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HomeMy WebLinkAboutH&L Concrete, Inc. - Insurance CertificateANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $$ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE Lockton Companies, LLC 500 W. Monroe, Ste. 3400 Chicago IL 60661 (312) 669-6900 midwestcertificates@lockton.com H&L Concrete, Inc. dba Naranjo Civil Constructors, Inc. 627 27TH ST GARDEN CITY CO 80631-8471 The Charter Oak Fire Insurance Company 25615 The Phoenix Insurance Company 25623 The Travelers Indemnity Company of America 25666 Travelers Property Casualty Company of America 25674 Convex Insurance UK Limited X X 1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000 X 1,000,000 XXXXXXX XXXXXXX XXXXXXX XXXXXXX X X X 10,000 8,000,000 8,000,000 XXXXXXX N X 1,000,000 1,000,000 1,000,000 Poll/Prof Install Floater Leased/Rented Equip $2M each claim/agg; $25,000 Ded $400,000 limit; $2,500 Ded $1M limit; $2,500 Ded B 810-B0395402-25-26-G 6/1/2025 6/1/2026 A DT-CO-5S978333-PHX-25 6/1/2025 6/1/2026 E CPL000050-0725 7/1/2025 7/1/2026 C QT-630-9X541435-TIL-25 7/1/2025 7/1/2026 C CUP-B1340806-25-26 6/1/2025 6/1/2026 D UB-B1304033-25-26-G 7/1/2025 7/1/2026 6/1/2026 1555778 Y Y Y Y Y Y Y 7/29/2025 N N 22232058 22232058 XXXXXXX City of Fort Collins Purchasing Division P.O. Box 580 Fort Collins CO 80522 X X X See Attachments Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required) ACORD 25 (2016/03) City of Fort Collins its officers, agents and employees is included as additional insured on a Primary and Non-contributory basis if required by written contract with respect to General Liability, Automobile Liability and Umbrella Liability per the terms and conditions of the policy. A waiver of subrogation applies in favor of Certificate Holder if required by written contract with respect to General Liability, Automobile Liability, Umbrella Liability, and Workers' Compensation per the terms and conditions of the policy where permitted by state law. Certificate Holder ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B architectural,engineering or surveyingAny person or organization that you agree in a services, including:written contract or agreement to include as an additional insured on this Coverage Part is an (a) The preparing, approving, or failing to insured, but only:prepare or approve,maps,shop a.With respect to liability for "bodily injury" or drawings,opinions,reports,surveys, "property damage" that occurs, or for "personal field orders or change orders, or the injury" caused by an offense that is committed,preparing,approving,or failing to subsequent to the signing of that contract or prepare or approve,drawings and agreement and while that part of the contract or specifications; andagreement is in effect; and (b)Supervisory,inspection,architectural orb.If,and only to the extent that,such injury or engineering activities.damage is caused by acts or omissions of you oryour subcontractor in the performance of "your (2) Any "bodily injury" or "property damage" work" to which the written contract or agreement caused by "your work" and included in the applies. Such person or organization does not "products-completed operations hazard" qualify as an additional insured with respect to unless the written contract or agreement the independent acts or omissions of such specifically requires you to provide such person or organization.coverage for that additional insured during The insurance provided to such additional insured is the policy period. subject to the following provisions:c.The additional insured must comply with the a.If the Limits of Insurance of this Coverage Part following duties: shown in the Declarations exceed the minimum (1)Give us written notice as soon as practicablelimitsrequiredbythewrittencontractorofan"occurrence"or an offense which mayagreement,the insurance provided to the result in a claim. To the extent possible, suchadditionalinsuredwillbetosuchnotice should include:minimum required limits.For the purposes of determining whether this applies,the (a)How,when and where the "occurrence"minimum limits required by the written contract or or offense took place;agreement will be considered to include the minimum limits of any Umbrella or Excess (b) The names and addresses of any injured liability coverage required for the additional persons and witnesses; and insured by that written contract or agreement.(c)The nature and location of any injury orThisprovisionwillnotincreasethelimitsofdamagearisingoutofthe"occurrence"insurance described in Section III –Limits Of or offense.Insurance. limited limitation b.The insurance provided to such additional (2) If a claim is made or "suit" is brought against insured does not apply to:the additional insured: CG D2 46 04 19 Page 1 of 2© 2018 The Travelers Indemnity Company. All rights reserved. COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (Includes Products-Completed Operations If Required By Contract) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS (1) Any "bodily injury", "property damage" or The following is added to SECTION II – WHO IS AN "personal injury" arising out of the providing, INSURED:or failure to provide,any professional Attachment Code: D673093 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B COMMERCIAL GENERAL LIABILITY (a) Immediately record the specifics of the (4) Tender the defense and indemnity of any claim or "suit" and the date received; and claim or "suit" to any provider of other insurance which would cover such additional(b)Notify us as soon as practicable and see insured for a loss we cover.However,thisto it that we receive written notice of the condition does not affect whether theclaim or "suit" as soon as practicable.insurance provided to such additional(3)Immediately send us copies of all legal insured is primary to other insurancepapers received in connection with the claim available to such additional insured whichor"suit",cooperate with us in the covers that person or as ainvestigationorsettlementoftheclaimornamed insured as described in Paragraph 4.,defense against the "suit",and otherwise Other Insurance, of Section IV – Commercialcomply with all policy conditions.General Conditions. organization Liability Page 2 of 2 CG D2 46 04 19© 2018 The Travelers Indemnity Company. All rights reserved. Attachment Code: D673093 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B WSR - c.Method Of Sharing a.The statements in the are If all of the other insurance permits contribution accurate and complete; by equal shares, we will follow this method also.b.Those statements are based upon Under this each insurer contributes representations you made to us; and equal amounts until it has paid its applicablec.We