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HomeMy WebLinkAboutBEGINNERS EDGE SPORTS TRAINING, LLC (3)INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES N-2024-130-01A MAYOR CITY CLi Valerie Amezcua DATE' APR MAYOR PRO TEM 0 9 2025 r^i Y..y Thai Viet Phan COUNCILMEMBERS Phil Bacerra,', ip Johnathan Ryan Hernandez Jessie Lopez David Penaloza Benjamin Vazquez CITY OF SANTA ANA PARKS, RECREATION, & COMMUNITY �� QeyUBJ SERVICES AGENCY 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 www.santa-ana.oro February 20, 2025 Beginners Edge Sports Training Attn: Mitchell Goldberg 24654 N. Lake Pleasant Pkwy. Suite 103-405 Peoria, AZ 85383 Re: Extension to Agreement (#N-2024-130) to Provide Multi -Sport Programming CITY MANAGER Alvaro Nunez CITY ATTORNEY Sonia R. Carvalho CITY CLERK Jennifer L. Hall Pursuant to Section 3 ("Term") of the above referenced Agreement, entered into between Beginners Edge Sports Training, LLC and the City of Santa Ana, dated March 21, 2024, as amended, the parties hereby agree to extend the term of the Agreement through March 31, 2026. All other terms and conditions of the Agreement, as amended, remain unchanged and in full force and effect. Sincerely, Hawk Scott Executive Director Parks, Recreation, & Community Services Agency APPROVED AS TO FORM / Jonathan T. Martinez Assistant City Attorney BEGINNERS EDGE SPORTS TRAINING Mitchell Goldberg President SANTA ANA CITY COUNCIL Valerie Amezcua Thai Viet Phan Benjamin Vazquez Jessie Lopez Phil Bacerra Johnathan Ryan Hemandez David Penaloza Mayor Mayor Pro Tem, Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 vamezcua(u)santa-ana.orq tohan(r _sama-ana.oto bvazouez(dsanta-ana.om iessielooezfaDsanla-ana.om obacerra(dsanta-ana.orq trvanhemandez(a)santa-ana.ora doenaloza(7a santa-ana oro SOCC-91 r A�oao CERTIFICATE OF LIABILITY INSURANCES"�`-"°°"Y" 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 WANED, 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). PPODUCER CONTACT RIPS Bollinngger Sports & Leisure PO Box 1322 PHONE FA• 1A'C, NR. E,:1 IAA. Net Morristown. NJ 07M E-MAIL DavidCampanelb MS VAER(Sl AFFORDING COVERAGE NAICS NSUREP A 'Markel Insurance Company 8970 NSUPED INSURER e B�.Lk�i— rA ESO. 3-nA'Yalnlrq ±SiLA Ndit LAX• PW—d Part At 9nSf3 NSUPER D INSURER E NSUPER F rnVFAAl:FC rrcTscrr aTC EIIIBAOCO- 7r.15 IS TO CERTIFY THAT TIHE POLICIES OF INSURANCE LI^TEL' BELOW HAVE BEEN iS ED TO THE INSURED PMIED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANCING ANY REOLAREMENT, TERM OR CONITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO Wl4CH TH S CERTIFICATE MAY BE 1S.iUm OR MAY PERTAIN. THE IWSURFNCE AFFORDED BY THE POLICIES DESCRIBED HERE;N IS SUBJECT TO ALL THE TERMS. EXCLUSION AND CONDITIONS OF "-UCH POLICIES UMTS SHOWN MAY HATE BEEN REDUCED BY PAID CIAING NSR TYPE OF INSURANCE AIM SUSFPOLICY NUMBER POU Y EFF POLICY EAP Lri Ti A X COMMERCIAL GENERAL LIABILITY C�A?JC:�4ti=_ O vccLR X BSB±AHBs'Bua 11105/2024 1110512025 EA.:.�r.�:UFRCN.:E 1,000,000 f REN Dq 17STr_--D 1 100,000 A X Incl Participants SIMILL:f2MILL 111051202411/0512025 =•n- _ o s 5,000 X Sexual AbuselMol =1=- r,.•�s�:•N;-^. s 1,000,000 =vL A3GRE _!'� =Lo= =e= =Er.f.•L ♦a3PcaATE 1 3,000,000 1 _THER AUTOMOBILE LIABILm -1:.. An AUTO e_.0 _. •. _ _ ALT03 ONLY •U'�C - __ r-'.RED AL:OO ONLY AU '_C ONLI ) UYB RELLA LUIB OCCLR c=LCF=•.-- 1-r. v,E-1— - - - S E•CESS LIAR:LA,rfC.1.lACE CEO =-=, T'-..I- I WORKERS COMPENSATION- ANOEYPLOYERS'LIABILn'f 1W FP.CRq-CvcAP.T.EP.'EYE:vT'.E ❑ ICEc.r1ELEER EXCLUDE=_ Y A _ EA:•+1•-ICE- �• f - - C=-E.EA E_.•_,:•E f IManaatwy In NN) r,r ar_mce waer _ :EtiE•P^J_Gr :N� S LE- _.e,;=*•n,I _ = r_EP.•- Win: [e.• -- - A Accident Insurance �_AHo±s±:a-r. 11:05'202i I1!05i2025 Med Max 25.000 Full E�rcess Ded. 500 DESCRIPTION OF OPERATIC"! LOCATIONS :VEHICLES (ACORD 101. Ad.dl al RnnM6R SanWNM mo DR ASIaaPN B mo1R I P ut i n,,"d) Certificate holder is included as an additional insured. Coverage is provided under these policies only for sponsoredlsupervised activities of the named insured for which a premium has been paid. CFRTIFICATF "m nFR reures I ETlnU COSANTA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Santa Ana Parks. THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN and Community ACCORDANCE'WITH THE POLICY PROVISIONSRecreation Services Agency AUTHCR'SEO REPP.ESEN-A 1825 W Civic Center Dr Santa Ana, CA 92703 ACORD 25 (2016103) D 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD APPROVED By Tu Tran Nguyen at 3:31 pm, Mar 12, 2025 Digitally signed Tu Tran by Tu Tran Nguyen Nguyen ° 25:03.,2 15:31:36-07'00' Auto Liability (Non -Use Agreement) Date 2/21 /2025 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 Re: Auto Insurance Requirement Dear City of Santa Ana Risk Management Division: Beginners Edge Sports Training. has intent to enter into an agreement with the City of Santa Ana. Throughout the course of this agreement, attests to the following: Beginners Edge Sports Training will not use/drive any vehicle during the course and scope of the services provided in the agreement/contract. 2_ Beginners Edge Sports Training will not use any owned/rented/leased vehicles during thecourse and scope of the services provided in the agreement/contract. 3. Beginners Edge Sports Training consultants/independent contractors/employees utilize their personal vehicles/non-company owned, borrowed, or rented/leased vehicles for transportation to and from work and if applicable carry their own automobile insurance. By signing below, I, Mitchell Goldberg attest that I possess the legal authority to enter into an agreement with the City of Santa Ana as well as the legal authority to attest to the statements above. If at any time it is found that is not adhering to any/all statements in this document and has not provided the minimum Auto liability insurance coverage of $ I million per occurrence, the contract will be considered null and void andthe company will be held fully liable for any and all damages. Signature: 7ee&/U& � ¢ Name: Mitchell GOld6erg U Job Title: Owner Company Name: Beginners Edge Sports Training, LLC Contact Phone: 682-348-1600 Email Address: mitch@best-sports-usa.com POLICY NUMBER: 8502AH011930-4 COMMERCIAL GENERAL LIABILITY CG20260413 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 20 Civic Center Plaza Santa Ana CA, 92702 City of Santa Ana, its City Council, officers, officials, employees, agents, and volunteers But only as required by contract with the named insured to provide primary insurance. The insurance provided by this endorsement is primary. Other insurance afforded to the above named additional insured shall apply as excess of, and does not contribute with, the insurance provided by this endorsement, 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 omis- sions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional in- sured 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 in- surance afforded to such additional insured will not be broader than that which you are re- quired by the contract or agreement to pro- vide 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 Insur- ance shown in the Declarations; whichever is less. This endorsement shall not increase the applica- ble Limits of Insurance shown in the Declarations. CG 20 26 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 8502AH011930-4 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: City of Santa Ana 20 Civic Center Plaza Santa Ana CA, 92702 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Sec- tion IV- Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 1 A� RL P CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1 /27/2026 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 Phone: (804)354-9020 Fax: (866)352-1401 The Monument Sports Group CONTACT Lori Isringhausen NAME: A CC No Ext : (804)256-8335, 301 FAX No): AD E-MRESS: Lori@monumentsports.com 1365 Overbrook Road INSURER(S) AFFORDING COVERAGE NAIC # Suite # 1 INSURERA: LIO Insurance Company 020918 Richmond, Virginia23220 INSURED INSURER B : INSURER C : Beginners Edge Sports Training LLC 29634 North Lake Pleasant Parkway Suite 103-405 INSURER D : Peoria, AZ 85383 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:5043 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 POLICY EXP MM/DD/YYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE YI OCCUR LIO1100084183-00 11/5/2025 11/5/2026 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 Incl Participants Y MED EXP (Any one person) $ 5' 000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 3,000,000 POLICY ❑ PRO ❑ JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 Abuse/Mol $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICE R/M EMBER EXCLUDED? ❑ N/A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Participant Accident LIO1100084189-00 11/5/2025 11/5/2026 MedMex: 25,000 $500 Ded DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) ity of Santa Ana, its City Council, officers, officials, employees, agents, and volunteers. are included as additional insured per form CG 001 01 04 13. aiver of Subrogation provided if required by written contract per form CC 20 01 04 13. his certificate is issued in reference to the named insureds operations and subject to the terms, conditions, and the provisions of the policies. CERTIFICATE HOLDER CANCELLATION APPROVED By Tu Tran Nguyen at 11:43 am, Mar, 18, 2026 Holder's Nature of Interest : Additional Insured SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana: Attn: Parks, Recreation, and Community THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Services Agency 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana, CA 92701 _61� @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: L101100084183-00 COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): City of Santa Ana, its City Council, officers, officials, employees, agents, and volunteers. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: 1_10 1100084183-00 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 1d:1R24kiIBiel :&941414kikgo]:/_1ki Eel *'1111111:I:1aellE 'A"A-119:1:7:F_1I7k907_10411111J1111M 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 SantaAna ,its City Council, its officers, employees ,agents ,and ,volunteers ATTN: Parks, Recreation,and Community Services Agency 20 Civic Center Plaza Santa Ana ,CA 92701 I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I 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 omis- sions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional in- sured 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 in- surance afforded to such additional insured will not be broader than that which you are re- quired by the contract or agreement to pro- vide 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 Insur- ance shown in the Declarations; whichever is less. This endorsement shall not increase the applica- ble Limits of Insurance shown in the Declarations. CG 20 26 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: L101100084183-00 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 Con- (2) You have agreed in writing in a contract or dition and supersedes any provision to the con- agreement that this insurance would be trary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy pro- vided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 1 T❑E ❑ARTFORD B❑SI❑ESS SER❑ICE CE❑TER THE 3600 WISEMA❑ BL❑D HARTFORD SA❑ A❑TO❑IO TO ❑82111 City of Santa Ana par-s, Recreation, and Comm-nity 20 C1AC CE-TER PC SA -TA A -A CA 92-01-40-8 Account Information: Policy Holder Details : Beginners Edge Sports Training FeOrEiary 19, 2026 L3 Contact Us Need Help? C:18t online or call ; at -866i❑46iD-8::30. Weil Dare Monday - Friday. Enclosed please find a Certificate Of Instance for t-le a::050 referenced Policy-- older. Please contact E8 if yoi❑ 08:0 any ❑�stions or concerns. Sincerely, Yoh ❑artford Ser:Jce Team WLTR005 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/19/2026 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 be endorsed. If SUBROGATIONIS 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: I-S-RA-CETRA- SERACES/PAC PHONE 8-282-0934 (A/C, No, Ext): FAX �-- 8-1--13- (A/C, No): -62-1042 4-1-C-L-ER RD S-ITE 206 ROC -ESTER -Y 14622 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: -artford Fire and Its P-C Affiliates 00914 INSURED INSURER B : BEGI--ERS EDGE SPORTS TRAI-I-G INSURERC: -432 E TIERRA B-E-A L- INSURER D : SCOTTSDALE A- 8260-1646 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TAS IS TO CERTIFY T-AT T-E POLICIES OF I-S-RA-CE LISTED BELOW -A-E BEE- ISS-ED TO T-E 18-RED -AMED ABO-E FOR T-E POLICY PERIOD I-DICATED.-OTVVIT-STA-DIG A-Y RE--IREME-T, TERM OR CO-DITIO- OF A-Y CO -TRACT OR OT-ER DOC-ME-T WIT- RESPECT TO W-IC_ TAS CERTIFICATE MAY BE ISS-ED OR MAY PERTAI-, T-E I-S-RA-CE AFFORDED BY T-E POLICIES DESCRIBED -EREI- IS S-B:ECT TO ALL T-E TERMS, E-CL-SIO-S A-D CO-DITIO-S OF S-C_ POLICIES. LIMITS SCOW- MAY -A-E BEE- RED-CED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YYYY MM/DD/YY COMMERCIAL GEOERAL LIABILITY EACD OCCORREDCE CLAIMS -MADE ❑ OCC ❑ R DAMAGE TO REOTED PREMISES FEa occOrrence0 MED EDP !Any one person❑ PERS05AL 0 AD'�-� I_=RY GEDL AGGREGATE LIMIT APPLIES PER❑ GEOERAL AGGREGATE POLICY ❑ ACT ❑ LOC PROD'OCTS-COMP/OPAGG OTOER❑ AUTOMOBILE LIABILITY COMBIOED SIOGLE LIMIT [Ea accidental BODILY IOJ:1RY [Per person — AOYADTO ALL OWDED SCOEDOLED AOTOS AOTOS BODILY IO!>=7RY !Ber accident AIRED ❑OO-OWOED PROPERTY DAMAGE AOTOS AOTOS Per accident❑ UMBRELLA LIAB CCOR EAC❑ OCCORREOCE EXCESS LIAB LAIMS- OADE AGGREGATE DED RETEDTIO❑ — WORKERS COMPENSATION — PER OTE- AND EMPLOYERS' LIABILITY STATOTE ER E.L. EAC❑ ACCIDEOT -1,000,000 AOY Y/N A PROPRIETOR/PARTOER/EOECOTIOE OFFICER/MEMBER EOCLDDED❑ N/A — — -6 WEG B-3-P- 11/04/202- 11/04/2026 E.L. DISEASE -EA EMPLOYEE -1,000,000 (Mandatory in NH) If yes, descriO= ❑ider E.L. DISEASE - POLICY LIMIT -1,000,000 DESCRIPTIOO OF OPERATIOnS Oelow DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) T-Ose _s-al tote Ins -reds Operations. Blanet Waier of S-rogation applies in fa -or of t e Certificate -older per t-e Waier of O-r RigA to Recoer from Ot-ers Endorsement WC040306, attacred to Lis policy. State o-is performed in -A- Payroll for -o-to s-pport waier :Wor-Comp-3-0 CERTIFICATE HOLDER CANCELLATION City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED pare, Recreation, and Comm-nity BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 20 CI -IC CE-TER PL- IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE SA -TA A -A CA 92-01-40-8 1 6eC � © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD WorEjars E:Compensation and Employers E:Lia E:Jlity Business Insurance Policy Tuc 1 "G HARTFORD Form WC 99 00 02 (03/14) Page 1 of 1 policy ProJsions11WC000000C❑ INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: SEE ATTAC❑ED E❑DORSEME❑T NCCI Company Number: 20621 Company Code: 9 Suffix LARS RENEWAL POLICY NUMBER: 6 WEG B❑3❑P❑ Previous Policy Number: 1:6 WEG A116AM❑ 1. Named Insured and Mailing Address: BEGI❑❑ERS EDGE SPORTS TRAI❑I❑G o., Street, Town, State, ❑ip Code- ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 FEIN Number: 26-2932264 State Identification Number(s): Refer to t❑e E❑TE❑SIO❑ OF TOE I❑FORMATIO❑ PAGE ❑ WC99036❑. The Named Insured is: LLC Business of Named Insured: Fitness and Recreational Sports Centers Other workplaces not shown above: See Endorsement - WC990366 2. Policy Period: From 11 /04/2 ❑ To 11 /04/26 A❑ ❑ ❑AL 12101 a.m., Standard time at tie insored® mailing address. Producer's Name: I❑S❑RA❑CETRA❑ SER❑ICES/PAC 4❑1 ❑C❑L❑ER RD S❑ITE 206 ROC❑ESTER ❑Y 14622 Producer's Code: ❑62❑1042 Issuing Office: T❑E ❑ARTFORD B❑SI❑ESS SER❑ICE CE❑TER 3600 WISEMA❑ BL❑D SA❑ A❑TO❑IO T❑ ❑82111 18❑❑❑28 E� 1316 Total Estimated Annual Premium: 11q❑83 Deposit Premium: Policy Minimum Premium: 600 CA 7ncl❑des Increased Limit Min. Prem.- Audit Period: A❑❑❑AL Installment Term: Tie policy is not ❑ending -iless co-itersigned ❑y oEir aEtEori-ed representati-e. Co-itersigned ❑y AAEOri❑ed Representati::e 11 /04/2 ❑ Date Form WC 00 00 01 A (1) Printed in D.S.A. Page 1 :Contin❑ed on neEt page[] Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 INFORMATION PAGE (Continued) Policy Number: 6 WEG B❑3❑P❑ 3. A. Workers Compensation Insurance: Part one of t❑e policy applies to tie Wor ers Compensation Law of tie states listed ere❑T❑ SEE E❑DORSEME❑T - WC 99 03 6❑ B. Employers Liability Insurance: Part Two of t❑e policy applies to wor❑in eac❑ state listed in Item 3.A. T❑e limits of o-r liaJlity Ender 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 TJee of t❑e policy applies to t❑e states, if any , listed ere❑ ALL STATES E❑CEPT ❑ORT❑ DA❑OTA, 0❑10, WAS11111GTO❑, WYOMI❑G, ❑.S.TERRITORIES A❑D STATES DESIG❑ATED I❑ ITEM 3.A. OF T❑E 111FORMATIO❑ PAGE. D. This policy includes these endorsements and schedule: SEE E❑DORSEME❑T-WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premi-n Premi-n Disco-nt E-pense Constant Terrorism Ris❑Instance Program Rea❑t❑briEotion Act Disclos-re Endorsement Catastrope COt❑er T❑an Certified Acts Of Terrorism[] Estimated Ann❑al PremiErn ❑efore Siic❑arges❑ Total Estimated S❑c❑arges FSee to attac❑ed Sc❑edde[SEof Operations for Location and State Le el Premi-n Information Total Estimated Annual Premium: ❑y 83 Deposit Premium: Policy Minimum Premium: ❑600 CA [Encl❑des Increased Limit Min. Prem.- Interstate/intrastate Identification Number: Refer to Sc❑edde of Operations Labor Contractors Policy Number: ❑AICS 111113940 SIC: ❑991 Form WC 00 00 01 A (1) Printed in O.S.A. Page 2 Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 Effecti❑e Eolir is t0e same as stated on tie Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Item 1 of tie Information Page is completed to incl❑de otier wor-places of t❑e named insEired❑ ❑432 E TIERRA B❑E❑A L❑, SCOTTSDALE, All 8E260 ❑900 Balcones Dr., A❑stin, TO ❑81131 8300 SA❑TA MO❑ICA BL❑D, WEST ❑OLLYWOOD, CA 90069-6216 O SPECIFIC LOCATIO❑ I❑ STATE OF COSTA MESA, CA 92626 Form WC 99 03 66 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Item 3.A. of t❑e Information Page is completed to incl❑de t❑e following states❑ TeEos TO California CA AriEona All Form WC 99 03 67 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 EXTENSION OF THE INFORMATION PAGE - ITEM 3.1) - ENDORSEMENTS Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e CbC7 is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Item 3.D. of t❑e Information Page is completed to incl❑de t❑e following endorsements[] G-4119-0 POLICY❑OLDER ❑OTICE-PAYROLL BILLI❑G P11049901 ❑ POLICY❑OLDER ❑OTICE - YO❑R RIG❑T TO RATI❑G A❑D DI❑IDE❑D I❑FORMATIO❑ WC000000C WOR❑ERS COMPE❑SATIO❑ A❑D EMPLOYERS LIABILITY I❑S❑RA❑CE POLICY WC000001A.1 111FORMATIO❑ PAGE WC000001A.2 I❑FORMATIO❑ PAGE WC000313 WAI❑ER OF O❑R RIG❑T TO RECO❑ER FROM OT❑ERS E❑DORSEME❑T WC000403 E❑PERIE❑CE RATI❑G MODIFICATIO❑ FACTOR E❑DORSEME❑T WC000406 Premi-n Disco—nt Endorsement WC000414A 90-DAY REPORTI❑G RE❑❑IREME❑T- ❑OTIFICATIO❑ OF C❑A❑GE I❑ OW❑ERS❑IP E❑DORSEME❑T WC000419A PART FI❑E - PREMI❑M AME❑DATORY E❑DORSEME❑T WC000421 F CATASTROP❑E COT❑ER TOAD CERTIFIED ACTS OF TERRORISM ❑PREMI❑M E❑DORSEME❑T WC000422C TERRORISM RIS❑ I❑S❑RA❑CE PROGRAM REA❑T❑ORI❑ATIO❑ ACT DISCLOS❑RE E❑DORSEME❑T WC000424 A❑DIT ❑O❑COMPLIA❑CE C❑ARGE E❑DORSEME❑T WCO20401C ARI❑O❑AALCO❑OLA❑D DR❑G-FREE WOR❑PLACE PREMI❑M CREDIT E❑DORSEME❑T WCO20601C Ari❑bna Cancellation and ❑onrenewal Endorsement WCO20603A ARI❑O❑A AME❑DATORY E❑DORSEME❑T WC040301 BB POLICY AME❑DATORY E❑DORSEME❑T - CALIFOR❑IA Form WC 99 03 68 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 EXTENSION OF THE INFORMATION PAGE - ITEM 3.1) - ENDORSEMENTS Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Item 3.D. of t❑e Information Page is completed to incl❑de t❑e following endorsements[] WC040306 WAI _ER OF O❑R RIG❑T TO RECO❑ER FROM OT❑ERS E❑DORSEME❑T - CALI FOR❑IA WC040360B EMPLOYERS LIABILITY CO❑ERAGE AME❑DATORY E❑DORSEME❑T - CALIFOR❑IA WC040421 OPTIO❑AL PREMI❑M 111CREASE E❑DORSEME❑T - CALIFOR❑IA WC040601 B CALIFOR❑IA CA❑CELATIO❑ E❑DORSEME❑T WC420301L TE-AS AME❑DATORY E❑DORSEME❑T WC11❑0011 D Employees Claim for WorEors compensation Benefits WC❑E0022A ❑OTICE TO WOR❑ERSCCOMPE❑SATIO❑ POLICY❑OLDERS I❑ TEAS LETTER WC88040011 ❑otice to Employees - In❑ries CaCised By Wor❑ TITLE I ❑ SPA❑IS❑❑ WC880401 ❑ ❑otice to Employees - In❑ries CaE8ed By Wor❑ WC990001 ❑ Signat❑re/Copyrig::t WC990002 WOR❑ERS-COMPE❑SATIO❑ A❑D EMPLOYERSIIABILITY B❑SI❑ESS I❑S❑RA❑CE POLICY WC99000❑ SC❑ED❑LE OF OPERATIO❑S WC990302B WOR❑ERS COMPE❑SATIO❑ BROAD FORM E❑DORSEME❑T WC9903-813 AME❑DME❑T TO WOR❑ERS COMPE❑SATIO❑ BROAD FORM E❑DORSEME❑T - EMPLOYERS LIABILITY STOP GAP CO❑ERAGE WC990366 E❑TE❑SIO❑ OF T❑E I❑FORMATIO❑ PAGE - ITEM 1 - OT❑ER WOR❑PLACES WC9903611 E❑TE❑SIO❑ OF T❑E 111FORMATIO11 PAGE - ITEM 3.A - STATES CO❑ERED