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HomeMy WebLinkAboutCertificate of InsuranceAC"R" '�� CERTIFICATE OF LIABILITY INSURANCE �,,,,..�' DATE /2018 IYYYY) 12/28/2018 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(les) 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 Marsh USA Inc. 125 Ottawa Avenue NW Suite 400 Grand Rapids, MI 49503 CONTACT NAME: PHONE C FAX � o Ex AIC No E-MAIL ADDRESS: :rCOMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X Attn: grandrapids.certrequest@marsh.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: HDI Global Insurance Company 41343 CN108159189-MX-GAW-19-20 Livrmr _ INSURED Cosco Fire Protection, Inc. INSURER B: ACE American Insurance Company - 22667 INSURER C : Berkley Assurance Company 39462 7455 Longard Rd, Livermore, CA 94551 INSURER D INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: CHI -008775843-08 REVISION NUMBER- 2 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. INSIR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DD/YYOLICY YY CY EXP MM/DDIYYYY LIMITS A :rCOMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X X GLD1447202 01/01/2019 01/01/2020 EACH OCCURRENCE $ 2,000,000 DAMAGETO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT F—] LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 $ OTHER. B AUTOMOBILE LIABILITY X X ISAII25273618 01/01/2019 01/01/2020 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURYPer accident $ ( ) X HIREDX NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ SIR: $ 250,000 X UMBRELLA LIAB X occuR X X CUD1447302 01/01/2019 01/01/20208,000,000 EACH OCCURRENCE $ AGGREGATE $ 8,000,000 EXCESS LAB CLAIMS -MADE DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEM BER EXCLUDED? ❑N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA X WLRC65439372 WA Stop Gap 01/01/2020X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 C Pollution Professional PCAB-5006758-0119 01/01/2019 01/01/2020 Each claim/aggregate $5,000,000 SIR 100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Re: All Operations of the Named Insured during the policy period Town of Los Altos Hills, its elective and appointed officers, employees and volunteers is/are included as additional insured (except workers' compensation) where required by written contract. Waiver of subrogation is applicable where required by written contract and subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION Town of Los Altos Hills SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 26379 W Fremont Rd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Los Altos Hills, CA 94022-2698 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Scott Pell @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD 1111111-011 1k HMIN Named I»edWX Holdings US, Inc. Endorsement Number Policysymbol P0110yNUrnber Policy Period Effective Date of Endorsement ISA H25273618 101/01/2019 TO 01/01/2020 ACE American Insurance Company Insertthepollcy number, The rernander of the information Istobe completed onlywhen thisendorternentis Issued subsequent to tile preparation ofthe Do5cv. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ QTCAREFULLY. This Endorsement modifies insurance provided under the following: Business Auto Coverage Form Excess Business Auto Coverage Form Auto Dealers Coverage Part Schedule: All ofthe following are called the "Scheduled EnUties": Coouo Fire Protection, Inc., Firetro| Protection Systems, |nc.'CFP Fire Protection, CFP Inc., Fire Call, Inc., Firetrcd Protection Systems, Inc. dbaAhzona Fina & Security, F|amex, Inc., PredomontGound 8 Signal, Inc., Minimax Fire Solutions, |nc,K4XHoldings US, Inc. The Named Insured shown inthe Declarations |mamended toread msfollows: The Scheduled Entities, and/or any entity over which any one or more of the Scheduled Entities has mune than tfty percent ownership