DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 11/14/2024
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Yates, LLC PHONE FAX
2800 Century Parkway NE (A/C, No, Ext): 404-633-4321 (A/C, No): 404-633-1312
E-MAIL
Suite 300 ADDRESS: certs@yatesins.com
Atlanta GA 30345- INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : Amerisure Insurance Company 19488
SHEPPA01-C
INSURED INSURER B : Amerisure Mutual Insurance Company 23396
Shepco Paving Inc.
INSURER C : Travelers Property Casualty Co of America 25674
4080 McGinnis Ferry Rd
Bldg 200 Suite 203 INSURER D :
Alpharetta GA 30005 INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1509289924 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY CPP21125860501 8/1/2024 8/1/2025 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 100,000
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY X JECT
PRO-
LOC PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER: $
A COMBINED SINGLE LIMIT $ 1,000,000
AUTOMOBILE LIABILITY CA21125850501 8/1/2024 8/1/2025 (Ea accident)
X ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
NON-OWNED
X HIRED
AUTOS ONLY
X AUTOS ONLY
PROPERTY DAMAGE
(Per accident) $
$
B X UMBRELLA LIAB X OCCUR CU21125870502 8/1/2024 8/1/2025 EACH OCCURRENCE $ 5,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
X RETENTION $ $
DED 0
PER OTH-
B WORKERS COMPENSATION WC21125880502 8/1/2024 8/1/2025 X STATUTE ER
AND EMPLOYERS' LIABILITY Y/N
ANYPROPRIETOR/PARTNER/EXECUTIVE
N E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
C Leased/Rented Equipment 660-6Y824196-TIL-24 8/1/2024 8/1/2025 All Risk/$2,500 Ded. $400,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Subject to policy terms, conditions, forms, and exclusions, the insurance coverage afforded by the policies above include the following when required by written
contract for the certificate holder and/or entities listed below: Blanket Additional Insured in regards to General Liability for ongoing and completed operations,
Automobile Liability, Umbrella Liability; Blanket Primary and Non-Contributory in regards to General Liability and Umbrella Liability; Blanket Waiver of
Subrogation in regards to General Liability, Automobile Liability, Umbrella Liability, and Workers Compensation. Blanket Thirty (30) day notice of cancellation in
regards to General Liability, Automobile Liability, Umbrella Liability, and Workers Compensation. Per Project Aggregate applies to the General Liability when
required by written contract.
Forms:
See Attached...
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Dekalb County School District
1780 Montreal Rd
Tucker GA 30084- AUTHORIZED REPRESENTATIVE
USA
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: SHEPPA01-C
LOC #:
ADDITIONAL REMARKS SCHEDULE Page 1 of 1
AGENCY NAMED INSURED
Yates, LLC Shepco Paving Inc.
4080 McGinnis Ferry Rd
POLICY NUMBER Bldg 200 Suite 203
Alpharetta GA 30005
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE
CG7324 0323 - Contractor’s Blanket Additional Insured Endorsement – Form A
CG7049 0417 - Contractors General Liability Extension Endorsement
CA7115 1109 - Advantage Commercial Automobile Broad Form Endorsement
CUDS7102 0414 – Schedule of Underlying Insurance
CU0001 0413 - Commercial Liability Umbrella Coverage Form
CU7467 0323 - Additional Insured - Primary/Non-Contributory Coverage when Required by Written Contract, Written Agreement, or Certificate of Insurance
CU2401 0918 – Waiver of Transfer of Rights of Recovery Against Others to Us
WC000313 (Ed. 4-84) – Waiver of Our Right to Recover from Others Endorsement
WC990645 0714 – Notice of Cancellation or Renewal - Third Party
IL7066 0714 – Notice of Cancellation, Nonrenewal or Material Change – Third Party
Entities: Dekalb County School District, Dekalb County Board of Education and its employees
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTOR’S BLANKET FLEX ADDITIONAL INSURED
ENDORSEMENT – FORM A
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Policy Number Agency Number Policy Effective Date
CPP21125860501 0805518 08/01/2024
Policy Expiration Date Date Account Number
08/01/2025 08/21/2024 20030683
Named Insured Agency Issuing Company
SHEPCO PAVING INC YATES, LLC AMERISURE INSURANCE
COMPANY
A. SECTION II - WHO IS AN INSURED is amended to add as an additional insured:
1. Any person or organization with whom you have agreed in a “written agreement” that such person or
organization be added as an additional insured on this policy, and any other person or organization
you are required to add as an additional insured under such “written agreement”.
2. If “your work” began under a written letter of intent or written work order, any person or organization
who issued the written letter of intent or written work order, but:
a. such coverage will apply only for 30 calendar days following the date the written letter of intent
or written work order was issued; and
b. the person or organization is an additional insured only for, and to the extent of, liability arising
out of “bodily injury”, “property damage”, or “personal and advertising injury” caused, in whole
or in part, by your negligent acts or omissions, or the negligent acts or omissions of others
working on your behalf, in the performance of your work as specified in the written letter of
intent or written work order. This coverage does not apply to liability arising out of the
independent acts or omissions of the additional insured.
For the purposes of the coverage provided by this endorsement, a “written agreement” means a written
contract or written agreement that:
1. requires you to include a person or organization as an additional insured for a period of time during
the policy period; and
2. is executed prior to the occurrence of “bodily injury”, “property damage”, or “personal and
advertising injury” that forms the basis for a claim under this policy.
The insurance provided by this endorsement does not apply to any person or organization that is
specifically listed as an additional insured on another endorsement attached to this policy.
CG 73 24 03 23 Includes copyrighted material of the Insurance Services Office, Inc., with its permission Page 1 of 3
B. The coverage provided to any person or organization added as an additional insured pursuant to
Paragraph A.1 is limited as follows:
1. If the “written agreement” specifically and exclusively requires you to name the person or
organization as an additional insured using the ISO CG 20 10 endorsement with edition dates of 11
85 or 10 01, or the ISO CG 20 37 10 01 endorsement, that person or organization is an additional
insured, but only with respect to liability for “bodily injury”, “property damage”, or “personal and
advertising injury” arising out of “your work” for that insured by or for you.
2. If the “written agreement” requires you to name the person or organization as an additional insured
using the ISO CG 20 10 and or CG 20 37 endorsements without specifically and exclusively
requiring the 11 85 or 10 01 edition dates, that person or organization is an additional insured, 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.
3. If the “written agreement” requires you to name the person or organization as an additional insured
for operations arising out of your work and does not specify an ISO additional insured
endorsement, that person or organization is an additional insured, but only with respect to liability
for “bodily injury”, “property damage”, or “personal and advertising injury” arising out of your acts or
omissions, or the acts or omissions of others working on your behalf, in the performance of your
work as specified in the “written agreement”. This coverage does not apply to liability arising out of
the sole negligence of the additional insured unless specifically required in the “written agreement”.
4. If none of the above paragraphs apply, then the person or organization is an additional insured only
for, and to the extent of, liability arising out of “bodily injury”, “property damage”, or “personal and
advertising injury” caused, in whole or in part, by your negligent acts or omissions, or the negligent
acts or omissions of others working on your behalf, in the performance of your work as specified in
the “written agreement”. This coverage does not apply to liability arising out of the independent
acts or omissions of the additional insured.
However, the insurance afforded to such additional insured only applies to the extent permitted by law.
C. The insurance provided to an additional insured under this endorsement does not apply to:
1. “Bodily injury” or “property damage” included in the “products-completed operations hazard”
unless the “written agreement” specifically requires such coverage (including by specifically
requiring the CG 20 10 11 85). To the extent the “written agreement” requires such coverage for a
specified amount of time, the coverage provided by this endorsement is limited to the amount of
time required for such coverage by the “written agreement”.
2. “Bodily injury”, “property damage”, or “personal and advertising injury” arising out of an architect’s,
engineer’s, or surveyor’s rendering of, or failure to render, any professional services, including but
not limited to:
a. The preparing, approving, or failing to prepare or approve:
(1) Maps;
(2) Drawings;
(3) Opinions;
(4) Reports;
(5) Surveys;
(6) Change orders;
CG 73 24 03 23 Includes copyrighted material of the Insurance Services Office, Inc., with its permission Page 2 of 3
(7) Design specifications; and
b. Supervisory, inspection, or engineering services.
D. The limits of insurance that apply to the additional insured are the least of those specified in the “written
agreement” or declarations of this policy.
Coverage provided by this endorsement for any additional insured shall not increase the applicable
Limits of Insurance shown in the Declarations. The limits of insurance that apply to the additional
insured are inclusive of, and not in addition to, the Limits of Insurance shown in the Declarations.
E. With respect to the coverage provided by this endorsement, SECTION IV – COMMERCIAL GENERAL
LIABILITY CONDITIONS, Paragraph 4. Other Insurance is deleted and replaced with the following:
4. Other Insurance.
a. Coverage provided by this endorsement is excess over any other valid and collectible insurance
available to the additional insured whether:
(1) Primary;
(2) Excess;
(3) Contingent; or
(4) On any other basis.
In addition, this insurance is excess over any self-insured retentions, deductibles, or captive
retentions payable by the additional insured or payable by any person or organization whose
coverage is available to the additional insured.
However, if the “written agreement” requires primary and non-contributory coverage, this
insurance will be primary and non-contributory relative only to the other insurance available to the
additional insured which covers that person or organization as a Named Insured, and we will not
share with that other insurance. For any other insurance available to the additional insured where
that person or organization is not a Named Insured, this policy will share coverage with that other
insurance based on the terms specified in Paragraph b. Method of Sharing below.
b. Method of Sharing
If all the other insurance permits contribution by equal shares, we will follow this method also.
