4WRL
CSGCONS-01 MHILL
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
12/7/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
Alliant Insurance Services, Inc.
575 Market St Ste 3600
San Francisco, CA 94105
INSURED
CSG Consultants, Inc.
550 Pilgrim Drive
Foster City, CA 94404
CONTACT Melissa Hill
NAME:
PHONE FAX
(A/C, No, Ext): (A/C, No):
E-MAILDSS: [email protected]
INSURER A
INSURER B
INSURER C
INSURER D
INSURER E
INSURER F
INSURER(S) AFFORDING COVERAGE
Travelers Property Casualty Company of America
:Arch Insurance Company
NAIC #
25674
11150
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH DOLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY DAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP
LTR INSD WVD (MM/DDIYYYYI (MM/DDIYYYY)
A X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE X OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY X PRO- LOC
JECT
OTHER:
A AUTOMOBILE LIABILITY
A
A
X ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
X APD Owned Autos
X UMBRELLA LIAB
EXCESS LIAB
■
■
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
X
DED X RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
IfQiION Eonal Lia�RATIONS below
B Profess
OCCUR
CLAIMS -MADE
10,000
Y/N
Y
X P -660 -5R143841 -TIL -21 12/4/2021 12/4/2022
X 810 -5R143576 -21-43-G 12/4/2021 12/4/2022
NIA
CUP -7S954134 -21 -NF
X UB -5R147157 -21-43-G
PAAEP0008806
12/4/2021 12/4/2022
12/4/2021 12/4/2022
12/4/2021 12/4/2022
LIMITS
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
Comp/Coll Ded.
EACH OCCURRENCE
AGGREGATE
X PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
Ded: $50,000; Agg:
$
1,000,000
1,000,000
10,000
1,000,000
2,000,000
2,000,000
1,000,000
2,000
5,000,000
5,000,000
1,000,000
1,000,000
1,000,000
5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Placentia and its elected and appointed boards, officers, officials, agents, employees, and volunteers are included as additional insureds on a Primary & Non -Contributory basis on General Liability and 30 Day Notice of Cancellation per attached. Waiver of Subrogation on WC and 30 Day Notice of Cancellation on Professional per attached. Contractual Liability on Auto and Professional & 30 Day Notice of Cancellation on WC is not available.
CERTIFICATE HOLDER
City of Placentia
401 E Chapman Ave
Placentia, CA 92870
ACORD 25 (2016/03)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
© 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: P -660 -5R143841 -TIL -21
COMMERCIAL GENERAL LIABILITY
ISSUE DATE: 12-4-21
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - WRITTEN
CONTRACTS (ARCHITECTS, ENGINEERS AND
SURVEYORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. The following is added to SECTION II — WHO IS
AN INSURED:
Any person or organization that you agree in a
"written contract requiring insurance" to include as
an additional insured on this Coverage Part, but:
a. Only with respect to liability for "bodily injury",
"property damage" or "personal injury"; and
b. If, and only to the extent that, the injury or
damage is caused by acts or omissions of
you or your subcontractor in the performance
of "your work" to which the "written contract
requiring insurance" applies. The person or
organization does not qualify as an additional
insured with respect to the independent acts
or omissions of such person or organization.
The insurance provided to such additional insured
is limited as follows:
c. In the event that the Limits of Insurance of
this Coverage Part shown in the Declarations
exceed the limits of liability required by the
"written contract requiring insurance", the in-
surance provided to the additional insured
shall be limited to the limits of liability required
by that "written contract requiring insurance".
This endorsement shall not increase the limits
of insurance described in Section 111 — Limits
Of Insurance.
d. This insurance does not apply to the render-
ing of or failure to render any "professional
services" or construction management errors
or omissions.
e. This insurance does not apply to "bodily in-
jury" or "property damage" caused by "your
work" and included in the "products -
completed operations hazard" unless the
"written contract requiring insurance" specifi-
cally requires you to provide such coverage
for that additional insured, and then the insur-
ance provided to the additional insured ap-
CG D4 14 04 08
plies only to such "bodily injury" or "property
damage" that occurs before the end of the pe-
riod of time for which the "written contract re-
quiring insurance" requires you to provide
such coverage or the end of the policy period,
whichever is earlier.
