SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A : NAIC #
NAME: CONTACT
(A/C, No): FAX
E-MAIL ADDRESS:
PRODUCER
(A/C, No, Ext): PHONE
INSURED
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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).
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.
OTHER:
(Per accident)
(Ea accident)
$
$
N / A
SUBR WVDADDL
INSD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $
$
$
$ PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person) COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOS ONLY AUTOS NON-OWNED OWNED SCHEDULED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) DESCRIPTION OF OPERATIONS below
If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
$
$
$ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEEE.L. EACH ACCIDENT EROTH- STATUTE PER
(MM/DD/YYYY) LIMITS POLICY EXP(MM/DD/YYYY) POLICY EFFLTR TYPE OF INSURANCE POLICY NUMBER INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB EACH OCCURRENCE $ AGGREGATE $
$
OCCUR
CLAIMS-MADE DED RETENTION $
PRODUCTS - COMP/OP AGG $ GENERAL AGGREGATE $ PERSONAL & ADV INJURY $ MED EXP (Any one person) $
EACH OCCURRENCE $ DAMAGE TO RENTED
PREMISES (Ea occurrence) $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
11/14/2023
Venbrook Insurance Services
6320 Canoga Avenue, 12th Floor
Woodland Hills, CA 91367
818-598-8900 818-598-8910
www.venbrook.com CA Lic No. 0D80832 Continental Insurance Company A XV 35289 Hartford Casualty Insurance Company A+ XV 29424
Beazley Insurance Company, Inc. A XV 37540
A 7039996776 9/1/2023 9/1/2024 1,000,000
100,000
✓
15,000
✓
1,000,000
✓ Contractual Liability
2,000,000
✓ 2,000,000
A 7040001609 9/1/2023 9/1/2024 1,000,000
✓
✓ ✓
✓ Comp/Coll Deductible $1,000
A ✓ ✓ 7040002176 9/1/2023 9/1/2024 9,000,000
9,000,000 (underlying GL, AL, EL)
✓ 10,000
B 72WEOL6H1H 9/1/2023 9/1/2024 ✓
1,000,000 N
1,000,000
1,000,000
C Professional/Pollution Liability V27737230501 9/1/2023 9/1/2024 $2,000,000 Per Claim/$4,000,000 Aggregate Karen Smith
Venbrook Insurance Services
Cannon Corporation
1050 Southwood Drive
San Luis Obispo CA 93401
77196058
✓ ✓
✓ ✓
✓
**SEE ATTATCHED ADDENDUM***
City of Redando Beach
Public Works Department,
Engineering Services Division
415 Diamond Street, Door E
Redondo Beach CA 90227
RE: All Operations of the Named Insured
77196058 | 23-24 GL/AL/WC/UM/PL | Adrianna Padilla | 11/14/2023 2:08:47 PM (PST) | Page 1 of 13 ACORD 101 (2008/01)
The ACORD name and logo are registered marks of ACORD
© 2008 ACORD CORPORATION. All rights reserved.
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE:
ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY CUSTOMER ID:
LOC #:
AGENCY
CARRIER NAIC CODE
POLICY NUMBER
NAMED INSURED
EFFECTIVE DATE:
RE: All Operations of the Named Insured
The City, its officers, elected and appointed officials, employees, and volunteers are named as Additional Insured under the General Liability and Automobile Liability policy if required by written contract with the Named Insured but only for coverage and limits provided by the policy and the additional insured endorsement. Primary and NonContributory coverage applies to General Liability and Automobile Liability. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation.
Excess/Umbrella follows form. *10 Days Notice of Cancellation for Non-Payment of Premium, 30 Days All Other.
Venbrook Insurance Services Cannon Corporation
1050 Southwood Drive
San Luis Obispo CA 93401
25 Certificate of Liability (03/16)
ADDENDUM
HOLDER:
ADDRESS:
City of Redando Beach Public Works Department, Engineering Services Division 415 Diamond Street, Door E Redondo Beach CA 90227
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CNA PARAMOUNT
Blanket Additional Insured - Owners, Lessees or
Contractors - with Products-Completed
Operations Coverage Endorsement
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
It is understood and agreed as follows:
I. WHO IS AN INSURED is amended to include as an Insured any person or organization whom you are required by written contract to add as an additional insured on this coverage part, but only with respect to liability for bodily injury, property damage or personal and advertising injury caused in whole or in part by your acts or omissions, or the acts or omissions of those acting on your behalf:
A. in the performance of your ongoing operations subject to such written contract; or B. in the performance of your work subject to such written contract, but only with respect to bodily injury or property damage included in the products-completed operations hazard, and only if:
1. the written contract requires you to provide the additional insured such coverage; and
2. this coverage part provides such coverage.
