Agenda Item
i. Contract Renewal and Ratification ~ RFQu 24-752-023 ~ Professional Geotechnical, Environmental and Construction Material Testing Services ~ ECS Southeast, LLC, Goodwyn Mills and Cawood LLC, Matrix Engineering Group, Inc., Nova Engineering & Environmental, LLC, Oasis Consulting Services, United Consulting ~ Contract Renewal #1 of 4 (Not to exceed $5,000,000) Updated 11.5.2025
Summary: Presented by: Mr. Erick Hofstetter, Chief Operating Officer, Division of Operations
Request: It is requested that the DeKalb County Board of Education (“the Board”) approve the renewal and ratification of RFQu No. 24-752-023 for Professional Geotechnical, Environmental, and Construction Material Services in the not-to-exceed amount of $5,000,000. This is the first of four (#1 of 4) contract renewals with ratification as follows:
ECS Southeast, LLC - Ratification required from October 8, 2025
Goodwyn Mills Cawood, LLC - Ratification required from October 8, 2025
Matrix Engineering Group, Inc. - Ratification required from September 30, 2025
Nova Engineering - Ratification required from August 30, 2025
Oasis Consulting Services - Ratification required from October 8, 2025
United Consulting - Ratification required from October 8, 2025
Why: This request is a contract renewal for the above firms to provide Professional Geotechnical, Environmental, and Construction Material Services throughout DeKalb County School District (“DCSD”) on an as-needed basis for various remodeling, renovations, life safety, maintenance and repair projects, for both SPLOST and Non-SPLOST projects.
This is the first of four (#1 of 4) one (1) year renewal options.
Details: On August 12, 2024, the Board approved the award of contract RFQu No. 24-752-023 for Professional Geotechnical, Environmental, and Construction Material Services on an as needed basis, districtwide.
Specific details related to the scope of work for Professional Geotechnical, Environmental, and Construction Material Services can be found on the District’s solicitation website at http://www.dekalbschoolsga.ionwave.net
Financial impact: The total contract amount for these services in an amount not to exceed $5,000,000, will be allocated from the various General Fund Budget and E-SPLOST charge codes.
Board Policy DJE requires the Board of Education to approve the expenditure of any vendor that provides goods and/or services to the school system that may exceed $100,000 in purchases for the fiscal year. All single projects over the $100,000 threshold will be presented to the Board for formal approval in accordance with Board policy.
The ratification amount of $55,135 is funded from E-SPLOST VI.
Contact: Mr. Erick Hofstetter, Chief Operating Officer, Division of Operations, 678.676.1332
Mr. Hans Williams, Director of Planning & CIP Programming, Division of Operations, 678.676.1483
Effective: Upon Board Approval
Status: Approved by Office of Legal Affairs
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 09/18/2025
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).
PRODUCER CONTACT Christine Massey
NAME:
Partners Risk Services, LLC PHONE (770) 609-2700 FAX (770) 609-2749
(A/C, No, Ext): (A/C, No):
10692 Medlock Bridge Road E-MAIL cmassey@partnersrs.com
ADDRESS:
Suite 200 INSURER(S) AFFORDING COVERAGE NAIC #
Johns Creek GA 30097 INSURER A : Utica National Assurance Company 10687
INSURED INSURER B : Graphic Arts Mutual Insurance Co 25984
United Consulting Group, LTD INSURER C : Utica Mutual Insurance Company 25976
625 Holcomb Bridge Road INSURER D : Insurance Company of the West 27847
INSURER E : Westchester Surplus Lines Insurance Company.
Norcross GA 30071 INSURER F :
COVERAGES CERTIFICATE NUMBER: 24-25 MASTER 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
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 100,000
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $
MED EXP (Any one person) $ 10,000
A Y Y CPP5482467 11/01/2024 11/01/2025 PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
PRO- 2,000,000
POLICY JECT LOC PRODUCTS - COMP/OP AGG $
OTHER: Employment Related $ 1,000,000
Practices SINGLE LIMIT
COMBINED
AUTOMOBILE LIABILITY
(Ea accident)
$ 1,000,000
ANY AUTO BODILY INJURY (Per person) $
B OWNED SCHEDULED Y Y 5482468 11/01/2024 11/01/2025 BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
Medical payments $ 5,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000
C EXCESS LIAB CLAIMS-MADE Y Y CULP5489674 11/01/2024 11/01/2025 AGGREGATE $ 10,000,000
DED RETENTION $ 10,000 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY STATUTE ER
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
D OFFICER/MEMBER EXCLUDED? N N/A Y WGA506168004 11/01/2024 11/01/2025
(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
General Aggregate $3,000,000
Cyber Liability
E F17196492002 11/01/2024 11/01/2025
Deductible $10,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Re: Project: RFQu 24-752-023 Continuing Contract for Professional Geotechnical, Environmental and Construction Material Testing Services.
DeKalb County School District and The DeKalb County Board of Education as an additional insureds under the liability policies.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
DeKalb County School District ACCORDANCE WITH THE POLICY PROVISIONS.
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
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 990627
(Ed. 10-98)
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, 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: ALABAMA OPERATIONS ONLY
3. Premium
The premium charge for this endorsement shall be 2 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. Minimum Premium
5. Advance Premium
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The infonnation below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement No.
Endorsement Effective 11/01/2024 Policy No. WGA 506168004
Premium $ INCL .
Insured UNITED CONSULTING GROUP LTD
--------------
Insurance Company INSURANCE COMPANY OF THE WEST
WC 990627
(Ed. 10-98)
INSURED
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 990627
(Ed. 10-98)
Countersigned By
--------------
WC 990627
(Ed. 10-98)
INSURED
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ADDITIONAL COVERAGES
Ref # Description Coverage Code Form No. Edition Date
Uninsured motorist combined single limit UMCSL
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
1,000,000
Ref # Description Coverage Code Form No. Edition Date
Underinsured motorist combined single limit UNCSL
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
1,000,000
Ref # Description Coverage Code Form No. Edition Date
WC & Employer's liability WCEL
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
1,000,000 1,000,000 1,000,000 2,500
Ref # Description Coverage Code Form No. Edition Date
Experience Mod Factor 1 EXP01
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
Ref # Description Coverage Code Form No. Edition Date
Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium
OFADTLCV Copyright 2001, AMS Services, Inc.
