MSSA-PBK COI - June 9, 2025 - DCSD Board Meeting Archive

DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 4/8/2025
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).
CONTACT
PRODUCER
NAME: Michelle Serrell
Arthur J. Gallagher Risk Management Services, LLC PHONE FAX
2618 E Broadway (A/C, No, Ext): 281-670-2956 (A/C, No): 281-485-6933
E-MAIL
Pearland TX 77581 ADDRESS: Michelle_serrell@ajg.com
INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : Continental Casualty Company 20443
PBKARCH-01
INSURED INSURER B : LM Insurance Corporation 33600
MSSA-PBK
INSURER C : Liberty Insurance Corporation 42404
525 East Taylor Street
Griffin, GA 30223 INSURER D :

INSURER E :

INSURER F :
COVERAGES CERTIFICATE NUMBER: 537601676 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
B X COMMERCIAL GENERAL LIABILITY Y Y TB5-Z91-472898-024 4/25/2024 4/25/2025 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 1,000,000
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 X LOC
PRO-
PRODUCTS - COMP/OP AGG $ 2,000,000

OTHER: $
C Y Y COMBINED SINGLE LIMIT $ 1,000,000
AUTOMOBILE LIABILITY AS7-Z91-472898-034 4/25/2024 4/25/2025 (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) $
$
C X UMBRELLA LIAB X OCCUR TH7-Z91-472898-054 4/25/2024 4/25/2025 EACH OCCURRENCE $ 9,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 9,000,000

DED RETENTION $ $
PER OTH-
B WORKERS COMPENSATION Y WC5-Z91-472898-014 4/25/2024 4/25/2025 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
A Professional Liability AEH591912035 8/1/2024 8/1/2025 Each Claim $10,000,000
Claims Made Form Aggregate $10,000,000
Retro Date 08/01/2017

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The General Liability and Auto policies include a Blanket additional insured endorsement that provides additional insured status when there is a written contract,
agreement or permit between the named insured and the certificate holder that requires such status.

The General Liability, Auto, Professional Liability and Workers Compensation policies include a Blanket waiver of subrogation endorsement that provides this
feature when there is a written contract, agreement or permit between the named insured and the certificate holder that requires such status.

General Liability is primary & non-contributory when required by written contract, agreement or permit.

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 Road AUTHORIZED REPRESENTATIVE
Tucker, GA 30084

© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: PBKARCH-01
LOC #:

ADDITIONAL REMARKS SCHEDULE Page 1 of 1

AGENCY NAMED INSURED
Arthur J. Gallagher Risk Management Services, LLC MSSA-PBK
525 East Taylor Street
POLICY NUMBER Griffin, GA 30223

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
Auto liability is primary & non-contributory as respects the insured's owned & covered vehicles.

The umbrella is follow form and does not include the professional liability.
RE: Project: RFQu 24-752-017 A/E Continuing Contract for Professional Services.

Additional Insureds: DeKalb County School District and the DeKalb County Board of Education and Owner.

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
2024 COMPLETE NAMED INSURED:

PBK Architects, Inc.

PBR Architects, Inc. Suite 2210

PBK Architects, Inc. d/b/a PBK Engineers Houston, TX 77046

PBK Architects, Inc. d/b/a PBK Roof Consultants

PBK Architects, Inc. d/b/a PBK Facility Consulting

PBK Architects, Inc. d/b/a PBK Architects

PBK Architects, Inc. d/b/a PBK

PBK, Inc.

PBK Architects, Inc. d/b/a PBK Healthcare

PBK Architects, Inc. d/b/a Campaign Communications

PBK Architects, Inc. d/b/a PBK Engineering

PBK Architects, Inc. d/b/a Cunico Consulting

PBK Architects, Inc. d/b/a PBK Sports

PBK Architects, Inc. d/b/a PBK University

PBK Architects, Inc. d/b/a PBK Higher Education

PBK Architects, Inc. d/b/a PBK Interiors

PBK Architects, Inc. dba PBK

PBK Architects, Inc. dba DIG Engineers

PBK Architects, Inc. dba LEAF Engineers

PBK Architects, Inc. dba The Educated Vote

PBK Architects, Inc. dba Building Envelope & Asset Management Professionals (BEAM)

Smith Iwanaga Milhous Pryce Architects, Inc. (legal)

S.I.M Architects, Inc. (DBA)

SIM+PBK (DBA)

PBK Architects, Inc. dba Edgeland Design Group 11/2/2021

PBK Architects, Inc. dba Kubala Engineers 9/30/2021

Wolff/Lang/Christopher Architects, Incorporated 2/1/2022
WLC Architects, Inc. 2/1/2022

WLC Architects 2/1/2022

PBK-WLC 2/1/2022

PBK-WLC Architects 2/1/202

PBK Holdco LLC (added 6/21/22)

PBK IntermediateCo, Inc. (added 6/21/22)

Manley Spangler Smith Architects, P.C. (added 9/15/22)

Spangler & Manley Architects, P.C.

