Agenda Item
ii. Contract Renewal ~ RFP 24-752-037 ~ Third Party Commissioning Services ~ Total Systems Commissioning, Inc., TLC Engineering Solutions ~ Contract Renewal (1 of 4) (Not to exceed $2,000,000)
Summary: Presented by: Mr. Erick Hofstetter, Chief Operating Officer, Division of Operations
Request: It is requested that the DeKalb County Board of Education approve the first of four (1 of 4) contract renewals for RFP 24-752-037 Third Party Commissioning Services in the not-to-exceed amount of $2,000,000 to:
Total Systems Commissioning, Inc.
TLC Engineering Solutions (TLC)
Why: This request is to approve the contract renewal for the above firms to provide Third Party Commissioning Services throughout DeKalb County School District (“DCSD”) on an as-needed basis as required and directed, for various remodeling, renovations, life safety, maintenance and repair projects, for both E-SPLOST and Non-E-SPLOST projects.
This request extends the agreement for an additional year effective February 25, 2026, through February 24, 2027.
Details: On December 9, 2024, the Board of Education approved the award of contract RFP 24-752-037 for Third Party Commissioning Services on an as-needed basis for various remodeling, renovations, life safety, maintenance and repair projects, for E-SPLOST and Non-E-SPLOST projects for the Facilities/Maintenance Department and the E-SPLOST program. This recommendation is for the first of four (#1 of 4) one-year (1-year) contract renewal options.
Comprehensive information on Third Party Commissioning Services and their function is attached as an information sheet.
The scope of work for these services includes Third Party Commissioning Services. Additional project information can be found on the DeKalb County School District’s solicitation website at: https://dekalbschoolsga.ionwave.net/.
Total Systems Commissioning, Inc. is located at 2148 Hills Avenue NW, Suite I, Atlanta, GA 30318.
TLC Engineering Solutions is located at 4360 Chamblee Dunwoody Road, Suite 210, Atlanta, Georgia 30341.
Financial impact: It is anticipated that the cost for these services may exceed $100,000 within a fiscal year and will be allocated to various General Fund and E-SPLOST charge codes.
Purchasing Board Policy DJE III (C) (3) 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 purchases over the $100,000 threshold will be presented to the Board for formal approval in accordance with Board policy.
Contact: Mr. Erick Hofstetter, Chief Operating Officer, Division of Operations, 678.676.1447
Mr. Hans Williams, Director of Planning & CIP Programming, Division of Operations, 678.676.1483
Effective: Upon Board Approval
Status: Approved by the Office of Legal Affairs
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 09/25/2025
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 Megan Willard
NAME:
RSC Insurance Brokerage, Inc. PHONE FAX
(A/C, No, Ext): (A/C, No):
1745 N. Brown Road E-MAIL mwillard@risk-strategies.com
ADDRESS:
Suite 250 INSURER(S) AFFORDING COVERAGE NAIC #
Lawrenceville GA 30043 INSURER A : Travelers Property Casualty Company of America 25674
INSURED INSURER B : Phoenix Insurance Co 25623
Total Systems Commissioning, Inc. INSURER C : Travelers Cas Co of CT 36170
2148 Hills Ave NW INSURER D : XL Specialty Insurance Company 37885
Ste I INSURER E :
Atlanta GA 30318 INSURER F :
COVERAGES CERTIFICATE NUMBER: CL2592599671 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 1,000,000
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $
MED EXP (Any one person) $ 5,000
A Y Y 6803R90931A 10/10/2025 10/10/2026 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: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY (Per person) $
B OWNED SCHEDULED Y Y BA3R909517 10/10/2025 10/10/2026 BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000
A EXCESS LIAB CLAIMS-MADE Y Y CUP3R909683 10/10/2025 10/10/2026 AGGREGATE $ 5,000,000
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
C OFFICER/MEMBER EXCLUDED? N N/A Y UB3R909634 10/10/2025 10/10/2026
(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
Each Claim $5,000,000
Professional Liability
D DPR5048637 10/10/2025 10/10/2026 Annual Aggregate $5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
FRP No. 24-752-037 Third Party Commissioning Services
DaKalb County Board of Education and DaKalb County School District are included as additional insured in respects to the General Liability, Auto Liability
and Umbrella Liability. Waiver of Subrogation applies to General Liability, Auto Liability, Umbrella Liability and Workers Compensation. General Liability,
Auto Liability and Umbrella Liability are primary and non-contributory. A 30 Day Notice of Cancellation applies, except for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
DeKalb County Board of Education ACCORDANCE WITH THE POLICY PROVISIONS.