interest, orover which any Pfthe Scheduled Entities exercises active management control, during the policy period. Each of the Scheduled Entities is also a Named Insured as respects the interest of such Scheduled Entity in the operations ofany joint venture, co-ventune'joint lease, joint operation agreement,limited liability company, partnership or any other organization, other than a direo± or indirect subsidiary, division or affiliate of the Scheduled Entity (hereinafter collectively called "Joint Ventura").during the policy period, provided that: (a) The insurance available under this Policy (\) shall be the product of(i)the Scheduled Entity's percentage interest in the Joint Venture, and (ii) the Joint Venture's total liability to the claimant; and (B) shall be subject to the Limits of Insurance. (b) Notwithstanding the provisions of (m) above' if the Scheduled Entity has sole responsibility for the management or operation of the Joint Venture, orifthe Scheduled Entity has agreed by contract to provide the insurance coverage for the Joint Venture, then this policy shall cover the Joint Venture in the same manner as the Scheduled Entity is covered hereunder. (o) Such coverage afforded for the Scheduled Entity in any Joint Venture, or for the Joint Venture itself if applicable under (b) above, shall apply in excess of any other insurance specifically maintained by or on behalf of the Joint Venture. (d)With respect toJoint Ventures that a Scheduled Entity newly forms 0rnewly acquires aninterest induring the policy period, the Scheduled Entity will be a Named Insured for its interest in such Joint Venture tothe extent specified in (a) above, orthe Joint Venture itself will bemNamed Insured ifeospec|fiedin(b)above, solong msyou notify umofsuch acquisition or formation not later than 80 days after the end of the policy pehod. No coverage will be provided for such Joint Venture beyond 80 days after the policy period if you do not give us such notice. Such coverage afforded for the Scheduled Entity in any Joint Venture, or for the Joint Venture itself if applicable under (b) above, shall apply in excess of any other insurance specifically maintained by or on behalf of the Joint Venture. (e) As respects entities newly formed or acquired during the policy period` other than e Joint Ventun*, and over which m Scheduled Entity maintains ownership or majority intenmst, or active management oonLrcU' or has agreed by contract boprovide insurance, such entities are also Named |nsunad'a,provided: 1) there ianoother similar insurance available tothat organization; and DA -20420a (06/14) Page 1of2 Named Insured MX Holdings US, Inc. I Endorsement Number 4 ISA I H25273618 101/01/2019 TO 01/0112020 issuea tsy (r4ame or insurance uompany) ACE American Insurance Company orsernen the policy number. The remainder Of the Information Is to be Completed only when this 6ndomement Is Issued subsequent to the preparation of the Qrganigiation Additional Insured Endorsement Any additional insured with whom you have agreed to provide such non- contributory insurance, pursuant to and as required under a written contract executed prior to the date of loss (if no intbrination is filled in, the schedule shall read: "All persons or entities added as additional insureds through an endorseinent with the tens 'Additional Insured' in the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added.to the Other Insurance Condition under General Conditions: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured") for a loss We cover under this policy, this insurance will apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured. Authorized Representative DA -21886b (06/14) Page 1 of 1 POLICY NUMBER: ISA H25273618 This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM 1 Endorsement Number: 3 aw ■ With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: MX Holdings US, Inc. Endorsement Effective Date, Name(s) Of Pers,on(s) Or Organization(s): Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. ation reauired to complete this Schedule, if not shown The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. be shown in the Decl CA 04 44 10 13 0 Insurance Services Office, Inc., 2011 Page 1 of I i Named Insured ENDORSELENT HDI Global Insurance Company MX HOLDINGS US, INC EffectiVeDate 01,101/2019 12:01 A.M., Standard Time Agent Name MIARSH USA INC . OF MI (GIRAP) Agent No, P02082030 Thk EadOts%mrg Changes'rhO if yr Pbase Fkad R Lawfully; N INSURED ENDORSEhENT THE NAMED INSURED IS AMENDED TO READ AS FOLLOWS. MX HOLDINGS US, INC. MINIMAX FIRE SOLUTIONS, INC, COSGO FIRE PROTECTION, INC, FLAMEX INC, CFP, IN(-,. IVIINIMAX CHINA.FIRE PROTECTION SYSTEM CO., LIMITED FIRETROI- PROTECTION SYSTEMS, INC, CFP FIRE PROTECTION, INC, PIEDMONT SOUND & SIGNAL, INC. FI TOL PROTECTION SYSTEMS, INC, DBA ARIZONA FIRE AND SECURITY KLISTER LLC ALL OTHER TERMS AND CONDITIONS REMAIN THE SAME. MAN-GIL (01/0 ) GLD1447202 ENDORSEMENT HDI Global Insurance Company Narned Insured MX HOLDINGS US, INC. Eflective Date: 01---01 19 12:01 A.M., Standard Time Agent Name MARSH USA INC. OF MI (GRAP) Agent No. P02082030 This Endorserwi# Changes The Policy. Please Read It CatefuNy. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION CG 201010 01 VERSION AS PER THE WRITTEN CONTRACT INCLUDING PROJECT/JOB NUMBER (IF NO ENTRY APPEARS ABOVE, INFORMATION REQUIRED 1-0 COMPLETE THIS ENDORSEMENT WILL BE SHOWN IN THE DECLARATIONS AS APPLICABLE TO THIS ENDORSEMENT.) A. SECTION 11--- WHO IS AN INSURED IS AMENDED TO INCLUDE AS AN INSURED THE PERSON OR ORGANIZATION SHOWN IN THE SCHEDULE, BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF YOUR ONGOING OPERATIONS PERFORMED FOR THAT INSURED. B. WITH RESPECT TO THE INSURANCE AFFORDED TO THESE ADDITIONAL INSUREDS, THE FOLLOWING EXCLUSION Is ADDED: 2. EXCLUSIONS THIS INSURANCE DOES NOT APPLY TO "BODILY INJURY" OR "PROPERTY DAMAGE" OCCURRING AFTER: (1) ALL WORK, INCLUDING MATERIALS, PARTS OR EQUIPMENT FURNISHED IN CONNECTION WITH SUCH WORK, ON THE PROJECT (OTHER THAN SERVICE, MAINTENANCE OR REPAIRS) TO BE PERFORMED BY OR ON BEHALF OF THE ADDITIONAL INSURED(S) AT THE SITE OF THE COVERED OPERATIONS HAS BEEN COMPLETED; OR (2) THAT PORTION OF "YOUR WORK" OUT OF WHICH THE INJURY OR DAMAGE ARISES HAS BEEN PUT TO ITS INTENDED USE BY ANY PERSON OR ORGANIZATION OTHER THAN ANOTHER CONTRACTOR OR SUBCONTRACTOR ENGAGED IN PERFORMING OPERATIONS FOR A PRINCIPAL AS A PART OF THE SAME. PROJECT. MAN -GL (01/02) F0110y NUMwr GLD1447202 ENDORSEMENT HDI Global Insurance Company Named Insured MX HOLDINGS US, INC. Effective Date: 01-01-19 12:01 A.M., Standard Time Agent Name MARSH tJSA INC. OF MI (GRAP) Agent Na. P02082030 This Endorsermrd Changes The Policy. Please Read It Cawfully. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS ® COMPLETED OPERATIONS CG 203710 01 AS PER THE WRITTEN CONTRACT INCLUDING PROJEC T/JOB NUMBER (IF NO ENTRY APPEARS ABOVE, INFORMATION REQUIRED TO COMPLETE THIS ENDORSEMENT WILL BE SHOWN IN THE DECLARATIONS AS APPLICABLE TO THIS ENDORSEMENT.) SECTION 11 - WHO IS AN INSURED IS AMENDED TO INCLUDE AS AN INSURED THE PERSON OR ORGANIZATION SHOWN IN THE SCHEDULE, BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF "YOUR WORK" AT THE LOCATION DESIGNATED AND DESCRIBED IN THE SCHEDULE OF THIS ENDORSEMENT PERFORMED FOR THAT INSURED AND INCLUDED IN THE "PRODUCTS -COMPLETED OPERATIONS HAZ- ARD". MAN -GL (01 /02) POLICY NUMBER: CJLD1447202 VIT -W IA kyj A ;16] a I MOYA 0 61 9A 0011141, a MW This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/ COMPLETED OPERATIONS LIABILITY COVERAGE PART W ORT r TITRim''All qW, 1 TTRITF-70111W &D i , V I - , i I The following is added to Paragraph & Transfer 01 Rights Of Recovery Against Others To Us of Section 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 products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above, CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 9 LI Workers' Compensation and Ernplovers' Liabilitv Pali r4amea insurea Endorsement Number MX HOLDINGS US, INC. 153 TECHNOLOGY DRIVE Policy Number IRVINE CA 92618 13 ymbol WLR Number. 