2. The following is added to Paragraph 4.a. of SEC-
TION IV — COMMERCIAL GENERAL LIABILITY
CONDITIONS:
The insurance provided to the additional insured
is excess over any valid and collectible "other in-
surance", whether primary, excess, contingent or
on any other basis, that is available to the addi-
tional insured for a loss we cover. However, if you
specifically agree in the "written contract requiring
insurance" that this insurance provided to the ad-
ditional insured under this Coverage Part must
apply on a primary basis or a primary and non-
contributory basis, this insurance is primary to
"other insurance" available to the additional in-
sured which covers that person or organization as
a named insured for such loss, and we will not
share with that "other insurance". But this insur-
ance provided to the additional insured still is ex-
cess over any valid and collectible "other insur-
ance", whether primary, excess, contingent or on
any other basis, that is available to the additional
insured when that person or organization is an
additional insured under any "other insurance".
3. The following is added to SECTION IV — COM-
MERCIAL GENERAL LIABILITY CONDITIONS:
Duties Of An Additional Insured
As a condition of coverage provided to the addi-
tional insured:
a. The additional insured must give us written
notice as soon as practicable of an 'occur-
rence" or an offense which may result in a
claim. To the extent possible, such notice
should include:
© 2008 The Travelers Companies, Inc. Page 1 of 2
POLICY NUMBER: P -660 -5R143841 -TIL -21
I. How, when and where the "occurrence"
or offense took place;
ii. The names and addresses of any injured
persons and witnesses; and
iii. The nature and location of any injury or
damage arising out of the "occurrence" or
offense.
b. If a claim is made or "suit" is brought against
the additional insured, the additional insured
must:
1. Immediately record the specifics of the
claim or "suit" and the date received; and
ii. Notify us as soon as practicable.
The additional insured must see to it that we
receive written notice of the claim or "suit" as
soon as practicable.
c. The additional insured must immediately send
us copies of all legal papers received in con-
nection with the claim or "suit", cooperate with
us in the investigation or settlement of the
claim or defense against the "suit", and oth-
erwise comply with all policy conditions.
d. The additional insured must tender the de-
fense and indemnity of any claim or "suit" to
COMMERCIAL GENERAL LIABILITY
ISSUE DATE: 12-4-21
any provider of other insurance which would
cover the additional insured for a loss we
cover. However, this condition does not affect
whether this insurance provided to the addi-
tional insured is primary to that other insur-
ance available to the additional insured which
covers that person or organization as a
named insured.
4. The following is added to the DEFINITIONS Sec-
tion
"Written contract requiring insurance" means that
part of any written contract or agreement under
which you are required to include a person or or-
ganization as an additional insured on this Cover-
age Part, provided that the "bodily injury" and
"property damage" occurs and the "personal in-
jury" is caused by an offense committed:
a. After the signing and execution of the contract
or agreement by you;
b. While that part of the contract or agreement is
in effect; and
c. Before the end of the policy period.
© 2008 The Travelers Companies, Inc. CG D4 14 04 08
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: P -660 -5R143841 -TIL -21 ISSUE DATE: 12-4-21 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS
AND SURVEYORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. Non -Owned Watercraft — 75 Feet Long Or Less
B. Who Is An Insured — Unnamed Subsidiaries
C. Who Is An Insured — Retired Partners, Members,
Directors And Employees
D. Who Is An Insured — Employees And Volunteer
Workers — Bodily Injury To Co -Employees, Co -
Volunteer Workers And Retired Partners,
Members, Directors And Employees
E. Who Is An Insured — Newly Acquired Or Formed
Limited Liability Companies
F. Blanket Additional Insured — Controlling Interest
G. Blanket Additional Insured — Mortgagees,
Assignees, Successors Or Receivers
PROVISIONS
A. NON -OWNED WATERCRAFT — 75 FEET
LONG OR LESS
1. The following replaces Paragraph (2) of
Exclusion g., Aircraft, Auto Or Watercraft,
in Paragraph 2. of SECTION I —
COVERAGES — COVERAGE A — BODILY
INJURY AND PROPERTY DAMAGE
LIABILITY
(2) A watercraft you do not own that is:
(a) 75 feet long or less; and
(b) Not being used to carry any person
or property for a charge;
2. The following replaces Paragraph 2.e. of
SECTION II — WHO IS AN INSURED
e. Any person or organization that, with
your express or implied consent, either
CG D3 79 02 19
H. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Premises
I. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Operations
J. Incidental Medical Malpractice
K. Medical Payments — Increased Limit
L. Amendment Of Excess Insurance Condition —
Professional Liability
M. Blanket Waiver Of Subrogation — When Required
By Written Contract Or Agreement
N. Contractual Liability — Railroads
uses or is responsible for the use of a
watercraft that you do not own that is:
(1) 75 feet long or less; and
(2) Not being used to carry any person
or property for a charge;
B. WHO IS AN INSURED — UNNAMED
SUBSIDIARIES
The following is added to SECTION II — WHO IS
AN INSURED:
Any of your subsidiaries, other than a partnership
or joint venture, that is not shown as a Named
Insured in the Declarations is a Named Insured
if:
a. You are the sole owner of, or maintain an
ownership interest of more than 50% in, such
subsidiary on the first day of the policy
period; and
© 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
POLICY NUMBER: P -660 -5R143841 -TIL -21
b. Such subsidiary is not an insured under
similar other insurance.