WC990368 E❑TE❑SIO❑ OF T❑E 111FORMATIO11 PAGE - ITEM 3.D. - E❑DORSEME❑TS Form WC 99 03 68 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 EXTENSION OF THE INFORMATION PAGE - ITEM 3.1) - ENDORSEMENTS Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Item 3.D. of t❑e Information Page is completed to incl❑de t❑e following endorsements[] WC9903111A ARI❑O❑A CO❑❑TERSIG❑AT❑IRE E❑CL❑SIO❑ E❑DORSEME❑T WC99031111 CALIFOR❑IA 111STALLME11T FEE DISCLOS❑RE E❑DORSEME❑T WC990689 GOODS A❑D SER❑ICES E❑DORSEME❑T WC990694 GOODS A❑D SER❑ICES E❑DORSEME❑T Form WC 99 03 68 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 f7 POLICY INSURER LIST BY JURISDICTION INSURER NAIC JURISDICTION ❑artford Cas-aIty Ins❑-ance Company 29424 CA O❑E ❑ARTFORD PLA❑A ❑ARTFORD CT 061 ❑❑ ❑artford Instance Company of t❑e SoEtEoast 38261 All O❑E ❑ARTFORD PLA❑A ❑ARTFORD CT 061 ❑❑ ❑artford Ins❑rance Company of Illinois 38288 T❑ O❑E ❑ARTFORD PLA❑A ❑ARTFORD CT 061 ❑❑ TOE CO❑ERAGE PRO❑IDED I❑ EAC❑ mRISDICTIO❑ IS WIT❑ RESPECT TO TOE LOCATIO❑S OF TEE ❑AMED I❑S❑RED I❑ T❑AT mRISDICTIO❑ I❑ ACCORDA❑CE WIT❑ TOE WOR❑ERS❑COMPE❑SATIO❑ LAW OF T❑AT mRISDICTIO❑. AS ❑SED I❑ T❑IS POLICY, ICOMPA❑Y4 IWE4 111S❑A❑D CO❑RS❑MEA❑ T❑E MEMBER I❑S❑RA❑CE COMPA❑IES OF T❑E ❑ARTFORD I❑S❑RA❑CE GRO❑P COLLECTI❑ELY PRO❑IDI❑G T❑IS I❑S❑RA❑CE. ❑otEJng ❑erein, contained s❑all ❑e ❑eld to Cary, wai❑e, alter or eEtend any of t❑e terms, conditions, agreements or information of tie policy, ot❑er t❑an as ❑erein stated. Form WC 66 04 40 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 SCHEDULE OF OPERATIONS T❑is Sc❑edde of Operations forms a part of t❑e policy effecti-e on t❑e inception date of tie policy _nless anot❑er date is indicated ❑elow❑ INSURER: ❑ARTFORD I❑S❑RA❑CE COMPA❑Y OF T❑E SO❑T❑EAST Company Code: ❑ Policy Number: ❑6 WEG B❑3❑P❑ Schedule Number: 01-02-01 Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Location Address of operations covered by this schedule: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 FEIN: 26-2932264 ❑AICS 11❑13940 SIC❑❑991 ❑O. OF EMPL 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 9063 306,811.00 0.300000 920 ❑EALT OR E❑ERCISE I❑STIT❑TE ❑ CLERICAL Total State Summary Total Class Premi-n 920 Wai-er of S❑rogation 2 0 Emp lia-increased limits 0.011000 10 Total Estimated Ann -al Standard PremiErn 1,180 Terrorism Ris❑Ins-rance Program ReaEt❑briE:ition Act 306,811.00 0.010000 31 Disclos-re Endorsement Catastrop❑e Cot❑er t❑an certified acts of terrorism- 306,811.00 0.010000 31 Total Estimated Ann❑al Premi-n 1,242 Co-ntersigned -y A t❑ori-ed Representati e Form WC 99 00 05 d ❑Printed in ❑.S.A. Process Date: 11/04/20 Policy Expiration Date: 11/04/26 SCHEDULE OF OPERATIONS T❑is Sc❑edde of Operations forms a part of t❑e policy effecti-e on t❑e inception date of tie policy -nless anot❑er date is indicated ❑elow❑ INSURER: ❑ARTFORD CAS❑ALTY I❑S❑RA❑CE COMPA❑Y Company Code: 3 Policy Number: ❑6 WEG B❑3❑P❑ Schedule Number: 01-04-03 Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Location Address of operations covered by this schedule: Beginners Edge Sports Training 8300 SA❑TA MO❑ICA BL❑D WEST ❑OLLYWOOD CA 90069 FEIN: 26-2932264 ❑AICS ❑❑13940 SIC❑❑991 ❑O. OF EMPL❑1 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 88EO FIT❑ESS I ❑STR❑CTIO❑ PROGRAMS OR ST❑DIOS - ALL EMPLOYEES - I❑CL❑DI❑G RECEPTIO❑ISTS Co-ntersigned ❑y 2,000.00 1.490000 30 A t❑ori-ed Representati e Form WC 99 00 05 d ❑Printed in ❑.S.A. Process Date: 11/04/20 Policy Expiration Date: 11/04/26 SCHEDULE OF OPERATIONS T❑is Sc❑edde of Operations forms a part of t❑e policy effecti-e on t❑e inception date of tie policy -nless anot❑er date is indicated ❑elow❑ INSURER: ❑ARTFORD CAS❑ALTY I❑S❑RA❑CE COMPA❑Y Company Code: 3 Policy Number: ❑6 WEG B❑3❑P❑ Schedule Number: 01-04-04 Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Location Address of operations covered by this schedule: Beginners Edge Sports Training ❑O SPECIFIC LOCATIO❑ COSTA MESA CA 92626 FEIN: 26-2932264 ❑AICS 11❑13940 SIC❑❑991 ❑O. OF EMPL::2 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 88EO 180,141.00 1.490000 2,684 FIT❑ESS I ❑STR❑CTIO❑ PROGRAMS OR ST❑DIOS - ALL EMPLOYEES - I❑CL❑DI❑G RECEPTIO❑ISTS Total State Summary Total Class Premi -n 2, ❑14 CA Territorial Differential 1.03 000 9❑ Wai-er of S❑rogation 1,000 Total Estimated Ann -al Standard PremiEn 3,809 Premi-n discoEtit 0.001000 -4 E-pense constant 200 Terrorism Ris❑Ins rance Program ReaEt❑briC:Ation Act 182,141.00 0.020000 36 Disclos-re Endorsement CA ❑ser F-nd 1.23 000 0 CA Fra❑d 0.409600 1 ❑ CA ❑nins-red Employers Benefit Tr❑st Fed 0.081800 3 CA S❑Else❑❑ent Iniries Benefit Tr❑st F-nd Assessments 3.014800 122 CA OccEpational Safety ❑ ❑ealt❑ FEnd 0.188❑DO 8 CA LaEor Enforcement ❑ Compliance F-nd 0.10❑800 4 Total Estimated Ann -al Premi-n 4,24❑ Co-ntersigned y A t❑ori-ed Representati e Form WC 99 00 05 d ❑Printed in ❑.S.A. Process Date: 11/04/20 Policy Expiration Date: 11/04/26 SCHEDULE OF OPERATIONS T❑is Sc❑edde of Operations forms a part of t❑e policy effecti-e on t❑e inception date of tie policy -nless anot❑er date is indicated ❑elow❑ INSURER: ❑ARTFORD I❑S❑RA❑CE COMPA❑Y OF ILLI❑OIS Company Code: F Policy Number: ❑6 WEG B❑3❑P❑ Schedule Number: 01-42-02 Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Location Address of operations covered by this schedule: Beginners Edge Sports Training ❑900 Balcones Dr. A❑stin TO ❑BE31 FEIN: 26-2932264 ❑AICS ❑❑13940 SIC❑❑991 ❑O. OF EMPL❑1 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 9063 2 q ❑34.00 0.180000 46 ❑EALT OR E❑ERCISE I❑STIT❑TE ❑ DRI❑ERS Total State Summary Total Class Premi-n 46 Emp lia❑ increased limits 0.014000 1 Employer LiaJlity Increase Limits ❑glance to Minim-n 139 PremiLirn PremiErn Incenti-e For Small Employers 0.8 0000 -28 ScEedde Rating Factor 0.600000 -63 Total Estimated Ann -al Standard PremiErn 9❑ Terrorism Ris❑Ins rance Program ReaEt❑briC:Ation Act 2q❑34.00 0.00 000 1 Disclose Endorsement CatastropEle Cot❑er t❑an certified acts of terrorism- 2q❑34.00 0 Total Estimated Ann❑al Premi-n 96 CoAtersigned -y A t❑ori-ed Representati e Form WC 99 00 05 d ❑Printed in ❑.S.A. Process Date: 11/04/20 Policy Expiration Date: 11/04/26 THIS LETTER CONTAINS IMPORTANT INFORMATION. PLEASE READ CAREFULLY AND RETAIN THIS LETTER FOR FUTURE USE. TO-- WOR❑ERS-COMPE❑SATIO❑ POLICY❑OLDERS 1❑ TE❑AS THE A • • / • TeCas Regional Office 4C0 Gears Road, SEJte 000 ❑oi-ston, Tu uLI6a4C8❑ P.O. BoL14611 ❑oCston, To 0E210-4611 TelepEjone [2810804-9600 T❑an❑yo❑for c oosing T❑e ❑artford as yob wor ers compensation carrier. We as❑t❑at yo❑tae a min to to familiarie yoEirselfwit❑t❑e forms and reporting re❑Eirements for t❑e State of TeE:is wElc❑we ❑ae incl❑ded in t'js pac et. 1. Eac❑ employer s❑bdd maintain a record of all in -Ties reported or made ❑sown tote employer. T❑e Tees Department of Instance, Di:jsion of Worers❑Compensation :DWC-may at times re❑❑est tese records for resew. 2. Ift❑e inky cases an employee to ❑e off wor❑more t❑an one day OR in❑bl❑e a claim for an occ-pational disease yo❑ mC:8t immediately report t❑e loss. 3. Please refer to Form WC 66 02 ❑1 for LossConnect loss reporting instr❑ctions. 4. LossConnect will file all necessary state reports. ❑ T❑E CLAIM MOST BE REPORTED ❑O LATER TOAD TOE EIG❑T❑ DAY AFTER T❑E LOSS OF O❑E DAY OF WORD OR T❑E FIRST ❑OTICE OF All OCC❑PATIO❑AL DISEASE. FAIL❑RE TO COMPLY MAY RES❑LT 1❑ All ADMI❑ISTRATI❑E ❑IOLATIO❑ W❑IC❑ CO❑LD I❑CL❑DE ❑P TO A 11E00.00 FI-E. 6. T❑e FROI mC:8t ❑e filed een on a do❑❑tff:l or disp❑ted claim. Yoh lac❑of Enowledge of tie claim details siedd ❑e reflected on t❑e report. COMPLETION OF A FROI IS NOT CONSIDERED AN ADMISSION OF OR EVIDENCE OF A COMPENSABLE INJURY IF THE FACTS CONTAINED THEREIN ARE LATER CONTRADICTED. Fi Te Employers Wage Statement DWC-3❑s❑bdd ❑e pro:jded to tie carrier, employee, and DWC if yo❑ E1ow or e-pect 8 days of disa::jlity. 8. T❑e S-pplemental Report of In❑ry EDWC-6❑s❑bdd ❑e filed wit❑ t❑e carrier weneer yo❑ [as to employer -are aware of any cenge in wor❑statC:8 or earnings de to t❑e in—ry. DO ❑OT SE❑D TO T❑E DWC. We, as tie carrier, cannot act 11EJc1y and efficiently in yo-r interest _nless immediate notice of an inky is receied. Yoh cooperation is imperati e and we stand to assist yo❑ in any way we can. Form WC 55 00 22 A Printed in O.S.A. T-e-artford Ins-rance Gro—p -artford Fire Ins—rance Company and its Affiliates -artford PlaE8, Cartford, Connectic-t 0611- WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE Beginning on Page Beginning on Page INFORMATION PAGE PART TWO - Continued 1 G. Limits of LiaE lity.............................................. 4 General Section.............................................................. 1 ❑. Recoery From Ot❑ers..................................... 4 A. T❑e Policy............................................................... 1 I. Actions Against❑s........................................... 4 B. W❑b Is Ins —red ....................................................... 1 C. Worers Compensation Law .................................. 1 PART THREE - OTHER STATES INSURANCE 4 D. State....................................................................... 1 A. ❑ow TEJs Ins—rance Applies............................. 4 E. Locations................................................................ 1 B. Elotice ............................................................... ❑ PARTONE- WORKERS COMPENSATION INSURANCE... 1 PART FOUR -YOUR DUTIES IF INJURY OCCURS..... ❑ A. —ow T::js Instance Applies ................................... 1 B. We Will Pay............................................................ 1 PART FIVE - PREMIUM ............................................... ❑ C. We Will Defend ....................................................... 1 A. O-r Man❑als..................................................... ❑ D. We Will Also Pay .................................................... 1 B. Classifications.................................................. ❑ E. Ot❑er Ins—rance...................................................... 2 C. RemAeration................................................... ❑ F. Payments Yo❑MC:8t Mae ...................................... 2 D. PremiEin Payments.......................................... ❑ G. Recoery From Ot❑ers........................................... 2 E. Final Premi-n.................................................. ❑ ❑. Stat tory Prolsions................................................ 2 F. Records............................................................ 6 G. A❑dit................................................................. 6 PART TWO - EMPLOYERS LIABILITY INSURANCE...... 2 A. —ow T::js Ins—rance Applies ................................... 2 PART SIX - CONDITIONS ....................................... 6 B. We will Pay............................................................. 3 A. Inspection......................................................... 6 C. Eeleions.............................................................. 3 B. Long Term Policy ............................................. 6 D. We Will Defend ....................................................... 3 C. Transfer of Yo—r RigEts and DEties.................. 6 E. We Will Also Pay .................................................... 4 D. Cancellation..................................................... 6 F. Ot er Ins—rance...................................................... 4 E. Sole Representatie......................................... 6 IMPORTANT: T❑is ❑❑ic❑Reference is not part of t❑e Worers Compensation and Employers LiaE lity Policy and does not prodde coerage. Refer to tie Wor ers Compensation and Employers LiaE lity Policy itself for act❑al contract❑al prorsions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREFULLY. Form WC 66 01 56 B Printed in O.S.A. Process Date: 11/04/211 Policy Expiration Date: 11/04/26 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In ret:1n for tip payment of t-e premiiErn and si-❑iect to all terms of tits policy, we agree wit❑yo❑ as follows -I GENERAL SECTION A. The Policy TEis policy incliEdes at its effecti::6 date tip Information Page and all endorsements and sc:led:les listed t0ere. It is a contract of ins0rance -etween yo❑ Ft -le employer named in Item 1 of tip Information Page❑and ::8 iYle insi-i-er named on tFle Information Pageil Ti-e only agreements relating to tEls ins0rance are stated in ti-Js policy. Ti-e terms of ti-Js policy may not Fie changed or waiiEOd ei-(,ept Dy endorsement issi ed :y ❑s to :]a part of tEJs policy. B. Who Is Insured Yo❑ are ins�Ted if yoDare an employer named in Item 1 of tie Information Page. If tEat employer is a partnersi-- ip, and if yo❑ are one of its partners, yo❑ are insi-Ted, Fi-t only in yo:l- capacity as an employer of tip partnersi�pi-9 employees. C. Workers Compensation Law Wor-erS Compensation Law means t-e worEors or wor-rnenS compensation law and occ-pational disease law of eac❑ state or territory named in Item 3.A. of tip Information Page. It incliEdes any amendments to that law wuc-are in effect dimming tip policy period. It does not inch -le any federal wori-:Ors or wor::nen:g compensation law, any federal occgpational disease law or tip pro:1sions of any law that proElde nonocci-pational disa::Jlity iElenefits. D. State State means any state of t-e ❑nited States of America, and tile District of ColEME]a. E. Locations TEis policy coi-ers all of yoi-i- woriEplaces listed in Items 1 or 4 of tie Information Pagei-and it co -ors all ot:ler wor!Eplaces in Item 3.A. states bless yo❑ :]8i-:0 ot:ler ins-rance or are self-insiFi-ed for si:ci- woriEplaces. PART ONE - WORKERS COMPENSATION INSURANCE A. How This Insurance Applies TJs worEors compensation ins:lance applies to Fodily inEry i:y accident or iFodily inufl-y -y disease. Bodily in -may inclLdes resiElting deat❑. 1. Bodily iniEEry Dy accident mC:8t occEir d0ring t-� policy period. 2. Bodily inlory Dy disease milt Fle cared or aggrai:ated Ey tip conditions of yo:lr employment. T❑e employees last day of last eEposL]re to t0e conditions ca-5ing or aggra-sting s❑c❑ -odily inmy Ey disease m-st ocCir doing t-e policy period. B. We Will Pay We will pay promptly wiDen dim tip iDenefits re-i�red of yo❑ Dy t-le wor[ors compensation law. C. We Will Defend We 08i-:0 tip rigi-t and dAy to defend at o0- eiEpense any claim, proceeding or sut against yo❑for Jenefits paya:Ae Ey ti-Js insFirance. We 08-e tDa rig Et to inEostigate and settle tFlase claims, proceedings or sits. We 08E:0 no dirty to defend a claim, proceeding or sit tilat is not coEOred Dy tiis insFirance. D. We Will Also Pay We will also pay tE ese costs, in addition to ot:ler amoiAts payaie iAder tis insuance, as part of any claim, proceeding or snit we defend❑ 1. reasonaie egcenses inured at o0r re-Eest, ❑A not loss of earnings❑ Form WC 00 00 00 C Printed in ❑.S.A. Process Date: 11/04/2❑ Page 1 of 6 Policy Expiration Date: 11/04/26 2. premi::ns for i:onds to release attaciEnents and for appeal ends in i:ond amoiEnts i--p to tip amo:Ant paya:]e iEnder Lis ins:1-ancei❑ 3. litigation costs taEod against yo❑❑ 4. interest on a ❑dgment as re❑Eired ❑y law Entil we offer t❑e amount d0a ceder t❑is insLiranceLiand El e::penses we inc:1-. E. Other Insurance We will not pay more tFian o!-ir sere of Flanefits and costs co::Ored y tEJs instance and ot:ler instance or self-insFirance. S❑❑iiect to any limits of lia-- Jlity that may apply, all sires will Da e:]Fial ❑ntil tip loss is paid. If any instance or self-insi rance is e=8::8ted, Lie shares of all remaining insFirance will Da e❑❑al Entil ti❑e loss is paid. F. Payments You Must Make You are responsiiJe for any payments in eE(,ess of tip Lienefits regElarly pro:1ded y tip wor::Ors compensation law incli❑ding ti❑ose re❑❑fired —ecaF]se❑ 1. of yoFir serioC:8 and willfF] miscondEc-t❑ 2. yo❑ Lnowingly employ an employee in dolation of law ❑ 3. yo❑ fail to comply wit❑ a malt❑ or safety law or reg nation ::or 4. yo❑ discharge, coerce or oti-lerwise discriminate against any employee in !Jolation of tip worii;rs compensation law. If we matt; any payments in e::(,ess of tip iDenefits regJarly pro:Jded iy tie worEors compensation law on yoii- i❑eiialf, yoi❑will reim❑ irse ::8 promptly. G. Recovery From Others We i❑aEo yoii- rig::ts, and tip rig::ts of persons entitled to tip iDenefits of tiffs ins❑rance, to recoii;r oiir payments from anyone liaise for tiDa iniiry. Yo❑ will do e::Oryti❑ing necessary to protect Lose rigs is for ❑s and to Delp E8 enforce t❑em. H. Statutory Provisions T❑ese statements apply wDere t❑ey are re❑Eired ❑y law. 1. As iDetween an iniii ed worEor and ice, we F18::0 notice oft❑e iniii ywi❑en yo❑:18[0 notice. 2. YoFir defailt or tip i�aniEr::ptcy or insol::Oncy of yo❑or yos estate will not reliei-:0 i-:8 of oi-i- dries finder tiffs insiiance after an iniEry occ:lrs. 3. We are directly and primarily liaiFle to any person entitled to t!-10 iDenefits paya!Fle y t!As ins!-irance. Ti❑ose persons may enforce o0r d-ties❑so may an agency aiFt❑oriiEod y law. Enforcement may Da against yo❑and Ds. 4. i=risdiction oEor yo❑ is Edrisdiction o::Or ::8 for p0rposes of tip wori-:Ors compensation law. We are iEoiEnd y decisions against yo❑ ❑nder tiDat law, s❑i❑act to to pro:lsions of tiffs policy that are not in conflict wit❑ ti at law. El Ti❑is ins:1-ance conforms to tie parts of t❑e wor::Ors compensation law tiFlat apply to:] a. ❑enefits payade ❑y tEJs instance❑ El special tacos, payments into seclirity or ot❑er special finds, and assessments payaEle iy ❑; tinder tiat law. 6. Terms of tiffs inssance tit t conflict wit❑ Lie worii;rs compensation law are changed ❑y tEJs statement to conform to t❑at law. ❑ot::Jng in ti;se paragrapi❑; relie!i;s yo❑ of yoj dries ❑nder tJs policy. PART TWO - EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies T❑is employers liaiJlity insurance applies to ::odily iniii y iy accident or Eodily inii y y disease. Bodily inEEEry inclides resifting deat❑. 1. T❑e ❑odily in❑7y mEM arise oE1 of and in t❑e coii-se of t0a inEEEred employee® employment iy yo h 2. T!❑e employment mi❑;t DO necessary or incidental to yoir wor❑ in a state or territory listed in Item 3.A. of t❑ e Information Page. 3. Bodily inii y iy accident mist occii- during to policy period. 4. Bodily in[Ei]-y uy disease m❑st ❑e ca❑sed or aggravated uy t❑e conditions of yoa- employment. T❑e employee® last day of last Form WC 00 00 00 C Printed in ❑.S.A. Page 2 of 6 egcosilre to tDO conditions caring or aggraL:8ting s❑c❑ iEodily in iiry ❑y disease mi-st occ:1r dimming t0e policy period. If yo❑ are s0ed, t❑e original sElt and any related legal actions for damages for ❑odily iniFiry ❑y accident or ❑y disease mCst DO oroEgEt in tDO ❑nited States of America, its territories or possessions, or Canada. B. We Will Pay We will pay all suns t:18t yo❑ legally milt pay as damages :Ieca::8e of iEodily ini!i y to yo:1- employees, pro:1ded tija iEodily ini❑ry is co::Ored i❑y tips Employers Lia::Jlity Ins0rance. Tie damages we will pay, were reco::Ory is permitted ❑y law, incl!-de damages-] 1. For w!Jc❑ yoi❑ are lime to a turd party i❑y reason of a claim or silt against yo❑ �y that turd party to reco-:Or tip damages claimed against siEc❑ t-Jrd party as a rest of ins -Ty to yob employee-] 2. For care and loss of sericesEand 3. For conse❑iential Fodily ini❑ry to a spore, c::Jld, parent, iOroti-er or sister of tip inbred employees❑ pro:Jded tlEot t0ese damages are tip direct conse❑jence of ::Odily inEry tiEot arises oil of and in tip conse of t❑e inHred employee8 employment ❑y yo❑end 4. Became of ❑tidily inliry to yob employee tit arises oEt of and in t❑e copse of employment, claimed against yo❑ in a capacity ot❑er tin as employer. C. Exclusions Tus insiFiance does not coEer❑ 1. Lia::Jlity assigned Ender a contract. T❑is ei-(,Ii-:tion does not apply to a warranty t!-at yo:lr wor❑will DO done in a worErnanli-:0 manner-] 2. Pi-:niti::o or ei-:Omplary damages :IecaL:te of iEodily inlory to an employee employed in Jolation of law❑ 3. Bodily iniii y to an employee wile employed in Jolation of law wit:] yob actual :nowledge or tip actin I :Powledge of any of yob e::OcEti::o officers❑ 4. Any odigation imposed ❑y a worEors com- pensation, occ::pational disease, ❑nemployment compensation, or disa❑ility Eenefits law, or any similar law❑ a Bodily inQry intentionally cared or aggraL:8ted ❑y yo ❑❑ 6. Bodily inEdry occilrring onside tip ❑nited States of America, its territories or possessions, and Canada. T❑is eiipl::8ion does not apply to iFodily ininry to a citi::On or resident of t e❑nited States of America or Canada wig is temporarily of=tside t:10se coEntriesi❑ a Damages arising oEt of coercion, criticism, demotion, eC:il❑ation, reassignment, discipline, defamation, Elarassment, ❑liniliation, dis- crimination against or termination of any employee, or any personnel practices, policies, acts or omissions❑ 8. Bodily inliry to any person in wor❑s❑❑iect to tie LongsLore and ❑ar❑or WorEorsOCompensation Act :33 ❑.S.C. Sections 901 et se:IQ tEO ❑oappropriated F:Ind Instr!Enentalities Act FT D.S.C. Sections 81 ❑1 et seal tEO O❑ter Continental S:IeIf Lands Act :43 ❑.S.C. Sections 1331 et seam tEO Defense Base Act F42 E.S.C. Sections 1601-16::4:� tip Federal Mine Safety and ❑ealt❑ Act :30 ❑.S.C. Sections 801 et seia and 901-944❑ any ot:ler federal worEors or wor::neniig compensation law or otter federal occ!