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2016-325-E Health - The NC Public Health Foundation for smoking cessation counseling
DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B [Departmental Use Only] TITLE NCPHF Quitline FY 2016-17 ORANGE COUNTY CONTRACT UNDER$15,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this first day of July, 2016, ("Effective Date")by and between Orange County, North Carolina, a political subdivision of the State of North Carolina, (the "County"),party of the first part; and The North Carolina Public Health Foundation (the "Provider"),party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following services to the County in accordance with the terms of this Agreement, time being of the essence: The services and/or materials (hereinafter referred to collectively as "Services") to be furnished under this Agreement are as follows: Services as described in Exhibit A, "Cost Sharing Agreement for QuitlineNC Comprehensive Services"which is attached and hereby incorporated by reference. The term of this agreement rendered shall be from July 1, 2016 to June 30, 2017. Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement,without the prior written approval of the County. SPECIFIC TERMS 1. Payment: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed Five Thousand Dollars, ($5,000). Payment shall be made within thirty(30) days of an invoice properly submitted to County. Should Provider fail to perform its duties under the terms of this Agreement, County may,without fault or penalty,withhold any payment associated with the work to be performed until such time as said work is completed. 2. Non—waiver: Failure by County at any time to require the performance by Provider of any of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of this Non-Waiver Clause. 3. Independent Contractor: The Provider shall operate as an independent contractor and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 4. Insurance: Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may be required by County's Risk Manager as such insurance requirements are described in the Orange County Revised 6/16 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing division/contracts.php). If County's Risk Manager determines additional insurance coverage is required such additional insurance shall consist of N/A (if no additional insurance required mark N/A as being not applicable). Provider shall not commence work until such insurance is in effect and certification thereof has been received by the County's Risk Manager. 5. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider, its agents, or assigns directly or indirectly related to the Services to be performed pursuant to this Agreement on the part of the Provider. 6. Termination: This Agreement may be terminated at any time by mutual written agreement of the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon reasonable notice to the Provider. 7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. 8. Priority: In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms of this Agreement shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. 9. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Anti-Discrimination Policy. Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 10. Dispute Resolution: Any and all suits or actions to enforce, interpret, or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. 11. Non Appropriation: Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non-appropriation of public funds. Revised 6/16 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B IN WITNESS WHEREOF, County and the Provider have signed this Agreement, effective as of the day first written above. O G5l��NTY PR blFs�bed by: 1jblAkuit, tka" tt,V'Stui ��Vl ) By. os ssaa s ... By. tt7 rec or County Manager Title: 200 S. Cameron St. The North Carolina Public Health Foundation P.O. Box 8181 PO Box 18763 Hillsborough,NC 27278 Raleigh,NC 27619 Revised 6/16 3 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Exhibit A Cost Sharing Agreement for QuitlineNC Comprehensive Services Introduction The North Carolina tobacco and Prevention and Control Branch (TPCB") of the North Carolina Division of Public Health in the North Carolina Department of Health and Human Services ("DHHS") works with diverse communities to reduce tobacco disease, death and health care costs. The North Carolina Tobacco-Use Quitline ("QuitlineNC"), funded by TCPB, employs scientific evidence-based methods to help tobacco users quit smoking. The North Carolina Public Health Foundation ("PHF") has entered into a Memorandum of Agreement with TPCB to enable third-parties to enter into cost-sharing agreements with the PHF for Quitline services. The Orange County Health Department has expressed interest in becoming a third party payer to expand the sources of payment for purchase Nicotine Replacement Therapy for Orange County residents enrolled in the QuitlineNC. The following represents a proposal for service delivery between the Orange County Health Department and the NC Public Health Foundation (PHF). General Demographic Information The Orange County Health Department requests Quitline NC provide Nicotine Replacement Therapy for residents of Orange County, North Carolina. There are approximately 133,800 residents, of which approximately [16% (n=21,408)] are tobacco users. Based on historical trends in 2012 and 2013, the projected "reach" or number of residents expected to call the QuitlineNC for services is 220 per year. Eligible service users are Orange County residents who are 18 years or older. Cessation Service for Orange County Residents During the period July 1, 2016 — June 30, 2017, Orange County residents that enroll in the Quitline will receive telephone-based and integrated web-based counseling or web only counseling and free Nicotine Replacement Therapy (NRT) as follows: an initial telephone screening call, four or eight of weeks of free nicotine patches, gum, lozenges or combination therapy, up to four counseling calls per member, mailed materials, and unlimited courtesy calls to the Orange County participant for additional Quitline support. QuitlineNC participants must speak with a coach to receive free NRT. The Orange County Health Department will also be able to take advantage of any statewide or nationwide promotion of 1-800- QuitNow. Per the Memorandum of Agreement between PHF and the DHHS (see Contract Number 00030671, Scope of Services), specific service delivery protocol by QuitlineNC will be as follows: • Initial screening to determine Orange County participant smoking status, provide service explanation and offer counseling; initial counseling call may be completed "on the spot" if a counselor is available; otherwise an appointment will be made for a date and time selected by the Orange County participant. QuitlineNC will initiate the counseling call at the scheduled time. If the Orange County participant is not reached within a total of four (4) call backs, other attempts will be made to try to reach the Orange County participant to complete the engagement. • Up to four (4) telephone counseling sessions (one 45 minute session and three 15 minute sessions) Revised 12/8/15 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Exhibit A • Eight weeks of nicotine replacement therapy (NRT), based on participation in counseling sessions: four weeks sent to the Orange County participant home address via UPS upon completion of the first telephone counseling call (45 min.) and an additional 4 weeks sent via UPS if the Orange County Health Department participant completes second counseling call. OR • Four weeks of NRT sent to Orange County participant home address via UPS upon completion of the first telephone counseling call. • An information packet which includes a quit tobacco use guide will be mailed to all participants completing the screener call. Those who complete the first counseling call and are approved for NRT will also receive simplified instructions along with the NRT kit. QuitlineNC Reports The Orange County Health Department has requested the following reports: • Monthly aggregate report on services provided, corresponding costs paid with funds from Orange County Health Department, and remaining balance of funds. Report includes # of Orange County participants served, by month and year to date, as well as demographics information, services offered, and amount and type of NRT sent to participants. Costs for Services, Protocol/Database Changes,Verification,and utco a Evaluation Alere Wellbeing, Inc. ("Alere") is the prime vendor to QuitlineNC. Alere, while contracted with the TPCB, will provide QuitlineNC services, including up to 8 weeks of Nicotine Replacement Therapy, at State specific unit cost rates. This is a cost-sharing agreement, whereby selected services will be paid by the Orange County Health Department, while other services will be provided by the TPCB at no cost to the Orange County Health Department, as shown below: Pricing structure Nicotine Replacement Unit Costs 4 weeks 8 weeks Patches $48.00 per shipment $48.00 $96.00 Gum $30.00 per box $90.00 $150.00 Lozenges $38.00 per box $152.00 $190.00 Combination Therapy - 4 $108 per first 4 weeks $108.00 $156.00 wks patches and two boxes $48 per second 4 weeks of gum Combination Therapy - 4 $124 per first 4 weeks $124.00 $172.00 wks patches and two boxes $48 per second 4 weeks of lozenges In addition, an Administrative fee equal to 5% of the total contract price will be charged for the cost of administrative services including the monthly cost and aggregate service reports. 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Exhibit A Promotional evelo ent The Orange County Health Department agrees to partner with TPCB to initiate promotional development for roll-out of the project. This will be done on an interim basis. TPCB will let Orange County Health Department know of any statewide or nationwide media campaigns that will reach Orange County residents. Payment for Services The Orange County Health Department will pay directly to Public Health Foundations ("PHF") for participant services and for the administration fees which include monthly reporting. Orange County Health Department will make advance payment for contracted services to: NC Public Health Foundation PO Box 18763 Raleigh, NC 27619 3 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Broker • BB&T Insurance Services, Inc. P.O. Box 168 Winston Salem, NC 27102 IMPORTANT POLICY INFORMATION ENCLOSED 10,,0101,111 AIAN O NONPROFITS LL CE FOR F INSURANCE A Head for Insurance A Heart for Nonprofits. July 16, 2015 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B ALLIANCE OF Finand*Lbefigth M BEST ❑ NONPROFITS FOR naae INSURANCE P.O. Box 8507, Santa Cruz, CA 95061-8507 (831) 459-0980 (800) 359-6422 Fax (831) 459-0853 aw 1uuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu A Head for Insurance.A Heart for Nonprofits. www.insurancefornonprofits.orq Dear ANI Member, Your insurance broker has put your policy on our Direct Bill Program. We have developed this more flexible billing system in response to feedback from our members. Each month you will receive a statement documenting recent activity on your account. Similar to a credit card statement, you will have the choice to pay off the entire balance or make the minimum payment. Your first statement will require a minimum payment of 20% of the total annual premiums. The second through ninth statements will require a minimum payment of 10% of the total annual premiums, plus any unpaid portion of the previous minimum payment. In addition, the minimum payment will reflect adjustments for changes in coverage, and a charge for interest. Please note that an interest charge will be assessed on all outstanding balances after the first statement. Our current simple interest charge is equivalent to 3% APR (.25% per month). This charge will be itemized in the detail section of each statement. We hope this more flexible payment method meets the needs of your organization. If you have any questions or comments, feel free to call our accounting department at (800) 359-6422. Sincerely, Kimberly Aday Chief Financial Officer Statutory Office:2386 Airport Road,Barre,VT 05641 ANI is a nonprofit 501(c)(3)tax-exempt organization DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY CG 21 87 01 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONDITIONAL EXCLUSION OF TERRORISM (RELATING TO DISPOSITION OF FEDERAL TERRORISM RISK INSURANCE ACT) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART EMPLOYEE BENEFITS LIABILITY ENDORSEMENT IMPROPER SEXUAL CONDUCT LIABILITY COVERAGE PART DIRECTORS AND OFFICERS LIABILITY A. Applicability Of The Provisions Of This (3) Redefine terrorism or make insur- Endorsement ance coverage for terrorism subject 1. The provisions of this endorsement be- to provisions or requirements that come applicable commencing on the date differ from those that apply to other when any one or more of the following first types of events or occurrences under occurs. But if your policy (meaning the pol- this policy. icy period in which this endorsement ap- 2. If the provisions of this endorsement be- plies) begins after such date, then the pro- come applicable,such provisions: visions of this endorsement become a. Supersede any terrorism endorsement applicable on the date your policy begins. already endorsed to this policy that ad- a. The federal Terrorism Risk Insurance dresses "certified acts of terrorism" Program ("Program"), established by the and/or"other acts of terrorism", but only Terrorism Risk Insurance Act, has ter- with respect to an incident(s) of terror- minated with respect to the type of in- ism (however defined) which results in surance provided under this Coverage injury or damage that occurs on or after Part or Policy; or the date when the provisions of this en- b. A renewal, extension or replacement of dorsement become applicable (for the Program has become effective with- claims made policies, such an endorse- out a requirement to make terrorism ment is superseded only with respect to coverage available to you and with revi- an incident of terrorism (however de- sions that: fined)that results in a claim for injury or damage first being made on or after the (1) Increase our statutory percentage date when the provisions of this en- deductible under the Program for ter- dorsement become applicable); and rorism losses. (That deductible de- termines the amount of all certified b. Remain applicable unless we notify you terrorism losses we must pay in a of changes in these provisions, in re- calendar year, before the federal sponse to federal law. government shares in subsequent payment of certified terrorism loss- es.); or (2) Decrease the federal government's statutory percentage share in poten- tial terrorism losses above such de- ductible; or CG 21 87 01 07 © ISO Properties, Inc., 2005 Page 1 of 3 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 3. If the provisions of this endorsement do C. The following exclusion is added: NOT become applicable, any terrorism en- EXCLUSION OF TERRORISM dorsement already endorsed to this policy, that addresses "certified acts of terrorism" We will not pay for any injury or damage" caused and/or "other acts of terrorism", will con- directly or indirectly by "terrorism", including action tinue in effect unless we notify you of in hindering or defending against an actual or ex- changes to that endorsement in response pected incident of "terrorism". Any injury or dam- to federal law. age" is excluded regardless of any other cause or event that contributes concurrently or in any se- B. The following definitions are added and apply quence to such injury or damage. But this exclu- under this endorsement wherever the term terror- sion applies only when one or more of the fol- ism, or the phrase any injury or damage, are en- lowing are attributed to an incident of closed in quotation marks: "terrorism": 1. "Terrorism" means activities against persons, 1. The "terrorism" is carried out by means of the organizations or property of any nature: dispersal or application of radioactive material, a. That involve the following or preparation for or through the use of a nuclear weapon or de- the following: vice that involves or produces a nuclear reac- (1) Use or threat of force or violence; or tion, nuclear radiation or radioactive contami- nation; or (2) Commission or threat of a dangerous act; or 2. Radioactive material is released, and it ap- pears that one purpose of the "terrorism" was (3) Commission or threat of an act that to release such material; or interferes with or disrupts an electronic, communication, information, or mechan 3. The "terrorism" is carried out by means of the ical system; and dispersal or application of pathogenic or poi- sonous biological or chemical materials; or b. When one or both of the following applies: 4. Pathogenic or poisonous biological or chemical (1) The effect is to intimidate or coerce a materials are released, and it appears that one government or the civilian population or purpose of the "terrorism" was to release such any segment thereof, or to disrupt any materials; or segment of the economy; or 5. The total of insured damage to all types of (2) It appears that the intent is to intimidate property exceeds $25,000,000. In determining or coerce a government, or to further whether the $25,000,000 threshold is exceed- political, ideological, religious, social or ed, we will include all insured damage sus- economic objectives or to express (or tained by property of all persons and entities express opposition to) a philosophy or affected by the "terrorism" and business inter- ideology. ruption losses sustained by owners or occu- 2. Any injury or damage" means any injury or pants of the damaged property. For the pur- damage covered under any Coverage Part or pose of this provision, insured damage means Policy to which this endorsement is applicable, damage that is covered by any insurance plus and includes but is not limited to "bodily injury", damage that would be covered by any insur- "property damage", "personal and advertising ance but for the application of any terrorism injury", "injury' or "environmental damage" as exclusions; or may be defined in any applicable Coverage 6. Fifty or more persons sustain death or serious Part or Policy. physical injury. For the purposes of this provi- sion, serious physical injury means: a. Physical injury that involves a substantial risk of death; or b. Protracted and obvious physical disfigure- ment; or c. Protracted loss of or impairment of the function of a bodily member or organ. Page 2 of 3 © ISO Properties, Inc., 2005 CG 21 87 01 07 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Multiple incidents of"terrorism" which occur within a 72-hour period and appear to be carried out in concert or to have a related purpose or common leadership will be deemed to be one incident, for the purpose of determining whether the thresholds in Paragraphs C.S. or C.6. are exceeded. With respect to this Exclusion, Paragraphs C.S. and C.6. describe the threshold used to measure the magnitude of an incident of"terrorism" and the circumstances in which the threshold will apply, for the purpose of determining whether this Exclusion will apply to that incident. When the Exclusion ap- plies to an incident of"terrorism", there is no cov- erage under this Coverage Part or Policy. In the event of any incident of "terrorism" that is not subject to this Exclusion, coverage does not apply to any injury or damage" that is otherwise excluded under this Coverage Part or Policy. CG 21 87 01 07 © ISO Properties, Inc., 2005 Page 3 of 3 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Iri NONPROFITS ILA INSURANCE Including ALLIANCE OF NONPROFITS FOR INSURANCE(ANI) & NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA(NIAC) ALLIANCE ROU P www.insurancefornonprofits.org A Head for Insurance.A Heart for Nonprofits. Claims Reporting Procedure REPORT CLAIMS IMMEDIATELY! There is no negative impact on your policy for reporting an incident. When in doubt— report it! If you have any questions concerning whether to report an incident or claim, call your broker. HOW DO YOU KNOW WHEN AN INCIDENT REQUIRES A CLAIM TO BE REPORTED? 1. There's been an accident 2. Someone has been hurt 3. Property has been damaged 4. You think someone ought to know "just in case" IF YOU NEED TO REPORT A CLAIM: 1. Complete the appropriate reporting form: • Driver Accident Report Form — motor vehicle accident • Incident Report Form — all other accidents An original of these forms follows this page of your policy. Additional forms are available at our secure website: www.insurancefornonprofits.org_ NOTE: Claims for North American Elite Property Insurance do not require a separate form. Your insurance broker will send us an ACORD claim form. 2. Tell your insurance broker to report the claim to the AMS Insurance Services, Inc. Claims Department by email at: newclaimsninsurancefornonarofits.orq_ EMERGENCY SITUATIONS If you need to report a claim during non-business hours and cannot reach your broker, call 1-866-718-1947. This number should only be used for true claims emergencies. Rev.10/2014 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 1 MI NONPROFITS ElINSURANCE Including ALLIANCE OF NONPROFITS FOR INSURANCE(ANI) & NONPROFITS INSURANCE ALLIANCE OF CALIFORNIA(NIAC) LLIANCE GROUP www.insurancefornonprofits.org A Head for Insurance,A Heart for Nonprofits. Incident Report Form CLAIMS REPORTING PROCEDURE If you have a question concerning whether to report an incident or claim,call your broker. NONPROFIT/INSURED - Complete all items to the best of your ability,sign and date page 2,and immediately give it to your supervisor. Supervisor - Fax this Incident Report Form to your insurance broker immediately. Important: Retain any equipment or furniture which caused or contributed to an injury until it can be inspected by an insurance representative. BROKER- Refer to our website for instructions on claim reporting. If a claim needs to be reported after business hours or on the weekend,call(866)718-1947. This number is reserved for true claims emergencies after business hours and weekends. General Information Name of Nonprofit Organization ANI/NIAC Policy Number Name of Contact Title Nonprofit Address-Street City State Zip Business Phone# Ext. Business Fax# E-mail Address Incident Information Date of Incident Day of Week(circle one) Time of Incident Did the incident occur on organization's premises? Mon Tue Wed Thurs Fri Sat Sun AM I PM ❑ Yes ❑ No Location of Incident Of possible,take pictures of the area with a digital or disposable camera) Description of Incident (A brief factual account of the incident;include who was involved,how the incident occurred and what action is being taken in response to the incident.Use the back of the sheet if more space is needed.) Witness Information Name and Address Daytime Phone Email Address DOB 1. 2. Rev.10/2014 Page 1 of 3 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Claimant Information 1.Name of Injured Party DOB ❑ Employee ❑ Client ❑ Volunteer ❑ Visitor ❑ Other- Address-Street City State Zip Home Phone# Business Phone# Email Address ( ) ( ) Description of Injury (nature and extent of;please be specific): Transported by Ambulance Name and Phone#of Hospital or Doctor,if applicable ❑ Yes ❑ No Observations of Nonprofit Claimant's Attire/Description of Clothing(i.e.,shorts,t-shirt) Type of Shoes Was Claimant carrying anything?(if yes,what) ❑ No ❑ Yes- Describe claimant's demeanor when making the report (i.e.,agitated,in obvious or no obvious pain,able to move around while describing what happened,etc.) (use the back of the form or attach an additional sheet of paper if needed) Claimant Information 2.Name of Injured Party DOB ❑ Employee ❑ Client ❑ Volunteer ❑ Visitor ❑ Other- Address-Street City State Zip Home Phone# Business Phone# Email Address ( ) ( ) Description of Injury (nature and extent of;please be specific): Transported by Ambulance Name and Phone#of Hospital or Doctor,if applicable ❑ Yes ❑ No Observations of Nonprofit Claimant's Attire/Description of Clothing(i.e.,shorts,t-shirt) Type of Shoes Was Claimant carrying anything?(if yes,what) ❑ No ❑ Yes- Describe claimant's demeanor when making the report (i.e.,agitated,in obvious or no obvious pain,able to move around while describing what happened,etc.) (use the back of the form or attach an additional sheet of paper if needed) PRINT NAME OF INDIVIDUAL COMPLETING THE FORM SIGNATURE DATE Rev.10/2014 Page 2 of 3 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 9Q� 1� I ALLIANCE OF ❑(' NONPROFITS FOR ALLIANCE OF NONPROFITS FOR INSURANCE INSURANCE RISK RETENTION GROUP(ANI) www.insurancefornonprofits.org A Head for Insurance.A Heart for Nonprofits. COMMERCIAL LINES COMMON POLICY DECLARATIONS PRODUCER: POLICY NUMBER: 2015-37160 BB&T Insurance Services, Inc. P.O. Box 168 RENEWAL OF NUMBER: 2014-37160 Winston Salem, NC 27102 NAME OF INSURED AND MAILING ADDRESS: North Carolina Public Health Foundation P.O. Box 18763 Raleigh, NC 27619 POLICY PERIOD: FROM 07/19/2015 TO 07/19/2016 AT 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE BUSINESS DESCRIPTION: Public health program IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE COVERAGE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.THESE PREMIUMS MAY BE SUBJECT TO ADJUSTMENT. PREMIUM COMMERCIAL GENERAL LIABILITY COVERAGE PART - OCCURRENCE $844 COMMERCIAL AUTO LIABILITY COVERAGE PART Not Covered IMPROPER SEXUAL CONDUCT COVERAGE PART Not Covered COMMERCIAL LIQUOR LIABILITY COVERAGE PART INCLUDED TERRORISM COVERAGE (Certified Acts) $4 TOTAL: $848 FORM(S)AND ENDORSEMENT(S)MADE A PART OF THIS POLICY AT TIME OF ISSUE:* ANI-RRG-E03 01 13, ANI-RRG-E11 07 92, ANI-RRG-E12 05 92, ANI-RRG-E15 02 09, ANI-RRG-E22 08 95, ANI-RRG-E25 01 98, ANI-RRG-E28 01 99, ANI-RRG-E29 12 09, ANI-RRG-E33 01 02, ANI-RRG-E42 07 06, ANI-RRG-E52 07 13, ANI-RRG-E60 07 12, ANI-RRG-E61 02 13, ANI-RRG-E7 10 04, ANI-RRG-E70 07 13, ANI-RRG-E74 03 14, ANI-RRG-GL 04 01, ANI-RRG-LL 04 01, ANI-RRG-X1 02 15, CG 00 01 07 98, CG 00 33 01 96, CG 20 10 07 04, CG 20 11 01 96, CG 20 12 07 98, CG 20 18 11 85, CG 20 20 11 85, CG 20 21 07 98, CG 20 26 07 04, CG 20 34 07 04, CG 20 37 07 04, CG 21 16 07 98, CG 21 70 01 15, CG 22 44 1 1 85, CG 24 07 1 1 85, CG 25 04 11 85, CG 77 94 04 93, IL 00 17 11 98, IL 02 69 09 00, IL 09 99 01 15, NPO-001 04 09, SCHEDULE G 01 80, SCHEDULE L 01 80, *Omits applicable forms and endorsement if shown in specific coverage part/coverage form declarations. These declarations and the common policy declarations,if applicable,together with the common policy conditions,coverage form(s)and forms and endorsements,if any,issued to form a part thereof,complete the above numbered policy. "NOTICE This policy is issued by your risk retention group.Your risk retention group may not be subject to all of the insurance laws BY and regulations of your State.State insurance insolvency (AUTHORIZED REPRESENTATIVE) guaranty funds are not available for your risk retention group." 