No such subsidiary is an insured for "bodily
injury" or "property damage" that occurred, or
"personal and advertising injury" caused by an
offense committed:
a. Before you maintained an ownership interest
of more than 50% in such subsidiary; or
b. After the date, if any, during the policy period
that you no longer maintain an ownership
interest of more than 50% in such subsidiary.
For purposes of Paragraph 1. of Section II — Who
Is An Insured, each such subsidiary will be
deemed to be designated in the Declarations as:
a. A limited liability company;
b. An organization other than a partnership,
joint venture or limited liability company; or
c. A trust;
as indicated in its name or the documents that
govern its structure.
C. WHO IS AN INSURED — RETIRED PARTNERS,
MEMBERS, DIRECTORS AND EMPLOYEES
The following is added to Paragraph 2. of
SECTION II — WHO IS AN INSURED
Any person who is your retired partner, member,
director or "employee" that is performing services
for you under your direct supervision, but only for
acts within the scope of their employment by you
or while performing duties related to the conduct
of your business. However, no such retired
partner, member, director or "employee" is an
insured for:
(1) "Bodily injury":
(a) To you, to your current partners or
members (if you are a partnership or
joint venture), to your current members
(if you are a limited liability company) or
to your current directors;
(b) To the spouse, child, parent, brother or
sister of that current partner, member or
director as a consequence of Paragraph
(1)(a) above;
(c) For which there is any obligation to
share damages with or repay someone
else who must pay damages because of
the injury described in Paragraph (1)(a)
or (b) above; or
(d) Arising out of his or her providing or
failing to provide professional health care
services.
COMMERCIAL GENERAL LIABILITY
ISSUE DATE: 12-4-21
Unless you are in the business or occupation
of providing professional health care
services, Paragraphs (1)(a) (b) (c) and (d)
above do not apply to "bodily injury" arising
out of providing or failing to provide first aid
or "Good Samaritan services" by any of your
retired partners, members, directors or
"employees", other than a doctor. Any such
retired partners, members, directors or
"employees" providing or failing to provide
first aid or "Good Samaritan services" during
their work hours for you will be deemed to be
acting within the scope of their employment
by you or performing duties related to the
conduct of your business.
(2) "Personal injury':
(a) To you, to your current or retired
partners or members (if you are a
partnership or joint venture), to your
current or retired members (if you are a
limited liability company), to your other
current or retired directors or
"employees" while in the course of his or
her employment or performing duties
related to the conduct of your business,
or to your other "volunteer workers"
while performing duties related to the
conduct of your business;
(b) To the spouse, child, parent, brother or
sister of that current or retired partner,
member, director, "employee" or
"volunteer worker" as a consequence of
Paragraph (2)(a) above;
(c) For which there is any obligation to
share damages with or repay someone
else who must pay damages because of
the injury described in Paragraph (2)(a)
or (b) above; or
(d) Arising out of his or her providing or
failing to provide professional health care
services.
(3) "Property damage" to property:
(a) Owned, occupied or used by; or
(b) Rented to, in the care, custody or control
of, or over which physical control is
being exercised for any purpose by;
you, any of your retired partners, members
or directors, your current or retired
"employees" or "volunteer workers", any
current partner or member (if you are a
partnership or joint venture), or any current
member (if you are a limited liability
company) or current director.
© 2017 The Travelers Indemnity Company. All rights reserved. CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
POLICY NUMBER: P -660 -5R143841 -TIL -21
D. WHO IS AN INSURED — EMPLOYEES AND
VOLUNTEER WORKERS — BODILY INJURY
TO CO -EMPLOYEES, CO -VOLUNTEER
WORKERS AND RETIRED PARTNERS,
MEMBERS, DIRECTORS AND EMPLOYEES
The following is added to Paragraph 2.a.(1) of
SECTION II — WHO IS AN INSURED
Paragraphs (1)(a), (b) and (c) above do not
apply to "bodily injury" to a current or retired co -
"employee" while in the course of the co -
"employee's" employment by you or performing
duties related to the conduct of your business, or
to "bodily injury" to your other "volunteer
workers" or retired partners, members or
directors while performing duties related to the
conduct of your business.