POLICY NUMBER: CPP5482467
COMMERCIAL GENERAL LIABILITY
CG20010413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRO DUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to the Other Insurance (2) You have agreed il writing il a contract or
Condition and supersedes any provision to the agreement that this insurance would be
contrary: primary and would not seek contribution
Primary And Noncontributory Insurance from any other insurance available to the
additional insured.
This insurance is primary to and will not seek
contribution from any other insurance available
to an additional insured under your policy
provided that:
(1) The additional insured is a Named Insured
under such other insurance; and
CG20010413 © Insurance Services Office, Inc., 2012 Page 1 of 1
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POLICY NUMBER: CPP5482467 COMMERCIAL GENERAL LIABILITY
CG 20 10 0413
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 Oraanization(s) Location(s) Of Covered Operations
All person(s)/organization(s) with which you have written
contract., All locations required to be covered under All locations and completed operations
written, contracts with you, , GA 30071 required to be covered under written
contracts with you.
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
1. Your acts or omissions; or equipment furnished in connection with such
2. The acts or omissions of those acting on your work, on the project (other than service,
behalf; maintenance or repairs) to be performed by or
in the performance of your ongoing operations for on behalf of the additional insured(s) at the
the additional insured(s) at the location(s) location of the covered operations has been
designated above. completed; or
However: 2. That portion of "your work" out of which the
injury or damage arises has been put to its
1. The insurance afforded to such additional intended use by any person or organization
insured only applies to the extent permitted by other than another contractor or subcontractor
law; and engaged in performing operations for a
2. If coverage provided to the additional insured is principal as a part of the same project.
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 10 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 990627
(Ed. 10-98)
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, 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: GEORGIA OPERATIONS ONLY
3. Premium
The premium charge for this endorsement shall be 2 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. Minimum Premium
5. Advance Premium
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The infonnation below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement No.
Endorsement Effective 11/01/2024 Policy No. WGA 506168004
Premium $ INCL .
Insured UNITED CONSULTING GROUP LTD
--------------
Insurance Company INSURANCE COMPANY OF THE WEST
WC 990627
(Ed. 10-98)
INSURED
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 990627
(Ed. 10-98)
Countersigned By
--------------
WC 990627
(Ed. 10-98)
INSURED
BULLETIN 24-EX-4
TO: ALL INSURANCE AGENTS WRITING BUSINESS IN THE STATE OF
GEORGIA
FROM: JOHN F. KING
INSURANCE AND SAFETY FIRE COMMISSIONER
DATE: MARCH 14, 2024
RE: FREQUENTLY ASKED QUESTIONS REGARDING CERTIFICATES OF
INSURANCE IN GEORGIA
This Bulletin is issued by the Office of the Commissioner of Insurance and Safety-Fire to stand in place
of and supersede Bulletin 23-EX-9.
This document is designed to provide the public with information regarding certificates of insurance.
Basic questions about certificates are addressed and the process for filing complaints is explained. All
information contained herein is merely informal persuasive authority, is not law, and is not binding on
OCI. Nothing contained herein shall be construed by any person or entity as an approval of any
certificate of insurance by OCI.
What is a certificate of insurance?
A certificate of insurance provides a synopsis of coverage under an insurance policy as it exists at the
time the certificate is issued. A certificate is not an insurance policy and cannot be used to alter or
expand coverage. The statutory definition of “certificate of insurance” is: “’Certificate’ or ‘certificate
of insurance’ means any document or instrument, no matter how titled or described, which is prepared
or issued by an insurer or insurance producer as evidence of property or casualty insurance coverage.
‘Certificate’ or ‘certificate of insurance’ shall not include a policy of insurance or insurance binder,
including any policy of insurance which may be referred to as a certificate, or any insurance
information card of identification card issued in conjunction with a motor vehicle insurance policy.”
What are the requirements for the certificate forms?
Certificates must be issued on ACORD or ISO forms or on other forms specifically approved by the
Insurance Commissioner’s Office. Certificate forms cannot be altered. They must contain the
following or similar disclaimer language: “This certificate of insurance is issued as a matter of
information only and confers no rights upon the certificate holder. This certificate does not amend,
extend or alter the coverage, terms exclusions and conditions afforded by the policies referenced
herein.”
What is the Insurance Commissioner’s regulatory authority?
The Insurance Commissioner’s regulatory authority applies not only to insurance agents and
insurance companies but also to entities requesting certificates of insurance, certificate monitoring
companies, certificate compliance companies, certificate holders, individuals, partnerships,
corporations, associations, or other legal entities, including any government or governmental
subdivision or agency.
Applicability Status
The certificates law and regulations apply to all certificate holders, those who request that certificates
be issued, policyholders, insurers, insurance producers, certificate monitoring companies, certificate
compliance companies, anyone acting on behalf of a certificate holder, and certificate of insurance
forms issued as evidence of insurance coverage on property, operations, or risks located in this state,
regardless of where the person requesting the issuance of a certificate, the certificate holder,
policyholder, insurer, or insurance producer is located.
Prohibited Practices and Violations
It is a violation of the law to provide a certificate on an unapproved or altered form or to include
information on a certificate that purports to alter or expand coverage. It is also a violation of the law to
request such a certificate.
Examples of improper requests and improper completion of certificates include (but are not limited to)
the following:
1. Use of a Form that has not been filed with and approved by the Insurance Commissioner’s
Office;
2. Use of an edition of an ACORD or ISO form other than the current approved editions;
3. Use of a form called something other than a “Certificate of insurance” as a means of evading the
requirements of the law (the same rules apply however the form is titled);
4. Use of a form that certifies that insurance coverage complies with the provisions of the insured’s
contract with the certificate holder;
5. Alteration of an approved form;
6. Language on a certificate that purports to, affirmatively or negatively amend, extend, modify or
alter coverage in any way;
7. Language on a certificate that purports to affirmatively or negatively determine an outcome;
8. Utilizing a third party website or non-approved form to answer coverage questions;
9. Requiring that a summary of a policy provision be added to the certificate which varies from the
precise and complete language of the provision;
10. Use of the description of operations box on the ACORD25 form in any manner inconsistent with
the provisions of statute or regulation. In particular, the prohibition against summarizing policy
language (see bullet point above) applies to the description of operations box as well as other
sections of the certificate. Reference to policy provisions in the operations box are permitted (by
the form’s exact title, form number, and edition date) and copies of the provisions can be
attached.