07/16/2015 ANI -RRG -CO (02651-DB) DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B ` ALLIANCE OF ❑ NONPROFITS FOR ALLIANCE OF NONPROFITS FOR INSURANCE INSURANCE RISK RETENTION GROUP(ANI) www.insurancefornonprofits.org A Head for Insurance.A Heart for Nonprofits. COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS PRODUCER: POLICY NUMBER: 2015-37160 BB&T Insurance Services, Inc. P.O. Box 168 RENEWAL OF NUMBER: 2014-37160 Winston Salem, NC 27102 NAME OF INSURED AND MAILING ADDRESS: North Carolina Public Health Foundation P.O. Box 18763 Raleigh, NC 27619 POLICY PERIOD: FROM 07/19/2015 TO 07/19/2016 AT 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE BUSINESS DESCRIPTION: Public health program IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE COVERAGE AS STATED IN THIS POLICY. LIMITS OF COVERAGE: GENERAL AGGREGATE LIMIT(OTHER THAN PRODUCTS-COMPLETED OPERATIONS) $2,000,000 PRODUCTS - COMPLETED OPERATIONS AGGREGATE LIMIT $2,000,000 PERSONAL AND ADVERTISING INJURY LIMIT $1,000,000 EACH OCCURRENCE LIMIT $1,000,000 DAMAGE TO PREMISES RENTED TO YOU $500,000 any one premise MEDICAL EXPENSE LIMIT 20,000 any one person ADDITIONAL COVERAGES: SOCIAL SERVICE PROFESSIONAL LIABILITY EXCLUDED CLASSIFICATION(S) SEE ATTACHED SUPPLEMENTAL DECLARATIONS SCHEDULE G PREMIUM $844 FORMS AND ENDORSEMENTS APPLICABLE TO THIS POLICY ARE INCLUDED IN COMMERCIAL LINES COMMMON POLICY DECLARATIONS 07/16/2015 BY (AUTHORIZED REPRESENTATIVE) THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS,IF APPLICABLE,TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY. "NOTICE : This Policy is issued by your risk retention group.Your risk retention group may not be subject to all the insurance laws and regulations of your State.State insurance insolvency guaranty funds are not available for your risk retention group." ANI - RRG - GL (02651) DocuSign Envelope ID e1F43AFA-8004-4861-887A'F304o7A6614o 111111 � — ALLIANCE OF NONPROFITS FOR ALLIANCE OF NONPROFITS FOR INSURANCE � K���V�U� /k �T��l� �|�k�RETENT|{�NC�RDUP(�\N|) � � Xx�u'«�x~�������m~ vvmxwineuranoofornonpnofito.org•DAWN MINKNIMEMMEMMWDMWIM A Head for Insurance.A Heart for Nonprofits. COMMERCIAL GENERAL LIABILITY EXTENSION OF DECLARATIONS Schedule G POLICY NUMBER: 2015-37160 Page 1 NAME OF INSURED: North Carolina Public Health Foundation PREMISES PREMIUM *ADVANCED CODE/CLASS *LOC BASIS RATE PREMIUM 47366/Sales, Service or Consulting Organizations- 1 600.842 .652 $451 NOC-includes products and/or completed operations ADDITIONAL COVERAGES Increased Aggregate $117 Additional Premium to Meet Minimum $276 *See Common Declarations for Total Advanced Premium and Schedule L for locations. �� /O. 07/10/2015 BY (AUTHORIZED REPRESENTATIVE) "NOTICE : This Policy is issued by your risk retention group.Your risk retention group may not be subject to all the insurance laws and regulations of your State.State insurance insolvency guaranty funds are not available for your risk retention group." ANI - RRG - SCHEDULE G (02051) DocuSign Envelope ID:91F43AFA-8CB4-4861-887A-F304C7A6614B ALLIANCE OF 010 NONPROFITS FOR ALLIANCE OF NONPROFITS FOR INSURANCE INSURANCE RISK RETENTION GROUP(ANI) www.insurancefornonprofits.org A Head for Insurance.A Heart for Nonprofits. COMMERCIAL GENERAL LIABILITY EXTENSION OF DECLARATIONS Schedule L POLICY NUMBER: 201 5-371 60 Page 1 NAME OF INSURED: North Carolina Public Health Foundation PREMISES DESIGNATED PREMISES ADDITIONAL INSUREDS LOC/BLDG ADDRESS. CITY. STATE. ZIP AND OTHER INTERESTS 1 308-F West Millbrook Road,Suite 1 Raleigh, NC 27609 07/16/2015 BY (AUTHORIZED REPRESENTATIVE) "NOTICE : This Policy is issued by your risk retention group.Your risk retention group may not be subject to all the insurance laws and regulations of your State.State insurance insolvency guaranty funds are not available for your risk retention group." ANI -RRG -SCHEDULE L (02651) DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B ALLIANCE OF ❑ NONPROFITS FOR ALLIANCE OF NONPROFITS FOR INSURANCE ,111\\\\\\\`\\\ INSURANCE RISK RETENTION GROUP(AND IMMIMMINIMMW www.insurancefornonprofits.org A Head for Insurance.A Heart for Nonprofits. COMMERCIAL LIQUOR LIABILITY COVERAGE PART DECLARATIONS PRODUCER: POLICY NUMBER: 2015-37160 BB&T Insurance Services, Inc. RENEWAL OF NUMBER: 2014-37160 P.O. Box 168 Winston Salem, NC 27102 NAME OF INSURED AND MAILING ADDRESS: North Carolina Public Health Foundation P.O. Box 18763 Raleigh, NC 27619 POLICY PERIOD: FROM 07/19/2015 TO 07/19/2016 AT 12:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE BUSINESS DESCRIPTION: Public health program IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE COVERAGE AS STATED IN THIS POLICY. LIMITS OF COVERAGE: GENERAL AGGREGATE LIMIT $ 1,000,000 EACH COMMON CAUSE LIMIT $ 1,000,000 PREMIUM: Included FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE PART AND MADE PART OF THIS POLICY AT THE TIME OF ISSUANCE: CG 00 33/01 96 THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS,IF APPLICABLE,TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE FORM(S)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY. 07/16/2015 BY (AUTHORIZED REPRESENTATIVE) "NOTICE : This Policy is issued by your risk retention group.Your risk retention group may not be subject to all the insurance laws and regulations of your State.State insurance insolvency guaranty funds are not available for your risk retention group." ANI - RRG - LL (02651) DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B hd1111 P ALLIANCE OF ❑ NONPROFITS FOR ALLIANCE OF NONPROFITS FOR INSURANCE 11 INSURANCE RISK RETENTION GROUP(ANI) 11� www.insurancefornonprofits.org A Head for Insurance.A Heart for Nonprofits. INDEX OF FORMS ATTACHED TO THE POLICY POLICY NUMBER: 2015-37160 NAME OF INSURED: North Carolina Public Health Foundation Page 1 LIABILITY FORMS AND ENDORSEMENTS FORM NUMBER/EDITION DATE Member Criteria ANI-RRG-E03 01 13 Fireworks Exclusion ANI-RRG-E11 07 92 Nuclear Energy Liability Exclusion Endorsement ANI-RRG-E12 05 92 Blood Testing Exclusion ANI-RRG-E15 02 09 Asbestos Exclusion ANI-RRG-E22 08 95 Additional Insured- Designated Person or Organization ANI-RRG-E25 01 98 Property Damage to Personal Property in the Care, Custody or Control of the Insured ANI-RRG-E28 01 99 Employee Personal Auto Reimbursement ANI-RRG-E29 12 09 Mold, Fungus Exclusion ANI-RRG-E33 01 02 Nuclear, Chemical and Biological Hazard Exclusion ANI-RRG-E42 07 06 Privacy Liability and Cyber Coverage ANI-RRG-E52 07 13 Volunteer Medical Payments ANI-RRG-E60 07 12 Additional Insured- Primary and Non-Contributory Endorsement for Public Entities ANI-RRG-E61 02 13 Exclusion of Coverage for Claims By and Related to Past and Present Employees ANI-RRG-E7 10 04 Fundraiser Endorsement ANI-RRG-E70 07 13 Mental Anguish Endorsement ANI-RRG-E74 03 14 Commercial General Liability Coverage Part Declarations ANI-RRG-GL 04 01 Commercial Liquor Liability Coverage Part Declarations ANI-RRG-LL 04 01 Improper Sexual Conduct and Physical Abuse Exclusion-GL ANI-RRG-X1 02 15 Commercial General Liability Coverage Form CG 00 01 07 98 Liquor Liability Coverage Form CG 00 33 01 96 Additional Insured-Owners, Lessees or Contractors CG 20 10 07 04 Additional Insured- Managers or Lessors of Premises CG 20 11 01 96 Additional Insured-State or Political Subdivisions-Permits CG 20 12 07 98 Additional Insured- Mortgagee,Assignee or Receiver CG 20 18 11 85 Additional Insured-Charitable Institutions CG 20 20 11 85 Additional Insured-Volunteers CG 20 21 07 98 Additional Insured- Designated Person or Organization CG 20 26 07 04 Additional Insured- Lessor of Leased Equipment-Automatic Status-Lease CG 20 34 07 04 Additional Insured-Owners, Lessees or Contractors-Completed Operations CG 20 37 07 04 Designated Professional Services Exclusion CG 21 16 07 98 Cap on Losses from Certified Acts of Terrorism CG 21 70 01 15 Health or Cosmetic Services Exclusion CG 22 44 11 85 Products/Completed Operations Hazard Redefined CG 24 07 11 85 Amendment-Aggregate Limits of Insurance(Per Location) CG 25 04 11 85 Liability Arising Out of Lead Exclusion CG 77 94 04 93 Common Policy Conditions IL 00 17 11 98 North Carolina Changes-Cancellation and Nonrenewal IL 02 69 09 00 Disclosure Of Premium for Certified Acts of Terrorism Coverage IL 09 99 01 15 Nonprofits' OWN Enhancement Endorsement NPO-001 04 09 Commercial General Liability Class Code Schedule SCHEDULE G 01 80 Commercial General Liability Location Schedule SCHEDULE L 01 80 This list of forms is not part of the actual policy, but is for your information only. Please refer to the policy(s)for actual limits, coverages and exclusions. DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY CG 00 01 07 98 COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage. b. This insurance applies to "bodily injury' and Read the entire policy carefully to determine rights, "property damage"only if: duties and what is and is not covered. (1) The "bodily injury' or "property damage" is Throughout this policy the words you and "your" refer caused by an "occurrence" that takes place to the Named Insured shown in the Declarations, and in the"coverage territory"; and any other person or organization qualifying as a (2) The "bodily injury' or "property damage" Named Insured under this policy.The words "we", "us" occurs during the policy period. and our refer to the company providing this insur- ance. c. Damages because of "bodily injury' include damages claimed by any person or organiza- The word "insured" means any person or organization tion for care, loss of services or death resulting qualifying as such under Section II — Who Is An In- at any time from the"bodily injury'. sured. Other words and phrases that appear in quotation 2 Exclusions marks have special meaning. Refer to Section V — This insurance does not apply to: Definitions. a. Expected Or Intended Injury SECTION I—COVERAGES "Bodily injury' or "property damage" expected COVERAGE A BODILY INJURY AND PROPERTY or intended from the standpoint of the insured. DAMAGE LIABILITY This exclusion does not apply to "bodily injury" resulting from the use of reasonable force to 1. Insuring Agreement protect persons or property. a. We will pay those sums that the insured be- b. Contractual Liability comes legally obligated to pay as damages be- cause of"bodily injury' or "property damage" to "Bodily injury' or "property damage" for which which this insurance applies. We will have the the insured is obligated to pay damages by right and duty to defend the insured against any reason of the assumption of liability in a con- "suit"seeking those damages. However,we will tract or agreement. This exclusion does not have no duty to defend the insured against any apply to liability for damages: "suit" seeking damages for "bodily injury' or (1) That the insured would have in the absence "property damage"to which this insurance does of the contract or agreement; or not apply. We may, at our discretion, investi- (2) Assumed in a contract or agreement that is gate any "occurrence" and settle any claim or an "insured contract", provided the "bodily suit"that may result. But: injury' or "property damage" occurs subse- (1) The amount we will pay for damages is quent to the execution of the contract or limited as described in Section III — Limits agreement. Solely for the purposes of liabil- Of Insurance; and ity assumed in an "insured contract", rea- (2) Our right and duty to defend end when we sonable attorney fees and necessary litiga- have used up the applicable limit of insur- tion expenses incurred by or for a party ance in the payment of judgments or set- other than an insured are deemed to be tlements under Coverages A or B or medi- damages because of "bodily injury' or cal expenses under Coverage C. "property damage", provided: No other obligation or liability to pay sums or (a) Liability to such party for, or for the cost perform acts or services is covered unless ex- of, that party's defense has also been plicitly provided for under Supplementary Pay- assumed in the same "insured contract"; ments—Coverages A and B. and CG 00 01 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 13 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B (b) Such attorney fees and litigation ex- f. Pollution penses are for defense of that party (1) "Bodily injury' or "property damage" arising against a civil or alternative dispute reso- out of the actual, alleged or threatened dis- lution proceeding in which damages to charge, dispersal, seepage, migration, re- which this insurance applies are alleged. lease or escape of"pollutants": c. Liquor Liability (a) At or from any premises, site or location "Bodily injury' or "property damage" for which which is or was at any time owned or any insured may be held liable by reason of: occupied by, or rented or loaned to, any (1) Causing or contributing to the intoxication of insured. However, this subparagraph any person; does not apply to: (2) The furnishing of alcoholic beverages to a (i) "Bodily injury if sustained within a person under the legal drinking age or un- and caused by smoke, der the influence of alcohol; or fumes, vapor or soot from equipment used to heat that building; (3) Any statute, ordinance or regulation relating to the sale, gift, distribution or use of alco- (ii) "Bodily injury' or "property damage" holic beverages. for which you may be held liable, if you are a contractor and the owner This exclusion applies only if you are in the or lessee of such premises, site or business of manufacturing, distributing, selling, location has been added to your pol- serving or furnishing alcoholic beverages. icy as an additional insured with re- d. Workers' Compensation And Similar Laws spect to your ongoing operations per- Any obligation of the insured under a workers' formed for that additional insured at compensation, disability benefits or unemploy that premises, site or location and ment compensation law or any similar law. such premises, site or location is not and never was owned or occupied e. Employer's Liability by, or rented or loaned to, any in- "Bodily injury'to: sured, other than that additional in- (1) An "employee" of the insured arising out of sured; or and in the course of: (iii) "Bodily injury' or "property damage" (a) Employment by the insured;or arising out of heat, smoke or fumes from a"hostile fire"; (b) Performing duties related to the conduct (b) At or from any premises, site or location of the insured's business; or which is or was at any time used by or (2) The spouse, child, parent, brother or sister for any insured or others for the han- of that "employee" as a consequence of dling, storage, disposal, processing or Paragraph (1)above. treatment of waste; This exclusion applies: (c) Which are or were at any time trans- (1) Whether the insured may be liable as an ported, handled, stored, treated, dis- employer or in any other capacity; and posed of, or processed as waste by or (2) To any obligation to share damages with or for any insured or any person or organi- zation someone else who must pay dam- nation for whom you may be legally re ages because of the injury. sponsible;or This exclusion does not apply to liability as- sumed by the insured under an "insured con- tract". Page 2 of 13 Copyright, Insurance Services Office, Inc., 1997 CG 00 01 07 98 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B (d) At or from any premises, site or location (2) Any loss, cost or expense arising out of any: on which any insured or any contractors (a) Request, demand, order or statutory or or subcontractors working directly or in- regulatory requirement that any insured directly on any insured's behalf are per- or others test for, monitor, clean up, re- forming operations if the "pollutants" are move, contain, treat, detoxify or neutral- brought on or to the premises, site or lo- ize, or in any way respond to, or assess cation in connection with such opera- the effects of, "pollutants";or tions by such insured, contractor or sub- contractor. However, this subparagraph (b) Claim or suit by or on behalf of a gov- does not apply to: ernmental authority for damages be- cause of testing for, monitoring, cleaning(i) "Bodily injury' or "property damage" up, removing, containing, treating, de- arising out of the escape of fuels, lu- toxifying or neutralizing, or in any way bricants or other operating fluids responding to, or assessing the effects which are needed to perform the of, "pollutants". normal electrical, hydraulic or me- chanical functions necessary for the However, this paragraph does not apply to operation of "mobile equipment" or liability for damages because of "property its parts, if such fuels, lubricants or damage" that the insured would have in the other operating fluids escape from a absence of such request, demand, order or vehicle part designed to hold, store statutory or regulatory requirement, or such or receive them. This exception does claim or "suit" by or on behalf of a govern- not apply if the "bodily injury' or mental authority. "property damage" arises out of the g. Aircraft, Auto Or Watercraft intentional discharge, dispersal or re- "Bodily injury' or "property damage" arising out lease of the fuels, lubricants or other of the ownership, maintenance, use or en- operating fluids, or if such fuels, lu- trustment to others of any aircraft, "auto"or wa- bricants or other operating fluids are tercraft owned or operated by or rented or brought on or to the premises, site or loaned to any insured. Use includes operation location with the intent that they be and "loading or unloading". discharged, dispersed or released as part of the operations being per- This exclusion does not apply to: formed by such insured, contractor (1) A watercraft while ashore on premises you or subcontractor; own or rent; (ii) "Bodily injury' or "property damage" (2) A watercraft you do not own that is: sustained within a building and caused by the release of gases, (a) Less than 26 feet long; and fumes or vapors from materials (b) Not being used to carry persons or brought into that building in connec- property for a charge; tion with operations being performed (3) Parking an "auto" on, or on the ways next by you or on your behalf by a con- to, premises you own or rent, provided the tractor or subcontractor; or "auto" is not owned by or rented or loaned (iii) "Bodily injury' or "property damage" to you or the insured; arising out of heat, smoke or fumes (4) Liability assumed under any "insured con- from a"hostile fire". tract" for the ownership, maintenance or (e) At or from any premises, site or location use of aircraft or watercraft; or on which any insured or any contractors (5) "Bodily injury' or "property damage" arising or subcontractors working directly or in- out of the operation of any of the equipment directly on any insured's behalf are per- listed in Paragraph f.(2) or f.(3) of the defini- form ing operations if the operations are tion of"mobile equipment". to test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the ef- fects of, "pollutants". CG 00 01 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 3 of 13 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B h. Mobile Equipment k. Damage To Your Product "Bodily injury" or "property damage" arising out "Property damage" to your product"arising out of: of it or any part of it. (1) The transportation of"mobile equipment" by I. Damage To Your Work an "auto" owned or operated by or rented or "Property damage" to your work" arising out of loaned to any insured; or it or any part of it and included in the "products- (2) The use of "mobile equipment" in, or while completed operations hazard". in practice for, or while being prepared for, This exclusion does not apply if the damaged any prearranged racing, speed, demolition, work or the work out of which the damage or stunting activity. arises was performed on your behalf by a sub- i. War contractor. "Bodily injury"or"property damage"due to war, m. Damage To Impaired Property Or Property whether or not declared, or any act or condition Not Physically Injured incident to war. War includes civil war, insurrec- "Property damage" to "impaired property' or tion, rebellion or revolution. This exclusion op- property that has not been physically injured, plies only to liability assumed under a contract arising out of: or agreement. (1) A defect, deficiency, inadequacy or danger- j. Damage To Property ous condition in your product" or your "Property damage"to: work"; or (1) Property you own, rent, or occupy; (2) A delay or failure by you or anyone acting (2) Premises you sell, give away or abandon, if on your behalf to perform a contract or the"property damage"arises out of any part agreement in accordance with its terms. of those premises; This exclusion does not apply to the loss of use (3) Property loaned to you; of other property arising out of sudden and ac- cidental physical injury to your product" or (4) Personal property in the care, custody or your work" after it has been put to its intended control of the insured; use. (5) That particular part of real property on which n. Recall Of Products,Work Or Impaired you or any contractors or subcontractors Property working directly or indirectly on your behalf are performing operations, if the "property Damages claimed for any loss, cost or expense damage"arises out of those operations; or incurred by you or others for the loss of use, withdrawal, recall, inspection, repair, replace- (6) That particular part of any property that ment, adjustment, removal or disposal of: must be restored, repaired or replaced be- cause your work" was incorrectly per- formed on it. (2) Your work"; or Paragraphs (1), (3) and (4) of this exclusion do (3) "Impaired property'; not apply to "property damage" (other than if such product, work, or property is withdrawn damage by fire) to premises, including the con- or recalled from the market or from use by any tents of such premises, rented to you for a pe- person or organization because of a known or riod of 7 or fewer consecutive days.A separate suspected defect, deficiency, inadequacy or limit of insurance applies to Damage To Prem- dangerous condition in it. ises Rented To You as described in Section III —Limits Of Insurance. o. Personal And Advertising Injury Paragraph (2)of this exclusion does not apply if "Bodily injury' arising out of "personal and ad- the premises are your work" and were never vertising injury'. occupied, rented or held for rental by you. Exclusions c. through n. do not apply to damage Paragraphs (3), (4), (5) and (6)of this exclusion by fire to premises while rented to you or temporar- do not apply to liability assumed under a side- ily occupied by you with permission of the owner.A track agreement. separate limit of insurance applies to this coverage as described in Section III—Limits Of Insurance. Paragraph (6) of this exclusion does not apply to "property damage" included in the "products- completed operations hazard". Page 4 of 13 Copyright, Insurance Services Office, Inc., 1997 CG 00 01 07 98 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COVERAGE B PERSONAL AND ADVERTISING (6) Arising out of a breach of contract, except INJURY LIABILITY an implied contract to use another's adver- t. Insuring Agreement tising idea in your"advertisement"; a. We will pay those sums that the insured be- (7) Arising out of the failure of goods, products comes legally obligated to pay as damages be or services to conform with any statement of cause of "personal and advertising injury" to quality or performance made in your"adver- which this insurance applies. We will have the tisement"; right and duty to defend the insured against any (8) Arising out of the wrong description of the "suit"seeking those damages. However,we will price of goods, products or services stated have no duty to defend the insured against any in your"advertisement"; "suit" seeking damages for "personal and ad- (9) Committed by an insured whose business is vertising injury" to which this insurance does advertising, broadcasting, publishing or not apply. We may, at our discretion, investi- telecasting. However, this exclusion does gate any offense and settle any claim or "suit" not apply to Paragraphs 14.a., b. and c. of that may result. But: "personal and advertising injury" under the (1) The amount we will pay for damages is Definitions Section; or limited as described in Section III — Limits (10) Arising out of the actual, alleged or threat- Of Insurance; and ened discharge, dispersal, seepage, migra- (2) Our right and duty to defend end when we tion, release or escape of"pollutants"at any have used up the applicable limit of insur- time. ance in the payment of judgments or set- b. Any loss, cost or expense arising out of any: tlements under Coverages A or B or medi- cal expenses under Coverage C. (1) Request, demand or order that any insured or others test for, monitor, clean up, re- No other obligation or liability to pay sums or move, contain, treat, detoxify or neutralize, perform acts or services is covered unless ex- or in any way respond to, or assess the ef- plicitly provided for under Supplementary Pay- fects of, "pollutants"; or ments—Coverages A and B. (2) Claim or suit by or on behalf of a govern- b. This insurance applies to "personal and adver- mental authority for damages because of tising injury'caused by an offense arising out of testing for, monitoring, cleaning up, remov- your business but only if the offense was com- ing, containing, treating, detoxifying or neu- mitted in the "coverage territory'during the pol- tralizing, or in any way responding to, or as- icy period. sessing the effects of, "pollutants". 