E. WHO IS AN INSURED — NEWLY ACQUIRED
OR FORMED LIMITED LIABILITY COMPANIES
The following replaces Paragraph 3. of
SECTION II — WHO IS AN INSURED
3. Any organization you newly acquire or form,
other than a partnership or joint venture, and
of which you are the sole owner or in which
you maintain an ownership interest of more
than 50%, will qualify as a Named Insured if
there is no other similar insurance available
to that organization. However:
a. Coverage under this provision is
afforded only:
(1) Until the 180th day after you acquire
or form the organization or the end
of the policy period, whichever is
earlier, if you do not report such
organization in writing to us within
180 days after you acquire or form it;
or
(2) Until the end of the policy period,
when that date is later than 180 days
after you acquire or form such
organization, if you report such
organization in writing to us within
180 days after you acquire or form it;
b. Coverage A does not apply to "bodily
injury" or "property damage" that
occurred before you acquired or formed
the organization; and
c. Coverage B does not apply to "personal
and advertising injury" arising out of an
offense committed before you acquired
or formed the organization.
For the purposes of Paragraph 1. of Section
11 — Who Is An Insured, each such
CG D3 79 02 19
COMMERCIAL GENERAL LIABILITY
ISSUE DATE: 12-4-21
organization will be deemed to be
designated in the Declarations as:
a. A limited liability company;
b. An organization other than a partnership,
joint venture or limited liability company;
or
c. A trust;
as indicated in its name or the documents
that govern its structure.
F. BLANKET ADDITIONAL INSURED
CONTROLLING INTEREST
1. The following is added to SECTION II —
WHO IS AN INSURED
Any person or organization that has financial
control of you is an insured with respect to
liability for "bodily injury", "property damage"
or "personal and advertising injury" that
arises out of:
a. Such financial control; or
b. Such person's or organization's
ownership, maintenance or use of
premises leased to or occupied by you.
The insurance provided to such person or
organization does not apply to structural
alterations, new construction or demolition
operations performed by or on behalf of such
person or organization.
2. The following is added to Paragraph 4. of
SECTION II — WHO IS AN INSURED
This paragraph does not apply to any
premises owner, manager or lessor that has
financial control of you.
G. BLANKET ADDITIONAL INSURED —
MORTGAGEES, ASSIGNEES, SUCCESSORS
OR RECEIVERS
The following is added to SECTION II — WHO IS
AN INSURED:
Any person or organization that is a mortgagee,
assignee, successor or receiver and that you
have agreed in a written contract or agreement
to include as an additional insured on this
Coverage Part is an insured, but only with
respect to its liability as mortgagee, assignee,
successor or receiver for "bodily injury", "property
damage" or "personal and advertising injury"
that:
a. Is "bodily injury" or "property damage" that
occurs, or is "personal and advertising injury"
caused by an offense that is committed,
© 2017 The Travelers Indemnity Company. All rights reserved. Page 3 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
POLICY NUMBER: P -660 -5R143841 -TIL -21
subsequent to the signing of that contract or
agreement; and
b. Arises out of the ownership, maintenance or
use of the premises for which that
mortgagee, assignee, successor or receiver
is required under that contract or agreement
to be included as an additional insured on
this Coverage Part.
The insurance provided to such mortgagee,
assignee, successor or receiver is subject to the
following provisions:
a. The limits of insurance provided to such
mortgagee, assignee, successor or receiver
will be the minimum limits that you agreed to
provide in the written contract or agreement,
or the limits shown in the Declarations,
whichever are less.
b. The insurance provided to such person or
organization does not apply to:
(1) Any "bodily injury" or "property damage"
that occurs, or any "personal and
advertising injury" caused by an offense
that is committed, after such contract or
agreement is no longer in effect; or
(2) Any "bodily injury", "property damage" or
"personal and advertising injury" arising
out of any structural alterations, new
construction or demolition operations
performed by or on behalf of such
mortgagee, assignee, successor or
receiver.
