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HomeMy WebLinkAbout4Leaf, Inc. 03.16.2026�../ CERTIFICATE OF LIABILITY INSURANCE S DATE (MM/DD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 03/12/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS TYPE OF INSURANCEADDLSUBR CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES WVD BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED POLICY EFF ,MM/DD/YYYY REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. LIMITS IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. X1 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_]OCCUR If SUBROGATION, IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Brent Nishikawa NAME: DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ The Liberty Company Insurance Brokers PHONE (888) 918-3960 FAX RAIC, A/C No Ext : No): Lic #OD79653 E-MAIL bnishikawa@libertycompany.com ADDRESS: &ADV INJURY $ 1,000,000 5955 De Soto Ave, Ste 250 INSURER(S) AFFORDING COVERAGE NAIC # Woodland Hills CA 91367 INSURER A: Travelers Property Casualty Co of America 25674 INSURED INSURER B: The Travelers Indemnity Co of CT' 25682 4Leaf, Inc. INSURER C : Berkshire Hathaway Homestate Insurance Company 20044 INSURER D: Pacific Insurance Company, Limited 10046 2126 Rheem Dr INSURER E: $ Pleasanton CA 94588 INSURER F COVERAGES CERTIFICATE NUMBER: 2026 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 INSURANCEADDLSUBR INSD WVD POLICY NUMBER POLICY EFF ,MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS X1 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_]OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 &ADV INJURY $ 1,000,000 A Y Y 6600519865A 03/15/2026 03/15/2027PERSONAL GENERAL AGGREGATE $ 2,OQO,00.0 GEN'LAGGREGATE LIMITAPPLIES PER: X POLICY ❑ PRO ❑ JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident)$ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ B OWNED X SCHEDULED AUTOS ONLY /� AUTOS Y Y BAC4831196 03/15/2026 03/15/2027 BODILY INJURY (Per accident) $ X HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) X UMBRELLA LIAB ,X OCCUR EACH OCCURRENCE $ 61000,000 A EXCESS LIAB CLAIMS -MADE CUPC4831922 03/15/2026 03/15/2027 AGGREGATE $ 6,000,000 DED X RETENTION $ O $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /A Y FOWC725735 03/15/2026 03/15/2027 X STATUTE EORH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 D Professional Liability Retroactive Date: 04/01/2007 130H0881505-26 --- - _ 03/15/2026 - 03/15/2027 Per Claim $5,000,000 Aggregate $5,000;000 Retention $50,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Los Altos, its officers, officials, employees, and volunteers are named as Additional Insured as respects to General Liability and Automobile Liability per attached endorsements. General Liability and Automobile Liability policies are Primary and Non -Contributory per attached endorsements. Waivers of Subrogation apply on General Liability, Automobile Liability and Workers' Compensation policies per attached endorsements. Excess Liability Follows Form over General Liability, Automobile Liability and Employers' Liability policies. CERTIFICATE HOLDER conlcFl i ATinKI @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Los Altos ACCORDANCE WITH THE POLICY PROVISIONS. 26379 W Fremont Rd AUTHORIZED REPRESENTATIVE Los Altos Hills CA 94022" % B @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Additional Named Insureds Other Named Insureds 4LEAF CONSULTING INC. 4LEAF CONSULTING, LLC OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED (ARCHITECTS, ENGINEERS AND SURVEYORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. The following is added to SECTION 11 — WHO IS AN INSURED: Any person or organization that you' agree in a ""written contract requiring insurance" to include as an additional insured on this Coverage Part, but: a. Only with respect to liability for "bodily injury", "property damage" or "personal injury"; and b. If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies, or in connection with premises owned by or rented to you. The person or organization does not qualify as an additional insured: c. With respect to the independent acts -or omissions of such person or organization; or d. For "bodily injury", "property damage" or ""personal injury" for which such person or, organization has assumed liability in a contract or agreement. The insurance provided to such additional insured is limited as follows: e. This insurance does not apply .on any basis to any person or organization for *which coverage as an additional insured specifically is added by another endorsement to this Coverage Part. f. This insurance does not apply to the rendering of or failure to render any "professional services". g. In the event that the Limits of Insurance of the Coverage Part shown in the Declarations exceed the limits of liability required by the ""written contract requiring insurance", , the insurance provided to the additional insured shall be limited to the limits of liability required by that "written contract requiring insurance". This endorsement does not increase the limits of insurance described in Section III -- Limits Of Insurance. h. This insurance does ' not apply to "bodily injury" or "'property damage" caused by ""your work" and included in the ""products - completed operations hazard" unless the '"written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured applies only to such "bodily injury" or "property damage" that occurs before the end of the period of time for which the "written contract requiring insurance" requires you .to provide such coverage or the end of the policy period, whichever is earlier. 2. The following is added to Paragraph 4.a. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: The insurance provided to the additional insured, is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the ----------ad-d-iti-onal-insu-r-ed-fo-r-a-l-oss-w-e-c-o-v-e-r.-H-ow-e-v-er.,-if- you specifically agree in the "written contract requiring insurance"" that this insurance provided to the additional insured under this Coverage Part must apply on a primary basis or a primary and non-contributory basis, this insurance is primary to other insurance available to the additional insured which covers that person or organizations as a named insured for such loss, and we will not share with the other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is: sought occurs; and (2) The "personal injury" for which coverage is sought arises 'out of an offense committed; after you have signed that "written contract requiring insurance". But this insurance provided to the additional insured still is excess over valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the additional insured when that person or organization is an additional insured under any other insurance. CG D3 81 09 15 @ 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 2 Includes the copyrighted material of Insurance Services Office, Inc., with its permission COMMERCIAL GENERAL LIABILITY 3. The following is added to Paragraph 8., Transfer 4. The following definition is added to the Of Fights Of Recovery Against others To Us, DEFINITIONS Section: of SECTION IV — COMMERCIAL GENERAL "Written contract requiring insurance" means that LIABILITY CONDITIONS: part of any written contract under which you are We waive any right of recovery we may have required to include a person or organization as an against any person or I organization because of additional' insured on this coverage Part, payments we make, for ""bodily injury"", ""property provided that the "bodily injury" and "property damage" or "personal injury" arising out of "your. damage" .occurs and the "Personal injury" is work!' performed by you, or on your behalf, done caused by an offense committed: under a �"written contract requiring insurance" with that person or organization. 11t1e waive this right p g g a• After you have signed that written contract; only where you have agreed to do so as part of b. while that part of the written contract is in the "written contract requiring insurance" with effect; and such person or organization signed by you "" c• Before the end. of the policy period. rY or .before and in effect when, the "bodily injury" property damage" occurs, or the "personal injury" offense is committed. Page 2 of 2 @ 2015 The Travelers Indemnity Company. All rights reserved. CG D3 81 09 15 Includes the copyrighted material of Insurance services Office, Inc., with its permission COMMERCIAL GENERAL LIABILITY 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 LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (1) The additional insured is a Named Condition and supersedes any provision to the Insured under such other insurance; and contrary: (2) You have agreed in writing in a contract Primary And Noncontributory Insurance or agreement that this insurance would This insurance is primary to and will not seek be primary and would not seek contribution from any other insurance available contribution from any other insurance to an additional insured under your policy available to the additional insured. provided that: CG 20 01 12 19 0 Insurance Services Office, Inc., 2018 Page 1 of 1 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. XTE NQ ENDORSEMENT FOR ARCHITECTS, ENGINEERS ANDSUR1/EY O RS This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION: OF COVE -RAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described, in any of the 'promsions of this endorsement may be excluded, or limited by another endorsement to this Coverage Part, and .these coverage broadening provisions do not, apply to the extent . that coverage is -excluded or limited by.such an indorsement. The following listing is a general coverage description only. Read all the provisions sions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. Non -Owned Watercraft — 7.5 Feet Long Or Less H. Blanket Additional Insured Governmental B. Who Is An Insured — Unnamed Subsidiaries Entities — Permits Or Authorizations Relating To Premises C. Who Is An Insured — Retired, Partners, Members, I. Blanket , Additional , Insured Governmental Directors And Employees Entiti e*s — Permits Or Authorizations Relating To D. Who Is An Insured — Employees And Volunteer Operations Workers — Bodily Injury To Co -Employees, Co - Volunteer Workers And Retired Partners, J. Incidental. Medical Malpractice Members, Directors And Employees K. Medical Payments — Increased Limit E. Who Is An Insured — Newly Acquired Or Formed L. Amendment Of. Excess Insurance Condition Limited Liability Companies Professional Liability F. Blanket Additional Insured — Control,ling Interest M. Blanket Waiver Of Subrogation — When Required G. Blanket Additional Insured Mortgagees, By Written Contract Or Agreement Assignees, Successors Or Receivers No Contractual Liability Railroads PROVISIONS A. NON -OWNED WATERCRAFT 75 FEET LONG OR LESS 1. The following replaces Paragraph (2) of Exclusion g., Aircraft, Auto Or Watercraft, in Paragraph. 2. of SECTION I — COVERAGES — COVERAGE 'A BODILY INJURY AND PROPERTY DAMAGE LIABILITY: (2) A watercraft you do. not own that is: (a) 75 feet long or less; and (b) Not being used to carry any person or property for a charge; 2. The following replaces Paragraph 2-e. of SECTION 11 — WHO IS AN INSURED: e. Any person or organization that. with your express or implied consent, either uses or is responsible for the use of a watercraft that you do not own that is: (1) 75 feet long or less; and .