08-0304_J. DE SIGIO CONSTRUCTION, INC._Insurance CertificateACORD CERTIFICATE OF LIABILITY INSURANCE
9�2' 008 '
8101 L111 el (111)860-0!91 FAX: (905)8(11-,1119
THIS CERTIRICATE IS ISSUED AS A MATIUR OF INFORMATION
Western Iasuna na a Mar Q
VE D
ONLY Atli] CONFER! NO RIGH79 UPON THE aBRTINICATE
HOLDER. 11-11S CERTIRICATB DOES NOT AMEND, BXTEIID OR
! II N Diamond H ar BIM 11 C
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
San Juan aapistrano, GA 91675
M j O ense # 0!48(11,1
Diamond Bar 0 0 t
INSURERS AFFORDING COVERAGE NAM #
11SLIRED
INSURER A: Travelers C&S Co of 31194
INSURER B: Travelers indemnity as . 35682
J. Desigio Conal ruction 6ff, r I LERK
9 3 ! S. Mayflower g API JUAN CAIN ISTRANO
INSURERC:Rockhill Insurance
INSURER D:
II ISI IREIR E:
lima ad3 a CA 91000
OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A BOl IE NOR THE POLICY PERIOD It IO ICA TR D. NOTWITHSTANDING All Ill
RHQUIRSMEtIT, TERM OR(IONDITIdP ON Al I)ICOtITRACTOR OIHNR DOaUMEN1 VUIIH R8SN13CI Ta WFIV TI IS aBRIISICA1■ MAY BE IS! LIEU OR MAY 08R7AIt1.
TF E IN! UR,IMCM ARFa R DEI] I Y 7HM Pa L la IM! U BSa R IE BD HER BIt Ic ! UBJMa T TO AL I -1HE TN RMS, EXCL U: ION! ASID a ONDITIONS OM : L ICH POL la IES .
LIMITSREG, STE Y HAVE BEE 4 REDUCED BY
ADDIRATION
INSR
TYPE OF INSURANCE
POLICY NUMBER
DATEEYMWDdm
PDATEY EM DIYYY)
LIMITS
r1hISR
GNNBRAI IIABILITY
EACH OCCURRENCE$ 11000,000
DAMAGE TO RENTED $ 300,001
X COMMERCIAL 0 E I IERJ L I IA BILIN
Cultism OCCUR
D3H-CO-09911(1137-73L-C7
1/179/2011
8/3SI11"s 409
MED EXP An one rsan $ R,000
PERSONAL $ 31000,000
GENERAL AGGREGATE $ 3,000,000
$ 1,000,010
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY PRO LOC
A U7101
X
IC BE B LIA1 III"
AN11AIrm
COMM It IED I It IGLIf LIA 117
(8aacmider1) $ 7'000,000
BOMILYIPIJURY
(Per person) $
Al
ALL OWHEEAIITOIS
5CHEEIILEDALf1OS
D7-130-C 51 EIC327-117-01
1/125/7101
1/129/20111
BOD ILY INIURY
(fleraccidenl) $
I IIR ED A UIRE
PI 1I-0WI'IND Al ITa S
RROPE0TYOANIAUE $
(Her accidrint)
(IARA4 E ILIA E IL ITY
AUTO ONLY - EA ACCIDENT $
aTFII RTFW1
AtIYAUTO
A 111H 11 PILY: A G $
E) CBISJU1181 BI LA LIANA ITY
:X0 0410 IR F-I Cly IMS MADE
EACH OCCURRENCE $ 4,400 , 000
AGGREGATE $ 4,000,000
$
$
A
RDEIDLICIIBII
DTSM- CUR -CIS 60321 -T: 1
11 /15 12008
8/3 3,110 C 9
X RET I N S 10,000
WON KIIR9 001 IF ■NSA71C N At ID
X WC STATU- O R
EI IP L OY11RS' LIAE II rP
AtIY■FOR111TaRIPAR711ERIEXENLf1[1E
E.L. EACH ACCIDENT $ 11000,000
E.L. DISEASE - EA EMPLOYEES 110 d 0 , 01 0
IBC
011101ER/MBMBI IREIICLIE]ED?
If yeas, describe and+I r
SPECIAL PROVISIONS beI
prAg-UH-19911413-7-C8
3,130/2011
1/30/12409
E.L. DIS -POLICY LIMIT 7, 6100,010
OTIEN Pp33ution IIabilaly
RaPLBC1102+13-00
8/125/2118
8/39)12009
$3,01C,000 �Iaeh Occurence
$3,C1C,0011 Aggregate
Sub TO 5000 Ded
II■51 RIFTIO N OR a PNRAT101 SA CIA TIONSNEI la 1.11151111X0 LUSIOI 11 A 11181 ■Y EI Da RSEIIENTJIFMCIAI RNC VISIOIIS
'Exaepl 10 daye nolJca of cmmee33allion fan man-payrileLlt as Llaendum Ce)It1licste toldell iA naned addiljomel jnlllrmd
Annelepecla la ganeael end alto 3ialiljty pmi endmisenenl
CERTIFICATE HOLDER CANCFI I AT1nN
0,19)493-30!3
SI01111 ANT OF TIB AICVE CNS11RIBe13 POLICIES 95 CANCELINE INBORN THB
City Of Ian Juan Capi a 1 rano
E) PIRATI01 DATN 11F1111RN011, TIB ISSUING INSURER M LL ENDEAVOR 70 HAIL
Att. MAI 31 ] a Morris
1 3 1 DA Y9 VW IT1BI NO TNI B 110 THE CNI IIRICA TE HOWSE NAMED TO THE I EFT, 8117
32400 Paseo Aldelanto
San Juan aapistrano, GA 91675
RAIIIIRNTOOO80SIIAII IMPOSE I000111IAWNONILIBILITYOFANY NINE UROtITHE
INSURER 1T5 AGENTS OR REPRESENTATIVES.
ALITHI FIMID REPRESENTATIVE
Debbie Abund] s 11113BBIE 1L N
ACORD 25 (2001108) m ACORD 4ORPORATK III 1181
111907 5 (il lm).a 88 Rage t of
1101 ICY NUN OEM ME -a 0459SC-12 7
COIN MERCIAL GENERAII LIABII ITY
'PH IS ENuaRSIEMBNi CIHAhGES 1H E pal Kull. PLEASE REBID 11 CAF EFL LLN.
