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ALTERNATE EMPLOYER ENDORSEMENT This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be canceled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Schedule 1. Alternate Employer Address If Any 2. State of Special or Temporary Employment If Any 3. Contract or Project Issued by Liberty Mutual Fire Insurance Company 16586 For attachment to Policy No. WA2-66D-067200-499 Effective Date Premium $ Issued to Cosco Fire Protection, Inc. WC 00 03 01 A © 1984, 1988 National Council on Compensation Insurance. Page 1 of 1 Ed. 02/01/1989 | 2 |
XL XL CATLIN Regulatory Office 505 Eagleview Blvd., Suite 100 Dept: Regulatory Exton, PA 19341-1120 Telephone: 800-688-1840 COMMERCIAL LINES POLICY COMMON POLICY DECLARATIONS NOTICE: THIS POLICY IS ISSUED BY AN INSURER NOT AUTHORIZED TO DO BUSINESS IN KANSAS AND, AS SUCH, THE FORM, FINANCIAL CONDITION AND RATES ARE NOT SUBJECT TO REVIEW BY THE COMMISSIONER OF INSURANCE AND THE INSURED IS NOT PROTECTED BY ANY GUARANTY FUND. COMPANY PROVIDING COVERAGE: Indian Harbor Insurance Company POLICY NO.: ESG004140005 RENEWAL OF: ESG004140004 Named Insured: INTERNET RETAIL HOLDING COMPANY Address: 5370 W 95TH STREET City/State/Zip: PRAIRIE VILLAGE KS 66207 Policy Period: From: July 1, 2018 To: July 1, 2019 at 12:01 A.M., Standard Time at your mailing address shown above. Business Description: INTERNET RETAILER IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Property Coverage Part $ Commercial General Liability Coverage Part $ 25,000.00 Commercial Crime Coverage Part $ Commercial Inland Marine Coverage Part $ Commercial Automobile Coverage Part $ Boiler and Machinery Coverage Part $ Taxes/Surcharges $ 0.00 Inspection Fee $ 500.00 Policy Premium: $ 25,000.00 Premium For Certified Acts of Terrorism: $ Excluded Policy Fee: $600.00 Premium For Non-Certified Acts of Terrorism: $ Excluded Agent to File Taxes ESLCPD2 0915 © 2015 X.L. America, Inc. All Rights Reserved. Page 1 of 2 May not be copied without permission. | 2 |
United Educators Item 7. Applicable Initial Endorsements: Excess General Liability attached Endorsements Endorsement Total Description GLX512A 1 GLX - Employee Benefits Liability (Claims-Made) GLX643L 1 Amended Limit of Liability (Annual Aggregate and Defense Outside Limit of Liability) GLX692G 1 GLX - Policy Correction Endorsement GLX817L 1 GLX - Amended Definition of Occurrence (Occurrence Coverage with Aggregate) GLX818G 1 GLX - Amended Renewal Provisions GLX822N 1 GLX- UE Change of Address GLX909C 1 GLX - Limited UAV Coverage GLX910C 1 Seamless Coverage Endorsement ( GLX - UE CGL/BLX Underlying) Item 8. Applicable Forms and Initial Schedules: Form: GLX 06-2008 Schedule(s): GLX - Schedule A GLXDEC Version Date: 06/01/2008 Excess General Liability Print Date: 11/01/2018 Page 3 of 4 | 0 |
AAIS This endorsement changes CU 0733 09 10 the policy Page 1 of 1 -- PLEASE READ THIS CAREFULLY -- EXCLUSION -- ATHLETIC OR SPORTS PARTICIPANTS COVERAGES E AND U The Commercial Excess/Umbrella Liability Coverage is amended as follows. All other "terms" of the policy apply, except as amended by this endorsement. COMMERCIAL EXCESS/UMBRELLA LIABILITY COVERAGES The following exclusion is added under Coverage E and Coverage U, item 2. Exclusions: "We" do not pay for "bodily injury" to any person participating in or practicing for any athletic or sports activity that "you" sponsor. CU 0733 09 10 Copyright, American Association of Insurance Services, Inc., 2010 | 2 |
ANNUAL MEETING NOTICE Your policy includes a statement regarding membership rights in the Liberty Mutual Holding Company Inc. Liberty Mutual Fire Insurance Company is a Massachusetts stock insurance company subsidiary of the Liberty Mutual Holding Company Inc., a Massachusetts mutual holding company. Insurance is provided by Liberty Mutual Fire Insurance Company. The named insured first named in the Information Page is a member of Liberty Mutual Holding Company Inc. As a member of Liberty Mutual Holding Company Inc., the named insured first named is entitled, among other things, to vote either in person or by proxy at the annual meeting or special meetings of said company. The Annual Meeting of Liberty Mutual Holding Company Inc. is at its offices located at 175 Berkeley Street, Boston, Massachusetts, on the second Wednesday in April each year at ten o'clock in the morning. Members of Liberty Mutual Holding Company Inc. may request a copy of the company's annual financial statements, which are posted on Liberty Mutual's website at www.libertymutual.com or by writing to Liberty Mutual Holding Company Inc., 175 Berkeley Street, Boston, Massachusetts, 02116, Attention: Corporate Secretary. CNI 90 02 07 11 V2.0 © 2011, Liberty Mutual Group. All Rights Reserved. Page 1 of 1 | 2 |
AIG SPECIALTY INSURANCE COMPANY (A Capital Stock Company, herein called the Company) 175 WATER STREET NEW YORK, NY 10038 COMMERCIAL EXCESS FOLLOW FORM DECLARATIONS POLICY NUMBER: PROU 1920977 RENEWAL OF: 1920977 Item 1. NAMED INSURED: TERRACON CONSULTANTS, INC ADDRESS: 18001 W. 106TH STREET, SUITE 300 OLATHE, KS 66061 PRODUCER: PRODUCER NO: 0000036877 LOCKTON COMPANIES LLC 444 W. 47TH STREET SUITE 900 KANSAS CITY, MO 64112 Item 2. POLICY PERIOD: FROM: January 1, 2015 TO: January 1, 2016 at 12:01 A.M. Standard Time at the address of the Named Insured shown above. Item 3. LIMITS OF INSURANCE: (a) Each Occurrence, Offense or Loss $10,000,000 (b) Aggregate Limits - Separately as respects: (i) Products Hazard and Completed Operations Hazard Combined $10,000,000 (ii) All other Coverages Combined other than CrisisResponse Costs or $10,000,000 Crisis Management Loss (Except Automobile Liability, which is not subject to aggregate limit) (c) CrisisResponse® Limit of Insurance $250,000 (d) Crisis Management Limit of Insurance $ 50,000 Item 4. POLICY PREMIUM: $538,803.00 Premium for Certified Acts of Terrorism Coverage Under Terrorism Risk Insurance Act 2002: Not Applicable 1201 AUTHORIZED REPRESENTATIVE or countersignature (in states where applicable) NOTICE: THIS INSURER IS NOT LICENSED IN THE STATE OF NEW YORK AND IS NOT SUBJECT TO ITS SUPERVISION 105613 (11/13) Copyright 2010, American International Group, Inc. PAGE 1 OF 1 CI5369 | 2 |
CHUBE U.S. FOREIGN ACCOUNT TAX COMPLIANCE ACT ("FATCA") The U.S. Foreign Account Tax Compliance Act, commonly known as "FATCA", became the law in the U.S. in March of 2010 and becomes effective July 1, 2014. Pursuant to FATCA, brokers, producers, agents and/or clients may need to obtain withholding certificates from insurance companies. For information on how to obtain the applicable withholding certificate from Chubb U.S. insurance companies, please go to the following web site: tp://www2.chubb.com/us-en/u-s-foreign-account-tax-compliance-act-fatca.asp WC 99 99 29A (07/16) | 2 |
POLICY NUMBER: 37 UEA AA2667 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PREMIUM COMPUTATION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART (1) The Advance Premium set forth in Item 2. of the Declarations is adjustable, and is only an estimated premium for the Audit Period set forth in Item 1. of the Declarations. The final earned premium for the Audit Period shall be determined as specified in paragraph b. of the Premium Audit Condition (Section IV). The Audit Premium referred to in such paragraph b. shall be computed by applying the Rate of $4.5856 per $1,000 of the Premium Base identified in (2) below. Such Rate is net of any taxes, licenses, or fees. (2) The Premium Base shall be identified in (A) and (B) below: (A) PREMIUM BASE: Gross "Sales," excluding "aircraft products;" "intercompany sales;" and "foreign sales." "Payroll," as determined immediately below: Gross Unmodified "Payroll" "Workers Compensation Payroll" "Workers Compensation Payroll" excluding: (1) "Clerical Office Employees;" (2) "Salesmen, Collectors, Messengers;" (3) Drivers and their helpers if principal duties are to work on or in connection with "autos." Other: (Describe) THE ABOVE RATE OF $4.5856 APPLIES PER $1, 000 OF WORKERS COMPENSATION PAYROLL LESS CLERICAL, SALES AND DRIVERS A SEPARATE RATE OF $0.70 APPLIES PER $1,000 OF SUBCONTRACTED COST (B) SPECIFIC DELETIONS FROM PREMIUM BASE, IF ANY: Designated Products described in the following endorsements: Designated Operations described in the following endorsements: Other, described in the following endorsements: Form HS 99 06 06 05 Page 1 of 2 (c) 2005, The Hartford | 2 |
SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: HARTFORD CASUALTY INSURANCE COMPANY Company Code: 3 Policy Number: 37 WE BP6053 Schedule Number: 01-37-01 Effective Date: 01/01/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: TRG CUSTOMER SOLUTIONS INC 2701 RENAISSANCE BLVD KING OF PRUSSIA PA 19406 NAICS: 541618 FEIN: 721583550 UIN: SIC: 8748 NO. OF EMPL: 0 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 951 IF ANY .89 SALESPERSONS - OUTSIDE Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 01/16/14 Policy Expiration Date: 01/01/15 | 1 |
ENDORSEMENT # This endorsement, effective 12:01 a.m., December 30, 2018 forms a part of Policy No. US00088723LI18A issued to Polarville Cold Storage, LLC dba Coldco Logistics by XL Specialty Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ILLINOIS CHANGES This endorsement modifies insurance provided under the following: COMMERCIAL EXCESS FOLLOW FORM AND UMBRELLA LIABILITY POLICY I. Section I. Insuring Agreements, (C) Insuring Agreement C - Disaster Response Coverage Item (3) is deleted and replaced with the following: (3) If we and the insured disagree on whether a disaster event has occurred, the insured's right of reimbursement under Insuring Agreement C shall be arbitrated pursuant to the rules of the American Arbitration Association for the state shown in Declarations Item 1. This arbitration will take place only if both you and we agree, voluntarily, for the arbitration. II. Exclusion (12) Pollution under Section V. Exclusions, (C) Exclusions Applicable to Insuring Agreement B Only, is deleted and replaced with the following: (12) Pollution (a) The actual, alleged, or threatened discharge, dispersal, seepage, migration, release, or escape of pollutants. (b) Any request, demand, order or statutory or regulatory requirement that the insured or others test for, monitor, clean-up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of pollutants. (c) Any claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of pollutants. Paragraph (a) of this exclusion does not apply to bodily injury or property damage arising out of heat, smoke or fumes from a hostile fire unless that hostile fire occurred or originated: (i) At any premises, site or location which is or was at any time used by or for any insured or others for the handling, storage, disposal, processing or treatment of waste; or (ii) At any premises, site or location on which any insured or any contractors or subcontractors working directly or indirectly on any insured's behalf are performing operations to test for, monitor, clean up, remove, contain, treat, detoxify, neutralize or in any way respond to, or assess the effects of, pollutants. All other terms and conditions remain the same. XCU 101-IL 0412 2012 X.L. America, Inc. All Rights Reserved. Page 1 of 1 May not be copied without permission. Includes copyrighted material of Insurance Services Offices, Inc., with its permission. | 2 |
WC 00 04 22 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-2021) Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: The act is an act of terrorism. The act is violent or dangerous to human life, property, or infrastructure. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. 1 of 2 © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. | 2 |
COMMERCIAL AUTO CA 01 13 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO CHANGES For a covered "auto" licensed or principally garaged in, or "auto dealer operations" conducted in, Colorado, 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. Changes In Conditions B. The following condition is added: A. The last paragraph in the Other Insurance If the "insured's" whereabouts for service of process Condition in the Auto Dealers and Business Auto cannot be determined through reasonable effort, the Coverage Forms and the last paragraph in the Other "insured" agrees to designate and irrevocably Insurance - Primary And Excess Insurance appoint us as the agent of the "insured" for service Provisions Condition in the Motor Carrier Coverage of process, pleadings or other filings in a civil action Form are replaced by the following: brought against the "insured" or to which the When this Coverage Form and any other Coverage "insured" has been joined as a defendant or Form or policy covers on the same basis, either respondent in any Colorado court if the cause of excess or primary, the loss will be paid in action concerns an incident for which the "insured" accordance with the following method: can possibly claim coverage. Subsequent termination of the insurance policy does not affect 1. All applicable policies will pay on an equal basis the appointment for an incident that occurred when until the policy with the lowest limit of insurance the policy was in effect. The "insured" agrees that is exhausted. any such civil action may be commenced against 2. If any loss remains and there: the "insured" by the service of process upon us as if a. Are two or more remaining policies whose personal service had been made directly on the applicable limits of insurance have not been "insured". We agree to forward all communications exhausted, then such policies will continue related to service of process to the last-known e- to pay in accordance with Paragraph 1.; or mail and mailing address of the policyholder in order to coordinate any payment of claims or defense of b. Is one remaining policy, then such policy claims that are required. will continue to pay until its limit of insurance has been exhausted. CA 01 13 10 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 | 2 |
COMMERCIAL AUTO CA 99 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOSS PAYABLE CLAUSE 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. A. We will pay, as interest may appear, you and the Cancellation ends this agreement as to the loss loss payee named in the policy for "loss" to a payee's interest. If we cancel the policy, we will covered "auto". mail you and the loss payee the same advance B. The insurance covers the interest of the loss notice. payee unless the "loss" results from conversion, D. If we make any payments to the loss payee, we secretion or embezzlement on your part. will obtain his or her rights against any other party. C. We may cancel the policy as allowed by the Cancellation Common Policy Condition. CA 99 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 | 2 |
Policy Number AS2-641-444149-054 FORMS INVENTORY COVERAGE FORMS PARTS AND ENDORSEMENTS FORMING A PART OF THIS POLICY AT INCEPTION: Listed below are possible coverage forms and the states in which they apply. CA 00 01 03 06 FL, HI, VA CA 00 01 03 10 AK, CT, MA, NY, PR CA 00 01 10 13 AL, AR, AZ, CA, CO, DC, DE, GA, GU, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VI, VT, WA, WI, WV, WY Applicable to Form Number Form Description Coverage Form CA 00 01 10 13 AX 12 10 B Waiver of Transfer of Rights of Recovery Against O CA 00 01 03 06 CA 00 01 03 10 CA 00 01 10 13 CA 20 01 03 06 Lessor-Additional Insured and Loss Payee CA 00 01 03 06 CA 00 01 03 10 CA 20 01 10 13 Lessor - Additional Insured and Loss Payee CA 00 01 10 13 MM 20 26 04 11 Lessor-Additional Insured and Loss Payee Massachus CA 00 01 03 10 ACS 00 11 11 11 Schedule of Additional Insured - Lessor(s) CA 00 01 03 06 CA 00 01 03 10 CA 00 01 10 13 MM 99 50 04 11 Massachusetts Additional Insured CA 00 01 03 10 ACS 20 05 10 13 Designated Insured Schedule CA 00 01 03 06 CA 00 01 03 10 CA 00 01 10 13 CA 20 54 10 01 Employee Hired Autos CA 00 01 03 06 CA 00 01 03 10 CA 20 54 10 13 Employee Hired Autos CA 00 01 10 13 CA 20 55 10 01 Fellow Employee Coverage CA 00 01 03 06 CA 00 01 03 10 CA 00 01 10 13 Business Auto Coverage Form CA 00 01 10 13 CA 00 01 03 06 Business Auto Coverage Form CA 00 01 03 06 CA 00 01 03 10 Business Auto Coverage Form CA 00 01 03 10 IC0018 04-92 Countersignature Endorsement CA 00 01 03 06 CA 00 01 03 10 CA 00 01 10 13 LIL 90 04 06 13 Annual Meeting Notice CA 00 01 03 06 CA 00 01 03 10 CA 00 01 10 13 SNI 90 01 05 12 Policyholder Notice - Company Contact Information CA 00 01 03 06 CA 00 01 03 10 CA 00 01 10 13 CNA 90 04 08 12 Policyholder Notice - Audit Basis Beginning/Ending CA 00 01 03 06 CA 00 01 03 10 ACS 00 26 04 13 © 2012 Liberty Mutual Insurance. All rights reserved. Page 4 of 5 | 0 |
SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: TWIN CITY FIRE INSURANCE COMPANY Company Code: 7 Policy Number: 37 WB BN3284 Schedule Number: 01-40-01 Effective Date: 10/01/13 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: WALSWORTH PUBLISHING COMPANY, INC. NO SPECIFIC LOCATION IN STATE OF SD NAICS: 323110 FEIN: 430718484 UIN: SIC: 2752 NO. OF EMPL: 0 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 8742 IF ANY .73 SALESPERSONS OR COLLECTORS - OUTSIDE INTERSTATE EXPERIENCE MODIFICATION 910456369 (PRELIMINARY) 1.670 TERRORISM (9740) 0 .020 0 CATASTROPHE (9741) 0 .020 0 Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 10/10/13 Policy Expiration Date: 10/01/14 | 1 |
COMMERCIAL GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ADJ. NO. Everest Indemnity Insurance Company NAMED INSURED DATE POLICY NUMBER Time & Alarm Systems Inc 05/31/2020 51GL008096-201 CLASS CODE PREMIUM BASIS PREMISES / OPERATIONS 91127 Gross Sales LOCATION EXPOSURE All 30,000,000 RATE PREMIUM CLASS DESCRIPTION Alarms and Alarm Systems - installation, servicing or repair 2.600 78,000.00 PRODUCTS / COMPL OPERATIONS RATE PREMIUM Included Included CLASS CODE PREMIUM BASIS PREMISES / OPERATIONS LOCATION EXPOSURE RATE PREMIUM CLASS DESCRIPTION PRODUCTS / COMPL OPERATIONS RATE PREMIUM CLASS CODE PREMIUM BASIS PREMISES / OPERATIONS LOCATION EXPOSURE RATE PREMIUM CLASS DESCRIPTION PRODUCTS / COMPL OPERATIONS RATE PREMIUM PAGE 1 OF 1 EDEC 158 07 00 | 1 |
