CTR066209_WestCare_Foundation_-_State_of_Arizona_COI.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

Scottsdale Insurance Company

Berkshire Hathaway Homestate Ins. Co.

Endurance American Specialty Ins Co

MSIG Specialty Insurance USA, Inc.

National Liability & Fire Insurance Co.

8/06/2025

USI Insurance Services, LLC 1120 N Town Center Drive Suite 240 Las Vegas, NV 89144

Rachel Forney

Rachel.Forney@usi.com

WestCare Foundation Inc P.O. Box 94738 Las Vegas, NV 89193-4738

41297 20044 41718 34886 20052

A X

X

X X OPS1586865 07/01/2025 07/01/2026 1,000,000

300,000 5,000 1,000,000 3,000,000 3,000,000

1,000,000HNOA

E

X

X X 73APB011956 07/01/2025 03/01/2026 1,000,000

A X X

XLS1229407 07/01/2025 07/01/2026 1,000,000

1,000,000

B

N

X WEWC621460 03/01/2025 03/01/2026 X

1,000,000

1,000,000 1,000,000

A C D

Prof. Liability Excess Auto Excess Liability

X X OPS1586865

EXT30091931200

PPA0000092

07/01/2025 07/01/2025 07/01/2025

07/01/2026 03/01/2026 07/01/2026

$1M Occur./ $3M Agg.

$1M Occur./ $1M Agg.

$2M Occur./ $2M Agg.

Additional Named Insureds Include (As it Relates to Liability Coverages):

Westcare Foundation, Inc.

WestCare Arizona I, Inc.

WestCare Gulf Coast - Florida, Inc.

WestCare Florida, Inc.

(See Attached Descriptions)

The State of Arizona, Department of Economic Security C/O: myCOI P.O. Box# 501970, 8710 Bash Street Indianapolis, IN 46256-0000

#S50387179/M50304382

WESTCFOUClient#: 1813669

DXLJD

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) The Village South, Inc.

Guidance/ Care Center, Inc.

WestCare Georgia, Inc.

WestCare Kentucky, Inc.

WestCare Illinois, Inc.

WestCare Nevada, Inc.

FitzHouse Enterprises, Inc. f/k/a Westcare Works, Inc.

Westcare Works, Inc.

WestCare North Carolina, Inc.

WestCare Wisconsin, Inc.

The Family Agencies for Veterans of America, Inc.

WestCare Oregon, Inc.

WestCare Texas, Inc.

WestCare Tennessee, Inc.

WestCare California, Inc.

Guara BI, Inc.

WestCare Washington, Inc.

WestCare Endowment, Inc.

WestCare Iowa, Inc.

WestCare Minnesota, Inc.

WestCare Pacific Islands, Inc.

WestCare Wyoming, Inc.

The Village - Virgin Islands Partner in Recovery, Inc.

The Village South, Inc. Profit Sharing Plan WestCare West Virginia, Inc.

WestCare Ohio, Inc.

WestCare Foundation, Inc. Retirement Plan WestCare Maryland Inc.

OMF Coummuity Ouchreach The Village South Institute of Human Resources, Inc.

The Village Foundation, Inc.

The Guidance Clinic of The Middle Keys, Inc.

The Care Center for Mental Health, Inc.

WestCare Puerto Rico, Inc.

Family Alliance for Veterans of America, Inc.

WestCare Endowment, Inc.

Operation Military Family

The General Liability and Professional Liability policies include an automatic Additional Insured endorsement that provides Additional Insured status to the Certificate Holder only when there is a written contract that requires such status, and only with regard to work performed on behalf of the named insured.

The General Liability and Professional Liability policies contains a special endorsement with "Primary and Noncontributory" wording, when required by written contract. The General Liability, Professional Liability and Workers Compensation policies provide a Waiver of Subrogation when required by written contract.

Additional Coverages:

Coverage: Abuse and Molestation INSURER AFFORDING COVERAGE: Scottsdale Insurance Company

POLICY NUMBER: OPS1586865 EFF DATE: 07/01/2025 EXP DATE: 07/01/2026

LIMIT AMOUNT:

Per Occurrence $1,000,000 Aggregate $3,000,000

Coverage: Hired Auto/NonOwned Auto Liability - Coverage is for liability only--not physical damage to the vehicle.

EFF DATE: 07/01/2025 EXP DATE: 07/01/2026

INSURER AFFORDING COVERAGE: Scottsdale Insurance Company

#S50387179/M50304382

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) Claims made with a retroactive date of 7/1/2025 Nonowned Auto Liability Sublimit-$1,000,000 each occurrence /$1,000,000 aggregate, Hired Auto Liability Sublimit-$1,000,000 each occurrence /$1,000,000 aggregate, $50,00 deductible - each and every claim

Coverage: Management Liability INSURER AFFORDING COVERAGE: Federal Insurance Company

POLICY NUMBER: J06324733 EFF DATE: 07/01/2025 EXP DATE: 07/01/2026

LIMIT AMOUNT:

Aggregate $6,000,000 Retro: 9/21/2007 Division Name: ADES. Contract ID: CTR066209

#S50387179/M50304382

Underwritten by Scottsdale Insurance Company ENDORSEMENT

NO.