1701 Mountain Industrial Blvd
AUTHORIZED REPRESENTATIVE
Stone Mountain GA 30083
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GENERAL DESCRIPTION OF COVERAGE – This endorsement broadens coverage. However, coverage for any
injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover-
age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. BROAD FORM NAMED INSURED H. HIRED AUTO PHYSICAL DAMAGE – LOSS OF
B. BLANKET ADDITIONAL INSURED USE – INCREASED LIMIT
I. PHYSICAL DAMAGE – TRANSPORTATION
C. EMPLOYEE HIRED AUTO
EXPENSES – INCREASED LIMIT
D. EMPLOYEES AS INSURED J. PERSONAL PROPERTY
E. SUPPLEMENTARY PAYMENTS – INCREASED K. AIRBAGS
LIMITS
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
F. HIRED AUTO – LIMITED WORLDWIDE COV- LOSS
ERAGE – INDEMNITY BASIS M. BLANKET WAIVER OF SUBROGATION
G. WAIVER OF DEDUCTIBLE – GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS
PROVISIONS
A. BROAD FORM NAMED INSURED this insurance applies and only to the extent that
person or organization qualifies as an "insured"
The following is added to Paragraph A.1., Who Is under the Who Is An Insured provision contained
An Insured, of SECTION II – COVERED AUTOS in Section II.
LIABILITY COVERAGE:
C. EMPLOYEE HIRED AUTO
Any organization you newly acquire or form dur-
ing the policy period over which you maintain 1. The following is added to Paragraph A.1.,
50% or more ownership interest and that is not Who Is An Insured, of SECTION II – COV-
separately insured for Business Auto Coverage. ERED AUTOS LIABILITY COVERAGE:
Coverage under this provision is afforded only un- An "employee" of yours is an "insured" while
til the 180th day after you acquire or form the or- operating an "auto" hired or rented under a
ganization or the end of the policy period, which- contract or agreement in an "employee's"
ever is earlier. name, with your permission, while performing
duties related to the conduct of your busi-
B. BLANKET ADDITIONAL INSURED ness.
The following is added to Paragraph c. in A.1., 2. The following replaces Paragraph b. in B.5.,
Who Is An Insured, of SECTION II – COVERED Other Insurance, of SECTION IV – BUSI-
AUTOS LIABILITY COVERAGE: NESS AUTO CONDITIONS:
Any person or organization who is required under b. For Hired Auto Physical Damage Cover-
a written contract or agreement between you and age, the following are deemed to be cov-
that person or organization, that is signed and ered "autos" you own:
executed by you before the "bodily injury" or (1) Any covered "auto" you lease, hire,
"property damage" occurs and that is in effect rent or borrow; and
during the policy period, to be named as an addi-
(2) Any covered "auto" hired or rented by
tional insured is an "insured" for Covered Autos
your "employee" under a contract in
Liability Coverage, but only for damages to which an "employee's" name, with your
CA T3 53 02 15 © 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 4
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
permission, while performing duties (a) With respect to any claim made or "suit"
related to the conduct of your busi- brought outside the United States of
ness. America, the territories and possessions
However, any "auto" that is leased, hired, of the United States of America, Puerto
rented or borrowed with a driver is not a Rico and Canada:
covered "auto". (i) You must arrange to defend the "in-
D. EMPLOYEES AS INSURED sured" against, and investigate or set-
tle any such claim or "suit" and keep
The following is added to Paragraph A.1., Who Is us advised of all proceedings and ac-
An Insured, of SECTION II – COVERED AUTOS tions.
LIABILITY COVERAGE:
(ii) Neither you nor any other involved
Any "employee" of yours is an "insured" while us-
"insured" will make any settlement
ing a covered "auto" you don't own, hire or borrow
without our consent.
in your business or your personal affairs.
(iii) We may, at our discretion, participate
E. SUPPLEMENTARY PAYMENTS – INCREASED
in defending the "insured" against, or
LIMITS
in the settlement of, any claim or
1. The following replaces Paragraph A.2.a.(2), "suit".
of SECTION II – COVERED AUTOS LIABIL-
(iv) We will reimburse the "insured" for
ITY COVERAGE:
sums that the "insured" legally must
(2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily
cluding bonds for related traffic law viola- injury" or "property damage" to which
tions) required because of an "accident" this insurance applies, that the "in-
we cover. We do not have to furnish sured" pays with our consent, but
these bonds. only up to the limit described in Para-
2. The following replaces Paragraph A.2.a.(4), graph C., Limits Of Insurance, of
SECTION II – COVERED AUTOS
of SECTION II – COVERED AUTOS LIABIL-
LIABILITY COVERAGE.