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FELLOW EMPLOYEE COVERAGE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM Under Section II - WHO IS AN INSURED, paragraphs 2.a.(1)(a), 2.a(1)(b) and 2.a(1)(c) are deleted in their entirety. All other terms and conditions of this Policy remain unchanged. Endorsement Number: Policy Number: 41GPP1010201 Named Insured: HNI CORPORATION This endorsement is effective on the inception date of this Policy unless otherwise stated herein: Endorsement Effective Date: 07-01-19 00 GL0590 00 04 10 Page 1 of 1 ADVANCE COPY | 2 |
NOTICE TO TEXAS POLICYHOLDERS Pursuant to Texas Labor Code 411.066, The Hartford is required to notify its policyholders that accident prevention services are available from The Hartford at no additional charge. These services may include surveys, recommendations, training programs, consultations, analyses of accident causes, industrial hygiene and industrial health services. The Hartford is also required to provide return-to-work coordination services as required by Texas Labor Code $413.021 and to notify you of the availability of the return-to-work reimbursement program for employers under Texas Labor Code $413.022. If you would like more information, contact The Hartford at 1-860-547-7761 and email contactlosscontrol@thehartford.com for accident prevention services or 1-877-889-9222 and email CentralClaimCenter.WCEDM@thehartford.comfor return-to-work coordination services. For information about these requirements call the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) at 1-800-687-7080 or for information about the return-to-work reimbursement program for employers call the TDI-DWC at 1-512-804-5000. If The Hartford fails to respond to your request for accident prevention services or return-to-work coordination services, you may file a complaint with the TDI-DWC in writing at http://www.tdi.texas.gov or by mail to Texas Department of Insurance, Division of Workers' Compensation, MS-8, at 7551 Metro Center Drive, Austin, Texas 78744-1645. Form 97485 14th Rev. Printed in U.S.A. Page 5 of 6 | 2 |
Page 1 of 1 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 065-43-7240 IDAHO 910317113 Policy Prefix & No. Schedule INTRA/Independent State Risk ID 013-52-0618-31 KRAUS USA, INC. Item 4. Classification of Operations Premium Basis Rates Code Estimated Total Per $100 of Estimated No. Annual Remuneration Remuneration Annual Premiums RATING GROUP: 0031-01 SALESPERSONS OR COLLECTORS-OUTSIDE 8742 65,496 0.51 334 STATE OF IDAHO TOTALS TOTAL CLASSIFICATION PREMIUM 334 BLANKET WAIVER 2.00% 0930 7 INCREASE LIMITS 1,10% 9812 4 TOTAL UNMODIFIED PREMIUM 345 EXPERIENCE PREMIUM (ACTUAL) 0.7900 9898 -72 MODIFIED STANDARD PREMIUM 273 UNDISCOUNTED PREMIUM 273 PREMIUM DISCOUNT -7.70% 0063 -21 DISCOUNTED PREMIUM 252 TERRORISM 0.01 9740 7 CATASTROPHE (SEE WC 00 04 21C) 0.01 9741 7 TOTAL ESTIMATED PREMIUM 266 TOTAL DUE 266 EXPERIENCE RATING MODIFICATION = 0.79 TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED IN TOTAL ESTIMATED PREMIUM $7 WC 7754 (Ed. 4-81) (Rev'd 04/08) | 1 |
Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number E.E. BISS HEATING & COOLING INC. 1144 MAPLE DRIVE Policy Number FREDERICKSBURG PA 17026 Symbol: RWC Number: C58581872 Policy Period Effective Date of Endorsement 04-17-2020 TO 12-01-2020 04-17-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B), attached to this policy. For purposes of this endorsement, the following definitions apply: Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and C. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. WC 00 04 21D (01/15) © Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 2 | 2 |
Schedule Of Covered Autos You Own (Cont'd) Coverages - Premiums, Limits And Deductibles (Absence of a deductible or limit entry in any column below means that the limit or deductible entry in the corresponding Item Two column applies instead.) Coverages Limit Premium Covered Autos Liability $ 1,000,000 $ Personal Injury Stated In Each Personal Injury Protection $ Protection Endorsement Minus $ Deductible Added Personal Stated In Each Added Personal Injury $ Injury Protection Protection Endorsement Property Protection Stated In The Property Protection $ Insurance Insurance Endorsement Minus (Michigan Only) $ Deductible Auto Medical $ 5,000 $ Payments Medical Expense And Stated In Each Medical Expense And In- $ Income Loss Benefits come Loss Benefits Endorsement For (Virginia Only) Each Person Comprehensive Stated In Item Two Minus $ $ 1,000 Deductible Specified Causes Stated In Item Two Minus $ Of Loss $ 0 Deductible Collision Stated In Item Two Minus $ $ 1,000 Deductible Towing and Labor $ 50 Per Disablement $ CA DS 03 10 13 © Insurance Services Office, Inc., 2011 Page 9 of 47 | 2 |
4. liability for any consequence, whether of America necessarily incurred as a direct direct or indirect, of war, invasion, act of result of bodily injury. Foreign enemy, hostilities (whether war be Our reimbursement shall be limited as follows: declared or not), civil war, rebellion, revolution, insurrection or military or 1. to the amount by which such expenses usurped power. No endorsement now or exceed the normal cost of returning the subsequently attached to this policy shall officer or employee if in good health, or be construed as overriding or waiving this 2. in the event of death, to the amount by limitation unless specific reference is which such expenses exceed the normal made thereto. cost of returning the officer or employee if D. Before We Pay alive and in good health. In no event shall our reimbursement exceed Before we reimburse you for the benefits to the persons entitled to them, you must have them: the bodily injury by accident limit shown in Item 3.B. of the Information Page as respects 1. release you and us, in writing, of all any one such officer or employee whether responsibility for the injury or death, dead or alive. 2. transfer to us their right to recover from H. Endemic Disease others who may be responsible for their injury or death, The word "disease" includes any endemic diseases. 3. cooperate with us and do everything necessary to enable us to enforce the right The coverage applies as if endemic diseases to recover from others. were included in the provisions of the workers' compensation law. If the persons entitled to the benefits paid fail to do these things, our duty to reimburse ends 5. Longshore and Harbor Workers' Compensation at once. If they claim damages from us for the Act Coverage injury or death, our duty to reimburse ends at General Section C. Workers' Compensation once. Law is replaced by the following: E. Recovery From Others C. Workers' Compensation Law If we make a recovery from others, we will Workers' Compensation Law means the keep an amount equal to our expenses of workers or workers' compensation law and recovery and the benefits we reimbursed. We occupational disease law of each state or will pay the balance to the persons entitled to territory named in Item 3.A. of the Information it. If persons entitled to the benefits make a Page and the Longshore and Harbor Workers' recovery from others, they must repay us for Compensation Act (33 USC Sections 901- the amounts that we have reimbursed you. 950). It includes any amendments to those F. Reimbursement for Actual Loss Sustained laws that are in effect during the policy period. It does not include any other federal workers This endorsement provides only for or workers' compensation law, other federal reimbursement for the loss you actually occupational disease law or the provisions of sustain. In order for you to recover loss or any law that provide nonoccupational disability expenses under this reimbursement you must: benefits. 1. actually sustain and pay the loss or Part Two (Employers' Liability Insurance), C. expense in money after trial, or Exclusions, exclusion 8, does not apply to 2. secure our consent for the payment of the work subject to the Longshore and Harbor loss or expense. Workers' Compensation Act. G. Repatriation This coverage does not apply to work subject Our reimbursement includes the additional to the Defense Base Act, the Outer expenses of repatriation to the United States Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Form WC 99 03 03 Printed in U.S.A. (Ed. 8/00) Page 5 of 6 | 2 |
Coverage Is Provided In: Policy Number: Liberty Ohio Security Insurance Company BAS (18) 58 48 91 09 Mutual. Policy Period: INSURANCE From 01/18/2018 To 11/30/2018 Common Policy Declarations 12:01 am Standard Time at Insured Mailing Location Named Insured & Mailing Address Agent Mailing Address & Phone No. TOTAL MALL MAINTENANCE, LLC (816) 960-9000 13110 W 62ND TER LOCKTON COMPANIES LLC SHAWNEE MISSION, KS 66216 444 W 47TH ST STE 900 KANSAS CITY, MO 64112-1906 Named Insured Is: LIMITED LIABILITY COMPANY Named Insured Business Is: BUILDING OWNER LESSORS RISK In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. SUMMARY OF COVERAGE PARTS AND CHARGES This policy consists of this Common Policy Declarations page, Common Policy Conditions, Coverage Parts (which consist of coverage forms and other applicable forms and endorsements, if any, issued to form a part of them) and any other forms and endorsements issued to be part of this policy. COVERAGE PART CHARGES 330 Business Auto $4,395.00 Total Charges for all of the above coverage parts: $4,395.00 Coverage for Terrorism resulting from Nuclear, Biological or Chemical Acts is Excluded Note: This is not a bill IMPORTANT MESSAGES Issue Date 12/26/17 Authorized Representative To report a claim, call your Agent or 1-800-362-0000 DS 70 21 11 16 12/26/17 58489109 N0106449 330 ACAOPPNO INSURED COPY 000529 PAGE 7 OF 72 | 2 |
Coverage Is Provided In: Policy Number: Liberty Ohio Security Insurance Company BAS (19) 56 61 27 35 Mutual. Policy Period: INSURANCE From 02/01/2018 To 02/01/2019 Common Policy Declarations 12:01 am Standard Time at Insured Mailing Location Named Insured & Mailing Address Agent Mailing Address & Phone No. SWEETBRIAR SYNDICATE (402) 970-6100 13625 CALIFORNIA ST STE 333 LOCKTON COMPANIES LLC OMAHA, NE 68154 13710 FNB PKWY STE 400 OMAHA, NE 68154-5298 Named Insured Is: LIMITED LIABILITY COMPANY Named Insured Business Is: BUSINESS In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. SUMMARY OF COVERAGE PARTS AND CHARGES This policy consists of this Common Policy Declarations page, Common Policy Conditions, Coverage Parts (which consist of coverage forms and other applicable forms and endorsements, if any, issued to form a part of them) and any other forms and endorsements issued to be part of this policy. COVERAGE PART CHARGES 340 Business Auto $7,242.00 Total Charges for all of the above coverage parts: $7,242.00 Coverage for Terrorism resulting from Nuclear, Biological or Chemical Acts is Excluded Note: This is not a bill 00 of IMPORTANT MESSAGES Servicing Office Mid-West Regional Office and Issue Date 12/04/17 Authorized Representative To report a claim, call your Agent or 1-800-362-0000 DS 70 21 11 16 12/04/17 56612735 POLSVCS 340 ICAFPPNO INSURED COPY 003008 PAGE 7 OF 70 | 2 |
OLD REPUBLIC INSURANCE COMPANY FORMS INDEX FORMS MADE A PART OF THIS POLICY AT TIME OF ISSUANCE: Form Number Description J-01 (01/16) BUSINESS AUTO INSURANCE POLICY JACKET CA DEC GN 0003 01 16 BUSINESS AUTO DECLARATIONS ORRM 2008 FORMS INDEX ORRM 2009 SCHEDULE OF NAMED INSUREDS PCA 071 01 09 COMPOSITE RATE ENDORSEMENT PCA 116 01 16 AUTO PHYSICAL DAMAGE DEDUCTIBLES IL 00 17 11 98 COMMON POLICY CONDITIONS CA 182 (2-91) QUICK REFERENCE COMMERCIAL AUTO COVERAGE PART CA 00 01 10 13 BUSINESS AUTO COVERAGE FORM PCA 048 10 13 ADDITIONAL INSURED/DESIGNATED INSURED AMENDMENT - PRIMARY AND NON-CONTRIBUTORY PCA 118 03 14 AIRBAG COVERAGE PIL 042 01 16 BROAD FORM NAMED INSURED PIL 028 05 10 DESIGNATED ENTITY - NOTICE OF CANCELLATION PROVIDED BY US ORRM 2008 MWTB 309996 Fansteel Inc. 03/01/2017 03/01/2018 Page 1 of 4 | 0 |
Page 1 of 1 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 065-43-7240 MONTANA 910317113 Policy Prefix & No. Schedule INTRA/Independent State Risk ID 013-52-0618-31 KRAUS USA, INC. Item 4. Classification of Operations Premium Basis Rates Code Estimated Total Per $100 of Estimated No. Annual Remuneration Remuneration Annual Premiums RATING GROUP: 0007-01 SALESPERSONS, COLLECTORS, OR 8742 76,688 0.81 621 MESSENGERS-OUTSIDE. STATE OF MONTANA TOTALS TOTAL CLASSIFICATION PREMIUM 621 BLANKET WAIVER 2.00% 0930 12 INCREASE LIMITS 1.10% 9812 7 TOTAL UNMODIFIED PREMIUM 640 EXPERIENCE PREMIUM (ACTUAL) 0.7900 9898 -134 MODIFIED STANDARD PREMIUM 506 UNDISCOUNTED PREMIUM 506 PREMIUM DISCOUNT -10.10% 0063 -51 DISCOUNTED PREMIUM 455 TERRORISM 0.092 9740 71 CATASTROPHE (SEE WC 00 04 21C) 0.018 9741 14 TOTAL ESTIMATED PREMIUM 540 WC REGULATORY ASSESSMENT 1.4749% 0939 8 WC SUBSEQUENT INJURY FUND 0.2701% 0935 1 REGULATORY ASSESSMENT SURCHARGE 0.6684% 9616 4 TOTAL DUE 553 EXPERIENCE RATING MODIFICATION = 0.79 TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED IN TOTAL ESTIMATED PREMIUM $71 WC 7754 (Ed. 4-81) (Rev'd 04/08) | 1 |
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A Edition 1/08 EXTENSION OF INFORMATION PAGE Name and Address of Insured: Policy No.: RWR943531802 POCH STAFFING, INC. DBA TRILLIUM STAFFING SOLUTIONS AND SUBSIDIARIES NO FIXED ADDRESS Policy Period: SALT LAKE CITY, UT 84101 July 1, 2013 to July 1, 2014 NAICS#: 561311 FEIN: 383270222 # Of Employees: Insured/State/Location No: 01 - 43 - 001 - - 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code No. Premium Basis Rate Per Estimated Total Estimated $100 of Annual Annual Remuneration Remuneration Premium WELDING OR CUTTING NOC & 3365 25,000 4.6100 $1,153.00 DRIVERS WAIVER OF SUBROGATION 0.0200 - (0930) $250.00 CATASTROPHE PROVISIONS FOR TERRORISM 0.0100 - (9740) $3.00 CATASTROPHE PROVISIONS FOR CATASTROPHE (OTHER THAN CERTIFIED $3.00 ACTS OF TERRORISM) 0.0100 - (9741) INCREASED EMPLOYERS LIABILITY LIMITS - $1,000,000/1,000,000/1,000,000 $13.00 0.0110 - (9812) EXPERIENCE PREMIUM 1.2100 - (9898) $297.00 DEPOSIT PREMIUM - UT $1,719.00 XLINSURANCE Date of Issue: 07/31/2013 WC 00 00 01A 1987 National Council on Compensation Insurance. Edition 1/08 c 2007 XL America, Inc. NBUT 07/31/2013 | 1 |
Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number UNION COUNTY CONSTRUCTION GROUP, INC. 638 CHERRY STREET Policy Number GLOUCESTER CITY NJ 08030 Symbol: RWC Number: C58582542 Policy Period Effective Date of Endorsement 04-29-2020 TO 12-01-2020 04-29-2020 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. CONTROLLED INSURANCE PROGRAM - AMENDATORY ENDORSEMENT This endorsement applies because the policy is providing workers compensation coverage as part of a Controlled Insurance Program. The Project Sponsor of this Controlled Insurance Program is: AHOLD USA, INC. ("Project Sponsor"). This policy is amended to reflect the following changes and/or additions to clarify the policy provisions as they apply to the operations of Controlled Insurance Programs. General Section, Item E. Location is replaced with the following: E. Locations This policy covers operations conducted at the workplace defined in the Designated Workplace Exclusion. Part Five - Premium, Item D. is replaced with the following: D. Premium Payments The Project Sponsor will pay all premium when due. The Project Sponsor will pay the premium even if part or all of a workers compensation law is not valid. Part Five - Premium, Item E. is replaced with the following: E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the Project Sponsor paid to us, the Project Sponsor must pay us the balance. If it is less, we will refund the balance to the Project Sponsor. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. WC 99 03 34 (7/06) Page 1 of 2 | 2 |
POLICY NUMBER: CL00169642 PIL 10 10 08 18 CO 10 10 12 07 SCHEDULE OF FORMS AND ENDORSEMENTS Insured Name: CHILDREN'S HOUR MONTESSORI, LLC Form(s) and Endorsement(s) made a part of this policy at time of issue: Forms Applicable - MULTIPLE LINES OF BUSINESS PIL 20 10 08 18 MINIMUM AND DEPOSIT ENDORSEMENT PIL 01 52 08 18 TX IMPORTANT NOTICE PIL 20 01 05 18 POLICYHOLDER DISCLOSURE NOTICE TERRORISM INS COV PIL 10 12 08 18 SERVICE OF SUIT PIL 10 16 08 18 EARNED PREMIUM ENDORSEMENT PCG 14 52 08 18 EXCLUSION - ASSAULT AND/OR BATTERY IL 00 03 09 08 CALCULATION OF PREMIUM IL 00 17 11 98 COMMON POLICY CONDITIONS IL 00 21 09 08 NUCLEAR ENERGY LIABILITY EXCL ENDT (BROAD FORM) Forms Applicable GENERAL LIABILITY 2018 PCG 00 01 08 18 COMML GENERAL LIABILITY COVERAGE PART DECLARATIONS PCG 14 46 08 18 LIMITATION OF COV TO CLASSIFICATIONS LISTED ON POLICY PCG 14 87 08 18 VOLUNTARY LABOR EXCLUSION PCG 15 80 08 18 AMENDMENT OF PREMIUM AUDIT CONDITION PCG 16 59 08 18 EMPLOYER'S LIABILITY EXCLUSION PCG 16 60 08 18 EXCLUSION - OPERATIONS OR WORK IN NEW YORK STATE PCG 16 64 08 18 ABUSE OR MOLESTATION SUBLIMIT - LIMITED FORM PCG 21 02 08 18 DELETE NONRENEWAL NOTICE PCG 21 17 08 18 PROFESSIONAL LIABILITY COVERAGE PCG 21 21 08 18 ANIMAL EXCLUSION PCG 40 10 08 18 ASBESTOS OR LEAD EXCLUSION PCG 40 11 08 18 EXPLOSIVES EXCLUSION PCG 40 12 08 18 CHANGES TO PERSONAL & ADVERTISING INJURY DEFINITION PCG 40 13 08 18 CHROMATED COPPER ARSENATE TREATED WOOD EXCLUSION PCG 40 15 08 18 CROSS SUITS EXCLUSION PCG 40 16 08 18 INFRINGE COPYRIGHT, PATENT, TRADEMARK LIAB EXCL PCG 40 18 08 18 AMENDMENT TO OTHER INSURANCE PCG 40 19 08 18 PUNITIVE, EXEMPLARY, TREBLE DAMAGE, MULTI ATTY FEE EXCL PCG 40 20 08 18 SUBSIDENCE EXCLUSION CG 00 01 04 13 COMMERCIAL GENERAL LIABILITY COVERAGE FORM PIL 10 10 08 18 Page 1 of 2 | 0 |
AIG AIG Insurance 877-To-Serve (867-3783) Email: toserve@AIG.com 05/08/2015 AMBER ANDERSON AON RISK INSURANCE SERVICES WEST, INC. 851 SW 6TH AVENUE, SUITE 385 PACIFIC CENTER BUILDING PORTLAND, OR 97204-1309 Re: INSURED NAME: STERLING GOLD MINING CORP Policy No.: CA 363-24-28 Effective Date: 04/12/2015 Dear AMBER ANDERSON: Enclosed please find the following document: New Policy Thank you for your binder. Enclosed please find the original and broker copies of the policy issued to the above named insured. Renewal Thank you for your renewal binder. Enclosed, please find the original and broker copies of the policy issued to the above named insured. Endorsement(s) No. and Type of Change Enclosed please find the original and one copy of the change endorsement(s) as requested. The enclosed documents provide a complete and accurate representation of the coverages agreed to under the terms and conditions set out in the binder or change request document. Upon your review, please contact your underwriter promptly with any questions or concerns. We appreciate your business and strive to make your satisfaction our #1 priority. | 2 |