MSSA-PBK

MSSA-PBK Architects

PBK Architects, Inc. dba Blue Ring Creative (9/28/22)

d/b/a Harvard Jolly Architecture (3/31/23)

Harvard Jolly, Inc. (3/31/23)

Harvard Jolly, Inc. d/b/a Harvard Jolly Architecture & PBK (3/31/23)

d/b/a Harvard Jolly & PBK (3/31/23)

d/b/a Harvard Jolly Architecture PBK

Tercilla Courtemanche Architects Inc – merger in 2015, only on PL (3/31/23)

PBK Architects, Inc. d/b/a Harvard Jolly PBK Sports

McGranahan Associates, Inc. (4/19/2024)

McGranahan Architects, PS (4/19/2024)

McGranahan Partnership (4/19/2024)

MMA Architecture (4/19/2024)

James McGranahan & Associates (4/19/2024)

Rue Butler Marshall Associates (4/19/2024)

McGranahanPBK
POLICY NUMBER: TB5-Z91-472898-024 COMMERCIAL GENERAL LIABILITY
CG 20 10 07 04

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – OWNERS, LESSEES OR
CONTRACTORS – SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s)
Or Organization(s): Location(s) Of Covered Operations
$Q\SHUVRQRURUJDQL]DWLRQ\RXDUHUHTXLUHGWRDGGDV All locations DQGMREVSHUIRUPHGWKDWKDYHDZULWWHQ
DGGLWLRQDOLQVXUHGXQGHUDZULWWHQFRQWUDFWRUDJUHHPHQWLQ FRQWUDFWDJUHHPHQWRUSHUPLW
HIIHFWSULRUWRDQ\DFFLGHQWLQMXU\RUGDPDJH

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II – Who Is An Insured is amended to B. With respect to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the following additional
organization(s) shown in the Schedule, but only exclusions apply:
with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or
damage" or "personal and advertising injury" "property damage" occurring after:
caused, in whole or in part, by:
1. All work, including materials, parts or equipment
1. Your acts or omissions; or furnished in connection with such work, on the
2. The acts or omissions of those acting on your project (other than service, maintenance or
behalf; repairs) to be performed by or on behalf of the
in the performance of your ongoing operations for additional insured(s) at the location of the
the additional insured(s) at the location(s) covered operations has been completed; or
designated above. 2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a principal
as a part of the same project.

CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1
POLICY NUMBER: TB5-Z91-472898-024 COMMERCIAL GENERAL LIABILITY
CG 20 37 07 04

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – OWNERS, LESSEES OR
CONTRACTORS – COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s)
Or Organization(s): Location And Description Of Completed Operations
$Q\SHUVRQRURUJDQL]DWLRQ\RXDUHUHTXLUHWRDGGDV All locations as required by a written contract or
DGGLWLRQDOLQVXUHGXQGHUDZULWWHQFRQWUDFWRU agreement entered into prior to an "occurrence" or
DJUHHPHQWLQHIIHFWSULRUWRDQ\DFFLGHQW offense.
LQMXU\ORVVRUGDPDJH

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Section II – Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only with
respect to liability for "bodily injury" or "property
damage" caused, in whole or in part, by "your work"
at the location designated and described in the
schedule of this endorsement performed for that
additional insured and included in the "products-
completed operations hazard".

CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1
POLICY NUMBER: AS7-Z91-472898-034 COMMERCIAL AUTO
CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by the endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage
under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage
provided in the Coverage Form.

SCHEDULE
Name Of Person(s) Or Organization(s):

Any person or organization whom you have agreed in writing to add as an additional insured, but only to
coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either
the scope of coverage or the limits of insurance provided in this policy.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies
as an "insured" under the Who Is An Insured provision
contained in Paragraph A.1. of Section II - Covered
Autos Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms and Paragraph D.2. of
Section I - Covered Autos Coverages of the Auto
Dealers Coverage Form.

CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1
Policy Number TB5-Z91-472898-024
Issued by LM Insurance Corporation

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

NOTICE OF CANCELLATION TO THIRD PARTIES

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE PART
MOTOR CARRIER COVERAGE PART
GARAGE COVERAGE PART
TRUCKERS COVERAGE PART
EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART
SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
COMMERCIAL LIABILITY- UMBRELLA COVERAGE FORM

A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or
organizations shown in the Schedule of this endorsement. We will send notice to the email or mailing address
listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes
effective. In no event does the notice to the third party exceed the notice to the first named insured.
B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to
provide such advance notification will not extend the policy cancellation date nor negate cancellation of the
policy.
All other terms and conditions of this policy remain unchanged.

