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HomeMy WebLinkAboutPROTECTION AMERICA, INC. (4)INSURANCE NOT ON FILE WORK MAY NOT PROCEED CLERK OF COUNCIL DATE: A-2021-080-01 FIRST AMENDMENT TO AGREEMENT WITH PROTECTION AMERICA, INC. JAN 0 6 2022 TO PROVIDE SECURITY SERVICES THIS FIRST AMENDMENT to the above -referenced agreement is entered into on December, 2021, by and between Protection America, Inc., a California 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"). 616,0 C,�le 1�) C��\ � RECITALS A. The parties entered into Agreement No. A-2021-080, dated June 1, 2021, by which Consultant agreed to provide security services for the property located at 1815 Carnegie Avenue, Santa Ana, California 92705, the future site of a City homeless shelter ("Agreement'). B. The parties now wish to: increase the maximum amount of compensation that maybe expended under the Agreement; and, extend the term of the Agreement. The Parties therefore agree: Section 2, Compensation, subsection a, is amended to increase the total not -to -exceed amount by $63,360 for the extended term, such that the new total amount to be expended during the term of this Agreement shall not exceed $158,400. 2. Section 3, Term, is amended to extend the Term of the Agreement through March 31, 2022. This Amendment shall also cover any services provided since December 1, 2021. The Term of the Agreement shall may continue to be extended by a writing executed by the City Manager and City Attorney. 3. Except as modified by this First Amendment, all terms and conditions of said Agreement shall remain in full force and effect. Page 1 of 2 IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to said Agreement on the date and year first written above. ATTEST Daisy Gomez Clerk of the Council APPROVED AS TO FORM Sonia R. Carvalho City Attorney By: Ryan O. Hodge Assistant City Attorney FOR APPROVAL Steven Executive Director Community Development Agency CITY OF SANTA ANA l// Kristine Ridge City Manager CONSULTANT �A�Aw Ahmed Ali Chief Executive Officer Page 2 of 2 Tod Pierson Tori Pierson DaM 20219m1213001D -DJ'DD' ACORO® CERTIFICATE OF LIABILITY INSURANCE DAM(MMIODNYYY) 1 `I 4121 /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 Venture Pacific Insurance Services, Inc. 111 Corporate Drive Suite 200 Ladera Ranch, CA 92694 NAMEACT Tracy Mullins PHONE AM. No. Exth 949 421-3540 FM nL Na: g4g-297 4911 EMAIL oDRESS: TMullins v isrisk.com INSURERS AFFORDING COVERAGE NAIC# INSURER A: Burlington Insurance Company 23620 www.venturepacificinsumnce.com Llc#OD10299 INSURED Protection America, Inc. 21350 Nordhoff St. #104C INSURER B : INSURER C: INSURER D: Chatsworth CA 91311 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: R131437Q 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 INSURANCEJHM ADDL SUER POLICYNUMBER POLICY EFF MMIDD/YYYY1 POLICY EXP (MMIDDlYYYYI LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1Z OCCUR ✓ 398BG02530 4/15/2021 4/15/2022 EACH OCCURRENCE $1000000 DAMA ETO RENTED PREMISES fEa occunence $1 OO 000 ✓ MED EXP (Any one arson) $10 000 Errors S Omissions PERSONAL B ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PE' LOG GENERAL AGGREGATE $2,000,000 PRODUCTS -COMPIOP ADS $2000000 $ OTHER: AUTOMOBILE LIABILITY COMBINEOSINGLE LIMIT Ea..do t $ BODILY INJURY (Parperson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Par assistant ) $ HIRED F I NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE Per accident $ 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIM& ADE DED I I RETENTION$ $ I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YINI IPER I OTH- STATUTE ER E.L. EACH ACCIDENT $ ANYPROPRIETORIPARTNERIEXECUTIVE OFFICEWMEMBEREXCLUDEDT NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory, In NH) If yes, desodbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT I $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Santa Ana, its officers, employees, agents, and representatives are named as additional insured on this policy pursuant to written contract, agreement, or memorandum of understanding. Coverage is primary and non-contributory. 