2. Exclusions COVERAGE C MEDICAL PAYMENTS This insurance does not apply to: 1. Insuring Agreement a. "Personal and advertising injury': a. We will pay medical expenses as described (1) Caused by or at the direction of the insured below for"bodily injury'caused by an accident: with the knowledge that the act would vio- (1) On premises you own or rent; late the rights of another and would inflict "personal and advertising injury"; (2) On ways next to premises you own or rent; or (2) Arising out of oral or written publication of material, if done by or at the direction of the (3) Because of your operations; insured with knowledge of its falsity; provided that: (3) Arising out of oral or written publication of (1) The accident takes place in the "coverage material whose first publication took place territory'and during the policy period; before the beginning of the policy period; (2) The expenses are incurred and reported to (4) Arising out of a criminal act committed by or us within one year of the date of the acci- at the direction of any insured; dent; and (5) For which the insured has assumed liability (3) The injured person submits to examination, in a contract or agreement. This exclusion at our expense, by physicians of our choice does not apply to liability for damages that as often as we reasonably require. the insured would have in the absence of the contract or agreement; CG 00 01 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 5 of 13 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B b. We will make these payments regardless of e. All costs taxed against the insured in the "suit". fault. These payments will not exceed the ap- f. Prejudgment interest awarded against the plicable limit of insurance. We will pay reason- insured on that part of the judgment we pay. If able expenses for: we make an offer to pay the applicable limit of (1) First aid administered at the time of an insurance, we will not pay any prejudgment in- accident; terest based on that period of time after the of- (2) Necessary medical, surgical, x-ray and fer. dental services, including prosthetic de- g. All interest on the full amount of any judgment vices; and that accrues after entry of the judgment and be- (3) Necessary ambulance, hospital, profes fore we have paid, offered to pay, or deposited sional nursing and funeral services. in court the part of the judgment that is within the applicable limit of insurance. 2. Exclusions These payments will not reduce the limits of insur- We will not pay expenses for"bodily injury': ance. a. To any insured. 2. If we defend an insured against a "suit" and an b. To a person hired to do work for or on behalf of indemnitee of the insured is also named as a party any insured or a tenant of any insured. to the "suit", we will defend that indemnitee if all of c. To a person injured on that part of premises the following conditions are met: you own or rent that the person normally occu- a. The "suit" against the indemnitee seeks dam- pies. ages for which the insured has assumed the li- d. To a person, whether or not an "employee" of ability of the indemnitee in a contract or agree- any insured, if benefits for the"bodily injury'are ment that is an "insured contract"; payable or must be provided under a workers' b. This insurance applies to such liability assumed compensation or disability benefits law or a by the insured; similar law. c. The obligation to defend, or the cost of the e. To a person injured while taking part in athlet- defense of, that indemnitee, has also been as- ics. sumed by the insured in the same "insured f. Included within the "products-completed opera- contract"; tions hazard". d. The allegations in the "suit" and the information g. Excluded under Coverage A. we know about the "occurrence" are such that no conflict appears to exist between the inter- h. Due to war, whether or not declared, or any act ests of the insured and the interests of the in- or condition incident to war. War includes civil demnitee; war, insurrection, rebellion or revolution. e. The indemnitee and the insured ask us to con- SUPPLEMENTARY PAYMENTS—COVERAGES A duct and control the defense of that indemnitee AND B against such "suit" and agree that we can as- 1. We will pay, with respect to any claim we investi- sign the same counsel to defend the insured gate or settle, or any "suit" against an insured we and the indemnitee;and defend: f. The indemnitee: a. All expenses we incur. (1) Agrees in writing to: b. Up to $250 for cost of bail bonds required be- (a) Cooperate with us in the investigation, cause of accidents or traffic law violations aris- settlement or defense of the"suit"; ing out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do (b) Immediately send us copies of any de not have to furnish these bonds. mands, notices, summonses or legal papers received in connection with the c. The cost of bonds to release attachments, but "suit"; only for bond amounts within the applicable (c) Notify any other insurer whose coverage limit of insurance. We do not have to furnish these bonds. is available to the indemnitee; and d. All reasonable expenses incurred by the in- (d) Cooperate with us with respect to coor sured at our request to assist us in the investi dinating other applicable insurance gation or defense of the claim or "suit", includ- ing to the indemnitee; and ing actual loss of earnings up to $250 a day because of time off from work. Page 6 of 13 Copyright, Insurance Services Office, Inc., 1997 CG 00 01 07 98 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B (2) Provides us with written authorization to: 2. Each of the following is also an insured: (a) Obtain records and other information a. Your "employees", other than either your "ex- related to the"suit"; and ecutive officers" (if you are an organization (b) Conduct and control the defense of the other than a partnership,joint venture or limited indemnitee in such "suit". liability company) or your managers (if you are So long as the above conditions are met, attor- a limited liability company), but only for acts g within the scope of their employment by you or neys' fees incurred by us in the defense of that in- while performing duties related to the conduct demnitee, necessary litigation expenses incurred of your business. However, none of these "em- by us and necessary litigation expenses incurred ployees" is an insured for: by the indemnitee at our request will be paid as Supplementary Payments. Notwithstanding the (1) "Bodily injury' or "personal and advertising provisions of Paragraph 2.b.(2) of Section I—Cov- injury': erage A — Bodily Injury And Property Damage Li- (a) To you, to your partners or members (if ability, such payments will not be deemed to be you are a partnership or joint venture), to damages for "bodily injury' and "property damage" your members (if you are a limited liabil- and will not reduce the limits of insurance. ity company), or to a co-"employee" Our obligation to defend an insured's indemnitee while that co "employee" is either in the and to pay for attorneys'fees and necessary litiga course of his or her employment or per- tion expenses as Supplementary Payments ends forming duties related to the conduct of when: your business; a. We have used up the applicable limit of insur- (b) To the spouse, child, parent, brother or ance in the payment of judgments or settle sister of that co "employee" as a copse ments; or quence of Paragraph (1)(a) above; b. The conditions set forth above, or the terms of (c) For which there is any obligation to the agreement described in Paragraph f. share damages with or repay someone above, are no longer met. else who must pay damages because of the injury described in Paragraphs (1)(a) SECTION II—WHO IS AN INSURED or(b)above; or 1. If you are designated in the Declarations as: (d) Arising out of his or her providing or a. An individual, you and your spouse are insur- failing to provide professional health eds, but only with respect to the conduct of a care services. business of which you are the sole owner. (2) "Property damage"to property: b. A partnership or joint venture, you are an in- (a) Owned, occupied or used by, sured. Your members, your partners, and their spouses are also insureds, but only with re- (b) Rented to, in the care, custody or control spect to the conduct of your business. of, or over which physical control is be ing exercised for any purpose by c. A limited liability company, you are an insured. Your members are also insureds, but only with you, any of your "employees", any partner respect to the conduct of your business. Your or member (if you are a partnership or joint managers are insureds, but only with respect to venture), or any member (if you are a lim their duties as your managers. ited liability company). d. An organization other than a partnership, joint b. Any person (other than your "employee"), or venture or limited liability company, you are an any organization while acting as your real es insured. Your "executive officers" and directors tate manager. are insureds, but only with respect to their du- c. Any person or organization having proper tem- ties as your officers or directors. Your stock- porary custody of your property if you die, but holders are also insureds, but only with respect only: to their liability as stockholders. (1) With respect to liability arising out of the maintenance or use of that property; and (2) Until your legal representative has been appointed. CG 00 01 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 7 of 13 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B d. Your legal representative if you die, but only 2. The General Aggregate Limit is the most we will with respect to duties as such.That representa- pay for the sum of: tive will have all your rights and duties under a. Medical expenses under Coverage C; this Coverage Part. b. Damages under Coverage A, except damages 3. With respect to "mobile equipment" registered in because of "bodily injury" or "property damage" your name under any motor vehicle registration included in the "products-completed operations law, any person is an insured while driving such hazard"; and equipment along a public highway with your per- mission. Any other person or organization respon- c. Damages under Coverage B. sible for the conduct of such person is also an in- 3. The Products-Completed Operations Aggregate sured, but only with respect to liability arising out of Limit is the most we will pay under Coverage A for the operation of the equipment, and only if no other damages because of "bodily injury" and "property insurance of any kind is available to that person or damage" included in the "products-completed op- organization for this liability. However, no person or erations hazard". organization is an insured with respect to: 4. Subject to 2. above, the Personal and Advertising a. "Bodily injury" to a co-"employee"of the person Injury Limit is the most we will pay under Coverage driving the equipment; or B for the sum of all damages because of all "per- b. "Property damage" to property owned by, sonal and advertising injury" sustained by any one rented to, in the charge of or occupied by you person or organization. or the employer of any person who is an in- 5. Subject to 2. or 3. above, whichever applies, the sured under this provision. Each Occurrence Limit is the most we will pay for 4. Any organization you newly acquire or form, other the sum of: than a partnership, joint venture or limited liability a. Damages under Coverage A; and company, and over which you maintain ownership b. Medical expenses under Coverage C or majority interest,will qualify as a Named Insured if there is no other similar insurance available to because of all "bodily injury" and "property dam- that organization. However: age"arising out of any one"occurrence". a. Coverage under this provision is afforded only 6. Subject to 5. above, the Damage To Premises until the 90th day after you acquire or form the Rented To You Limit is the most we will pay under organization or the end of the policy period, Coverage A for damages because of "property whichever is earlier; damage"to any one premises, while rented to you, b. Coverage A does not apply to "bodily injury or or in the case of damage by fire, while rented to you f the or temporarily occupied by you with permission "property damage" that occurred before you of t acquired or formed the organization; and he owner. c. Coverage B does not apply to "personal and 7. Subject to 5. above, the Medical Expense Limit is the most we will pay under Coverage C for all advertising injury" arising out of an offense sus- committed before you acquired or formed the medical expenses because of "bodily injury" sus tained by any one person. organization. No person or organization is an insured with respect The Limits of Insurance of this Coverage Part apply to the conduct of any current or past partnership, joint separately to each consecutive annual period and to venture or limited liability company that is not shown any remaining period of less than 12 months, starting as a Named Insured in the Declarations. with the beginning of the policy period shown in the Declarations, unless the policy period is extended SECTION III—LIMITS OF INSURANCE after issuance for an additional period of less than 12 1. The Limits of Insurance shown in the Declarations months. In that case, the additional period will be and the rules below fix the most we will pay re- deemed part of the last preceding period for purposes gardless of the number of: of determining the Limits of Insurance. a. Insureds; b. Claims made or"suits" brought; or c. Persons or organizations making claims or bringing "suits". Page 8 of 13 Copyright, Insurance Services Office, Inc., 1997 CG 00 01 07 98 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B SECTION IV—COMMERCIAL GENERAL LIABILITY b. To sue us on this Coverage Part unless all of CONDITIONS its terms have been fully complied with. 1. Bankruptcy A person or organization may sue us to recover on Bankruptcy or insolvency of the insured or of the an agreed settlement or on a final judgment insured's estate will not relieve us of our obliga against an insured obtained after an actual trial; tions under this Coverage Part. but we will not be liable for damages that are not payable under the terms of this Coverage Part or 2. Duties In The Event Of Occurrence, Offense, that are in excess of the applicable limit of insur- Claim Or Suit ance. An agreed settlement means a settlement a. You must see to it that we are notified as soon and release of liability signed by us, the insured as practicable of an "occurrence"or an offense and the claimant or the claimant's legal represen- which may result in a claim. To the extent pos- tative. sible, notice should include: 4. Other Insurance (1) How, when and where the "occurrence" or If other valid and collectible insurance is available offense took place; to the insured for a loss we cover under Cover- (2) The names and addresses of any injured ages A or B of this Coverage Part, our obligations persons and witnesses; and are limited as follows: (3) The nature and location of any injury or a. Primary Insurance damage arising out of the "occurrence" or This insurance is primary except when b. below offense. applies. If this insurance is primary, our obliga- b. If a claim is made or "suit" is brought against tions are not affected unless any of the other any insured,you must: insurance is also primary. Then, we will share (1) Immediately record the specifics of the with all that other insurance by the method de- claim or"suit"and the date received; and scribed in c. below. (2) Notify us as soon as practicable. b. Excess Insurance You must see to it that we receive written no This insurance is excess over: tice of the claim or "suit" as soon as practica- (1) Any of the other insurance, whether pri- ble. mary, excess, contingent or on any other c. You and any other involved insured must: basis: (1) Immediately send us copies of any de- (a) That is Fire, Extended Coverage, mands, notices, summonses or legal pa Builder's Risk, Installation Risk or similar pers received in connection with the claim coverage for your work"; or"suit"; (b) That is Fire insurance for premises (2) Authorize us to obtain records and other rented to you or temporarily occupied by information; you with permission of the owner; (3) Cooperate with us in the investigation or (c) That is insurance purchased by you to settlement of the claim or defense against cover your liability as a tenant for "prop the"suit"; and erty damage" to premises rented to you or temporarily occupied by you with (4) Assist us, upon our request, in the en- permission of the owner; or forcement of any right against any person or organization which may be liable to the in- (d) If the loss arises out of the maintenance sured because of injury or damage to which or use of aircraft, "autos"or watercraft to this insurance may also apply. the extent not subject to Exclusion g. of Section I — Coverage A — Bodily Injury d. No insured will, except at that insured's own And Property Damage Liability. cost, voluntarily make a payment, assume any (2) Any other primary insurance available to obligation, or incur any expense, other than for you covering liability for damages arising first aid,without our consent. out of the premises or operations for which 3. Legal Action Against Us you have been added as an additional in- No person or organization has a right under this sured by attachment of an endorsement. Coverage Part: a. To join us as a party or otherwise bring us into a"suit"asking for damages from an insured; or CG 00 01 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 9 of 13 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B When this insurance is excess, we will have no 6. Representations duty under Coverages A or B to defend the in- By accepting this policy, you agree: sured against any"suit" if any other insurer has a duty to defend the insured against that "suit". a. The statements in the Declarations are accu- If no other insurer defends, we will undertake to rate and complete; do so, but we will be entitled to the insured's b. Those statements are based upon representa- rights against all those other insurers. tions you made to us; and When this insurance is excess over other in- c. We have issued this policy in reliance upon surance, we will pay only our share of the your representations. amount of the loss, if any, that exceeds the 7. Separation Of Insureds sum of: (1) The total amount that all such other insur Except with respect to the Limits of Insurance, and ance would pay for the loss in the absence any rights or duties specifically assigned in this a a this insurance; and Coverage Part to the first Named Insured, this in- of this insurance; and surance applies: (2) The total of all deductible and self-insured a. As if each Named Insured were the only amounts under all that other insurance. Named Insured;and We will share the remaining loss, if any, with b. Separately to each insured against whom claim any other insurance that is not described in this is made or"suit" is brought. Excess Insurance provision and was not bought specifically to apply in excess of the 8. Transfer Of Rights Of Recovery Against Others Limits of Insurance shown in the Declarations To Us of this Coverage Part. If the insured has rights to recover all or part of any c. Method Of Sharing payment we have made under this Coverage Part, If all of the other insurance permits contribution those rights are transferred to us. The insured by equal shares, we will follow this method must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer also. Under this approach each insurer contrib- utes equal amounts until it has paid its applica those rights to us and help us enforce them. ble limit of insurance or none of the loss re- 9. When We Do Not Renew mains, whichever comes first. If we decide not to renew this Coverage Part, we If any of the other insurance does not permit will mail or deliver to the first Named Insured contribution by equal shares, we will contribute shown in the Declarations written notice of the by limits. Under this method, each insurers nonrenewal not less than 30 days before the expi- share is based on the ratio of its applicable limit ration date. of insurance to the total applicable limits of in- If notice is mailed, proof of mailing will be sufficient surance of all insurers. proof of notice. 5. Premium Audit SECTION V—DEFINITIONS a. We will compute all premiums for this Cover- 1. "Advertisement" means a notice that is broadcast age Part in accordance with our rules and or published to the general public or specific mar- rates. ket segments about your goods, products or ser- b. Premium shown in this Coverage Part as ad- vices for the purpose of attracting customers or vance premium is a deposit premium only. At supporters. the close of each audit period we will compute 2. "Auto" means a land motor vehicle, trailer or semi- the earned premium for that period. Audit pre- trailer designed for travel on public roads, including miums are due and payable on notice to the any attached machinery or equipment. But "auto" first Named Insured. If the sum of the advance does not include"mobile equipment". and audit premiums paid for the policy period is 3. "Bodily injury' means bodily injury, sickness or greater than the earned premium, we will return disease sustained by a person, including death re- the excess to the first Named Insured. suiting from any of these at any time. c. The first Named Insured must keep records of 4. "Coverage territory"means: the information we need for premium computa- tion, and send us copies at such times as we a. The United States of America (including its may request. territories and possessions), Puerto Rico and Canada; Page 10 of 13 Copyright, Insurance Services Office, Inc., 1997 CG 00 01 07 98 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B b. International waters or airspace, provided the d. An obligation, as required by ordinance, to injury or damage does not occur in the course indemnify a municipality, except in connection of travel or transportation to or from any place with work for a municipality; not included in a. above; or e. An elevator maintenance agreement; c. All parts of the world if: f. That part of any other contract or agreement (1) The injury or damage arises out of: pertaining to your business (including an in- (a) Goods or products made or sold by you demnification of a municipality in connection in the territory described in a. above; or with work performed for a municipality) under which you assume the tort liability of another (b) The activities of a person whose home is party to pay for "bodily injury'or"property dam- in the territory described in a. above, but age" to a third person or organization. Tort li- is away for a short time on your busi- ability means a liability that would be imposed ness; and by law in the absence of any contract or (2) The insured's responsibility to pay damages agreement. is determined in a "suit" on the merits, in the Paragraph f. does not include that part of any territory described in a. above or in a set- contract or agreement: tlement we agree to. (1) That indemnifies a railroad for"bodily injury" 5."Employee" includes a "leased worker". "Employee" or "property damage" arising out of con- does not include a"temporary worker". struction or demolition operations, within 50 6. "Executive officer means a person holding any of feet of any railroad property and affecting the officer positions created by your charter, con- any railroad bridge or trestle, tracks, road- stitution, by-laws or any other similar governing beds,tunnel, underpass or crossing; document. (2) That indemnifies an architect, engineer or 7. "Hostile fire" means one which becomes uncontrol- surveyor for injury or damage arising out of: lable or breaks out from where it was intended to (a) Preparing, approving, or failing to pre- be. pare or approve, maps, shop drawings, 8. "Impaired property' means tangible property, other opinions, reports, surveys, field orders, than your product" or your work", that cannot be change orders or drawings and specifi- used or is less useful because: cations;or a. It incorporates your product" or your work" (b) Giving directions or instructions, or fail- that is known or thought to be defective, defi- ing to give them, if that is the primary cient, inadequate or dangerous;or cause of the injury or damage; or b. You have failed to fulfill the terms of a contract (3) Under which the insured, if an architect, or agreement; engineer or surveyor, assumes liability for if such property can be restored to use by: an injury or damage arising out of the in sured's rendering or failure to render pro- a. The repair, replacement, adjustment or re- fessional services, including those listed in moval of your product"or your work"; or (2) above and supervisory, inspection, ar- b. Your fulfilling the terms of the contract or chitectural or engineering activities. agreement. 