11. Requesting or issuing a certificate which appears to convey or substantiate insurance coverage
which does not exist under the policy for which the certificate is being issued.
12. Requesting or issuing a certificate to include construction or service contract language other than
project identifying information.
13. Requesting an agent to issue an opinion or document in addition to or in lieu of a certificate other
than an actual copy of the insurance policy, insurance binder, or relevant policy provisions to
demonstrate contractual compliance.
Frequently Asked Questions
1. What are the penalties for violating Georgia certificate of insurance requirements?
The possible penalties for noncompliance include cease and desist orders, injunctive relief,
administrative penalties, civil penalties of up to $5,000 for each infraction, or any combination of
these actions. See generally, O.C.G.A. §§ 33-24-19.1(n); (o); 33-2-24. These penalties can apply to
certificate holders, certificate monitoring companies, agents, insurers, those who request certificates
on a holders’ behalf, and any entities defined under O.C.G.A. § 33-24-19.1(a)(5).
2. May any party request language be placed on a Certificate of Insurance that affirmatively or
negatively purports to amend, extend, or alter the coverage afforded by the policy to which
the Certificate of Insurance makes reference?
No, language may not be requested or included on a certificate that expresses a coverage
determination. A certificate of insurance shall not confer to a certificate holder new or additional
rights beyond what the referenced policy expressly provides. Examples of language violations that
express a coverage determination include, but are not limited to:
• “The policy WILL BE Primary Non-Contributory”
• “Subcontracted work IS NOT Excluded.”
• “Umbrella Liability Coverage IS follow form”
• “Company XYZ, their employees, clients and any other related parties ARE additional
insureds and coverage WILL BE extended.”
See Rules and Regulations, Rule 120-2-103.07 “Prohibited Practices” as set forth in 33-24-
19.1(f), (g), (k)
3. May a certificate holder require that a certificate of insurance include a broad statement
that there are no limitations or exclusions for a specific exposure?
No. A certificate cannot say anything that is not the same as what is stated in the insurance policy.
A statement such as “there are no limitations or exclusions for residential construction exposure”
would have to be stated exactly like that in the policy to be added to certificate.
No certificate filed with OCI can say more than what’s in the related policy, pursuant to O.C.G.A
§ 33-24-19.1(j). However, a certificate holder may ask the agent whether the policy contains
specific language or a specific exclusion or may request a copy of the policy.
4. In addition to providing a Certificate of Insurance, what other documents and/or forms is an
agent allowed to provide to a certificate holder?
In addition to a certificate of insurance or any other form that is approved by the Commissioner of
Insurance, an agent may provide copies of the actual policy coverage forms or endorsements in
order for a certificate holder to verify coverage. However, it is a violation for any party to request
or provide any form, document, or other method that is not filed and approved by the
Commissioner of Insurance.
Examples violations include:
• An Affidavit, whether physical or electronic, attesting to coverage.
• A Supplemental Questionnaire, whether physical or electronic, attesting to coverage.
• Utilizing a third-party website or electronic form to answer questions on coverage.
• Providing a summary or interpretation of coverage whether written or oral.
See Rules and Regulations, Rule 120-2-103.07 “Prohibited Practices” (3) as set forth in 33-24-
19.1(p), (3)
5. May the Acord 101 form be used to include additional information that is not permitted on
the Acord 25 form, such as reference to insurance requirements of another contract,
additional parties to be included as Additional Insured, specific exclusions, etc.?
No. The Acord 101 is considered a Schedule to the Acord 25 and cannot say anything that is not
the same as what is stated in the insurance policy.
6. Does Georgia law apply to all certificate holders including certificate monitoring companies,
certificate compliance companies, or any other person or entity engaging on behalf of a
certificate holder?
Yes, the certificate law and all applicable penalties apply to all parties involved with Georgia
insurance consumers including certificate monitoring companies and certificate compliance
companies. O.C.G.A § 33-24-19.1(a)(2) defines “Certificate Holder” as any person other than the
policy holder that requests, obtains, or possesses a certificate of insurance.
7. When is the Georgia Certificate of Insurance statute applicable?
The Georgia certificate of insurance law is applicable when a certificate or evidence of insurance is
in reference to coverages on property, operations, or risks located in the state of Georgia. See
O.C.G.A. § 33-24-19.1(i)
Complaints
Any complaints regarding violations of Georgia’s Certificate of Insurance law can be made through
the Consumer Portal on the Insurance Commissioner’s website.
JOHN F. KING
INSURANCE AND SAFETY FIRE COMMISSIONER
STATE OF GEORGIA
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 990634
(Ed. 8-00)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET
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).
The additional premium for this endorsement shall be 2 % of the total California Workers' Compensation premium
otherwise due.
Schedule
Person or Organization Job Description
ANY PERSON OR CALIFORNIA
ORGANIZATION FOR OPERATIONS ONLY.
WHOM THE NAMED
INSURED IS REQUIRED
UNDER WRITTEN
CONTRACT TO FURNISH
THIS WAIVER
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The infonnation below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 11/01/2024 Policy No. WGA 506168004 Endorsement No.
Insured UNITED CONSULTING GROUP LTD Premium $ INCL .
--------------
Insurance Company INSURANCE COMPANY OF THE WEST
WC 990634
(Ed. 8-00)
INSURED
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 990634
(Ed. 8-00)
Countersigned By
--------------
WC 990634
(Ed. 8-00)
INSURED
Policy Number: 5482468 COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL AUTOMOBILE
EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL AUTOMOBILE COVERAGE PART
Only that insurance provided below that broadens coverage under the Commercial Auto Coverage Part applies.
A. Fellow Employee Exclusion Exception 3. As respects the Physical Damage Coverage
The following modification applies on an excess provided for hired "autos" under this
basis over any other insurance. Coverage Extension, our obligation to pay for,
Exclusion 5. (Fellow Employee) of SECTION II - repair, return or replace damaged or stolen
LIABILITY COVERAGE is replaced by the property will be reduced by the largest
following: deductible for such coverage applicable to
5. "Bodily injury" to any fellow employee of the any owned covered "auto." In the event of
"insured" arising out of and in the course of "loss" caused by fire or lightning, no
the fellow employee's employment. deductible shall apply.