(2) Not being used to carry any person or property for a charge; B. WHO IS AN INSURED — UNNAMED SUBSIDIARIES The following is added to SECTION 11 — WHO IS AN INSURED: Any of your subsidiaries, other than a partnership or joint venture, that is not shown as a Named Insured in the Declarations is a Named Insured if: a. You are the sole owner of, or maintain an ownership interest of more than 50% in, such subsidiary on the first day of the policy period; and CG D3 79 02 19 @ 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY b. Such subsidiary is not an insured under similar other insurance. No such subsidiary is an insured for "bodily injury" or "property damage" that occurred, or "personal and advertising injury" caused by an offense committed: a. Before you maintained an ownership interest of more than 50% in such subsidiary; or b. After the date, if any, during the policy period that you no longer maintain an ownership interest of more than 50% in such subsidiary. For purposes of Paragraph 1. of Section 11—Who Is An Insured, each such subsidiary will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that govern its structure. C. WHO IS AN INSURED — RETIRED PARTNERS, MEMBERS, DIRECTORS AND EMPLOYEES The following is added to Paragraph 2. of SECTION 11 — WHO IS AN INSURED: Any person who is your retired partner, member, director or "employee" that is performing services for you under your direct supervision, but only for acts within the scope of their employment by you or while performing duties related to the conduct --Of—your--business,--H-owe-ver-i—n-o—s-uc-h—retir-ed---- partner, member, director or "employee" is an insured for: (1) "Bodily injury": (a) To you, to your current, partners or members of you are a partnership or joint venture), to your current members (if you are a limited liability company) or to your current directors; (b) To the spouse, child, parent,, brother or sister of.that current partner, member or director as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraph (1)(a) or {b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury' arising out of. providing or failing to provide first aid or "Good Samaritan services" by any of your retired partners, members, directors or "employees", other than a doctor. Any such retired partners, members, directors or "employees" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed to be acting within the scope of their employment by you or performing duties related to the conduct of your business. (2) "Personal injury': (a) To you, to your current or retired partners or members (if you are a partnership or joint venture), to your current or retired members of you are a limited liability company), to your other current or retired directors or "employees" while in the course of his or her employment or performing duties .related to the conduct of your business, or to your other "volunteer workers" while, performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or .sister of that current or retired partner, member, director, "employee" or "volunteer worker' as a consequence of Paragraph (2)(a) above;. ------ — - ---- Ac)—F-or—wh-ich—there—m --- a-ny---obligati-on--t-6 share damages with or repay someone else who must pay damages because of the injury. described in Paragraph (2)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. (3) "Property damage" to property: (a) Owned, occupied or used by; or (b) Rented to, in the care, custody or control of, or over which physical control is being. exercised for any purpose by; you, any of your retired partners, members or directors, your current or retired "employees" or "volunteer workers", any current partner or member (if you are a partnership or joint venture), or any current member (if you are a limited liability company) or current director. Page 2 of 6 @ 2017 The Travelers Indemnity Company. All rights reserved. CG D3 79 02 119 Includes copyrighted material of Insurance Services Office, Inc. with its permission. D. WHO IS AN INSURED EMPLOYEES AND VOLUNTEER WORKERS — BODILY INJURY TO CO-EMPLOYEES5 CO -VOLUNTEER WORKERS AND RETIRED PARTNERS, MEMBERS, DIRECTORS AND EMPLOYEES The following is added to Paragraph 2.a.(I) of SECTION 11 — WHO Is AN. INSURED. Paragraphs (1)(a), (b) and (c) above do not apply to "bodily injury" to ..'a current., or retired co- ""employee"" while in the course.. of the co- Ifemployeels". employment by yo'u. or performing duties related to the conduct of your business, or to "bodily injury" to your other "volunteer workers" or retired partners, members or directors while performing duties related. to the conduct of your business... E. WHO IS AN INSURED — NEWLY ACQUIRED OR FORMED LIMITED LIABILITY COMPANIES The following replaces Paragraph 3. of SECTION 11 — WHO IS AN INSURED: 3. Any organization you newly acquire or form, other than a partnership or joint venture, and of which you are the sole owner or in which you maintain an ownership interest of more than 50%, will qualify as a Named Insured. if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only: (1) Until the 180th day after you acquire or form the organization or the end of the policy' period,, whichever is earlier, if you -do -not. report such organization in writing to us within 9 180 days after you acquire e or form it; or (2) Until the end of the ' policy period, when that date is later than 180 days after you acquire or form such organization, if you report such organization. in writing to us within 180 days after. you acquire or form it; b. Coverage A does not apply to "bodily injury" or - "property damage" that occurred before you acquired or formed the organization; and c., Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. For the purposes of Paragraph 1. of Section 11 — Who Is An Insured, each such COMMERCIAL GENERAL LIABILITY organization will be deemed to be designated in the Declarations as: al.A limited liability company; b.'