--lpational disease law, or any amendments to terse laws❑ 9. Bodily iniEry to any person in wor❑s❑❑iact to tDO Federal Employers-] Lia�lity Act :4❑ D.S.C. Sections ❑1 et seam any otter federal laws o!Fligating an employer to pay damages to an employee d:1e to iEodily inlory arising oil of or in tFle conse of employment, or any amendments to t::Ose laws 10. Bodily iniUry to a master or mem:ler of tDO crew of any Fossel, and does not co::Or p::niti::e damages related to yo:1- d-ty or oiJigation to pro:Jde transportation, wages, maintenance, and cDre Ender any applicaEle maritime law❑ 11. Fines or penalties imposed for Jolation of federal or state lawEiand 12. Damages payade ❑nder tip Migrant and Seasonal AgricdtEiral WorEor Protection Act E29 ❑.S.C. Sections 1801 et sea❑and ❑nder any ot❑er federal law awarding damages for Jolation of t❑ose laws or regdations iss❑ed tElereErider, and any amendments to tEose laws. D. We Will Defend We :18![0 t-le rigid and d::ty to defend, at oil e:pense, any claim, proceeding or silt against yo❑ for damages payade ❑y tEis instance. We DOCO t:le rigEt to ins-estigate and settle ti-lese claims, proceedings and sits. Form WC 00 00 00 C Printed in ❑.S.A. Page 3 of 6 We ilae no d::ty to defend a claim, proceeding or siAt A disease is not iedily iniii y ❑y accident Mess it tet is not coered i❑y tiffs ins:l-ance. We ieie no resiAts directly from ❑odily inlry ❑y accident. di ty to defend or continie defending after we ilae 2. Bodily In❑ry ❑y Disease. T❑e limit siewn for paid oil- applicaiFle limit of liai�lity Ender tiffs Mbdily in❑ry ❑y disease policy limitrr�is to most ins:l-ance. we will pay for all damages coered ❑y tEJs E. We Will Also Pay instance and arising oEt of iedily in❑ry ❑y We will also pay tese costs, in addition to otter disease, regardless of t❑e nEn❑er of employees amounts payade Ender tEJs instance, as part of any w❑e sCStain ❑odily in❑ry ❑y disease. T❑e limit claim, proceeding or s❑it we defend❑ sown for ❑bodily in❑ry ❑y disease eac❑ employees is to most we will pay for all 1. Reasona:le eigenses inc:lrred at oDr re❑❑est, ❑iA damages ❑eca❑se of ❑odily in❑ry ❑y disease to not loss of earnings❑ any one employee. 2. Premi::ns for tends to release attaci-inents and Bodily ininry Ey disease does not incl::de disease for appeal tends in tend amounts ig to tie limit tet resiAts directly from a ❑odily iniii y Ey of o:lr lia::Jlity Aider tJs instance❑ accident. 3. Litigation costs taied against yo❑❑ 3. We will not pay any claims for damages after we 4. Interest on a Edgment as re❑EJred i❑y law ❑ntil we lae paid tie applicaiAe limit of oDr liar-Jlity under offer tie amol]nt die iEnder t0is insFiranceiland tiffs insurance. Eigenses we inc:1. F. Other Insurance We will not pay more titan o0r share of damages and costs coered ❑y tEJs instance and otter instance or self-ins0rance. S❑❑Cect to any limits of liaEJlity tet apply, all sCiares will ❑e a❑❑al ❑ntil to loss is paid. If any instance or self -instance is e=OC75ted, to shares of all remaining ins:1-ance and self -instance will ie e❑ilal Entil tie loss is paid. G. Limits of Liability H. Recovery From Others We ilae yoi r rig::ts to recoier oi-i- payment from anyone liaiAe for an inEffl-y coered i❑y ti-Js insi-Irance. Yo❑ will do eerytung necessary to protect tiese rig::ts for ie and to ielp ie enforce teem. I. Actions Against Us Tere will e no rig Et of action against ❑5 ❑nder tEJs insFirance ❑nless❑ 1. Yo❑ eie complied wit❑ all to terms of tEJs policyend OFT lia::Jlity to pay for damages is limited. OFT limits of 2. Tie amount yo❑ owe ies Teen determined wit❑ liaiJlity are sewn in Item 3.B. of tie Information Page. oil- consent or i❑y actilal trial and final lidgment. Tey apply as eiglained Blow. T❑is insisance does not gie anyone tie rigid to add 1. Bodily InEflry ❑y Accident. Tie limit siewn for e as a defendant in an action against yo❑ to Mbdily inlry ❑y accident eac❑ accidentnis t❑ a determine yoij liaE lity. Tie lane-r'gtcy or most we will pay for all damages coffered i❑y ti-Js insoliency of yo❑ or yoij estate will not reliee E8 of ins:1-ance iecaiee of iedily inlry to one or more oil- o:ligations ❑nder ti-Js Part. employees in any one accident. PART THREE - OTHER STATES INSURANCE A. How This Insurance Applies Ti❑is otter states ins:1-ance applies only if one or more states are siewn in Item 3.C. of t❑ a Information Page. 2. If yo❑ iegin wor❑ in any one of tiese states after tie effectie date of t::Js policy and are not insiFi-ed or are not self-ins:lred for set❑worq all pro:1sions of tie policy will apply as t❑o g❑t❑at state were listed in Item 3.A. of tie Information Page. 3. We will reim❑i-irse yo❑for tie enefits re -]tired i❑y tie worers compensation law of ti et state if we are not permitted to pay to enefits directly to persons entitled to tem. 4. If yo❑ ❑ae wor❑ on t❑e effectie date of t::js policy in any state not listed in Item 3.A. of t❑e Form WC 00 00 00 C Printed in ❑.S.A. Page 4 of 6 Information Page, coiEorage will not Lie afforded for B. Notice tiE t state Bless we are notified witi�n t::Jrty days. Tell ❑5 at once if yo❑ ❑egin wor❑ in any state listed in Item 3.C. of tie Information Page. PART FOUR - YOUR DUTIES IF INJURY OCCURS Tell C:8 at once if inky occlirs tit may :]a coEored ❑y Lis policy. Yoh otDer dEties are listed ire. 1. Prodde for immediate medical and otter serElces re❑Eired ❑y t❑e worEors compensation law. 2. Gi![0 F:8 or oil agent tie names and addresses of tip inEred persons and of witnesses, and ot:ler information we may need. 3. Promptly gi::o i-:8 all papers related to tip s ::Jt. A. Our Manuals notices, demands and legal inky, claim, proceeding or 4. Cooperate wit❑ ❑5 and assist E8, as we may re❑❑est, in tFie instigation, settlement or defense of any claim, proceeding or sElt. El Do notElng after an in❑ry occlirs tit world interfere wit❑oOr rig to reco❑er from ot0ers. 6. Do not FoliEntarily maims payments, ass —me oiJigations or inc:lr e:A)enses, e:cept at yo:lr own cost. PART FIVE - PREMIUM All premi:1n for tiffs policy will 00 determined i❑y oij manlals of rues, rates, rating plans and classifications. We may c0ange oi-i- maniFials and apply tip Clanges to tiEis policy if a::t❑orii-:Od ❑y law or a go::Ornmental agency reg:lating t❑is ins rance. B. Classifications Item 4 of t0e Information Page sows t❑e rate and premiErn psis for certain ❑❑siness or wor❑ classifications. T❑ese classifications were assigned used on an estimate of t0e e'EposEires yo❑ wo'Eld E]aL:o d0ring t❑e policy period. If yob actDal eEposEires are not properly descried ❑y t❑ose classifications, we will assign proper classifications, rates and premiE]rn Dasis ❑y endorsement to Lis policy. C. Remuneration Premi inn for eac❑ wor❑ classification is determined i❑I m:1tiplying a rate times a premi::rn Oasis. RemErieration is tie most common premi::n iFlasis. T❑is premiiErn :18sis incl❑des payroll and all oti-ler remErieration paid or paya:le dimming tip policy period for tFle ser:lces of:] 1. All yo:l- officers and employees engaged in wor❑ co::Ored ❑y tiffs policyiland 2. all oti-ler persons engaged in wor❑ t0at cord maims -:8 liaLle ceder Part One :Wormers Compensation Insi-irance❑of tits policy. If yo❑do not 08::0 payroll records for ti-lese persons, tie contract price for tE]eir ser:lces and materials may 00 wed as tie premi::n Oasis. T❑is paragrap❑ 2 will not apply if yoi❑ gi::0 ::8 proof t!1at tie employers of tFlase persons lawf:11y sec!-ired t:leir worEors compensation oiJigations. D. Premium Payments Yo❑will pay all premiLirn wFlan d' e. Yo❑will pay tie premiErn e❑en if part or all of a wormers compensation law is not ❑Alid. E. Final Premium T❑e premi::n s::own on tip Information Page, sciOadiles, and endorsements is an estimate. T❑e final premiEM will 00 determined after tits policy ends ❑y ring t:le actin 1, not t❑e estimated, premi::n iFlasis and tip proper classifications and rates tip t lawf:11y apply to tip ❑iciness and wor❑ co::Ored ❑y tiJs policy. If t�le final premi::n is more t:18n tip premi::n yo❑ paid to ice, yo❑ milt pay ::8 tip :181ance. If it is less, we will ref::nd tip :181ance to you T❑e final premi::n will not Da less tin tip -Jgi-lest minim::n premi::n for tie classifications coJOred :y ti❑is policy. Form WC 00 00 00 C Printed in ❑.S.A. Page 5 of 6 If tips policy is cancelled, final premi::n will Lie determined in tEje following way EnIess oiEr maniEoIs pro:Jde ot:1erwisei❑ 1. If we cancel, final premiEn will ❑e calcFlated pro rata ❑ased on toe time tEJs policy was in force. Final premiEn will not ❑e less tin tip pro rata share oft❑e minimErn premiEn. 2. If yo❑ cancel, final premilin will Lie more tFian pro rata❑it will Lie chased on t0e time tEJs policy was in force, and increased ❑y olir sort rate cancellation taLle and proced:lre. Final premiE]n will not Lie less tihan t❑e minim::n premi-n. F. Records Yo❑ will Eoep records of information needed to comp::te premi::n. Yo❑ will pro:Jde F:8 wit:] copies of t!Eose records win we as -]for t!-lem. A. Inspection G. Audit Yo❑will let E8 eF:8mine and a❑dit all yo0r records thhat relate to tEis policy. T❑ese records inclhle ledgers, 100nals, registers, EbEc❑ers, contracts, ta❑ reports, payroll and dis❑lirsement records, and programs for storing and retriedng data. We may condEct tEie a❑dits ding regdar ❑C:8iness iEoa-s d0ring t❑e policy period and witEJn twee years after tip policy period ends. Information deEoloped ❑y a dit will ❑e Clsed to determine final premiEn. Instance rate serdce organiF:8tions F18C:8 tFe same rigEls we ihaC:o ❑nder tEJs proidsion. PART SIX - CONDITIONS We ]ai-:o tE8 rigs, ❑ t are not oAigated to inspect yob wore[places at any time. Oil inspections are not safety inspections. Ti❑ey relate only to t—e insDra!Dility of tip woriEplaces and t-10 premiEns to Ele c❑urged. We may giE0 yo❑ reports on tip conditions we find. We may also recommend Ganges. Wile tidy may Delp red❑ce losses, we do not iEnderta::o to perform tip dEty of any person to proilde for tie malt-1 or safety of yoi-ir employees or tEe p❑Aic. We do not warrant thhat yo:1r worEplaces are safe or malt❑fE] or thhat tidy comply wit-] laws, reg:lations, codes or standards. Ins:1rance rate ser:Ace organic-ations iDOiE0 tip same rigiEts we :18[0 iEnder tJs proilsion. B. Long Term Policy If t0e policy period is longer tEian one year and siEteen days, all proElsions of tJs policy will apply as trEoEg❑ a new policy were iss❑ed on eac❑ annul anniEorsary tit tEJs policy is in force. C. Transfer of Your Rights and Duties YoiEr rigs-ts or dries Finder ti-Js policy may not Fie transferred wit::oiA oiJ written consent. If yo❑die and we recei::0 notice wit::Jn tarty days after yo!-ir deat❑, we will coEor yoi-ir legal representati::0 as ins -Ted. D. Cancellation 1. Yo❑ may cancel tiffs policy. Yo❑ milt mail or deli -:Or adi:ance written notice to E8 stating wien t—e cancellation is to tail effect. 2. We may cancel tEJs policy. We milt mail or delii-er to yo❑ not less t❑an ten days adi-:8nce written notice stating win tip cancellation is to tail effect. Mailing thhat notice to yo❑ at yoEr mailing address s::own in Item 1 of tie Information Page will Eje s❑Fficient to proms notice. 3. T❑e policy period will end on tE-e day and ❑oil stated in t❑e cancellation notice. 4. Any of t❑ase prodsions tit conflict wit❑ a law tit controls tE0 cancellation of t❑e ins0rance in tEls policy is changed ❑y t is statement to comply wit[] that law. E. Sole Representative T❑e insFired first named in Item 1 of tFle Information Page will act on Da❑alf of all insilreds to change tiffs policy, receii-:0 ret:1n premi!7rn, and giF:0 or recei::0 notice of cancellation. Form WC 00 00 00 C Printed in ❑.S.A. Page 6 of 6 POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS PFIrsi—ant to Section 11 ❑2.8 of tip California Insi]'ance Code, we are promding yoi❑ wit❑ an e::planation of t—e California woriEOrs:Pompensation rating laws. We estadis❑ oEir own rates for worE0rs❑ compensation. OFT rates, rating plans, and related information are filed wit❑ tDe insFirance commissioner and are open for p❑dic inspection. 2. Ti❑e insEirance commissioner can disapproE0 oilr rates, rating plans, or classifications only if DO or sib ilas determined after p❑::Iic raring t0at oil rates migi t :eopardiEo o[]r ai�lity to pay claims or create a monopoly in tip mar::Ot. A monopoly is defined ❑y law as a mar::Ot wire one insFirer writes 20❑ or more of t-at part of tip California wor::Ors❑ compensation ins:1-ance tilat is not written ❑y tip State Compensation Instance F❑nd. If tip ins:1rance commissioner disappro::Os o[ir rates, rating plans, or classifications, 00 or sib may order an increase in t❑ e rates applicaiFle to of-tstanding policies. Rating organi:ations may de::Olop pi-i-e premi:jn rates ti-at are s❑❑act to tDa insi-irance commissioners approi❑al. A p0re premi7n rate reflects tie anticipated cost and e:])enses of claims per ❑100 of payroll for a gin classification. Pie premi::n rates are adElsory only, as we are not re❑iAred to ire tip p0re premi::n rates deiceloped ❑y any rating organii:ation in estaiFlis::Jng o0r own rates. 4. We mi—st admire to a single, iEniform ei[perience rating plan. If yo❑ are eligiiJe for e::perience rating ceder t❑e plan, we will ❑e re❑Elred to ad—st yo-r premi::n to reflect yoij claim iJstory. A utter claim Jstory generally resits in a lower eEperience rating modifications❑ more claims, or more e:])ensiL:e claims, generally resElt in a ::Jg:ler e:])erience rating modification. T❑e iEniform e:])erience rating plan, w::Jc❑ is deiFoloped ❑y tie instance rating organiL:8tion designated ❑y t❑e ins:1rance commissioner, is s❑i❑iect to approL:81 ❑y tip instance commissioner. El A standard classification system, de❑oloped ❑y to instance rating organiEAtion designated ❑y to instance commissioner, is s❑❑lect to approC81 y t❑e instance commissioner. Tile standard classification system is a met' od of recogniEJng and separating policy❑olders into indL8try or occEpational groEps according to t0eir similarities and/or differences. We can adopt and apply to standard classification system or deEolop and apply oil- own classification system, prouded we can report tip payroll, e::penses, and otter costs of claims in a way t0at is consistent wit❑ tija Eniform statistical plan or tie standard classification system. Oj rates and classifications may not Flolate tip ❑nr❑❑CiiFJl Rig Ets Act or i-le iEnfairly discriminatory. ❑ We will proiJde an appeal process for yo❑to appeal tFle way we rate yo:lr insi-i-ance policy. Ti❑e process re❑Fires .8 to respond to yo:lr written appeal witiAn 30 days. If yo❑ are not satisfied wit❑ tie res:]t of yo:1- appeal, yo❑ may appeal o0r decision to t-le insErance commissioner. Form PN 04 99 02 B (Ed. 5-02) Printed in ❑.S.A. Page 1 of 2 CALIFORNIA WORKERS' COMPENSATION INSURANCE NOTICE OF NONRENEWAL Section 11664 of to California Insiance Code re -Ares -IF,, in most instances, to proElde yo❑ wit-] a notice of nonrenewal. Eiuept as specified in paragrapu 1 tmo-g❑ 6 !ulow, if we elect to nonrenew yoj policy, we are re❑fired to deliur or mail to yo❑ a written notice stating t!u reason or reasons for to nonrenewal of to policy. T❑e notice is re❑cored to iu sent to yo❑ no earlier tun 120 days !ufore tiu end of tiu policy period and no later tun 30 days ufore t!u end of tiu policy period. If we fail to pro:Jde yo❑ to re -cored notice, we are re❑cored to continu to courage .nder to policy wit❑ no change in to premi::n rate iEntil 60 days after we pros-Ide yo❑wit❑tiu re❑cored notice. We are not re -]tired to pro!lde yo❑ wit❑ a notice of nonrenewal in any of t❑e following sit❑ations❑ YoLlr policy was transferred or renewed witium a ciunge in its terms or conditions or tiu rate on wimc❑ Lie premiErn is used to anotiur insider or otiur ins-irers w❑o are memijers of t-e same insilrance groDp as iu. 2. T❑e policy was emended for 90 days or less and tiu re -]fired notice was giun prior to ti❑e emension. Yo❑ oimained replacement courage or agreed, in writing, witmn 60 days of tiu termination of to policy, to oimain t❑at courage. 4. T❑e policy is for a period of no more titan 60 days and yo❑ were notified at tiu time of issiunce tut it may not !Da renewed. Yo❑ re❑Dusted a cunge in tiu terms or conditions or risiu coured i❑y t!u policy witimn 60 days prior to t!u end of t!u policy period. 6. We made a written offer to yo❑ to renew to policy at a premi::n rate increase of less tun 2❑ percent. -A❑If to premi::n rate in yo:lr gourning classification is to iu increased 2❑ percent or greater and we intend to renew t-e policy, we still proEJde a written notice of a renewal offer not less tiun 30 days prior to tiu policy renewal date. T❑e gourning classification si-all iu determined ❑y tEb rues and regimations estamisud in accordance wit❑ California Instance Code 11 ❑i❑D.3:0i❑ -B❑For p:lrposes of tms ❑otice, Cpremion rate❑ means tiu cost of ins:l-ance per Tlit of e:])osim-e prior to t❑e application of indi:ldi:al ris❑ iuriations used on loss or e--pense considerations si❑c❑ as scudmed rating and ei-lperience rating. Tms notice does not cunge tiu policy to wmc❑ it is attaciud. Form PN 04 99 02 B (Ed. 5-02) Printed in D.S.A. Page 2 of 2 POLICY HOLDER NOTICE - PAYROLL BILLING T❑an❑yo❑for cEoosing T❑e ❑artford. Yo-r policy is on o-r payroll Filling met❑od. T❑e payroll EiIling met❑cd -Ses act❑al payrolls receiEod tilro❑gEoEt t❑e policy period and a dended rate CS❑to determine premiEMs d❑e doming t❑e policy period. To learn more aEoEt ❑bw yo-r premiEn is calcdated on t❑e payroll EiIling met❑od please Eisit❑ EttDsit/www.tELmElartford.conVE]ended Below are t❑e dended rateCS❑❑eing ESed for eac❑state and classification code on yoJ policy-] State Class Code Blended Rate Effecti::6 2❑ 900 Balcones Dr., A-stin, 9063 0.380000 11/04/20211 T❑ 411COSTA MESA, CA 8811D 2.220000 11/04/20211 3❑WOS❑8300 SA11TA 8811D 2.220000 11/04/20211 MO❑ICA BL❑D, WEST ❑OLLYWOOD, CA 1❑❑432 E TIERRAB❑E❑A 9063 0.400000 11/04/202❑ L❑, SCOTTSDALE, All Form G-4119-0 Printed in ❑.S.A. © 2017, The Hartford 4tThe Hartford POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION Information Available to You A. Information Available from Us - Hartford Casualty Insurance Company :1 ❑ General ❑FOstions regarding yoi-ir policy s❑o:ld ❑ e directed to your Hartford Agent or Hartford Casualty Insurance Company 3600 Wiseman Blvd San Antonio, TX 78251 Telephone: (877) 287-1316 agency.services@thehartford.com www.thehartford.com I❑ Dividend Calculation. If tiffs is a participating policy :a policy on wiJc❑ a di:Jdend may DO paid Epon payment or non-payment of a diijdend, we s0aII pro:Jde a written e:])lanation to yo❑ tiFlat sets ford❑ tEe psis of tip di:Jdend calciFlation. T❑e e:])lanation will Da in clear, iEnderstandaiJe Iang0age and will eEpress tip di:ldend as a dollar amo❑ht and as a percentage of t e earned premiiErn for tEe policy year on w-Jc❑t❑e diddend is calcdated. :3❑ Claims Information. Pjs:ant to Sections 3C61 and 3::62 of t—e California La❑or Code, yo❑ are entitled to recei::6 information in oij claim files t0at affects yoj premiE n. Copies of docErnents will 00 s!—pplied at yob eEpense d❑ring reasona:Ae ❑F:8iness Eo❑rs. For claims cored Ender tiEis policy, we will estimate t0a :1timate cost of iEnsettled claims for statistical piposes eigEteen mont::8 after t❑e policy incomes effecti::0 and will report t❑ose estimates to tie WoriEorsECompensation Instance Rating Bjea❑of California :WCIRB❑no later t0an twenty month after tEle policy ❑ecomes effecti::0. T❑e cost of any settled claims will also Ele reported at t0at time. At twelEo- mont❑ interF:8Is t0ereafter, we will iodate and report to tip WCIRB tEe estimated cost of any iEnsettled claims and t0e actual final cost of any claims settled in tip interim. T❑e amoEnts we report will Da iced ❑y tip WCIRB to compEle yoEr e:A)erience modification if yo❑ are eligiiJe for e:A)erience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California :1 ❑ T❑e WCIRB is a licensed rating organii:ation and ti—e California Instance Commissioners designated statistical agent. As s:Pq ti—e WCIRB is responsi:Ae for administering ti—e California Workers' Compensation Uniform Statistical Reporting Plan-1995 iii]SRP❑ and tEe California Workers' Compensation Experience Rating Plan-1995 LERP❑ WCIRB contact information isi❑ WCIRB, One Montgomery Street, SiJte 400, San Francisco, CA 94104, Attn❑C::8tomer Serucei❑B88.229.24E2 :P❑onei ii 41❑.