But this exclusion does not apply to "bodily D. Leased Auto Additional Legal Obligation
injury" to any fellow employee which results Coverage
from the use of a covered "auto" you own or The following coverage is added to SECTION Ill -
hire. PHYSICAL DAMAGE COVERAGE:
B. Increased Supplementary Payments For any covered "auto" for which this Coverage
The amount we will pay for the cost of bail bonds Form includes a lessor as an additional "insured"
and for reasonable expenses incurred by the under the Additional Insured Lessor
"insured" under the Supplementary Payments endorsement, we will pay your additional "legal
Coverage Extension of SECTION II - LIABILITY obligation" to such lessor in the event of a total
COVERAGE is increased to $2,500 and $300 "loss."
respectively. As used in this coverage, "legal obligation" shall
C. Automatic Hired Auto Physical Damage mean and be the difference between the amount
Coverage owed on your lease and the actual cash value of
the "auto." The amount owed on your lease shall
1. Subject to 2. and 3. below, the broadest of not include any taxes; overdue payments or
the Physical Damage Coverages provided interest resulting from overdue payments;
under this Coverage Part for "autos" you own penalties; lease termination fees; and charges
are also provided for hired "autos" which are resulting from mileage, overdue payments or
covered for Liability Coverage under this excess wear and tear. The actual cash value of
Coverage Part. the "auto" and the amount owed on your lease
2. The most we will pay for "loss" in any one shall be based on the time of the "loss."
"accident" is the lesser of: E. Theft Extension
a. The actual cash value of the damaged or The coverage provided under SECTION Ill -
stolen property as of the time of the PHYSICAL DAMAGE COVERAGE for
"loss"; transportation expenses incurred by you because
b. The cost of repairing or replacing the of a total theft of a covered "auto" of the private
damaged or stolen property with other passenger type is increased to $50 per day and to
property of like kind and quality; or a maximum of $1,000.
c. $35,000.
8-E-2419 Ed. 04-2017 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 3
with its permission.
Copyright, Utica Mutual Insurance Company, 2017.
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 FOR WHOM THE NAMED INSURED IS
REQUIRED UNDER WRITTEN CONTRACT TO FURNISH THIS WAIVER, FOR
NORTH CAROLINA OPERATIONS ONLY.
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 11-01-24 Policy No. WGA 5061680 04 Endorsement No.
Insured UNITED CONSULTING GROUP LTD Premium $ INCL.
Insurance Company INSURANCE COMPANY OF THE WEST
WC 00 03 13
(Ed. 4-84)
1983 National Council on Compensation Insurance.
INSURED
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
Countersigned By
WC 00 03 13
(Ed. 4-84)
1983 National Council on Compensation Insurance.
INSURED
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 42 03 04 B
(Ed. 6-14)
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
( ) Blanket Waiver
Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.
2. Operations:
TEXAS OPERATIONS ONLY
3. Premium:
The premium charge for this endorsement shall be 2 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:
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 11-01-24 Policy No. WGA 5061680 04 Endorsement No.
Insured UNITED CONSULTING GROUP LTD Premium $ INCL.
Insurance Company INSURANCE COMPANY OF THE WEST
Countersigned By
WC 42 03 04 B
(Ed. 6-14)
© Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved.
INSURED
AGENCY CUSTOMER ID: 00003748
LOC #:
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY NAMED INSURED
Partners Risk Services, LLC United Consulting Group, LTD
POLICY NUMBER
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: Notes
This certificate has been issued in accordance with Georgia State statute, 33-24-19.1 and Bulletin 24-EX-4 (3/14/2024) from the Georgia Insurance
Commissioner's office. Agents & Brokers are no longer legally able to add wording in the description of operations section of a certificate of insurance other
than a reference number from the contract for identification purposes only. This reference may include but not be limited to project number, project name,
project description or a general description of work to be performed.
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 00003748
LOC #:
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY NAMED INSURED
Partners Risk Services, LLC United Consulting Group, LTD
POLICY NUMBER
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: Notes
This certificate has been issued in accordance with Georgia State statute, 33-24-19.1 and Bulletin 24-EX-4 (3/14/2024) from the Georgia Insurance
Commissioner's office. Agents & Brokers are no longer legally able to add wording in the description of operations section of a certificate of insurance other
than a reference number from the contract for identification purposes only. This reference may include but not be limited to project number, project name,
project description or a general description of work to be performed.
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
GENERAL LIABILITY EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
1. INCIDENTAL MALPRACTICE This exclusion applies even if the claims against
a. The definition of “bodily injury” in SECTION any insured allege negligence or other
V - DEFINITIONS is amended to include wrongdoing in the supervision, hiring,
injury arising out of rendering or failing to employment, training or monitoring of others by
render medical or paramedical services to that insured, if the “occurrence” which caused
persons by any physician, dentist, nurse, the “bodily injury” or “property damage” involved
emergency medical technician or paramedic the ownership, maintenance, use or
who is employed by you to provide such entrustment to others of any aircraft, “auto” or
services. watercraft that is owned or operated by or
b. Paragraph 2.a.(1)(d) of SECTION II - WHO rented or loaned to any insured.
IS AN INSURED does not apply to nurses, This exclusion does not apply to:
emergency medical technicians or
(1) An aircraft that is:
paramedics described in paragraph a.
above. (a) Hired, chartered or loaned to an insured
c. Part (1) of the Employers Liability with a paid crew; and
exclusion under Paragraph 2. Exclusions, (b) Not owned by an insured;
of SECTION - I COVERAGE A does not (2) A watercraft while ashore on premises you
apply to injury to the emotions or reputation own or rent;
of a person arising out of such services. (3) A watercraft you do not own that is:
This Incidental Malpractice Coverage does not (a) Less than 51 feet long; and
apply if you are engaged in the business or
profession of providing services described in (b) Not being used to carry persons or
paragraph a. above. property for a charge;
2. EXTENDED PROPERTY DAMAGE Exceptions (1) and (3) to this exclusion g. do
Under Paragraph 2. Exclusions of SECTION - I not apply, and exclusion g. is fully applicable, to
COVERAGE A, the Expected Or Intended any aircraft or watercraft to which any other
Injury exclusion is replaced by the following: insurance covering “bodily injury” or “property
Expected Or Intended Injury damage” is available to the insured. This is so
“Bodily injury” or “property damage” expected or whether the other insurance applies on a
intended from the standpoint of the insured. primary, excess, contingent or any other basis.