. -An organization other than a partnership, joint venture or limited liability company; or CE A trust; as indicated in its name or the documents that govern its. structure. FS BLANKET ADDITIONAL INSURED CONTROLLING INTEREST I The following is added to SECTION 11 WHO IS AN INSURED,: Any person or organization that has financial control of -you is an insured with respect to .liability for "bodily injury", "property damage" or '.'personal and advertising injury" that arises out of: a. Such financial control; or b. Such person's or organization's ownership, maintenance or use of premises leased to or occupied by you. The insurance provided to such person or organization does not apply to structural alterations, new construction or demolition o . perations performed by or on behalf of such ..Person. or organization. 2N The following is added to *Paragraph 4. of SECTION 11 — WHO IS AN INSURED: This paragraph does not apply to any premises owner, manager or lessor that has financial control of you. G. BLANKET ADDITIONAL INSURED MORTGAGEES,- ASSIGNEES, SUCCESSORS OR. RECEIVERS The following. is added to SECTION 11— WHO IS .AN INSURED: Any person or organization that is a mortgagee, assignee, successor or receiver and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to its liability as mortgagee, assignee, ..successor or receiver for *"bodily injury", "property damage". or "personal and advertising injury" that: a. Is "bodily injury" or "property damage" that occurs, or is "personal and advertising injury" caused by an offense that is committed, CG D3 79 02 19 @ 2017 The Travelers Indemnity Company. All rights reserved. Page 3 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY subsequent to the signing of that contract or agreement; and b. Arises out of the ownership, maintenance or use of the premises for which that mortgagee, assignee, successor or receiver is required under that contract or agreement to be included as an additional insured on this Coverage Part. The insurance provided to such mortgagee, assignee, successor or receiver is subject to the following provisions: a. The limits of insurance provided to such mortgagee, assignee, successor or receiver will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. b. The insurance provided to such person or organization does not apply to: (1) Any "bodily injury' or "property damage" that occurs, or any "personal and advertising injury" caused by an offense that is committed, after such contract or agreement is no longer rin, effect; or (2) Any "bodily injury", "property damage" or "personal and advertising injury" arising out of any structural alterations, new construction , or demolition operations performed by or. on behalf . of such mortgagee, assignee, successor or receiver. H. BLANKET ADDITIONAL INSURED GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO PREMISES The following is added to SECTION 11 — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to premises owned or occupied by, or rented or loaned to, you and that you are- required by any ordinance,. law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury' arising out of the existence, ownership, use, maintenance, repair, construction, erection or removal of any of the following for which that governmental entity has issued such permit or authorization: advertising signs, 'awnings, canopies, cellar entrances, , coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, elevators, street banners or decorations. I. BLANKET ADDITIONAL INSURED GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO OPERATIONS The following is added to SECTION 11 — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with , respect to operations performed by you or on your behalf and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of such operations. The insurance provided to such governmental entity does not apply to: a.. Any "bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the governmental. entity; or b. Any "bodily injury" or "property damage" included , in the 'products -completed operations hazard". J. INCIDENTAL MEDICAL MALPRACTICE 1. The following replaces Paragraph b. of the definition of "occurrence" in the DEF1 NITIONS-S-et-c-on: b. Arte act or omission committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to a person, unless you are in the business or occupation of providing professional health care services. 2. The following replaces the last paragraph of Paragraph 2.a.(1) of SECTION 11 — WHO IS AN INSURED: Unles's you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury" arising out of providing or failing to provide: (a) "Incidental medical services" by any of your "employees" who is a nurse, nurse assistant, emergency medical technician, paramedic, athletic trainer, audiologist, dietician, nutritionist, Page 4 of 6 0 2017 The Travelers Indemnity Company. All rights reserved. CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. occupational therapist or. occupational ..therapy assistant, physical., therapist or speech-language pathologist; or (b) First aid or "Good. Samaritan services" by any of you r "employees" or "volunteer workers", other than, an employed or volunteer doctor..Any. such "employees" or "volunteer workers" providing or failing to provide first. aid or "Good Samaritan services" during their Work hours for you will be deemed:to be acting within the scope of their employment by you or performing duties related to the conduct of your business. 