MM 99 35 04 11 exceed the cost of renewing or continuing such policy for a period of two years after the "accident." Also, our payment will not operate to reduce the benefits otherwise payable under this coverage. F. Definitions The following definitions are added for Personal Injury Protection Coverage: 1. "Occupying" means in, upon, getting in, on, out or off. 2. "Pedestrian" includes anyone incurring bodily injury as a result of being struck by an auto in an accident and who is not occupying an auto at the time of the accident. MM 99 35 04 11 Copyright, Automobile Insurers Bureau, 1998 Page 4 of 4 | 2 |
PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. Not Applicable in Arizona, Massachusetts, Oregon and Texas Issued by Liberty Mutual Fire Insurance Company 16586 For attachment to Policy No. WA2-66D-067199-279 Effective Date Premium $ Issued to Penhall Company WC 00 04 19 © Copyright 2000 National Council on Compensation Insurance, Inc. Page 1 of 1 Ed. 01/01/2001 All Rights Reserved. | 2 |
Schedule of Forms and Endorsements ace group NAMED INSURED POLICY NUMBER POLICY PERIOD Dillard's Inc. XOO G27373938 1/28/2014 - 1/28/2015 Endorsement Form Number - Title Number Edition Date XS-9U57b (08/09) Schedule of Underlying Insurance XS-20835 (08/06) Commercial Umbrella Liability Policy ALL-20887 (10/06) ACE Producer Compensation Practices & Policies XS-28500a (08/13) ACE Group Specialty Claims Loss Notification Form IL P 001 (01/04) U.S. Treasury Department's Office of Foreign Assets Control ("OFAC") Advisory Notice To Policyholders XS-22552 (06/07) Catastrophe Management Policyholder Notice ALL2Y31a (02/06) Arkansas Notice to Policyholders 1 CC-1K11g (01/11) Signatures 2 XS-20745 (08/06) Aircraft Products And Grounding Exclusion 3 XS-20746 (08/06) Anti-Stacking Endorsement 4 XS-25998 (11/08) Auto Liability Follow Form Endorsement 5 XS-23629 (01/2008) Discrimination Follow Form Endorsement 6 XS-20750 (08/06) Contractors Limitation Endorsement 7 XS-20772 (08/06) Residential Stucco/Eifs Exclusion Endorsement 8 XS-20779 (08/06) Fungi Or Bacteria Exclusion 9 XS-20782 (08/06) Cancellation Amendatory Endorsement 10 XS-20796 (08/06) Cross Suits Exclusion 11 XS-20803 (08/06) Earth Movement Exclusion 12 XS-20819 (08/06) Professional Services Liability Exclusion - Absolute 13 XS-20827 (08/06) Unimpaired Aggregate Endorsement 14 XS-20854 (08/06) Lead Exclusion 15 XS-26431 (02/09) Silica or Silica-Related Dust Exclusion 16 XS-34018 (01/12) Unsolicited Communications Exclusion Amendment to Include FACTA XS-27991 (08/09) © 2009 Page 1 of 2 | 0 |
Page 1 of 2 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 034-15-7226 SOUTH CAROLINA 917854726 Policy Prefix & No. Schedule INTRA/Independent State Risk ID 082-02-0414-00 TRADESMEN INTERNATIONAL, INC Item 4. Classification of Operations Premium Basis Rates Code Estimated Total Per $100 of Estimated No. Annual Remuneration Remuneration Annual Premiums RATING GROUP: 0028-01 WELDING OR CUTTING NOC & DRIVERS 3365 267,864 10.70 28,661 WELDING OR CUTTING NOC & DRIVERS 3365F 1,475 17.98 265 MACHINE SHOP NOC 3632 851 4.90 42 MACHINERY OR EQUIPMENT ERECTION OR 3724 108,592 6.32 6,863 REPAIR NOC & DRIVERS MASONRY NOC 5022 16,047 11.42 1,833 IRON OR STEEL-ERECTION-IRON-EXTERIOR. 5040 97,383 16.18 15,757 IRON OR STEEL-ERECTION-STEEL 5057 4,081 8.19 334 FRAME-INTERIOR-LIGHT GAUGE STEEL-NOC PLUMBING NOC & DRIVERS 5183 271,249 5.39 14,620 ELECTRICAL WIRING-WITHIN BUILDINGS & 5190 1,207,971 6.92 83,592 DRIVERS CONCRETE OR CEMENT WORK-FLOORS, 5221 186,738 6.02 11,242 DRIVEWAYS, YARDS, OR SIDEWALKS & DRIVERS CERAMIC TILE, INDOOR STONE, MARBLE, OR 5348 2,450 5.89 144 MOSAIC WORK CARPENTRY-INSTALLATION OF CABINET WORK 5437 107,224 9.56 10,251 OR INTERIOR TRIM WALLBOARD, SHEETROCK, DRYWALL, 5445 5,177 8.97 464 PLASTERBOARD OR CEMENT BOARD INSTALLATION-WITHIN BUILDINGS & DRIVERS PAINTING NOC & SHOP OPERATIONS, DRIVERS 5474 11,450 11.12 1,273 INSULATION WORK NOC & DRIVERS 5479 334 8.62 29 SHEET METAL WORK-INSTALLATION & DRIVERS 5535 68,233 9.46 6,455 ROOFING-ALL KINDS & DRIVERS 5551 2,376 35.04 833 CARPENTRY-DETACHED ONE- OR TWO-FAMILY 5645 798,023 22.88 182,588 DWELLINGS GRADING OF LAND NOC & DRIVERS 6217 102,723 8.55 8,783 AUDIO OR INTERCOMMUNICATION SYSTEM 7605 15,765 3.06 482 INSTALLATION WITHIN BUILDINGS SALESPERSONS OR COLLECTORS-OUTSIDE 8742 324,105 0.69 2,236 CLERICAL OFFICE EMPLOYEES NOC. 8810 121,773 0.34 414 STATE OF SOUTH CAROLINA TOTALS TOTAL CLASSIFICATION PREMIUM 377,161 BLANKET WAIVER 2.00% 0930 7,543 INCREASE LIMITS 1.10% 9812 4,149 TOTAL UNMODIFIED PREMIUM 388,853 EXPERIENCE PREMIUM (ACTUAL) 1.2300 9898 89,436 MODIFIED STANDARD PREMIUM 478,289 UNDISCOUNTED PREMIUM 478,289 LOSS REIMB PLAN (NON-FEDERAL) -55.89% 9866 -267,128 LOSS REIMB PLAN (FEDERAL) -42.17% 9866 -142 WC 7754 (Ed. 4-81) (Rev'd 04/08) | 1 |
CHUBB Name of Insured Attached to and Forming Part of TORTOISE CAPITAL ADVISORS, LLC Policy Number (14)7174-28-82 FEIN 223875939 Policy Period 09/27/13 to 09/27/14 Location of Operations NO SPECIFIC Effective Date 09/27/13 LOCATION NY Producer Name Name of Company LOCKTON COMPANIES, LLC CHUBB INDEMNITY INSURANCE COMPANY Producer Number 8-37949 999 Endorsement Number EXTENSION OF INFORMATION PAGE ITEM 4 - SCHEDULE NUMBER: 0001-31-0001 (INSD-ST-LOC) Premium Basis Total Estimated Rate Per Estimated Code Annual $100 of Re- Annual Classification of Operations No. Remuneration muneration Premium SALESPERSONS, COLLECTORS OR MESSENGERS- 8742 170,000 .40 680 OUTSIDE MINIMUM PREMIUM FOR WAIVER CODE: 0930 250 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 930 All Other Terms and Conditions Remain Unchanged Authorized Representative Issue Date 07/23/13 KCO DFI 710 RW( 14 ) 71742882 WC 00 00 01A (Rev. 5-88) Page 2 of 6 | 1 |
IFG Policy Number: 959B001177 Companies COMMERCIAL GENERAL LIABILITY DECLARATIONS Named Insured: Effective Date: ABRON TRUCKING, LLC 07/24/2018 Item 1. LIMITS OF INSURANCE $ 1,000,000 General Aggregate Limit (Other Than Products - Completed Operations) $ Incl. In Gen. Agg. Products - Completed Operations Aggregate Limit $ 1,000,000 Personal and Advertising Injury Limit $ 1,000,000 Each Occurrence Limit $ 100,000 Damage To Premises Rented To You Limit (Any One Premises) $ 5,000 Medical Expense Limit (Any One Person) Refer to individual policy forms and/or endorsements for various coverage sublimits, if applicable. Item 2. AUDIT PERIOD (If Applicable): Annually Semi-Annually Quarterly Monthly Item 3. FORM(S) AND ENDORSEMENT(S) made a part of this policy at time of issue: See Listing of Forms and Endorsements (IFG-I-0150) Item 4. COMPOSITE RATE If box is checked, see Composite Rate Endorsement (IFG-I-0152) for applicable classification, rates and premiums. If box is not checked, see page 2 of these Declarations for applicable classifications, rates and premiums. Item 5. RETROACTIVE DATE (CG 00 02 only) : Coverage A of this Insurance does not apply to "bodily injury" or "property damage' which occurs before the Retroactive Date, if any, shown here: None (Enter Date or "None" If no Retroactive Date applies.) Item 6. PREMIUMS $ 214.00 Total Coverage Part Advance Premium $ 450.00 Coverage Part Minimum Premium (if applicable) These Declarations are part of the Policy Declarations containing the name of the insured and the policy period. IFG-G-0002-DL 0503 Page 1 of 2 | 2 |
EXCESS LIABILITY DECLARATIONS Starr Indemnity & Liability Company Dallas, Texas Administrative Office: 399 Park Avenue, 8th Floor, New York, NY 10022 POLICY NUMBER: 1000035092151 RENEWAL OF: 1000035092141 PRODUCER NAME: Lockton Companies ADDRESS: 444 W. 47th St., Suite 900 Kansas City, MO 64112 ITEM 1. NAMED INSURED: IPHFHA Risk Purchasing Group c/o Daniel Vincent O'Leary Jr. ADDRESS: 333 W. Wacker Drive, Suite 300 Chicago, IL. 60606 ITEM 2: POLICY PERIOD: FROM 7/1/2015 TO 7/1/2016 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED INSURED SHOWN ABOVE. ITEM 3. COVERAGE: Commercial Excess Liability ITEM 4. LIMITS OF INSURANCE: The Limits of Insurance, subject to all the terms of this Policy, are: A. $ 3,000,000 Each Occurrence B. $ 3,000,000 Other Aggregate(s), Where Applicable ITEM 5. "UNDERLYING INSURANCE" A. First Underlying Insurance Policy(ies) Insurer Policy No. Policy Period See attached Schedule of Underlying Insurance B. Additional Underlying Insurance Policy(ies) Insurer Policy No. Policy Period See attached Schedule of Underlying Insurance XS - 101 - D (10/08) Page 1 of 2 Copyright © C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved. Includes copyrighted material of ISO Properties, Inc., used with its permission. | 2 |
Liability Policy - 8842740 - for Express Services of Canada Inc. 13 5.5.2 Advertising Advertising means a notice that is broadcast or published to the general public or specific market segments about your goods, products or services for the purposes of attracting customers or supporters. For the purposes of this definition: a) Notices that are published include material placed on the Internet or on similar electronic means of communication: and b) Regarding web-sites, only that part of a web-site that is about your goods, products or services for the purposes of attracting customers or supporters is considered an advertisement. 5.6 Employee Benefits Zurich will pay on behalf of the Insured all sums which the Insured shall become legally obligated to pay as compensatory damages with respect to any claim made against the Insured by an employee, former employee or the beneficiaries or legal representatives thereof caused by the negligent act, error or omission of the Insured, or any other person for whose acts the Insured is legally liable in the administration of Employee Benefits during the Period of Insurance. 5.6.1 Exclusions This extension does not apply to: a) any dishonest, fraudulent, criminal or malicious act, libel, slander, discrimination, or humiliation; b) Bodily Injury to, or sickness, or death, of any person or to injury to or destruction of any tangible property including the loss of use thereof; c) any claim for failure of performance of a contract by any Insurer; d) any claim based upon the Named Insured's failure to comply with any law, regulation or policy concerning worker's compensation, employment or unemployment insurance, social security, social insurance or disability benefits of any kind; e) any claim based upon the failure of stock or other securities to perform as represented by an Insured; f) any claim based upon advice given by an Insured to participate or not to participate in stock or other securities subscription plans; g) any claim, that is the result of circumstances of which the Insured has knowledge at the effective date of this insurance; h) any claim, that is the result of circumstances which the Insured could reasonably have foreseen at the effective date of this insurance; i) any claim, that is covered under another liability insurance policy. This coverage applies only, if the claim is brought against an Insured during the policy period. 5.7 Employers' Liability Zurich will pay on behalf of the Insured all sums which the Named Insureds shall become legally obligated to pay as compensatory damages, including care and loss of services because of Bodily Injury caused by an Occurrence and arising out of and in the course of any person's employment by a Named Insured. 5.7.1 Exclusions This extension does not apply to: | 2 |
ENDORSEMENT NO. 5 CONTINUED Marsh, Inc. (Reputational Risk & Crisis Management Group) 1166 Avenue of the Tracy Knippenburg Gillis (877) 246-2774 Public Relations, Crisis Americas Managing Consultant Management services. New York, NY (212) 345-3886 Direct 10036 (516) 661-0308 Cell (516) 536-5845 Other Serving clients in the (212) 948-8638 Fax US. tracy.knippenburggillis@marsh.com 345 California Street Simon R. Baker Suite 1300 Vice President San Francisco, (415) 743-8648 Direct California (415) 367-5707 Cell 94104 simon.r.baker@marsh.com rbb Public Relations 355 Alhambra Circle, Bruce S. Rubin (305) 807-2704 Public Relations, Crisis Suite 800 Senior Counselor Management services. Miami, Florida (305) 448-2640 Direct 33134 (305) 807-2704 Cell (305) 448-5027 Fax Serving clients in the Bruce.rubin@rbbpr.com US. Sard Verbinnen & Co. 630 Third Avenue, George Sard (917) 750-4392 Public Relations, Crisis 9th Floor Chairman and CEO Management services. New York, NY (212) 687-8080 Office 10017 (212) 687-8344 Fax Serving clients in the gsard@sardverb.com US. 475 Sansome Street, Paul Kranhold Suite 1750 Managing Director San Francisco, CA (415) 618-8750 Office 94111 (415) 568-9580 Fax pkranhold@sardverb.com 105646 (10/12) PAGE 4 OF 8 CI5240 | 2 |
THIS FORM APPLIES IN: TX COMMERCIAL AUTO CA 99 03 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AUTO MEDICAL PAYMENTS 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 the endorsement. A. Coverage 3. "Bodily injury" sustained by any "family We will pay reasonable expenses incurred for member" while "occupying" or struck by any necessary medical and funeral services to or for vehicle (other than a covered "auto") owned by an "insured" who sustains "bodily injury" caused or furnished or available for the regular use of by "accident". We will pay only those expenses any "family member". incurred, for services rendered within three years 4. "Bodily injury" to your "employee" arising out of from the date of the "accident". and in the course of employment by you. B. Who Is An Insured However, we will cover "bodily injury" to your domestic "employees" if not entitled to workers' 1. You while "occupying" or, while a pedestrian, compensation benefits. For the purposes of when struck by any "auto". this endorsement, a domestic "employee" is a 2. If you are an individual, any "family member" person engaged in household or domestic while "occupying" or, while a pedestrian, when work performed principally in connection with a struck by any "auto". residence premises. 3. Anyone else "occupying" a covered "auto" or a 5. "Bodily injury" to an "insured" while working in temporary substitute for a covered "auto". The a business of selling, servicing, repairing or covered "auto" must be out of service because parking "autos" unless that business is yours. of its breakdown, repair, servicing, loss or 6. "Bodily injury" arising directly or indirectly out destruction. of: C. Exclusions a. War, including undeclared or civil war; This insurance does not apply to any of the b. Warlike action by a military force, including following: action in hindering or defending against an 1. "Bodily injury" sustained by an "insured" while actual or expected attack, by any "occupying" a vehicle located for use as a government, sovereign or other authority premises. using military personnel or other agents; or 2. "Bodily injury" sustained by you or any "family C. Insurrection, rebellion, revolution, usurped member" while "occupying" or struck by any power, or action taken by governmental vehicle (other than a covered "auto") owned by authority in hindering or defending against you or furnished or available for your regular any of these. use. CA 99 03 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 2 MWTB 309996 Fansteel Inc. 03/01/2017 - 03/01/2018 | 2 |
Policy Number AS2-641-437443-064 ITEM THREE - SCHEDULE FOR COMPOSITE STATE SUMMARY State Exposure Premium IL 18.00 $12,996 IN 1.00 $722 NE 5.00 $3,610 ACS 99 02 08 12 © 2012 Liberty Mutual Insurance. All rights reserved Page 1 of 1 | 2 |
Endorsement No.: 10 Effective Date: December 01, 2020 Issue Date: Attached to and forming part of Policy No.: US00011830L120A Issued To: Burns & McDonnell, Inc. By: XL Insurance America, Inc. Drop Down & Non-Accumulation of Limits Endorsement This endorsement changes the policy. Please read it carefully. This endorsement modifies insurance provided under the following: Commercial Excess Liability Policy It is agreed that the following condition is added to this policy: We will pay on behalf of the Insured: 1. In excess of all underlying policies; and 2. Only after all underlying policies have been exhausted by payment of limits of such insurance for losses arising out of occurrences that take place during our policy period and are insured by all underlying policies as shown in the Schedule of Underlying Insurance. If any underlying policy does not pay a loss for reasons other than exhaustion of an aggregate limit of insurance, then this policy will not pay such loss. With respect to coverage provided by owner controlled insurance programs, contractor controlled insurance programs, or consolidated (wrap-up) programs, it is agreed that this policy will drop-down and pay loss in excess of the underlying insurance but only if such policy for owner controlled insurance program, contractor controlled insurance program or consolidated (wrap-up) program has been issued by one of the following members of the ACE Group of Companies: 1. Westchester Fire Insurance Company; 2. Westchester Surplus Lines Insurance Company; 3. Illinois Union Insurance Company; 4. Ace American Insurance Company. Notwithstanding anything to the contrary above, if this insurance and any other insurance issued to the Insured by this company or any affiliated company applies to the same claim, suit or occurrence, the maximum limit of insurance available for such claim, suit, loss or occurrence will not exceed the highest applicable limit of insurance available under any one policy. This condition does not apply to any other insurance issued by us or any of our affiliated companies specifically to apply as excess insurance over this policy unless such policy is for owner controlled insurance programs, contractor controlled insurance programs or consolidated (wrap-up) programs which has been issued by one of the following members of the ACE Group of Companies: 1. Westchester Fire Insurance Company; 2. Westchester Surplus Lines Insurance Company; Manuscript Page 1 of 2 ©2011 X.L. America, Inc. All rights reserved. May not be copied without permission. | 2 |
THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA WorldSource A CAPITAL STOCK COMPANY (HEREIN CALLED THE COMPANY) A MEMBER COMPANY OF AIG, EXECUTIVE OFFICES: 175 WATER STREET, 19TH FLOOR, NEW YORK NY DECLARATIONS FOREIGN COMMERCIAL PACKAGE POLICY Policy No.: Policy Term: Date of Issue: WS11009178 From: September 15, 2015 To: September 15, 2016 09/14/2015 12:01 A.M. AT THE "PRINCIPAL PLACE OF BUSINESS" ADDRESS SET FORTH BELOW Named Insured(s) and Address(es): Form of Business: GUARANTEE INSURANCE GROUP, INC. Corporation First Named Insured's Address (principal place of business): 401 E LAS OLAS BLVD # 1650 FORT LAUDERDALE, FL 33301 Mailing Address (if different): Detailed descriptions and certain limitations applicable to this insurance policy (or parts of this insurance policy) can be found in the specific coverage parts, forms, endorsements, schedules of limits, and other materials attached to and made a part of this policy at the time of issuance or subsequent thereto. This policy, including the forms, endorsements, schedules of limits, and other materials shown on the Schedule of Documents attached hereto, is effective only for the Policy Term indicated above. Thus, for the avoidance of doubt, any forms, endorsements, schedules of limits, and other materials that form a part of any prior Policy Term correspond only to such prior Policy Term, and have no effect on this Policy Term. All Premiums and amounts indicated in the forms, endorsements, schedules of limits, and other materials attached to and made a part of this policy at the time of issuance or subsequent thereto are in the currency of US$ dollar. Coverages Premiums Foreign Commercial General Liability $7,500 Foreign Commercial Auto Liability $150 Foreign Voluntary Compensation and Employers Liability $500 Foreign Commercial Travel Accident and Sickness $410 Total (US$) Premium $8,560 Minimum Earned Premium: $5,000 Deposit Premium: $8,560 Broker: Broker Number: MARSH & MCLENNAN AGENCY LLC 0000102075 9850 NW 41ST ST STE 100 MIAMI, FL 33178 By signing below, the President and Secretary of the Insurer agree on behalf of the Insurer to all the terms of this Policy. This policy shall not be valid unless signed at the time of issuance by an Authorized Representative of the Insurer. Ral Schine Deingof Jam D hugar President Secretary Authorized Representative 84025WR (07/04) Page 1 of 1 | 2 |
Tata AIG General Insurance Company Ltd. TATA AIG INSURANCE COMMERCIAL GENERAL LIABILITY SCHEDULE Agent/Broker Producer Name:- - J B Boda Insurance Brokers Pvt Ltd Agent/Broker License Code:- DB138/03 Agent/Broker Contact No:- 022-66314949 POLICY NO. - 0301004560 COMPANY NAME AREA PRODUCER NAME AREA NAMED INSURED: Perkins Eastman Design Consultants India Pvt., Ltd MAILING ADDRESS: Forbes Building, Floor 5 Charanjit Rai Marg, Fort Mumbai, Maharashtra, India, PIN CODE - 400001 POLICY PERIOD: From: 10-08-2016 To: 09-08-2017 IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. LIMITS OF INSURANCE MASTER CONTROL PROGRAM AGGREGATE LIMIT: NA GENERAL AGGREGATE LIMIT: INR 6.7 Crores Any One Occurrence and in the Aggregate. (Other Than Products - Completed Operations) PRODUCTS / COMPLETED OPERATIONS LIMIT: NA PERSONAL & ADVERTISING INJURY LIMIT: INR 6.7 Crores Any One Occurrence and in the Aggregate. DAMAGE TO PREMISES RENTED TO YOU: INR 335,000 per occurrence MEDICAL EXPENSE LIMIT: INR 67,000 per person Coverage A of this insurance does not apply to "bodily injury" or "property damage" which occurs before the Retroactive Date, if any, shown below Retroactive Date: NA. Page 1 of 47 TATA AIG General Insurance Company Limited Regd. Office: 15th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel, Mumbai-400013, Maharashtra, India. IRDA Registration No. 108 CIN no. U85110MH2000PLC128425 TEL +91-22-66699696 FAX +91-22-66546464 For more information call the Tata AIG Helpline 1800-266-7780 / 1800-11-9966 www.tataaiginsurance.in | 2 |
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A Edition 1/08 TRUCKING--LOCAL HAULING ONLY-- 7228 35,207 6.36 $2,239 ALL EMPLOYEES AND DRIVERS AUTOMOBILE--HAULAWAY OR 7229 2,028 7.53 $153 DRIVEAWAY--LONG DISTANCE HAULING--ALL EMPLOYEES AND DRIVERS TRUCKING--PARCEL OR PACKAGE 7230 3,388 7.38 $250 DELIVERY--ALL EMPLOYEES AND DRIVERS DRIVERS, CHAUFFEURS, 7380 3,156,851 5.56 $175,521 MESSENGERS AND THEIR HELPERS NOC--COMMERCIAL GASOLINE STATION--SELF-SERVICE 8006 182 2.67 $5 AND CONVENIENCE/GROCERY-- RETAIL STORE--CLOTHING, WEARING 8008 80,262 1.16 $931 APPAREL OR DRY GOODS--RETAIL STORE--HARDWARE 8010 34,988 1.71 $598 STORE--RETAIL NOC 8017 126,080 1.90 $2,396 WHOLESALE STORE NOC 8018 821,276 2.80 $22,996 BUILDING MATERIAL DEALER--NEW 8058 14,065 2.59 $364 MATERIALS ONLY: STORE EMPLOYEES IRON OR STEEL--MERCHANT AND 8106 28,705 3.67 $1,053 DRIVERS MACHINERY DEALER NOC--STORE 8107 55,547 2.44 $1,355 OR YARD--AND DRIVERS LUMBERYARD NEW MATERIALS 8232 63,688 5.27 $3,356 ONLY: ALL OTHER EMPLOYEES AND YARD, WAREHOUSE, DRIVERS SASH, DOOR OR ASSEMBLED 8235 2,681 4.56 $122 MILLWORK--DEALER AND DRIVERS STORAGE WAREHOUSE NOC 8292 36,557 2.70 $987 AIR-CONDITIONING SYSTEMS: 8391 29,006 2.92 $847 AUTOMOBILE: INSTALLATION, SERVICE OR REPAIR AND DRIVERS METAL SCRAP DEALER AND 8500 50,550 5.70 $2,881 DRIVERS INSURANCE COMPANIES-- 8723 31,076 0.26 $81 INCLUDING CLERICAL AND SALESPERSONS SALESPERSONS OR COLLECTORS-- 8742 236,967 0.33 $782 OUTSIDE MAILING OR ADDRESSING 8799 5,031 0.85 $43 COMPANY OR LETTER SERVICE SHOP-CLERICAL STAFF CLERICAL OFFICE EMPLOYEES NOC 8810 2,036,857 0.21 $4,277 CLERICAL OFFICE EMPLOYEES 8815 243 0.49 $1 NOC--PROGRAM II--USL ACT BUILDINGS-OPERATION BY 9014 267 3.07 $8 CONTRACTORS GARBAGE, ASHES OR REFUSE 9403 58,432 8.05 $4,704 COLLECTION AND DRIVERS XLINSURANCE WC 00 00 01A © 1987 National Council on Compensation Insurance. Page 94 Edition 1/08 © 2007 XL America, Inc. | 1 |
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 59 (01-05) EXTENSION OF INFORMATION PAGE Schedule of Forms ITEM 3D POLICY NO. (22) 7177-67-12 Form Numbers Applicable States WORKERS COMPENSATION FORMS AND ENDORSEMENTS WC 90 03 84 07-18 CHUBB WC CLAIM KIT CA PN 04 99 08 12-19 CA POLICYHOLDER NOTICE-ASSEMBLY BILL N05 CA WC 00 00 01A 05-88 INFORMATION PAGE WC AND EMPL LIABIL POL CA WC 00 00 01A 05-88 SCHEDULE OF NAMES & LOCATIONS CA WC 00 00 01A 05-88 WC CLASSIFICATION SCHEDULE CA 08 02 0109 04-84 WORK COMP POLICY COVER PAGE CA WC 00 00 00C 01-15 WORKERS COMPENSATION AND EMPLOYERS LIAB CA WC 00 04 06 A 07-95 PREMIUM DISCOUNT ENDT CA WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT CA WC 00 04 21 E 01-21 CATASTROPHE (OTHER THAN CERT ACTS) ENDT CA WC 00 04 22 C 01-21 TERRORISM RISK PGM REAUTH ACT DISCL ENDT CA WC 04 03 01 D 02-18 CA POLICY AMENDATORY ENDORSEMENT CA WC 04 03 60 B 01-15 CA EMPLOYERS' LIAB COV AMENDATORY ENDT CA WC 04 04 21 01-08 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT CA WC 04 06 01 A 12-93 CA CANCELATION ENDT CA WC 90 03 75 05-18 CA WAIVER OF OUR RIGHT TO RECOVER FROM CA 08 02 0261 03-12 CIVIL UNIONS OR DOMESTIC PARTNERSHIPS CA WC 990605 05-88 INSTALLMENTS CA WC 99 07 73 11-06 TRADE OR ECONOMIC SANCTIONS CA © 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual © 2001. | 0 |
IL 02 31 09 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ARKANSAS CHANGES - CANCELLATION AND NONRENEWAL This endorsement modifies insurance provided under the following: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART EMPLOYMENT-RELATED PRACTICES LIABILITY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART FARM UMBRELLA LIABILITY POLICY LIQUOR LIABILITY COVERAGE PART MEDICAL PROFESSIONAL LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Paragraph 5. of the Cancellation Common Policy d. The cancellation will be effective even if we Condition is replaced by the following: have not made or offered a refund. 5.a. If this policy is cancelled, we will send the first e. If the first Named Insured cancels the Named Insured any premium refund due. policy, we will retain no less than $100 of b. We will refund the pro rata unearned premium the premium, subject to the following: if the policy is: (1) We will retain no less than $250 of the (1) Cancelled by us or at our request; premium for the Equipment Break- down Coverage Part. (2) Cancelled but rewritten with us or in our company group; (2) We will retain the premium developed for any annual policy period for the (3) Cancelled because you no longer have an General Liability Classifications, if any, insurable interest in the property or busi- shown in the Declarations. ness operation that is the subject of this insurance; or (3) If the Commercial Auto Coverage Part covers only snowmobiles or (4) Cancelled after the first year of a prepaid golfmobiles, we will retain $100 or the policy that was written for a term of more premium shown in the Declarations, than one year. whichever is greater. c. If the policy is cancelled at the request of the (4) If the Commercial Auto Coverage Part first Named Insured, other than a cancellation covers an "auto" with a mounted described in b.(2), (3) or (4) above, we will re- amusement device, we will retain the fund 90% of the pro rata unearned premium. premium shown in the Declarations for However, the refund will be less than 90% of the amusement device and not less the pro rata unearned premium if the refund of than $100 for the auto to which it is such amount would reduce the premium re- attached. tained by us to an amount less than the minim- um premium for this policy. IL 02 31 09 08 © ISO Properties, Inc., 2007 Page 1 of 2 | 2 |
SCHEDULE OF COVERED AUTOS YOU OWN (ITEM THREE OF THE DECLARATIONS) (Continued) POLICY NUMBER: 37 UEN KW8365 Absence, if any, of a limit entry below means that the limit entry shown in the corresponding ITEM TWO of the Declarations Limit Column applies instead. NO. 00044 96 FORD ID NO. 1FDKE30F6THA50368 GARAGED: LOUISVILLE KY TERR: 101 CLASS: 01499 TAX LOC: 9009 EXEMPT ZIP CODE: 40202 RADIUS: L SIZE: 10000 COVERAGES: SEQ. NO. 00054 PREMIUMS LIABILITY $ 776.00 PERSONAL INJURY PROTECTION $ 37.00 UNINSURED MOTORISTS $ 25.00 UNDERINSURED MOTORISTS $ 88.00 NO. 00045 13 FORD ID NO. 1FDEE3FS3DDA28984 GARAGED: LOUISVILLE KY TERR: 101 CLASS: 01499 ORIG. COST NEW: $ 26,520 TAX LOC: 9009 EXEMPT ZIP CODE: 40202 RADIUS: L SIZE: 10000 COVERAGES: SEQ. NO. 00055 PREMIUMS LIABILITY $ 776.00 PERSONAL INJURY PROTECTION $ 37.00 UNINSURED MOTORISTS $ 25.00 UNDERINSURED MOTORISTS $ 88.00 COMPREHENSIVE $ 1,000 DEDUCTIBLE $ 97.00 COLLISION $ 1,000 DEDUCTIBLE $ 202.00 NO. 00046 13 FORD ID NO. NMOKS9BN7DT173094 GARAGED: LOUISVILLE KY TERR: 101 CLASS: 01499 ORIG. COST NEW: $ 25,000 TAX LOC: 9009 EXEMPT ZIP CODE: 40202 RADIUS: L SIZE: 10000 COVERAGES: SEQ. NO. 00056 PREMIUMS LIABILITY $ 776.00 PERSONAL INJURY PROTECTION $ 37.00 UNINSURED MOTORISTS $ 25.00 UNDERINSURED MOTORISTS $ 88.00 COMPREHENSIVE $ 1,000 DEDUCTIBLE $ 78.00 COLLISION $ 1,000 DEDUCTIBLE $ 154.00 Form HA 00 12 11 02T PAGE 15 (CONTINUED ON NEXT PAGE) | 2 |
II 3005 MS (08 13) APPLICABLE IN LOUISIANA LOUISIANA FRAUD STATEMENT Any person who knowingly presents a fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN MAINE MAINE FRAUD STATEMENT It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits. APPLICABLE IN NEW JERSEY NEW JERSEY FRAUD STATEMENT Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicant's Signature Date APPLICABLE IN NEW MEXICO NEW MEXICO FRAUD STATEMENT Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. APPLICABLE IN NEW YORK NEW YORK FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicant's Signature Date APPLICABLE IN OKLAHOMA OKLAHOMA FRAUD STATEMENT Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. 3 of 4 II 3005 MS (08 13) | 2 |
Endorsement No.: 03 Form: CUU 401 0805 Rev. Page: Effective Date: January 1, 2014 Issue Date: Attached to and forming part of Policy No.: US00045338LI14A Issued To: American Automobile Association of Northern California, Nevada & Utah By: XL Insurance America, Inc. Amendment of Cancellation Provisions This endorsement changes the policy. Please read it carefully. This endorsement modifies insurance provided under the following: Commercial Umbrella Liability Policy SCHEDULE Number of Days' Notice: 90 (If no entry appears above, information required to complete this Schedule will be shown in the Declarations as applicable to this endorsement.) For any statutorily permitted reason other than nonpayment of premium, the number of days required for notice of cancellation, as provided in Paragraph 2. of either the Cancellation Condition or as amended by an applicable state cancellation endorsement, is increased to the number of days shown in the Schedule above. All other terms, definitions, conditions and exclusions of this Policy remain unchanged. CUU 401 0805 © XL America, Inc. 2004 Includes copyrighted material of Insurance Services Office, Inc. with its permission | 2 |
A person or organization may sue us to recover on an agreed settlement or on a final judgment against you obtained after trial. We will not be liable for damages that are not payable under the terms of this policy or that are in excess of the applicable limit of this policy. An agreed settlement means a settlement and release of liability signed by us, you and the claimant or the claimant's legal representative. G. First Named Insured Responsibilities and Duties The Named Insured first listed in Item 1 of the Declarations will be responsible for and act on behalf of all "Insureds" with respect to the payment of any premiums and determination and receipt of payments of "Loss" due under this policy. H. Underlying Insurance The "Insured' represents that the applicable limit of the "Underlying Insurance" will be unimpaired as of the effective date of this policy. In the event of non-concurrent policy periods between this policy and any "Underlying Insurance", only covered "Occurrences" taking place during the Policy Period of this policy will be considered in determining the extent of any erosion or exhaustion of the applicable limit of "Underlying Insurance". I. Cancellation and Non-Renewal The cancellation and non-renewal provisions of this policy will follow the cancellation and non- renewal provisions of the "Controlling Underlying Insurance" except as provided by endorsement to this policy. J. Other Insurance If other valid and collectible insurance is available to you covering a "Loss" also covered by this policy, other than a policy that is specifically written to apply in excess of this policy, the insurance afforded by this policy shall apply in excess of and will not contribute with such "Other Insurance". SECTION VI - DEFINITIONS A. "Controlling Underlying Policy" means the policy shown in Item A. of the Schedule of "Underlying Insurance" of this policy. B. "Defense Expenses" will have the same definition as such term or the equivalent term in the "Controlling Underlying Policy". If not defined in the "Controlling Underlying Policy", "Defense Expenses" will mean reasonable and necessary expenses and costs incurred in investigating and defending against any claim, suit or other proceeding, and will include, without limitation, attorneys' fees. C. "Insured" means each entity or person which is insured under all "Underlying Insurance" in the same capacity as which such insurance is afforded. D. "Loss" will have the same definition as such term or the equivalent term in the "Controlling Underlying Policy". If there is no definition of "Loss" or equivalent term in the "Controlling Underlying Policy" then "Loss" shall mean: CXU 050 0509 Page 6 of 7 ©2009 X.L. America, Inc. All rights reserved. May not be copied without permission. | 2 |
Policy Number AS2-641-433446-140 GARAGEKEEPERS SCHEDULE Applicable to: CA 01 94 10 13, CA 99 37 10 13, CA 99 71 10 11 Location Number Address Where You Conduct Garage Operations 14 3052 W Martin Luther King Blvd, Fayetteville, AR 72701 Coverages Limit Of Insurance And Deductible Premium Comprehensive $60,000 Limit Of Insurance INCL $500 Deductible For Each Customer's Auto For Loss Caused By Theft Or Mischief Or Vandalism $2,500 Maximum Deductible For Loss Caused By Theft Or Mischief Or Vandalism In Any One Event OR Limit Of Insurance Deductible For All Perils For Each Customer's Auto Maximum Deductible For All Loss In Any One Event Specified Limit Of Insurance Causes Of Loss Deductible For Each Customer's Auto For Loss Caused By Theft Or Mischief Or Vandalism Maximum Deductible For Loss Caused By Theft Or Mischief Or Vandalism In Any One Event OR Limit Of Insurance Deductible For All Perils For Each Customer's Auto Maximum Deductible For All Loss In Any One Event Collision $60,000 Limit Of Insurance INCL $500 Deductible For Each Customer's Auto ACS 99 07 11 16 © 2016 Liberty Mutual Insurance Page 14 of 36 Includes copyrighted material of Insurance Services Office, Inc., with its permission. | 2 |
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A Edition 1/08 FINISHING OF TOOLS OR DIE MAKING OPERATIONS ELECTRICAL APPARATUS MFG. NOC 3179 1,915,381 1.62 $31,029 ELECTRIC OR GAS LIGHTING 3180 78,391 2.77 $2,171 FIXTURES MFG. HEAT TREATING--METAL 3307 16,229 3.07 $498 WELDING OR CUTTING NOC AND 3365 13,944 6.63 $924 DRIVERS METAL STAMPED GOODS MFG. NOC 3400 96,658 3.25 $3,141 CONSTRUCTION OR AGRICULTURAL 3507 27,814 3.44 $957 MACHINERY MFG. COMPUTING, RECORDING OR 3574 2,892,533 0.79 $22,851 OFFICE MACHINE MFG. NOC PUMP MFG. 3612 121,277 2.13 $2,583 MACHINED PARTS MFG. NOC 3629 54,356 1.40 $761 MACHINE SHOP NOC 3632 688,446 3.21 $22,099 VALVE MFG. 3634 330,358 1.68 $5,550 ELECTRIC POWER OR 3643 43,034 2.46 $1,059 TRANSMISSION EQUIPMENT MFG. TELEVISION, RADIO, TELEPHONE 3681 205,161 0.94 $1,929 OR TELECOMMUNICATION DEVICE MFG. NOC INSTRUMENT MFG. NOC 3685 212,945 1.01 $2,151 MACHINERY OR EQUIPMENT 3724 22,706 3.25 $738 ERECTION OR REPAIR NOC AND DRIVERS AUTOMOBILE--RADIATOR MFG. 3807 881,052 2.20 $19,383 AUTOMOBILE--MFG. OR ASSEMBLY 3808 1,799 3.58 $64 CONCRETE PRODUCTS MFG. AND 4034 675 6.07 $41 DRIVERS INTEGRATED CIRCUIT MFG. 4109 15,671 0.44 $69 GLASSWARE MFG. NOC 4114 109,730 2.40 $2,634 BOX MFG.--FOLDING PAPER--NOC 4243 1,664 2.20 $37 CORRUGATED OR FIBERBOARD 4244 161,971 2.17 $3,515 CONTAINER MFG. PAPER COATING 4250 4,805 1.97 $95 FIBER GOODS MFG. 4263 11,448 2.35 $269 BAG MFG.-PLASTIC OR PAPER 4273 20,372 3.80 $774 PAPER GOODS MFG. NOC 4279 64,732 2.14 $1,385 PRINTING 4299 642,389 2.25 $14,454 RUBBER GOODS MFG. NOC 4410 37,387 3.50 $1,309 PLASTICS MFG.--FABRICATED 4452 38,065 3.38 $1,287 PRODUCTS NOC PLASTICS MFG.--MOLDED 4484 4,192,743 3.14 $131,652 PRODUCTS NOC BUFFING OR POLISHING 4557 47,273 2.01 $950 COMPOUNDS MFG. DRUG, MEDICINE OR 4611 6,652 1.03 $69 PHARMACEUTICAL PREPARATION-- NO MFG. OF INGREDIENTS DRUG, MEDICINE OR 4825 40,345 0.72 $290 PHARMACEUTICAL PREPARATION XLINSURANCE WC 00 00 01A © 1987 National Council on Compensation Insurance. Page 12 Edition 1/08 © 2007 XL America, Inc. | 1 |