H. BLANKET ADDITIONAL INSURED —
GOVERNMENTAL ENTITIES — PERMITS OR
AUTHORIZATIONS RELATING TO PREMISES
The following is added to SECTION II — WHO IS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to premises owned
or occupied by, or rented or loaned to, you and
that you are required by any ordinance, law,
building code or written contract or agreement to
include as an additional insured on this
Coverage Part is an insured, but only with
respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
arising out of the existence, ownership, use,
maintenance, repair, construction, erection or
removal of any of the following for which that
governmental entity has issued such permit or
authorization: advertising signs, awnings,
canopies, cellar entrances, coal holes,
driveways, manholes, marquees, hoist away
COMMERCIAL GENERAL LIABILITY
ISSUE DATE: 12-4-21
openings, sidewalk vaults, elevators, street
banners or decorations.
I. BLANKET ADDITIONAL INSURED —
GOVERNMENTAL ENTITIES — PERMITS
OR AUTHORIZATIONS RELATING TO
OPERATIONS
The following is added to SECTION II — WHO IS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to operations
performed by you or on your behalf and that you
are required by any ordinance, law, building code
or written contract or agreement to include as an
additional insured on this Coverage Part is an
insured, but only with respect to liability for
"bodily injury", "property damage" or "personal
and advertising injury" arising out of such
operations.
The insurance provided to such governmental
entity does not apply to:
a. Any "bodily injury", "property damage" or
"personal and advertising injury" arising out
of operations performed for the
governmental entity; or
b. Any "bodily injury" or "property damage"
included in the "products -completed
operations hazard".
J. INCIDENTAL MEDICAL MALPRACTICE
1. The following replaces Paragraph b. of the
definition of "occurrence" in the
DEFINITIONS Section:
b. An act or omission committed in
providing or failing to provide "incidental
medical services", first aid or "Good
Samaritan services" to a person, unless
you are in the business or occupation of
providing professional health care
services.
2. The following replaces the last paragraph of
Paragraph 2.a.(1) of SECTION II — WHO IS
AN INSURED:
Unless you are in the business or occupation
of providing professional health care
services, Paragraphs (1)(a) (b) (c) and (d)
above do not apply to "bodily injury" arising
out of providing or failing to provide:
(a) "Incidental medical services" by any of
your "employees" who is a nurse,
nurse assistant, emergency medical
technician, paramedic, athletic trainer,
audiologist, dietician, nutritionist,
© 2017 The Travelers Indemnity Company. All rights reserved. CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
POLICY NUMBER: P -660 -5R143841 -TIL -21
occupational therapist or occupational
therapy assistant, physical therapist or
speech-language pathologist; or
(b) First aid or "Good Samaritan services"
by any of your "employees" or "volunteer
workers", other than an employed or
volunteer doctor. Any such "employees"
or "volunteer workers" providing or failing
to provide first aid or "Good Samaritan
services" during their work hours for you
will be deemed to be acting within the
scope of their employment by you or
performing duties related to the conduct
of your business.
3. The following replaces the last sentence of
Paragraph 5. of SECTION III — LIMITS OF
INSURANCE:
For the purposes of determining the
applicable Each Occurrence Limit, all related
acts or omissions committed in providing or
failing to provide "incidental medical
services", first aid or "Good Samaritan
services" to any one person will be deemed
to be one "occurrence".
4. The following exclusion is added to
Paragraph ?. Ezt:lusions SECTION I —
COVERAGES — COVERAGE A — BODILY
INJURY AND PROPERTY DAMAGE
LIABILITY
Sale Of Pharmaceuticals
"Bodily injury" or "property damage" arising
out of the violation of a penal statute or
ordinance relating to the sale of
pharmaceuticals committed by, or with the
knowledge or consent of the insured.
5. The following is added to the DEFINITIONS
Section:
"Incidental medical services" means:
a. Medical, surgical, dental, laboratory, x-
ray
ray or nursing service or treatment,
advice or instruction, or the related
furnishing of food or beverages; or
b. The furnishing or dispensing of drugs or
medical, dental, or surgical supplies or
appliances.
6. The following is added to Paragraph 4.b.,
Excess Insurance, of SECTION IV —
COMMERCIAL GENERAL LIABILITY
CONDITIONS:
This insurance is excess over any valid and
collectible other insurance, whether primary,
excess, contingent or on any other basis,
CG D3 79 02 19
COMMERCIAL GENERAL LIABILITY
ISSUE DATE: 12-4-21
that is available to any of your "employees"
for "bodily injury" that arises out of providing
or failing to provide "incidental medical
services" to any person to the extent not
subject to Paragraph 2.a.(1) of Section 11 —
Who Is An Insured.