II. But if the written contract requires:
A. additional insured coverage under the 11-85 edition, 10-93 edition, or 10-01 edition of CG2010, or under the 10- 01 edition of CG2037; or
B. additional insured coverage with "arising out of" language; or C. additional insured coverage to the greatest extent permissible by law; then paragraph I. above is deleted in its entirety and replaced by the following:
WHO IS AN INSURED is amended to include as an Insured any person or organization whom you are required by written contract to add as an additional insured on this coverage part, but only with respect to liability for bodily injury, property damage or personal and advertising injury arising out of your work that is subject to such written contract.
III. Subject always to the terms and conditions of this policy, including the limits of insurance, the Insurer will not provide such additional insured with:
A. coverage broader than required by the written contract; or B. a higher limit of insurance than required by the written contract.
IV. The insurance granted by this endorsement to the additional insured does not apply to bodily injury, property damage, or personal and advertising injury arising out of:
A. the rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including:
1. the preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and
2. supervisory, inspection, architectural or engineering activities; or B. any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this coverage part.
V. Under COMMERCIAL GENERAL LIABILITY CONDITIONS, the Condition entitled Other Insurance is amended to add the following, which supersedes any provision to the contrary in this Condition or elsewhere in this coverage part:
Policy No:
Effective Date:
CNA75079XX (10-16)
Insured Name:
Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 00020002460792047243224
Cannon Corporation
09/01/2023
7039996776
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CNA PARAMOUNT
Blanket Additional Insured - Owners, Lessees or
Contractors - with Products-Completed
Operations Coverage Endorsement
Primary and Noncontributory Insurance
With respect to other insurance available to the additional insured under which the additional insured is a named insured, this insurance is primary to and will not seek contribution from such other insurance, provided that a written contract requires the insurance provided by this policy to be:
1. primary and non-contributing with other insurance available to the additional insured; or
2. primary and to not seek contribution from any other insurance available to the additional insured.
But except as specified above, this insurance will be excess of all other insurance available to the additional insured.
VI. Solely with respect to the insurance granted by this endorsement, the section entitled COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows:
The Condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit is amended with the addition of the following:
Any additional insured pursuant to this endorsement will as soon as practicable:
1. give the Insurer written notice of any claim, or any occurrence or offense which may result in a claim;
2. send the Insurer copies of all legal papers received, and otherwise cooperate with the Insurer in the investigation, defense, or settlement of the claim; and
3. make available any other insurance, and tender the defense and indemnity of any claim to any other insurer or self-insurer, whose policy or program applies to a loss that the Insurer covers under this coverage part. However, if the written contract requires this insurance to be primary and non-contributory, this paragraph 3. does not apply to insurance on which the additional insured is a named insured.
The Insurer has no duty to defend or indemnify an additional insured under this endorsement until the Insurer receives written notice of a claim from the additional insured.
VII. Solely with respect to the insurance granted by this endorsement, the section entitled DEFINITIONS is amended to add the following definition:
Written contract means a written contract or written agreement that requires you to make a person or organization an additional insured on this coverage part, provided the contract or agreement:
A. is currently in effect or becomes effective during the term of this policy; and B. was executed prior to:
1. the bodily injury or property damage; or
2. the offense that caused the personal and advertising injury; for which the additional insured seeks coverage.
Any coverage granted by this endorsement shall apply solely to the extent permissible by law.
All other terms and conditions of the Policy remain unchanged.
This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy.
Policy No:
Effective Date:
CNA75079XX (10-16)
Insured Name:
Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 7039996776
Cannon Corporation
09/01/2023
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CNA PARAMOUNT
Waiver of Transfer of Rights of Recovery Against
Others to the Insurer Endorsement
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
ANY PERSON OR ORGANIZATION WHOM THE NAMED INSURED HAS AGREED IN WRITING IN A
CONTRACT OR AGREEMENT TO WAIVE SUCH RIGHTS OF RECOVERY, BUT ONLY IF SUCH CONTRACT OR AGREEMENT:
1.IS IN EFFECT OR BECOMES EFFECTIVE DURING THE TERM OF THIS COVERAGE PART; AND
2.WAS EXECUTED PRIOR TO THE BODILY INJURY, PROPERTY DAMAGE OR PERSONAL AND ADVERTISING INJURY GIVING RISE TO THE CLAIM.
(Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) Under COMMERCIAL GENERAL LIABILITY CONDITIONS, it is understood and agreed that the condition entitled Transfer Of Rights Of Recovery Against Others To Us is amended by the addition of the following:
With respect to the person or organization shown in the Schedule above, the Insurer waives any right of recovery the Insurer may have against such person or organization because of payments the Insurer makes for injury or damage arising out of the Named Insured’s ongoing operations or your work included in the products-completed operations hazard.
All other terms and conditions of the Policy remain unchanged.
This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy.
Policy No:
Effective Date:
CNA75008XX (10-16)
Insured Name:
Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. 00020002460792047243228
Cannon Corporation
7039996776
09/01/2023
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Endorsement
Policy No:
Policy Effective Date:
Policy Page: 1 of 5
Form No: SCA 23 500 D 10 11
Endorsement Effective Date:
Endorsement No:
Underwriting Company:
© Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
I. LIABILTY COVERAGE
A. Who Is An Insured
The following is added to SECTION II, Paragraph A.1., Who Is An Insured:
1. a. Any incorporated entity of which the Named Insured owns a majority of the voting stock on the date of inception of this Coverage Form; provided that, b. The insurance afforded by this provision A.1. does not apply to any such entity that is an insured under any other liability “policy” providing auto coverage.
2. Any organization you newly acquire or form, other than a limited liability company, partnership or joint venture, and over which you maintain majority ownership interest.
The insurance afforded by this provision A.2.:
a. Is effective on the acquisition or formation date, and is afforded only until the end of the policy period of this Coverage Form, or the next anniversary of its inception date, whichever is earlier. b. Does not apply to:
(1) Bodily injury or property damage caused by an accident that occurred before you acquired or formed the organization; or
(2) Any such organization that is an insured under any other liability “policy” providing auto coverage.
3. Any person or organization that you are obligated to provide Insurance where required by a written contract or agreement is an insured, but only with respect to legal responsibility for acts or omissions of a person for whom Liability Coverage is afforded under this policy.
4. An employee of yours is an insured while operating an auto hired or rented under a contract or agreement in that employee's name, with your permission, while performing duties related to the conduct of your business.
“Policy”, as used in this provision A. Who Is An Insured, includes those policies that were in force on the inception date of this Coverage Form but:
1. Which are no longer in force; or
2. Whose limits have been exhausted.
B. Bail Bonds and Loss of Earnings
SECTION II, Paragraphs A.2.a.(2) and A.2.a.(4) are revised as follows:
1. In a.(2), the limit for the cost of bail bonds is increased from $2,000 to $5,000, and
2. In a.(4), the limit for the loss of earnings is increased from $250 to $500 a day.
C. Fellow Employee
EXTENDED COVERAGE ENDORSEMENT - BA PLUS
09/01/2023
Continental Insurance Company A XV
09/01/2023
7040001609
Cannon Corporation
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Endorsement
Policy No:
Policy Effective Date:
Policy Page: 2 of 5
Form No: SCA 23 500 D 10 11
Endorsement Effective Date:
Endorsement No:
Underwriting Company:
© Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission.
SECTION II, Paragraph B.5 does not apply.
Such coverage as is afforded by this provision C. is excess over any other collectible insurance.
II. PHYSICAL DAMAGE COVERAGE
A. Towing
SECTION III. Paragraph A.2., is revised to include Light Trucks up to 10,000 pounds G.V.W.
B. Glass Breakage – Hitting A Bird Or Animal – Falling Objects Or Missiles The following is added to SECTION III, Paragraph A.3.:
With respect to any covered auto, any deductible shown in the Declarations will not apply to glass breakage if such glass is repaired, in a manner acceptable to us, rather than replaced.
C. Transportation Expenses
SECTION III, Paragraph A.4.a. is revised, with respect to transportation expense incurred by you, to provide:
a. $60 per day, in lieu of $20; subject to
b. $1,800 maximum, in lieu of $600.
D. Loss of Use Expenses
SECTION III, Paragraph A.4.b. is revised, with respect to loss of use expenses incurred by you, to provide:
a. $1,000 maximum, in lieu of $600.
E. Personal Property
The following is added to SECTION III, Paragraph A.4.
c. We will pay up to $500 for loss to Personal Property which is:
(1) Owned by an insured; and
(2) In or on the covered auto.