❑❑8.22 :a=and c::8tomerser7ce❑ wcir❑.com Cemail❑ T❑e regFlations contained in t❑e ❑SRP and ERP are ai:ailaE]e for p❑lic mewing t❑ro-g❑tip WCIRI38 we::8ite at wcir-1com. _2❑ Policyholder Information. PjsiEant to California Instance Code !SIC❑Section 11 ❑2.6, iDpon written re❑!-iest, yo❑are entitled to information relating to loss ei-A)erience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manLiaI r!Fles, or ot❑ er information impacting yos premi::n t!1at is maintained in tie records of tie WCIRB. Complaints and Re❑❑ests for Action re❑sting policy older information s❑o:ld DO forwarded to❑WCIRB, One Montgomery Street, SJte 400, San Francisco, CA 94104, Attn❑ CC78todian of Records. T❑e Ci�todian of Records can Lie reaci-led at 41 ::I❑❑❑.0❑❑❑ iEu::One❑and 41 iEFiEB.22 Elam :30 Experience Rating Form. Eac❑e:A)erience rated ris❑may receii[o a single copy of its c:l-rent ExEperience Rating Form/WoriESEeet free of Clarge ❑y completing a Policy❑older E:A)erience Rating Wor-8:10et Rei❑❑est Form on tip WCIRB8 we::8ite at wciri!com/rates:10et. TOO E:A)erience Rating Form/Wor-8:10et will incl❑de a Loss -Free Rating, w::Jc❑ is tEe eL])erience modification tiFlat word EOE0 Deen calcElated if Form PN 04 99 01 J (06/25) Printed in 0-S.A. Process Date: 11/04/20 Page 1 of 3 Policy Expiration Date: 11/04/26 ❑D ro❑actual losses were inciired dimming tiu eEperience period. Tins i❑ypotiutical rating calcnation is pronded for informational p0rposes only. Dispute Process Yo❑ may dispi to oil actions or tiu actions of tiu WCIRB piers❑ant to CIC Sections 11 ❑3❑ and 11 ❑iE3.1. A. Our Dispute Resolution Process. Yo❑ may send u a written Complaint and Re❑❑est for Action re❑lusting that we reconsider a cunge in a classification assignment tut resnts in an increased premiiE n and/or re❑lusting tut we renew tiu manner in wnc❑ oil- rating system us iuen applied in connection wit❑ tiu ins:l-ance afforded or offered you Written Complaints and Re❑lists for Action s0nd Fie forwarded to❑ Hartford Casualty Insurance Company One Pointe Drive, Suite 200, Brea, CA 92821; Telephone (800) 451-6944; Fax (860) 723-4289. After yoi❑ send yoi- Complaint and Re❑❑est for Action, we lulu 30 days to send yo❑ a written notice indicating wutiur yoi written re❑lust will iu renewed. If we agree to renew yoi re❑lust, we mint condiut to renew and issiu a decision granting or re�octing yoi- re❑lust witinn 60 days after sending yo❑t❑e written notice granting renew. If we decline to reinew yoi-i- re❑list, if yo❑ are dissatisfied wit❑ tiu decision Egon reinew, or if we fail to grant or re:ect yoi r rei❑i Ost or issiu a decision —pon reinew, yo❑ may appeal to tEe Insi-i-ance Commissioner as descriiud in paragrap❑ II.C., Mow. B. Disputing the Actions of the WCIRB. If yo❑ uu ❑een aggrieud ❑y any decision, action, or omission to act of tiu WCIRB, yo❑ may re❑list, in writing, tut tiu WCIRB reconsider its decision, action, or omission to act. Yo❑ may also re''❑❑est, in writing, tut tlu WCIRB renew tiu manner in wnc❑ its rating system us iuen applied in connection wit❑ tiu ins0rance afforded or offered yoi For re❑lusts related to classification dispi tes, to reporting of ei[perience, or courage issius, yoi initial re —lust for renew milt iu receiud Ey tiu WCIRB witnn 12 montiu after tiu ei[piration date of tlu policy to wnc❑ tiu re❑list for renew pertains, eiuept if tiu re❑lust in!ulus tiu application of tiu Rension of Losses rive. For re —lists related to yo:lr ei[perience modification, yoi initial re❑list for reinew mint a receiud i❑y tiu WCIRB witnn 6 montiu after tiu issuance, or 12 montiu after tiu eEpiration date, of tiu e�j)erience modification to wnc❑ to re —lust for reinew pertains, wnci❑eur is later, eiuept if to re❑list for reinew inulus to application of tiu Rension of Losses rive. If tiu re❑lust inulius tiu Reinsion of Losses rive, tiu time to state yoi- appeal may iu longer. :See Section ❑I, Rne ❑oftu ERP❑ Yo❑ may commence to renew process i❑y sending tiu WCIRB a written In❑nry. Written In❑nries siund iu sent toi❑WCIRB, One Montgomery Street, Suite 400, San Francisco, CA 94104, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice(&wcirb.com (email). If yo❑ are dissatisfied wit❑ to WCIRB19 decision —pon an In❑inry, or if tlu WCIRB fails to respond witinn 90 days after receipt of to In❑inry, yo❑ may pijsiu tiu s❑i❑:Oct of tiu In❑inry i❑y sending tiu WCIRB a written Complaint and Re❑i— st for Action. After yo❑ send yoi - Complaint and Re❑i❑est for Action, tiu WCIRB us 30 days to send yo❑written notice indicating wiutur yoij written re❑list will iu renewed. If tiu WCIRB agrees to reinew yoFir re❑lust, it mint condiut to renew and issiu a decision granting or reFecting yoij re❑lust witnn 60 days after sending yo❑ tiu written notice granting reinew. If to WCIRB declines to renew yoij re❑list, if yo❑ are dissatisfied wit❑ tiu decision ikon renew, or if tlu WCIRB fails to grant or re:ect yoij re❑list or issiu a decision —pon reinew, yo❑ may appeal to tiu Insiance Commissioner as descriiud in paragrap❑ II.C., iulow. Written Complaints and Re❑❑ests for Action siEond ❑e forwarded to❑WCIRB, One Montgomery Street, Suite 400, San Francisco, CA 94104, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerservice(&-wcirb.com (email). C. California Department of Insurance - Appeals to the Insurance Commissioner. After yo❑ follow tiu appropriate dispi❑te resoliEtion process descriiud aiuu, if :1 ❑we or tiu WCIRB decline to reinew yoEir re❑lust, -2❑yo❑ are dissatisfied wit❑ t❑e decision ikon renew, or :3❑we or tlu WCIRB fail to grant or re:ect yoiEr rei❑rust or issiu a decision ikon reinew, yo❑ may appeal to tiu Instance Commissioner pEirsunt to CIC Sections 11 ❑Yq 11 ❑i .6, 11 ❑❑3.1 and Title 10, California Code of Reg:lations, Section 2i❑09.40 et se:1 Yoi❑ mint file yoi - appeal witinn 30 days after we or tiu WCIRB send yoi❑ tiu notice re:ecting reinew of yoEr Complaint and Rei❑❑est for Action or tiu decision ikon yoi Complaint and Re❑i❑est for Action. If no written decision regarding yoi Complaint and Re❑Cest for Action is sent, yoi appeal mut iu filed witinn 120 days after yo❑sent yoij Complaint and Re❑i❑est for Action to iu or to tiu WCIRB. Ti❑e filing address for all appeals to t❑e Insurance Commissioner is❑ Form PN 04 99 01 J (06/25) Printed in ❑.S.A. Page 2 of 3 Administrati::0 Dearing B rea❑ California Department of Ins:1rance 1901 ❑arrison Street, 3rd Floor Mailroom Oaidand, CA 94612 41 ❑.::38.4243 Yo❑ :18[:6 t0a rigid to a earing iDafore tip Insurance Commissioner, and o-r action, or tip action of t e WCIRB, may :]a affirmed, modified or reEorsed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pi�s:lant to California Insurance Code Section 11 ❑i-2.6, a policyEolder om❑❑dsman is a[LiilaF]e at t❑e WCIRB to assist yo❑ in oEtaining and e[LiI❑ating t0a rating, policy, and claims information referenced in I.A. and I.B., a❑o[Fe. T❑e om❑❑dsman may ad[Else yo❑on any disp❑te wit❑ ❑s, to WCIRB, or on an appeal to t❑e Instance Commissioner p❑rsEiant to Section 11 ❑30 of tE-e InsFirance Code. T❑e address of tEle policy❑older om❑❑dsman is WCIRB, One Montgomery Street, SE]te 400, San Francisco, CA 94104, Attn❑Policy❑older Om❑Edsman. T❑e policyEolder om❑Edsman can ❑a reac❑ad at 41 ❑.❑❑8.01119 [p❑one441 [E1301.E288 [famand om❑F-dsman❑ wciracom [email[] B. California Department of Insurance - Information and Assistance. Information and assistance on policy ❑❑astions can ❑e oElained from to Department of Ins[rance ConsEner ❑OTLI❑E, 800.9211.11ELP 143❑❑❑or ins Orance.ca.go❑ For ❑❑astions and correspondence regarding appeals to t❑e AdministratiE0 Dearing Berea❑, see t-e contact information in paragrap❑ II.C. Tus notice does not ciange t:1a policy to wuc❑ it is attac:10d. Form PN 04 99 01 J (06/25) Printed in ❑.S.A. Page 3 of 3 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 We ❑85e t❑e rig t to reco-er oEir payments from anyone liade for an in❑]y coE0red ❑y tEis policy. We will not enforce o-r rig Et against tie person or organii�tion named in t:10 Sc❑wide. T❑is agreement s-all not operate directly or indirectly to ❑enefit anyone not named in t❑e Sc❑edde. SCHEDULE City of Scottsdale, 9191 E SA❑ SAL❑ADOR DR, SCOTTSDALE, A❑, 8E2E8 CoAtersigned ❑y AEtEoriE0d Representati-e Form WC 00 03 13 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT Policy Number: ❑6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on tie Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 T❑e premi-n for t❑e policy will ❑e ad❑Ated ❑y an eEperience rating modification factor. t❑e policy was iss❑ed. T❑e factor, if any, sown on t❑e Information Page is an estimate. s❑bw t❑e proper factor, if different from to factor sown, w❑en it is calc:1ated. Co-ntersigned ❑y T❑e factor was not aE]3ilade w❑en We will iss❑e an endorsement to AAEoried Representatie Form WC 00 04 03 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 1d:IRI4kiIBiel :4.1- 4 M14kik1[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIIIIA-l"ANA-1111kIDEA N411111111MA PREMIUM DISCOUNT ENDORSEMENT Policy Number: ❑6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Tie premi-n for toms policy and t❑e policies, if any, listed in Item 3 of t❑e Sc❑edde may ❑e eligi:]e for a disco At. T-is endorsement sE0ws yo-r estimated disco-nt in Item 1 or 2 of tie Sc❑wide. T❑e final calcdation of premi-n disco❑nt will ❑e determined ❑y of man-als and yo-r premi-n ❑asis as determined ❑y a❑dit. Premi::n s❑❑act to retrospecti!5e rating is not s❑❑lect to premiEM disco_nt. SCHEDULE 1. Ta Je of States California or any otter State t❑at ❑as approiLad t❑e premiEn disco-nt plan applica:]e to tie total policy premi-n on an interstate psis at t❑e effecti�:o date of t e policy. 2. A!-0rage percentage discoAtEO.10 ❑ 3. Ot❑er policies[] 4. If t❑ere are no entries in Items 1, 2 and 3 of tJa Sc❑edde, see t❑e PremiEn Disco-nt Endorsement attac❑ed to yo-r policy n0n❑er❑ CoEntersigned ❑y AEtEoriC:od Representati e Form WC 00 04 06 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 90-DAY REPORTING REQUIREMENT - NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Policy Number: F:6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/20 Effecti-:0 iE0:1r is tFle same as stated on t❑e Information Page of t�le policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE A❑ 8160 Yo❑ mC:8t report any cEiange in ownersEJp to ❑s in writing witEJn 90 days of t❑e date of t❑e c❑ange. CF]ange in ownersEJp inclEdes sales, p0rcEiases, oti-lar transfers, mergers, consolidations, dissolEtions, formations of a new entity and ot❑er cF]anges prodded for in t0a applicaFle eEperience rating plan. EEperience rating is mandatory for all eligiFle insEireds. T❑e eEperience rating modification factor, if any, applicaFle to tEJs policy, may cF]ange if tDare is a c❑ange in yo❑r ownersEJp or in t❑at of one or more of t0e entities eligide to ❑e comCined wit❑yo❑for eEperience rating plirposes. Faille to report any cLiange in ownersEJp, regardless of w0et!�r tLie cEiange is reported witEJn 90 days of s❑c❑ cEiange, may resdt in reEJsion of t❑e eEperience rating modification factor C8ed to determine yob premiE n. T❑is reporting re❑EJrement applies regardless of wL]etjer an eEperience rating modification is cEirrently applicaEle to tEJs policy. Form WC 00 0414 A Printed in O.S.A. Process Date: 11/04/2i❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PART FIVE - PREMIUM AMENDATORY ENDORSEMENT Policy Number: -6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 EffectiE0 iFO❑r is t-e same as stated on t❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training F-432 E TIERRA B❑E❑A L❑ SCOTTSDALE A❑ 8-160 Ti❑is endorsement amends Part FiE0 - Premi::n of tip policy as follows❑ Part FiEe - PremiiEn, Section A. i:Oj Manilals❑is replaced iy tip following proEJsion❑ A. Our Manuals All premiLin for tEJs policy will Da determined y oiEr manilals of rues, rates and loss costs :as applicaJeQ rating plans, forms, endorsements, and classifications, and sib❑ mane-als are e:pressly incorporated y reference into, and apply to, tits policy and any renewals i:oj manilals❑ As iced in tJs policy and any renewals, oLir manilals means mantels tit EaCO ❑een❑ 1. DeEoloped in any format and filed ❑y tie state -designated worEors compensation rating or addsory organiE:8tion on olir ❑eCialfwit❑t❑e appropriate state instance regdatory aEt❑ority❑or 2. DeEoloped in any format and filed y tip respectii-:0 state rating ❑lea❑ on oil :10❑alf wit❑ t0e appropriate state instance regi-latory ai-t❑ority❑or 3. DeEoloped in any format and filed y ❑s witi❑ti0e appropriate state insiiance reg:1atory aiEtEorityiland 4. For eac❑ or any of tip tree scenarios a❑oil, tie manilals also mE8t :10 approiEed for ::8e y tip appropriate state insi-irance regiJatory ai-t❑ority, or as ot:lerwise aEt❑ori!Eod y law as applicaiEle. We may c!lange of manilals and apply t❑ e c!langes to toms policy and any renewals if s❑c❑ manlal clanges are approiEed for Se y t❑e appropriate state ins❑rance reg:latory aAEority, or an otEierwise ai_t❑orii_:0d ❑y law as applicaJe. Part Fib - Premii-in, Section D. FPremi::rn Payments❑is replaced y t❑e following pro:lsion❑ D. Premium Payments Yo❑ will pay all premiiE n w0en d!-10. Yo❑ will pay tile premi!Ern e.on if part or all of a worEors compensation law is not E8Iid. TOO d!-le date for a!llit and retrospectiE6 premiE ns is t0a dFle date specified in tFle !JIling for tFla policy. Form WC 00 0419 A Printed in O.S.A. Process Date: 11/04/202❑ Policy Expiration Date: 11/04/2026 li:IRI4kiIBiel :4.1- 4 114ki III 1[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIA-l"ANA-1117111IDEA N 4111111MA CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 Effecti❑e Eolir is t0e same as stated on tie Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 T❑is endorsement is notification t❑at we are clarging premi-n to co-er t❑e losses t❑at may occ-r in t❑e e❑ent of a Catastrop❑e COt❑er T❑an Certified Acts of Terrorism❑as t❑at term is defined ❑elow. Yo-r policy proddes coEorage for worCO3rs compensation losses caF8ed ❑y a Catastrop❑e COt❑er T❑an Certified Acts of Terrorism❑ Co❑erage for s❑c❑ losses is s❑❑sect to all terms, definitions, eEcIC:8ions, and conditions in yoj policy, and any applicade federal and/or state laws, riles, or reg:lations. T❑is premiEn c❑arge does not prodde fEnding for Certified Acts of Terrorism contemplated Ender t❑e Terrorism Ris❑ Ins-rance Program Rea t❑ori_:8tion Act Disclos-re Endorsement attac❑ed to toms policy. State See Attac❑ed Sc❑edde For p-rposes of t:js endorsement, Catastrop❑e COt❑er T❑an Certified Acts of Terrorism -is defined as❑A single e❑ent or peril resdting in a gro-p of claims wit - aggregate wor-ers compensation losses in e cess of ❑❑D million. T❑is 11❑0 million tilres❑old applies per occ[Irrence, across all states for wE]c❑ claims arise from a single e-ent or peril. T❑e premilin cEiarge for t_e co erage yo-r policy proddes for worEOrs compensation losses caked ❑y a Catastrop❑e COt❑ar T❑an Certified Acts of Terrorism❑is sown in Item 4 of t❑e Information Page or in t❑e Sc❑edde ❑elow. Schedule Rate Premium Form WC 00 04 21 F Printed in O.S.A. Process Date: 11/04/20 Policy Expiration Date: 11/04/26 1111:IRI4kiIBiel :4.14114ki III 1[s]:/_1kiM4:19:I:11e7lill[WMJIIIIA-l"ANA-1117111IDEA N 4111111MA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT Policy Number: ❑6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 Effectie Eolir is t❑e same as stated on t❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training 432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Part Fi e - Premi-n, Section G. [A❑dit❑of t❑e Wor❑ers Compensation and Employers LiaJlity Ins-rance Policy is reused ❑y adding t❑e following❑ If yo❑ do not allow e to eemine and a❑dit all of yob records t-at relate to tEJs policy, and/or do not pro:jde a❑dit information as re❑❑ested, we may apply an A❑dit ❑oncompliance C❑arge. T❑e met❑od for determining tie A❑dit ❑oncompliance Cerge y state, were applicade, is sEown in t❑e Scedde ❑elow. If yo❑ allow ❑s to eemine and aF-dit all of yoj records after we ❑ae applied an A❑dit ❑oncompliance Cerge, we will redse yo-r premi❑m in accordance wit❑off manels and Part ❑- Premi-n, E. final PremiE]n❑of tEis policy. Fail -re to cooperate wit[] tEJs policy prodsion may rest in t❑e cancellation of yo-r instance co erage, as specified eder tie policy. Schedule Basis of Audit Noncompliance Maximum Audit Noncompliance State(s) Charge Charge Multiplier AL, AR, CO, CT, DC, DE, GA, IA, ID, Estimated Anne] Premi-m ❑p to two times IL, ❑Y, MD, ME, MI, M❑, MS, ❑E, ❑q ❑M, OR, RI, SC, SD, T❑, ❑T, ❑A, ❑T, W❑ All, ❑I, ❑S, O❑ Estimated Ann -al Premi-n Two times ❑C Estimated Ann -al Premi-m ❑p to tree times ❑❑ Estimated Ann❑al PremiErn ❑p to one times WI Estimated Annel Premi::n One time Form WC 00 04 24 Printed in ❑.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ARIZONA ALCOHOL- AND DRUG -FREE WORKPLACE PREMIUM CREDIT ENDORSEMENT Policy Number: E6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti—e ❑o r is t­e same as stated on ti❑e Information Page of t e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE A❑ 8-160 Ti❑is endorsement applies only to tie insiiance pro:1ded ❑y tip policy iDecaE8e AriEona is sown in Item 3.A. of tEie Policy Information Page. T❑is endorsement proddes notice tit premiun for yoLir policy may ❑e affected ❑y tie AriFona Alco❑ol-and Dr❑g- Free WorEplace Premiun Credit Program. Yo❑ may ❑E81ify for a ❑❑ premiiun credit if yo❑ Fia::o esta:lis❑ed and maintain a ❑ilalifying alco❑ol- and driug- free worEplace program in accordance wit-] Title 23, Cif pter 2, Article 14 ofAriiEona Statues. We will determine yoij eligiiility for tics premiiun credit after total premiiun iEas !Feen paid for tip policy period and may Ele reused at tie time yoij final premii7n ai-lit is processed. Ti❑e determination tit yo❑ iDaLla a ❑Eialifying program m❑5t Lie made eac❑ year t-at yo❑ receiC:o t❑a premiun credit. To implement a premiun credit program, tip following gidelines m❑st ❑e estaiis❑ed❑ 1. Inssers offering t e premiiun credit program may apply a ❑i❑ premiErn credit to ❑Ealifying employers. 2. To recei::0 t❑e premiiun credit, yo❑ mi❑;t❑ a. Proide a written statement to t0a insuer prior to or witin 30 days after t0a ❑eginning of tDO policy effectiE0 date eac❑ year, certifying tLiat t❑e ❑Clsiness Elas implemented a program meeting tip re❑irements of Title 23, CF18pter 2, Article 14. At any time dimming tiDa term of tiDa policy, proiide additional information to t❑r insiier, as re❑fired, to confirm tiEat a ❑E81ifying program iDas iDeen estaiiisL]ed and is ring maintained. c. Comply wit❑ t%e alcoi❑oI and drug testing policy re❑EJrements in accordance wit❑ Title 23, CE18pter 2, Article 14. d. Cond❑ct alco❑ol and driig testing of prospectiE0 employees. e. Condit alco❑ol and dr❑g testing of an employee after tip employee iDas i-leen iniEred. f. Allow E8 to iDOiE0 access to t❑ e alco❑ol and drJg testing resits Finder d. and e. a❑o::O. 3. Tile determination t-at yo❑ LIOiEO estaiis❑ed and maintain a ❑Lialifying program m❑5t Lie made d0ring eac❑ policy term t et yo❑ receiC:o t0a premiun credit. 4. Yoij certification and any otDar information relied —pon ❑y tEie insiier in granting tip premiiun credit m—st ❑a Copt in t0a insierS Enderwriting files and made ai:ailaE]e to t0e Department of Ins ance Egon re ❑lest. a T❑e premiiun credit may !Da applied after total premiiun -as Deen paid for t!❑r policy period and may De reused at final ai—dit to tiDO employers policy. T❑e credit is applicaie as a s—pplement to deiated rates and is applied in a mitiplicatiEo manner, after ti❑r application of ti❑r ei-I)erience modification, and ❑✓fore ti❑r application of t❑a premiiun discoiEnt and eiEpense constant. 6. Yo❑ milt reim❑iJse tEla premiiun credit if it is determined tiDat yo❑were not in compliance wit❑t❑a proisions of tEla program. :1 Minimiun premiun policies are eligiie for tics premiiun credit. 8. Residi❑al mariEot employers are eligiie to apply for tics premiiun credit. Form WC 02 04 01 C Printed in ❑.S.A Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ARIZONA CANCELLATION AND NONRENEWAL ENDORSEMENT Policy Number: E6 WEG Bi❑3❑Pi❑ Endorsement Number: Effective Date: 11/04/211 Effectiu iuu is to same as stated on ti❑e Information Page of to policy. Named Insured and Address: Beginners Edge Sports Training 432 E TIERRA Bi❑E❑A L❑ SCOTTSDALE A❑ 8E260 Tus endorsement applies ❑ecaiue Ari❑bna is sewn in Item 3.A. of tiu Information Page. Part Si-1- Conditions, Section D. :Cancellationi--lof t❑e policy is replaced i❑jr tEe following❑ D. Cancellation and Nonrenewal 1. Yo❑ may cancel tus policy. Yo❑ mut mail or deliur adL:8nce written notice to ❑8 stating w❑en t❑e cancellation is to taiu effect. 