HomeMy WebLinkAbout2016-732-E DSS - Dickerson Fencing Co fence installation DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
[Departmental Use Only]
TITLE Fencing
FY 2016-16
ORANGE COUNTY
CONTRACT UNDER $15,000.00
NORTH CAROLINA
THIS AGREEMENT, made and entered into this 13 day of June, 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 Dickerson Fencing Co., Inc. (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: Furnish materials and labor to install security gates, exit device, slide
operator and other items as requested to finish project at 113 Mayo Street.
The term of this agreement rendered shall be from June 13, 2016 to June 30,2016.
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 Ten
Thousand Dollars, ($10,000). 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
Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is
Revised 6/16 1
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
incorporated herein by reference and may be viewed at
http://www.orangecounty.nc.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 Si age tares: 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 I IA and Article 40 of
North Carolina General Statute Chapter 66.
8. Priori : 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. GoverningLaw:aw: 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.
It. 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:CDB26ED1-82FE-487A-872C-345E8A833228
IN WITNESS WHEREOF,County and the Provider have signed this Agreement, effective as of
the day first written above.
ORANGE 1�6'
ocu5igned by: PROVIDER oocusigned by:
By: 379946755E477.. By. 0D7615A5A0EF46C
County Manager Title: v"-� r i c_�i Uc...�L
200 S. Cameron St. William Dickerson, III
P.O. Box 8181 202 N. Hoover Rd.
Hillsborough,NC 27278 Durham,NC 27703-2302
Revised 6/16 4
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
DATE(MMIDDIYYYY)
AC"Rv CERTIFICATE OF LIABILITY INSURANCE
10/6/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT rate Ewald
NAME:
SIA Group Inc. PHONE ztg (910)455-7576 {arc,No):(910)455-7481
827 Gum Branch Road -MAIL carts@sia rou com
ADDRESS: g P
INSURERS)AFFORDING COVERAGE NAIL N
Jacksonville NC 28540 INSURERA: National Trust Insurance
INSURED INSURER B:The Hanover Insurance Company
Dickerson Fencing Co. , Inc dba Dickerson Fencing and INSURERC:_ _
202 N Hoover Road INSURERD:
Lisa Tilley INSURER E: _
Durham NC 27703-2302 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL1592404659 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _
fLTR TYPE OF INSURANCE AOOL SUBR POLICY NUMBER MMIL�6IYYYY MM)DDIYY Y LIMITS
LTR
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
A CLAIMS-MADE X i OCCUR PREM SES(Ea occurrence) $ 100,000
X Y CPP0011769 10/24/2015 10/24/2016 MEDEXP(Anycneperson) $ 5,000
PERSDNAL E AC)V INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
X PRO POLICY —1 � -] LOC PRODUCTS-COMP OPAGG $ 2,00Q,O-
JECT
OTHER: Employee Benefits $ 11
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
A X ANY AUTO _ BODILY INJURY(Perperson) $
ALL OWNED - SCHEDULED
AUTOS X Y CA0017095 10/24/2015 10/24/2016 BODILY INJURY(Peraccident) $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
Uninsured motorist combined $ 1,000,000
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000
A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
. RETENTION$ 10,000 UMBOOI1508 10/24/2015 10/24/2016 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETORiPARTNERlEXECUTIVE E.L.EACH AG_C_ID_ENT $ 1,000,000
OFFICERIMEMBER EXCLUDED? I� N I A
A (Mandatory in NH) y 01Dt4C15A71429 10/24/2015 10/24/2016 E_L.DISEASE-EA EMPLOYE $ - 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS bell I E.L.DISEASE.-POLICY LIMIT $ 11000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
Orange County is included as additional insured on the general and auto liability per forms CGLO88 and
CAU058. Waiver of subrogation applies in favor of the additional insured with regards to workers
compensation (WC000313) , general liability (CGLO88) , and auto liability (CAU014) per written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Tammy Comar ACCORDANCE WITH THE POLICY PROVISIONS.
P.O. sox 8181
Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE
Diana Evans/CHARLH �y J
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
I N S625 r2n1401 ti
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
POLICY NUMBER: CPPOO11769 5
SUMMARY OF ENDORSEMENTS
APPLICABLE TO ALL COVERAGES
1-UNGL-9512-MU-04,04/04 Commercial General Liability Coverage Part Declarations
IL 09 85(01 08)- Disclosure Pursuant To Terrorism Risk insurance Act
Premium:$134
APPLICABLE TO SPECIFIC STATES
STATE: NC
CG 00 01 (12/07)Commercial General Liability Coverage
CG 00 99(11185)-Changes in Generat Liability Forms for CPP
CG 03 00(01196)-Deductible Liability Insurance
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your coverage.
Please refer to the above numbered endorsement(attached)for details.
Deductible: PD Per Occurrence
Deductible Amount: $250
CG 20 10(07/04)-Addl Insured-Owners,Lessees or Contractors
Premium:$49
CG 2010(07104)-Addl Insured-Owners,Lessees or Contractors
Premium:$92
CG 20 28 (07/04)-Additional Insured-Lessor of Leased Equipment
Premium:$50
CG 2149(09199)-Total Pollution Exclusion
CG 2167(12104)-Fungi Or Bacteria Exclusion
CG 21 70(01 08)-Cap on Losses From Certified Acts of Terrorism
CG 2176(01 08)-Excl Of Punitive Damages Related To A Cert Act Of Terror
CG 21 B6(12104)-Exclusion- Exterior Insulation and Finish systems
CG 24 04(10/93) -Waiver of Transfer of Rights
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your coverage.
Please refer to the above numbered endorsement(attached)for details.
Prem ium:$100
Name of Person or Organization:S kanska USA Building Inc; Skanska USA Inc&Fidelity Investment Inc 4309 Emperor Blvd Ste
200 Durham, NC 27703-8046
CGL 025(11 08)-Addl Insured-Primary/Non-Contributory Coverage
CGL 030(11108)-Employee Benefits Liability Coverage
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your coverage.
Please refer to the above numbered endorsement(attached)for details.
Premium:$225
Limit Of Insurance:$1,000,000 per claim/$1,000,000 aggregate
CGL 084(11/08)- Employment Related Practices Exclusion
CGL 072 (11108)- Exclusion-Ops Covered by a Consolidated Ins. Prog.
CGL 084 (10113)-Adds Insured-Owners Lessees or Contractor-Automatic Status
CGL 088(10113)- First Choice Contractors Liability Endorsement
Premium: $200
CGL 123(10/13)-Employment Practices Liability Insurance Coverage Endo
CGL 137(10113)-North Carolina Changes
IL 00 03(09/07)-Calculation of Premium
IL OO 17(11/98)-Common Policy Conditions
IL 00 21 (07102)- Nuclear Energy Exclusion(Broad Form)
1-UNGL-9512-MU-04, 04104 PREPARED:10-30-2014 PAGE 4 OF 5
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
POLICY NUMBER: CPP0011769 5
IL 00$ (11108)-Total Lead Exclusion
IL 009(11108)-Total Asbestos Exclusion
IL 013(12106)-Two Or More Coverage Forms Or Policies Issued By Us
IL0269(09107)North Carolina Changes-Cancellation and Nonrenewal
APPLICABLE TO SPECIFIC PREMISES/COVERAGES
LOCATION: 1 202 N Hoover Rd Durham, NC 27703-2304
CG 20 11 (01196)-Additional Insured-Managers or Lessors of Premises
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your
coverage. Please refer to the above numbered endorsement(attached)for details.