This coverage applies only in the event of a total theft of your covered auto.
This insurance is excess over any other collectible insurance and no deductible applies.
F. Rental Reimbursement
The following is added to SECTION III, Paragraph A.4.:
d. We will pay for rental reimbursement expenses incurred by you for the rental of an auto because of loss to a covered auto. Payment applies in addition to the otherwise applicable amount of each coverage you have on a covered auto. No deductibles apply to this coverage.
1. We will pay only for those expenses incurred during the policy period beginning 24 hours after the loss and ending, regardless of the policy's expiration, with the lesser of the following number of days:
(a) The number of days reasonably required to repair or replace the covered auto; or, (b) 15 days.
2. Our payment is limited to the lesser of the following amounts:
(a) Necessary and actual expenses incurred; or,
(b) $25 per day subject to a maximum of $375.
09/01/2023
Continental Insurance Company A XV
09/01/2023
Cannon Corporation
7040001609
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Endorsement
Policy No:
Policy Effective Date:
Policy Page: 3 of 5
Form No: SCA 23 500 D 10 11
Endorsement Effective Date:
Endorsement No:
Underwriting Company:
© Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission.
3. This coverage does not apply while there are spare or reserve autos available to you for your operations.
4. If loss results from the total theft of a covered auto of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided for under the Physical Damage Coverage Extension.
G. Hired “Autos”
The following is added to SECTION III. Paragraph A.:
5. Hired Autos
If Physical Damage coverage is provided under this policy, and such coverage does not extend to Hired Autos, then Physical Damage coverage is extended to:
a. Any covered auto you lease, hire, rent or borrow without a driver; and b. Any covered auto hired or rented by your employee without a driver, under a contract in that individual employee's name, with your permission, while performing duties related to the conduct of your business.
c. The most we will pay for any one accident or loss is the actual cash value, cost of repair, cost of replacement or $75,000 whichever is less minus a $500 deductible for each covered auto. No deductible applies to loss caused by fire or lightning. d. The physical damage coverage as is provided by this provision will be limited to the types of physical damage coverage(s) provided on your owned autos. e. Such physical damage coverage for hired autos will:
(1) Include loss of use, provided it is the consequence of an accident for which the Named Insured is legally liable, and as a result of which a monetary loss is sustained by the leasing or rental concern.
(2) Such coverage as is provided by this provision G.e.(1) will be subject to a limit of $750 per accident.
H. Airbag Coverage
The following is added to SECTION III, Paragraph B.3.
The accidental discharge of an airbag shall not be considered mechanical breakdown.
I. Electronic Equipment
SECTION III, Paragraphs B.4.c and B.4.d. are deleted and replaced by the following:
c. Physical Damage Coverage on a covered auto also applies to loss to any permanently installed electronic equipment including its antennas and other accessories d. A $100 per occurrence deductible applies to the coverage provided by this provision.
J. Diminution In Value
The following is added to SECTION III, Paragraph B.6.
Subject to the following, the diminution in value exclusion does not apply to:
a. Any covered auto of the private passenger type you lease, hire, rent or borrow, without a driver for a period of 30 days or less, while performing duties related to the conduct of your business; and 7040001609
Cannon Corporation
09/01/2023
Continental Insurance Company A XV
09/01/2023
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Endorsement
Policy No:
Policy Effective Date:
Policy Page: 4 of 5
Form No: SCA 23 500 D 10 11
Endorsement Effective Date:
Endorsement No:
Underwriting Company:
© Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission. b. Any covered auto of the private passenger type hired or rented by your employee without a driver for a period of 30 days or less, under a contract in that individual employee's name, with your permission, while performing duties related to the conduct of your business. c. Such coverage as is provided by this provision is limited to a diminution in value loss arising directly out of accidental damage and not as a result of the failure to make repairs; faulty or incomplete maintenance or repairs; or the installation of substandard parts. d. The most we will pay for loss to a covered auto in any one accident is the lesser of:
(1) $5,000; or
(2) 20% of the auto's actual cash value (ACV)
III. Drive Other Car Coverage – Executive Officers
The following is added to SECTIONS II and III:
1. Any auto you don't own, hire or borrow is a covered auto for Liability Coverage while being used by, and for Physical Damage Coverage while in the care, custody or control of, any of your “executive officers”, except:
a. An auto owned by that “executive officer” or a member of that person's household; or b. An auto used by that “executive officer” while working in a business of selling, servicing, repairing or parking autos.