10."Leased worker" means a person leased to you by 9."Insured contract" means: a labor leasing firm under an agreement between a. A contract for a lease of premises. However, you and the labor leasing firm, to perform duties that portion of the contract for a lease of preen related to the conduct of your business. "Leased ises that indemnifies any person or organize worker"does not include a"temporary worker". organiza- tion for damage by fire to premises while rented 11."Loading or unloading" means the handling of to you or temporarily occupied by you with property: permission of the owner is not an "insured con- a. After it is moved from the place where it is tract"; accepted for movement into or onto an aircraft, b. A sidetrack agreement; watercraft or"auto"; c. Any easement or license agreement, except in b. While it is in or on an aircraft, watercraft or connection with construction or demolition op- "auto"; or erations on or within 50 feet of a railroad; CG 00 01 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 11 of 13 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B c. While it is being moved from an aircraft, water- 13."Occurrence" means an accident, including con- craft or "auto" to the place where it is finally de- tinuous or repeated exposure to substantially the livered; same general harmful conditions. but "loading or unloading" does not include the 14."Personal and advertising injury" means injury, movement of property by means of a mechanical including consequential "bodily injury', arising out device, other than a hand truck, that is not at- of one or more of the following offenses: tached to the aircraft,watercraft or"auto". a. False arrest, detention or imprisonment; 12."Mobile equipment" means any of the following b. Malicious prosecution; types of land vehicles, including any attached ma- chinery or equipment: c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a. Bulldozers, farm machinery, forklifts and other a room, dwelling or premises that a person oc- vehicles designed for use principally off public cupies, committed by or on behalf of its owner, roads; landlord or lessor; b. Vehicles maintained for use solely on or next to d. Oral or written publication of material that slan- premises you own or rent; ders or libels a person or organization or dis- c. Vehicles that travel on crawler treads; parages a person's or organization's goods, d. Vehicles, whether self-propelled or not, main-products or services; tained primarily to provide mobility to perma- e. Oral or written publication of material that vio- nently mounted: lates a person's right of privacy; (1) Power cranes, shovels, loaders, diggers or f. The use of another's advertising idea in your drills; or "advertisement"; or (2) Road construction or resurfacing equipment g. Infringing upon another's copyright, trade dress such as graders, scrapers or rollers; or slogan in your"advertisement". e. Vehicles not described in a., b., c. or d. above 15."Pollutants" mean any solid, liquid, gaseous or that are not self-propelled and are maintained thermal irritant or contaminant, including smoke, primarily to provide mobility to permanently at- vapor, soot, fumes, acids, alkalis, chemicals and tached equipment of the following types: waste. Waste includes materials to be recycled, (1) Air compressors, pumps and generators, reconditioned or reclaimed. including spraying, welding, building clean- 16."Products-completed operations hazard": ing, geophysical exploration, lighting and a. Includes all "bodily injury" and "property dam- well servicing equipment;or age" occurring away from premises you own or (2) Cherry pickers and similar devices used to rent and arising out of "your product" or "your raise or lower workers; work"except: f. Vehicles not described in a., b., c. or d. above (1) Products that are still in your physical pos- maintained primarily for purposes other than session; or the transportation of persons or cargo. (2) Work that has not yet been completed or However, self-propelled vehicles with the fol- abandoned. However, "your work" will be lowing types of permanently attached equip- deemed completed at the earliest of the fol- ment are not "mobile equipment" but will be lowing times: considered "autos": (a) When all of the work called for in your (1) Equipment designed primarily for: contract has been completed. (a) Snow removal; (b) When all of the work to be done at the (b) Road maintenance, but not construction job site has been completed if your con or resurfacing; or tract calls for work at more than one job site. (c) Street cleaning; (c) When that part of the work done at a job (2) Cherry pickers and similar devices mounted site has been put to its intended use by on automobile or truck chassis and used to any person or organization other than raise or lower workers; and another contractor or subcontractor (3) Air compressors, pumps and generators, working on the same project. including spraying, welding, building clean- Work that may need service, maintenance, ing, geophysical exploration, lighting and correction, repair or replacement, but which well servicing equipment. is otherwise complete, will be treated as completed. Page 12 of 13 Copyright, Insurance Services Office, Inc., 1997 CG 00 01 07 98 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B b. Does not include "bodily injury" or "property 20. Your product'means: damage"arising out of: a. Any goods or products, other than real prop- (1) The transportation of property, unless the erty, manufactured, sold, handled, distributed injury or damage arises out of a condition in or disposed of by: or on a vehicle not owned or operated by (1) You; you, and that condition was created by the "loading or unloading" of that vehicle by any (2) Others trading under your name; or insured; (3) A person or organization whose business or (2) The existence of tools, uninstalled equip- assets you have acquired; and ment or abandoned or unused materials; or b. Containers (other than vehicles), materials, (3) Products or operations for which the classi- parts or equipment furnished in connection with fication, listed in the Declarations or in a pol- such goods or products. icy schedule, states that products- Your product' includes: completed operations are subject to the a. Warranties or representations made at any General Aggregate Limit. time with respect to the fitness, quality, durabil- 17."Property damage"means: ity, performance or use of your product'; and a. Physical injury to tangible property, including all b. The providing of or failure to provide warnings resulting loss of use of that property. All such or instructions. loss of use shall be deemed to occur at the Your product' does not include vending machines time of the physical injury that caused it;or or other property rented to or located for the use of b. Loss of use of tangible property that is not others but not sold. physically injured. All such loss of use shall be 21."Your work" means: deemed to occur at the time of the 'occur- rence"that caused it. a. Work or operations performed by you or on 18."Suit' means a civil proceeding in which damages your behalf; and because of "bodily injury", "property damage" or b. Materials, parts or equipment furnished in con- "personal and advertising injury" to which this in- nection with such work or operations. surance applies are alleged. "Suit' includes: Your work" includes: a. An arbitration proceeding in which such dam- a. Warranties or representations made at any ages are claimed and to which the insured time with respect to the fitness, quality, durabil- must submit or does submit with our consent; ity, performance or use of your work"; and or b. The providing of or failure to provide warnings b. Any other alternative dispute resolution pro- or instructions. ceeding in which such damages are claimed and to which the insured submits with our con- sent. 19."Temporary worker" means a person who is fur- nished to you to substitute for a permanent "em- ployee" on leave or to meet seasonal or short-term workload conditions. CG 00 01 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 13 of 13 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NONPROFITS' OWN ENHANCEMENT ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Except where designated below,the terms of the coverage part to which this endorsement is attached apply to the insurance provided by this endorsement. I. SCHEDULE OF ADDITIONAL COVERAGES AND LIMITS The following is a summary of additional coverages and limits provided by this endorsement: Limit Non-owned Watercraft(up to 75 feet) N/A Supplementary Payments —Bail Bonds $5,000 Supplementary Payments — Investigation or Defense $1,000/per day Newly Formed Entities-until end of policy period N/A Workplace Violence Counseling $50,000 Unsatisfied Contributions $25,000 Identity Theft Expense $30,000 Terrorism Travel Reimbursement $30,000 Kidnap Expense $50,000 Executive Recruitment Expense $50,000 Abuse of Process Included Damage to Property of Others $5,000 Occurrence/ $25,000 Aggregate NPO-001 04 09 Page 1 of 5 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B II. ADDITIONAL COVERAGES Non-owned Watercraft COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Paragraph 2.g. Exclusions, Aircraft,Auto, or Watercraft Subparagraph (2)(a)is replaced by the following: (a)Less than 75 feet long; and Supplementary Payments —Bail Bonds Supplementary Payments —Coverages A and B, Paragraph 1. b. is replaced by the following: b.Up to$5,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. Supplementary Payments —Investigation or Defense Supplementary Payments —Coverages A and B, Paragraph 1.d. is replaced by the following: d.All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or"suit," including actual loss of earnings up to $1,000 a day because of time off from work. Newly Formed Entities Section II —Who is an Insured, Paragraph 4.a. is replaced by the following: a.Coverage under this provision is afforded until the end of the policy period. Workplace Violence Counseling We will pay, with respect to an act of"workplace violence"during the policy period, all reasonable expenses you incur for psychological counseling of your"employees"during the following six months, up to an annual aggregate amount of$50,000. This coverage is subject to Exclusion 2.d.of Section I, Coverage A, regarding workers'compensation and similar laws. Unsatisfied Contributions We will pay, with respect to an "unsatisfied contribution,"the unpaid balance of a prior written pledge to contribute, up to an annual aggregate amount of$25,000 for all such claims. This Additional Coverage does not apply to: 1. An "unsatisfied contribution"from a donor who filed for, or who was in, bankruptcy before you received the donor's written pledge to contribute: 2. Any amount in excess of the fair market value of an "unsatisfied contribution"of goods, services or property; 3. An "unsatisfied contribution"where either the donor or you believed at the time of the written pledge that the donor would not be able to contribute the full amount pledged; NPO-001 04 09 Page 2 of 5 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 4. An "unsatisfied contribution"arising out of a written pledge made prior to the policy period; 5. An "unsatisfied contribution"first known to you after the policy period. Identity Theft Expense We will reimburse any current"Member", except the"Organization", for necessary and reasonable"Identity Theft Expense" due to an "Identity Theft" first discovered by the "Member" during the policy period, reported to us within 60 days after discovery, and if the"Identity Theft" occurred while the "Member"was acting within the scope of employment for the"Organization." This additional coverage is subject to an annual aggregate of$30,000,which is the most we will pay for the sum of all"Identity Theft Expense" claims under this policy. Terrorism Travel Reimbursement We will reimburse any current"Member" for necessary and reasonable"Extraordinary Travel Expense" incurred because of a"Certified Act of Terrorism" during the policy period. This additional coverage is subject to an annual aggregate of$30,000, which is the most we will pay for the sum of all"Extraordinary Travel Expense" claims under this policy. Kidnap Expense We will reimburse necessary and reasonable expenses incurred by the"Organization" resulting directly from the kidnapping of a"Member" or a"Relative" during the policy period. This additional coverage is subject to an annual aggregate of$50,000, which is the most we will pay for the sum of all kidnap expense claims under this policy. Necessary and reasonable kidnap expenses include: 1. Fees and costs of independent negotiators; 2. Travel costs and accommodations incurred by a"Member" or a"Relative"; 3. Salary paid by the"Organization"to a"Member"who is kidnapped, from the date of abduction to the earliest of: a. Up to 30 days after release if the kidnapped"Member" has not yet returned to work; b. Discovery of the kidnapped "Member's" death; c. 120 days after the last credible evidence following abduction that the kidnapped "Member" is still alive; or d. 60 months after the "Member's" abduction. 4. Interest costs for any loan from a financial institution taken by the"Organization"to pay a ransom demand; 5. Reward money paid by the"Organization"to an informant, other than a"Member" or a"Relative", that leads to the arrest and conviction of parties responsible for loss under this additional coverage. NPO-001 04 09 Page 3 of 5 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Executive Recruitment Expense We will reimburse necessary and reasonable extra expense incurred to recruit a person to replace the Chief Executive Officer or Executive Director of the "Organization" if the Chief Executive Officer or the Executive Director dies by accident during the policy period. Such extra expense includes amounts paid by the "Organization"for advertising, travel reimbursement, legal costs and executive search firm consulting fees. This additional coverage is subject to an annual aggregate of$50,000,which is the most we will pay for the sum of all recruitment expense claims under this policy. Abuse of Process Section V—Definitions, Paragraph 14.b. is replaced by the following: b. Malicious prosecution or abuse of process; Damage to Property of Others We will pay for damage to property of others when such damage is the result of an act committed by a client of the first Named Insured, and the property damaged is owned by someone other than the Named Insured or any of the Named Insured's clients, employees or volunteers. This additional coverage is subject to an occurrence limit of $5,000 for any act, and an annual aggregate of$25,000. III. ADDITIONAL DEFINITIONS "Certified Act of Terrorism" means an act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State and the Attorney General of the United States, to be an act of terrorism pursuant to the federal Terrorism Risk Insurance Act of 2002. "Extraordinary Travel Expense" means necessary and reasonable hotel expense incurred within 48 hours of a"Certified Act of Terrorism"that caused a"Member's" commercial train trip or airline flight to be cancelled, as well as the increased amount necessarily and reasonably incurred by the"Member" due to rescheduling train or airline transportation that was cancelled as a result of a"Certified Act of Terrorism". "Identity Theft" means fraudulent use of the social security number or other method of identifying a current"Member", except the"Organization", and includes fraudulently using the personal identity of the"Member"to establish credit, secure loans, enter into contracts or commit crimes. "Identity Theft Expense" means necessary and reasonable expense for: 1. Costs of re-filing applications for loans, grants or other credit instruments that are rejected solely as the result of an"Identity Theft"; 2. Costs of notarizing affidavits or other similar documents, long distance telephone calls and postage solely as a result of the"Member's" efforts to report an"Identity Theft" or amend or rectify records with respect to the"Member's"true name or identity as a result of an "Identity Theft". "Member" means the"Organization" and any natural person who was, is, or becomes duly elected a director or trustee,or duly elected or appointed officer,employee,committee member, volunteer, intern or student in training of the"Organization", solely in his or her capacities as such."Member"also means the spouse of a director, trustee,officer, employee, committee member, volunteer, intern or student in training for a claim arising solely out of his or her status as the spouse of a member. NPO-001 04 09 Page 4 of 5 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B "Organization" means the entity(ies)designated as insured in the declarations. "Relative" means the spouse, parent, child (including a ward or foster child) or legally recognized domestic partner of a"Member". "Unsatisfied contribution" means a contribution of money, goods, services or property, pledged to you in writing, that is not honored because of the donor's bankruptcy, reorganization, unemployment or incapacitation where such bankruptcy, reorganization, unemployment or incapacitation prevents the donor from fulfilling its terms of the contribution. "Workplace violence"means any intentional threat or act of deadly force occurring on your premises and resulting in "bodily injury"to your"employee"or to your guest. NPO-001 04 09 Page 5 of 5 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 114NONPROFITS � INSURANCE A Head for Insurance,A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. IMPROPER SEXUAL CONDUCT AND PHYSICAL ABUSE EXCLUSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SOCIAL SERVICE PROFESSIONAL LIABILITY ENDORSEMENT The insurance provided by this policy affords NO COVERAGE with respect to any claim, suit or cause of action which arises from, or is in any way related to: A. Any form of improper sexual conduct (including but not limited to sexual abuse, sexual molestation, sexual harassment, sexual assault, sexual battery, sexual exploitation or sexual injury) ,whether actual or threatened or physical abuse, (including but not limited to assault, including assault with a deadly weapon or with force likely to produce bodily harm, battery, or unreasonable physical restraint or constraint), committed or allegedly committed by any Named Insured, insured or: 1. any Alliance of Nonprofits for Insurance member; 2. any employee or volunteer of any Alliance of Nonprofits for Insurance member; 3. any other person performing services for or on behalf of any Alliance of Nonprofits for Insurance member; 4. any client, participant, service recipient, student or patient of any Alliance of Nonprofits for Insurance member; or 5. any person relating to or in any way interacting with any Alliance of Nonprofits for Insurance member; or B. Employment practices concerning a person who commits or allegedly commits any of the acts cited in paragraph A above, including but not limited to hiring, reference checks, background investigation, improper or inadequate supervision or failure to suspend, discipline or terminate; or C. Failure to report an incident of any form of improper sexual conduct or physical abuse to the proper authorities, or the withholding of pertinent information concerning same from such authorities. ANI-RRG-X1 0215 Page 1 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B This exclusion shall apply regardless of the legal form ANY claim or complaint may take, and shall apply to each and every cause of action and allegation contained in a claim or complaint if ANY cause of action or allegation in that claim or complaint in ANY manner sets forth an allegation of ANY form of improper sexual conduct or physical abuse. For example, if a claim is made or a complaint is filed against an individual or entity referred to in paragraph A above,there is NO COVERAGE for ANY individual or entity under the policy, regardless of ANY other coverage provisions that might otherwise apply. BINDING ARBITRATION CLAUSE All disputes which may arise under or in connection with the applicability of this exclusion shall be submitted to the American Arbitration Association under and in accordance with its then prevailing commercial arbitration rules.The arbitration shall be held in San Francisco, California. The decision rendered by the arbitration shall be final and binding upon all parties and judgment thereon may be entered in any court having jurisdiction thereof, COVERAGE AVAILABLE (OPTIONAL) IMPROPER SEXUAL CONDUCT AND PHYSICAL ABUSE LIABILITY COVERAGE Coverage for improper sexual conduct and physical abuse liability may be purchased as an optional coverage.This optional improper sexual abuse and physical abuse liability coverage is provided only by the Improper Sexual Conduct and Physical Abuse Liability Coverage Form. Such coverage is provided only if the coverage is shown in the Declarations, the additional premium indicated has been paid and the Improper Sexual Conduct and Physical Abuse Liability Coverage Form has been attached to this insurance policy. ANI-RRG-X1 0215 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 11:1"1 ALLIANCE RF F I INSURANCE A Head for insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY MEMBER CRITERIA This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL AUTO COVERAGE PART IMPROPER SEXUAL CONDUCT LIABILITY COVERAGE PART A named insured of the Alliance of Nonprofits for Insurance, Risk Retention Group (ANI-RRG) must meet at least the following criteria: 1. is organized chiefly to provide charitable, religious, educational, or scientific services, but does not include a hospital; 2. is an organization described in section 501(c)(3) of the Internal Revenue Code and exempt from tax under section 501(a), or any corresponding sections of any future federal tax code. Any member which receives a final determination that it no longer qualifies as an organization described in section 501(c)(3) of the Internal Revenue Code, or corresponding section of any future tax code, shall immediately notify the corporation of such determination and the effective date of such determination. ANI-RRG E03 01 13 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 111.3h""1 ALLIANCE RF F I INSURANCE A Head for insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. VOLUNTEER MEDICAL PAYMENTS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Part 2, Exclusions, of COVERAGE C MEDICAL PAYMENTS is hereby amended to read: 2. Exclusions a.To any insured, except a volunteer worker while acting at your direction and within the scope of their duties as a volunteer for you. ANI-RRG E60 07 12 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B LLIA ° F F Ot e a l OR h INSURANCE A Bird for MMswrrmcc A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT FOR PUBLIC ENTITIES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION II —WHO IS AN INSURED is amended to include any public entity as an additional insured for whom you are performing operations when you and such person or organization have agreed in a written contract or written agreement that such public entity be added as an additional insured(s) on your policy, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of, in whole or in part, by: 1. Your negligent acts or omissions; or 2. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing operations. No such public entity is an additional insured for liability arising out of the "products-completed operations hazard"or for liability arising out of the sole negligence of that public entity. B. With respect to the insurance afforded to these additional insured(s), 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 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. The following is added to SECTION III—LIMITS OF INSURANCE: The limits of insurance applicable to the additional insured(s) are those specified in the written contract between you and the additional insured(s), or the limits available under this policy, whichever are less. These limits are part of and not in addition to the limits of insurance under this policy. D. With respect to the insurance provided to the additional insured(s), Condition 4. Other Insurance of SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance a. Primary Insurance This insurance is primary if you have agreed in a written contract or written agreement: (1) That this insurance be primary. If other insurance is also primary, we will share with all that other insurance as described in c. below; or ANI-RRG E61 02 13 Page 1 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B (2) The coverage afforded by this insurance is primary and non-contributory with the additional insured(s)'own insurance. Paragraphs (1) and (2) do not apply to other insurance to which the additional insured(s) has been added as an additional insured or to other insurance described in paragraph b. below. b. Excess Insurance This insurance is excess over: 1. Any of the other insurance, whether primary,excess, contingent or on any other basis: (a) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for your work"; (b) That is fire, lightning, or explosion insurance for premises rented to you or temporarily occupied by you with permission of the owner; (c) That is insurance purchased by you to cover your liability as a tenant for "property damage"to premises temporarily occupied by you with permission of the owner;or (d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of SECTION I — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE. (e) That is any other insurance available to an additional insured(s) under this Endorsement covering liability for damages arising out of the premises or operations, or products- completed operations, for which the additional insured(s) has been added as an additional insured by that other insurance. (1) When this insurance is excess, we will have no duty under Coverages A or B to defend the additional insured(s)against any"suit" if any other insurer has a duty to defend the additional insured(s) against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured(s)' rights against all those other insurers. (2) When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (a) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (b) The total of all deductible and self-insured amounts under all that other insurance. (3) We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Methods of Sharing If all of the other insurance available to the additional insured(s) permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any other the other insurance available to the additional insured(s)does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. ANI-RRG E61 02 13 Page 2 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 01,1,1,8 I N IT ����� INSURANCE A Had for Insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FUNDRAISER ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART This insurance applies to those sums that an insured becomes legally obligated to pay as damages because of "bodily injury,""property damage,"or"personal and advertising injury"arising out of a 'fundraiser." Except for a 'fundraiser"that is specifically scheduled on the policy to which this endorsement is included, this insurance does not apply to liability arising out of a 'fundraiser"which involves, directly or indirectly, any of the following: • Any event with more than 500 people present at any one time • Aircraft • Animals(including, but not limited to, animals involved in rodeos, petting zoos, animal exhibitions) • Athletic activities or contests • Carnivals, circuses,fairs or festivals • Motorized vehicle events (including, but not limited to, auto rallies,ATV off-roading, motorcycle runs, snowmobiles, tractor pulls) • Firearms or weapons • Fireworks • Home or garden tours • Flea markets or swap meets • Parades • Water events(including, but not limited to, activities involving swimming pools, lakes, rivers or other bodies of water) "Fundraiser" is any event sponsored or co-sponsored by you with the primary purpose of raising monetary contributions. ANI-RRG E70 07 13 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 14:1"1 ALLIANCE RF F I INSURANCE A Head for insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION OF COVERAGE FOR CLAIMS BY AND RELATED TO PAST AND PRESENT EMPLOYEES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART This coverage does not apply to: Any claim by, or liability to, any"employee claimant'or to any obligation to indemnify another because of any claim by or liability to an "employee claimant." Additional definition applicable to this exclusion: "Employee claimant" includes, but is not limited to, employees, applicants for employment,former employees, officers,former officers, directors and former directors of any insured,while acting in their capacity as employees, applicants for employment, former employees, officers or former officers, directors or former directors of the insured,as well as any derivative claim of any spouse, child, brother,sister, parent,dependent, successor, subrogee or assignee of any such employee, applicant for employment, former employee, officer, former officer, director or former director. It is also agreed that part b.of paragraph 2. Exclusions, (SECTION I, COVERAGE A.) is deleted and replaced by the following: 2. Exclusions. This insurance does not apply to: b. "Bodily injury"or"property damage"for which the insured is obligated to pay damages by reason of the assumption of liability in a contract or agreement.This exclusion does not apply to liability for damages: (1)Assumed in a contract or agreement that is an "insured contract,"provided the"bodily injury"or "property damage"occurs subsequent to the execution of the contract or agreement; or (2)That the insured would have in the absence of the contract or agreement; or (3)Assumed by you in a contract or agreement with a governmental agency, public entity or your funding source that is an "insured contract," provided the"bodily injury"or"property damage"occurs subsequent to the execution of the contract or agreement and which "bodily injury"or"property damage" is sustained by an"employee claimant,"as defined in this endorsement. ANI-RRG E7 10 04 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B rink— ALLIANCE OF mio„lololoo NON PROFITS FOR. INSURANCE A Mead for Insurance.A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MENTAL ANGUISH ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION V—DEFINITIONS, Paragraph 3 is replaced with the following: 3. "Bodily injury" means bodily injury, sickness or disease sustained by a person, including death or mental anguish resulting from any of these. ANI-RRG E74 03 14 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 01,1,1,8 I N IT ����� INSURANCE A Had for Insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FIREWORKS EXCLUSION This insurance does not apply to any liability caused, directly or indirectly, by fireworks or any similar explosive material. ANI-RRG El 1 07 92 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B rink— ALLIANCE OF mio„lolololc NON PROFITS FOR. INSURANCE A Mead for Insurance.A Heart for Nonprofits. NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (Broad Form) This endorsement modifies insurance provided under the following: BUSINESS OWNERS POLICY COMMERCIAL AUTO COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART FARM COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART SPECIAL PROTECTIVE AND HIGHWAY LIABILITY POLICY NEW YORK DEPARTMENT OF TRANSPORTATION 1. The insurance does not apply: injury" resulting from the "hazardous A. Under any Liability Coverage, to "bodily properties" of "nuclear material" and arising injury", "personal injury" or "property out of the operation of a "nuclear facility' by damage:" any person or organization. (1) With respect to which an "insured" under C. Under any Liability Coverage, to "bodily the policy is also an insured under a injury', "personal injury'or"property damage" nuclear energy liability policy issued by resulting from the "hazardous properties" of Nuclear Energy Liability Insurance "nuclear material,"if: Association, Mutual Atomic Energy (1) The "nuclear material" (a) is at any Liability Underwriters, Nuclear Insurance "nuclear facility' owned by, or operated Association of Canada or any of their by or on behalf of, an "insured"or(b)has successors, or would be an insured been discharged or dispersed therefrom; under any such policy but for its (2) The "nuclear material" is contained in termination upon exhaustion of its limit of "spent fuel" or "waste" at any time liability; or possessed, handled, used, processed, (2) Resulting from the "hazardous stored, transported or disposed of by or properties"of"nuclear material"and with on behalf of an "insured;"or respect to which (a) any person or (3) The "bodily injury", "personal injury" or organization is required to maintain "property damage" arises out of the financial protection pursuant to the furnishing by an "insured" of services, Atomic Energy Act of 1954, or any law materials, parts or equipment in amendatory thereof, or (b) the "insured" connection with the planning, is, or had this policy not been issued construction, maintenance, operation or would be, entitled to indemnity from the use of any "nuclear facility," but if such United States of America, or any agency facility is located within the United States thereof, under any agreement entered of America, its territories or possessions into by the United States of America, or or Canada, this exclusion (3)applies only any agency thereof, with any person or to "property damage" to such "nuclear organization. facility'and any property thereat. B. Under any Medical Payments coverage, to expenses incurred with respect to "bodily 2. As used in this endorsement: ANI-RRG E12 05 92 Page 1 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B "Hazardous properties" include radioactive, toxic amount of such material in the custody of or explosive properties; the "insured"at the premises where such "Nuclear material" means "source material," equipment or device is located consists "special nuclear material" or "by-product of or contains more than 25 grams of material;" plutonium or uranium 233 or any "Source material," "special nuclear material," and combination thereof; or more than 250 "by-product material" have the meanings given grams of uranium 235; them in the Atomic Energy Act of 1954 or in any (d) Any structure, basin, excavation, law amendatory thereof; premises or place prepared or used for "Spent fuel" means any fuel element or fuel the storage or disposal of"waste;" component, solid or liquid, which has been used and includes the site on which any of the or exposed to radiation in a"nuclear reactor;" foregoing is located, all operations conducted on "Waste" means any waste material (a)containing such site and all premises used for such "by-product material" other than the tailings or operations; wastes produced by the extraction or "Nuclear reactor means any apparatus designed concentration of uranium or thorium from any ore or used to sustain nuclear fission in a self- processed primarily for its "source material" supporting chain reaction or to contain a critical content, and (b) resulting from the operation by mass of fissionable material; any person or organization of any"nuclear facility" "Property damage" includes all forms of included under the first two paragraphs of the radioactive contamination of property. definition of"nuclear facility." "Nuclear facility'means: (a) Any"nuclear reactor;" (b) Any equipment or device designed or used for (1) separating the isotopes of uranium or plutonium, (2) processing or utilizing "spent fuel," or (3) handling, processing or packaging "waste;" (c) Any equipment or device used for the processing, fabricating or alloying of "special nuclear material" if at any time the total ANI-RRG E12 05 92 Page 2 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 1[� � ALLIANCE OF mio„ololololUlUl NON PROFITS FOR. INSURANCE A Mead for Insurance.A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - BLOOD TESTING This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SOCIAL SERVICES PROFESSIONAL LIABILITY ENDORSEMENT This insurance does not apply to claims for damages arising out of: 1. Services in connection with the donating, drawing, or testing of blood, except for any evaluation, consultation or advice given by or on behalf of any insured in connection with such services; 2. Any error,omission, defect or deficiency in any such test performed; 3. The handling,transportation,distribution or storage of any blood product by any insured; 4. The liability of any insured for acts or omissions of any doctor of medicine, technician, phlebotomist, or nurse with respect to any activities listed in 1.through 3.above. 5. The liability of any insured for the negligent hiring or supervision of any employee, volunteer, independent contractor, or agent of the insured with respect to any activities listed in 1.through 3.above. ANI-RRG E15 02 09 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B rink— ALLIANCE OF Ackwil NON PROFITS FOR. INSURANCE A Mead for Insurance.A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION -ASBESTOS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL AUTO COVERAGE PART This insurance does not apply to "bodily injury," "property damage," "personal injury" or "advertising injury" arising out of or related in any way to asbestos or asbestos-containing materials. We shall not have the duty to defend any such claim or"suit." ANI-RRG E22 08 95 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 1[� � ALLIANCE OF mio„ololololUlUl NON PROFITS FOR. INSURANCE A Mead for Insurance.A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Any person or organization that you are required to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy, in consideration of food contributions or client referrals you receive from them. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. ANI-RRG E25 01 98 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 14:1"1 ALLIANCE RF F I INSURANCE A Head for insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY PROPERTY DAMAGE TO PERSONAL PROPERTY IN THE CARE, CUSTODY OR CONTROL OF THE INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. It is agreed that the following is added to COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY, Number 2. Exclusions., Letter j."Property damage"to: Item (4): (a) This exclusion applies to"property damage" to personal property in the care, custody or control of the insured when the personal property is valued greater than $25,000. This is excess over any other valid collectible insurance. (b) Defense costs arising from "property damage" to personal property in the care, custody or control of the insured are limited to$25,000 per claim or suit. ANI-RRG E28 01 99 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 1[� � ALLIANCE OF mio„ololololUlUl NON PROFITS FOR. INSURANCE A Mead for Insurance.A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EMPLOYEE PERSONAL AUTO REIMBURSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART We agree to pay the lesser of the personal auto insurance comprehensive deductible, or the actual cost of repair in the absence of personal auto insurance comprehensive coverage, up to $1,000 to an employee or volunteer of the Insured if the personal auto of the employee or volunteer is damaged by a client of the Insured. The most we will pay during a policy term is limited to$3,000. ANI-RRG E29 12 09 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B lin ALNLII)AR NCE OF 0, 0, 0,!! INSURANCE A Had for Insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MOLD, FUNGUS OR MICROBIAL CONTAMINATION EXCLUSION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL AUTO POLICY COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART EMPLOYEE BENEFITS LIABILITY ENDORSEMENT SOCIAL SERVICES PROFESSIONAL LIABILITY ENDORSEMENT IMPROPER SEXUAL CONDUCT LIABILITY COVERAGE PART It is agreed that this policy does not apply to any claim, suit or cause of action for "damages" due to: We shall have no duty or obligation to 1. "Bodily injury," "property damage,"or provide or pay for the investigation or "personal injury"arising out of or contributed defense of any loss, cost, expense, to by mold, fungus or"microbial claim, or suit excluded under any contamination"; provision set forth above. 2. Any loss, cost or expense arising out of Section B- Defense and any: Supplementary Payments shall not a. Request, demand or order that any apply to any loss, cost, expense, claim "insured" or others test for, monitor, or suit excluded under any provisions clean up, remove, contain, treat, set forth above. detoxify or neutralize, or in any way "Microbial contamination"means any respond to or assess the effects of contamination,either airborne or mold, fungus or "microbial surface, which arises out of or is contamination"; or related to the presence of mold, b. Claim or suit by or on behalf of a fungus, or spores, including, without governmental agency or entity for limitation, Penicillium, Aspergillus, or damages because of testing for, Stachybotrys chartarum. monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to or assessing the effects of mold, fungus or"microbial contamination." ANI-RRG E33 01 02 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 14:1"1 ALLIANCE RF F I INSURANCE A Head for insurance.A Heart for Nonprofits, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIVACY LIABILITY AND CYBER COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRIVACY AND ELECTRONIC DATA LIABILITY(IDENTITY THEFT INCLUDED) A. The following paragraphs are added to the Definitions Section: "Electronic data means information, facts or programs stored as or on, created or used on, or transmitted to or from computer software, including systems and applications software, hard or floppy disks, CD- ROMS, tapes, drives, cells, data processing devices or any other media which are used with electronically controlled equipment. "Identity theft" means fraudulent appropriation and use of a person's identification or personal information, including both"electronic data as well as information contained in printed or written format. "Loss of electronic data means: 1. Damage to, loss of, loss of use of, corruption of, inability to access or inability to manipulate "electronic data;"and 2. "Identity theft." "Protected health information"means any information, whether oral or recorded in any form or medium: (i) That relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; (ii) That identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify that individual; and (iii) as defined within the Health Insurance Portability and Accountability Act of 1996,42 U.S.C. §1320d-1320d-8("HIPAA")and other similar federal, state or local laws or statutes. B. The following paragraph is added to the definition of"insured contract" in the Definitions Section: g. That part of any other contract or agreement pertaining to your business that indemnifies another party for tort liability arising out of"loss of electronic data". C. For the purposes of the coverage provided by this endorsement, the definition of"occurrence"in the Definitions Section is replaced by the following: ANI-RRG E52 07 13 Page 1 of 3 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 13. "Occurrence" means an accident, including continuous or repeated exposure to substantially the same general harmful conditions.With respect to"loss of electronic data," "occurrence"shall mean an accident, or a negligent act, error or omission or series of causally related accidents, negligent acts, or errors or omissions. D. For the purposes of the coverage provided by this endorsement, the following paragraph is added to the definition of"property damage" in the Definitions Section: c. "Loss of electronic data."All "loss of electronic data shall be deemed to occur at the time of the "occurrence"that caused it. E. For purposes of the coverage provided by this endorsement, the definition of"personal and advertising injury" is amended to include: h. The disclosure, loss or use of"protected health information". All damages which arise out of an offense which constitutes a disclosure, loss or use of"protected health information"or a series of continuous or interrelated disclosures, losses or uses of "protected health information"will be considered as arising out of one disclosure, loss or use of"protected health information'which shall be deemed to have been an offense committed on the date of the first such disclosure, loss or use of"protected health information"or violation of privacy rights through the disclosure loss or use of"protected health information". F. For purposes of the coverage provided by this endorsement, the following paragraph is added to the definition of"property damage" in the Definitions Section: c. "Loss of electronic data." All "loss of electronic data"shall be deemed to occur at the time of the"occurrence"that caused it. G. For the purposes of the coverage provided by this endorsement the following Exclusion is added to Coverage B Personal and Advertising Injury Liability: 2. Exclusions: (11)fines, penalties, sanctions, punitive or exemplary damages, the multiplied portion of multiplied damages, non-pecuniary relief or any amount arising from matters deemed uninsurable under the law pursuant to which this policy shall be construed. II. SECURITY EVENT COSTS AND EXPENSES A. We will reimburse you for reasonable costs and expenses you incur, with our prior written consent, for notification of a"security event"to third parties in compliance with governmental or judicial requirements, or for credit protection services furnished to third parties whose private information may have been disclosed. B. The following paragraphs are added to the Definitions Section: "Security event" means: 1. An act, error or omission that results, during the policy period, in unauthorized access or unauthorized use of your computer system; or 2. Unauthorized or unexpected interference by anyone that restricts or prevents access, during the policy period, to a computer system by persons who are authorized to gain such access; or 3. Infection of your computer system, during the policy period, by corrupting or harmful computer code. ANI-RRG E52 07 13 Page 2 of 3 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B C. Our maximum aggregate limit of liability for all "security event'costs and expenses covered by this policy shall be$50,000. III. CYBER EXTORTION A. We will reimburse you for reasonable costs and expenses you incur,with our prior written consent, because of a threat or threats, during the policy period, that include an actual extortion demand related to your computer system. B. Our maximum aggregate limit of liability for all costs and expenses due to extortion covered by this policy shall be$50,000. IV. CRISIS MANAGEMENT AND REWARD EXPENSES A. We will reimburse you for all reasonable costs and expenses you incur, with our prior written consent, for "crisis management'due to a"security event,"if that"security event'takes place during the policy period. B. The following paragraph is added to the Definitions Section: "Crisis management"means hiring for a specified period of time following a"security event'such organizations as a law firm, an information security firm or a public relations firm, as well as preparation and placement of advertisements and public relations activities. C. We will reimburse you for all reasonable costs and expenses you incur, with our prior written consent, for payment of a"reward." D. The following paragraph is added to the Definitions Section: "Reward" means the reasonable amount that you pay a person for information regarding a"security event'or threatened or actual extortion covered by this policy; provided that the information is not otherwise available and leads to the arrest and conviction of a person responsible for the crime. E. Our maximum aggregate limit of liability for all "crisis management'and"reward"costs and expenses covered by this policy shall be$25,000. ANI-RRG E52 07 13 Page 3 of 3 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B rink— ALLIANCE OF 11000ololUlUl NON PROFITS FOR. INSURANCE A Mead for Insurance.A Heart for Nonprofits. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NUCLEAR, CHEMICAL AND BIOLOGICAL HAZARD EXCLUSION This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART EMPLOYEE BENEFITS LIABILITY ENDORSEMENT SOCIAL SERVICES PROFESSIONAL LIABILITY ENDORSEMENT IMPROPER SEXUAL CONDUCT LIABILITY COVERAGE PART DIRECTORS AND OFFICERS LIABILITY This insurance does not apply to any liability, loss, cost or expense of whatsoever nature directly or indirectly caused by, contributed to by, resulting from, arising out of or in connection with the use or release, or threat thereof, of any nuclear weapon or device or chemical or biological agent, regardless of any other cause or event contributing concurrently or in any other sequence to the loss. ANI-RRG E42 07 06 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY CG 00 33 01 96 LIQUOR LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage. 2. Exclusions Read the entire policy carefully to determine rights, duties and what is and is not covered. This insurance does not apply to: Throughout this policy the words you and "your" refer a. Expected or Intended Injury to the Named Insured shown in the Declarations, and "Injury' expected or intended from the stand- any other person or organization qualifying as a point of the insured. This exclusion does not Named Insured under this policy.The words "we", "us" apply to "bodily injury' resulting from the use of and our refer to the Company providing this insur- reasonable force to protect persons or prop- ance. erty. The word "insured" means any person or organization b. Workers Compensation and Similar Laws qualifying as such under WHO IS AN INSURED (Sec- Any obligation of the insured under a workers tion II). compensation, disability benefits or unemploy- Other words and phrases that appear in quotation ment compensation law or any similar law. marks have special meaning. Refer to DEFINITIONS c. Employer's Liability (Section V). SECTION I—LIQUOR LIABILITY COVERAGE "Bodily injury to: 1. Insuring Agreement (1) An "employee" of the insured arising out of and in the course of: a. We will pay those sums that the insured be- (a) Employment by the insured;or comes legally obligated to pay as damages be- cause of"injury'to which this insurance applies (b) Performing duties related to the conduct if liability for such "injury' is imposed on the in- of the insured's business; or sured by reason of the selling, serving or fur- (2) The spouse, child, parent, brother or sister nishing of any alcoholic beverage. We will have of that "employee" as a consequence of the right and duty to defend the insured against paragraph (1)above. any "suit" seeking those damages. However, This exclusion applies: we will have no duty to defend the insured against any "suit" seeking damages for "injury' (1) Whether the insured may be liable as an to which this insurance does not apply. We employer or in any other capacity; and may, at our discretion, investigate any "injury' (2) To any obligation to share damages with or and settle any claim or "suit" that may result. repay someone else who must pay dam- But: ages because of the"injury'. (1) The amount we will pay for damages is d. Liquor License Not in Effect limited as described in LIMITS OF "Injury' arising out of any alcoholic beverage INSURANCE(Section III); and sold, served or furnished while any required li- (2) Our right and duty to defend end when we cense is suspended or after such license ex- have used up the applicable limit of insur- pires, is cancelled or revoked. ance in the payment of judgments or set- tlements. e. Your Product No other obligation or liability to pay sums or "Injury' arising out of "your product". This ex perform acts or services is covered unless ex- clusion does not apply to "injury" for which the plicitly provided for under SUPPLEMENTARY insured or the insured's indemnitees may be PAYMENTS. held liable by reason of: b. This insurance applies to "injury' which occurs (1) Causing or contributing to the intoxication of during the policy period in the "coverage terri- any person; tory'. CG 00 33 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 5 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B (2) The furnishing of alcoholic beverages to a SECTION II—WHO IS AN INSURED person under the legal drinking age or un- 1. If you are designated in the Declarations as: der the influence of alcohol; or a. An individual, you and your spouse are insur- (3) Any statute, ordinance or regulation relating eds. to the sale, gift, distribution or use of alco- holic beverages. b. A partnership or joint venture, you are an in- sured. Your members, your partners, and their f. Other Insurance spouses are also insureds, but only with re- Any "injury' with respect to which other insur- spect to the conduct of your business. ance is afforded, or would be afforded but for c. A limited liability company, you are an insured. the exhaustion of the limits of insurance. Your members are also insureds, but only with This exclusion does not apply if the other insur- respect to the conduct of your business. Your ance responds to liability for "injury' imposed managers are insureds, but only with respect to on the insured by reason of the selling, serving their duties as your managers. or furnishing of any alcoholic beverage. d. An organization other than a partnership, joint SUPPLEMENTARY PAYMENTS venture or limited liability company, you are an We will pay, with respect to any claim we investigate insured. Your "executive officers" and directors or settle,or any"suit"against an insured we defend: are insureds, but only with respect to their du ties as your officers or directors. Your stock- 1. All expenses we incur. holders are also insureds, but only with respect 2. The cost of bonds to release attachments, but only to their liability as stockholders. for bond amounts within the applicable limit of in- 2. Each of the following is also an insured: surance.We do not have to furnish these bonds. a. Your "employees", other than either your "ex- 3. All reasonable expenses incurred by the insured at ecutive officers" (if you are an organization our request to assist us in the investigation or de- other than a partnership,joint venture or limited fense of the claim or "suit", including actual loss of liability company) or your managers (if you are earnings up to$250 a day because of time off from a limited liability company), but only for acts work. within the scope of their employment by you or 4. All costs taxed against the insured in the "suit". while performing duties related to the conduct 5. Prejudgment interest awarded against the insured of your business. However, none of these "em on that part of the judgment we pay. If we make an ployees" is an insured for: offer to pay the applicable limit of insurance, we (1) "Injury': will not pay any prejudgment interest based on that (a) To you, to your partners or members (if period of time after the offer. you are a partnership or joint venture), to 6. All interest on the full amount of any judgment that your members (if you are a limited liabil- accrues after entry of the judgment and before we ity company), or to a co-"employee" have paid, offered to pay, or deposited in court the while that co-"employee"is either in the part of the judgment that is within the applicable course of his or her employment or per- limit of insurance. forming duties related to the conduct of 7. Expenses incurred by the insured for first aid ad your business; ad- ministered to others at the time of an event to (b) To the spouse, child, parent, brother or which this insurance applies. sister of that co-"employee" as a conse- These payments will not reduce the limits of insur- ance. (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 paragraphs (1)(a) or(b)above. Page 2 of 5 Copyright, Insurance Services Office, Inc., 1994 CG 00 33 01 96 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B (2) "Property damage"to property: 2. The Aggregate Limit is the most we will pay for all (a) Owned or occupied by, or "injury' as the result of the selling, serving or fur- nishing of alcoholic beverages. (b) Rented or loaned 3. Subject to the Aggregate Limit, the Each Common to that "employee", any of your other "em- Cause Limit is the most we will pay for all "injury" ployees", by any of your partners or mem- sustained by one or more persons or organizations bers (if you are a partnership or joint ven- as the result of the selling, serving or furnishing of ture), or by any of your members (if you are any alcoholic beverage to any one person. a limited liability company). The Limits of Insurance of this Coverage Part apply b. Any person or organization having proper tem- separately to each consecutive annual period and to porary custody of your property if you die, but any remaining period of less than 12 months, starting only: with the beginning of the policy period shown in the (1) With respect to liability arising out of the Declarations, unless the policy period is extended maintenance or use of that property; and after issuance for an additional period of less than 12 (2) Until your legal representative has been months. In that case, the additional period will be appointed. deemed part of the last preceding period for purposes of determining the Limits of Insurance. c. Your legal representative if you die, but only SECTION IV—LIQUOR LIABILITY CONDITIONS with respect to duties as such.That representa- tive will have all your rights and duties under 1. Bankruptcy this Coverage Part. Bankruptcy or insolvency of the insured or of the 3. Any organization you newly acquire or form, other insured's estate will not relieve us of our obliga- than a partnership, joint venture or limited liability tions under this Coverage Part. company, and over which you maintain ownership 2. Duties In The Event Of Injury, Claim Or Suit or majority interest,will qualify as a Named Insured if there is no other similar insurance available to a. You must see to it that we are notified as soon that organization. However: as practicable of an "injury'which may result in a claim. To the extent possible, notice should a. Coverage under this provision is afforded only include: until the 90th day after you acquire or form the organization or the end of the policy period, (1) How, when and where the "injury' took whichever is earlier; and place; b. Coverage does not apply to "injury' that oc (2) The names and addresses of any injured curred before you acquired or formed the or- ganization. (3) The nature and location of any "injury' aris- No person or organization is an insured with respect ing out of an occurrence. to the conduct of any current or past partnership, joint b. If a claim is made or "suit" is brought against venture or limited liability company that is not shown any insured,you must: as a Named Insured in the Declarations. (1) Immediately record the specifics of the SECTION III—LIMITS OF INSURANCE claim or"suit"and the date received; and 1. The Limits of Insurance shown in the Declarations (2) Notify us as soon as practicable. and the rules below fix the most we will pay re- You must see to it that we receive written no- gardless of the number of: tice of the claim or "suit" as soon as practica- a. Insureds; ble. b. Claims made or"suits" brought; or c. Persons or organizations making claims or bringing "suits". CG 00 33 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 3 of 5 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B c. You and any other involved insured must: b. Method of Sharing (1) Immediately send us copies of any de- If all of the other insurance permits contribution mands, notices, summonses or legal pa- by equal shares, we will follow this method pers received in connection with the claim also. Under this approach each insurer contrib- or"suit"; utes equal amounts until it has paid its applica- (2) Authorize us to obtain records and other ble limit of insurance or none of the loss re information; mains, whichever comes first. (3) Cooperate with us in the investigation or If any of the other insurance does not permit settlement of the claim or defense against contribution by equal shares, we will contribute the"suit"; and by limits. Under this method, each insurers share is based on the ratio of its applicable limit (4) Assist us, upon our request, in the en- of insurance to the total applicable limits of en- forcement of any right against any person or surance of all insurers. organization which may be liable to the in- sured because of "injury' to which this in- surance may also apply. a. We will compute all premiums for this Cover- d. No insured will, except at that insured's own age Part in accordance with our rules and cost, voluntarily make a payment, assume any rates. obligation, or incur any expense, other than for b. Premium shown in this Coverage Part as ad- first aid,without our consent. vance premium is a deposit premium only. At 3. Legal Action Against Us the close of each audit period we will compute the earned premium for that period. Audit pre- No person or organization has a right under this miums are due and payable on notice to the Coverage Part: first Named Insured. If the sum of the advance a. To join us as a party or otherwise bring us into and audit premiums paid for the policy period is a"suit"asking for damages from an insured; or greater than the earned premium, we will return b. To sue us on this Coverage Part unless all of the excess to the first Named Insured. its terms have been fully complied with. c. The first Named Insured must keep records of A person or organization may sue us to recover on the information we need for premium computa an agreed settlement or on a final judgment tion, and send us copies at such times as we against an insured obtained after an actual trial; may request. but we will not be liable for damages that are not 6. Representations payable under the terms of this Coverage Part or By accepting this policy, you agree: that are in excess of the applicable limit of insur- ance. An agreed settlement means a settlement a. The statements in the Declarations are accu and release of liability signed by us, the insured rate and complete; and the claimant or the claimant's legal represen- b. Those statements are based upon representa- tative. tions you made to us; and 4. Other Insurance c. We have issued this policy in reliance upon If other valid and collectible insurance is available your representations. to the insured for a loss we cover under this Cov- 7. Separation Of Insureds erage Part, our obligations are limited as follows: Except with respect to the Limits of Insurance, and a. Primary Insurance any rights or duties specifically assigned in this This insurance is primary. Our obligations are Coverage Part to the first Named Insured, this in not affected unless any of the other insurance surance applies: is also primary. Then, we will share with all that a. As if each Named Insured were the only other insurance by the method described in b. Named Insured;and below. b. Separately to each insured against whom claim is made or"suit" is brought. Page 4 of 5 Copyright, Insurance Services Office, Inc., 1994 CG 00 33 01 96 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 8. Transfer Of Rights Of Recovery Against 6. "Leased worker" means a person leased to you by Others To Us a labor leasing firm under an agreement between If the insured has rights to recover all or part of any you and the labor leasing firm, to perform duties payment we have made under this Coverage Part, related to the conduct of your business. "Leased those rights are transferred to us. The insured worker"does not include a"temporary worker". must do nothing after loss to impair them. At our 7. "Property damage"means: request, the insured will bring "suit" or transfer a. Physical injury to tangible property, including all those rights to us and help us enforce them. resulting loss of use of that property. All such 9. When We Do Not Renew loss of use shall be deemed to occur at the If we decide not to renew this Coverage Part, we time of the physical injury that caused it;or will mail or deliver to the first Named Insured b. Loss of use of tangible property that is not shown in the Declarations written notice of the physically injured. All such loss of use shall be nonrenewal not less than 30 days before the expi- deemed to occur at the time of the occurrence ration date. that caused it. If notice is mailed, proof of mailing will be sufficient 8. "Suit" means a civil proceeding in which damages proof of notice. because of "injury' to which this insurance applies SECTION V—DEFINITIONS are alleged. "Suit"includes: 1. "Bodily injury' means bodily injury, sickness or a. An arbitration proceeding in which such dam disease sustained by a person, including death re- ages are claimed and to which the insured suiting from any of these at any time. must submit or does submit with our consent; or 2. "Coverage territory'means: b. Any other alternative dispute resolution pro- a. The United States of America (including its ceeding in which such damages are claimed territories and possessions), Puerto Rico and and to which the insured submits with our con- Canada; sent. b. International waters or airspace, provided the 9. "Temporary worker" means a person who is fur- "injury" does not occur in the course of travel or nished to you to substitute for a permanent "em- transportation to or from any place not included ployee" on leave or to meet seasonal or short-term in a. above; or workload conditions. c. All parts of the world if: 10. Your product"means: (1) The"injury'arises out of: a. Any goods or products, other than real prop- (a) Goods or products made or sold by you erty, manufactured, sold, handled, distributed in the territory described in a. above; or or disposed of by: (b) The activities of a person whose home is (1) You; in the territory described in a. above, but (2) Others trading under your name; or is away for a short time on your busi- ness; and (3) A person or organization whose business or assets you have acquired; and (2) The insured's responsibility to pay damages is determined in a "suit" on the merits, in the b. Containers (other than vehicles), materials, territory described in a. above or in a set- parts or equipment furnished in connection with tlement we agree to. such goods or products. 3. "Employee" includes a "leased worker". "Your product" includes: "Em- ployee"does not include a"temporary worker". a. Warranties or representations made at any 4. "Executive Officer means a person holding any of time with respect to the fitness, quality, durabil the officer positions created by your charter, con ity, performance or use of your product"; and stitution, by-laws or any other similar governing b. The providing of or failure to provide warnings document. or instructions. 5. "Injury' means all damages, including damages Your product" does not include vending machines because of "bodily injury' and "property damage", or other property rented to or located for the use of and including damages for care, loss of services or others but not sold. loss of support. CG 00 33 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 5 of 5 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICY NUMBER: IL 09 99 01 15 THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. DISCLOSURE OF PREMIUM AND ESTIMATED PREMIUM FOR CERTIFIED ACTS OF TERRORISM COVERAGE (PURSUANT TO TERRORISM RISK INSURANCE ACT) SCHEDULE SCHEDULE—PART I Terrorism Premium (Certified Acts) (A) Premium through end of year(12/31/ ) $ See Declarations (B) Estimated Premium beyond the date specified above $ See Declarations (Refer to Paragraph D. in this endorsement.) This premium is the total Certified Acts premium attributable to the following Coverage Part(s), Coverage Form(s)and/or Policy(ies): All coverage parts other than: Social Service Professional Liability Endorsement; and Business Auto Coverage Additional information, if any,concerning the terrorism premium: SCHEDULE—PART II Federal share of terrorism losses %Year: 20 (Refer to Paragraph B. in this endorsement.) SCHEDULE—PART II Federal share of terrorism losses 85% Year: 2015 Federal share of terrorism losses 84% Year: 2016 Federal share of terrorism losses 83% Year: 2017 Federal share of terrorism losses 82% Year: 2018 Federal share of terrorism losses 81% Year: 2019 Federal share of terrorism losses 80% Year: 2020 (Refer to Paragraph B. of this endorsement) Federal share of terrorism losses %Year: 20 (Refer to Paragraph B. in this endorsement.) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. IL 09 99 01 15 © Insurance Services Office, Inc., 2015 Page 1 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B A. Disclosure Of Premium D. Possibility Of Additional Or Return Premium In accordance with the federal Terrorism Risk The premium for certified acts of terrorism Insurance Act, we are required to provide you with coverage is calculated based in part on the federal a notice disclosing the portion of your premium, if participation in payment of terrorism losses as set any, attributable to coverage for terrorist acts forth in the Terrorism Risk Insurance Act. The certified under that Act. The portion of your federal program established by the Act is premium attributable to such coverage is shown in scheduled to terminate at the end of the year the Schedule of this endorsement or in the policy specified in Part I of the Schedule of this Declarations. endorsement, unless extended by the federal B. Disclosure Of Federal Participation In Payment government. If the federal program terminates or if Of Terrorism Losses the level or terms of federal participation change, the estimated premium shown in (B) in Part I of The United States Government, Department of the the Schedule may not be appropriate. Treasury, will pay a share of terrorism losses insured under the federal program. The federal If this policy contains a Conditional Exclusion, share equals a percentage (as shown in Part II of continuation of coverage for certified acts of the Schedule of this endorsement or in the policy terrorism, or termination of such coverage, will be Declarations)of that portion of the amount of such determined upon disposition of the federal insured losses that exceeds the applicable insurer program, subject to the terms and conditions of retention. However, if aggregate insured losses the Conditional Exclusion. If this policy does not attributable to terrorist acts certified under the contain a Conditional Exclusion, coverage for Terrorism Risk Insurance Act exceed $100 billion certified acts of terrorism will continue. In either in a calendar year, the Treasury shall not make case, when disposition of the federal program is any payment for any portion of the amount of such determined, we will recalculate the premium losses that exceeds$100 billion. shown in (B) in Part I of the Schedule and will charge additional premium or refund excess C. Cap On Insurer Participation In Payment Of premium, if indicated. Terrorism Losses If we notify you of an additional premium charge, If aggregate insured losses attributable to terrorist the additional premium will be due as specified in acts certified under the Terrorism Risk Insurance such notice. Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. Page 2 of 2 © Insurance Services Office, Inc., 2015 IL 09 99 01 15 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s)Of Covered Operations Any person or organization that you are required to All insured premises and operations add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "properly damage" occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- operations has been completed;or nated above. 2. That portion of your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 11 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1. Designation of Premises(Part Leased to You): 2. Name of Person or Organization (Additional Insured): Any person or organization acting as a manager or lessor of a covered premises that you are required to name as an additional insured on this policy, under a written contract, lease or agreement currently in effect, or becoming effective during the term of this policy. 3. Additional Premium: Included (If no entry appears above, the information required to complete this endorsement will be shown in the Declara- tions as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the prem- ises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any"occurrence"which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 12 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Political Subdivision: Any State or Political Subdivision that issues a permit to the named insured. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II — Who Is An Insured is amended to 2. This insurance does not apply to: include as an insured any state or political subdivi- a. "Bodily injury," "property damage"or"personal sion shown in the Schedule, subject to the following and advertising injury" arising out of opera- provisions: tions performed for the state or municipality; 1. This insurance applies only with respect to opera- or tions performed by you or on your behalf for b. "Bodily injury" or "property damage" included which the state or political subdivision has issued within the "products-completed operations a permit. hazard". CG 20 12 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MORTGAGEE, ASSIGNEE, OR RECEIVER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization acting as a Mortgagee, Assignee, or Receiver with respect to locations scheduled on the policy. Designation of Premises: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 1. WHO IS AN INSURED (Section II) is amended to include as an insured the person(s)or organization(s)shown in the Schedule but only with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of the premises by you and shown in the Schedule. 2. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. CG 20 18 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 1/98 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - CHARITABLE INSTITUTIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. WHO IS AN INSURED (Section II) is amended to include as an insured: 1. Your members but only with respect to their liability for your activities or activities they perform on your behalf; and 2. Your trustees or members of the board of governors while acting within the scope of their duties as such on your behalf. CG 20 20 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY CG 20 21 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VOLUNTEER WORKERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Section II — Who Is An Insured is amended to in- c. For which there is any obligation to share dude as an insured any person(s) who are volunteer damages with or repay someone else who worker(s)for you, but only while acting at the direction must pay damages because of the injury of, and within the scope of their duties for you. How- described in Paragraphs 1.a. or b. above; or ever, none of these volunteer worker(s) are insureds d. Arising out of his or her providing or failing for: to provide professional health care services. 1. "Bodily injury' or "personal and advertising 2. "Property damage"to property: injury': a. To you, to your partners or members (if you a. Owned, occupied, or used by, are a partnership or joint venture), to your b. Rented to, in the care, custody or control of, members (if you are a limited liability com- or over which physical control is being exer- pany), to your other volunteer worker(s) or cised for any purpose by to your"employees"arising out of and in the you, any of your other volunteer workers, your course of their duties for you; "employees", any partner or member(if you are b. To the spouse, child, parent, brother or a partnership or joint venture), or any member sister of your volunteer worker(s) or your (if you are a limited liability company). "employees" as a consequence of Para- graph 1.a. above; CG 20 21 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Any person or organization that you are required to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s)or organi- zation(s)shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY CG 20 34 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - LESSOR OF LEASED EQUIPMENT - AUTOMATIC STATUS WHEN REQUIRED IN LEASE AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Who Is An Insured (Section II) is amended to A person's or organization's status as an additional include as an additional insured any person or or- insured under this endorsement ends when their ganization from whom you lease equipment when contract or agreement with you for such leased you and such person or organization have agreed equipment ends. in writing in a contract or agreement that such per- B. With respect to the insurance afforded to these son or organization be added as an additional in- additional insureds, this insurance does not apply sured on your policy. Such person or organization to any "occurrence" which takes place after the is an insured only with respect to liability for"bodily equipment lease expires. injury', "property damage" or "personal and adver- tising injury' caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization. CG 20 34 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Any person or organization that you are required All insured premises and operations to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or"property dam- age" caused, in whole or in part, by your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products- completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 21 16 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - DESIGNATED PROFESSIONAL SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Description Of Professional Services: 1.Any and all professional services 2. 