Schedule

Name of other Person(s) / Email Address or mailing address: Number Days Notice:
Organization(s):

Per Schedule On File With The Company Per Schedule On File With The Company Per Schedule On File With The Company

LIM 99 01 0511 © 2011, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc., with
its permission.
Policy Number AS7-Z91-472898-034
Issued by Liberty Insurance Corp.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

AUTO ENHANCEMENT ENDORSEMENT

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

I. Newly Acquired or Formed Organizations
II. Employees as Insureds
III. Lessor - Additional Insured and Loss Payee
IV. Supplementary Payments - Increased Limits
V. Fellow Employee Coverage
VI. Personal Property of Others
VII. Additional Transportation Expense and Cost to Recover Stolen Auto
VIII. Airbag Coverage
IX. Tapes, Records and Discs Coverage
X. Physical Damage Deductible - Single Deductible
XI. Physical Damage Deductible - Glass
XII. Physical Damage Deductible - Vehicle Tracking System
XIII. Duties in Event of Accident, Claim, Suit or Loss
XIV. Unintentional Failure to Disclose Hazards
XV. Worldwide Liability Coverage - Hired and Nonowned Autos
XVI. Hired Auto Physical Damage
XVII. Auto Medical Payments Coverage Increased Limits
XVIII. Drive Other Car Coverage - Broadened Coverage for Designated Individuals
XIX. Rental Reimbursement Coverage
XX. Notice of Cancellation or Nonrenewal
XXI. Loan/Lease Payoff Coverage
XXII. Limited Mexico Coverage
XXIII. Waiver of Subrogation

I. NEWLY ACQUIRED OR FORMED ORGANIZATIONS

Throughout this policy, the words "you" and "your" also refer to any organization you newly acquire or form,
other than a partnership or joint venture, and over which you maintain ownership of more than 50 percent
interest, provided:

A. There is no similar insurance available to that organization;

B. Unless you notify us to add coverage to your policy, the coverage under this provision is afforded only
until:

1. The 90th day after you acquire or form the organization; or

2. The end of the policy period,

whichever is earlier; and

C. The coverage does not apply to an "accident" which occurred before you acquired or formed the
organization.

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 1 of 10
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
II. EMPLOYEES AS INSUREDS

Paragraph A.1. Who Is An Insured of SECTION II - COVERED AUTOS LIABILITY COVERAGE is
amended to add the following:

Your "employee" is an "insured" while using with your permission a covered "auto" you do not own, hire or
borrow in your business or your personal affairs.

III. LESSOR - ADDITIONAL INSURED AND LOSS PAYEE

A. Any "leased auto" will be considered an "auto" you own and not an "auto" you hire or borrow. The
coverages provided under this section apply to any "leased auto" until the expiration date of this policy or
until the lessor or his or her agent takes possession of the "leased auto" whichever occurs first.

B. For any "leased auto" that is a covered "auto" under SECTION II - COVERED AUTOS LIABILITY
COVERAGE, Paragraph A.1. Who Is An Insured provision is changed to include as an "insured" the
lessor of the "leased auto". However, the lessor is an "insured" only for "bodily injury" or "property
damage" resulting from the acts or omissions by:

1. You.

2. Any of your "employees" or agents; or

3. Any person, except the lessor or any "employee" or agent of the lessor, operating a "leased auto"
with the permission of any of the above.

C. Loss Payee Clause

1. We will pay, as interests may appear, you and the lessor of the "leased auto" for "loss" to the covered
"leased auto".

2. The insurance covers the interest of the lessor of the "leased auto" unless the "loss" results from
fraudulent acts or omissions on your part.

3. If we make any payment to the lessor of a "leased auto", we will obtain his or her rights against any
other party.

D. Cancellation

1. If we cancel the policy, we will mail notice to the lessor in accordance with the Cancellation Common
Policy Condition.

2. If you cancel the policy, we will mail notice to the lessor.

3. Cancellation ends this agreement.

E. The lessor is not liable for payment of your premiums.

F. For purposes of this endorsement, the following definitions apply:

"Leased auto" means an "auto" which you lease for a period of six months or longer for use in your
business, including any "temporary substitute" of such "leased auto".

"Temporary substitute" means an "auto" that is furnished as a substitute for a covered "auto" when the
covered "auto" is out of service because of its breakdown, repair, servicing, "loss" or destruction.

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 2 of 10
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
IV. SUPPLEMENTARY PAYMENTS - INCREASED LIMITS

Subparagraphs A.2.a.(2) and A.2.a.(4) of SECTION II - COVERED AUTOS LIABILITY COVERAGE are
deleted and replaced by the following:

(2) Up to $3,000 for 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.

V. FELLOW EMPLOYEE COVERAGE

A. Exclusion B.5. of SECTION II - COVERED AUTOS LIABILITY COVERAGE does not apply.

B. For the purpose of Fellow Employee Coverage only, Paragraph B.5. of SECTION IV - BUSINESS AUTO
CONDITIONS is changed as follows:

This Fellow Employee Coverage is excess over any other collectible insurance.

VI. PERSONAL PROPERTY OF OTHERS

Exclusion 6. in SECTION II - COVERED AUTOS LIABILITY COVERAGE for a covered "auto" is amended to
add the following:

This exclusion does not apply to "property damage" or "covered pollution cost or expense" involving "personal
property" of your "employees" or others while such property is carried by the covered "auto". The Limit of
Insurance for this coverage is $5,000 per "accident". Payment under this coverage does not increase the
Limit of Insurance.

For the purpose of this section of this endorsement, "personal property" is defined as any property that is not
used in the individual's trade or business or held for the production or collection of income.