Such Liability and/or Physical Damage Coverage as is afforded by this provision will be:
(1) Equal to the greatest of those coverages afforded any covered auto; and (2) Excess over any other collectible insurance.
2. For purposes of this provision, “executive officer” means a person holding any of the officer positions created by your charter, constitution, by-laws or any other similar governing document, and, while a resident of the same household, includes that person's spouse.
Such “executive officers” are insureds while using a covered auto described in this provision.
IV. BUSINESS AUTO CONDITIONS
A. Duties In The Event Of Accident, Claim, Suit Or Loss The following is added to SECTION IV, Paragraph A.2.a.
(4) Your employees may know of an accident or loss. This will not mean that you have such knowledge, unless such accident or loss is known to you or if you are not an individual, to any of your executive officers or partners or your insurance manager.
The following is added to SECTION IV, Paragraph A.2.b.
(6) Your employees may know of documents received concerning a claim or suit. This will not mean that you have such knowledge, unless receipt of such documents is known to you or if you are not an individual, to any of your executive officers or partners or your insurance manager.
B. Concealment, Misrepresentation or Fraud
The following is added to SECTION IV, Paragraph B.2.
Your failure to disclose all hazards existing on the date of inception of this Coverage Form shall not prejudice you with respect to the coverage afforded provided such failure or omission is not intentional.
C. Policy Period, Coverage Territory
SECTION IV, Paragraphs 7.(5).(a). is revised to provide:
Cannon Corporation
7040001609
09/01/2023 09/01/2023
Continental Insurance Company A XV
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Endorsement
Policy No:
Policy Effective Date:
Policy Page: 5 of 5
Form No: SCA 23 500 D 10 11
Endorsement Effective Date:
Endorsement No:
Underwriting Company:
© Copyright CNA All Rights Reserved. Includes copyrighted material of the Insurance Services Office, Inc., used with its permission. a. 45 days of coverage in lieu of 30 days
V. DEFINITIONS
SECTION V. Paragraph C. is deleted and replaced by the following:
Bodily injury means bodily injury, sickness or disease sustained by a person, including mental anguish, mental injury or death resulting from any of these
Cannon Corporation
7040001609
Continental Insurance Company A XV
09/01/2023 09/01/2023
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Endorsement
ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY
It is understood and agreed that this endorsement amends the BUSINESS AUTO COVERAGE FORM as follows:
SCHEDULE
Name of Additional Insured Person Or Organization
ANY PERSON OR ORGANIZATION THAT YOU ARE REQUIRED BY WRITTEN CONTRACT OR WRITTEN AGREEMENT TO NAME AS AN ADDITIONAL INSURED.
1. In conformance with paragraph A.1.c. of Who Is An Insured of Section II - LIABILITY COVERAGE, the person or organization scheduled above is an insured under this policy.
2. The insurance afforded to the additional insured under this policy will apply on a primary and non-contributory basis if you have committed it to be so in a written contract or written agreement executed prior to the date of the “accident” for which the additional insured seeks coverage under this policy.
All other terms and conditions of the policy remain unchanged This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy.
Policy No:
Policy Effective Date:
Policy Page: 1 of 1
Form No: CNA71527XX (10-2012)
Endorsement Effective Date:
Endorsement No:
Underwriting Company:
© Copyright CNA All Rights Reserved.
Cannon Corporation
7040001609
09/01/2023
Continental Insurance Company A XV
09/01/2023
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CA 04 4410 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
SCHEDULE
The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with
that person or organization.
CA 04441013 © Insurance Services Office, Inc., 2011 Page 1 of 1 Name(s) Of Person(s) Or Organization(s):
All persons or organizations as required by written contract or agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Named Insured:
Endorsement Effective Date:
Cannon Corporation
7040001609
09/01/2023
77196058 | 23-24 GL/AL/WC/UM/PL | Adrianna Padilla | 11/14/2023 2:08:47 PM (PST) | Page 12 of 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Countersigned by
Authorized Representative
Form WC 04 03 06 (1) Printed in U.S.A.
Policy Expiration Date:
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
Policy Number:
Effective Date:
Named Insured and Address:
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule.
The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration.
SCHEDULE
Person or Organization Job Description
Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights from us
09/01/2023
09/01/2024
72WEOL6H1H
Cannon Corporation
1050 Southwood Drive
San Luis Obispo CA 93401
77196058 | 23-24 GL/AL/WC/UM/PL | Adrianna Padilla | 11/14/2023 2:08:47 PM (PST) | Page 13 of 13