issue:

THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.

Includes Copyrighted Material of the Insurance Service Office, Inc Used with its Permission.

PHPK2516867

CORPORATION

Non Profit Organization

02/06/2023

$ 12,340.00

04/22/1994

1,000,000

2,000,000

POLICY CHANGE DOCUMENT

POLICY NO.:

CHANGE EFFECTIVE CHANGE # REVISION #

DESCRIPTION

PHPK2516867

209/13/2023

10/09/2023____________________ Issue Date

Amended:

Additional Insured -The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent and employees [as additional insureds] with respect to liability arising out of activities performed by or on behalf of the Contractor 1789 W Jackson St, Mail Drop 1222, Phoenix, AZ 85007

The following forms have been applied:

PI-CANXAICH 002 - 30 DAYS Notice of Cancellation CG 20 37 - Additional Insured - Owners, Lessees or Contractors - Completed operations PI GL 005 - Primary Non Contributory

Philadelphia Indemnity Insurance Company

NAMED INSURED

25816 Southwest Risk Management, LLC

Graham County Rehabilitation Center

MAILING ADDRESS PO Box 870 Safford, AZ 85548-0870

POLICY PERIOD: FROM TO at 12:01 A.M. Standard Time at your mailing address shown above.

Path ID 16942343

0.00

NO CHANGE

COUNTERSIGNED BY

(Date) (Authorized Representative)

02/06/2023 02/06/2024

In consideration of the premium reflected, the policy is amended as indicated below:

Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $

Total Prorate

NO CHANGE

Insurance Policy

PI-AI-SCH (08/20)

Page of

Additional Insured Schedule

Policy Number:

Philadelphia Indemnity Insurance Company

Div of Developmental Disabilities

Additional Insured

1789 W Jefferson St Site code 791A

B&M Carl Williams Inc, an Arizona, Phoenix, AZ 85007-3202

Phoenix, AZ 85007-3202

Commercial Automobile of Arizona 5875 Castle Creek Parkway, Suite 400

Additional Insured

Indianapolis, IN 46250

AZ Dept of Economic Security

Commercial Automobile

Limited Liability Company 2111 W 1st St

CG2026 - General Liability

Knowledge Services & The State

Thatcher, AZ 85552

Additional Insured

CG2018 - AZ - Loc #2

Kenneth Stroud and Nina Stroud

Additional Insured

2204 N Maple Ave Huachuca City, AZ 85616-8119

AZ Dept of Economic Security Div of Developmental Disabilities

AZ - Loc #5

1789 W Jefferson St Site code 791A

Additional Insured

1 3

Page of and employees [as additional insureds] with respect to liability arising out of

Additional Insured activities performed by or on behalf of the Contractor 1789 W Jackson St

Knowledge Services & The State

Mail Drop 1222

CG2018 - AZ - Loc #6

Additional Insured

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent of Arizona

Phoenix, AZ 85007-3218

5875 Castle Creek Parkway, Suite 400 Indianapolis, IN 46250

CG2026 - General Liability

CG2026 - General Liability

CG2037 - General Liability

Additional Insured

Christopher Cleland 123 Main St Stafford, AZ 85546

2 3

Page of

Additional Insured

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent and employees [as additional insureds] with respect to liability arising out of activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor 1789 W Jackson St Mail Drop 1222 Phoenix, AZ 85007-3218

CA2048 - AZ - Veh #0 - MANUSCRIPT ENDORSEMENT - AUTO

3 3

PI-CANXAICH-002 (05/11)

Page of

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION NOTICE TO SCHEDULED ADDITIONAL INSURED OR

CERTIFICATE HOLDER

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PROFESSIONAL LIABILITY COVERAGE PART

COMMERCIAL CRIME COVERAGE PART

COMMERCIAL INLAND MARINE COVERAGE PART

COMMERCIAL PROPERTY COVERAGE PART

COMMERCIAL AUTOMOBILE COVERAGE PART

SCHEDULE OF ADDITIONAL INSUREDS OR CERTIFICATE HOLDERS

AI or CH Additional Insured or Certificate Holder Address

The following is added to A. CANCELLATION of the Common Policy Conditions of the above applicable coverage part:

A. In the event we cancel the policy in accordance with the policy’s terms and conditions, we will endeavor to mail written notice of cancellation to Additional Insureds or Certificate Holders, shown in the above SCHEDULE within the time frame listed below. However, failure to mail such notice shall impose no obligation of any kind upon us, our agents or representatives.

1. days before the effective date of cancellation if we cancel for any reason other than for non - payment of premium.

As respects Additional Insureds, the above cancellation provision applies only when the Additional Insured shown in the above SCHEDULE is added to the policy by a separate additional insured endorsement as the CANCELLATION NOTICE TO ADDITIONAL INSURED OR CERTIFICATE HOLDER does not provide additional insured coverage.

AI The State of Arizona 1789 W Jackson St, Mail Drop See schedule for full name 1222, Phoenix, AZ 85007

CG 20 37 04 13

CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page of

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – COMPLETED OPERATIONS

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

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

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

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

PHPK2516867

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent

PI-GL-005 (07/12)

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

ADDITIONAL INSURED

PRIMARY AND NON-CONTRIBUTORY INSURANCE

SCHEDULE

Effective Date:

Name of Person or Organization (Additional Insured):

SECTION II – WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or relating to your negligence in the performance of “your work” for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule.

This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization.

This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or ”occurrence” we cover for this Additional Insured.

The Additional Insured’s limits of insurance do not increase our limits of insurance, as described in

SECTION III – LIMITS OF INSURANCE.

All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged.

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent and employees [as additional insureds] with respect to liability arising out of activities performed by or on behalf of the Contractor 1789 W Jackson St, Mail Drop 1222, Phoenix, AZ 85007

09/13/2023

POLICY CHANGE DOCUMENT

POLICY NO.:

CHANGE EFFECTIVE CHANGE # REVISION #

DESCRIPTION

410/12/2023

11/08/2023____________________ Issue Date

Adding PI-CA-023 Primary and NonContributory - Other Ins Condition in favor of the following:

The State of Arizona and Dept of Economic Security C/O: my COI 1075 Broad Ripple Ave., Suite 313 Indianapolis, IN 46220

Philadelphia Indemnity Insurance Company

NAMED INSURED

25816 Southwest Risk Management, LLC

Graham County Rehabilitation Center

MAILING ADDRESS PO Box 870 Safford, AZ 85548-0870

POLICY PERIOD: FROM TO at 12:01 A.M. Standard Time at your mailing address shown above.

Path ID 17042129

COUNTERSIGNED BY

(Date) (Authorized Representative)

02/06/2023 02/06/2024

In consideration of the premium reflected, the policy is amended as indicated below:

0.00

NO CHANGE

Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $

Total Prorate

NO CHANGE

Insurance Policy

PI-CA-023 (07/19)

PI-CA-023 (07/19)

Includes copyrighted material of Insurance Services Office, Inc., with permission.

PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE

CONDITION

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

GARAGE COVERAGE FORM

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

A. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and supersedes any provision to the contrary:

This Coverage Form’s Covered Autos Liability Coverage is primary to and will not seek contribution from any other insurance available to an “insured” under your policy provided that:

1. Such “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 such “insured”.

B. The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and the Garage Coverage Form and supersedes any provision to the contrary:

This Coverage Form’s Covered Autos Liability Coverage and General Liability Coverages are primary to and will not seek contribution from any other insurance available to an “insured” under your policy provided that:

1. Such “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 such “insured”.