065439372 Po—licy _Period Effective Date of Endorsement 01-01-2019 TO 01-01-2020 01-01-2019 - - - ---- -------- -- --- - -- - ----- - - - - ----- ------ - ------- Is y (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The. remainder of the i nform ation is to be carn p let ed only Me n this endorsement is issued subsequent to the Drei) aration of the D al jcv; We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule, ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. Thisendorsement is not applicable in KY, NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications, For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K,S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. Authorized Representative WC 00 03 13 (11106) Copyright 1982-83, National Council on Compensation Named InsuredM HOLDINGS US, INC. Policy Number A- 52 -9232.18--09 Endorsement No. DOO Policy Period 01/01/201.8 ta 01101/20.19 Endorsement Effective Date: D1/01/2018 Producer's Name: OLD REPUBLIC CONTRACTORS INSUR)WCE AGENCY, INC. Producer Number: 7005 AUTHORIZED REPRESENTATIVE CA EN GN 0044 0212 Page 2 of 2 [by -IMA WORKERS COMPENSATION & EMPLOYERS LIABILITYINSURANCE POLICY EXTENSION OF INFORMATION PAGE - EX TENDED NAME SCHEDULE POLICY NO. , - D " S 1. -10 ENDOR 000 ACCOUNT NUMBER' OK00392 NAMED INSURED AND MAILING ADDRES NIS: HOLDINGS US, INC,, 163 TECHNOLOGY OLOGY OVINE SUITE 200 IRVINE, CA 9261.8 OLD REPUBLIC CONTRACTORS INSURANCE AGENCY, TNC 4307 N. MICHIGAN AVE, SUITE CIS& C-RICAGO, IIS 60601-0 000 N D E D X A M E D I N S U R E This extension includes additional ilame�d insureds'. COSCO FIRE PROTECTT"'N, INC, UNEMPLOYMENT NO: F°IRU'>". RTL PRO"TECI`T°ION SYSTEMS, INC UNEMPLIOYMENT NO, ENTITY NCI SEQ, NOa 2 1°E N T:°,TRETROL I;'ROTECIIwON SY`s"!`.}°fMS,, -INC. ;SBA ARIZONA FIRE & SEC ORI.` Y UNEMPL0,YMENT NO: C'FP INC. SEQ. NOw 1 B:EiceN4 UNEMPLOYMENT NO, T......... ......... ._.............. ........... CF11 FIRE PROTECTION, INC. UNEMPLOYMENT NO: we 49 06 32 (0211n, 01-04-A T6 cj3.naenox pap I of 2 POLICY NUMBER: 2019-04654 Named Insured: CHAC COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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): Any person or organization that you are required to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II —Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 BB&T TANNER INS SRVC 4480 WILLOW RD PLEASANTON, CA 94588 TOWN OF LOS ALTOS 26379 FREMONT LOS ALTOS HIL, CA 94022 Additional insured endorsement Name of Person or Organization TOWN OF LOS ALTOS 26379 FREMONT LOS'ALTOS HIL, CA 94022 PMERFIRYFO COMMERCIAL Policy number: 05922280-2 Underwritten by: United Financial Cas Co Insured: BYLDAN CORPORATION February 1, 2019 Policy Period: Feb 23, 2019 - Feb 23, 2020 Mailing Address United Financial Cas Co PO Box 94739 Cleveland, OH 44101 1-800-444.4487 For customer service, 24 hours a day, 7 days a week The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to said insured only as a person liable for the conduct of another insured and then only to the extent of that liability, We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page, Limit of Liability Bodily Injury Not applicable Property Damage Not applicable Combined. Liability $1,000,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 05922280-2 Issued to (Name of Insured): BYLDAN CORPORATION CLARUM HOMES & CLARUM COM Effective date of endorsement: 02/23/2019 Policy expiration date: 02/23/2020 Form 1198 (01/04)