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HomeMy WebLinkAboutTetra Insurance CertA ono DATE0(9/ 0/22018 ) CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Aon Risk Insurance Services West, Inc, Los Angeles CA Office 707 Wilshire Boulevard Suite 2600 CONTACT PHFAx (Naa, No, Ext): (866) 283-7122 WC. No ); (600) 363-0105 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Los Angeles CA 90017-0460 USA INSURED INSURER A: Lexington Insurance Company 19437 Tetra Tech, Inc. (IEW) INSURER B: Zurich American Ins co 16535 711 Tank Farm Road, Suite 110 San Luis Obispo CA 93401 USA INSURERC: AIG Europe Limited AA1120841 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570073377244 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. Limits shown are as requested T TYPE OF INSURANCE INS WVO POLICY NUMBER MMfD07YYYY mmmo '!Y LIMITS X COMMERCIAL GENERAL LIABILITY GLO 14 EACH OCCURRENCE $2,000,000 CLAIMS -MADE E OCCUR PREMISES Ea occurrence $1,000,000 X MED EXP (Any one person) $10, 000 X,C,U Coverage PERSONAL&ADV INJURY $2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $4,000,005 POLICY � PRO JECT EILOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: B AUTOMOBILE LIABILITY BAP 1857085-00 101011201810/01/2019 COMBINED SINGLE LIMIT $2,000,000 BODILY INJURY ( Per person) X ANYAUTO BODILY INJURY (Per accident) OWNED SCHEDULED AUTOS ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Per acciden C X UMBRELLA LIAB OCCUR 62785232 10/01/2018 10/01 2U19 EACH OCCURRENCE $10,on, 0()0 EXCESS LIAB H CLAIMS -MADE AGGREGATE $10,000,000 IDED I X RETENTION $100. 000 B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER /EXECUTIVE N wC254061600 WC185708700 10/01/2018 10/01/2018 10/01/2019 10/01/2019 X STATUTE OTH- ER EL EACHACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA E.L DISEASE -EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below D EL DISEASE -POLICY LIMIT $1,000,000 A Env contr Prof 028182375 10/01/2017 10/01/2019 Each Clain $5,000,000 Prof/Poll Liab Agggregate $5,000,000 SIR applies per policy tens & condi ions DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: City of San Luis Obispo Civil Engineering On -Call. The city of San Luis Obispo, its officers, officials, employees, agents and volunteers are included as Additional Insured in accordance with the policy provisions of the General Liability and Automobile Liability policies. General Liability and Automobile Liability evidenced herein is Primary to other insurance available to an Additional Insured, but only in accordance with the policy's provisions. Deductibles: General Liability: $250,000., Auto Liab: $250,0000. Comp/Coll: $1,000. Workers Compensation: $0, Prof/Poll SIR:500,000. Stop Gap Coverage for the following states: OH, WA, WY. N r nO CO 0 r L0 O Z Y l4 V N U CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE �Wu EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of San Luis Obispo Atten: David Athey AUTHORIZED REPRESENTATIVE 919 Palm street San Luis Obispo CA 93401 USA � / �i � X JI n nar�tanear 6fit/tzd .JG�-�fc�J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD A&Iitional Insured — Automatic — Owners, Lessees Or Contractors Policy No. I Eff. Date of Pol. I Exp. Date of Pol. I Eff, Date of End. G LO 1817406-00 1 10/01 /2018 Named Insured: 10/01 /2019 1 10/01 /2018 Producer No. AddT Prem 7527200 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Address (including ZIP Code): This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part 0 ZURICH Return Prem. A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property 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 or "your work" as included in the "products -completed operations hazard", which is the subject of the written contract or written agreement. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the 'occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. U-GL-1175-F CW (04/13) Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV — Commercial General Liability Conditions: The additional insured must see to it that: 1. We are notified as soon as practicable of an 'occurrence" or offense that may result in a claim; 2. We receive written notice of a claim or "suit" as soon as practicable; and 3. A request for defense and indemnity of the claim or "suit' will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured if the written contract or written agreement requires that this coverage be primary and non-contributory. D. For the purposes of the coverage provided by this endorsement: 1. The following is added to the Other Insurance Condition of Section IV — Commercial General Liability Conditions: Primary and Noncontributory insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured provided that: a. The additional insured is a Named Insured under such other insurance; and b. You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition 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, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same 'occurrence", offense, claim or "suit'. This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by a written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. E. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement; 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. All other terms and conditions of this policy remain unchanged. U-GL-1175-F CW (04/13) Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: GLO 1817406-00 COMMERCIAL GENERAL LIABILITY CG 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 SCHEDULE Name Of Person Or Organization: ANY PERSON OR ORGANIZATION THAT REQUIRES YOU TO WAIVE YOUR RIGHTS OF RECOVERY, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT WITH THE NAMED INSURED THAT IS EXECUTED PRIOR TO THE ACCIDENT OR LOSS. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery 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 Wolters Kluwer Financial Services I Uniform FormsTM POLICY NUMBER: GLO 1817406-00 COMMERCIAL GENERAL LIABILITY CG24171001 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTUAL LIABILITY - RAILROADS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Scheduled Railroad: Designated Job ALL CONTRACTS FOR WORK DONE FOR RAILROADS. Site: ANY JOB SITE (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) With respect to operations performed for, or affecting, Paragraph f. does not include that part of any a Scheduled Railroad at a Designated Job Site, the contract or agreement: definition of "insured contract" in the Definitions sec- (1) That indemnifies an architect, engineer or tion is replaced by the following: surveyor for injury or damage arising out 9. "Insured Contract" means: of: a. A contract for a lease of premises. However, (a) Preparing, approving or failing to that portion of the contract for a lease of prepare or approve maps, shop premises that indemnifies any person or or- drawings, opinions, reports, surveys, ganization for damage by fire to premises field orders, change orders or draw - while rented to you or temporarily occupied by ings and specifications; or you with permission of the owner is not an (b) Giving directions or instructions, or "insured contract"; failing to give them, if that is the pri- b. A sidetrack agreement; mary cause of the injury or damage; c. Any easement or license agreement; (2) Under which the insured, if an architect, d. An obligation, as required by ordinance, to engineer or surveyor, assumes liability for indemnify a municipality, except in connection an injury or damage arising out of the with work for a municipality; insured's rendering or failure to render professional services, including those e. An elevator maintenance agreement; listed in Paragraph (1) above and super- f. That part of any other contract or agreement visory, inspection, architectural or engi- pertaining to your business (including an in- neering activities. demnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury" or "property damage" to a third person or organization. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement. CG 2417 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 POLICY NUMBER: BAP 1857085-00 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following. - AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this, endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement Identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Endorsement Effective Date: SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization to whom or which you are required to provide additional insured status or additional insured status on a primary, non-contributory basis, in a written contract or written agreement executed prior to loss, except where such contract or agreement is prohibited by law. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 Wolters Kluwer Financial Services I Uniform FormsTM 0 Blanket Notification to Others of Cancellation ZURICH or Non -Renewal Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem Return Prem. G LO 1817406-00 1 10/01 /2018 10/01 /2019 10/01 /2018 75272000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. If we cancel or non -renew this Coverage Part by written notice to the first Named Insured, we will mail or deliver notification that such Coverage Part has been cancelled or non -renewed to each person or organization shown in a list provided to us by the first Named Insured if you are required by written contact or written agreement to provide such notification. However, such notification will not be mailed or delivered if a conditional notice of renewal has been sent to the first Named Insured. Such list: 1. Must be provided to us prior to cancellation or non -renewal; 2. Must contain the names and addresses of only the persons or organizations requiring notification that such Coverage Part has been cancelled or non -renewed; and 3. Must be in an electronic format that is acceptable to us. B. Our notification as described in Paragraph A. of this endorsement will be based on the most recent list in our records as of the date the notice of cancellation or non -renewal is mailed or delivered to the first Named Insured. We will mail or deliver such notification to each person or organization shown in the list: 1. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or 2. At least 30 days prior to the effective date of: a. Cancellation, if cancelled for any reason other than nonpayment of premium; or b. Non -renewal, but not including conditional notice of renewal. C. Our mailing or delivery of notification described in Paragraphs A. and B. of this endorsement is intended as a courtesy only. Our failure to provide such mailing or delivery will not: 1. Extend the Coverage Part cancellation or non -renewal date; 2. Negate the cancellation or non -renewal; or 3. Provide any additional insurance that would not have been provided in the absence of this endorsement. D. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs A. and B. of this endorsement. All other terms and conditions of this policy remain unchanged. U-GL-1521-A CW (10/12) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Blanket Notification to Otlhers of Cancellation or Non -Renewal 0 ZURICH Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add'I. Prem Return Prem. BAP 1857085-00 10-01-2018 10-01-2019 10-01-2018 75272000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Commercial Automobile Coverage Part A. If we cancel or non -renew this Coverage Part by written notice to the first Named Insured, we will mail or deliver notification that such Coverage Part has been cancelled or non -renewed to each person or organization shown in a list provided to us by the first Named Insured if you are required by written contract or written agreement to provide such notification. However, such notification will not be mailed or delivered if a conditional notice of renewal has been sent to the first Named Insured. Such list: 1. Must be provided to us prior to cancellation or non -renewal; 2. Must contain the names and addresses of only the persons or organizations requiring notification that such Coverage Part has been cancelled or non -renewed; and 3. Must be in an electronic format that is acceptable to us. B. Our notification as described in Paragraph A. of this endorsement will be based on the most recent list in our records as of the date the notice of cancellation or non -renewal is mailed or delivered to the first Named Insured. We will mail or deliver such notification to each person or organization shown in the list: 1. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or 2. At least 30 days prior to the effective date of: a. Cancellation, if cancelled for any reason other than nonpayment of premium; or b. Non -renewal, but not including conditional notice of renewal. C. Our mailing or delivery of notification described in Paragraphs A. and B. of this endorsement is intended as a courtesy only. Our failure to provide such mailing or delivery will not: 1. Extend the Coverage Part cancellation or non -renewal date; 2. Negate the cancellation or non -renewal; or 3. Provide any additional insurance that would not have been provided in the absence of this endorsement. D. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs A. and B. of this endorsement. All other terms and conditions of this policy remain unchanged. U-CA-832-A CW (01/13) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 43 BLANKET NOTIFICATION TO OTHERS OF CANCELLATION OR NONRENEWAL ENDORSEMENT This endorsement adds the following to Part Six of the policy. PART SIX CONDITIONS Blanket Notification to Others of Cancellation or Nonrenewal 1. If we cancel or non -renew this policy by written notice to you, we will mail or deliver notification that such policy has been cancelled or non -renewed to each person or organization shown in a list provided to us by you if you are required by written contract or written agreement to provide such notification. However, such notification will not be mailed or delivered if a conditional notice of renewal has been sent to you. Such list: a. Must be provided to us prior to cancellation or non -renewal; b. Must contain the names and addresses of only the persons or organizations requiring notification that such policy has been cancelled or non -renewed; and c. Must be in an electronic format that is acceptable to us. 2. Our notification as described in Paragraph 1. above will be based on the most recent list in our records as of the date the notice of cancellation or non -renewal is mailed or delivered to you. We will mail or deliver such notification to each person or organization shown in the list: a. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or b. At least 30 days prior to the effective date of: (1) Cancellation, if cancelled for any reason other than nonpayment of premium; or (2) Non -renewal, but not including conditional notice of renewal. 3. Our mailing or delivery of notification described in Paragraphs 1. and 2. above is intended as a courtesy only. Our failure to provide such mailing or delivery will not: a. Extend the policy cancellation or non -renewal date; b. Negate the cancellation or non -renewal; or c. Provide any additional insurance that would not have been provided in the absence of this endorsement. 4. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs 1. and 2. above. All other terms and conditions of this policy remain unchanged. 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 10-01-2018 Policy No. WC 2540616-00 Endorsement No. Insured Premium $ Insurance Company Zurich American Insurance Company WC 99 06 43 Page 1 of 1 (Ed. 01-13) Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. © 2012 Copyright National Council on Compensation Insurance, Inc. All Rights Reserved. ENDORSEMENT This endorsement, effective 12:01 AM, 10/01/2017 Forms a part of Policy No: 028182375 Issued to: TETRA TECH, INC. By: LEXINGTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED(S) ENDORSEMENT It is hereby agreed that: 1. The following entity(s) is (are) included as additional Insured(s) under Section VI. DEFINITIONS, Paragraph I. Insured solely as respects to Coverage B and solely as respects liability arising out of Covered Operations performed by the Named Insured. Coverage is not afforded for any Loss arising from the scheduled additional Insured's own liability. Additional Insured 1 . Any entity where required by written contract with the first Named Insured indicated in Item 1. of the Declarations. 