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CORRESPONDENCE - BID - 7674 PARKING GARAGE REPAIRS & WATERPROOFING (15)
August 3, 2018 Summit Sealants Inc Attn: Jacob Holland 13671 Carefree Drive Montrose, CO 81403 RE: Renewal, 7674 Parking Garages Repairs & Waterproofing Dear Mr. Holland: The City of Fort Collins wishes to extend the agreement term for the above captioned proposal per the existing terms and conditions and the following: 1) The term will be extended for one (1) additional year, September 1, 2018 through August 31, 2019. If the renewal is acceptable to your firm, please sign this letter in the space provided and include a current copy of insurance certificate naming the City as an additional insured for General and Automotive Liability within the next fifteen (15) days. If this extension is not agreeable with your firm, we ask that you send us a written notice stating that you do not wish to renew the contract and state the reason for non-renewal. Please contact Doug Clapp, CPPB, Senior Buyer at (970) 221-6776 if you have any questions regarding this matter. Sincerely, Gerry S. Paul Director of Purchasing ____________________________________ _______________________ Signature Date (Please indicate your desire to renew 7674 by signing this letter and returning it to Purchasing Division within the next fifteen days.) GSP:kr Financial Services Purchasing Division 215 N. Mason St. 2nd Floor PO Box 580 Fort Collins, CO 80522 970.221.6775 970.221.6707- fax fcgov.com/purchasing DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E 8/3/2018 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS 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 $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC JECT PRODUCTS - COMP/OP AGG OTHER: $ COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ 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 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 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 CGL 0036925 - 29 06/01/18 SRH 06/01/18 CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) or Organization(s): All Person or Organizations when additional insured status is required by written contract with you. Location(s) Of Covered Operations: All locations you perform work for the additional insured. (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to lia- bility for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the follow- ing additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another con- tractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E CGL 0036925 - 29 06/01/18 SRH 06/01/18 CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): All Person or Organizations when additional insured status is required by written contract with you. Location And Description Of Completed Operations: All locations you perform work for the additional insured. (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to lia- bility for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". CG 20 37 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR404G (05/09) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONSTRUCTION PROJECT GENERAL AGGREGATE LIMIT WHEN REQUIRED BY CONTRACT AND MAXIMUM PER POLICY GENERAL AGGREGATE LIMIT This Endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Limits of Insurance Maximum Per Policy General Aggregate Limit $5,000,000 A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which can be attributed only to ongoing operations at a single construction project: 1. A separate Construction Project General Aggregate Limit applies to each construction project when required in a written construction contract or agreement, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard", and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Construction Project General Aggregate Limit for that construction project.Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Construction Project General Aggregate Limit for any other construction project. 4. The limits shown in the Declarations for Each Occurrence,Damage To Premises Rented To You and Medical Expense continue to apply.However, instead of being subject to the General Aggregate Limit shownintheDeclarations, such limits will be subject to the applicable Construction Project General Aggregate Limit. 5. The Maximum Per Policy General Aggregate Limit shown in the Schedule is the most we will pay for the sum of all Construction Project General Aggregate Limits and the General Aggregate Limit shown in the Declarations regardless of the number of: a. Insureds; b. Claims made or "suits" brought; c. Persons or organizations making claims or bringing "suits"; or d. Construction projects. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR404G (05/09) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 2 of 2 B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which cannot be attributed only to ongoing operations at a single construction project: 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit shown in the Declarations or the Products-Completed Operations Aggregate Limit shown in the Declarations, whichever is applicable; and 2. Such payments shall not reduce any Construction Project General Aggregate Limit. C. When coverage for liability arising out of the "products-completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard" will reduce the Products-Completed Operations Aggregate Limit shown in the Declarations, and not reduce the General Aggregate Limit shown in the Declarations nor the Construction Project General Aggregate Limit. D. If the applicable construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications, or timetables, the project will still be deemed to be the same construction project. E. The provisions of Section III - Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. All other terms and conditions of this policy remain unchanged. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR405G (04/10) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOCATION GENERAL AGGREGATE LIMIT AND MAXIMUM PER POLICY GENERAL AGGREGATE LIMIT This Endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Limits of Insurance Maximum Per Policy General Aggregate Limit $5,000,000 A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which can be attributed only to operations at asingle location : 1. A separate Location General Aggregate Limit applies to each location ,and that limit is equal to the amount of the General Aggregate Limit showninthe Declarations. 2. The Location General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard", and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Location General Aggregate Limit for that location .Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Location General Aggregate Limit for any other location . 4. The limits shown in the Declarations for Each Occurrence,Damage To Premises Rented To You and Medical Expense continue to apply.However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Location General Aggregate Limit. 5. The Maximum Per Policy General Aggregate Limit shown in the Schedule is the most we will pay for the sum of all Location General Aggregate Limits and the General Aggregate Limit shown in the Declarations regardless of the number of: a. Insureds; b. Claims made or "suits" brought; c. Persons or organizations making claims or bringing "suits"; or d. Locati ons . B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which cannot be attributed only to ongoing operations at a single location : DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR405G (04/10) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 2 of 2 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit shown in the Declarations or the Products-Completed Operations Aggregate Limit shown in the Declarations, whichever is applicable; and 2. Such payments shall not reduce any Location General Aggregate Limit. C. When coverage for liability arising out of the "products-completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard" will reduce the Products-Completed Operations Aggregate Limit shown in the Declarations, and not reduce the General Aggregate Limit shownintheDeclarations nor the Location General Aggregate Limit. D. With respect to the insurance provided by this endorsement, the following definition is added to the Definitions section: Locati on means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. E. The provisions of Section III - Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. All other terms and conditions of this policy remain unchanged. 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ocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3100 (08-04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT OWNERS, LESSEES OR CONTRACTORS OWNERS, LESSEES OR CONTRACTORS – – SCHEDULED SCHEDULED PERSON OR ORGANIZATION PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR’S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3101 (08-04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON-CONTRIBUTORY) Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON-CONTRIBUTORY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR’S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) SECTION II - WHO IS AN INSURED is amended to include: A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3225 (10-08) Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT – PRODUCTS-COMPLETED OPERATIONS HAZARD A DDITIONAL INSURED ENDORSEMENT – PRODUCTS-COMPLETED OPERATIONS HAZARD Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR’S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work performed for that additional insured and included in the products-completed operations hazard. All other terms and conditions remain the same. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3226 (10-08) Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT – PRODUCTS-COMPLETED OPERATIONS HAZARD PRIMARY & NON-CONTRIBUTORY Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR’S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work performed for that additional insured and included in the products-completed operations hazard. Furthermore, the coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. All other terms and conditions remain the same. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3143 (03-05) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products-completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain the same. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E 7501 E Lowry Blvd Denver, CO 80230-7006 303-361-4000 / 800-873-7242 www.pinnacol.com Summit Sealants Inc 13671 Carefree Drive Montrose, CO 81403 Hub International/BW 1125 17th St. Ste 900 Denver, CO 80202 (970) 223-0924 Page 1 of 1 P ISA - 7501 E Lowry Blvd Denver, CO 80230-7006 06/01/2018 4076879 49253814 359-B NCCI #: WC000313B Policy #: 4076879 ENDORSEMENT: Blanket Waiver of Subrogation Effective Date:June 1, 2018 Expires on: June 1, 2019 Pinnacol Assurance has issued this endorsement June 1, 2018 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 anyone not named in the Schedule. SCHEDULE To any person or organization when agreed to under a written contract or agreement, as defined above and with the insured, which is in effect and executed prior to any loss. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS 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 $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC JECT PRODUCTS - COMP/OP AGG OTHER: $ COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ 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 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 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 CGL 0036925 - 29 06/01/18 SRH 06/01/18 CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) or Organization(s): All Person or Organizations when additional insured status is required by written contract with you. Location(s) Of Covered Operations: All locations you perform work for the additional insured. (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to lia- bility for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the follow- ing additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another con- tractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E CGL 0036925 - 29 06/01/18 SRH 06/01/18 CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): All Person or Organizations when additional insured status is required by written contract with you. Location And Description Of Completed Operations: All locations you perform work for the additional insured. (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to lia- bility for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". CG 20 37 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR404G (05/09) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONSTRUCTION PROJECT GENERAL AGGREGATE LIMIT WHEN REQUIRED BY CONTRACT AND MAXIMUM PER POLICY GENERAL AGGREGATE LIMIT This Endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Limits of Insurance Maximum Per Policy General Aggregate Limit $5,000,000 A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which can be attributed only to ongoing operations at a single construction project: 1. A separate Construction Project General Aggregate Limit applies to each construction project when required in a written construction contract or agreement, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard", and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Construction Project General Aggregate Limit for that construction project.Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Construction Project General Aggregate Limit for any other construction project. 4. The limits shown in the Declarations for Each Occurrence,Damage To Premises Rented To You and Medical Expense continue to apply.However, instead of being subject to the General Aggregate Limit shownintheDeclarations, such limits will be subject to the applicable Construction Project General Aggregate Limit. 5. The Maximum Per Policy General Aggregate Limit shown in the Schedule is the most we will pay for the sum of all Construction Project General Aggregate Limits and the General Aggregate Limit shown in the Declarations regardless of the number of: a. Insureds; b. Claims made or "suits" brought; c. Persons or organizations making claims or bringing "suits"; or d. Construction projects. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR404G (05/09) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 2 of 2 B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which cannot be attributed only to ongoing operations at a single construction project: 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit shown in the Declarations or the Products-Completed Operations Aggregate Limit shown in the Declarations, whichever is applicable; and 2. Such payments shall not reduce any Construction Project General Aggregate Limit. C. When coverage for liability arising out of the "products-completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard" will reduce the Products-Completed Operations Aggregate Limit shown in the Declarations, and not reduce the General Aggregate Limit shown in the Declarations nor the Construction Project General Aggregate Limit. D. If the applicable construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications, or timetables, the project will still be deemed to be the same construction project. E. The provisions of Section III - Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. All other terms and conditions of this policy remain unchanged. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR405G (04/10) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOCATION GENERAL AGGREGATE LIMIT AND MAXIMUM PER POLICY GENERAL AGGREGATE LIMIT This Endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Limits of Insurance Maximum Per Policy General Aggregate Limit $5,000,000 A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which can be attributed only to operations at asingle location : 1. A separate Location General Aggregate Limit applies to each location ,and that limit is equal to the amount of the General Aggregate Limit showninthe Declarations. 2. The Location General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard", and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Location General Aggregate Limit for that location .Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Location General Aggregate Limit for any other location . 4. The limits shown in the Declarations for Each Occurrence,Damage To Premises Rented To You and Medical Expense continue to apply.However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Location General Aggregate Limit. 5. The Maximum Per Policy General Aggregate Limit shown in the Schedule is the most we will pay for the sum of all Location General Aggregate Limits and the General Aggregate Limit shown in the Declarations regardless of the number of: a. Insureds; b. Claims made or "suits" brought; c. Persons or organizations making claims or bringing "suits"; or d. Locati ons . B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section I - Coverage A - Bodily Injury And Property Damage Liability, and for all medical expenses caused by accidents under Section I - Coverage C - Medical Payments, which cannot be attributed only to ongoing operations at a single location : DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E BR405G (04/10) Includes copyrighted material of Insurance Services Office,Inc., with its permission Page 2 of 2 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit shown in the Declarations or the Products-Completed Operations Aggregate Limit shown in the Declarations, whichever is applicable; and 2. Such payments shall not reduce any Location General Aggregate Limit. C. When coverage for liability arising out of the "products-completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard" will reduce the Products-Completed Operations Aggregate Limit shown in the Declarations, and not reduce the General Aggregate Limit shownintheDeclarations nor the Location General Aggregate Limit. D. With respect to the insurance provided by this endorsement, the following definition is added to the Definitions section: Locati on means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. E. The provisions of Section III - Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. All other terms and conditions of this policy remain unchanged. 