CTR066290_135830-E24-G-Ends-N001-11122024-Forms.pdf

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

IL 12 09 08 23

POLICY NUMBER:

© Insurance Services Office, Inc., 2022 Page to IL 12 09 08 23

ARIZONA POLICY CHANGES

Policy Number: Company:

From: 12:01 AM

12:01 AM

Authorized Representative:

Coverage Parts Affected:

Changes

Named Insured's Mailing Address:

Named Insured:

At the named insured's mailing address shown below.

To:

Policy Changes Effective:

Policy Change Number:

47-SPK-265007-01

47-SPK-265007-01

12/27/2024

11/12/2025

Berkshire Hathaway Specialty Insurance Company

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Old Concho Community Assistance Center

PO Box 50 Concho, AZ 85924

Irwin Siegel Agency 25 Lake Louise Marie Road Rock Hill, NY 12775

General Liability

It is hererby understood and agreed that the Schedule of Forms and Endorsements is amended as follows:

ADD; CG 20 26 Additional Insured - Owners, Lessees Or Contractors - Completed Operations with respects to:

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

All other terms and conditions remain unchanged.

© Insurance Services Office, Inc., 2022 IL 12 09 08 23Page to

The above amendments result in a change in the premium as follows:

NO CHANGES TO BE ADJUSTED

AT AUDIT

RETURN PREMIUMADDITIONAL PREMIUM

REMOVAL PERMIT

If this Policy includes the Commercial Property Coverage Part, the following applies with respect to such Coverage Part(s):

If Covered Property is removed to a new location that is described on this Policy Change, you may extend this insurance to include that Covered Property at each location during the removal. Coverage at each location will apply in the proportion that the value at each location bears to the value of all Covered Property being removed.

This permit applies up to 10 days after the effective date of this Policy Change; after that, this insurance does not apply at the previous location.

Countersignature Of Authorized Representative

Date:

Signature:

Title:

Name:

oo

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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

COMMERCIAL GENERAL LIABILITY

CG 20 37 12 19

POLICY NUMBER:

© Insurance Services Office, Inc., 2018 Page of CG 20 37 12 19

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;

whichever is less.

This endorsement shall not increase the applicable limits of insurance.

Location And Description Of Completed Operations

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

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

See Schedule See Schedule

47-SPK-265007-01

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SCHEDULE

© Insurance Services Office, Inc., 2018 CG 20 37 12 19Page of

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

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