Page 3 of 8 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 024-78-0994 COLORADO 917019479 Policy Prefix & No. Schedule INTRA/Independent State Risk ID 055-09-1016-10 EXPRESS SERVICES, INC. Item 4. Classification of Operations Premium Basis Rates Code Estimated Total Per $100 of Estimated No. Annual Remuneration Remuneration Annual Premiums SCREEN PROCESS FILM PRINT SHOPS-ALL EMPLOYEES & 4361 1,546 2.24 35 CLERICAL, SALESPERSONS, DRIVERS BOOT OR SHOE MFG. RUBBER 4410 28,148 4.62 1,300 BONE OR IVORY GOODS MFG. 4452 9,003 4.50 405 CABLE MFG. INSULATED ELECTRICAL 4470 8,790 2.98 262 BUTTON MFG. NOC 4484 409,936 3.95 16,192 ANALYTICAL LABORATORIES OR 4511 72,466 0.63 457 ASSAYING-INCLUDING LABORATORY, OUTSIDE EMPLOYEES, COLLECTORS OF SAMPLES, & DRIVERS COLOR GRINDING, BLENDING, OR TESTING 4558 36,403 2.14 779 COSMETICS MFG. 4611 58,013 1.31 760 ACETYLENE GAS MFG. & DRIVERS 4635 140,963 2.99 4,215 ARTIFICIAL LIMB MFG. 4693 103,349 0.86 889 DRUG, MEDICINE OR PHARMACEUTICAL 4825 61,816 0.98 606 PREPARATION MFG. & INCLUDES MFG. OF INGREDIENTS CHEMICAL BLENDING OR MIXING NOC-ALL 4828 29,121 1.83 533 OPERATIONS & DRIVERS BASEBALL MASK MFG. 4902 141,189 3.19 4,504 AWNING ERECTION-METAL-ERECTION BY AN 5102 1,745 7.15 125 INSURED ENGAGED IN THE ERECTION OF CANVAS PRODUCTS. FIXTURES OR FURNITURE 5146 17,224 5.61 966 INSTALLATION-PORTABLE-NOC AIR-CONDITIONING SYSTEMS: NON-PORTABLE: 5183 10,736 5.62 603 PLUMBING & DRIVERS AIR CONDITIONING SYSTEMS: NON-PORTABLE: 5190 14,197 3.64 517 CLEANING, OILING OR ADJUSTING & DRIVERS COMPUTER-DEVICE INSTALLATION, 5191 11,879 1.04 124 INSPECTION, SERVICE, OR REPAIR COFFEE SERVICE COMPANIES-ALL OPERATIONS 5192 193,522 4.03 7,799 & SALESPERSONS, DRIVERS CLEANING OR RENOVATING BUILDING 5213 61,882 6.93 4,288 EXTERIORS CONCRETE OR CEMENT WORK-FLOORS, 5221 9,332 7.78 726 DRIVEWAYS, YARDS, OR SIDEWALKS & DRIVERS SWIMMING PO0L-CONSTRUCTION-NOT IRON OR 5223 389 6.70 26 STEEL & DRIVERS CERAMIC TILE, INDOOR STONE, MARBLE, OR 5348 1,404 6.18 87 MOSAIC WORK GREENHOUSE ERECTION-ALL OPERATIONS 5402 1,777 8.58 152 BRIDGE CONSTRUCTION-WOOD 5403 337,590 8.40 28,358 CARPENTRY-INSTALLATION OF CABINET WORK 5437 221 8.21 18 OR INTERIOR TRIM IRON OR STEEL-ERECTION-STEEL 5445 44,190 8.83 3,902 WC 7754 (Ed. 4-81) (Rev'd 04/08) | 1 |
POLICY NUMBER: 37 UEA AA2667 LISTING OF COVERAGE PARTS AND ENDORSEMENTS FORMING A PART OF THE POLICY The following is a listing of policy provisions, forms and endorsements by Form Number and Title that form a part of the policy at issue. FORM NUMBER TITLE 25 IL0261 09-07 KANSAS CHANGES - CANCELLATION AND NONRENEWAL 26 HC2190 06-08 EXCLUSION - FUNGI, BACTERIA AND VIRUSES 27 IL0021 09-08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT 28 IH9940 04-09 U.S. DEPT OF THE TREASURY, OFFICE OF FOREIGN ASSETS CONTROL ("OFAC") ADVISORY NOTICE TO POLICYHOLDERS 29 IH9941 04-09 TRADE OR ECONOMIC SANCTIONS ENDORSEMENT 30 HG0068 12-10 RECORDING AND DISTRIBUTION OF MATERIAL OR INFORMATION IN VIOLATION OF LAW EXCLUSION 31 HC2183 10-01 ABSOLUTE POLLUTION EXCLUSION EXCEPTION FOR MOBILE EQUIPMENT 32 IL0017 11-98 COMMON POLICY CONDITIONS 33 G-3418-0 PRODUCER COMPENSATION NOTICE Form HS 99 22 06 08 (c) 2008, The Hartford | 0 |
LIQUOR LIABILITY COVERAGE PART - SCHEDULE Insurance for this coverage part provided by: ZURICH AMERICAN INSURANCE COMPANY Prem. Bldg. Class No. No. Exposure Premium Base Code 001 001 58161 $ 75,000 PER 1,000 OF GROSS SALES Class Description: RESTAURANTS, TAVERNS, HOTELS, MOTELS, INCLUDING PACKAGE SALES Rate Premium 1.29 $ 97 Prem. Bldg. Class No. Exposure Premium Base No. Code 004 001 58161 $ 75,000 PER 1,000 OF GROSS SALES Class Description: RESTAURANTS, TAVERNS, HOTELS, MOTELS, INCLUDING PACKAGE SALES Rate Premium 1.29 $ 97 Prem. Bldg. Class No. Exposure Premium Base No. Code 005 002 58161 $ 150,000 PER 1,000 OF GROSS SALES Class Description: RESTAURANTS, TAVERNS, HOTELS, MOTELS, INCLUDING PACKAGE SALES Rate Premium 1.29 $ 194 Prem. Bldg. Class No. Code Exposure Premium Base No. 006 001 58161 $ 250,000 PER 1,000 OF GROSS SALES Class Description: RESTAURANTS, TAVERNS, HOTELS, MOTELS, INCLUDING PACKAGE SALES Rate Premium 1.29 $ 323 U-GL-505-A (01/93) Page 1 See next page | 1 |
U United Educators withhold or delay), other than a settlement for which no payment for Damages or Defense Costs is sought by the Insureds under this Policy. 9. If the Insured elects not to appeal a judgment in which Damages and Defense Costs are in excess of the Deductible, if applicable, we may appeal at our own cost (including disbursements and interest on judgments incidental to the appeal), but in no event shall our liability for Damages exceed the Limit of Liability of this Policy applicable to each Occurrence and in the aggregate for all Occurrences. EXCLUSIONS 10. This Policy does not apply to: a. any liability of an Insured as an employer or any obligation for which any Insured or any company as its insurer may be held liable under any workers' compensation, unemployment compensation or disability benefits law or the Longshoremen's and Harbor Workers' Compensation Act, or any similar law; b. Wrongful Employment Practices; C. Personal Injury or Advertising Injury (1) resulting from an act by or at the direction of any Insured if performed with the knowledge that such act would cause injury; or (2) arising out of the oral or written publication of material (i) first published prior to the beginning of the Policy Period; or (ii) by or at the direction of the Insured with knowledge of its falsity; Exception: Item (2)(i) of this Exclusion does not apply to any Clerical or Administrative Error; d. Advertising Injury arising out of (1) breach of contract; (2) the failure of goods, products or services to conform to advertised quality or performance; or (3) incorrect description or mistake in advertised price; Exception: Item (1) of this exclusion does not apply to misappropriation of advertising ideas under an implied contract; e. any liability arising out of the ownership, repair, maintenance, use or entrustment to others of any Automobile; Exception: This exclusion does not apply to (1) liability of the Educational Organization arising out of the use of an Automobile rented by an employee of the Educational Organization for a period of 120 days or less for use by an employee of the Educational Organization while temporarily outside the United States, its possessions or territories, or Canada, on Educational Organization business; (2) the limited coverage with respect to pollution provided by Paragraph 10.m.(1)(b) of this Policy; (3) the parking of any Automobile not owned by or rented or loaned to any Insured on or adjacent to premises owned or rented by an Included Entity; or (4) liability arising out of the repair or maintenance of Automobiles by students or employees of the Educational Organization as part of any curriculum-related instruction; f. any liability arising out of rendering or failure to render any Professional Services; Exception: This exclusion shall not apply to (1) the liability of an Insured caused by a student intern while participating in any paid and supervised practicum, field work experience, or internship program; however, this Exception shall not apply to internships that may be legally performed only by a person holding a professional license, regardless of whether the student is licensed or not; or (2) the liability of the Educational Organization and its employed Insureds from Claims first made against any Insured during the Policy Period for an Occurrence on or after the Inception Date arising out of the rendering or failure to render health care services by a CGLLanguage Version Date: 06/01/2008 CGL 06-2008 Print Date: 11/01/2018 Page 7 of 14 | 2 |
Z R Extended Schedule of Underlying Insurance ZURICH Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer Add'l Prem. Return Prem. AUC 0179037-05 06/15/2020 06/15/2021 06/15/2020 28832000 Named Insured and Mailing Address: Producer: MAX MANDELL MUNICIPAL GOLF COURSE LOCKTON COMPANIES, LLC 27700 FM 1472 1015 N 98TH ST STE 101 LAREDO, TX 78045-5022 OMAHA, NE 68114-2357 Company, Policy No. and Term Coverage Applicable Limits Company: Zurich American Insurance Liquor Liability $1,000,000 Each Occurrence Company Policy No: CPO-0179034-05 liquor liability $1,000,000 Aggregate Term: 06/15/2020 to 06/15/2021 U-UMB-106-A CW (07/99) Page 1 of 1 | 2 |
4. The Each Occurrence Limit of Insurance shown in the Declarations continues to apply. However, instead of being subject to the Aggregate Limit of Insurance shown in the Declarations, such limit will be subject to the applicable Designated Construction Project Aggregate Limit. B. This insurance only applies in excess of the "retained limit." C. If the Limits of Insurance of the "controlling underlying insurance" are reduced by defense expenses by the terms of that policy, any payments for defense expenses we make will reduce our applicable Limits of Insurance in the same manner. D. If any "controlling underlying insurance" has a policy period that is different from the policy period of this Coverage Part then, for the purposes of this insurance, the "retained limit" will only be reduced or exhausted by payments made for "injury or damage" covered under this insurance. AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2012 XLS-2354 (1-14) Page 2 of 2 Insured Copy | 2 |
PAGE 3 POLICYWRITING INDEX ACCOUNT NUMBER POLICY NUMBER PREVIOUS POLICY NUMBER EFFECTIVE DATE - EXPIRATION DATE 1006340000 GLO 0144516-01 GLO 0144516-00 02-27-2018 02-27-2019 CG 20 10 04-13 ADDL INSD - OWNERS/LESSEES/CONTRACTORS CG 20 26 04-13 ADDL INSD-DESIGNATED PERSON/ORGANIZATION CG 21 06 05-14 EXCL-ACC/DISCL OF CONFI OR PERSONAL INFO CG 21 16 04-13 EXCL-DESIGNATED PROFESSIONAL SERVICES CG 21 47 12-07 EMPLOYMENT-RELATED PRACTICES EXCLUSION CG 21 73 01-15 EXCLUSION OF CERTIFIED ACTS OF TERRORISM CG 26 55 11-08 NH CHANGES-AMEND OF REPRESENT CONDITION CG 26 88 01-15 AK EXCL OF CERTIFIED ACTS OF TERRORISM CG 27 19 07-09 NH EMPLOYEE BENEFITS LIABILITY COVG IL 00 03 09-08 CALCULATION OF PREMIUM IL 00 17 11-98 COMMON POLICY CONDITIONS IL 00 21 09-08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDT IL 01 35 09-08 NEW HAMPSHIRE CHANGES-CANC & NONRENEWAL U-GL-2110-A CW 01-15 PN - ACCESS OR DISCLOSURE OF CONF INFO U-GU-298-B CW 04-94 CANCELLATION BY US U-GU-630-D CW 01-15 DISCLOSURE OF INFO RELATING TO TRIA U-GU-1191-A CW 03-15 SANCTIONS EXCLUSION ENDORSEMENT | 0 |
Liberty Mutuál. IRONSHORE™ Railroad General Liability INSURANCE A Liberty Mutual Company LIBERTY SURPLUS INSURANCE CORPORATION (A New Hampshire Stock Insurance Company, hereinafter the "Company") 175 Berkeley Street, Boston, MA 02116 Toll-Free number: 1-800-677-9163 Policy Number: Broker Name and Address Renewal of 1st Yr. Liab. Pol. GLHV452159-7 R T SPECIALTY, LLC GLHV452159-6 2014 1100 Walnut Street, Suite 3200 Kansas City, MO 64106 Item 1. Named Insured: Freedom Railcar Solutions, LLC Address: 250 South Castle Rock Lane Mustang, OK 73064 First Named Insured: Freedom Railcar Solutions, LLC The Named Insured is: Individual Partnership LLC An organization other than a Partnership, Joint Venture or LLC Business of the Insured is: Railroad Repair Item 2. Policy Period: From June 20, 2020 To June 20, 2021 12:01 A.M., standard time at the address of the Named Insured as stated herein Item 3. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. LIMITS OF INSURANCE GENERAL AGGREGATE LIMIT (Other than Products-Completed Operations $4,000,000 PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT $4,000,000 BODILY INJURY AND PROPERTY DAMAGE LIABILITY (Each Occurrence) $2,000,000 DAMAGES TO PREMISES RENTED TO YOU LIMIT (Each Occurrence) $50,000 PERSONAL INJURY AND ADVERTISING INJURY (Each Occurrence) $2,000,000 MEDICAL PAYMENTS $5,000 Item 4. DEDUCTIBLE AMOUNT The Deductible Amount is $5,000 Per Occurrence including Loss Adjustment Expense Item 1. PREMIUM Classifications or Premium Basis Certified TRIA Locations Revenues Rate Premium Policy Premium Railcar $2,500,000 $10.86 per $1,000 of Revenue $1,358 $28,508 Repair/Cleaning up to $2,500,000 $7.00 rate per $1,000 of Revenue 1 2 GL 1001 (07/01) | 2 |
(5) "Waste" means any waste material: (a) Containing "byproduct material" other than the tailings or wastes produced by the extraction or concentration of uranium or thorium from any ore processed primarily for its "source material" content; and (b) Resulting from the operation by any person or organization of any "nuclear facility" included under the first two paragraphs of the definition of "nuclear facility"; (6) Nuclear facility means: (a) Any "nuclear reactor"; (b) Any equipment or device designed or used for (i) Separating the isotopes of uranium or plutonium; (ii) Processing or utilizing spent fuel; or (iii) Handling, processing or packaging waste; (c) Any equipment or device used for the processing, fabricating or alloying of special nuclear material if at any time the total amount of such material in the custody of the "insured" at the premises where such equipment or device is located consists of or contains more than 25 grams of plutonium or uranium 233 or any combination thereof, or more than 250 grams of uranium 235; (d) Any structure, basin, excavation, premises, or place prepared or used for the storage or disposal of waste; (e) The site on which any of the foregoing is located, all operations conducted on such site and all premises used for such operations. (7) "Nuclear reactor" means any apparatus designed or used to sustain nuclear fission in a self-supporting chain reaction or to contain a critical mass of fissionable material. (8) "Property damage" includes all forms of radioactive contamination of property. All other terms and conditions of this policy remain unchanged. Authorized Representative PC-26738 (03/09) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 2 | 2 |
SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: HARTFORD CASUALTY INSURANCE COMPANY Company Code: 3 Policy Number: 37 WB BN3284 Schedule Number: 01-26-01 Effective Date: 10/01/13 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: WALSWORTH PUBLISHING COMPANY, INC. 1508 CHANDLER OMAHA NE 68147 NAICS: 323110 FEIN: 430718484 UIN: SIC: 2752 NO. OF EMPL: 3 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 4299 IF ANY 3.49 PRINTING 7380 IF ANY 7.18 DRIVERS, CHAUFFEURS, MESSENGERS, AND THEIR HELPERS NOC - COMMERCIAL 8742 620,000 .64 3,968 SALESPERSONS OR COLLECTORS - OUTSIDE 8810 IF ANY .32 CLERICAL OFFICE EMPLOYEES NOC Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 10/10/13 Policy Expiration Date: 10/01/14 | 1 |
AAIS This endorsement changes CU 0705 09 10 the policy Page 1 of 1 -- PLEASE READ THIS CAREFULLY -- EXCLUSION -- EXTERIOR INSULATION AND FINISH SYSTEMS COVERAGES E AND U The Commercial Excess/Umbrella Liability "We" do not pay for: Coverage is amended as follows. All other "terms" of the policy apply, except as amended by a. actual or alleged "bodily injury", "property this endorsement. damage", or "personal and advertising injury" that arises out of the design, manufacture, sale, service, construction, fabrication, preparation, installation, application, DEFINITIONS maintenance, or repair, including any remodeling, correction, or replacement of an "EIFS" or any part thereof, or any Under Definitions, the following definition is substantially similar system or any part added: thereof, including any method or procedure to correct problems with installed or partially "EIFS" means an exterior wall cladding or finish installed systems performed by or on behalf of an "insured". system used on any part of any structure, and consisting of: b. actual or alleged "bodily injury", "property a. a rigid or semi-rigid insulation board made of damage", or "personal and advertising injury" expanded polystyrene or other materials; that arises out of "your work" and that results directly or indirectly from any exterior b. an adhesive or mechanical fastener used for component, fixture, or feature of any the attachment of the insulation board to the structure if an "EIFS" is used on any part of that structure. substrate; C. a reinforced or unreinforced base coat on the C. actual or alleged "bodily injury" or "property face of the insulation board or base coat and damage" included in the "products/completed mesh; work hazard" and that results directly or indirectly from any exterior component, d. a protective finish applied to the surface of fixture, or feature of any structure if an "EIFS" the base coat providing surface texture to is used on any part of that structure. which color may be added; and d. "bodily injury" or "property damage" liability e. any conditioners, primers, accessories, assumed by an "insured" under a contract or flashings, coatings, caulking, and sealants agreement for the design, manufacture, sale, that interact to form an energy efficient wall. service, construction, fabrication, preparation, installation, application, maintenance, or repair, including any remodeling, correction, or replacement of an "EIFS" or any part thereof, or any substantially similar system or COMMERCIAL EXCESS/UMBRELLA any part thereof. LIABILITY COVERAGES CU 0705 09 10 The following exclusions are added under Coverage E and Coverage U, item 2. Exclusions: Copyright, American Association of Insurance Services, Inc., 2010 | 2 |
