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2021-242-E-AMS-Summit Design and Engineering Services- PFAP generator design
DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF [Departmental Use Only] TITLE PFAP Generator FY FY2020-2021 NORTH CAROLINA SERVICES AGREEMENT NO RFP/RFQ ORANGE COUNTY This Services Agreement (hereinafter "Agreement"), made and entered into this 17th day of May, 2021, ("Effective Date") by and between Orange County, North Carolina a political subdivision of the State of North Carolina (hereinafter, the "County") and Summit Design and Engineering Services, PLLC, (hereinafter, the 'Provider"). WITNESSETH: That the County and Provider, for the consideration herein named, do hereby agree as follows: 1. Services a. Scope of Work. i) This Agreement is for services to be rendered by Provider to County with respect to (insert type of project): Professional Services for Piedmont Food and Ag Processing for Generator Installation ii) By executing this Agreement, the 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. iii) Time is of the essence with respect to this Agreement. iv) The services to be performed under this Agreement consist of Basic Services, as described and designated in Section 3 hereof. Compensation to the Provider for Basic Services under this Agreement shall be as set forth herein. 2. Responsibilities of the Provider a. Services to be provided. The Provider shall provide the County with all services required in Section 3 to satisfactorily complete the Project within the time limitations set forth herein and in accordance with the highest professional standards. b. Standard of Care. i) The Provider shall exercise reasonable care and diligence in performing services under this Agreement in accordance with the highest generally accepted standards of this type of Provider practice throughout the United States and in accordance with applicable federal, state and local laws and regulations applicable to the performance of these services. Provider is solely responsible for the professional Revised 07/20 1 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF quality, accuracy and timely completion and submission of all work related to the Basic Services. ii) Provider shall be responsible for all errors or omissions of its agents, contractors, employees, or assigns 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. iii) The Provider shall not, except as otherwise provided for in this Agreement, subcontract the performance of any work under this Agreement without prior written permission of the County. No permission for subcontracting shall create, between the County and the subcontractor, any contract or any other relationship. iv) Provider is an independent contractor of County. Any and all employees of the Provider engaged by the Provider in the performance of any work or services required of the Provider under this Agreement, shall be considered employees or agents of the Provider only and not of the County, and any and all claims that may or might arise under any workers compensation or other law or contract on behalf of said employees while so engaged shall be the sole obligation and responsibility of the Provider. v) If activities related to the performance of this Agreement require specific licenses, certifications, or related credentials Provider represents that it or its employees, agents and subcontractors engaged in such activities possess such licenses, certifications, or credentials and that such licenses certifications, or credentials are current, active, and not in a state of suspension or revocation. vi) In determining the Basic Services to be provided, should any documents be referenced in 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. vii) Should this Agreement involve project designs, the construction or creation of which is to be bid out or fulfilled by other contractors, and bidding or negotiation with contractors produce prices which, when added to the other elements of the approved total project cost, produce a cost that is in excess of the approved total project cost, the Provider shall participate with the County in negotiation and design adjustments to the extent such are necessary to obtain prices within the approved total project cost. All activity of the Provider with respect to these matters shall constitute Basic Services and shall be performed by the Provider without additional compensation. If negotiation and design adjustments fail to bring costs within the total project cost the County may reject all bids and Provider will redesign or reduce portions of the project in an effort to reduce the bid prices to within the total project cost and rebid the project. One such redesign is included within Basic Services. If this second letting for bids does not produce bids that are within the approved total project cost initially or after negotiations with the contractor the cost is not reduced to an amount within the total project cost, the Provider is not obligated to engage in further redesign. Revised 07/20 2 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF 3. Basic Services a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows (fully describe services to be provided): Provide Design Development Site Plans, Town Review, Permitting, Construction Administration and Inspections per proposal dated April 8, 2021. 4. Duration of Services a. Term. The term of this Agreement shall be from May 17, 2021 to April 30, 2022. b. Scheduling of Services. i) The Provider shall schedule and perform its activities in a timely manner. ii) Should the County determine that the Provider is behind schedule, it may require the Provider to expedite and accelerate its efforts, including providing additional resources and working overtime, as necessary, to perform its services in accordance with the approved project schedule at no additional cost to the County. iii) The Commencement Date for the Provider's Basic Services shall be May 3, 2021. 5. Compensation a. Compensation for Basic Services. Compensation for Basic Services shall include all compensation due the Provider from the County for all services satisfactorily (as determined by the County) performed pursuant to this Agreement. The maximum amount payable for Basic Services shall not exceed Fifteen Thousand Two Hundred Seventy Dollars ($15,270.00). Payment for satisfactorily performed Basic Services shall become due and payable within thirty (30) days of Provider properly invoicing County. Payment shall be subject to provisions of Section 5(b). b. Disputes. In the event the amount stated on an invoice is disputed by the County, the County may withhold payment of all or a portion of the amount stated on an invoice until the parties resolve the dispute. 