K. MEDICAL PAYMENTS — INCREASED LIMIT
The following replaces Paragraph 7. of
SECTION III — LIMITS OF INSURANCE
7. Subject to Paragraph 5. above, the Medical
Expense Limit is the most we will pay under
Coverage C for all medical expenses
because of "bodily injury" sustained by any
one person, and will be the higher of:
a. $10,000; or
b. The amount shown in the Declarations of
this Coverage Part for Medical Expense
Limit.
L. AMENDMENT OF EXCESS INSURANCE
CONDITION — PROFESSIONAL LIABILITY
The following is added to Paragraph 4.b.,
Excess Insurance, of SECTION IV —
COMMERCIAL GENERAL LIABILITY
CONDITIONS:
This insurance is excess over any of the other
insurance, whether primary, excess, contingent
or on any other basis, that is Professional
Liability or similar coverage, to the extent the
loss is not subject to the professional services
exclusion of Coverage A or Coverage B
M. BLANKET WAIVER OF SUBROGATION —
WHEN REQUIRED BY WRITTEN CONTRACT
OR AGREEMENT
The following is added to Paragraph 0. Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS
If the insured has agreed in a written contract or
agreement to waive that insured's right of
recovery against any person or organization, we
waive our right of recovery against such person
or organization, but only for payments we make
because of:
a. "Bodily injury" or "property damage" that
occurs; or
b. "Personal and advertising injury" caused by
an offense that is committed;
subsequent to the signing of that contract or
agreement.
© 2017 The Travelers Indemnity Company. All rights reserved. Page 5 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: P -660 -5R143841 -TIL -21 ISSUE DATE: 12-4-21 N. CONTRACTUAL LIABILITY — RAILROADS
1. The following replaces Paragraph c. of the
definition of "insured contract" in the
DEFINITIONS Section:
c. Any easement or license agreement;
2. Paragraph f.(1) of the definition of "insured
contract" in the DEFINITIONS Section is
deleted.
© 2017 The Travelers Indemnity Company. All rights reserved. CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
Policy Number: 810 -5R143576 -21-43-G
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINES S AUTO EXTEN SION ENDOR SEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A.
B.
C.
D.
BROAD FORM NAMED INSURED
BLANKET ADDITIONAL INSURED
EMPLOYEE HIRED AUTO
EMPLOYEES AS INSURED
E. SUPPLEMENTARY PAYMENTS - INCREASED
LIMITS
F. HIRED AUTO - LIMITED WORLDWIDE COV-
ERAGE - INDEMNITY BASIS
G. WAIVER OF DEDUCTIBLE - GLASS
PROVISIONS
A. BROAD FORM NAMED INSURED
The following is added to Paragraph A.1., Who Is
An Insured, of SECTION II - COVERED AUTOS
LIABILITY COVERAGE:
Any organization you newly acquire or form dur-
ing the policy period over which you maintain
50% or more ownership interest and that is not
separately insured for Business Auto Coverage.
Coverage under this provision is afforded only un-
til the 180th day after you acquire or form the or-
ganization or the end of the policy period, which-
ever is earlier.
B. BLANKET ADDITIONAL INSURED
The following is added to Paragraph c. in A.1.,
Who Is An Insured, of SECTION II - COVERED
AUTOS LIABILITY COVERAGE:
Any person or organization who is required under
a written contract or agreement between you and
that person or organization, that is signed and
executed by you before the "bodily injury' or
"property damage" occurs and that is in effect
during the policy period, to be named as an addi-
tional insured is an "insured" for Covered Autos
Liability Coverage, but only for damages to which
CAT3530215
H. HIRED AUTO PHYSICAL DAMAGE - LOSS OF
USE - INCREASED LIMIT
I. PHYSICAL DAMAGE - TRANSPORTATION
EXPENSES - INCREASED LIMIT
J. PERSONALPROPERTY
K. AIRBAGS
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
M. BLANKET WAIVER OF SUBROGATION
N. UNINTENTIONAL ERRORS OR OMISSIONS
this insurance applies and only to the extent that
person or organization qualifies as an "insured"
under the Who Is An Insured provision contained
in Section II.
C. EMPLOYEE HIRED AUTO
1. The following is added to Paragraph A.1.,
Who Is An Insured, of SECTION II - COV-
ERED AUTOS LIABILITY COVERAGE:
An "employee" of yours is an "insured" while
operating an "auto' hired or rented under a
contract or agreement in an "employee's"
name, with your permission, while performing
duties related to the conduct of your busi-
ness.