3. (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 any professional services shown in the Schedule, the following exclusion is added to Paragraph 2., Exclusions of Section I — Coverage A— Bodily Injury And Property Damage Liability and Paragraph 2., Ex- clusions of Section I—Coverage B—Personal And Advertising Injury Liability: This insurance does not apply to "bodily injury", "property damage" or"personal and advertising injury" due to the rendering of or failure to render any professional service. CG 21 16 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY CG 21 70 01 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART EMPLOYEE BENEFITS LIABILITY ENDORSEMENT IMPROPER SEXUAL CONDUCT LIABILITY COVERAGE PART DIRECTORS AND OFFICERS LIABILITY A. If aggregate insured losses attributable to terrorist 2. The act is a violent act or an act that is acts certified under the federal Terrorism Risk dangerous to human life, property or Insurance Act exceed $100 billion in a calendar infrastructure and is committed by an individual year and we have met our insurer deductible or individuals as part of an effort to coerce the under the Terrorism Risk Insurance Act, we shall civilian population of the United States or to not be liable for the payment of any portion of the influence the policy or affect the conduct of the amount of such losses that exceeds $100 billion, United States Government by coercion. and in such case insured losses up to that amount B. The terms and limitations of any terrorism are subject to pro rata allocation in accordance exclusion, or the inapplicability or omission of a with procedures established by the Secretary of terrorism exclusion, do not serve to create the Treasury. coverage for injury or damage that is otherwise "Certified act of terrorism" means an act that is excluded under this Coverage Part. certified by the Secretary of the Treasury, in accordance with the provisions of the federal Terrorism Risk Insurance Act, to be an act of terrorism pursuant to such Act. The criteria contained in the Terrorism Risk Insurance Act for a "certified act of terrorism" include the following: 1. The act resulted in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insurance Act; and CG 21 70 01 15 © Insurance Services Office, Inc., 2015 Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - HEALTH OR COSMETIC SERVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Description of Operations: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The following exclusion is added to COVERAGES A b. Any health service or treatment; or and B(Section I): c. Any cosmetic or tonsorial service or treatment. With respect to any operation shown in the Schedule, 2. The furnishing or dispensing of drugs or medical, this insurance does not apply to "bodily injury," "prop- dental or surgical supplies or appliances; or erty damage," "personal injury' or 'advertising injury" arising out of: 3. The handling or treatment of dead bodies, includ- ing autopsies, organ donation or other procedures. 1. The rendering or failure to render: a. Medical, surgical, dental, x-ray or nursing ser- vice or treatment, or the related furnishing of food or beverages; CG 22 44 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRODUCTS/COMPLETED OPERATIONS HAZARD REDEFINED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Description of Premises and Operations: Any premises and operations shown in the Declarations. (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 "bodily injury" or "property damage" Paragraph a. of the definition of "Products-completed arising out of "your products" manufactured, sold, operations hazard" in the DEFINITIONS Section is handled or distributed: replaced by the following: 1. On, from or in connection with the use of any a. "Products-completed operations hazard" in- premises described in the Schedule, or cludes all "bodily injury"and "property damage" 2. In connection with the conduct of any operation that arises out of "your products" if the "bodily described in the Schedule, when conducted by you injury" or "property damage" occurs after you or on your behalf, have relinquished possession of those prod- ucts. CG 24 07 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT-AGGREGATE LIMITS OF INSURANCE (PER LOCATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. The General Aggregate Limit under LIMITS OF INSURANCE (Section III)applies separately to each of your"loca- tions"owned by or rented to you. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway,waterway or right-of-way of a railroad. CG 25 04 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - LIABILITY ARISING OUT OF LEAD This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART. PRODUCTS/COMPLETED OPERATIONS COVERAGE PART. This insurance does not apply to: 1. "bodily injury', "property damage", "personal injury', or"advertising injury' arising out of, resulting from, or in any way caused by or related to the actual, alleged or threatened ingestion, inhalation, absorption, or exposure to lead in any form from any source;or 2. any loss, expense, liability or other type of obligation arising out of or resulting from, or in any way related to any: a. claim, suit, request, demand, directive, or order by or on behalf of any person, entity, or governmental authority that any"insured"or others test for, monitor, clean up, remove, contain, treat, detoxify, neutralize, or in any way respond to, or assess the effects of lead in any form from any source, or to any b. claim or suit by or on behalf of any person, entity, or governmental authority for damages or any other relief or remedy because of testing for, monitoring, cleaning up, removing, containing, treating or detoxifying or neutralizing, or in any way responding to, or assessing the effects of lead in any form. We shall not be obligated to investigate on behalf of an "insured"or to defend or indemnify an "insured"or any person or entity claiming any right under the policy for the matters excluded in this endorsement. CG 7794(4/93) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B IL 00 17 11 98 COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions. A. Cancellation b. Give you reports on the conditions we find; 1. The first Named Insured shown in the Declara- and tions may cancel this policy by mailing or deliv- c. Recommend changes. ering to us advance written notice of cancella- 2. We are not obligated to make any inspections, tion. surveys, reports or recommendations and any 2. We may cancel this policy by mailing or deliver- such actions we do undertake relate only to in- ing to the first Named Insured written notice of surability and the premiums to be charged. We cancellation at least: do not make safety inspections. We do not un- a. 10 days before the effective date of cancel- organization to perform the duty of any person or lation if we cancel for nonpayment of pre organization to provide for the health or safety mium; or of workers or the public. And we do not warrant that conditions: b. 30 days before the effective date of cancel- lation if we cancel for any other reason. a. Are safe or healthful; or 3. We will mail or deliver our notice to the first b. Comply with laws, regulations, codes or Named Insured's last mailing address known to standards. us. 3. Paragraphs 1. and 2. of this condition apply not 4. Notice of cancellation will state the effective only to us, but also to any rating, advisory, rate date of cancellation. The policy period will end service or similar organization which makes in on that date. surance inspections, surveys, reports or rec- ommendations. 5. If this policy is cancelled, we will send the first Named Insured any premium refund due. If we 4. Paragraph 2. of this condition does not apply to cancel, the refund will be pro rata. If the first any inspections, surveys, reports or recom Named Insured cancels, the refund may be mendations we may make relative to certifica- less than pro rata. The cancellation will be of tion, under state or municipal statutes, ordi- fective even if we have not made or offered a nances or regulations, of boilers, pressure ves refund. sels or elevators. 6. If notice is mailed, proof of mailing will be suffi- E. Premiums cient proof of notice. The first Named Insured shown in the Declara- B. Changes tions: This policy contains all the agreements between 1. Is responsible for the payment of all premiums; you and us concerning the insurance afforded. and The first Named Insured shown in the Declarations 2. Will be the payee for any return premiums we is authorized to make changes in the terms of this pay. policy with our consent. This policy's terms can be F. Transfer Of Your Rights And Duties Under This amended or waived only by endorsement issued Policy by us and made a part of this policy. Your rights and duties under this policy may not be C. Examination Of Your Books And Records transferred without our written consent except in We may examine and audit your books and re- the case of death of an individual named insured. cords as they relate to this policy at any time dur- If you die, your rights and duties will be transferred ing the policy period and up to three years after- to your legal representative but only while acting ward. within the scope of duties as your legal representa- D. Inspections And Surveys tive. Until your legal representative is appointed, 1. We have the right to: anyone having proper temporary custody of your property will have your rights and duties but only a. Make inspections and surveys at any time; with respect to that property. IL 00 17 11 98 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B IL 02 69 09 00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NORTH CAROLINA CHANGES - CANCELLATION AND NONRENEWAL This endorsement modifies insurance provided under the following: BOILER AND MACHINERY COVERAGE PART BUSINESSOWNERS POLICY COMMERCIAL CRIME COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART EMPLOYMENT-RELATED PRACTICES LIABILITY COVERAGE PART FARM COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART PROFESSIONAL LIABILITY COVERAGE PART A. Paragraph 2. of the Cancellation Common Policy (b) An act or omission by the insured or Condition is replaced by the following: his or her representative that consti- 2. Cancellation Requirements tutes material misrepresentation or nondisclosure of a material fact in a. Policies In Effect Less Than 60 Days obtaining this policy, continuing this If this policy has been in effect for less than policy or presenting a claim under 60 days, we may cancel this policy by mail- this policy; ing or delivering to the first Named Insured (c) Increased hazard or material change written notice of cancellation at least: in the risk assumed that could not (1) 15 days before the effective date of have been reasonably contemplated cancellation if we cancel for nonpayment by the parties at the time of assump- of premium; or tion of the risk; (2) 30 days before the effective date of (d) Substantial breach of contractual cancellation if we cancel for any other duties, conditions or warranties that reason. materially affects the insurability of b. Policies In Effect More Than 60 Days the risk; If this policy has been in effect for 60 days (e) A fraudulent act against us by the or more or is a renewal of a policy we is- insured or his or her representative sued,we may cancel this policy prior to the: that materially affects the insurability of the risk; (1) Expiration of the policy term; or (f) Willful failure by the insured or his or (2) Anniversary date, her representative to institute rea- stated in the policy only for one or more of sonable loss control measures that the following reasons: materially affect the insurability of the (a) Nonpayment of premium; risk after written notice by us; (g) Loss of facultative reinsurance, or loss of or substantial changes in ap- plicable reinsurance as provided in G.S. 58-41-30; IL 02 69 09 00 Copyright, Insurance Services Office, Inc., 2000 Page 1 of 2 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B (h) Conviction of the insured of a crime B. The following provisions are added and supersede arising out of acts that materially af- any other provisions to the contrary: fect the insurability of the risk; 1. Nonrenewal (i) A determination by the Commis- a. If we elect not to renew this policy, we will sioner of Insurance that the continua- mail or deliver to the first Named Insured tion of the policy would place us in shown in the Declarations written notice of violation of the laws of North Caro- nonrenewal at least 45 days prior to the: lina; or (1) Expiration of the policy if this policy has (j) You fail to meet the requirements been written for one year or less; or contained in our corporate charter, articles of incorporation or by-laws (2) Anniversary date of the policy if this when we are a company organized policy has been written for more than for the sole purpose of providing one year or for an indefinite term. members of an organization with in- b. We need not mail or deliver the notice of surance coverage in North Carolina. nonrenewal if you have: We will mail or deliver written notice of can- (1) Insured property covered under this cellation to the first Named Insured at least: policy, under any other insurance policy; (i) 15 days before the effective date (2) Accepted replacement coverage;or of cancellation if we cancel for (3) Requested or agreed to nonrenewal of nonpayment of premium; or this policy. (ii) 30 days before the effective date c. If notice is mailed, proof of mailing will be of cancellation if we cancel for sufficient proof of notice. any other reason. c. Cancellation for nonpayment of premium 2. The written notice of cancellation or nonre- will not become effective if you pay the newal will: premium amount due before the effective a. Be mailed or delivered to the first Named date of cancellation. Insured and any designated mortgagee or d. We may also cancel this policy for any loss payee at their addresses shown in the reason not stated above provided we obtain policy, if not indicated in the policy, at their last t known addresses; and your prior written consent. b. State the reason or reasons for cancellation or nonrenewal. Page 2 of 2 Copyright, Insurance Services Office, Inc., 2000 IL 02 69 09 00 ❑ DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICYHOLDER NOTICE - NORTH CAROLINA Date: 08/01/15 Policy Number: 22 WBC CN3905 THE Renewal Date: 10/01/15 HARTFQRD Your Hartford Agent: BB&T INSURANCE SERVICES INC/PHS (866) 467-8730 NORTH CAROLINA PUBLIC HEALTH PO BOX 18763 RALEIGH NC 27619 Dear Valued Hartford Customer, Your current policy provided by The Hartford will expire shortly. The purpose of this notice is to advise you of changes to your policy for the upcoming policy term. This is not a bill. You will receive a separate bill for all or part of the premium due for your upcoming policy. A. Policy Premium The premium indicated below is based on the underwriting information that we currently have on file and may be subject to change based on additional information that may be developed during the underwriting process. If you desire additional information regarding your premium determination, please contact your agent or broker, or you may contact us directly. Renewal Premium=$ 2,652.00 B. Coverage Changes(if applicable) Your policy for the upcoming term will include certain reductions or additional restrictions in coverage, as indicated by an (x)below. ( ) Increase in Deductible to: ( ) Reduction in Limits to: ( ) Reductions in Coverage: ( ) Other Changes, Clarifications or Restrictions in Coverage: You may receive other notices of coverage changes for the upcoming policy term under separate cover. Those other changes will apply in addition to the changes described above. Some states consider the change(s)described in this notice to be a nonrenewal of your prior policy, in which case this is our notice to you in compliance with the applicable law. If you would like more information about this notice or your policy, please contact your agent or broker, or you may contact us directly. We look forward to continuing our relationship and fulfilling your insurance needs. Thank you for your business. Form IH 70 41 01 13 (WC 66 03 27 F) DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B NORTH CAROLINA PUBLIC HEALTH THE ,•".' HARTFORD PO BOX 18763 RALEIGH NC 27619 Policy Number: 22 WBC CN3905 Renewal Date: 10/01/15 Thank you for being a loyal customer of The Hartford. #1:Your Hartford Policy Enclosed are renewal documents for your policy,which is scheduled to renew on 10/01/15 .Along with a new Declarations Page, which details the coverages provided by your policy, we are enclosing important policy documents. Please be aware that you will receive an invoice separately for this new policy term approximately 30 days prior to the renewal date; no action is required now. To ensure the premium you paid for this past policy term was accurate, we may contact you by letter, phone or email to conduct a premium audit. If contacted, we will advise what information is needed to complete the audit. #2:Your Business Insurance Coverage Checkup Now is a great time to complete a business insurance coverage checkup with a Hartford Insurance Professional. Because you wear so many hats each day, you may not be thinking about how changes to your business can impact the type and amount of insurance coverage needed to protect it. Together we will evaluate how your needs may have changed over the past year. Examples include: - Has your mailing address and/or the physical location of your business changed? - Has there been any increase/decrease in the amount of business property/equipment you own? - Has there been any increase/decrease in your company's payroll or sales? - Have you added or eliminated any vehicles used in your business operations? - Are the bill plan and deductible on your policy right for your business? During the review we may make coverage recommendations, provide peace of mind solutions, and possibly reduce your costs. Here is all you need to do: - Call toll free (866) 467-8730 , and select our renewal review service option any weekday from 8 A.M. to 6 P.M. EST and request your business insurance check-up. - To best serve you, please have your Policy Number or Account Number and a Copy of your current Renewal Policy in hand when you call. #3: Servicing Your Needs To login or register for our Online Business Service Center, go to www.thehartford.com/servicecenter where any time,day or night you can: - Pay your bill, view payment history and enroll in Auto Pay - Request Auto ID Cards and Certificates of Insurance - View electronic copies of billing and policy documents and sign up for paperless delivery #4: If You've Had A Loss or Accident... Report It Immediately We want to help! Contact us as quickly as possible at 1-800-327-3636. - Representatives are available 24-7 to assist in helping you recover from your loss. CO behalf of BB&T INSURANCE SERVICES INC/PHS and The Hartford, we appreciate the opportunity to have been of service to you this past year and look forward to serving your business insurance needs for the upcoming year. Sincerely, Your Hartford Team DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B 05 (Policy Provisions: wC o0 00 0o B) 39 CN INFORMATION PAGE WBC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD FIRE INSURANCE COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 tea• NCCI Company Number: 13269 THE 40'Company Code: 1 HARTFORD Suffix LARS RENEWAL POLICY NUMBER: 22 WBC CN3905 I 02 Previous Policy Number: 22 WBC CN3905 HOUSING CODE: DV 1. Named Insured and Mailing Address: NORTH CAROLINA PUBLIC HEALTH (No., Street, Town, State, Zip Code) FOUNDATION PO BOX 18763 FEIN Number: 470921425 RALEIGH, NC 27619 State Identification Number(s): The Named Insured is: NON-PROFIT ORGANIZATION Business of Named Insured: ASSOCIATION - CIVIC NON PROFIT Other workplaces not shown above: SEE ATTACHED SCHEDULES 2. Policy Period: From 10/01/15 To 10/01/16 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: BB&T INSURANCE SERVICES INC/PHS PO BOX 29611 CHARLOTTE, NC 28229 Producer's Code: 273438 Issuing Office: THE HARTFORD 8711 UNIVERSITY EAST DRIVE CHARLOTTE NC 28213 (866) 467-8730 Total Estimated Annual Premium: $2,652 Deposit Premium: Policy Minimum Premium: $352 NC Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by 08/01/15 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B INFORMATION PAGE (Continued) Policy Number: 22 WBC CN3905 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here:NC (SPO ) . B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $100,000 each accident Bodily injury by Disease $500,000 policy limit Bodily injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 99 00 05 WC 00 04 21D WC 00 04 22B WC 99 03 02B WC 99 03 66 WC 00 04 14 WC 00 04 19 WC 32 03 01C WC 99 02 77 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium (SEE ATTACHED SCHEDULES) TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2,224 EXPENSE CONSTANT (0900) 250 TERRORISM (9740) 885,600 .010 89 CATASTROPHE (9741) 885,600 .010 89 TOTAL ESTIMATED ANNUAL PREMIUM 2,652 Total Estimated Annual Premium: $2,652 Deposit Premium: Policy Minimum Premium: $352 NC Interstate/Intrastate Identification Number: NAICS: Labor Contractors Policy Number: SIC: 8641 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: HARTFORD FIRE INSURANCE COMPANY Company Code: 1 Policy Number: 22 WBC CN3905 Schedule Number: 01-32-01 Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: NORTH CAROLINA PUBLIC HEALTH FOUNDATION NO SPECIFIC LOCATION IN STATE OF NC NAICS: FEIN: 470921425 UIN: SIC: 8641 NO. OF EMPL: 000005 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 8742 121,600 .51 620 SALESPERSONS OR COLLECTORS - OUTSIDE Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: HARTFORD FIRE INSURANCE COMPANY Company Code: 1 Policy Number: 22 WBC CN3905 Schedule Number: 01-32-03 Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: NORTH CAROLINA PUBLIC HEALTH FOUNDATION 308 WEST MILL BROOK RD, STE F RALEIGH NC 27609 NAICS: FEIN: 470921425 UIN: SIC: NO. OF EMPL: 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 8810 764,000 .21 1,604 CLERICAL OFFICE EMPLOYEES NOC TOTAL CLASS PREMIUM 2,224 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2,224 EXPENSE CONSTANT (0900) 250 TERRORISM (9740) 885,600 .010 89 CATASTROPHE (9741) 885,600 .010 89 TOTAL ESTIMATED ANNUAL PREMIUM 2,652 Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number: 22 WEC CN3905 Endorsement Number: Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: NORTH CAROLINA PUBLIC HEALTH FOUNDATION PO BOX 18763 RALEIGH, NC 27619 This endorsement is notification that your insurance Terrorism Risk Insurance Act of 2002 (as carrier is charging premium to cover the losses that amended) but that meets all of the following may occur in the event of a Catastrophe (other than criteria: Certified Acts of Terrorism) as that term is defined a. It is an act that is violent or dangerous to below. Your policy provides coverage for workers human life, property, or infrastructure; compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This b. The act results in damage within the United premium charge does not provide funding for States, or outside of the United States in the Certified Acts of Terrorism contemplated under the case of the premises of United States Terrorism Risk Insurance Program Reauthorization missions or air carriers or vessels as those Act Disclosure Endorsement (WC 00 04 22 B), terms are defined in the Terrorism Risk attached to this policy. Insurance Act of 2002(as amended);and c. It is an act that has been committed by an For purposes of this endorsement, the following individual or individuals as part of an effort to definitions apply: coerce the civilian population of the United o Catastrophe (other than Certified Acts of States or to influence the policy or affect the Terrorism): Any single event, resulting from an conduct of the United States Government by Earthquake, Noncertified Act of Terrorism, or coercion. Catastrophic Industrial Accident, which results in o Catastrophic Industrial Accident: A chemical aggregate workers compensation losses in release, large explosion, or small blast that is excess of$50 million. localized in nature and affects workers in a small o Earthquake: The shaking and vibration at the perimeter the size of a building. surface of the earth resulting from underground The premium charge for the coverage your policy movement along a fault plane or from volcanic provides for workers compensation losses caused by activity. a Catastrophe (other than Certified Acts of o Noncertified Act of Terrorism: An event that is Terrorism) is shown in Item 4 of the Information not certified as an Act of Terrorism by the Page or in the Schedule below. Secretary of Treasury pursuant to the Schedule State Rate Premium Form WC 00 04 21 D Printed in U.S.A. Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT Policy Number: 22 WEC CN3905 Endorsement Number: Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: NORTH CAROLINA PUBLIC HEALTH FOUNDATION PO BOX 18763 RALEIGH, NC 27619 This endorsement addresses the requirements of "Act of Terrorism" means any act that is certified by the Terrorism Risk Insurance Act of 2002 as the Secretary of the Treasury, in consultation with amended and extended by the Terrorism Risk the Secretary of Homeland Security, and the Insurance Program Reauthorization Act of 2015. It Attorney General of the United States as meeting all serves to notify you of certain limitations under the of the following requirements: Act, and that your insurance carrier is charging a. The act is an act of terrorism. premium for losses that may occur in the event of an Act of Terrorism. b. The act is violent or dangerous to human life, property or infrastructure. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, c. The act resulted in damage within the United including workers compensation benefit obligations States, or outside of the United States in the dictated by state law. Coverage for such losses is case of the premises of United States missions still subject to all terms, definitions, exclusions, and or certain air carriers or vessels. conditions in your policy, and any applicable federal d. The act has been committed by an individual or and/or state laws, rules,or regulations. individuals as part of an effort to coerce the Definitions civilian population of the United States or to influence the policy or affect the conduct of the The definitions provided in this endorsement are United States Government by coercion. based on and have the same meaning as the definitions in the Act. If words or phrases not defined "Insured Loss" means any loss resulting from an act in this endorsement are defined in the Act, the of terrorism (and, except for Pennsylvania, including definitions in the Act will apply. an act of war, in the case of workers compensation) that is covered by primary or excess property and "Act" means the Terrorism Risk Insurance Act of casualty insurance issued by an insurer if the loss 2002, which took effect on November 26, 2002, and occurs in the United States or at the premises of any amendments thereto, including any amendments United States missions or to certain air carriers or resulting from the Terrorism Risk Insurance Program vessels. Reauthorization Act of 2015. "Insurer Deductible" means, for the period beginning on January 1, 2015, and ending on December 31, 2020, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year. Form WC 00 04 22 B Printed in U.S.A. Page 1 of 2 Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Limitation of Liability The Act limits our liability to you under this policy. If d. $160,000,000, with respect to such Insured aggregate Insured Losses exceed$100,000,000,000 Losses occurring in calendar year 2018, the in a calendar year and if we have met our Insurer United States Government would pay 82% Deductible, we are not liable for the payment of any of our Insured Losses that exceed our portion of the amount of Insured Losses that Insurer Deductible. exceeds $100,000,000,000; and for aggregate e. $180,000,000, with respect to such Insured Insured Losses up to $100,000,000,000, we will pay Losses occurring in calendar year 2019, the only a pro rata share of such Insured Losses as United States Government would pay 81% determined by the Secretary of the Treasury. of our Insured Losses that exceed our Policyholder Disclosure Notice Insurer Deductible. 1. Insured Losses would be partially reimbursed by f. $200,000,000, with respect to such Insured the United States Government. If the aggregate Losses occurring in calendar year 2020, the industry Insured Losses exceed: United States Government would pay 80% a. $100,000,000, with respect to such Insured of our Insured Losses that exceed our Losses occurring in calendar year 2015, the Insurer Deductible. United States Government would pay 85% 2. Notwithstanding item 1 above, the United States of our Insured Losses that exceed our Government will not make any payment under Insurer Deductible. the Act for any portion of Insured Losses that b. $120,000,000, with respect to such Insured exceed$100,000,000,000. Losses occurring in calendar year 2016, the 3. The premium charge for the coverage your United States Government would pay 84% policy provides for Insured Losses is included in of our Insured Losses that exceed our the amount shown in Item 4 of the Information Insurer Deductible. Page or in the Schedule below. c. $140,000,000, with respect to such Insured Losses occurring in calendar year 2017, the United States Government would pay 83% of our Insured Losses that exceed our Insurer Deductible. Schedule State Rate Premium Form WC 00 04 22 B Printed in U.S.A. Page 2 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PREMIUM DUE DATE ENDORSEMENT Policy Number: 22 WEC CN3905 Endorsement Number: Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: NORTH CAROLINA PUBLIC HEALTH FOUNDATION PO BOX 18763 RALEIGH, NC 27619 Section D of Part Five of the policy is replaced by this provision: PART FIVE PREMIUM D. Premium is amended to read: compensation law is not valid. The due date for You will pay all premium when due. You will pay audit and retrospective premiums is the date of the premium even if part or all of a workers the billing. Countersigned by Authorized Representative Form WC 00 04 19 Printed in U.S.A. Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Coverage for acts of terrorism is included in your policy. You are hereby notified that under the Terrorism Risk Insurance Act, as amended in 2015, the definition of act of terrorism has changed. As defined in Section 102(1) of the Act: The term "act of terrorism"means any act or acts that are certified by the Secretary of the Treasury-in consultation with the Secretary of Homeland Security, and the Attorney General of the United States-to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; and to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Under your coverage, any losses resulting from certified acts of terrorism may be partially reimbursed by the United States Government under a formula established by the Terrorism Risk Insurance Act, as amended. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear events. Under the formula, the United States Government generally reimburses 85%through 2015; 84%beginning on January 1, 2016; 83% beginning on January 1, 2017; 82% beginning on January 1, 2018; 81% beginning on January 1, 2019 and 80% beginning on January 1, 2020, of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The Terrorism Risk Insurance Act, as amended, contains a $100 billion cap that limits U.S. Government reimbursement as well as insurers' liability for losses resulting from certified acts of terrorism when the amount of such losses excceds$100 billion in any one calendar year. If the aggregate insured losses for all insurers exceed$100 billion, your coverage may be reduced. The portion of your annual premium that is attributable to coverage for acts of terrorism is$ 89 and does not include any charges for the portion of losses covered by the United States government under the Act. Name of Insurer: HARTFORD FIRE INSURANCE COMPANY Policy Number: 22 WBC CN3905 Form WC 66 04 24 Printed in U.S.A. Page 1 of 1 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B • THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WORKERS' COMPENSATION BROAD FORM ENDORSEMENT Policy Number: 22 WBC CN3905 Endorsement Number: Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: NORTH CAROLINA PUBLIC HEALTH FOUNDATION PO BOX 18763 RALEIGH, NC 27619 Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section III of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: INDEX SUBJECT PAGE SECTION I 2 PARTS ONE and TWO 2 01 We Will Also Pay 2 PART-THREE 2 02 How This Insurance Works 2 PART-SIX 2 03 Transfer of Your Rights and Duties 2 04 Liberalization 2 SECTION II 2 VOLUNTARY COMPENSATION INSURANCE 2 05 Voluntary Compensation Insurance 2 A. How This Insurance Applies 2 B. We will Pay 3 C. Exclusions 3 D. Before We Pay 3 E. Recovery From Others 3 F. Employers' Liability Insurance 3 EMPLOYERS'LIABILITY STOP GAP COVERAGE 3 06 Employers' Liability Stop Gap Coverage 3 A. Stop Gap Coverage Limited Montana, North Dakota, Ohio, Washington, 3 West Virginia and Wyoming B. Part One does not Apply 3 C. Application of Coverage 3 D. Additional Exclusions 3 E. West Virginia 3 SECTION III 4 07 Schedule of Covered States 4 Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Page 1 of 4 Process Date: 08/01/15 Policy Expiration Date: 10/01/16 ©2000, The Hartford DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B SECTION I PARTS ONE and TWO PART THREE 1. WE WILL ALSO PAY 2. How This Insurance Applies D. We Will Also Pay of Part One (WORKERS' Paragraph 4.of A. How This Insurance COMPENSATION INSURANCE); and Applies of Part 3 (Other States Insurance) is E. We Will Also Pay of Part Two(EMPLOYERS' replaced by the following: LIABILITY INSURANCE) is replaced by the 4. If you have work on the effective date of this following: policy in any state not listed in Item 3.A. of the We Will Also Pay Information Page, coverage will not be We will also pay these costs, in addition to afforded for that state unless we are notified other amounts payable under this insurance, within sixty days. as part of any claim, proceeding, or suit we defend: PART SIX 1. reasonable expenses incurred at our 3. Transfer Of Your Rights and Duties request, INCLUDING loss of earnings; C. Transfer Of Your Rights and Duties of Part 6 2. premiums for bonds to release (Conditions) is replaced by the following: attachments and for appeal bonds in bond Your rights or duties under this policy may not amounts up to the limit of our liability be transferred without our written consent. under this insurance; If you die and we receive notice within sixty 3. litigation costs taxed against you; days after your death, we will cover your legal 4. interest on a judgment as required by law representative as insured. until we offer the amount due under this 4. Liberalization law; and If we adopt a change in this form that would 5. expenses we incur. broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS' to work in a state shown in Item 3.A. of the LIABILITY COVERAGE Information Page. 5. Voluntary Compensation Insurance 3. The bodily injury must occur in the United A. How This Insurance Applies States of America, its territories or possessions, or Canada, and may occur This insurance applies to bodily injury by elsewhere if the employee is a United accident or bodily injury by disease. Bodily States or Canadian citizen, or otherwise injury includes resulting death. legal resident, and legally employed, in the 1. The bodily injury must be sustained by any United States or Canada and temporarily officer or employee not subject to the away from those places. workers' compensation law of any state 4. Bodily injury by accident must occur shown in Item 3.A. of the Information during the policy period. Page. 5. Bodily injury by disease must be caused 2. The bodily injury must arise out of and in or aggravated by the conditions of the the course of employment or incidental officer's or employee's employment. Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Page 2 of 4 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B The officer's or employee's last day of last If the persons entitled to the benefits of this exposure to the conditions causing or insurance make a recovery from others, they aggravating such bodily injury by disease must reimburse us for the benefits we paid must occur during the policy period. them. B. We Will Pay F. Employers'Liability Insurance We will pay an amount equal to the benefits Part Two (Employers' Liability Insurance) that would be required of you as if you and applies to bodily injury covered by this your employees were subject to the workers' endorsement as though the State of compensation law of any state shown in Item Employment was shown in Item 3.A. of the 3.A. of the Information Page. We will pay Information Page. those amounts to the persons who would be This provision 5. does not apply in New Jersey or entitled to them under the law. Wisconsin. C. Exclusion EMPLOYERS'LIABILITY STOP GAP COVERAGE This insurance does not cover: 6. Employers'Liability Stop Gap Coverage 1. any obligation imposed by workers' A. This coverage only applies in Montana, North compensation or occupational disease law Dakota, Ohio, Washington, West Virginia and or any similar law. Wyoming. 2. bodily injury intentionally caused or B. Part One (Workers' Compensation Insurance) aggravated by you. does not apply to work in states shown in 3. officers or employees who have elected Paragraph A above. not to be subject to the state workers' C. Part Two (Employers' Liability Insurance) compensation law. applies in the states, shown in Paragraph A., 4. partners or sole proprietors not covered as though they were shown in Item 3.A. of the under the Standard Sole Proprietors, Information Page. Partners, Officers and Others Coverage D. Part Two, Section C. Exclusions is changed Endorsement. by adding these exclusions. D. Before We Pay This insurance does not cover; Before we pay benefits to the persons entitled 5. bodily injury intentionally caused or to them, they must: aggravated by you or in Ohio bodily injury 1. Release you and us, in writing, of all resulting from an act which is determined responsibility for the injury or death. by an Ohio court of law to have been 2. Transfer to us their right to recover from committed by you with the belief than an others who may be responsible for the injury is substantially certain to occur. injury or death. However, the cost of defending such claims or suits in Ohio is covered. 3. Cooperate with us and do everything necessary to enable us to enforce the right 13. bodily injury sustained by any member of to recover from others. the flying crew of any aircraft. If the persons entitled to the benefits of this 14. any claim for bodily injury with respect to insurance fail to do those things, our duty to which you are deprived of any defense or pay ends at once. If they claim damages from defenses or are otherwise subject to you or from us for the injury or death, our duty penalty because of default in premium to pay ends at once. under the provisions of the workers' compensation law or laws of a state E. Recovery From Others shown in Paragraph A. If we make a recovery from others, we will E. This insurance applies to damages for which keep an amount equal to our expenses of you are liable under West Virginia Code Annot. recovery and the benefits we paid. We will S 23-4-2. pay the balance to the persons entitled to it. Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Page 3 of 4 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B SECTION III 7. SCHEDULE OF COVERED STATES B. If a state, shown in Item 3.A. of the Information A. This endorsement only applies in the states Page, approves this endorsement after the listed in this Schedule of Covered States. effective date of this policy, this endorsement will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. C. Schedule of Covered States: NC Countersigned by Authorized Representative Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Page 4 of 4 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES Policy Number: 22 WBC CN3905 Endorsement Number: Effective Date: 10/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: NORTH CAROLINA PUBLIC HEALTH FOUNDATION PO BOX 18763 RALEIGH, NC 27619 Item 1 of the Information Page is completed to include other workplaces of the named insured: NO SPECIFIC LOCATION IN STATE OF NC NC 308 WEST MILL BROOK RD, STE F RALEIGH NC 27609 NC Form WC 99 03 66 Printed in U.S.A. Process Date: 08/01/15 Policy Expiration Date: 10/01/16 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Privacy Policy and Practices of The Hartford Financial Services Group,Inc.and its Affiliates (herein called "we,our,and us") This Privacy Policy applies to our United States Operations We value your trust. We are committed to the d) administrators;and responsible: e) service providers; a) management; who help us serve You and service our business. b) use; and c) protection; When allowed by law, we may share certain of Personal Information. Personal Financial Information with other unaffiliated third parties who assist us by performing This notice describes how we collect, disclose, and services or functions such as: protect Personal Information. a) taking surveys; We collect Personal Information to: b) marketing our products or services;or c) offering financial products or services under a a) service your Transactions with us; and joint agreement between us and one or more b) support our business functions. financial institutions. We may obtain Personal Information from: We, and third parties we partner with, may track a) You; some of the pages You visit through the use of: b) your Transactions with us; and a) cookies; c) third parties such as a consumer-reporting b) pixel tagging; or agency. c) other technologies; Based on the type of product or service You apply and currently do not process or comply with any web for or get from us, Personal Information such as: browser's "do not track" signal or other similar mechanism that indicates a request to disable online a) your name; tracking of individual users who visit our websites or b) your address; use our services. c) your income; d) your payment; or We will not sell or share your Personal Financial e) your credit history; Information with anyone for purposes unrelated to may be gathered from sources such as applications, our business functions without offering You the Transactions,and consumer reports. opportunity to: To serve You and service our business, we may a) "opt-out;"or share certain Personal Information. We will share b) "opt-in;" Personal Information, only as allowed by law, with as required by law. affiliates such as: We only disclose Personal Health Information with: a) our insurance companies; a) your proper written authorization; or b) our employee agents; b) as otherwise allowed or required by law. c) our brokerage firms;and d) our administrators. Our employees have access to Personal As allowed by law, we may share Personal Information in the course of doing their jobs, such Financial Information with our affiliates to: as: a) market our products;or a) underwriting policies; b) market our services; c) paying claims; to You without providing You with an option to c) developing isin new customers of or d) advising customers of our products and prevent these disclosures. services. We may also share Personal Information, only as We use manual and electronic security procedures allowed by law, with unaffiliated third parties to maintain: including: a) the confidentiality;and a) independent agents; b) the integrity of; b) brokerage firms; Personal Information that we have. We use these c) insurance companies; procedures to guard against unauthorized access. Form WC 66 03 30 H Page 1 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Some techniques we use to protect Personal Personal Financial Information means financial Information include: information such as: a) secured files; a) credit history; b) user authentication; b) income; c) encryption; c) financial benefits;or d) firewall technology;and d) policy or claim information. e) the use of detection software. Personal Health Information means health We are responsible for and must: information such as: a) identify information to be protected; a) your medical records; or b) provide an adequate level of protection for that b) information about your illness,disability or injury. data; Personal Information means information that c) grant access to protected data only to those people who must use it in the performance of identifies You personally and is not otherwise their job related duties. available to the public. It includes: a) Personal Financial Information; and Employees who violate our Privacy Policy will be b) Personal Health Information. subject to discipline, which may include ending their employment with us. Transaction means your business dealings with us, At the start of our business relationship, we will give such as: You a copy of our current Privacy Policy. a) your Application; b) your request for us to pay a claim; and We will also give You a copy of our current Privacy c) your request for us to take an action on your Policy once a year if You maintain a continuing account. business relationship with us. You means an individual who has given us Personal We will continue to follow our Privacy Policy Information in conjunction with: regarding Personal Information even when a a) asking about; business relationship no longer exists between us. b) applying for; or As used in this Privacy Notice: c) obtaining, a financial product or service from us if the product Application means your request for our product or or service is used mainly for personal, family, or service. household purposes. This Privacy Policy is being provided on behalf of the following affiliates of The Hartford Financial Services Group, Inc.: lstAGChoice, Inc.; Access CoverageCorp, Inc.; Access CoverageCorp Technologies, Inc.; American Maturity Life Insurance Company; Archway 60 R, LLC; Business Management Group, Inc.; DMS R, LLC; First State Insurance Company; Fountain Investors I LLC; Fountain Investors II LLC; Fountain Investors III LLC; Fountain Investors IV LLC; FTC Resolution Company LLC; Hart Re Group L.L.C.; Hartford Accident and Indemnity Company; Hartford Administrative Services Company; Hartford Casualty General Agency, Inc.; Hartford Casualty Insurance Company; Hartford Financial Services, LLC; Hartford Fire General Agency, Inc.; Hartford Fire Insurance Company; Hartford Funds Distributors, LLC; Hartford Funds Management Company, LLC; Hartford Funds Management Group, Inc.; Hartford Holdings, Inc.; Hartford HLS Series Fund II, Inc.; Hartford Insurance Company of Illinois; Hartford Insurance Company of the Midwest; Hartford Insurance Company of the Southeast; Hartford Integrated Technologies, Inc.; Hartford International Life Reassurance Corporation; Hartford Investment Management Company; Hartford Life and Accident Insurance Company; Hartford Life and Annuity Insurance Company; Hartford Life Insurance Company; Hartford Life, Inc.; Hartford Life International Holding Company; Hartford Life Private Placement, LLC; Hartford Lloyd's Corporation; Hartford Lloyd's Insurance Company; Hartford of Texas General Agency, Inc.; Hartford Residual Market, L.C.C.; Hartford Securities Distribution Company, Inc.; Hartford Series Fund, Inc.; Hartford Specialty Insurance Services of Texas, LLC; Hartford Strategic Investments, LLC; Hartford Underwriters General Agency, Inc.; Hartford Underwriters Insurance Company; Hartford-Comprehensive Employee Benefit Service Company; HDC R, LLC; Heritage Holdings, Inc.; HIMCO Distribution Services Company; HIMCO Variable Insurance Trust; HLA LLC; HL Investment Advisors, LLC; Horizon Management Group, LLC; HRA Brokerage Services, Inc.; Lanidex Class B, LLC; New England Insurance Company; New England Reinsurance Corporation; Nutmeg Insurance Agency, Inc.; Nutmeg Insurance Company; Padfic Insurance Company, Limited; Planco, LLC; Property and Casualty Insurance Company of Hartford; Revere R, LLC; RVR R, LLC; Sentinel Insurance Company, Ltd.; Sunstone R, LLC; Symphony R, LLC; The Evergreen Group Incorporated; The Hartford Alternative Strategies Fund; The Hartford Mutual Funds, Inc.; The Hartford Mutual Funds II, Inc.; Trumbull Flood Management, L.L.C.;Trumbull Insurance Company;Twin City Fire Insurance Company. Form WC 66 03 30 H Page 2 of 2 DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B Reporting a Work-Related Injury is Time Sensitive! Call The Hartford's LossConnect immediately to report a claim. 1-800-327-3636 Available 24 hours a day, 365 days a year. The Benefits of Timely Loss Reporting: Research has shown that faster loss reporting significantly affects loss costs.The sooner we are notified,the sooner we can investigate the accident and coordinate with you,the injured employee,and the medical team to ensure the fastest possible return to health and work. The Effect of Timely Reporting on Controlling the Cost of Your Loss: Average Loss for Closed Claims (Accident Years 2002-2005) Report Lag in Days Percent Change in Loss Costs Compared to First Week Report Incident Day -6% Week 1 0% Week 2 13% Week 3 or 4 16% 1 Month or Later 24% Statutory requirements also necessitate the prompt initial reporting of the accident causing injury or death. Failure to comply may result in a fineable offense by the State. Information You'll Need Company Information Incident Information o Account Number o Type of injury(burn,cut, etc.)? o Location Code(if applicable) o Exact body part injured? o Parent Company(or program name) o What caused the accident? o Policy Number o Any reason to question the injury? o Any witnesses? Worker Information o Address where injury occurred? o Name, DOB,Address, Phone o Where was the injured employee treated? o Social Security Number (Provide name,address, phone of medical o Age, Gender provider.) o Marital Status, Number of Dependants o When was the accident reported to you and o Hire Date,Years in Current Position by whom(date,time)? o Wage Information Network Providers A listing of more than 400,000 network providers qualified to treat work-related injuries is available online at www.talispoint.com/hartext or by calling our Network Referral Unit at 1-800-327-3636(select 4 at the prompt). Since network referrals are often impacted by state specific rules, please call to learn how to maximize our network capabilities on behalf of your employees. Form WC 66 03 84 Printed in U.S.A.