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Home My WebLink AboutBACKHAUS DANCECity of Santa ' na � I / O� Clerk of the Courrcil fir! AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. / Is the agreement(s) a permanent record? Yes No COTC Office Use On J Return form to the Clerk of the Council Office (M-30). CLERK OF THE COUNCIL Call 647-1520 if you have any questions. Al"10 922 ey= 2 -12 The agreement with bad'= —Names D(A-ACQ. No. N-2021-075 was completed on a 1 and final payment has been made. (List all amendments. Use space below if needed.) Department: Phone/Ext.: X� Signature: / Date: iiagreementslformslform- agreement termination form_goldenrotldoc INSURANCE NOT ON FILE WORK MAY NOTPPROCEED N-2021-075 CLERK OF COUNCIL. APR 2 2 2021 DATE AGREEMENT WITH BACKHAUS DANCE FOR YOUTH 0)CSy� ��,f;p� PROGRAMS AND SERVICES THIS AGREEMENT is made and entered into this 7 day of April , 2021, by and between Backhaus Dance, a California non-profit public benefit corporation ("Consultant'), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. On November 6, 2020, the City released Request for Proposal No. 20-143 ("RFP") for youth programs and services through the City's Parks, Recreation and Community Services Agency to be financed by the City's Cannabis Public Benefit Fund. B. Many proposals were received and evaluated, including Consultant's proposal. Consultant was one of several vendors providing youth programs and services that was selected to provide services pursuant to the RFP. C. The City desires to retain a consultant having special skill and knowledge in the field of providing youth programs and services. D. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional provider in the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: 1. SCOPE OF SERVICES Consultant shall perform during the term of this Agreement, the tasks and obligations including all labor, materials, tools, equipment, and incidental customary work required to fully and adequately complete the services attached as Exhibit A to this Agreement, incorporated by reference and set forth as part of consultant's proposal in response to RFP No. 20-143. Specifically, Consultant will teach ballet and creative dance workshops for youth ages 3-12. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit B. The total sum expended shall not to exceed thirteen thousand and five hundred dollars ($13,500.00) during the entire term of this Agreement (including any extensions of time). Page 1 of 9 b. Payment by City shall be made within 45 days (forty-five) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work that fails to meet the standards of performance set forth in the Recitals, which may reasonably be expected by City. 3. TERM This Agreement shall commence on April 1, 2021 and continue through December 31, 2021, unless terminated earlier in accordance with Section 15, below. 4. INDEPENDENT CONTRACTOR Consultant shall, during the entire term of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise discretion or control over the professional manner in which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5. OWNERSHIP OF MATERIALS This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Consultant under this Agreement ("Documents & Data"). Consultant shall require all subcontractors to agree in writing that City is granted a non-exclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Consultant represents and warrants that Consultant has the legal right to license any and all Documents & Data. Consultant makes no such representation and warranty in regard to Documents & Data, which were provided, to Consultant by the City. City shall not be limited in any way in its use of the Documents and Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk. 6. INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a) Commercial General Liability (CGL): Insurance Services Office Form CG 00 01covering CGL on an "occurrence" basis, including products and completed Page 2 of 9 operations, property damage, bodily injury and personal & advertising injury with limits no less than $2,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. b) Automobile Liability: Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto), or if Instructor has no owned autos, Code 8 (hired) and 9 (non - owned), with limits no less than $1,000,000 per accident for bodily injury and property damage. (Note — required only if auto is used in performance of work). c) Workers' Compensation: as required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. d) Sexual Abuse or Molestation (SAM) Liability: If the CGL policy referenced above is not endorsed to include affirmative coverage for sexual abuse or molestation, Consultant shall obtain and maintain a policy covering Sexual Abuse and Molestation with a limit no less than $5,000,000 per occurrence or claim. e) If the Consultant maintains broader coverage and/or higher limits than the minimums shown above, the City of Santa Ana requires and shall be entitled to the broader coverage and/or the higher limits maintained by the Consultant. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to the City of Santa Ana. f) Other Insurance Provisions - The insurance policies are to contain, or be endorsed to contain, the following provisions: 1) Additional Insured Status- The City of Santa Ana, its officers, officials, employees, and volunteers are to be covered as additional insureds on the CGL and SAM policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to the Consultant's insurance (at least as broad as ISO Form CG 20 10 11 85 or if not available, through the addition of both CG 2010, CG 20 26, CG 20 33, or CG 20 38; and CG 20 37 if a later edition is used). 2) Primary Coverage- For any claims related to this contract, the Consultant's insurance coverage shall be primary coverage at least as broad as ISO CG 20 01 04 13 as respects the City of Santa Ana, its officers, officials, employees, and volunteers. Any insurance or self-insurance maintained by the City of Santa Ana, its officers, officials, employees, or volunteers shall be excess of the Consultant's insurance and shall not contribute with it. 3) Notice of Cancellation- Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation in a form approved by the City. 4) Waiver of Subrogation- Consultant hereby grants to City of Santa Ana a waiver of any right to subrogation, which any insurer of said Consultant may acquire against the Entity by virtue of the payment of any loss under such insurance. Consultant agrees to obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies Page 3 of 9 regardless of whether or not the Entity has received a waiver of subrogation endorsement from the insurer. 5) Self -Insured Retentions- Self -insured retentions must be declared to and approved by the City of Santa Ana. The City of Santa Ana may require the Consultant to purchase coverage with a lower retention or provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention. The policy language shall provide, or be endorsed to provide, that the self -insured retention may be satisfied by either the named insured or the City of Santa Ana. 6) Failure to provide or maintain insurance coverage as required by this Agreement is grounds for immediate terminate of this Agreement. 7. INDEMNIFICATION Consultant agrees to defend, and shall indemnify and hold harmless the City, its officers, agents, employees, contractors, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Consultant, its subcontractors, agents, employees, or other persons acting on its behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. Notwithstanding the foregoing, to the extent Consultant's services are subject to Civil Code Section 2782.8, the above indemnity shall be limited, to the extent required by Civil Code Section 2782.8, to claims that arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of the Consultant. 8. BACKGROUND CHECK PROVISIONS Consultant shall not assign any employee, agent, subcontractor or volunteer to provide services pursuant to this Agreement, if that employee, agent, subcontractor or volunteer is required to register as a sex offender under California Penal Code Section 290 et seq, has a conviction for any crime of moral turpitude, has a conviction for a violent felony as defined in California Penal Code Section 667.5(c), or has a conviction for a serious felony as defined in California Penal Code Section 1192.7(c). Disqualifying convictions include but are not limited to, violations of California Penal Code Sections 37, 128, 136. 1 with Section 186. 22, 187, 190- 190.4 and 192(a), 205, 206, 207- 209.5, 211, 212, 212. 5, 213, 214, 215, 218- 219, 220, 236.1(b) or 236.1(c), 243.4, 261, 261.5, 273.5, 262, 264.1, 266, 266c, 266h, 266i, 266j, 267, 269, 272, 273a, 273ab, 273d, 285, 286, 288, Page 4 of 9 288a, 288.2, 288.3, 288.4, 288.5, 288.7, 289, 290, 311.1, 311.2, 311.3, 311.4, 311, 314, 347(a), 368, 417(b), 451(a), 518 with 186. 22, 647.6, 653f(c), 664 and 187, 667.5(c), 18745, 18750, or 18755, 12022.53, 11418(b)(1) or (b)(2); Business and Professions Code Section 729. Failure to comply with this Section shall be grounds for immediate termination of this Agreement. 9. RECORDS A. Consultant shall keep records and invoices in connection with the work to be performed under this Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to Consultant under this Agreement. All such records and invoices shall be clearly identifiable. Consultant shall allow a representative of the City to examine, audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date of final payment to Consultant under this Agreement. B. City may request enrollment and attendance reports for participants of the program. Consultant will also provide bi-monthly program reports to the City. 10. CONFIDENTIALITY If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Consultant without reference to information disclosed by the City. 11. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. Page 5 of 9 12. DISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, gender identity, gender expression, gender, medical conditions, genetic information, or military and veteran status, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 13. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Consultant. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the terms and conditions hereof, shall not bind or obligate Consultant or the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 14. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services, which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 15. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the City Manager may require Consultant to deliver to the City all work product(s) completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes, as the City deems appropriate. Page 6 of 9 b. Payment need not be made for work, which fails to meet the standard of performance specified in the Recitals of this Agreement. 16. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. 17. JURISDICTION— VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 18. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 19. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature herein below has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 20. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: Page 7 of 9 To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax: 714- 647-6956 Copies to: M City Manager City of Santa Ana 20 Civic Center Plaza (M-31) P.O. Box 1988 Santa Ana, California 92702 Fax:714-647-6954 City Attorney City of Santa Ana 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 Fax:714-647-6515 To Consultant: Backhaus Dance P.O. Box 5890 Orange, California 92863 Email: Nancy@backhausdance.org A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above. For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. Page 8 of 9 N-2021-075 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA: rI YGOMEZ — KRISTINE E of the Council City Manager APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney X., A. R Laura A. Rossini Chief Assistant City Attorney FOR APPROVAL: LIWRUDLOFF Executive Director Recreation & Community Services Agency BACKHAUS DANCE: Jennifer Backhaus Artistic Director • Page 9 of 9 Exhibit A Scope of Work Backhausdance Education Program: Ballet and Creative Dance Group 1: ages 3-5 Group 2: ages 6-8 Group 3: ages 9-12 Maximum of 20 students per group for children in the City of Santa Ana • Schedule: classes meet 2 x week for 50-60 minutes depending on age level. Total of 30 weeks annually. • Format: live and in person when it is safe to do so in compliance with CDC and City of Santa Ana health guidelines. Alternatively, classes will be offered virtually, with dancers teaching remotely and connecting with students via Zoom or another comparable program. Classes will be designed for small spaces at home. • Location: in compliance with CDC guidelines, either indoors and/or outdoors at City of Santa Ana community locations in parks and recreation areas. • Description Backhausdance professional dancers present inspiring 50-60 minute ballet and creative movement experiences for young children and youth focusing on basic ballet technique, discovery, creativity, and movement. Young dancers will enjoy using their bodies and imaginations and gain awareness of the way they can express themselves through dance. In a structured and fun class series, students will learn basic ballet terminology and technique through joy of movement from a professional dancer. The classes focus on skills as well as creativity, exploration and the combinations of the beauty of dance, music, and art. The class series will strengthen students' bodies as they gain coordination and self-confidence. Performances will be held in December and June for families and friends. Special bonuses of classes are learning to count from 1 - 10 in Japanese and playing Japanese games! Open to everyone! No prior dance experience needed. w Exhibit B Fee Proposal Backhausdance: Ballet and Creative Dance Youth Programs/Services: Youth Class Series & Performances Description of Unit # of Units X Cost per Unit = Total Service Description Ballet and Creative 1 Week 30 $150 $4,500 Dance: ages 3-5 (Twice (up to 20 students) per week) Ballet and Creative 1 Week 30 $150 $4,500 Dance: ages 6-8 (Twice (up to 20 students) per week) Ballet and Creative 1 Week 30 $150 $4,600 Dance: ages 9-12 (Twice (up to 20 students) per week) Total: $13,500 15 Francine R. Villareal Digitally signed by Francine R.Villareal Date: 2021.06.2217.35.10-07'00' BACKDAN-01 TPRETO d►c , CERTIFICATE OF LIABILITY INSURANCE �� DATE(MM/D2YYYY) 6/3/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE (A/C, No, Ext): (410) 685-4625 (A/c, No):(410) 685-3071 Maury, Donnelly & Parr 24 Commerce St. Baltimore, MD 21202 E-MAIL DD RIESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA: Great American Insurance Cornan # 16691 INSURED INSURER B : INSURER C7 Backhaus Dance INSURER D 7 PO Box 5890 Orange, CA 92863 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR X GLP3961460 6/3/2021 6/3/2022 DAMAGE TO RENTED PREMISES Ea occurrence 1,000,000 $ MED EXP (Any oneperson) $ 20,000 PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY jE LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COBINED SINGLE LIMIT Ea Maccident $ BODILY INJURY Perperson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ PROPERTY DAMAGE ccident Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS -MADE X UMB3961461 6/3/2021 6/3/2022 AGGREGATE $ 4,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OF EXCLUDED? ❑ (Mandatory in NH) N / A E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Abuse & Molestation X GLP3961460 6/3/2021 6/3/2022 Each Abuse 1,000,000 A Abuse & Molestation X GLP3961460 6/3/2021 6/3/2022 Aggregate Limit 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The City of Santa Ana, Risk Management, its officers, employees, agents, representatives, and volunteers are additional insured. Coverage is primary and non-contributory. 30 day prior written notice of cancellation is in favor of the City of Santa Ana, Risk Management, its officers, employees, agents, representatives, and volunteers. The $4,000,000 Umbrella Liability policy goes overtop of the $1,000,000 each abuse limit, bringing the total abuse & molestation per occurrence limit to $5,000,000. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE RisieMallagementDiviaian ,�oRaN� REVIEWED & APPROVED BY.- z a v� ACORD 25 (2016/03) © 1988-2015 ACORD C The ACORD name and logo are registered marks of ACORD Risk Management Analyst Named Insured: Backhaus Dance Policy Number: PHPK2177052 Policy Period: 10/02/2020 - 10/02/2021 PI-GL-005 (07/12) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Effective Date: 03/29/2021 Name of Person or Organization (Additional Insured): City of Santa Ana, Risk Management, its officers, employees, agents, representatives, and volunteers 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 SECTION II —WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of or relating to your negligence in the performance of "your work" for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or "occurrence" we cover for this Additional Insured. The Additional Insured's limits of insurance do not increase our limits of insurance, as described in SECTION III — LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its pei �oRaN } r RAMwaganadDMsiun REVIEWED & APPROVED BY.- PZ. VSA44a Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6001 (Ed. 06 97) Policy No. UMB 3-96-14-61 - 00 Renewal Of - THE PROTECTOR COMMERCIAL UMBRELLA DECLARATIONS PAGE 1 NAMED INSURED AND ADDRESS: 2. POLICY PERIOD: BACKHAUS DANCE 12:01 A.M. Standard Time at the address of the Named Insured P.O. BOX 5890 shown at left. ORANGE, CA 92863 From 06/03/2021 To 06/03/2022 IN RETURN FOR PAYMENT OF THE PREMIUM, PRODUCER'S NAME AND ADDRESS: AND SUBJECT TO ALL TERMS OF THIS MAURY DONNELLY & PARR INC POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS 24 COMMERCE ST POLICY. BALTIMORE, MD 21202 3208 Insurance is afforded by: GREAT AMERICAN ALLIANCE INSURANCE COMPANY 3. PREMIUM: Commercial Umbrella Premium $ 3,250.00 Total Advance Premium $ 3,250.00 Total $ 3,250.00 In the event of cancellation by the Named Insured, the company will receive and retain no less than $ 650.00 as a policy minimum premium. BASIS OF PREMIUM: Non - Auditable ( X) Auditable ( ) 4. LIMITS OF INSURANCE: $ 4,000,000 Each Occurrence $ 4,000,000 General Aggregate (Where Applicable) $ 4,000,000 Products -Completed Operations Aggregate 5. SELF -INSURED RETENTION: $ 10 , 000 6. FORMS AND ENDORSEMENTS applicable to all Coverage Forms and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule, GAI 6013 (Ed. 06/97). GAI 6001 (Ed. 06/97) PRO (Page 1 of 1 ) HORaN } z RiskMwag medDMsian REVIEWED & APPROVED BY.- f R. V;d Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6003 (Ed. 06 97) THE PROTECTOR SCHEDULE A - SCHEDULE OF UNDERLYING POLICIES Carrier, Policy Number and Type of Coverage Limits of Insurance Period GR AMER ASSURANCE CO Commercial $2,000,000 Aggregate Limit GLP 396 14 60 General Liability $2,000,000 Products - 06/03/2021 Occurrence Form Completed Operations 06/03/2022 Aggregate Limit $1,000,000 Personal and Advertising Injury Limit $1,000,000 Each Occurrence Carrier, Policy Number and Type of Coverage Limits of Insurance Period GR AMER ASSURANCE CO Abuse/Molestation GLP 396 14 60 06/03/2021 $2,000,000 AGGREGATE 06/03/2022 $1,000,000 EACH ABUSE LIMIT BUSINESSPRO (Reg. U.S. Pat. Off.) GAI 6003 (Ed. 06/97) (Page 1 of 1) HortaN RiskMmWmentDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6013 (Ed. 06 97) FORMS AND ENDORSEMENTS SCHEDULE I t is hereby understood and agreed the following forms and endorsements are attached to and are a part of this policy: Date Added* or Form and Edition ST Date Deleted Form Description 1. GAI6001 06/97 CA COMM'L UMBRELLA COV PART DEC 2. GAI6002 04/10 CA THE PROTECTOR UMBRELLA COV. FORM 3. GAI6003 06/97 CA SCHEDULE A - UNDERLYING POLICIES 4. GAI6047 04/10 CA ADVERTISING INJURY -FOLLOWING FORM 5. GAI6107 02/12 CA AUTOMOBILE LIABILITY EXCLUSION 6. GAI6129 04/10 CA PERSNL INJURY LIA (FOLLOWING FORM) 7. GAI6135 06/97 CA PROFESSIONAL LIABILITY EXCLUSION 8. GAI6158 01/13 CA CA CHANGES-CANCELLATION/NONRENEWAL 9. GAI6442 04/10 CA FUNGI, MOLD OR SPORES EXCLUSION 10. GAI6452 04/15 CA CAP ON LOSSES - CERT ACTS OF TERROR 11. GAI6458 04/15 CA EXCL-PUNITIVE DAM REL TO CERT TERRO 12. GAI6472 04/15 CA DISCLOSURE TO TERRORISM RISK ACT OF 13. GAI6475 04/10 CA ACT OF TERRORISM RETAINED LIMIT 14. GAI6807 08/14 CA ORGANIC PATHOGENS EXCLUSION 15. GAI6819 10/04 CA SILICA OR RELATED DUST EXCLUSION 16. GAI6869 08/05 CA NUCLEAR, BIOLOGICAL OR CHEMICAL EXC 17. GAI7111 04/10 CA INFRINGEMENT OF COPYRIGHT, PATENT, 18. GAI7251 08/14 CA ABUSE OR MOLESTATION COVERAGE - FF 19. GAI7269 05/14 CA EXCL.-ACCESS/WITH LIMITED BODILY IN 20. IL7268 09/09 CA IN WITNESS CLAUSE 21 22 * I f not at inception GAI 6013 (Ed. 06/97) PRO HORaN RiskMmWmentDMsian REVIEWED & APPROVED BY.- r f R. Vj&wd Risk Management Analyst (Page 1 of 1 ) T * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 70 01 (Ed. 10/07) Policy No. GLP 3961460 00 Renewal Of POLICY COMMON DECLARATIONS VAMED INSURED BACKHAUS DANCE %ND ADDRESS: P.O. BOX 5890 ORANGE, CA 92863 IN RETURN FOR PAYMENT OF THE PREMIUM, AGENT'S NAME AND ADDRESS: AND SUBJECT TO ALL TERMS OF THIS POLICY, MAURY DONNELLY & PARR INC WE AGREE WITH YOU TO PROVIDE THE 24 COMMERCE ST INSURANCE AS STATED IN THIS POLICY. BALTIMORE, MD 21202 3208 Insurance is afforded by the Company named below, a Capital Stock Corporation: GREAT AMERICAN ASSURANCE COMPANY 'OLICY PERIOD: From 06/03/2021 To 06/03/2022 12:01 A.M. Standard Time at the address of the Named Insured This policy consists of the following Coverage Parts for which a premium is indicated. This premium may be subject to adjustment. Premium Commercial Property Commercial General Liability $ 3,625.00 Commercial Crime and Fidelity Commercial Inland Marine Commercial Equipment Breakdown Commercial Auto Commercial Umbrella FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule IL 88 01(11/85). TOTAL $ 3,625.00 POLICY ALTERNATE MAILING ADDRESS: IL 70 01 (Ed. 10/07) (Page 1 of 1) �oRaN } z a RAMwaganadDMsiun REVIEWED & APPROVED BY.- p R. W&Wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 88 01 (Ed. 11/85) FORMS AND ENDORSEMENTS SCHEDULE It is hereby understood and agreed the following forms and endorsements are attached to and are a part of this policy: Form and Edition Date Added or Date Deleted Form Description 1. CG2167 12/04 FUNGI OR BACTERIA EXCLUSION 2. IL0017 11/98 COMMON POLICY CONDITIONS 3. IL0021 09/08 NUCLEAR ENERGY LIABILITY EXCLUSION 4. IL0270 07/20 CA CHANGES-CANCELLATION/NON RENEWAL 5. IL7001 10/07 BUSINESSPRO POLICY COMMON DEC 6. IL7069 03/16 EXCLUSION - ASBESTOS 7. IL7268 09/09 IN WITNESS CLAUSE 8. IL7273 08/08 LOSS PREVENTION SERVICES 9. IL7324 08/12 ECONOMIC AND TRADE SANCTIONS CLAUSE 10. IL7368 01/20 TERRORISM PREMIUM DISCLOSURE 11. 0790SHS SHS POLICY COVER PAGE * If not at inception IL 88 01 (Ed. 11/85) (Page 1 of 1) �oRaN 3 RAMmWmentDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 74 00 (Ed. 07/01) Policy No. GLP 3961460 00 GENERAL LIABILITY COVERAGE PART DECLARATION PAGE NAMED INSURED: BACKHAUS DANCE POLICY PERIOD: 06/03/2021 to 06/03/2022 LIMITS OF INSURANCE: General Aggregate Limit (Other Than Products - Completed Operations) $ 2,000,000 Products - Completed Operations Aggregate Limit $ 2,000,000 Personal and Advertising Injury Limit $ 1,000,000 Each Occurrence Limit $ 1,000,000 Damage to Premises Rented to You Limit $ 100,000 Any One Premises Medical Expense Limit $ 5,000 Any One Person FORM OF BUSINESS: NOT FOR PROFIT ORGANIZATION TOTAL ESTIMATED PREMIUM: $ 2,837.00 Products/Completed Operations All Other $ $ 2,837.00 SCHEDULE OF LOCATIONS Location: 0001 Building: 0001 P. 0. BOX 5890 ORANGE, CA 92863 CODE NUMBER: 01211 PREMIUM BASIS: MANUAL RATED - NON -AUDIT Classification: SIGNATURE GENERAL LIABILITY BROADENING ENDORSEMENT Products/Completed Operations EXPOSURE: RATE: PREMIUM: $0.00 All Other EXPOSURE: IF ANY RATE: PREMIUM: $165.00 CG 74 00 (Ed. 07/01) (Page 1 of 2) �oRaN } z a RiskMmWmentDMsian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CODE NUMBER: 49891 LOC: 0001 BLDG: 0001 PREMIUM BASIS: PER EACH REGISTRANT Classification: YOUTH RECREATION PROGRAMS - NOT -FOR -PROFIT PRODUCTS -COMPLETED OPERATIONS COVERAGE IS INCLUDED BUT IS SUBJECT TO THE GENERAL AGGREGATE LIMIT NOT THE PRODUCT COMPLETED OPERATION AGGREGATE LIMIT, IF ANY Products/Completed Operations All Other EXPOSURE: EXPOSURE: 220 RATE: INCLUDED RATE: 4.847 PREMIUM: INCLUDED PREMIUM: $1,066.00 CODE NUMBER: 99718 LOC: 0001 BLDG: 0001 PREMIUM BASIS: PER $1000 PAYROLL Classification: THEATRICAL COMPANIES - TRAVELING PRODUCTS -COMPLETED OPERATIONS COVERAGE IS INCLUDED BUT IS SUBJECT TO THE GENERAL AGGREGATE LIMIT NOT THE PRODUCT COMPLETED OPERATION AGGREGATE LIMIT, IF ANY Products/Completed Operations All Other EXPOSURE: EXPOSURE: 143,500 RATE: INCLUDED RATE: 11.193 PREMIUM: INCLUDED PREMIUM: $1,606.00 FORMS AND ENDORSEMENTS applicable to this Coverage Part and made part of this Policy at time of issue: SEE CG 88 01 11/85 CG 74 00 (Ed. 07/01) (Page 2 of 2) �oRaN } z a RiskMmWmentDMsian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 82 82 (Ed. 12/09) Policy No. GLP 3961460 00 ABUSE OR MOLESTATION COVERAGE FORM DECLARATIONS PAGE NAMED INSURED: BACKHAUS DANCE POLICY PERIOD: 06/03/2021 to 06/03/2022 LIMITS OF INSURANCE: Aggregate Limit $ 2,000,000 Each Abuse Limit $ 1,000,000 DESCRIPTION OF BUSINESS: Form of Business NOT FOR PROFIT ORGANIZATION READ YOUR POLICY CAREFULLY, OPTIONAL COVERAGES ARE PROVIDED BY PREMIUM INSERTION. Abuse or Molestation Coverage Premium shown is payable: $ Premium $ 788 TOTAL ADVANCE PREMIUM $ 788 at inception; FORMS AND ENDORSEMENTS Applicable to this Coverage Part and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule CG 88 01 (11/85). CG 82 82 (Ed. 12/09) (Page 1 of 1) �oRaN } z a RAMmagzmentcMsiun REVIEWED & APPROVED BY: p R. W&Wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 88 01 (Ed. 11/85) FORMS AND ENDORSEMENTS SCHEDULE It is hereby understood and agreed the following forms and endorsements are attached to and are a part of this policy: Form and Edition Date Added or Date Deleted Form Description 1. CG0001 04/13 COMML GENERAL LIABILITY COVERAGE 2. CG2106 05/14 EXCLUSION -PERSONAL INFO & DATA-LIMI 3. CG2147 12/07 EMPLOYMENT RELATED PRACTICES EXCL 4. CG2171 01/15 LTD TERROR EXCL(O/T CERTIFIED)CAP L 5. CG2176 01/15 EXCL OF PUN DAMAGES RELATED TO TERR 6. CG2426 04/13 AMENDMENT OF INSURED CONTRACT DEFIN 7. CG7400 07/01 GENERAL LIABILITY DEC PAGE 8. CG7794 07/98 EXCL-LIABILITY ARISING OUT OF LEAD 9. CG8282 12/09 ABUSE & MOLESTATION 10. CG8361 02/05 SILICA OR DUST RELATED EXCL 11. CG8366 06/05 NUCLEAR, BIOLOGICAL, CHEMICAL EXCL 12. CG8440 08/09 COORDINATION OF LIMITS ENDORSEMENT 13. CG8481 08/14 EXCLUSION - ORGANIC PATHOGENS 14. CG8565 01/12 ABUSE OR MOLESTATION COVERAGE FORM 15. CG8970 11/14 SIGNATURE-GL-BROADNING ENDT 16. CG9082 06/17 EXCLUSION - PROFESSIONAL SERVICES 17. CG9083 06/17 ABUSE, MOL, HARASSMENT OR SEXUAL EX 18. CG9169 02/20 MEDICAL PAYMENTS AT YOUR REQUEST * If not at inception CG 88 01 (Ed. 11/85) (Page 1 of 1) �oRaN 3 RAMmWmentDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 MAURY DONNELLY & PARR INC 24 COMMERCE ST BALTIMORE, MD 21202 3208 �oRaN } z a RAMmWmerdDMaian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 The Moment of Truth: Reporting a Claim GREATU ERICAN INSURANCE GROUP Specialty Human Services Online MyGreatAmerican.gaig.com Email SpecialtyHumanServicesClaims@gaig.com Phone Toll Free: 888-317-4828 Fax: 888-307-3180 Mail Great American Insurance Group Specialty Human Services Division Claims Department, P.O. Box 1997 Cincinnati, OH 45202 ;ems DMsian �P4P'R.OgVq D BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 301 E. Fourth St., Cincinnati, OH 45202 GREAT AMERICAN INSURANCE GROUP Specialty Human Services If you prefer to view your Specialty Human Services insurance policy online, please visit MyGreatAmerican.gaig.com Log into this secure portal • Access policy documents with the policy number(s) and ZIP Code • Follow a claim of any valid Great American policy • Pay a bill • See additional policy benefits 800-545-4269 © 2017 Great American Insurance Company SpecialtyHumanServices.com Risk MwagmerdDiMsiun REVIEWED & APPROVED BY.- o r cc 4' Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 NOTICE TO POLICYHOLDERS No coverage is provided by this summary nor can it be construed to replace or modify any provision of your policy. You should read your policy and review your Declarations Page for complete information on the coverages you are provided. If there is any conflict between the policy and this Notice to Policyholders, the provisions of the policy shall prevail. This policy contains an exclusion for claims arising from, in whole or in part, the actual, alleged, threatened, or suspected inhalation or ingestion of, exposure to, or contact with "silica" or dust that includes or contains "silica"; and any loss, cost or expense arising out of the abating, testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, neutralizing, remediating or disposing of, or in any way responding to or assessing the effects of, "silica" or dust that includes or contains "silica," by any insured or by any other person or entity, as described in the endorsement. For further information, please review the provisions of your policy. SDM-570 (Ed. 02/05) XS HortaN 3 z Risk MwagemertLD sign REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IMPORTANT INFORMATION TO POLICYHOLDERS CALIFORNIA TO OBTAIN INFORMATION OR TO MAKE A COMPLAINT In the event you need to contact someone about this Policy for any reason please contact your agent. If you have additional questions, you may contact the insurance company issuing this Policy at the following address and telephone number: Great American Insurance Group Administrative Offices 301 East 4th Street Cincinnati, OH 45202 Or you may call the toll -free telephone number for information or to make a complaint at: 1-800-972-3008 If you have a problem with your insurance company, its agent or representative that has not been resolved to your satisfaction, please call or write to the Department of Insurance. California Department of Insurance Consumer Services Division 300 South Spring Street, South Tower Los Angeles, California 90013 1-800-927-4357 213-897-8921 (if calling from within the Los Angeles area) 1-800-482-4833 (TDD Number) Written correspondence is preferable so that a record of your inquiry can be maintained. When contacting your agent, company or the Bureau of Insurance, have your Policy Number available. ATTACH THIS NOTICE TO YOUR POLICY This notice is for information only and does not become a part or condition of the attached document. SDM-705 (Ed. 11/08) HortaN Risk MwagemertLD sign REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 70 01 (Ed. 10/07) Policy No. GLP 3961460 00 Renewal Of POLICY COMMON DECLARATIONS VAMED INSURED BACKHAUS DANCE %ND ADDRESS: P.O. BOX 5890 ORANGE, CA 92863 IN RETURN FOR PAYMENT OF THE PREMIUM, AGENT'S NAME AND ADDRESS: AND SUBJECT TO ALL TERMS OF THIS POLICY, MAURY DONNELLY & PARR INC WE AGREE WITH YOU TO PROVIDE THE 24 COMMERCE ST INSURANCE AS STATED IN THIS POLICY. BALTIMORE, MD 21202 3208 Insurance is afforded by the Company named below, a Capital Stock Corporation: GREAT AMERICAN ASSURANCE COMPANY 'OLICY PERIOD: From 06/03/2021 To 06/03/2022 12:01 A.M. Standard Time at the address of the Named Insured This policy consists of the following Coverage Parts for which a premium is indicated. This premium may be subject to adjustment. Premium Commercial Property Commercial General Liability $ 3,625.00 Commercial Crime and Fidelity Commercial Inland Marine Commercial Equipment Breakdown Commercial Auto Commercial Umbrella FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule IL 88 01(11/85). TOTAL $ 3,625.00 POLICY ALTERNATE MAILING ADDRESS: IL 70 01 (Ed. 10/07) (Page 1 of 1) �oRaN } z a RAMwaganadDMsiun REVIEWED & APPROVED BY.- p R. W&Wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 88 01 (Ed. 11/85) FORMS AND ENDORSEMENTS SCHEDULE It is hereby understood and agreed the following forms and endorsements are attached to and are a part of this policy: Form and Edition Date Added or Date Deleted Form Description 1. CG2167 12/04 FUNGI OR BACTERIA EXCLUSION 2. IL0017 11/98 COMMON POLICY CONDITIONS 3. IL0021 09/08 NUCLEAR ENERGY LIABILITY EXCLUSION 4. IL0270 07/20 CA CHANGES-CANCELLATION/NON RENEWAL 5. IL7001 10/07 BUSINESSPRO POLICY COMMON DEC 6. IL7069 03/16 EXCLUSION - ASBESTOS 7. IL7268 09/09 IN WITNESS CLAUSE 8. IL7273 08/08 LOSS PREVENTION SERVICES 9. IL7324 08/12 ECONOMIC AND TRADE SANCTIONS CLAUSE 10. IL7368 01/20 TERRORISM PREMIUM DISCLOSURE 11. 0790SHS SHS POLICY COVER PAGE * If not at inception IL 88 01 (Ed. 11/85) (Page 1 of 1) �oRaN 3 RAMmWmentDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 73 68 (Ed. 01/20) THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT Schedule Schedule - Part I Terrorism Premium (Certified Acts) $ 0 . 00 This premium is the total Certified Acts premium attributable to the following Coverage Part(s), Coverage Form(s) and/or Policy(ies): GLP 396 - 1 4 - 60 - 00 Additional information, if any, concerning the terrorism premium: Schedule - Part II Federal share of terrorism losses is 80% (Refer to Paragraph B. in this endorsement.) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Disclosure of Premium In accordance with the federal Terrorism Risk Insurance Act, we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for terrorist acts certified under the Terrorism Risk Insurance Act. The portion of your premium attributable to such coverage is shown in the Schedule of this endorsement or in the policy Declarations. Includes copyrighted material of Insurance Services Office, Inc., with it IL 73 68 (Ed. 01/20) (Page 1 of 2) HORaN � z RiskMmWmentDMsian REVIEWED & APPROVED BY.- f R. V;d Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 B. Disclosure of Federal Participation in Payment of Terrorism Losses The United States Government, Department of the Treasury, will pay a share of terrorism losses insured under the federal program. The federal share equals a percentage (as shown in Part II of the Schedule of this endorsement) of that portion of the amount of such insured losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. C. Cap on Insurer Participation in Payment of Terrorism Losses If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. Includes copyrighted material of Insurance Services Office, Inc., with it IL 73 68 (Ed. 01/20) (Page 2 of 2) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 70 69 (Ed. 03/16) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - ASBESTOS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS AND COMPLETED OPERATIONS COVERAGE PART OWNER AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART FARM COVERAGE PART This insurance does not apply to "bodily injury," "property damage," or "personal and advertising injury" arising out of or related in any way to asbestos, asbestos -containing materials, or asbestos -containing products. We shall not have the duty to defend any such claim or "suit." IL 70 69 (Ed. 03/16) HORaN } z RiskMwaganedDMsian REVIEWED & APPROVED BY.- f R. V;&wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 In Witness Clause IL 72 68 (Ed. 09 09) In Witness Whereof, we have caused this Policy to be executed and attested, and, if required by state law, this Policy shall not be valid unless countersigned by our authorized representative. President Secretary IL7268G2 (09/09) Copyright Great American Insurance Co., 2009 IL 72 68 (Ed. 09/09) a�e_ortaN� RiskMwaganedDMsian z ' REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 72 73 (Ed. 08 08) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOSS PREVENTION SERVICES This endorsement modifies insurance provided under the following COMMON POLICY CONDITIONS The following is added to the Common Policy to, safety and prevention training, consulta- Conditions tions, safety devices, health screenings and analyses of accident causes. G. Loss Prevention Services At our cost, we may provide or recommend a broad range of loss prevention services de- signed to improve the acceptability of an in- sured. These services may require your co- operation to make them effective. We provide these services based on need as indicated by the size, hazard and experience of your operation. We may elect to provide these services through another entity. In addition to inspections and surveys, re- ferenced in D. Inspections and Surveys, these services may include, but are not limited We are not obligated to provide any loss pre- vention services and any inspections, surveys, reports or recommendations and any such ac- tions we do undertake relate only to insurabil- ity and the premiums to be charged. We do not make safety inspections. We do not un- dertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions: a. are safe or healthful; or b. comply with laws, regulations, codes or standards. This endorsement does not change any other provision of the Policy. IL 72 73 (Ed. 08/08) XS HortaN 3 z RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 73 24 (Ed. 08 12) THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ IT CAREFULLY. ECONOMIC AND TRADE SANCTIONS CLAUSE This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance. IL 73 24 (Ed. 08/12) �oRaN } z a Risk MwaganadDMsiun REVIEWED & APPROVED BY.- p R. VSA44a Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 COMMON POLICY CONDITIONS All Coverage Parts included in this Policy are subject to the following conditions. A. Cancellation 1. The first Named Insured shown in the Declarations may cancel this Policy by mailing or delivering to us advance written notice of cancellation. 2. We may cancel this Policy by mailing or delivering to the first Named Insured writ- ten notice of cancellation at least: a. 10 days before the effective date of cancellation if we cancel for nonpay- ment of premium; or b. 30 days before the effective date of cancellation if we cancel for any other reason. 3. We will mail or deliver our notice to the first Named Insured's last mailing address known to us. 4. Notice of cancellation will state the effec- tive date of cancellation. The policy period will end on that date. 5. If this Policy is cancelled, we will send the first Named Insured any premium refund due. If we cancel, the refund will be pro rata. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will be effective even if we have not made or offered a refund. 6. If notice is mailed, proof of mailing will be sufficient proof of notice. B. Changes This Policy contains all the agreements be- tween you and us concerning the insurance afforded. The first Named Insured shown in the Declarations is authorized to make changes in the terms of this Policy with our consent. This policy's terms can be amended or waived only by endorsement issued by us and made a part of this Policy. IL 00 17 (Ed. 11 98) C. Examination of Your Books and Records We may examine and audit your books and records as they relate to this Policy at any time during the policy period and up to three years afterward. D. Inspections and Surveys 1. We have the right to: a. make inspections and surveys at any time; b. give you reports on the conditions we find; and c. recommend changes. 2. We are not obligated to make any inspec- tions, surveys, reports or recommenda- tions and any such actions we do under- take relate only to insurability and the pre- miums to be charged. We do not make safety inspections. We do not undertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions: a. are safe or healthful; or b. comply with laws, regulations, codes or standards. 3. Paragraphs 1. and 2. of this condition ap- ply not only to us, but also to any rating, advisory, rate service or similar organiza- tion which makes insurance inspections, surveys, reports or recommendations. 4. Paragraph 2. of this condition does not apply to any inspections, surveys, reports or recommendations we may make relative to certification, un statutes, ordinance boilers, pressure ve Copyright, ISO Properties, Inc., 1998 IL 00 17 (Ed. 11/98) XS (Page 1 of 2) Ride Management DMsian 3 REVIEWED & APPROVED BY.- r Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 E. Premiums The first Named Insured shown in the Dec- larations: 1. is responsible for the payment of all pre- miums; and 2. will be the payee for any return premiums we pay. F. Transfer of Your Rights and Duties Under this Policy Your rights and duties under this Policy may not be transferred without our written con- sent except in the case of death of an in- dividual named insured. If you die, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representative. Until your legal re- presentative is appointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. Copyright, ISO Properties, Inc., 1998 IL 00 17 (Ed. 11/98) XS (Page 2 of 2) HortaN 3 z RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (Broad Form) This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART MEDICAL PROFESSIONAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY 1. The insurance does not apply: A. Under any Liability Coverage, to "bodily in- jury" or "property damage": (1) with respect to which an "insured" un- der the Policy is also an insured under a nuclear energy liability policy issued by Nuclear Energy Liability Insurance Association, Mutual Atomic Energy Li- ability Underwriters, Nuclear Insurance Association of Canada or any of their successors, or would be an insured under any such policy but for its ter- mination upon exhaustion of its Limit of Liability; or (2) resulting from the "hazardous prop- erties" of "nuclear material" and with respect to which (a) any person or organization is required to maintain fi- nancial protection pursuant to the Atomic Energy Act of 1954, or any law amendatory thereof, or (b) the "In- sured" is, or had this Policy not been issued would be, entitled to indemnity from the United States of America, or any agency thereof, under any agree- ment entered into by the United States of America, or any agency thereof, with any person or organization. IL0021 (Ed. 09 08) B. Under any Medical Payments Coverage, to expenses incurred with respect to "bodily injury" resulting from the "hazardous properties" of "nuclear material" and aris- ing out of the operation of a "nuclear fa- cility" by any person or organization. C. Under any Liability Coverage, to "bodily in- jury" or "property damage" resulting from "hazardous properties" of "nuclear mate- rial," if: (1) the "nuclear material" (a) is at any "nu- clear facility" owned by, or operated by or on behalf of, an "insured" or (b) has been discharged or dispersed therefrom; (2) the "nuclear material" is contained in "spent fuel" or "waste" at any time possessed, handled, used, processed, stored, transported or disposed of, by or on behalf of an "insured"; or (3) the "bodily injury" or "property dam- age" arises out of the furnishing by an "insured" of services, materials, parts or equipment in connection with the planning, construction, maintenance, operation or use of any "nuclear fa- cility," but if s within the Unite Copyright, ISO Properties, Inc., 2007 IL 00 21 (Ed. 09/08) XS (Page 1 of 2) d �oRaN ltiskMa�agzmerttDMsfan REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 territories or possessions or Canada, this exclusion (3) applies only to "property damage" to such "nuclear facility" and any property thereat. 2. As used in this endorsement: "Hazardous properties" includes radioactive, toxic or explosive properties. "Nuclear material" means "source material," "special nuclear material" or "by-product ma- terial." "Source material," "special nuclear material," and "by-product material" have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof. "Spent fuel" means any fuel element or fuel component, solid or liquid, which has been used or exposed to radiation in a "nuclear reactor." "Waste" means any waste material (a) con- taining "by-product material" other than the tailings or wastes produced by the extraction or concentration of uranium or thorium from any ore processed primarily for its "source material" content, and (b) resulting from the operation by any person or organization of any "nuclear facility" included under the first two paragraphs of the definition of "nuclear facility." "Nuclear facility" means: (a) any "nuclear reactor"; (b) any equipment or device designed or used for (1) separating the isotopes of uranium or plutonium, (2) processing or utilizing "spent fuel," or (3) handling, processing or packaging "waste"; (c) any equipment or device used for the processing, fabricating or alloying of "special nuclear material" if at any time the total amount of such material in the cus- tody of the "Insured" at the premises where such equipment or device is lo- cated consists of or contains more than 25 grams of plutonium or uranium 233 or any combination thereof, or more than 250 grams of uranium 235; (d) any structure, basin, excavation, premises or place prepared or used for the storage or disposal of "waste"; and includes the site on which any of the foregoing is located, all operations conducted on such site and all premises used for such operations. "Nuclear reactor" means any apparatus de- signed or used to sustain nuclear fission in a self-supporting chain reaction or to contain a critical mass of fissionable material. "Property damage" includes all forms of ra- dioactive contamination of property. Copyright, ISO Properties, Inc., 2007 IL 00 21 (Ed. 09/08) XS (Page 2 of 2) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 IL 02 70 (Ed. 07/20) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA CHANGES - CANCELLATION AND NONRENEWAL This endorsement modifies insurance provided under the following: CAPITAL ASSETS PROGRAM (OUTPUT POLICY) COVERAGE PART COMMERCIAL AUTOMOBILE COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART CRIME AND FIDELITY COVERAGE PART EMPLOYMENT -RELATED PRACTICES LIABILITY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART MEDICAL PROFESSIONAL LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Paragraphs 2. and 3. of the Cancellation Common Policy Condition are replaced by the following: 2. All Policies In Effect For 60 Days Or Less If this policy has been in effect for 60 days or less, and is not a renewal of a policy we have previously issued, we may cancel this policy by mailing or delivering to the first Named Insured, at the mailing address shown in the policy, and to the producer of record, advance written notice of cancellation, stating the reason for cancellation, at least: a. 10 days before the effective date of cancellation if we cancel for: (1) Nonpayment of premium; or (2) Discovery of fraud by: (a) Any insured or his or her representative in obtaining this insurance; or (b) You or your representative in pursuing a claim under this policy. b. 30 days before the effective date of cancellation if we cancel for any other reason. 3. All Policies In Effect For More Than 60 Days a. If this policy has been in effect for more than 60 days, or is a renewal of a policy we issued, we may cancel this policy only upon the occurrence, after the effective date of the policy, of one or more of the following: (1) Nonpayment of premium, including payment due on a prior policy we issued and due during the current policy term covering the same risks. (2) Discovery of fraud or material misrepresentation by: (a) Any insured or his or her representative in obtaining this insurance; or (b) You or your representative in pursuing a claim under this policy. (3) A judgment by a court or an administrative tribunal that you have violated a California or Federal law, having as one of its necessary elements an act which materially increases any of the risks insured against. © Insurance Services Office, Inc., 2020 IL 02 70 (Ed. 07/20) (Page 1 of 4) �oRaN } z RAMmWmedDMsian REVIEWED & APPROVED BY.