BLANKET ACDI'I'ICINAL iNSIUREC
(C ONTRAC TORI OPERATIONS)
HN endors erne nt mos ifioe lost rrnae pravidec unc er tl a 1a Ilawing:
CaN N EF CML CIENRRAl LIABII ITY CCNERAIGE PAFF
9. WHCI 19 AN INSURED - (Seation II) if an anted
to inaftde amI person or orglaniaation that !lou
agree in o "v rattan contras re qi iring ami t range"
to ini luda as an additions l insurerI an tills Cover-
age Pa rl, bt t:
a) C1r ly %ilh nlspacttc IiabilibI'br't odily injury",
"property daraago" or "ps rsanal lnjury"; anti
b) t, and only to Ula extant that, We Injury or
dam al It I; aaut ec b, I aah or on 1; s font of
yet or Maur t tbcantractor in the performance
011 "yotr % a W to v tloh the "writ en aantract
req t irin g it st rano e" a ppliet . The per: of or
ori anizatlon sloes not ylualifj as an a dditlor al
in s urs d with res pea to tl a ins iepe nda nt acts
or a miss lone of a uah p t rsan a r orga nization.
a. Tt a Imsura nee r ro, Ida cl to the addltlor all insurer
I )I tt is endorst me nt is limited as fallow a:
a) In the Meat tt at the Limits a-1 Insurar ce of
thls CoN erage Part ahowr in tt a Dealaratio ns
muceed the llmitt of tial ilia regnirer I 11 the
"wrttion out tract requiring iroturan ae", it In-
stranee providerI to We aclditioi a Insured
shr:li be limited to the lirrit: of liabilitj re-
qi first b,I t1lat 'writter cantn at req airing In-
surance'. This enclarsemert stall not In-
crease the lirrlt< of lneurance descrit ei In
Seation ill — UmIts 011 Inst ranee.
b) Ti a Inst raince pros ids d to the additional in-
sured floes not applytc "bo(illi injury",'grop-
et I clam a gi " on "po monal it ji ary' arlsln g out
oil the re nda ring a I, a faint re to render, any
profeasianal arci iteetural, enclineea'ng or aur-
veyin g services, Inc tdin g:
1. The g reparini , a ppraiving, or -lailin g to
prepare or approve, nap,-, stop draw-
ings, oliniani , raporta, st rvells, leld or-
der ai or change ordeal, or the pre paring,
approving, or -iall ln4 to g rel a re or ap-
pror e, clrav ins E and ipocftications; and
Ii. Sups rvls ory, fns po ci la n, a rchitectura I or
enc insarin4 ac ivltles.
o) Tie Intrt rano pra%icled to the additional in -
St red does r of applil to 'i adily lnjt ry' or
"preipaM damage" caused bll "your v arae"
and inalucled in tele "products -completed op -
a ratio r s ha: and",
The in si ra nce proN li Ie d to the additional insured
t till: entlarsement is wcose aver an)I vaflil and
aollec able "otl er insurance", W ether grin ary,
t xa ess, coni'nge n t or on a ny off or ba sis , tha t is
evallati.e to Ula addilional insured lor a loss ue
c o) er t n de r t1 is endorse m ent Ho%a N er, 111 the
"writteul contract regltidrg Ina un nce" specifically
re qt fret 9 at this inet ranae apply on a prin ary
bat It or a primary and nor -a ntrit utory I a: is,
thl. Insurarce is primary to "other insurarce"
avaHeIle to tl a {dditional lnsuroid whist covers
that ptrsaan or organl3ation a: a namacl ins tired
for s t ct Aoss, and we vrill not stare with that
"cth( r inst Bance". But ti a instranae praviclerl to
the addittor al insured 111 this endorsiement still Is
excess over any valid and aollec lble "other N-
e uralnca", wtettler pr mart', excess, aontinc a nt or
on ata)l ottleu basis, that is a, ailable to the addi-
tion al instured A an t}lat person or orggnizartion is
an a cWit on I inst ret under suet "otl t r it s r-
anee".
4. As a condit'on o I aoi a rallle provided to the
adr litior al ins un d b1l this a r dors ement:
a) Tie addffonai insunid mutt ghn us wttten
natlae as soon as Iraicticat le soil an "oocur-
ren co" or an offs no a which m a y ret ult in a
claim. To the ex ent potisli le, stall notice
s t of Id Inclut le:
1. Ho , %I on and who re U e "ocaurn nce"
or offense taol plaae;
11. The names and acldnu s,- es a I an}I Injured
persons and witnesses; ani
lit. The nature and location of any injury or
dernac Ie arising out oil tt a "oast rren c e" a r
ofh noe.
CG 11 411 Oil 05 0 2005 The St. Paul Tar elers Con pan lea, Ina. Page 9 oil 3
CC IMN ERCIAt CIE P IERAIL l ABILITY
b) if a claire is made or "si it" is E rought a gain: t
tt a ac IcI do na I ins urec I, tt a ai Iditia na I ins ure d
mu: t:
I. Inirrecliately recard the spinIfics of tie
claln or "suit" and the flate recelve d; and
Ii. Notify i iE as soon as praoti(:: ble.
Tt a at ditic na I ins urn d must see to it that we
raaeive witlen nol'ce of the claicr or "suit" as
a oon as pra ci it at to.
a) Tt e a dditlor al in; ure d Must irnme clieteh I
sent us coF ie; of all legal p ape n re ca ivad it
tonnectlon wi h ti a claim or "suit", cooperate
with us Is the Investic_al'an or set lerreat of
Ole clalm or deflam a against the "slit", anti
o tt erwis e o ou ply I witl all F olicy can dition s.
ti) Tta additional Insured nlLst tender the dei
Un: a anti Indemnity of any alaim or ": ult" to
any I rovider o f'otl er insurance' v hie h win ulc
t ovi r the at Iditic nal in a ure d fa r a loss we
cave untlar this encomament. Htwvevier, IM3
condition does not affect whettler the insctr-
anae provided to the ac c itlonal insi red t y
this a nc a rse rr ent is prirr an to "ott er Ins ur-
anae' avalletle to Ve additlanal Insured
Which covers Mat person or organization a- a
named insc red as described it Faraicral t 3.
above.
9. The follomilag definition Is added to SE CTIC)IN V.
— DEFIP I171DNS:
"N rltl en cantre ct requiring Ine l ran c e" n east
ttat part of arnl writian aantracl or agreement
t nde r wihicl yo L are required to ii clude a
Ferre or argaaization as an additional in-
s ure d (in tHi: Coverage Fart, provided that
the "bodily injun" entl'Fropelrty damage" oc-
ours Saddle "persional Injcrry" it cr used t y an
o ffenstr corn mitted:
a. After file signing a nd execu Ion of 0 e
contrac or agreement bbl you;
b. While that [art o'I the contract or
agn ement is in effect; anti
c. More the encI oil tt e I a lit y A eria d.
Page 9 otl 3 C 2005 V a 9t. Paul Trartele rs Compania a, Inc. CG D] 44 CS 05
POLICI HUMBYRgOTH-CO-0596a1T
CCIN N ERCIAIL C Nt IERAI L 011311 ITY
THIS B a ORSEIV Eh i OHAIN GES 7 H E PCILIM . PLEASE REAL IT CIAREFULLY.