This exclusion does not apply to “bodily injury” (4) Parking an “auto” on, or on the ways next
or “property damage” resulting from the use of to, premises you own or rent, provided the
reasonable force to protect persons or property. “auto” is not owned by or rented or loaned
3. NONOWNED AIRCRAFT AND WATERCRAFT to you or the insured;
Under Paragraph 2. Exclusions of SECTION - I (5) Liability assumed under any “insured
COVERAGE A, the Aircraft, Auto or contract” for the ownership, maintenance or
Watercraft is replaced by the following: use of aircraft or watercraft; or
Aircraft, Auto or Watercraft (6) “Bodily injury” or “property damage” arising
“Bodily injury” or “property damage” arising out out of:
of the ownership, maintenance, use or
entrustment to others of any aircraft, “auto” or
watercraft owned or operated by or rented or
loaned to any insured. Use includes operation
and “loading or unloading.”
8-E-3548 Ed. 7-2011 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 9
with its permission.
Copyright, Utica Mutual Insurance Company, 2007.
(a) The operation of machinery or 5. CONTRACTUAL PERSONAL AND ADVERTISING
equipment that is attached to, or part of, INJURY
a land vehicle that would qualify under Under Paragraph 2. Exclusions of SECTION - I
the definition of “mobile equipment” if it COVERAGE B, the Contractual Liability
were not subject to a compulsory or exclusion is deleted. However, the coverage
financial responsibility law or other provided by this section will not apply if
motor vehicle insurance law in the state COVERAGE B PERSONAL AND
where it is licensed or principally ADVERTISING INJURY LIABILITY is excluded
garaged; or by any of the exclusions or other provisions of
(b) The operation of any of the machinery the Coverage Form or by any endorsement.
or equipment listed in Paragraph f.(2) or
6. FIRE, LIGHTNING OR EXPLOSION DAMAGE
f.(3) of the definition of “mobile
equipment”. a. The last paragraph of SECTION I -
4. PROPERTY DAMAGE LIABILITY - COVERAGE A (after the exclusions) is
ELEVATORS, BORROWED EQUIPMENT and replaced by the following:
LIMITED COVERAGE FOR DAMAGE TO Exclusions c. through n. do not apply to
PERSONAL PROPERTY IN YOUR CARE, damage by fire, lightning or explosion to
CUSTODY OR CONTROL premises rented to you or temporarily
a. Under Paragraph 2. Exclusions of occupied by you with permission of the
SECTION - I COVERAGE A, part (4) of the owner. A separate limit of insurance
Damage To Property exclusion applies as applies to this coverage as described in
follows: SECTION III - LIMITS OF INSURANCE.
(1) This exclusion always applies to b. Paragraph 6. of Section III - Limits Of
“property damage” to property of others Insurance is replaced by the following:
which occurs at premises you own, rent 6. Subject to 5. above, the greater of:
or control. (1) $500,000; or
(2) With respect to “property damage” to
personal property of others which (2) The Damage To Premises Rented
occurs away from premises you own, To You Limit shown in the
rent or control, this exclusion will apply Declarations;
only when the “property damage” is: is the most we will pay under Coverage
(a) To property which you have A for damages because of “property
contracted to install; damage” to any one premises, while
(b) The direct result of the property rented to you, or in the case of damage
being raised, lowered or otherwise by fire, lightning or explosion, while
moved by a crane; rented to you, or temporarily occupied
(c) To “mobile equipment” or an “auto”; by you with permission of the owner.
(d) To that particular part of property The Damage To Premises Rented To
which you are attempting to service You Limit applies to all loss or damage
or repair; or caused by or resulting from fire,
(e) Covered by other insurance which lightning, or explosion; or any
will pay for the “property damage.” combination of these causes
(3) This exclusion does not apply to c. Under SECTION IV - COMMERCIAL
“property damage” to borrowed GENERAL LIABILITY CONDITIONS,
equipment while not being used to OTHER INSURANCE, the Excess
perform operations at the job site. Insurance provision pertaining to fire
b. Parts (3), (4) and (6) of the Damage To insurance for premises rented to you or
Property exclusion do not apply to the use temporarily occupied by you with
of elevators. permission of the owner is replaced by the
c. The insurance afforded by this section is following:
excess over any valid and collectible That is Fire and Extended Coverage
property insurance (including any deductible insurance for premises rented to you or
portion thereof) available to the insured temporarily occupied by you with
whether primary, excess, contingent or on permission of the owner;
any other basis, and the OTHER
INSURANCE condition is deemed changed
accordingly.
Page 2 of 9 8-E-3548 Ed. 07-2011
7. SUPPLEMENTARY PAYMENTS (iii) For which there is any
obligation to share damages
Under SUPPLEMENTARY PAYMENTS -
with or repay someone else
COVERAGES A AND B:
who must pay damages
a. The most we will pay for the cost of bail because of the injury
bonds required because of accidents or described in Paragraphs
traffic law violations arising out of the use of (1)(a)(i) or (ii) above; or
any vehicle to which the Bodily Injury (iv) Arising out of his or her
Liability Coverage applies is increased by providing or failing to
$2,250. provide professional health
b. The most we will pay for actual loss of care services. However, if
earnings because of time off from work is you have “employees” who
increased by $250. are pharmacists in your
8. BROADENED COVERAGE - EMPLOYEES/ retail druggist or drugstore
VOLUNTEERS operation, they are insured
The following replaces paragraph 2.a. under with respect to their
SECTION II - WHO IS AN INSURED: providing or failing to
provide professional health
2. Each of the following is also an insured: care services.
a. Your “volunteer workers” only while (b) “Property damage” to property:
performing duties related to the conduct (i) Owned, occupied or used
of your business, or your “employees”, by,
other than either your “executive (ii) Rented to, in the care,
officers” (if you are an organization custody or control of, or
other than a partnership, joint venture over which physical control
or limited liability company) or your is being exercised for any
managers (if you are a limited liability purpose by
company), but only for acts within the you, any of your “employees”,
scope of their employment by you or “volunteer workers”, any partner
while performing duties related to the or member (if you are a
conduct of your business. However, partnership or joint venture), or
none of these: any member (if you are a
(1) “Employees” is an insured for: limited liability company).
