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HomeMy WebLinkAboutCARE AMBULANCE SERVICES INC. (2012-196-01)IN6t111AR1t,'B ON rlu. , 6 WORK MAY PROCEED MAYOR Miguel A. PUlldo MAYOR PRO TEM Vincent F. Sarmlemo COUNCIL.MEMBERS Angelica Amezcua P. David Benavides Michele Martinez Roman Rayne Sal Tinajero September 3, 2015 CITY OF SANTA ANA 20 Civic Center Plaza . P.O. Box 1988 Santa Ana, California 92702 714 - 647 -6944 www santa-ana.ora Troy Hagen, Chief Executive Officer CARE Ambulance Service, Inc. 151.7 W. Braden Court Orange, CA 92868 A- 2012 - 196 -01 CITY MANAGER David Cavazos CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Maria D. Huizar Re: Agreement A- 2012 -196, Agreement for EMS Emergency Transportation Services Dcar Mr. Hagen, Pursuant to Agreement A- 2012 -196 ("Agreement"), entered into between CARE Ambulance Service, Inc. ( "Contractor ") and the City of Santa Ana ( "City "), dated September 17, 2013, Section 5 Term, the time period of said Agreement is hereby extended for one (1) additional year. In accordance with the provisions of Section 5 of the Agreement the City's decision to grant an extension has been made with the concurrence of the Orange County Fire Authority. The term of this extension shall begin 12 a.m. on September 20, 2015 . and end on 1.2 a.m. September 20, 2016. The insurance certificates required pursuant Section 8 of the Agreement shall be required to be extended and /or renewed to cover this extension. All other terms and conditions of said Agreement remain unchanged and in full forte and effect. If you have any questions regarding this matter, please contact Willard Holt, Treasury and Customer Services Manager in the Finance and Management Services Agency at 714 - 647 -5456. Sincerel 1 CITY OF A1VT ANA David Cavazos City Manager APPROVED AS TO FORM: Sonia R. Carvalho City Attorney y� Lisa Storck Assistant City Attorney e: Clerk of the Council ATTEST:: Marta D. Huizar Clerk of the Council "CONTRACTOR" CARE AMBULANCE SERVICE, INC. By: �--- . Name Tr agen Title Chief Executive Officer SANTA ANA CITY COUNCIL Moral A. Fulido Vlnowo F. Sarmlento mldheie Mannez Angelico Amowe P. David eanavaea Roman Repo $v Tinniarc Mayor Mayor Pro Tem, Ward i Ward2 Ward3 Ward Ward s Ward mouido!tusaM,e -e am vsami aniata2 Ma-ana orn mmert'ngz(C� z ana ero aemezcualLSa�ta -ana oru tlto' aviges�aar+�tta -eCa ory «avna�iszv5is- ana.orA n�Jgm(@santa ana orn :S MAYOR Miguel A. Pulido MAYOR PRO TEM Vincent F. Sarmiento COUNCILMEMBERS Angelica Al P. David Benavides Michele Martinez Roman Rayne Sal Tinajero INSURANCr ON FILL WORK MAY PROCEED UNTIL ppINSURANCE EXPlt E', CLERK OF COUNCIL CATE: q --15 September 3, 2015 CITY OF SANTA ANA 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 714 - 647 -6900 www.santa- ana.oro Troy Hagen, Chief Executive Officer CARE Ambulance Service, Inc. 1517 W. Braden Court Orange, CA 92868 Re: Agreement A -2012 -196, Agreement for EMS Emergency Transportation Services Dear Mr. Hagen, Pursuant to Agreement A- 2012 -1.96 ( "Agreement "), entered into between CARE Ambulance Service, Inc. ( "Contractor") and the City of Santa Ana ( "City "), dated September 17, 2013, Section 5 Term, the time period of said Agreement is hereby extended for one (1) additional year. In accordance with the provisions of Section 5 of the Agreement the City's decision to grant an extension has been made with the concurrence of the Orange County Fire Authority. The term of this extension shall begin 12 a.m. on September 20, 2015 and end on 12 a.m. September 20, 2016. The insurance certificates required pursuant Section 8 of the Agreement shall be required to be extended and /or renewed to cover this extension. All other terms and conditions of said Agreement remain unchanged and in full force and effect. If you have any questions regarding this matter, please contact Willard Holt, Treasury and Customer Services