Under this method, each insurer contributes equal amounts until it has paid its applicable limit of
insurance or none of the loss remains, whichever comes first.
If any of the other insurance does not permit contribution by equal shares, we will contribute by
limits. Under this method, each insurer’s share is based on the ratio of its applicable limit of
insurance to the total applicable limits of insurance of all insurers.
CG 73 24 03 23 Includes copyrighted material of the Insurance Services Office, Inc., with its permission Page 3 of 3
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTORS GENERAL LIABILITY EXTENSION ENDORSEMENT
TABLE OF CONTENTS Page
1. Additional Definitions 9
2. Aggregate Limits Per Location 7
3. Aggregate Limits Per Project 7
4. Blanket Contractual Liability – Railroads 3
5. Broadened Bodily Injury Coverage 11
6. Broadened Knowledge Of Occurrence 8
7. Broadened Legal Liability Coverage For Landlord’s Business Personal Property 8
8. Broadened Liability Coverage For Damage To Your Product And Your Work 10
9. Broadened Who Is An Insured 3
10. Co-Employee Bodily Injury Coverage for Managers, Supervisors, Directors or Officers 4
[see provision 9, Broadened Who Is An Insured, paragraph 2.a.(1)]
11. Contractual Liability – Personal And Advertising Injury 3
12. Damage To Premises Rented To You – Specific Perils and Increased Limit 7
13. Designated Completed Projects – Amended Limits of Insurance 11
14. Extended Notice Of Cancellation And Nonrenewal 9
15. Incidental Malpractice Liability 7
16. Increased Medical Payments Limit And Reporting Period 7
17. Mobile Equipment Redefined 9
18. Nonowned Watercraft And Nonowned Aircraft (Hired, Rented Or Loaned With Paid Crew) 3
19. Product Recall Expense 2
20. Property Damage Liability – Alienated Premises 2
21. Property Damage Liability – Elevators And Sidetrack Agreements 2
22. Property Damage Liability – Property Loaned To The Insured Or Personal Property In The Care, 2
Custody And Control Of The Insured
23. Reasonable Force – Bodily Injury or Property Damage 10
24. Supplementary Payments 3
25. Transfer Of Rights (Blanket Waiver Of Subrogation) 9
26. Unintentional Failure To Disclose Hazards 8
Includes copyrighted material of Insurance Services Office, Inc.
CG 70 49 04 17 Page 1 of 11
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Under SECTION I – COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY, paragraph 2.
EXCLUSIONS, provisions 1. through 6. of this endorsement are excess over any valid and collectible insurance
(including any deductible) available to the insured, whether primary, excess or contingent (SECTION IV –
COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph 4. Other Insurance is changed accordingly).
Provisions 1. through 6. of this endorsement amend the policy as follows:
1. PROPERTY DAMAGE LIABILITY – ALIENATED PREMISES
A. Exclusion j. Damage to Property, paragraph (2) is deleted.
B. The following paragraph is also deleted from Exclusion j. Damage to Property:
Paragraph (2) of this exclusion does not apply if the premises are “your work” and were never occupied,
rented or held for rental by you.
2. PROPERTY DAMAGE LIABILITY – ELEVATORS AND SIDETRACK AGREEMENTS
A. Exclusion j. Damage to Property, paragraphs (3), (4), and (6) do not apply to the use of elevators.
B. Exclusion k. Damage to Your Product does not apply to:
1. The use of elevators; or
2. Liability assumed under a sidetrack agreement.
3. PROPERTY DAMAGE LIABILITY – PROPERTY LOANED TO THE INSURED OR PERSONAL PROPERTY
IN THE CARE, CUSTODY AND CONTROL OF THE INSURED
A. Exclusion j. Damage to Property, paragraphs (3) and (4) are deleted.
B. Coverage under this provision 3. does not apply to "property damage" that exceeds $25,000 per
occurrence or $25,000 annual aggregate.
4. PRODUCT RECALL EXPENSE
A. Exclusion n. Recall Of Products, Work Or Impaired Property does not apply to “product recall
expenses” that you incur for the “covered recall” of “your product”. This exception to the exclusion does
not apply to “product recall expenses” resulting from:
1. Failure of any products to accomplish their intended purpose;
2. Breach of warranties of fitness, quality, durability or performance;
3. Loss of customer approval or any cost incurred to regain customer approval;
4. Redistribution or replacement of “your product”, which has been recalled, by like products or
substitutes;
5. Caprice or whim of the insured;
6. A condition likely to cause loss, about which any insured knew or had reason to know at the
inception of this insurance;
7. Asbestos, including loss, damage or clean up resulting from asbestos or asbestos containing
materials;
8. Recall of “your product(s)” that have no known or suspected defect solely because a known or
suspected defect in another of “your product(s)” has been found.
B. Under SECTION III – LIMITS OF INSURANCE, paragraph 3. is replaced in its entirety as follows and
paragraph 8. is added:
3. The Products-Completed Operations Aggregate Limit is the most we will pay for the sum of:
Includes copyrighted material of Insurance Services Office, Inc.
Page 2 of 11 CG 70 49 04 17
a. Damages under COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY
because of “bodily injury” and “property damage” included in the “products-completed
operations hazard” and
b. “Product recall expenses”.
8. Subject to paragraph 5. above [of the CGL Coverage Form], $25,000 is the most we will pay for all
“product recall expenses” arising out of the same defect or deficiency.
5. NONOWNED WATERCRAFT AND NONOWNED AIRCRAFT (HIRED, RENTED OR LOANED WITH PAID
CREW)
Exclusion g. Aircraft, Auto or Watercraft, paragraph (2) is deleted and replaced with the following:
[This exclusion does not apply to:]
(2) A watercraft you do not own that is:
(a) Less than 75 feet long; and
(b) Not being used to carry any person or property for a charge;
Exclusion g. Aircraft, Auto or Watercraft, paragraph (6) is added as follows:
[This exclusion does not apply to:]
(6) An aircraft you do not own, provided that:
(a) The pilot in command holds a currently effective certificate issued by the duly constituted authority of
the United States of America or Canada, designating that person as a commercial or airline transport
pilot;
(b) The aircraft is rented to you with a trained, paid crew; and
(c) The aircraft is not being used to carry any person or property for a charge.
6. BLANKET CONTRACTUAL LIABILITY – RAILROADS
Under SECTION V – DEFINITIONS, paragraph c. of “Insured Contract” is deleted and replaced by the
following:
c. Any easement or license agreement;
’Under SECTION V – DEFINITIONS, paragraph f.(1) of “Insured Contract” is deleted.
7. CONTRACTUAL LIABILITY – PERSONAL AND ADVERTISING INJURY
Under SECTION I – COVERAGE B., paragraph 2. Exclusions, paragraph e. Contractual Liability is deleted.
8. SUPPLEMENTARY PAYMENTS
Under SECTION I – SUPPLEMENTARY PAYMENTS – COVERAGES A AND B, paragraphs 1.b. and 1.d.
are deleted and replaced with the following:
b. Up to $5,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the
use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these
bonds.
d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense
of the claim or “suit”, including actual loss of earnings up to $1,000 a day because of time off from work.
9. BROADENED WHO IS AN INSURED
SECTION II – WHO IS AN INSURED is deleted and replaced with the following:
1. If you are designated in the Declarations as:
a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business
of which you are the sole owner.
Includes copyrighted material of Insurance Services Office, Inc.
CG 70 49 04 17 Page 3 of 11
b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses
are also insureds, but only with respect to the conduct of your business.
c. A limited liability company, you are an insured. Your members are also insureds, but only with
respect to the conduct of your business. Your managers are insureds, but only with respect to their
duties as your managers.
d. An organization other than a partnership, joint venture or limited liability company, you are an
insured. Your "executive officers" and directors are insureds, but only with respect to their duties as
your officers or directors. Your stockholders are also insureds, but only with respect to their liability
as stockholders.
e. A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as
trustees.
2. Each of the following is also an insured:
a. Your “volunteer workers” only while performing duties related to the conduct of your business, or
your "employees," other than either your "executive officers," (if you are an organization other than a
partnership, joint venture or limited liability company) or your managers (if you are a limited liability
company), but only for acts within the scope of their employment by you or while performing duties
related to the conduct of your business. However, none of these "employees" or “volunteer workers”
are insured for:
(1) "Bodily injury" or "personal and advertising injury":
(a) To you, to your partners or members (if you are a partnership or joint venture), to your
members (if you are a limited liability company), to a co-"employee" while in the course of
his or her employment or performing duties related to the conduct of your business, or to
your other “volunteer workers” while performing duties related to the conduct of your
business;
(b) To the spouse, child, parent, brother or sister of that co-"employee" or “volunteer worker”
as a consequence of paragraph (1)(a) above;
(c) For which there is any obligation to share damages with or repay someone else who must
pay damages because of the injury described in paragraphs (1)(a) or (b) above; or
(d) Arising out of his or her providing or failing to provide professional health care services
except as provided in provision 10. of this endorsement.
Paragraphs (1)(a), (1)(b) and (1)(c) above do not apply to your “employees” who are:
(i) Managers;
(ii) Supervisors;
(iii) Directors; or
(iv) Officers;
with respect to “bodily injury” to a co-“employee”.