2. The following replaces Paragraph b. in B.5.,
Other Insurance, of SECTION IV - BUSI-
NESS AUTO CONDITIONS:
b. For Hired Auto Physical Damage Cover-
age, the following are deemed to be cov-
ered "autos" you own:
(1) Any covered "auto' you lease, hire,
rent or borrow; and
(2) Any covered "auto" hired or rented by
your "employee' under a contract in
an "employee's" name, with your
© 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
Policy Number: 810 -5R143576 -21-43-G
COMMERCIAL AUTO
permission, while performing duties
related to the conduct of your busi-
ness.
However, any "auto' that is leased, hired,
rented or borrowed with a driver is not a
covered "auto".
D. EMPLOYEES AS INSURED
The following is added to Paragraph Al., Who Is
An Insured, of SECTION II — COVERED AUTOS
CEOBEFERGE:
Any "employee" of yours is an "insured" while us-
ing a covered "auto" you dont own, hire or borrow
in your business or your personal affairs.
E. SUPPLEMENTARY PAYMENTS — INCREASED
LIMITS
1. The following replaces Paragraph A.2.a.(2),
of SECTION II — COVERED AUTOS LIABIL-
ITY COVERAGE:
(2) Up to $3,000 for cost of bail bonds (in-
cluding bonds for related traffic law viola-
tions) required because of an "accident"
we cover. We do not have to furnish
these bonds.
2. The following replaces Paragraph A.2.a.(4),
of SECTION II — COVERED AUTOS LIABIL-
ITY COVERAGE:
(4) All reasonable expenses incurred by the
"insured" at our request, including actual
loss of earnings up to $500 a day be-
cause of time off from work.
F. HIRED AUTO — LIMITED WORLDWIDE COV-
ERAGE — INDEMNITY BASIS
The following replaces Subparagraph (5) in Para-
graph B.7., Policy Period, Coverage Territory,
of SECTION IV — BUSINESS AUTO CONDI-
TIONS:
(5) Anywhere in the world, except any country or
jurisdiction while any trade sanction, em-
bargo, or similar regulation imposed by the
United States of America applies to and pro-
hibits the transaction of business with or
within such country or jurisdiction, for Cov-
ered Autos Liability Coverage for any covered
"auto" that you lease, hire, rent or borrow
without a driver for a period of 30 days or less
and that is not an "auto' you lease, hire, rent
or borrow from any of your "employees",
partners (if you are a partnership), members
(if you are a limited liability company) or
members of their households.
(a) With respect to any claim made or "suit"
brought outside the United States of
America, the territories and possessions
of the United States of America, Puerto
Rico and Canada:
(i)
You must arrange to defend the 'in-
sured" against, and investigate or set-
tle any such claim or "suit" and keep
us advised of all proceedings and ac-
tions.
(ii) Neither you nor any other involved
"insured' will make any settlement
without our consent.
(iii) We may, at our discretion, participate
in defending the "insured" against, or
in the settlement of, any claim or
(iv) We will reimburse the "insured" for
sums that the "insured' legally must
pay as damages because of "bodily
injury" or "property damage" to which
this insurance applies, that the 'in-
sured" pays with our consent, but
only up to the limit described in Para-
graph C., Limits Of Insurance, of
SECTION II — COVERED AUTOS
LIABILITY COVERAGE.
(v) We will reimburse the "insured" for
the reasonable expenses incurred
with our consent for your investiga-
tion of such claims and your defense
of the "insured" against any such
but only up to and included
within the limit described in Para-
graph C., Limits Of Insurance, of
SECTION II — COVERED AUTOS
LIABILITY COVERAGE, and not in
addition to such limit. Our duty to
make such payments ends when we
have used up the applicable limit of
insurance in payments for damages,
settlements or defense expenses.
(b) This insurance is excess over any valid
and collectible other insurance available
to the "insured' whether primary, excess,
contingent or on any other basis.
(c) This insurance is not a substitute for re-
quired or compulsory insurance in any
country outside the United States, its ter-
ritories and possessions, Puerto Rico and
Canada.
© 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
Policy Number: 810 -5R143576 -21-43-G
You agree to maintain all required or
compulsory insurance in any such coun-
try up to the minimum limits required by
local law. Your failure to comply with
compulsory insurance requirements will
not invalidate the coverage afforded by
this policy, but we will only be liable to the
same extent we would have been liable
had you complied with the compulsory in-
surance requirements.
(d) It is understood that we are not an admit-
ted or authorized insurer outside the
United States of America, its territories
and possessions, Puerto Rico and Can-
ada. We assume no responsibility for the
furnishing of certificates of insurance, or
for compliance in any way with the laws
of other countries relating to insurance.