CONTRACIICIRSI YTEND ENDORSEMENT
This 1 r do rse rrent modiflo s Ir suranoe II ro vide+l uncler the fa Ilcwingl:
CCINN ER(IIAL C ENEIRAI LIABILITY CCIVE3IRAGE PART
GENERAL DESCRIPTICIN OF COVERACIE - Promus for s Al. -H. a rd .I. -N. of ails endc moment broaden cave reigc ,
anc Frorlslon t. of tt ii a ndt moment rral limit covervlle. The following listing is a IlenareI coverega description
only. I irnitat'ons and e)ichsioss nisy all ph to Mass caper gas. React E It tt a PROVISICIINS of ttlts a nclomernent
care -lull to cletf rine rlgl ts, clulles, and wl at is ant I Is not capered.
A. I rc ade no d Narr ed I no ured
S. Exi e n slop of Co% eni ge - Darns go To Prerr ices
Ra r tac Tc Yon
" F e rfis a f ire, a xp los Ion , Iightninl , smol e, W. ter
Limit inc res sect to j 300,000
C. I Ia6et Waiver of Stlbroglai'an
D. I Ian ket A Idi itis nal Ins uro cl — N an a go rs or L e: sorsi
a -I Premise s
E. Inc Idanb I h edits I N alpract'ca
F. Exte ns ion of Ca va ra go — Bodlill li Jury
G. Contra dual L is bifid — Railroa ds
H. Pdc itianal. Insured — Sh to or F olltical Subdivlslons
1. Cltherinstirance Condit'on
.I. Increased Supt lemente rM Payments
" Cost of tail W nch Inareasecl to 12,900
" Lo ss of a arninga inures sed to 150Q per dal
K. Knowledge and No loci ail Clccurro nca or Men so
I . Unintentional arsission
M. PersionaIInjuryl--Adsumec bi Ccntrcl:
N. Blanket At clitia nal Ins ured —Lessor a f La asec
Ellulpment
PRCI111SICINS
A. I3RCIAIDENED NAN ED INSURED
1. It a Ns coed Insured ii Iten 1. of the Dec lara-
t'ons is s sfallcws: S
It a persa n or orglaniza kion n ame:c in Item 1.
( I the De cit rallona and any organization,
other than a partrersihil , joint venture or lim-
Itet lial ility cc ml an) , of wt is h ) ou n ain taln
cmnership or in wit ict you maintgn Me rnEgo r-
ity Into res t a n Ola elle ctN a date of the I ollcy.
Homiewr, cam erage far an)I stict aticiitional
c rga n Izaile n will[ ce w a as of the i ate, if any,
cuing the paliay parioe, It at you n longer
rr aints In a in or, hip of, a r tho m ajo rit7 In teree
in, shah a rga n iaatia n.
2. WHO IS AIN IM LIRED (Sec Ion II) Item jI.a.
is deleted and replacec bil the follow ingl:
a. Covoraga under this proNisioo is afforded
anl5l until tt a 00t1 clay after yau aagi ire
a r form the a rga n izatic n or ti a en cl of ttie
p olicy pe ria , v it is he per Is a a rlie r.
7. This Proi Ision X. does no t app ly to any 11 a r -
son or o.rganlzation fa r wt tat ca ver ge is eai-
cluded bl eaclor, amart,
EXTENSICIN CIN COVERACIII — OAlh AGE TCI
PR9N 19 E9 RENTED TCI YCIU
1. Thi last I arallraph of CICNNRAGE iI. BOD-
ILY INJURY AND PROPERTY Da INK E I (-
ABILITY (Secton I — Coveiages) is delated
and rep iace d t y tt a Ia llowingl:
l
Ext luala ns c . throtlgl n. do not apply to dam-
age
am aye to pro rrises while ranted o yau, or tern -
pori riill a cnipie d t y you with perm l; slan a1
the owns r, cs used by:
a. f Ire;
b. Explosion;
c, Iigttning;
d. 9 mol a resulting from sect fire, e: ip lc s is n ,
ar lightning ; or
e. Water.
A sen arate lin It of ins uran co al plies to 'his
coverage as cleacril ad In Seatian Ill I in is Clf
Ins urs nce .
OG Di 16 [7 t4 Copyright, The Trac elorsi Indemnity Company, 2004 Page 1 of 6
CCIN N ERCIAI GENIE RAI LIABIl. ITY
TI is lnsuranca does not al pill to damage to 5. Vis F ravisian B. c oes not E ppiy if am Qralle .,
premises vihile rented to yau, or tarrporarily far Damage To Pren ices Rented To You cf
oacupled b11 lot vitt pe rmisslon of tie CCNERAGE P. EICIIDII Y IPI, lJH Y AND
owinar, aat so cl b11: PRCIPERTY DAiVICIE 11.4 Sit II (Seal'an I —
a. R t ptt re, bursting, or o p erat on of prea- Clover ges) is exclt det bi enc ora e n e nt.
sire re lie devices; C. BLANKET WAIVIR OF SUBROGAITION
b. Rt ph re or burslIng di to to e:ipansian or
:wielling o the contents of anll bt ilt ing or
stN ch re, cause c b, or rat ul ing fron wa-
ter;
c. EAploalon oil steam Iollena, steam piFes,
silvan enc inas, or s earn td rt in as.
3. ParagraiF h 1. of UNITS CIF INSURANCE
(Seatia n III) is de lets d ant rep laced br I tt e
following:
Si I]eat to 5. at o+ e, the Den age To Prerr-
Is es Rented To You Limit is 0 a most vie will
pi y under CCN ERAIGE A- -br ti a sum of all
r a me get It eeause a I "propel) t o mage" to
e r y a no pre rr Ise: wt Ile renter to ) a u, or
to mp a rally a cn upled b) )lot Witt pe rrniss is n
of the owner, cEiused I y; Ura; explosion; Ilghl-
mini ; amako resulting frdm such fire, w1lo-
ston-, or Ilghtningl; or %iter. The Denage To
Pre m Is es Rente<I to Ye a LIrrIt wpl a ppily to all
"p rope rty clan age' p roxin atoll cause+ t y tfle
sane "ooctmence", whether such clemace
re Euta frdn ; fire; e)ipiasion; Ilgt thing; am oil e
re suiting from sttct firm, explosion, or III tt-
ning ; or water; or ary coml inatian of an)l of
tt ase tai set.
Tie Darrage To Premise: Rented To You
Lin it will I e tt e I Ighe r of:
a. $] 00,( 0( ; or
I. The a m it t nt st a v n an the Dedaratlon E
•br Damage To Promises f anted To Y( u
Lim It.