VII. ADDITIONAL TRANSPORTATION EXPENSE AND COST TO RECOVER STOLEN AUTO

A. Paragraph A.4.a. of SECTION III - PHYSICAL DAMAGE COVERAGE is amended as follows:

The amount we will pay is increased to $50 per day and to a maximum limit of $1,000.

B. Paragraph A.4.a. of SECTION III - PHYSICAL DAMAGE COVERAGE is amended to add the following:

If your business is shown in the Declarations as something other than an auto dealership, we will also
pay up to $1,000 for reasonable and necessary costs incurred by you to return a stolen covered "auto"
from the place where it is recovered to its usual garaging location.

VIII. AIRBAG COVERAGE

Exclusion B.3.a. in SECTION III - PHYSICAL DAMAGE COVERAGE is amended to add the following:

This exclusion does not apply to the accidental discharge of an airbag.

IX. TAPES, RECORDS AND DISCS COVERAGE

Exclusion B.4.a. of SECTION III - PHYSICAL DAMAGE COVERAGE is deleted and replaced by the
following:

a. Tapes, records, discs or other similar audio, visual or data electronic devices designed for use with audio,
visual or data electronic equipment except when the tapes, records, discs or other similar audio, visual or
data electronic devices:

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 3 of 10
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
(1) Are your property or that of a family member; and

(2) Are in a covered "auto" at the time of "loss".

The most we will pay for "loss" is $200. No Physical Damage Coverage deductible applies to this
coverage.

X. PHYSICAL DAMAGE DEDUCTIBLE - SINGLE DEDUCTIBLE

Paragraph D. in SECTION III - PHYSICAL DAMAGE COVERAGE is deleted and replaced by the following:

D. Deductible

For each covered "auto", our obligation to pay for, repair, return or replace damaged or stolen property
will be reduced by the applicable deductible shown in the Declarations. Any Comprehensive Coverage
deductible shown in the Declarations does not apply to "loss" caused by fire or lightning.

When two or more covered "autos" sustain "loss" in the same collision, the total of all the "loss" for all the
involved covered "autos" will be reduced by a single deductible, which will be the largest of all the
deductibles applying to all such covered "autos".

XI. PHYSICAL DAMAGE DEDUCTIBLE – GLASS

Paragraph D. in SECTION III - PHYSICAL DAMAGE COVERAGE is amended to add the following:

No deductible applies to "loss" to glass if you elect to patch or repair it rather than replace it.

XII. PHYSICAL DAMAGE DEDUCTIBLE - VEHICLE TRACKING SYSTEM

Paragraph D. in SECTION III - PHYSICAL DAMAGE COVERAGE is amended to add:

Any Comprehensive Coverage Deductible shown in the Declarations will be reduced by 50% for any "loss"
caused by theft if the vehicle is equipped with a vehicle tracking device such as a radio tracking device or a
global positioning device and that device was the method of recovery of the vehicle.

XIII. DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS

Subparagraphs A.2.a. and A.2.b. of SECTION IV- BUSINESS AUTO CONDITIONS are changed to:

a. In the event of "accident", claim, "suit" or "loss", your insurance manager or any other person you
designate must notify us as soon as reasonably possible of such "accident", claim, "suit" or "loss". Such
notice must 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.

Knowledge of an "accident", claim, "suit" or "loss" by your agent, servant or "employee" shall not be
considered knowledge by you unless you, your insurance manager or any other person you designate
has received notice of the "accident", claim, "suit" or "loss" from your agent, servant or "employee".

b. Additionally, you and any other involved "insured" must:

(1) Assume no obligation, make no payment or incur no expense without our consent, except at the
"insured's" own cost.

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 4 of 10
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
(2) Immediately send us copies of any request, demand, order, notice, summons or legal paper received
concerning the claim or "suit".

(3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit".

(4) Authorize us to obtain medical records or other pertinent information.

(5) Submit to examination, at our expense, by physicians of our choice, as often as we reasonably
require.

XIV. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS

Paragraph B.2. in SECTION IV - BUSINESS AUTO CONDITIONS is amended to add the following:

Any unintentional failure to disclose all exposures or hazards existing as of the effective date of the Business
Auto Coverage Form or at any time during the policy period will not invalidate or adversely affect the
coverage for such exposure or hazard. However, you must report the undisclosed exposure or hazard to us
as soon as reasonably possible after its discovery.

XV. WORLDWIDE LIABILITY COVERAGE - HIRED AND NONOWNED AUTOS

Condition B.7. in SECTION IV - BUSINESS AUTO CONDITIONS is amended to add the following:

For "accidents" resulting from the use or operation of covered "autos" you do not own, the coverage territory
means all parts of the world subject to the following provisions:

a. If claim is made or "suit" is brought against an "insured" outside of the United States of America, its
territories and possessions, Puerto Rico and Canada, we shall have the right, but not the duty to
investigate, negotiate, and settle or defend such claim or "suit".

If we do not exercise that right, the "insured" shall have the duty to investigate, negotiate, and settle or
defend the claim or "suit" and we will reimburse the "insured" for the expenses reasonably incurred in
connection with the investigation, settlement or defense. Reimbursement will be paid in the currency of
the United States of America at the rate of exchange prevailing on the date of reimbursement.