Premium:$50
Name and Address:WLD Properties, LLC 202 N Hoover Rd Durham, NC 27703-2304
CG 20 37(07/04)-Addl Insured-Owners, Lessees,Contractors-C ompOps
Premium:$33
CG 20 37(07104)-Addl Insured-Owners, Lessees,Contractors-CompOps
Premium: $63
CG 2142(12/04)-Exci.-Explosion Collapse Underground PD Haz_
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your
coverage. Please refer to the above numbered endorsement(attached)for details_
Excluded Hazards: Explosion Hazard
Location And Description Of Operations: BLASTING ONLY
CG 21 54(01/96)-Exclusion Designated Operations Covered by Wrap-Up
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your
coverage. Please refer to the above numbered endorsement(attached)for details.
Description and Location of Operations: LEND LEASE (US)CONSTRUCTION INC., 324 BLACKWELL ST, STE 130.,
DURHAM, NC 27701
PROJECT:VA HOSPITAL IN KERNERSVILL NC
CG 21 54(01196)-Exclusion Designated Operations Covered by Wrap-Up
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your
coverage. Please refer to the above numbered endorsement(attached)for details.
Description and Location of Operations: SKANSKA USA BUILDING INC&SKANSKA USA INC
PROJECT:UNC HOSPITAL
CG 21 54(01196)-Exclusion Designated Operations Covered by Wrap-Up
The information that follows completes the schedule portion of this endorsement. This endorsement modifies your
coverage. Please refer to the above numbered endorsement(attached)for details.
Description and Location of Operations: TURNER CONSTRUCTION CO., 1500 SUNDAY DRIVE.,STE 101.,RALEIGH,
NC 27607
JOB: SYNGENTA BIOTECHNOLOGY
1-UNGL-9512-MU-154, 04/04 PREPARED: 10-30-2014 PAGE 5 OF 5
Includes copyrighted material or Insurance Services Office, Inc.with its permission.
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
COMMERCIAL GENERAL LIABILITY
CGL 084(10 13)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS
AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION
AGREEMENT WITH YOU - ONGOING OPERATIONS AND
PRODUCTS-COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE OPTIONAL
Name of Additional insured Persons or Organizations
(As required by written contract or agreement per Paragraph A. below.)
Locations of Covered Operations
(As per the written contract or agreement, provided the location is within the"coverage territory".)
(Information required to complete this Schedule, if not shown above, will be shown in the declarations.)
A, Section II—Who Is An Insured is amended to include as an additional insured;
1. Any person or organization for whom you are performing operations when you and such person or
organization have agreed in writing in a contract or agreement in effect during the term of this policy that
such person or organization be added as an additional insured on your policy; and
2. Any other person or organization you are required to add as an additional insured gander the contract or
agreement described in Paragraph 1_ above; and
3. The particular person or organization, if any, scheduled above.
Such person(s)or organization(s)is an additional insured only with respect to liability for"bodily injury",
"property damage"or"personal and advertising injury" occurring after the execution of the contract or
agreement described in Paragraph 1. above and caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf in the performance of your ongoing operations for
the additional insured; or
3. Your work" performed for the additional insured and included in the"products-completed operations
hazard" if such coverage is specifically required in the written contract or agreement.
CiGL o84(1013) Includes copyrighted material of the Insurance Services Offices, Inc.with its permission. Page 1 of 3
Copyright 2013 FCCI Insurance Group.
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
COMMERCIAL GENERAL LIABILITY
CGL 084(10 13)
However, the insurance afforded to such additional insured(s) described above:
1. Only applies to the extent permitted by law;
2. Will not be broader that that which you are required by the contract or agreement to provide for such
additional insured;
3. Will not be broader than that which is afforded to you under this policy; and
4. Nothing herein shall extend the term of this policy.
B. The insurance provided to the additional insured does not apply to"bodily injury", "property damage" or
"personal and advertising injury"arising out of the rendering of, or the failure to render, any professional
architectural, engineering or surveying services, including:
1. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports,
surveys,field orders,change orders or drawings and specifications; or
2. Supervisory, inspection, architectural or engineering activities.
C. This insurance is excess over any other valid and collectible insurance available to the additional insured
whether on a primary, excess, contingent or any other basis; unless the written contract or agreement
requires that this insurance be primary and non-contributory, in which hich case this insurance will be primary and
non-contributory relative to insurance on which the additional insured is a Named Insured.
D.. With respect to the insurance afforded to these additional insureds, the following is added to Section III—
Limits of Insurance.
The most we will pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement described in Paragraph A.1.; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
E. Section IV--Commercial General Liability Conditions is amended as follows:
The Duties In The Event of Occurrence, Offense, Claim or Suit ccndition is amended to add the following
additional conditions applicable to the additional insured:
An additional insured under this endorsement must as soon as practicable:
1. Give us written notice of an "occurrence"or an offense which may result in a claim or"suit° under this
insurance, and of any claim or"suit°that does result;
2. Send us copies of all legal papers received in connection with the claim or"suit cooperate with us in the
investigation or settlement of the claim or defense against the"suit", and otherwise comply with all policy
conditions; and
3. Tender the defense and indemnity of any claim or"suit" to any provider of other insurance which would
cover the additional insured for a lass we cover under this endorsement and agree to mare available all
such other insurance. However, this condition does not affect Paragraph C. above_
CGL 084(1013) Includes copyrighted material of the Insurance Services Offices, Inc.with its permission. Page 2 of 3
Copyright 2013 FCCI Insurance Group.
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
COMMERCIAL GENERAL LIABILITY
CGL 084(1013)
We have no duty to defend or indemnify an additional insured under this endorsement until we receive from
the additional insured written notice of a claim or"suit".
F. This endorsement does not apply to any additional insured or project that is specifically identified in any other
additional insured endorsement attached to the Commercial General Liability Coverage Form.
CGL 084(10 13) Includes copyrighted material of the Insurance Services Offices,Inc.with its permission. Page 3 of 3
Copyright 2013 FOCI Insurance Group.
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
COMMERCIAL GENERAL LIABILITY
CGL 025(11 08)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSUREDS - PRIMARYINON-CONTRIBUTORY
COVERAGE WHEN REQUIRED BY CONTRACT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
The following is added to SECTION IV—Commercial General Liability Conditions, Paragraph 4, entitled"Other
Insurance", subsection In. entitled "Excess Insurance", paragraph (1):
This insurance is excess over:
(v) Any other insurance naming an additional insured as an insured on a primary basis, excess, contingent or
on any other basis unless a written contract specifically requires that this insurance be primary and
noncontributing. The written contract must be currently in effect or become effective during the term of
this policy and must be executed prior to the"bodily injury", "property damage"or"personal and
advertising injury."
CGL 025(11 08) Includes copyrighted material of Insurance Services Office,with its permission. Page 1 of 1
Copyright 2008 FCCI Insurance Group.
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
FIRST CHOICE CONTRACTORS LIABILITY ENDORSEMENT
TABLE OF CONTENTS
DESCRIPTION PAGE
AdditionalInsured coverage..................... ...................................................................... .......................................10
BailBonds....................... ....... .................................................................................................................... .............9
BlanketWaiver of Subrogation...................................................................__................................................-.11.....16
Bodily Injury and Property Damage................................................................ ................................................ ..........1
Care, Custody or Control................. ..........................................................................................................................3
ContractorsErrors and Omissions .......................................................................... ........ .............. ..........................7
Contractual Liability(Personal&Advertising Injury) ................................................................................ .................2
ElectronicData Liability..... ......................................................................................................... ..............................I
GeneralLiability Conditions.......... ................. ................................................... ........ ....................... ........14
IncidentalMalpractice............... .................... ......... ... .................................................... ............... .......................10
Insured........ ............. ........................................... ...............................................................................................10
Limited Product Withdrawal Expense.........__............................................................ ..........................................4
Limitsof Insurance....................................................................................................................................................12
Lossof Earnings............. .................................... ........................................................................ .......................10
Newly Formed or Acquired Organizations.................... ...........................................................................................12
Non-Owned Watercraft......................................................................................................................................... ....1
Property Damage Liability—Borrowed Equipment-_.................................. ....................................... ......................1
Tenant's Property and Premises Rented To You.................................... ...... ...........................................................9
VoluntaryProperty Damage...... .............................. ............................................................. ........ ..........................2
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
COMMERCIAL GENERAL LIABILITY
CGL 088(10 13)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
FIRST CHOICE CONTRACTORS LIABILITY ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
NOTE:The following are additions, replacements and amendments to the Commercial General Liability Coverage
Form,and will apply unless excluded by separate endorsement(s)to the Commercial General Liability Coverage Form.