(2) "Property damage" to property:
(a) Owned, occupied or used by;
(b) Rented to, in the care, custody or control of, or over which physical control is being
exercised for any purpose by
you, any of your "employees," “volunteer workers”, any partner or member (if you are a
partnership or joint venture), or any member (if you are a limited liability company).
b. Any person (other than your "employee" or “volunteer worker”), or any organization while acting as
your real estate manager.
c. Any person or organization having proper temporary custody of your property if you die, but only;
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Page 4 of 11 CG 70 49 04 17
(1) With respect to liability arising out of the maintenance or use of that property; and
(2) Until your legal representative has been appointed.
d. Your legal representative if you die, but only with respect to duties as such. That representative will
have all your rights and duties under this Coverage Form.
e. Your subsidiaries if:
(1) They are legally incorporated entities; and
(2) You own more than 50% of the voting stock in such subsidiaries as of the effective date of this
policy.
If such subsidiaries are not shown in the Declarations, you must report them to us within 180 days of
the inception of your original policy.
f. Any person or organization, including any manager, owner, lessor, mortgagee, assignee or receiver
of premises, to whom you are obligated under a written contract to provide insurance such as is
afforded by this policy, but only with respect to liability arising out of the ownership, maintenance or
use of that part of any premises or land leased to you, including common or public areas about such
premises or land if so required in the contract.
However, no such person or organization is an insured with respect to:
(1) Any "occurrence" that takes place after you cease to occupy or lease that premises or land; or
(2) Structural alterations, new construction or demolition operations performed by or on behalf of
such person or organization.
g. Any state or political subdivision but only as respects legal liability incurred by the state or political
subdivision solely because it has issued a permit with respect to operations performed by you or on
your behalf.
However, no state or political subdivision is an insured with respect to:
(1) "Bodily injury", "property damage", and "personal and advertising injury" arising out of
operations performed for the state or municipality; or
(2) "Bodily injury" or "property damage" included within the "products-completed operations
hazard."
h. Any person or organization who is the lessor of equipment leased to you to whom you are obligated
under a written contact to provide insurance such as is afforded by this policy, but only with respect
to their liability arising out of the maintenance, operation or use of such equipment by you or a
subcontractor on your behalf with your permission and under your supervision.
However, no such person or organization is an insured with respect to any "occurrence" that takes
place after the equipment lease expires.
i. Any architect, engineer, or surveyor engaged by you under a written contract but only with respect to
liability arising out of your premises or "your work."
However, no architect, engineer, or surveyor is an insured with respect to "bodily injury," "property
damage," or "personal and advertising injury" arising out of the rendering of or the failure to render
any professional services by or for you, including:
(1) The preparing, approving, or failing to prepare or approve maps, drawings, opinions, reports,
surveys, change orders, designs or specifications; or
(2) Supervisory, inspection, or engineering services.
This paragraph i. does not apply if a separate Additional Insured endorsement providing liability
coverage for architects, engineers, or surveyors engaged by you is attached to the policy.
If the written contract, written agreement, or certificate of insurance requires primary and non-contributory
coverage, the insurance provided by paragraphs f. through i. above will be primary and non-contributory
Includes copyrighted material of Insurance Services Office, Inc.
CG 70 49 04 17 Page 5 of 11
relative to other insurance available to the additional insured which covers that person or organization as
a Named Insured, and we will not share with that other insurance.
3. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability
company and over which you maintain ownership or majority interest, will qualify as a Named Insured if
there is no other similar insurance available to that organization. However:
a. Coverage under this provision is afforded until the end of the policy period.
b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired
or formed the organization.
c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed
before you acquired or formed the organization.
d. Coverage A does not apply to “product recall expense” arising out of any withdrawal or recall that
occurred before you acquired or formed the organization.
4. Any person or organization (referred to below as vendor) with whom you agreed under a written contract
to provide insurance is an insured, but only with respect to "bodily injury" or "property damage" arising out
of "your products" that are distributed or sold in the regular course of the vendor's business.
However, no such person or organization is an insured with respect to:
a. "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of
the assumption of liability in a contract or agreement. This exclusion does not apply to liability for
damages that the vendor would have in the absence of the contract or agreement.
b. Any express warranty unauthorized by you;
c. Any physical or chemical change in “your product” made intentionally by the vendor;
d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or
the substitution of parts under instructions from the manufacturer, and then repackaged in the
original container;
e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to
make or normally undertakes to make in the usual course of business, in connection with the
distribution or sale of “your products”;
f. Demonstration, installation, servicing or repair operations, except such operations performed at the
vendor's premises in connection with the sale of “your product”;
g. “Your products” which, after distribution or sale by you, have been labeled or relabeled or used as a
container, part or ingredient of any other thing or substance by or for the vendor.
h. “Bodily injury” or “property damage” arising out of the sole negligence of the vendor for its own acts
or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion
does not apply to:
(1) The exceptions contained in subparagraphs d. or f.; or
(2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally
undertakes to make in the usual course of business, in connection with the distribution or sale
of the products.
This paragraph 4. does not apply to any insured person or organization from which you have acquired
“your product”, or any ingredient, part, or container, entering into, accompanying or containing “your
product”. This paragraph 4. also does not apply if a separate Additional Insured endorsement, providing
liability coverage for “bodily injury” or “property damage” arising out of “your product” that is distributed or
sold in the regular course of a vendor’s business, is attached to the policy.
No person or organization is an insured with respect to the conduct of any current or past partnership, joint
venture or limited liability company that is not shown as a Named Insured in the Declarations.
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Page 6 of 11 CG 70 49 04 17
10. INCIDENTAL MALPRACTICE LIABILITY
As respects provision 9., SECTION II – WHO IS AN INSURED, paragraph 2.a.(1)(d) does not apply to any
nurse, emergency medical technician or paramedic employed by you to provide medical or paramedical
services, provided that you are not engaged in the business or occupation of providing such services, and
your “employee” does not have any other insurance that would also cover claims arising under this provision,
whether the other insurance is primary, excess, contingent or on any other basis.
Under SECTION II – LIMITS OF INSURANCE, provisions 11. through 14. of this endorsement amend the policy as
follows:
11. AGGREGATE LIMITS PER PROJECT
The General Aggregate Limit applies separately to each of your construction projects away from premises
owned by or rented to you.
12. AGGREGATE LIMITS PER LOCATION
The General Aggregate Limit applies separately to each of your locations, but only when required by written
contract, written agreement or certificate of insurance. As respects this provision 12., your locations are
premises you own, rent or use 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. However, your locations do not
include any premises where you, or others acting on your behalf, are performing construction operations.
13. INCREASED MEDICAL PAYMENTS LIMIT
A. SECTION III – LIMITS OF INSURANCE, paragraph 7., the Medical Expense Limit, is subject to all of the
terms of SECTION III – LIMITS OF INSURANCE and is the greater of:
1. $10,000; or
2. The amount shown in the Declarations for Medical Expense Limit.
B. This provision 13. does not apply if COVERAGE C MEDICAL PAYMENTS is excluded either by the
provisions of the Coverage Form or by endorsement.
14. DAMAGE TO PREMISES RENTED TO YOU – SPECIFIC PERILS AND INCREASED LIMIT
A. The word fire is changed to "specific perils" where it appears in:
1. The last paragraph of SECTION I – COVERAGE A, paragraph 2. Exclusions;
2. SECTION IV, paragraph 4.b. Excess Insurance.
B. The Limits of Insurance shown in the Declarations will apply to all damage proximately caused by the
same event, whether such damage results from a "specific peril" or any combination of "specific perils."
C. The Damage To Premises Rented To You Limit described in SECTION III – LIMITS OF INSURANCE,
paragraph 6., is replaced by a new limit, which is the greater of:
1. $1,000,000; or
2. The amount shown in the Declarations for Damage To Premises Rented To You Limit.
D. This provision 14. does not apply if the Damage To Premises Rented To You Limit of SECTIONI –
COVERAGE A is excluded either by the provisions of the Coverage Form or by endorsement.
E. “Specific Perils” means fire; lightning; explosion; windstorm or hail; smoke; aircraft or vehicles; riot or civil
commotion; vandalism; leakage from fire extinguishing equipment; weight of snow, ice or sleet; or “water
damage”.
“Water damage” means accidental discharge or leakage of water or steam as the direct result of the
breaking or cracking of any part of a system or appliance containing water or steam.
15. BROADENED LEGAL LIABILITY COVERAGE FOR LANDLORD’S BUSINESS PERSONAL PROPERTY
Under SECTION I – COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2.
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CG 70 49 04 17 Page 7 of 11
Exclusions, j. Damage to Property, the first paragraph following paragraph (6) is deleted and replaced with
the following:
Paragraphs (1), (3) and (4) of this exclusion do not apply to “property damage” (other than damage by fire) to
a landlord’s business personal property that is subject to, or part of, a premises lease or rental agreement with
that landlord.
The most we will pay for damages under this provision 15. is $10,000. A $250 deductible applies.