- f R. V;d Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (4) Discovery of willful or grossly negligent acts or omissions, or of any violations of state laws or regulations establishing safety standards, by you or your representative, which materially increase any of the risks insured against. (5) Failure by you or your representative to implement reasonable loss control requirements, agreed to by you as a condition of policy issuance, or which were conditions precedent to our use of a particular rate or rating plan, if that failure materially increases any of the risks insured against. (6) A determination by the Commissioner of Insurance that the: (a) Loss of, or changes in, our reinsurance covering all or part of the risk would threaten our financial integrity or solvency; or (b) Continuation of the policy coverage would: (i) Place us in violation of California law or the laws of the state where we are domiciled; or Threaten our solvency (7) A change by you or your representative in the activities or property of the commercial or industrial enterprise, which results in a materially added, increased or changed risk, unless the added, increased or changed risk is included in the policy. b. We will mail or deliver advance written notice of cancellation, stating the reason for cancellation, to the first Named Insured, at the mailing address shown in the policy, and to the producer of record, at least: (1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium or discovery of fraud; or (2) 30 days before the effective date of cancellation if we cancel for any other reason listed in Paragraph 3.a. B. The following provision is added to the Cancellation Common Policy Condition: 7. Residential Property This provision applies to coverage on real property which is used predominantly for residential purposes and consisting of not more than four dwelling units, and to coverage on tenants' household personal property in a residential unit, if such coverage is written under one of the following: Commercial Property Coverage Part Farm Coverage Part — Farm Property — Farm Dwellings, Appurtenant Structures And Household Personal Property Coverage Form a. If such coverage has been in effect for 60 days or less, and is not a renewal of coverage we previously issued, we may cancel this coverage for any reason, except as provided in b. and c. below. b. We may not cancel this policy solely because the first Named Insured has: (1) Accepted an offer of earthquake coverage; or (2) Cancelled or did not renew a policy issued by the California Earthquake Authority (CEA) that included an earthquake policy premium surcharge. However, we shall cancel this policy if the first Named Insured has accepted a new or renewal policy issued by the CEA that includes an earthquake policy premium surcharge but fails to pay the earthquake policy premium surcharge authorized by the CEA. c. We may not cancel such coverage solely because corrosive soil conditions exist on the premises. This restriction (c.) applies only if coverage is subject to one of the following, which exclude loss or damage caused by or resulting from corrosive soil conditions: (1) Commercial Property Coverage Part — Causes Of Loss — Special Form; or (2) Farm Coverage Part — Causes Of Loss Form — Farm Property, Paragraph D. Covered Causes Of Loss — Special. © Insurance Services Office, Inc., 2020 IL 02 70 (Ed. 07/20) (Page 2 of 4) �oRaN } z RAMmVmedDMsiun REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 d. If a state of emergency under California Law is declared and the residential property is located in any ZIP Code within or adjacent to the fire perimeter, as determined by California Law, we may not cancel this policy for one year, beginning from the date the state of emergency is declared, solely because the dwelling or other structure is located in an area in which a wildfire has occurred. However, we may cancel: (1) When you have not paid the premium, at any time by letting you know at least 10 days before the date cancellation takes effect; (2) If willful or grossly negligent acts or omissions by the Named Insured, or his or her representatives, are discovered that materially increase any of the risks insured against; or (3) If there are physical changes in the property insured against, beyond the catastrophe -damaged condition of the structures and surface landscape, which result in the property becoming uninsurable. C. The following is added and supersedes any provisions to the contrary: Nonrenewal Subject to the provisions of Paragraphs C.2. and C.3. below, if we elect not to renew this policy, we will mail or deliver written notice, stating the reason for nonrenewal, to the first Named Insured shown in the Declarations, and to the producer of record, at least 60 days, but not more than 120 days, before the expiration or anniversary date. We will mail or deliver our notice to the first Named Insured, and to the producer of record, at the mailing address shown in the policy. 2. Residential Property This provision applies to coverage on real property used predominantly for residential purposes and consisting of not more than four dwelling units, and to coverage on tenants' household property contained in a residential unit, if such coverage is written under one of the following: Commercial Property Coverage Part Farm Coverage Part — Farm Property — Farm Dwellings, Appurtenant Structures And Household Personal Property Coverage Form a. If this policy provides coverage as described in the preceding paragraph, and we elect not to renew this policy, we will mail or deliver written notice, stating the reason for nonrenewal, to the first Named Insured shown in the Declarations, and to the producer of record, at the mailing address shown in the policy, at least 75 days, but not more than 120 days, before the expiration or anniversary date. If we fail to give the first Named Insured shown in the Declarations notice of nonrenewal at least 75 days prior to the policy expiration, as required in the paragraph above, this policy, with no change in its terms and conditions, shall remain in effect for 75 days from the date that the notice of nonrenewal is delivered or mailed to the Named Insured. A notice to this effect shall be provided by us to the first Named Insured with the notice of nonrenewal. b. We may elect not to renew such coverage for any reason, except as provided in Paragraphs c., d. and e. below. c. We will not refuse to renew such coverage solely because the first Named Insured has accepted an offer of earthquake coverage. However, the following applies only to insurers who are associate participating insurers as established by Cal. Ins. Code Section 10089.16. We may elect not to renew such coverage after the first Named Insured has accepted an offer of earthquake coverage, if one or more of the following reasons applies: (1) The nonrenewal is based on sound underwriting principles that relate to the coverages provided by this policy and that are consistent with the approved rating plan and related documents filed with the Department of Insurance as required by existing law; © Insurance Services Office, Inc., 2020 IL 02 70 (Ed. 07/20) (Page 3 of 4) �oRaN } z RAMmVmedDMsiun REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (2) The Commissioner of Insurance finds that the exposure to potential losses will threaten our solvency or place us in a hazardous condition. A hazardous condition includes, but is not limited to, a condition in which we make claims payments for losses resulting from an earthquake that occurred within the preceding two years and that required a reduction in policyholder surplus of at least 25% for payment of those claims; or (3) We have (a) Lost or experienced a substantial reduction in the availability or scope of reinsurance coverage; or (b) Experienced a substantial increase in the premium charged for reinsurance coverage of our residential property insurance policies; and the Commissioner has approved a plan for the nonrenewals that is fair and equitable, and that is responsive to the changes in our reinsurance position. d. We will not refuse to renew such coverage solely because the first Named Insured has cancelled or did not renew a policy, issued by the California Earthquake Authority, that included an earthquake policy premium surcharge. e. We will not refuse to renew such coverage solely because corrosive soil conditions exist on the premises. This restriction (e.) applies only if coverage is subject to one of the following, which exclude loss or damage caused by or resulting from corrosive soil conditions: (1) Commercial Property Coverage Part — Causes Of Loss — Special Form; or (2) Farm Coverage Part — Causes Of Loss Form — Farm Property, Paragraph D. Covered Causes Of Loss — Special. f. If a state of emergency under California Law is declared and the residential property is located in any ZIP Code within or adjacent to the fire perimeter, as determined by California Law, we may not nonrenew this policy for one year, beginning from the date the state of emergency is declared, solely because the dwelling or other structure is located in an area in which a wildfire has occurred. However, we may nonrenew: (1) If willful or grossly negligent acts or omissions by the Named Insured, or his or her representatives, are discovered that materially increase any of the risks insured against; (2) If losses unrelated to the postdisaster loss condition of the property have occurred that would collectively render the risk ineligible for renewal; or (3) If there are physical changes in the property insured against, beyond the catastrophe -damaged condition of the structures and surface landscape, which result in the property becoming uninsurable. We are not required to send notice of nonrenewal in the following situations: a. If the transfer or renewal of a policy, without any changes in terms, conditions or rates, is between us and a member of our insurance group. b. If the policy has been extended for 90 days or less, provided that notice has been given in accordance with Paragraph CA. c. If you have obtained replacement coverage, or if the first Named Insured has agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. d. If the policy is for a period of no more than 60 days and you are notified at the time of issuance that it will not be renewed. e. If the first Named Insured requests a change in the terms or conditions or risks covered by the policy within 60 days of the end of the policy period. f. If we have made a written offer to the first Named Insured, in accordance with the timeframes shown in Paragraph CA., to renew the policy under changed terms or conditions or at an increased premium rate, when the increase exceeds 25%. © Insurance Services Office, Inc., 2020 IL 02 70 (Ed. 07/20) (Page 4 of 4) �oRaN } z RAMmVmedDMsiun REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 74 00 (Ed. 07/01) Policy No. GLP 3961460 00 GENERAL LIABILITY COVERAGE PART DECLARATION PAGE NAMED INSURED: BACKHAUS DANCE POLICY PERIOD: 06/03/2021 to 06/03/2022 LIMITS OF INSURANCE: General Aggregate Limit (Other Than Products - Completed Operations) $ 2,000,000 Products - Completed Operations Aggregate Limit $ 2,000,000 Personal and Advertising Injury Limit $ 1,000,000 Each Occurrence Limit $ 1,000,000 Damage to Premises Rented to You Limit $ 100,000 Any One Premises Medical Expense Limit $ 5,000 Any One Person FORM OF BUSINESS: NOT FOR PROFIT ORGANIZATION TOTAL ESTIMATED PREMIUM: $ 2,837.00 Products/Completed Operations All Other $ $ 2,837.00 SCHEDULE OF LOCATIONS Location: 0001 Building: 0001 P. 0. BOX 5890 ORANGE, CA 92863 CODE NUMBER: 01211 PREMIUM BASIS: MANUAL RATED - NON -AUDIT Classification: SIGNATURE GENERAL LIABILITY BROADENING ENDORSEMENT Products/Completed Operations EXPOSURE: RATE: PREMIUM: $0.00 All Other EXPOSURE: IF ANY RATE: PREMIUM: $165.00 CG 74 00 (Ed. 07/01) (Page 1 of 2) �oRaN } z a RiskMmWmentDMsian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CODE NUMBER: 49891 LOC: 0001 BLDG: 0001 PREMIUM BASIS: PER EACH REGISTRANT Classification: YOUTH RECREATION PROGRAMS - NOT -FOR -PROFIT PRODUCTS -COMPLETED OPERATIONS COVERAGE IS INCLUDED BUT IS SUBJECT TO THE GENERAL AGGREGATE LIMIT NOT THE PRODUCT COMPLETED OPERATION AGGREGATE LIMIT, IF ANY Products/Completed Operations All Other EXPOSURE: EXPOSURE: 220 RATE: INCLUDED RATE: 4.847 PREMIUM: INCLUDED PREMIUM: $1,066.00 CODE NUMBER: 99718 LOC: 0001 BLDG: 0001 PREMIUM BASIS: PER $1000 PAYROLL Classification: THEATRICAL COMPANIES - TRAVELING PRODUCTS -COMPLETED OPERATIONS COVERAGE IS INCLUDED BUT IS SUBJECT TO THE GENERAL AGGREGATE LIMIT NOT THE PRODUCT COMPLETED OPERATION AGGREGATE LIMIT, IF ANY Products/Completed Operations All Other EXPOSURE: EXPOSURE: 143,500 RATE: INCLUDED RATE: 11.193 PREMIUM: INCLUDED PREMIUM: $1,606.00 FORMS AND ENDORSEMENTS applicable to this Coverage Part and made part of this Policy at time of issue: SEE CG 88 01 11/85 CG 74 00 (Ed. 07/01) (Page 2 of 2) �oRaN } z a RiskMmWmentDMsian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 82 82 (Ed. 12/09) Policy No. GLP 3961460 00 ABUSE OR MOLESTATION COVERAGE FORM DECLARATIONS PAGE NAMED INSURED: BACKHAUS DANCE POLICY PERIOD: 06/03/2021 to 06/03/2022 LIMITS OF INSURANCE: Aggregate Limit $ 2,000,000 Each Abuse Limit $ 1,000,000 DESCRIPTION OF BUSINESS: Form of Business NOT FOR PROFIT ORGANIZATION READ YOUR POLICY CAREFULLY, OPTIONAL COVERAGES ARE PROVIDED BY PREMIUM INSERTION. Abuse or Molestation Coverage Premium shown is payable: $ Premium $ 788 TOTAL ADVANCE PREMIUM $ 788 at inception; FORMS AND ENDORSEMENTS Applicable to this Coverage Part and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule CG 88 01 (11/85). CG 82 82 (Ed. 12/09) (Page 1 of 1) �oRaN } z a RAMmagzmentcMsiun REVIEWED & APPROVED BY: p R. W&Wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 88 01 (Ed. 11/85) FORMS AND ENDORSEMENTS SCHEDULE It is hereby understood and agreed the following forms and endorsements are attached to and are a part of this policy: Form and Edition Date Added or Date Deleted Form Description 1. CG0001 04/13 COMML GENERAL LIABILITY COVERAGE 2. CG2106 05/14 EXCLUSION -PERSONAL INFO & DATA-LIMI 3. CG2147 12/07 EMPLOYMENT RELATED PRACTICES EXCL 4. CG2171 01/15 LTD TERROR EXCL(O/T CERTIFIED)CAP L 5. CG2176 01/15 EXCL OF PUN DAMAGES RELATED TO TERR 6. CG2426 04/13 AMENDMENT OF INSURED CONTRACT DEFIN 7. CG7400 07/01 GENERAL LIABILITY DEC PAGE 8. CG7794 07/98 EXCL-LIABILITY ARISING OUT OF LEAD 9. CG8282 12/09 ABUSE & MOLESTATION 10. CG8361 02/05 SILICA OR DUST RELATED EXCL 11. CG8366 06/05 NUCLEAR, BIOLOGICAL, CHEMICAL EXCL 12. CG8440 08/09 COORDINATION OF LIMITS ENDORSEMENT 13. CG8481 08/14 EXCLUSION - ORGANIC PATHOGENS 14. CG8565 01/12 ABUSE OR MOLESTATION COVERAGE FORM 15. CG8970 11/14 SIGNATURE-GL-BROADNING ENDT 16. CG9082 06/17 EXCLUSION - PROFESSIONAL SERVICES 17. CG9083 06/17 ABUSE, MOL, HARASSMENT OR SEXUAL EX 18. CG9169 02/20 MEDICAL PAYMENTS AT YOUR REQUEST * If not at inception CG 88 01 (Ed. 11/85) (Page 1 of 1) �oRaN 3 RAMmWmentDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this Policy restrict coverage. Read the entire Policy carefully to determine rights, duties and what is and is not covered. Throughout this Policy the words "you" and "your" refer to the Named Insured shown in the Declara- tions, and any other person or organization quali- fying as a named insured under this Policy. The words "we", "us" and "our" refer to the company providing this insurance. The word "insured" means any person or or- ganization qualifying as such under SECTION II - WHO IS AN INSURED. Other words and phrases that appear in quotation marks have special meaning. Refer to SECTION V - DEFINITIONS. SECTION I - COVERAGES Coverage A - Bodily Injury and Property Dam- age Liability 1. Insuring Agreement a. We will pay those sums that the Insured becomes legally obligated to pay as dam- ages because of "bodily injury" or "prop- erty damage" to which this insurance ap- plies. We will have the right and duty to defend the Insured against any "suit' seek- ing those damages. However, we will have no duty to defend the Insured against any "suit" seeking damages for "bodily injury" or "property damage" to which this insur- ance does not apply. We may, at our dis- cretion, investigate any "occurrence" and settle any claim or "suit' that may result. But: (1) the amount we will pay for damages is limited as described in SECTION III - LIMITS OF INSURANCE; and (2) our right and duty to defend ends when we have used up the applicable Limit of Insurance in the payment of judgments or settlements under Cov- erages A or B or medical expenses under Coverage C. CG 00 01 (Ed. 04 13) No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Sup- plementary Payments - Coverages A and B. b. This insurance applies to "bodily injury" and "property damage" only if: (1) the "bodily injury" or "property dam- age" is caused by an "occurrence" that takes place in the "coverage territory"; (2) the "bodily injury" or "property dam- age" occurs during the policy period; and (3) prior to the policy period, no insured listed under paragraph 1. of SECTION II - WHO IS AN INSURED and no "employee" authorized by you to give or receive notice of an "occurrence" or claim, knew that the "bodily injury" or "property damage" had occurred, in whole or in part. If such a listed in- sured or authorized "employee" knew, prior to the policy period, that the "bodily injury" or "property damage" occurred, then any continuation, change or resumption of such "bodily injury" or "property damage" during or after the policy period will be deemed to have been known prior to the policy period. c. "Bodily injury" or "property damage" which occurs during the policy period and was not, prior to the policy period, known to have occurred by any insured listed under paragraph 1. of SECTION II - WHO IS AN INSURED or any "employee" authorized by you to give or receive notice of an "oc- currence" or claim, includes any continu- ation, change or resumption of that "bodily injury" or "property damage" after the end of the policy period. d. "Bodily injury" or "property damage" will be deemed to have been known to have occurred at the e insured listed under Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 1 of 20) �oRaN Risk ManagementDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 TION II - WHO IS AN INSURED or any "employee" authorized by you to give or receive notice of an "occurrence" or claim: (1) reports all, or any part, of the "bodily injury" or "property damage" to us or any other insurer; (2) receives a written or verbal demand or claim for damages because of the "bodily injury" or "property damage"; or (3) becomes aware by any other means that "bodily injury" or "property dam- age" has occurred or has begun to occur. e. Damages because of "bodily injury" include damages claimed by any person or or- ganization for care, loss of services or death resulting at any time from the "bodi- ly injury." 2. Exclusions This insurance does not apply to: a. Expected or Intended Injury "Bodily injury" or "property damage" ex- pected or intended from the standpoint of the Insured. This exclusion does not apply to "bodily injury" resulting from the use of reasonable force to protect persons or property. b. Contractual Liability "Bodily injury" or "property damage" for which the Insured is obligated to pay dam- ages by reason of the assumption of li- ability in a contract or agreement. This ex- clusion does not apply to liability for dam- ages: (1) that the Insured would have in the ab- sence of the contract or agreement; or (2) assumed in a contract or agreement that is an "insured contract," provided the "bodily injury" or "property dam- age" occurs subsequent to the execu- tion of the contract or agreement. Solely for the purposes of liability as- sumed in an "insured contract," rea- sonable attorneys' fees and necessary litigation expenses incurred by or for a party other than an insured are deemed to be damages because of "bodily injury" or "property damage," provided: (a) liability to such party for, or for the cost of, that party's defense has also been assumed in the same "insured contract"; and (b) such attorneys' fees and litigation expenses are for defense of that party against a civil or alternative dispute resolution proceeding in which damages to which this in- surance applies are alleged. c. Liquor Liability "Bodily injury" or "property damage" for which any insured may be held liable by reason of: (1) causing or contributing to the intoxi- cation of any person; (2) the furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol; or (3) any statute, ordinance or regulation relating to the sale, gift, distribution or use of alcoholic beverages. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in: (a) the supervision, hiring, employment, training or monitoring of others by that Insured; or (b) providing or failing to provide trans- portation with respect to any person that may be under the influence of alcohol; if the "occurrence" "bodily injury" or "p volved that which graph (1), (2) or (3) J Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 2 of 20) which caused the Ride Management DMsian REVIEWED & APPROVED BY.- r Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 However, this exclusion applies only if you are in the business of manufacturing, dis- tributing, selling, serving or furnishing al- coholic beverages. For the purposes of this exclusion, permitting a person to bring alcoholic beverages on your premises, for consumption on your premises, whether or not a fee is charged or a license is required for such activity, is not by itself considered the business of selling, serving or furnishing alcoholic beverages. d. Workers' Compensation and Similar Laws Any obligation of the Insured under a workers' compensation, disability benefits or unemployment compensation law or any similar law. e. Employer's Liability "Bodily injury" to: (1) an "employee" of the Insured arising out of and in the course of: (a) employment by the Insured; or (b) performing duties related to the conduct of the Insured's business; or (2) the spouse, child, parent, brother or sister of that "employee" as a con- sequence of paragraph (1) above. This exclusion applies whether the Insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the injury. This exclusion does not apply to liability assumed by the Insured under an "insured contract." f. Pollution (1) "Bodily injury" or "property damage" arising out of the actual, alleged or threatened discharge, dispersal, seep- age, migration, release or escape of "pollutants": (a) at or from any premises, site or location which is or was at any time owned or occupied by, or rented or loaned to, any insured. However, this subparagraph does not apply to: (i) "bodily injury" if sustained within a building and caused by smoke, fumes, vapor or soot produced by or origi- nating from equipment that is used to heat, cool or de- humidify the building, or equipment that is used to heat water for personal use, by the building's occupants or their guests; (i i) "bodily injury" or "property damage" for which you may be held liable, if you are a contractor and the owner or lessee of such premises, site or location has been added to your policy as an addi- tional insured with respect to your ongoing operations performed for that Addi- tional Insured at that prem- ises, site or location and such premises, site or loca- tion is not and never was owned or occupied by, or rented or loaned to, any in- sured, other than that Addi- tional Insured; or (iii) "bodily injury" or "property damage" arising out of heat, smoke or fumes from a "hostile fire"; (b) at or from any premises, site or location which is or was at any time used by or for any insured or others for the handling, stor- age, disposal, processing or treatment of waste; (c) which are or were at transported, handled, treated, disposed of, cessed as waste by or f Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 3 of 20) (i) any i any time stored, or pro - Ride Management DMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (ii) any person or organization being performed by you or for whom you may be legally on your behalf by a contrac- responsible; or for or subcontractor; or (d) at or from any premises, site or location on which any insured or any contractors or subcontrac- tors working directly or indirectly on any insured's behalf are per- forming operations if the "pollu- tants" are brought on or to the premises, site or location in con- nection with such operations by such insured, contractor or sub- contractor. However, this sub- paragraph does not apply to: (i) "bodily injury" or "property damage" arising out of the escape of fuels, lubricants or other operating fluids which are needed to per- form the normal electrical, hydraulic or mechanical functions necessary for the operation of "mobile equip- ment" or its parts, if such fuels, lubricants or other operating fluids escape from a vehicle part designed to hold, store or receive them. This exception does not ap- ply if the "bodily injury" or "property damage" arises out of the intentional discharge, dispersal or release of the fuels, lubricants or other operating fluids, or if such fuels, lubricants or other operating fluids are brought on or to the premises, site or location with the intent that they be discharged, dis- persed or released as part of the operations being per- formed by such insured, contractor or subcontractor; (ii) "bodily injury" or "property damage" sustained within a building and caused by the release of gases, fumes or vapors from materials brought into that building in connection with operations (iii) "bodily injury" or "property damage" arising out of heat, smoke or fumes from a "hostile fire." (e) at or from any premises, site or location on which any insured or any contractors or subcontrac- tors working directly or indirectly on any insured's behalf are per- forming operations if the oper- ations are to test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, "pollutants." (2) Any loss, cost or expense arising out of any: (a) request, demand, order or statu- tory or regulatory requirement that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neu- tralize, or in any way respond to, or assess the effects of, "pollu- tants"; or (b) claim or suit by or on behalf of a governmental authority for dam- ages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way re- sponding to, or assessing the ef- fects of, "pollutants." However, this paragraph does not ap- ply to liability for damages because of "property damage" that the Insured would have in the absence of such request, demand, order or statutory or regulatory requirement, or such claim or "suit" by or on behalf of a gov- ernmental authority. g. Aircraft, Auto or Watercraft "Bodily injury" or ' ing out of the c use or entrustmer Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 4 of 20) p oDeriv aama a ares- t Ride Management DMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 craft, "auto" or watercraft owned or op- h. Mobile Equipment erated by or rented or loaned to any in- sured. Use includes operation and "loading "Bodily injury" or "property damage" aris- or unloading." ing out of: This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hir- ing, employment, training or monitoring of others by that Insured, if the "occurrence" which caused the "bodily injury" or "prop- erty damage" involved the ownership, maintenance, use or entrustment to others of any aircraft, "auto" or watercraft that is owned or operated by or rented or loaned to any insured. This exclusion does not apply to: (1) a watercraft while ashore on premises you own or rent; (2) a watercraft you do not own that is: (a) less than 26 feet long; and (b) not being used to carry persons or property for a charge; (3) parking an "auto" on, or on the ways next to, premises you own or rent, provided the "auto" is not owned by or rented or loaned to you or the Insured; (4) liability assumed under any "insured contract" for the ownership, mainten- ance or use of aircraft or watercraft; or (5) "bodily injury" or "property damage" arising out of: (a) the operation of machinery or equipment that is attached to, or part of, a land vehicle that would qualify under the definition of "mobile equipment" if it were not subject to a compulsory or finan- cial responsibility law or other motor vehicle insurance law where it is licensed or principally garaged; or (b) the operation of any of the ma- chinery or equipment listed in paragraph f.(2) or f.(3) of the definition of "mobile equipment." (1) the transportation of "mobile equip- ment" by an "auto" owned or operated by or rented or loaned to any insured; or (2) the use of "mobile equipment" in, or while in practice for, or while being prepared for, any prearranged racing, speed, demolition, or stunting activity. L War "Bodily injury" or "property damage," however caused, arising, directly or in- directly, out of: (1) war, including undeclared or civil war; (2) warlike action by a military force, in- cluding action in hindering or defend- ing against an actual or expected at- tack, by any government, sovereign or other authority using military personnel or other agents; or (3) insurrection, rebellion, revolution, usurped power, or action taken by governmental authority in hindering or defending against any of these. j. Damage to Property "Property damage" to: (1) property you own, rent, or occupy, including any costs or expenses in- curred by you, or any other person, organization or entity, for repair, re- placement, enhancement, restoration or maintenance of such property for any reason, including prevention of in- jury to a person or damage to an - other's property; (2) premises you sell, give away or aban- don, if the "property damage" arises out of any part of those premises; (3) property loaned to you; (4) personal proper or control of the Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 5 of 20) Ride Management DMsian REVIEWED & APPROVED BY. - Risk Management Analyst y NJ * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (5) that particular part of real property on which you or any contractors or sub- contractors working directly or indi- rectly on your behalf are performing operations, if the "property damage" arises out of those operations; or (6) that particular part of any property that must be restored, repaired or re- placed because "your work" was in- correctly performed on it. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire) to premises, including the contents of such premises, rented to you for a period of seven or fewer con- secutive days. A separate Limit of Insur- ance applies to Damage to Premises Ren- ted to You as described in SECTION III - LIMITS OF INSURANCE. Paragraph (2) of this exclusion does not apply if the premises are "your work" and were never occupied, rented or held for rental by you. Paragraphs (3), (4), (5) and (6) of this ex- clusion do not apply to liability assumed under a sidetrack agreement. Paragraph (6) of this exclusion does not apply to "property damage" included in the "products -completed operations hazard." k. Damage to Your Product "Property damage" to "your product" aris- ing out of it or any part of it. I. Damage to Your Work "Property damage" to "your work" arising out of it or any part of it and included in the "products -completed operations haz- ard." This exclusion does not apply if the damaged work or the work out of which the damage arises was performed on your behalf by a subcontractor. m. Damage to Impaired Property or Prop- erty Not Physically Injured "Property damage" to "impaired property" or property that has not been physically injured, arising out of: (1) a defect, deficiency, inadequacy or dangerous condition in "your product" or "your work"; or (2) a delay or failure by you or anyone acting on your behalf to perform a contract or agreement in accordance with its terms. This exclusion does not apply to the loss of use of other property arising out of sudden and accidental physical injury to "your product" or "your work" after it has been put to its intended use. n. Recall of Products, Work or Impaired Property Damages claimed for any loss, cost or expense incurred by you or others for the loss of use, withdrawal, recall, inspection, repair, replacement, adjustment, removal or disposal of: (1) "your product"; (2) "your work"; or (3) "impaired property"; if such product, work, or property is withdrawn or recalled from the market or from use by any person or organization because of a known or suspected defect, deficiency, inadequacy or dangerous con- dition in it. o. Personal and Advertising Injury "Bodily injury" arising out of "personal and advertising injury." p. Electronic Data Damages arising out of of use of, damage to ability to access, or electronic data. Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 6 of 20) the loss of, loss enrriintinn of in - Risk Management DMsian REVIEWED & APPROVED BY. - Risk Management Analyst V NJ * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 However, this exclusion does not apply to Coverage B - Personal and Advertising Injury liability for damages because of "bodily Liability i nj u ry." As used in this exclusion, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer soft- ware, including systems and applications software, hard or floppy disks, CD-ROMs, tapes, drives, cells, data processing de- vices or any other media which are used with electronically controlled equipment. q. Recording and Distribution of Material or Information in Violation of Law "Bodily injury" or "property damage" aris- ing directly or indirectly out of any action or omission that violates or is alleged to violate: (1) the Telephone Consumer Protection Act (TCPA), including any amendment of or addition to such law; (2) the CAN-SPAM Act of 2003, including any amendment of or addition to such law; (3) the Fair Credit Reporting Act (FCRA), and any amendment of or addition to such law, including the Fair and Ac- curate Credit Transactions Act (FACTA); or (4) any federal, state or local statute, or- dinance or regulation, other than the TCPA, CAN-SPAM Act of 2003 or FCRA and their amendments and addi- tions, that addresses, prohibits, or lim- its the printing, dissemination, disposal, collecting, recording, sending, trans- mitting, communicating or distribution of material or information. Exclusions c. through n. do not apply to dam- age by fire to premises while rented to you or temporarily occupied by you with permis- sion of the owner. A separate Limit of Insur- ance applies to this coverage as described in SECTION III - LIMITS OF INSURANCE. 1. Insuring Agreement a. We will pay those sums that the Insured becomes legally obligated to pay as dam- ages because of "personal and advertising injury" to which this insurance applies. We will have the right and duty to defend the Insured against any "suit' seeking those damages. However, we will have no duty to defend the Insured against any "suit' seeking damages for "personal and ad- vertising injury" to which this insurance does not apply. We may, at our discretion, investigate any offense and settle any claim or "suit' that may result. But: (1) the amount we will pay for damages is limited as described in SECTION III - LIMITS OF INSURANCE; and (2) our right and duty to defend end when we have used up the applicable Limit of Insurance in the payment of judg- ments or settlements under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Sup- plementary Payments - Coverages A and B. b. This insurance applies to "personal and advertising injury" caused by an offense arising out of your business but only if the offense was committed in the "coverage territory" during the policy period. 2. Exclusions This insurance does not apply to: a. Knowing Violation of Rights of Another "Personal and advertising injury" caused by or at the direction of the Insured with the knowledge that the act would violate the rights of another a sonal and advertisin Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 7 of 20) o Ride Management DMsian REVIEWED &APPROVED BY.- � Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 b. Material Published with Knowledge of i. Infringement of Copyright, Patent, Falsity Trademark or Trade Secret "Personal and advertising injury" arising out of oral or written publication, in any man- ner, of material, if done by or at the di- rection of the Insured with knowledge of its falsity. c. Material Published Prior to Policy Pe- riod "Personal and advertising injury" arising out of oral or written publication, in any man- ner, of material whose first publication took place before the beginning of the policy period. d. Criminal Acts "Personal and advertising injury" arising out of a criminal act committed by or at the direction of the Insured. e. Contractual Liability "Personal and advertising injury" for which the Insured has assumed liability in a con- tract or agreement. This exclusion does not apply to liability for damages that the Insured would have in the absence of the contract or agreement. f. Breach of Contract "Personal and advertising injury" arising out of a breach of contract, except an implied contract to use another's advertising idea in your "advertisement." g. Quality or Performance of Goods - Failure to Conform to Statements "Personal and advertising injury" arising out of the failure of goods, products or ser- vices to conform with any statement of quality or performance made in your "ad- vertisement." h. Wrong Description of Prices "Personal and advertising injury" arising out of the wrong description of the price of goods, products or services stated in your "advertisement." "Personal and advertising injury" arising out of the infringement of copyright, patent, trademark, trade secret or other intellec- tual property rights. Under this exclusion, such other intellectual property rights do not include the use of another's advertis- ing idea in your "advertisement." However, this exclusion does not apply to infringement, in your "advertisement," of copyright, trade dress or slogan. j. Insureds in Media and Internet Type Businesses "Personal and advertising injury" commit- ted by an insured whose business is: (1) advertising, broadcasting, publishing or telecasting; (2) designing or determining content of web sites for others; or (3) an Internet search, access, content or service provider. However, this exclusion does not apply to paragraphs 14.a., b. and c. of "personal and advertising injury" under the Defini- tions section. For the purposes of this exclusion, the placing of frames, borders or links, or advertising, for you or others anywhere on the Internet, is not by itself, considered the business of advertising, broadcasting, publishing or telecasting. k. Electronic Chat Rooms or Bulletin Boards "Personal and advertising injury" arising out of an electronic chat room or bulletin board the Insured hosts, owns, or over which the Insured exercises control. I. Unauthorized Use of Another's Name or Product "Personal and advertisin iniur " arisina out of the unauthorized or product in your Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 8 of 20) Ride Managem * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 name or metatag, or any other similar tac- p. Recording and Distribution of Material tics to mislead another's potential custom- or Information in Violation of Law ers. m. Pollution "Personal and advertising injury" arising out of the actual, alleged or threatened dis- charge, dispersal, seepage, migration, re- lease or escape of "pollutants" at any time. n. Pollution -related Any loss, cost or expense arising out of any: (1) request, demand, order or statutory or regulatory requirement that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of, "pollutants"; or (2) claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of, "pollutants." o. War "Personal and advertising injury," however caused, arising, directly or indirectly, out of: (1) war, including undeclared or civil war; (2) warlike action by a military force, in- cluding action in hindering or defend- ing against an actual or expected at- tack, by any government, sovereign or other authority using military personnel or other agents; or (3) insurrection, rebellion, revolution, usurped power, or action taken by governmental authority in hindering or defending against any of these. "Personal and advertising injury" arising di- rectly or indirectly out of any action or omission that violates or is alleged to vio- late: (1) the Telephone Consumer Protection Act (TCPA), including any amendment of or addition to such law; (2) the CAN-SPAM Act of 2003, including any amendment of or addition to such law; (3) the Fair Credit Reporting Act (FCRA), and any amendment of or addition to such law, including the Fair and Ac- curate Credit Transactions Act (FACTA); or (4) any federal, state or local statute, or- dinance or regulation, other than the TCPA, CAN-SPAM Act of 2003 or FCRA and their amendments and addi- tions, that addresses, prohibits, or lim- its the printing, dissemination, disposal, collecting, recording, sending, trans- mitting, communicating or distribution of material or information. Coverage C - Medical Payments 1. Insuring Agreement a. We will pay medical expenses as de- scribed below for "bodily injury" caused by an accident: (1) on premises you own or rent; (2) on ways next to premises you own or rent; or (3) because of your operations; provided that: (a) the accident takes place in the "cov- erage territory" and during the policy period; (b) the expenses are incurred and re ort- ed to us within o the accident; and Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 9 of 20) Ride Management DMsian REVIEWED &APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (c) the injured person submits to exami- f. Products -Completed Operations Hazard nation, at our expense, by physicians of our choice as often as we reason- Included within the "products -completed ably require. operations hazard." b. We will make these payments regardless of fault. These payments will not exceed the applicable Limit of Insurance. We will pay reasonable expenses for: (1) first aid administered at the time of an accident; (2) necessary medical, surgical, X-ray and dental services, including prosthetic devices; and (3) necessary ambulance, hospital, pro- fessional nursing and funeral services. 2. Exclusions We will not pay expenses for "bodily injury": a. Any Insured To any insured, except "volunteer work- ers." b. Hired Person To a person hired to do work for or on behalf of any insured or a tenant of any insured. c. Injury on Normally Occupied Premises To a person injured on that part of prem- ises you own or rent that the person nor- mally occupies. d. Workers' Compensation and Similar Laws To a person, whether or not an "employ- ee" of any insured, if benefits for the "bodily injury" are payable or must be provided under a workers' compensation or disability benefits law or a similar law. e. Athletics Activities To a person injured while practicing, in- structing or participating in any physical exercises or games, sports, or athletic contests. g. Coverage A Exclusions Excluded under Coverage A. Supplementary Payments - Coverages A and B 1. We will pay, with respect to any claim we investigate or settle, or any "suit" against an insured we defend: a. All expenses we incur. b. Up to $250 for cost of bail bonds re- quired because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to fur- nish these bonds. c. The cost of bonds to release attachments, but only for bond amounts within the ap- plicable Limit of Insurance. We do not have to furnish these bonds. d. All reasonable expenses incurred by the Insured at our request to assist us in the investigation or defense of the claim or "suit," including actual loss of earnings up to $250 a day because of time off from work. e. All court costs taxed against the Insured in the "suit." However, these payments do not include attorneys' fees or attorneys' expenses taxed against the Insured. f. Prejudgment interest awarded against the Insured on that part of the judgment we pay. If we make an offer to pay the ap- plicable Limit of Insurance, we will not pay any prejudgment interest based on that period of time after the offer. g. All interest on the full amount of any judgment that accrues after entry of the judgment and before we have paid, of- fered to pay, or deposited in court the part of the judgment that is within the applicable Limit of Insurance. These payments will nc Insurance. Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 10 of 20) Ride Management DMsian REVIEWED & APPROVED BY.- PZ. VSA44a Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 2. If we defend an insured against a "suit" and an (2) Provides us with written authorization indemnitee of the Insured is also named as a to: party to the "suit," we will defend that indem- nitee if all of the following conditions are met: (a) obtain records and other infor- mation related to the "suit"; and a. the "suit" against the indemnitee seeks damages for which the Insured has as- sumed the liability of the indemnitee in a contract or agreement that is an "insured contract"; b. this insurance applies to such liability as- sumed by the Insured; c. the obligation to defend, or the cost of the defense of, that indemnitee, has also been assumed by the Insured in the same "insured contract"; d. the allegations in the "suit" and the in- formation we know about the "occur- rence" are such that no conflict appears to exist between the interests of the Insured and the interests of the indemnitee; e. the indemnitee and the Insured ask us to conduct and control the defense of that indemnitee against such "suit" and agree that we can assign the same counsel to defend the Insured and the indemnitee; and f. the indemnitee: (1) Agrees in writing to: (a) cooperate with us in the inves- tigation, settlement or defense of the "suit"; (b) immediately send us copies of any demands, notices, summonses or legal papers received in con- nection with the "suit"; (c) notify any other insurer whose coverage is available to the in- demnitee; and (d) cooperate with us with respect to coordinating other applicable in- surance available to the indem- nitee; and (b) conduct and control the defense of the indemnitee in such "suit." So long as the above conditions are met, at- torneys' fees incurred by us in the defense of that indemnitee, necessary litigation expenses incurred by us and necessary litigation ex- penses incurred by the indemnitee at our re- quest will be paid as Supplementary Payments. Notwithstanding the provisions of paragraph 2.b.(2) of SECTION I - COVERAGE A - Bodi- ly Injury and Property Damage Liability, such payments will not be deemed to be damages for "bodily injury" and "property damage" and will not reduce the Limits of Insurance. Our obligation to defend an insured's indem- nitee and to pay for attorneys' fees and nec- essary litigation expenses as Supplementary Payments ends when we have used up the applicable Limit of Insurance in the payment of judgments or settlements or the conditions set forth above, or the terms of the agree- ment described in paragraph f. above, are no longer met. SECTION II - WHO IS AN INSURED 1. If you are designated in the Declarations as: a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses are also insureds, but only with respect to the conduct of your busi- ness. c. A limited liability company, you are an in- sured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insur- eds, but only with as your managers. Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 11 of 20) Ride Management DMsian REVIEWED &APPROVED BY.- � Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 d. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your "executive of- ficers" and directors are insureds, but only with respect to their duties as your of- ficers or directors. Your stockholders are also insureds, but only with respect to their liability as stockholders. e. A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as trustees. 2. Each of the following is also an insured: a. Your "volunteer workers" only while per- forming duties related to the conduct of your business, or your "employees," other than either your "executive officers" (if you are an organization other than a part- nership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these "employees" or "volunteer workers" are insureds for: (1) "Bodily injury" or "personal and ad- vertising injury": (a) to you, to your partners or mem- bers (if you are a partnership or joint venture), to your members (if you are a limited liability com- pany), to a co -"employee" while in the course of his or her em- ployment or performing duties related to the conduct of your business, or to your other "volun- teer workers" while performing duties related to the conduct of your business; (b) to the spouse, child, parent, brother or sister of that co -"em- ployee" or "volunteer worker" as a consequence of paragraph (1)(a) above; (c) for which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraph (1)(a) or (b) above; or (d) arising out of his or her providing or failing to provide professional health care services. (2) "Property damage" to property: (a) owned, occupied or used by; (b) rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by; you, any of your "employees", "volun- teer workers", any partner or member (if you are a partnership or joint ven- ture), or any member (if you are a limited liability company). b. Any person (other than your "employee" or "volunteer worker"), or any organization while acting as your real estate manager. c. Any person or organization having proper temporary custody of your property if you die, but only: (1) with respect to liability arising out of the maintenance or use of that prop- erty; and (2) until your legal representative has been appointed. d. Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this Coverage Part. 3. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as a named insured if there is no other similar insurance available to that organization. However: a. coverage under this provision is afforded only until the 90th av after vou ac uire or form the organiz policy period, which Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 12 of 20) Ride ManagementDit isian REVIEWED &APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 b. Coverage A does not apply to "bodily in- 5. Subject to paragraph 2. or 3. above, which - jury" or "property damage" that occurred ever applies, the Each Occurrence Limit is the before you acquired or formed the or- most we will pay for the sum of: ganization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. No person or organization is an insured with re- spect to the conduct of any current or past part- nership, joint venture or limited liability company that is not shown as a named insured in the Dec- larations. SECTION III - LIMITS OF INSURANCE 1. The Limits of Insurance shown in the Declara- tions and the rules below fix the most we will pay regardless of the number of: a. insureds; b. claims made or "suits" brought; or c. persons or organizations making claims or bringing "suits." 2. The General Aggregate Limit is the most we will pay for the sum of: a. medical expenses under Coverage C; b. damages under Coverage A, except dam- ages because of "bodily injury" or "prop- erty damage" included in the "products - completed operations hazard"; and c. damages under Coverage B. 3. The Products -Completed Operations Aggre- gate Limit is the most we will pay under Cov- erage A for damages because of "bodily in- jury" and "property damage" included in the "products -completed operations hazard". 4. Subject to paragraph 2. above, the Personal and Advertising Injury Limit is the most we will pay under Coverage B for the sum of all damages because of all "personal and adver- tising injury" sustained by any one person or organization. a. damages under Coverage A; and b. medical expenses under Coverage C because of all "bodily injury" and "property damage" arising out of any one "occurrence". 6. Subject to paragraph 5. above, the Damage to Premises Rented to You Limit is the most we will pay under Coverage A for damages be- cause of "property damage" to any one prem- ises, while rented to you, or in the case of damage by fire, while rented to you or tem- porarily occupied by you with permission of the owner. 7. Subject to paragraph 5. above, the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by any one person. The Limits of Insurance of this Coverage Part apply separately to each consecutive annual pe- riod and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations, unless the poli- cy period is extended after issuance for an addi- tional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determin- ing the Limits of Insurance. SECTION IV - COMMERCIAL GENERAL LIABIL- ITY CONDITIONS 1. Bankruptcy Bankruptcy or insolvency of the Insured or of the Insured's estate will not relieve us of our obligations under this Coverage Part. 2. Duties in the Event of Occurrence, Offense, Claim or Suit a. You must see to it that we are notified as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, notice should include: (1) how, when ar rence" or offen Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 13 of 20) Ride Management DMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (2) the names and addresses of any in- b. to sue us on this Coverage Part unless all jured persons and witnesses; and of its terms have been fully complied with. (3) the nature and location of any injury or damage arising out of the "occurrence" or offense. b. If a claim is made or "suit" is brought against any insured, you must: (1) immediately record the specifics of the claim or "suit" and the date re- ceived; and (2) notify us as soon as practicable. You must see to it that we receive written notice of the claim or "suit" as soon as practicable. c. You and any other involved insured must: (1) immediately send us copies of any de- mands, notices, summonses or legal papers received in connection with the claim or "suit"; (2) authorize us to obtain records and other information; (3) cooperate with us in the investigation or settlement of the claim or defense against the "suit"; and (4) assist us, upon our request, in the en- forcement of any right against any person or organization which may be liable to the Insured because of injury or damage to which this insurance may also apply. d. No insured will, except at that Insured's own cost, voluntarily make a payment, as- sume any obligation, or incur any expense, other than for first aid, without our con- sent. 3. Legal Action Against Us No person or organization has a right under this Coverage Part: a. to join us as a party or otherwise bring us into a "suit" asking for damages from an insured; or A person or organization may sue us to re- cover on an agreed settlement or on a final judgment against an insured; but we will not be liable for damages that are not payable under the terms of this Coverage Part or that are in excess of the applicable Limit of Insur- ance. An agreed settlement means a settle- ment and release of liability signed by us, the Insured and the claimant or the claimant's legal representative. 4. Other Insurance If other valid and collectible insurance is avail- able to the Insured for a loss we cover under Coverages A or B of this Coverage Part, our obligations are limited as follows: a. Primary Insurance This insurance is primary except when paragraph b. below applies. If this insur- ance is primary, our obligations are not affected unless any of the other insurance is also primary. Then, we will share with all that other insurance by the method de- scribed in paragraph c. below. b. Excess Insurance (1) This insurance is excess over: (a) Any of the other insurance, whether primary, excess, contin- gent or on any other basis: Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 14 of 20) (i) that is Fire, Extended Cov- erage, Builder's Risk, Installa- tion Risk or similar coverage for "your work"; (ii) that is Fire insurance for premises rented to you or temporarily occupied by you with permission of the own- er; (iii) that is insurance purchased by you to cover your liability as a tenant for "property damage" to premises rented to you or tem oraril occu- pied b of the Ride Management i?710n REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (iv) if the loss arises out of the maintenance or use of air- craft, "autos" or watercraft to the extent not subject to exclusion g. of SECTION I - COVERAGE A - Bodily In- jury and Property Damage Liability. (b) Any other primary insurance available to you covering liability for damages arising out of the premises or operations, or the products and completed oper- ations, for which you have been added as an additional insured. (2) When this insurance is excess, we will have no duty under Coverages A or B to defend the Insured against any "suit" if any other insurer has a duty to de- fend the Insured against that "suit." If no other insurer defends, we will un- dertake to do so, but we will be en- titled to the Insured's rights against all those other insurers. (3) When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (a) the total amount that all such oth- er insurance would pay for the loss in the absence of this insur- ance; and (b) the total of all deductible and self -insured amounts under all that other insurance. (4) We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insur- ance Provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Dec- larations of this Coverage Part. c. Method of Sharing If all of the other insurance permits con- tribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable Limit of Insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this meth- od, each insurer's share is based on the ratio of its applicable Limit of Insurance to the total applicable Limits of Insurance of all insurers. 5. Premium Audit a. We will compute all premiums for this Coverage Part in accordance with our rules and rates. b. Premium shown in this Coverage Part as advance premium is a deposit premium only. At the close of each audit period we will compute the earned premium for that period and send notice to the first Named Insured. The due date for audit and ret- rospective premiums is the date shown as the due date on the bill. If the sum of the advance and audit premiums paid for the policy period is greater than the earned premium, we will return the excess to the first Named Insured. c. The first Named Insured must keep records of the information we need for premium computation, and send us copies at such times as we may request. 6. Representations By accepting this Policy, you agree: a. the statements in the Declarations are ac- curate and complete; b. those statements are based upon repre- sentations you made to us; and c. we have issued this Policy in reliance upon your representations. 7. Separation of Insureds Except with respect to the Limits of Insur- ance, and any rights or duties sipecifically as- signed in this Covera Named Insured, this insu Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 15 of 20) Ride Management DMsian REVIEWED &APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 a. as if each named insured were the only b. any other land vehicle that is subject to a named insured; and compulsory or financial responsibility law or other motor vehicle insurance law b. separately to each insured against whom where it is licensed or principally garaged. claim is made or "suit" is brought. 8. Transfer of Rights of Recovery Against Others to Us If the Insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The Insured must do nothing after loss to impair them. At our request, the Insured will bring "suit" or transfer those rights to us and help us enforce them. 9. When We Do Not Renew If we decide not to renew this Coverage Part, we will mail or deliver to the first Named Insured shown in the Declarations written no- tice of the nonrenewal not less than 30 days before the expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. SECTION V - DEFINITIONS 1. "Advertisement" means a notice that is broadcast or published to the general public or specific market segments about your goods, products or services for the purpose of attracting customers or supporters. For the purposes of this definition: a. notices that are published include material placed on the Internet or on similar elec- tronic means of communication; and b. regarding web sites, only that part of a web site that is about your goods, pro- ducts or services for the purposes of attracting customers or supporters is considered an advertisement. 2. "Auto" means: a. a land motor vehicle, trailer or semitrailer designed for travel on public roads, in- cluding any attached machinery or equip- ment; or However, "auto" does not include "mobile equipment." 3. "Bodily injury" means bodily injury, sickness or disease sustained by a person, including death resulting from any of these at any time. 4. "Coverage territory" means: a. the United States of America (including its territories and possessions), Puerto Rico and Canada; b. international waters or airspace, but only if the injury or damage occurs in the course of travel or transportation between any places included in paragraph a. above; or c. all other parts of the world if the injury or damage arises out of: (1) goods or products made or sold by you in the territory described in para- graph a. above; (2) the activities of a person whose home is in the territory described in para- graph a. above, but is away for a short time on your business; or (3) "personal and advertising injury" of- fenses that take place through the In- ternet or similar electronic means of communication; provided the Insured's responsibility to pay damages is determined in a "suit" on the mer- its, in the territory described in paragraph a. above or in a settlement we agree to. 5. "Employee" includes a "leased worker". "Em- ployee" does not include a "temporary work- er". 6. "Executive officer" means a person holding any of the officer positions created by your charter, constitution, similar governing docu Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 16 of 20) m Ride ManagementDit isian REVIEWED &APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 7. "Hostile fire" means one which becomes un- Paragraph f. does not include that part of controllable or breaks out from where it was any contract or agreement: intended to be. (1) that indemnifies a railroad for "bodily 8. "Impaired property" means tangible prop- injury" or "property damage" arising erty, other than "your product" or "your out of construction or demolition op - work", that cannot be used or is less useful erations, within 50 feet of any railroad because: property and affecting any railroad bridge or trestle, tracks, road -beds, a. it incorporates "your product" or "your tunnel, underpass or crossing; work" that is known or thought to be de- fective, deficient, inadequate or danger- (2) that indemnifies an architect, engineer ous; or or surveyor for injury or damage aris- ing out of: b. you have failed to fulfill the terms of a contract or agreement; (a) preparing, approving, or failing to if such property can be restored to use by prepare or approve, maps, shop the repair, replacement, adjustment or remov- drawings, opinions, reports, sur- al of "your product" or "your work" or your veys, field orders, change orders fulfilling the terms of the contract or agree- or drawings and specifications; or ment. (b) giving directions or instructions, 9. "Insured contract" means: or failing to give them, if that is the primary cause of the injury or a. a contract for a lease of premises. How- damage; or ever, that portion of the contract for a lease of premises that indemnifies any (3) under which the Insured, if an archi- person or organization for damage by fire tect, engineer or surveyor, assumes li- to premises while rented to you or tem- ability for an injury or damage arising porarily occupied by you with permission out of the Insured's rendering or fail - of the owner is not an "insured contract"; ure to render professional services, including those listed in (2) above and b. a sidetrack agreement; supervisory, inspection, architectural or engineering activities. c. any easement or license agreement, ex- cept in connection with construction or 10. "Leased worker" means a person leased to demolition operations on or within 50 feet you by a labor leasing firm under an agree - of a railroad; ment between you and the labor leasing firm, to perform duties related to the conduct of d. an obligation, as required by ordinance, to indemnify a municipality, except in con - your business. "Leased worker" does not in- nection with work for a municipality; clude a "temporary worker." e. an elevator maintenance agreement; 11. "Loading or unloading" means the handling of property: f. that part of any other contract or agree- ment pertaining to your business (including an indemnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury" or "property damage" to a third person or organization. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement. a. after it is moved from the place where it is accepted for movement into or onto an aircraft, watercraft or "auto"; b. while it is in or on an aircraft, watercraft or "auto"; or c. while it is being moved watercraft or "auto" is finally delivered; Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 17 of 20) from An aircraft Risk Management Divisian REVIEWED & APPROVED BY.- � Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 but "loading or unloading" does not include the movement of property by means of a me- chanical device, other than a hand truck, that is not attached to the aircraft, watercraft or "auto". 12. "Mobile equipment" means any of the fol- lowing types of land vehicles, including any attached machinery or equipment: a. bulldozers, farm machinery, forklifts and other vehicles designed for use principally off public roads; b. vehicles maintained for use solely on or next to premises you own or rent; c. vehicles that travel on crawler treads; d. vehicles, whether self-propelled or not, maintained primarily to provide mobility to permanently mounted: (1) power cranes, shovels, loaders, dig- gers or drills; or (2) road construction or resurfacing equipment such as graders, scrapers or rollers; e. vehicles not described in paragraph a., b., c. or d. above that are not self-propelled and are maintained primarily to provide mobility to permanently attached equip- ment of the following types: (1) air compressors, pumps and gener- ators, including spraying, welding, building cleaning, geophysical explora- tion, lighting and well servicing equip- ment; or (2) cherry pickers and similar devices used to raise or lower workers; f. vehicles not described in paragraph a., b., c. or d. above maintained primarily for purposes other than the transportation of persons or cargo. However, self-propelled vehicles with the following types of permanently attached equipment are not "mobile equipment" but will be considered "autos": (1) equipment designed primarily for: (a) snow removal; (b) road maintenance, but not con- struction or resurfacing; or (c) street cleaning; (2) cherry pickers and similar devices mounted on automobile or truck chas- sis and used to raise or lower work- ers; and (3) air compressors, pumps and gener- ators, including spraying, welding, building cleaning, geophysical explora- tion, lighting and well servicing equip- ment. However, "mobile equipment" does not include any land vehicles that are subject to a com- pulsory or financial responsibility law or other motor vehicle insurance law where it is li- censed or principally garaged. Land vehicles subject to a compulsory or financial respon- sibility law or other motor vehicle insurance law are considered "autos". 13. "Occurrence" means an accident, including continuous or repeated exposure to substan- tially the same general harmful conditions. 14. "Personal and advertising injury" means in- jury, including consequential "bodily injury," arising out of one or more of the following offenses: a. false arrest, detention or imprisonment; b. malicious prosecution; c. the wrongful eviction from, wrongful en- try into, or invasion of the right of private occupancy of a room, dwelling or prem- ises that a person occupies, committed by or on behalf of its owner, landlord or lessor; d oral or written publication, in any manner, of material that slanders or libels a person or organization or Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 18 of 20) is ara es a erson's * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 e. oral or written publication, in any manner, b. Does not include "bodily injury" or "prop - of material that violates a person's right of erty damage" arising out of: privacy; f. the use of another's advertising idea in your "advertisement"; or g. infringing upon another's copyright, trade dress or slogan in your "advertisement". 15. "Pollutants" mean any solid, liquid, gaseous or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled, reconditioned or reclaimed. 16. "Products -completed operations hazard": a. Includes all "bodily injury" and "property damage" occurring away from premises you own or rent and arising out of "your product" or "your work" except: (1) products that are still in your physical possession; or (2) work that has not yet been completed or abandoned. However, "your work" will be deemed completed at the earli- est of the following times: (a) When all of the work called for in your contract has been complet- ed. (b) When all of the work to be done at the job site has been com- pleted if your contract calls for work at more than one job site. (1) the transportation of property, unless the injury or damage arises out of a condition in or on a vehicle not owned or operated by you, and that condition was created by the "loading or un- loading" of that vehicle by any insured; (2) the existence of tools, uninstalled equipment or abandoned or unused materials; or (3) products or operations for which the classification, listed in the Declarations or in a policy Schedule, states that products -completed operations are subject to the General Aggregate Limit. 17. "Property damage" means: (c) When that part of the work done at a job site has been put to its 18 intended use by any person or organization other than another contractor or subcontractor working on the same project. Work that may need service, main- tenance, correction, repair or replace- ment, but which is otherwise com- plete, will be treated as completed. a. physical injury to tangible property, in- cluding all resulting loss of use of that property. All such loss of use shall be deemed to occur at the time of the phys- ical injury that caused it; or b. loss of use of tangible property that is not physically injured. All such loss of use shall be deemed to occur at the time of the "occurrence" that caused it. For the purposes of this insurance, electronic data is not tangible property. As used in this definition, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including sys- tems and applications software, hard or flop- py disks, CD-ROMs, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equip- ment. "Suit" means a civil proceeding in which damages because of "bodily injury", "property damage" or "personal and advertising injury" to which this insurance applies are alleged. "Suit" includes: a. an arbitration proceeding in which such damages are claimed and to which the In- sured must submit our consent; or Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 19 of 20) Ride Management DMsian REVIEWED &APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 b. any other alternative dispute resolution proceeding in which such damages are claimed and to which the Insured submits with our consent. 19. "Temporary worker" means a person who is furnished to you to substitute for a permanent "employee" on leave or to meet seasonal or short-term workload conditions. 20. "Volunteer worker" means a person who is not your "employee", and who donates his or her work and acts at the direction of and within the scope of duties determined by you, and is not paid a fee, salary or other com- pensation by you or anyone else for their work performed for you. 21. "Your product": a. Means: (1) any goods or products, other than real property, manufactured, sold, handled, distributed or disposed of by: (a) you; (b) others trading under your name; or (c) a person or organization whose business or assets you have ac- quired; and (2) containers (other than vehicles), ma- terials, parts or equipment furnished in connection with such goods or pro- ducts. b. Includes: (1) warranties or representations made at any time with respect to the fitness, quality, durability, performance or use of "your product"; and (2) the providing of or failure to provide warnings or instructions. c. Does not include vending machines or other property rented to or located for the use of others but not sold. 22. "Your work": a. Means: (1) work or operations performed by you or on your behalf; and (2) materials, parts or equipment furnished in connection with such work or op- erations. b. Includes: (1) warranties or representations made at any time with respect to the fitness, quality, durability, performance or use of "your work"; and (2) the providing of or failure to provide warnings or instructions. Copyright, ISO Properties, Inc., 2012 CG 00 01 (Ed. 04/13) (Page 20 of 20) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 21 06 (Ed. 05 14 ) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION AND DATA -RELATED LIABILITY - WITH LIMITED BODILY INJURY EXCEPTION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Exclusion 2.p. of SECTION I - COVERAGE A - Bodily Injury and Property Damage Li- ability is replaced by the following: 2. Exclusions This insurance does not apply to: p. Access or Disclosure of Confiden- tial or Personal Information and Data -related Liability Damages arising out of: (1) any access to or disclosure of any person's or organization's confidential or personal informa- tion, including patents, trade se- crets, processing methods, cus- tomer lists, financial information, credit card information, health in- formation or any other type of nonpublic information; or (2) the loss of, loss of use of, dam- age to, corruption of, inability to access, or inability to manipulate electronic data. This exclusion applies even if damages are claimed fo r notification costs, credit monitoring expenses, forensic expenses, public relations expenses or any other loss, cost or expense in- curred by you or others arising out of that which is described in paragraph (1) or (2) above. However, unless paragraph (1) above applies, this exclusion does not apply to damages because of "bodily injury." As used in this exclusion, electronic data means information, facts or pro- grams stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD-ROMs, tapes, drives, cells, data processing devices or any other media which are used with elec- tronically controlled equipment. B. The following is added to paragraph 2. Exclu- sions of SECTION I - COVERAGE B - Per- sonal and Advertising Injury Liability: 2. Exclusions This insurance does not apply to: Access or Disclosure of Confidential or Personal Information "Personal and advertising injury" arising out of any access to or disclosure of any person's or organization's confidential or personal information, including patents, trade secrets, processing methods, cus- tomer lists, financial information, credit card information, health information or any other type of nonpublic information. This exclusion applies even if damages are claimed for notification costs, credit mon- itoring expenses, forensic expenses, pub- lic relations expenses or any other loss, cost or expense incurred by you or others arising out of any a of any person's or dential or personal i Copyright, Insurance Services Office, Inc., 2013 CG 21 06 (Ed. 05/14) Ride Management DMsian REVIEWED & AP4P'.gq ROVED BY.- � Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 21 47 (Ed. 12 07) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EMPLOYMENT -RELATED PRACTICES EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following exclusion is added to paragraph B. The following exclusion is added to paragraph 2., Exclusions of Section I - Coverage A - 2., Exclusions of Section I - Coverage B - Bodily Injury and Property Damage Liability: Personal and Advertising Injury Liability: This insurance does not apply to: "Bodily injury" to: (1) a person arising out of any: (a) refusal to employ that person; (b) termination of that person's employ- ment; or (c) employment -related practices, poli- cies, acts or omissions, such as coer- cion, demotion, evaluation, reassign- ment, discipline, defamation, harass- ment, humiliation, discrimination or malicious prosecution directed at that person; or (2) the spouse, child, parent, brother or sister of that person as a consequence of "bodily injury" to that person at whom any of the employment -related practices de- scribed in paragraphs (a), (b) or (c) above is directed. This exclusion applies: (1) whether the injury -causing event de- scribed in paragraphs (a), (b) or (c) above occurs before employment, during employment or after employ- ment of that person; (2) whether the Insured may be liable as an employer or in any other capacity; and (3) to any obligation to share damages with or repay someone else who must pay damages because of the injury. This insurance does not apply to: "Personal and advertising injury" to: (1) a person arising out of any: (a) refusal to employ that person; (b) termination of that person's employ- ment; or (c) employment -related practices, poli- cies, acts or omissions, such as coer- cion, demotion, evaluation, reassign- ment, discipline, defamation, harass- ment, humiliation, discrimination or malicious prosecution directed at that person; or (2) the spouse, child, parent, brother or sister of that person as a consequence of "per- sonal and advertising injury" to that person at whom any of the employment -related practices described in paragraphs (a), (b) or (c) above is directed. This exclusion applies: (1) whether the injury -causing event de- scribed in paragraphs (a), (b) or (c) above occurs before employment, during em- ployment or after employment of that person; (2) whether the Insured may be liable as an employer or in any other capacity; and (3) to any obligation to share damages with or repay someone els ages because of the Copyright, ISO Properties, Inc., 2006 CG 21 47 (Ed. 12/07) XS � oRaN a tvskManagementDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG2167 (Ed. 12 04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FUNGI OR BACTERIA EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following exclusion is added to paragraph B. The following exclusion is added to paragraph 2. Exclusions of SECTION I - Coverage A - 2. Exclusions of SECTION I - Coverage B - Bodily Injury and Property Damage Liability: Personal and Advertising Injury Liability: 2. Exclusions This insurance does not apply to: Fungi or Bacteria a. "Bodily injury" or "property damage" which would not have occurred, in whole or in part, but for the actual, alleged or threatened inhalation of, in- gestion of, contact with, exposure to, existence of, or presence of, any "fungi" or bacteria on or within a building or structure, including its con- tents, regardless of whether any other cause, event, material or product con- tributed concurrently or in any se- quence to such injury or damage. b. Any loss, cost or expenses arising out of the abating, testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, neutralizing, re - mediating or disposing of, or in any way responding to, or assessing the effects of, "fungi" or bacteria, by any insured or by any other person or en- tity. This exclusion does not apply to any "fungi" or bacteria that are, are on, or are contained in, a good or product intended for bodily consumption. 2. Exclusions This insurance does not apply to: Fungi or Bacteria a. "Personal and advertising injury" which would not have taken place, in whole or in part, but for the actual, alleged or threatened inhalation of, ingestion of, contact with, exposure to, existence of, or presence of any "fungi" or bac- teria on or within a building or struc- ture, including its contents, regardless of whether any other cause, event, material or product contributed con- currently or in any sequence to such injury. b. Any loss, cost or expense arising out of the abating, testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, neutralizing, re - mediating or disposing of, or in any way responding to, or assessing the effects of, "fungi" or bacteria, by any insured or by any other person or en- tity. C. The following definition is added to the Defi- nitions Section: "Fungi" means any type or form of fungus, including mold or mildew and any mycotoxins, spores, scents or byproducts produced or released by fungi. Copyright, ISO Properties, Inc., 2003 CG 21 67 (Ed. 12/04) XS HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 21 76 (Ed. 01/15) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION OF PUNITIVE DAMAGES RELATED TO A CERTIFIED ACT OF TERRORISM This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY A. The following exclusion is added: This insurance does not apply to: TERRORISM PUNITIVE DAMAGES Damages arising, directly or indirectly, out of a "certified act of terrorism" that are awarded as punitive damages. B. The following definition is added: "Certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in accordance with the provisions of the fed- eral Terrorism Risk Insurance Act, to be an act of terrorism pursuant to such Act. The criteria contained in the Terrorism Risk Insurance Act for a "certified act of terrorism" include the following: 1. The act resulted in insured losses in ex- cess of $5 million in the aggregate, attrib- utable to all types of insurance subject to the Terrorism Risk Insurance Act; and 2. The act is a violent act or an act that is dangerous to human life, property or in- frastructure and is committed by an in- dividual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. C. The terms and limitations of any terrorism exclusion, or the inapplicability or omission of a terrorism exclusion, do not serve to create coverage for injury or damage that is other- wise excluded under this Coverage Part. ©Insurance Services Office, Inc., 2015 CG 21 76 (Ed. 01/15) HORaN } z RiskMwaganedDMsian REVIEWED & APPROVED BY.- f R. V;&wd Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 24 26 (Ed. 04 13) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT OF INSURED CONTRACT DEFINITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The definition of "insured contract" in the Defini- your assumption of the tort liability is permit- tions section is replaced by the following: ted by law. Tort liability means a liability that would be imposed by law in the absence of "Insured contract" means: any contract or agreement. a. a contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or or- ganization for damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract"; b. a sidetrack agreement; c. any easement or license agreement, except in connection with construction or demolition operations on or within 50 feet of a railroad; d. an obligation, as required by ordinance, to in- demnify a municipality, except in connection with work for a municipality; e. an elevator maintenance agreement; f. that part of any other contract or agreement pertaining to your business (including an in- demnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury" or "property damage" to a third person or organization, provided the "bodily injury" or "property dam- age" is caused, in whole or in part, by you or by those acting on your behalf. However, such part of a contract or agreement shall only be considered an "insured contract" to the extent Paragraph f. does not include that part of any contract or agreement: (1) that indemnifies a railroad for "bodily in- jury" or "property damage" arising out of construction or demolition operations, within 50 feet of any railroad property and affecting any railroad bridge or tres- tle, tracks, road -beds, tunnel, underpass or crossing; (2) that indemnifies an architect, engineer or surveyor for injury or damage arising out of: (a) preparing, approving, or failing to pre- pare or approve, maps, shop drawings, opinions, reports, surveys, field or- ders, change orders or drawings and specifications; or (b) giving directions or instructions, or failing to give them, if that is the pri- mary cause of the injury or damage; or (3) under which the Insured, if an architect, engineer or surveyor, assumes liability for an injury or damage arising out of the Insured's rendering or failure to render professional services, including those list- ed in (2) above and supervisory, inspec- tion, architectural or engineering activities. Copyright, ISO Properties, Inc., 2012 CG 24 26 (Ed. 04/13) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - LIABILITY ARISING OUT OF LEAD This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS COVERAGE PART This insurance does not apply to: 1. "bodily injury," "property damage," or "per- sonal and advertising injury" arising out of, resulting from, or in any way caused by or related to the actual, alleged or threatened ingestion, inhalation, absorption, or exposure to lead in any form from any source; or 2. any loss, cost, expense, liability or other type of obligation arising out of or resulting from, or in any way related to, any: CG 77 94 (Ed. 07 98) tralize, or in any way respond to, or as- sess the effects of lead in any form from any source, or to any b. claim or suit by or on behalf of any per- son, entity, or governmental authority for damages or any other relief or remedy because of testing for, monitoring, clean- ing up, removing, containing, treating or detoxifying or neutralizing, or in any way responding to, or assessing the effects of lead in any form. a. claim, suit, request, demand, directive, or We shall not be obligated to investigate on behalf order by or on behalf of any person, en- of an Insured or to defend or indemnify an In- tity, or governmental authority that any In- sured or any person or entity claiming any right sured or others test for, monitor, clean under the policy for the matters excluded in this up, remove, contain, treat, detoxify, neu- endorsement. Includes copyrighted material of Insurance Services Office, Inc., with it CG 77 94 (Ed. 07/98) XS �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 COORDINATION OF LIMITS ENDORSEMENT This endorsement modifies insurance provided under the following: PROFESSIONAL LIABILITY INSURANCE COMMERCIAL GENERAL LIABILITY ABUSE OR MOLESTATION COVERAGE 1. This endorsement applies if we have issued to you an Abuse or Molestation Coverage Form, whether on a claims -made basis or otherwise, and either: a. a Professional Liability Insurance Cov- erage Form, whether on a claims -made basis or otherwise; b. a Commercial General Liability Cover- age Form, whether on a claims -made ba- sis or otherwise; or c. both a. and b. 2. If we have both: a. either a duty to defend or a duty to in- demnify any one or more insureds under the Abuse or Molestation Coverage Form with respect to all or any part of a claim, "claim" (if the Coverage Form de- fines "claim"), or "suit'; and b. either a duty to defend or a duty to in- demnify any one or more insureds under either: (1) the Professional Liability Insurance Coverage Form; (2) the Commercial General Liability Coverage Form; or (3) both a. and b.; with respect to all or any part of the same claim, "claim" (if the Coverage Form de- fines "claim"), or "suit' then: c. the applicable Limits of Insurance of the Abuse or Molestation Coverage Form are the only Limits of Insurance that apply CG 84 40 (Ed. 08/09) XS CG 84 40 (Ed. 08 09) to that entire claim, "claim" (if the Cov- erage Form defines "claim") or "suit "; d. no part of the Limits of Insurance of any Coverage Form described in 2.b. (1) through 2.b. (3) applies to any part of that claim, "claim" (if the Coverage Form de- fines "claim"), or "suit'; and e. our total potential liability for that entire claim, "claim" (if the Coverage Form de- fines "claim"), or "suit' will not exceed the applicable Limits of Insurance of the Abuse or Molestation Coverage Form. 3. The foregoing applies regardless: a. whether we learn that insurance under the Abuse or Molestation Coverage Form and insurance under another Coverage Form apply to the same claim, "claim" (if the Coverage Form defines "claim"), or "suit": (1) when we receive initial notice of the claim, "claim" (if the Coverage Form defines "claim"), or "suit," or thereafter; (2) from the initial pleadings in a "suit' or an amended pleading during discovery, at trial, during an appeal, or at any other time. b. the number or kinds of: (1) theories of recovery asserted in the claim or "claim" (if the Coverage Form defines "claim"), or pleaded or asserted in the "suit'; (2) the number or kinds of counts, causes of action, or prayers for relief pleaded or asserted in th HORaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 84 81 (Ed. 08 14) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - ORGANIC PATHOGENS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE FORM The following is added to COMMERCIAL GEN- ERAL LIABILITY COVERAGE FORM, SECTION I - COVERAGES, Coverage A. Bodily Injury and Property Damage Liability, 2. Exclusions and Coverage B. Personal and Advertising Injury, 2. Exclusions or PRODUCTS/COMPLETED OPER- ATIONS LIABILITY COVERAGE FORM, SECTION I - COVERAGES PRODUCTS/COMPLETED OP- ERATIONS, 2. Exclusions: Organic Pathogens a. "Bodily injury," "property damage," or "per- sonal and advertising injury" arising out of any actual, alleged or threatened infectious, pathogenic, toxic or other harmful properties of any "organic pathogen." b. Any loss, cost or expense arising out of any: contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of any "organic pathogen," or (ii) claim or "suit' by or on behalf of a gov- ernmental authority for damages because of testing for, monitoring, cleaning up, re- moving, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of any "organic pathogen." The following definition is added to the Defini- tions Section: "Organic pathogen" means any: A. bacteria; mildew, mold or other fungi; other microorganisms; or mycotoxins, spores or other by-products of any of the foregoing; B. viruses or other pathogens (whether or not a (i) request, demand, order or statutory or microorganism); or regulatory requirement that any insured or others test for, monitor, clean up, remove, C. colony or group of any of the foregoing. This endorsement does not change any other provision of the Policy. CG 84 81 (Ed. 08/14) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 90 82 (Ed. 06/17) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - PROFESSIONAL SERVICES This endorsement modifies and is subject to the insurance provided under the following form: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. The following exclusion is added to paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability and paragraph 2. Exclusions of SECTION I - COVERAGE B - Personal and Advertising Injury Liability: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" due to the rendering of or failure to render any "professional service". This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that Insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or failure to render any "professional service". 2. The following is added to SECTION V. DEFINITIONS: a. "Professional Services" includes any service: 1. that involves specialized education, knowledge, labor, judgment, and skill, and is predominantly mental or intellectual (as opposed to physical or manual) in nature. b. "Professional Services" includes the following: 1. advice, guidance, or assistance; 2. counseling; 3. social work: 4. therapy; 5. daycare; 6. nursing or health care; 7. educational instruction or teaching; 8. job training, job placement, job referral, and vocational services; and 9. other services of the kind described in a., above. c. "Professional Services" includes the furnishing, dispensing, or administrati drug. oRaNe RiskMmagzmedDMsfan REVIEWED & APPROVED BY. - Includes copyrighted material of Insurance Services Office, Inc., with it Risk Management Analyst CG 90 82 (Ed. 06/17) (Page 1 of 1) * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 21 71 (Ed. 01 / 1 5 ) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION OF OTHER ACTS OF TERRORISM COMMITTED OUTSIDE THE UNITED STATES; CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY A. The following exclusion is added: This insurance does not apply to: TERRORISM "Any injury or damage" arising, directly or in- directly, out of an "other act of terrorism" that is committed outside of the United States (including its territories and possessions and Puerto Rico), but within the "coverage terri- tory". However, this exclusion applies only when one or more of the following are at- tributed to such act: 1. The total of insured damage to all types of property exceeds $25,000,000 (valued in U.S. dollars). In determining whether the $25,000,000 threshold is exceeded, we will include all insured damage sustained by property of all persons and entities affected by the terrorism and business in- terruption losses sustained by owners or occupants of the damaged property. For the purpose of this provision, insured damage means damage that is covered by any insurance plus damage that would be covered by any insurance but for the ap- plication of any terrorism exclusions; or 2. Fifty or more persons sustain death or serious physical injury. For the purposes of this provision, serious physical injury means: a. Physical injury that involves a substan- tial risk of death; or b. Protracted and obvious physical dis- figurement; or c. Protracted loss of or impairment of the function of a bodily member or organ; or 3. The terrorism involves the use, release or escape of nuclear materials, or directly or indirectly results in nuclear reaction or ra- diation or radioactive contamination; or 4. The terrorism is carried out by means of the dispersal of application of pathogenic or poisonous biological or chemical ma- terials; or 5. Pathogenic or poisonous biological or chemical materials are released, and it ap- pears that one purpose of the terrorism was to release such materials. With respect to this exclusion, Paragraphs 1. and 2. describe the thresholds used to mea- sure the magnitude of an incident of an "other act of terrorism" and the circumstances in which the threshold will apply for the purpose of determining whether ply to that incident. ©Insurance Services Office, Inc., 2015 CG 21 71 (Ed. 01 / 1 5) (Page 1 of 2) �oRaN Risk ManagementDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 B. The following definitions are added: (b) The premises of any United States mission; and 1. For the purposes of this endorsement, "any injury or damage" means any injury or damage covered under any Coverage Part to which this endorsement is applicable, and includes but is not limited to "bodily injury", "property damage", "personal and advertising injury", "injury" or "environ- mental damage" as may be defined in any applicable Coverage Part. 2. "Certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in accordance with the provi- sions of the federal Terrorism Risk Insur- ance Act, to be an act of terrorism pursu- ant to such Act. The criteria contained in the Terrorism Risk Insurance Act for a "certified act of terrorism" include the following: a. The act resulted in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insur- ance Act; b. The act resulted in damage: (1) Within the United States (including its territories and possessions and Puerto Rico); or (2) Outside of the United States in the case of: (a) An air carrier (as defined in Section 40102 of title 49, United States Code) or Unit- ed States flag vessel (or a vessel based principally in the United States, on which United States income tax is paid and whose insurance coverage is subject to regu- lation in the United States), regardless of where the loss occurs; or c. The act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. 