The COMMERCIAL GENERAL LIABILITY COVERAGE FORM is amended as follows:
SECTION I-COVERAGES,COVERAGE A.BODILY INJURY AND PROPERTY DAMAGE is amended as follows:
1. Extended "Property Damage"
Exclusion 2_a., Expected or Intended Injury, is replaced with the following:
a. "Bodily injury" or"property damage"expected or intended from the standpoint of the insured. This
exclusion does not apply to bodily injury"or"property damage" resulting from the use of reasonable
force to protect persons or property.
2. Non-owned Watercraft
Exclusion 2.g. (2)(a) is replaced with the following:
(a) Less than 51 feet long; and
3. Property Damage Liability—Borrowed Equipment
The following is added to Exclusion 2.j. (4):
Paragraph (4)of this exclusion does not apply to"property damage"to borrowed equipment while at a
jobsite and not being used to perform operations. The most we will pay for"property damage"to any one
borrowed equipment item under this coverage is$25,000 per"occurrence". The insurance afforded under
this provision is excess over any other valid and collectible property insurance(including deductible)
available to the insured,whether primary, excess, contingent or on any other basis.
4. Limited Electronic Data Liability
Exclusion 2.p. is replaced with the following:
p. Electronic Data
Damages arising out of the loss of, loss of use of, damage to, corruption of, inability to access,or
inability to manipulate electronic data"that does not result from physical injury to tangible property.
The most we will pay under Coverage A for"property damage"because of all loss of"electronic data"
arising out of any one"occurrence" is$10,000.
CGL 088(10 13) Includes copyrighted material of the Insurance Services Office, Inc.,with its permission. Page 1 of 16
Copyright 2013 FOCI Insurance Group
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
COMMERCIAL GENERAL LIABILITY
CGL 088(10 13)
We have no duty to investigate or defend claims or"suits"covered by this Limited Electronic Data Liability
coverage_
The following definition is added to SECTION V—DEFINITIONS of the Coverage Form:
"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.
For purposes of this Limited Electronic Data Liability coverage, the definition of"Property Damage' in
SECTION V—DEFINITIONS of the Coverage Form is replaced by the following:
17_ "Property damage" means:
a. Physical injury to tangible property, including all resulting loss of use of that property. All such loss
of use shall be deemed to occur at the time of the physical injury that caused it;
b. Loss of use of tangible property that is not physically injured. All such loss of use shall be deemed
to occur at the time of the"occurrence" that caused it;
c. Loss of, loss of use of, damage to, corruption of, inability to access, or inability to properly
manipulate "electronic data", resulting from physical injury to tangible property. All such loss of
"electronic data"shall be deemed to occur at the time of the"occurrence"that caused it_
Far purposes of this insurance,"electronic data" is not tangible property.
SECTION I—COVERAGES,COVERAGE B. PERSONAL AND ADVERTISING INJURY LIABILITY is amended
as follows'
Paragraph 2_e. Exclusions—the Contractual Liability Exclusion is deleted.
SECTION I—COVERAGES,the following coverages are added:
COVERAGE D.VOLUNTARY PROPERTY DAMAGE
1_ Insuring Agreement
We will pay, at your request, for"property damage'caused by an "occurrence", to property of others
caused by you, or while in your possession, arising out of your business operations.The amount we will
pay for damages is described in SECTION Ill LIMITS OF INSURANCE.
2. Exclusions
This insurance does not apply to:
"Property Damage"to.
a. Property at premises owned, rented, leased or occupied by you;
b_ Property while in transit;
c. Property owned by, rented to, leased to, loaned to, borrowed by, or used by you;
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d. Premises you sell, give away, or abandon, if the: property damage"arises out of any part of those
premises;
e. Property caused by or arising out of the"products-completed operations hazard";
f. Motor vehicles;
g. "Your product" arising out of it or any part of it; or
h. "Your work" arising out of rt or any part of it.
3. Deductible
We will not pay for loss in any one"occurrence" until the amount of loss exceeds$250 We will then pay
the amount of loss in excess of$250 up to the applicable limit of insurance.
4. Cost Factor
In the event of a covered lass, you shall, if requested by us, replace the damaged property or furnish the
labor and materials necessary for repairs thereto at your actual cost, excluding profit or overhead
charges.
The insurance afforded under COVERAGE D is excess over any other valid and collectible property or inland
marine insurance (including the deductible applicable to the property or inland marine coverage)available to
you whether primary, excess, contingent or any other basis.
Coverage D covers unintentional damage or destruction, but does not cover disappearance, theft, or loss of
use.
The insurance under COVERAGE D does not apply if a loss is paid under COVERAGE E.
COVERAGE E. CARE, CUSTODY OR CONTROL
1. Insuring Agreement
We will pay those sums that the insured becomes legally obligated to pay as damages because of
"'property damage"caused by an 'occurrence", to property of others while in your care, custody, or control
or property of others as to which you are exercising physical control if the"property damage"arises out of
your business operations, The amount we will pay for damages is described in SECTION III LIMITS OF
INSURANCE.
2. Exclusions
This insurance does not apply to:
"Property Damage"to:
a. Property at premises awned, rented, leased or occupied by you;
b. Property while in transit;
c- Premises you sell, give away, or abandon, if the"property damage"arises out of any part of those
premises;
d. Property caused by or arising out of the "products-completed operations hazard";
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e. Motor vehicles;
f. "Your product*arising out of it or any part of it; or
g. "Your work"arising out of it or any part of it.
3. Deductible
We will not pay for loss in any one"occurrence" until the amount of loss exceeds$250,We will then pay
the amount of loss in excess of$250 up to the applicable limit of insurance.
4_ Cost Factor
In the event of a covered loss, you shall, if requested by us, replace the damaged property or furnish the
labor and materials necessary for repairs thereto at your actual cost, excluding profit or overhead
charges.
The insurance afforded under COVERAGE E is excess over any other valid and collectible property or inland
marine insurance (including the deductible applicable to the property or inland marine coverage)available to
you whether primary, excess, contingent or any other basis.
The insurance under COVERAGE E does not apply if a loss is paid under COVERAGE D.
COVERAGE F. LIMITED PRODUCT WITHDRAWAL EXPENSE
1. Insuring Agreement
a. If you are a"selller', we will reimburse you for"product withdrawal expenses"associated with"your
product" incurred because of a"product withdrawal"to which this insurance applies.
The amount of such reimbursement is limited as described in SECTION III - LIMITS OF
INSURANCE. No other obligation or liability to pay sums or perform acts or services is covered.
a, This insurance applies to a "product withdrawal" only if the "product withdrawal" is initiated in the
"coverage territory" during the policy period because:.