Under SECTION IV – COMMERCIAL GENERAL LIABILITY CONDITIONS, provisions 16. through 18. of this
endorsement amend the policy as follows:
16. BROADENED KNOWLEDGE OF OCCURRENCE
Under 2. Duties In The Event Of Occurrence, Offense, Claim, Or Suit, paragraph a. is deleted and replaced
and paragraphs e. and f. are added as follows:
a. You must see to it that we are notified as soon as practicable of an "occurrence" or an offense,
regardless of the amount, which may result in a claim. Knowledge of an "occurrence" or an offense by
your “employee(s)” shall not, in itself, constitute knowledge to you unless one of your partners, members,
“executive officers”, directors, or managers has knowledge of the "occurrence" or offense. To the extent
possible, notice should include:
(1) How, when and where the "occurrence" or offense took place;
(2) The names and addresses of any injured persons and witnesses; and
(3) The nature and location of any injury or damage arising out of the "occurrence" or offense.
e. If you report an “occurrence” to your workers compensation carrier that develops into a liability claim for
which coverage is provided by this Coverage Form, failure to report such an “occurrence” to us at the
time of the “occurrence” shall not be deemed a violation of paragraphs a., b., and c. above. However,
you shall give written notice of this “occurrence” to us as soon you become aware that this “occurrence”
may be a liability claim rather than a workers compensation claim.
f. You must see to it that the following are done in the event of an actual or anticipated “covered recall” that
may result in “product recall expense”:
(1) Give us prompt notice of any discovery or notification that “your product” must be withdrawn or
recalled. Include a description of “your product” and the reason for the withdrawal or recall;
(2) Cease any further release, shipment, consignment or any other method of distribution of like or
similar products until it has been determined that all such products are free from defects that could
be a cause of loss under the insurance.
17. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS
Paragraph 6. Representations is deleted and replaced with the following:
6. Representations
By accepting this policy, you agree:
a. The statements in the Declarations are accurate and complete;
b. Those statements are based upon representations you made to us;
c. We have issued this policy in reliance upon your representations; and
d. This policy is void in any case of fraud by you as it relates to this policy or any claim under this
policy.
We will not deny coverage under this Coverage Form if you unintentionally fail to disclose all hazards
existing as of the inception date of this policy. You must report to us any knowledge of an error or
omission in the description of any premises or operations intended to be covered by this Coverage Form
as soon as practicable after its discovery. However, this provision does not affect our right to collect
additional premium or exercise our right of cancellation or nonrenewal.
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18. TRANSFER OF RIGHTS (BLANKET WAIVER OF SUBROGATION)
Paragraph 8. Transfer of Rights Of Recovery Against Others To Us is deleted and replaced with the
following:
8. If the insured has rights to recover all or part of any payment we have made under this Coverage Form,
those rights are transferred to us. The insured must do nothing after loss to impair them. At our request,
the insured will bring "suit" or transfer those rights to us and help us enforce them. However, if the
insured has waived rights to recover through a written contract, or if "your work" was commenced under a
letter of intent or work order, subject to a subsequent reduction to writing with customers whose
customary contracts require a waiver, we waive any right of recovery we may have under this Coverage
Form.
19. EXTENDED NOTICE OF CANCELLATION AND NONRENEWAL
Paragraph 2.b. of A. Cancellation of the COMMON POLICY CONDITIONS is deleted and replaced with the
following:
b. 60 days before the effective date of the cancellation if we cancel for any other reason.
Under SECTION IV – COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 9. When We Do Not
Renew is deleted and replaced with the following:
9. When We Do Not Renew
If we decide not to renew this Coverage Part, we will mail or deliver to the first Named Insured
shown in the Declarations written notice of the nonrenewal not less than 60 days before the
expiration date.
If notice is mailed, proof of mailing will be sufficient proof of notice.
20. MOBILE EQUIPMENT REDEFINED
Under SECTION V – DEFINITIONS, paragraph 12. "Mobile equipment", paragraph f. (1) does not apply to
self-propelled vehicles of less than 1,000 pounds gross vehicle weight.
21. ADDITIONAL DEFINITIONS
1. SECTION V – DEFINITIONS, paragraph 4. “Coverage territory” is replaced by the following definition:
“Coverage territory” means anywhere in the world with respect to liability arising out of “bodily injury,”
“property damage,” or “personal and advertising injury,” including “personal and advertising injury”
offenses that take place through the Internet or similar electronic means of communication provided the
insured’s responsibility to pay damages is determined in a settlement to which we agree or in a “suit” on
the merits, in the United States of America (including its territories and possessions), Puerto Rico and
Canada.
2. SECTION V – DEFINITIONS is amended by the addition of the following definitions:
“Covered recall” means a recall made necessary because you or a government body has determined that
a known or suspected defect, deficiency, inadequacy, or dangerous condition in “your product” has
resulted or will result in “bodily injury” or “property damage”.
“Product Recall expenses" mean only reasonable and necessary extra costs, which result from or are
related to the recall or withdrawal of “your product” for:
a. Telephone and telegraphic communication, radio or television announcements, computer time and
newspaper advertising;
b. Stationery, envelopes, production of announcements and postage or facsimiles;
c. Remuneration paid to regular employees for necessary overtime or authorized travel expense;
d. Temporary hiring by you or by agents designated by you of persons, other than your regular
employees, to perform necessary tasks;
e. Rental of necessary additional warehouse or storage space;
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CG 70 49 04 17 Page 9 of 11
f. Packaging of or transportation or shipping of defective products to the location you designate; and
g. Disposal of “your products” that cannot be reused. Disposal expenses do not include:
(1) Expenses that exceed the original cost of the materials incurred to manufacture or process
such product; and
(2) Expenses that exceed the cost of normal trash discarding or disposal, except as are necessary
to avoid “bodily injury” or “property damage”.
22. REASONABLE FORCE – BODILY INJURY OR PROPERTY DAMAGE
Under SECTION I – COVERAGE A., paragraph 2. Exclusions, subparagraph a. Expected Or Intended
Injury is deleted and replaced with the following:
[This insurance does not apply to:]
a. Expected Or Intended Injury
“Bodily injury” or “property damage” expected or intended from the standpoint of the insured. This
exclusion does not apply to “bodily injury” or “property damage” resulting from the use of reasonable force
to protect persons or property.
23. BROADENED LIABILITY COVERAGE FOR DAMAGE TO YOUR PRODUCT AND YOUR WORK
A. Under SECTION I – COVERAGE A., paragraph 2. Exclusions, exclusion k. Damage to Your Product
and exclusion l. Damage to Your Work are deleted and replaced with the following:
[This insurance does not apply to:]
k. Damage to Your Product
“Property damage” to “your product” arising out of it or any part of it, except when caused by or
resulting from:
(1) Fire;
(2) Smoke:
(3) “Collapse”; or
(4) Explosion.
For purposes of exclusion k. above, “collapse” means an abrupt falling down or caving in of a
building or any part of a building with the result that the building or part of the building cannot be
occupied for its intended purpose.
l. Damage to Your Work
“Property damage” to “your work” arising out of it or any part of it and included in the
“products-completed operations hazard”. This exclusion does not apply:
(1) If the damaged work or the work out of which the damage arises was performed on your behalf
by a subcontractor; or
(2) If the cause of loss to the damaged work arises as a result of:
(a) Fire;
(b) Smoke;
(c) “Collapse”; or
(d) Explosion.
For purposes of exclusion l. above, “collapse” means an abrupt falling down or caving in of a
building or any part of a building with the result that the building or part of the building cannot be
occupied for its intended purpose.
B. The following paragraph is added to SECTION III – LIMITS OF INSURANCE:
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Page 10 of 11 CG 70 49 04 17
Subject to 5. above [of the CGL Coverage Form], $100,000 is the most we will pay under Coverage A for
the sum of damages arising out of any one “occurrence” because of “property damage” to “your product”
and “your work” that is caused by fire, smoke, collapse or explosion and is included within the
“product-completed operations hazard”. This sublimit does not apply to “property damage” to “your work”
if the damaged work, or the work out of which the damage arises, was performed on your behalf by a
subcontractor.
24. BROADENED BODILY INJURY COVERAGE
Under SECTION V – DEFINITIONS, the definition of “bodily injury” is deleted and replaced with the following:
3. "Bodily injury"
a. Means physical:
(1) Injury;
(2) Disability;
(3) Sickness; or
(4) Disease;
sustained by a person, including death resulting from any of these at any time.
b. Includes mental:
(5) Anguish;
(6) Injury;
(7) Humiliation;
(8) Fright; or
(9) Shock;
directly resulting from any "bodily injury" described in paragraph 3.a.
c. All "bodily injury" described in paragraph 3.b. shall be deemed to have occurred at the time the
"bodily injury" described in paragraph 3.a. occurred.
25. DESIGNATED COMPLETED PROJECTS – AMENDED LIMITS OF INSURANCE
When a written contract or written agreement between you and another party requires project-specific limits of
insurance exceeding the limits of this policy;
A. for “bodily injury” or “property damage” that occurs within any policy period for which we provided
coverage; and
B. for “your work” performed within the “products-completed operation hazard”; and
C. for which we previously issued Amendment Of Limits Of Insurance (Designated Project Or Premises) CG
71 94 either during this policy term or a prior policy term; and
D. that designated project is now complete;
the limits of insurance shown in the CG 71 94 schedule will replace the limits of insurance of this policy for the
designated project and will continue to apply for the amount of time the written contract or written agreement
requires, subject to the state statute of repose for the project location. These limits are inclusive of and not in
addition to the replaced limits.
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CG 70 49 04 17 Page 11 of 11
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADVANTAGE
COMMERCIAL AUTOMOBILE BROAD FORM ENDORSEMENT
This endorsement modifies insurance provided under the
BUSINESS AUTO COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by the endorsement.
The premium for this endorsement is $
1. EXTENDED CANCELLATION CONDITION
COMMON POLICY CONDITIONS - CANCELLATION, Paragraph A.2. is replaced by the following:
2. We may cancel this policy by mailing or delivering to the first Named Insured written notice of
cancellation at least:
a. 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or
b. 60 days before the effective date of cancellation if we cancel for any other reason.