4. PE ragrapi a. of the del nWon a "imturecl aan-
tract" (DENIP1171CIPIS — Sectiar U) is deleted
and re planed t y tele fa Ilow ng:
a. At iia ntract far a to, se of premises. How.
elver, that portion of the cantrac ibr a
lease of promises tlla t inden noes any
person or arfanizat'on for damage to
promises while rented to YOU, or ten g o-
rartl) c cc i p ie(I t y yc u v III p em Ise is n of
tl a owner, a au: ed 1): fire; enp to sla n;
Ilgltning; smale resulting fram stiol ire,
explosion, or Ilgl tnIngl; or water, I: not an
"ins tired ca ntrac ";
VIIe waive any right of recover} we mall I a, e
s ga ins any person or a rgan ize tia n t ecg use of
payment we nake far injtry or darrage arising
out o: pnimises awed aroccuple( ty orraintticl
or loaner to )lou; ongoing operations perfarmecl
ty!oi araryourtehElf,tanetinderaaontrac
wiith the t F eri a n or orge niaatlon; ") our v ori l"; a r
"l of r p ra di ct; ". We waive this rigt t wl a re yet
Iai a agrees to do so at part of a viritten aoatnaat,
e xe ci ted I y ! ou tK fore the "t of Ih Injt ry" c r
"p rope rty clan a ge" c cct r; a r the "pelre oni I In jury'
ar"advert'aini injtry" offense Is comreittecl.
D. BLANKET ADDITIONAL INSURED — MANAIG-
B R9 OR LESSORS CIII PREMISES
YII1• CI 14 AN INSURED (section Il) is amens ad to
Inalucle as an In; tired i ny F1 an c or argamize#lor
(raft rre d to I e low a s "e di ilia nal it E urs d") witt
wt on ya ti hi, c e a greet in a writte n cc ntraict; exec
at ted i efore the "I c diiy lnjurll" or "properb dan-
ago' acours or tta "pereoaal injury" or "ad, ortis-
Ino injury'i'offense hi cotrmtttec1. to name as an
ad(lii'anitI l6suneid, blit only %*th rasps ct to Iia bilit)
arising of It a the awnerstip, maintenance a use
of tt at part a ati) prorrika! to as ed to yc u, aubjeat
to It e faIla wlnip provisloris:
1. I units of Insurat ae. Tl a liraitl of It auraniia
of or led to the a(lditiot at In; urecI Ehe II I e ti a
Ilmis %it Ict llott agreed to pno%hle In the %irlt-
to n contra ct, a r t) to limits : hewn on the 11 a cla-
ration s, wl ict eve r are les s.
a . Tt a In: uran ce affa rde( to tt e e do Iltla n al In 4hu- —
a urs cl doe s n of a pply to:
a. In, "badity Injury" or "praipert) damage"
thi t oacurE , o r "gers oni t injury" or "E dve r-
th lac, lnjt ry" causF41 I y an offense wt 1ch
is co mn fted, at e r yc u cease to be a ten-
ant in that prea is es;
I . An)1 Il re misa E for wtl Ict a of erag a is wi-
cludad b) enclorsan ant; or
a. Strucura alterations, nevi construct'on or
de molls to n op orations pe rfclmi e d bll or a n
be t alf of E uch a clditbn al Ins ured.
3. Tile Ina uran ee affa role cl to tt a adclltia nr I In-
a urad is excess over r n %acid and callectible
F age 2 a 6 Cloflyright, The Tral a lens In dem nity Ca mill ani 1, 2U 04 CG D7 16 C7 14
"other it sure nae" ariallable to such adtIitiona]
it stared, iinissi i of i have a g revel in the wirit-
ter aontrac that 0 is in sl ranee miitt to pri-
mary to, or can-sontrlbi tory vitt, suet "other
laeureince".
0. INCIDENTAL N EDICAI MALPRACTICE
1. The follow log Is added to paragral t 1. Insur-
ing Agreament of COVERAGE A, — 0i7DILY
INJURY AND F ROPERTY DANAICIH 1IAIBIL-
ITY (Se at'c n I — Cover, g es):
"Bodil, injury" arising ou of tl a ren( aring of,
or f, i ih ire to reader, tt a fe Ilow in g v ill k e
deemacl to be causecl byl an "ocourrence":
a. N e(lica 1, , url teal, dental, labs ra tory, x-ray
or n urslnlll se rvict , i civica or Fnstnid'a n,
orthe related furnishing of loocl or bover-
t gal;
k. Tt a furoi: t it f a r clic pepsin g of dnig s or
medical, dental, or llrgiaal supplies or
a pplian cel ;
c. First ald, or
d. "Goad Samaritan servicer." A; use( In
tt is Provision E„ "Goo( Sarnarlts n ter -
Aces' ere those medleal sarwtcei ren-
terecl a Irovided In <n emergency and
ilnr %I ict no rerauneraition Is demanded
arreoelve( .
2. Paragraph 2.a,(1)(d) al WHO IS IN IN-
SLIRED (Section ll) c oet not a ppIII to any
registered a arse , Iia ens et p r< ctical nurse,
emergency rratical tectnicisn or paramedic
e ra n lo) let l I II ya (u, t ut on ly while p erfa nr In g
the servlces clesatll ed In paragraph 'I, abode
and wt ile ac Ing within tt a scope of it eir am-
llayment I II, cu. Anyl "ererlayleas" reecering
'Go& Sarrarttan t ervia e, " %illi be deemed to
be acting) w 110 in the a cop e o th eir ern l Is yl -
merit byl :lou.
3. The follow frig e)iclus foe Is add( d to pa ra gn I h
2. EAdusions of CCPwERAC16 Al. — BODILY
INJURY FIND PRCIPORTy DAN ACBE I IAII IL-
ITY (Sod Ian I — C;overagle: );
(I his lost rnoa do ei r of a pply tis:) "Bodily In-
jury,)" or "property damage" arlslcg out of Ite
wlltful %tiolai'oe of a penal stats to or ardinanae
rela tin gl to the sale o lit arrnai a uticals cum-
mitlet t y a r v itt the knawledge or cans er t of
the insurec.
a. Ror ti a purposes of clatermin[ni the appfiaa-
ble limits of insurance, any ac or ornisslan
CCIMN ERCIAL 031 IERAIL L IAIBiI ITY
to go tt er with a 11 relate cl acts or orn I:: is m it
the furnishing a l the services described in
I arag ra pi 1. at ova to a r: one l eras n %till I a
de armed a no "a co erre r ce".
a. Tt is ProvitAn E. does not al ph if � ori are Ir
ti e I usine: s a r occur atian o proNiidingl amyl of
0 e : e rvica s ( e sprit e d in ps r€ gr, ph 'I. at ave.