(1) You determine that the"product withdrawal" is necessary; or
(2) An authorized government entity has ordered you to conduct a"product withdrawal''.
c. We will reimburse only those"product withdrawal expenses"which are incurred and reported to us
within one year of the date the"product withdrawal"was initiated.
d. The initiation of a"product withdrawal"will be deemed to have been made only at the earliest of the
following times:
(1) When you have announced. in any manner, to the general public, your vendors or to your
employees(other than those employees directly involved in making the determination)your
decision to conduct a"product withdrawal"This applies regardless of whether the determination
to conduct a"product withdrawal" is made by you or is requested by a third party;
(2) When you received, either orally or in writing, notification of an order from an authorized
government entity to conduct a"product withdrawal; or
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(3) When a third party has initiated a"product withdrawal" and you communicate agreement with the
"product withdrawal", or you announce to the general public, your vendors or to your employees
(other than those employees directly involved in making the determination)your decision to
participate in the"product withdrawal", whichever comes first.
e- "Product withdrawal expenses" incurred to withdraw"your products" which contain:
(1) The same"defect"will be deemed to have arisen out of the same"product withdrawal', or
(2) A different"defect"will be deemed to have arisen out of a separate"product withdrawal"if newly
determined or ordered in accordance with paragraph 1.b of this coverage.
2. Exclusions
This insurance does not apply to"product withdrawal" expenses" arising out of:
a. Any"product withdrawal"initiated due to:
(1) The failure of"your products"'to accomplish their intended purpose, including any breach of
warranty of fitness,whether written or implied. This exclusion does not apply if such failure has
caused or is reasonably expected to cause"bodily injury"or physical damage to tangible
property.
(2) Copyright, patent,trade secret or trademark infringements;
(3) Transformation of a chemical nature, deterioration or decomposition of"your product", except if it
is caused by:
(a) An error in manufacturing, design, processing or transportation of"your product"; or
(b) "Product tampering".
(4) Expiration of the designated shelf life of"your product'.
b. A"product withdrawal", initiated because of a"defect" in"your product" known to exist by the Named
Insured or the Named Insured's "executive officers", prior to the inception date of this Coverage Part
or prior to the time"your product" leaves your control or possession.
c. Recall of any specific products for which"bodily injury" or"property damage" is excluded under
Coverage A- Bodily Injury And Property Damage Liability by endorsement.
d. Recall of"your products" which have been banned from the market by an authorized government
entity prior to the policy period.
e. The defense of a claim or"suit" against you for"product withdrawal expenses"_
3. For the purposes of the insurance afforded under COVERAGE F, the following is added to 2. [duties In
The Event Of Occurrence, Offense, Claim Or Suit Condition under SECTION IV—COMMERCIAL
GENERAL LIABILITY CONDITIONS:
e, Duties In The Event Of A"Defect"Or A"Product Withdrawal"
(1) You must see to it that we are notified as soon as practicable of any actual, suspected or
threatened"defect" in "your products", or any governmental investigation,that may result in a
"product withdrawal".To the extent possible, notice should include:
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(a) Now;when and where the"defect"was discovered;
(b) The names and addresses of any injured persons and witnesses; and
(c) The nature, location and circumstances of any injury or damage arising out of use or
consumption of"your product".
(2) If a"product withdrawal" is initiated, you must:
(a) Immediately record the specifics of the"product withdrawal"and the date it was initiated;
(b) Send us written notice of the"product withdrawal" as soon as practicable; and
(c) Not release, consign, ship or distribute by any other method, any product, or like or similar
products, with an actual, suspected or threatened defect.
(3) You and any other involved insured must:
(a) Immediately send us copies of pertinent correspondence received in connection with the
"product withdrawal";
(b) Authorize us to obtain records and other information; and
(c) Cooperate with us in our investigation of the"product withdrawal".
4. For the purposes of this Coverage F, the following definitions are added to the Definitions Section:
a. "Defect' means a defect, deficiency or inadequacy that creates a dangerous condition.
b- "Product tampering"is an act of intentional alteration of "your product"which may cause or has
caused"bodily injury" or physical injury to tangible property.
When"product tampering"is known, suspected or threatened, a"product withdrawal"will not be
limited to those batches of"your product"which are known or suspected to have been tampered with.
c. "Product withdrawal" means the recall or withdrawal of"your products", or products which contain
"your products",from the market or from use, by any other person or organization, because of a
known or suspected "defect"in"your product', or a known or suspected "product tampering",which
has caused or is reasonably expected to cause"bodily injury" or physical injury to tangible property.
d. 'Product withdrawal expenses" means those reasonable and necessary extra expenses, listed below
paid and directly related to a"product withdrawal":
(1) Costs of notification;.
(2) Costs of stationery, envelopes, production of announcements and postage or facsimiles;
(3) Costs of overtime paid to your regular non-salaried employees and costs incurred by your
employees, including costs of transportation and accommodations;
(4) Costs of computer time;
(5) Costs of hiring independent contractors and other temporary employees;
(6) Costs of transportation, shipping or packaging;
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(7) Costs of warehouse or storage space; or
(8) Costs of proper disposal of"your products"', or products that contain"your products",that cannot
be reused, not exceeding your purchase price or your cost to produce the products; but"product
withdrawal expenses" does not include costs of the replacement, repair or redesign of"your
product", or the costs of regaining your market share, goodwill, revenue or profit.
e. "Seller" means a person or organization that manufactures, sells or distributes goods or products.
"Seller' does not include a"contractor" as defined elsewhere in this endorsement.
The insurance under COVERAGE F does not apply if a loss is paid under COVERAGE G.
COVERAGE G. CONTRACTORS ERRORS AND OMISSIONS
1. Insuring Agreement
If you are a'contractor", we will pay those sums that you become legally obligated to pay as damages
because of"property damage"to"your product" "your work"or"impaired property", due to faulty
workmanship, material or design, or products including consequential loss, to which this insurance
applies. The damages must have resulted from your negligent act, error or omission while acting in your
business capacity as a contractor or subcontractor or from a defect in material or a product sold or
installed by you while acting in this capacity. The amount we will pay for damages is described in
SECTION III LIMITS OF INSURANCE.
We have no duty to investigate or defend claims or"suits" covered by this Contractors Errors or
Omissions coverage.
This coverage applies only if the"property damage" occurs in the"coverage territory"during the policy
period.
This coverage does not apply to additional insureds, if any.
Supplementary Payments—Coverage A and B do not apply to Coverage G. Contractors Errors and
Omissions.
2. Exclusions
This insurance does not apply to:
a. "Bodily injury"or"personal and advertising injury".
b. Liability or penalties arising from a delay or failure to complete a contract or project, or to complete a
contract or project on time.
c. Liability because of an error or omission:
(1) In the preparation of estimates or job costs:
(2) Where cost estimates are exceeded;
(3) In the preparation of estimates of profit or return on capital;
(4) In advising or failure to advise on financing of the work or project; or
(5) In advising or failing to advise on any legal work, title checks,form of insurance or suretyship.
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d. Any liability which arises out of any actual or alleged infringement of copyright or trademark or trade dress
or patent, unfair competition or piracy, or theft or wrongful taking of concepts or intellectual property.
e, Any liability for damages:
(1) From the intentional dishonest, fraudulent, malicious or criminal acts of the Named Insured, or by
any partner, member of a limited liability company, or executive officer, or at the direction of any
of there; or
(2) Which is in fact expected or intended by the insured, even if the injury or damage is of a different
degree or type than actually expected or intended.
f. Any liability arising out of manufacturer's warranties or guarantees whether express or implied..
g. Any iiabiiity arising from'property damage'to property owned by, rented or leased to the insured.
h. Any liability incurred or"property damage" which occurs, in whole or in part, before you have
completed"your work." "Your work"will be deemed completed at the earliest of the following times:
(1) When all of the work called for in your contract or work order has been completed;
(2) When all the work to be done at the job site has been completed if your contract calls for work at
more than one job site; or
(3) When that part of the work done at a job site has been put to its intended use by any person or
organization other than another contractor or subcontractor working on the same project.
Work that may need service or maintenance, correction, repair or replacement, but which is otherwise
complete, will be treated as complete.
i. Any liability arising from "property damage"to products that are still in your physical possession.
j. Any liability arising out of the rendering of or failure to render any professional services by you or on
your behalf, but only with respect to either or troth of the following operations
(1) Providing engineering, architectural or surveying services to others; and
(2) Providing or hiring independent professionals to provide engineering, architectural or surveying
services in connection with construction work you perform.