Policy Number 41WCI0840304 SCHEDULE OF FORMS AND ENDORSEMENTS ARCH INSURANCE COMPANY Named Insured HALL MECHANICAL CONTRACTORS, Effective Date: 10-26-2020 12:01 A.M., Standard Time Agent Name WILLIS TOWERS WATSON MIDWEST, INC. Agent No. 00267 WORKERS COMPENSATION FORMS AND ENDORSEMENTS 00 ML0042 44 12-19 IMPORTANT NOTICE TO ALL TX POLICYHOLDERS 00 ML0065 00 06-07 US TREASURY DEPT'S OFAC ADVISORY NOTICE 05 ML0043 44 01-13 TX WC LOSS CONTROL SERVICES POLICYHOLDER 05 ML0002 00 12-14 ARCH INSURANCE GROUP SIGNATURE PAGE WC 00 00 01 A 07-97 WC INFORMATION PAGE WC 89 04 15 07-97 WC CLASSIFICATION SCHEDULE WC 00 00 00 C 01-15 INSURANCE POLICY 00 ML0087 00 11-10 NOTICE OF CANC - SPECIFIED DAYS 00 WC004 00 11-03 EARLIER NOTICE OF CANCELLATION BY US WC 00 01 06 A 04-92 LONGSHORE & HARBOR WC ACT COVERAGE ENDT WC 00 03 01 04-84 ALTERNATE EMPLOYER ENDT WC 00 03 02 04-84 DESIGNATED WORKPLACES EXCLUSION ENDT WC 00 03 11 A 08-91 VOLUNTARY COMP AND EMPLOYERS LIAB COVG WC 00 04 14 A 01-19 90DAY REPORT-NOTIF CHANGE IN OWNERSHIP WC 00 04 22 B 01-15 TERRORISM RISK PGM REAUTH ACT DISCL ENDT WC 00 04 25 05-17 EXPERIENCE RATING MODIFICATION FCTR REV WC 42 03 01 J 06-20 TEXAS AMENDATORY ENDORSEMENT WC 42 03 04 B 06-14 TX-WAIVER OF OUR RIGHT TO RECOVER WC 42 04 07 03-02 TX AUDIT PREM AND RETRO PREM ENDT WC 42 04 08 A 06-14 TEXAS HEALTH CARE NETWORK ENDORSEMENT 00ML020700 11-03 ASSIGNMENT CONSENT ENDORSEMENT 00ML020700 11-03 DESIGNATED PROJECT - DECLARATION ENDT WC 89 06 14 | 0 |
POLICY NUMBER: FBCAT0256502 COMMERCIAL AUTO ARCH INSURANCE COMPANY MOTOR CARRIER DECLARATIONS ITEM ONE PRODUCER: FREBERG ENVIRONMENTAL INSURANCE, INC NAMED INSURED: M LAKE 23, LLC DBA: ABSOLUTE RECYCLING MAILING ADDRESS: 201 W. 11TH AVE NORTH KANSAS CITY, MO 64116 POLICY PERIOD: From 06-03-2015 to 06-03-2016 at 12:01 A.M. Standard Time at your mailing address shown above. PREVIOUS POLICY NUMBER: FBCAT0256501 FORM OF BUSINESS: CORPORATION X LIMITED LIABILITY COMPANY INDIVIDUAL PARTNERSHIP OTHER IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. Premium shown is payable at inception: $ 34,050.00 AUDIT PERIOD (IF APPLICABLE) ANNUALLY SEMI- QUARTERLY MONTHLY ANNUALLY ENDORSEMENTS ATTACHED TO THIS POLICY: IL 0017 - Common Policy Conditions (IL 01 46 in Washington) IL 00 21 - - Broad Form Nuclear Exclusion (Not Applicable in New York) (IL 01 98 in Washington) SEE SCHEDULE OF FORMS AND ENDORSEMENTS COUNTERSIGNED BY (Date) (Authorized Representative) MC-DEC C/W 10 13 Page 1 INSURED COPY | 2 |
(2) the amount of the covered claim, subject to (3) the applicable Limits of Insurance and any sublimits of insurance. Notwithstanding the foregoing, no person or entity shall be a Named Insured if trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims, for, on behalf of, or to such person or entity. With regard to joint ventures, partnerships, and limited liability companies, no member, partner, or joint venturer of such entity is a Named Insured, "you" or "your" unless separately shown as such in the Declarations or in paragraph A. above. 2. Notwithstanding any provision to the contrary in this policy, if other valid and collectible insurance is available to any organization covered by this policy solely because of the ownership or "control" by the First Named Insured, this insurance shall be excess with regard to such other insurance whether "contingent", "primary", excess or any other basis. This provision does not apply to any "underlyer policy", to which the terms of the Other Insurance condition applicable to the coverage form or part will apply. 3. For purposes of this endorsement: A. "Control" or "controls" means that the first Named Insured shown in the Declarations owns, during the policy period, a majority ownership of less than 100 percent (100%) in, or has "management control" over, the organization. "Management control" means: (1) The power to formulate or direct the policy of the organization; (2) The authority to hire and fire employees of the organization; (3) The authority to enter into contracts binding on the organization and to purchase or sell assets on behalf of the organization; or (4) The authority to delegate any of the foregoing to others. B. "Underlyer policy" means a policy or policies issued in a particular country by an admitted insurer in that country at our request or the request of our affiliated insurance company, and which policy or policies are part of a worldwide liability insurance program for which this policy provides coverage on a difference in conditions and/or difference in limits basis. All other terms and conditions of this policy remain unchanged. IT7100 version date: 11-2011 Page 2 of 2 © 2008. 2009 | 2 |
Premium Summary (continued) TOTAL $ 3,090 Renewal 13/14 If ATD coverage is provided on this policy, additional certificate and handling fees may be imposed during the policy term. Coverage Premium Additional certificate and handling fees may be imposed as respects to certification of pressure equipment as mandated by State and/or local jurisdictional authorities. Payment Plan This policy premium is being billed as follows. The amounts shown are due and payable as of the dates shown below: Date Payment Due Amount Due SEPTEMBER 1, 2013 $ 3,090.00 Issue Date: JUNE 5, 2013 last page Form 80-02-9009 (Rev. 10-05) Premium Summary Page 2 | 2 |
ITEM FOUR Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums (Cont'd) Cost Of Hire Rating Basis For Mobile Or Farm Equipment - Physical Damage Coverages Estimated Annual Cost Of Hire For Each State (Excluding Autos Hired With A Driver) Premiu Premium Mobile Farm Mobile Farm Coverages State Limit Of Insurance Equipment Equipment Equipment Equipment Comprehen Actual Cash Value Or Cost Of $ $ $ $ sive Repair, Whichever Is Less, Minus $ Deductible For Each Covered Auto, But No Deductible Applies To Loss Caused By Fire Or Lightning. Specified Actual Cash Value Or Cost Of $ $ $ $ Causes Of Repair, Whichever Is Less, Minus Loss $ Deductible For Each Covered Auto For Loss Caused By Mischief Or Vandalism Collision Actual Cash Value Or Cost Of $ $ $ $ Repair, Whichever Is Less, Minus $ Deductible For Each Covered Auto Total Hired Auto Premium $ $ For Physical Damage Coverages, cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for any "auto" that is leased, hired, rented or borrowed with a driver. CA DS 03 10 13 © Insurance Services Office, Inc., 2011 Page 43 of 47 | 2 |
"Source material", "special nuclear material", and (c) Any equipment or device used for the process- "by-product material" have the meanings given ing, fabricating or alloying of "special nuclear them in the Atomic Energy Act of 1954 or in any material" if at any time the total amount of such law amendatory thereof. material in the custody of the "insured" at the "Spent fuel" means any fuel element or fuel com- premises where such equipment or device is ponent, solid or liquid, which has been used or located consists of or contains more than 25 exposed to radiation in a "nuclear reactor". grams of plutonium or uranium 233 or any combination thereof, or more than 250 grams "Waste" means any waste material (a) containing of uranium 235; "by-product material" other than the tailings or wastes produced by the extraction or concentra- (d) Any structure, basin, excavation, premises or tion of uranium or thorium from any ore processed place prepared or used for the storage or dis- primarily for its "source material" content, and (b) posal of "waste"; resulting from the operation by any person or or- and includes the site on which any of the forego- ganization of any "nuclear facility" included under ing is located, all operations conducted on such the first two paragraphs of the definition of "nu- site and all premises used for such operations. clear facility". "Nuclear reactor" means any apparatus designed "Nuclear facility" means: or used to sustain nuclear fission in a self- (a) Any "nuclear reactor"; supporting chain reaction or to contain a critical mass of fissionable material. (b) Any equipment or device designed or used for (1) separating the isotopes of uranium or plu- "Property damage" includes all forms of radioactive tonium, (2) processing or utilizing "spent fuel", contamination of property. or (3) handling, processing or packaging "waste"; Page 2 of 2 © ISO Properties, Inc., 2001 IL 00 23 07 02 | 2 |
IMPORTANT NOTICE Effective July 1, 1978 The Georgia Workers' Compensation Law requires that compensation payments to injured workers begin within fourteen days after the employer has knowledge of the accident. If a delay is due to your failure to report a claim to the company the penalty will be paid by you. Your Insurance carrier will not reimburse you. To avoid any possibility of a substantial penalty, report all accidents and claims to our claims representative immediately. If you are unable to contact our claim representative, notify your agent and ask him/her to see that the claim report is made out and filed without delay Form WC 66 02 75 Printed in U.S.A. | 2 |
COMMERCIAL GENERAL LIABILITY CG 00 01 12 07 COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage. b. This insurance applies to "bodily injury" and Read the entire policy carefully to determine rights, "property damage" only if: duties and what is and is not covered. (1) The "bodily injury" or "property damage" is Throughout this policy the words "you" and "your" caused by an "occurrence" that takes place refer to the Named Insured shown in the Declarations, in the "coverage territory"; and any other person or organization qualifying as a (2) The "bodily injury" or "property damage" Named Insured under this policy. The words "we", "us" occurs during the policy period; and and "our" refer to the company providing this insur- ance. (3) Prior to the policy period, no insured listed under Paragraph 1. of Section II - Who Is The word "insured" means any person or organization An Insured and no "employee" authorized qualifying as such under Section II - Who Is An In- by you to give or receive notice of an "oc- sured. currence" or claim, knew that the "bodily in- Other words and phrases that appear in quotation jury" or "property damage" had occurred, in marks have special meaning. Refer to Section V - whole or in part. If such a listed insured or Definitions. authorized "employee" knew, prior to the SECTION - COVERAGES policy period, that the "bodily injury" or "property damage" occurred, then any con- COVERAGE A BODILY INJURY AND PROPERTY tinuation, change or resumption of such DAMAGE LIABILITY "bodily injury" or "property damage" during 1. Insuring Agreement or after the policy period will be deemed to a. We will pay those sums that the insured be- have been known prior to the policy period. comes legally obligated to pay as damages be- C. "Bodily injury" or "property damage" which cause of "bodily injury" or "property damage" to occurs during the policy period and was not, which this insurance applies. We will have the prior to the policy period, known to have OC- right and duty to defend the insured against curred by any insured listed under Paragraph any "suit" seeking those damages. However, we 1. of Section II - Who Is An Insured or any will have no duty to defend the insured against "employee" authorized by you to give or receive any "suit" seeking damages for "bodily injury" or notice of an "occurrence" or claim, includes any "property damage" to which this insurance continuation, change or resumption of that does not apply. We may, at our discretion, in- "bodily injury" or "property damage" after the vestigate any "occurrence" and settle any claim end of the policy period. or "suit" that may result. But: d. "Bodily injury" or "property damage" will be (1) The amount we will pay for damages is deemed to have been known to have occurred limited as described in Section III - Limits at the earliest time when any insured listed un- Of Insurance; and der Paragraph 1. of Section II - Who Is An In- (2) Our right and duty to defend ends when we sured or any "employee" authorized by you to have used up the applicable limit of insur- give or receive notice of an "occurrence" or claim: ance in the payment of judgments or set- tlements under Coverages A or B or medi- (1) Reports all, or any part, of the "bodily injury" cal expenses under Coverage C. or "property damage" to us or any other in- surer; No other obligation or liability to pay sums or perform acts or services is covered unless ex- (2) Receives a written or verbal demand or plicitly provided for under Supplementary Pay- claim for damages because of the "bodily in- ments - Coverages A and B. jury" or "property damage"; or (3) Becomes aware by any other means that "bodily injury" or "property damage" has OC- curred or has begun to occur. CG 00 01 12 07 © ISO Properties, Inc., 2006 Page 1 of 16 | 2 |
XS SU 3003 12 07 HDI GLOBAL INSURANCE COMPANY COMMERCIAL UMBRELLA LIABILITY DECLARATIONS Policy Number: XLD13304-02 EXTENSION SCHEDULE FOR COIM USA, INC. IL SU 4003 12 12 HDI GLOBAL INSURANCE COMPANY POLICY JACKET XS SU 3001 07 14 COMMERCIAL EXCESS LIABILITY DECLARATIONS PAGE XS SU 3002 12 07 COMMERCIAL EXCESS LIABILITY SCHEDULE OF UNDERLYING INSURANCE XS SU 3003 12 07 EXTENSION SCHEDULE CX 0001 04 13 COMMERCIAL LIABILITY UMBRELLA COVERAGE FORM CX 0238 09 08 NEW JERSEY CHANGES - CANCELLATION AND NONRENEWAL CX 2101 09 08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT CX 2131 01 15 EXCLUSION OF OTHER ACTS OF TERRORISM COMMITTED OUTSIDE THE UNITED STATES; CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM CX 2131 01 15 EXCLUSION OF OTHER ACTS OF TERRORISM COMMITTED OUTSIDE THE UNITED STATES; CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM CX 2143 05 14 EXCLUSION - ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION CX 2700 09 08 UNDERLYING CLAIMS-MADE COVERAGE IL 09 85 01 15 DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT MANUSCRIPT ENDT 1 EXCLUSION SPECIFIC SUBSTANCES II 3004 MS 08 11 ANTI-FRAUD WARNING LETTER II 3005 MS 08 13 STATE FRAUD STATEMENTS IL AM 4001 10 11 ECONOMIC OR TRADE SANCTIONS IL P 001 01 04 U.S. TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ("OFAC") ADVISORY NOTICE TO POLICYHOLDERS Page 1 of 1 XS SU 3003 12 07 | 0 |
NATIONWIDE MUTUAL INSURANCE COMPANY Nationwide Certificate of Insurance Common Declarations This Certificate of Insurance is issued to the Enrolled Member of the Sports, Leisure and Entertainment Risk Purchasing Group. In return for the payment of premium we agree to provide the Enrolled Member insurance, subject to all the terms and conditions of policy number FWC300347-00 issued to the Sports, Leisure and Entertainment Risk Purchasing Group, except as modified by this certificate including the forms and endorsements made a part of this certificate. Certificate Number: FWC0000030940900 Enrolled Member BOUNCETASTIC INFLATABLE (SEE SRPG17348) & Mailing Address: P.O. BOX 256 WOLFE CITY, TX 75496 Business Description: EQUIPMENT RENTAL Coverage Period: From 12:01 am on 09/10/19 to 12:01 am on 09/10/20 The coverages provided are indicated as follows: Included Not Included Commercial General Liability X Hired Auto and Employers' Nonownership Liability X Total Premium $ 875 Premium earned at inception $ 750 Form(s) and Endorsement(s) made a part of this certificate at time of issue: SRPG17348(12/02) IL0017(11/98) CAS3228 SRPG0103(09/08) SRPG00210 (09/08) IL0985(01/15) IL0168(03/12) IL0275(11/13) Acott humber Authorized Representative SRPG100 07/13 | 2 |
STARR Workers Compensation and Employers Liability Insurance Policy Policy Number: 100 0003868 INDEMNITY Named Insured: HOSPITAL COURIERS, LLC A MEMBER OF STARR COMPANIES Agent: CLAUDIA MANDATO 0502726 ENDORSEMENT SCHEDULE State Form Nbr. Ed. Date Description US WC000000C 1/15 WC & EL POLICY CA WC000404 4/84 PENDING RATE CHANGE ENDT CA WC000406A 7/95 PREMIUM DISCOUNT ENDT CA WC000419 1/01 PREMIUM DUE DATE ENDT CA WC000421D 1/15 CATASTROPHE (O/T C.A.T.) PRM EN CA WC000422B 1/15 TERR RISK INS REAUTHZ DISC END CA WC040301D 2/18 POLICY AMENDATORY ENDORSEMENT CA WC040305 1/85 CA VOLUNTARY COMPENSATION CA WC040306 4/84 CA WAIVER OF OUR RIGHT TO REC CA WC040310 1/95 CA DUTY TO DEFEND CA WC040421 1/08 CA OPTIONAL PREMIUM INCREASE CA WC040422 1/12 CA SHORT-RATE CANCELATION ENDT CA WC040601A 12/93 CA CANCELLATION ENDT CA WC990605 5/12 ADVANCED NOTICE OF CANCELLATIO CA WC990606 5/12 KNOWLEDGE OF OCCURRENCE ENDT CO WC000310 4/84 SOLE PROPRIETORS PARTNERS CO WC000311A 8/91 VOLUNTARY COMP & EL ENDT CO WC000313 4/84 WAIVER OF OUR RIGHT TO RECOVER CO WC000404 4/84 PENDING RATE CHANGE ENDT CO WC000406 8/84 PREMIUM DISCOUNT ENDT CO WC000414A 1/19 NOTIFICATION OF CHG IN OWNER CO WC000419 1/01 PREMIUM DUE DATE ENDT CO WC000421D 1/15 CATASTROPHE (O/T C.A.T. PRM EN CO WC000422B 1/15 TERR RISK INS REAUTHZ DISC END CO WC000424 1/17 AUDIT NONCOMPLIANCE CHARGE END CO WC000425 5/17 EXPER RATING MOD FACTOR REV CO WC050402 11/90 CLASSIFICATION ENDT CO WC050403 3/93 PREM CREDIT FOR CERTIFIED RISK CO WC990605 5/12 ADVANCED NOTICE OF CANCELLATIO CO WC990606 5/12 KNOWLEDGE OF OCCURRENCE ENDT Issued Date: 09/29/2019 00 WC000001A (Ed. 05/88) INSURED'S COPY Page 27 of 33 | 0 |
Policy Number GLO 6555467-04 ENDORSEMENT ZURICH AMERICAN INSURANCE COMPANY Named Insured FIRSTSERVICE CORPORATION Effective Date: 10-25-13 12:01 A.M., Standard Time Agent Name LOCKTON COMPANIES LLC Agent No. 37385-000 DESIGNATED ENTITY EXCLUSION THIS INSURANCE DOES NOT APPLY TO "BODILY INJURY", "PROPERTY DAMAGE" OR "PERSONAL AND ADVERTISING INJURY" ARISING OUT OF THE FOLLOWING ENTITIES: ANY NAMED INSURED OR ANY SUBSIDIARY COMPANY THAT HAS OWNERSHIP INTEREST OF 50% OR MORE AND COVERED ELSEWHERE WILL NOT BE COVERED UNDER THIS POLICY. REGARDLESS OF OTHER INSURANCE LIMITS AND COVERAGE, THIS POLICY WILL NOT BE PRIMARY, EXCESS, CONTINGENT, NOR CONTRIBUTE ON ANY OTHER BASIS. THIS EXCLUSION DOES NOT APPLY FOR NEWLY ACQUIRED ENTITIES UP TO 90 DAYS FOR WHICH THERE IS OWNERSHIP INTEREST OF 50% OR MORE. U-GL-1114-A CW (10/02) | 2 |