30 Day Notice of Cancellation with 10 Days Notice for Non -Payment of Premium in accordance with the policy provisions. City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-2015 ACORD C(L) ""aolc ""OCJX1O` ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 61314379 21-22 GL W/A1 WOS I Tracy Mullins 1 4/21/2021 3:39:06 PM (PDT) I Page 1 f 4 This car ificate cancels and supersedes ALL previously issued certificates. POLICY NUMBER:39asc02530 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92702 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. 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 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. B. 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: 1. Required by the contract or agreement; or 2. 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. w.Mre ge�toh+ Ih+nEwm6 Nvxw®&rBr. nux Manage„mt am�ai,tiae CG 20 26 04 13 © Insurance Services Office, Inc., 2012 G1314379 1 21 22 cL w/Ax coos I 'Macy Mullins 1 4/21/2021 3:39: 06 PM (eoV I edge z o£ 4 This certificate cancels and supersedes ALL previously issued certificates. Kri:1:iH�rk�:n; COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory 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 CG 20 01 04 13 (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- 0 Insurance Services Office, Inc, 2012 w��.�ton4�R - %u PicsJorc Rek Mar,agertm[ ClmrslNJ< 00 61314379 1 21-22 GL W/AI WOS 1 Tracy Mullins 1 4/21/2021 3:33:.6 PM (POT) i Paqe 3 of 4 This certificate cancels and supersedes ALL previously issued certificates. ADDITIONAL INSURED ENDORSEMENT Insurance Company Burlington Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # 398BG02530 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers, employees, agents and representative are named as additional insureds (`additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective 4/21/2021 this endorsement form as part of Policy # 398BG02530 Issued to Protection America, Inc. Name Insured Countersigned by xsktn�.ge,wlonewn I�VIE`Pm 6 /wPRw®Br. rs�xntnag�„�.namviaae :` Page 20 of 20 61314379 � 21-22 GL W/A1 WO5 I Tiacy Mullins 14/21/2021 3:39:06 PM PDT) I Page 4 of 4 This car ificate cancels and supersedes ALL previously issued certificates. YRUIE24 OP ID:M DATE 1o/06/2021osno2l A`iR0 CERTIFICATE OF LIABILITY INSURANCE 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 877-242.9600 Central Insurance Agency, Inc. 93 East Main Street Smithtown, NY 11787 CONTACT Central Insurance Agency, Inc PHONE g77.242-9600 FAX 877-243-8995 AIC, No, Eat : A/C, No E-MAI George Gavaris INSUREI AFFORDING COVERAGE NAICIt INSURER A: NSUREO, rotectlon America Inc. INSURER B INSURER C PPO#120313 21350 Nordhoff St # 104C Chatsworth, CA 91311 United Financial Casualty INSURER D: y 1177D INSURER E NSURER F : COVERAGES CERTIFICATE NUMBER- REvlglnN 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 TYPE OF INSURANCE OOL UBR POLICY NUMBER POLICY EFF POLICY UP LIMITS COMMERCIALGENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED MED EXPArr one erson PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY � JEC'T LOC OTHER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGO $ D AUTOMOBILE X LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY �OP X X 041698620 10/0812021 04108/2022 COMBINED SINGLE LIMIT acdoem 1,000,000 BODILY INJURY Per oer ..n I $ BODILY INJURY Peraccident OPEeMAGE $ UMBRELLA LIMB EXCESS LIAR HOCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERAXECUTIVE ❑ pFFIM ICEREMBER EXCLUDED' ,Mandatory In NH) 1 yes, describe under DESCRIPTION OF OPERATIONS below I STATUTE I OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE E.L. DISEASE -POLICY LIMIT IS DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached if more space is required) City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 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 Xti N^"8°"Mar Al VKu LD (m IOIUJ) U 1988-2015 ACORD CC The ACORD name and logo are registered marks of ACORD PRU I L24 DATE41211221/2I021 A`oFro CERTIFICATE OF LIABILITY INSURANCE 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 877-242.9600 Central Insurance Agency, Inc. 93 East Main StreetINC. Smithtown, NY 11787 CONTNAMEACT Central Insurance Agency, Inc PHONE B77-242.9600 FAX g77.243-8995 No, Est): NC, No): E-MAIL 55 George Gavaris INSURJER(Sl AFFORDING COVERAGE NNC If INSURERA: Employers Assurance Company 25402 NSURED P°3merica Inc. PO#12a31 21350Q NOrdhoff St. 91041 Chatsworth, CA INSURER B: Infinity Select Insurance Company wsuRERc: ty P Y 20260 INSURER D: NSURERE: 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 TYPE OF INSURANCE DOL UBR POLICY NUMBER POLICY EFF I- POLICY UP HOWDDYNY11 LIMITS COMMERCUILGENERAL LIABILITY CLAIMS -MADE ❑OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED 8 MED UP An one arson PERSONAL S ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO - JECT LOG GENERAL AGGREGATE PRODUCTS-COMP/OP AGG $ OTHER OTHER: C AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUU�TTNOpSSVW�NEE X X 504610110722001 10/08/2020 10108/2021 COMBINED SINGLE LIMIT IEa accident) $ 1,000,000 X BODILY INJURY Per arson S BODILY INJURY Per accWent S Pere ER n AMAGE $ AUTOS ONLY AUTOS O $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERJUECUTIVE Y N 1MardERNEMBER EXCLUDED' Y ry in NH) If yes, describe under DESCRIPTIONOFOPERATIONSbel. NIA X EIG2562084-02 11 /06/2020 11/0612021 OTH- X PERTUTE E.L. EACH ACCIDENT 11000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE -POUCY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES )ACORD tat, Additional Remarks Schedule, may be attached if more space is required) The City of Santa Ana, its officers, employees, agents, and representatives are named as additional insured under the Commercial Auto Liability on this policy pursuant to written contract, agreement, or memorandum of understanding. Waiver of subrogation applies to the Workers Compensation per the attached endorsement. City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92702 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 REPRESENTATIVE8vnail°A p7�' REVIBv®6�n/wNtOVDJ Br. �� L I cif E_ %u YiCSJOx ACORD 25 (2015103) ©1988.2015 ACORD CC-�- The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description With respect to all employees subject to the workers' compensation laws of the state of California, any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. This policy is subject to a minimum charge of $250 for the issuance of waivers of subrogation 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.) This endorsement, effective 11/06/2020 Policy No. EIG 2562084 02 at 12:01 AM standard time, forms a part of Of the EMPLOYERS ASSURANCE CO. Carrier Code 00919 Issued to PROTECTION AMERICA INC Endorsement No. Premium j ^ n Countersigned at on By: I " Authorize �^6Mrxw®ev° ' %u puuas WC 04 03 06 4�a�xxu„ase„a„om�iae� (Ed. 4-84) © 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights re_ . _ GuardPro COMMERCIAL GENERAL LIABILITY COVERAGE WRITTEN ON: Occurrence Form Insured: Protection America Inc. Insurer: Burlington Insurance Company Policy Number: 398BG02530 COVERAGE LIMITS LIABILITY: General Aggregate Limit $2,000,000 Products/Completed Operations Aggregate Limit Included Personal/Advertising Injury Limit $1,000,000 Each Occurrence $1,000,000 Fire Damage Limit - Any One Fire $100,000 Medical Expense Limit- Any One Person $10,000 Deductible Per Occurrence: $5,000 Premium Basis: Based on Annual Estimated Guard