Professional services include the preparing, approving or failing to prepare or approve, reaps, shop
drawings, opinions, reports, surveys, field orders, change orders, or drawings and specifications.
Professional services also include supervisory or inspection activities performed as part of any related
architectural or engineering activities.
But, professional services do not include services within construction means, methods,techniques,
sequences and procedures employed by you in connection with construction work you perform.
k. Your loss of profit or expected profit and any liability arising therefrom.
1. "Property damage"to property other than"your product,""your work"or"impaired properly."
m. Any liability arising from claims or"suits"where the right of action against the insured has been
relinquished or waived.
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n. Any liability for"property damage`to"your worts" if the damaged work or the work out of which the
damage arises was performed on your behalf by a subcontractor_
o_ Any liability arising from the substitution of a material or product for one specified on blueprints,work
orders. contracts or engineering specifications unless there has been written authorization, or unless
the blueprints, work orders, contracts or engineering specifications were written by you, and you have
authorized the changes.
p. Liability of others assumed by the insured under any contract or agreement, whether oral or in writing.
This exclusion does not apply to liability for damages that the insured would have in the absence of
the contract or agreement.
3. For the purposes of Coverage G,the following definition is added to the Definitions section:
a. "Contractor' means a person or organization engaged in activities of building., clearing, filing,
excavating or improvement in the size, use or appearance of any structure or land: "Contractor"does
not include a`seller'as defined elsewhere in this endorsement.
4. Deductible
We will not pay for loss in any one"occurrence" until the amount of loss exceeds$250_ The limits of
insurance will not be reduced by the application of the deductible amount.
We may pay any part or all of the deductible amount to effect settlement of any claim or"suit", and upon
notification of the action taken, you shall promptly reimburse us for such part of the deductible amount as
has been paid by us.
S. Cost Factor
In the event of a covered loss, you shall, if requested by us, replace the damaged property or furnish the
labor and materials necessary for repairs thereto at your actual cost,excluding profit or overhead
charges.
The insurance under COVERAGE G does not apply if a loss is paid under COVERAGE F.
EXPANDEDCOVERAGE FOR TENANT'S PROPERTY AND PREMISES RENTED TO YOU
The first paragraph after subparagraph (6) in Exclusion j., Damage to Property is amended to read as follows?
Paragraphs(1).,(3) and (4) of this exclusion do not apply to"property damage" (other than damage by fire)
to premises, including the contents of such premises, rented to you. A separate limit of insurance applies
to Damage To Premises Rented To You as described in Section III—Limits Of Insurance.
SECTION I -COVERAGES,SUPPLEMENTARY PAYMENTS—COVERAGE A and B is amended as follows:
All references to SUPPLEMENTARY PAYMENTS—COVERAGES A and B are amended to SUPPLEMENTARY
PAYMENTS--COVERAGES A, B, D, E, and G.
1. Cost of Bail Bonds
Paragraph 1,b. is replaced with the following:
b. Up to$2,500 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.
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2. Loss of Earnings
Paragraph 1.d. is replaced with 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$500 a day because of time off from work.
SECTION II—WHO IS AN INSURED Is amended as follows:
1. Incidental Malpractice
Paragraph Za.(1)(d) is replaced with the following:
(d) Arising out of his or her providing or failing to provide professional health care services. However, this
exclusion does not apply to a nurse, emergency medical technician or paramedic employed by you to
provide medical services, unless:
(i) You are engaged in the occupation or business of providing or offering medical, surgical, dental, x-ray
or nursing services, treatment, advice or instruction; or
(ii) The"employee'has another insurance that would also cover claims arising under this provision,
whether the other insurance is primary, excess, contingent or on any other basis.
2. Broadened Who Is An Insured
The following are added to Paragraph 2,;
Subsidiaries
e. Your subsidiaries if:
(1) They are legally incorporated entities; and
(2) You own more than 50%of the voting stock in such subsidiaries as of the effective date of this policy.
If such subsidiaries are not shown in the Declarations, you must report them to us within 180 days of
the inception of your original policy.
Additional Insureds
f. Any person or organization described in paragraphs g.through k. below whom you are required to add as
an additional insured on this policy under a written contract or agreement in effect during the term of this
policy, provided the written contract or agreement was executed prior to the"bodily injury", "property
damage" or"personal and advertising injury"for which the additional insured seeks coverage.
However, the insurance afforded to such additional insured(s):
(1) Only applies to the extent permitted by law;
(2) Will not be broader than that which you are required by the contract or agreement to provide for such
additional insured;
(3) Will not be broader than that which is afforded to you under this policy;
(4) Is subject to the conditions described in paragraphs g. through k. below; and
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(5) Nothing herein shall extend the terra of this policy.
g, Owner, Lessor or Manager of Premises
If the additional insured is an owner,lessor or manager of premises, such person or organization shall be
covered only with respect to liability arising out of the ownership, maintenance or use of that part of any
premises leased to you and subject to the following additional exclusions:
(1) Any"occurrence"that takes place after you cease to occupy those premises; or
(2) Structural alterations, new construction or demolition operations performed by or on behalf of such
person or organization.
h. State or Governmental Agency or Subdivision or Political Subdivision—Permits or Authorizations
If the additional insured is the state or any political subdivision,the state or political subdivision shall be
covered only with respect to operations performed by you or on your behalf for which the state or political
subdivision has issued a permit or authorization. This insurance does not apply to:
(1) "Bodily injury` "property damage", or "personal and advertising injury" arising out of operations
performed for the federal govemment, state or municipality;or
(2) `Bodily injury'or"property damage" included within the "products-completed operations hazard".
i. Lessor of Leased Equipment
If the additional insured is a lessor of leased equipment, such lessor shall be covered only with respect to
liability for"bodily injury', °property damage"or personal and advertising injury"caused,in whole or in
part, by your maintenance, operation or use of equipment leased to you by such person(s) or
organization(s). With respect to the insurance afforded to these additional insureds,this insurance does
not apply to any"occurrence"which takes place after the equipment lease expires.
j. Mortgagee,Assignee, or Receiver
If the additional Insured is a mortgagee, assignee,or receiver of premises,such mortgagee, assignee or
receiver of premises is an additional insured 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. This insurance
does not apply to structural alterations, new construction and demolition operations performed by or for
that person or organization.
k.. Vendor
If the additional insured is a vendor, such vendor is an additional insured only with respect to`bodily
injury" or"property damage"caused by"your products"which are distributed or sold in the regular course
of the vendor's business, subject to the following additional exclusions:
(1) The insurance afforded to the vendor does not apply to:
(a) "Bodily injury" or"property damage"for which the vendor 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 that the vendor would have in absence of the contract or agreement.
(b) Any express warranty unauthorized by you;
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(c) Any physical or chemical change in"your product" made intentionally by the vendor;
(d) Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing, or the
substitution of parts under instructions from the manufacturer, and then repackaged in the original
container;
(a) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed
to make or normally undertakes to make in the usual course of business, in connection with the
distribution or sale of the products;
(f) Demonstration, installation, servicing or repair operations, except such operations performed at
the vendor's premises in connection with the sale of the product;
(g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a
container, part or ingredient of any other thing or substance by or for the vendor;or
(h) "Bodily injury" or"property damage"arising out of the sole negligence of the vendor for its own
acts or omissions or those of its own acts or omissions or those of its employees or anyone else
acting on its behalf. However, this exclusion does not apply to:
i. The exceptions contained in Subparagraphs d. orf.; or
ii. Such inspections, adjustments, tests or servicing as the vendor has agreed to make or
normally undertakes to make in the usual course of business, in connection with the
distribution or sale of the products,
(2) This insurance does not apply to any insured person or organization,from whom you have acquired such
products, or any ingredient, part or container, entering into,accompanying or containing such products.