Manager in the Finance and Management Services Agency at 714 -647 -5456. Sincerely, �_.._ CITY ANA David Cavazos to City Manager APPROVED AS TO FORM: Sonia R. Carvalho City Attorney By:t Lisa Storck Assistant City Attorney c: Clerk of the Council Miguel A. Polido Vincent F. Sarmanto Mayor Mayor Pro Tom, Ward 1 m*Urdd@}sanoa sc4ac vsar pyIX�s ana oro ATTEST: Maria D. huizar Clerk of the Council "CONTRACTOR" CARE AMBULANCE SERVICE, INC. By: Name Troy Hagen Title Chief Executive Officer SANTA ANA CITY COUNCIL Michel. Marunaz Angelica Amezcua P. David B.navides Roman Reyna Sal Tinajero Ward 2 ward 3 Ward 4 Ward 5 Ward 6 dmazno samaana oro Aac?Uua4�sanra -.tame d1don— Uga2sama -are9rd !aT a sgpavrofrasaniaarl rg CITY MANAGER David Cavazos i�� CITY ATTORNEY Sonia R. Carvalho �(} t t 11� �•�/ [ I CLERK OF THE COUNCIL Maria D. Huizar CITY OF SANTA ANA 20 Civic Center Plaza • P.O. Box 1988 Santa Ana, California 92702 714 - 647 -6900 www.santa- ana.oro Troy Hagen, Chief Executive Officer CARE Ambulance Service, Inc. 1517 W. Braden Court Orange, CA 92868 Re: Agreement A -2012 -196, Agreement for EMS Emergency Transportation Services Dear Mr. Hagen, Pursuant to Agreement A- 2012 -1.96 ( "Agreement "), entered into between CARE Ambulance Service, Inc. ( "Contractor") and the City of Santa Ana ( "City "), dated September 17, 2013, Section 5 Term, the time period of said Agreement is hereby extended for one (1) additional year. In accordance with the provisions of Section 5 of the Agreement the City's decision to grant an extension has been made with the concurrence of the Orange County Fire Authority. The term of this extension shall begin 12 a.m. on September 20, 2015 and end on 12 a.m. September 20, 2016. The insurance certificates required pursuant Section 8 of the Agreement shall be required to be extended and /or renewed to cover this extension. All other terms and conditions of said Agreement remain unchanged and in full force and effect. If you have any questions regarding this matter, please contact Willard Holt, Treasury and Customer Services Manager in the Finance and Management Services Agency at 714 -647 -5456. Sincerely, �_.._ CITY ANA David Cavazos to City Manager APPROVED AS TO FORM: Sonia R. Carvalho City Attorney By:t Lisa Storck Assistant City Attorney c: Clerk of the Council Miguel A. Polido Vincent F. Sarmanto Mayor Mayor Pro Tom, Ward 1 m*Urdd@}sanoa sc4ac vsar pyIX�s ana oro ATTEST: Maria D. huizar Clerk of the Council "CONTRACTOR" CARE AMBULANCE SERVICE, INC. By: Name Troy Hagen Title Chief Executive Officer SANTA ANA CITY COUNCIL Michel. Marunaz Angelica Amezcua P. David B.navides Roman Reyna Sal Tinajero Ward 2 ward 3 Ward 4 Ward 5 Ward 6 dmazno samaana oro Aac?Uua4�sanra -.tame d1don— Uga2sama -are9rd !aT a sgpavrofrasaniaarl rg - -, - CERTIFICATE OF LIABILITY INSURANCE GP.re1MMrODIrYYV) 00!30(2018 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 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 Aon Risk Services Northeast, Inc. New York NY Office CONTACT NAME: tpIC NO. EZI: (866) 233 -7122 ,No.l: (800) 3G3-0105 199 Water- Street New York NY 10038 -355L USA E-MAIL ADDRESS: INSURER(5) AFFORDING COVERAGE NAICI INSURED INSURER A: Liberty Mutual Fire Ins CO .- .-- ..— ._..._...._.___ 33035 care W. trader Service, Care AnlbUlante Service. Inc. 1517gW CA 92868 LISA ..___.._ INSURER In Liberty insurance Corporation _�. —.._. 