The "insured" shall provide us with such information we shall reasonably request regarding such claim or
"suit" and its investigation, negotiation, and settlement or defense.

The "insured" shall not agree to any settlement of the claim or "suit" without our consent. We shall not
unreasonably withhold consent.

b. We are not licensed to write insurance outside of the United States of America, its territories or
possessions, Puerto Rico and Canada.

We will not furnish certificates of insurance or other evidence of insurance you may need for the purpose
of complying with the laws of other countries relating to auto insurance.

Failure to comply with the auto insurance laws of other countries may result in fines or penalties. This
insurance does not apply to such fines or penalties.

XVI. HIRED AUTO PHYSICAL DAMAGE

If no deductibles are shown in the Declarations for Physical Damage Coverage for Hired or Borrowed Autos,
the following will apply:

A. We will pay for "loss" under Comprehensive and Collision coverages to a covered "auto" of the private
passenger type hired without an operator for use in your business:

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 5 of 10
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1. The most we will pay for coverage afforded by this endorsement is the lesser of:

a. The actual cost to repair or replace such covered "auto" with other property of like kind and
quality; or

b. The actual cash value of such covered "auto" at the time of the "loss".

2. An adjustment for depreciation and physical condition will be made in determining actual cash value
in the event of a total "loss".

3. If a repair or replacement results in better than like kind or quality, we will not pay for the amount of
the betterment.

B. For each covered "auto", our obligation to pay for, repair, return or replace the covered "auto" will be
reduced by any deductible shown in the Declarations that applies to private passenger "autos" that you
own. If no applicable deductible is shown in the Declarations, the deductible will be $250.

If the Declarations show other deductibles for Physical Damage Coverages for Hired or Borrowed Autos,
this Section XVI of this endorsement does not apply.

C. Paragraph A.4.b. of SECTION III - PHYSICAL DAMAGE COVERAGE is replaced by the following:

b. Loss of Use Expenses

For Hired Auto Physical Damage provided by this endorsement, we will pay expenses for which an
"insured" becomes legally responsible to pay for loss of use of a private passenger vehicle rented or
hired without a driver, under a written rental contract or agreement. We will pay for loss of use
expenses caused by:

(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 under this coverage is $30 per day, subject to a maximum of $900.

XVII. AUTO MEDICAL PAYMENTS COVERAGE - INCREASED LIMITS

For any covered "loss", the Limit of Insurance for Auto Medical Payments will be double the limit shown in the
Declarations if the "insured" was wearing a seat belt at the time of the "accident". This is the maximum
amount we will pay for all covered medical expenses, regardless of the number of covered "autos",
"insureds", premiums paid, claims made, or vehicles involved in the "accident".

If no limit of insurance for Auto Medical Payments is shown on the Declarations, this paragraph Section XVII
of this endorsement does not apply.

XVIII. DRIVE OTHER CAR COVERAGE - BROADENED COVERAGE FOR DESIGNATED INDIVIDUALS

A. This endorsement amends only those coverages indicated with an "X" in the Drive Other Car section of
the Schedule to this endorsement.

B. SECTION II - COVERED AUTOS LIABILITY COVERAGE is amended as follows:

1. Any "auto" you don't own, hire or borrow is a covered "auto" for Liability Coverage while being used
by any individual named in the Drive Other Car section of the Schedule to this endorsement or by his
or her spouse while a resident of the same household except:

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 6 of 10
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
a. Any "auto" owned by that individual or by any member of his or her household; or

b. Any "auto" used by that individual or his or her spouse while working in a business of selling,
servicing, repairing or parking "autos".

2. The following is added to Who Is An Insured:

Any individual named in the Drive Other Car section of the Schedule to this endorsement and his or
her spouse, while a resident of the same household, are "insureds" while using any covered "auto"
described in Paragraph B.1. of this endorsement.

C. Auto Medical Payments, Uninsured Motorist, and Underinsured Motorist Coverages are amended as
follows:

The following is added to Who Is An Insured:

Any individual named in the Drive Other Car section of the Schedule to this endorsement and his or her
"family members" are "insured" while "occupying" or while a pedestrian when struck by any "auto" you
don't own except:

Any "auto" owned by that individual or by any "family member".

D. SECTION III - PHYSICAL DAMAGE COVERAGE is changed as follows:

Any private passenger type "auto" you don't own, hire or borrow is a covered "auto" while in the care,
custody or control of any individual named in the Drive Other Car section of the Schedule to this
endorsement or his or her spouse while a resident of the same household except:

1. Any "auto" owned by that individual or by any member of his or her household; or

2. Any "auto" used by that individual or his or her spouse while working in a business of selling,
servicing, repairing or parking "autos".

E. For purposes of this endorsement, SECTION V - DEFINITIONS is amended to add the following:

"Family member" means a person related to the individual named in the Drive Other Car section of the
Schedule to this endorsement by blood, marriage or adoption who is a resident of the individual's
household, including a ward or foster child.