3. "Other act of terrorism" means a violent act or an act that is dangerous to human life, property or infrastructure that is committed by an individual or individuals and that appears to be part of an effort to coerce a civilian population or to influence the policy or affect the conduct of any government by coercion, and the act is not a "certified act of terrorism". Multiple incidents of an "other act of ter- rorism" which occur within a seventy-two hour period and appear to be carried out in concert or to have a related purpose or common leadership shall be considered to be one incident. C. The terms and limitations of any terrorism exclusion, or the inapplicability or omission of a terrorism exclusion, do not serve to create coverage for injury or damage that is other- wise excluded under this Coverage Part. D. If aggregate insured losses attributable to ter- rorist acts certified under the federal Terror- ism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. ©Insurance Services Office, Inc., 2015 CG 21 71 (Ed. 01 / 1 5) (Page 2 of 2) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SILICA OR RELATED DUST EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM - COVERAGE FOR OPERATIONS OF DESIGNATED CONTRACTOR A. The following exclusion is added to paragraph 2., Exclusions, of SECTION I. Coverage A. Bodily Injury and Property Damage Liabil- ity, of the Commercial General Liability Coverage Form, and to paragraph 2., Exclu- sions, of SECTION I. COVERAGES, of the Owners and Contractors Protective Liability Coverage Form - Coverage for Operations of Designated Contractor: 2. Exclusions This insurance does not apply to: Silica or Related Dust a. Any "bodily injury" which would not have occurred, in whole or in part, but for the actual, alleged, threatened, or suspected inhalation or ingestion of, exposure to, or contact with, "silica" or dust that includes or contains "sili- ca.,, b. Any "property damage" which would not have occurred, in whole or in part, but for the actual, alleged, threatened, or suspected contact with, exposure to, existence of, or presence of, "sili- ca" or dust that includes or contains "silica." c. Any loss, cost or expense arising out of the abating, testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, neutralizing, re - mediating or disposing of, or in any way responding to or assessing the CG8361 (Ed. 02 05) effects of, "silica" or dust that includes or contains "silica," by any insured or by any other person or entity This exclusion applies regardless of: (i) the circumstances of or leading to such actual, alleged, threat- ened, or suspected inhalation, in- gestion, exposure, contact, exis- tence, or presence; and (ii) whether the "silica" or dust that includes or contains "silica," is mixed or combined with, or also includes or contains, any other substance. B. The following exclusion is added to paragraph 2., Exclusions of SECTION I. Coverage B. Personal and Advertising Injury Liability of the Commercial General Liability Coverage Form: 2. Exclusions This insurance does not apply to: Silica or Related Dust a. Any "personal and advertising injury" which would not have taken place, in whole or in part, but for the actual, alleged, threatened, or suspected in- halation or ingestion of, contact with, exposure to, existence of, or pres- ence of, "silica" or dust that includes or contains "silic �oRaN RiskMmWmentDMsian REVIEWED & APPROVED BY. - Risk Management Analyst CG 83 61 (Ed. 02/05) XS (Page 1 of 2) * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 b. Any loss, cost, or expense arising out of the abating, testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, neutralizing, re - mediating or disposing of, or in any way responding to or assessing the effects of, "silica" or dust that includes or contains "silica," by any insured or by any other person or entity. This exclusion applies regardless of (i) the circumstances of or leading to such actual, alleged, threat- ened, or suspected inhalation, in- gestion, exposure, contact, exis- tence, or presence; and (ii) whether the "silica" or dust that includes or contains "silica," is mixed or combined with, or also includes or contains, any other substance. C. The following definition is added to the Defi- nitions Section: "Silica" means silicon dioxide (Si02) in any form, from any source. CG 83 61 (Ed. 02/05) XS (Page 2 of 2) HortaN 3 z RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR, BIOLOGICAL, OR CHEMICAL EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM - COVERAGE FOR OPERATIONS OF DESIGNATED CONTRACTORS A. The following exclusion is hereby added to paragraph 2. Exclusions of SECTION I - COVERAGE A. Bodily Injury and Property Damage Liability, of the Commercial Gen- eral Liability Coverage Form, and to para- graph 2., Exclusions, of SECTION I. COV- ERAGES, of the Owners and Contractors Protective Liability Coverage Form - Cov- erage for Operations of Designated Con- tractor: 2. Exclusions Nuclear, Biological, or Chemical Notwithstanding any other provision of this policy, this insurance does not apply to any "bodily injury" or "property damage" caused, directly or indirectly, in whole or in part, by any of the following, regardless of any other cause(s) or event(s) that may contribute concurrently or in any other sequence to the "bodily injury" or "prop- erty damage": (1) Any actual, attempted, suspected, or threatened use of any "NBC material" as part of any plan, effort, or design, actually or apparently intended to cause any: (a) loss or damage to any tangible or intangible property, or (b) "bodily injury" or emotional dis- tress. CG 83 66 (Ed. 06/05) XS (Page 1 of 2) CG 83 66 (Ed. 06 05) (2) Any actual, attempted, suspected, or threatened presence, spread, dissemi- nation, release, escape, or distribution of any "NBC material" as a direct or indirect result of any actual, attempted, suspected, or threatened plan, effort, or design, actually or apparently in- tended to cause any: (a) loss or damage to any tangible or intangible property, or (b) "bodily injury" or emotional dis- tress. "NBC Material" means any nuclear, bio- logical, or chemical material or substance that causes damage to property or is harmful to human health. "NBC material" includes, but is not limited to: (1) any radioactive substance or material, and the radiation it releases, (2) any pathogen, bacterium, microbe, virus, or other organism, (3) any substance or material produced by or from any pathogen, bacterium, mi- crobe, virus, or other organism, and (4) any poison, toxin, or other harmful chemical, substance, or material. The foregoing list (1) through (4) is only illustrative, and should not be construed as a complete, exclusiv all "NBC materials." �oRaN Risk ManagementDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 B. The following exclusion is hereby added to of any "NBC material" as a direct or paragraph 2., Exclusions of SECTION I. indirect result of any actual, attempted, COVERAGE B., Personal and Advertising In- suspected, or threatened plan, effort, jury Liability of the Commercial General Li- or design, actually or apparently in- ability Coverage Form: tended to cause any: 2. Exclusions Nuclear, Biological, or Chemical Notwithstanding any other provision of this policy, this insurance does not apply to any "personal or advertising injury" caused, directly or indirectly, in whole or in part, by any of the following, regardless of any other cause(s) or event(s) that may contribute concurrently or in any other sequence to the "personal and advertising injury": (1) Any actual, attempted, suspected, or threatened use of any "NBC material" as part of any plan, effort, or design, actually or apparently intended to cause any: (a) loss or damage to any tangible or intangible property, or (b) "bodily injury" or emotional dis- tress. (2) Any actual, attempted, suspected, or threatened presence, spread, dissemi- nation, release, escape, or distribution (a) loss or damage to any tangible or intangible property, or (b) "bodily injury" or emotional dis- tress. "NBC Material" means any nuclear, bio- logical, or chemical material or substance that causes damage to property or is harmful to human health. "NBC material" includes, but is not limited to: (1) any radioactive substance or material, and the radiation it releases, (2) any pathogen, bacterium, microbe, virus, or other organism, (3) any substance or material produced by or from any pathogen, bacterium, mi- crobe, virus, or other organism, and (4) any poison, toxin, or other harmful chemical, substance, or material. The foregoing list (1) through (4) is only illustrative, and should not be construed as a complete, exclusive, or exhaustive list of all "NBC materials." This endorsement does not change any other provision of the policy. CG 83 66 (Ed. 06/05) XS (Page 2 of 2) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 85 65 (Ed. 01 12 ) ABUSE OR MOLESTATION COVERAGE FORM Various provisions in this Coverage Form restrict coverage. Read the entire policy carefully to determine rights, duties and what is and is not covered. Throughout this Coverage Form the words "you" and "your" refer to the Named Insured shown in the Declarations, and any other person or organization qualifying as a named insured under this Coverage Form. The words "we," "us" and "our" refer to the Company providing this insurance. The word "Insured" means any person or organization qualifying as such under SECTION III - WHO IS AN INSURED of this Coverage Form. Other words and phrases that appear in quotation marks have special meaning. Refer to SECTION VI - DEFINITIONS of this Coverage Form. SECTION I - ABUSE OR MOLESTATION COV- ERAGE 1. Insuring Agreement a. We will pay those sums the Insured be- comes legally obligated to pay as "dam- ages" because of "abuse" to which this insurance applies. We will have the right and duty to defend the Insured against any "suit' seeking those "damages." However, we will have no duty to defend the Insured against any claim or "suit" seeking "damages" because of "abuse" to which this insurance does not apply. We may, at our discretion, investi- gate any actual, threatened, or alleged "abuse" and settle any claim or "suit' that may result. But: (1) the amount we will pay for "damages" is limited as described in SECTION IV - LIMITS OF INSURANCE of this Coverage Form; and (2) our right and duty to defend end when we have used up the applicable Limit of Insurance in the payment of judg- ments, or settlements. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under this Coverage Form. b. This insurance applies to "abuse" only if: (1) the "abuse" takes place in the "cov- erage territory"; (2) the "abuse" takes place during the policy period; and (3) prior to the policy period, no insured knew the "abuse" had occurred, in whole or in part. If any insured knew, prior to the policy period, that the "abuse" had occurred, in whole or in part, then any continuation, change, or resumption of such "abuse" during or after the policy period will be deemed to have been known prior to the policy period. c. Any "abuse" that occurs during the policy period and was not, prior to the policy period, known by any insured to have oc- curred, includes any continuation, change, or resumption of that "abuse" after the end of the policy period. d. Any "abuse" will be deemed to have been known to have occurred at the earliest time when any insured: CG 85 65 (Ed. 01/12) (Page 1 of 10) (1) reports all, or any part, of the "abuse" to us or any other insurer; �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (2) receives a written or oral demand or (2) furnishing alcoholic beverages to a claim for "damages" because of the person under the legal drinking age or "abuse"; or under the influence of alcohol; or (3) becomes aware by any other means that the "abuse" has occurred or begun to occur. Regardless of the number of acts or omis- sions constituting "abuse," the period of time over which such acts or omissions occur, or the number of persons performing, partici- pating in, or subject to such acts or omis- sions, all injury arising out of all "abuse" by one person, or by any two or more persons acting together or in concert, is deemed one and the same "abuse," subject to one and the same Limit of Liability. 2. Exclusions This insurance does not apply to any: a. "Damages" because of any injury, loss, harm, cost, or expense, expected or in- tended from the standpoint of the Insured. b. "Damages" because of any liability arising out of any criminal or fraudulent act com- mitted by or at the direction of the In- sured. c. Administrative hearing, investigation, licen- sure proceeding, enforcement proceeding, or any similar proceeding by any federal, state, or local governmental, administra- tive, or regulatory agency. d. "Damages" because of any: (1) Liability assumed by any insured under any contract or agreement. (2) Insured's failure to perform or comply with any duty or requirement under a contract, express or implied warranty, or agreement. This exclusion does not apply to liability that the Insured would have in the absence of the contract or agreement. e. "Damages" because of any liability by rea- son of: (1) causing or contributing to the intoxi- cation of any person; (3) any statute, ordinance, or regulation relating to the sale, gift, distribution, or use of alcoholic beverages. f. Obligation of any insured under a workers' compensation, disability benefits, or un- employment compensation law, or any similar law. g. "Damages" because of any liability to: (1) Any person, arising out of any: (a) refusal to employ that person; (b) termination of that person's em- ployment; or (c) employment -related practices, policies, acts, or omissions, in- cluding but not limited to coer- cion, demotion, evaluation, reas- signment, discipline, defamation, harassment, humiliation, or dis- crimination directed at that per- son; or (2) The spouse, child, parent, brother, or sister of that person as a consequence of any employment -related practice described in (1)(a), (1)(b), or (1)(c). This exclusion applies: (i) whether the Insured may be liable as an employer or in any other capacity; and (ii) to any obligation to share "damages" with or repay someone else who must pay "damages" to the "employee" or to the "employee's" spouse, child, parent, brother, or sister. h. "Damages" because of any liability to: CG 85 65 (Ed. 01/12) (Page 2 of 10) (1) Any "employee" of the Insured arising out of and in the course of that "em- ployee's": (a) employment by the Insured; or HORaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (b) performing duties related to the n. "Damages" because of any: conduct of the Insured's business; or (1) Liability arising in whole or in part from the actual, alleged, or threatened (2) The spouse, child, parent, brother, or discharge, dispersal, seepage, migra- sister of that "employee" as a con- tion, release, escape, or presence of, sequence of paragraphs (1)(a) or (1)(b). or exposure to, any "pollutant," from any source, at any location, at any time. This exclusion applies: (i) whether the Insured may be liable as an employer or in any other capacity; and (ii) to any obligation to share "damages" with or repay someone else who must pay "damages" to the "employee" or to the "employee's" spouse, child, parent, brother, or sister. L "Damages" because of any liability of any insured to any other insured. This exclu- sion does not apply to "damages" for harm to one of your "volunteer workers." j. "Damages" because of any liability arising out of any employee benefit plan or self - insured fund, or for any amount due under any fringe benefit or retirement program. k. "Damages" because of any liability under the Employment Retirement Income Secu- rity Act of 1974 (as amended) or any similar federal or state law. I. "Damages" because of any insured's hiring, employment, or retention in employment, of any person with a prior history of committing "abuse," if any insured knew of that history either before, or at any time during, the policy period. m. "Damages" arising out of any insured's knowing: (1) concealment of, (2) failure to report, or (3) failure to comply with federal, state, or local or regulation, requiring of, any "abuse." CG 85 65 (Ed. 01/12) any applicable law, ordinance, the reporting (2) Loss, cost, or expense which would not have occurred in whole or in part but for any: (a) request, demand, or order that any insured or others test for, monitor, clean up, remove, con- tain, treat, detoxify, abate, or neutralize, or in any way respond to or assess the effects of, any "pollutant"; or (b) claim or "suit" by or on behalf of any federal, state, or local gov- ernmental authority because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, abating, or neutraliz- ing, or in any way responding to or assessing the effects of, any "pollutant." o. "Damages" because of any: (Page 3 of 10 ) (1) Liability arising in whole or in part from the actual, alleged, or threatened discharge, dispersal, seepage, migra- tion, release, escape, inhalation, ab- sorption, ingestion, or presence of, or exposure to, lead in any form, from any source, in any location, at any time. (2) Loss, cost, or expense which would not have occurred in whole or in part but for any: (a) request, demand, or order that any insured or others test for, monitor, clean up, remove, con- tain, treat, detoxify, abate, or neutralize, or in any way respond to or assess the effects of, lead in any form, from any source, or (b) claim or "suit" by or on behalf of any federal, state, or local gov- ernmental authority because of testing for, monitoring, cleaning �oRaN RiskMmaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 up, removing, containing, treating, detoxifying, abating, or neutraliz- ing, or in any way responding to or assessing the effects of, lead in any form, from any source. p. "Damages" because of any: (1) Liability arising in whole or in part from the actual, alleged, or threatened discharge, dispersal, seepage, migra- tion, release, escape, inhalation, ab- sorption, ingestion, or presence of, or exposure to, asbestos in any form, from any source, in any location, at any time. (2) Loss, cost, or expense which would not have occurred in whole or in part but for any: (a) request, demand, or order that any insured or others test for, monitor, clean up, remove, con- tain, treat, detoxify, abate, or neutralize, or in any way respond to or assess the effects of, as- bestos in any form, from any source, or (b) claim or suit by or on behalf of any federal, state, or local gov- ernmental authority because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, abating, or neutraliz- ing, or in any way responding to or assessing the effects of, as- bestos in any form, from any source. q. "Damages" because of any: (1) liability arising in whole or in part from the actual, alleged, or threatened in- halation of, ingestion of, contact with, exposure to, existence of, or pres- ence of, any "fungi" or bacteria on or within a building or structure, including its contents, regardless of whether any other cause, event, material, or product contributed concurrently or in any sequence to such injury or dam- age; or (2) loss, cost, or expense which would not have occurred in whole or part but for any: (a) request, demand, or order that any insured or others test for, monitor, clean up, remove, con- tain, treat, detoxify, abate, or neutralize, or in any way respond to or assess the effects of, "fungi" or bacteria in any form, from any source, or (b) claim or suit by or on behalf of any federal, state, or local gov- ernmental authority because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, abating, or neutraliz- ing, or in any way responding to or assessing the effects of, any "fungi" or bacteria, in any form, from any source. This exclusion does not apply to any "fungi" or bacteria that are intended to be, be on, or be contained in, a good or product intended for human consumption as food. r. "Damages" because of any liability arising out of the ownership, maintenance, use, or entrustment to others of any aircraft, "auto," or watercraft, whether or not owned or operated by, or rented or loaned to, any insured. Use includes op- eration and loading or unloading. This exclusion applies even if the claim or "suit" against any insured alleges negli- gence or other wrongdoing in the super- vision, hiring, employment, training, or monitoring of others by that Insured, if the liability arises from the ownership, main- tenance, use, or entrustment to others of any aircraft, "auto," or watercraft, whether or not owned or operated by, or rented or loaned to, any insured. s. "Damages" because of any insured's liabil- ity to any: CG 85 65 (Ed. 01/12) (Page 4 of 10) (1) company, corporation, or other orga- nization, or �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (2) shareholder, owner, or creditor of any company, corporation, or other orga- nization, of which that Insured is a director or officer, if such liability arises directly or indirectly out of any act, error, or omission by that Insured, committed in that Insured's capacity as a director or officer of that company, corporation, or other organization. This exclusion applies regardless of whether or not the act, error, or omission was per- formed by or on behalf of the Named Insured. t. "Damages" because of any liability arising directly or indirectly out of: (1) service by any insured for or as a member of any board or committee of any organization other than the Named Insured. This includes, but is not limited to, any board or committee relating to peer review, credentialing, quality as- surance, utilization review, profession- al discipline, risk management, patient or client grievances, staff grievances, or professional education; or (2) the activities of any insured as a pro- prietor, superintendent, officer, direc- tor, shareholder, manager, or employ- ee of any organization other than the Named Insured; or (3) any insured's capacity as a fiduciary, trustee, legal representative, guardian, banker, creditor, tax preparer, or lender. u. "Damages" because of any liability arising out of any failure to integrate, segregate, or desegregate: (1) enrollment; (2) participation in educational or non- educational activities; (3) busing or other transportation; or (4) the provision or receipt of any ser- vice, accommodation, or benefit; on the basis of race, religion, sex, age, ethnic background, national origin, physical or mental disability, sexual orientation, or any other basis prohibited by applicable law. v. "Damages" because of any liability arising out of any discrimination, or failure to discriminate, on account of race, religion, sex, age, ethnic background, national ori- gin, physical or mental disability, or sexual orientation, or arising out of any actual, threatened, or alleged violation of any lo- cal, state, or federal civil rights law, regu- lation, or ordinance. w. Civil or criminal fine or penalty, and any loss, cost, or expense paid or incurred in defending against any such fine or penalty. x. "Damages" arising out of the following professional services: legal, accounting, financial, appraisal, architectural, or engi- neering services. SECTION II - SUPPLEMENTARY PAYMENTS We will pay, with respect to any claim we inves- tigate or settle, or any "suit" we defend or settle: 1. All expenses we incur. 2. The cost of bonds to release attachments, but only for bond amounts within the applicable Limit of Insurance. We do not have to furnish these bonds. 3. All reasonable expenses incurred by the In- sured at our request to assist us in the inves- tigation or defense of the claim or "suit," in- cluding actual loss of earnings up to $250 a day because of time off from work. 4. All court costs taxed against the Insured in the "suit." However, these payments do not in- clude attorneys' fees or attorneys' expenses taxed against the Insured. 5. Prejudgment interest awarded against the In- sured on that part of a judgment we pay. If we make an offer to pay the applicable Limit of Insurance, we will not pay any prejudgment interest based on that period of time after the offer. CG 85 65 (Ed. 01/12) (Page 5 of 10) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 6. All interest on the full amount of any judgment that accrues after entry of the judgment and before we have paid, offered to pay, or de- posited in court the part of the judgment that is within the applicable Limit of Insurance. These payments will not reduce the Limits of Insurance. SECTION III - WHO IS AN INSURED 1. Subject to 4., below, if you are designated in the Declarations as: a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses are also insureds, but only with respect to the conduct of your busi- ness. c. A limited liability company, you are an in- sured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insur- eds, but only with respect to their duties as your managers. d. An organization other than a partnership, joint venture, or limited liability company, you are an insured. Your "executive of- ficers," board members and directors are also insureds, but only with respect to their duties as your officers or directors. Your stockholders are also insureds, but only with respect to their liability as your stockholders. e. A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as trustees. 2. Subject to 4., below, each of the following is also an insured: a. If you are a religious or educational in- stitution: (1) your elders, deacons, vestrymen, councilmen, clergy, and teachers; (2) members of your Board of Trustees, Board of Governors, or other govern- ing body created by your charter, constitution, by-laws, or other similar governing document, but only while acting within the scope of their duties as such; and (3) any subsidiary organization that is con- trolled by the Named Insured. A sub- sidiary organization is controlled by the Named Insured if the Named Insured owns a majority of the voting shares of that organization. 3. Subject to 4., below, your "employees," other than those already described in 1. or 2., above, are also insureds, but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. Your "volunteer workers" are insureds, but only while performing duties re- lated to the conduct of your business with your knowledge and consent. 4. However: a. No "employee," "volunteer worker," direc- tor, "executive officer," officer, or other person is an insured for any liability: (1) to you, to your partners or members (if you are a partnership or joint ven- ture), to your members (if you are a limited liability company), to any of your directors, "executive officers," officers, "employees," or "volunteer workers"; (2) to the spouse, child, parent, brother, sister, or next of kin of any person in connection with or as a consequence of 4.a.(1); or (3) for which there is any obligation to share damages with or repay someone else who must pay damages, as a con- sequence of 4.a.(1) or (2). b. No person or organization is an insured with respect to the conduct of any cur- rent or past partnership, joint venture, re- ligious or educational institution, or other organization that is not shown as a named insured in the Declarations. CG 85 65 (Ed. 01/12) (Page 6 of 10) HORaN 3 RiskMwaganedDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 c. If we designate a person, an organization, b. claims made or "suits" brought; or a class of persons or organizations, as an additional insured under this Coverage c. persons or organizations making claims or Form, then that designation does not in- bringing "suits"; or clude any "employee," "volunteer worker," "executive officer," officer, director, d. coverage parts or insuring agreements in agent, representative, subsidiary, or affili- this Policy ate of that additional insured. No such "employee," "volunteer worker," "executive 2. The Aggregate Limit shown in the Abuse or officer," officer, director, agent, repre- Molestation Coverage Part Declarations is the sentative, subsidiary, or affiliate of an ad- most we will pay for the sum of all "damages" ditional insured is an insured under this under this Abuse or Molestation Coverage Coverage Form unless expressly desig- Part. nated as an insured in an endorsement we issue. 3. Subject to 2., the Each Abuse Limit is the most we will pay for the sum of all "damages" d. No person or organization is an insured as because of all injury arising out of all "abuse" respects any "abuse" that person or or- by any one person or organization, or by any ganization is proved to have knowingly: two or more persons or organizations acting together or in concert, regardless of the (1) committed, participated in, aided, as- number of insureds, claims, "suits," or claim- sisted; ants. (2) concealed; or (3) attempted to do (1) or (2). For purposes of this provision, a person or organization is proved to have know- ingly committed conduct described in d.(1), (2), or (3) if that person or organization: (a) admits to having done so; or (b) is found to have done so by a final judgment in a criminal or civil pro- ceeding, including but not limited to a "suit" to which this insurance applies. Upon the happening of either (a) or (b), that person or organization is not an in- sured, even if that person or organization was an insured before the happening of (a) or (b). An unproven allegation made in a claim or "suit" is not, by itself, sufficient to prove that a person or organization knowingly committed conduct described in d.(1), (2), or (3). SECTION IV - LIMITS OF INSURANCE 1. The Limits of Insurance shown in the Declara- tions and the rules below fix the most we will pay regardless of the number of: a. insureds; The Limits of Insurance of this Coverage Part apply separately to each consecutive annual pe- riod and to any remaining period of less than 12 months, starting with the beginning of the policy period in the Declarations, unless the policy pe- riod is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. SECTION V - CONDITIONS 1. Bankruptcy Bankruptcy or insolvency of the Insured or of the Insured's estate will not relieve us of our obligations under this Coverage Part. 2. Duties in the Event of Abuse, Claim or Suit a. You must see to it that we are notified as soon as practicable of any actual, threat- ened, or alleged "abuse" which may result in a claim or "suit." To the extent possible, notice should include: CG 85 65 (Ed. 01/12) (Page 7 of 10) (1) how, when, and where the "abuse" took place; (2) the names and addresses of injured persons and witnesses; and HORaN 3 RiskMwaganedDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (3) the nature and location of any injury or damage. b. If a claim is made or "suit" is brought against any insured, you must: (1) immediately record the specifics of the claim or "suit" and the date re- ceived; and (2) notify us as soon as practicable. You must see to it that we receive written notice of the claim or "suit" as soon as practicable. c. You and any other involved insured must: (1) immediately send us copies of any de- mands, notices, summonses, or legal papers in connection with the claim or "suit"; (2) authorize us to obtain records and other information; (3) cooperate with us in the investigation, settlement, or defense of the claim or "suit"; and (4) assist us, upon our request, in the en- forcement of any right against any person or organization which may be liable to the Insured because of injury or damage to which this insurance may also apply. d. No insured will, except at that Insured's own cost, voluntarily make a payment, as- sume any obligation, or incur any expense, other than for first aid, without our con- sent. 3. Legal Action Against Us No person or organization has a right under this Coverage Part: a. to join us as a party or otherwise bring us into a "suit" asking for "damages" from an insured; or b. to sue us on this Coverage Part unless all of its terms have been fully complied with. A person or organization may sue us to re- cover on an agreed settlement or on a final judgment against an insured; but we will not be liable for "damages" that are not payable under the terms of this Coverage Part or that are in excess of the applicable Limits of In- surance. An agreed settlement means a settle- ment and release of liability signed by us, the Insured and the claimant or the claimant's legal representative. 4. Other Insurance a. If other insurance is available to the In- sured for a loss we cover under this Abuse or Molestation Coverage Part, our obligations are limited as follows: (1) This insurance applies only in excess of, and does not contribute with, the sum of the applicable limits of any and all such other insurance, whether that other insurance: (a) is valid or not; (b) is collectible or not; or (c) describes itself as primary, ex- cess, contingent, contributing, or otherwise. However, this provision a.(1) does not apply to other insurance that is issued expressly to apply only in excess of the applicable Limit of Insurance of this insurance. b. If any insurer affording such other insur- ance refuses to defend the Insured under that other insurance, we will defend the Insured as though that other insurance were not available. If we defend, we are subrogated to all of the Insured's rights under such other insurance. The Insured must do all things necessary to help us enforce such rights. c. If the Coordination of Limits Endorsement is attached to this Abuse or Molestation Coverage Form, and both: CG 85 65 (Ed. 01/12) (Page 8 of 10) (1) this Abuse or Molestation Coverage Form; and (2) any other coverage form, coverage part, or policy issued by us, or by a company affiliated with us, HORaN 3 RiskMwaganedDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 apply, in whole or in part, to the same claim, "suit," "abuse," or "damages," then this Abuse or Molestation Coverage Form and all such other coverage forms, coverage parts, or policies described in (2) are all subject to the Coordination of Lim- its Endorsement. 5. Representations By accepting this Policy, you agree: a. the statements in the Abuse and Molesta- tion Application are accurate and com- plete; b. those statements are representations you made to us; and c. we have issued this Policy in reliance upon your representations. 6. Separation of Insureds Except with respect to the Limit of Insurance, and any rights or duties specifically assigned in this Coverage Part to the first Named In- sured, this insurance applies: a. as if each named insured were the only Named Insured; and b. separately to each insured against whom claim is made or "suit' is brought. 7. Transfer of Rights of Recovery Against Others to Us If the Insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The Insured must do nothing after loss to impair them. At our request, the Insured will bring "suit' or transfer those rights to us and help us enforce them. 8. When We Do not Renew If we decide not to renew this Coverage Part, we will mail or deliver to the first Named Insured shown in the Declarations written no- tice of the nonrenewal not less than 30 days before the expiration date. If such notice is mailed, proof of mailing will be sufficient proof of notice. SECTION VI - DEFINITIONS 1. "Abuse" means: a. any actual, threatened, or alleged act, er- ror, omission, conduct, or misconduct, that a claim or "suit' alleges to be, or to constitute, any form of abuse (including, but not limited to, elder abuse, child abuse, patient abuse, or abuse of a dependent person) under any applicable state or fed- eral statute or regulation; and b. any actual, threatened, or alleged act, er- ror, omission, conduct, or misconduct, of one or more of the following kinds: CG 85 65 (Ed. 01/12) (Page 9 of 10) (1) sexual behavior, sexual conduct or misconduct, sexual assault, sexual bat- tery, sexual abuse, or sexual molesta- tion, of or directed at a person; (2) non -sexual assault, non -sexual bat- tery, or non -sexual abuse, of or di- rected at a person; and (3) any: (i) employment; (ii) investigation; (iii) supervision; (iv) reporting to proper authorities, or failure to so report; or (v) retention in employment; of any person committing conduct or misconduct described in b.(1) or b.(2); or (vi) referral of a patient, student, pa- rishioner, client, or person, to any other person whose conduct or misconduct is described in a., b.(1), or b.(2). Conduct or misconduct described in b.(1) through b.(3) constitutes "abuse" within the meaning of this definition regardless of whether or not it is alleged to be neg- �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 ligent, reckless, knowing, intentional, fraudulent, oppressive, malicious, or oth- erwise. 2. "Auto" means a land motor vehicle, mobile equipment, trailer, or semi trailer, including any attached or towed machinery or equipment. 3. "Coverage territory" means: a. the United States of America (including its territories and possessions), Puerto Rico and Canada; 7. "Fungi" means any type or form of fungus, including mold or mildew and any mycotoxin, spore, scent, or byproduct produced or re- leased by any fungus or by the death or decay of any fungus. 8. "Leased worker" means a person leased to you by a labor leasing firm under an agree- ment between you and the labor leasing firm, to perform duties related to the conduct of your business. "Leased worker" does not in- clude a "temporary worker." b. international waters or airspace, provided 9. "Pollutant" means any solid, liquid, gaseous, the injury or damage does not occur in the or thermal irritant or contaminant, including course of travel or transportation to or smoke, vapor, soot, fumes, acids, alkalis, from any place not included in paragraph chemicals, and waste. Waste includes materi- a. above. als to be recycled, reconditioned, or re- claimed. c. all parts of the world if: (1) the injury or damages arise out of the activities of a person whose home is in the territory described in paragraph a. above, but is away for a short time on your business; and (2) the Insured's responsibility to pay damages is determined in a "suit" on the merits, in the territory described in paragraph a. above or in a settlement we agree to. 4. "Damages" means money damages awarded to compensate for harm, except those as to which applicable law prohibits liability insur- ance. "Damages" does not include the cost of complying with injunctive relief, declaratory relief, or other equitable actions; fines, penal- ties, punitive damages, exemplary damages, or any multiplied or enhanced damages; fees, de- posits, or commissions; charges for goods or services, or the return, disgorgement, or re- imbursement of such charges; or awards of attorneys' fees, attorneys' expenses, or other costs of making a claim or bringing a "suit." 5. "Employee" includes a "leased worker." "Em- ployee" does not include a "temporary work- er." 6. "Executive officer" means a person holding any of the officer positions created by your charter, constitution, by-laws or any other similar governing document. 10. "Suit" means a civil proceeding in which "damages" to which this coverage applies are alleged. "Suit" includes: a. an arbitration proceeding in which such "damages" are claimed and to which you must submit or do submit with our con- sent; or b. any other alternative dispute resolution proceeding in which such "damages" are claimed and to which you must submit or do submit with our consent. "Suit" does not include any administrative hearing, investigation, licensure proceeding, enforcement proceeding, or any similar pro- ceeding by any federal, state, or local gov- ernmental, administrative, or regulatory agen- cy. 11. "Temporary worker" means a person who is furnished to you to substitute for a permanent "employee" on leave or to meet seasonal or short-term workload conditions. 12. "Volunteer worker" means a person who is not your "employee" and who donates his or her work and acts at the direction of and within the scope of duties determined by you, and is not paid a fee, salary, or other com- pensation by you or anyone else for their work performed for you. CG 85 65 (Ed. 01/12) (Page 10 of 10) HortaN 3 z a RiskMmaganedDMsian REVIEWED & APPROVED BY.- PZ. V Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 89 70 (Ed. 11/14) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SIGNATURE GENERAL LIABILITY BROADENING ENDORSEMENT This Endorsement modifies and is subject to the insurance provided under the following form: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following extension only applies in the event that no other specific coverage for the indicated loss exposure is provided under this Policy. If other specific coverage applies, the terms, conditions and limits of that Coverage are the exclusive coverage applicable under this Policy, unless otherwise noted in this Endorsement. This is a summary of the various additional coverages and coverage modifications provided by this Endorsement. For complete details on specific coverages, consult the actual policy wording. Coverage Description Limit of Insurance Page Non -Owned Aircraft Included 2 Non -Owned Watercraft Included 2 Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Included 3 Medical Payments $ 20,000 3 Damage to Premises Rented to You $ 1,000,000 3 Supplementary Payments - Bail Bonds $ 3,000 4 Supplementary Payments - Loss of Earnings $ 1,000 per day 4 Newly Formed or Acquired Organizations Included 4 Unintentional Failure to Disclose Hazards Included 5 Knowledge of Occurrence, Claim or Suit Included 5 Property Damage Liability - Elevators Included 5 Property Damage Liability - Borrowed Equipment Included 5 Liberalization Clause Included 6 Amendment of Pollution Exclusion (Premises) Included 6 Limited Property Damage to Property of Others $ 5,000 6 Additional Insured - Manager or Lessor of Premises Included 7 HORaN RiskManaganad Msian REVIEWED & APPROVED BY.- } z f R. W&Wd Risk Management Analyst CG 89 70 (Ed. 11/14) (Page 1 of 12) * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 Coverage Description Limit of Insurance Page Additional Insured - Funding Sources Included 7 Additional Insured - By Contract Included 8 Primary and Non -Contributory Additional Insured Extension Included 10 Additional Insureds - Protection of Your Limits Included 10 Blanket Waiver of Transfer of Rights of Recovery Against Others to Us (Subrogation) Included 11 Property Damage Extension With Voluntary Payments $ 1 ,000/$ 5,000 11 Who Is An Insured - Fellow Employee Extension - Management Employees Included 12 Broadened Personal and Advertising Injury Included 12 A. Non -Owned Aircraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, exclusion g. Aircraft, Auto or Watercraft does not apply to an aircraft provided: 1. it is not owned by any insured; 2. it is hired, chartered or loaned with a trained paid crew; 3. the pilot in command holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating him or her a commercial or airline pilot; and 4. it is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the Insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this Policy), contingent or on any other basis, that would also apply to the loss covered under this provision. B. Non -Owned Watercraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraph (2) of exclusion g. Aircraft, Auto or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) less than 60 feet long; and CG 89 70 (Ed. 11/14) (Page 2 of 12) HortaN RiskMmaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (b) not being used to carry persons or property for a charge. C. Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Under SECTION V - DEFINITIONS, Definition 3. is replaced by the following: 3. "Bodily Injury" means physical injury, sickness, or disease, including death of a person. "Bodily Injury" also means mental injury, mental anguish, humiliation, or shock if directly resulting from physical injury, sickness, or disease to that person. D. Medical Payments If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this Policy are amended as follows: The Medical Expense Limit in paragraph 7. of SECTION III - LIMITS OF INSURANCE is replaced by the following Medical expense Limit: The Medical Expense Limit provided by this Policy shall be the greater of: a. $ 20,000; or b. the amount shown in the Declarations for Medical Expense Limit This provision 7. is subject to all the terms of SECTION III - LIMITS OF INSURANCE. E. Damage to Premises Rented to You If Damage to Premises Rented to You is not otherwise excluded from this Coverage Part: 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: 3. The last paragraph of paragraph 2. Exclusions is deleted in its entirety and replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke, leakage from an automatic fire protection system or water to premises while rented to you or temporarily occupied by you with permission of the owner. A separate Limit of Insurance applies to this coverage as described in SECTION III - LIMITS OF INSURANCE. However, this insurance does not apply to damage to premises while rented to you, or temporarily occupied by you with the permission of the owner, caused by: i. rupture, bursting, or operation of pressure relief devices; ii. rupture or bursting due to expansion or swelling of the contents of any building or structure, caused by or resulting from water; iii. explosion of steam boilers, steam pipes, steam engines, or steam turbines; or iv. flood 2. Paragraph 6. Under SECTION III - LIMITS OF INSURANCE is deleted in its entirety and replaced with the following: CG 89 70 (Ed. 11/14) (Page 3 of 12) HortaN 3 z RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 6. Subject to paragraph 5. above, the most we will pay under Coverage A for damages because of "property damage" to any one premises, while rented to you, or in the case of damage caused by fire, lightning, explosion, smoke, leakage from automatic fire protection system or water while rented to you or temporarily occupied by you with the permission of the owner, for all such damage caused by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water or any combination of the six, is the higher of $ 1,000,000 or the amount shown in the Declarations for the Damage to Premises Rented to You Limit. 3. Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, subsection 4. Other Insurance, paragraph b. Excess Insurance where the words "Fire insurance" appear they are changed to "insurance for fire, lightning, explosion, smoke, leakage from an automatic fire protection system or water." 4. As regards coverage provided by this provision I. Damage to Premises Rented to You - paragraph 9.a. of Definitions is replaced with the following: 9. a. a contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water to premises while rented to you or temporarily occupied by you with the permission of the owner is not an "insured contract"; F. Supplementary Payments 1. In the Supplementary Payments - Coverages A and B provision, paragraph 1.b. is replaced with: b. Up to $ 3,000 for the cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 2. Paragraph 1.d. is replaced by the following: d. All reasonable expenses incurred by the Insured at our request to assist us in the investigation or defense of the claim or "suit," including actual loss of earnings up to $ 1,000 a day because of time off work. G. Newly Formed or Acquired Organizations Paragraph 3. of SECTION II - WHO IS AN INSURED is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a named insured if there is no other similar insurance available to that organization. However: a. coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. coverage A does not apply to "bodily injury" or property damage that occurred before you acquired or formed the organization; and c. coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. CG 89 70 (Ed. 11/14) (Page 4 of 12) HortaN 3 z RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 d. records and descriptions of operations must be maintained by the first named insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a named insured in the Declarations or qualifies as an insured under this provision. H. Unintentional Failure to Disclose Hazards Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 6. Representations: Failure of the Insured to disclose all hazards existing as of the inception date of this Policy shall not prejudice the insurance with respect to the coverage afforded by this Policy, provided such failure or omission is not intentional on the part of the Insured. I. Knowledge of Occurrence, Claim or Suit Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit: Knowledge of any occurrence, claim, or suit by any agent, servant or employee of the Named Insured does not in itself constitute knowledge by the Insured unless notice of such injury, claim or suit shall have been received by: a. you, if you are an individual; b. a partner, if you are a partnership c. an executive officer or insurance manager, if you are a corporation. J. Property Damage Liability - Elevators 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraphs (3), (4) and (6) of exclusion j. Damage to Property do not apply if such property damage results from the use of elevators. 2. The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 4. Other Insurance, paragraph b. Excess Insurance: The insurance afforded by this provision of this Endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. K. Property Damage Liability - Borrowed Equipment 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraph (4) of exclusion j. Damage to Property does not apply to "property damage" to borrowed equipment while not being used to perform operations at a job site. 2. The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY Conditions, Condition 4. Other Insurance, paragraph b. Excess Insurance: The insurance afforded by this provision of this Endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. CG 89 70 (Ed. 11/14) (Page 5 of 12) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 L. Liberalization Clause If we revise this Signature General Liability Broadening Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the date the revision is effective in your state. M. Amendment of Pollution Exclusion (Premises) 1. The following is added to paragraph (1)(a) of Exclusion f. of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: (iv) "Bodily injury" or "property damage" arising out of the actual discharge, dispersal, seepage, migration, release or escape of "pollutants." As used in this Endorsement, the actual discharge, dispersal, seepage, migration, release or escape of pollutants must: (aa) commence on a clearly identifiable day during the policy period; and (bb) end, in its entirety, within seventy-two (72) hours of the commencement of the discharge, dispersal, seepage, migration, release or escape of "pollutants"; and (cc) be discovered and reported to us within fifteen (15) days of the clearly identifiable day that the discharge, dispersal, seepage, migration, release or escape of "pollutants" commences; and (dd) be neither expected nor intended from the standpoint of any insured; and (ee) be unrelated to any previous discharge, dispersal, seepage, migration, release or escape; and (ff) not originate at or from a storage tank or other container, duct or piping which: a. is below the surface of the ground or water; or b. at any time has been buried under the surface of the ground or water and then is subsequently exposed. 2. For the purposes of this coverage, the following is added to the definition of "property damage" of SECTION V - DEFINITIONS and applies only as respects this coverage: Land or water, whether below ground level or not, is not tangible property. 