CTR063144 Certificate of Insurance.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

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 EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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

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

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

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

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

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

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

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Starr Indemnity & Liability Company

Zurich American Insurance Company

Allied World Assurance Company (U.S.) I

Endurance American Specialty Insurance

Gemini Insurance Insurance Co.

Hallmark Specialty Ins. Co.

11/18/2022

Marsh & McLennan Agency LLC 11330 Lakefield Drive Suite 100 Johns Creek, GA 30097-1508

Vera F Cohan 770-476-1770 770-476-3651

Vera.Cohan@MarshMMA.com

Mansfield Oil Company of Gainesville, Inc.

1025 Airport Parkway, SW Gainesville, GA 30501

38318 16535 19489 41718 10833 26808

A X X

1000090701221 02/01/2022 02/01/2023 1,000,000 1,000,000 10,000 1,000,000 2,000,000 2,000,000

B X

X MCS90

X X

X CA9948

BAP015277702 02/01/2022 02/01/2023 1,000,000

SEE BELOW 02/01/2022 02/01/2023

B

N

WC015277502

(FL,MA,WI)

WC015277602

02/01/2022 02/01/2023 X 1,000,000

1,000,000 1,000,000

C Pollution Liab.- Claims Made

03059391

GVE100229304

12/23/2020 12/23/2023 $10,000,000 Each Inc.

$10,000,000 Aggregate

INSURER G - RSUI Indemnity Co. - NAIC #22314

EXCESS AUTO LIABILITY:

Insurer D - Policy #EXT30003209601 - $1,000,000 xs Primary Insurer E - Policy #GVE100229304 - $5,000,000 xs $1,000,000 Insurer F - Policy #77HX225CD2 - $3,000,000 xs $6,000,000 (See Attached Descriptions)

The State of Arizona or Arizona Department of Transportation 1324 N 22nd Ave M 128A Phoenix, AZ 85009

#S12021994/M9258132

MANSFENERGClient#: 644412

JJKHL

#S12021994/M9258132 e6906

ACCEPTED

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) Insurer D - Policy #EXT30015570400 - $5,000,000 xs $9,000,0000

EXCESS GENERAL LIABILITY:

Insurer A - Policy #1000095554221 - $10,000,000 xs Primary

EXCESS EMPLOYERS LIABILITY:

Insurer D - Policy #EXT30015570400 - $5,000,000 xs Primary Insurer G - Policy #NHA096895 - $5,000,000 xs $5,000,000 (GL) Additional Insured per form OG183 04/12 - Additional Insured - Where Required Under Contract or Agreement (Primary Coverage) (GL) Additional Insured per form CG2037 0413 - Additional Insured Owners, Lessees or Contractors - Completed Operations (GL) Additional Insured Primary & Non-Contributory per form CG2001 0413 Primary and Non-Contributory -Other Insurance Condition (GL) Waiver of Subrogation per form CG2404 0509 - Waiver of Transfer of Rights of Recovery Against Others To Us (Auto) Additional Insured per form CA2048 1013 Designated Insured For Covered Autos Liability Coverage (Auto) Waiver of Subrogation per form CA0444 1013 Waiver of Transfer of Rights of Recovery Against Others to Us (Waiver of Subrogation) (WC) Waiver of Subrogation per form: WC000313 0484 - Waiver of Transfer of Rights of Recovery Against Others To Us Excess Liability Follow Form per forms:

Policy #EXT30003209601 - Form EXL0203 0813 - Excess Liability Coverage Follow Form (Short Form) Policy #GVE100229304 - Form GEMFFXLT 08/2020 - Excess Liability Policy Policy #77HX225CD2 - Form HX0002 0109 - Excess Liability Policy Policy #1000095554221 - Form XS-100 10/08 - Excess Liability Policy Form Policy #EXT30015570400 - Form EXL2003 0813 - Excess Liability Coverage Follow Form (Short Form) Policy #NHA096895 - Form #RSG31001 0507 - Commercial Excess Liability Policy

#S12021994/M9258132

WC 00 03 13

(Ed. 4-84)

1983 National Council on Compensation Insurance.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

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

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

Schedule

ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN

CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE

ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS

POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION

POLICY NUMBER: BAP 0152777-01 COMMERCIAL AUTO

CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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: MANSFIELD ENERGY CORPORATION

Endorsement Effective Date:

SCHEDULE

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

ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO

PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A

PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN

AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR

AGREEMENT IS PROHIBITED BY LAW.

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

CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 2

BAP015277702

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.

CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 2 of 2

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

POLICY NUMBER: BAP 0152777-01 COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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: MANSFIELD ENERGY CORPORATION

Endorsement Effective Date:

SCHEDULE

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

ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN

CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE

ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER

THIS POLICY.

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.

BAP015277702BAP015277702

COMMERCIAL GENERAL LIABILITY

CG 24 04 05 09

POLICY NUMBER: 1000090701221

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

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

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.

Any person or organization to whom you become obligated to waive your rights of recovery against, under any contract or agreement you enter into prior to the occurrence of loss.

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

Name Of Person Or Organization:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 37 04 13

POLICY NUMBER: 1000090701221

© Insurance Services Office, Inc., 2012 Page 1 of 1CG 20 37 04 13

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

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.

Location And Description Of Completed Operations

Where Required By Written Contract

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

Where Required By Written Contract

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

Dallas, TX 1-866-519-2522

OG 183 (04/12) Page 1 of 1 Copyright © C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved.

Includes copyrighted material of ISO Properties, Inc., used with its permission

ADDITIONAL INSURED - WHERE REQUIRED UNDER

CONTRACT OR AGREEMENT

(Primary Coverage)

Policy Number: 1000090701221 Effective Date: 02/01/2022 at 12:01 A.M.

Named Insured: Mansfield Energy Corp This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

SCHEDULE

ADDITIONAL INSURED:

Where Required By Written Contract

SECTION II - WHO IS AN INSURED, 1., is amended to add:

Any person or organization, shown in the schedule above, to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance for that person or organization of the type provided by this policy, but only with respect to liability arising out of your operations or premises owned by or rented to you. However, the insurance provided will not exceed the lesser of:

The coverage and/or limits of this policy, or

The coverage and/or limits required by said contract or agreement.

SECTION IV – COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance a. Primary Insurance, is amended to read:

a. Primary Insurance

This insurance is primary except when b. below applies. If this insurance is primary, our obligations are not affected unless any of the other insurance is also primary, however, where required by contract the additional insured's own insurance will not be deemed primary. Then, we will share with all that other insurance by the method described in c. below.

All other terms, exclusions, and conditions of this policy remain unchanged.

Dallas, TX 1-866-519-2522

OG 183 (04/12) Page 2 of 1 Copyright © C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved.

Includes copyrighted material of ISO Properties, Inc., used with its permission

Signed for STARR INDEMNITY & LIABILITY COMPANY

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 01 04 13

© Insurance Services Office, Inc., 2012 Page 1 of 1CG 20 01 04 13

PRIMARY AND NONCONTRIBUTORY �

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

The following is added to the Other Insurance Condition and supersedes any provision to the contrary:

Primary And Noncontributory Insurance

This insurance is primary to and will not seek contribution from any other insurance available to 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.

Policy No. 1000090701221

Mansfield Oil Endorsements