XIX. RENTAL REIMBURSEMENT COVERAGE

A. For any owned covered "auto" for which Collision and Comprehensive Coverages are provided, we will
pay for rental reimbursement expenses incurred by you for the rental of an "auto" because of a covered
physical damage "loss" to an owned covered "auto". Such payment applies in addition to the otherwise
applicable amount of physical damage coverage you have on a covered "auto". No deductibles apply to
this coverage.

B. We will pay only for those expenses incurred during the policy period beginning 24 hours after the "loss"
and ending with the earlier of the return or repair of the covered "auto", or the exhaustion of the coverage
limit.

C. Our payment is limited to the lesser of the following amounts:

1. Necessary and actual expenses incurred; or

2. $30 per day with a maximum of $900 in any one period.

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 7 of 10
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
D. This coverage does not apply:

1. While there are spare or reserve "autos" available to you for your operations; or

2. If coverage is provided by another endorsement attached to this policy.

E. If a covered "loss" results from the total theft of a covered "auto" of the private passenger type, we will
pay under this coverage only that amount of your rental reimbursement expenses which is not already
provided for under Paragraph A.4. Coverage Extensions of SECTION III – PHYSICAL DAMAGE
COVERAGE of the Business Auto Coverage Form or Section VII of this endorsement.

XX. NOTICE OF CANCELLATION OR NONRENEWAL

A. Paragraph A.2. of the COMMON POLICY CONDITIONS is changed to:

2. We may cancel or non-renew this policy by mailing written notice of cancellation or non-renewal to
the Named Insured, and to any name(s) and address(es) shown in the Cancellation and Non-renewal
Schedule:

a. For reasons of non-payment, the greater of:

(1) 10 days; or

(2) The number of days specified in any other Cancellation Condition attached to this policy; or

b. For reasons other than non-payment, the greater of:

(1) 60 days;

(2) The number of days shown in the Cancellation and Non-renewal Schedule; or

(3) The number of days specified in any other Cancellation Condition attached to this policy,

prior to the effective date of the cancellation or non-renewal.

B. All other terms of Paragraph A. of the COMMON POLICY CONDITIONS, and any amendments thereto,
remain in full force and effect.

XXI. LOAN/LEASE PAYOFF COVERAGE

The following is added to Paragraph C. Limits Of Insurance of SECTION III - PHYSICAL DAMAGE
COVERAGE:

In the event of a total "loss" to a covered "auto" of the private passenger type shown in the schedule or
declarations for which Collision and Comprehensive Coverage apply, we will pay any unpaid amount due on
the lease or loan for that covered "auto", less:

1. The amount paid under the PHYSICAL DAMAGE COVERAGE SECTION of the policy; and

2. Any:

a. Overdue lease/loan payments at the time of the "loss";

b. Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high
mileage;

c. Security deposits not returned by the lessor;

d. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance
purchased with the loan or lease; and

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 8 of 10
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e. Carry-over balances from previous loans or leases.

This coverage is limited to a maximum of $1,500 for each covered "auto".

XXII.LIMITED MEXICO COVERAGE

WARNING
AUTO ACCIDENTS IN MEXICO ARE SUBJECT TO THE LAWS OF MEXICO ONLY - NOT THE LAWS OF THE
UNITED STATES OF AMERICA. THE REPUBLIC OF MEXICO CONSIDERS ANY AUTO ACCIDENT A
CRIMINAL OFFENSE AS WELL AS A CIVIL MATTER.

IN SOME CASES THE COVERAGE PROVIDED UNDER THIS ENDORSEMENT MAY NOT BE RECOGNIZED
BY THE MEXICAN AUTHORITIES AND WE MAY NOT BE ALLOWED TO IMPLEMENT THIS COVERAGE AT
ALL IN MEXICO. YOU SHOULD CONSIDER PURCHASING AUTO COVERAGE FROM A LICENSED
MEXICAN INSURANCE COMPANY BEFORE DRIVING INTO MEXICO.

THIS ENDORSEMENT DOES NOT APPLY TO ACCIDENTS OR LOSSES WHICH OCCUR BEYOND 25 MILES
FROM THE BOUNDARY OF THE UNITED STATES OF AMERICA.

A. Coverage

1. Paragraph B.7. of SECTION IV - BUSINESS AUTO CONDITIONS is amended by the addition of the
following:

The coverage territory is extended to include Mexico but only if all of the following criteria are met:

a. The "accidents" or "loss" occurs within 25 miles of the United States border; and

b. While on a trip into Mexico for 10 days or less.

2. For coverage provided by this section of the endorsement, Paragraph B.5. Other Insurance in
SECTION IV - BUSINESS AUTO CONDITIONS is replaced by the following:

The insurance provided by this endorsement will be excess over any other collectible insurance.

B. Physical Damage Coverage is amended by the addition of the following:

If a "loss" to a covered "auto" occurs in Mexico, we will pay for such "loss" in the United States. If the
covered "auto" must be repaired in Mexico in order to be driven, we will not pay more than the actual
cash value of such "loss" at the nearest United States point where the repairs can be made.