2. BROAD FORM INSURED
SECTION II - LIABILITY COVERAGE A.1. WHO IS AN INSURED is amended by the addition of the
following:
d. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability
company, and over which you maintain ownership or a majority interest, will qualify as a Named Insured.
However,
(1) Coverage under this provision is afforded only until the end of the policy period;
(2) Coverage does not apply to “accidents” or “loss” that occurred before you acquired or formed the
organization; and
(3) Coverage does not apply to an organization that is an “insured” under any other policy or would be
an “insured” but for its termination or the exhausting of its limit of insurance.
e. Any “employee” of yours using:
(1) A covered “auto” you do not own, hire or borrow, or a covered “auto” not owned by the “employee”
or a member of his or her household, while performing duties related to the conduct of your
business or your personal affairs; or
(2) 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. However, your
“employee” does not qualify as an insured under this paragraph (2) while using a covered “auto”
rented from you or from any member of the “employee’s” household.
f. Your members, if you are a limited liability company, while using a covered “auto” you do not own, hire,
or borrow, while performing duties related to the conduct of your business or your personal affairs.
g. Any person or organization with whom you agree in a written contract, written agreement or permit, to
provide insurance such as is afforded under this policy, but only with respect to your covered “autos”.
This provision does not apply:
(1) Unless the written contract or agreement is executed or the permit is issued prior to the “bodily
injury” or “property damage”;
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CA 71 15 11 09 Page 1 of 5
(2) To any person or organization included as an insured by an endorsement or in the Declarations; or
(3) To any lessor of “autos” unless:
(a) The lease agreement requires you to provide direct primary insurance for the lessor;
(b) The “auto” is leased without a driver; and
(c) The lease had not expired.
Leased “autos” covered under this provision will be considered covered “autos” you own and not covered
“autos” you hire.
h. Any legally incorporated organization or subsidiary in which you own more than 50% of the voting stock
on the effective date of this endorsement.
This provision does not apply to “bodily injury” or “property damage” for which an “insured” is also an
insured under any other automobile policy or would be an insured under such a policy, but for its
termination or the exhaustion of its limits of insurance, unless such policy was written to apply
specifically in excess of this policy.
3. COVERAGE EXTENSIONS - SUPPLEMENTARY PAYMENTS
Under SECTION II - LIABILITY COVERAGE, A.2.a. Supplementary Payments, paragraphs (2) and (4) are
deleted and replaced with the following:
(2) Up to $2500 for the cost of bail bonds (including bonds for related traffic law violations) required because
of an “accident” we cover. We do not have to furnish these bonds.
(4) All reasonable expenses incurred by the “insured” at our request, including actual loss of earnings up to
$500 a day because of time off from work.
4. AMENDED FELLOW EMPLOYEE EXCLUSION
SECTION II - LIABILITY COVERAGE, B. EXCLUSIONS, paragraph 5. Fellow Employee is deleted and
replaced by the following:
5. Fellow Employee
“Bodily injury” to:
a. Any fellow “employee” of the “insured” arising out of and in the course of the fellow “employee’s”
employment or while performing duties related to the conduct of your business. However, this
exclusion does not apply to your “employees” that are officers, managers, supervisors or above.
Coverage is excess over any other collectible insurance.
b. The spouse, child, parent, brother or sister of that fellow “employee” as a consequence of
paragraph a. above.
5. HIRED AUTO PHYSICAL DAMAGE COVERAGE AND LOSS OF USE EXPENSE
A. Under SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, the following is added:
If any of your owned covered “autos” are covered for Physical Damage, we will provide Physical Damage
coverage to “autos” that you or your “employees” hire or borrow, under your name or the “employee’s”
name, for the purpose of doing your work. We will provide coverage equal to the broadest physical
damage coverage applicable to any covered "auto" shown in the Declarations, Item Three, Schedule of
Covered Autos You Own, or on any endorsements amending this schedule.
B. Under SECTION III - PHYSICAL DAMAGE COVERAGE, A.4. COVERAGE EXTENSIONS, paragraph
b. Loss of Use Expenses is deleted and replaced with the following:
b. Loss Of Use Expenses
For Hired Auto Physical Damage, we will pay expenses for which an “insured” becomes legally
responsible to pay for loss of use of a vehicle rented or hired without a driver, under a written rental
contract or agreement. We will pay for loss of use expenses if caused by:
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(1) Other than collision, only if the Declarations indicate that Comprehensive Coverage is provided
for any covered “auto”;
(2) Specified Causes of Loss, only if the Declarations indicate that Specified Causes Of Loss
Coverage is provided for any covered “auto”; or
(3) Collision, only if the Declarations indicate that Collision Coverage is provided for any covered
“auto”.
However, the most we will pay for any expenses for loss of use is $30 per day, to a maximum of
$2,000.
C. Under SECTION IV – BUSINESS AUTO CONDITIONS, paragraph 5.b. Other Insurance is deleted and
replaced by the following:
b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "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 that individual
"employee's" name, with your permission, while performing duties related to the conduct of your
business.
However, any “auto” that is leased, hired, rented or borrowed with a driver is not a covered “auto”,
nor is any “auto” you hire from any of your “employees”, partners (if you are a partnership),
members (if you are a limited liability company), or members of their households.
6. LOAN OR LEASE GAP COVERAGE
Under SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, the following is added:
If a covered “auto” is owned or leased and if we provide Physical Damage Coverage on it, we will pay, in the
event of a covered total “loss”, any unpaid amount due on the lease or loan for a covered “auto”, less:
(a) The amount paid under the Physical Damage Coverage Section of the policy; and
(b) Any:
(1) Overdue lease or loan payments including penalties, interest or other charges resulting from
overdue payments at the time of the “loss”;
(2) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high
mileage;
(3) Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance
purchased with the loan or lease;
(4) Security deposits not refunded by a lessor; and
(5) Carry-over balances from previous loans or leases.
7. RENTAL REIMBURSEMENT
SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, paragraph 4. Coverage Extensions is
deleted and replaced by the following:
4. Coverage Extensions
(a) We will pay up to $75 per day to a maximum of $2000 for transportation expense incurred by you
because of covered "loss”. We will pay only for those covered "autos" for which you carry Collision
Coverage or either Comprehensive Coverage or Specified Causes of Loss Coverage. We will pay
for transportation expenses incurred during the period beginning 24 hours after the covered "loss"
and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we
pay for its "loss". This coverage is in addition to the otherwise applicable coverage you have on a
covered "auto". No deductibles apply to this coverage.
(b) This coverage does not apply while there is a spare or reserve "auto" available to you for your
operation.
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CA 71 15 11 09 Page 3 of 5
8. AIRBAG COVERAGE
SECTION III - PHYSICAL DAMAGE, B. EXCLUSIONS, Paragraph 3. is deleted and replaced by the
following:
We will not pay for “loss” caused by or resulting from any of the following unless caused by other “loss” that is
covered by this insurance:
a. Wear and tear, freezing, mechanical or electrical breakdown. However, this exclusion does not include
the discharge of an airbag.
b. Blowouts, punctures or other road damage to tires.
9. GLASS REPAIR - WAIVER OF DEDUCTIBLE
SECTION III - PHYSICAL DAMAGE COVERAGE, D. DEDUCTIBLE is amended to add the following:
No deductible applies to glass damage if the glass is repaired rather than replaced.
10. COLLISION COVERAGE – WAIVER OF DEDUCTIBLE
SECTION III - PHYSICAL DAMAGE COVERAGE, D. DEDUCTIBLE is amended to add the following:
When there is a “loss” to your covered “auto” insured for Collision Coverage, no deductible will apply if the
“loss” was caused by a collision with another “auto” insured by us.
11. KNOWLEDGE OF ACCIDENT
SECTION IV - BUSINESS AUTO CONDITIONS, A. LOSS CONDITIONS, 2. DUTIES IN THE EVENT OF
ACCIDENT, CLAIM, SUIT OR LOSS, paragraph a. is deleted and replaced by the following:
a. You must see to it that we are notified as soon as practicable of an “accident”, claim, “suit” or “loss".
Knowledge of an “accident”, claim, ”suit” or “loss” by your “employees” shall not, in itself, constitute
knowledge to you unless one of your partners, executive officers, directors, managers, or members (if
you are a limited liability company) has knowledge of the “accident”, claim, “suit” or “loss". Notice should
include:
(1) How, when and where the “accident” or “loss” occurred;
(2) The “insured’s” name and address; and
(3) To the extent possible, the names and addresses of any injured persons and witnesses.
12. TRANSFER OF RIGHTS (BLANKET WAIVER OF SUBROGATION)
SECTION IV - BUSINESS AUTO CONDITIONS A.5. TRANSFER OF RIGHTS OF RECOVERY AGAINST
OTHERS TO US is deleted and replaced by the following:
If any person or organization to or for whom we make payment under this Coverage Form has rights to
recover damages from another, those rights are transferred to us. That person or organization must do
everything necessary to secure our rights and must do nothing after “accident” or “loss” to impair them.
However, if the insured has waived rights to recover through a written contract, or if your work was
commenced under a letter of intent or work order, subject to a subsequent reduction in writing with customers
whose customary contracts require a waiver, we waive any right of recovery we may have under this
Coverage Form.
13. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS
SECTION IV - BUSINESS AUTO CONDITIONS, B. GENERAL CONDITIONS, 2. CONCEALMENT,
MISREPRESENTATION OR FRAUD is amended by the addition of the following:
We will not deny coverage under this Coverage Form if you unintentionally fail to disclose all hazards existing
as of the inception date of this policy. You must report to us any knowledge of an error or omission in your
representations as soon as practicable after its discovery. This provision does not affect our right to collect
additional premium or exercise our right of cancellation or non-renewal.