ITY COVERAGE:
(4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for
"insured" at our request, including actual the reasonable expenses incurred
loss of earnings up to $500 a day be- with our consent for your investiga-
cause of time off from work. tion of such claims and your defense
of the "insured" against any such
F. HIRED AUTO – LIMITED WORLDWIDE COV- "suit", but only up to and included
ERAGE – INDEMNITY BASIS within the limit described in Para-
The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of
graph B.7., Policy Period, Coverage Territory, SECTION II – COVERED AUTOS
of SECTION IV – BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in
TIONS: addition to such limit. Our duty to
make such payments ends when we
(5) Anywhere in the world, except any country or have used up the applicable limit of
jurisdiction while any trade sanction, em- insurance in payments for damages,
bargo, or similar regulation imposed by the settlements or defense expenses.
United States of America applies to and pro-
hibits the transaction of business with or (b) This insurance is excess over any valid
within such country or jurisdiction, for Cov- and collectible other insurance available
ered Autos Liability Coverage for any covered to the "insured" whether primary, excess,
"auto" that you lease, hire, rent or borrow contingent or on any other basis.
without a driver for a period of 30 days or less (c) This insurance is not a substitute for re-
and that is not an "auto" you lease, hire, rent quired or compulsory insurance in any
or borrow from any of your "employees", country outside the United States, its ter-
partners (if you are a partnership), members ritories and possessions, Puerto Rico and
(if you are a limited liability company) or Canada.
members of their households.
Page 2 of 4 © 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
You agree to maintain all required or (2) In or on your covered "auto".
compulsory insurance in any such coun- This coverage applies only in the event of a total
try up to the minimum limits required by theft of your covered "auto".
local law. Your failure to comply with
compulsory insurance requirements will No deductibles apply to this Personal Property
not invalidate the coverage afforded by coverage.
this policy, but we will only be liable to the K. AIRBAGS
same extent we would have been liable The following is added to Paragraph B.3., Exclu-
had you complied with the compulsory in- sions, of SECTION III – PHYSICAL DAMAGE
surance requirements. COVERAGE:
(d) It is understood that we are not an admit- Exclusion 3.a. does not apply to "loss" to one or
ted or authorized insurer outside the more airbags in a covered "auto" you own that in-
United States of America, its territories flate due to a cause other than a cause of "loss"
and possessions, Puerto Rico and Can- set forth in Paragraphs A.1.b. and A.1.c., but
ada. We assume no responsibility for the only:
furnishing of certificates of insurance, or a. If that "auto" is a covered "auto" for Compre-
for compliance in any way with the laws hensive Coverage under this policy;
of other countries relating to insurance.
b. The airbags are not covered under any war-
G. WAIVER OF DEDUCTIBLE – GLASS ranty; and
The following is added to Paragraph D., Deducti- c. The airbags were not intentionally inflated.
ble, of SECTION III – PHYSICAL DAMAGE We will pay up to a maximum of $1,000 for any
COVERAGE: one "loss".
No deductible for a covered "auto" will apply to L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
glass damage if the glass is repaired rather than LOSS
replaced.
The following is added to Paragraph A.2.a., of
H. HIRED AUTO PHYSICAL DAMAGE – LOSS OF SECTION IV – BUSINESS AUTO CONDITIONS:
USE – INCREASED LIMIT
Your duty to give us or our authorized representa-
The following replaces the last sentence of Para- tive prompt notice of the "accident" or "loss" ap-
graph A.4.b., Loss Of Use Expenses, of SEC- plies only when the "accident" or "loss" is known
TION III – PHYSICAL DAMAGE COVERAGE: to:
However, the most we will pay for any expenses (a) You (if you are an individual);
for loss of use is $65 per day, to a maximum of (b) A partner (if you are a partnership);
$750 for any one "accident".
(c) A member (if you are a limited liability com-
I. PHYSICAL DAMAGE – TRANSPORTATION pany);
EXPENSES – INCREASED LIMIT (d) An executive officer, director or insurance
The following replaces the first sentence in Para- manager (if you are a corporation or other or-
graph A.4.a., Transportation Expenses, of ganization); or
SECTION III – PHYSICAL DAMAGE COVER- (e) Any "employee" authorized by you to give no-
AGE: tice of the "accident" or "loss".