POLICY NUMBER: XSL G27855702 Texas Notice - ace group Information and Complaints AVISO IMPORTANTE IMPORTANT NOTICE Para obtener información o para presentar una queja: To obtain information or make a complaint: Usted puede llamar al número de teléfono gratuito de la You may call the Company's toll-free telephone number Compañía para obtener información o para presentar una for information or to make a complaint at: queja al: 1 (800) 352-4462 1 (800) 352-4462 You may also write to the Company at: Usted también puede escribir a la Compañía: ACE USA ACE USA Customer Services Customer Services PO Box 1000 PO Box 1000 Philadelphia, PA 19106-3703 Philadelphia, PA 19106-3703 You may contact the Texas Department of Insurance to Usted puede comunicarse con el Departamento de obtain information on companies, coverages, rights or Seguros de Texas para obtener información sobre complaints at: compañías, coberturas, derechos, o quejas al: 1 (800) 252-3439 1 (800) 252-3439 You may write the Texas Department of Insurance: Usted puede escribir al Departamento de Seguros de Texas a: P. O. Box 149104 Austin, TX 78714-9104 P.O. Box 149104 Fax: (512) 490-1007 Austin, TX 78714-9104 Web: www.tdi.texas.gov Fax: (512) 490-1007 E-mail: ConsumerProtection@tdi.texas.gov Sitio web: www.tdi.texas.gov E-mail: ConsumerProtection@tdi.texas.gov PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or DISPUTAS POR PRIMAS DE SEGUROS o about a claim, you should contact your agent or the RECLAMACIONES: company first. If the dispute is not resolved, you may Si tiene una disputa relacionada con su prima de seguro o contact the Texas Department of Insurance. con una reclamación, usted debe comunicarse con el agente o la compañía primero. Si la disputa no es ATTACH THIS NOTICE TO YOUR POLICY: resuelta, usted puede comunicarse con el Departamento This notice is for information only and does not become a de Seguros de Texas part or condition of the attached document. ADJUNTE ESTE AVISO A SU PÓLIZA: Este aviso es solamente para propósitos informativos y no se convierte en parte o en condición del documento adjunto. ALL-4Y30f (06/15) Page 1 of 1 | 2 |
Page 1 of 1 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 067-71-2693 NEW HAMPSHIRE 910520598 Policy Prefix & No. Schedule INTRA/Independent State Risk ID 082-14-0714-10 THE DAY & ZIMMERMANN GROUP INC Item 4. Classification of Operations Premium Basis Rates Code Estimated Total Per $100 of Estimated No. Annual Remuneration Remuneration Annual Premiums RATING GROUP: 0003-01 RADIO OR TELEVISION BROADCASTING 7610 12,663 1.54 195 STATION-ALL EMPLOYEES & CLERICAL, DRIVERS ARCHITECTURAL OR ENGINEERING FIRM 8601 66,660 0.89 593 INCLUDING SALESPERSONS & DRIVERS CLERICAL OFFICE EMPLOYEES NOC. 8810 94,026 0.30 282 STATE OF NEW HAMPSHIRE TOTALS TOTAL CLASSIFICATION PREMIUM 1,070 INCREASE LIMITS 1.10% 9812 12 TOTAL UNMODIFIED PREMIUM 1,082 EXPERIENCE PREMIUM (ACTUAL) 0.5400 9898 -498 MODIFIED STANDARD PREMIUM 584 UNDISCOUNTED PREMIUM 584 LOSS REIMB PLAN (NON-FEDERAL) -60.16% 9864 -351 TAX PROVISION IN PREMIUM 10.01% 9719 23 DISCOUNTED PREMIUM 256 CATASTROPHE (SEE WC 00 04 21C) 0.012 9741 21 TOTAL ESTIMATED PREMIUM 277 TOTAL DUE 277 EXPERIENCE RATING MODIFICATION = 0.54 TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED IN TOTAL ESTIMATED PREMIUM $19 WC 7754 (Ed. 4-81) (Rev'd 04/08) | 1 |
Z ZURICH COMMON POLICY DECLARATIONS Policy Number BAP 9670773-05 Renewal of Number BAP 9670773-04 Named Insured and Mailing Address Producer and Mailing Address THE PERKINS + WILL GROUP, LTD LOCKTON COMPANIES LLC (SEE NAMED INSURED ENDT) 444 W 47TH ST STE 900 185 BERRY ST LOBBY 1 KANSAS CITY MO 64112-1906 STE 5100 SAN FRANCISCO CA 94107-5705 Producer Code 37385-000 Policy Period: Coverage begins 07-01-2013 at 12:01 A.M.; Coverage ends 07-01-2014 at 12:01 A.M. The name insured is Individual Partnership Corporation Other: This insurance is provided by one or more of the stock insurance companies which are members of the Zurich-American Insurance Group. The company that provides coverage is designated on each Coverage Part Common Declarations. The company or companies providing this insurance may be referred to in this policy as "The Company", we, us, or our. The address of the companies of the Zurich-American Insurance Group are provided on the next page. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE(S): BUSINESS AUTOMOBILE PREMIUM $ 6,507.00 issued by ZURICH AMERICAN INSURANCE COMPANY TX VOLUNTEER FIRE DEPT ASSISTANCE FUND $ .14 VA-BIRTH-RELATED NEURO INJURY COMP FUND $ .36 THIS PREMIUM MAY BE SUBJECT TO AUDIT. TOTAL $ 6,507.00 This premium does not include Taxes and Surcharges. SEE INSTALLMENT SCHEDULE Taxes and Surcharges TOTAL $ .50 SEE INSTALLMENT SCHEDULE Form(s) and Endorsement(s) made a part of this policy at time of issue are listed on the SCHEDULE of FORMS and ENDORSEMENTS. Countersigned this day of Authorized Representative THIS DECLARATION TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART FORM(S), FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. U-GU-D-365-A (03/94) Page 1 of 1 | 2 |
COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS ADJ. NO. NAMED INSURED EFFECTIVE DATE POLICY NUMBER Time & Alarm Systems Inc 05/31/2020 51GL008096-201 FORM OF BUSINESS: Individual Joint Venture Limited Liability Company Partnership Trust Organization including a corporation (but not including a Partnership, Joint Venture or Limited Liability Company) ALL PREMISES YOU OWN, RENT OR OCCUPY. (See DESIGNATION OF PREMISES SCHEDULE) THESE DECLARATIONS ARE COMPLETED ON THE ATTACHED COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE(S). LIMITS OF INSURANCE General Aggregate Limit $ 2,000,000 Products-Completed Operations Aggregate Limit $ 2,000,000 Personal Injury and Advertising Injury Limit $ 1,000,000 Any one person or organization Each Occurrence Limit $ 1,000,000 Damage To Premises Rented To You Limit $ 100,000 Any one premises Medical Expense Limit $ 5,000 Any one person RETROACTIVE DATE (For Claims Made Coverage Only) This insurance does not apply to any "bodily injury" or "property damage" which occurs, or an offense committed, before the Retroactive Date, if any, shown below: Retroactive Date: None (Enter date or "None" if no Retroactive Date applies) FORMS AND ENDORSEMENTS FORMS AND ENDORSEMENTS ATTACHED TO THIS COVERAGE PART: See EDEC 114 (03/99) Schedule of Forms and Endorsements, attached. PREMIUM STATE TAX OR $ 3,280.50 OTHER CHARGE (If Applicable): $ ADVANCE PREMIUM FOR PREMISES/OPERATIONS $ 79,050.00 ADVANCE PREMIUM FOR PRODUCTS/COMPLETED OPERATIONS $ Included TOTAL COVERAGE PART PREMIUM $ 82,330.50 EDEC 108 10 01 | 2 |
Liberty Insurance Corporation Item 3. Coverage D - Extension of Information Page Miscellaneous Form and Endorsement Schedule Continued: Policy Endorsements Comments Form Number Form Name WC 00 03 13 Waiver of Our Right to Recover From Others Endorsement WC 00 04 01 A Aircraft Premium Endorsement WC 00 04 14 Notification of Change in Ownership Endorsement WC 00 04 19 Premium Due Date Endorsement WC 00 04 21 C Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement WC 00 04 22 A Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement WC 09 03 03 Florida Employers Liability Coverage Endorsement WC 09 04 03 A Florida Terrorism Risk Insurance Program Reauthorization Act Endorsement WC 09 04 07 Florida Non-Cooperation with Premium Audit WC 09 06 06 Florida Employment and Wage Information Release WC 10 06 01 A Georgia Cancelation, Nonrenewal and Change Endorsement WC 32 03 01 C North Carolina Amended Coverage Endorsement WC 45 06 02 Virginia Amendatory WC 47 03 01 A West Virginia Employers Liability Insurance Intentional Act Exclusion Endorsement WC 47 03 02 West Virginia Workers Compensation Insurance Recovery From Others Endorsement WC 47 06 01 West Virginia Cancellation Endorsement WC 49 03 01 Wyoming Amendatory Endorsement WC 99 06 25 R2 Deductible Endorsement WC 99 06 27 R2 Deductible Endorsement WC 99 16 64 WV Large Deductible - Per Occurrence Basis Deductible Limit Includes ALAE Policy No. WA7-64D-438890-014 Page 2 of 3 GPO 4741 WC 00 00 01 A Ed.01/01/2001 | 0 |
Page 1 of 1 EXTENSION OF ITEM 4. OF THE INFORMATION PAGE WC 066-45-5273 GEORGIA 913142063 Policy Prefix & No. Schedule INTRA/Independent State Risk ID 026-75-0713-00 PERGAN MARSHALL, LLC Item 4. Classification of Operations Premium Basis Rates Code Estimated Total Per $100 of Estimated No. Annual Remuneration Remuneration Annual Premiums RATING GROUP: 0001- SALESPERSONS OR COLLECTORS-OUTSIDE 8742 172,200 0.61 1,050 STATE OF GEORGIA TOTALS TOTAL CLASSIFICATION PREMIUM 1,050 INCREASE LIMITS 1.10% 9812 12 TOTAL UNMODIFIED PREMIUM 1,062 EXPERIENCE PREMIUM (ACTUAL) 1.0600 9898 64 MODIFIED STANDARD PREMIUM 1,126 UNDISCOUNTED PREMIUM 1,126 PREMIUM DISCOUNT -11.50% 0063 -129 DISCOUNTED PREMIUM 997 EXPENSE CONSTANT 0900 230 TERRORISM 3.00% 9740 32 CATASTROPHE (SEE WC 00 04 21C) 0.023 9741 40 TOTAL ESTIMATED PREMIUM 1,299 TOTAL DUE 1,299 EXPERIENCE RATING MODIFICATION = 1.06 TOTAL PREMIUM FOR TERRORISM COVERAGE INCLUDED IN TOTAL ESTIMATED PREMIUM $32 WC 7754 (Ed. 4-81) (Rev'd 04/08) | 1 |
ITEM THREE Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums (Cont'd) Cost Of Hire Rating Basis For Mobile Or Farm Equipment - Other Than Physical Damage Coverages Estimated Annual Cost Of Hire For Each State Premium Coverages State Mobile Equipment Farm Equipment Mobile Equipment Farm Equipment Covered Autos $ $ $ $ Liability - Primary Coverage Covered Autos $ $ $ $ Liability - Excess Coverage Personal Injury $ $ $ $ Protection Medical $ $ $ $ Expense Benefits (Virginia Only) Income Loss $ $ $ $ Benefits (Virginia Only) Auto Medical $ $ $ $ Payments Total Hired Auto Premium $ $ Cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. Page 8 of 13 © Insurance Services Office, Inc., 2011 CA DS 03 10 13 | 2 |
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Longshore and Harbor Workers' Compensation Act Coverage Endorsement Policy Number: 37 WBR QU2574 Endorsement Number: 4 Effective Date: 06/01/2016 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: THE WEITZ GROUP, LLC 420 WATSON POWELL JR WAY . , SUITE 100 DES MOINES, IA 50309 This endorsement applies only to work subject to the Longshore and Harbor Workers' Compensation Act in a state shown in the Schedule. The policy applies to that work as though that state were listed in item 3.A of the Information Page. General Section C. Workers' Compensation Law is replaced by the following: C. Workers' Compensation Law Workers' Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in item 3.A. of the Information Page and the Longshore and Harbor Workers' Compensation Act (33 USC Sections 901-950). It includes any amendments to those laws that are in effect during the policy period. It does not include any other federal workers or workmen's compensation law, other federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. Part Two (Employers Liability Insurance), C. Exclusions., exclusions 8, does not apply to work subject to the Longshore and Harbor Workers' Compensation Act. This endorsement does not apply to work subject to the Defense Base Act, the Outer Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Schedule Longshore and Harbor Workers' State Compensation Act Coverage Percentage IF ANY TO BE DETERMINED AT AUDIT The rates for classifications with code numbers not followed by the letter "F" are rates for work not ordinarily subject to the Longshore and Harbor Workers' Compensation Act. If this policy covers work under such classifications, and if the work is subject to the Longshore and Harbor Workers' Compensation Act, those non-F classification rates will be increased by the Longshore and Harbor Workers' Compensation Act Coverage Percentage shown in the Schedule. Countersigned by Suear L. Castaneda Form WC 00 01 06A Printed in U.S.A. Authorized Representative | 2 |
NOTICE TO POLICYHOLDERS Access to Your Information Our employees, employees of our affiliated companies, and third party service providers will have access to information we collect about you and your business as is necessary to effect transactions with you. We may also disclose information about you to the following categories of person or entities: Your independent insurance agent or broker; An independent claim adjuster or investigator, or an attorney or expert involved in the claim; Persons or organizations that conduct scientific studies, including actuaries and accountants; An insurance support organization; Another insurer if to prevent fraud or to properly underwrite a risk; A state insurance department or other governmental agency, if required by federal, state or local laws; or Any persons entitled to receive information as ordered by a summons, court order, search warrant, or subpoena. Violation of the Privacy Policy Any person violating the Privacy Policy will be subject to discipline, up to and including termination. For more information or to address questions regarding this privacy statement, please contact your broker. PN CW 02 0119 Page 3 of 3 © 2019 X.L. America, Inc. All Rights Reserved. May not be copied without permission. | 2 |
362201500005400010 Form Number/Edition Date Title LC 29 08 10 11 Advertisement Redefined LC 04 02 10 11 Professional Health Care Services by Employees or Volunteer Workers Coverage LC 24 27 10 13 Non-Owned Watercraft Amendment With Limitation of Coverage LC 25 19 01 15 Designated Construction Project or Designated Location Combined Aggregate Limits - With Total Project and Location Aggregate Limit LIM 99 01 05 11 Notice of Cancellation to Third Parties LC 29 09 10 11 Bodily Injury Redefined Additional Insured(s) LN 20 01 06 05 Blanket Additional Insured LC 24 20 02 13 Other Insurance Amendment Scheduled Additional Insured TRIA Exclusion(s) CG 21 70 01 15 CAP ON LOSSES FROMCERTIFIED ACTS OF TERRORISM CG 21 76 01 15 EXCLUSION OF PUNITIVE DAMAGES RELATED TO A CERTIFIED ACT OF TERRORISM CG 26 86 01 15 ARKANSAS EXCLUSION OF PUNITIVE DAMAGES RELATED TO A CERTIFIED ACT OF TERRORISM CG 26 93 01 15 ALASKA EXCLUSION OF PUNITIVE DAMAGES RELATED TO A CERTIFIED ACT OF TERRORISM Other Exclusion(s) CG 21 16 04 13 EXCLUSION - DESIGNATED PROFESSIONAL SERVICES CG 21 47 12 07 Employment-Related Practices Exclusion CG 65 12 04 Total Pollution Exclusion With a Building Heating, Cooling and Dehumidifying Equipment Exception and a Hostile Fire Exception CG 21 67 12 04 Fungi or Bacteria Exclusion CG 22 50 04 13 EXCLUSION - FAILURE TO SUPPLY IL 00 21 09 08 Nuclear Energy Liability Exclusion Endorsement (Broad Form) LC 21 01 06 05 Asbestos Exclusion Endorsement LC 21 02 06 05 Silica Exclusion Endorsement LC 21 04 06 05 Discrimination Exclusion LC 21 06 06 07 Lead Exclusion LC 21 38 06 07 Polychlorinated Biphenyls (PCBs) Exclusion LC 21 39 06 07 Radioactive Matter Exclusion LC 21 42 06 07 Electromagnetic Fields and Electromagnetic Radiation Exclusion LC 21 65 08 07 MTBE Exclusion CG 21 06 05 14 Exclusion - Access or Disclosure of Confidential or Personal Information and Data-Related Liability - With Limited Bodily Injury Exception IL 01 17 12 10 Indiana Changes Workers' Compensation Exclusion State Mandatory CG 01 23 03 97 Indiana Pollution Exclusion Endorsement IL 01 58 09 08 Indiana Changes IC 00 42 07 09 © 2008, Liberty Mutual Group of Companies. All rights reserved. Page 2 of 3 | 0 |
ENDORSEMENT AGREEMENT LIMITING AND RESTRICTING THIS INSURANCE Designated Location(s) Coverage The insurance under this policy is limited as follows: It is AGREED that, anything in this policy to the contrary notwithstanding, this policy DOES NOT INSURE: THIS POLICY DOES Any liability you may have for any injury to any employee(s) engaged in any work NOT INSURE ANY not directly connected with operation(s) conducted at or in the location(s) EMPLOYEE(S) OTHER described below. THAN AT/ OR IN DESIGNATED LOCATION(S) Operation(s) Name Operation(s) Title (optional) Location(s) address The Regents of The University University of California Santa Cruz of California University of California San Diego University of California San Francisco Check box if policyholder has affirmed in writing that other coverage is secured or the entity is lawfully uninsured. Check box if liability is lawfully uninsured. If alternate coverage information is available, complete the following (OPTIONAL): Insured Name Insurer Policy # Policy Effective Dates This policy may be deemed unlimited to the extent that any of the following requirements are not met: (1) the employer affirms in writing to the insurer that coverage for the excluded liability is secured and (2) the employer actually obtains coverage for the excluded liability. Nothing in this endorsement shall be held to vary, alter, waive or extend any of the terms, conditions, agreements, or limitations of this policy other than as above stated. Nothing elsewhere in this policy shall be held to vary, alter, waive or limit the terms, conditions, agreements, or limitations of this endorsement. It is further agreed that "remuneration" when used as a premium basis for such insurance as is afforded by this policy shall not include the remuneration of any person excluded from coverage in accordance with the foregoing. FAILURE TO SECURE THE PAYMENT OF FULL COMPENSATION BENEFITS FOR ALL EMPLOYEES AS REQUIRED BY LABOR CODE SECTION 3700 IS A VIOLATION OF LAW AND MAY SUBJECT THE EMPLOYER TO THE IMPOSITION OF A WORK STOP ORDER, LARGE FINES, AND OTHER SUBSTANTIAL PENALTIES (Labor Code Section 3710.1, et seq.). Issued by Liberty Mutual Fire Insurance Company 16586 For attachment to Policy No. WA2-66D-067199-279 Effective Date Premium $ Issued to Penhall Company Endorsement No. WC 04 03 40 B Page 1 of 1 Ed. 02/01/2018 | 2 |
IMPORTANT NOTICE TO OUR POLICYHOLDERS THANK YOU FOR RENEWING YOUR POLICY WITH THE HARTFORD. WITH THIS NOTICE WE ARE PROVIDING YOU ONLY WITH THE DECLARATIONS PAGE, WHICH OUTLINES YOUR COVERAGES, AND WITH THOSE POLICY FORMS, NOTICES, AND BROCHURES WHICH ARE DIFFERENT FROM THOSE WHICH WE PROVIDED WITH YOUR PREVIOUS POLICY. YOU SHOULD RETAIN ALL OF THESE DOCUMENTS AND THOSE PROVIDED WITH YOUR PREVIOUS POLICY INDEFINITELY SO THAT YOU WILL HAVE A COMPLETE SET OF POLICY FORMS AT ALL TIMES FOR YOUR REFERENCE. IF YOU HAVE QUESTIONS, OR IF AT ANY TIME YOU NEED COPIES OF ANY OF THE FORMS LISTED ON YOUR POLICY, PLEASE CALL YOUR HARTFORD AGENT OR BROKER, OR THE OFFICE OF THE HARTFORD IDENTIFIED ON YOUR POLICY, AS APPROPRIATE. Form G-3187-0 | 2 |