2. If yo❑cancel or fail to renew tus policy, we mint promptly notify tiu Indiutrial Commission of Arii3Dna. 3. We may cancel tus policy if yo❑ fail to pay premiun wun du, or w❑en one or iut❑ of to parties to a professional employer agreement terminate t❑e agreement. o If we cancel or nonrenew tus policy, we milt proude to yo❑ and t!u Indiutrial Commission of Ariiuna at least 30 days❑Potice of tiu cancellation or nonrenewal. o ❑otice to yoi❑ may iDe sent iJa mail or deli::Ored ❑y electronic means as followsi❑ o Mailing tut notice to yo❑ at you last -mown mailing address on file wit❑ iEs will iu s❑fficient proof of notice. o Deliury to an email address at wuc❑yoi❑ iuu consented to receiu notices or dociunents. o Posting on a portal, seciue weiuite, electronic networ❑ or site accessiue ua tiu Internet or a motile application, comps ter, motile deice, tauet, or otiur electronic deuce, toget!ur wit❑ a separate notice tut inclihles a description of to dociunent or notice tut was posted and tilat was prouded Dy email to tiu email address at wuc❑yo❑ consented to receiu notice, or ❑y any otiur deliiury meti❑od to wuc❑ yo❑ consented. o Ifyo❑consented to uu tlu notice emailed in accordance wit❑AriiFona law, emailing that notice to yo❑at yoiu last -mown email address as prouded ❑y yo❑to ❑s will iu s❑fficient proof of notice. o If to email notice is❑11 ❑re:ected for deliury❑i-2❑retuned to iu❑or F3❑we ucome aware that to email address prouded ❑y yo❑ is no longer Mid, t-en we will also mail tut notice to yo❑ i❑y ❑S Postal Seruce certified mail, certificate of mailing, or first-class mail ring intelligent mail urcode, or anot!ur similar tracing meta bd i❑sed or approud i❑y to ❑S Postal Seruce. o If we nonrenew tEis policy and fail to giu yo❑ notice of nonrenewal, courage will not emend iuyond tiu policy period. 4. T❑e policy period will end on t❑e date and time stated in tiu cancellation or nonrenewal notice. F! Any of tiuse prolusions tint conflict wit❑ a law that controls to cancellation of t—e insivance in tins policy is changed i❑y fius statement to comply wit❑ ti❑e law. Form WC 02 06 01 C Printed in O.S.A. Process Date: 11/04/2i❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY AMENDATORY ENDORSEMENT - CALIFORNIA Policy Number: F-6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effectie ieDr is t!e same as stated on tle Information Page of to policy. Named Insured and Address: Beginners Edge Sports Training 432 E TIERRA B❑E❑A L❑ SCOTTSDALE A❑ 8E260 It is agreed tet, anytEJng in to policy to t❑e contrary notwitetanding, s❑c❑ ins❑rance as is afforded ❑y tEJs policy ❑y reason of t❑e designation of California in Item 3 of to Information Page is s❑❑iect to t❑e following prodsions❑ 1. Minors Illegally Employed - Not Insured. Tus policy does not coer liai�lity for additional compensation imposed on yo❑ Ender Section 4❑❑❑, DiJsion I❑, La!er Code of to State of California, y reason of inilry to an employee ceder si::teen years of age and illegally employed at to time of inEry. 2. Punitive or Exemplary Damages - Uninsurable. T!❑is policy does not co -:Or pEnitie or eemplary damages were instance of lia::Jlity t!erefor is pro!JJted y law or contrary to p❑tic policy. 3. Increase in Indemnity Payment - Reimbursement. Yo❑ are o:ligated to reim❑--se s for tie amo—nt of increase in indemnity payments made p—rsent to S❑❑di:jsion -d—of Section 46 0 of tie California La or Code, if tie late indemnity payment wJc❑ gies rise to tie increase in tie amo—nt of payment is d❑e less ten seen ❑ days after we receie tie completed claim form from yo❑. Yo❑ are o:ligated to reim❑--se e for any increase in indemnity payments not coered —nder toms policy and will reim❑use E8 for any increase in indemnity payment not coered Ender to policy wen to aggregate total amoEnt of to reim❑lirsement payments paid in a policy year eC(,eeds one ❑Endred dollars Fill00❑ If we notify yo❑ in writing, witEJn 30 days of to payment, tat yo❑are odigated to reim❑use e, we will EJII yo❑ for to amoLjit of increase in indemnity payment and collect it no later ten t❑e final aLdit. Yo❑ will ❑ae 60 days, following notice of to oEligation to reim❑use, to appeal to decision of t a insilrer to to Department of Instance. 4. Application of Policy. Part One, "Worers Compensation Instance", A, "Dow T❑is Inssance Applies", is amended to read as follows❑ T❑is worers compensation ins!-irance applies to edily inlory y accident or disease, incl-ling deat❑ resElting terefrom. Bodily inEflry y accident meet occ!-ir d!-iring to policy period. Bodily inky ❑y disease meet !e caeed or aggra::8ted y t!e conditions of yo!j employment. YoOr employee's eiEposi-1re to t❑ose conditions caging or aggrai-:8ting s❑ ic❑ edily in❑ry y disease meet occOr ding t❑ e policy period. :1 Rate Changes. Tle premiiE n and rates wit❑ respect to tle instance pro:jded ❑y toms policy ❑y reason of tie designation of California in Form WC 04 03 01 BB Printed in O.S.A. Process Date: 11/04/2❑ Page 1 of 2 Policy Expiration Date: 11/04/26 El Item 3 of tip Information Page are s❑❑iect to cE:Onge if ordered ❑y t e Insr7ance Commissioner of tDO State of California pL]rsi:ant to Section 11 i❑3❑ of t❑e California Ins:lrance Code. Long Term Policy. If tEls policy is written for a period longer tDan one year, all t❑a proElsions of tEls policy smell apply separately to eac❑ consecEliC:o twel❑e-mont❑ period or, if tE-e first or last consecEliC:o period is less tin twelEo montE8, to s❑c❑ period of less tin twelEo montE8, in tE-e same manner as if a separate policy Elad ❑een written for eac❑consecEliC:o period. Statutory Provision. Yoh employee Eas a first lien !won any amoEint wJc❑ Flecomes owing to yo❑ ❑y ::8 on acco::nt of tits policy, and in t0e case of yo:lr legal incapacity or inai lity to receiC:o t!Da money and pay it to t0b claimant, we will pay it directly to t!-le claimant. Part Fi!EO, " PremiE n", E, "Final PremiiE n", is amended to read as follows❑ T❑e premi::n siEown on t!-la Information Page, scDed�es, and endorsements is an estimate. T❑e final premiErn will !Da determined after tiffs policy ends ❑y ring tEa act -al, not t!-le estimated, premi�n psis and tDO proper classifications and rates t❑at lawf:lly apply to t❑e ❑❑siness and wor❑ cored ❑y tips policy. If tip final premi❑m is more tiEan tip premi::n yo❑ paid to ice, yo❑ mi—st pay ::8 t0e glance. If it is less, we will refEnd t:1e :1lance to yo:1 TCe final premi::n will not Da less t:an t e JgElest minimiEn premiiErn for t0a classifications cored Dy tips policy. If tEJs policy is canceled, final premiErn will ❑e determined in t❑e following way ❑mess oFir manDals prodde ot❑arwise❑ a. If we cancel, final premiErn will ❑e calcL]ated pro rata used on t❑a time tEJs policy was in force. Final premiErn will not ❑e less tin t❑e pro rata si:are of t!Da minim:ln premi:ln. :1 If yo❑ cancel, final premi:ln may 00 more ti n pro rata❑it will !Da :lased on t0a time tiJs policy was in force, and may Da increased ❑y o:lr smart -rate cancelation taEle and proced:lre. Final premiErn will not 00 less tFlan t0a pro rata stare of t!Da minim:ln premi:ln. It is fiErt:ler agreed t❑at tiffs policy, incl❑ding all endorsements forming a part t:lereof, constitEtes tEe entire contract of ins:l-ance. ❑o condition, prodsion, agreement, or iEnderstanding not set fort❑ in tEJs policy or sue❑ endorsements sell affect sue❑ contract or any rigs, dries, or priijleges arising ti—erefrom. Form WC 04 03 01 BB Printed in❑.S.A. Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: L6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/20 Effecti!E0 E0:1r is t:10 same as stated on t❑e Information Page of t�le policy. Named Insured and Address: Beginners Edge Sports Training ::432 E TIERRA B❑E❑A Li❑ SCOTTSDALE A❑ 8E260 We EIOFA� tip rigiA to recoFor oil- payments from anyone liaise for an inFiry co:�Ored i❑y t[js policy. We will not enforce oEr rig❑t against t0a person or organiE8tion named in t0e Sc ed:le. bus agreement applies only to tEie eEtent tEat yo❑ perform wor❑ Ender a written contract tilt re❑EJres yo❑to oEtain tips agreement from iDs.❑ Yo❑ milt maintain payroll records acciiately segregating t❑e remiEneration of yob employees wile engaged in tEJe wori❑ descrl❑ed in tip Sci—ed:le. T❑e additional premi::n for tus endorsement sell Da ❑ ❑ of tip California wormers -compensation premi::n oti-erwise d❑e on s❑c❑remEneratio n. Person or Organization Ti❑e City of Mission ❑ie:o SCHEDULE CoiEntersigned ❑y Job Description 01 Ail❑ori::Od Representatii-:0 Form WC 04 03 06 :1 ❑Printed in D.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: L6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/20 Effecti!E0 E0:1r is t:10 same as stated on t❑e Information Page of t�le policy. Named Insured and Address: Beginners Edge Sports Training ::432 E TIERRA B❑E❑A Li❑ SCOTTSDALE A❑ 8E260 We EIOFA� tip rigiA to recoFor oil- payments from anyone liaise for an inFiry co:�Ored i❑y t[js policy. We will not enforce oEr rig❑t against t0a person or organiE8tion named in t0e Sc ed:le. bus agreement applies only to tEie eEtent tEat yo❑ perform wor❑ Ender a written contract tilt re❑EJres yo❑to oEtain tips agreement from iDs.❑ Yo❑ milt maintain payroll records acciiately segregating t❑e remiEneration of yob employees wile engaged in tEJe wori❑ descrl❑ed in tip Sci—ed:le. T❑e additional premi::n for tus endorsement sell Da ❑ ❑ of tip California wormers -compensation premi::n oti-erwise d❑e on s❑c❑remEneratio n. SCHEDULE Person or Organization Beginners Edge Sports Training, LLC❑432 East Tierra B❑ena Site 102 Scottsdale AD 8i[26 CoiEntersigned ❑y Job Description 02 Ail❑ori::Od Representatii-:0 Form WC 04 03 06 :1 ❑Printed in D.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: L6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/20 Effecti!E0 E0:1r is t:10 same as stated on t❑e Information Page of t�le policy. Named Insured and Address: Beginners Edge Sports Training ::432 E TIERRA B❑E❑A Li❑ SCOTTSDALE A❑ 8E260 We EIOFA� tip rigiA to recoFor oil- payments from anyone liaise for an inFiry co:�Ored i❑y t[js policy. We will not enforce oEr rig❑t against t0a person or organiE8tion named in t0e Sc ed:le. bus agreement applies only to tEie eEtent tEat yo❑ perform wor❑ Ender a written contract tilt re❑EJres yo❑to oEtain tips agreement from iDs.❑ Yo❑ milt maintain payroll records acciiately segregating t❑e remiEneration of yob employees wile engaged in tEJe wori❑ descrl❑ed in tip Sci—ed:le. T❑e additional premi::n for tus endorsement sell Da ❑ ❑ of tip California wormers -compensation premi::n oti-erwise d❑e on s❑c❑remEneratio n. SCHEDULE Person or Organization City of West ❑ollywood, 8300 Santa Monica BlEd, West ❑ollywood, CA 90069. CoiEntersigned ❑y Job Description 003 Ail❑ori::Od Representatii-:0 Form WC 04 03 06 :1 ❑Printed in D.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: L6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/20 Effecti!E0 E0:1r is t:10 same as stated on t❑e Information Page of t�le policy. Named Insured and Address: Beginners Edge Sports Training ::432 E TIERRA B❑E❑A Li❑ SCOTTSDALE A❑ 8E260 We EIOFA� tip rigiA to recoFor oil- payments from anyone liaise for an inFiry co:�Ored i❑y t[js policy. We will not enforce oEr rig❑t against t0a person or organiE8tion named in t0e Sc ed:le. bus agreement applies only to tEie eEtent tEat yo❑ perform wor❑ Ender a written contract tilt re❑EJres yo❑to oEtain tips agreement from iDs.❑ Yo❑ milt maintain payroll records acciiately segregating t❑e remiEneration of yob employees wile engaged in tEJe wori❑ descrl❑ed in tip Sci—ed:le. T❑e additional premi::n for tus endorsement sell Da ❑ ❑ of tip California wormers -compensation premi::n oti-erwise d❑e on s❑c❑remEneratio n. SCHEDULE Person or Organization City of Ri:�Orside, 3900 Main St Ri:�Orside, CA CoiEntersigned ❑y Job Description 2 Ail❑ori::Od Representatii-:0 Form WC 04 03 06 :1 ❑Printed in D.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 Ii:IRI4kiIBiel :4-1. 4 M14ki III I[s]:/_1ki It] 4•'19:I:11e7lill[wMJIIIIA-l"ANA-1117111IDEA N4111111MA ARIZONA AMENDATORY ENDORSEMENT Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 EffectiEe F-01ir is tFia same as stated on t❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 T❑is endorsement applies ❑ecaF:8e AriEona is s❑ own in Item 3.A. of t❑e Information Page. Item 2. of t❑e Information Page is replaced ❑y t❑e following❑ 2. T❑e policy period is from 11/04/211to 11/04/26 12101 a.m. in t❑e time Eone of tip insEred19 mailing address. For endorsements iss❑ed d—ring t::0 policy period, t❑e effecti—e date is in t❑e time ❑one of t❑e insEredCs mailing address. Form WC 02 06 03 A Printed in O.S.A. Process Date: 11/04/20 Policy Expiration Date: 11/04/26 Ill i:IRI4kiIBiel :4.1. 4 M14kikl[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIIIIA-l"ANA-1111kIDEA N411111111MA EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/20 EffectiC:8 Eolir is t❑e same as stated on t❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training 432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 T❑e instance afforded ❑y Part Two employers❑LiaEJIity C. T❑e "Exclusions" section is modified as follows Call Instance❑❑y reason of designation of California in Item 3 ot❑er eEcIC:8ions in t❑e "Exclusions" section remain of t❑e Information Page is s❑❑lact to tie following as ism prodsions❑ 1. ECP,IClsion 1 is amended to read as follows[] A. "How This Insurance Applies," is amended to read 1. liaE lity assErned ceder a contract. as follows❑ 2. E❑clC:8ion 2 is deleted. A. ❑ow TEJs Instance Applies 3. ECPIC:8ion El is amended to read as follows❑ T❑is employers diaE lity instance applies to ❑odily a damages arising oEt of coercion, criticism, in❑ry ❑y accident or ❑odily in❑ry ❑y disease. demotion, eC:il❑ation, reassignment, Bodily in❑ry means a p❑ysical in❑ry, incl❑ding discipline, defamation, ❑arassment, resdting deata ❑Erniliation, discrimination against or 1. T❑e ❑tidily inky mC:8t arise oEt of and in t❑e termination of any employee, termination of copse of t❑e in❑red employee® employment employment, or any personnel practices, ❑y you policies, acts or omissions. 2. T❑e employment mC:8t ❑e necessary or 4. T❑e following e❑ IE:8ions are added❑ incidental to yob wor❑ in California. 1. ❑tidily in❑ry to any mem❑er of t❑e flying crew 3. Bodily in❑ry ❑y accident mC:8t occEir ding of any aircraft. t❑e policy period. 2. ❑odily in❑ry to an employee w❑en yo❑ are 4. Bodily in❑ry ❑y disease m❑st ❑e ca❑sed or depri❑ed of statEtory or common law aggra❑ated ❑y t❑e conditions of yob defenses or are s❑❑lect to penalty ❑eca❑se employment. T❑e employee® last day of last of yob faille to secEire yob odigations eEpos❑re to t❑e conditions caC:8ing or Ender t❑e worEors❑ compensation IaWCS❑ aggraE:Ating s❑c❑ ❑tidily in❑ry ❑y disease applicade to yo❑ or ot❑erwise fail to comply mC:8t occEir ding t❑e policy period. wit❑t❑at law. a If yo❑ are s❑ed, t❑e original sEJt and any 3. liaE lity arising from California La❑or Code related legal actions for damages for ❑tidily Section 2810.3 wEJc❑ relates to la❑or in❑ry ❑y accident or ❑y disease m❑st ❑e contracting. Eiro❑gEt in t❑e ❑nited States of America, its territories or possessions, or Canada. CoEritersigned ❑y AEtEoriEod Representati-e Form WC 04 03 60 B Printed in O.S.A. Process Date: 11/04/20 Policy Expiration Date: 11/04/26 111:IRI4kiIBiel :4.1- 4 M14ki III I[s]:/_1ki It] 4•'19:I:11s7ll![WMJIIIIIA-l"ANA-1117111IDEA N4111111111MA OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is Cie same as stated on tile Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Yo❑ m❑st prodde E8, or oEir aEtEori❑ed representatiE0, access to records necessary to perform a payroll ❑erification a❑dit. If yo❑ fail to prodde access witEjn 90 days after expiration of t❑e policy, yo❑are liade to pay a total premiEn e❑❑al to 3 times olir ca-rent estimate of t❑e ann❑al premiEn for yob policy. In addition, ifyo❑fail to prodde access after olir tEJrd re❑❑est witEJn a 90 day or longer period, yo❑ are also liade for olir costs in attempting to perform t❑e a❑dit Ehless yo❑ prodde a compelling ❑❑siness reason for yob faille. We will contact yo❑ to sc❑edde appointments d-ring normal ❑-siness ❑ohs. We will notify yo❑ of yob fail -re to pro:jde access ❑y mailing a certified, retlim-receipt docErnent stating t❑e increased premiEn and t❑e total amooht of o-r costs incEirred in olir attempt[SE]to perform an a❑dit. In addition to any ot❑er odigations ❑nder tEJs contract, 30 days after yo❑ recei❑e t❑e notification, yo❑will ❑e odigated to pay t❑e total premiEin and costs referenced a❑b❑e. If, t❑ereafter, yo❑ prodde access to yob records witEJn tEree years after t❑e policy expires, or witEJn anot❑er mCd❑ally agreed xpon time, and we s❑cceed in performing t❑e a❑dit to oEir satisfaction, we will ruse yo❑r total premiEn and t❑e costs d❑e to reflect t❑e rests of t❑e a❑dit. Form WC 04 04 21 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Page 1 of 1 Policy Expiration Date: 11/04/26 Ii:IRI4kiIBiel :4.1. 4 M14ki III l[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIA-l"ANA-1117111IDEA N4111111MA CALIFORNIA CANCELATION ENDORSEMENT Policy Number: 6 WEG B❑3❑P11 Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training 1:432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Name of California Insurer: ❑artford CasEialty Instance Company TCis endorsement applies only to t❑e instance prodded ❑y t❑e policy ❑eca❑se California is s❑own in Item 3.A. of t❑e Information Page. T❑e cancelation condition in Part Si❑ [Conditions❑of t❑e policy is replaced ❑y t❑ese conditions❑ Cancelation Yo❑ may cancel toms policy. Yo❑ mC:8t mail or deli-er adi8nce written notice to Cls stating w❑en t❑e cancelation is to ta-e effect. 2. We may cancel t:js policy for one or more of tie following reasons❑ a. ❑on -payment of premiEn❑ a Fail❑re to report payroll❑ c. Faille to permit ❑s to a❑dit payroll as re❑EJred ❑y t❑e terms of tEJs policy or of a predo❑s policy iss❑ed ❑y ❑s❑ d. FailEre to pay any additional premiLirn resdting from an a❑dit of payroll re❑EJred ❑y t❑e terms of tJs policy or any preJoCl�, policy iss❑ed ❑y C8❑ e. Material misrepresentation made ❑y yo❑ or yob agent[] f. Faillire to cooperate wit❑ E8 in t❑e inCiestigation of a claim❑ g. Material faille to comply wit❑ federal or state safety orders or written recommendations of o-r designated loss control representati-es❑ Tie occlirrence of a material c-ange in tie ownersElp of yob ❑❑siness❑ i. T❑e occErrence of any c❑ange in yob ❑CSiness or operations tit materially increases t❑e ❑aC:8rd for fre_ ency or seerity of loss[] Form WC 04 06 01 B (01/22) Printed in ❑.S.A. Process Date: 11 /04/2 ❑ ❑ T❑e occlirrence of any c❑ange in yob ❑C:8iness or operation t-at re❑EJres additional or different classification for premilin calcdation❑ El T❑e occlirrence of any c❑ange in yob ❑C:8iness or operation wEJc❑ contemplates an actidty e❑cl❑ded ❑y olir reinsilrance treaties. 3. If we cancel yob policy for any of t❑e reasons listed in Ca❑tilro❑g❑ Jiq we will giE0 yo❑ 10 days adCAnce written notice, stating w❑en t❑e cancelation is to taco effect. Mailing t❑et notice to yo❑ at yob mailing address s❑bwn in Item 1 of t❑e Information Page will ❑e sE ficient to pro1:0 notice. If we cancel yolir policy for any of t❑e reasons listed in Items Cg❑tEiro❑g❑ ❑❑L� we will giE0 yo❑ 30 days adCance written notice[] ❑owe❑er, we agree t❑at in t❑e eEOnt of cancelation and reiss❑ance of a policy effectiDe Epon a material c❑ange in ownersEJp or operations, notice will not ❑e prodded. 4. If we mail t❑e notice to yoq t❑e stated periods of notice and yob rig Et to remedy t❑e condition will ❑e eEtended ❑y ❑ days if t❑e place of mailing and yoEr mailing address is witEJn California, 10 days if t❑e place of mailing or yob mailing address is oEtside of California and 20 days if t❑e place of mailing or yoEr mailing address is oEtside of t❑e ❑nited States. El T❑e policy period will end on t❑e day and ❑b❑r stated in t❑e cancelation notice. Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TEXAS AMENDATORY ENDORSEMENT Policy Number: ❑6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e olir is t❑e same as stated on tie Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training 432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 T❑is endorsement applies only to to ins❑rance proEJded ❑y t❑e policy eca❑se Tees is sown in Item 3.A. of to Information Page. GENERAL SECTION B. Who Is Insured is amended to read❑ Yo❑ are insilred if yo❑ are an employer named in Item 1 of to Information Page. If tot employer is a partners::ip or flint entlire, and if yoi❑are one of its partners or mem❑ers, yo❑are insEired, ❑Et only in yo-r capacity as an employer of tie partners❑ipis or Joint entEireiss employees. D. State is amended to read[] State means any state or territory of to ❑nited States of America, and t e District of ColErnEJa. PART ONE - WORKERS COMPENSATION INSURANCE E. Other Insurance is amended Ey adding tLis sentence❑ T❑is Section only applies if yo❑ ❑ae ot❑er ins-rance or are self -ins -red for tie same loss. F. Payments You Must Make T❑is Section is amended ❑y deleting t❑e words "worers compensation" from nLIn❑er 4. ❑. Statutory Provisions T❑is Section is amended ❑y deleting t❑e words "after an in—ry occ-s" from nErner 2. PART TWO - EMPLOYERS LIABILITY INSURANCE C. Exclusions Sections 2 and 3 are amended to add[] T::js eclC:8ion does not apply Enless t❑e dolation of law ca-sed or contri❑ ted to to odily in—ry. Section 6 is amended to read ❑ 6. odily inky occ-rring o tside to ❑nited States of America, its territories or possessions, and Canada. T❑is e cicion does not apply to odily inmy to a citien or resident of to ❑nited States of America, Medco or Canada wo is temporarily o tside t❑ese cootries. D. We Will Defend T❑is Section is amended ❑y deleting tie last sentence. PART FOUR - YOUR DUTIES IF INJURY OCCURS ❑-ner 6 of t::js part is amended to read❑ 6. Tees law allows yo❑to mae weedy payments to an in —red employee in certain instances. ❑nless aEtoried ❑y law, do not olEntarily mae payments, ass -me o:ligations or inch eEpenses, ecept at yob own cost. Form WC 42 03 01 L Printed in O.S.A. Page 1 of 3 Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 PART FIVE - PREMIUM A. Our Manuals is amended Dy adding tiffs sentenceEl In tus part, "oil- manials" means mani=als approud or prescriiud ❑y tin Tei❑as Department of InsiFi-ance. C. Remuneration ❑i-irniur 2 is amended to read:] 2. All ot❑er persons engaged in wor❑tut word maize iu llaEle iEnder Part One iWorurs Compensation Ins0rance❑ of tits policy. Ti❑is paragrap❑ 2 will not apply if yo❑ giiu a proof tut tin employers of t❑ese persons IawfElly sec:1red woriurs compensation ins:lrance. D. Premium Payments is amended ❑y adding tiffs sentence❑ Tu JIling statement or iniuice for a::dit additional premiims and/or retrospectiu additional premi:Ins esta:lisius tin date t-e premiErn is die. E. Final Premium ❑inn❑er 2 is amended to read❑ 2. If yo❑ cancel, final premi::n will iu calcElated pro rata rased on tin time tiffs policy was in force. Final premi:]n will not iu less tiun tiie pro rata sure of tin minimErn premi::n. PART SIX - CONDITIONS A. Inspection is amended Dy adding tEJs sentence[] Yoor failore to comply wit❑t'ia safety recommendations made as a resElt of an inspection may case tEle policy to ❑e canceled ❑y u. C. Transfer of Your Rights and Duties is amended to read❑ Yoor rigEts and dries ❑ader tiEis policy may not u transferred witioEt OFT written consent. If yo❑ die, courage will u prodded for yoir sF]rddng spoClse or yob legal representatiu. TCJS applies only wit❑ respect to t❑eir acting in tie capacity as an employer and only for t❑e worEplaces listed in Items 1 and 4 on t❑e Information Page. D. Cancellation is amended to read[] 1. Yo❑ may cancel tEJs policy. Yo❑ mClst mail or deliur adiunce notice to C:8 stating w❑en to cancellation is to tau effect. 2. We may cancel tEJs policy. We may also decline to renew it. We mint gin yo❑written notice of cancellation or nonrenewal. T❑at notice will ❑e sent certified mail or deliured to yo❑ in person. A copy of to written notice will ❑e sent to the TeCLis Department of Instance-Didsion of WorursiCompensation. 3. ❑otice of cancellation or nonrenewal mint a sent to yo❑ not later tun t❑e 30t❑ day ❑efore to date on wEJc❑ t-e cancellation or nonrenewal ucomes effectiu, eE0ept that we may send t❑e notice not later titan t❑e 10t❑ day ❑efore to date on wCic❑ t❑e cancellation or nonrenewal ucomes effectiu if we cancel or do not renew ❑eca❑se Of Li a. Fra❑d in o❑taining courage❑ C.i Misrepresentation of t❑e amount of payroll for p0rposes of premiErn calcdation❑ c. Faille to pay a premiErn w❑en payment was dull d. An increase in to DaE:8rd for wEJc❑yo❑see❑courage ti at resdts from an action or omission and tut world prod❑ce an increase in to rate, incl❑ding an increase ucaise of faille to comply wit❑ reasonade recommendations for loss control or to comply wit::jn a reasonaiFle period wit❑ recommendations designed to rediue a uiurd tint is Ender yo:1- control❑ e. A determination Dy tin Commissioner of Ins:1rance tut tin continution of to policy word place iu in uolation of tin law, or world !u-ai:ardoiu to tin interests of s❑iucriiurs, creditors, or tin general p❑tic. 4. If anotiur ins:1rance company notifies tin Tei❑as Department of Ins:lrance-Di:lsion of Woriursi--ompensation t0at it is insFiring yo❑ as an employer, size❑ notice mint u a cancellation of tits policy effectiu wizen tin otiur policy starts. Add tin following to t❑e policy❑ PART SEVEN - OUR DUTY TO YOU FOR CLAIM NOTIFICATION A. Claims Notification We are re❑EJred to notify yo❑ of any claim tut is filed against yoir policy. T❑ereafter we mint notify yo❑ of any proposal to settle a claim or, on receipt of a written re❑zest from yoq of any administratiu or Hdicial proceeding relating to tie resol::tion of a claim, incliEding a ❑enefit renew conference conducted ❑y tiFe Tei❑as Department of Ins:lrance-Di:lsion of Worursi❑✓ompensation. Yo❑ may, in writing, elect to waiiu tAs notification re❑i-- Jrement. We mint, on tin written re❑E0st from yoq pro:Jde yo❑ wit❑ a list of claims curged against yoi-ir policy, payments made and reserius esta:1isi-ed on eac❑ claim, and a statement e:A)laining tin effect of claims on yo:1r premi::n rates. We mint fijnis❑ tie reiiiested information to you in writing no later tian tin 30t❑ day after tin date we receiu yos re❑lust. Tile information is considered to ie proEJded on tin date tin information is receiiud ❑y to ❑nited States Postal Ser:Jce or is personally deliured. Form WC 42 03 01 L Printed in O.S.A. Page 2 of 3 COMPLAINT NOTICE: DISPUTE RESOLUTION SERVICES NCCI'S DISPUTE RESOLUTION PROCESS DOES NOT APPLY TO WORKERS COMPENSATION CLAIMS. For workers compensation claim disputes, see "CLAIM COMPLAINT" below. For issues related to a violation of law related to your policy, see "VIOLATIONS OF LAW" below. Important Note: T❑e disp❑te resolLtion ser[ces prouded tL]roEg❑ t❑e Disp❑te Resol tion Process iProcess❑of t❑e ❑ational CoAcil on Compensation Insisance 1111CCI11are voluntary. T❑e Process is not an administratie remedy t❑at m❑st e e2aC:sted ❑efore yo❑ plirs❑e relief in coErt. ❑sing to Process does not preent yo❑ or to carrier t❑at issed t❑e policy from plirsEJng any aeilade legal remedies at any time. []CC[ can assist in t'e resol tion of a disp to regarding yo-r policy t❑at is related to any of t❑e following matters[] o T❑e application or interpretation of ryes contained in to CarioC:8 ❑CCI manels CChcl❑ding, ❑A not limited to, classification codes and e-perience rating modifications❑ o Rating programs o Endorsements o Forms Contact to carrier ti❑at iss❑ed t❑e policy and attempt to resole to disp❑te directly. If yo❑ and tie carrier cannot agree, t❑en contact ❑CCI to as❑for assistance. ❑CCIs Basic Manual rAe, Disp❑te Resol tion Process, addresses disp tes. Yo❑ may oEtain disp❑te resolEtion serdces only after yo❑ ❑ae made a reasona:Ae attempt to first resole t❑e disp❑te directly wit❑t❑e carrier and after yo❑ ❑ae paid any odispEted premilin de to tie carrier. Send yos re❑❑est for assistance ❑y mail to ❑CCI, Disp❑te Resol tion Serdces, 901 Penins-la Corporate Circle, Boca Raton, FL 3348D-1362or ❑y fa❑to ❑61-893-E043or ❑y email to disp teresolEtion❑ ncci.com. THIS NOTICE OF THE DISPUTE RESOLUTION PROCESS IS FOR INFORMATION ONLY AND DOES NOT BECOME A PART, TERM, OR CONDITION OF THIS POLICY. VIOLATIONS OF LAW: If yo❑ ❑eliee t❑ere ❑as ❑een a Jolation of law related to yo-r policy, file a complaint wit[] t❑e Tees Department of Instance❑ Phone: 1-800-2E2-3439 Online: tdi.tees.go❑ Email: Cons linerProtection❑ tdi.teEas.go❑ Mail: MC CO-CP, PO Bo❑12030, AC:8tin, TO ❑81111-2030 CLAIM COMPLAINT: If t ere is a worers compensation claim complaint inolrng one of yo-r employees, ten contact t❑e Tees Department of Ins-rance - Di:jsion of Worers❑Compensation, Compliance and Inestigations ❑y mail to MC❑CI, PO Bo-1 1201:0, Aetin, T❑ ❑81111-20EOor ❑y fa❑to 1112-490-1030 or -_y email to DWCCOMPLAI❑TS❑ tdi.tees.go❑ THIS NOTICE IS FOR INFORMATION ONLY AND DOES NOT BECOME A PART, TERM, OR CONDITION OF THIS POLICY. Form WC 42 03 01 L Printed in O.S.A. Page 3 of 3 III i:IRI4kiIBiel :4.1- 4 M14kikI[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIIIIA-l"ANA-1111kIDEA N411111111MA WORKERS' COMPENSATION BROAD FORM ENDORSEMENT Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effecti❑e Eolir is t❑e same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training 432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Section I of t!Eis endorsement e-pands coerage prodded Ader WC 00 00 00. Section II of tEJs endorsement proddes additional coerage C:80aIIy only proEJded ❑y endorsement. Section III of t❑is endorsement is a Sc❑edde of Coered States. Yo❑ may Cie t❑e inde❑to locate tese coerage featilres ❑EJcdy❑ INDEX SUBJECT SECTION I PARTS ONE and TWO 01 We Will Also Pay PART -THREE 02 [low TCis Instance Wor-s PART - SIX 03 Transfer of Yoh Rig is and D ties 04 Li❑eraliE:ition SECTION II VOLUNTARY COMPENSATION INSURANCE 0❑ ❑olEntary Compensation Ins-rance A. [low TCis Ins-rance Applies B. We will Pay C. EelC:8ions D. Before We Pay E. Recoery From Ot❑ers F. Employers ElLiaE lity Ins-rance EMPLOYERS' LIABILITY STOP GAP COVERAGE 06 Employers::Lia:jlity Stop Gap Coerage A. Stop Gap Coerage Limited Montana, ❑ort❑Da❑bta, OEJo, WasJngton, West ❑irginia and Wyoming B. Part One does not Apply C. Application of Coerage D. Additional EelC:8ions E. West ❑irginia SECTION III 0❑ Sc❑edde of Co Bred States Form WC 99 03 02 B Printed in O.S.A. EEd. 8/0011 Process Date: 11 /04/2 ❑ PAGE 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 Page 1 of 4 Policy Expiration Date: 11/04/26 112000, T❑e ❑artford SECTION I PARTS ONE and TWO 1. WE WILL ALSO PAY D. We Will Also Pay of Part One 1WOR11ERS11 COMPE❑SATIO❑ I❑S❑RA❑CEEnand E. We Will Also Pay of Part Two EMPLOYERS❑LIABILITY I❑S❑RA❑CE❑ is replaced ❑y t❑e following❑ We Will Also Pay We will also pay tese costs, in addition to ot_er amoLnts payade Ender t::js ins-rance, as part of any claim, proceeding, or sit we defend[] 1. reasona:]e e-penses inc-rred at oEir re❑❑est, INCLUDING loss of earnings[] 2. premilins for ❑onds to release attaclinents and for appeal ❑onds in ❑bnd amoEnts Ep to to limit of o-r liaE lity -nder tEJs ins❑-ance❑ 3. litigation costs taed against yo❑❑ 4. interest on a ❑dgment as re❑EJred ❑y law _ntil we offer tie amo-nt de ❑nder tCns law -land El eEpenses we inc-r. VOLUNTARY COMPENSATION AND EMPLOYERS' LIABILITY COVERAGE 5. Voluntary Compensation Insurance A. How This Insurance Applies T❑is ins-rance applies to ❑odily in—ry ❑y accident or ❑odily in❑]y ❑y disease. Bodily in—ry inclEdes resdting deat❑. 1. T❑e ❑tidily in❑ry mC:8t ❑e sC:8tained y any officer or employee not s❑❑sect to t❑e worers❑compensation law of any state sEown in Item 3.A. of tie Information Page. 2. T❑e ❑tidily in—ry m_st arise o t of and in t❑e co --se of employment or incidental PART THREE 2. How This Insurance Applies Paragrap❑ 4. of A. How This Insurance Applies of Part 3 �Dt❑er States Ins-rance❑ is replaced ❑y t❑e following❑ 4. If yo❑ ee wor❑ on t❑e effecti a date of tEJs policy in any state not listed in Item 3.A. of t❑e Information Page, co erage will not e afforded for t-at state _nless we are notified wit::jn sixty days. PART SIX 3. Transfer Of Your Rights and Duties C. Transfer Of Your Rights and Duties of Part 6 LConditions❑is replaced ❑y t❑e following❑ Yoh rig is or dEties -nder tEJs policy may not ❑e transferred witEoEt o_-written consent. If yo❑ die and we recei e notice wit::jn sixty days after yo'7r deatq we will co-er yo-r legal representati e as insEred. 4. Liberalization If we adopt a c❑ange in t::js form t❑at world Eiroaden t❑e co❑erage of tEJs form wit❑oEt eEtra c❑arge, to loader coerage will apply to tEJs policy. It will apply wen to c❑ange ecomes effectie in yob state. to wor❑ in a state sewn in Item 3.A. of to Information Page. 3. T❑e Cbdily in—ry met occ-r in to ❑nited States of America, its territories or possessions, or Canada, and may occ-r elsewere if t!e employee is a ❑nited States or Canadian citien, or oterwise legal resident, and legally employed, in t❑e ❑nited States or Canada and temporarily away from t ose places. 4. Bodily in❑iy ❑y accident mE8t occEir ding t❑e policy period. El Bodily in❑]y ❑y disease met e caE8ed or aggraeted ❑y to conditions of tie officer18 or employeei8 employment. Form WC 99 03 02 B Printed in O.S.A. EEd. 8/0011 Page 2 of 4 Ti❑e officers or employee-9 last day of last e::posiEre to tiu conditions caring or aggraCating s--t❑ ❑odily inUry ❑y disease milt occ:1- diFi-ing tiu policy period. B. We Will Pay We will pay an amoEnt e❑uI to to unefits tut world ❑e re❑Eired of yo❑ as if yo❑ and yob employees were s❑❑iect to to worurs❑ compensation law of any state sown in Item 3.A. of to Information Page. We will pay t❑ose amounts to to persons w❑o woLld u entitled to tium iEnder tiu law. C. Exclusion T!❑is insi-iance does not cour❑ 1. any oFligation imposed ❑y worurs❑ compensation or occ-A)ational disease law or any similar law. 2. Fodily inE:Dry intentionally caiued or aggrauted ❑y yo❑. 3. officers or employees w::o uiu elected not to iu s❑❑iiect to tiu state worurs❑ compensation law. 4. partners or sole proprietors not coured Ender to Standard Sole Proprietors, Partners, Officers and Oturs Courage Endorsement. D. Before We Pay Before we pay unefits to tiFe persons entitled to tium, tuy mint❑ 1. Release yo❑ and i-is, in writing, of all responsii❑ility for tiu inTUry or deatEl 2. Transfer to iu tiuir rigid to recour from of ers w❑o may a responsiiFle for tiu inufly or deat:1 3. Cooperate wit❑ iu and do eiuryti❑ing necessary to ena:1e iu to enforce tiu rigid to recoiur from oturs. If to persons entitled to to unefits of tEJs instance fail to do t❑ose t-Jngs, o0- dEty to pay ends at once. If tuy claim damages from yo❑ or from E8 for to iniFiry or deatq oFir dEty to pay ends at once. E. Recovery From Others If we mau a recoury from oturs, we will uep an amount e❑Llal to oil e:])enses of recoiury and tiu iunefits we paid. We will pay t❑e ❑alance to tie persons entitled to it. If tiu persons entitled to tiu iunefits of tus insEirance main a recoury from oturs, t❑ey miut reim❑Erse iu for tiu unefits we paid tium. F. Employers' Liability Insurance Part Two [Employers ELiaEIity Ins tance❑applies to ❑odily in❑ry coured ❑y tEJs endorsement as t biEg❑ to State of Employment was sown in Item 3.A. of t❑e Information Page. Ti❑is pro:1sion :1 does not apply in ❑ew ursey or Wisconsin. EMPLOYERS' LIABILITY STOP GAP COVERAGE 6. Employers' Liability Stop Gap Coverage A. Ti❑is courage only applies in Montana, ❑ort❑ Daiuta, OIJo, Wasungton, West ❑irginia and Wyoming. B. Part One Worurs❑ Compensation Insurance❑ does not apply to wor❑ in states s❑own in Paragrap❑A a❑ou. C. Part Two [Employers ELiaE lity Ins tance❑applies in to states, sown in Paragrap❑ A., as t❑oiEg❑ tuy were sown in Item 3.A. of tiu Information Page. D. Part Two, Section C. Exclusions is cunged ❑y adding tuse eiulC�-,ions. T❑is insisance does not coiur'❑ El iudily iniii y intentionally ca!ued or aggrauted i❑y yo❑ or in Oi❑io ::tidily inlory res:1ting from an act wiJc❑ is determined !❑y an O❑io coi-irt of law to uu uen committed ❑y yo❑ wit❑ tiu iulief tun an inlory is s❑iutantially certain to occij. ❑oweur, to cost of defending siu❑ claims or sits in Oi❑io is coiured. 13. iudily ini❑ry siutained i❑y any memur of to flying crew of any aircraft. 14. any claim for iudily inE:Iry wit❑ respect to w::Jci❑ yo❑ are depriud of any defense or defenses or are oturwise s❑❑iiect to penalty ucaiue of defa:]t in premii-n i-nder to pro:Jsions of tiu worurs❑compensation law or laws of a state si:own in Paragrap❑A. E. T❑is instance applies to damages for wEJc❑ yo❑ are liade Ender West ❑irginia Code Annot. S 23- 4-2. Form WC 99 03 02 B Printed in -.S.A. iFEd. 8/00❑ Page 3 of 4 SECTION III 7. SCHEDULE OF COVERED STATES A. T❑is endorsement only applies in tip states listed in tiffs Sc ed:le of Co::Ored States. C. ScOadile of CoEored States[] CA CoiEntersigned ❑y B. If a state, sewn in Item 3.A. of t!-le Information Page, approEOs tits endorsement after tFle effectiE0 date of tips policy, tEJs endorsement will apply to tits policy. T❑e courage will apply in t:1a new state on t:1e effectii:0 date of t0a state appro::8l. A::t❑ori::Od Representati::0 Form WC 99 03 02 B Printed in -.S.A. !-Ed. 8/00❑ Page 4 of 4 III i:IRI4kiIBiel :4.1. 4 M14kikI[s]:/_1ki It] 4•'19:I:11e7lill[wMJIIIIIIIA-l"ANA-1111kIDEA N411111111MA AMENDMENT TO WORKERS' COMPENSATION BROAD FORM ENDORSEMENT- EMPLOYERS' LIABILITY STOP GAP COVERAGE Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effectie Eolir is to same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 T❑is endorsement cenges tie Worers❑ Compensation Broad Form Endorsement ❑ Employers- LiaJlity Stop Gap Co erage 6. Employers- LiaJlity Stop Gap Coerage A. T❑is coerage only applies in ❑ort❑ Da❑bta, O❑io, WasJngton, and Wyoming E. T❑is paragrap❑ is remoed. Form WC 99 03 58 B Printed in ❑.S.A [Ed. ❑/0811 Process Date: 11 /04/2 ❑ Policy Expiration Date: 11/04/26 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ARIZONA COUNTERSIGNATURE EXCLUSION ENDORSEMENT Policy Number: E6 WEG Bii3iP-1 Endorsement Number: Effective Date: 11/04/2❑ Effecti�0 -os is t:]a same as stated on the Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training E432 E TIERRA BiEiA L❑ SCOTTSDALE A❑ 8E260 TiJs endorsement applies only to tie insiiance proEJded Dy tip policy Lieca::8e Ari:ona is siEown in Item 3.A. of tie Information Page. T❑e following wording, as may Da contained in tEJs policy, does not apply in Ari:ona❑ "Tits policy is not Jnding Mess coEntersigned Qy oil a❑tEorii-ed representati::O." "Tus endorsement sill not Da Finding Mess coEntersigned Dy a d:]y aEt:oriL:od agent of tie company, pro:Jded tiEat if tits endorsement tams effect as of tip effectii[o date of tip policy and, at iss:10 of said policy, forms a part t:10reof, coEritersigned on tie Information Page of said policy Dy a dEly ait::Ori::Od Agent of t:1e company sill constitite E:8Iid coEntersignatiie of tits endorsement." Form WC 99 03 71 A Printed in O.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 Ill i:IRI4kiIBiel :4.1- 4 M14kikI[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIIIIA-l"ANA-1111kIDEA N411111111MA CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT Policy Number: ❑6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 Effecti❑e Eolir is t0e same as stated on t❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 T❑is endorsement applies only to t❑e ins-rance pro:jded ❑eca❑se California is sewn in Item 3.A. of tie Information Page. A ser:jce fee of ❑ 00 is c❑arged for eac❑ installment w❑en yob premi-n is paid in installments. T❑e ser:jce fee is 11a00 per wit drawal w❑On yo❑ select an electronic f❑nd transfer payment plan. T❑e serdce fee will Ja added to t❑e premi-n amodt s❑bwn on yo-r premiEn EiIling statement. Form WC 99 03 75 Printed in ❑.S.A. Process Date: 11 /04/2 ❑ Policy Expiration Date: 11/04/26 Ii:IRI4kiIBiel :4.1. 4 M14ki III I[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIA-l"ANA-1117111IDEA N4111111MA GOODS AND SERVICES ENDORSEMENT Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 Effecti❑e Eolir is to same as stated on tie Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Name of Insurer: ❑artford Cas❑alty Ins�:rance Company T❑is endorsement modifies instance pro:jded Ender all Coerage Parts of tEJs Policy. We may offer or mae Goods or ser[EJces❑ aeila'Je to yo❑ tE]ro❑g❑ tEJs Enderwriting company, a non-ins-rer s❑[t,idiary, or ❑naffiliated tEJrd parties as a part of toms policy. T❑e Goods or serdces❑may -e pro:jded for a cerge, at a discoErit, on a s❑❑Fidi❑ed ❑asis, or free of cerge. In some cases, we may receie a fee from t❑e Enaffiliated tEJrd parties tet prodde Goods or serices❑ We do not warrant or gerantee tie 3goods or serdces❑prodded ❑y tEJrd parties, and s❑c❑tEJrd parties s❑all ❑e solely lime and responsi-le for t❑e Goods or serdces❑tey prodde. T❑e Goods or serdces❑offered or made aeilade ❑y [8 may ❑e modified or discontin❑ed at any time. [Goods or serdces❑means goods, prod❑cts or ser:jces, incl❑ding ❑[t not limited to ris❑mitigation, safety, and/or loss preention serdces or e❑Jpment. Form WC 99 06 89 (02/21) Printed in ❑.S.A. Page 1 of 1 Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 Ii:IRI4kiIBiel :4.1. 