3. The following replaces the last sentence of Paragraph S. of SECTION III LIMITS OF INSURANCE: For the purposes... of determining . the applicable Each Occurrence Limit, all related acts or omissions committed in providing or failing to provide '"incidental medical services", first aid or "Good Samaritan services" to any one person will be deemed to be one "occurrence 4. The following exclusion is added to Paragraph 2, Exclusions, of SECTION I COVERAGES — COVERAGE:A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY: Sale Of Pharmaceuticals "Bodily injury" or "property damage" arising out of the violation of a pen al statute or ordinance relating to the sale of pharmaceuticals committed by, or with the knowledge or consent of the. insured. 5. The following is added to. the DEFINITIONS Section: '"Incidental medical services" means: a. Medical, surgical, dental,., laboratory, x- ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; or b. The furnishing or dispensing of drugs or medical, dental, or surgical supplies or appliances. 6. The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV — COMMERCIAL. GENERAL LIABILITY CONDITIONS: This insurance. is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, 1:1 LE [a COMMERCIAL GENERAL LIABILITY I that is. available to any of your "employees" for "bodily injury" that arises out of providing or failing to provide "incidental medical services to any person to the extent not subject to Paragraph 2.a.(I) of Section 11 — Who Is An Insured. MEDICAL, PAYMENTS — INCREASED LIMIT The following replaces Paragraph- 7. of SECTION III — LIMITS OF. INSURANCE: 7. Subject to Paragraph 6. above, the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses beeause of "bodily injury" sustained by any one person, and will be the higher of: a. .$10,000; or b. The amount shown in the Declarations of this Coverage Part for Medical Expense Limit. AMENDMENT OF EXCESS INSURANCE CONDITION — PROFESSIONAL LIABILITY The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV COMMERCIAL GENERAL LIABILITY CONDITIONS: This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any other . basis, that is Professional Liability or similar coverage, e, to the extent the loss is not subject to the professional services exclusion of Coverage A or Coverage B. BLANKET WAIVER OF SUBROGATION — WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT The f ollowing is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, .of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If the insured has agreed in a written contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: a.. "Bodily injury" or "property damage" that occu rs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the signing of that contract or agreement. CG D3 79 02 19 @ 2017 The Travelers Indemnity Company. All rights reserved. Page 5 of 6 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY N. CONTRACTUAL LIABILITY — RAILROADS 1. The following replaces Paragraph c. of the definition of "insured contract" in the DEFINITIONS Section: c. Any easement or license agreement; 2. Paragraph f.(1) of the definition of "insured contract" in the DEFINITIONS Section is deleted. Page 6 of 6 @ 2017 The Travelers Indemnity Company. All rights reserved. CG D3 79 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. POLICY NUMBER: 660-0519865A ISSUE DATE: 3/15/2026 THIS ENDORSEMENT CHAN.GES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED PERSON OR ORGANIZATION NOTICE 0 CANCELLATION PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice: PERSON OR ORGANIZATION: ADDRESS: 30 PROVISIONS If we cancel this policy for any legally permitted reason other than nonpayment of premium, and a number of days is shown for Cancellation in the Schedule above, we will mail notice of cancellation to the person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for Cancellation in such Schedule before the effective date of cancellation. IL T4 05 05 19 @ 2019 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any, of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. BROAD FORM NAMED INSURED B. BLANKET ADDITIONAL INSURED C. EMPLOYEE HIRED AUTO D. EMPLOYEES AS INSURED E. SUPPLEMENTARY PAYMENTS — INCREASED LIMITS F. HIRED AUTO — LIMITED WORLDWIDE COV- ERAGE — INDEMNITY BASIS G. WAIVER OF DEDUCTIBLE — GLASS PROVISIONS A. BROAD FORM NAMED INSURED The following is added to Paragraph A.I., Who Is An Insured, of SECTION 11 — COVERED AUTOS ______LIAB [L,I_T_Y_C_0_V_E. R -A GE_:_ Any organization you newly acquire or form dur- ing the policy period over which you maintain 50% or more ownership interest and that is not separately insured for Business Auto Coverage. Coverage under this provision is afforded only un- til the 180th day after you acquire or form the or- ganization or the end of the policy period, which- ever is earlier. B. BLANKET ADDITIONAL INSURED The following is added to Paragraph c. in A.I., Who Is An Insured, of SECTION 11 - COVERED AUTOS LIABILITY COVERAGE: Any person or organization who is required under a written contract or agreement between you and that person or organization, that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to be named as an addi- tional insured is an "insured" for Covered Autos Liability Coverage, but only for damages to which H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT J. PERSONAL PROPERTY K. AIRBAGS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS M. BLANKET WAIVER OF SUBROGATION N. UNINTENTIONAL ERRORS OR OMISSIONS this insurance applies and only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section 11. C. EMPLOYEE HIRED AUTO 1. The following is added to Paragraph A.I., Who Is An Insured, of