3. Coverage provided hereunder does not apply to any discharge, dispersal, seepage, migration, release or escape that is merely threatened or alleged rather than shown to have actually occurred. N. Limited Property Damage to Property of Others The following is added under SECTION I - SUPPLEMENTARY PAYMENTS - COVERAGES A and B: 3. We will pay up to $ 5,000 for loss to personal property of others while in the temporary care, custody or control of an insured caused by any person participating in your organized activities. For the purpose of this supplementary payment, loss shall mean damage or destruction but does not include mysterious disappearance or loss of use. In the event of a theft, a police report must be filed. This supplementary payment does not apply if: a. coverage is otherwise provided by the Property Coverage part (if and CG 89 70 (Ed. 11/14) (Page 6 of 12) Risk Management DMsian & APPROVED BY.- cREVIEWED Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 b. the loss is covered by any other insurance you have or by any insurance of such person who causes such loss. These payments will not reduce the Limits of Insurance. O. Additional Insured - Manager or Lessor of Premises 1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any person or organization from whom you lease or rent property and which requires you to add such person or organization as an additional insured on this Policy under: (a) a written contract; or (b) an oral agreement or contract where a Certificate of Insurance showing that person or organization as an additional insured has been issued; but the written or oral contract or agreement must be an "insured contract," and, (i) currently in effect or become effective during the term of this Policy; and (ii) executed prior to the "bodily injury," "property damage," "personal and advertising injury." 2. With respect to the insurance afforded to the Additional Insured identified in paragraph 1 above, the following additional provisions apply: (a) This insurance applies only with respect to the liability arising out of the ownership, maintenance or use of that part of the premises leased to you. (b) The Limits of Insurance applicable to the Additional Insured are the lesser of those specified in the written contract or agreement or in the Declarations for this Policy and subject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. (c) In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. (d) Coverage provided herein is excess over any other valid and collectible insurance available to the Additional Insured whether the other insurance is primary, excess, contingent or on any other basis unless a written contractual arrangement specifically requires this insurance to be primary. (e) This insurance applies only to the extent permitted by law. 3. This insurance does not apply to: (a) Any "occurrence" or offense which takes place after you cease to be a tenant in that premises. (b) Structural alterations, new construction or demolition operations performed by or on behalf of the Additional Insured. P. Additional Insured - Funding Sources 1 SECTION II - WHO IS AN INSURED is amended to include as an additional insured any Funding Source which requires you in a written contract to name the Funding Source as an additional insured but only with respect to liability arising out of: CG 89 70 (Ed. 11/14) (Page 7 of 12) HORaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 a. your premises; or b. "your work" for such additional insured; or c. acts or omissions of such additional insured in connection with the general supervision of "your work" and only to the extent set forth as follows: a. The Limits of Insurance applicable to the Additional Insured are the lesser of those specified in the written contract or agreement or in the Declarations for this Policy and subject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. b. The insurance afforded to the Additional Insured only applies to the extent permitted by law c. If coverage provided to the Additional Insured is 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. d. In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. Q. Additional Insureds - By Contract 1. SECTION II - WHO IS AN INSURED is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of: a. your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the Additional Insured that are subject of the written contract or written agreement provided that the "bodily injury" or "property damage occurs, or the "personal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or b. the maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or c. the Additional Insureds financial control of you; or d. operations performed by you or on your behalf for which the state or political subdivision has issued a permit However: 1. the insurance afforded to such additional insured only applies to the extent permitted by law; and 2. if coverage provided to the Additional Insured is required by 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 such additional insured. With respect to paragraph 1.a. above, a person's or organization's status as an additional insured under this Endorsement ends when: CG 89 70 (Ed. 11/14) (Page 8 of 12) HORaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (1) all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2) that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. With respect to paragraph 1.b. above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this Endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage." We have no duty to defend an additional insured under this Endorsement until we receive written notice of a "suit' by the Additional Insured as required in paragraph b. of Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITION. 2. With respect to the insurance provided by this Endorsement, the following are added to paragraph 2. Exclusions under SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: This insurance does not apply to: a. "Bodily injury" or "property damage" that occurs prior to your commencing operations at the location where such "bodily injury" or "property damage" occurs. b. "Bodily injury," "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services, including: (1) the preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that Insured, if the "occurrence" which caused the "bodily injury" or "property damage," or the offense which caused the "personal and advertising injury," involved the rendering of, or failure to render, any professional architectural, engineering or surveying services. c. "Bodily injury" or "property damage" occurring after: (1) all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2) that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 89 70 (Ed. 11/14) (Page 9 of 12) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY.- � Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 d. Any person or organization specifically designated as an additional insured for ongoing operations by a separate additional insured endorsement issued by us and made part of this Policy. 3. With respect to the insurance afforded to these Additional Insureds, the following is added to SECTION III - LIMITS OF INSURANCE: If coverage provided to the Additional Insured is required by a contract or agreement, the most we will pay on behalf of the Additional Insured is the amount of insurance: a. required by the contract or agreement; or b. available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This Endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. R. Primary and Non -Contributory Additional Insured Extension This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this Policy. Condition 4. Other Insurance of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: a. The following is added to paragraph a. Primary Insurance: 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 (2) you have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the Additional Insured. b. The following is added to paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the Additional Insured is designated as a named insured. Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the Additional Insured has been added as an additional insured on other policies. S. Additional Insureds - Protection of Your Limits This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this Policy. 1. The following is added to Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit: An additional insured under this Endorsement will as soon as practicable: CG 89 70 (Ed. 11/14) (Page 10 of 12) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 a. give written notice of an "occurrence" or an offense that may result in a claim or "suit' under this insurance to us; b. tender the defense and indemnity of any claim or "suit' to all insurers whom also have insurance available to the Additional Insured; and c. agree to make available any other insurance which the Additional Insured has for a loss we cover under this Coverage Part. d. we have no duty to defend or indemnify an additional insured under this Endorsement until we receive written notice of a "suit' by the Additional Insured. 2. The Limits of Insurance applicable to the Additional Insured are those specified in a written contract or written agreement or the Limits of Insurance stated in the Declarations of this Policy and defined in SECTION III - LIMITS OF INSURANCE of this Policy, whichever are less. These limits are inclusive of and not in addition to the Limits of Insurance available under this Policy. T. Blanket Waiver of Transfer of Rights of Recovery Against Others to Us (Subrogation) Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 8. Transfer of Rights of Recovery Against Others to Us: If required by a written contract or written agreement, we waive any right of recovery we may have against a person or organization because of payment we make for injury or damage arising out of your ongoing operations or "your work" done under a contract for that person or organization and included in the "products -completed operations hazard" provided that the injury or damage occurs subsequent to the execution of the written contract or written agreement. U. Property Damage Extension with Voluntary Payments 1. The following is added to paragraph 1. Insuring Agreement of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: At your request we will pay for "loss" to property of others caused by your business operations for which this Policy provides liability insurance. Such payment will be made without regard to your legal obligation to do so. The "loss" must occur during the policy period and must take place in the "coverage territory." 2. With respect to the coverage afforded under paragraph 1. above, paragraph 2. Exclusions of SECTION I - COVERAGES A - Bodily Injury and Property Damage Liability is amended as follows: Exclusions j.(3), j.(4), j.(5) and j.(6) are deleted. 3. As respects coverage afforded by this coverage, SECTION III - LIMITS OF INSURANCE is replaced by the following: Regardless of the number of insureds, claims made or "suits" brought or persons or organizations making claims or bring "suits": 1. Subject to 2. Below, the most we will pay for one or more "loss" arising out of any one "occurrence" is $ 1,000. 2. The aggregate amount we will pay for the sum of all "loss" in an annual period is $ 5,000. This aggregate amount is part of and not in addition to the General Aggregate Limit described in paragraph 2. of SECTION III - LIMITS OF INSURANCE. CG 89 70 (Ed. 11/14) (Page 11 of 12) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 V. Who Is an Insured - Fellow Employee Extension - Management Employees 1. The following is added to paragraph 2.a.(1) of SECTION II - WHO IS AN INSURED: Paragraph (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, including the direct supervision of other "employee" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury" or "personal and advertising injury," caused in whole or in part by their intoxication by liquor or controlled substances. This coverage is excess over any other valid and collectable insurance available to your "employee." W. Broadened Personal and Advertising Injury 1. Unless "Personal and Advertising Injury" is excluded from this Policy, the following is added to SECTION V - DEFINITIONS Item 14.: h. mental injury, mental anguish, humiliation, or shock, if directly resulting from Items 14.a. through 14.e. CG 89 70 (Ed. 11/14) (Page 12 of 12) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 90 83 (Ed. 06/17) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - ABUSE, MOLESTATION, HARASSMENT OR SEXUAL CONDUCT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to the Exclusions section of the policy: This insurance does not apply to "bodily injury," "property damage," or "personal and advertising injury" arising out of: (a) the actual, threatened or alleged "abuse", molestation, harassment or sexual conduct by anyone of any person; or (b) the negligent: (i) employment; (ii) investigation; (iii) supervision; (iv) reporting to the proper authorities, (v) or failure to so report; (vi) retention; or (vii) referral of a person for whom any insured is or ever was legally responsible and whose conduct would be excluded by a. above. For the purpose of this endorsement: "Abuse" means: a. any actual, threatened, or alleged act, error, omission, conduct, or misconduct, that a claim or "suit' alleges to be, or to constitute, any form of abuse (including, but not limited to, elder abuse, child abuse, patient abuse, or abuse of a dependent person) under any applicable state or federal statute or regulation; and b. any actual, threatened, or alleged act, error, omission, conduct, or misconduct, of one or more of the following kinds: (1) sexual behavior, sexual conduct or misconduct, sexual assault, sexual battery, sexual abuse, or sexual molestation, of or directed at a person; Includes copyrighted material of Insurance Services Office, Inc., with it CG 90 83 (Ed. 06/17) (Page 1 of 2) HORaN RiskMmaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 (2) non -sexual assault, non -sexual battery, or non -sexual abuse, of or directed at a person; and (3) any: (i) employment; (ii) investigation; (iii) supervision; (iv) reporting to proper authorities, or failure to so report; or (v) retention in employment; of any person committing conduct or misconduct described in b.(1) or b.(2); or (vi) referral of a patient, student, parishioner, client, or person, to any other person whose conduct or misconduct is described in a., b.(1), or b.(2). Conduct or misconduct described in b.(1) through b.(3) constitutes "abuse" within the meaning of this definition regardless of whether or not it is alleged to be negligent, reckless, knowing, intentional, fraudulent, oppressive, malicious, or otherwise. This endorsement does not change any other provision of the policy. Includes copyrighted material of Insurance Services Office, Inc., with it CG 90 83 (Ed. 06/17) (Page 2 of 2) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * S9 * 06/11/2021 * GLP 3961460 00 GREAT AMERICAN ASSURANCE COMPANY *D/B* 072977484 262428 CG 91 69 (Ed. 02/20) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MEDICAL PAYMENTS AT YOUR REQUEST ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following is added to SECTION I — COVERAGES - COVERAGE C - MEDICAL PAYMENTS: If medical payments are covered and not otherwise excluded under the policy, medical payments will be paid only if you request that we pay such expenses. All other terms and conditions of the policy remain unchanged. © Insurance Services Office, Inc., 2019 CG 91 69 (Ed. 02/20) �oRaN } z RiskMmWmentDMsfan REVIEWED & APPROVED BY.- f R. V;d Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 MAURY DONNELLY & PARR INC 24 COMMERCE ST BALTIMORE, MD 21202 3208 �oRaN } z a RAMmWmerdDMaian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * 081 * 06/11/2021 * LIMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 IF'I The Moment of Truth: Reporting a Claim GREATU ERICAN INSURANCE GROUP Specialty Human Services Online MyGreatAmerican.gaig.com Email SpecialtyHumanServicesClaims@gaig.com Phone Toll Free: 888-317-4828 Fax: 888-307-3180 Mail Great American Insurance Group Specialty Human Services Division Claims Department, P.O. Box 1997 Cincinnati, OH 45202 ;ems DMsian �P4P'R.OgVq D BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 IMPORTANT INFORMATION TO POLICYHOLDERS CALIFORNIA TO OBTAIN INFORMATION OR TO MAKE A COMPLAINT In the event you need to contact someone about this Policy for any reason please contact your agent. If you have additional questions, you may contact the insurance company issuing this Policy at the following address and telephone number: Great American Insurance Group Administrative Offices 301 East 4th Street Cincinnati, OH 45202 Or you may call the toll -free telephone number for information or to make a complaint at: 1-800-972-3008 If you have a problem with your insurance company, its agent or representative that has not been resolved to your satisfaction, please call or write to the Department of Insurance. California Department of Insurance Consumer Services Division 300 South Spring Street, South Tower Los Angeles, California 90013 1-800-927-4357 213-897-8921 (if calling from within the Los Angeles area) 1-800-482-4833 (TDD Number) Written correspondence is preferable so that a record of your inquiry can be maintained. When contacting your agent, company or the Bureau of Insurance, have your Policy Number available. ATTACH THIS NOTICE TO YOUR POLICY This notice is for information only and does not become a part or condition of the attached document. SDM-705 (Ed. 11/08) HortaN Risk MwagemertLD sign REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 COMMERCIAL UMBRELLA ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION EXCLUSION ADVISORY NOTICE TO POLICYHOLDERS This Notice does not form part of your policy. No coverage is provided by this Notice nor can it be construed to replace any provision of your policy. You should read your policy and review your Declarations page for complete information on the coverages you are provided. If there is any conflict between the Policy and this Notice, THE PROVISIONS OF THE POLICY SHALL PREVAIL. Carefully read your policy, including the endorsements attached to your policy. Please note that not all the forms listed below may be applicable to your policy. This Notice provides information concerning the following new endorsement, which applies to your renewal policy being issued by us: GAI 7269 Exclusion - Access or Disclosure of Confidential or Personal Information and Data -Related Liability - With Limited Bodily Injury Exception When this endorsement is attached to your policy: Your policy excludes damages arising out of any access to or disclosure of any person's or organization's confidential or personal information, including patents, trade secrets, processing methods, customer lists, financial information, credit card information, health information or any other type of nonpublic information; or the loss of, loss of use of, damage to, corruption of, inability to access, or inability to manipulate electronic data. This exclusion applies even if damages are claimed for notification costs, credit monitoring expenses, forensic expenses, public relations expenses or any other loss, cost or expense incurred by you or others arising out of that which is described in the paragraph above. However, this exclusion does not apply to damages because of "bodily injury" arising out of any access to or disclosure of any person's or organization's confidential or personal information. GAI 7268 Exclusion - Access or Disclosure of Confidential or Personal Information and Data -Related Liability - Limited Bodily Injury Exception Not Included When this endorsement is attached to your policy Your policy excludes damages arising out of any access to or disclosure of any person's or organization's confidential or personal information, including patents, trade secrets, processing methods, customer lists, financial information, credit card information, health information or any other type of nonpublic information; or the loss of, loss of use of, damage to, corruption of, inability to access, or inability to manipulate electronic data, which results in a reduction of coverage. This exclusion will apply even if damages are claimed for notification costs, credit monitoring expenses, forensic expenses, public relations expenses or any other loss, cost or expense incurred by you or others arising out of that which is described in the paragraph above. SDM-851 (Ed. 05/14) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6001 (Ed. 06 97) Policy No. UMB 3-96-14-61 - 00 Renewal Of - THE PROTECTOR COMMERCIAL UMBRELLA DECLARATIONS PAGE 1 NAMED INSURED AND ADDRESS: 2. POLICY PERIOD: BACKHAUS DANCE 12:01 A.M. Standard Time at the address of the Named Insured P.O. BOX 5890 shown at left. ORANGE, CA 92863 From 06/03/2021 To 06/03/2022 IN RETURN FOR PAYMENT OF THE PREMIUM, PRODUCER'S NAME AND ADDRESS: AND SUBJECT TO ALL TERMS OF THIS MAURY DONNELLY & PARR INC POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS 24 COMMERCE ST POLICY. BALTIMORE, MD 21202 3208 Insurance is afforded by: GREAT AMERICAN ALLIANCE INSURANCE COMPANY 3. PREMIUM: Commercial Umbrella Premium $ 3,250.00 Total Advance Premium $ 3,250.00 Total $ 3,250.00 In the event of cancellation by the Named Insured, the company will receive and retain no less than $ 650.00 as a policy minimum premium. BASIS OF PREMIUM: Non - Auditable ( X) Auditable ( ) 4. LIMITS OF INSURANCE: $ 4,000,000 Each Occurrence $ 4,000,000 General Aggregate (Where Applicable) $ 4,000,000 Products -Completed Operations Aggregate 5. SELF -INSURED RETENTION: $ 10 , 000 6. FORMS AND ENDORSEMENTS applicable to all Coverage Forms and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule, GAI 6013 (Ed. 06/97). GAI 6001 (Ed. 06/97) PRO (Page 1 of 1 ) HORaN } z RiskMwag medDMsian REVIEWED & APPROVED BY.- f R. V;d Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6013 (Ed. 06 97) FORMS AND ENDORSEMENTS SCHEDULE I t is hereby understood and agreed the following forms and endorsements are attached to and are a part of this policy: Date Added* or Form and Edition ST Date Deleted Form Description 1. GAI6001 06/97 CA COMM'L UMBRELLA COV PART DEC 2. GAI6002 04/10 CA THE PROTECTOR UMBRELLA COV. FORM 3. GAI6003 06/97 CA SCHEDULE A - UNDERLYING POLICIES 4. GAI6047 04/10 CA ADVERTISING INJURY -FOLLOWING FORM 5. GAI6107 02/12 CA AUTOMOBILE LIABILITY EXCLUSION 6. GAI6129 04/10 CA PERSNL INJURY LIA (FOLLOWING FORM) 7. GAI6135 06/97 CA PROFESSIONAL LIABILITY EXCLUSION 8. GAI6158 01/13 CA CA CHANGES-CANCELLATION/NONRENEWAL 9. GAI6442 04/10 CA FUNGI, MOLD OR SPORES EXCLUSION 10. GAI6452 04/15 CA CAP ON LOSSES - CERT ACTS OF TERROR 11. GAI6458 04/15 CA EXCL-PUNITIVE DAM REL TO CERT TERRO 12. GAI6472 04/15 CA DISCLOSURE TO TERRORISM RISK ACT OF 13. GAI6475 04/10 CA ACT OF TERRORISM RETAINED LIMIT 14. GAI6807 08/14 CA ORGANIC PATHOGENS EXCLUSION 15. GAI6819 10/04 CA SILICA OR RELATED DUST EXCLUSION 16. GAI6869 08/05 CA NUCLEAR, BIOLOGICAL OR CHEMICAL EXC 17. GAI7111 04/10 CA INFRINGEMENT OF COPYRIGHT, PATENT, 18. GAI7251 08/14 CA ABUSE OR MOLESTATION COVERAGE - FF 19. GAI7269 05/14 CA EXCL.-ACCESS/WITH LIMITED BODILY IN 20. IL7268 09/09 CA IN WITNESS CLAUSE 21 22 * I f not at inception GAI 6013 (Ed. 06/97) PRO HORaN RiskMmWmentDMsian REVIEWED & APPROVED BY.- r f R. Vj&wd Risk Management Analyst (Page 1 of 1 ) T * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6003 (Ed. 06 97) THE PROTECTOR SCHEDULE A - SCHEDULE OF UNDERLYING POLICIES Carrier, Policy Number and Type of Coverage Limits of Insurance Period GR AMER ASSURANCE CO Commercial $2,000,000 Aggregate Limit GLP 396 14 60 General Liability $2,000,000 Products - 06/03/2021 Occurrence Form Completed Operations 06/03/2022 Aggregate Limit $1,000,000 Personal and Advertising Injury Limit $1,000,000 Each Occurrence Carrier, Policy Number and Type of Coverage Limits of Insurance Period GR AMER ASSURANCE CO Abuse/Molestation GLP 396 14 60 06/03/2021 $2,000,000 AGGREGATE 06/03/2022 $1,000,000 EACH ABUSE LIMIT BUSINESSPRO (Reg. U.S. Pat. Off.) GAI 6003 (Ed. 06/97) (Page 1 of 1) HortaN RiskMmWmentDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6002 (Ed. 04 10) T H E P R O T E C T O R COMMERCIAL UMBRELLA COVERAGE FORM There are provisions in this Policy that restrict coverage. Read the entire Policy carefully to determine rights, duties and what is and is not covered. Throughout this Policy, the words "you" and "your" refer to the Named Insured as defined in Insuring Agreement, V. DEFINITIONS. The words "we," "us," and "our" refer to the Company providing this insurance. The word "Insured" means any person or organization qualifying as such in Insuring Agreement, V. DEFINITIONS. Words and phrases that appear in quotation marks have special meanings that can be found in V. DEFINITIONS or in the specific Policy provision where those words appear. In consideration of the payment of the premium and in reliance upon the statements in the Declarations we agree with you to provide coverage as follows: INSURING AGREEMENTS I. COVERAGE A. We will pay on behalf of the "Insured" those sums in excess of the "retained limit" that the "Insured" becomes legally obligated to pay as damages, by reason of liability imposed by law or assumed by the "Insured" under an "insured contract," because of: 1. "bodily injury" or "property damage" that takes place; or 2. "personal injury" or "advertising injury" arising from an offense committed; during the Policy Period and caused by an "occurrence" happening anywhere. If we are prevented by law or statute from paying such sums on behalf of the "Insured," then we will indemnify the "Insured" for them. The amount we will pay for damages is limited as described below in Section II. LIMITS OF INSURANCE. B. This insurance applies to "bodily injury," "property damage," "personal injury," or "advertising injury" only if, prior to the Policy Period, no "Insured" knew that the "bodily injury," "property damage," "personal injury," or "advertising injury" had occurred, in whole or in part. If any "Insured" knew, prior to the Policy Period, that the "bodily injury," "property damage," "personal injury," or "advertising injury" had occurred in whole or in part, then any continuation, change, or resumption of such "bodily injury," "property damage," "personal injury," or "advertising injury," during or after the Policy Period, will be deemed to have been known prior to the Policy Period. C. "Bodily injury," "property damage," "personal injury," or "advertising injury" which occurs during the Policy Period and was not, prior to the Policy Period, known to have occurred by any "Insured," includes any continuation, change, or resumption of that "bodily injury," "property damage," "personal injury," or "advertising injury" after the end of the Policy Period. GAI 6002 (Ed. 04/10) XS (Page 1 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 D. "Bodily injury," "property damage," "personal injury," or "advertising injury" will be deemed to have been known by all "Insureds" to have occurred at the earliest time when any "Insured": 1. reports all, or any part, of the "bodily injury," "property damage," "personal injury," or "advertising injury" to us or any other insurer; 2. receives a written or verbal demand or "claim" for damages because of the "bodily injury," "property damage," "personal injury," or "advertising injury"; or 3. becomes aware by any other means that "bodily injury," "property damage," "personal injury," or "advertising injury" has occurred or has begun to occur. II. LIMITS OF INSURANCE A. The Limits of Insurance shown in Item 4. of the Declarations and the rules below state the most we will pay regardless of the number of: 1. "Insureds"; 2. "claims" made or "suits" brought; or 3. persons or organizations making "claims" or bringing "suits." B. The General Aggregate Limit is the most we will pay for all damages covered under the Insuring Agreement in Section I., except: 1. damages included in the "products -completed operations hazard"; and 2. coverages included in the policies listed in the Schedule of Underlying Insurance to which no underlying aggregate limit applies. The amount stated in the Declarations as the General Aggregate Limit is the most we will pay for all damages arising out of any "bodily injury," "property damage," "personal injury," or "advertising injury" subject to an aggregate limit in the "underlying insurance." The General Aggregate Limit applies separately and in the same manner as the aggregate limits in the "underlying insurance." C. The Products -Completed Operations Aggregate Limit stated in the Declarations is the most we will pay for all damages included in the "products -completed operations hazard." D. Subject to B. or C. in Section II. LIMITS OF INSURANCE, whichever applies, the Each Occurrence Limit stated in the Declarations is the most we will pay for damages covered under the Insuring Agreement in Section I. because of all "bodily injury," "property damage," "personal injury," and "advertising injury" arising out of any one "occurrence." E. If the applicable Limits of Insurance of the policies listed in the Schedule of Underlying Insurance or of other insurance providing coverage to the "Insured" are reduced or exhausted by actual payment for one or more "claims" or "suits," then, subject to all applicable terms and conditions of this Policy, we will: 1. in the event of reduction, pay in excess of the reduced underlying Limits of Insurance, or; GAI 6002 (Ed. 04/10) XS (Page 2 of 26) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 2. in the event of exhaustion, continue in force as "underlying insurance"; Coverage provided pursuant to E.1. or E.2. above will be subject to the exclusions, terms, and conditions of this Policy. F. The Limits of Insurance of this Policy apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the Policy Period shown in the Declarations, unless the Policy Period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. G. Retained Limit Subject to the applicable Limits of Insurance stated in the Declarations and described in A. through F., above, we will be liable only for that portion of damages that is in excess of the "retained limit." The "retained limit" is the greater of: 1. the total amounts stated as the applicable limits of the underlying policies listed in the Schedule of Underlying Insurance and the applicable limits of all other insurance providing coverage to the "Insured" during the Policy Period; or 2. the amount stated in the Declarations as "Self -Insured Retention," as respects any "occurrence" covered by none of the underlying policies listed in the Schedule of Underlying Insurance and by no other insurance providing coverage to the "Insured" during the Policy Period. Once the "Self -Insured Retention" has been fully exhausted by the Insured's actual payment of damages because of "claims" and "suits," the "Self -Insured Retention" will not be reapplied or again payable by the "Insured" because of any "bodily injury," "property damage," or offense that takes place or is committed during the Policy Period. III. DEFENSE A. We will have the right and duty to investigate any "claim" and defend any "suit" seeking damages covered by the terms and conditions of this Policy when: 1. the applicable Limits of Insurance of the underlying policies listed in the Schedule of Underlying Insurance and the Limit of Insurance of all other insurance providing coverage to the "Insured" have been exhausted by actual payment of "claims" for any "occurrence" to which this Policy applies; or 2. damages are sought for any "occurrence" which is covered by this Policy but covered by none of the underlying policies listed in the Schedule of Underlying Insurance and by no other insurance providing coverage to the "Insured." B. When we assume the defense of any "claim" or "suit": 1. we will investigate any "claim" and defend any "suit" against the "Insured" seeking damages on account of any "occurrence" covered by this Policy. We have the right to investigate, defend, and settle the "claim" or "suit" as we deem expedient. 2. all expenses we incur in the investigation of any "claim" or defense of any "suit" are in addition to our Limits of Insurance. GAI 6002 (Ed. 04/10) XS (Page 3 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 3. we will pay the following as expenses, but only to the extent they are neither paid nor required to be paid by one or more of the underlying policies listed in the Schedule of Underlying Insurance nor by any other insurance providing coverage to the "Insured": a. premiums on bonds to release attachments, but only for bond amounts within our applicable Limit of Insurance. We are not obligated to apply for or furnish any such bond. b. premiums on appeal bonds required by law to appeal any "claim" or "suit" we defend, but only for bond amounts within our applicable Limit of Insurance. We are not obligated to apply for or furnish any such bond. c. all court costs taxed against the "Insured" in any "claim" or "suit" we defend. However, we will not pay for attorneys' fees or attorneys' expenses taxed against the "Insured." d. pre -judgment interest awarded against the "Insured" on that part of the judgment we pay that is within our applicable Limit of Insurance. If we make an offer to pay the applicable Limit of Insurance, we will not pay any pre -judgment interest based on the period of time after the offer; e. all interest that accrues after entry of judgment and before we have paid, offered to pay or deposited in court the part of the judgment that is within our applicable Limit of Insurance; f. the "Insured's" actual and reasonable expenses incurred at our request. C. We will not investigate any "claim" or defend any "suit" after our applicable Limits of Insurance have been exhausted by payment of judgments or settlements. D. Except for those instances described in Subsection A. in Section III. DEFENSE, we will not be obligated to assume charge of the investigation, settlement, or defense of any "claim" or "suit" against the "Insured." We will, however, have the right and will be given the opportunity to participate in the settlement, defense, and trial of any "claim" or "suit" relative to any "occurrence" which, in our opinion, may create liability on our part under the terms of this Policy. If we exercise such right, we will do so at our own expense. IV. EXCLUSIONS This insurance does not apply to: A. Asbestos "Bodily injury," "property damage," "personal injury," "advertising injury," and any other liability, including, but not limited to, settlements, judgments, costs, charges, expenses, costs of investigations, or the fees of attorneys, experts, or consultants, arising out of or related in any way, either directly or indirectly, to: 1. asbestos, asbestos products, asbestos -containing materials or products, asbestos fibers or asbestos dust, including, but not limited to, any manufacture, mining, use, sale, installation, removal, or distribution activities related to any form of asbestos; 2 exposure to, testing for, monitoring of, cleaning up, removing, containing, or treating of asbestos, asbestos products, asbestos -containing materials or products, asbestos fibers or asbestos dust; or GAI 6002 (Ed. 04/10) XS (Page 4 of 26) HORaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 3. any obligation to investigate, settle, or defend, or indemnify any person against, any "claim" or "suit" arising out of, or related in any way, either directly or indirectly, to asbestos, asbestos products, asbestos -containing materials or products, asbestos fibers or asbestos dust. B. Breach of Contract "Personal injury" or "advertising injury" arising out of a breach of contract, except an implied contract to use another's advertising idea in your "advertisement." C. Criminal Acts "Personal injury" or "advertising injury" arising out of a criminal act committed by or at the direction of the "Insured." D. Damage to Impaired Property Or Property Not Physically Injured "Property damage" to "impaired property" or property that has not been physically injured, arising out of: 1. a defect, deficiency, inadequacy or dangerous condition in "your product" or "your work"; or 2. a delay or failure by you or anyone acting on your behalf to perform a contract or agreement in accordance with its terms. This exclusion does not apply to the loss of use of other property arising out of sudden and accidental physical injury to "your product" or "your work" after it has been put to its intended use. E. Damage to Property "Property damage" to: 1. property you own, rent, or occupy, including any costs or expenses incurred by you or any other person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property; 2. premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises; 3. property loaned to you; 4. personal property in the care, custody or control of the "Insured"; 5. that particular part of real property on which you or any contractor or subcontractor working directly or indirectly on your behalf is performing operations, if the "property damage" arises out of those operations; or 6. that particular part of any property that must be restored, repaired or replaced because "your work" was incorrectly performed on it. Paragraph 2. of this exclusion does not apply if the premises are "your occupied, rented, or held for rental by you. �ortaNe 1tAMwagzmedDMsian REVIEWED & APPROVED BY.- � f�+s•e �. V� Risk Management Analyst GAI 6002 (Ed. 04/10) XS (Page 5 of 26) y NJ * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 Paragraphs 3., 4., 5., and 6. of this exclusion do not apply to liability assumed under a railroad sidetrack agreement. Paragraph 6. of this exclusion does not apply to "property damage" included in the "products -completed operations hazard." F. Damage to Your Product "Property damage" to "your product" arising out of it or any part of it. G. Damage to Your Work "Property damage" to "your work" arising out of it or any part of it and included in the "products -completed operations hazard." This exclusion does not apply if the damaged work or the work out of which the damage arises was performed on your behalf by a subcontractor. H. Distribution Of Material In Violation Of Statutes "Bodily injury," "property damage," "personal injury" or "advertising injury" arising, directly or indirectly, out of any act or omission that violates or is alleged to violate: 1. the Telephone Consumer Protection Act (TCPA), including any amendment of or addition to that law, by the sending or transmitting of a fax or the placing of a phone call; 2. the CAN-SPAM Act of 2003, including any amendment of or addition to that law, by the sending or transmittal of an email; or 3. the Fair Credit Reporting Act (FCRA), and any such amendment of or addition to such law, including the Fair and Accurate Credit Transaction Act (FACTA); or 4. any federal, state or local statute, ordinance or regulation, other than the TCPA, CAN-SPAM Act of 2003 or FCRA and their amendments and additions, that addresses, prohibits, or limits the printing, dissemination, disposal, collecting, recording, sending, transmitting, communicating or distribution of material or information. I. Electronic Chat Rooms or Bulletin Boards "Personal injury" or "advertising injury" arising out of an electronic chat room, bulletin board, website, social networking site or service, or blog the "Insured" hosts or owns, or over which the "Insured" exercises control. J. Electronic Data "Bodily injury," "property damage," "personal injury" or "advertising injury" arising out of the loss of, loss of use of, damage to, corruption of, inability to access, or inability to manipulate "electronic data." K. Employment -Related Practices "Bodily injury", "personal injury," or "advertising injury," however caused, arising directly or indirectly out of any: 1. refusal to employ or promote; GAI 6002 (Ed. 04/10) XS (Page 6 of 26) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 2. termination of employment; 3. coercion, demotion, evaluation, reassignment, discipline, defamation, harassment, molestation, humiliation, discrimination, or malicious prosecution, directed at a person, or other employment -related practice, policy, act, or omission; or 4. consequential "bodily injury," "property damage," "personal injury," or "advertising injury," as a result of paragraphs 1. through 3. of this exclusion. This exclusion applies whether the injury -causing event described in paragraphs 1. through 4. occurs before employment, during employment, or after employment of that person, and whether the "Insured" may be held liable as an employer or in any other capacity, and to any obligation to share damages with or to repay someone else who must pay damages because of the "bodily injury," "property damage," "personal injury," or "advertising injury." L. ERISA Any obligation of the "Insured" under the Employee Retirement Income Security Act of 1974 (ERISA) or, any amendment to this act, or under any similar law, regulation, or ordinance. M. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the "Insured." This exclusion does not apply to "bodily injury" resulting from the use of reasonable force to protect persons or property. N. Infringement of Copyright, Patent, Trademark or Trade Secret "Personal injury" or "advertising injury" arising out of the infringement of copyright, patent, trademark, trade secret or other intellectual property rights. Under this exclusion, such other intellectual property rights do not include the use of another's advertising idea in your "advertisement." O. Knowing Violation of Rights of Another "Personal injury" or "advertising injury" caused by or at the direction of the "Insured" with the knowledge that the act would violate the rights of another and would inflict "personal injury" or "advertising injury." P. Material Published Prior to Policy Period "Personal injury" or "advertising injury" arising out of oral or written publication of material whose first publication took place before the beginning of the Policy Period. Q. Material Published with Knowledge of Falsity "Personal injury" or "advertising injury" arising out of oral or written publication of material, if done by or at the direction of the "Insured" with knowledge of its falsity. R. Nuclear Energy Liability 1. "Bodily injury," "property damage," "personal injury," "advertising injury," or "nuclear property damage," however caused: GAI 6002 (Ed. 04/10) XS (Page 7 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 a. with respect to which an "Insured" under this Policy is also insured under a nuclear energy liability policy issued by Nuclear Energy Liability Insurance Association, Mutual Atomic Energy Liability Underwriters, Nuclear Insurance Association of Canada, or any of their successors, or would be insured under any such policy but for its termination upon exhaustion of its Limit of Liability; or b. resulting from the "hazardous properties" of "nuclear material" and with respect to which (a) any person or organization is required to maintain financial protection pursuant to the Atomic Energy Act of 1954, or any law amendatory thereof, or (b) any "Insured" is, or had this Policy not been issued would be, entitled to indemnity from the United States of America, or any agency thereof, under any agreement entered into by the United States of America, or any agency thereof, with any person or organization. 2. "Bodily injury," "property damage," "personal injury," "advertising injury," or "nuclear property damage," however caused, arising or resulting from, directly or indirectly, the "hazardous properties" of "nuclear material," if: a. the "nuclear material" (a) is at any "nuclear facility" owned by, or operated by or on behalf of, any "Insured" or (b) has been discharged or dispersed therefrom; b. the "nuclear material" is contained in "spent fuel" or "nuclear waste" at any time possessed, handled, used, processed, stored, transported or disposed of, by or on behalf of any "Insured"; or c. the "bodily injury," "property damage," "personal injury," "advertising injury," or "nuclear property damage" arises out of the furnishing by an "Insured" of services, materials, parts or equipment in connection with the planning, construction, maintenance, operation or use of any "nuclear facility," but if such facility is located within the United States of America, its territories or possessions or Canada, this exclusion 2.c. applies only to "property damage" to such "nuclear facility" and any property in or at that "nuclear facility." 3. As used in this Nuclear Energy Liability exclusion: "Hazardous properties" includes radioactive, toxic or explosive properties. "Nuclear material" means "source material," "special nuclear material" or "by-product material." "Source material," "special nuclear material," and "by-product material" have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof. "Spent fuel" means any fuel element or fuel component, solid or liquid, which has been used or exposed to radiation in a "nuclear reactor." "Nuclear waste" means any waste material (a) containing "by-product material" other than the tailings or wastes produced by the extraction or concentration of uranium or thorium from any ore processed primarily for its "source material" content, and (b) resulting from the operation by any person or organization of any "nuclear facility" included under the first two paragraphs of the definition of "nuclear facility." "Nuclear facility" means: a. any "nuclear reactor"; GAI 6002 (Ed. 04/10) XS (Page 8 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 b. any equipment or device designed or used for (a) separating the isotopes of uranium or plutonium, (b) processing or utilizing "spent fuel," or (c) handling, processing or packaging "nuclear waste"; c. any equipment or device used for the processing, fabricating or alloying of "special nuclear material" if at any time the total amount of such material in the custody of any "Insured" at the premises where such equipment or device is located consists of or contains more than 25 grams of plutonium or uranium 233 or any combination thereof, or more than 250 grams of uranium 235; d. any structure, basin, excavation, premises or place prepared or used for the storage or disposal of "nuclear waste"; and includes the site on which any of the foregoing is located, all operations conducted on such site and all premises used for such operations. "Nuclear reactor" means any apparatus designed or used to sustain nuclear fission in a self-supporting chain reaction or to contain a critical mass of fissionable material. "Nuclear property damage" includes all forms of radioactive contamination of tangible property. S. Pollution 1. Any "bodily injury," "property damage," "personal injury," "advertising injury," and any other liability, including, but not limited to, settlements, judgments, costs, charges, expenses, costs of investigations, or the fees of attorneys, experts, or consultants, arising out of or related in any way, either directly or indirectly, in whole or in part, to the actual, alleged, or threatened discharge, dispersal, seepage, migration, release, escape, presence of, or exposure to, any "pollutant," from any source, at any location, at any time. 2. Any loss, cost, or expense which would not have occurred in whole or in part but for any: a. Request, demand, or order that any "Insured" or others test for, monitor, clean up, remove, contain, treat, detoxify, abate, or neutralize, or in any way respond to or assess the effects of, any "pollutant'; or b. "Claim" or "suit' by or on behalf of any federal, state, or local governmental authority because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying, abating, or neutralizing, or in any way responding to or assessing the effects of, any "pollutant." This exclusion does not apply to "bodily injury" or "property damage" caused by smoke, fumes, vapor, or soot from a "hostile fire," or sustained within a building and caused by smoke, fumes, vapor, or soot from equipment used to heat that building. "Hostile fire" means a fire that becomes uncontrollable or breaks out from where it was intended to be. T. Quality or Performance of Goods - Failure to Conform to Statements "Personal injury" or "advertising injury" arising out of the failure of goods, products or services to conform with any statement of quality or performance made in your "advertisement." GAI 6002 (Ed. 04/10) XS (Page 9 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 U. Recall of Products, Work or Impaired Property Damages claimed for any loss, cost or expense incurred by you or others for the loss of use, withdrawal, recall, inspection, repair, replacement, adjustment, removal or disposal of: 1. "your product"; 2. "your work"; or 3. "impaired property"; if such product, work or property is withdrawn or recalled from the market or from use by any person or organization because of a known or suspected defect, deficiency, inadequacy or dangerous condition in it. V. Unauthorized Use of Another's Name or Product "Personal injury" or "advertising injury" arising out of the unauthorized use of another's name or product in your e-mail address, domain name or metatag, or any other similar tactic to mislead another's potential customers. W. Un-Insured/Under-Insured Motorists and Similar Laws Any obligation of the "Insured" under a No Fault, Uninsured Motorist or Underinsured Motorist law, or under any similar law, regulation or ordinance. X. War "Bodily injury," "property damage," "personal injury," or "advertising injury," however caused, arising directly or indirectly out of: 1. war, including undeclared or civil war; 2. warlike action by military force, including action in hindering or defending against an actual or expected attack, by any government, sovereign or other authority using military personnel or other agents; or 3. insurrection, rebellion, revolution, usurped power, or action taken by governmental authority in hindering or defending against any of these. Y. Workers' Compensation And Similar Laws Any obligation of the "Insured" under a Workers Compensation, Unemployment Compensation or, Disability Benefits Law, or under any similar law, regulation, or ordinance. Z. Wrong Description of Prices "Advertising injury" arising out of the wrong description of the pricing of goods, products or services stated in your "advertisement." AA. Following Form The following exclusions 1. through 6. do not apply to the extent that such coverage is provided by "underlying insurance" or would have been provided by "un for the exhaustion of the applicable limits of the "underlying insuranc damages for "bodily injury," "property damage," "personal injury," or "adv GAI 6002 (Ed. 04/10) XS (Page 10 of 26) �oRaN '�'�i 3 Risk ManagementDMsian REVIEWED &APPROVED BY.