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14. BLANKET COVERAGE FOR CERTAIN OPERATIONS IN CONNECTION WITH RAILROADS
When required by written contract or written agreement, the definition of “insured contract” is amended as
follows:
— The exception contained in paragraph H.3. relating to construction or demolition operations on or within
50 feet of a railroad; and
— Paragraph H.a.
are deleted with respect to the use of a covered "auto" in operations for, or affecting, a railroad.
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CA 71 15 11 09 Page 5 of 5
SCHEDULE OF UNDERLYING INSURANCE
The Schedule of Underlying Insurance is part of Policy No. CU 21125870502
Carrier,
Policy Number, Type of Limits of
Policy Period Policy Liability
AMERISURE MUTUAL INSURANCE Standard Workers Employers Liability
COMPANY Compensation and $1,000,000 Bodily Injury by Accident - each accident
WC 21125880502 Employers Liability $1,000,000 Bodily Injury by Disease - each employee
08/01/2024 - 08/01/2025 $1,000,000 Bodily Injury by Disease - policy limit
AMERISURE INSURANCE COMPANY General Liability Each Occurrence
CPP21125860501 $1,000,000
08/01/2024 - 08/01/2025
Personal & Advertising Injury (Any one person or organization)
$1,000,000
Aggregates
$2,000,000 General Aggregate
$2,000,000 Products - completed operations
Aggregate
AMERISURE INSURANCE COMPANY Automobile Liability
Each Accident
CA 21125850501
08/01/2024 - 08/01/2025 $1,000,000
AMERISURE INSURANCE COMPANY Employee Benefits
CPP21125860501 Liability $1,000,000 Each Employee
08/01/2024 - 08/01/2025
$1,000,000 Annual Aggregate
CU DS 71 02 04 14
COMMERCIAL LIABILITY UMBRELLA
CU 00 01 04 13
COMMERCIAL LIABILITY UMBRELLA COVERAGE FORM
Various provisions in this policy restrict coverage. No other obligation or liability to pay sums or
Read the entire policy carefully to determine rights, perform acts or services is covered unless
duties and what is and is not covered. explicitly provided for under Supplementary
Throughout this policy the words "you" and "your" Payments – Coverages A and B.
refer to the Named Insured shown in the Declarations, b. This insurance applies to "bodily injury" or
and any other person or organization qualifying as a "property damage" that is subject to an
Named Insured under this policy. The words "we", applicable "retained limit". If any other limit,
"us" and "our" refer to the company providing this such as a sublimit, is specified in the
insurance. "underlying insurance", this insurance does not
The word "insured" means any person or organization apply to "bodily injury" or "property damage"
qualifying as such under Section II – Who Is An arising out of that exposure unless that limit is
Insured. specified in the Declarations under the
Schedule of "underlying insurance".
Other words and phrases that appear in quotation
marks have special meaning. Refer to Section V – c. This insurance applies to "bodily injury" and
Definitions. "property damage" only if:
SECTION I – COVERAGES (1) The "bodily injury" or "property damage" is
caused by an "occurrence" that takes place
COVERAGE A – BODILY INJURY AND PROPERTY in the "coverage territory";
DAMAGE LIABILITY
(2) The "bodily injury" or "property damage"
1. Insuring Agreement occurs during the policy period; and
a. We will pay on behalf of the insured the (3) Prior to the policy period, no insured listed
"ultimate net loss" in excess of the "retained under Paragraph 1.a. of Section II – Who Is
limit" because of "bodily injury" or "property An Insured and no "employee" authorized
damage" to which this insurance applies. We by you to give or receive notice of an
will have the right and duty to defend the "occurrence" or claim, knew that the "bodily
insured against any "suit" seeking damages for injury" or "property damage" had occurred,
such "bodily injury" or "property damage" when in whole or in part. If such a listed insured
the "underlying insurance" does not provide or authorized "employee" knew, prior to the
coverage or the limits of "underlying insurance" policy period, that the "bodily injury" or
have been exhausted. When we have no duty "property damage" occurred, then any
to defend, we will have the right to defend, or continuation, change or resumption of such
to participate in the defense of, the insured "bodily injury" or "property damage" during
against any other "suit" seeking damages to or after the policy period will be deemed to
which this insurance may apply. However, we have been known prior to the policy period.
will have no duty to defend the insured against
any "suit" seeking damages for "bodily injury" d. "Bodily injury" or "property damage" which
or "property damage" to which this insurance occurs during the policy period and was not,
does not apply. At our discretion, we may prior to the policy period, known to have
investigate any "occurrence" that may involve occurred by any insured listed under
this insurance and settle any resultant claim or Paragraph 1.a. of Section II – Who Is An
"suit" for which we have the duty to defend. Insured or any "employee" authorized by you to
But: give or receive notice of an "occurrence" or
claim, includes any continuation, change or
(1) The amount we will pay for the "ultimate net resumption of that "bodily injury" or "property
loss" is limited as described in Section III – damage" after the end of the policy period.
Limits Of Insurance; and
(2) Our right and duty to defend ends when we
have used up the applicable limit of
insurance in the payment of judgments or
settlements under Coverages A or B.
CU 00 01 04 13 © Insurance Services Office, Inc.,2012 Page 1 of 18
(d) Cooperate with us with respect to (5) A trust, you are an insured. Your trustees
coordinating other applicable insurance are also insureds, but only with respect to
available to the indemnitee; and their duties as trustees.
(2) Provides us with written authorization to: b. Each of the following is also an insured:
(a) Obtain records and other information (1) Your "volunteer workers" only while
related to the "suit"; and performing duties related to the conduct of
your business, or your "employees", other
(b) Conduct and control the defense of the than either your "executive officers" (if you
indemnitee in such "suit". are an organization other than a
So long as the above conditions are met, partnership, joint venture or limited liability
attorneys' fees incurred by us in the defense of company) or your managers (if you are a
that indemnitee, necessary litigation expenses limited liability company), but only for acts
incurred by us and necessary litigation expenses within the scope of their employment by you
incurred by the indemnitee at our request will be or while performing duties related to the
paid as Supplementary Payments. conduct of your business. However, none of
Notwithstanding the provisions of Paragraph these "employees" or "volunteer workers"
2.b.(2) of Section I – Coverage A – Bodily Injury are insureds for:
And Property Damage Liability, such payments will
(a) "Bodily injury" or "personal and
not be deemed to be damages for "bodily injury"
advertising injury":
and "property damage" and will not reduce the
limits of insurance. (i) To you, to your partners or members
(if you are a partnership or joint
Our obligation to defend an insured's indemnitee
venture), to your members (if you are
and to pay for attorneys' fees and necessary
a limited liability company), to a co-
litigation expenses as Supplementary Payments
"employee" in the course of his or
ends when we have used up the applicable limit of
her employment or performing duties
insurance in the payment of judgments or
related to the conduct of your
settlements or the conditions set forth above, or
business or to your other "volunteer
the terms of the agreement described in
workers" while performing duties
Paragraph f. above, are no longer met.
related to the conduct of your
SECTION II – WHO IS AN INSURED business;
1. Except for liability arising out of the ownership, (ii) To the spouse, child, parent, brother
maintenance or use of "covered autos": or sister of that co-"employee" or
a. If you are designated in the Declarations as: "volunteer worker" as a consequence
of Paragraph (a)(i) above; or
(1) An individual, you and your spouse are
insureds, but only with respect to the (iii) For which there is any obligation to
conduct of a business of which you are the share damages with or repay
sole owner. someone else who must pay
damages because of the injury
(2) A partnership or joint venture, you are an described in Paragraph (a)(i) or (ii)
insured. Your members, your partners, and above.
their spouses are also insureds, but only
with respect to the conduct of your (b) "Property damage" to property:
business. (i) Owned, occupied or used by;
(3) A limited liability company, you are an (ii) Rented to, in the care, custody or
insured. Your members are also insureds, control of, or over which physical
but only with respect to the conduct of your control is being exercised for any
business. Your managers are insureds, but purpose by;
only with respect to their duties as your you, any of your "employees", "volunteer
managers. workers", any partner or member (if you
(4) An organization other than a partnership, are a partnership or joint venture), or
joint venture or limited liability company, any member (if you are a limited liability
you are an insured. Your "executive company).
officers" and directors are insureds, but only (2) Any person (other than your "employee" or
with respect to their duties as your officers "volunteer worker"), or any organization
or directors. Your stockholders are also while acting as your real estate manager.
insureds, but only with respect to their
liability as stockholders.
Page 10 of 18 © Insurance Services Office, Inc.,2012 CU 00 01 04 13
(3) Any person or organization having proper (4) Anyone other than your "employees",
temporary custody of your property if you partners (if you are a partnership),
die, but only: members (if you are a limited liability
(a) With respect to liability arising out of the company), or a lessee or borrower or any of
maintenance or use of that property; their "employees", while moving property to
and or from a "covered auto".