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DFRYHUHGDXWRIRU/LDELOLW\&RYHUDJHZKLOH EHLQJXVHGE\ &: ,QFOXGHV&RS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV 3DJHRI 2IILFH,QFZLWKLWVSHUPLVVLRQ 7 81,17(17,21$/20,66,216 7KHIROORZLQJLVDGGHG3DUDJUDSK%RI6HFWLRQ ,9%XVLQHVV$XWR&RQGLWLRQV ,I\RXXQLQWHQWLRQDOO\IDLOWRGLVFORVHDQ\KD]DUGV H[LVWLQJDWWKHLQFHSWLRQRIWKLVSROLF\VXFKIDLOXUH ZLOO QRW SUHMXGLFH WKH FRYHUDJH SURYLGHG WR \RX +RZHYHUWKLVSURYLVLRQGRHVQRWDIIHFWRXUULJKWWR FROOHFWDGGLWLRQDOSUHPLXPRUH[HUFLVHRXUULJKWRI FDQFHOODWLRQRUQRQUHQHZDO 8 /,%(5$/,=$7,21 ,IZHUHYLVHWKLVHQGRUVHPHQWWRSURYLGHJUHDWHU FRYHUDJHZLWKRXWDGGLWLRQDOSUHPLXPFKDUJHZH ZLOODXWRPDWLFDOO\SURYLGHWKHDGGLWLRQDOFRYHUDJH WR DOO HQGRUVHPHQW KROGHUV DV RI WKH GD\ WKH UHYLVLRQLVHIIHFWLYHLQ\RXUVWDWH DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3100 (08-04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT OWNERS, LESSEES OR CONTRACTORS OWNERS, LESSEES OR CONTRACTORS – – SCHEDULED SCHEDULED PERSON OR ORGANIZATION PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR’S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3101 (08-04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON-CONTRIBUTORY) Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON-CONTRIBUTORY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR’S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) SECTION II - WHO IS AN INSURED is amended to include: A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3225 (10-08) Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT – PRODUCTS-COMPLETED OPERATIONS HAZARD A DDITIONAL INSURED ENDORSEMENT – PRODUCTS-COMPLETED OPERATIONS HAZARD Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR’S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work performed for that additional insured and included in the products-completed operations hazard. All other terms and conditions remain the same. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3226 (10-08) Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT – PRODUCTS-COMPLETED OPERATIONS HAZARD PRIMARY & NON-CONTRIBUTORY Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR’S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work performed for that additional insured and included in the products-completed operations hazard. Furthermore, the coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. All other terms and conditions remain the same. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E ENV-3143 (03-05) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Named Insured Summit Sealants Inc Endorsement Number Policy Symbol CPW Policy Number G46645017 002 Policy Period 06/01/2018 to 06/01/2019 Effective Date of Endorsement 06/01/2018 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products-completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain the same. DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E 7501 E Lowry Blvd Denver, CO 80230-7006 303-361-4000 / 800-873-7242 www.pinnacol.com Summit Sealants Inc 13671 Carefree Drive Montrose, CO 81403 Hub International/BW 1125 17th St. Ste 900 Denver, CO 80202 (970) 223-0924 Page 1 of 1 P ISA - 7501 E Lowry Blvd Denver, CO 80230-7006 06/01/2018 4076879 49253814 359-B NCCI #: WC000313B Policy #: 4076879 ENDORSEMENT: Blanket Waiver of Subrogation Effective Date:June 1, 2018 Expires on: June 1, 2019 Pinnacol Assurance has issued this endorsement June 1, 2018 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 anyone not named in the Schedule. SCHEDULE To any person or organization when agreed to under a written contract or agreement, as defined above and with the insured, which is in effect and executed prior to any loss. 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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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD PVIANZON Lynn Bosman 06/04/2018 SUMMSEA-02 C ZUP13T04762 B CPA3135992-22 D 4076879 A CGL0036925 E G46645017 002 1,000,000 1,000,000 1,000,000 10,000 10,000,000 10,000,000 2,000,000 1,000,000 2,000,000 5,000 100,000 1,000,000 1,000,000 X X X X X X X X X E G46645017 002 License # 0757776 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 Project: Civic Center Parking Garage City of Fort Collins is an additional insured for General Liability. 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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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD PVIANZON Lynn Bosman 06/04/2018 SUMMSEA-02 C ZUP13T04762 B CPA3135992-22 D 4076879 A CGL0036925 E G46645017 002 1,000,000 1,000,000 1,000,000 10,000 10,000,000 10,000,000 2,000,000 1,000,000 2,000,000 5,000 100,000 1,000,000 1,000,000 X X X X X X X X X E G46645017 002 License # 0757776 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 06/01/2018 06/01/2019 Project: Repairs Old Town Garage City of Fort Collins is an additional insured for General Liability. HUB International Insurance Services (COL) 2742 Crossroads Blvd. Grand Junction, CO 81506 (303) 252-3762 (866) 243-0727 City of Fort Collins Accounting Department PO Box 580 Fort Collins, CO 80522-0580 Summit Sealants, Inc. 2450 North Townsend Ave. Montrose, CO 81401 Berkley Regional Specialty Insurance Company Union Insurance Company St. Paul Fire & Marine Insurance Company Pinnacol Assurance Company Westchester Surplus Lines Insurance Co. 10172 31295 25844 41190 24767 X X X X Lynn.bosman@hubinternational.com X X X X X Each Condition Aggregate 2,000,000 2,000,000 Contract Poll Liab Contract Poll Liab DocuSign Envelope ID: 51754633-89A9-4885-A3E2-1531E73FEF3E