2. Solely wither respect to coverage afforded in this Endorsement, the following is added to the end of Section V. CONDITIONS, Paragraph A. HOW OTHER INSURANCE APPLIES, Subparagraph 2., as amended in Endorsement 9, WORLDWIDE TERRITORY - CLAIMS IN UNITED STATES OR CANADA HOW OTHER INSURANCE APPLIES - EXCLUSION FOR PROFESSIONAL SERVICES AND COVERED OPERATIONS INSURED UNDER A SEPARATE PROJECT ENDORSEMENT: b. This insurance is primary and non-contributory, and the Company's obligations are not affected by any other insurance carried whether primary, excess, contingent, or on any other basis. The Company's limits of liability as specified in the Declarations of this Policy are not increased. All other terms, conditions, and exclusions shall remain the same. Page 1 of 1 ENDORSEMENT This endorsement, effective 12:01 AM 10/01/2017 Forms a part of policy no.: 028182375 Issued to: TETRA TECH, INC., ET AL By:LEXINGTON INSURANCE COMPANY ADVICE OF CANCELLATION TO ENTITIES OTHER THAN THE NAMED INSURED LIMITED TO E-MAIL NOTIFICATION This policy is amended as follows: In the event that the Insurer cancels this policy for any reason other than non payment of premium, and 1. The cancellation effective date is prior to this policy's expiration date; 2. The First Named Insured is under an existing contractual obligation to notify a certificate holder when this policy is canceled (hereinafter, the "Certificate Holderls)"); and has provided to the Insurer, either directly or through its broker of record, the email address of the contact at such entity, and the Insurer received this information after the First Named Insured receives notice of cancellation of this policy and prior to this policy's cancellation effective date, via an electronic spreadsheet that is acceptable to the Insurer, the Insurer will provide advice of cancellation (the "Advice") via e-mail to such Certificate Holders Proof of the Insurer emailing the Advice, using the information provided by the First Named Insured, will serve as proof that the Insurer has fully satisfied its obligations under this endorsement. This endorsement does not affect, in any way, coverage provided under this policy or the cancellation of this policy or the effective date thereof, nor shall this endorsement invest any rights in any entity not insured under this policy. The following Definitions apply to this endorsement: 1. First Named Insured means the Named Insured shown on the Declarations Page of this policy. 2. Insurer means the insurance company shown in the header on the Declarations Page of this policy. All other terms, conditions and exclusions shall remain the same. LX8960 (05/13) Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 43 BLANKET NOTIFICATION TO OTHERS OF CANCELLATION OR NONRENEWAL ENDORSEMENT This endorsement adds the following to Part Six of the policy. PART SIX CONDITIONS Blanket Notification to Others of Cancellation or Nonrenewal 1. If we cancel or non -renew this policy by written notice to you, we will mail or deliver notification that such policy has been cancelled or non -renewed to each person or organization shown in a list provided to us by you if you are required by written contract or written agreement to provide such notification. However, such notification will not be mailed or delivered if a conditional notice of renewal has been sent to you. Such list: a. Must be provided to us prior to cancellation or non -renewal; b. Must contain the names and addresses of only the persons or organizations requiring notification that such policy has been cancelled or non -renewed; and c. Must be in an electronic format that is acceptable to us. 2. Our notification as described in Paragraph 1. above will be based on the most recent list in our records as of the date the notice of cancellation or non -renewal is mailed or delivered to you. We will mail or deliver such notification to each person or organization shown in the list: a. Within seven days of the effective date of the notice of cancellation, if we cancel for non-payment of premium; or b. At least 30 days prior to the effective date of: (1) Cancellation, if cancelled for any reason other than nonpayment of premium; or (2) Non -renewal, but not including conditional notice of renewal. 3. Our mailing or delivery of notification described in Paragraphs 1. and 2. above is intended as a courtesy only. Our failure to provide such mailing or delivery will not: a. Extend the policy cancellation or non -renewal date; b. Negate the cancellation or non -renewal; or c. Provide any additional insurance that would not have been provided in the absence of this endorsement. 4. We are not responsible for the accuracy, integrity, timeliness and validity of information contained in the list provided to us as described in Paragraphs 1. and 2. above. All other terms and conditions of this policy remain unchanged. 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 10-01-2018 Policy No. WC 1857087-00 Endorsement No. Insured Premium $ Insurance Company Zurich American Insurance Company WC 99 06 43 Page 1 of 1 (Ed. 01-13) Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. 0 2012 Copyright National Council on Compensation Insurance, Inc. All Rights Reserved.