9. Ti a ins uran as provided b:l tt is Provis la n E.
shall be ezaer s oder any rialid and collectible
"otter it st trance" miallable to tt a Inca t ret I,
w he the r p tin a ry, expels, aontingle ni or on
any ether t ail: , excel t for Insure nae tt at Ilou
baugt t ipealScaIII 1 tc api ly in excess c this
Limit` c f Ir Wr<nee shows on the Dealan -
tla n: of ttlls Col reran ( Part.
F. E)O IHN$iaN CIA COVERAGE — BODII 11 III -
JURY
t e definition of "t odlli l Injury" (DEFINITIONS —
Section V) is deletac antl replaced ty tte hallow-
ing:
'Bodily injury" nears k odily Injt ry, trental an-
guish, reentd I injury, st ooli, frigt t, dh abfilty, hu-
miliaton, sickness or cls; ease sustained b:l a per-
son, including deatl re,i Lilting frc m a ny al tt e; a at
a m I time.
C. CCINTRA U 11U.4 L L IAE IIUTY — RAILROAi S
1. Para gra{ t c. of tl le dot niton of 'tn sure d a on-
tracl" (DEF INITICIN9 - Soci'an V) Is da Is tet
an d rel tae ed by the follo+r Ing
c. Any eaiameni orllaer se agreement;
1. Parsig rapt iL(•I) of tla definition of "Insured
contraat" (I EF it iT1CINS — Sec ion V) is de -
la ted.
H. AIDDITICINAI INSURE D — 4TA11S CIR PCIIJTI-
CA L SUBDIVISICIN I — PERB ITS
WHCI IS AIN INSURED (Sack an II) Is amendecl to
Include es or Insured any state or politloal tut dl-
rntsion, subject tc 0 e follo%(ng provisions:
'I. This Insurance applies only when regluirad to
be prcvtcle( I II you ky an orclinanee, law or
bulkling soda an( only will respect to ogeira-
tons parformed t yl yg ti or on 1 our behatl for
v hie h tt a state or political sub( � isioa tai Is-
sued a pa rrr it.
1. TI Is Instnrance cloes not al ly to;
a. "Bodily injury," "prop e rt damage,* "p er-
sonel lnjrrrM" or "adverlising injury" arising
aut of opani ifons perforniad �br ft a state
a r pollllaal a ubdlvit it n; a r
UG D3164714 Canysfcht, Tte1 rave lers Inclen rit} Company, 30011 Page 3 of 6
CCIN N 9RCIAII C IENERAL L LABII ITY
b. "Bodily injury" or "FroFertil damage" In -
CIL dod in tt a "pro di atd-corrpletc d of ora-
tions I azo rd".
I. OTHER INSURANCE CCINDITICIN
A. CCINN ERCIAII C19P19RAL LIAAILITYI CON-
DITICINS (Secion 111), paral1raipl 4. (Otter
lesunirce) is deleted and rel laaed ty the ilal-
Ic wing:
4. Otho r Inscin nca
if valid enol collectible "ott er insurance" is
avallatle to the tnll.recl llor a lass we
coder tinder Covera des A or B of this
Cow ra go R art, aur of .Ilgeltons are limits d
a s follom s:
e. Prirnarylusuranae
This ti a umi noe Is F rine ary e)icc F t
when t . t elav applies. II this ins ur-
a n ce is primary, our of ik allow are
rat affected unless any of Me'otter
Insurance' Is also primarl . Then, we
viill ahan witt ail that "otter Insur-
ance" I the methoc clescdbecl it a.
N low. -
b. EAaes s Insurance
Tt Is In: t rat ce is excess over anal al
tt a "other Inst ire rice", whether p ri-
mar, excess, aantintlen or on any
other It as In:
(1) That Is Rini, ExtAr de cl Coverage,
Builder's Rist, Ins tailallon Rist,
or similar coverage be 'your
Y cork';
(2) That Is Fire Irsurance for prem-
Isw ranted to you os tomporaril)l
occugled It !lou wittI gormhsic n
oil tt a owner;
(1) The t is inI urancc pural asecl 151
you to cover your Ilal Illty as a
tenant ilor "prof ern dams go" to
pro ails on ret ted tc ya u or tong a
MAY osuipled I you wit per -
to iss for of the ovi nenl or
(+I) If t1 a lass arises out a l thc main-
tenance or us of aircraft,
'at ttos", or v ate rc rat h tIIE w -
tont not subject to E., toItistan gl, of
Sea tor I — Cove raga A — Bedi(II
Injur And Pnapett� Damage Ili -
at ility; r r
insured under an)l otl e poliay,
inaludinc, ae51 unit rella or E;ice.a
policy.
Wien this insurance is a atce sI , W
,AIII have no duty cinder Cloeeragles Al
or B to detncl the h cured against
any "suit" if ami pro) itlar a "athe r in-
surance" i as a dut�l to cle'lend the in-
sured against tt at "sut ". If no pro-
Ader of "otter insurance" dela nils,
+ne wiill t nderlal a to do so, 1 t t Nie wall
I a antitled to the Ir at red's rigs is
s c atnst all tt ose I roltiders of 'otter
insc ra rice".
Wien this Insurance is e)ice s s oder
'ottler Imo urei ce", wie will pay only
of r sl are of the aniaunt o the lose, i#
any, that exaec d,i the euro a:
('I) The total aniouitt that all such
"other Iasuranrai" voulcl pay Lor
the Ions in the absence optics In -
sura nw and
(7) The total of all deducible and
sat -Insured amaunb under ttlat
oil ariesum nce".
We will share tt a remaining lo. -s, 11
, ar y, vvtth arty "a the i li s uran ce" tt at is
, n a c Ioscltba d in tt is Excess hat ir-
3nce provlslor .
N a thud C11 She ring
11 all of tt a 'ott e r ins uran ae" pe rm Its
contrit uilon bll equal sl are: , %is will
bila% this metllad alse. Under ti is
apprmcl aact providerofirnsturance
aantributc s ac u. I amounts un 11 it has
laid it, applicable lintt all insurance
or none of the lass ro rr aln s. m ihia h -
Won comes fimut. 41101,", T
If aell a the "ottler insurance' does
net permit contribution t y e qua l
stares, we will contt Lute ty limit.
Uncler thle niethad, tt a stare of each
provider of Inc urance is basecl on the
ratio of its apilicable limit of Insur-
ance to tl a total applicwtle limits of
Irstirance of all pro0densi of InEur-
an ce.