42404 INSORERC: 1- Cyd'S Syndicate No. 2623 �� ,1,11128623 INSURER D: Steadfast Insurance Company 26387 INSURER E: u L PPEMEES IEa octiV Nncol INSURER IF NED ESP 1A, orw person( COVERAGES CERTIFICATE NUMBER: 570055353066 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. Limps shown are as requested LTR TYPE OF INSURANCE INSD AWO POUCYNUMeER MMIDOIYYY MMIOOIYYYy LIMITS C X COMMERCIAL GENERAL LIABIUTy 1447,8102 I( J , 1 EACHOCCURRENCE $2,000,000 CLAIMSAADE OCCUR u L PPEMEES IEa octiV Nncol 5100,000 NED ESP 1A, orw person( _ 55,000 X PNUOCI- Clabii6Mede _ PERSONALS ADV INJURY Included GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 X POLICY PRO- II-7� LO �HO- u PRODUCTS - COMPrOP AGO $2,000,000 OTHER: r A AU fOMOBILE LIABILITY A52- 631 - 510005 -024 10/01/2011111101 /2015 COMBINED SINGLE LIMIT e ar Tae 5210801090 BODILY INJURY l Pnr person) AI NY AUTO X ALL DINNED SCHEDULED AUTOS AUTOS HIRED NO FOS NON-OWNED AUTOS BODILY INJURY (Per Iradene PROPERTY DAMAGE POf 3CGi4flnll 0 X UMBRELLA LIAB X OCCUR UMB541477001. 10 /01 ✓2014 10/01 /2015 EACFI CCCURRENcc 510,000,000 EXCESS LIAB CLAINISIMADE AGGREGATE 510,000,000 DEO RETENTION 8 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANVPROPRIETOR:PARTNERIEXECUTIVE OFFICERAS1,15ER E.XCLUDEDF NIA WA76305JD005014 10/01/2014 10 /0 U? 15 PER OTH- Y` E1'AR)iE E1, EACH ACCIDENT $1 „000,000 F,L. DISEASE EA EMPLOYEE $1,000,000 (Mandmary In NF) Ryyes' describe dndaT 0 SCRIPTIONOFOPF,RATIONSbalaw E.L. DISEASE -PCUCY LIMIT $110001000 C Nisc Ned Prof W1 4387140201 10/01/2014 10/012015 Ea. Medical incTden' $2,000,000 Aggregate Limit 52,000,000 AbusaOMOl =station $2,000,000 DESCRIPTION OF OPERATIONS /LOCATIONS' VEHICLES (ADORN IDI, Additional RomaAa Smbedeii may be a tachod it mom space is reynioun Tile City of Santa Ana and OCFA, and their' respective officers. Offi CIa15, employee.$, representative And Volunteer's are included as Additional IGSUred pot' COntraCC Or Agreelnent5 With the City Of Santa Ana in accordance with the policy provisions Of the General Liability and Autmobile Liability policies, The Policies evidenced herein are Primary and Nor- coilzributory to other instranco, available to an Additional Insured, but only in acc01'dance with the polity's provisions. A waiver of suhrogation is granter! in favor of The City of Santa Ana and OCPA, their respective officers, officials, employees, representatives and volunteers in accordance With the policy provisions of the Workers compensation policy. CERTIFICATE HOLDER CANCELLATION 01988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (201,1101) The ACORD name and logo are registered marks of ACORD M11(' 4I 30t zaI i A(,vit> IF iu `N C N b 6 O S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W ACCORDANCE WITH THE POLICY PROVISIONS. The City Of Santa Ana and OCFA F1nanCL cc Manag6ment SLI -ViCPS Agency 20 Civic Center P132a - M -17 v0 Box 1983 AUTHORIZED RFPRESENTARVE �/.7 ,{,/"�d. Sanata Ana CA 92702 USA c.j�c to C.,f�' c%t2rlcc"[tcil'VO 7ZZP 01988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (201,1101) The ACORD name and logo are registered marks of ACORD M11(' 4I 30t zaI i A(,vit> IF iu `N C N b 6 O S Effective date of this Endorsement: 01 -Oct -2014 This Endorsement is attached to and forms a part of Policy Number: W143137140201 Syndicates 2623/623 at Lloyd's Referred to in this endorsement as either the "Insurer" or the "Underwriters" SCHEDULED ADDITIONAL INSURED ENDORSEMENT — GENERAL LIABILITY COVERAGE ONLY This endorsement modifies insurance provided under the following: Beazley Miscellaneous Healthcare In consideration of the premium charged for the Policy, it is hereby understood and agreed that solely in relation to coverage provided under INSURING AGREEMENTS, A. 2, General Liability, Clause II. PERSONS INSURED is amended to include the Additional Insureds listed in Item 8. below for which the Insured has assumed such person's /entities liability in a written contract or agreement (an "Additional Insured ") solely for services rendered by or on behalf of the Named Insured and that is also named in a Claim if all of the following conditions are met: 1. The Claim against the Additional Insured seeks damages for which the Insured has assumed liability; 2. This insurance applies to such liability assumed by the Insured; 3 The obligation to defend the Additional Insured, has also been assumed by the Insured in the same contract