C. Additional Exclusions

The following additional exclusions are added:

This insurance does not apply:

1. If the covered "auto" is not principally garaged and principally used in the United States.

2. To any "insured" who is not a resident of the United States.

XXIII. WAIVER OF SUBROGATION

Paragraph A.5. in SECTION IV - BUSINESS AUTO CONDITIONS does not apply to any person or organization
where the Named Insured has agreed, by written contract executed prior to the date of "accident", to waive rights
of recovery against such person or organization.

AC 84 07 11 17 © 2017 Liberty Mutual Insurance Page 9 of 10
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POLICY NUMBER:TB5-Z91-472898-024 COMMERCIAL GENERAL LIABILITY
CG 24 041219

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 GENERAL LIABILITY COVERAGE PART
ELECTRONIC DATA LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES
POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
RAILROAD PROTECTIVE LIABILITY COVERAGE PART
UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS

The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV - Conditions:
We waive any right of recovery against the person(s)
or organization(s) shown in the Schedule above
because of payments we make under this Coverage
Part. Such waiver by us applies only to the extent that
the insured has waived its right of recovery against
such person(s) or organization(s) prior to loss. This
endorsement applies only to the person(s) or
organization(s) shown in the Schedule above.

SCHEDULE

Name Of Person(s) Or Organization(s):
As required by written contract or agreement entered into prior to loss.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

CG 24041219 © Insurance Services Office, Inc., 2018 Page 1 of 1
Policy #TB5-Z91-472898-024
4/25/2024-4/25/2025
Policy Number TB5-Z91-472898-024
Issued by LM Insurance Corporation

THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.

DESIGNATED CONSTRUCTION PROJECT OR DESIGNATED LOCATION
COMBINED AGGREGATE LIMITS-WITH TOTAL AGGREGATE LIMIT
FOR ALL PROJECTS AND LOCATIONS

This endorsement modifies insurance provided under the fo llowing:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under
Section I - Coverage A, and for all medical expenses caused by accidents under Section I - Coverage C, which
can be attributed only to ongoing operations at a single designated construction project or a single designated
"location":
1. A separate Designated General Aggregate Limit applies to each designated construction project and to
each designated "location", and that limit is equal to the amount of the General Aggregate Limit shown in
the Declarations.
2. The Designated General Aggregate Limit is the most we will pay for the sum of all damages under Section I
- Coverage A, except damages because of "bodily injury'' or "property damage" included in the
"products-completed operations hazard", and for medical expenses under Section I - Coverage C
regardless of the number of:
a. Insureds;
b. Claims made or "suits" brought; or
c. Persons or organizations making claims or bringing "suits".
3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall
reduce the Designated General Aggregate Limit for that designated construction project or designated
"location". Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor
shall they reduce any other Designated General Aggregate Limit for any other designated construction
project or designated "location",
4. The limits shown in the Declarations for Each Occurrence, Damage to Premises Rented to You and
Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit
shown in the Declarations, such limits will be subject to the applicable Designated General Aggregate Limit
and the Total Aggregate Limit for all Projects and Locations.
5. The Total Aggregate Limit for all Projects and Locations shown in the Schedule of this endorsement is the
most we will pay for the sum of all damages caused by "occurrences" under Section I - Coverage A and all
medical expenses caused by accidents under Section I - Coverage C which can be attributed only to
ongoing operations at a designated construction project or designated "location" shown in the Schedule of
this endorsement, regardless of the number of construction projects, "locations", "occurrences" or
accidents.
6. Each Designated General Aggregate Limit is subject to the Total Aggregate Limit for all Projects and
Locations shown in the Schedule of this endorsement.
B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under
Section I - Coverage A, and for all medical expenses caused by accidents under Section I - Coverage C,
which cannot be attributed only to ongoing operations at a single designated construction project or single
designated "location":
LC 25 19 0115 © 2014 Liberty Mutual Insurance Page 1 of 2
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
TEXAS NOTICE OF MATERIAL CHANGE ENDORSEMENT

This endorsement applies only to the insurance provided by the policy because Texas is shown in item 3.A. of the
Information Page.

In the event of cancelation or other material change of the policy, we will mail advance notice to the person or
organization named in the Schedule. The number of days advance notice is shown in the Schedule.

This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

1. Number of days advance notice: 60

2. Notice will be mailed to: Per schedule on file with company

Issued by LM Insurance Corporation 27243

For attachment to Policy No.WC5 Z91-472898-014 Effective Dale Premium$

Issued to PBK Architects, Inc. Endorsement No.

WC 42 06 01 Page 1 of 1
Ed. 07/01/1984
TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the
Information Page.

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, but this waiver applies only with respect
to bodily injury arising out of the operations described in the Schedule where you are required by a written contract
to obtain this waiver from us.

This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

The premium for this endorsement is shown in the Schedule.

Schedule
1. ( ) Specific Waiver
Name of person or organization

(X) Blanket Waiver
Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

2. Operations:
All Texas Operations

3. Premium:
The premium charge for this endorsement shall be 2.0 percent of the premium developed on payroll in
connection with work performed for the above person(s) or organization(s) arising out of the operations
described.

4. Advance Premium:

Issued by LM Insurance Corporation 27243 For

attachment to Policy No. WC5-Z91-472898-014 Effective Date Premium$

Issued to PBK Architects, Inc. Endorsement No.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by the endorsement.