SECTION 11 — COV- ERED AUTOS LIABILITY COVERAGE: An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in an "employee's" name, with your permission, while performing duties related to the conduct of your busi- ness. 2. The following replaces Paragraph b. in B.S., Other Insurance, of SECTION IV — BUSI- NESS AUTO CONDITIONS: bw For Hired Auto Physical Damage Cover- age, the following are deemed to be cov- ered autos" you own: (1) Any covered "auto" you lease, hire, rent or borrow; and (2) Any covered "auto" hired or rented by your "employee" under a contract in an "employee's" name, with your CA T3 53 02 15 @ 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL AUTO permission, while performing duties (a) With respect to any claim made or "suit" related to the conduct .df your busi- brought outside the United States of ness. America, the territories .and possessions However, any auto„ that is leased hired of the United States of America, Puerto rented or borrowed with a driver is nota Rico and Canada: covered "auto". Vii) You must arrange to defend the "in- D. EMPLOYEES As INSURED sured" against, and investigate or set - "suit” tie any such claim or and keep The following is added to Paragraph A.1 Who -isus advised of all proceedings and ac- An Insured, of SECTION 11- COVERED AUTOS tions. LIABILITY COVERAGE: (h) Neither you nor any other involved 'Any "employee" of yours is an "insured" while us- "insured"will make any settlement ing a covered "auto" you don't own, hire or borrow without our consent. in your business or your personal affairs. . (iii) We may, at our discretion, participate E. SUPPLEMENTARY PAYMENTS — INCREASED in defending the "insured" against, or LIMITS in the settlement of, any claim or 1. The following replaces Paragraph A.2.a.(2),' "suit". of SECTION II — COVERED AUTOS LIABIL- (iv) e will reimburse the "insured" for ITY COVERAGE: sums that the "insured" legally must (2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily cluding bonds for related traffic law viola- injury" or "property damage" to which tions) required because of an "accident" this insurance applies, that the "in - we cover. We do not have to furnish sured" pays with our consent, but these bonds. only up to the limit described in Para 2. c s ` Para rah A.2.a. 4 2. The following reply e g p � ), graph C., Limits Of Insurance, of of SECTION 11- COVERED.. AUTOS LIABIL- SECTION II - COVERED AUTOS ITY COVERAGE: LIABILITY COVERAGE. ses` incurred b the �4) All reasonable expen y {v) Vile will reimburse the "insured" for "insured" at our request, including actual the reasonable expenses incurred 500 a da y loss of earnings u be- p to $ with our consent for your investiga- . cause of time off from work. tion of such claims and your defense of the "insured" against any such F. HIRED AUTO — LIMITED WORLDWIDE COV- "suit", but only up to and included ERAGE — INDEMNITY BASIS within the limit described in Para - The following replaces Subparagraph () in Para- graph C., Limits Of Insurance, of graph B.7., Policy Period, Coverage Territory, SECTION II — COVERED AUTOS of SECTION IV - BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in TIONS: addition to such limit.. Our duty to 0 (5) Anywhere in the world except any country or , make such payments ends when we Jurisdiction while an y trade sanction, em- have used up the applicable limit of bargo, or similar regulation imposed. by the insurance in payments for damages, United States of America applies to and pro- settlements or defense expenses. hibits the transaction of business with or (b) This insurance is excess over any valid within such country or jurisdiction, for Cov- and collectible other insurance available ered Autos Liability Coverage for any covered to the "insured" whether primary, excess, "auto"- that you lease, .. hire, rent or borrow contingent or on any other basis. without a driver for a period of 30 days or less c This insurance is not a substitute for re - and that is not an auto you lease, hire, rent quired or compulsory insurance in any or borrow from any of your "employees", country outside the United States, its ter - partners (if you are a partnership), members ritories and possessions, Puerto Rico and (if you are a limited liability company) or Canada. members of their households. Page 2 of 4 @ 2415 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. You agree to maintain all required or compulsory insurance in any such coun- try up to the minimum limits required by local law. Your failure to comply with compulsory insurance requirements will not invalidate the coverage. afforded by this policy, but we will only be liable to the same extent we would have been liable had you complied with the compulsory in- surance requirements. (d) It is understood that we are not an admit- ted or authorized insurer outside the United States of America, its territories and possessions, Puerto Rico and Can- ada. We assume .no responsibility for the furnishing of certificates of insurance, or for compliance in any way with the laws of other countries relating to insurance. G. WAIVER OF DEDUCTIBLE — GLASS The following is added to Paragraph D., Deducti- ble, of SECTION III — PHYSICAL DAMAGE COVERAGE: No deductible for a covered "auto" will apply to glass damage if the glass is repaired rather than replaced. H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF USE — INCREASED LIMIT The following replaces the last sentence of Para- graph A.4.b., Loss .Of Use Expenses, of SEC- TION 111111 — PHYSICAL DAMAGE COVERAGE: --However, the most we will pay for any expenses -_ for loss of use is $65 per day, to a maximum of $750 for any one "accident". 1. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES — INCREASED LIMIT The following replaces the first sentence in Para- graph A.4.a., Transportation Expenses, of SECTION 111111 — PHYSICAL DAMAGE COVER- AGE: We will pay up to $50 per day to a maximum of $1,500 for temporary transportationexpense in- curred by you because of the total theft of a cov- ered "auto" of the private passenger type. J. PERSONAL PROPERTY COMMERCIAL AUTO (2) In or on your covered "auto". This coverage applies only in the event of a total theft of your covered "auto". No deductibles apply to this Personal Property coverage. K. AIRBAGS The following is added to Paragraph 13.3, Exclu- sions, of SECTION III — PHYSICAL DAMAGE COVERAGE: Exclusion 3.a. does not apply to "loss" to one or more airbags in a covered "auto',' you own that in- flate due to a cause other than a cause of "loss" set forth in Paragraphs A.I.b. and A.I.c., but only: a. If that "auto" is a covered "auto" for Compre- hensive Coverage under this policy; b. The airbags are not covered under any war- ranty; and c. The airbags were not intentionally inflated. We will pay up to a maximum of $1,000 for any one "loss". L. NOTICE AND KNOWLEDGE OF ACCIDENT OR LOSS The following is added to Paragraph A.2.a., of SECTION IV — BUSINESS AUTO CONDITIONS: Your duty to give us or our authorized representa- tive prompt notice of the "accident" or "loss" ap- plies only when the "accident" or "loss" is known to: (a) You (if you are an individual); (b) A partner of you are a partnership); (c) A member (if you are a limited liability com- pany); (d) An executive officer, director or insurance manager (if you are a corporation or other or- ganization); or (e) Any "employee" authorized by you to give no- tice of the "accident" or "loss". M. BLANKET WAIVER OF SUBROGATION The following replaces Paragraph A.5, Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — BUSINESS AUTO CONDI- TIONS: The following is added to Paragraph A.4, Cover- 5. Transfer Of Rights Of Recovery Against age Extensions, of SECTION III — PHYSICAL Others To Us DAMAGE COVERAGE: We waive any right of recovery we may have Personal Property against any person or organization to the ex - We will pay up to $400 for "loss" to wearing ap- tent required of you by a written contractI signed and executed prior to any "accident" parel and other personal property which is: or "loss", provided that the "accident" or "loss" (1) Owned by an "insured"; and arises out of operations contemplated by CA T3 53 02'15 @ 2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission. t COMMERCIAL AUTO such contract. The Waiver applies only to the The unintentional omission of, or unintentional person or organization designated in such error in, any information given by you shall not contract. prejudice your rights under this insurance. How - N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to Paragraph B.2.� Con col - The following �s added g to Para lect additional premium or exorcise our right of cealment, Misrepresentation, Or Fraud, of cancellation or non -renewal. SECTION IV - BUSINESS AUTO CONDITIONS: Page 4 of 4 U 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office, Inc. with its permission. 0: 1 It lei: afr- s u re n f I u . .. .... ... .. . . ..... .. . .. .. ...... .. ..................... . .... ........... .......... ...... ...... ........................... . ............ . . ........... I ........................... AE 00 M008 01 0422 @ 2022, The Hartfori Page 1 of 1 111 iq��111111; !1 , 1111q 111111 A I a gal, M IL M The Insurer shall be entitled to impose such additional terms, conditions, and premium as the Insurer, in its absolute discretion, chooses. WORKERS. COM PEN SATI ON AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 10 C (Ed. 01-19) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS.ENDORSEMENT-CALIFORNIA BLANKET BASIS 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 ion named in the Schedule. (This agreement applies only I to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) The additional premium for this endorsement shall be calculated by applying a factor of, 2% to the total manual premium, with a minimum initial charge of $350, then applying all other pricing factors for.the policy to this calculated charge to derive the final cost of this endorsement. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Blanket Waiver Person/Organization Blanket Waiver — Any person or organization for. whom the Named Insured has agreed by written contract to furnish this waiver. Job Description Waiver Premium (prior to adjustments) All CA Operations 4209.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 03/15/2026 PolicyN.o.: FOWC725735 Endorsement No.: Insured: Premium $ Insurance Company: Berkshire Hathaway Homestate Ins Co Countersigned by WC 99 04 10 C (Ed. 01-19) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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 anyone not named in the Schedule. Schedule Blanket Waiver Person/ Organization: Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Job Description Waiver Premium All Other States Operations 9.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is "issued subsequent to preparation of the policy.) Endorsement Effective: 03/15/2026 Policy No.: FOWC725735 Endorsement No.: Insured: Premium $ Insurance Company: Berkshire Hathaway Homestate Ins Co, WC 00 03 13 Countersigned by (Ed. 4-84) ©1983 National Council on Compensation Insurance WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 07 E (Ed. 01-22) CALIFORNIA* CANCELLATION ENDORSEMENT This 'endorsement applies only totheinsurance provided by.the policy because California is shown in Item 3A. of the, Information Page. The cancellation condition in Part Six .