4 M14ki III I[s]:/_1ki It] 4•'19:I:11e7lill[WMJIIIIA-l"ANA-1117111IDEA N4111111MA GOODS AND SERVICES ENDORSEMENT Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: Effective Date: 11/04/211 Effecti❑e Eolir is t0e same as stated on tie Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE All 8E260 Name of Insurer: ❑artford Ins rance Company of Illinois We may offer or maims Goods or serEJces❑ aL:8ilade to yo❑ tE]ro❑g❑ tEJs Enderwriting company, a non-ins-rer s❑C:8idiary, or -naffiliated tJrd parties as a part of tEJs policy. T❑e Goods or ser:lces❑are optional and may ❑e prodded for a c-arge, at a discoAt, on a s11C:8idiC:0d psis, or free of cEiarge. In some cases, we may receiC:o a fee from t❑e Enaffiliated tJrd parties t❑at prodde Goods or serdces❑ We do not warrant or g-arantee t❑e Goods or ser:jces❑prodded ❑y tEJrd parties, and s❑c❑ tEJrd parties s❑all ❑e solely Iiade and responsi-le for t❑e Goods or ser:jces❑t❑ey prodde. T❑e [goods or serdces❑offered or made aE:8ilade ❑y CIF, may ❑e modified or discontin❑ed at any time. moods or ser:lces❑means ris❑mitigation, safety, and/or loss pre Ontion goods, prod❑cts, ser:jces or e❑Jpment. Form WC 99 06 94 (06/21) Printed in ❑.S.A. Page 1 of 1 Process Date: 11 /04/2 ❑ Policy Expiration Date: 11 /04/26 MAINTAINING YOUR RECORDS FOR AUDIT PURPOSES WHAT IS A PREMIUM ADJUSTMENT? W❑en yoC7 WorEors❑Compensation policy was iss❑ed yo❑ paid a deposit premiCrn Cased on t❑e natC7e of yoC7 11C:8iness and estimates of yoC7 payroll. At t❑e end of t❑e policy period, we cond❑ct an a❑dit to compare t❑e estimates against t❑e actCial figC7es and operations. Based on tCEJs comparison an ad❑iAtment is made. If t❑e actilal premiCrn is less titan what yo❑ already CiaC:o paid, a refC7nd will Lie made. If its more, yo❑ will Lie CfIled for t❑e difference. Ti❑ese adAtments are s❑❑Cect to any minimCrn premiEns tCiat apply. HOW WILL THE PREMIUM ADJUSTMENT BE MADE? On smaller, less comple❑ operations we may e-mail yoq call yoq or mail yo❑ a re❑lest to as❑yo❑ to proEide t0e information :ja oij online weiD-ihased portal, mail or telepi—one. If we re❑i re tiffs information, we will pro:1de an electronic tin❑ to, or a paper copy of, tE0 necessary forms for yo❑to complete. On larger, more comple❑ operations one of oij Premi::n Ahiitors will contact yo❑ for an appointment. Yo❑ will iDe contacted eit:ler Dy e-mail, telep:one or mail. If directed, tie aihlitor will contact yoij accoiEntant to oEtain as mi❑c❑ information as possiC7e and contact yo❑ at a later time for additional information that may DO needed. BASIS OF PREMIUM Remuneration (Payroll) in most states, inclhles❑ Payment of:] Wages, F:OniEses, commissions, oCortime,❑ sic❑ pay, C:8cation pay, El tool allowances, contri❑loons to indi:1d 8I retirement accoErits, employee contri❑Etions to employee iDenefit plans. Payments on ❑psis of-] Piece worq incentii-:0 plans, profit sharing. Ti❑e C81:10 of❑ ❑oiling f:lrnis❑ed to employees,-] meals f0misFied to employees,❑store certificates, merchandise and ot:ler dollar s❑E8titi-tes. The Hartford Remuneration does not include: a. Employer contri❑Coons to a grogp ins0-ance or pension plan ot❑er tCian statEtory plans of insFirance. El Special awards for indiudC]al inContions or discoEories. c. OEOrtime. ❑ Subcontractors. In tie aCL8ence of ot❑er insC7ance, most state laws ❑old a contractor responside for in❑ries to employees of s❑❑contractors. At t❑e time of a❑dit Certificates of InsC7ance mC8t Lie aElailade for s❑Contractors wit[] employees, in order to a❑bid payment of premiC7n. Independent Contractors, wit::0iA employees, wise dies closely resemFle t::ose of an employee, will ija considered yob employee wit❑ t0a appropriate premiiEn ciharged. Ti❑e actilal wor ing relationsi❑ip !Fetween yo❑ and tija Independent Contractor is e!:amined. Items s❑c❑ as, ❑i t not limited to❑ w0et:ler tiDa wor❑ performed is an integral part of yoij operations, wFlatiDar yo❑ ila-e tiDa rig Et to control t0e details of t!Da worq tip meti❑od of payment, wig si—pplied tip materials wed, does tip person regiFlarly wor❑ for ot:lers, wEose reg:1atory aiFt!Eority did person operate iEnder, wi-latEler tip person is iniEol::Od in a separate and distinct ❑iciness offering tip same ser:1ces to t❑e p❑Jic. RECORDS As part of tFle policy conditions, we are allowed to e!iamine yoi-ir financial ❑boil and records to determine actihal eiEposjes and operations. We woEld appreciate yoi-i- cooperation in maiing t❑e needed records a::8ila:le for tiDa aihlitorig inspection. What Records Will Be Needed? Ti❑e records needed will iLary. In most cases, tip Premi::n Aihlitor will De aide to oEtain tip necessary aihlit data from two or more of tip following records❑ iFoDnals, Ledgers, State and Federal Tai❑ Reports, IndiJdi❑al Earning Cards, C❑ecmooL:S and Contracts. Form 98456 5th Rev. 12-13 Printed in O.S.A. Page 1 of 2 How You Should Keep Your Records By maintaining yo❑r payroll records in accordance wit❑tip following giJdelines, yo❑ mig❑t red❑ce yob insr7ance costs. Overtime. In most states, ti—e amo—nt paid in e:cess of straig❑t time pay can ❑e dedi❑cted if it can Lie Eorified in yob records. Yo❑ mkt maintain yoor records to siEow pay separately ❑y employee and in s::nmary ❑y classification of wori❑ *Division of an employee's payroll to more tlDan one classification is not allowed in most states. Exception: For constr❑ction, erection or ste❑edoring operations tEe payroll of an employee may De allocated to eac❑ type of wor❑ performed if proper records are Eopt. Yoh records mEM s❑ow tE0 nEn❑er of ❑cis and amo-Ant of payroll for eac❑ type of wor❑ If yo❑ do not Eoep s❑c❑ a Firea❑down, t❑e f71 salary mC:st Ele cEiarged to tEle EJg❑est rated classification to w❑ic❑t❑e employee is eEposed. Executive Officers in most states are considered employees of t❑eir corporation and incl❑ded in t❑e compEtation of premii-in. T❑eir remLineration is assigned wit❑a❑t diiJsion to tE:O actlal operation in wiJc❑ ti-ey are engaged. If tFlair dElies are t e same as tiEose of a worEOr, foreman or siEperintendent, tiDair payroll is assigned to tip classification tilt de::OIops tip Jg—est payroll. MinimLin and ma:lm::n payrolls apply to e:�OciEti:A� officers. Automated Records. If yoEr records are aiAomated or yoi❑ plan to aiAomate in t0a near fiAilre yo❑ can o❑tain maijmEM iDenefits ❑y setting Ep yob records to incl❑de insiErance re❑iEirements. OLT PremiiErn A::ditor will Lie pleased to assist yo❑ in setting qa yob records. Contact yob ❑artford RepresentatiE0 if yo❑ world li❑e tAs assistance. NOTE: T❑e contents of tEJs p❑dication are not intended to sEpersede any definitions or conditions of yob policy, t❑e WorEorsECompensation Law or any legal rdings. *Your state may have specific rules or exceptions. Please contact your Hartford Representative for details that may apply and answer questions you may have. Form 98456 5th Rev. 12-13 Printed in O.S.A. Page 2 of 2 Customer Privacy Notice The Hartford Insurance Group, Inc. and Affiliates erein called -we, o-r, and t;EE This Privacy Policy applies to our United States Operations We Cal❑a yot tr❑st. We are committed to t❑a responside❑ all management[] ❑❑ ❑send c❑ protection-] of Personal Information. T❑is notice descri❑as Cow we collect, disclose, and protect Personal Information. We collect Personal Information WE all serdce yot Transactions wit[] ❑s❑and ❑❑ sEpport olir ❑❑siness f_nctions. We may o tain Personal Information from[] all You❑ ❑❑ yotr Transactions wit❑ C811and c❑ tEJrd parties s❑c❑as a constner-reporting agency. Based on tie type of prod❑ct or ser:jce You apply for or get from E8, Personal Information s❑c❑as❑ all yot name--] ❑❑ yot address[] c❑ yotr income[] d❑ yot paymentEor e❑ yotr credit Elstory❑ may ❑a gat❑ared from sotces s❑c❑ as applications, Transactions, and constner reports. To serEb You and serdce of ❑CSiness, we may s-are certain Personal Information. We will sire Personal Information, only as allowed ❑y law, wit❑ affiliates s❑c❑ as❑ all of instance companies[] ❑❑ oLir employee agents[] c❑ of toClerage firmsEland d❑ of administrators. As allowed ❑y law, we may s❑are Personal Financial Information wit❑ot affiliates to❑ a❑ marEot of prod❑cts❑or ❑❑ marC:81 oEir serdces❑ to You wit❑ot prodding You wit❑ an option to pre':Ont t❑ese disclostes. We may also s❑are Personal Information, only as allowed y law, wit❑ tiaffiliated turd parties incl❑ding❑ a❑ independent agents❑ ❑❑ toEbrage firms - The Hartford c❑ instance companies[] d❑ administrators Eland e❑ serdce prodders❑ wEo ❑alp _s ser❑e You and ser:jce of ❑C:8iness. W❑an allowed ❑y law, we may s❑are certain Personal Financial Information wit❑ot❑ar tiaffiliated turd parties w❑b assist t; ❑y performing serEJces or f_nctions s❑c❑ as ❑ a❑ taring s❑r❑eys❑ ❑❑ marEoting of prod❑cts or serdces❑br c❑ offering financial prod❑cts or serdces trader a Sint agreement ❑etween ❑s and one or more financial instit tions. We, and tEJrd parties we partner wit" may trac❑ some of t e pages You dsit tt-o❑g❑t❑a Else of❑ all cooties❑ ❑❑ piCAal tagging❑or c❑ ot❑er tectiologies❑ For more information, of Online PriC:8cy Policy, w❑Jc❑ goE0ms information we collect on of we❑site and of affiliate weC:8ites, is aE8ilade at Ettpsl//www.tEiaElartford.corrVonline-priE:8cy-policy We will not sell or s❑are yot Personal Financial Information wit❑ anyone for ptposes tirelated to o-r ❑❑siness f_nctions witEot offering You t❑e opport-pity to ❑ all Copt-otE[Dor ❑❑ Copt -ink as re❑Eired ❑y law. We only disclose Personal Health Information wit -- all yot at❑ori❑ationEor ❑❑ as ot❑erwise allowed or re -gyred ❑y law. Ot employees ❑a❑e access to Personal Information in t❑a cotse of doing t❑air 10❑s, s❑c❑as❑ all ❑nderwriting policies[] ❑❑ paying claims❑ c❑ deEbloping new prod❑ctsEor d❑ addsing ct;tomers of oEir prod❑cts and ser:jces. Form WC 66 03 30 R Printed in E.S.A. Page 1 of 2 We ire manila) and electronic seci-i-ity proced:lres to maintain[] a❑ t0b confidentiality::Ond ❑❑ tie integrity of:] Personal Information t0at we 08::0. We ire t❑ese proced:lres to g-ard against ::na::ti—ori::Od access. Some tec::ni❑ids we ::8e to protect Personal Information incl::de❑ a❑ secied files[] ❑❑ der a::ti❑entication❑ c❑ encryption❑ d❑ firewall tec::nologyiland e❑ tip ❑se of detection software. We are responsi:]e for and milt❑ a❑ identify information to 00 protected❑ ❑❑ pro:Jde an ade❑date le::01 of protection for t of data❑ and c❑ grant access to protected data only to tEose people wiFo milt ::8e it in t0e performance of tE]eir [OD - related dries. Employees wiEo Jolate o r pri::8cy policies and proced::res may :10 s❑❑sect to discipline, wiJc❑ may incline termination of t0bir employment witi❑ ice. We will continiDe to follow oil Primacy Policy regarding Personal Information e::On w0en a ❑iciness relations::jp no longer e:1sts iDetween ice. As Eked in t❑is PriFlacy ❑otice❑ Application means yolr re❑Elest for o0r prod❑ct or serlice. Personal Financial Information means financial information s❑c❑as❑ a❑ credit Jstory❑ ❑❑ income❑ c❑ financial iDenefits::or d❑ policy or claim information. Personal Financial Information may inclEde Social Sec:1-ity ❑iErnDers, Drii�eri_g license n::n❑ers, or ot❑ or goiEornment-iss!Ded identification non❑ ors, or credit, dent card, or Ilan❑acco❑1t nEEn:Iers. Personal Health Information means Ewalt❑ information s-]c❑as❑ a❑ yo:l- medical records::Or ❑❑ information aiEoEt yoiEr illness, disa::Jlity or iniEry. Personal Information means information tlat identifies You personally and is not ot:lerwise ai-:8ila:le to tip p❑ilic. It incl!-des❑ a❑ Personal Financial Information Dand ❑❑ Personal Health Information. Transaction means yo!-ir ❑E8iness dealings wit-] ice, sib❑ as:] a❑ yoFFi Application[] ❑❑ yo:l- re❑EOst for E:8 to pay a claimEland c❑ yoFir re❑❑est for 1:5 to taJe an action on yolr acco❑nt. You means an indidd❑al wLo las giE:on E8 Personal Information in conQYlction wit❑❑ a❑ as:Jng a❑0A:1 ❑❑ applying for❑cr c❑ o::taining❑ a financial prod❑ct or serElce from E:8 if to prod❑ct or ser7ce is Csed mainly for personal, family, or EOE:8eEold p0rposes. If yo- -ae any - estions or comments a o::t t:js priecy notice, please feel free to contact -s at T-e -artford - Cons-ner Rig As and Priecy Compliance -nit, One -artford Plae, Mail Drop--01-09, -artford, CT 061--, or at Cons-nerPriecyln-:jriesMail-o t eertford.com. T:js C-stomer Priecy -otice is -eing pro:jded on -eelf of T-e -artford Ins-rance Gro-p, Inc. and its affiliates 7ncl-ding t-e following as of Fe_r-ary 202-Y tote event re -gyred -y t-e Gramm-Leac--Bliley Act and implementing reg:lations- 1stAGC nice, Inc. -Access CoerageCorp, Inc. -Access CoerageCorp Tecoologies, Inc.-B-siness Management Gro-p, Inc.-Cer=s Claim SolAions, LLC- First State Ins-rance Company -FTC ResolAion Company LLC--art Re Gro-p L.L.C.--artford Accident and Indemnity Company --artford Administratie Serices Company--artford Asia Limited--artford Cas-alty General Agency, Inc.--artford Cas-alty Ins-rance Company--artford Corporate -nderwriters Limited--artford Fire General Agency, Inc.--artford Fire Ins-rance Company--artford Fods Distri--tors, LLC--artford Fods Management Company, LLC--artford Fods Management Gro-p, Inc.--artford -oldings, Inc.--artford Ins-rance Company of Illinois--artford Ins-rance Company of t-e Midwest--artford Ins-rance Company of t-e Sod-east--artford Ins-rance, Ltd.--artford Integrated Tecoologies, Inc.- - artford Inestment Management Company--artford Life and Accident Ins-rance Company--artford Lloyds Corporation--artford Lloyds Ins-rance Company--artford Management, Ltd.--artford Management --Limited--artford Prod-cti:jty Ser:ices LLC--artford Singapore Pte. Ltd--artford of tie Sod -east General Agency, Inc.--artford of Tees General Agency, Inc.--artford Residel Maret, L.C.C.- -artford Specialty Ins-rance SerJCes of Tees, LLC--artford STAG-ent--es LLC--artford Strategic Inestments, LLC--artford -nderwriters General Agency, Inc.--artford -nderwriters Ins-rance Company- -artford -nderwriting Agency Limited- -eritage -oldings, Inc.- -eritage Reins-rance Company, Ltd.- -LA LLC- -orion Management Gro-p, LLC--RA Broerage SerJCes, Inc. -Lattice Strategies LLC-Ma—n Caselty Ins-rance Company-Ma—n Indemnity Company- Main Specialty SerJCes Corporation -Millenni_n -nderwriting Limited-MPC ResolAion Company LLC--a:jgators -oldings ---Limited--a:jgators Ins-rance Company--a:jgators Management Company, Inc.--a:jgators Specialty Ins-rance Company--a:jgators -nderwriting Limited--ew England Ins-rance Company--ew England Reins-rance Corporation--ew Ocean Ins-rance Co., Ltd. --IC Inestments :C:jIe-SpA--Ameg Ins-rance Agency, Inc.--Ameg Ins-rance Company -Pacific Ins-rance Company, Limited -Property and Cas-alty Ins-rance Company of-artford-Sentinel Ins-rance Company, Ltd.-T-e-a:jgators Gro-p, Inc.-Tr::n-:11 Flood Management, L.L.C.-Tr-n-:11 Ins-rance Company -Twin City Fire Ins-rance Company-Y- Ris-, LLC. Form WC 66 03 30 R Printed in ❑.S.A. Page 2 of 2 POLICYHOLDER NOTICE PAYROLL RECORD AND AUDIT REQUIREMENTS FOR DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Yoh policy incl::des one or more constr❑ction or erection classifications. Dilal wage classifications are pairs of classifications tit descriFle tile same constr ction or erection operation yet are assigned Eased won wiletiu✓r tip employees iuoFirly wage is auo70or flow a specified tFires uold. Eacu pair of dilal wage classifications contains one "EJg❑ wage" classification t!lat is assignaEle to payrolls earned iDy employees wiFose regiJar -o:lrly wage e❑uals or e:ceeds a specified wage t:lresiuold and one "low wage" classification t!lat is assigna:]e to payrolls earned iDy employees wuose regdar iuoOrly wage is less tDan tip specified t:lresiuold. Payroll Record Requirements T❑e assignment of a iJgu wage classification is contingent on Eorifying that tDO employees i-b:lIy wage e❑❑als or eiECeeds tip specified wage t0resiuold. Tile determination of t:1e reg:1ar uo:lrly wage for any non -salaried employee mii;t -10 sibported iuy one of tip following so:lrces❑ o Original time cards or time ::oou entries for eacu employee. Original records must incline tile operations performed, tip total uo:ls word eac:l day and tile times tip employee started and ended eac❑ wor❑ period t:lroEgiuo❑t tip wor[lay. At :0�] locations w0are all of tie employers operations cease for a iEniform iripaid meal period, recording tCe start and stop times of tEe iEniform idea❑period is not re -Tired. A i:alid collecti::o ilargaining agreement that sEows tip reg:1ar Lo:l-ly wage rate iDy :ou classification of a woriurr. If ring a collecti::o ❑argaining agreement, tile records milt incllle an employee roster iuy :o❑ classification that permits tile reconciliation of indi:Adlal employees to tile :0u classifications set forte in tEe collecti::o ilargaining agreement. Tile non -salaried employees regiJar uo:lrIy wage silall Lie determined iuy diijding that employees total remiEneration iuy tEe uoErs woriurd diEring tip pay period, irrespectiE0 of wElatEer tile employee is paid on an iuo:IrIy, pieceworq production or commission ilasis. Tee payroll earned Cy any non -salaried employees for wuom tCe records specified aCoCe are not maintained and/or made aE:8ilaF]e will Fie assigned to tu✓ low wage classification teat descriEles tEJe operations performed. Tee reg::Iar uolir1y wage of salaried employees is determined Cy didding tDe total annilal rem❑neration uy 2000 uoas. If an employee is salaried for less tin 12 montE8, tCe regdar uoaly wage for tip salaried period is calcdated on a prorated psis. Audit Requirements If yoi-ir policy ilas an effectiur date on or after i:anilary 1, 2020 and prod❑ces a final premi!Ern of ❑10_00 or more, a p!uysical allit is re -]!fired at least once a year::Jf it prod❑ces a final premiE n of less titan ❑10,❑ 0 and de. clops payroll in a ::Jg❑wage classification, a p!uysical a::dit of tip policy is re❑EJred !Enless tip policy is a renewal and a piuysical a!-dit was completed for one of tip two immediately preceding policy periods. A "p4sical a::dit" is defined as an ai-lit of payroll, wFlet-ler conducted at tip policy❑older location or at a remote site, that is !lased Dpon an allitor:g eihmination of tie policyuolderi-9 Cboiu; of accoiEnts and original payroll records Fin eiti-ler electronic or Dard copy form -]as necessary to determine and !unify tee eiEpos:lre amo::nts ❑y classification. If yo❑ -old a C-39 Roofing Contractor license from tElb California Contractors State License Board, a puysical a-dit is re❑EJred on tie complete policy period of eac❑ policy regardless of t-e amo7nt of final premi::n. See California Instance Code Section 1166iu180for additional re❑iirements regarding tile a::dit of C-39 license ❑olders. Form PN 04 99 06 D Printed in E.S.A. The Hartford POLICYHOLDER NOTICE OF SHORT RATE CANCELLATION PROVISIONS If tie policy is cancelled lar tFia ins:1red More t0e end of tie policy term, eF:(,ept if to reason for cancellation is permanent clos!ie or sale of t%e 0:13iness, T❑e iartford will apply a sEort rate cancellation fee. TEis means t0at tie final premi::n will ie more tiEan pro rata, as it will Lie increased Dy a sort rate cancellation fee. T❑e amo::nt of tie fee will :ary depending on iEow early tie policy is cancelled or w:letF]er yoiEr policy is s❑❑ect to an ann:18l minimErn premi::n. T❑e range of tie fee is ❑❑ to 100❑ of t0e fill premiiErn, and t0a final premi::rn will not i-e less tFian tFle minim::n premi::n. T❑e met❑od for determining tFla short rate cancellation fee can iEAary 4 state❑contact yo!j agent or :Iroi�r if more information is re -]!fired. !Uote!Ma S!--ort Rate Cancellation rues do not apply in tFla state ofT❑.