POLICY NUMBER: GLO 5833581-06 COMMERCIAL GENERAL LIABILITY CG 03 00 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DEDUCTIBLE LIABILITYINSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Coverage Amount and Basis of Deductible PER CLAIM or PER OCCURRENCE Bodily Injury Liability $ $ OR Property Damage Liability $ $ OR Bodily Injury Liability and/or Property Damage Liability Combined $ $ (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) APPLICATION OF ENDORSEMENT (Enter below any limitations on the application of this endorsement. If no limitation is entered, the deductibles apply to damages for all "bodily injury" and "property damage", however caused): A. Our obligation under the Bodily Injury Liability b. Under Property Damage Liability Cover- and Property Damage Liability Coverages to pay age, to all damages sustained by any one damages on your behalf applies only to the amount person because of "property damage"; or of damages in excess of any deductible amounts c. Under Bodily Injury Liability and/or stated in the Schedule above as applicable to such Property Damage Liability Coverage coverages. Combined, to all damages sustained by any B. You may select a deductible amount on either a one person because of: per claim or a per "occurrence" basis. Your se- (1) "Bodily injury"; lected deductible applies to the coverage option (2) "Property damage"; or and to the basis of the deductible indicated by the (3) "Bodily injury" and "property damage" placement of the deductible amount in the Sched- combined ule above. The deductible amount stated in the as the result of any one "occurrence". Schedule above applies as follows: If damages are claimed for care, loss of serv- 1. PER CLAIM BASIS. If the deductible amount ices or death resulting at any time from "bodily indicated in the Schedule above is on a per injury", a separate deductible amount will be claim basis, that deductible applies as follows: applied to each person making a claim for such a. Under Bodily Injury Liability Coverage, to damages. all damages sustained by any one person With respect to "property damage", person in- because of "bodily injury"; cludes an organization. CG 03 00 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 2 | 2 |
COMMERCIAL LIABILITY - Liberty UMBRELLA DECLARATIONS Mutuál. INSURANCE Issued by: Liberty Insurance Corporation Policy Number: TH7-681-041343-861 Producer: LOCKTON COMPANIES LLC Renewal of: TH7-681-041343-860 444 W 47TH ST STE 900 KANSAS CITY, MO 64112-1906 Item 1. Named Insured and Mailing Address: CARROLS RESTAURANT GROUP, INC. 968 JAMES STREET SYRACUSE, NY 13217-6969 The Named Insured is: Corporation Item 2. Policy Period: 1/01/2021 to 1/01/2022 at 12:01 A.M. standard time at above mailing address. Item 3. Limits of Insurance: Each Occurrence Limit $ 10,000,000 General Aggregate Limit $ 10,000,000 Products-Completed Operations Aggregate Limit $ 10,000,000 Item 4. Self-Insured Retention - Each Occurrence: $ 0 Item 5. Premium: Premium Basis Audit Basis Estimated Exposure Rate Advance Premium Flat Charge 0 $ 322,605 Certified Acts of Terrorism Coverage: $ 0 Total Advance Premium: $ 322,605 KY Firefighters Surcharge $ 154 KY Municipal Tax $ 528 Minimum Retained Premium: $ 0 Issued Code Number Account Number Sub-Account Number PP 1/28/2021 99935 8-041343 0003 LCU 00 02 01 18 © 2017 Liberty Mutual Insurance Page 1 of 2 | 2 |
IL 00 21 09 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (Broad Form) This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART MEDICAL PROFESSIONAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY 1. The insurance does not apply: C. Under any Liability Coverage, to "bodily injury" or "property damage" resulting from A. Under any Liability Coverage, to "bodily injury" "hazardous properties" of "nuclear material", if: or "property damage": (1) The "nuclear material" (a) is at any "nuclear (1) With respect to which an "insured" under facility" owned by, or operated by or on the policy is also an insured under a behalf of, an "insured" or (b) has been nuclear energy liability policy issued by discharged or dispersed therefrom; Nuclear Energy Liability Insurance Association, Mutual Atomic Energy Liability (2) The "nuclear material" is contained in Underwriters, Nuclear Insurance "spent fuel" or "waste" at any time Association of Canada or any of their possessed, handled, used, processed, successors, or would be an insured under stored, transported or disposed of, by or on any such policy but for its termination upon behalf of an "insured"; or exhaustion of its limit of liability; or (3) The "bodily injury" or "property damage" (2) Resulting from the "hazardous properties" arises out of the furnishing by an "insured" of "nuclear material" and with respect to of services, materials, parts or equipment in which (a) any person or organization is connection with the planning, construction, required to maintain financial protection maintenance, operation or use of any pursuant to the Atomic Energy Act of 1954, "nuclear facility", but if such facility is or any law amendatory thereof, or (b) the located within the United States of America, "insured" is, or had this policy not been its territories or possessions or Canada, this issued would be, entitled to indemnity from exclusion (3) applies only to "property the United States of America, or any damage" to such "nuclear facility" and any agency thereof, under any agreement property thereat. entered into by the United States of 2. As used in this endorsement: America, or any agency thereof, with any "Hazardous properties" includes radioactive, toxic person or organization. or explosive properties. B. Under any Medical Payments coverage, to "Nuclear material" means "source material", expenses incurred with respect to "bodily "special nuclear material" or "by-product material". injury" resulting from the "hazardous properties" of "nuclear material" and arising out of the operation of a "nuclear facility" by any person or organization. IL 00 21 09 08 © ISO Properties, Inc., 2007 Page 1 of 2 | 2 |
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A Edition 1/08 PIANO--MFG. 2923 65,115 1.87 $1,218 IRON OR STEEL--FABRICATION-- 3030 26,347 4.41 $1,162 IRONWORKS OR STEELWORKS-- SHOP--STRUCTURAL AND DRIVERS SHEET METAL PRODUCTS MFG. 3076 1,104,260 2.24 $24,735 TOOL MFG.--NOT DROP OR 3113 96 1.48 $1 MACHINE FORGED--NOC TOOL MFG.--AGRICULTURAL, 3126 22,115 1.78 $394 CONSTRUCTION, LOGGING, MINING, OIL OR ARTESIAN WELL HARDWARE MFG. NOC 3146 2,585 1.88 $49 STOVE MFG. 3169 25,224 2.45 $618 ELECTRICAL APPARATUS MFG. NOC 3179 1,543,682 1.33 $20,531 PLUMBERS' SUPPLIES MFG. NOC 3188 447,107 1.26 $5,634 ALUMINUM WARE MFG. 3227 153,784 2.58 $3,968 WELDING OR CUTTING NOC AND 3365 56,847 4.94 $2,808 DRIVERS JEWELRY MFG. 3383 4,043 1.05 $42 METAL STAMPED GOODS MFG. NOC 3400 404,320 2.47 $9,987 CONSTRUCTION OR AGRICULTURAL 3507 933,134 1.79 $16,703 MACHINERY MFG. PRINTING OR BOOKBINDING 3548 69,904 1.02 $713 MACHINE MFG. COMPUTING, RECORDING OR 3574 64,142 0.56 $359 OFFICE MACHINE MFG. NOC FUEL INJECTION DEVICE MFG. 3581 328,959 0.77 $2,533 PUMP MFG. 3612 81,458 1.53 $1,246 MACHINED PARTS MFG. NOC 3629 22,421 1.47 $330 MACHINE SHOP NOC 3632 1,068,574 2.31 $24,684 VALVE MFG. 3634 88,263 1.29 $1,139 GEAR MFG. OR GRINDING 3635 279,169 2.15 $6,002 TELEVISION, RADIO, TELEPHONE 3681 2,031,577 0.67 $13,612 OR TELECOMMUNICATION DEVICE MFG. NOC INSTRUMENT MFG. NOC 3685 46,208 0.89 $411 MACHINERY OR EQUIPMENT 3724 144,017 2.68 $3,860 ERECTION OR REPAIR NOC AND DRIVERS AUTOMOBILE--MFG. OR ASSEMBLY 3808 449,722 3.89 $17,494 CONCRETE PRODUCTS MFG. AND 4034 1,452 5.05 $73 DRIVERS PLASTER MIXING AND DRIVERS 4036 24,688 2.32 $573 POTTERY MFG.-CHINA OR 4053 93,618 1.61 $1,507 TABLEWARE GLASS MFG.--AND DRIVERS 4101 17,188 2.22 $382 INTEGRATED CIRCUIT MFG. 4109 4,795 0.33 $16 BOX MFG.-SET-UP PAPER 4240 32,183 1.89 $608 CORRUGATED OR FIBERBOARD 4244 3,388,639 1.71 $57,946 CONTAINER MFG. PAPER COATING 4250 32,335 1.60 $517 FIBER GOODS MFG. 4263 109,856 2.85 $3,131 XLINSURANCE WC 00 00 01A © 1987 National Council on Compensation Insurance. Page 74 Edition 1/08 © 2007 XL America, Inc. | 1 |
1. Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease-aggregate" is the most we will pay for all damages covered by this insurance because of bodily injury by disease to one or more employees. The limit applies separately to bodily injury by disease arising out of work in each state shown in Item 3.A. of the Information Page. Bodily injury by disease will be deemed to occur in the state of the vessel's home port. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. Schedule 1. Description of work: If Any 2. Transportation, Wages, Maintenance, and Cure Premium $ Exclusion: This insurance does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law even if a premium is paid for transportation, wages, maintenance, and cure coverage. 3. Limits of Liability Bodily Injury by Accident $100,000 each accident Bodily Injury by Disease $100,000 aggregate Issued by Liberty Mutual Fire Insurance Company 16586 For attachment to Policy No. WA2-66D-067200-499 Effective Date Premium $ Issued to Cosco Fire Protection, Inc. WC 00 02 01 B © Copyright 1983-2013 National Council on Compensation Insurance, Inc. Page 2 of 2 Ed. 01/01/2015 All Rights Reserved. | 2 |
BUSINESS AUTO COVERAGE FORM DECLARATIONS Policy Number (06) 7498-55-64 ITEM ONE Named Insured Agent Name MILBANK MANUFACTURING CO LOCKTON COMPANIES, INC Effective Date: 09-01-2006 12:01 A.M., Standard Time Agent No. 35773-999 ITEM TWO - SCHEDULE OF COVERAGES AND COVERED AUTOS This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "autos" shown as covered "autos". "Autos" are shown as covered "autos" for a particular coverage by the entry of one or more of the symbols from the Covered Autos Section of the Business Auto Coverage Form next to the name of the coverage. Limit Covered Coverages The most we will pay for any Premium Autos* one accident or loss Liability 1 $1,000,000 $ 20,360 Personal Injury Protection*** 5 Separately stated in each P.I.P. endorsement $ 24 minus Ded. Added Personal Injury Separately stated in each added P.I.P. Protection endorsement. Separately stated in the P.P.I. endorsement Property Protection Insurance minus Ded. for each (Michigan only) accident. Auto Medical Payments 2 $ 5,000 $ 1,096 Uninsured Motorists 6 $ 1,000,000 $ 479 Underinsured Motorists (When not 6 included in UM Coverage) $ 1,000,000 $ 754 SEE SCHEDULE ded. for each COV- P Actual ered auto, but no deductible Comprehensive Coverage 2, 8 $ cash 1,318 applies to loss caused by fire or H D value or lightning. Y A cost of S M Specified Causes of Loss repair, $25 ded. for each covered auto for Coverage which- loss caused by mischief or I A ever is vandalism. C G less Collision Coverage 2,8 minus SEE SCHEDULE ded. for each cov- A E $ ered auto. 3,405 L Towing and Labor (Not SEE SCHEDULE for each disablement of a 3 $ 25 available in California) private passenger "auto". Forms and Endorsements applying to this coverage part and made a Tax/Surcharge/Fee part of this policy at time of issue: Premium for Endorsements $ 88 SEE SCHEDULE OF FORMS AND ENDORSEMENTS *Estimated Total Premium $ 27,549.00 * This policy may be subject to final audit. Entry of one or more of the symbols from the COVERED AUTOS Section of the Business Auto Coverage Form shows which autos are covered autos. Or equivalent No-Fault Coverage Or equivalent added No-Fault coverage See ITEM FOUR for Hired or Borrowed "Autos". This policy declaration and the supplemental declaration(s), together with the common policy conditions, coverage parts, coverage form(s) and forms and endorsements, if any, complete the above numbered policy. 16-02-0214 (Ed. 1-01) Page 1 of 3 | 2 |
FORMS SCHEDULE EFFECTIVE DATE: 09/01/2017 NAMED INSURED: AMTECOL, INC. AMERICAN HI-TECH PETROLEUM & CHEMICALS, INC. U.S. AUTOMOTIVE, INC. POLICY NO: CA 441-66-06 CA0001 (0310) BUSINESS AUTO COVERAGE FORM CAO143 (0507) CALIFORNIA CHANGES CAO424 (0406) CALIFORNIA AUTO MED PAY COV CA2048 (0299) DESIGNATED INSURED CA2154 (0909) CA UNINSURED MOTORISTS COVERAGE- IL0017 (1198) COMMON POLICY CONDITIONS IL0021 (0908) NUCLEAR ENERGY LIAB EXCLUSION IL0270 (0912) CA CHANGES-CANCEL & NONRENEWAL 89187 (0406) TERRORISM EXCLUSION 89644 (0613) ECONOMICS SANCTIONS ENDORSEMENT 102303 (0809) LOSS PAYABLE CLAUSE 102987 (0909) AUTO PHYSICAL DAMAGE ALT FUEL | 0 |
Schedule Designated Workers' Employees State of Employment Compensation Law All employees not All states except CA, State of hire subject to the Workers HI, NJ, WI & WY Compensation Law Issued by Liberty Mutual Fire Insurance Company16586 For attachment to Policy No.WA2-C2D-095587-652 Effective Date Premium $ Issued to Cross Country Food Service Installers, Inc. WC 00 03 11 A © 1991 National Council on Compensation Insurance Page 3 of 3 | 2 |
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A Edition 1/08 EXTENSION OF INFORMATION PAGE Name and Address of Insured: Policy No: RWR9435384-02 Towne Holdings, Inc. 1201 Market Street Policy Period: 01-01-2015 To 01-01-2016 Philadelphia, PA 19107 NAICS#: 812930 FEIN: 770685277 # Of Employees: 390 Insured/State/Location No: Pennsylvania 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Classifications Code No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium AUTOMOBILE STORAGE GARAGE 825 3,319,669 4.56 $151,377 RETAIL STORE, N.O.C. 928 91,581 3.19 $2,921 SALESPERSON - OUTSIDE 951 41,972 0.50 $210 CLERICAL OFFICE EMPLOYEES 953 1,021,470 0.23 $2,349 Stat Rate Premium Manual Premium: $156,857 Employer Liability Increased Limits: 9812 1.4% $2,196 Waiver of Subrogation Charge: 0930 .0200 $3,137 Subject Premium: $162,190 Experience Modification: 9898 .92 -$12,813 Modified Premium: $149,377 Scheduled Modification: 9887 .750 -$37,344 Total Standard Premium: $112,033 Terrorism: 9740 .0300 $1,342 Catastrophe: 9741 .0200 $895 Estimated Annual Premium: $114,270 PA Assessment: .0195 $2,228.00 Total State Premium: $116,498.00 Date of Issue: 01-06-2015 XLINSURANCE WC 00 00 01A c 1987 National Council on Compensation Insurance. Page 29 Edition 1/08 © 2007 XL America, Inc. | 1 |
Liability Policy - 8842740 - for Express Services of Canada Inc. 2 1.9 Period of Insurance Inception: 01. October 2015 Expiration: 01. October 2016 At 12:01 a.m. Standard Time at the address of the First Named Insured 1.10 Premium $ 29,888 Flat Premium $ 29,888 Minimum Premium (Retained) 1.11 Broker's Name and BFL Canada Risk and Insurance Services Inc. Address 181 University Avenue, Suite 1605 Toronto, Ontario M5H 3M7 ZURICH Insurance Company Ltd Maya 23/11/2015 Dated at Toronto, on Authorized Representative (Date) Certain provisions in this policy restrict coverage. Read the entire policy carefully to determine your rights and duties, and what is and is not covered. The word Zurich refers to Zurich Insurance Company Ltd. The word Insured means any person or entity qualifying as such under section 4 "WHO IS AN INSURED". Defined terms are shown in bold at the place in the policy where the term is defined; otherwise, they are capitalized. | 2 |
IL N 106 09 03 VIRGINIA FRAUD STATEMENT It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the pur- pose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. IL N 106 09 03 © ISO Properties, Inc., 2003 Page 1 of 1 | 2 |
The payroll of all executive officers of a e. The payroll of clerical office employees; corporation and individual insureds or co- partners engaged principally in clerical Clerical office employees are those operations or as salespersons, and officers employees who work in an area which is and co-partners who are inactive for the entire physically separated by walls, floors or policy period, shall not be included for partitions from all other work areas of the premium purposes. insured and whose duties are strictly limited to n. The payroll of leased workers furnished to the keeping the insured's books or records or named insured by a labor leasing firm. conducting correspondence, including any Premium on such payroll shall be based on other employees engaged in clerical work in the classifications and rates which would have the same area. applied if the leased workers had been the f. The payroll of salespersons, collectors or direct employees of the named insured. If messengers who work principally away from payroll is unavailable, use 100% of the total the insured's premises. Salespersons, cost of the contract for leased workers as the collectors or messengers are those payroll of leased workers. The premium shall employees engaged principally in any such be charged on that amount as payroll; duties away from the premises of the If investigation of a specific employee leasing employer; contract discloses that a definite amount of the contract price represents payroll, such amount This term does not apply to any employee shall be considered payroll for premium whose duties include the delivery of any computation purposes. merchandise handled, treated or sold. O. Fees paid to employment agencies for g. The payroll of drivers and their helpers if their temporary personnel provided to the insured. principal duties are to work on or in connection with automobiles; 3. Payroll does not include: h. The payroll of aircraft pilots or co-pilots if their principal duties are to work on or in connection a. Tips and other gratuities received by with aircraft in either capacity; and employees; i. The payroll of draftsmen if their duties are b. Payments by an employer to group insurance limited to office work only and who are or group pension plans for employees, other engaged strictly as draftsmen in such a than payments covered by Paragraph E.2.e.; manner that they are not exposed to the C. The value of special rewards for individual operative hazards of the business. invention or discovery; d. Dismissal or severance payments except for The rates apply per $1,000 of payroll. time worked or accrued vacation; All other terms, conditions and exclusions remain unchanged. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Policy No.: Endorsement No. Insured: Premium: Insurance Company: Authorized Signature: CAAP 423 0814 Includes copyrighted material of Insurance Services Page 3 of 0 Office, Inc., with its permission | 2 |
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