- r Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 by our Policy. However, under no circumstances will the coverage provided by our Policy for the risks described in the following exclusions 1. through 6. be any broader than the coverage provided for those risks by the "underlying insurance." Subject to the preceding paragraph, this insurance does not apply to: 1. Aircraft "Bodily injury" or "property damage" arising out of the ownership, maintenance, operation, use, or "loading or unloading" of any aircraft, if such aircraft is owned, or hired without pilot or crew, by or on behalf of any "Insured." 2. Auto "Bodily injury" or "property damage" arising out of the ownership, maintenance, operation, use, or "loading or unloading" of any "auto." 3. Contractual Liability "Bodily injury," "property damage," "personal injury" or "advertising injury" for which any "Insured" is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages: a. that the "Insured" would have in the absence of the contract or agreement; or b. assumed in a written contract or written agreement that is an "Insured contract," but only if the "bodily injury," "property damage," "personal injury" or "advertising injury" occurs after the "Insured" signs or otherwise formally executes that contract or agreement. 4. Employee Liability Liability of any "employee" with respect to "bodily injury," "property damage," "personal injury" or "advertising injury" to you or to another "employee" of the same employer injured in the course of such employment. 5. Employer's Liability a. "Bodily injury" to: (1) an "employee" of any "Insured," arising out of and in the course of: (a) employment by any "Insured"; or (b) performing duties related to the conduct of any "Insured's" business; or (2) the spouse, child, parent, brother or sister of that "employee" as a consequence of Paragraph a. (1) of this exclusion. b. This exclusion applies: (1) whether any "Insured" may be liable as an employer or in any other capacity; and (2) to any obligation to share damages with or repay someor damages because of the injury. GAI 6002 (Ed. 04/10) XS (Page 11 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 6. Watercraft "Bodily injury" or "property damage" arising out of the ownership, maintenance, operation, use, or "loading or unloading" of any watercraft, if such watercraft is owned, or chartered without crew, by or on behalf of any "Insured." This exclusion does not apply to watercraft while ashore on any premises owned by, rented to, or controlled by you. V. DEFINITIONS A. "Advertisement" means a notice that is broadcast or published to the general public or specific market segments about your goods, products or services for the purpose of attracting customers or supporters. For the purposes of this definition: 1. notices that are published include material placed on the Internet or on similar electronic means of communication; 2. regarding web sites, only that part of a web site that is about your goods, products or services for the purposes of attracting customers or supporters is considered an advertisement. B. "Advertising injury" means injury, including consequential "bodily injury," arising out of advertising activities of any "Insured" as a result of one or more of the following offenses committed during the Policy Period in the course of advertising your goods, products, or services: 1. oral or written publication, in any manner, that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; 2. oral or written publication, in any manner, of material that violates a person's right of privacy; 3. misappropriating another's advertising ideas in your "advertisement"; or 4. infringing upon another's copyright, trade dress, or slogan in your "advertisement." "Advertising injury" does not include "personal injury." C. "Auto" means: 1. a land motor vehicle, trailer or semitrailer designed for travel on public roads, including any attached machinery or equipment; or 2. any other land vehicle that is subject to a compulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged. However, "auto" does not include "mobile equipment." D. "Bodily injury" means physical injury, sickness, or disease sustained by a person, including death resulting from any of those at any time. "Bodily injury" also means mental injury, mental anguish, humiliation, or shock sustained by a person, if directly resulting from a physical injury, sickness, or disease of that person. E. "Claim" means a demand, made under an assertion of legal right, for mone "bodily injury," "property damage," "advertising injury," or "personal injury.' GAI 6002 (Ed. 04/10) XS (Page 12 of 26) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 F. "Electronic data" means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, hardware, or media, including systems and applications software, hard or floppy disks, CD-ROMS, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment. G. "Employee" includes a "leased worker." "Employee" does not include a "temporary worker." H. "Executive officer" means a person holding any of the officer positions created by your charter, constitution, bylaws or any other similar governing document. I. "Impaired property" means tangible property, other than "your product" or "your work," that cannot be used or is less useful because: 1. it incorporates "your product" or "your work" that is known or thought to be defective, deficient, inadequate or dangerous; or 2. you have failed to fulfill the terms of a contract or agreement; if such property can be restored to use by the repair, replacement, adjustment or removal of "your product" or "your work" or your fulfilling the terms of the contract or agreement. "Impaired property" does not include "electronic data." J. "Insured" means each of the following, to the extent set forth: 1. The Named Insured meaning: a. any person or organization listed in Item 1. of the Declarations, and any Company of which you own more than 50% as of the beginning of the Policy Period. b. any organization you newly acquire or form during the Policy Period, other than a partnership, joint venture or limited liability company, and of which you maintain ownership of more than 50%, will qualify to be a Named Insured. However: (1) coverage for such an organization under this provision is afforded only until the 90th day after you acquire or form the organization or the end of the Policy Period, whichever is earlier; (2) coverage under this provision does not apply to any "bodily injury," "property damage," "personal injury" or "advertising injury" that occurred before you acquired or formed the organization; and (3) coverage under this provision applies only if the organization is insured under one or more of the policies listed in the Schedule of Underlying Insurance, and then for no broader coverage than is provided for that organization under such underlying policies. 2. If you are an individual: a. you and your spouse, but only with respect to the conduct of a business of which you are the sole owner as of the beginning of the Policy Period. . any person or organization having proper temporary custody of your property if you die, but only: (1) with respect to liability arising out of the maintenance or use GAI 6002 (Ed. 04/10) XS (Page 13 of 26) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 (2) until your legal representative has been appointed; and c. your legal representative if you die, but only with respect to duties as such. That representative will have all of your rights and duties under this insurance. 3. If you are a partnership or joint venture, your partners or members and their spouses, but only as respects the conduct of your business. 4. If you are a limited liability company, your members and your managers, but only as respects the conduct of your business. 5. If you are a trust, you are an "Insured." Your trustees are also "Insureds," but only with respect to their duties as your trustees. 6. Any person or organization, other than a Named Insured, included as an additional "Insured" by virtue of an "insured contract" or a contract that includes an "insured contract," and to which coverage is provided by the "underlying insurance," but for no broader coverage under this Policy than the coverage the "underlying insurance" provides for such additional "Insured." 7. Subject to 12., below, any of your "executive officers" or directors (if you are an organization other than a partnership, joint venture, or limited liability company) and any of your "employees," but only while acting within the scope of their duties as such. Your stockholders (if you are an organization other than a partnership, joint venture, or limited liability company) are also "Insureds," but only with respect to their liability as your stockholders. But no person or organization that is an "Insured" solely by virtue of this subparagraph is an "Insured" as respects any: a. "bodily injury" or "property damage" arising out of the ownership, maintenance, use, or "loading or unloading" of any "auto," aircraft or watercraft. However, if valid "underlying insurance" affords such coverage for that person or organization, or would have afforded such coverage but for the exhaustion of underlying limits for "bodily injury" or "property damage," then, subject to all the other terms and conditions of our Policy, that person or organization is also an "Insured" under our Policy as respects a. In that case, the coverage our Policy provides that person or organization for a. will follow the provisions, exclusions, and limitations of, and be no broader than, the coverage that "underlying insurance" provides that person or organization for a. 8. Subject to 12., below your "volunteer workers," but only while performing duties related to the conduct of your business. 9. Any person or organization, other than one of your "employees," while acting as your real estate manager. 10. Any person or organization (other than your partners, "executive officers," directors, stockholders or "employees") with respect to any "auto" owned by you, loaned to you, or hired by you or on your behalf, and used by that person or organization with your permission. But no person or organization that is an "Insured" solely by virtue of this subparagraph is an "Insured" as respects using an "auto" while working in a business that sells, services, repairs, or parks "autos" unless you are in that business. 11 No person or organization is an "Insured" with respect to the conduct of any current or past partnership or joint venture that is not shown as a Named Insu or unless added via endorsement to this Policy. GAI 6002 (Ed. 04/10) XS (Page 14 of 26) Ride Management DMsian & APPROVED BY.- ccREVIEWED Risk Management Analyst * 081 * 06/11/2021 * LIMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 12. None of your "employees" or "volunteer workers" is an "Insured" as respects any: a. "Bodily injury," "personal injury" or "advertising injury": (1) to you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co -"employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (2) to the spouse, child, parent, brother or sister of that co -"employee" or "volunteer worker" as a consequence of paragraph a. (1) above; (3) for which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraph a.(1) or a.(2) above; or b. "Property damage" to property: (1) owned, occupied, or used by, (2) rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees" or "volunteer workers," any of your partners or members (if you are a partnership or joint venture), or any of your members (if you are a limited liability company). K. "Insured contract" means: 1. a contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire to premises while rented to you, or while temporarily occupied by you with permission of the owner, is not an "insured contract"; 2. a sidetrack agreement; 3. any easement or license agreement, except in connection with construction or demolition operations on or within 50 feet of a railroad; 4. an obligation, as required by ordinance, to indemnify a municipality, except in connection with work for a municipality; 5. an elevator maintenance agreement; 6. that part of any other contract or agreement pertaining to your business (including an indemnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury," "property damage," "personal injury" or "advertising injury" to a third person or organization. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement. Paragraph 6. does not include that part of any contract or agreement: GAI 6002 (Ed. 04/10) XS (Page 15 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 a. that indemnifies a railroad for "bodily injury" or "property damage" arising out of construction or demolition operations, within 50 feet of any railroad property and affecting any railroad bridge or trestle, tracks, roadbeds, tunnel, underpass or crossing; b. that indemnifies an architect, engineer or surveyor for injury or damage arising out of: (1) preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) giving directions or instructions, or failing to give them, if that is the primary cause of the injury or damage; or c. under which the "Insured," if an architect, engineer or surveyor, assumes liability for an injury or damage arising out of the "Insured's" rendering or failure to render professional services, including those listed in b. above and supervisory, inspection, architectural or engineering activities. L. "Leased worker" means a person leased to you by a labor leasing firm under an agreement between you and the labor leasing firm, to perform duties related to the conduct of your business. "Leased worker" does not include a "temporary worker." M. "Loading or unloading" means the handling of property: 1. after it is removed from the place where it is accepted for movement into or onto an aircraft, watercraft, or "auto"; 2. while it is in or on an aircraft, watercraft, or "auto"; 3. while it is being moved from an aircraft, watercraft or "auto" to the place where it is finally delivered. However, "loading or unloading" does not include the movement of property by means of a mechanical device, other than a hand truck, that is not attached to the aircraft, watercraft, or "auto." N. "Mobile equipment" means any of the following types of land vehicles, including any attached machinery or equipment: 1. bulldozers, farm machinery, forklifts and other vehicles designed for use principally off public roads; 2. vehicles maintained for use solely on or next to premises you own or rent; 3. vehicles that travel on crawler treads; 4. vehicles, whether self-propelled or not, maintained primarily to provide mobility to permanently mounted: a. power cranes, shovels, loaders, diggers or drills; or b. road construction or resurfacing equipment such as graders, scrapers or rollers; 5. vehicles not described in paragraphs 1., 2., 3., or 4. above that are are maintained primarily to provide mobility to permanently attac oRaNe 1tAMwagzmedDMsian following types: }% r REVIEWED & APPROVED BY. - Risk Management Analyst GAI 6002 (Ed. 04/10) XS (Page 16 of 26) * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 a. air compressors, pumps and generators, including spraying, welding, building cleaning, geophysical exploration, lighting and well servicing equipment; or b. cherry pickers and similar devices used to raise or lower workers; 6. vehicles not described in 1., 2., 3., or 4. above maintained primarily for purposes other than the transportation of persons or cargo. However, self-propelled vehicles with the following types of permanently attached equipment are not "mobile equipment' but will be considered "autos": a. equipment designed primarily for: (1) snow removal; (2) road maintenance, but not construction or resurfacing; or (3) street cleaning; b. cherry pickers and similar devices mounted on auto or truck chassis and used to raise or lower workers; and c. air compressors, pumps and generators, including spraying, welding, building cleaning, geophysical exploration, lighting and well servicing equipment. However, "mobile equipment' does not include any land vehicle that is subject to a compulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged. Land vehicles subject to a compulsory or financial responsibility law or other motor vehicle insurance law are considered "autos." O. "Occurrence" means: 1. as respects "bodily injury" or "property damage," an accident, including continuous or repeated exposure to substantially the same general harmful conditions. All such exposure to substantially the same general harmful conditions will be deemed to arise out of one "Occurrence"; 2. as respects "personal injury," an offense, arising out of your business, that results in "personal injury," but only if that offense is committed during the Policy Period. All "personal injury" that arises from the same offense, or from repeated or related offenses, will be considered as arising out of one and the same "occurrence," regardless of the frequency or repetition thereof, the number or kinds of media, or the number of people or organizations making "claims" or bringing "suits"; 3. as respects "advertising injury," an offense, committed in the course of advertising your goods, products and services, that results in "advertising injury," but only if that offense is committed during the Policy Period. All "advertising injury" that arises from the same offense, or from repeated or related offenses, will be considered as arising out of one and the same "occurrence," regardless of the frequency or repetition thereof, the number or kinds of media used, or the number of people or organizations making "claims" or bringing "suits." P. "Personal injury" means injury, including consequential "bodily injury," arising out of one or more of the following offenses committed during the Policy Period: 1. false arrest, detention or imprisonment; GAI 6002 (Ed. 04/10) XS (Page 17 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 2. malicious prosecution; 3. the wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room, dwelling or premises that a person occupies, committed by or on behalf of its owner, landlord or lessor; 4. oral, or written publication, in any manner, that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; or 5. oral or written publication, in any manner, that violates a person's right of privacy. "Personal injury" does not include "advertising injury." Q. "Pollutant" means any solid, liquid, gaseous or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled, reconditioned or reclaimed. R. "Pollution cost or expense" means any loss, cost or expense arising out of any: 1. request, demand, order or statutory or regulatory requirement that any "Insured" or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, abate, or in any way respond to or assess the effects of, any "pollutant"; or 2. "claim" or "suit" by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, abating, or in any way responding to or assessing the effects of, any "pollutant." S. "Products -completed operations hazard": 1. Includes all "bodily injury" and "property damage" occurring away from premises you own or rent and arising out of "your product" or "your work" except: a. products that are still in your physical possession; or b. work that has not yet been completed or abandoned. "Your work" will be deemed completed at the earliest of the following times: (1) when all of the work called for in your contract has been completed. (2) when all of the work to be done at the job site has been completed if your contract calls for work at more than one job site. (3) when that part of the work done at a job site has been put to its intended use by any person or organization other than another contractor or subcontractor working on the same project. Work that may need service, maintenance, correction, repair or replacement, but which is otherwise complete, will be treated as completed. 2. Does not include "bodily injury" or "property damage" arising out of: a. the transportation of property, unless the injury or damage arises out of a condition in or on a vehicle not owned or operated by you, and that conditi "loading or unloading" of that vehicle by any "Insured"; _ �oRaNe Risk MmWmedDMsian �. REVIEWED & APPROVED BY. - Risk Management Analyst GAI 6002 (Ed. 04/10) XS (Page 18 of 26) * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 b. the existence of tools, uninstalled equipment or abandoned or unused materials. T. "Property damage" means: 1. physical injury to tangible property, including all resulting loss of use of that property. All such loss of use will be deemed to occur at the time of the physical injury that caused it; or 2. loss of use of tangible property that is not physically injured. All such loss will be deemed to occur at the time of the "occurrence" that caused it. For the purposes of this insurance, "electronic data" is not tangible property. U. "Self -Insured Retention" means the dollar amount listed in Item 5. of the Declarations that will be paid by the "Insured" before this insurance becomes applicable, with respect to "occurrences" or offenses not covered by "underlying insurance." The "Self -Insured Retention" does not apply to "occurrences" or offenses which would have been covered by "underlying insurance" but for the exhaustion of applicable limits of the "underlying insurance." V. "Suit" means a civil proceeding which seeks monetary damages because of "bodily injury," "property damage," "personal injury," or "advertising injury" to which this insurance applies. "Suit' includes: 1. an arbitration proceeding in which such damages are claimed and to which you must submit or do submit with our consent; or 2. any other alternative dispute resolution proceeding in which such damages are claimed and to which you submit with our consent. W. "Temporary worker" means a person who is furnished to you to substitute for a permanent "employee" on leave or to meet seasonal or short-term workload conditions. X. "Underlying insurance" means the insurance coverage provided under policies shown in the Schedule of Underlying Insurance, or any additional policies agreed to by us in writing. It includes any policy issued to replace one of those policies during the term of this insurance that provides: 1. at least the same policy limits; and 2. insurance for the same hazards, except as to any modifications which are agreed to by us in writing. "Underlying insurance" does not include any insurance policy specifically purchased to apply only in excess of this Policy. Y. "Volunteer worker" means a person who is not your "employee," and who donates his or her work and acts at the direction of and within the scope of duties determined by you, and is not paid a fee, salary, or other compensation by you or anyone else for their work performed for you. Z. "Your product" means: 1. any goods or products, other than real property, manufactured, sold, handled, distributed or disposed of by: a. you; GAI 6002 (Ed. 04/10) XS (Page 19 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 b. others trading under your name; or c. a person or organization whose business or assets you have acquired; and 2. containers (other than vehicles), materials, parts or equipment furnished in connection with such goods or products. "Your product" includes: 1. warranties or representations made at any time with respect to the fitness, quality, durability, performance or use of "your product"; and 2. the providing of or failure to provide warnings or instructions. "Your product" does not include vending machines or other property rented to or located for the use of others but not sold. AA. "Your work" means: 1. work or operations performed by you or on your behalf; and 2. materials, parts or equipment furnished in connection with such work or operations. "Your work" includes: 1. warranties or representations made at any time with respect to the fitness, quality, durability, performance or use of "your work"; and 2. the providing of or failure to provide warnings or instructions. VI. CONDITIONS A. Appeals If the "Insured" or an "Insured's" underlying insurers do not appeal an award or judgment in excess of the "retained limit," we have the right to make such an appeal. Whether or not we elect to appeal, and regardless of the result of any appeal we elect to make, the amount we pay in connection with such an award or judgment will not exceed our applicable Limit of Insurance, as stated in Item 4. of the Declarations plus expenses we incur in the defense of the "suit." B. Audit We may audit and examine your books and records as they relate to this Policy or the premium to be charged, at any time during the Policy Period of this Policy and for up to three years after the end of that Policy Period. C. Bankruptcy or Insolvency The bankruptcy, insolvency or inability to pay of any "Insured," or the bankruptcy, insolvency or inability to pay of any of the Underlying Insurers, will not relieve us from the payment of any "claim" or "suit" covered by this Policy. Under no circumstances will any such bankruptcy, insolvency or inability to pay require us to drop down and replace the "retained limit" or to bear or assume any obligation within the "retained limit." GAI 6002 (Ed. 04/10) XS (Page 20 of 26) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 D. Cancellation 1. You may cancel this Policy before the end of the Policy Period. To do so, you must mail or deliver advance written notice to us stating the day and hour the cancellation takes effect. 2. We may cancel this Policy before the end of the Policy Period. If we cancel because of nonpayment of premium, we must mail or deliver advance written notice to you stating when, not less than ten (10) days thereafter, the cancellation takes effect. If we cancel for any other reason, we must mail or deliver advance written notice to you stating when, not less than thirty (30) days thereafter, the cancellation takes effect. Mailing that notice to you at your mailing address shown in Item 1. of the Declarations will be sufficient notice of cancellation, and proof of such mailing will be sufficient proof of notice. 3. If you or we cancel, the Policy Period ends when the cancellation takes effect. 4. If we cancel, final premium will be calculated pro rata based on the time this Policy was in force. Final premium will not be less than the Minimum Premium shown in Item 3. of the Declarations. 5. If you cancel, final premium may be more than pro rata; it will be based on the time this Policy was in force and may be increased by our short rate cancellation table and procedure. Final premium will not be less than the Minimum Premium shown in Item 3. of the Declarations. 6. Premium adjustment may be made at the time of cancellation or as soon as practicable thereafter, but the cancellation will be effective even if we have not made or offered any refund due you. Our check or our representative's check, mailed or delivered, will be sufficient tender of any refund due you. 7. The first Named Insured in Item 1. of the Declarations will act on behalf of all other "Insureds" with respect to the giving and receiving of notice of cancellation and the receipt of any refund that may become payable under this Policy. 8. Any of these provisions that conflicts with an applicable law that controls the cancellation of this Policy is changed by this statement to comply with the minimum mandatory requirements of that law. E. Changes This Policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in Item 1. of the Declarations is authorized to act on behalf of all Insureds in making or agreeing to changes in the terms of this Policy, but only with our consent. Notice to our agent, or knowledge possessed by our agent or any other person, will not effect a waiver or a change in any part of this Policy. This Policy can be changed only by a written endorsement we issue that becomes a part of this Policy and that is signed by one of our authorized representatives. F. Duties in The Event of An "Occurrence," "Claim" Or "Suit" 1. You must see to it that we are notified as soon as practicable of an "occurrence" which may result in a "claim" or "suit" involving this Policy. To the extent possible, such notice should include: a. how, when and where the "occurrence" took place; GAI 6002 (Ed. 04/10) XS (Page 21 of 26) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 b. the names and addresses of any injured person and witnesses; c. the nature and location of any injury or damage arising out of the "occurrence." 2. If a "claim" or "suit' against any "Insured" is reasonably likely to involve this Policy you must notify us in writing as soon as practicable. 3. You and any other involved "Insured" must: a. immediately send us copies of any demands, notices, summonses or legal papers received in connection with the "claim" or "suit'; b. authorize us to obtain records and other information; c. cooperate with us in the investigation, settlement or defense of the "claim" or "suit'; and d. assist us, upon our request, in the enforcement of any right against any person or organization which may be liable to the "Insured" because of injury or damage to which this insurance may also apply. 4. No "Insured" will voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent, except at their own cost. G. Inspection We have the right, but are not obligated, to inspect the premises and operations of any "Insured" at any time. Our inspections are not safety inspections. They relate only to the insurability of the premises and operations of the "Insured" and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While such inspections may help reduce losses, we do not undertake to perform the duty of any person or organization to provide for the health or safety of any employees or the public. We do not warrant that the premises or operations of any "Insured" are safe or healthful or that they comply with laws, regulations, codes or standards. H. Legal Actions Against Us There will be no right of action against us under this Policy unless: 1. you and any other involved "Insured" have complied with all the terms of this Policy; and 2. the amount you owe has been determined, either by settlement with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a party in an action against you to determine your liability. I. Knowledge of "Occurrence" Knowledge of any "occurrence," "claim," or "suit' by any agent, servant, or employee of the "Insured" does not in and of itself constitute knowledge by the "Insured" unless notice of such "occurrence," "claim," or "suit' has been received by an officer, manager, risk manager, authorized employee, or partner of a Named Insured. GAI 6002 (Ed. 04/10) XS (Page 22 of 26) ortaN }: Y RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 J. Maintenance of "Underlying Insurance" During the period of this Policy, you agree: 1. to keep the policies listed in the Schedule of Underlying Insurance in full force and effect; 2. that no renewal or replacement of any policy listed in the Schedule of Underlying Insurance will be more restrictive in coverage than the policy it renews or replaces; 3. that the Limits of Insurance of the policies listed in the Schedule of Underlying Insurance will be maintained except for any reduction or exhaustion of aggregate limits by actual payment of "claims" or "suits" for "occurrences" covered by "underlying insurance"; and 4. that the terms, conditions and endorsements of the policies listed in the Schedule of Underlying Insurance will not change during the Policy Period of this Policy in any way that: a. increases the coverage afforded under this Policy; or b. causes the applicable Limits of Insurance of the policies listed in the Schedule of Underlying Insurance or of other insurance providing coverage to the "Insured" to be reduced or exhausted at an earlier time than they would have been reduced or exhausted in the absence of such change. If you fail to comply with any one or more of these requirements, we will be liable only to the same extent we would have been had you fully complied with all of these requirements. K. Nonrenewal If we decide not to renew this Policy, we will mail or deliver to the first Named Insured shown in the Declarations written notice of the nonrenewal not less than 30 days before the end of the Policy Period. If notice is mailed, proof of mailing will be sufficient proof of notice. L. Other Insurance If other insurance applies to a liability that is also covered by this Policy, this Policy will apply only in excess of the applicable limits of that other insurance. Nothing in this provision will be construed to make this Policy subject to the terms, conditions and limitations of such other insurance. However, this provision will not apply if the other insurance is specifically written to apply only in excess of the applicable Limits of Liability of this Policy. M. Policy Period Subject to Condition D. Cancellation, the Policy Period of this Policy: 1. begins at the date and time shown as From; and 2. ends at the date and time shown as To; in Item 2. of the Declarations. N. Premium The first Named Insured designated in Item 1. of the Declarations will be responsible for payment of all premiums when due. The premium for this Policy will be computed on the basis set for GAI 6002 (Ed. 04/10) XS (Page 23 of 26) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 Declarations. At the beginning of the Policy Period, you must pay us the Advance Premium shown in Item 3. of the Declarations. When this Policy expires or if it is canceled, we will compute the earned premium for the time this Policy was in force. If this Policy is subject to audit adjustment, the actual exposure basis will be used to compute the earned premium. If the earned premium is greater than the Advance Premium, you will promptly pay us the difference. If the earned premium is less than the Advance Premium, we will return the difference to you. But in any event we will retain the Minimum Premium as shown in Item 3. of the Declarations for each twelve months of our Policy Period. O. Separation of Insureds Except with respect to our Limits of Insurance and any rights or duties specifically assigned to the first Named Insured designated in Item 1. of the Declarations, this insurance applies: 1. as if each Named Insured were the only Named Insured; and 2. separately to each "Insured" against whom "claim" is made or "suit" brought. P. Trade Sanctions This Policy is void from its inception as respects any Policy term or condition that violates any law or regulation of the United States of America (U.S.) concerning economic and trade embargoes including, but not limited to, such laws or regulations respecting any of the following: 1. any "Insured," or any person or entity claiming the benefits of an "Insured," who is or becomes a "Specially Designated National" or "Blocked Person" who is otherwise subject to the economic sanctions of the U.S.; 2. any "claim" or "suit" that is brought in a "Sanctioned Country" or by the government of a "Sanctioned Country," where any action in connection with such "claim" or "suit" is prohibited by U.S. economic or trade sanctions; 3. any "claim" or "suit" that is brought by any "Specially Designated National," "Blocked Person," or any person or entity who is otherwise subject to U.S. economic or trade sanctions; 4. property that is located in a "Sanctioned Country" or that is owned by, rented to or in the care, custody or control of a "Sanctioned Country" government, where any activities related to such property are prohibited by U.S. economic or trade sanctions; 5. property that is owned by, rented to or in the care, custody, or control of a "Specially Designated National," "Blocked Person," or any person or entity who is otherwise subject to U.S. economic or trade sanctions. As used in this Policy a "Specially Designated National" or "Blocked Person" is any person or entity that is on the list of "Specially Designated Nationals" and "Blocked Persons" issued by the United States Treasury Department's Office of Foreign Asset Control (O.F.A.C.) as it may be amended from time to time. As used in this Policy a "Sanctioned Country" is any country that is the subject of trade or economic embargoes imposed by the laws of the U.S. GAI 6002 (Ed. 04/10) XS (Page 24 of 26) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 Q. Transfer of Rights of Recovery Against Others to Us If any "Insured" has rights to recover all or part of any payment we have made under this Policy, those rights are transferred to us. The "Insured" must do nothing after loss to impair those rights and must help us enforce them. At our request, the "Insured" will bring "suit" or transfer those rights to us and help us enforce them. Any recoveries will be applied as follows: 1. any interests, including the "Insured," that have paid an amount in excess of our payment under this Policy will be reimbursed first; 2. we then will be reimbursed up to the amount we have paid; and 3. lastly, any interests, including the "Insured," over which our insurance is excess, are entitled to claim the residue. Expenses incurred in the exercise of rights of recovery will be apportioned between the interests, including the "Insured," in the ratio of their respective recoveries as finally settled. R. Terms Conformed to Statute The terms of this Policy which are in conflict with the statutes of the state where this Policy is issued are amended to conform to the minimum mandatory requirements of such statutes. If we are prevented by law or statute from paying on behalf of an "Insured," then we will, where permitted by law or statute, indemnify the "Insured" for those sums in excess of the "retained limit." S. Titles and Headings Headings and titles contained in this Policy are for purposes of organization and reference only. They do not, and shall not be deemed to, control or affect the meaning or construction of any provision of this Policy. T. Transfer of Your Rights And Duties No "Insured" may transfer any of its rights or duties under this Policy without our written consent. If you die or are legally declared bankrupt, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representative. However, notice of cancellation sent to the first Named Insured designated in Item 1. of the Declarations and mailed to the address shown in this Policy will be sufficient notice to effect cancellation of this Policy, even if you have died or been legally declared bankrupt. U. Unintentional Failure to Disclose Hazards An "Insured's" failure to disclose all hazards existing as of the inception date of this Policy will not prejudice that "Insured's" insurance with respect to the coverage afforded by this Policy, provided such failure is both: a. not intentional on the part of that "Insured" and GAI 6002 (Ed. 04/10) XS (Page 25 of 26) HortaN 3 z RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 b. reported to us as soon as practicable after its discovery by any Named Insured. V. When Loss Is Payable Coverage under this Policy does not apply unless and until the "Insured" or its underlying insurer is obligated to pay the "retained limit." When the amount of loss has finally been determined, we will promptly pay on behalf of the "Insured" the amount of loss covered under the terms of this Policy. We may, at our sole discretion, advance on behalf of an "Insured" sums within the "Self -Insured Retention" in order to effect settlement of a "claim" or "suit." If we do so, you will promptly reimburse us for any such amount we advance on behalf of any "Insured." GAI 6002 (Ed. 04/10) XS (Page 26 of 26) HortaN � RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6158 (Ed. 01 13 ) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA CHANGES This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM The following is added to Section V - DEFINITIONS: The term "spouse" is defined as a spouse or registered domestic partner under California law. Section VI - CONDITIONS D. Cancellation is deleted and replaced by the following: D. Cancellation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. If this policy has been in effect for 60 days or less, and is not a renewal of a policy we have previously issued, we may cancel this policy by mailing or delivering to the first Named Insured, at the mailing address shown in the policy and to the producer of record, advance written notice of cancellation, stating the reason for cancellation, at least: a. 10 days before the effective date of cancellation if we cancel for: (1) Nonpayment of premium; or (2) Discovery of fraud by: (a) Any insured or his or her representative in obtaining this insurance; or (b) You or your representative in pursuing a claim under this policy. b. 30 days before the effective date of cancellation if we cancel for any other reason. 3. The policy period will end on the day and hour stated in the cancellation notice. 4. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the Minimum Premium as shown in Item 3. of the Declarations. 5. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force and increased by our short rate cancellation table and procedure. Final premium will not be less than the Minimum Premium as shown in Item 3. of the Declarations. GAI 6158 (Ed. 01 / 1 3) (Page 1 of 3) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 6. Premium adjustment may be made at the time of cancellation or as soon as practicable thereafter but the cancellation will be effective even if we have not made or offered any refund due you. Our check or our representative's check, mailed or delivered, will be sufficient tender of any refund due you. 7. The first Named Insured in Item 1. of the Declarations will act on behalf of all other Insureds with respect to the giving and receiving notice of cancellation and the receipt of any refund that may become payable under this policy. 8. Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with the law. 9. If this policy has been in effect for more than 60 days, or is a renewal of a policy we issued, we may cancel this policy only upon the occurrence, after the effective date of the policy, of one or more of the following: 10. (a) Nonpayment of premium, including payment due on a prior policy the company issued and due during the current policy term covering the same risks. (b) Discovery of fraud or material misrepresentation by: (1) Any insured or his or her representative in obtaining this insurance; or (2) You or your representative in pursuing a claim under this policy. (c) A judgment by a court or an administrative tribunal that you have violated a California or Federal law, having as one of its necessary elements an act which materially increases any of the risks insured against. (d) Discovery of willful or grossly negligent acts or omissions, or of any violations of state laws or regulations establishing safety standards, by you or your representative, which materially increase any of the risks insured against. (e) Failure by you or your representative to implement reasonable loss control requirements, agreed to by you as a condition of policy issuance, or which were conditions precedent to our use of a particular rate or rating plan, if that failure materially increases any of the risks insured against. (f) A determination by the Commissioner of Insurance that the: (1) Loss of, or changes in, our reinsurance covering all or part of the risk would threaten our financial integrity or solvency; or (2) Continuation of the policy coverage would: (a) Place us in violation of California law or the laws of the state where we are domiciled; or (b) Threaten our solvency. (g) A change by you or your representative in the activities or property of the commercial or industrial enterprise, which results in a materially added, increased or changed risk, unless the added, increased or changed risk is included in the policy. We will mail or deliver advance written notice of cancellation, stating the reason for cancellation, to the first Named Insured, at the mailing address shown in the policy, and to the producer of record, at least: GAI 6158 (Ed. 01 / 1 3) (Page 2 of 3) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY.- � Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 a. 10 days before the effective date of cancellation if we cancel for: (1) Nonpayment of premium, including payment due on a prior policy we issued and due during the current policy term covering the same risks. (2) Discovery of fraud by: (a) Any Insured or his or her representative in obtaining this insurance; or (b) You or your representative in pursuing a claim under this policy. b. 30 days before the effective date of cancellation if we cancel for any other reason listed in Paragraph 9. The following CONDITION is added and supersedes any provision to the contrary: Nonrenewal 1. If we decide not to renew this policy, we will mail or deliver written notice, stating the reason for nonrenewal, to the first Named Insured and to the producer of record, at least: a. 60 days, but not more than 120 days, before the expiration or anniversary date, if the aggregate policy premium is $10,000 or less. 2. We will mail or deliver notice to the first Named Insured, and to the producer of record, at the mailing address shown in the policy. 3. We are not required to send notice of nonrenewal in the following situations: a. If the transfer or renewal of a policy, without any changes in terms, conditions, or rates, is between us and a member of our insurance group. b. If the policy has been extended for 90 days or less, provided that notice has been given in accordance with Paragraph 1. c. If you have obtained replacement coverage, or if the first Named Insured has agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. d. If the policy is for a period of no more than 60 days and you are notified at the time of issuance that it will not be renewed. e. If the first Named Insured requests a change in the terms or conditions or risks covered by the policy within 60 days of the end of the policy period. f. If we have made a written offer to the first Named Insured, in accordance with the timeframes shown in Paragraph 1., to renew the policy under changed terms or conditions or at an increased premium rate, when the increase exceeds 25%. This endorsement does not change any other provision of the policy. GAI 6158 (Ed. 01 / 1 3) (Page 3 of 3) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 In Witness Clause IL 72 68 (Ed. 09 09) In Witness Whereof, we have caused this Policy to be executed and attested, and, if required by state law, this Policy shall not be valid unless countersigned by our authorized representative. President Secretary IL7268G2 (09/09) Copyright Great American Insurance Co., 2009 IL 72 68 (Ed. 09/09) a�e_ortaN� RiskMwaganedDMsian z ' REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6047 (Ed. 04 10) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADVERTISING INJURY - FOLLOWING FORM This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM The following exclusion is added to Section IV. EXCLUSIONS, AA. Following Form: Any liability imposed by law, or assumed by any "Insured" under an "insured contract," because of "advertising injury". This endorsement does not change any other provision of the policy. GAI 6047 (Ed. 04/10) XS �oRaN } z a RiskMwaganadDMsiun REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6107 (Ed. 02 12) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AUTOMOBILE LIABILITY EXCLUSION The following exclusion is added to Section IV - EXCLUSIONS: Any liability arising out of the ownership, maintenance, operation, use, "loading or unloading" of any "auto." This endorsement does not change any other provision of the policy. GAI 6107 (Ed. 02/12) �oRaN } z a Risk MmaganadDMsiun REVIEWED & APPROVED BY.