❑ Form WC 66 04 51 Printed in i.S.A. Page 1 of 1 PRODUCER COMPENSATION NOTICE Yo❑ can renew and o tain information on T❑e ❑artfordis prod❑cer compensation practices at www.T❑e❑artford.com or at 1-800- 92-❑❑l a Form G-3418-0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT Policy Number: E6 WEG Bi❑3❑P❑ Endorsement Number: Effective Date: 11/04/2❑ Effectiu u r is to same as stated on ti❑e Information Page of t❑e policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE A❑ 8E260 Name of California Insurer: Ti❑is endorsement addresses to rei❑irements of to Terrorism Risi❑ Instance Act of 2002 as amended and e-tended -y tin Terrorism Risi❑ Ins0rance Program Rea❑t7eriiution Act of 2019. It series to notify yo❑ of certain limitations Ender tin Act, and tut yoj instance carrier is ciurging premiErn for losses tint may occ-r in to eiunt of an Act of Terrorism. Yoij policy pro:Jdes courage for worurs compensation losses caned Ey Acts of Terrorism, incl::ding worurs compensation iunefit oJigations dictated Qy state law. Courage for si❑c❑ losses is still s❑❑ect to all terms, definitions, eiEoliuions, and conditions in yoij policy, and any applicaJe federal and/or state laws, rues, or regElations. Definitions T❑e definitions prouded in tEJs endorsement are Cased on and iuu to same meaning as to definitions in to Act. If words or pLi ases not defined in tCJs endorsement are defined in to Act, to definitions in to Act will apply. "Act" means tin Terrorism Ris❑ Insiiance Act of 2002, wiJc❑ too:] effect on ❑oiumiur 26, 2002, and any amendments Hereto, incl❑ding any amendments resiFIting from t❑ e Terrorism Ris❑ Insi-irance Program Rea❑tiuriution Act of 2019. "Act of Terrorism" means any act that is certified ❑y tin Secretary of to TreasFiry, in consEltation wit❑ tin Secretary of❑omeland Sec-irity, and t e Attorney General of t e ❑nited States as meeting all of tin following re❑-Jrementsi❑ a. T❑e act is an act of terrorism. :1 T❑e act is iJolent or dangeroiu to i❑irnan life, property or infrastriutiEre. c. T❑e act resdted in damage witEJn t❑e ❑nited States, or oEtside of t❑e ❑nited States in to case of to premises of ❑nited States missions or certain air carriers or ussels. d. Tie act us uen committed ❑y an indiEjdi:al or indiiJduls as part of an effort to coerce to ci:lIian pop:Aation of tin ❑nited States or to infliunce t!u policy or affect to cond❑ct of tin ❑nited States Gournment ❑y coercion. "Insiied Loss" means any loss resiElting from an act of terrorism lend, e!uept for Pennsyliunia, inch -ding an act of war, in to case of woriurs compensation❑tint is coured ❑y primary or euess property and casulty insi-irance issud y an insi=7er if tin loss occijs in tin ❑nited States or at tin premises of ❑nited States missions or to certain air carriers or ussels. "Insider Ded❑rtii-le" means, for t❑ e period uginning on =anury 1, 2021, and ending on Decemur 31, 202q an amo::nt e❑uI to 20❑ of oij direct earned premiC7ns d0ring tin immediately preceding calendar year. Form WC 00 04 22 C (01/21) Printed in :].S.A. Process Date: 11/04/2❑ Page 1 of 2 Policy Expiration Date: 11/04/26 Limitation of Liability T❑e Act limits o'er liaE lity to yo❑ Ender tEls policy. If aggregate InsEired Losses eEceed ❑100,000,000,000 in a calendar year and if we NCO met oEir InsEirer Ded❑ctiFle, we are not llaFle for t0e payment of any portion of tie amount of InsEired Losses tit eC(,eeds Ell 00,000,000,000Eland for aggregate InsEired Losses Ep to ❑l00,000,000,000, we will pay only a pro rata sCiare of s❑c❑ InsEired Losses as determined ❑y t!--le Secretary of tie TreasEiry. Policyholder Disclosure Notice 1. Insied Losses woF]d Oa partially reim❑used ❑y t0a ❑nited States Go�Ornment. Ifti-le aggregate indi�try Ins:1red Losses occ:lrring in any calendar year ei-(,eed 100,000,000, tLie ❑nited States Go:ernment word pay 801 of o0r Insi-Ted Losses t:18t e:ceed oir Insirer Ded:ttii-le. State See Attac❑ed SciedFle 2. ❑otwitE:8tanding ite GoFernment will n< Act for any portion 0100,000,000,000. Schedule Rate n 1 aioEO, t0e ❑nited States maw any payment Ender tie of Ins red Losses tit eC(,eed T❑e premiErn cEiarge for t0a coC:Orage yob policy proddes for Insilred Losses is inclEded in t0e amo7nt siown in Item 4 of t0e Information Page or in t❑e Sc❑edde ielow. Premium Form WC 00 04 22 C (01/21) Printed in D.S.A. Page 2 of 2 The Hartford ARIZONA NOTICE INDEPENDENT CONTRACTORS Section 23-902 of tn✓ Ari:ona states states tlat a contractor is deemed an employee of tn✓ "employer" for w::Jc❑ t!Foy are worAng ifs o Tne employer retains si--lper:1sion or control oi-:Or tin✓ contractor and o T❑e worn is ongoing, regJar, ordinary, or ro::tine in yo:lr operation and is ro::tinely done ny yoj own employees If tFle ai-070 conditions are met, we will treat to contractor as an employee and ma1:6 t!-10 appropriate premi!EM clarge. Section 23-964, Section L of t:10 Ari![ona stat-tes allows a contractor w!Eo is a sole proprietor to wai!nr rigs to Wor-ers Compensation courage. ❑o additional premi::n clarge will i-10 made, if t:10 sole proprietor completes form WC 66 02 3n "Ari-ona Sole Proprietor Wai![or". For f:jtner information, please contact yob agent or Dro!nrr. Form WC 66 02 48 Printed in Q.S.A. The Hartford CALIFORNIA NOTICE CALIFOR❑IA LABOR CODE 311111 PRO❑IDES T-AT E❑ERY EMPLOYER S❑BJECT TO TOE COMPE❑SATIO❑ PRO❑ISIO❑S OF T❑IS CODE, E❑CEPT EMPLOYERS OF EMPLOYEES DEFI❑ED 10 S❑BDI❑ISIO❑ All OF SECTIO❑ 3301, S❑ALL GI❑E E❑ERY ❑EW EMPLOYEE, EIT❑ER AT TOE TIME OF ❑IRE, OR BY TOE E❑D OF TOE FIRST PAY PERIOD, WRITTE❑ ❑OTICE OF TOE 111FORMATIO❑ CO❑TAI❑ED 10 SECTIO❑ 311110. CALIFOR❑IA LABOR CODE 3111D PRO❑IDES T❑AT E❑ERY EMPLOYER S❑BEECT TO T❑E COMPE❑SATIO❑ PRO❑ISIO❑S OF T❑IS DI❑ISIO❑ S❑ALL POST A❑D ❑EEP POSTED 10 A CO❑SPIC❑O❑S LOCATIO❑ FRE❑❑E❑TED BY EMPLOYEES, A❑D W❑ERE TOE ❑OTICE MAY BE EASILY READ BY EMPLOYEES D❑RI❑G TOE ❑O❑RS OF TOE WOR❑DAY, A ❑OTICE W❑IC❑ S❑ALL STATE TOE DAME OF TOE C❑RRE❑T COMPE❑SATIO❑ I❑S❑RA❑CE CARRIER OF TOE EMPLOYER, OR W❑E❑ S❑C❑ IS TOE FACT, T❑AT TOE EMPLOYER IS SELF-111S❑RED, A❑D W❑O IS RESPO❑SIBLE FOR CLAIMS ADEOSTME❑T. Form WC 66 00 15 A Printed in E.S.A. The Hartford NOTICE TO POLICYHOLDER CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS PISSI-ant to Section 11 ❑i1.8 of t0e California Insi-i-ance Code, we are promding yo❑ wit[] an eEplanation of fie California worE:Ors❑compensation rating laws applicade to new and renewal policies wit[] policy effectiC:0 dates on and after ::8ni:ary 1, 199�:! Ti❑e laws re❑ring all insiiers to Clarge t0e same minim::n rate iEniformly to all employers witi�n a gi::On classification his ileen repealed. Beginning i:an:lary 1, 199❑, we will esta�lis❑ of own rates for worl�ersi❑ compensation. 0-ir rates will not 00 applica�le prior to tE8 first normal policy effecti-:0 date of a policy incepting on or after i:ani-ary 1, 199❑. OFT rates, rating plans and related information are filed witi❑t❑ e Ins:1rance Commissioner and are open for p❑EJic inspection. 2. Ti❑e Insisance Commissioner can disapproEo oi-i- rates, rating plans or classifications only if 00 iOas determined after p❑i lic raring t:18t os rates mig::t :6opardi::6 oil ai-Jlity to pay claims or create a monopoly in tie mar::Ot. A monopoly is defined iEy law as a marEot wire one insider writes 20❑ or more of t❑at part of tie California wor::Ors❑ compensation insi-irance tiFat is not written ❑y tie State Compensation Ins:1rance Find. If tip insFirance Commissioner disappro::Os o!-ir rates, rating plans or classification, Ele may order an increase in tip rates applicaiFle to o❑tstanding policies. 3. Rating organi❑8tions may de::Olop p:1re premi::n rates w::Jc❑ are s❑❑Act to tip Ins:1rance Commissioners approi❑al. A p0re premi::n rate reflects t0a anticipated cost and e:A)enses of claims per 0100 of payroll for a gi::On classification. Pore premi-n rates are ad:1sory only, as we are not re❑i�red to sib tija p:1re premiEn rates de::Oloped Ey any rating organiCation in esta:lisi❑ing oil own rates. 4. We m❑st ad ❑ere to a single, ❑niform eEperience rating plan. If yo❑ are eligiEle for eEperience rating Ender tip plan, we will ❑e re❑EJred to ad❑8t yoFir premiEn to reflect yob claim EJstory. A ❑etter claim EJstory generally resdts in a lower eEperience rating modification❑more claims, or more eEpensi❑e claims, generally resdt in a EJg❑er eEperience rating modification. Ti❑e Eniform eEperience rating plan deEoloped ❑y t❑e instance rating organiE:8tion designated ❑y t❑e Instance commissioner is s❑❑iect to toe approE:81 of t❑e Instance Commissioner. :1 A standard classification system deiceloped i❑y tip insiFi-ance rating organii❑ation designated i❑y t0e Instance Commissioner is si❑❑:Oct to approi❑al of toe InsiErance Commissioner. Ti❑e standard classification system is a met❑od of recogniiJng and separating policyi❑olders into ind::8try or occi—pational groEps according to t0eir similarities and/or differences. We can adopt and apply tip standard classification system or de::Olop and apply oil- own classification system, pro:1ded t0at we can report t0e payroll, ei[penses and ot:1er costs of claims in a way w::Jc❑ is consistent wit❑ tip standard classification system. 6. Oil rates and classifications may not !Jolate to ❑nr❑❑ CiE]l Rig-ts Act or De Affairly discriminatory. :1 We will proude an appeal process for yo❑to appeal t❑ e way we rate yos insFirance policy. T❑e process will re❑iJre ::8 to respond to yoi-i- written appeal wit- n 30 days. If yo❑ are not satisfied wit❑ tip resift of yoij appeal, yo❑ may appeal oil decision to to Insi-irance Commissioner. Form WC 66 02 05 A Printed in ❑.S.A. The Hartford DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS COMPENSATION BENEFITS Teas law permits an employer to o❑tain WoriEors:Compensation ins0rance wit❑ a ded❑ctiiJe. T❑e ded❑cti:le applies to Denefits paya:]e Ender Te::8s Wor!Eors❑Compensation Law. T❑e ins0rance applies only to iDenefits in e::(,ess of tip ded❑cti:le amoEnt. T❑e ded❑ctii1e applies separately to eac❑ accident or disease regardless of t:le nErn:ler of people wig s::8tain inny ❑y s:j,,❑accident or disease or claim or medical -only claim. T❑e ded❑ctii1e plans !1a::o iDeen eEplained to me. Premi::n red:jrtions are determined iOased on tFle ded❑cti:le selected, and tip iOal:8rd groom. T❑e :a!:ard groi-p is determined ❑y t:le classification t0at prod❑ces tie largest amoFlnt of estimated Terms standard premiiErn. Yo❑ are not re❑fired to ci-oose a ded❑cti:le. If yo❑ do ciEoose one, yoi-ir instance company will pay tElb ded❑ctiFle amoi�t for yoq ❑ t yo❑ m::8t reim❑use tEib instance company witi-lin 30 days after t❑ ey send yo❑ notice tFlat payment is dF8. If yo❑ fail to reim❑i-irse tip company, tidy may cancel tEie policy, iEpon ten days written notice, and any resifting premi:in may De applied to t❑e dedEti:le amoEnt owed. If a ded❑cti:le amoEnt is desired, please indicate Mow. ❑ ❑ Yes, I want a dedi-Ptii-le of❑ -Select only one❑ 1 ❑ per accident 2. ❑ per claim 3. ❑ per medical -only claim applied to :10nefits payaiJe Ender tEib Tei-:8s Wori�ers❑Compensation Law. I iEnderstand tit t❑e company will pay tLie dedEctiLle amoEnt and see❑reim❑:Irsement inonti-ly, ❑❑erterly or ot❑ er❑ ❑ ❑ ❑o, I do not want a ded❑ctiiFle applied to ❑enefits pays[le Ender tip Te!-:8s Wor!_:Ors!FCompensation Law ❑ ❑ Yes, I do want a ded❑cti:le policy, ❑!A am iEna!Fle to oEtain for t❑e following reason:] Beginners Edge Sports Training Employer Flame [print or type[] Signatie and Title Date 6 WEG B❑3❑P❑ Policy ❑iEM-lar WC 66 01 25 A Printed in D.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 POLICY NUMBER: :ro WEG B❑3i❑P❑ NAME OF INSURER: ❑artford Insi-irance Company of Illinois Oil President and Secretary iEaEo signed t:Js policy co htersigned Ey o:l-d:1y a::t::Ori::Od representatiE0. ❑e:ln Barnett, Secretary W'❑ere re❑gyred ❑y law, t'—e Information Page iDas iDeen A. Morris TooiFor, President InclEdes copyrigiA material ofti-le ❑ational CoEncil on Compensation Ins!iance, Inc. !wed wit❑its permission. ❑ 2000 ❑ational Co!Encil on Compensation Instance, Inc. All Rig!Ets ReseriEod. DELAWARE ❑ Delaware forms i-18::0 iDeen copyrigEted ❑y tEe Delaware Compensation Rating Berea❑Inc. ❑EW YOR'❑'❑ Inch -des copyrig❑ted material of tEie ❑ew Yor❑Compensation Insiiance Rating Board, 'wed wit❑ its permission. ❑ 2021 ❑ewYor❑Compensation Insiiance Rating Board, all rig As reseriEOd. ❑ORT❑ CAROLI ❑A❑ Inch -des copyrigiAed material of tEie ❑ort❑Carolina Rate Berea❑, 'wed wit❑its permission. PE❑❑SYL❑A❑IA'❑ PennsylE:inia forms Fia::o iDeen copyrigEted ❑y tEe Pennsyli-:8nia Compensation Rating BF1reaE1 Form WC 99 00 01 K Printed in ❑.S.A. Page 1 of 1 Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 THE A • • / • INSTRUCTIONS EMPLOYEE'S CLAIM FOR WORKERS' COMPENSATION BENEFITS As of CAn❑ary 1, 1990, California employers are re❑fired ❑y law to finis❑ a claim form to an in —red worer witJn one wordng day of ❑nowledge of a wor- related inky or illness Cot❑er t❑an First Aid❑ Wile it is mandatory for t❑e employer to finis❑ t❑e claim form to t❑e employee, it is not mandatory for the employee to complete it. T❑e employer s❑bdd complete sections 9-1 ❑, wit❑ t❑e eeeption of section 13 [VvE]c❑ reads, "Date employer recei[od claim form"❑ T❑is is to ❑e completed after t❑e claimant es completed Els or ❑er portion of t❑e claim form and ret-ned it to yoq at wE]c❑time section 13 s❑bdd ❑e immediately filled oEt or date stamped. Penalties can e in❑bed if employers fail to proElde an in❑red employee an EMPLOYEEiS CLAIM FOR COMPE❑SATIO❑ BE❑EFITS form or if employers fail to report t❑e claim to tie worers❑compensation ins-rance carrier. DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: W❑et❑er or not tie employee completes t❑e EMPLOYEES CLAIM FOR WOR❑ERIS COMPE❑SATIO❑ BE❑EFITS, please contact T❑e ❑artfordig LossConnect (1-800-327-3636) to report eery occ-pational in—ry or illness w❑ic❑resdts in lost time eyond t❑e date of tie incident or re -gyres medical treatment eyond First Aid. Form WC 55 00 11 D Printed in O.S.A. 16The Hartford Reporting a Work -Related Injury is Time Sensitive! Call The Hartford's LossConnect immediately to report a claim. 1-800-327-3636 Available 24 hours a day, 365 days a year. The Benefits of Timely Loss Reporting: Researc❑ ❑as sown tCot faster loss reporting significantly affects loss costs. Tie sooner we are notified, t❑e sooner we can in[ostigate t❑e accident and coordinate wit❑yoq t❑e in❑red employee, and tie medical team to ensC7e t❑e fastest possi:]e retC7n to ❑ealt❑and wor❑ The Effect of Timely Reporting on Controlling the Cost of Your Loss: Average Loss for Closed Claims (Accident Years 2002-2005) Report Lag in Days Percent Change in Loss Costs Compared to First Week Report Incident Day -6❑ Wee❑1 0❑ Wee❑2 13❑ Wee❑3 or 1611 1 Mont❑or Later 2411 Statutory requirements also necessitate the prompt initial reporting of the accident causing injury or death. Failure to comply may result in a fineable offense by the State. Information You'll Need Company Information o AccoC7it ❑EMEJer o Location Code Cif applicade❑ o Parent Company -or program name[] o Policy ❑EMEJer Worker Information o :lame, DOB, Address, PCone o Social SecFirity ❑EMEJer o Age, Gender o Marital Stat❑s, ❑En❑er of Dependants o —ire Date, Years in C_rrent Position o Wage Information Incident Information o Type of in❑ry C❑C]m, cCt, etc.C❑ o EL:8ct Cody part in❑red❑ o W1at caC:8ed t❑e accident[] o Any reason to ❑❑estion t❑e in❑ry❑ o Any witnesses[] o Address w—ere in❑ry occC7red❑ o W—ere was t❑e in [Hired employee treated ❑ EProdde name, address, pEone of medical prodder.❑ o W❑en was tie accident reported to yo❑ and CCy w❑bm Cdate, timeCZ Network Providers A listing of more twin 400,000 networ❑prodders ❑Eialified to treat worE4elated in❑iries is aE:8ilade online at www.talispoint.com/ilarteEt or ❑y calling oC7 ❑etwor❑Referral —nit at 1-800-32C-3636 -select 4 at t❑e prompt❑ Since networ❑referrals are often impacted !❑y state specific ryes, please call to learn Cow to madmiCo oCr networ❑capa::jlities on Da❑alf of yo-r employees. Form WC 66 03 84 Printed in ❑.S.A. The Hartford DEDUCTIBLE NOTICE OF ELECTION TO ACCEPT TEXAS WORKERS COMPENSATION BENEFITS Teas law permits an employer to o❑tain WoriEors:Compensation ins0rance wit❑ a ded❑ctiiJe. T❑e ded❑cti:le applies to Denefits paya:]e Ender Te::8s Wor!Eors❑Compensation Law. T❑e ins0rance applies only to iDenefits in e::(,ess of tip ded❑cti:le amoEnt. T❑e ded❑ctii1e applies separately to eac❑ accident or disease regardless of t:le nErn:ler of people wig s::8tain inny ❑y s:j,,❑accident or disease or claim or medical -only claim. T❑e ded❑ctii1e plans !1a::o iDeen eEplained to me. Premi::n red:jrtions are determined iOased on tFle ded❑cti:le selected, and tip iOal:8rd groom. T❑e :a!:ard groi-p is determined ❑y t:le classification t0at prod❑ces tie largest amoFlnt of estimated Terms standard premiiErn. Yo❑ are not re❑fired to ci-oose a ded❑cti:le. If yo❑ do ciEoose one, yoi-ir instance company will pay tElb ded❑ctiFle amoi�t for yoq ❑ t yo❑ m::8t reim❑use tEib instance company witi-lin 30 days after t❑ ey send yo❑ notice tFlat payment is dF8. If yo❑ fail to reim❑i-irse tip company, tidy may cancel tEie policy, iEpon ten days written notice, and any resifting premi:in may De applied to t❑e dedEti:le amoEnt owed. If a ded❑cti:le amoEnt is desired, please indicate Mow. ❑ ❑ Yes, I want a dedi-Ptii-le of❑ -Select only one❑ 1 ❑ per accident 2. ❑ per claim 3. ❑ per medical -only claim applied to :10nefits payaiJe Ender tEib Tei-:8s Wori�ers❑Compensation Law. I iEnderstand tit t❑e company will pay tLie dedEctiLle amoEnt and see❑reim❑:Irsement inonti-ly, ❑❑erterly or ot❑ er❑ ❑ ❑ ❑o, I do not want a ded❑ctiiFle applied to ❑enefits pays[le Ender tip Te!-:8s Wor!_:Ors!FCompensation Law ❑ ❑ Yes, I do want a ded❑cti:le policy, ❑!A am iEna!Fle to oEtain for t❑e following reason:] Beginners Edge Sports Training Employer Flame [print or type[] Signatie and Title Date 6 WEG B❑3❑P❑ Policy ❑iEM-lar WC 66 01 25 A Printed in D.S.A. Process Date: 11/04/2❑ Policy Expiration Date: 11/04/26 16The Hartford THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 6 WEG B❑3❑P❑ Endorsement Number: 003 Effective Date: 03/12/26 EffectiEo Foil is tFia same as stated on t❑e Information Page of tie policy. Named Insured and Address: Beginners Edge Sports Training ❑432 E TIERRA B❑E❑A L❑ SCOTTSDALE A❑ 8E260 We ❑a❑e t❑e rigA to reco-er o-r payments from anyone liade for an in❑ry coEered ❑y tEJs policy. We will not enforce oEir rigEt against t❑e person or organiCation named in tEja Sc❑edde. ISEJs agreement applies only to t--:0 eEtent t❑at yo❑ perform wor❑ Ender a written contract tit re❑EJres yo❑to oEtain tEJs agreement from E8.11 Yo❑ mC:8t maintain payroll records accilrately segregating t❑e rem-neration of yo-r employees wile engaged in tie wor❑ descried in tEle Sc❑ed!Fle. Tie additional premi-n for t::js endorsement s❑all ❑e 1111 of t❑e California worEors❑compensation premi-n otierwise d❑e on s❑c❑rem-neration. SCHEDULE Person or Organization City of Santa Ana, its City Co❑ncil, officers, officials, employees, agents and EoIEnteers, 20 CIAC CE❑TER PLO, SA❑TA A❑IA, CA, 92F-01 CoAtersigned ❑y Job Description AEtEofI❑ed Representati-e Form WC 04 03 06 :1 []Printed in O.S.A. Process Date: 03/12/26 Policy Expiration Date: 11/04/26 CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE I, Mitchell Goldberg ("Representative"), attest that I am an authorized (Name and Title of Vendor Representative) representative of Begnners Edge Sports Training (Consultant/Company Name) possess the authority to legally bind Company. ("Company"), and In my capacity as Representative of Company, I represent and confirm the following, as relates to the agreement between Company and City of Santa Ana, agreement number ("Agreement") to provide Youth Sports Classes and Sports Camps (Services to be provided under agreement/contract) ("Services"): During the course and scope of Company's agreement with the City of Santa Ana, Company employees, consultants, representatives, and agents will not use and/or drive any Company owned/rented/leased/borrowed vehicles to perform Services to, for, or on behalf of City of Santa Ana. If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum automobile liability insurance coverage as required in the Agreement, it will be considered a breach of Agreement rendering the Agreement null and void and Company will be fully liable for any and all damages. 1/27/2026 Date Mitchell J Goldberg Print Name Owner Title 714-874-4737, mitch@best-sports-usa.com Contact Information, i.e., Telephone Number and/or Email Address Affidavit of Exemption for Automobile Liability Insurance 11.12.2024 Nguyen, Tu Tran From: Uribe, Juan Sent: Wednesday, March 18, 2026 11:13 AM To: RM D Cc: Soriano, Destinee Subject: RE: Request for COI Review: Beginners Edge Sports Training, LLC Hello, Yes I can confirm the vendor will not be driving to City premises to perform their services on the agreement. Sincerely, - Juan Magana Uribe I Management Aide ' City of Santa Ana, Parks, Recreation and Community Services 20 Civic Center Plaza, Santa Ana, CA 92701 (714) 571-4276 1 iuribe(aD-santa-ana.orq "City Hall is closed every other Friday. Click here for dates" From: RMD Sent: Wednesday, March 18, 2026 11:04 AM To: Uribe, Juan <juribe@santa-ana.org> Cc: Soriano, Destinee <dsoriano@santa-ana.org> Subject: RE: Request for COI Review: Beginners Edge Sports Training, LLC Hi Juan, Can you please confirm that the vendor will not be driving to any City Premises to perform services on the agreement? Kind regards, Tu Tran Nguyen I Risk Management Technician City of Santa Ana - Human Resources Department 20 Civic Center Plaza I Santa Ana, CA 92701 Office: 714-647-5141 Email: TNguyen20(aD-santa-ana.orq I santa-ana.orq/human-resources I Linkedln I nstagram City Hall hours are 8 a.m. to 5 p.m. Monday through Thursday, and 8:00 a.m. to 5:00 p.m. every other Friday. Click here for a list of observed holidays and Friday closure dates.