ATTACHED TO AND

FORMING A PART OF

POLICY NUMBER

ENDORSEMENT EFFECTIVE

DATE

(12:01 A.M. STANDARD TIME)

NAMED INSURED AGENT NO.

Negley Associates

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED—AUTOMATIC STATUS WHEN REQUIRED BY A

CONTRACT OR AGREEMENT EXTENSION

This endorsement modifies insurance provided under the following:

PROFESSIONAL LIABILITY COVERAGE PART

For the purposes of this endorsement the coverage part is amended as follows:

A. The following is added to SECTION III—WHO IS AN INSURED:

Any person(s) or organization(s) to whom you become contractually required to include as an insured, as specifically required in a written contract or agreement executed prior to loss, only with respect to vicarious liability as specified in the written contract or agreement with the Named Insured.

However, the insurance afforded to such additional insured only applies to the extent permitted by law and will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

Coverage does not apply for any additional insured under this policy unless the liability of such additional insured arises from acts or omissions of the Named Insured while the Named Insured is performing services directly for such additional insured.

This insurance does not apply to the sole acts, errors or omissions of the additional insured.

B. Vicarious liability coverage for the additional insured listed in this endorsement will apply only when a CLAIM or SUIT for DAMAGES resulting from a WRONGFUL ACT is also made and continuously maintained against the Named Insured for the Named Insured’s negligence.

C. With respect to the insurance afforded to additional insureds under this endorsement, the following is added to SECTION IV—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 you have entered into with the additional insured; or

2. Available under the applicable Limits of Insurance shown in the Professional Liability Coverage Part Supplemental Declarations whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Professional Liability Coverage Part Supplemental Declarations.

CLS-596-PROCM (09-24) Page 1 of 2 rachel.forney Typewritten text WestCare Foundation Inc rachel.forney Typewritten text 07/01/2025 rachel.forney Typewritten text

OPS1586865

D. With respect to the insurance afforded to the additional insureds under this endorsement, the following Conditions apply only when required by contract or agreement:

1. Cancellation Notification Condition:

If this policy is cancelled, we will endeavor to give written notice of such cancellation to the person(s) or organization(s) provided additional insured status under this endorsement at least thirty (30) days before the effective date of cancellation. If the contract or agreement you have entered into with the additional insured requires a shorter notification period, we will endeavor to give written notice in the time required by such agreement. Such notice may be provided before or after the effective date of cancellation. The notice will state the effective date of cancellation.

However, such notice of cancellation is solely for the purpose of informing person(s) or organization(s) provided additional insured status, of the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy.

Failure to give notice in accordance with the terms of this endorsement does not:

a. Alter the effective date of policy cancellation;

b. Render such cancellation ineffective;

c. Grant, alter, or extend any rights or obligations under this policy; or

d. Extend the insurance beyond the effective date of cancellation.

2. Primary Noncontributory Condition:

Coverage provided by this endorsement is amended to be afforded to the person(s) or organization(s) provided additional insured status under this endorsement on a primary, noncontributory or primary and noncontributory basis when and as agreed to in writing in a contract or agreement between you and such person(s) or organization(s).

3. Waiver of Transfer of Rights of Recovery Against Others to Us:

We waive any right of recovery we may have against the person(s) or organization(s) provided additional insured status under this endorsement because of payments we make for injury or damage arising out of your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your ongoing operations for the additional insured. This waiver applies only to the person(s) or organization(s) provided additional insured status under this endorsement.

All other terms and conditions of this policy remain unchanged.

CLS-596-PROCM (09-24)

Underwritten by Scottsdale Insurance Company ENDORSEMENT

NO.

ATTACHED TO AND

FORMING A PART OF

POLICY NUMBER

ENDORSEMENT EFFECTIVE

DATE

(12:01 A.M. STANDARD TIME)

NAMED INSURED AGENT NO.

Negley Associates

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED EXTENSIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

The following Additional Insured Extensions only apply in the event that no other specific coverage for the indicated loss exposure is provided under this policy. If such specific coverage applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this policy, unless otherwise noted in this endorsement.

A. Additional Insured—Managers, Landlords, or Lessors of Premises

1. SECTION II—WHO IS AN INSURED is amended to include as an additional insured the following:

Any person or organization, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or caused in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf and in connection with the ownership, maintenance or use of that part of the premises leased to you.

However:

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

and

b. 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.

2. This insurance does not apply to:

a. Any “occurrence” which takes place after you cease to be a tenant in that premises.

b. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization.

3. Coverage does not apply for any additional insured under this policy unless the liability of such additional insured arises from acts or omissions of the Named Insured while the Named Insured is performing services directly for such additional insured.

This insurance does not apply to the sole acts, errors or omissions of the additional insured.

B. Additional Insured—Lessor of Leased Equipment (Automatic Status When Required in Lease Agreement With You)

CLS-585-CGL (09-24) Page 1 of 4 rachel.forney Typewritten text WestCare Foundation Inc rachel.forney Typewritten text 07/01/2025 rachel.forney Typewritten text

OPS1586865

1. SECTION II—WHO IS AN INSURED is amended to include as an additional insured the following:

Any person(s) or organization(s) from whom you lease equipment when you and such person(s) or organization(s) have agreed in writing in a contract or agreement that such person(s) or organization(s) is to be added as an additional insured on your policy. Such person(s) or organization(s) is an insured only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or organization(s).