or agreement; 4. The allegations in the Claim and the Information known about the incident are such that no conflict appears to exist between the interests of the Insured and the interests of the Additional Insured; 5. The Additional Insured and the Insured ask Underwriters to conduct and control the defense of that Additional Insured against such Claim and agree that Underwriters can assign the same counsel to defend the Insured and the Additional Insured; 6. The Additional Insured agrees in writing to: a. Cooperate with the Underwriters in the investigation, settlement or defense of the Claim; L Immediately send Underwriters copies of any demands, notices, summonses or legal papers received in connection with the Claim; C. Notify any other insurer whose coverage Is available to the Additional Insured; and d. Cooperate with Underwriters with respect to coordinating other applicable insurance available to the Additional Insured; and The Additional Insured provides Underwriters with written authorization to: a. Obtain records and other information related to the Claim; and b. Conduct and control the defense of the Additional Insured In such Claim. All other terms and conditions of this Policy remain unchanged. 8. City of Santa Ana County of Marin 20 North San Pedro Road San Rafael, CA 94903 E02474 012011 ed. �.t arc% v�U lta( pppPage 1 of 1 NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least '10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. Schedule Name of Other Person(s) / Email Address or mailing address: Number Days Notice: Organization (s): City of Santa Ana 20 Civic Center Plaza (M -30) 30 PO Box 1988 Santa Ana, CA 92702-1988 All other terms and conditions of this policy remain unchanged. Issued by Liberty Insurance Corporation 2 1814 For attachment to Policy No. WA7- 63D- 510005 -014 Effective Date Premium $ Issued to Falck USA, Inc. WNl 90 18 06 1'1 © 2011, Liberty Mutual Group. All Rights Reserved, Ed. 06101/2011 f /l/le'ti�"l, /Cr5' ipPf ,© Page 1 of 1 v Ui'I 287211tA0e011- IOOU'7J Policy Number: A52- 631- 510005 -029 Issued By: Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Name of Other Person(s)/ Organ)zation (s): City of Santa Ana Schedule Email Address or mailing address: 20 Civic Center Plaza (M -30) PO Box 1988 Santa Ana., CA 92702 -1988 Number Days Notice: 30 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least '10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy, All other terms and conditions of this policy remain unchanged. LIM 99 tit 05 11 02011, Liberty Mutual Group of Companies. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1 iii rw lc iL)l Z00; app�O��D INSURER(S) AFFORDING COVERAGE NAI . . ....... . . . .... . . ........ . ... .... INSURER A: Coverys Specialty Insurance Company 15686 INSURED —INSURER B; Greenwich Insurance Company 22322 Care Ambulance Services, Inc. INSURER C: Steadfast Insurance Company 26387 1517 West Braden Court INSURER D:XL Insurance America, Inc. 24554 Orange, CA 92868 INSURER E:: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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. �j� . ..... ..... ... ....... . . . . ....... ADD L. .. .. .... ... LTR TYPIE OF INSURANCE DE un POLICY NUMBER LIMITS (MMIDDrVrYYY jk-,- _T ­C_ _0MME­RC1A_LGEN`ERAL LIAWLITY EACH OCCURRENCE $ 1,0100,000 "DAMAGETCRENTED CLAIMS -MADE F OCCUR X 5-10,013 1010112015 10101120116 $ 100:,000 pFFpJpS Products Claims Made MED EXP (Any one person) $ 6,000 Included GEN'L AGGREGATE LIMIT APPLIES PRO- PER: GENERAL AGGREGATE S 21010010001 X POLICY PRO- ELOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i'mo,000 X_ _(�a �ib_cLq�51....._._....- .... . . .. . ANY AUTO X RADS000476 10101/20,15 101011/201�6 BODILY INJURY (Per person) S ALL OWNED SCHEDULED BODILY INJURY (Per acdclent) AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ ... ... . . ......... . ..... ... . .. ..... . ...... . ............ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 15,000,000 C EXCESS LIAR CLAIMS-MADE X UMB 5414770-02 1010112015 10/0112 AGGREGATE GREGATE $ 15,0010,000 DEL} � I RETENI . .... WORKERS COMPENSADON AND EMPLOYERS' LIABILITY Y�N =XS1 D ANY PROPRII ETC R/PARTNFR/EXEG UTrVE RWD3000955 1010112015 10101/2016 E L. EACH ACCIDENT $ 1,0100,000 OFFICER�MEMBER EXCLUDED? NIA (Mandatory in NH) E Lr DISEASE.. -EA EMPLOYEE $ 1,0�00,000 If gs, describe under —1 ­ ­ -­­- D SCROWTION OF OPERATIONS below E L DISEASE » POLICY LIMIT $ 1,000,000 A Misc Medical Prof. 5-10013 10101/2015 10101120116 See Attached DESCRIPTION OF OPERATIONS; LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) THIS VOIDS AND REPLACES PREVIOUSLY ISSUED CERTIFICATE DATED 11/241201I5 Umibrella/Excess Follows Form. The City of Santa Ana and OCFA, and their respective officers, officials, employees, representative and volunteers are included as Additional Insureds per Contract or Agreements with the City of Santa Ana in accordance with the policy provisions of the General Liability, Automobile Liability, and Umbrella /Excess Liability policies. The Policies evidenced herein are Primary and Non-Contributory to other insurance available to Additional Insureds, but only !in accordance, with the pollcy's provisions. Excess coverage of $15,000,000 applies as Excess coverage over Commercial General:, Liability, Products; Medical Professional Liability and Automobile Liability coverage. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN A ACCORDANCE WITH THE POLICY PROVISIONS, 01,L,61 e.. AUTHORIZED REPRESENTATR/E The City of Santa Ana and OCFA 555 E. Memory Lane San!aita Ana, CA 92702 @ 1988-2'014 ACORID CORPORATION. All rights reserved. ACO,RD 25 (2�014101) The ACCORD name and logo are registered marks of ACORD 12 /I/ X�' V I APPROVED �� � y \^ � �/ � r - « Subject to alil other terms and conditions of the POLICY, it is agreed and understood that Section +w Insured is amended to include as an INSURED the Person(s) or Organization(s) shown in the Schedu�e above, but only with respect to the activities indicated above. This additional insured shall share in the Limits of Liability of the RRST NAMED INSURED, and this extension of coverage shall not increase OUR Limit of Liability. We agree R. notify the Named "' Organization at .. thirty (30) days in advance of cancell,+ of this policy. than as expressly stated above. 4 Sam Mezzich Richard G, Hayes e • COM 003 1 ProdUced: 10/09/2015 d AP'1111 1� av �" �, .. ..._.Page 1 COV E RsY, b P E C i Aisil Y i NSURANCE COMPANY Subject to alil other terms and conditions of the POLICY, it is agreed and understood that Section +w Insured is amended to include as an INSURED the Person(s) or Organization(s) shown in the Schedu�e above, but only with respect to the activities indicated above. This additional insured shall share in the Limits of Liability of the RRST NAMED INSURED, and this extension of coverage shall not increase OUR Limit of Liability. We agree R. notify the Named "' Organization at .. thirty (30) days in advance of cancell,+ of this policy. than as expressly stated above. 4 Sam Mezzich Richard G, Hayes e • COM 003 1 ProdUced: 10/09/2015 d AP'1111 1� av �" �, .. ..._.Page 1 millf"W'211111,111 1 1; HIM "I'lla Iffift 1103 1 AUX- R=. 1 Wl Named Insured: FALCK USA, INC. Endorsement Effective Date: October 1, 2015 WWWWWWOrm4w Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph Di.2. of Section I — Covered Autos Coverages of the Auto Dea�ers Coverage Form, CA 20 4,8 10 13 0 Insurance Serv�ces Office, �nc., 20". Page I of 1 POLICY NUMBER: RAD5000476 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: FALCK USA, INC. Endorsement Effective Date: October 1, 2015 SCHEDULE Name Of Person(s) Or Organization(s): Where required by written contract executed prior to loss. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1