B. Tt a lallowingl deinitioi is adtlod to DEFINITIOt S
(Seclion V):
"C the r insc it nae":
(!) Tlat is available to the irsured a. Meats insurance, or tte func11ng of losses,
v he r the insure cl is an aclditiona l tl at is iraiviclet I by, thn lugt or on bet 19 of:
Page 'I of 9 Col IIrlgltt, 7 to 7 raivc lore Inclernnit Company, 2004 CG D3 14 0'10j
(1) Plsathii r insurance carrianNI;
(7) W c r an)I of our affiliated instlramie com-
pa nies, eaice At v he n ti e t an cumulatio n
of Eact Clcciirrenae Limit section of
Paragraph 5 of LIN 179 CIF 1NSUF ANCE
(Seatia r III) of tie Non curri llailon a f Per-
sonal and ilivertislsE cajun limit sections
of Raragraipl 4 of LINi7S OF IN9UR-
PINCE (Section ill) appllas;
(3) Ph)I risk retention group;
(4 ) pin) self -Insurance rreft( oc or program,
Wer than a r y llun de d k y you end oder
which tt i; Col is ragle Pa rl appllesr; a r
(9) Pls3 sinilar nsl trans-er or ilsk mange-
r e nt rr ett od.
b. Does mat Include tmkrella insurance, ar ex-
cess insurance, that ya L I oug ht spea ifcalli I to
apply in excess a l file I Inti of Iru Uranc:e
sl awn on the Deah rations a l alis Glverage
Part.
J. INCREA9 MID 9 UPPLEN ENTAIRY P1IYM ENTS
Paragraip hs 'I.b. and 1.cl. of SUPPLEN E W WRY
PA" ENIS — COVE RACES Pl E ND B (Sc ct am 1
— Coverages) a re amended as follows-.
1. In leraglrapl 1.b„ die amount we will pc )I far
dle cost of W it k oasis is increased to 42540.
3. In paragrapl 1I.d., tt a arrot nt Hie wdq pay lar
lass of c emir g:l is increased is W 0 a dal.
K. KNCIWLEDGE FIND NOTICE CIF CICCIJR-
RENCE C R OFFENSE
1. TI a folioMngl is addccl to CON MERCIAI
t 13NERAL LIAR ILITY CUNDITICINS (Se cyton
IV), pe ragraiF h 3. (Dutias In The E vent of Clc-
currence, Ofle n so, Clain or SI lit):
Notice of an "ooeurrenco' or of an offense
whiah rr ey result is a Gairr ri List I e given as
oon a: pra cl icable after kr owie dge of the
"occurre nca" or offer e 1 as 1 eon to porteId tc
you, one a f ) our "ea ecutive ofiYco rse (if ) or i
ii to a corp oration), one of ) our p artne rs Who
is an ins livklual (d ) oc i a re a F artn eri t 11), one
a f your man ago a (if ) ou a re a IT Red iia bilitl
con pan) ), or an 'employee' (sticl as ait In-
;urainco, loiia control a rsl mai r: ger or sd-
rr inistraitor) cls; ignated t y yaLr to gliv( suet
a of e,
Knowledge k y a m I otter "employee" a s ri
"a catrreuca' or 4enso da es oat imply that
) oc i also I ave si ich I nrnniedge,
CON N 91RCIAII GENERAL L ABILITY
I . Notice of an "occurrence" or of an of en se
v high n al I result ins c Iain will l e doe me d to
be give n as a oa n as practicable to us it fl is
glven In goal faltl as so os as pra atical ie to
yot r workers rmnipensai an h surer. This ap-
plies 4n111 if you sutscquentl)I gliva notiae of
the "acaurrance' or offense to us as soon as
prod ioal le of er you, one of your "w esuthie
offlccnrs" (ill you are a aorporation), one oil our
pa rlr era mho is at Individual (if you are a
parirenhip),one alyourmanages (If jou are
a ilmiled lial il.lty can gany), or in "erap loyee"
(such as an insurance. loss control or risk
mi nailer or a(lmlr is tratar) Iles igsatccl k y i ou
to give seal notice clisomier, that the "oeaur-
reni ca" a r offens e rr ay Involve this pa Ila y.
3. This Provialot K. does not app ly as re; pectin
tha spe clfic nun ber of days watt In which ) of i
are reigc Ired to n olify us It v citing of the
at n.1 pt corr roe nos roe nt of a dlsahc rile, re-
lease a escape of'Fc lutanti' that ea us es
"boclil) it ji rr) " or "g rope rly c I oma ge" which
n a y a the rwise be covered c in der tt is pa lia y.
L. UNINTENTICINPIL CIMI99ION
The fa low ng is n tided to CM N ERCIAL GIEW
3RAll LIAI IL ITY COND[TICINS (Sect o n IV),
p ora iglrap F' 6. (Repraeenta6c ns):
The unintentional orolss Ion of, or w into ntio nal
error In, any leforrsiation provided ty yqU whici
we relied upon in is:aiing tl is policy stall not
prejtdlce your rigtti under alis Insurance. F ovi-
eve r, this Proils Ion l . does not affec our iglht to
collect additional premium a to exeraies our rigl t
cf cancellation or nonrerneual in acearcanae with
applicable state Insurance lavls, codes or regula-
tion s.
h. F I RSCINfII INJURN — ASSUMED E Y CCINAj%„F._,,,,.
TRACT
1. T} a following is added to E)ic union e. ('I) of
Paraigraph 9., Ucluslons of Coiierage B.
Personal Ir jury, fildlier isiingl Injury, and
We b Site Injury I labllktyl o the Vlleb XTEND
Llabiilit) endorsement -
So lely 11or the p urpose s a fl Iia bilitj a ss un e d in
an 'Insured co ntracl ", reasonable atta me)
lees and necessary ffglatia n expenses in-
ourrod bi or alar a part) other ttlan an insured
a re de a me d to be i lama goo becai iee of "p er-
a on a l lnjury p ro, iidec :
(a) Liability to sect part) lot, or 1 o ti a cost
ol, tho t par ly's de ferisa t as also be en a s -
CG D3 10 1 104 Cop)lrlg tt, Tt e Traivalers Indsni nit! I Comp an)l, ;I t 0,1 F age 5 of 6
COMN ERCIAL C ENORAI LIAIBIL [TY
sumed in the sarre "Insured cantraot";
and
(1) Suah atta mei l fees and lit'gatioa ex-
po n se s are for clela nse of tiat part
al a In st a c h ill a r alta mative ells pi ite res o-
li ifon proaee dine in a high cfarnagli s to
whla h t Is ins uran ce apl lies are alleged.