However:

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

and

b. 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.

2. A person’s or organization’s status as an additional insured under this endorsement ends when their contract or agreement with you for such leased equipment ends.

With respect to the insurance afforded to these additional insureds, this insurance does not apply to any “occurrence” which takes place after the equipment lease expires.

C. Additional Insured—Mortgagee, Assignee, or Receiver

1. SECTION II—WHO IS AN INSURED is amended to include as an additional insured:

Any person(s) or organization(s) with whom you are contractually required to include as an additional insured only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or caused in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of the premises by you.

However:

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

and

b. 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.

2. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization

3. There is not coverage for the person(s) or organization(s) for its sole acts or omissions.

D. Additional Insured—Automatic Status

1. SECTION II—WHO IS AN INSURED is amended to include as an additional insured:

Any person(s) or organization(s) to whom you become contractually required to include as an additional insured, as specifically required in a written contract or agreement executed prior to loss, only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or caused in whole or in part by your acts or omissions or the acts or omissions of those acting on your behalf with respect to their liability as specified in the written contract or agreement with the Named Insured:

a. In the performance of your ongoing operations; or

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

CLS-585-CGL (09-24) Page 2 of 4

However, the insurance afforded to such additional insured:

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

b. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

2. There is no coverage for the person(s) or organization(s) as an additional insured for its sole acts or omissions unless it is the acts or omissions of the Named Insured and such acts or omissions arise directly from the Named Insured’s activities performed for the additional insured.

3. This insurance does not apply to the sole acts, errors or omissions of the additional insured.

E. Coverage for the additional insureds listed in this endorsement will apply only when a claim or “suit” for “bodily injury,” or “property damage” or “personal and advertising injury” is also made and continuously maintained against the Named Insured for the Named Insured’s acts or omissions or the acts or omissions of those acting on behalf of the Named Insured which give rise to the liability of the additional insured.

F. With respect to the insurance afforded to additional insureds under this endorsement, the following is added to SECTION Ill—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 you have entered into with the additional insured; or

2. Available under the applicable Limits of Insurance shown in the Commercial General Liability Coverage Part Supplemental Declarations whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Commercial General Liability Coverage Part Supplemental Declarations.

G. With respect to the insurance afforded to additional insureds under this endorsement, the following Conditions apply only when required by contract or agreement:

1. Cancellation Notification Condition:

If this policy is cancelled, we will endeavor to give written notice of such cancellation to the person(s) or organization(s) provided additional insured status under this endorsement at least thirty (30) days before the effective date of cancellation. If the contract or agreement you have entered into with the additional insured requires a shorter notification period, we will endeavor to give written notice in the time required by such agreement. Such notice may be provided before or after the effective date of cancellation. The notice will state the effective date of cancellation. However, such notice of cancellation is solely for the purpose of informing person(s) or organization(s) provided additional insured status, of the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy.

Failure to give notice in accordance with the terms of this endorsement does not:

a. Alter the effective date of policy cancellation;

b. Render such cancellation ineffective;

c. Grant, alter, or extend any rights or obligations under this policy; or

d. Extend the insurance beyond the effective date of cancellation.

CLS-585-CGL (09-24) Page 3 of 4

2. Primary Noncontributory Condition:

Coverage provided by this endorsement is amended to be afforded to the person(s) or organization(s) provided additional insured status under this endorsement on a primary, noncontributory or primary and noncontributory basis when and as agreed to in writing in a contract or agreement between you and such person(s) or organization(s).

3. Waiver of Transfer of Rights of Recovery Against Others to Us:

We waive any right of recovery we may have against the person(s) or organization(s) provided additional insured status under this endorsement because of payments we make for injury or damage arising out of your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your ongoing operations for the additional insured. This waiver applies only to the person(s) or organization(s) provided additional insured status under this endorsement.

All other terms and conditions of this policy remain unchanged.

CLS-585-CGL (09-24) Page 4 of 4

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All AL Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

Premium $

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All AR Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All AZ Operations 162.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All CO Operations 2.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All DE Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All FL Operations 5,677.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All GA Operations 760.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All HI Operations 2.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All IA Operations 70.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All ID Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All IL Operations 1,004.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All IN Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All KS Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All LA Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All MD Operations 171.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All MI Operations 1.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All MN Operations 19.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All MO Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All NC Operations 6.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All NV Operations 1,371.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All NY Operations 2.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All OK Operations 0.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

Waiver PremiumJob Description

All OR Operations 264.00

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

© 1983 National Council on Compensation Insurance

(Ed. 4-84)

Countersigned by ____________________________________WC 00 03 13

Insurance Company: Berkshire Hathaway Homestate Ins Co

Insured:

Endorsement No.: Policy No.: WEWC621460Endorsement Effective: 03/01/2025

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

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

Blanket Waiver

Person/Organization: Blanket Waiver -…