(2) “Volunteer workers” is an insured
(a) “Personal and advertising for:
injury”: (a) “Bodily injury” or “personal and
(i) To you, to your partners or advertising injury”:
members (if you are a (i) To you, to your partners or
partnership or joint members (if you are a
venture), to your members partnership or joint
(if you are a limited liability venture), to your members
company), to a co- (if you are a limited liability
”employee” while in the company), to a co-
course of his or her ”employee” while in the
employment or performing course of his or her
duties related to the employment or performing
conduct of your business, duties related to the
or to your other “volunteer conduct of your business,
workers” while performing or to your other “volunteer
duties related to the workers” while performing
conduct of your business; duties related to the
(ii) To the spouse, child, conduct of your business;
parent, brother or sister of (ii) To the spouse, child,
that co-”employee” or parent, brother or sister of
“volunteer worker” as a that co-”employee” or
consequence of Paragraph “volunteer worker” as a
(1)(a)(i) above; consequence of Paragraph
(2)(a)(i) above;
8-E-3548 Ed. 07-2011 Page 3 of 9
(iii) For which there is any 10. SUBSIDIARIES
obligation to share The following is added under SECTION II -
damages with or repay WHO IS AN INSURED:
someone else who must a. Any organization, not shown in the
pay damages because of Declarations as a Named Insured, which is
the injury described in a legally incorporated entity, if you own
Paragraphs (2)(a)(i) or (ii) more than 50% of the outstanding securities
above; or representing the present right to vote for the
(iv) Arising out of his or her election of its directors; or
providing or failing to b. Any organization, not shown in the
provide professional health Declarations as a Named Insured, which is
care services. a legally incorporated entity, if more than
(b) “Property damage” to property: 50% of the outstanding securities
(i) Owned, occupied or used representing the present right to vote for the
by, election of its directors is owned by an
organization described in paragraph 10.a.
(ii) Rented to, in the care,
above; is also an insured.
custody or control of, or
over which physical control The insurance afforded under paragraphs
is being exercised for any 10.a. and 10.b. applies only if no other
purpose by insurance of any kind is available to such
entity for this kind of liability.
you, any of your “employees”,
“volunteer workers”, any partner 11. ADDITIONAL INSUREDS - BY CONTRACT,
or member (if you are a AGREEMENT OR PERMIT - INCLUDING
partnership or joint venture), or LESSOR OF LEASED EQUIPMENT, OWNER
any member (if you are a OF LEASED LAND, MANAGERS OR
limited liability company). LESSORS OF PREMISES, ENGINEERS,
9. NEWLY FORMED OR ACQUIRED ARCHITECTS AND SURVEYORS AND
ORGANIZATIONS VENDORS
Paragraph 3. under SECTION II - WHO IS AN The following is added to SECTION II - WHO IS
INSURED, is replaced by the following: AN INSURED:
3. Any organization you newly acquire or form; a. Additional Insureds - By Contract,
other than a partnership, joint venture or Agreement or Permit
limited liability company; and over which (1) Any person or organization with whom
you maintain ownership or majority interest, you have entered into a written
will qualify as a Named Insured if there is no contract, agreement or permit requiring
other similar insurance available to that you to provide insurance such as is
organization. However: afforded by this Commercial General
a. Coverage under this provision is Liability Coverage Form will be an
afforded only until the 180th day after additional insured, but only:
you acquire or form the organization or (a) To the extent that such additional
the end of the policy period, whichever insured is held liable for acts or
is earlier; and omissions committed by you or your
b. Coverage under this provision does not subcontractors during the performance
apply to: of your ongoing operations for the
additional insured.
(1) “Bodily injury” or “property damage”
that occurred; or (b) With respect to property owned or
used by, or rented or leased to,
(2) “Personal and advertising injury”
you.
arising out of an offense committed;
The insurance afforded any additional
before you acquired or formed the
insured under this paragraph 11.a.(1)
organization.
will be subject to all applicable
exclusions or limitations described in
paragraphs 11.b.(1), (2), (3) and (4)
and in 11.c.(1), (2), (3), (4), (5) and (6)
below.
Page 4 of 9 8-E-3548 Ed. 07-2011
(2) Such insurance as is provided by (4) Engineers, Architects or Surveyors
paragraph 11.a.(1) for any additional If an engineer, architect or surveyor is
insured will be primary, if so required by an additional insured as a result of the
the written contract, agreement or provisions of paragraphs 11.a.(1), (2)
permit. Any other insurance available to and (3) above, the following additional
such person or organization shall be exclusions apply:
excess over this insurance.
This insurance does not apply to “bodily
(3) A person's or organization's status as injury,” “property damage,” “personal
an additional insured in connection with and advertising injury” arising out of the
a written contract, agreement or permit rendering or failing to render any
under paragraphs 11.a.(1), (2) and (3) professional services by or for you,
ends when your operations for that including:
additional insured are completed or the
(a) The preparing, approving, or failing
written contract, agreement or permit is
to approve, maps, shop drawings,
terminated or expires.
opinions, reports, surveys, field
b. Additional Exclusions or Limitations
orders, change orders or drawings
(1) Lessor of Leased Equipment and specifications; or
If an equipment lessor is an additional
(b) Giving directions or instructions, or
insured as a result of the provisions of
failing to give them, if that is the
paragraphs 11.a.(1), (2) and (3) above,
primary cause of injury.
the following additional exclusion
applies: (5) Vendors of “Your Products”
This insurance does not apply to “bodily If a vendor of “your products” is an
injury” or “property damage” arising out additional insured under this Coverage
of the sole negligence of such Part, such insurance as is provided to
additional insured. the additional insured applies only with
(2) Owner of Leased Land respect to “bodily injury” or “property
damage” arising out of “your products”
If an owner or other interest from whom
which are distributed or sold in the
land has been leased is an additional
regular course of the vendor's business
insured as a result of the provisions of
and subject to the following additional
paragraphs 11.a.(1), (2) and (3) above,
exclusions:
the following additional exclusions
apply: (a) This insurance afforded the vendor
This insurance does not apply to: does not apply to:
(a) Any “occurrence” that takes place (i) “Bodily injury” or “property
after you cease to lease that land; damage” for which the vendor
or is obligated to pay damages by
(b) Structural alterations, new reason of the assumption of
construction or demolition liability in a contract or
operations performed by or for the agreement. This exclusion does
owner or other interest from whom not apply to liability that the
the land was leased. vendor would have in the
absence of the contract or
(3) Managers or Lessors of Premises
agreement;
If a manager or lessor of premises you
rent or lease is an additional insured as (ii) Any express warranty
a result of the provisions of paragraphs unauthorized by you;
11.a.(1), (2) and (3) above, the (iii) Any physical or chemical
following additional exclusions apply: change in the product made
This insurance does not apply to: intentionally by the vendor;
(a) Any “occurrence” that takes place (iv) Repackaging, unless unpacked
after you cease to be a tenant in solely for the purpose of
those premises; or inspection, demonstration,
(b) Structural alterations, new testing or the substitution of
construction or demolition operations parts under instructions from
performed by or for the manager or the manufacturer, and then
lessor of those premises. repackaged in the original
container;
8-E-3548 Ed. 07-2011 Page 5 of 9
(v) Any failure to make such (3) Construction or demolition activities
inspections, adjustments, tests within 50 feet of any railroad property
or servicing as the vendor has and affecting any railroad bridge or
agreed to make or normally trestle, track, road-bed, tunnel,
undertakes to make in the usual underpass or crossing.