Payroll: $800,000 Initial X AA This General Liability policy is auditable: Audit will occur 30 to 60 days after the expiration. Claims & Loss History have no bearing on the audit process. Initial ) is b, �MOYgpIIOQ�AI 00 `4 1�41EWm6/1PPR�TI®BV: - %au �icuar Minimum Earned Premium: Premium Subject to Audit: Premium Payment Terms: Premium Payment is due: ENDORSEMENTS/EXCLUSIONS: 25% of Minimum Premium if cancelled within the 1 st 90 days, otherwise Pro Rata (except for that portion of the premium shown in the policy as fully earned) Yes Premium is adjustable (with the exception of Flat Premium items) Based on a composite rate of: 93.7500 Per $1000 Payroll. Estimated Payroll: $ 800,000 Applies to: Exposure is subject to audit and will be calculated in accordance with ISO Commercial Lines Manual Rule 24. Basis of Premium. If the actual exposure is greater than the estimated exposure the insured will owe additional premium, unless otherwise specified in this quote. Annual Pay Down Payment: 100% Upon receipt of the premium accounting statement BG-G-004 03 17 Exclusion - Lead Substance BG-G-005 03 17 Exclusion - Punitive Damages BG-G-007 03 17 Exclusion - Asbestos, Silica BG-G-119 03 17 Definition - Employee BG-G-345 06 19 Condo or Tract Home Exclusion BG-G-446-ST 03 17 Amendment - Insuring Agreement CG 00 01 04 13 General Liability Coverage Form CG 20 01 04 13 Primary And Noncontributory CG 20 26 04 13 Addl Insured - Designated (Blanket Wording Applies) CG 21 32 05 09 Communicable Disease Exclusion CG 21 36 03 05 Exclusion -- New Entities CG 21 47 12 07 Employment Practices Exclusion CG 21 54 01 96 Exclusion - Designated Operations ` CG 21 67 12 04 Fungi or Bacteria Exclusion CG 21 86 12 04 Exclusion - EIFS w.�kn�.q�RiokmR z ,,Y.,'. %si f�icwee R6k M1LrugmvrctlmolMde CG 22 29 11 85 Exclusion - Property Entrusted CG 24 04 05 09 Waiver Of Rights Of Recovery (Blanket Wording Applies) D-2 01 20 California Surplus Lines Notice GSG-G-021 03 17 Exclusion - Intellectual Properties IFG-G-0002-DL 05 03 General Liability Declarations IFG-G-0052 03 17 Deductible Liability Insurance IFG-G-0086 04 19 Total Pollution Exclusion IFG-G-0093 03 17 Exclusion - Cross Suits NI v NI IFG-G-0105 03 17 Exclusion - Professional Liability IFG-G-0194 01 20 Excl-Confd Info & Comp Syst Liab IFG-G-0201 03 17 Exclusion - Aircraft, Auto Or Watercraft IFG-G-0240 03 17 Exclusion - Canines, Firearms, Or Incapacitating Devices IFG-1-0002 06 20 Policy Cover Page IFG-1-0101 03 18 Common Policy Declarations IFG-1-0140 10 02 Supplemental Schedule of Locations IFG-1-0150 03 03 Listing of Forms and Endts IFG-1-0152 09 09 Composite Rate Endorsement IFG-1-0155 11 00 Amendment - Cancellation Notice IFG-1-0168 03 17 Minimum Premium IFG-1-0408 01 17 CA Service of Suit Amendment IL 00 17 11 98 Common Policy Conditions IL 00 21 09 08 Nuclear Energy Liability Exclusion IL P 001 01 04 OFAC - Notice to Policyholder *More details applicable to the exclusions and/or limitations asterisked above are provided below CG 21 54 01 96 - All locations where you perform or have performed work that is or was to be insured under a consolidated (wrap-up) insurance program as described below. Snecial Disclosure on Terrorism ToApplicant: Under the Terrorism Risk Insurance Act, as amended (TRIA), the applicant has the right to purchase Terrorism coverage. Additional premium would be 5 % of the premium shown on Page 1 or $250, whichever is greater. The premium for Terrorism is flat, fully earned. Per Terrorism Risk Insurance Act, as amended (TRIA), the United States Government generally reimburses a share of losses caused by certified acts of terrorism. THIS IS TO ADVISE THE APPLICANT THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS' LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURER; R�kM..g..dMe. YOUR COVERAGE MAY BE REDUCED. / ���; �- ft`^E"'Eo s A� er Rek Mana9mmtOmralNtle