(b) Until your legal representative has been (5) A partner (if you are a partnership), or a
appointed. member (if you are a limited liability
company) for a "covered auto" owned by
(4) Your legal representative if you die, but only him or her or a member of his or her
with respect to duties as such. That
household.
representative will have all your rights and
duties under this Coverage Part. (6) "Employees" with respect to "bodily injury"
to:
c. Any organization you newly acquire or form,
other than a partnership, joint venture or limited (a) Any fellow "employee" of the insured
liability company, and over which you maintain arising out of and in the course of the
ownership or majority interest, will qualify as a fellow "employee's" employment or
Named Insured if there is no other similar while performing duties related to the
insurance available to that organization. conduct of your business; or
However: (b) The spouse, child, parent, brother or
(1) Coverage under this provision is afforded sister of that fellow "employee" as a
only until the 90th day after you acquire or consequence of Paragraph (a) above.
form the organization or the end of the c. Anyone liable for the conduct of an insured
policy period, whichever is earlier; described above is also an insured, but only to
(2) Coverage A does not apply to "bodily injury" the extent of that liability.
or "property damage" that occurred before 3. Any additional insured under any policy of
you acquired or formed the organization; "underlying insurance" will automatically be an
and insured under this insurance.
(3) Coverage B does not apply to "personal Subject to Section III – Limits Of Insurance, if
and advertising injury" arising out of an coverage provided to the additional insured is
offense committed before you acquired or required by a contract or agreement, the most we
formed the organization. will pay on behalf of the additional insured is the
2. Only with respect to liability arising out of the amount of insurance:
ownership, maintenance or use of "covered a. Required by the contract or agreement, less
autos": any amounts payable by any "underlying
a. You are an insured. insurance"; or
b. Anyone else while using with your permission a b. Available under the applicable Limits of
"covered auto" you own, hire or borrow is also Insurance shown in the Declarations;
an insured except: whichever is less.
(1) The owner or anyone else from whom you Additional insured coverage provided by this
hire or borrow a "covered auto". This insurance will not be broader than coverage
exception does not apply if the "covered provided by the "underlying insurance".
auto" is a trailer or semitrailer connected to
No person or organization is an insured with respect
a "covered auto" you own.
to the conduct of any current or past partnership, joint
(2) Your "employee" if the "covered auto" is venture or limited liability company that is not shown
owned by that "employee" or a member of as a Named Insured in the Declarations.
his or her household.
(3) Someone using a "covered auto" while he
or she is working in a business of selling,
servicing, repairing, parking or storing
"autos" unless that business is yours.
CU 00 01 04 13 © Insurance Services Office, Inc.,2012 Page 11 of 18
SECTION III – LIMITS OF INSURANCE SECTION IV – CONDITIONS
1. The Limits of Insurance shown in the Declarations 1. Appeals
and the rules below fix the most we will pay If the "underlying insurer" or insured elects not to
regardless of the number of: appeal a judgment in excess of the "retained limit",
a. Insureds; we may do so at our own expense. We will also
b. Claims made, "suits" brought, or number of pay for taxable court costs, pre- and postjudgment
vehicles involved; or interest and disbursements associated with such
appeal. In no event will this provision increase our
c. Persons or organizations making claims or liability beyond the applicable Limits of Insurance
bringing "suits". described in Section III – Limits Of Insurance.
2. The Aggregate Limit is the most we will pay for the 2. Bankruptcy
sum of all "ultimate net loss" under:
a. Bankruptcy Of Insured
a. Coverage A, except "ultimate net loss"
because of "bodily injury" or "property damage" Bankruptcy or insolvency of the insured or of
arising out of the ownership, maintenance or the insured's estate will not relieve us of our
use of a "covered auto"; and obligations under this Coverage Part.
b. Coverage B. b. Bankruptcy Of Underlying Insurer
3. Subject to Paragraph 2. above, the Each Bankruptcy or insolvency of the "underlying
Occurrence Limit is the most we will pay for the insurer" will not relieve us of our obligations
sum of all "ultimate net loss" under Coverage A under this Coverage Part.
because of all "bodily injury" and "property However, this insurance will not replace the
damage" arising out of any one "occurrence". "underlying insurance" in the event of bankruptcy
4. Subject to Paragraph 2. above, the Personal And or insolvency of the "underlying insurer". This
Advertising Injury Limit is the most we will pay insurance will apply as if the "underlying
under Coverage B for the sum of all "ultimate net insurance" were in full effect.
loss" because of all "personal and advertising 3. Duties In The Event Of Occurrence, Offense,
injury" sustained by any one person or Claim Or Suit
organization. a. You must see to it that we are notified as soon
5. If there is "underlying insurance" with a policy as practicable of an "occurrence" or an offense,
period that is nonconcurrent with the policy period regardless of the amount, which may result in a
of this Commercial Liability Umbrella Coverage claim. To the extent possible, notice should
Part, the "retained limit(s)" will only be reduced or include:
exhausted by payments for: (1) How, when and where the "occurrence" or
a. "Bodily injury" or "property damage" which offense took place;
occurs during the policy period of this (2) The names and addresses of any injured
Coverage Part; or persons and witnesses; and
b. "Personal and advertising injury" for offenses (3) The nature and location of any injury or
that are committed during the policy period of damage arising out of the "occurrence" or
this Coverage Part. offense.
However, if any "underlying insurance" is written b. If a claim is made or "suit" is brought against
on a claims-made basis, the "retained limit(s)" will any insured, you must:
only be reduced or exhausted by claims for that
insurance that are made during the policy period,
(1) Immediately record the specifics of the
claim or "suit" and the date received; and
or any Extended Reporting Period, of this
Coverage Part. (2) Notify us as soon as practicable.
The Aggregate Limit, as described in Paragraph 2. You must see to it that we receive written
above, applies separately to each consecutive annual notice of the claim or "suit" as soon as
period and to any remaining period of less than 12 practicable.
months, starting with the beginning of the policy c. You and any other involved insured must:
period shown in the Declarations, unless the policy
period is extended after issuance for an additional (1) Immediately send us copies of any
period of less than 12 months. In that case, the demands, notices, summonses or legal
additional period will be deemed part of the last papers received in connection with the
preceding period for purposes of determining the claim or "suit";
Limits of Insurance.
Page 12 of 18 © Insurance Services Office, Inc.,2012 CU 00 01 04 13
(2) Authorize us to obtain records and other (2) The total of all deductible and self-insured
information; amounts under all that other insurance.
(3) Cooperate with us in the investigation or 6. Premium Audit
settlement of the claim or defense against a. We will compute all premiums for this
the "suit"; and Coverage Part in accordance with our rules
(4) Assist us, upon our request, in the and rates.
enforcement of any right against any b. Premium shown in this Coverage Part as
person or organization which may be liable advance premium is a deposit premium only.
to the insured because of injury or damage At the close of each audit period we will
to which this insurance may also apply. compute the earned premium for that period
d. No insured will, except at that insured's own and send notice to the first Named Insured.
cost, voluntarily make a payment, assume any The due date for audit and retrospective
obligation, or incur any expense, other than for premiums is the date shown as the due date
first aid, without our consent. on the bill. If the sum of the advance and audit
4. Legal Action Against Us premiums paid for the policy period is greater
than the earned premium, we will return the
No person or organization has a right under this excess to the first Named Insured.
Coverage Part:
c. The first Named Insured must keep records of
a. To join us as a party or otherwise bring us into the information we need for premium
a "suit" asking for damages from an insured; or computation, and send us copies at such times
b. To sue us on this Coverage Part unless all of as we may request.
its terms have been fully complied with. 7. Representations Or Fraud
A person or organization may sue us to recover on By accepting this policy, you agree:
an agreed settlement or on a final judgment
against an insured; but we will not be liable for a. The statements in the Declarations are
damages that are not payable under the terms of accurate and complete;
this Coverage Part or that are in excess of the b. Those statements are based upon
applicable limit of insurance. An agreed settlement representations you made to us;
means a settlement and release of liability signed c. We have issued this policy in reliance upon
by us, the insured and the claimant or the your representations; and
claimant's legal representative.
d. This policy is void in any case of fraud by you
5. Other Insurance as it relates to this policy or any claim under
a. This insurance is excess over, and shall not this policy.
contribute with any of the other insurance, 8. Separation Of Insureds
whether primary, excess, contingent or on any
other basis. This condition will not apply to Except with respect to the Limits of Insurance, and
insurance specifically written as excess over any rights or duties specifically assigned in this
this Coverage Part. Coverage Part to the first Named Insured, this
insurance applies:
When this insurance is excess, we will have no
duty under Coverages A or B to defend the a. As if each Named Insured were the only
insured against any "suit" if any other insurer Named Insured; and
has a duty to defend the insured against that b. Separately to each insured against whom claim
"suit". If no other insurer defends, we will is made or "suit" is brought.
undertake to do so, but we will be entitled to
9. Transfer Of Rights Of Recovery Against Others
the insured's rights against all those other
To Us
insurers.
If the insured has rights to recover all or part of
b. When this insurance is excess over other any payment we have made under this Coverage
insurance, we will pay only our share of the
Part, those rights are transferred to us. The
"ultimate net loss" that exceeds the sum of: insured must do nothing after loss to impair them.