G. WAIVER OF DEDUCTIBLE — GLASS
The following is added to Paragraph D., Deducti-
ble, of SECTION III - PHYSICAL DAMAGE
COVERAGE:
No deductible for a covered "auto" will apply to
glass damage if the glass is repaired rather than
replaced.
H. HIRED AUTO PHYSICAL DAMAGE - LOSS OF
USE - INCREASED LIMIT
The following replaces the last sentence of Para-
graph A.4.b., Loss Of Use Expenses, of SEC-
TION III - PHYSICAL DAMAGE COVERAGE:
However, the most we will pay for any expenses
for loss of use is $65 per day, to a maximum of
$750 for any one "accident".
I. PHYSICAL DAMAGE - TRANSPORTATION
EXPENSES - INCREASED LIMIT
The following replaces the first sentence in Para-
graph A.4.a., Transportation Expenses, of
SECTION III - PHYSICAL DAMAGE COVER-
AGE:
We will pay up to $50 per day to a maximum of
$1,500 for temporary transportation expense in-
curred by you because of the total theft of a cov-
ered "auto" of the private passenger type.
J. PERSONAL PROPERTY
The following is added to Paragraph A.4., Cover-
age Extensions, of SECTION III - PHYSICAL
DAMAGE COVERAGE:
Personal Property
We will pay up to $400 for "loss" to wearing ap-
parel and other personal property which is:
(1) Owned by an "insured"; and
CAT3530215
COMMERCIAL AUTO
(2) In or on yotaered "auto".
This coverage applies only in the event of a total
theft of your covered "auto".
No deductibles apply to this Personal Property
coverage.
K. AIRBAGS
The following is added to Paragraph B3., Exclu-
sions, of SECTION III - PHYSICAL DAMAGE
COVERAGE:
Exclusion 3.a. does not apply to "loss" to one or
more airbags in a covered "auto" you own that in-
flate due to a cause other than a cause of "loss"
set forth in Paragraphs A.1.b. and A.1.c., but
only:
a. If that "auto" is a covered "auto" for Compre-
hensive Coverage under this policy;
b. The airbags are not covered under any war-
ranty; and
c. The akbegs not intentionally inflated.
We will pay up to a maximum of $1,000 for any
one "loss".
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
The following is added to Paragraph A.2.a., of
SECTION IV — BUSINESS AUTO CONDITIONS:
Your duty to give us or our authorized representa-
tive prompt notice of the "accident" or "loss" ap-
plies only when the "accident" or "loss" is known
to:
(a) You (if you are an individual);
(b) A partner (if you are a partnership);
(c) A member (if you are a limited liability com-
pany);
(d) An executive officer, director or insurance
manager (if you are a corporation or other or-
ganization); or
(e) Any "employee" authorized by you to give no-
tice of the "accident" or "loss".
M. BLANKET WAIVER OF SUBROGATION
The following replaces Paragraph A5., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV - BUSINESS AUTO CONDI-
TIONS:
5. Transfer Of Rights Of Recovery Against
Others To Us
We waive any right of recovery we may have
against any person or organization to the ex-
tent required of you by a written contract
signed and executed prior to any "accident"
or "loss", provided that the "accident" or "loss"
arises out of operations contemplated by
© 2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
Policy Number: 810 -5R143576 -21-43-G
COMMERCIAL AUTO
such contract. The waiver applies only to the
person or organization designated in such
contract.
N. UNINTENTIONAL ERRORS OR OMISSIONS
The following is added to Paragraph B.2., Con-
cealment, Misrepresentation, Or Fraud, of
SECTION IV — BUSINESS AUTO CONDITIONS:
The unintentional omission of, or unintentional
error in, any information given by you shall not
prejudice your rights under this insurance. How-
ever this provision does not affect our right to col-
lect additional premium or exercise our right of
cancellation or non -renewal.
© 2015 The Travelers Indemnity Compa ny. All rights reserved . CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
TRAVELERS
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 99 03 76 ( A) —
POLICY NUMBER: UB -5R147157 -21-43-G
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKET WAIVER)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule.
The additional premium for this endorsement shall be °/O of the California workers' compensation pre- mium.
Schedule
Person or Organization Job Description
ANY PERSON OR ORGANIZATION FOR WHICH
THE INSURED HAS AGREED BY WRITTEN
CONTRACT EXECUTED PRIOR TO LOSS TO
FURNISH THIS WAIVER.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 12/04/2021 Policy No. UB -5R147157 -21-43-G Endorsement No.
Insured Premium
Insurance Company
Countersigned by
DATE OF ISSUE: — — ST ASSIGN: Page 1 of 1