(Conditions) of the policy is replaced by these conditions: Cabcellatlon: I.. You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2. We may cancel this policy for one or more of the following reasons: a. Non-payment of premium; b. Failure to report payroll; c. Non-payment of deductiblebilling; d. Failure to permit us to audit payroll as required by the terms of this .,policy *or of a previous policy issued by us*; e. Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; f.. Material misrepresentation made by you or your agent; g. Failure to cooperate with us in the investigation of a claim; h. Material failure to comply with Federal or State safety orders; i. ..Material failure to comply with written recommendations of our designated loss control representatives;. j. The occurrence of a material change in the ownership of your business; k. The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; I. The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; m. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. 3. If we cancel your policy for any.of the reasons listed in (a) through (g), we will give you 10 days advance written notice, stating when the cancellation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to provide notice. If we cancel your policy for any of the reasons listed in Items (h) through (m), we will give you 30 days advance written notice; however, we .agree that in the event of cancellation and reissuance of a policy effective upon a material .change in ownership or operations, notice will not be provided. 4. If we mail the notice to you, the. Stated periods of notice and your right to remedy the condition will be extended by 5 days if the place of mailing and your mailing address is within California, 10 days if the place of mailing or your mailing y address is outside of Cal.ifornia and 20 days if the place of mailing or your mailing address is outside of the United States. 5. The, policy period will end on the. day and hour stated in the cancellation notice. 6. A short rate penalty applies if You cancel . this policy or if we cancel due to non-payment of premium, failure to report payroll, or non-payment of deductible billing. First, the standard premium, defined as the base premium (computed in accordance with Part 1, Section 2, S.ubsection.2 of the WCIRB's California Basic Underwriting Manual) adjusted for the experience modification factor and all other- Pricing factorsexcept for premium discount and expense constant, will be multiplied by the quotient of the number of days for which.the policy was written divided by the number of days the policy remained in force to produce the full standard premium. Second, the extended number of days will be determined by dividing the number of days the policy was in force by the number of days for which the policy was written and multiplying the quotient by 365 days. When the policy is written for a one-year period, the extended number of days will equal the number of days the policy remained in force. Third, the short rate percentage corresponding, to the extended number of days will be obtained from the short rate cancellation table. Fourth, the short rate premium will be equal to the product of the full standard premium times the short rate percentage. The short rate table below will be. used in computing the short rate premium. In no event will the final earned premium be less than'the, policy minimum premium. WC 99 06 07 E Page I of 2 (Ed. 01-22) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY- WC 99 06 07 E (Ed. 01-22) Rhart Rate Ta -hip Extended Number of Das Percent of Full Policy Premium Extended Number of Das Percent of Full Policy Premium Extended Number of Das Percent of Full Policy Premium 1 ...... 5% 95-98 ...... 37% 219-223 ...... 69% 2 ...... 6% 99-102 ...... 38% 224-228 ...... 70% 3-4 ...... 7% 103-105 ...... 39% 229-232 ...... 71% 5-6 ...... 8% 106-109 ...... 40% 233-237 ...... 72% 7-8 ...... 9% 110-113 ...... 41% 238-241 ...... 73% 9-10 ...... 10% 114-116 ...... 42% 242-246 (8 mos.) 74% 11-12 ...... 11% 117-120 ...... 43% 247-250 ...... 75% 13-14 ...... 12% 121-124 (4 mos.) 44% 251-255 ...... 76% 15-16 ...... 13% 125-127 ...... 45%° 256-260 ...... 77% 17-18 ...... 14% 128-131 ...... 46% 261-264 ...... 78% 19-20 ...... 15% 132-135 ...... 47% 265-269 ....79% 21-22 ...... 16% 136.138 ...... 48% 270-273 (9 mos.) 80% 23-25 ...... 17% 139-142 ...... 49% 274-278 ...... 81% 26-29 ...... 18% 143-146 ...... 50% 279-282 ...... 82% 30-32 (1 mo.) 19% 147-149 ...... 51% 283-287 ...... 83% 33-36 ...... 20% 150-153 (5 mos.) 52% 288-291 ...... 84% 37-40 ...... 21% 154-156 ...... 53% 292-296 ...... 85% 41-43 ...... 22% 157-160 ...... 54% 297-301 ...... 86% 44-47 ...... 23% 161-164 ...... 55% 302-305 (10 mos.) 87% 48-51 ...... 24% 165-167 ...... 56% 306-310 ...... 88% 52-54 ...... 25% 168-171 ...... 57% 311-314 ...... 89% 55-58 ...... 26% 172-175 ...... 58% 315-319 ...... 90% 59-62 (2 mos.) 27% 176-178 ...... 59% 321-323 ...... 91% 63-65 ...... 28% 179-182 (6 mos.) 60% 324-328 ...... 92% 66-69 ...... 29% 183-187 ...... 61% 329-332 ...... 93%° 70-73 ...... ° 30% 188-191 ..... 62% 333-337 11 mos. ( ) 94% 74-76 ...... 31% 192-196 ...... 63% 338-342 ...... 95% 77-80 ...... 32% 197-200 ...... 64% 343-346 ...... 96% 81-83 ...... 33% 201-205 ...... 65% 347-351 ...... 97% 84-87 ...... 34% 206-209 ...... 66% 352-355 ...... 98% 88-91 (3 mos.) 35% 210-214 (7 mos.) 67% 356-360 ...... 99% 92-94 :..... 36% 215-218 . ...... 68% 361-365 12 mos. 100% This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 03/15/2026 Policy No.: FOWC725735 Endorsement No.: Insured: Insurance Company: Berkshire Hathaway Homestate Ins Co WC 99 06 07 E (Ed. 01-22) Countersigned by Page 2 of 2 Premium $