We will pay up to $50 per day to a maximum of M. BLANKET WAIVER OF SUBROGATION
$1,500 for temporary transportation expense in-
The following replaces Paragraph A.5., Transfer
curred by you because of the total theft of a cov-
Of Rights Of Recovery Against Others To Us,
ered "auto" of the private passenger type.
of SECTION IV – BUSINESS AUTO CONDI-
J. PERSONAL PROPERTY TIONS :
The following is added to Paragraph A.4., Cover- 5. Transfer Of Rights Of Recovery Against
age Extensions, of SECTION III – PHYSICAL Others To Us
DAMAGE COVERAGE: We waive any right of recovery we may have
against any person or organization to the ex-
Personal Property
tent required of you by a written contract
We will pay up to $400 for "loss" to wearing ap- signed and executed prior to any "accident"
parel and other personal property which is: or "loss", provided that the "accident" or "loss"
(1) Owned by an "insured"; and arises out of operations contemplated by
CA T3 53 02 15 © 2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 4
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
such contract. The waiver applies only to the The unintentional omission of, or unintentional
person or organization designated in such error in, any information given by you shall not
contract. prejudice your rights under this insurance. How-
N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col-
The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of
cealment, Misrepresentation, Or Fraud, of cancellation or non-renewal.
SECTION IV – BUSINESS AUTO CONDITIONS:
Page 4 of 4 © 2015 The Travelers Indemnity Compa ny. All rights reserved . CA T3 53 02 15
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
30
30
POLICY NUMBER: 680-3R90931A-25-47 ISSUE DATE: 07/30/2025
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED PERSON OR ORGANIZATION – NOTICE OF
CANCELLATION OR NONRENEWAL PROVIDED BY US
This endorsement modifies insurance provided under the following:
ALL COVERAGE PARTS INCLUDED IN THIS POLICY
SCHEDULE
CANCELLATION: Number of Days Notice: 30
WHEN WE DO NOT RENEW (Nonrenewal): Number of Days Notice: 30
PERSON OR
ORGANIZATION:
ANY PERSON OR ORGANIZATION TO WHOM YOU
HAVE AGREED IN A WRITTEN CONTRACT THAT
NOTICE OF CANCELLATION OR NONRENEWAL OF THIS POLICY
WILL BE GIVEN, BUT ONLY IF:
1. YOU SEND US A WRITTEN REQUEST TO
PROVIDE SUCH NOTICE, INCLUDING THE
NAME AND ADDRESS OF SUCH PERSON OR
ORGANIZATION, AFTER THE FIRST NAMED
INSURED RECEIVES NOTICE FROM US OF
THE CANCELLATION OR NONRENEWAL OF THIS POLICY; AND
2. WE RECEIVE SUCH WRITTEN REQUEST AT
LEAST 14 DAYS BEFORE THE BEGINNING OF
THE APPLICABLE NUMBER OF DAYS SHOWN
IN THIS SCHEDULE.
ADDRESS:
THE ADDRESS FOR THAT PERSON OR ORGANIZ-
ATION INCLUDED IN SUCH WRITTEN REQUEST
FROM YOU TO US.
PROVISIONS B. If we do not renew this policy for any legally
A. If we cancel this policy for any legally permitted permitted reason other than nonpayment of
reason other than nonpayment of premium, and a premium, and a number of days is shown for
number of days is shown for Cancellation in the When We Do Not Renew (Nonrenewal) in the
Schedule above, we will mail notice of Schedule above, we will mail notice of
cancellation to the person or organization shown nonrenewal to the person or organization shown
in such Schedule. We will mail such notice to the in such Schedule. We will mail such notice to the
address shown in the Schedule above at least the address shown in the Schedule above at least the
number of days shown for Cancellation in such number of days shown for When We Do Not
Schedule before the effective date of cancellation. Renew (Nonrenewal) in such Schedule before the
effective date of nonrenewal.