3. Newty Formed or Acquired Organizations
Paragraph 3_ is amended as follows:
a. Coverage under this provision is afforded until the end of the policy period.
d. Coverage A does not apply to product recall expense arising out of any withdrawal or recall that occurred
before you acquired or formed the organization.
SECTION III—LIMITS OF INSURANCE is amended as follows.:
1. Paragraph 2. is replaced with the following:
2. The General Aggregate Limit is the most we will pay for the sum of:
a. Medical expenses under Coverage C;
b. Damages under Coverage A, except damages because of"bodily injury'or"property damage'
included in the"products-completed operations hazard";
c. Damages under Coverage B;
d. Voluntary property damage'payments under Coverage D; and
e. Care, Custody or Control damages under Coverage E.
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2. Paragraph 5.is replaced with the following:
5, subject to Paragraph 2. or 3, above, whichever applies,the Each Occurrence Limit is the most we will
pay for the sum of:
a. Damages under Coverage A;
b. Medical expenses under Coverage C;
c. Voluntary"property damage" payments under Coverage D;
d. Care, Custody or Control damages under Coverage E;
e. Limited Product Withdrawal Expense under Coverage F; and
f. Contractors Errors and Omissions under Coverage G.
because of ail"bodily injury" and property damage"arising out of any one"occurrence".
3. Paragraph 6.is replaced with the following;
6. Subject to Paragraph 5, above the Damage To Premises Rented To You Limit is the most we will pay
under Coverage A for damages because of"property damage"to any one premises, while rented to you,
or in the case of damage by fire or explosion,while rented to you or temporarily occupied by you with
permission of the owner.
The Damage to Premises Rented to You Limit is the higher of the Each Occurrence Limit shown in the
Declarations or the amount shown in the Declarations as Damage To Premises Rented To You. Limit.
4. Paragraph 7. is replaced with the following:
7. Subject to Paragraph 5.above, the higher of$10,000 or the Medical Expense Limit shown in the
Declarations is the most we will pay under Coverage C for all medical expenses because of"bodily injury"
sustained by any one person.
5. Paragraph 8. is added as follows:
8. Subject to Paragraph 5. above, the most we will pay under Coverage D. Voluntary Property Damage for
loss arising out of any one"occurrence"is$1,500. The most we will pay in any one-policy period,
regardless of the number of claims made or suits brought, is$3,000.
5. Paragraph 9.is added as follows:
9. Subject to Paragraph 5. above,the most we will pay under Coverage E. Care, Custody or Control for
"property damage" arising out of any one "occurrence" is$1,000. The most we will pay in any one-policy
period, regardless of the number of claims made or suits brought, is$5,DOC.
7, Paragraph 10. is added as follows:
10. Subject to Paragraph 5. above, the most we will pay under Coverage F. Limited Product Withdrawal
Expense for"product withdrawal expenses" in any one-policy period, regardless of the number of
insureds, "product withdrawals" initiated or number of"your products"withdrawn is$10,000.
CGL 088(10 13) Includes copyrighted material of the Insurance Services Office, Inc.,with its permission. Page 13 of 15
Copyright 2013 FOCI Insurance Group
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
COMMERCIAL GENERAL LIABILITY
C+GL 088(1013)
8. Paragraph 11. is added as follows:
11. Subject to Paragraph 5. above, the most we will pay under Coverage G. Contractors Errors and
Omissions for damage in any one-policy period, regardless of the number of insureds, claims or"suits"
brought, or persons or organizations making claim or bringing"suits"is$10,000.
For errors in contractor job specifications or in recommendations of products or materials to be used, this
policy will not pay for additional costs of products and materials to be used that would not have beer
incurred had the correct recommendations or specifications been made.
9. Paragraph 12. is added as follows;
12. The General Aggregate limit applies separately to:
a. Each of your projects away from premises owned by or rented to you; or
b. Each"location" owned by or rented to you.
"Location"as used in this paragraph 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.
10. Paragraph 13. is added as follows:
13. With respect to the insurance afforded to any additional insured provided overage under this
endorsement.
If coverage provided to the additional insured is required by a contract or agreement,the most we will pay
on behalf of the additional insured is the amount of insurance:
a. Required by the contract or agreement; or
b. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of insurance shown in the Declarations.
SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows:
1. Subparagraph 2.a.of Duties In The Event Of Occurrence,Offense, Claim,or Suit is replaced with the
following:
a. You must see to it that we are notified as soon as practicable of an"occurrence' or an offense which may
result in a claim. This requirement applies only when the "occurrence"or offense is known to the
following:
(1) An individual who is the sole owner,
(2) A partner, if you are a partnership orjoint venture;
(3) An "executive officer'or insurance manager, if you are a corporation,
(4) A manager, if you are a limited liability company;
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COMMERCIAL GENERAL LIABILITY
CGL 088(10 13)
(5) A person or organization having proper temporary custody of your property if you die;
(6) The legal representative of you if you die; or
(7) A person (other than an "employee") or an organization while acting as your real estate manager.
To the extent possible, notice should include:
(1) How,when and where the"occurrence"or offense took place;
(2) The names and addresses of any injured persons and witnesses;and
(3) The nature and location of any injury or damage arising out of the"occurrence or offense.
2. The fallowing is added to Subparagraph 2.b.of Duties In The Event Of Occurrence,Offense, Claim,or
Suit:
The requirement in 2.b.applies only when the "occurrence" or offense is known to the following:
(1) An individual who is the sole owner;
(2) A partner or insurance manager, if you are a partnership or joint venture;
(3) An"executive officer" or insurance manager, if you are a corporation;
(4) A manager or insurance manager, if you are a limited liability company;
(a) Your officials,trustees, board members or insurance manager, if you are a not-far-profit organization;
(6) A person or organization having proper temporary custody of your property if you die;
(7) The legal representative of you if you die; or
(8) A person (other than an "employee")or an organization while acting as your real estate manager.
3. The following is added to paragraph 2. of Duties in the Event of Occurrence, Offense, Claim or Suit:
e. If you report an "occurrence"to your workers compensation carrier that develops into a liability claim for
which coverage is provided by the Coverage Farm,failure to report such an"occurrence"to us at the
time of the"occurrence'shall not be deemed a violation of paragraphs a., b., and c. above. However,
you shall give written notice of this"occurrence"to us as soon as you become aware that this
"occurrence"may be a liability claim rather than a workers compensation claim.
4. Paragraph 6. is replaced with the following:
6. Representations
By accepting this policy, you agree:
a. The statements in the Declarations are accurate and complete;
b. Those statements are based upon representations you made to us, and
c. We have issued this policy in reliance upon your representations.
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COMMERCIAL GENERAL LIABILITY
CGL 088(10 13)
Any error or omission in the description of, or failure to completely describe or disclose any premises,
operations or products intended to be covered by the Coverage Form will not invalidate or affect coverage
for those premises, operations or products, provided such error or omission or failure to completely
describe or disclose premises, operations or products was not intentional_
You must report such error or omission to us as soon as practicable after its discovery. However; this
provision does not affect our right to collect additional premium charges or exercise our right of
cancellation or nonrenewal.
5. The following Is added to paragraph 8.Transfer Of Rights Of Recovery Against Others To Us:
However, we waive any right of recovery we may have because of payments we make for injury or
damage arising out of your ongoing operations or"your work" included in the"products-completed
operations hazard" under the following conditions:
a) Only when you have agreed in writing to waive such rights of recovery in a contract or agreement;
b) Only as to the personlentity as to whom you are required by the contract to waive rights of recovery;
and
c) Only if the contract or agreement is in effect during the terra of this policy, and was executed by you
prior to the loss,
6. Paragraph 10. Is added as follows:
10. Liberalization
If we revise this Coverage Form to provide more coverage without additional premium charge, your
policy will automatically provide the additional coverage as of the day the revision is effective in the
applicable state(s).