- p R. W&Wd Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6129 (Ed. 04 10) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PERSONAL INJURY - FOLLOWING FORM This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM The following exclusion is added to Section IV - EXCLUSIONS, AA. Following Form: Any liability imposed by law, or assumed by any "Insured" under an "insured contract," because of "personal injury". This endorsement does not change any other provision of the policy. GAI 6129 (Ed. 04/10) XS �oRaN } z a RiskMwaganadDMsiun REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6135 (Ed. 06 97) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PROFESSIONAL LIABILITY EXCLUSION The following exclusion is added to Section IV - EXCLUSIONS: Any liability for, caused by, arising out of, or in connection with the rendering of or failure to render any professional service. This endorsement does not change any other provision of the policy. GAI 6135 (Ed. 06/97) XS �oRaN } z a Risk MmaganadDMsiun REVIEWED & APPROVED BY.- p R. W&Wd Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6442 (Ed. 04 10) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FUNGI, MOLD OR SPORES EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM The following is added to Section IV - EXCLUSIONS: Any and all liability of any nature, including, but not limited to settlements, judgments, costs, charges, expenses, costs of investigations, or the fees of attorneys, experts, consultants or medical personnel, arising out of, caused by, resulting from, contributed to, aggravated by or related in any way, either directly or indirectly, and either in whole or in part, to: 1. Any actual, alleged or threatened exposure to, existence of, presence of, ingestion of, inhalation of or contact with any "fungi," mold or "spores," whether or not occurring alone, in combination with, before, after or concurrently with any other cause, contributing condition or circumstance, or aggravating factor, whether manmade, natural or any combination of manmade or natural. 2. Any request, demand, or order that any "Insured" or others test for, monitor, clean up, remove, contain, make repairs, treat, decontaminate, detoxify, neutralize, abate, or in any way respond to or assess any effects of any "fungi," mold or "spores." This includes, but is not limited to, any demand, directive, complaint, suit, order or request by any governmental or non -governmental entity or by any organization, person or group of persons. 3. Steps taken or amounts incurred by any governmental or non -governmental entity or by any organization, person or group of persons to test for, monitor, clean up, remove, contain, repair, treat, decontaminate, detoxify, neutralize, abate, or in any way respond to or assess any effects of any "fungi," mold or "spores." This exclusion applies regardless of whether or not the "fungi," mold or "spores," or any of their effects, were sudden, accidental, gradual, intended, expected, unexpected, preventable, not preventable, manmade, naturally occurring, or any combination of the foregoing. This exclusion does not apply to any "fungi" or bacteria that are, are on, or are contained in, a good or product intended for consumption. As used in this exclusion: "Fungi" include, but are not limited to, any of a major group of saprophytic and parasitic spore -producing organisms usually classified as plants that lack chlorophyll including, but not limited to, molds, rusts, mildews, smuts, mushrooms, and yeasts, and any toxins, mycotoxins, "spores," scents, waste products or by-products produced or released by "fungi," mold or "spores," or by the metabolism, death or decay of any "fungi," mold or "spores." "Spores" include, but are not limited to, any reproductive body produced by or arising out of any "fungi." This endorsement does not change any other provision of the GAI 6442 (Ed. 04/10) XS �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6452 (Ed. 04/15) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA EXCESS LIABILITY The following is added to SECTION II. LIMITS OF INSURANCE: If aggregate insured losses attributable to terrorist acts certified under the federal Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. "Certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in accordance with the provisions of the federal Terrorism Risk Insurance Act, to be an act of terrorism pursuant to the federal Terrorism Risk Insurance Act. The criteria contained in the Terrorism Risk Insurance Act for a "certified act of terrorism" include the following: 1. the act resulted in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insurance Act; and 2. the act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. This endorsement does not change any other provision of the policy. Includes copyrighted material of Insurance Services Office, Inc., with it GAI 6452 (Ed. 04/15) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6458 (Ed. 04/15) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION OF PUNITIVE DAMAGES RELATED TO A CERTIFIED ACT OF TERRORISM This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA EXCESS LIABILITY The following exclusion is hereby added: A. This insurance does not apply to: Terrorism Punitive Damages "Any injury or damage" arising, directly or indirectly, out of a "certified act of terrorism" that are awarded as punitive damages. B. The following definitions are added: 1. For the purposes of this endorsement, "any injury or damage" means any injury or damage covered under any Coverage Part to which this endorsement is applicable and includes but is not limited to "bodily injury," "property damage," "personal and advertising injury," "loss," "injury" or "environmental damage" as may be defined in any applicable Coverage Part or "underlying insurance." 2. "Certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in accordance with the provisions of the federal Terrorism Risk Insurance Act, to be an act of terrorism pursuant to the federal Terrorism Risk Insurance Act. The criteria contained in the Terrorism Risk Insurance Act for a "certified act of terrorism" include the following: a. the act resulted in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insurance Act; and b. the act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. This endorsement does not change any other provision of the policy. Includes copyrighted material of Insurance Services Office, Inc., with it GAI 6458 (Ed. 04/15) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6472 (Ed. 04/15) THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA EXCESS LIABILITY Schedule* Terrorism Premium (Certified Acts) $ 0 . 00 * Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Disclosure Of Premium In accordance with the federal Terrorism Risk Insurance Act, we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for terrorist acts certified under the Terrorism Risk Insurance Act. The portion of your premium attributable to such coverage is shown in the Schedule of this endorsement or in the policy Declarations. B. Disclosure Of Federal Participation In Payment Of Terrorism Losses The United States Government, Department of the Treasury, will pay a share of terrorism losses insured under the federal program. The federal share equals a percentage (as shown in paragraph D. below) of that portion of the amount of such insured losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. C. Cap On Insurer Participation In Payment Of Terrorism Losses If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. D. Federal Share of Losses Under the Terrorism Risk Insurance Act 85% Year: 2015 84% Year: 2016 83% Year: 2017 82% Year: 2018 81% Year: 2019 80% Year: 2020 This endorsement does not change any other provision of the Includes copyrighted material of Insurance Services Office, Inc., with ii GAI 6472 (Ed. 04/15) (Page 1 of 1) HORaN � z RiskMmaganedDMsian REVIEWED & APPROVED BY.- f R. W&Wd Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6475 (Ed. 04 10) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ACT OF TERRORISM RETAINED LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM The policy is amended as follows: A. ITEM 5. of the DECLARATIONS - SELF -INSURED RETENTION is amended to include the following Self -Insured Retention: Act of Terrorism Self -Insured Retention: $1 , 000 , 000 Each Occurrence B. SECTION II - LIMITS OF INSURANCE - G. - RETAINED LIMIT is deleted in its entirety and replaced by the following: We will be liable only for that portion of damages, subject to the Each Occurrence Limit stated in the Declarations, in excess of the "retained limit," which is the greater of: 1. the total amounts stated as the applicable limits of the underlying policies listed in the Schedule of Underlying Insurance and the applicable limits of any other insurance providing coverage to the "Insured" during the Policy Period; or 2. the amount stated in the Declarations as Self -Insured Retention or Act of Terrorism Self -Insured Retention as a result of any one "occurrence" not covered by the underlying policies listed in the Schedule of Underlying Insurance nor by any other insurance providing coverage to the "Insured" during the Policy Period; And then up to an amount not exceeding the Each Occurrence Limit as stated in the Declarations. All "claims" and "suits" seeking damages for any liability out of an "act of terrorism" are subject to the Act of Terrorism Self -Insured Retention. "Defense expenses" shall not erode the Act of Terrorism Self -Insured Retention. The Act of Terrorism Self -Insured Retention applies whether or not there is any applicable underlying policies listed in the Schedule of Underlying Insurance or applicable limits of any other underlying insurance providing coverage to the "Insured." If there is applicable underlying insurance listed in the Schedule of Underlying Insurance or any other underlying insurance providing coverage to the "Insured," amounts received through such underlying insurance may be applied to reduce or exhaust the Act of Terrorism Self -Insured Retention. However, in no event will amounts received through such underlying insurance for the payment of "defense expenses" reduce the Act of Terrorism Self -Insured Retention. Includes copyrighted material of ISO Properties, Inc., with its per GAI 6475 (Ed. 04/10) (Page 1 of 2) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 C. For the purposes of this endorsement, the following definitions are added to SECTION V - DEFINITIONS: 1. "Defense expenses" means any payment allocated to a specific loss, "claim" or "suit" for its investigation, settlement or defense, including but not limited to: a. attorney's fees and all other investigation, loss adjustment and litigation expenses; b. premiums on bonds to release attachments; c. premiums on appeal bonds required by law to appeal any "claim" or "suit"; d. costs taxed against the "Insured" in any "claim" or "suit"; e. pre -judgment interest awarded against the "Insured"; f. interest that accrues after entry of judgment. 2. "Act of terrorism" is defined as: a. A "certified act of terrorism" means any act that is certified by the Secretary of the Treasury of the United States, in concurrence with the Secretary of State, and the Attorney General of the United States to be an act of terrorism pursuant to the federal Terrorism Risk Insurance Act. The criteria contained in the Risk Insurance Act for a "certified act of terrorism" include the following: i. the act resulted in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insurance Act; and ii. the act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. D. Solely as respects any liability arising out of any "act of terrorism," SECTION III. - DEFENSE, Paragraphs A.1. and A.2., are deleted in their entirety, and replaced by the following: A. We will have the right and duty to defend any "claim" or "suit" seeking damages covered by the terms and conditions of this policy when the applicable Act of Terrorism Self -Insured Retention limit has been exhausted by actual payment of "claims" for any "occurrence" to which this policy applies. This endorsement does not change any other provision of the policy. Includes copyrighted material of ISO Properties, Inc., with its per GAI 6475 (Ed. 04/10) (Page 2 of 2) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 6807 (Ed. 08/14) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - ORGANIC PATHOGENS This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM The following is added to SECTION IV. EXCLUSIONS: Organic Pathogens 1. "Bodily injury", "property damage", "personal injury" or "advertising injury" arising out of any actual, alleged or threatened infectious, pathogenic, toxic or other harmful properties of any "organic pathogen." 2. Any loss, cost or expense arising out of any: a. request, demand, order or statutory or regulatory requirement that any "insured" or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of any "organic pathogen," or b. "claim" or "suit' by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of any "organic pathogen." The following definition is added to SECTION V. DEFINITIONS: "Organic pathogen" means any: 1. Bacteria; mildew, mold or other fungi; other microorganisms; or mycotoxins, spores or other by-products of any of the foregoing; 2. Viruses or other pathogens (whether or not a microorganism); or 3. Colony or group of any of the foregoing. All other terms and conditions of the Policy apply. GAI 6807 (Ed. 08/14) HortaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SILICA OR RELATED DUST EXCLUSION The following exclusion is added to SECTION IV - EXCLUSIONS: Any and all liability of any nature, including, but not limited to settlements, judgments, costs, charges, expenses, costs of investigations, or the fees of attorneys, experts, consultants or medical personnel, arising out of, caused by, resulting from, contributed to, aggravated by or related in any way, either directly or indirectly, and either in whole or in part, to: 1. Any actual, alleged or threatened exposure to, existence of, presence of, ingestion of, in- halation of or contact with "silica" or dust that includes or contains "silica," whether or not occurring alone, in combination with, before, after, or concurrently with any other cause, contributing condition or circumstance, or ag- gravating factor, whether manmade, natural, or any combination of manmade or natural. 2. Any request, demand, or order that any "In- sured" or others test for, monitor, clean up, remove, contain, make repairs, treat, decon- taminate, detoxify, neutralize, abate, or in any way respond to or assess any effects of "silica" or dust that includes or contains "sili- GAI 6819 (Ed. 10 04 ) ca." This includes, but is not limited to, any demand, directive, complaint, suit, order or request by any governmental or non -govern- mental entity or by any organization, person or group of persons. 3. Steps taken or amounts incurred by any gov- ernmental or non -governmental entity or by any organization, person or group of persons to test for, monitor, clean up, remove, con- tain, repair, treat, decontaminate, detoxify, neutralize, abate, or in any way respond to or assess any effects of "silica" or dust that includes or contains "silica." This exclusion applies regardless of whether or not the "silica" or dust that includes or contains "silica," or any of their effects, were sudden, accidental, gradual, intended, expected, unexpect- ed, preventable, not preventable, manmade, natu- rally occurring, or any combination of the fore- going. As used in this exclusion: "Silica" means silicon dioxide (Si02) in any form, from any source. This endorsement does not change any other provision of the policy. GAI 6819 (Ed. 10/04) XS HortaN � RiskMmaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * 081 * 06/11/2021 * LIMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR, BIOLOGICAL, OR CHEMICAL EXCLUSION The following exclusion is added to Section IV - EXCLUSIONS: Any and all liability of any nature, including, but not limited to settlements, judgments, costs, charges, expenses, costs of investigations, or the fees of attorneys, experts, consultants or medical personnel, arising out of, caused by, resulting from, contributed to, aggravated by or related in any way, either directly or indirectly, and either in whole or in part, to: 1. Any actual, attempted, suspected, or threat- ened use of any "NBC material" as part of any plan, effort, or design, actually or apparently intended to cause any: (a) loss or damage to any tangible or intangi- ble property, or (b) bodily injury, physical injury, sickness, or disease, including death of a person, or GAI 6869 (Ed. 08 05) (c) mental injury, mental anguish, emotional distress, humiliation, or shock if directly resulting from physical injury, sickness, or disease to that person. 3. Any request, demand, or order that any "In- sured" or others test for, monitor, clean up, remove, contain, make repairs, treat, decon- taminate, detoxify, neutralize, abate, or in any way respond to or assess any effects of "NBC material." This includes, but is not limited to, any demand, directive, complaint, suit, or- der or request by any governmental or non- governmental entity or by any organization, person or group of persons. 4. Steps taken or amounts incurred by any gov- ernmental or non -governmental entity or by any organization, person or group of persons to test for, monitor, clean up, remove, con- tain, repair, treat, decontaminate, detoxify, neutralize, abate, or in any way respond to or assess any effects of "NBC material." (c) mental injury, mental anguish, emotional This exclusion applies regardless of whether or distress, humiliation, or shock if directly not the "NBC material," or any of their effects, resulting from physical injury, sickness, or were sudden, accidental, gradual, intended, ex - disease to that person. pected, unexpected, preventable, not preventable, manmade, naturally occurring, or any combination of the foregoing. 2. Any actual, attempted, suspected, or threat- ened presence, spread, dissemination, release, escape, or distribution of any "NBC material" as a direct or indirect result of any actual, attempted, suspected, or threatened plan, ef- fort, or design, actually or apparently intended to cause any: (a) loss or damage to any tangible or intangi- ble property, or (b) bodily injury, physical injury, sickness, or disease, including death of a person, or As used in this exclusion: "NBC material" means any nuclear, biological, or chemical material or substance that causes dam- age to property or is harmful to human health. "NBC material" includes, but is not limited to: 1. any radioactive substance or material, and the radiation it releases, 2. any pathogen, bacterium, microbe, virus, or other organism, GAI 6869 (Ed. 08/05) XS (Page 1 of 2) HORaN 3 RiskMmaganedDMsian REVIEWED & APPROVED BY.- z Risk Management Analyst * 081 * 06/11/2021 * LIMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 3. any substance or material produced by or The foregoing list 1. through 4. is only illustrative, from any pathogen, bacterium, microbe, virus, and should not be construed as a complete, ex - or other organism, and clusive, or exhaustive list of all "NBC materials." 4. any poison, toxin, or other harmful chemical, substance, or material. This endorsement does not change any other provision of the policy. GAI 6869 (Ed. 08/05) XS (Page 2 of 2) HortaN 3 z RiskMwaganedDMsian REVIEWED & APPROVED BY.- Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 G A 1 7111 (Ed. 04 10) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. INFRINGEMENT OF COPYRIGHT, PATENT, TRADEMARK OR TRADE SECRET This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM SECTION IV. EXCLUSIONS, N. Infringement of Copyright, Patent, Trademark or Trade Secret is replaced by the following: N. "Personal injury" or "advertising injury" arising out of the infringement of copyright, patent, trademark, trade secret or other intellectual property rights. Under this exclusion, such other intellectual property rights do not include the use of another's advertising idea in your "advertisement." However, this exclusion does not apply to infringement, in your "advertisement," of copyright, trade dress or slogan. This endorsement does not change any other provision of the policy. GAI 7111 (Ed. 04/10) XS �oRaN } z a RiskMmWmerttDMsian REVIEWED & APPROVED BY.- p R. W&Wd Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 7251 (Ed. 08 14 ) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ABUSE OR MOLESTATION COVERAGE - FOLLOWING FORM This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM When Abuse or Molestation Coverage is listed in the Schedule of Underlying Insurance, this policy is modified as follows, but only when this policy is excess of the retained limit for that Abuse or Molestation Coverage: Section I. COVERAGE, paragraphs A. and B. of the COMMERCIAL UMBRELLA COVERAGE FORM are deleted and replaced with the following: A. We will pay on behalf of the "Insured" those sums in excess of the retained limit that the "Insured" becomes legally obligated to pay as damages, by reason of liability imposed by law or assumed by the "Insured" under an "insured contract," because of "abuse" to which this insurance applies. If we are prevented by law or statute from paying such sums on behalf of the "Insured," then we will indemnify the "Insured" for them. The amount we will pay for damages is limited as described below in Section II. LIMITS OF INSURANCE. B. This policy follows form to the remaining sections of the "underlying insurance" that provides "abuse" coverage under Section I. ABUSE OR MOLESTATION COVERAGE. Section II. LIMITS OF INSURANCE, paragraphs B. and C. of the COMMERCIAL UMBRELLA COVERAGE FORM are deleted and replaced with the following: B. The General Aggregate Limit is the most we will pay for all damages covered under the Insuring Agreement in Section I., except: 1. damages included within the "products completed operations hazard"; and 2. coverage included in the policies listed in the Schedule of Underlying Insurance to which no underlying aggregate limit applies. C. The amount stated in the Declarations as the General Aggregate Limit is the most we will pay for all damages arising out of any "bodily injury", "property damage", "personal injury", "advertising injury", "abuse", any act, error, or omission of the "Insured" arising out of the "Insured's" rendering or failure to render "professional services"; or any act, error or omission of the "Insured" negligently committed in the "administration" of your "employee benefit program." The General Aggregate Limit applies separately and in the same manner as the aggregate limits in the "underlying insurance." Includes copyrighted material of Insurance Services Office, Inc., with it GAI 7251 (Ed. 08/14) (Page 1 of 2) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 Section V. DEFINITIONS, paragraphs E. and V. of the COMMERCIAL UMBRELLA COVERAGE FORM are deleted and replaced with the following: E. "Claim" means a demand, made under an assertion of legal right, for money as compensation for "bodily injury", "property damage", "personal injury", "advertising injury", "abuse", any act, error, or omission of the "Insured" arising out of the "Insured's" rendering or failure to render "professional services"; or any act, error or omission of the "Insured" negligently committed in the "administration" of your "employee benefit program" "Claim" includes "suit." V. "Suit" means a civil proceeding which seeks monetary damages because of "bodily injury", "property damage", "personal injury", "advertising injury", "abuse", any act, error, or omission of the "Insured" arising out of the "Insured's" rendering or failure to render "professional services"; or any act, error or omission of the "Insured" negligently committed in the "administration" of your "employee benefit program" Suit includes: 1. an arbitration proceeding in which such damages are claimed and to which you must submit or do submit with our consent; or 2. any other alternative dispute resolution proceeding in which such damages are claimed and to which you submit with our consent. The following is added to Section V. DEFINITIONS: "Abuse" means "abuse" as defined in the "underlying insurance" that provides "abuse" coverage. This endorsement does not change any other provision of the policy. Includes copyrighted material of Insurance Services Office, Inc., with it GAI 7251 (Ed. 08/14) (Page 2 of 2) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst * 081 * 06/11/2021 * UMB 3961461 00 GREAT AMERICAN ALLIANCE INS CO *D/B* 072977484 262428 GAI 7269 (Ed. 05 14) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION AND DATA -RELATED LIABILITY - WITH LIMITED BODILY INJURY EXCEPTION This endorsement modifies insurance provided under the following: COMMERCIAL UMBRELLA COVERAGE FORM Exclusion J. under Section IV. EXCLUSIONS is replaced by the following: IV. Exclusions This insurance does not apply to: J. Access Or Disclosure Of Confidential Or Personal Information And Data -related Liability Damages arising out of: 1. Any access to or disclosure of any person's or organization's confidential or personal information, including patents, trade secrets, processing methods, customer lists, financial information, credit card information, health information or any other type of nonpublic information; or 2. The loss of, loss of use of, damage to, corruption of, inability to access, or inability to manipulate electronic data. This exclusion applies even if damages are claimed for notification costs, credit monitoring expenses, forensic expenses, public relations expenses or any other loss, cost or expense incurred by you or others arising out of that which is described in Paragraph 1. or 2. above. However, unless Paragraph 1. above applies, this exclusion does not apply to damages because of "bodily injury". As used in this exclusion, electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD-ROMs, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment. This endorsement does not change any other provision of the policy. Includes copyrighted material of Insurance Services Office, Inc., with it GAI 7269 (Ed. 05/14) �oRaN RiskMwaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst A� " CERTIFICATE OF LIABILITY INSURANCE DATE Y) 04/07/07021 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 CONT-NAMEAutomatic Data Processing Insurance Agency, Inc. Automatic Data Processing Insurance Agency, Inc. HONE Ext: 1-800-524-7024 (A///C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 1 Adp Boulevard INSURERA : Property And Casualty Insurance Company Of Hartford 34690 Roseland NJ 07068 INSURED Backhaus Dance INSURER B : INSURER C : INSURER D : 4365 Johanna Ave INSURER E : INSURERF: Lakewood CA 907133303 COVERAGES CERTIFICATE NUMBER: 1918370 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑PRO JECT ❑ LOC PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? � (Mandatory in NH) N/A N 76WEGAH1YT5 09/07/2020 09/07/2021 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION City of Santa Ana, Attn: Risk Management Division 20 Civic Center Plaza, 4th floor SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Santa Ana CA 92702 © 1988-2015 ACORD ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD �oRaN RiskMwagementDMsian REVIEWED & APPROVED BY.- � Risk Management Analyst backhausdance Backhausdance 2762 Circle Drive Newport Beach, Ca 90713 Jenny@backhuasdance.org 562-335-2442 4/7/2021 City of Santa Ana Risk Management Division, 4"floor 20 Civic Center Plaza, Santa Ana, CA 92702 Re: Auto Insurance Requirement and Release of Liability. Dear City of Santa Ana Risk Management Division: I, Jennifer Backhaus, Backhausdance hereby release the City of Automobile Liability. I do not use/drive any vehicle during the course and scope of my agreement with the City of Santa Ana, CA. Sincerely, Jennifer Backhaus - Artistic Director 3 RAMmWmedDMsiun REVIEWED & APPROVED BY.- z f R. VSA44a Risk Management Analyst backhausdance Backhausdance 2762 Circle Drive Newport Beach, Ca 90713 Jenny@backhuasdance.org 562-335-2442 4/7/2021 City of Santa Ana Risk Management Division 20 Civic Center Plaza, Santa Ana, CA 92702 Re: Professional Liability Insurance Requirement. Dear City of Santa Ana Risk Management Division: I, Jennifer Backhaus, Backhausdance am not a licensed professional and will not employ a licensed professional during the course of my contract with the City of Santa Ana, CA. Sincerely, Jennifer Backhaus RAMmWmedDMsiun REVIEWED & APPROVED BY. - Risk Management Analyst Francine R. Digitally signed by Francine R. Villareal Villareal Date: 2021.09.09 12:48:50 -07'00' ' ` CERTIFICATE OF LIABILITY INSURANCE °A9/�/202'1 "' 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 endorsements . PRODUCER Automatic Data Processing Insurance Agen CONTACT Jennifer Backhaus N PHONE NC No Ext: 949 433-7338 FAX vc No: In Partnership with Pie Insurance Servic 1 ADP Boulevard Roseland, NJ 07068 Email I-,iMLd13ACKHAUSDANCE.0RG Address: INSURERS AFFORDING COVERAGE NAIC # 1850 INSURER& SIRIUS AMERICA INS CO 38776 INSURED INSURER B: BACKHAUS DANCE 4365 Johanna Ave INSURERC: Lakewood, CA 90713-3303 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 REQUIREM ENT, TERM OR CONDITION OF ANY CONTRACTOR 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. LIMITSSHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INS LTR TYPE OF INSURANCE ADDL INSR SUBIR WVD POLICY NUMBER POLICY EFF (MM/DD/YY) POUCY EXP (MM/DD/YY) UMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED $ MED. EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PROJECT LOC ]POLICY PRODUCTS-COMP/OPAGG. $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXC ESS LIAR CLAIMS - MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N x PER STATUTE I OTH - ER A ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N / A WC80946-00 9/7/2021 9/7/2022 E.L. EACH ACCIDENT $ 1, 330,033 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EACH EMPLOYEE $ 1, 330,033 E.L. DISEASE- POLICY LIMIT $ 1, 030,000 If yes, describe under DESCRIPTON OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) DANCE CLASSES CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLZ SANTA ANA, CA 92VOl-4058 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE _.---- ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �oRaN RiskManagemerdDivisian REVIEWED & APPROVED BY: 3 z Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0400 04 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Schedule of Forms ITEM 3D POLICY NO. WC 80946 00 Form Numbers Applicable States WORKERS COMPENSATION FORMS AND ENDORSEMENTS WC 04 00 01 B 10-14 CA WC INFORMATION PAGE CA WC 04 00 05 07-98 CA EXTENSION OF INFORMATION PAGE CA WC 00 00 00 C 01-15 INSURANCE POLICY CA PN 04 99 01 H 05-20 CA POLICYHOLDER NOTICE CA PN 04 99 02 B 05-02 CA WC INSURANCE RATING LAWS CA PN 04 99 04 12-01 CA POLICYHOLDER NOTICE - CIGA CA PN 04 99 08 12-19 CA POLICYHOLDER NOTICE -ASSEMBLY BILL N05 CA WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT CA WC 00 04 21 E 01-21 CATASTROPHE (OTHER THAN CERT ACTS) ENDT CA WC 00 04 22 C 01-21 TERRORISM RISK PGM REAUTH ACT DISCL ENDT CA WC 04 03 01 D 02-18 CA POLICY AMENDATORY ENDORSEMENT CA WC 04 03 10 01-95 CA DUTY TO DEFEND CA WC 04 03 60 B 01-15 CA EMPLOYERS' LIAB COV AMENDATORY ENDT CA WC 04 04 21 01-08 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT CA WC 04 04 22 01-12 CA SHORT -RATE CANCELATION ENDORSEMENT CA WC 04 06 01 A 12-93 CA CANCELATION ENDT CA ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rig Its reserved. From the WCI RB's California Workers' Compensation I nsurance Forms Manual ©2001. HortaN 3 z Risk MwagementDMsian REVIEWED & APPROVED BY.- Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Sirius America Ins Co Insurer ID No(s). 28363 1. Named Insured: BACKHAUS DANCE Mailing Address: 4365 Johanna Ave Lakewood CA 90713-3303 Policy No. WC 80946 00 Prior Policy No. 0 Individual Corporation Partnership LLC LLP WC 04 00 01 B (Ed. 10-14) Email Address: KIM@BACKHAUSDANCE . ORG 0 Other: FEIN: 050575068 Non -Profit Intra/Interstate Risk ID No. Other workplaces not shown above: See Schedule of Locations 2. The policy period is from 09-07-2021to 09-07-2022 12:01 A.M. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: CA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AZ AR CO DE DC FL GA IL IN IA KS KY LA MD MI MS MO NE NV NH NJ NM NY NC OK PA RI SC TN TX UT VT VA WV WI D. This policy includes these endorsements and schedules: See Schedule of Forms and Endorsements 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Code Estimated Annual $100 of Annual No. Classifications Remuneration Remuneration Premium See Extension of Information Page Experience Modification See Extension of Information Page Total Estimated Annual Premium $ 5,861 Minimum Premium $ 1,590 Deposit Premium $ 978 Premium Adjustment Period: Annual Countersigned B Producer Information: Automatic Data Processing Insurance Agency;—inc. Servicing/Issuing Office 1015 15th Street NW, Suite 600, Washington, DC 20005-2605 Date Copyright 2014 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2014. �oRaN r� -:. ^ecoG< 4r of Risk ManagemedDiviaiun REVIEWED & APPROVED BY.- p L" PZ. v� Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Classifications ITEM 4 POLICY NO. WC 80946 00 Premium Basis Rate Per $100 Estimated Code Estimated Annual of Annual No. Classifications Remuneration Remuneration Premium 0001-01 BACKHAUS DANCE FEIN # 05-0575068 SIC CODE 5812 NAICS CODE 711110 CA ERN ## 1111 4365 Johanna Ave Lakewood CA 90713-3303 9156 Theaters - Dance/Opera $ 86,005 5.72 $ 4,919.00 Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. �oRaN r RiskMwaganedDivisian REVIEWED & APPROVED BY.- p P. Vj&,Vd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Classifications ITEM 4 POLICY NO. WC 80946 00 Premium Basis Rate Per $100 Estimated Code Estimated Annual of Annual No. Classifications Remuneration Remuneration Premium Total Class Premium $ 4,919.00 9036 Territory Modification 1.20 $ 984.00 9812 Increase Limits 1.011 $ 65.00 9848 Empl Minimum Difference $ 55.00 Total Subject Premium $ 6,023.00 9897 Experience Premium 1.00 $ 0.00 Total Modified Premium $ 6,023.00 9887 Schedule Modification .91 $ -542.00 Standard Total $ 5,481.00 0063 Premium Discount .99 $ -55.00 0900 Expense Constant $ 160.00 Terrorism Risk Ins Act 9740 2002 .04 $ 34.00 Catastrophe (Other Than Certified Acts of 9741 Terrorism) .02 $ 17.00 Total Estimated Premium $ 5,637.00 CA Admin Revolving Fund 0987 Assess 1.022646 $ 128.00 CA Occ Safety & Health 0000 Fund 1.002584 $ 15.00 0988 CA Fraud Assessment 1.004734 $ 27.00 CA Unins Empl Benefits 0000 Assess 1.000775 $ 4.00 CA Subs Inj Benefits 0000 Assess 1.006579 $ 37.00 California Labor Enforcement & Compliance (LECF) 0000 Assessment 1.002272 $ 13.00 Final Total $ 5,861.00 Policy Total Estimated Cost $ 5,861.00 Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. �oRaN r Risk MwagzmedDivisiun REVIEWED & APPROVED BY.- p P. vj&wd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self -insured for such workplaces. WC 00 00 00 C (Ed. 1-15) PART ONE WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } z RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- cc Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against 2 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. HORaN o r RiskManagemerdDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY such third party as a result of injury to your employee; 2. For care and loss of services; and For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. Punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. Any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonappropriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. WC 00 00 00 C (Ed. 1-15) and 901-944), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sections 51 et seq.), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10.Bodily injury to a master or member of the crew of any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11.Fines or penalties imposed for violation of federal or state law; and 12.Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our request, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgment as required by law until we offer the amount due under this insurance; and 5. Expenses we incur. 3 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } z a RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- p R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident —each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease —policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease —each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance You will do everything necessary to protect those rights for us and to help us enforce them. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self -insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal 4 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } z a RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- p R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. Premium Payments WC 00 00 00 C (Ed. 1-15) You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short -rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. 5 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } : RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- cc Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) PART SIX CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. Cancelation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to comply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. 6 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. HORaN o r RiskManagemerdDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst P N 04 99 01 H (Ed. 05-2020) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION Information Available to You A. Information Available from Us — APIAccountProd APIAccountProd (1) General questions regarding your policy should be directed to: SIRIUS AMERICA INSURANCE COMPANY 140 BROADWAY, 32ND FLOOR, NEW YORK, NY 10005-1108 855-705-2716 (2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non- payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan- 1995 (USRP) and the California Workers' Compensation Experience Rating Plan-1995 (ERP). WCIRB contact information is: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 (fax); and customerservice(a�wcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss -Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. [Optional language for insurers that have adopted the WCIRB's Advisory Basic Underwriting Manual: If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below.] You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: Sirius America Insurance Company 140 Broadway, 32nd Floor, New York, NY 10005-1108 After you send your Complaint and Request for Action, we have 30 days to send you a written your written request will be reviewed. If we agree to review your request, we must conduct the PN 04 99 01 H 1 of 2 (Ed. 05-2020) HORaN 3 RiskMmaganedDMsian REVIEWED & APPROVED BY. r Risk Management Analyst P N 04 99 01 H (Ed. 05-2020) granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice(a�wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerserviceawcirb.com (email). C. California Department of Insurance — Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Oakland, CA 94612 415.538.4243 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (fax) and ombudsmanp_wcirb.com (email). B. California Department of Insurance — Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. PN 04 99 01 H 2 of 2 (Ed. 05-2020) HortaN RiskMmaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst P N 04 99 02 B (Ed. 5-02) POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. We establish our own rates for workers' compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. Rating organizations may develop pure premium rates that are subject to the insurance commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. CALIFORNIA WORKERS' COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with t ©2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. RiskManagemerdDiviaiun REVIEWED & APPROVED BY.- Fu4w L. P1. Vi&4441 Risk Management Analyst P N 04 99 02 B (Ed. 5-02) We are not required to provide you with a notice of nonrenewal in any of the following situations: Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. The policy was extended for 90 days or less and the required notice was given prior to the extension. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate" means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. 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 09-07-21 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By ©2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Premium $ Incl . �oRaN } z a RiskMmaganadDiviaiun REVIEWED & APPROVED BY.- F R. vj&wd Risk Management Analyst PN 04 99 04 (Ed. 12-01) POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover those assessments. If your policy is surcharged, "CA Surcharge" or "CA Surcharge (CIGA Surcharge)" with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. 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 09-07-21 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By ©2001 by the Workers' Compensation Insurance Bureau of California. All rights reserved. Premium $ Incl . �oRaN } r RAMmVmentDMsian REVIEWED & APPROVED BY.- p PZ. vj&wd Risk Management Analyst PN 04 99 08 (Ed. 12-19) POLICYHOLDER NOTICE CALIFORNIA ASSEMBLY BILL NO. 5, INDEPENDENT CONTRACTORS Summary of Assembly Bill No. 5 (AB 5) For the purposes of wages, workers' compensation and other benefits, AB 5 creates a presumption that an entity's workers are employees unless the hiring entity can show that the worker meets three conditions, known as the "ABC Test". With respect to workers' compensation, AB 5 goes into effect on July 1, 2020 and applies to policies issued on or after July 1, 2020, as well as policies in force as of July 1, 2020. The bill adds Section 2750.3 to the California Labor Code, which provides in pertinent part: 2750.3. (a)(1) For purposes of the provisions of this code and the Unemployment Insurance Code, and for the wage orders of the Industrial Welfare Commission, a person providing labor or services for remuneration shall be considered an employee rather than an independent contractor unless the hiring entity demonstrates that all of the following conditions are satisfied: (A) The person is free from the control and direction of the hiring entity in connection with the performance of the work, both under the contract for the performance of the work and in fact. (B) The person performs work that is outside the usual course of the hiring entity's business. (C) The person is customarily engaged in an independently established trade, occupation, or business of the same nature as that involved in the work performed. (2) Notwithstanding paragraph (1), any exceptions to the terms "employee," "employer," "employ," or "independent contractor," and any extensions of employer status or liability, that are expressly made by a provision of this code, the Unemployment Insurance Code, or in an applicable order of the Industrial Welfare Commission, including, but not limited to, the definition of "employee" in subdivision 2(E) of Wage Order No. 2, shall remain in effect for the purposes set forth therein. (3) If a court of law rules that the three-part test in paragraph (1) cannot be applied to a particular context based on grounds other than an express exception to employment status as provided under paragraph (2), then the determination of employee or independent contractor status in that context shall instead be governed by the California Supreme Court's decision in S.G. Borello & Sons, Inc. v. Department of Industrial Relations (1989) 48 Cal.3d 341. AB 5 also provides an extensive list of occupations that are exempt from the application of Section 2750.3(a)(1). These exemptions are subject to revision. In addition, AB 5 amends Section 3351 of the California Labor Code and Sections 606.5 and 621 of the Unemployment Insurance Code. The pertinent sections of the California Labor Code and Unemployment Insurance Code may be accessed at http://leginfo.legislature.ca.gov. You may also access the California Labor & Workforce Development Agency webpage at https://www.labor.ca.gov/employmentstatus/ for more information. This notice does not change the policy to which it is attached. �ortaN RiskMmaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed. 1-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. 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 09-07-21 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By WC 00 04 19 (Ed. 1-01) © 2000 National Council on Compensation Insurance, Inc. Premium $ Incl . HORaN } r Risk ManagemendDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 E (Ed. 01-2021) Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 C), attached to this policy. For purposes of this endorsement, the following definitions apply: • Catastrophe (Other Than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. • Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of the Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA .02 $17 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Page 1 of 1 "oRa" F RAManWmerdDivisian WC 00 04 21 E } % z REVIEWED & APPROVED BY.- (Ed. 01-2021) p R. MmAd © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. ` Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-2021) Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property, or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. Page 1 of 2 © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. HORaN } z RiskManagemerdDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst WC 00 04 22 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-2021) Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA .04 $34 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Page 2 of 2 "oRa" F RAManWmerdDivisian WC OO 04 22 C J % r REviEWED & APPROVED BY.- (Ed. 01-2021) F R. MmAd © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. ` Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 2-18) POLICY AMENDATORY ENDORSEMENT—CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed —Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages — Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment — Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Department of Insurance. 4. Application of Policy. Part One, "Workers Compensation Insurance", A, "How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6. Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. 8. Part Five, "Premium", E, "Final Premium", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. Page 1 of 2 © Copyright 2018 by the Workers' Compensation Insurance Rating Bureau of California. All Rights Reserved. HortaN Risk Mwag merdDivisian REVIEWED & APPROVED BY. - Risk Management Analyst WC 04 03 01 D WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 2-18) If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short -rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Page 2 of 2 ; RtsieAQa�WmerdDiMawn H ortaN WC 04 03 01 D 3 r RE�AEWED & APPROVED BY.- (Ed. 2-18) FIIA . JZ. W&VAI © Copyright 2018 by the Workers' Compensation Insurance Rating Bureau of California. All Rights Reserved. Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 10 (Ed. 1-95) DUTY TO DEFEND-CALIFORNIA The insurance afforded by Part One, Section C, "We Will Defend", is hereby deleted and replaced with the following: WE WILL DEFEND We have the right and duty to defend at our expense any claim or proceeding against you before the California Workers' Compensation Appeals Board or its equivalent in any other state (and any appeal of a decision therefrom) for the benefits payable by this workers' compensation insurance. We have the right to investigate and settle these claims or proceedings. We have no duty to defend a claim, proceeding, or suit that is not covered by this insurance. Nothing contained in this Section shall amend, modify, restrict or otherwise alter any obligations or conditions under Part Two -Employer's Liability Insurance of the policy. 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 09-07-21 Policy No. WC 80946 00 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . WC 04 03 10 (Ed. 1-95) Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rightsreserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 194 �oRaN r� -:. ^ecoG< 4r q� Risk ManagemedDiviaian cREVIEWED & APPROVED BY.- rRd�-cG " PZ. v� Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B (Ed. 01-16) EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT—CALIFORNIA The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: A. How This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in California. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): 1. Exclusion 1 is amended to read as follows: 1. liability assumed under a contract. 2. Exclusion 2 is deleted. 3. Exclusion 7 is amended to read as follows 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, termination of employment, or any personnel practices, policies, acts or omissions. 4. The following exclusions are added 1. bodily injury to any member of the flying crew of any aircraft. 2. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s) applicable to you or otherwise fail to comply with that law. 3. liability arising from California Labor Code Section 2810.3 which relates to labor contracting. 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By © 2015 by the Workers' Compensation Insurance Bureau of California. All Rights Reserved. Endorsement No. Premium $ Incl . �oRaN } z a RiskMmWmerdDiviaian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 (Ed. 1-08) OPTIONAL PREMIUM INCREASE ENDORSEMENT— CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verification audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified, return -receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. 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 0 9 — 0 7 — 2 1 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By C 2007 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Premium $ Incl . �oRaN } z Risk ManaganadDMsfan REVIEWED & APPROVED BY.- f R. V;&wd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed.01-12) CALIFORNIA SHORT -RATE CANCELLATION ENDORSEMENT It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: If you cancel the policy and a disclosure was provided in accordance with Section 481(c) of the California Insurance Code, final premium will be based on the time this policy was in force and increased by the short -rate cancelation table below: Short Rate Cancellation Table flays n Poky pa Shot PAe Ps'osrtw- FaclortoAppllylo EariodPranii_mfd Period Poky in EF&d Dgjw nPoigr P"dad Shot Fa& P-111 sus Fadtorin Appiytn Earned fterimfor Pianod Pofyrn nrs m Pb r Phliod Sihot lisle P-t> Fat4+xtbap"lo Earned Prelim firfood PCkviti Ldfer4 2 6 1 V-1 f' 47 23 1,7861 9? 36 1.4203 3 7 8e5 , ' 48 24 1.8250 93 36 1.4129 4 7 6.3G'LJ 49 24 1.7877 94 36 1.3979 5 8 5.8394 50 24 1.7520 95 37 1.4216 6 8 4.8662 51 24 1,7176 96 37 1.4060 7 9 46924 52 25 1.7540 97 37 1.3923 8 9 4 10 5r, 53 25 1.721 Fi 92 37 1.3781 9 10 4 u-': _ 54 25 1.6399 99 38 1.4010 10 10 J 0��r) 55 25 1.7255 100 38 1.3670 11 11 36496 56 26 1.6947 101 38 1.3733 12 11 3 3455 57 26 1.6660 102 R 1 2590 13 12 3.36G9 58 26 1.6362 103 =.9 1.3820 14 1 ' 3.1 2t 1 59 27 1.6704 104 39 1.3688 15 I J 3.1 � .: J 60 27 1.6425 105 39 1.3557 16 13 2 9')F i 61 27 1.6156 106 40 1.3774 17 14 3 0:ir., 62 27 1,5895 107 40 1.3646 18 14 2e83t.3 63 29 1.6222 108 40 1.3519 19 15 2.8818 64 28 1.5969 109 40 1.3395 20 15 2.7377 65 23 1.5723 110 41 1.3605 21 16 27012 66 29 1.6038 ill 41 1.3492 22 16 26547 67 29 1.5799 112 Al 1.3362 23 17 2-69' 3 68 29 1.45565 113 Al 1.3243 24 17 2.5856 69 29 1.5341 114 42 1.3447 25 17 2.4621 70 30 1.5543 115 42 1.3330 26 113 25271 71 30 1.5423 116 42 1.3215 27 18 2 42` 1 72 30 1.53013 117 43 1.3414 0 18 2.3465 73 30 1.5000 118 43 1.3301 ±9 18 2.2656 74 31 1.5291 119 43 1.3189 30 19 2.3117 75 31 1.5367 120 43 1.3079 31 19 22371 76 31 1.4388 121 44 1.3273 2 10 " 1672 77 32 1.5169 122 44 1.3164 33 20 2.2121 78 32 1.4974 123 44 1.3057 34 2D 2.1471 79 32 1.4785 124 44 1.2951 35 20 2.0657 80 32 1.4500 125 =5 1.3140 36 20 2.0278 81 33 1.4370 126 -5 1.3036 37 21 20716 82 33 1.4689 127 45 1.2933 38 21 2.0171 93 33 1.4512 128 46 1.3117 39 21 1.9654 84 34 1.4774 129 46 1.3016 40 21 1_0162 85 34 1.4500 130 46 1.2916 41 22 1.9585 86 34 1.4430 131 46 1.2817 .2 22 19119 87 34 1.4264 132 47 1.2996 Y3 22 1.8674 98 35 1.4517 123 47 1.2899 44 23 1.9079 99 35 1.4354 134 47 1.2802 45 23 1.8655 g0 35 1.4194 135 47 1.2708 Risk Management D'I%islan REVIEWED & APPROVED BY. Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) Short Rate Cancellation Table (Cont'd) FactrrtrsA Iytn Far tpppnhjln Fw"tnAp*to Fa npd Prmtimfrr FamodPlrerpimf[T Famed PrarMm RaW n Pricy Short PAe Peri Pdx.y n Days n pa r 5trort F c PA.riod Pt*W in Day4 n Pricy %myt Fite for Prxk Ai Pcfm.yi7 Pori d P--Wbdg- V E fcd Period Fhorcemtagcs 9f K!t Period Pcrc-09cs aToct 137 4g f : 7- 1$2 60 v 1 2003 227 7r w 1,1255 139 49 ` ; r 183 61 1.2167 228 'r 1,1206 139 49 1.21,67 184 61 1-2101 222 71 1.1317 140 49 1.2775 165 61 1-211M 230 71 1.1267 141 49 1.2614 186 61 1.1970 231 71 1,1219 142 49 1.2 ': 187 61 1.1906 232 71 1.1170 143 50 1.2762 18B 62 1.2037 233 72 1,1279 144 60 1.26'4 189 62 1-1974 234 72 1.1231 145 50 1.2; -L 190 62 1-1910 235 12 1.1163 146 50 1.26uu 191 62 1.1048 236 72 1.1135 147 51 12663 192 63 1,1977 237 72 1.1009 140 51 1.2579 193 63 1.1914 238 73 1.1195 149 51 1.2493 194 63 1-1853 239 73 1.1149 150 52 1.2653 195 63 1-1792 240 73 1.1102 151 52 1.2560 195 61 1-1732 241 73 1.1055 162 52 1,2487 197 64 1,1968 242 74 1.1161 153 52 1.2405 198 64 1.1798 242 74 1,1115 154 53 1.2562 199 64 1-1739 244 74 1.1070 155 53 1.2491 200 64 1-1680 245 74 1.1025 156 53 1.2401 201 65 1.1004 246 74 1.0360 157 54 1,2554 202 65 1,1745 247 75 1.1003 168 54 1.2475 203 65 1-1587 248 75 1,1028 159 54 1.2396 204 65 1-1530 242 75 1.0924 180 54 1.2319 205 65 1-1573 250 75 1.0950 161 55 1.2460 206 66 1-1604 251 76 1,1052 162 55 1.2392 207 66 1.1638 252 76 1.1008 163 55 1.2316 200 66 1-1582 253 76 1,0064 164 55 1.22-' 1 209 65 1-1526 25' 713 1.0921 185 56 1.23bt; 210 67 1-1845 255 76 1.0878 166 56 1.2313 211 67 1-1590 256 77 1.0079 167 56 1.2240 212 67 1.1535 257 77 1.006 168 57 1.2384 213 67 1-1481 258 77 1,0883 169 57 1.2311 214 67 1-1428 259 77 1.0851 170 57 1.2238 215 60 1-1544 206 77 1.0810 171 57 1.2167 216 60 1-1491 261 78 1.0908 172 58 1 A P 217 60 1,1438 262 78 1,0366 173 58 - 21B 613 1.1386 262 78 1,0825 174 58 1.216 219 69 1-1 500 2134 78 1.0784 175 56 1.2097 220 69 1-1448 265 79 1.0861 176 59 1.2236 221 69 1.1396 266 79 1,0040 177 59 1.2167 222 69 1.1345 267 79 1.0800 170 59 1.2092 223 69 1.1294 268 79 1.0759 179 B0 1.2235 224 70 1.1406 269 79 1.0719 o Risk 3%Managern12itisia' REVIEWED & APPROVEDAPPROVEDBY. x n�c.ri e.e Z V Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Short Rate Cancellation Table (Cont'd) WC 04 04 22 (Ed.01-12) nayan Paioy Period Short late Perc-t ges Fadorlo Appyto EanedAwrkmf r Period Poky in wed n Poky Period Strait Rae Peraer "@- Fadarto AppVto EanedPreniin7f& PeriodPoigr n Fred Oayn nftiry Period Shart Rate P Faarxto Applyto Earted Pr emiirn fix PeriodAAW In BfeR 2; 1 b 1. 1 1 1. 111 272 80 1-0735 317 90 1.0363 362 100 1.0083 27: 80 1.0695 318 90 1.0330 363 1Q0 1.0055 274 81 1_0790 319 90 1.0298 364 100 1.0027 27" 81 1 0761 320 91 1A380 366 nn 1,0000 276 81 1.0712 321 91 1.0347 277 81 1.0673 322 91 10315 278 81 1.0635 323 91 1.0283 279 82 1.0728 324 92 1,6364 28u 82 1-0889 325 92 1.0332 281 82 1.0651 326 92 1.0301 262 82 1.0614 327 92 1 0269 283 83 1.0705 328 92 1.0238 28.1 83 10667 320 93 10318 286 83 1.0630 330 93 1.0286 28F 83 1.0593 331 93 1.0255 28i 83 1-0556 332 93 1.0224 288 84 1.0646 333 94 1.0303 28!_1 84 1.0609 334 94 1.0272 290 84 1.0572 335 94 1.0242 291 84 1.0526 336 94 1.0211 292 85 1.0625 337 94 1.0181 2V .-;5 10589 338 95 1:0259 294 85 1.0553 339 95 1.0229 295 85 1.0517 340 95 1.U198 296 85 1.0481 341 95 1.0169 297 86 1.0569 342 95 1.0139 298 85 1-0534 343 Be 1.0216 299 86 1.0498 344 96 1.0186 300 86 10463 345 96 1,0156 301 86 1.0429 346 96 1.0127 302 87 1.0515 347 97 1.0203 303 87 1.0400 348 97 1.0174 304 87 1.0445 349 97 1.0145 3.05 87 1.0411 350 97 1.0116 306 88 1_0497 351 97 1.0087 307 88 1.0462 362 98 1.01 V 308 88 1.0429 353 98 1.0133 309 88 1,0395 354 96 1.0106 310 88 1.0361 355 9B 1.0076 311 89 1.0445 356 99 1.0150 312 89 1.0412 357 99 1.0122 313 89 1-0379 358 99 1.0094 314 89 1.0345 359 99 1.0005 315 90 1_0429 360 99 1.0030 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Risk Managawnl DlAsian REVIEWED & APPROVED BY. Z Maud Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 A (Ed. 12/ 93) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the INFORMATION PAGE. The cancellation condition in Part Six (Conditions) of the policy is replaced by these conditions: CANCELATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Failure to comply with Federal or State safety orders; h. Failure to comply with written recommendations of our designated loss control representatives; i. The occurrence of a material change in the ownership of your business; j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; k. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; Copyright 1998by The Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 19 �ortaN RiskMmVmedDMsinn REVIEWED & APPROVED BY. - Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 A (Ed. 12/93) The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) through (1), we will give you 30 days advance written notice; however, we agree that in the event of cancellation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. The policy period will end on the day and hour stated in the cancellation notice. 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 0 9 - 0 7 - 2 1 Policy No. WC 80946 00 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Copyright 1998by The Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 194 �oRaN r� -:. ^ecoG< 4r q� Risk ManagemedDiviaian cREVIEWED & APPROVED BY.- rRd�-cG " R. v� Risk Management Analyst POLICYWRITING INDEX CLIENT NUMBER POLICY NUMBER PREVIOUS POLICY NUMBER 1 EFFECTIVE DATE 1 EXPIRATION DATE 1 WC 80946 00 NEW 09-07-2021 09-07-2022 NAMEDINSURED BACKHAUS DANCE MISCELLANEOUS INFORMATION TRANSACTION INFORMATION BILL TYPE DIRECT TRANS.TYPE New Business BILL PLAN Monthly TRANS. SEQ. # 001 OPERATOR I.D. JSPIVEY DATE PROCESSED 09-02-21 PROGRAM CODE TRANS.DATE 09-07-21 SIC CODE 5812 ENDORSEMENT # RECORD I.D. CANC/REIN REASON FAC REINS LINE OF BUSINESS/ COMMISSIONS: LINE OF BUSINESS COMMISSION % WORKERS' COMPENSATION TERM PREMIUM $ 5,861 BILLED PREMIUM $ 5,861 NAMED INSURED MAILING ADDRESS AGENT INFORMATION CODE 1850 BACKHAUS DANCE Automatic Data Processing Insurance Agency, Inc. 1 ADP Boulevard 4365 Johanna Ave Lakewood CA 90713-3303 Roseland NJ 07068 ASSEMBLY INFORMATION STAMPS/ STICKERS SPECIAL INSTRUCTIONS MAILING INSTRUCTIONS HortaN RiskMmRgzmentDMsian WCPWN DX1 i R�EWED & APPROVED BY: 3 r f R. Vj&wd Risk Management Analyst POLICYWRITING INDEX ACCOUNT NUMBER I POLICY NUMBER I PREVIOUS POLICY NUMBER I EFFECTIVE DATE - EXPIRATION DATE I WC 80946 00 1 NEW 1 09-07-2021 09-07-2022 1 COMPUTER PRODUCED FORMS WC 04 00 01 B 10-14 CA WC INFORMATION PAGE WC 04 00 05 07-98 CA EXTENSION OF INFORMATION PAGE WC 00 00 00 C 01-15 INSURANCE POLICY PN 04 99 01 H 05-20 CA POLICYHOLDER NOTICE PN 04 99 02 B 05-02 CA WC INSURANCE RATING LAWS PN 04 99 04 12-01 CA POLICYHOLDER NOTICE — CIGA PN 04 99 08 12-19 CA POLICYHOLDER NOTICE —ASSEMBLY BILL N05 WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT WC 00 04 21 E 01-21 CATASTROPHE (OTHER THAN CERT ACTS) ENDT WC 00 04 22 C 01-21 TERRORISM RISK PGM REAUTH ACT DISCL ENDT WC 04 03 01 D 02-18 CA POLICY AMENDATORY ENDORSEMENT WC 04 03 10 01-95 CA DUTY TO DEFEND WC 04 03 60 B 01-15 CA EMPLOYERS' LIAB COV AMENDATORY ENDT WC 04 04 21 01-08 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT WC 04 04 22 01-12 CA SHORT —RATE CANCELATION ENDORSEMENT WC 04 06 01 A 12-93 CA CANCELATION ENDT �oRaN } r RiskMmWmentDMsiun REVIEWED & APPROVED BY.- cc r6+" R. vj&wd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0400 04 (Ed. 7- 98) EXTENSION OF INFORMATION PAGE Schedule of Forms ITEM 3D POLICY NO. WC 80946 00 Form Numbers Applicable States WORKERS COMPENSATION FORMS AND ENDORSEMENTS WC 04 00 01 B 10-14 CA WC INFORMATION PAGE CA WC 04 00 05 07-98 CA EXTENSION OF INFORMATION PAGE CA WC 00 00 00 C 01-15 INSURANCE POLICY CA PN 04 99 01 H 05-20 CA POLICYHOLDER NOTICE CA PN 04 99 02 B 05-02 CA WC INSURANCE RATING LAWS CA PN 04 99 04 12-01 CA POLICYHOLDER NOTICE - CIGA CA PN 04 99 08 12-19 CA POLICYHOLDER NOTICE -ASSEMBLY BILL N05 CA WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT CA WC 00 04 21 E 01-21 CATASTROPHE (OTHER THAN CERT ACTS) ENDT CA WC 00 04 22 C 01-21 TERRORISM RISK PGM REAUTH ACT DISCL ENDT CA WC 04 03 01 D 02-18 CA POLICY AMENDATORY ENDORSEMENT CA WC 04 03 10 01-95 CA DUTY TO DEFEND CA WC 04 03 60 B 01-15 CA EMPLOYERS' LIAB COV AMENDATORY ENDT CA WC 04 04 21 01-08 CA OPTIONAL PREMIUM INCREASE ENDORSEMENT CA WC 04 04 22 01-12 CA SHORT -RATE CANCELATION ENDORSEMENT CA WC 04 06 01 A 12-93 CA CANCELATION ENDT CA ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rig Its reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001. �oRaN 3 Risk ManagemedDivisian REVIEWED & APPROVED BY. z 4' Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Sirius America Ins Co Insurer ID No(s). 28363 1. Named Insured: BACKHAUS DANCE Mailing Address: 4365 Johanna Ave Lakewood CA 90713-3303 Policy No. WC 80946 00 Prior Policy No. 0 Individual Corporation Partnership LLC LLP WC 04 00 01 B (Ed. 10-14) Email Address: KIM@BACKHAUSDANCE . ORG 0 Other: FEIN: 050575068 Non -Profit Intra/Interstate Risk ID No. Other workplaces not shown above: See Schedule of Locations 2. The policy period is from 09-07-2021to 09-07-2022 12:01 A.M. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: CA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AZ AR CO DE DC FL GA IL IN IA KS KY LA MD MI MS MO NE NV NH NJ NM NY NC OK PA RI SC TN TX UT VT VA WV WI D. This policy includes these endorsements and schedules: See Schedule of Forms and Endorsements 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Code Estimated Annual $100 of Annual No. Classifications Remuneration Remuneration Premium See Extension of Information Page Experience Modification See Extension of Information Page Total Estimated Annual Premium $ 5,861 Minimum Premium $ 1,590 Deposit Premium $ 978 Premium Adjustment Period: Annual Countersigned B Producer Information: Automatic Data Processing Insurance Agency;—inc. Servicing/Issuing Office 1015 15th Street NW, Suite 600, Washington, DC 20005-2605 Date Copyright 2014 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2014. �oRaN r� -:. ^ecoG< 4r of Risk ManagemedDiviaian REVIEWED & APPROVED BY.- PZ. v� Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Classifications ITEM 4 POLICY NO. WC 80946 00 Premium Basis Rate Per $100 Estimated Code Estimated Annual of Annual No. Classifications Remuneration Remuneration Premium 0001-01 BACKHAUS DANCE FEIN # 05-0575068 SIC CODE 5812 NAICS CODE 711110 CA ERN ## 1111 4365 Johanna Ave Lakewood CA 90713-3303 9156 Theaters - Dance/Opera $ 86,005 5.72 $ 4,919.00 Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. �oRaN r IZAManWmedDiviaian REVIEWED & APPROVED BY.- p P. Vj&,Vd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 00 05 (Ed. 7-98) EXTENSION OF INFORMATION PAGE Classifications ITEM 4 POLICY NO. WC 80946 00 Premium Basis Rate Per $100 Estimated Code Estimated Annual of Annual No. Classifications Remuneration Remuneration Premium Total Class Premium $ 4,919.00 9036 Territory Modification 1.20 $ 984.00 9812 Increase Limits 1.011 $ 65.00 9848 Empl Minimum Difference $ 55.00 Total Subject Premium $ 6,023.00 9897 Experience Premium 1.00 $ 0.00 Total Modified Premium $ 6,023.00 9887 Schedule Modification .91 $ -542.00 Standard Total $ 5,481.00 0063 Premium Discount .99 $ -55.00 0900 Expense Constant $ 160.00 Terrorism Risk Ins Act 9740 2002 .04 $ 34.00 Catastrophe (Other Than Certified Acts of 9741 Terrorism) .02 $ 17.00 Total Estimated Premium $ 5,637.00 CA Admin Revolving Fund 0987 Assess 1.022646 $ 128.00 CA Occ Safety & Health 0000 Fund 1.002584 $ 15.00 0988 CA Fraud Assessment 1.004734 $ 27.00 CA Unins Empl Benefits 0000 Assess 1.000775 $ 4.00 CA Subs Inj Benefits 0000 Assess 1.006579 $ 37.00 California Labor Enforcement & Compliance (LECF) 0000 Assessment 1.002272 $ 13.00 Final Total $ 5,861.00 Policy Total Estimated Cost $ 5,861.00 Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 2001. �oRaN r RAMarWmedDiviaian REVIEWED & APPROVED BY.- p P. vj&wd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an employer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any federal occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self -insured for such workplaces. WC 00 00 00 C (Ed. 1-15) PART ONE WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to investigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other 1 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } z RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- cc Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons entitled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our duties under this insurance after an injury occurs. 3. We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or other special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your duties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1. For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against 2 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. HORaN o r RiskManagemerdDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY such third party as a result of injury to your employee; 2. For care and loss of services; and For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2. Punitive or exemplary damages because of bodily injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. Any obligation imposed by a workers compensation, occupational disease, unemployment compensation, or disability benefits law, or any similar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonappropriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. WC 00 00 00 C (Ed. 1-15) and 901-944), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sections 51 et seq.), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10.Bodily injury to a master or member of the crew of any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11.Fines or penalties imposed for violation of federal or state law; and 12.Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our request, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgment as required by law until we offer the amount due under this insurance; and 5. Expenses we incur. 3 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } z a RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- p R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident —each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease —policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by disease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease —each employee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include disease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability under this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance You will do everything necessary to protect those rights for us and to help us enforce them. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this policy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Information Page. 2. If you begin work in any one of those states after the effective date of this policy and are not insured or are not self -insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other services required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal 4 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } z a RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- p R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 6. Do not voluntarily make payments, assume obligations or incur expenses, except at your own cost. PART FIVE PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons lawfully secured their workers compensation obligations. D. Premium Payments WC 00 00 00 C (Ed. 1-15) You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short -rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to compute premium. You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. 5 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. �oRaN } : RiskMmRgemerdDivisiun REVIEWED & APPROVED BY.- cc Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) PART SIX CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organizations have the same rights we have under this provision. B. Long Term Policy If the policy period is longer than one year and sixteen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days after your death, we will cover your legal representative as insured. D. Cancelation 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to comply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. 6 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. HORaN o r RiskManagemerdDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst P N 04 99 01 H (Ed. 05-2020) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION Information Available to You A. Information Available from Us — APIAccountProd APIAccountProd (1) General questions regarding your policy should be directed to: SIRIUS AMERICA INSURANCE COMPANY 140 BROADWAY, 32ND FLOOR, NEW YORK, NY 10005-1108 855-705-2716 (2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non- payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan- 1995 (USRP) and the California Workers' Compensation Experience Rating Plan-1995 (ERP). WCIRB contact information is: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 (fax); and customerservice(a�wcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss -Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. [Optional language for insurers that have adopted the WCIRB's Advisory Basic Underwriting Manual: If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below.] You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: Sirius America Insurance Company 140 Broadway, 32nd Floor, New York, NY 10005-1108 After you send your Complaint and Request for Action, we have 30 days to send you a written your written request will be reviewed. If we agree to review your request, we must conduct the PN 04 99 01 H 1 of 2 (Ed. 05-2020) HORaN 3 RiskMmaganedDMsian REVIEWED & APPROVED BY. r Risk Management Analyst P N 04 99 01 H (Ed. 05-2020) granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice(a�wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerserviceawcirb.com (email). C. California Department of Insurance — Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Oakland, CA 94612 415.538.4243 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (fax) and ombudsmanp_wcirb.com (email). B. California Department of Insurance — Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. PN 04 99 01 H 2 of 2 (Ed. 05-2020) HortaN RiskMmaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst P N 04 99 02 B (Ed. 5-02) POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. We establish our own rates for workers' compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. Rating organizations may develop pure premium rates that are subject to the insurance commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. CALIFORNIA WORKERS' COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with t ©2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. RiskManagemerdDiviaiun REVIEWED & APPROVED BY.- Fu4w L. P1. Vi&4441 Risk Management Analyst P N 04 99 02 B (Ed. 5-02) We are not required to provide you with a notice of nonrenewal in any of the following situations: Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. The policy was extended for 90 days or less and the required notice was given prior to the extension. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate" means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. 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 0 9 — 0 7 — 2 1 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By ©2002 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Premium $ Incl . �oRaN } z a RiskMmaganadDiviaiun REVIEWED & APPROVED BY.- F R. vj&wd Risk Management Analyst PN 04 99 04 (Ed. 12-01) POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover those assessments. If your policy is surcharged, "CA Surcharge" or "CA Surcharge (CIGA Surcharge)" with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. 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 0 9 — 0 7 — 2 1 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By ©2001 by the Workers' Compensation Insurance Bureau of California. All rights reserved. Premium $ Incl . �oRaN } r RAMmVmentDMsian REVIEWED & APPROVED BY.- p PZ. vj&wd Risk Management Analyst PN 04 99 08 (Ed. 12-19) POLICYHOLDER NOTICE CALIFORNIA ASSEMBLY BILL NO. 5, INDEPENDENT CONTRACTORS Summary of Assembly Bill No. 5 (AB 5) For the purposes of wages, workers' compensation and other benefits, AB 5 creates a presumption that an entity's workers are employees unless the hiring entity can show that the worker meets three conditions, known as the "ABC Test". With respect to workers' compensation, AB 5 goes into effect on July 1, 2020 and applies to policies issued on or after July 1, 2020, as well as policies in force as of July 1, 2020. The bill adds Section 2750.3 to the California Labor Code, which provides in pertinent part: 2750.3. (a)(1) For purposes of the provisions of this code and the Unemployment Insurance Code, and for the wage orders of the Industrial Welfare Commission, a person providing labor or services for remuneration shall be considered an employee rather than an independent contractor unless the hiring entity demonstrates that all of the following conditions are satisfied: (A) The person is free from the control and direction of the hiring entity in connection with the performance of the work, both under the contract for the performance of the work and in fact. (B) The person performs work that is outside the usual course of the hiring entity's business. (C) The person is customarily engaged in an independently established trade, occupation, or business of the same nature as that involved in the work performed. (2) Notwithstanding paragraph (1), any exceptions to the terms "employee," "employer," "employ," or "independent contractor," and any extensions of employer status or liability, that are expressly made by a provision of this code, the Unemployment Insurance Code, or in an applicable order of the Industrial Welfare Commission, including, but not limited to, the definition of "employee" in subdivision 2(E) of Wage Order No. 2, shall remain in effect for the purposes set forth therein. (3) If a court of law rules that the three-part test in paragraph (1) cannot be applied to a particular context based on grounds other than an express exception to employment status as provided under paragraph (2), then the determination of employee or independent contractor status in that context shall instead be governed by the California Supreme Court's decision in S.G. Borello & Sons, Inc. v. Department of Industrial Relations (1989) 48 Cal.3d 341. AB 5 also provides an extensive list of occupations that are exempt from the application of Section 2750.3(a)(1). These exemptions are subject to revision. In addition, AB 5 amends Section 3351 of the California Labor Code and Sections 606.5 and 621 of the Unemployment Insurance Code. The pertinent sections of the California Labor Code and Unemployment Insurance Code may be accessed at http://leginfo.legislature.ca.gov. You may also access the California Labor & Workforce Development Agency webpage at https://www.labor.ca.gov/employmentstatus/ for more information. This notice does not change the policy to which it is attached. �ortaN RiskMmaganedDMsian REVIEWED & APPROVED BY. - Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 19 (Ed. 1-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D. Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid. The due date for audit and retrospective premiums is the date of the billing. 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 0 9 - 0 7 - 2 1 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By WC 00 04 19 (Ed. 1-01) © 2000 National Council on Compensation Insurance, Inc. Premium $ Incl . HORaN } r Risk ManagemendDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 E (Ed. 01-2021) Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 C), attached to this policy. For purposes of this endorsement, the following definitions apply: • Catastrophe (Other Than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. • Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of the Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA .02 $17 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Page 1 of 1 "oRa" F RAManWmerdDivisian WC 00 04 21 E } % z REVIEWED & APPROVED BY.- (Ed. 01-2021) p R. MmAd © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. ` Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-2021) Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property, or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. Page 1 of 2 © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. HORaN } z RiskManagemerdDivisian REVIEWED & APPROVED BY.- f R. VSA44a Risk Management Analyst WC 00 04 22 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-2021) Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA .04 $34 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Page 2 of 2 "oRa" F RAManWmerdDivisian WC OO 04 22 C J % r REviEWED & APPROVED BY.- (Ed. 01-2021) F R. MmAd © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. ` Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 2-18) POLICY AMENDATORY ENDORSEMENT—CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1. Minors Illegally Employed —Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2. Punitive or Exemplary Damages — Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3. Increase in Indemnity Payment — Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Department of Insurance. 4. Application of Policy. Part One, "Workers Compensation Insurance", A, "How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. Rate Changes. The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6. Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7. Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. 8. Part Five, "Premium", E, "Final Premium", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. Page 1 of 2 © Copyright 2018 by the Workers' Compensation Insurance Rating Bureau of California. All Rights Reserved. HortaN Risk Mwag merdDivisian REVIEWED & APPROVED BY. - Risk Management Analyst WC 04 03 01 D WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 2-18) If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short -rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Page 2 of 2 ; RtsieAQa�WmerdDiMawn H ortaN WC 04 03 01 D 3 r RE�AEWED & APPROVED BY.- (Ed. 2-18) FIIA . JZ. W&VAI © Copyright 2018 by the Workers' Compensation Insurance Rating Bureau of California. All Rights Reserved. Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 10 (Ed. 1-95) DUTY TO DEFEND-CALIFORNIA The insurance afforded by Part One, Section C, "We Will Defend", is hereby deleted and replaced with the following: WE WILL DEFEND We have the right and duty to defend at our expense any claim or proceeding against you before the California Workers' Compensation Appeals Board or its equivalent in any other state (and any appeal of a decision therefrom) for the benefits payable by this workers' compensation insurance. We have the right to investigate and settle these claims or proceedings. We have no duty to defend a claim, proceeding, or suit that is not covered by this insurance. Nothing contained in this Section shall amend, modify, restrict or otherwise alter any obligations or conditions under Part Two -Employer's Liability Insurance of the policy. 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 0 9 — 0 7 — 2 1 Policy No. WC 80946 00 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . WC 04 03 10 (Ed. 1-95) Copyright 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rightsreserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 194 �oRaN r� -:. ^ecoG< 4r q� Risk ManagemedDiviaian cREVIEWED & APPROVED BY.- rRd�-cG " PZ. v� Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B (Ed. 01-16) EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT—CALIFORNIA The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A. "How This Insurance Applies," is amended to read as follows: A. How This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury means a physical injury, including resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or incidental to your work in California. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by disease must be brought in the United States of America, its territories or possessions, or Canada. C. The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): 1. Exclusion 1 is amended to read as follows: 1. liability assumed under a contract. 2. Exclusion 2 is deleted. 3. Exclusion 7 is amended to read as follows 7. damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimination against or termination of any employee, termination of employment, or any personnel practices, policies, acts or omissions. 4. The following exclusions are added 1. bodily injury to any member of the flying crew of any aircraft. 2. bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s) applicable to you or otherwise fail to comply with that law. 3. liability arising from California Labor Code Section 2810.3 which relates to labor contracting. 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By © 2015 by the Workers' Compensation Insurance Bureau of California. All Rights Reserved. Endorsement No. Premium $ Incl . �oRaN } z a RiskMmWmerdDiviaian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 21 (Ed. 1-08) OPTIONAL PREMIUM INCREASE ENDORSEMENT—CALIFORNIA You must provide us, or our authorized representative, access to records necessary to perform a payroll verification audit. If you fail to provide access within 90 days after expiration of the policy, you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy. In addition, if you fail to provide access after our third request within a 90 day or longer period, you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified, return -receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s) to perform an audit. In addition to any other obligations under this contract, 30 days after you receive the notification, you will be obligated to pay the total premium and costs referenced above. If, thereafter, you provide access to your records within three years after the policy expires, or within another mutually agreed upon time, and we succeed in performing the audit to our satisfaction, we will revise your total premium and the costs due to reflect the results of the audit. 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 0 9 — 0 7 — 2 1 Policy No. WC 80946 00 Endorsement No. Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By C 2007 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Premium $ Incl . �oRaN } z Risk ManaganadDMsfan REVIEWED & APPROVED BY.- f R. V;&wd Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed.01-12) CALIFORNIA SHORT -RATE CANCELLATION ENDORSEMENT It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: If you cancel the policy and a disclosure was provided in accordance with Section 481(c) of the California Insurance Code, final premium will be based on the time this policy was in force and increased by the short -rate cancelation table below: Short Rate Cancellation Table flays n Poky pa Shot PAe Ps'osrtw- FaclortoAppllylo EariodPranii_mfd Period Poky in EF&d Dgjw nPoigr P"dad Shot Fa& P-111 sus Fadtorin Appiytn Earned fterimfor Pianod Pofyrn nrs m Pb r Phliod Sihot lisle P-t> Fat4+xtbap"lo Earned Prelim firfood PCkviti Ldfer4 2 6 1 V-1 f' 47 23 1,7861 9? 36 1.4203 3 7 8e5 , ' 48 24 1.8250 93 36 1.4129 4 7 6.3G'LJ 49 24 1.7877 94 36 1.3979 5 8 5.8394 50 24 1.7520 95 37 1.4216 6 8 4.8662 51 24 1,7176 96 37 1.4060 7 9 46924 52 25 1.7540 97 37 1.3923 8 9 4 10 5r, 53 25 1.721 Fi 92 37 1.3781 9 10 4 u-': _ 54 25 1.6399 99 38 1.4010 10 10 J 0��r) 55 25 1.7255 100 38 1.3670 11 11 36496 56 26 1.6947 101 38 1.3733 12 11 3 3455 57 26 1.6660 102 R 1 2590 13 12 3.36G9 58 26 1.6362 103 =.9 1.3820 14 1 ' 3.1 2t 1 59 27 1.6704 104 39 1.3688 15 I J 3.1 � .: J 60 27 1.6425 105 39 1.3557 16 13 2 9')F i 61 27 1.6156 106 40 1.3774 17 14 3 0:ir., 62 27 1,5895 107 40 1.3646 18 14 2e83t.3 63 29 1.6222 108 40 1.3519 19 15 2.8818 64 28 1.5969 109 40 1.3395 20 15 2.7377 65 23 1.5723 110 41 1.3605 21 16 27012 66 29 1.6038 ill 41 1.3492 22 16 26547 67 29 1.5799 112 Al 1.3362 23 17 2-69' 3 68 29 1.45565 113 Al 1.3243 24 17 2.5856 69 29 1.5341 114 42 1.3447 25 17 2.4621 70 30 1.5543 115 42 1.3330 26 113 25271 71 30 1.5423 116 42 1.3215 27 18 2 42` 1 72 30 1.53013 117 43 1.3414 0 18 2.3465 73 30 1.5000 118 43 1.3301 ±9 18 2.2656 74 31 1.5291 119 43 1.3189 30 19 2.3117 75 31 1.5367 120 43 1.3079 31 19 22371 76 31 1.4388 121 44 1.3273 2 10 " 1672 77 32 1.5169 122 44 1.3164 33 20 2.2121 78 32 1.4974 123 44 1.3057 34 2D 2.1471 79 32 1.4785 124 44 1.2951 35 20 2.0657 80 32 1.4500 125 =5 1.3140 36 20 2.0278 81 33 1.4370 126 -5 1.3036 37 21 20716 82 33 1.4689 127 45 1.2933 38 21 2.0171 93 33 1.4512 128 46 1.3117 39 21 1.9654 84 34 1.4774 129 46 1.3016 40 21 1_0162 85 34 1.4500 130 46 1.2916 41 22 1.9585 86 34 1.4430 131 46 1.2817 .2 22 19119 87 34 1.4264 132 47 1.2996 Y3 22 1.8674 98 35 1.4517 123 47 1.2899 44 23 1.9079 99 35 1.4354 134 47 1.2802 45 23 1.8655 g0 35 1.4194 135 47 1.2708 Risk Management D'I%islan REVIEWED & APPROVED BY. Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) Short Rate Cancellation Table (Cont'd) FactrrtrsA Iytn Far tpppnhjln Fw"tnAp*to Fa npd Prmtimfrr FamodPlrerpimf[T Famed PrarMm RaW n Pricy Short PAe Peri Pdx.y n Days n pa r 5trort F c PA.riod Pt*W in Day4 n Pricy %myt Fite for Prxk Ai Pcfm.yi7 Pori d P--Wbdg- V E fcd Period Fhorcemtagcs 9f K!t Period Pcrc-09cs aToct 137 4g f : 7- 1$2 60 v 1 2003 227 7r w 1,1255 139 49 ` ; r 183 61 1.2167 228 'r 1,1206 139 49 1.21,67 184 61 1-2101 222 71 1.1317 140 49 1.2775 165 61 1-211M 230 71 1.1267 141 49 1.2614 186 61 1.1970 231 71 1,1219 142 49 1.2 ': 187 61 1.1906 232 71 1.1170 143 50 1.2762 18B 62 1.2037 233 72 1,1279 144 60 1.26'4 189 62 1-1974 234 72 1.1231 145 50 1.2; -L 190 62 1-1910 235 12 1.1163 146 50 1.26uu 191 62 1.1048 236 72 1.1135 147 51 12663 192 63 1,1977 237 72 1.1009 140 51 1.2579 193 63 1.1914 238 73 1.1195 149 51 1.2493 194 63 1-1853 239 73 1.1149 150 52 1.2653 195 63 1-1792 240 73 1.1102 151 52 1.2560 195 61 1-1732 241 73 1.1055 162 52 1,2487 197 64 1,1968 242 74 1.1161 153 52 1.2405 198 64 1.1798 242 74 1,1115 154 53 1.2562 199 64 1-1739 244 74 1.1070 155 53 1.2491 200 64 1-1680 245 74 1.1025 156 53 1.2401 201 65 1.1004 246 74 1.0360 157 54 1,2554 202 65 1,1745 247 75 1.1003 168 54 1.2475 203 65 1-1587 248 75 1,1028 159 54 1.2396 204 65 1-1530 242 75 1.0924 180 54 1.2319 205 65 1-1573 250 75 1.0950 161 55 1.2460 206 66 1-1604 251 76 1,1052 162 55 1.2392 207 66 1.1638 252 76 1.1008 163 55 1.2316 200 66 1-1582 253 76 1,0064 164 55 1.22-' 1 209 65 1-1526 25' 713 1.0921 185 56 1.23bt; 210 67 1-1845 255 76 1.0878 166 56 1.2313 211 67 1-1590 256 77 1.0079 167 56 1.2240 212 67 1.1535 257 77 1.006 168 57 1.2384 213 67 1-1481 258 77 1,0883 169 57 1.2311 214 67 1-1428 259 77 1.0851 170 57 1.2238 215 60 1-1544 206 77 1.0810 171 57 1.2167 216 60 1-1491 261 78 1.0908 172 58 1 A P 217 60 1,1438 262 78 1,0366 173 58 - 21B 613 1.1386 262 78 1,0825 174 58 1.216 219 69 1-1 500 2134 78 1.0784 175 56 1.2097 220 69 1-1448 265 79 1.0861 176 59 1.2236 221 69 1.1396 266 79 1,0040 177 59 1.2167 222 69 1.1345 267 79 1.0800 170 59 1.2092 223 69 1.1294 268 79 1.0759 179 B0 1.2235 224 70 1.1406 269 79 1.0719 o Risk 3%Managern12itisia' REVIEWED & APPROVEDAPPROVEDBY. x n�c.ri e.e Z V Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Short Rate Cancellation Table (Cont'd) WC 04 04 22 (Ed.01-12) nayan Paioy Period Short late Perc-t ges Fadorlo Appyto EanedAwrkmf r Period Poky in wed n Poky Period Strait Rae Peraer "@- Fadarto AppVto EanedPreniin7f& PeriodPoigr n Fred Oayn nftiry Period Shart Rate P Faarxto Applyto Earted Pr emiirn fix PeriodAAW In BfeR 2; 1 b 1. 1 1 1. 111 272 80 1-0735 317 90 1.0363 362 100 1.0083 27: 80 1.0695 318 90 1.0330 363 1Q0 1.0055 274 81 1_0790 319 90 1.0298 364 100 1.0027 27" 81 1 0761 320 91 1A380 366 nn 1,0000 276 81 1.0712 321 91 1.0347 277 81 1.0673 322 91 10315 278 81 1.0635 323 91 1.0283 279 82 1.0728 324 92 1,6364 28u 82 1-0889 325 92 1.0332 281 82 1.0651 326 92 1.0301 262 82 1.0614 327 92 1 0269 283 83 1.0705 328 92 1.0238 28.1 83 10667 320 93 10318 286 83 1.0630 330 93 1.0286 28F 83 1.0593 331 93 1.0255 28i 83 1-0556 332 93 1.0224 288 84 1.0646 333 94 1.0303 28!_1 84 1.0609 334 94 1.0272 290 84 1.0572 335 94 1.0242 291 84 1.0526 336 94 1.0211 292 85 1.0625 337 94 1.0181 2V .-;5 10589 338 95 1:0259 294 85 1.0553 339 95 1.0229 295 85 1.0517 340 95 1.U198 296 85 1.0481 341 95 1.0169 297 86 1.0569 342 95 1.0139 298 85 1-0534 343 Be 1.0216 299 86 1.0498 344 96 1.0186 300 86 10463 345 96 1,0156 301 86 1.0429 346 96 1.0127 302 87 1.0515 347 97 1.0203 303 87 1.0400 348 97 1.0174 304 87 1.0445 349 97 1.0145 3.05 87 1.0411 350 97 1.0116 306 88 1_0497 351 97 1.0087 307 88 1.0462 362 98 1.01 V 308 88 1.0429 353 98 1.0133 309 88 1,0395 354 96 1.0106 310 88 1.0361 355 9B 1.0076 311 89 1.0445 356 99 1.0150 312 89 1.0412 357 99 1.0122 313 89 1-0379 358 99 1.0094 314 89 1.0345 359 99 1.0005 315 90 1_0429 360 99 1.0030 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 09-07-21 Policy No. WC80946 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Risk Managawnl DlAsian REVIEWED & APPROVED BY. Z Maud Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 A (Ed. 12/ 93) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the INFORMATION PAGE. The cancellation condition in Part Six (Conditions) of the policy is replaced by these conditions: CANCELATION 1. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e. Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g. Failure to comply with Federal or State safety orders; h. Failure to comply with written recommendations of our designated loss control representatives; i. The occurrence of a material change in the ownership of your business; j. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; k. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; Copyright 1998by The Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 19 �ortaN RiskMmVmen DMsinn REVIEWED & APPROVED BY. - Risk Management Analyst WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 A (Ed. 12/ 93) The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g) through (1), we will give you 30 days advance written notice; however, we agree that in the event of cancellation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4. The policy period will end on the day and hour stated in the cancellation notice. 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 0 9 - 0 7 - 2 1 Policy No. WC 80946 00 Insured BACKHAUS DANCE Insurance Company Sirius America Ins Co Countersigned By Endorsement No. Premium $ Incl . Copyright 1998by The Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual Copyright 194 �oRaN r Risk ManagemedDiviaian REVIEWED & APPROVED BY.- p R. vj&wd Risk Management Analyst Named Insured Special Notes: Policy Number: Client Number: System Assign: System Release: Business Type: Insurance Co: Line Of Business: Effective Date: Anniversary Date: Policy Term: Predominant State: Transaction Type: POLICY DECISIONS Pie Insurance Holdings Inc. 101515th Street NW, Suite 600 Washington, DC 20005-2605 RATING WORKSHEETS BACKHAUS DANCE Date: DANCE EDUCATION THROUGH A WC80946 08209400000000 21.04 Non -Profit Sirius America Ins Co Workers Comp (Voluntary) 09/07/2021 1 Year CA NEW BUSINESS POLICY PREMIUM TOTALS Coverages Class Premium Employer's Liab Premium Empl Liab Min Diff Premium Schedule Mod Premium Territory Factor Standard Premium Premium Discount Expense Constant Terrorism Catastrophe Estimated Premium Taxes and Assessments Estimated Total Agy/Prod Number: Agy/Prod Name: Operator Expiration Date: Audit Frequency: 09/02/2021 1850 Automatic Data Processing Insurance Agency, Inc. JSPIVEY 09/07/2022 Annual Transaction Sequence: 001 Term Premium 4,919.00 65.00 55.00 -542.00 984.00 5,481.00 -55.00 160.00 34.00 17.00 5,63 7.00 224.00 5,861.00 �oRaN Ii:AMwag mentDMsian REVIEWED & APPROVED BY. - Risk Management Analyst Page 2 TERM STATE TOTALS State CA Estimated Totals Named Insured BACKHAUS DANCE Customer ID Policy Number WC80946 Transaction Type New Business Effective Exposure 86,005 86,005 9/7/2021 Estimated Taxes And State Premium Assessments Total 5,637.00 224.00 5,861.00 5,637.00 224.00 5,861.00 oRaN Risk Mwag merdDMsian REVIEWED & APPROVED BY. - Risk Management Analyst Page 3 Named Insured BACKHAUS DANCE Customer ID Policy Number WC80946 Transaction Type New Business Effective PREMIUM RECAP BY RATING GROUP 9/7/2021 State: CA Rating Group: 0001-01 Term Class Code Exposure Rate Premium 9156 86,005 5.72 4,919.00 Total Class Premium 4,919.00 Territory Modification (2) (SP: 4,919.00) 984.00 Increase Limits (.011) (SP: 5,903.00) 65.00 Empl Minimum Difference 55.00 Total Subject Premium 6,023.00 Total Modified Premium 6,023.00 Schedule Modification (-.09) (SP: 6,023.00) -542.00 Standard Total 5,481.00 Premium Discount (.01) (SP: 5,481.00) -55.00 Expense Constant 160.00 Terrorism Risk Ins Act 2002 (.04) (SP: 86,005.00) 34.00 **Terrorism Premium Is Per $100 Of Payroll** Catastrophe (O/T Acts of Terr) (.02) (SP: 86,005.00) 17.00 **Catastrophe Premium Is Per $100 Of Payroll** Total Estimated Premium 5,637.00 CA Admin Revolving Fund Assess (.022646) (SP: 5,637.00) 128.00 CA Occ Safety & Health Fund (.002584) (SP: 5,637.00) 15.00 CA Fraud Assessment (.004734) (SP: 5,637.00) 27.00 CA Unins Empl Benefits Assess (.000775) (SP: 5,637.00) 4.00 CA Subs Inj Benefits Assess (.006579) (SP: 5,637.00) 37.00 CA LECF Assessment (.002272) (SP: 5,637.00) 13.00 Final Total 5,861.00 �oRaN RAMmagementDMsian REVIEWED & APPROVED BY. - Risk Management Analyst Page 4 Named Insured BACKHAUS DANCE Customer ID Policy Number WC80946 Transaction Type New Business Effective WORKERS COMP POLICY INFORMATION RECAP Predominant State: CA Employers Liability: Each Accident: Policy Limit: Each Employee: Admiralty Limit: Per Accident: Program Type: FELA Limit: Per Accident: Program Type: Retro Plan: No Interstate Exper Mod ID: Effective Date: Exper Mod: Minimum Premium Term/Trans Policy: 1590 Empl Liab: 120 Admiralty: FELA: Combined Policy Premium: NJ Premium: Executive Officers: No Employee Leasing: No Deposit Factor: Installment Plan: 11 Highest Per Policy 1590 120 1,000,000 1,000,000 1,000,000 N/A N/A N/A N/A 9/7/2021 oRaN Ii:AMamaganentDMsian REVIEWED & APPROVED BY. - Risk Management Analyst Page 5 Named Insured BACKHAUS DANCE Customer ID Policy Number WC80946 Transaction Type New Business Effective WORKERS COMP STATE INFORMATION RECAP State: CA Rate Change Pending Insurance Co.: Split Period: Rate Mode: G Tier Level: Retro Plan: No Territory Zip Code: Deductible: Deductible Factor: Coinsurance: Deductible: Deductible Factor: Aggregate Limit: Hazard Group: Large Deductible: Large Aggregate Limit: Intermediate Deductible: Aggregate Deductible: Intra Exper Mod ID: Effective Date: 09/07/2021 Exper Mod: 1.00 (Tentative) Rate Revision Date: 09/01/2021 Dev Revision Date: Premium Discount First: NIL (5,000) Next: .109 (95,000) Next: .126 (400,000) Balance: .144 (Balance) Commission (Norm): Prem Subj to Comm: 5,637 Safety Group Program Rating Tier Original Rating Tier Rating Tier Override 9/7/2021 oRaN RiskMmWmentDMsian REVIEWED & APPROVED BY. - Risk Management Analyst Page 6 Named Insured BACKHAUS DANCE Customer ID Policy Number WC80946 Transaction Type New Business Effective CLASS CODE INFORMATION State: 04 (CA) Rating Group: 0001-01 Class Code: 9156 THEATERS - DANCE/OPERA Hazard Group: 1 (A) Analogy Desc: None Premium Type: 01 RATABLE USL&H Applies: No DC Ben Applies: No TWM&C Applies: No Disease Load: Base Rate Ovrd: 5.7200 Min Prem Ovrd: Exposure: 86,005 (A) Rate Class: CLASS CODE DEVIATION FACTORS Co. Rate Dev Co. Min Dev Class Prem Term Fact 1.000 1.000 4,919 1.000 CLASS CODE RATING FORMULAS BASE RATE=FINAL RATE*EXPOSURE/RATING BASIS Class Premium 5.720 = 5.72 *86005.00/ 100 Addl Factors: Pure Base Rate: 4.00 Base LCM: 1.0000 Exclude Med: Loss Cnst Ovrd: 0 Net Rate: 6.55 Class Min 1,590 =FINAL PREMIUM = 4,919.00 9/7/2021 Audit Fact N/A oRaN Risk MmRgementDMsian REVIEWED & APPROVED BY. - Risk Management Analyst Page 7 Named Insured BACKHAUS DANCE Customer ID Policy Number WC80946 Transaction Type New Business Effective 9/7/2021 Schedule Modification Date 09/02/2021 Name of Insured BACKHAUS DANCE Special Notes DANCE EDUCATION THROUGH A Policy Number WC80946 Client Number Insurance Co Sirius America Ins Co Line Of Business WK Subline Effective Date 09/07/2021 Policy Term 1 Year State(s) CA Trans Type New Business Schedule Modification Risk Characteristic Employees -Selection, Training, Supervision Justification Total Mod Agy/Prod Name Automatic Data Processing Insurance Agency, Inc. Operator JACK SPIVEY Expiration Date 09/07/2022 Credit/Debit 0.91 FORMAL WRITTEN SAFETY TRAINING IN PLACE 0.91 END OF WORKSHEET �oRaN RiskMmRgmerdDMsfan REVIEWED & APPROVED BY. - Risk Management Analyst