course of business, in (4) Any liability arising from injury or
connection with the distribution damage in connection with a permit
or sale of the products; issued by a state or political subdivision
(vi) Demonstration, installation, if the liability is from operations
servicing or repair operations, performed for the state or political
except such operations subdivision.
performed at the vendor's (5) Any liability from “bodily injury” or
premises in connection with the “property damage” arising out of “your
sale of the product; or work” which is included in the “products-
(vii) Products which, after completed operations hazard.”
distribution or sale by you, have This additional exclusion 11.c.(5) does
been labeled or relabeled or not apply with respect to such Vendors
used as a container, part or coverage as is provided under 11.b.(5)
ingredient of any other thing or above.
substance by or for the vendor. (6) Any person or organization included as
(b) This insurance afforded the vendor an insured under any other provision of
does not apply to any person or Section II - Who Is An Insured or
organization from whom you have included as an additional insured by
acquired such products, or any any endorsement to this policy.
ingredient, part or container 12. INSUREDS - NONOWNED WATERCRAFT
entering into, accompanying or
The following is added to SECTION II - WHO IS
containing such products.
AN INSURED:
No insurance will be provided under this
With respect to any watercraft you do not own
Vendors coverage if “bodily injury” or
that is:
“property damage” under the “products-
completed operations hazard” is a. Less than 51 feet long; and
excluded by any of the exclusions or b. Not being used to carry persons or property
other provisions of this Coverage Form for a charge;
or by any endorsement. any person who uses or is responsible for the
c. Such insurance as is afforded for any use of such watercraft, with your express or
additional insured under paragraph 11.a. or implied consent, is an insured.
b. above is subject to all applicable Any other person or organization responsible for
exclusions of 2. Exclusions, COVERAGE A the conduct of such person is also an insured,
(Section I), other than exclusion b. but only with respect to liability arising out of the
Contractual Liability, to all exclusions or operation or use of the watercraft, and only if no
limitations stated with the coverage other insurance of any kind is available to that
language, and to the following additional person or organization for this liability. However,
exclusions: no person or organization is an insured with
This insurance does not apply to: respect to:
(1) The independent acts or omissions of (1) “Bodily injury” to a co-”employee” of the
such additional insured. person operating or using the watercraft; or
(2) Any liability arising from injury or (2) “Property damage” to property owned by,
damage in connection with a contract or rented to, in the charge of or occupied by
agreement executed or permit issued you or the employer of any person who is
subsequent to: an insured under this provision.
(a) The occurrence of any “bodily
injury” or “property damage”; or
(b) The commission of any offense
which caused “personal and
advertising injury.”
Page 6 of 9 8-E-3548 Ed. 07-2011
13. MEDICAL PAYMENTS (3) A member or manager, if you are a
Paragraph 7. of SECTION III - LIMITS OF limited liability company; or
INSURANCE is replaced by the following: (4) An “executive officer” or insurance
7. Subject to 5. above, the most we will pay manager, if you are an organization
under Coverage C for all medical expenses other than a partnership, joint venture
because of “bodily injury” sustained by any or limited liability company.
one person is the Medical Expense Limit b. If a claim is made or “suit” is brought
which is the greater of: against any insured, you must:
a. $15,000; or (1) Immediately record the specifics of the
b. The Medical Expense Limit shown in claim or “suit” and the date received;
the Declarations. and
14. PRIORITY CONDITION (2) Notify us as soon as practicable.
The following paragraph is added to SECTION You must see to it that we receive written
III - LIMITS OF INSURANCE: notice of the claim or “suit” as soon as
8. In the event a claim or “suit” is brought practicable.
against more than one insured, due to This paragraph b. will be considered to
“bodily injury” or “property damage” from the have been violated only if the violation
same “occurrence”, or “personal and occurs after the claim or “suit” is known to:
advertising injury” from the same offense, (1) You;
the Limits of Insurance will apply in the (2) A partner or member, if you are a
following order: partnership or joint venture;
a. You; (3) A member or manager, if you are a
b. Your “executive officers”, directors, limited liability company; or
stockholders or “employees”, and (4) An “executive officer” or insurance
c. Any other insureds in any order that we manager, if you are an organization
choose. other than a partnership, joint venture
15. DUTIES IN THE EVENT OF OCCURRENCE, or limited liability company.
OFFENSE, CLAIM OR SUIT c. You and any other involved insured must:
Under SECTION IV - COMMERCIAL (1) Immediately send us copies of any
LIABILITY CONDITIONS, DUTIES IN THE demands, notices, summonses or legal
EVENT OF OCCURRENCE, OFFENSE, papers received in connection with the
CLAIM OR SUIT is replaced by the following: claim or “suit”;
Duties In The Event Of Occurrence, Offense, (2) Authorize us to obtain records and
Claim Or Suit other information;
a. You must see to it that we are notified as (3) Cooperate with us in the investigation,
soon as practicable of an “occurrence” or an or settlement of the claim or defense
offense which may result in a claim. To the against the “suit”; and
extent possible, notice should include: (4) Assist us, upon our request, in the
(1) How, when and where the “occurrence” enforcement of any right against any
or offense took place; person or organization that may be
(2) The names and addresses of any liable to the insured because of injury or
injured persons and witnesses; and damage to which this insurance may
(3) The nature and location of any injury or also apply.
damage arising out of the “occurrence” d. No insured will, except at that insured's own
or offense. cost, voluntarily make a payment, assume
This paragraph a. applies only if one of the any obligation, or incur any expense, other
following knows of the “occurrence” or than for first aid, without our consent.