CGL 088(10 13) Includes copyrighted material of the Insurance Services Office,Inc„with its permission. Page 16 of 16
Copyright 2013 FCCI Insurance Group
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
POLICY NUMBER: CA 0017095 5
SUMMARY OF ENDORSEMENTS
APPLICABLE TO ALL COVERAGES;
1-UNAU-9537-MU-04, 11/0$Business Auto Declarations
IL 0017(11/98) Common Policy Conditions
IL 0021 (07/02) Nuclear Energy Exclusion(Broad Form)
IL 00 03(09/07)-Calculation of Premium
STATE: NC
CA 0001 (03106)Business Auto Coverage Form
CA 0126(07110) North Carolina Changes
CA 2048 (02199) Designated Insured
Skanska Usa Building Inc; Skanska Usa Inc_And The Owner 4309 Emperor Blvd Ste 200 Durham, NC 27703-BD46
CA 2116 (04/10)North Carolina- Uninsured Molorist Coverage
CA 2384(01/06)Exclusion of Terrorism
CA 9903 (03106)Auto Medical Payments Coverage
CA 9910(09/02)Drive Other Car Ccv-Broad Cov For Named Individuals
Total Premium:$107
Name of Individuals: WILLIAM DICKERSON III
OTC Coverage: Yes
Collision Coverage: Yes
CAU 014(04104)Waiver Of Trnsfr Of Rights Of Recovery Against Olhers To Us
Name of Person or Organization:SKANSKA USA BUILDING INC;SKANSKA USA INC.AND THE OWNER.,4309 EMPEROR BLVD.,
STE 200., DURHAM, NC 27703,4309 Emperor Blvd, Ste 200_, Durham, NC 27703
CAU 014(04104)Waiver Of Trnsfr Of Rights Of Recovery Againsl Others To Us
Name of Person or Organization: BLANKET WHERE REQUIRED IN WRITTEN CONTRACT PRIOR TO LOSS
CAU 05$(12 09)Auto First Choice Endorsement
Premium:$250
Auto First Choice Physical Damage Premium:$ 125
Auto First Choice Liability Premium:$125
IL 008(11/08)-Total Lead Exclusion
IL 009(111DS)-Total Asbestos Exclusion
VEHICLE ENDORSEMENTS
Vehicle#2:2006 FORD CAB FORW 550 BLUE DIAMOND VIN:3FRMLSUBSV240526
CA 9944(12/93)Loss Payable Clause
See Schedule for Vehicle#2
Vehicle#3: 2006 GMC C4500 VIN: 1 GDE4Ci 27SF406919
CA 9944(12193)Loss Payable Clause
See Schedule for Vehicle#3
Vehicle#4:2006 CHEVROLET KODIAK VIN: 1GSE4C1276F412924
CA 9944 (12193) Loss Payable Clause
See Schedule for Vehicle#4
Vehicle#9:2011 FORD F150 VIN: 1FTFXIEFOBFA68694
CA 9944(12/93)Loss Payable Clause
See Schedule for Vehicle#9
Vehicle#11. 2015 CHEVROLET SILVERADO VIN: 1GCIKWEG4FF100809
CA 9944(12/93)Loss Payable Clause
1-UNAU-9537-NFU-04, 11l0a PREPARED:10-30-2014 Page S of 9
Includes copyrighted material of Insurance Services Office, Inc.with its permission_
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COMMERCIAL AUTO
GAU 014(04 04)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
SCHEDULE
Name of Person or Organization:
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
Paragraph 5. the Transfer of Rights of Recovery Against Others to Us Condition (Section IV—Business Auto
Conditions)is amended by the addition of the following:
However, we will waive any right of recovery we may have against the person or organization shown in the
Schedule above because of payments we make under this Coverage Form arising out of an"accident"or"loss"if:
a. The"accident" or"loss" is caused by operations undertaken by you in accordance with the contract
existing between you and such person or organization shown in the Schedule above: and
b_ The contractor agreement was executed prior to any"accident"or"loss."
Our waiver of our right to recovery applies only to the extent that the person or organization shown in the
Schedule above is considered to be either an Additional Insured under the policy or is entitled to indemnity from
you. No waiver of the right of recovery will directly or indirectly apply to your employees or employees of the
person or organization shown in the Schedule, and we reserve our rights or lien to be reimbursed from any
recovery funds obtained by an injured employee.
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AUTO FIRST CHOICE COVERAGE ENDORSEMENT
TABLE OF CONTENTS
DESCRIPTION PAGE
AirbagCoverage.......................................................................................................................................................3
AutoLoan/Lease Gap Coverage..............................................................................................................................3
BroadForm Insured...............................-..—............................................................................................................1
Concealment, Misrepresentation or Fraud...............................................................................................................5
Deductible................................. ...............................................................................................................................3
Duties in the Event of Accident, Claim, Suit or Loss................................................................................................4
FellowEmployee .................................................................................................................................... .....2
Fire Department Service Charge..............................................................................................................................3
HiredAuto Physical Damage....................................................................................................................................5
Lossof Earnings.......................................................................................................................................................2
Lossof Use Expenses............................................................_........................................._.............................
SupplementaryPayments ........................................................................................................................................2
Transfer of Rights of Recovery Against Others to Us ..............................................................................................4
TransportationExpenses..........................................................................................................................................2
DocuSign Envelope ID:CDB26ED1-82FE-487A-872C-345E8A833228
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
AUTO FIRST CHOICE COVERAGE ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
NOTE; The following are additions, replacements and amendments to the Business Auto Coverage Form, and
will apply unless excluded by separate endorsement(s)to the Business Auto Coverage Form.
With respect to coverages provided by this endorsement, the provisions of the Business Auto Coverage Form
apply unless modified by this endorsement.
The Business Auto Coverage Form is amended as follows:
SECTION II—LIABILITY COVERAGE is amended as follows:
A.1. Who Is An Insured provision is amended by adding the following:
d. Any legally incorporated subsidiary of yours in which you own more than 50% of the voting stock on the
effective date of this coverage form. However, "insured"does not include any subsidiary that is an
"insured"under any other liability policy qr would be an"insured"under such a policy but for its
termination or the exhaustion of its limits of insurance. In order for such subsidiaries to be considered
insured under this policy, you must notify us of such subsidiaries within 60 days of policy effective date.
e. Any organization you newly acquire or form during the policy period, other than a partnership or joint
venture, and over which you maintain sole ownership or a majority interest. However,coverage under
this provision:
(1) Does not apply if the organization you acquire or form is an"insured"under another liability policy
or would be an"insured" under such a policy but for its termination or the exhaustion of its limits of
insurance;
(2) Does not apply to'bodily injury"or"property damage"that occurred before you acquired or formed
the organization,and
(3) Is afforded only for the first 90 days after you acquire or form the organization or until the end of the
policy period, whichever comes first.
f. Any person or organization who is required under a written contract or agreement between you and that
person or organization, that is signed and executed by you before the"bodily injury" or"property
damage"occurs and that is in effect during the policy period, to be named as an additional insured is
an"Insured" for Liability Coverage, but only for damages to which this insurance applies and only to the
extent that person or organization qualifies as an "insured"under the Who Is.An Insured provision
contained in Section II.
g. Any"employee"of yours using:
(1) a covered "auto"you do not own, hire or borrow, or a covered"auto" not owned by an "employees
or a member of his or her household, while performing duties related to the conduct of your
business or your personal affairs; or
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COMMERCIAL AUTO
CAU 058(12 09)
(2) an"auto" hired or rented under a contract or agreement in that"employee's" name,with your
permission,while performing duties related to the conduct of your business. However, your
"employee" does not qualify as an insured under this paragraph (2)while using a covered"auto'
rented from you or from any member of the "employee's" household
h. Your members, if you are a limited liability company, while using a covered"auto"you do not own, hire
or borrow,while performing duties related to the conduct of your business or your personal affairs,
A.2. Coverage Extensions,supplementary Payments a.(2)and a(4)are deleted and replaced with the fallowing:
(2) Up to$3,000 for cost of bail bonds(including bond for related traffic violations) required because of an
"accident"we cover. We do not have to furnish these bonds.