A. The following is added to the Other Insurance B. The following is added to the Other Insurance
Condition in the Business Auto Coverage Form Condition in the Auto Dealers Coverage Form and
and the Other Insurance - Primary And Excess supersedes any provision to the contrary:
Insurance Provisions in the Motor Carrier This Coverage Form's Covered Autos Liability
Coverage Form and supersedes any provision to Coverage and General Liability Coverages are
the contrary: primary to and will not seek contribution from any
This Coverage Form's Covered Autos Liability other insurance available to an "insured" under
Coverage is primary to and will not seek your policy provided that:
contribution from any other insurance available to 1. Such "insured" is a Named Insured under such
an "insured" under your policy provided that: other insurance; and
.1. Such "insured" is a Named Insured under such 2. You have agreed in writing in a contract or
other insurance; and agreement that this insurance would be
2. You have agreed in writing in a contract or primary and would not seek contribution from
agreement that this insurance would be any other insurance available to such
primary and would not seek contribution from "insured".
any other insurance available to such
"insured".

Issued by: Liberty Insurance Corporation

Policy Number: TH7-Z91-472898-054 Producer:
ARTHUR J GALLAGHER RISK MANAGEMENT
SERVICES INC
Renewal of: TH7-Z91-472898-053 2618 BROADWAY ST
PEARLAND, TX 77581-4903

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Item 1. Named Insured and Mailing Address:

PBK Architects, Inc.
11 Greenway Plz 22nd Fl
Houston, TX 77046

The Named Insured is: Corporation

Item 2. Policy Period: 4/25/2024 to 4/25/2025 at 12:01 A.M. standard time at above mailing address.

Item 3. Limits of Insurance:

Each Occurrence Limit $ 5,000,000
General Aggregate Limit $ 5,000,000
Products-Completed Operations Aggregate Limit $ 5,000,000

Item 4. Self-Insured Retention – Each Occurrence: $ 0

Item 5. Premium:
Premium Basis Audit Basis Estimated Exposure Rate Advance Premium
Flat Charge 0 $ 24,173

Certified Acts of Terrorism Coverage: $0
Total Advance Premium: $ 24,173

Minimum Retained Premium: $0

Issued Code Number Account Number Sub-Account Number
WD 05/08/23 99935 9-472898 0000

Coverage Insurer Limits of Insurance
Policy Period
Policy Number
Employers Liability* LM Insurance Corporation $1,000,000 By Accident Each Accident
4/25/2024 to 4/25/2025 $1,000,000 By Disease Policy Limit
WC5-Z91-472898-014 $1,000,000 By Disease Each Employee

Auto Liability Liberty Insurance Corporation $1,000,000 CSL
4/25/2024 to 4/25/2025
AS7-Z91-472898-034

General Liability LM Insurance Corporation $1,000,000 Each Occurrence
4/25/2024 to 4/25/2025 $2,000,000 General Aggregate
TB5-Z91-472898-024 $2,000,000 Products/Completed Ops
Aggregate
$1,000,000 Pers & Adv Injury Limit
Employee Benefits LM Insurance Corporation $1,000,000 Each Employee
Liability 4/25/2024 to 4/25/2025 $1,000,000 Aggregate
TB5-Z91-472898-024

* In any jurisdiction, state or province where the amount of Employers Liability Insurance provided by the
underlying insurer(s) is by law unlimited, the underlying Employers Liability limits shown in the above schedule do
not apply and no coverage for Employers Liability shall be provided by this policy.

These Declarations and any Declarations Extension Schedules, together with the Coverage Form and any
Endorsement(s) complete this policy.

Forms and Endorsements attached to this policy: See Attached Schedule

Countersigned by:

________________________________________
Authorized Company Representative

A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or
organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at
least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event
does the notice to the third party exceed the notice to the first named insured.

B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to
provide such advance notification will not extend the policy cancellation date nor negate cancellation of the
policy.

Schedule

Name of Other Person(s) / Email Address or mailing address: Number Days Notice:
Organization(s):
Per schedule on file with Per schedule on file with 30
company company

All other terms and conditions of this policy remain unchanged.

Issued by LM Insurance Corporation 27243

For attachment to Policy No.WC5-Z91-472898-014 Effective Date Premium $

Issued to PBK Architects, Inc. Endorsement No.

WC 99 20 75 © 2016 Liberty Mutual Insurance Page 1 of 1
Ed. 12/01/2016
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -
CALIFORNIA

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.)

You must maintain payroll records accurately segregating the remuneration of your employees while engaged in
the work described in the Schedule.

The additional premium for this endorsement shall be 2.0% of the California workers' compensation premium
otherwise due on such remuneration.

Schedule
Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum
premium charge of $250 per policy.

Person or Organization Job Description
Where required by contract or Any
written agreement prior to loss and
allowed by law.

Issued by LM Insurance Corporation 27243

For attachment to Policy No.WC5-Z91-472898-014 Effective Date Premium $

Issued to PBK Architects, Inc. Endorsement No.

WC 04 03 06 R1 Page 1 of 1
Ed. 08/01/2013

Agenda Item