IL T4 00 05 19 © 2019 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
POLICY NUMBER: CUP-3R909683-25-47 ISSUE DATE: 07/30/2025
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED PERSON OR ORGANIZATION – NOTICE OF
CANCELLATION OR NONRENEWAL PROVIDED BY US
This endorsement modifies insurance provided under the following:
ALL COVERAGE PARTS INCLUDED IN THIS POLICY
SCHEDULE
CANCELLATION: Number of Days Notice: 30
WHEN WE DO NOT RENEW (Nonrenewal): Number of Days Notice: 30
PERSON OR
ORGANIZATION:
ANY PERSON OR ORGANIZATION TO WHOM YOU
HAVE AGREED IN A WRITTEN CONTRACT THAT
NOTICE OF CANCELLATION OR NONRENEWAL OF THIS POLICY
WILL BE GIVEN, BUT ONLY IF:
1. YOU SEND US A WRITTEN REQUEST TO
PROVIDE SUCH NOTICE, INCLUDING THE
NAME AND ADDRESS OF SUCH PERSON OR
ORGANIZATION, AFTER THE FIRST NAMED
INSURED RECEIVES NOTICE FROM US OF
THE CANCELLATION OR NONRENEWAL OF THIS POLICY; AND
2. WE RECEIVE SUCH WRITTEN REQUEST AT
LEAST 14 DAYS BEFORE THE BEGINNING OF
THE APPLICABLE NUMBER OF DAYS SHOWN
IN THIS SCHEDULE.
ADDRESS:
THE ADDRESS FOR THAT PERSON OR ORGANIZ-
ATION INCLUDED IN SUCH WRITTEN REQUEST
FROM YOU TO US.
PROVISIONS B. If we do not renew this policy for any legally
A. If we cancel this policy for any legally permitted permitted reason other than nonpayment of
reason other than nonpayment of premium, and a premium, and a number of days is shown for
number of days is shown for Cancellation in the When We Do Not Renew (Nonrenewal) in the
Schedule above, we will mail notice of Schedule above, we will mail notice of
cancellation to the person or organization shown nonrenewal to the person or organization shown
in such Schedule. We will mail such notice to the in such Schedule. We will mail such notice to the
address shown in the Schedule above at least the address shown in the Schedule above at least the
number of days shown for Cancellation in such number of days shown for When We Do Not
Schedule before the effective date of cancellation. Renew (Nonrenewal) in such Schedule before the
effective date of nonrenewal.
IL T4 00 05 19 © 2019 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD CT 06183
ENDORSEMENT WC 99 07 26 (00) - 001
POLICY NUMBER: UB-3R909634-25-47-G
GEORGIA NOTICE OF CANCELLATION OR NONRENEWAL
TO DESIGNATED THIRD PARTIES ENDORSEMENT
The following is added to PART SIX – CONDITIONS:
Notice Of Cancellation Or Nonrenewal To Designated Third Parties
If we cancel or non-renew this policy for any reason other than non-payment of premium by you, we will provide
notice of cancellation or non-renewal to each third party designated in the Schedule below. We will mail or deliver
such notice to each third party at its listed address at least ten days or the number of days shown in the Schedule
for that third party, whichever is greater, before the cancellation or nonrenewal is to take effect.
You are responsible for providing us with the information necessary to accurately complete the Schedule below. If
we cannot mail or deliver a notice of cancellation or nonrenewal to a designated third party because the name or
address of such designated third party provided to us is not accurate or complete, we have no responsibility to
mail, deliver or otherwise notify such designated third party of the cancellation or nonrenewal.
SCHEDULE
Name and Address of Designated Third Parties: Number of Days Notice:
ANY PERSON OR ORGANIZATION TO WHOM YOU HAVE AGREED IN A WRITTEN
CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY 30
WILL BE GIVEN, BUT ONLY IF:
1. YOU SEND US A WRITTEN REQUEST TO PROVIDE SUCH NOTICE, INCLUDIN
G THE NAME AND ADDRESS OF SUCH PERSON OR ORGANIZATION,
AFTER THE FIRST NAMED INSURED RECEIVES NOTICE FROM US OF THE
CANCELLATION OF THIS POLICY; AND
2. WE RECEIVE SUCH WRITTEN REQUEST AT LEAST 14 DAYS BEFORE THE
BEGINNING OF THE APPLICABLE NUMBER OF DAYS SHOWN IN
THIS ENDORSEMENT.
ADDRESS
THE ADDRESS FOR THAT PERSON OR
CONTINUED
All other terms and conditions of this policy remain unchanged.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise
stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective Policy No. Endorsement No.
Insured Premium $
Insurance Company Countersigned by
DATE OF ISSUE: 07-30-25 ST ASSIGN: Page 1 of 2
© 2024 The Travelers Indemnity Company. All rights reserved.