Loading...
HomeMy WebLinkAboutJensen Landscape Services, LLC 04.29.2025T rib CERTIFICATE OF LIABILITY INSURANCE ,.,....-- 5/1/2026 DATE (MM/DDIYYYY) 04/29/2025 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 Lockton Companies, LLC DBA Lockton Insurance Brokers, LLC in CA CA license #01715767 8110 E Union Ave., Ste. 100 NAE c PHONE nNE FAX E No): E-MAIL ADDRESS: )( COMMERCIAL GENERAL LIABILITY Denver CO 80237 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Liberty Mutual Fire Insurance Company 23035 denver-certs@lockton.com INSURED Jensen Landscape Services, LLC INSURER B: LM Insurance Corporation 33600 INSURER C: Starr Surplus Lines Insurance Company 13604 1554537 Jensen Landscape Contractor, LLC; Jensen Landscape & Construction Company, LLC 1250 Ames Avenue, INSURER D Milpitas, CA 95035 INSURER E: DAMAISE (E TO D occurrence) -$,$I,000,000 MED EXP An one person)$$10,000 INSURER F : P►r�0�conr*ce I°+C[f'tIC1AATG At1111AGlCO. '�I �'�Q�'�I crc�rtetnt►t wtttnnt�c�yYyX'XyX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. - NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. INSR LTR TYPE OF INSURANCE ADDLISUBR INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY - LIMITS A )( COMMERCIAL GENERAL LIABILITY TB2-661-067138-035 05/01/2025 05/01/2026 EACH OCCURRENCE $ $1.000,000 CLAIMS -MADE OCCUR . _ DAMAISE (E TO D occurrence) -$,$I,000,000 MED EXP An one person)$$10,000 Y Y PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $ $2,000,000 GEN''L AGGREGATE LIMIT APPLIES PER: POLICY JELOC PRODUCTS - COMP/OP AGG $ $22000,000 $ OTHER: A AUTOMOBILE LIABILITY AS2-661-067138-025 05/01 /2025 05/01 /202 SINGLE LIMIT $ $2,000,000 Ea accident) BODILY INJURY (Per person) $ X)(XX)( ( X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Y Y BODILY INJURY (Per accident) $ )(XYYk )(X PROPERTYct?AMAGE $ X(X()= $ x�c�;xxxx C UMBRELLA LIAB x OCCUR 100588967251 05/01/2025 05/01/2026 EACH OCCURRENCE $ 5,0Q0,000 AGGREGATE $ 53000,000 X EXCESS LIAB CLAIMS -MADE Y Y DED RETENTION $ Prod -Comp Ops $ 5,0003000 B WORKERS COMPENSATION�( AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / A Y WA5-66D-067138-015 05/01/2025 05/01/2026 TT R EACH ACCIDENT $ $1,000,000 E.L. DISEASE - EA EMPLOYEE $ $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $$1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder and any other entities as required by written contract are Additional Insured(s) as per the attached endorsement or policy language. Insurance provided to Additional Insured(s) is primary and non-contributory as per the attached endorsements or policy language. Waiver of subrogation applies as required by written contract as per the attached endorsements or policy language, where allowed by law. GLK'1_1V1(;A_1 L HULULK t;ANt;LLLA 1 IUM OGC r%LLt3 111111 RZO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 21538321 AUTHORIZED REPRESENTATIVE Town of Los Altos Hills Los Altos Hills Town Hall 26379 Fremont Road Los Altos CA 94022 N. '. zo U 1988-2015 ACOR,0 CORPORATION. Ali r'ghts reserved ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CONTINUATION UESUKIFTIUN OF UPEftXi-IUNS/LUVoATION5/VENIGLES/EXGLl151®N AUDEU BY ENUVKbEMhN1J5FhUAL PKVV1tS1UN5 (use only it more space is required) Re: Town of Los Altos. Town of Los Altos Hills is included as Additional Insured in accordance with the policy provisions of the General Liability Policy. ACORD 25 (2016/03) Certificate Holder ID: 21538321 Attachment Code: D661635 Master ID: 1554537, Certificate ID: 21538321 POLICY NUMBER: TB2-661-067138-035 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. co ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS Nw� SCHEDULED PERSON OR co M O ORGANIZATION a 00 0 This endorsement modifies insurance provided under the following: 0 C\1 A. Section 11 — 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", 11property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 additional exclusions apply: 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 location 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. C. 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. Location(s) Of Covered Operations All persons or organizations for whom you have All locations as required by a written contract or entered into a written contract or agreement, prior to agreement entered into prior to an "occurrence" or an offense. "'occurrence'" or offense, to provide additional insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 10 0413 @ Insurance Services Office, Inc., 2012 Page 1 of Attachment Code: D661636 Master ID: 1554537, Certificate ID: 21538321 POLICY NUMBER: TB2-661-067138-035 COMMERCIAL GENERAL LIABILITY CAREFULLY, This endorsement modifies insurance provided under the following: A. Section 11 — 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" or "property damage" caused, in whole or in part, by "'your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 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. Name Of Additional Insured Person(s) Or Organ ization(s): Any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement prior to an occurrence. B. With respect to the insurance afforded to these additional insureds, the following is added to Section 111111 — 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. Location And Description Of Completed Operations All locations as required by a written contract or agreement entered into prior to an "occurrence" or offense. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 @ Insurance Services Office, Inc., 2012 Page 1 o f Attachment Code: D661758 Master ID: 1554537, Certificate ID: 21538321 Policy, Number TB2-661-067138-035 Issued by Liberty Mutual Fire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT — SCHEDULED ADDITIONAL INSURED riXn This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule Name of Person(s) or Organ ization(s): Any person or organization that qualifies as an Additional Insured as required under a written contract or agreement. This endorsement applies unless the written contract or agreement obligates you to utilize ISO endorsement CG 20 01 and CG 20 01 is also attached to this policy. If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV — Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV — Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same "occurrence", claim or "suit". LC 24 20 11 18 @ 2018 Liberty Mutual Insurance Page I of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission, Attachment Attachment Code: D661637 Master ID: 1554537, Certificate ID: 21538321 POLICY NUMBER: TB2-661-067138-035 COMMERCIAL GENERAL LIABILITY CO 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART As required by written contract or agreement entered into prior to loss. Information reguired to corn lete this Schedule, if not shown above, Will be, shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Sec- tion IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 @ Insurance Services Office, Inc., 2008 Page 1 of 1 F1 Attachment Code: D661638 Master ID: 1554537, Certificate ID: 21538321 POLICY NUMBER: AS2-661-067138-025 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE co co This endorsement modifies insurance provided under the following: co 0 co AUTO DEALERS COVERAGE FORM Ir - BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM N 0 N 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 Insuredprovision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s) Or Organ'lzation(s): "Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this Poli 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.I. of Section 11— 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 Attachment Attachment Code: D661759 Master ID: 1554537, Certificate ID: 21538321 I 111111111m= 1K COMMERCIAL AUTO CA 04 491116 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 the endorsement. A. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance - Primary And Excess Insurance Provisions in the Motor Carrier Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage is primary to and will not seek contribution from any other insurance available to an "insuredill under your policy provided that: 1. Such "insured" is a Named Insured under such other insurance; and 2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured". B. The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision to the contrary: This Coverage Form's Covered Autos Liability Coverage and General Liability Coverages are primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that: 1. Such "insured" is a Named Insured under such other insurance; and 2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured". CA 04 491116 © Insurance Services Office, Inc., 2016 Page 1 of 1 Attachment Code: D644713 Master ID: 1554537, Certificate ID: 21538321 Town of Los Altos Hills Los Altos Hills Town Hall 26379 Fremont Road Los Altos CA 94022 To whom it may concern: In our continuing effort to provide timely certificate delivery, Lockton companies 'is transitioning to paperless delivery of Certificates of Insurance, thus this is your final hard -copy delivery. To ensure electronic delivery for future renewals of this certificate, we need your email address. Please contact us via one of the methods below, referencing Certificate ID 21538321. ig Email: mountainwestedelivery@lockton.com 1i Phone: 303-728-8060 If you received this certificate through an internet link where the current certificate is viewable, we have your email and no further action is needed. In.the event your mailing address has changed, will change in the f.uture, or you no longer require this certificate, please let us know using one of the methods above. the above inbox and phone number is for automating eZectronic delivery of certificates onZv. Please do NOT send future certificate requests to this inbox or contact the phone number beZow with ema7'Z updates. Thank you for your cooperation and willingness in reducing our environmental footprint. Lockton Companies 8110 E. Union Avenue, Suite 100 Denver, CO 80237 Attachmep ode: D661967 Master ID: 1554537, Certificate ID: 21538321 Starr Surplus Lines Insurance Company Waiver of Subrogation Endorsement EXCESS LIABILITY SL -233 (0221) co co 0. Policy Number: 100588967251 Effective Date: 05/01LO/2025 at 12:01 A.M. U_ 0� 00 Named Insured: Monarch Landscape Holdings, LLC This endorsement modifies the insurance coverage form(s) listed below that have been purchased by you and 00 evidenced as such on the declarations page. Please read the endorsement and respective policy(ies) carefully. N EXCESS LIABILITY POLICY 0(N It is hereby agreed that SECTION IV. CONDITIONS, K. Transfer of Rights of Recovery Against Others to Us is amended to include the following: UMM= Name Of Person(s) Or Organ ization(s): All as required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Policy. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. All other terms and conditions of this Policy remain unchanged. SL -233 (0221) Page I of 1 Copyright @ Starr Surplus Lines Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Attach ttach de: D661966 Master ID: 1554537, Certificate ID: 21538321 :�3 � Starr Surplus Lines Insurance Company Other Insurance � Primary and Noncontributory for Additional Insured Amendatory Endorsement Policy Number: 100588967251 Effective Date: 05/01/2025 at 12:01 A.M. Named Insured: Monarch Landscape Holdings, LLC This endorsement modifies insurance provided under the following: It is hereby agreed that SECTION IV. CONDITIONS, 1. Other Insurance is deleted in its entirety and replaced by the following: 1. other Insurance If other insurance applies to "Ultimate Net Loss" that is also covered by this Policy, this Policy will apply excess of, and will not contribute to, the other insurance. Nothing herein will be construed to make this Policy subject to the terms, conditions and limitations of such other insurance. However, other insurance does not include: 1. "Underlying Insurance"; 2. Insurance that is specifically written as excess over this Policy; or 3. Insurance held by a person(s) or organization(s) qualifying as an additional insured in "Underlying Insurance," but only when the written contract or agreement that mandates such additional insured status: a. Requires a specific limit of insurance that is in excess of the Underlying Limits of Insurance; b. Requires that your insurance be primary and not contribute with that of the additional insured; and c. Is executed prior to the loss. In such case as described in subparagraph 3. above, we shall not seek contribution from the additional insured's primary or excess insurance for which they are a named insured for amounts payable under this insurance. The Limits of Insurance afforded the additional insured pursuant to subparagraph 3. above shall be the lesser of the following: a. The minimum limits of insurance required in the contract or agreement; or b. The Limits of Insurance shown in the Declarations of this Policy. Other insurance includes any type of self-insurance or other mechanism by which an Insured arranges for the funding of legal liabilities. SL -373 (0219) Page 1 of 1 Copyright @ Starr Surplus Lines Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc. with its permission. Attac D661965 Master ID: 1554537, Certificate ID: 21538321 Insurance Company y"Starr ;surplus Lines 1Z 7j. Policy Number: 100588967251 Effective Date: 05/01/2025 at 12:01 A.M. Named Insured: Monarch Landscape Holdings, LLC I. Paragraph three of the Policy Introduction is deleted in its entirety and replaced with the following: The word Insured means the Named Insured and any person or organization qualifying as an Insured in the First Underlying Insurance Policy(ies), but only to the extent to which such person(s) or organization(s) qualify as an Insured in the First Underlying Insurance Policy(ies).. Newly acquired or formed -organizations must comply with SECTION IV. CONDITIONS, D. CHANGES in order to qualify for coverage. All other terms and conditions of this Policy remain unchanged. SL - 384 (01/12) Page I of 1 Copyright @ Starr Surplus Lines Insurance Company. All rights reserved. Includes copyrighted material of Insurance Services Office, Inc. with its permission. 00 n LO U_ M 1 C 0 co OT - 0 N Attachment Code: D661645 Master ID: 1554537, Certificate ID: 21538321 ; I i 1� 11111iiiiiii q I I F� 11 :4 Z'4 2 u�1111�1�171551 i : I =I - I• This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the Information Page. 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, but this waiver applies. only with respect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the Schedule. Schedule 1. () Specific Waiver Name of person or organization N Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: All Texas operations 3. Premium: The premium charge for this endorsement shall be 2 percent of the premium developed on payroll in connection with work performed for the above person(s) ororganizations)arising out of the operations described. 4. Advance Premium: Issued by LIVI Insurance Corporation For attachment to Policy No. WA5-66D-067138-01 5 Effective Date 05/01/2025 Premium $ Issued to Endorsement No. WC 42 03 04 B 0 Copyright 2014 National Council on Compensation Insurance, Inc. Page 1 of Ed. 06/01/2014 All Rights Reserved. Attachment Attachment Code: D661643 Master ID: 1554537, Certificate ID: 21538321 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the • extent that you perform work under a written contract that requires you to obtain this agreement from us.) C* a - You must maintain payroll records accurately segregating the remuneration of your employees while engaged in U1, LL the work described in the Schedule. CL co M The additional premium for this endorsement shall be. 2% of the California workers' compensation premium C* otherwise due on such remuneration. Schedule 0 C14 Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum premium charge of $250 per policy. Person or Organization Job Descri tion Where required by contract or written agreement prior to loss and allowed by law. Issued by LIVI Insurance Corporation For attachment to Policy No. WA5-66D-067138-015 Issued to WC 04 03 06 R1 Ed. 08/01/2013 Effective Date 05/01/2025 Premium $ Endorsement No. Page 1 of 1 Attachment Code: D6WA4IVMR0v&UR W9G5L TCOeREv e1V ERFROM 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 thatyou 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 Where required by contract or written agreement prior to loss and allowed by law In the state of Colorado and Michigan, the premium charge is 2% of the total manual premium, subject to a minimum premium of $100 per policy. In the state of Oregon, the premium charge is 1% of the total manual premium subject to a minimum premium of $250 per policy. For attachment to Policy No. Effective Date: 05/01/2025 Premium $ WA5-66D-067138-015 Issued to Endorsement No. WC 00 p313 @ 1983 National Council on Compensation Insurance. Page 1 of 1 Ed. 04/01/1984 Attachment Attachment Code: D661639 Master ID: 1554537, Certificate ID: 21538321 POLICY NUMBER: AS2-661-067138-025 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: 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 the endorsement. SCHEDULE Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring. Premium: INCL Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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 J'accidentif or the "loss" under a contract with that person or organization. CA 04 44 10 13 Insurance Services Office, Inc., 2011 Page 1 of 1