offense:
(1) You;
(2) A partner or member, if you are a
partnership or joint venture;
8-E-3548 Ed. 07-2011 Page 7 of 9
16. WAIVER OF TRANSFER OF RIGHTS OF b. International waters or airspace, provided
RECOVERY AGAINST OTHERS TO US the injury or damage does not occur in the
Under SECTION IV - COMMERCIAL course of travel or transportation to or from
GENERAL LIABILITY CONDITIONS, the any place not included in a. above; or
following replaces Transfer Of Rights Of c. All other parts of the world if:
Recovery Against Others To Us: 1) The injury or damage arises out of:
If the insured has rights to recover all or part of a) Goods or products made or sold by
any payment we have made under this policy, you in the territory described in a.
those rights are transferred to us. The insured above;
must do nothing after loss to impair them. At our b) The activities of a person whose
request, the insured will bring “suit” or transfer home is in the territory described in
those rights to us and help us enforce them. a. above, but is away for a short
We waive any right of recovery we may have time on your business; or
under such a transfer of rights against any
c) “Personal and advertising injury”
person or organization holding a waiver under a offenses that take place through the
written contract with the insured if such contract Internet or similar electronic means
was executed prior to the loss which generated of communication; and
such right of recovery. 2) The insured's responsibility to pay
17. NOTICE TO COMPANY damages is determined in a “suit” on
The following is added to SECTION IV - the merits, in:
COMMERCIAL GENERAL LIABILITY a) The territory described in a. above;
CONDITIONS: b) The Commonwealth of the
Notice To Company Bahamas, Bermuda, Cayman
If the insured reports an “occurrence” or offense Islands, and British Virgin Islands;
to its Workers Compensation insurer and such or in a settlement we agree to.
“occurrence” or offense later becomes a claim 20. BODILY INJURY DEFINITION
under this Coverage Part, failure to report such Under the Definitions Section, “bodily injury” is
“occurrence” or offense to us at the time of the replaced by the following:
“occurrence” or offense will not be considered a “Bodily injury” means:
violation of the Duties in the Event of a. Bodily injury, sickness or disease sustained
Occurrence, Offense, Claim or Suit Condition, by a person, including death resulting from
only if: any of these at any time; or
b. Shock, mental anguish or mental injury,
a. Such failure or omission is not intentional;
including death resulting therefrom, to a
and
person who sustained bodily injury,
b. You notify us as soon as practicable when sickness or disease, provided the shock,
you become aware that the “occurrence” or mental anguish or mental injury is a
offense has become a liability claim. consequence of the bodily injury, sickness
18. UNINTENTIONAL FAILURE TO DISCLOSE or disease.
HAZARDS 21. PERSONAL AND ADVERTISING INJURY
The following is added to SECTION IV - LIABILITY EXTENSION
COMMERCIAL GENERAL LIABILITY Under the Definitions Section, “personal and
CONDITIONS: advertising injury” is replaced by the following:
Unintentional Failure To Disclose Hazards “Personal and advertising injury” means injury
Failure of the insured to disclose all hazards including mental anguish, shock or humiliation
existing as of the inception date of the policy other than “bodily injury” arising out of one or
shall not prejudice the rights of the insured as more of the following offenses:
respects the insurance afforded by this policy if 1. False arrest, detention or imprisonment;
such failure or omission is not intentional. 2. Malicious prosecution or abuse of process;
3. Wrongful entry into, or eviction of a person
19. COVERAGE TERRITORY
from, a room, dwelling or premises that the
Under the Definitions Section, “coverage person occupies;
territory” is replaced by the following: 4. Oral or written publication, in any manner,
“Coverage territory” means: of material that slanders or libels a person
a. The United State of America (including its or organization or disparages a person's or
territories and possessions), Puerto Rico organization's goods, products or services;
and Canada;
Page 8 of 9 8-E-3548 Ed. 07-2011
5. Oral or written publication, in any manner, m. Loss Of Use Of Tangible Property
of material that violates a person's right of Loss of use of tangible property which
privacy; has not been physically injured or
6. The use of another's advertising idea in destroyed, resulting from:
your “advertisement”;
(1) A delay in or lack of performance by
7. Infringing upon another's copyright, trade
you or anyone on your behalf of any
dress or slogan in your “advertisement”; or
contract or agreement; or
8. Discrimination.
As used in this form, discrimination means (2) The failure of “your product” or
the act of differentiation based on age, race, “your work” to meet the level of
color, sex, religion, national origin, physical performance, quality, fitness or
handicap or sexual preference which durability warranted or represented
violates any applicable federal, state or by or on your behalf.
local statute which pertains to This exclusion does not apply to loss of
discrimination. use of other tangible property resulting
But discrimination does not include acts of from the sudden or accidental physical
differentiation that cause injury to: injury to or destruction of:
a. A person arising out of any: (1) “Your product”; or
(1) Refusal to employ that person; (2) “Your work”;
(2) Termination of that person's after such product or work has been put
employment; or to its intended use.
(3) Employment-related practices, n. Recall Of Products, Work Or Other
policies, acts or omissions, such as Property
coercion, demotion, evaluation, Damage claimed for any loss, cost or
reassignment, discipline, expense incurred by you or others for
defamation, harassment, humiliation the loss of use, withdrawal, recall,
or discrimination directed at that inspection, repair, replacement,
person; or adjustment, removal or disposal of:
b. The spouse, child, parent, brother or (1) “Your product”;
sister of that person as a consequence (2) “Your work”; or
of “bodily injury” to that person at whom (3) Any property of which “your
any of the employment-related product” or “your work” forms a
practices described in paragraphs (1), part;
(2) or (3) above as directed.
if such product, work, or property is
Paragraphs a. and b. above apply: withdrawn or recalled from the market
(1) Whether the “insured” may be liable or from use by any person or
as an employer or in any other organization because of a known or
capacity; and suspected defect, deficiency,
(2) To any obligation to share damages inadequacy or dangerous condition in it.
with or repay someone else who 23. LIBERALIZATION
must pay damages because of the If we adopt any revision that would broaden the
injury. coverage under this Coverage Part without
22. IMPAIRED PROPERTY additional premium within 45 days prior to or
a. Under the Definitions Section, the during the policy period, the broadened
definition of “impaired property” does not coverage will immediately apply to this
apply. Coverage Part.
b. Exclusions m. and n. under SECTION I -
COVERAGE A are replaced by the
following:
8-E-3548 Ed. 07-2011 Page 9 of 9