2. Paragrenh 2.d: of SUPPLER 9NTARY PAIY-
R Et ITS — COVERAC. EIS AIAND B (Section I
— Coverages) is clefeted and renlacecl k the
ft Ila wing:
d, Thi allec atians in tl a "s ul " a d the In-
forn atic n Mie knoN about the "c ccur-
rence" c r offs n se are s ua h ttlat ri o card lot
apl ear. to eiilat tetwi en tl a Intereeta al
the Insured and the interestd oil tl a in-
derr nitee;
1. T1 Ord sentence of Pargragh 2 of SUP-
PLEN EP TAIRY PAIYN ENI S — 0CIVERACIES
AI AINI B (Secdar I — Covareges) Is delete[
anc ntFlated by that IDllowing:
Notwlthstai cling tte provii loris of Paragral t
A .(2) of Section I — Coverage AI — 9 c dily Ir -
jury And Pra F ert7 Damage Lia bilit) , oc Me
provisio nt a•I Parag rapt 2.e.(1) df Se lion I —
Coverac e B — Per: on a I Iri jury, Ald%iertislng Ir -
jury Anil Web Site Injurl Latlllty, Suah pay -
n ent: v III riot be dee met to be darr at es fc r
"bc dllyl Injury" ar d "prof err! damage", or
damace: for "parse ral injt: ry", and will not rei
dt ce the limits olInourar aa.
4. TI is pro visia n M. do es n of al n IS If cove rage
for "persional lrJury" liability Is exalt ded b!l
er dorsien ant.
N. BLANKET AIDDITICLNAL INSURED — L M aR
OF LEASED ECIUIF MENT
WHO 1S AIN INSURED (Si Ilion II) is smencled to
include as an insured att)l person ca organl3ation
(referred to t elomi as "additioeal insr red") Kit
H he m N lou I ave afire ed In a Whitten con tract e: ie -
autacl before the "bcilll!l Injt.ry" or "Iropart l darn -
ace" occiirs or thi "I a rsonal Injury" or "ad ertis-
irig injury" offense h aomrnitted, to name as an
acldlt onal insured, t ut ( Q1 witl resl ec to ti sir &
atalltyfar "todil�l Injury", "Properly claniage", "I er-
a ona 1 in jury" c r "ac Iverl'sir g lnjc try" caused, in
mhole or lr pari, ty )lotir ads or c misslons In t1le
maintenance, cpertion or use of equipmeot
leased to lou I yl stch addltianal Insured, subjec
to the follom int pre visit ns:
-I. Limits of Insun nce. V e limits of Insurance
afforcled tc the addlilaria[ Insured s1 all I e the
fin N wt ich yc u al rced to I rc vide Ir the w Lit-
ten car trac , or the lin It.i sl owr on the Dc cla-
rations, whiaher er are less.
2. The li s un r ce a ffon e d to the adclitia r al it -
sure d da e s not al F lyl to ar y "bodily it jury" ar
"F rope rty darn age" that o= rs, or 'personal
Injury" a t 'a di ierdsir g it jury Meuse d ba an c 1-
fense "hicl H corr rolttecl, after t e eq utpmei t
lease 2lxl ices_
3. The Ins urarce aflbnled to the addii'onal ir-
surad Is excess over an,I valid and oollacilbie
"other insr rance" availal le to : uct additic nal
Insured, urless blot I ave agreed In the Krit-
te n contrast that tlis ins rat t e must be prl-
mary to, or f on-contri bu ory with, auct "c the r
Ins L rant a".
Pa( a EI of A Ca; yright, The Tramele rs Indo mnity Comilla n! 1, 2004 CGI Dl 161104
PC)L ICIY NUN BER: GTE -CO -0". 960121
CION N EROIAII GE1% 9RA11 L 1ABILITYI
ISSUE EVTE
TF 19 B11 CIORSEM011 CIF ANGB9 TF E ROLKIN. RLBASR REACT IT CIARBFULLY.
DESIGNATED PF OJECT(S)
GENERAL AC C REC- ATE LIMIT
Ttis on luTsemerImacMasInsurence prDwidec under ttle following:
CUN MURCIA[ GENERAI LIA E ILITN COVIIRAG9 PART
8CHEDUII
Do 14 naiad I rajeat(s):
EACH l 'IAO JE C'I' 101 M I Cel Yet O Iia VE ACRE 1 A , 5X
Al If81ITI M a NTRMC! W1IICH Ie IN EFABI= DI7»IG
TE l a X LICY P=1031, 10 1 AOVIDI A SMIARATY
aIENERhL AGCMI TE LnQT1 PRC V3 DE1 TRW,
TE S f'OATRAC:I I1 S: MM AIM 3tX1 Ci1TIM E RIGA
10 ANY IHSS F01 NIIICA COVERAGI IJ 8411GHT
A. I or 1 11 sun a wl is h llle Insu ier I becomes leg A IIf 1 :1.
obligate d U pt yl as de mage s ear is e d bll *oc cur-
rendls" um er COVERAGE AI (111 CTICIN I}, a nd
for a II ma dlcal a xpensa:i causes I b! I eccida rtes ur,
der CC3IVERAGE C (SECTIC 11 1), mil kb can be
a ttribula d only 14 operal lops at a sing 0 desigl
naled "pro]ad shown lr the Sd edula abet e:
1. A rA Ii to b Designate d Projec a t neral Ad -
I reglte I Imil epplles tt each i lenlgNW "pro
Jed', anal that lin ll Is equal b Thi arnourt e f
the Gi nere I Aggregate I hart shown In 11 le 4.
Dederatlon>s, 1 nleas t epsrs a Dem Ipr ate d
Irojset Glanersil Agglnegate(s) are e3efret-
ulerd aben e.
2. The Dei igneted Pro)ed Ge nere I Aggregate
L1mll 1s tete most we w 11 pall fa the Burn a a1
damaged urdeei CCIVERAIGE AI, except
damagq becat me of 'I a sly lrji it/ at 'prop•
arty damage` Induded In the "praducti-
eamg alae: operrefions hazard", and for raedl-
cel expoms r to er COVERAGI C, reigard-
less a. the number d,
u . int un ids:
I. Ch inlr made a r s ults' I rougl t: s r
a Pere ams or igen bstions making claims
a r I ringing 'a i ills".
Deall nate d I raiji at
GAnera I AgI reg! tel'):
ME1ARW AGGREGATE
1 IWIT I BMW OZ
1 ECLARATI0115
At y pay" Irma me t e at der U WI II AGE A.
fol damages or undl r CCIVERACIE C. for
madt:al expert ies st e t reiducu the Desig-
nated . Proje ci Gen re I Aggregate LJn It for- _
tt lat der ignatm 'proje e'. Sud puymen s
J hall rm reduce the Genian 1 Aggnlgarte I In It
shown b ttu l Declowiticird nor all" stall re-
duce any other Designated I rojec Gemaral
Aggregate IImIt fol any ober dedsigmated
'pr0]ee'shown In the Sche:t ufe ■ban .