(4) Ail reasonable expenses incurred by the`insured" solely at our request, including actual loss of
earnings up to$500 a day because of time off from work.
B. Exclusions
5_ Fellow Employee
"Bodily injury"to any fellow"employee"of the"insured"arising out of and in the course of a fellow
employee's" employment or while performing duties related to the conduct of your business. However,
this exclusion does not apply to your"employees" that are officers or managers if the"bodily injury"
results from the use of a covered "auto" you own, hire or borrow. Coverage is excess over any other
collectible insurance,
SECTION III—PHYSICAL DAMAGE COVERAGE is amended as follows:
A. 4. Coverage Extensions a. and b. are deleted and replaced with the following:
a. Transportation Expenses;
We will pay up to$75 per day to a total maximum of$2,000 for temporary transportation expense incurred
by you due to covered loss to any covered auto. We will pay only for those covered"autos for which you
carry either Comprehensive or Specified Causes Of Loss Coverage. We will payfor temporary
transportation expenses incurred during the period beginning 24 hours after a loss and ending, regardless
of the policy's expiration,when the covered'auto"is returned to use or we pay for its"loss".
b, Loss of Use Expenses
For Hired Auto Physical Damage,we will pay expenses for which an"insured" becomes legally
responsible to pay for loss of use of a vehicle rented or hired without a driver,under a written rental
contract or agreement, We will pay for loss of use expenses if caused by:
(1) Other than collision only if the Declarations indicate that Comprehensive. Coverage is provided for
hired "autos';
(2) Specified Causes of Loss only if the Declarations indicate that Specified Causes of Loss Coverage
is provided for hired "autos"; or
(3) Collision only V the Declarations indicate that Collision Coverage is provided for hired"autos
However, the most we will pay for any expense_s for loss of use to any one vehicle is$75 per day, to a total
maximum of$2,000.
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COMMERCIAL AUTO
CAU 058(12 09)
B. Exclusions
Paragraph 3. Is replaced with the following:
3. We will not pay for"loss"caused by or resulting from any of the following unless caused by other"loss"
that is covered by this insurance:
a. Wear and tear,freezing, mechanical or electrical breakdown
b. Blowouts, punctures or other road damage to tires
However, this exclusion does not include the discharge of an airbag in a covered"auto' you own that inflates due
to a cause other than a cause of"loss" set forth in Paragraphs A.1.b and A.9.c.but only:
a. If that"auto"is a covered`auto"for Comprehensive Coverage under this policy;
b. The airbags are not covered under any warranty; and
c. The airbags were not intentionally inflated
We will pay up to a maximum of$1,000 for any one"loss".
D. Deductible is replaced with the following:
For each covered "auto', our obligation to pay for, repair, return or replace damaged or stolen property will be
reduced by the applicable deductible shown in the Declarations subject to the following:
Any Comprehensive Coverage deductible shown in the Declarations does not apply to:
(1) "loss"caused by fire or lightning, and no deductible applies to glass damage if the glass is
repaired rather than replaced,
(2) the comprehensive deductible is waived for theft if your vehicle is equipped with an active GPS
tracking system.
The following Coverage Extension is added:
c. Eire Department Service Charge
When a fire department is called to save or protect a covered "auto", its equipment, its contents, or
occupants from a covered cause of loss,we will pay up to$1,000 for your liability for fire department
service charges assumed by contractor or agreement prior to loss.
No deductible applies to this additional coverage.
d. Auto Loan/Lease Gap Coverage
For those businesses not shown in the Declarations as"auto"dealerships,the follovng provisions apply:
(1) If a long term leased "auto", under an original lease agreement, is a covered"auto" under this
Coverage Form and the lessor of the covered "auto' is named as an additional insured under this
policy, in the event of a total loss to the leased covered "auto",we will pay any unpaid amount
due on the lease, less the amount paid under the Physical Damage Coverage Section of the
policy; and less any:
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COMMERCIAL AUTO
CAU 058(12 09)
(a) Overdue lease or loan payments including penalties, interest,or other charges resulting from
overdue payments at to time of the"loss";
(b) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high
mileage;
(c) Security deposits not refunded by the lessor;
(d) Costs for extended warranties,Credit Life Insurance, Health Accident or Disability Insurance
purchased with the loan or lease; and
(e) Carry-over balances from previous leases.
(2) If an owned "auto" is a covered"auto"under this Coverage Form and the loss payee of the
covered auto"is named p loss payee under this policy, in the event of a total lass to the covered
"auto"; we will pay any unpaid amount due on the loan, less the amount paid under the Physical
Damage Coverage Section of the policy;and less any;
(a) Overdue loan payments at the time of the"IoW;
(b) Costs for extended warranties,Credit Life Insurance, Heath Accident or Disability Insurance
purchased with the loan; and
(c) Carry-over balances from previous loans.
SECTION IV BUSINESS AUTO CONDITIONS is amended as follows:
A. Loss Condition$.
2.a. Duties In the Event of Accident, Claim,Suit or Loss is amended to add the following paragraph;
(4) This duty applies when the'accident', claim, "suit"or"loss"is first known to:
(a) You, if you are an individual;
(b) A partner, if you are a partnership;
(c) An executive officer or insurance manager, if you are a corporation; or
(d) A member or manager, if you are a limited liability company.
6. Transfer Of Rights Of Recovery Against Others To Us is replaced with the following:.
If a person or organization to or for whom we make payment under this Coverage Form has rights to
recover damages from another,those rights are transferred to us. That person or organization must do
everything necessary to secure our rights and must do nothing after"accident"or"loss'to impair them-
However, if the insured has waived rights to recover through a written contract,or if your work was
commenced under a letter of intent or work order, subject to a subsequent reduction in writing of such a
waiver with customers whose customary contracts require a waiver,we waive any right of recovery we
may have under this Coverage Form.
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COMMERCIAL AUTO
CAU 058(12 09)
S. General Conditions
2. Concealment, Misrepresentation or Fraud is amended to include the following:
However, if you unintentionally fail to disclose any hazards at the inception of your policy,we will not deny
coverage under this Coverage Form because of such failure. This provision does not affect our right to
collect additional premium or exercise our right of cancellation or non-renewal.
5. Other Insurance-Paragraph b. is replaced as follows:
b. For Hired Auto Physical Damage Coverage,the following are deemed lobe covered "autos"you own;
(1) Any covered auto" you lease, hire, rent or borrow; and
(2) Any covered auto' hired or rented by your"employee" under a contract in that individual
"employee's" name, with your permission, while performing duties related to the conduct of your
business. However, any'auto"that is leased, hired, rented or borrowed with a driver is not a
covered "auto", nor is any"auto"you hire from any of your"employees", partners (if you are a
partnership), members {if you are a limited liability company), or members of their households.
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Insured Name: DICKERSON FENCING CO INC dba
Policy Number: 010-WC14A-71429
Agency Name: 4009, SIA Group Inc
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
SCHEDULE
All persons or organizations that, in a written contract executed by both parties prior to the date of the injury covered
by this policy, require you to obtain this agreement from us.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise noted.
Issued by: National Trust Insurance company 27367
Endorsement dumber: 0000011
Effective Date: 10/2 4/14 Date Issued: 11/12/14
Countersigned by
Authorized Representative
WC 00 03 13
Copyright 1983 National Council on Compensation Insurance
Ezaao1, W4