have issued this policy in reliance upon limit of insurance or none of the loss remains,your representations. The unintentional omission of, or unintentional errorIf any of the other insurance does not permitin, any information provided by you which we relied contribution by equal shares, we will contributeupon in issuing this policy will not prejudice your by limits. Under this method, each insurer'srights under this insurance. However, this provision share is based on the ratio of its applicable limitdoes not affect our right to collect additional of insurance to the total applicable limits ofpremium or to exercise our rights of cancellation or insurance of all insurers.nonrenewal in accordance with applicable insurance d.Primary And Non-Contributory Insurance If laws or regulations. Required By Written Contract 7.Separation Of Insureds If you specifically agree in a written contract orExcept with respect to the Limits of Insurance, and agreement that the insurance afforded to an any rights or duties assigned in thisinsured under this Coverage Part must apply on Coverage Part to the first Named Insured, this a primary basis,or a primary and non-insurance applies: contributory basis,this insurance is primary to a.As if each Named Insured were the onlyother insurance that is available to Named Insured; andwhich covers such insured as a named insured,and we will not share with that other insurance,b.Separately to each insured against whom claim provided that:is made or "suit" is brought. (1) The "bodily injury" or "property damage" for 8.Transfer Of Rights Of Recovery Against Others which coverage is sought occurs; and To Us (2) The "personal and advertising injury" for If the insured has rights to recover all or part of any which coverage is sought is caused by an payment we have made under this Coverage Part, offense that is committed;those rights are transferred to us. The insured must do nothing after loss to impair them. At our request,subsequent to the signing of that contract or the insured will bring "suit" or transfer those rightsagreement by you.to us and help us enforce them.5.Premium Audit 9.When We Do Not Renewa.We will compute all premiums for this Coverage If we decide not to renew this Coverage Part, we willPart in accordance with our rules and rates.mail or deliver to the first Named Insured shown inb.Premium shown in this Coverage Part as the Declarations written notice of the nonrenewaladvance premium is a deposit premium only. At not less than 30 days before the expiration date.the close of each audit period we will compute If notice is mailed, proof of mailing will be sufficienttheearnedpremiumforthatperiodandsendproof of notice.notice to the first Named Insured. The due datefor audit and retrospective premiums is the date SECTION V – DEFINITIONS shown as the due date on the bill. If the sum of 1."Advertisement" means a notice that is broadcast or the advance and audit premiums paid for the published to the general public or specific market policy period is greater than the earned segments about your goods, products or servicespremium, we will return the excess to the first for the purpose of attra g customers or Named Insured.supporters. For the purposes of this definition: c.The first Named Insured must keep records of a.Notices that are published include material the information we need for premium placed on the Internet or on similar computation, and send us copies at such times means of communication; and as we may request.b.Regarding websites, only that part of a website 6.Representations that is about your goods, products or services By pting this policy, you agree:for the purposes of attra customers or approach specifically ctin cting electronic acce whichever comes first. Declarations such insured supporters is considered an advertisement. Page16 of 21 © 2017 The Travelers Indemnity Company. All rights reserved.CG T1 00 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY Attachment Code: D673414 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM CA T3 53 02 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO EXTENSION ENDORSEMENT © 2015 The Travelers Indemnity Company. All rights reserved.Page 1 of 4 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. BROAD FORM NAMED INSURED B. BLANKET ADDITIONAL INSURED C. EMPLOYEE HIRED AUTO D. 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 H. HIRED AUTO PHYSICAL DAMAGE – LOSS OF USE – INCREASED LIMIT I.PHYSICAL DAMAGE –TRANSPORTATION EXPENSES – INCREASED LIMIT J.PERSONAL PROPERTY 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 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL AUTO Attachment Code: D673124 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B 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 A.1., Who Is An Insured, of SECTION II – COVERED AUTOS LIABILITY COVERAGE: Any "employee" of yours is an "insured" while us- ing a covered "auto" you don't 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 (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 "suit". (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 "suit", 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. members of their households. Page 2 of 4 © 2015 The Travelers Indemnity Company. All rights reserved.CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Attachment Code: D673124 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B COMMERCIAL AUTO CA T3 53 02 15 Page 3 of 4© 2015 The Travelers Indemnity Company. All rights reserved. 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 (2) In or on your covered "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 B.3., 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 airbags were 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 A.5., 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 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Attachment Code: D673124 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B 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 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. SECTION IV – BUSINESS AUTO CONDITIONS: Page 4 of 4 © 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. Attachment Code: D673124 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B POLICY NUMBER: EMPLOYERS LIABILITY POLICY AND WORKERS COMPENSATION 001 ONE TOWER SQUARE HARTFORD CT 06183 UB-B1304033-25-26-G WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. SCHEDULE DESIGNATED PERSON: DESIGNATED ORGANIZATION: ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. DATE OF ISSUE: 07-08-25 ST ASSIGN:PAGE 1 OF1 ENDORSEMENT WC 00 03 13 (00) - Attachment Code: D673127 Certificate ID: 22232058 Docusign Envelope ID: D5F00204-C47F-49B3-90B3-9C07EF72490B