Th ll r Its shown In the Ded area ion* ft1r Each
Ocelunrainca, Damage To lPrwrJm Ron ed:
7a You and N a to I IiEA pgnsee continue trp
apt h . l 0VM Or, Inatee d of baro g subje C to
the General Aggro gate Limit shown In the
Dederadons, much lkr& will i a subject to the
A pplirs hle Dead nater Project Gerw ra 1 Ag -
g reegate I unit
8. A or all earns Whlct Hui Ineeued beComeJ legally
ob I0ec is pall as (lemageq esusee Iy'oeaur-
is nae' under CCr#IMGE A. (SECTICIN 1), and
for a p medical expermes caused by accide nt un
tier COVERAGE C. (SECT CMI 1), which cannot
I e 9 bft ed on ! I to opq `!tions mit e sing a del lig-
noted'prc* ct' of own In the Schedrlle oba e:
CG D7 111, a Collysighl The 1 ratielera Indi malty Company, 2OO4 Page 1 of I
Q ON MURCIA! GENERAL I IABIL ITY
1. Aril pI yrrlents mach under t 0119RA0 E A.
W darranges or under COVERAGE C. for
rnaidical er penmia shall reduce tt a art oust
mailable under the Ga neral A G re ga to I Imit
or dul Prodi cis-ConViated Operatlom Ag -
g rsgate L iml , wl lcheve r is a pp lis t k ; i rim I
I uch payments shm II not reduce am Dol -
natecl Projec General Aggregi to Llrrlt. E.
tl , f ar12. mal SEC71011 III — I IhI 115 Oil INSURANCE
Is del, led o rmm reph cod t y the fol lowing:
2. Thi Genera I A41grega a I inl it is Ole raosf we
win pe 11 fill r tics s urr c t.
a, Darr a gas alrider 0avelago 0;ancl
t . Darr a g es from 'oommnces' ander
CCIVERAGE A (SECTION 1) and 1h r an
readicel expenses caunved by ■oxldents
under COVERAGE C (I B CTION 1) which
eanr a be ettr1buted ony U operalim ns et
a single cl asigne ll d'prd acV s hown In th
SC"EDUL! above. F.
D. When cove ra ge 11or M Witty m isir g out of Wil
'prod mets -o mgW&d operation a I azard Is prgl
vided, any payments for damages lesamvse of
'bodiy irgury" or "prc party darnagol" Induc ec in
the 'pI oducts comp feted operaforis t azarc' will
reduce b It A rciducta-Cr rrpie ed Operatlons Ag-
gragete Urn I , and ne t reds a the Geners Aggre-
go a ll mt nor the Dealgr ate I Prcjeal Gar eras
AgI negate I Wt.
Ror ttW purposes a b 14 a radon emery the Deinl-
tlons Sr ctia n Is amei cad bj the addition of rile
following definition:
"Project" rales na an a ref away from pra miser
owned by or n nlec to yowl ami wi ich yoiI are per-
formini operations pursuant to a costr2c or
el regimen . Ror the purposes of detsrraining ilio:
aM icabie ■ggreigMe I'm it a insurance. mach
`pmlKt' thi t indudas prevrmnMem Involving Pie
same or consaatisf lots , or premises whose con-
ned on h Into rrup ed on y by a strec I, roadway,
waterway or rigjh -at wa! o ■ ra Proem shall b+
considered i a ingk "prc* ce.
The provisions of IOCTION 11 — IINITS CIF
INSURANCI i d other o so modM d t y tt h err
doreemen Blot cor tlrnam W appy as stipml lstec.
Pogo 2 of 2 Capp ght, The 1 rmmleri Indemnity Cc* any, 2004 CO D2 11 0104
K l I(N NUE 9R: 8' 0-0596C' 27
COVIN ERC IAL E UUTa
ISSL 8 DATE:;
-RHIS EN gOR:IEMEN I CIHAN GGS TEG A CII ICIY. PLEIIASE HE AU Ill CAFER I LN.
E E SIGNATED INSL REID
I his e j dd rearee nt modifies Insuten ce pro, ilde d under tt o folk wing:
BUSINE38 AUT9 001 i3RAGO FORM
GE RAGE COVERAa I FCIRN
MO" OR CARRIER COVHRA G9 FORN
TRUCKERA COVERAGE I ORN
Wilk roisped to coverige proy ii le d t y thi enclon emern , thw provlsiem of the Cavern go I orm apl 111 urde ss rnoi II -
f ed I y thi; endoma ment.
1 his a ndorserna rd lda nt&la p rs a n (: ) or a rga n izatlon(a) vibo an "insureds` ender Re V to It An Insures A rom i -
aim of the Covwrage I orm. THIS endormemerr cloet nol sitar oow rage pra4lclecl In the Cow rl ge Form.
$CHI DI. t E
I lame of Pa roon(s) or Or®a ninettan(o):
Aln I IPS3 Sint Oil ORGA191 ZX. I Otl THAT IOU ARE
REQ13IRXD TO INCIlt IE AS AN AMI T1 ORM II
l Numm W TRIP a 0VI IR36GE NORM IN A
"RI1Tmq CONTJ3J Cx OR AQR EMM THAT 7 S
8IC1I1b9 AI® EXEC'UTIM BY YOII SE9OR3 THE
' 80ni3 Y IXJUE31' 49 *FR(PEI TY DAYAMM'
OCCURS A)MI MRT 35 319 M FEC'T DUILUM
THE Pm,30311 1ERIOI .
(H no entry appean above, Infernoafon tequirad tc eomllena this andorsEment wlll be damn In the Dedarefom
as appllcat le M tl It a ndon anw t)
Eed pr raon a organUstion showr in thl Scher uk is an "Inst n Cl" fdr Ulibr1N; Cove raga, tut only tc the extant
U o t persar a or9al n hath r r ualH as tis a n "irx ured` i nde r the N he II Ai l Insured Prov cion con talo ed in I e c Ic n
11 of ttwl Coverage Norm.
CA :I 14S 1; 91 4 43 p) rig ht, Insurance 3 an fires Oftled, Ins ., 11H 8 Pe 9e 1 of 1
IMPORTANT
If tl a ■ertifcate holder is an AIDDITICINAII INSURED, tl a palie�I(ies) niust to endorsed. A stateniant an tl is
certificate does not confer rig is to the aertiflcate I alder in lieu of shah a ndorsemant(s).
If SIIBRCIGArrIaN IS WAIVED, sul jest to tie tern is and canditions of the policfl, certain polioiec niay rei dire an
endo rs11 rn ent. � I state me nt oa this car lificate does not c oefe r rig t is to the aertifica to I a Ida r in liel I of s uCI
enc la rsem ent(s ).
01WILAIMER
The Certificate of Insurance an the reverse side of this farm does not constitute a contract I etvleen tl a i€suing
insurer(s), a utha rized re n rese n tative or pre duce r, and the certificate I older, r, nor does it afllrmatk elyl or negatively
aniend, extend araltertte coverage affon ad blIthe nolicias listed thereon.
ACORD 15 (24C1101)
Nagel of.l
INS175 (cice).aea