(1) The total amount that all such other At our request, the insured will bring "suit" or
insurance would pay for the loss in the transfer those rights to us and help us enforce
absence of the insurance provided under them.
this Coverage Part; and
CU 00 01 04 13 © Insurance Services Office, Inc.,2012 Page 13 of 18
10.When We Do Not Renew 14.Expanded Coverage Territory
If we decide not to renew this Coverage Part, we a. If a "suit" is brought in a part of the "coverage
will mail or deliver to the first Named Insured territory" that is outside the United States of
shown in the Declarations written notice of the America (including its territories and
nonrenewal not less than 30 days before the possessions), Puerto Rico or Canada, and we
expiration date. are prevented by law, or otherwise, from
If notice is mailed, proof of mailing will be sufficient defending the insured, the insured will initiate a
proof of notice. defense of the "suit". We will reimburse the
insured, under Supplementary Payments, for
11.Loss Payable any reasonable and necessary expenses
Liability under this Coverage Part does not apply incurred for the defense of a "suit" seeking
to a given claim unless and until: damages to which this insurance applies, that
we would have paid had we been able to
a. The insured or insured's "underlying insurer"
exercise our right and duty to defend.
has become obligated to pay the "retained
limit"; and If the insured becomes legally obligated to pay
sums because of damages to which this
b. The obligation of the insured to pay the
insurance applies in a part of the "coverage
"ultimate net loss" in excess of the "retained
territory" that is outside the United States of
limit" has been determined by a final settlement
America (including its territories and
or judgment or written agreement among the
possessions), Puerto Rico or Canada, and we
insured, claimant and us.
are prevented by law, or otherwise, from
12.Transfer Of Defense paying such sums on the insured's behalf, we
When the underlying limits of insurance have been will reimburse the insured for such sums.
used up in the payment of judgments or b. All payments or reimbursements we make for
settlements, the duty to defend will be transferred damages because of judgments or settlements
to us. We will cooperate in the transfer of control will be made in U.S. currency at the prevailing
to us of any outstanding claims or "suits" seeking exchange rate at the time the insured became
damages to which this insurance applies which legally obligated to pay such sums. All
would have been covered by the "underlying payments or reimbursements we make for
insurance" had the applicable limit not been used expenses under Supplementary Payments will
up. be made in U.S. currency at the prevailing
13.Maintenance Of/Changes To Underlying exchange rate at the time the expenses were
Insurance incurred.
Any "underlying insurance" must be maintained in c. Any disputes between you and us as to
full effect without reduction of coverage or limits whether there is coverage under this policy
except for the reduction of the aggregate limit in must be filed in the courts of the United States
accordance with the provisions of such "underlying of America (including its territories and
insurance" that results from payment of claims, possessions), Canada or Puerto Rico.
settlement or judgments to which this insurance d. The insured must fully maintain any coverage
applies. required by law, regulation or other
Such exhaustion or reduction is not a failure to governmental authority during the policy
maintain "underlying insurance". Failure to period, except for reduction of the aggregate
maintain "underlying insurance" will not invalidate limits due to payments of claims, judgments or
insurance provided under this Coverage Part, but settlements.
insurance provided under this Coverage Part will Failure to maintain such coverage required by
apply as if the "underlying insurance" were in full law, regulation or other governmental authority
effect. will not invalidate this insurance. However, this
If there is an increase in the scope of coverage of insurance will apply as if the required coverage
any "underlying insurance" during the term of this by law, regulation or other governmental
policy, our liability will be no more than it would authority was in full effect.
have been if there had been no such increase.
You must notify us in writing, as soon as
practicable, if any "underlying insurance" is
cancelled, not renewed, replaced or otherwise
terminated, or if the limits or scope of coverage of
any "underlying insurance" is changed.
Page 14 of 18 © Insurance Services Office, Inc.,2012 CU 00 01 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY NON-CONTRIBUTORY COVERAGE WHEN
REQUIRED BY WRITTEN AGREEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL LIABILITY UMBRELLA COVERAGE FORM
With respect to any additional insured coverage provided under this policy, or by any endorsement to this
policy, SECTION IV – CONDITIONS, paragraph 5. Other Insurance is deleted and replaced by the
following:
5. Other Insurance
a. Coverage provided by this endorsement is excess over any other valid and collectible insurance
available to the additional insured whether:
(1) Primary;
(2) Excess;
(3) Contingent; or
(4) On any other basis.
In addition, this insurance is excess over any self-insured retentions, deductibles, or captive retentions
payable by the additional insured or payable by any person or organization whose coverage is available
to the additional insured.
However, if a “written agreement” requires primary and non-contributory coverage, this insurance will
be primary and non-contributory relative only to the other insurance available to the additional insured
which covers that person or organization as a Named Insured, and we will not share with that other
insurance. For any other insurance available to the additional insured where that person or organization
is not a Named Insured, this policy will share coverage with that other insurance based on the terms
specified in Paragraph b. Method of Sharing below.
b. Method of Sharing
If all the other insurance permits contribution by equal shares, we will follow this method also. Under
this method, each insurer contributes equal amounts until it has paid its applicable limit of insurance or
none of the loss remains, whichever comes first.
If any of the other insurance does not permit contribution by equal shares, we will contribute by
limits. Under this method, each insurer’s share is based on the ratio of its applicable limit of
insurance to the total applicable limits of insurance of all insurers.
For the purposes of the coverage provided by this endorsement, a “written agreement” means a
written contract or written agreement that:
1. requires you to include a person or organization as an additional insured for a period of time
during the policy period; and
2. is executed prior to the occurrence of “bodily injury”, “property damage”, or “personal and
advertising injury” that forms the basis for a claim under this policy.
CU 74 67 03 23 Includes copyrighted material of the Insurance Services Offices, Inc with its permission Page 1 of 1
POLICY NUMBER: CU 21125870502 COMMERCIAL LIABILITY UMBRELLA
CU 24 01 09 18
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:
COMMERCIAL LIABILITY UMBRELLA COVERAGE PART
This endorsement changes the Policy effective on the inception date of the Policy unless another date is indicated
below.
Named Insured: SHEPCO PAVING INC
Endorsement Effective Date: 08/01/2024
SCHEDULE
Name(s) Of Person(s) Or Organization(s):
ANY PERSON OR ORGANIZATION REQUIRED BY WRITTEN CONTRACT OR CERTIFICATE OF
INSURANCE.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
With respect to the coverage provided for the
ownership, maintenance or use of "covered autos",
the Coverage Form is modified as follows:
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.
CU 24 01 09 18 © Insurance Services Office, Inc., 2017 Page 1 of 1
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
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 anyone not named in the Schedule.
Schedule
• Any person or organization required by written contract or Certificate of Insurance. 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
endorsement is not applicable in California, Kentucky, New Hampshire, New Jersey, Texas, and Utah.
• The endorsement does not apply to policies or exposure in Missouri where the employer is in the construction group
of classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive
subrogation rights is against public policy and void where one party to the contract is an employer in the construction
group of code classifications. For policies or exposure in Missouri, the following must be included in the Schedule:
• Any person or organization for which the employer has agreed by written contract, executed prior to loss, may
execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of
subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover
from others (subrogation) rule in our manual.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective Policy No. Endorsement No.
Insured Premium:
Insurance Company Countersigned by
WC 00 03 13
(Ed. 4-84)
© 1983 National Council on Compensation Insurance.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION OR NONRENEWAL -
THIRD PARTY
This endorsement modifies insurance provided under the following:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Subject to the cancellation provisions of the Policy to which this endorsement is attached, we will not:
1.Cancel; or
2.Nonrenew
this Policy, except for nonpayment of premium, until we provide at least 30 days written notice of such cancellation
or nonrenewal. Written notice will be to the person or organization named in the Schedule. Such notice will be by certified
mail with return receipt requested.
This notification of cancellation or nonrenewal to the person or organization named in the Schedule is intended
as a courtesy only. Our failure to provide such notification will not:
1.Extend any Policy cancellation date;
2.Negate the cancellation as to any insured or any certificate holder;
3.Provide any additional insurance that would not have been provided in the absence of this endorsement; or
4.Impose liability of any kind upon us.
This endorsement does not entitle the person or organization named in the Schedule to any benefits, rights or protection
under this Policy.
SCHEDULE
Name Of Person Or Organization Mailing Address
Any person or organization holding a certificate of insurance The address shown for that person or organization in that
issued for you, provided that certificate: certificate of insurance
1. Refers to this policy;
2. States that notice of:
a. Cancellation;
b. Nonrenewal; or
c. Material change reducing or restricting coverage;
will be provided to that person or organization
3. Is in effect at the time of the:
a. Cancellation;
b. Nonrenewal; or
c. Material change reducing or restricting coverage; and
4. Is on file at your agent or broker's office for this policy
WC 99 06 45 (07 14)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATI ON, NONRENEWAL OR MATERIAL
CHANGE – THIRD PARTY
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
COMMERCIAL UMBRELLA LIABILITY COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE FORM
TRUCKERS COVERAGE FORM
Subject to the cancellation provisions of the Coverage Form to which this endorsement is attached, we will not:
1. Cancel;
2. Nonrenew; or,
3. Materially change (reduce or restrict)
this Coverage Form, except for nonpayment of premium, until we provide at least 30 days written notice of
such cancellation, nonrenewal or material change. Written notice will be to the person or organization named in
the Schedule. Such notice will be by certified mail with return receipt requested.
This notification of cancellation, nonrenewal or material change to the person or organization named in the
Schedule is intended as a courtesy only. Our failure to provide such notification will not:
1. Extend any Coverage Form cancellation date;
2. Negate the cancellation as to any insured or any certificate holder;
3. Provide any additional insurance that would not have been provided in the absence of this endorsement;
or
4. Impose liability of any kind upon us.
This endorsement does not entitle the person or organization named in the Schedule to any benefits, rights or
protection under this Coverage Form.
SCHEDULE
Name Of Person Or Organization Mailing Address
Any person or organization holding a certificate of insurance issued The address shown for that person or organization in
for you, provided the certificate: that certificate of insurance
1. Refers to this policy;
2. States that notice of:
a. Cancellation;
b. Nonrenewal; or
c. Material change reducing or restricting coverage;
will be provided to that person or organization;
3. Is in effect at the time of the:
a. Cancellation;
b. Nonrenewal; or
c. Material change reducing or restricting coverage; and
4. Is on file at your agent or broker's office for this policy
IL 70 66 07 14