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. c. Additional Services. County shall not be responsible for costs related to any services in addition to the Basic Services performed by Provider unless County requests such additional services in writing and such additional services are evidenced by a written amendment to this Agreement. 6. Responsibilities of the County a. Cooperation and Coordination. The County has designated (Angel Barnes) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Revised 07/20 3 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance a. General Requirements. 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 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. 8. Indemnity a. Indemnity. To the extent authorized by North Carolina law the Provider agrees, without limitation, to defend, indemnify and hold harmless the County from all loss, liability, claims or expense, including attorney's fees, arising out of or related to the Project and arising from property damage or bodily injury including death to any person or persons caused in whole or in part by the negligence or misconduct of the Provider except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this provision to require the Provider to indemnify the County to the fullest extent permitted under North Carolina law. 9. Amendments to the Agreement a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional compensation or a change in duration of this Agreement shall be made by a written Amendment to this Agreement executed by the County and the Provider. The Provider shall proceed to perform the Services required by the Amendment only after receiving a fully executed Amendment from the County. 10. Termination a. Termination for Convenience of the County. This Agreement may be terminated without cause by the County and for its convenience upon seven (7) days' prior written notice to the Provider. b. Other Termination. The Provider may terminate this Agreement based upon the County's material breach of this Agreement; provided, the County has not taken all reasonable actions to remedy the breach. The Provider shall give the County seven(7) days'prior written notice of its intent to terminate this Agreement for cause. Either party may terminate this Agreement upon notice to the other party that obligations pursuant to this Agreement are made impractical due to declarations of emergency by Orange County or by North Carolina due to events directly impacting Orange County. Both parties shall Revised 07/20 4 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF remain responsible for all payment and performance due up to the receipt of such notice, but shall have no further obligation or responsibility beyond that date provided the terminating party has taken all reasonable steps to complete the performance of its obligations. c. Compensation After Termination. i) In the event of termination, the Provider shall be paid that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. Upon request of the County, the Provider shall submit to County all relevant documentation, including but not limited to, job cost records, to support its claims for final compensation. ii) Should this Agreement be terminated, the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. d. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. e. Suspension. County may suspend the Basic Services and this Agreement at any time for County's convenience and without penalty to County upon three (3) days' notice to Provider. Upon any suspension by County, Provider shall discontinue work on the Basic Services and shall not resume the Basic Services until notified to proceed by County. 11. Additional Provisions a. Limitation and Assignment. The County and the Provider each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the Provider shall assign or transfer its interest in this Agreement without the written consent of the other. b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are 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 identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. c. Non-Discrimination. 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 Revised 07/20 5 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF and federal non-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy(each policy is incorporated herein by reference and may be viewed at http://www.oran eg countync.gov/departments/purchasing division/contracts.php.) Any violation of the Orange County Non-Discrimination Policy 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. d. 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. e. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. f. Severability. If any provision of this Agreement is held as a matter of law to be unenforceable, the remainder of this Agreement shall be valid and binding upon the Parties. g. Ownership of Work Product. Should Provider's performance of this Agreement generate documents, items or things that are specific to this Project such documents, items or things shall become the property of the County and may be used on any other project without additional compensation to the Provider. The use of the documents, items or things by the County or by any person or entity for any purpose other than the Project as set forth in this Agreement shall be at the full risk of the County. h. 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. It is expressly agreed that County shall not activate this non-appropriation provision for its convenience or to circumvent the requirements of this Agreement, but only as an emergency fiscal measure during a substantial fiscal crisis. In the event of a change in the County's statutory authority, mandate or mandated functions, by state or federal legislative or regulatory action, which adversely affects County's authority to continue its obligations under this Agreement, then this Agreement Revised 07/20 6 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF shall automatically terminate without penalty to County upon written notice to Provider of such limitation or change in County's legal authority. i. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. j. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Provider's Name Attention:AMS Summit Design& P.O. Box 8181 Engineering Services, PLLC Hillsborough,NC 27278 320 Executive Court Hillsborough,NC 27278 [SIGNATURE PAGE TO FOLLOW] Revised 07/20 7 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. ORANGE COUNTY: PROVIDER: Lb;-It- Bonnie 5'g—by: o s' tl by I-N*Ik 5/10/2021 5/6/2021 i5E6Ia.. BP.,f BSE5fi91lia.. Hammersley, County Manager Patrick Cummings, Vice President Printed Name and Title Revised 07/20 8 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA56lB203BF ORANGE COUNTY-DEPARTMENT USE ONLY Party/Vendor Name: Summit Design and Engineering Services Party/Vendor Contact Person: Tim Smith (Tim Smith, PE, PLS <tim.smith(&summitde.net>) Contact Phone: 919.732.3883 Party/Vendor Address: 320 Executive Court City Hillsborough State: NC Zip: 27278 Department: AMS Amount: $15,270.00 Purpose: Generator Design for PFAP Budget Code(s): 34600020-800000-30013 Vendor# 53403 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New ® Renewal ❑ Amendment ❑ Effective Date 5/17/2021 Approved by Board Yes❑No® Agenda Date: This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: D sg gby:Department Director's Signature Date: 5/7/2021 Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: N/A Information Technologies (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficiency of insurance standards,specifications,and requirements: D sg ea by: Office of the Risk Management Office ILlisa(anu$e Date:5/7/2021 �]FDC Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: D sg gbr: 5/10/2021 Office of the Chief Financial Officer[ �"" Date: Legal Services This agreement is approved as to legal form and sufficiency: D 5'g g by: Office of the County Attorney �kniv, Date:5/10/2021 ��m��DDFuesa�g_ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: Revised 07/20 9 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF Revised 07/20 10 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF dr USUMMIT 320 Executive Court, Hillsborough, NC 27278 DESIGN AND ENGINEERING SERVICES Phone // 919.132.3883 Web // www.summitde.net April 8, 2021 (EXHIBIT A) Orange County Attention: AMS P.O. Box 8181 Hillsborough, NC 27278 C/O: Angel Barnes— Capital Projects Manager Reference: Piedmont Food &Ag Processing—Change Order for Generator Installation (Orange County PIN 9874315787) - Hillsborough, North Carolina Dear Angel: SUMMIT is pleased with the opportunity to provide this scope and fee proposal to you for additional Engineering consulting services at the referenced project site. It is our understanding that you are wanting to install an emergency generator pack sufficient to provide power to the facility in the event of a power outage. Per your request the following scope and fees are intended to take the project through the design and permit process with the Town of Hillsborough. These tasks and our proposed full Scope of Work for the project are outlined in the following sections of our proposal. We look forward to continuing to work with you to meet the goals and needs for this facility. A. J A�dry� •� O C`OO�ss, 1101 o PROPOSED NEW GENERATORLOCATiON Project Location Map DocuSign Envelope ID:35DE8770-E58E 4C2C-927C 2DA561B203BF Vw SCOPE OF WORK Task 1 —Design Development/Site Plans: SUMMIT will prepare a Site/Utility Plan drawing specifically for the installation of a new backup generator to serve the building. Following a site inspection and meeting with Gerald Cates from Power Solutions and Eric Hallman,the Executive Director of the PFAP facility, the proposed design location for the generator is near the southwest corner at the rear of the building.This location is adjacent to a rear door and hallway that contains the existing service panel breaker boxes for the building. This proposed location will require the removal of 2 trees near the property line as well as temporarily removing and replacing an existing Duke Energy power line. The Site/Utility Plan will include the plan information needed for the installation of the generator, including any required demolition or temporary removal and replacement of other site features. Following preparation of the design drawings, we will submit to the Town of Hillsborough for review and approval of a Zoning Compliance Permit. For the Site/Utility Plan Design the following deliverables are included with this scope: Deliverables: 1. Detailed Cover Sheet a. Required notes and calculations per the Town of Hillsborough b. Site Data Tables c. Committed elements per the Development Plan 2. Existing Conditions and Demolition Plan Sheet a. Existing site data table b. Required notes, calculations and labels per the Review Checklist c. Existing site conditions/items to be demolished. 3. Site/Utility Plan a. Required notes and labels per the Review Checklist b. Utility information specifically related to the design and installation/replacement of the new grease interceptors. 4. Site/Utility Details a. Site and utility details as related specifically to the proposed work for the project. All drawings will be provided in AutoCAD format. SUMMIT will coordinate with the Town of Hillsborough Planning and the Town of Hillsborough Utilities Division as needed for plan reviews. Meetings and Coordination - On-going meetings and coordination with the Client, project team and reviewing agencies will be required throughout this phase. A total of two meetings for two staff members have been included for this phase of work. DocuSign Envelope ID:35DE8770-E58E 4C2C-927C 2DA561B203BF Task 2—Zoning Permit Review Process: SUMMIT will follow up with the Town of Hillsborough planning staff to obtain receipt of comments from the various Town departments. Upon receipt of the review letter/comments, SUMMIT will prepare revised plans and comment responses and submit back to the Town of Hillsborough for action/approval. For this TASK, SUMMIT will respond to two (2) review cycles. Any additional meetings or revisions required for subsequent review cycles will be done on a time- and-material basis according to the attached Schedule of Standard Rates. Task 3—Permitting: We anticipate that the following permits will be required as part of the Site Plan and Construction Drawings approval process and will be needed for construction of the project. SUMMIT will prepare and submit the applications to be reviewed by each authority.The scope of work for this task also includes plan/application revisions as may be requested from each authority for minor changes to the plans and documents. Any major changes or requests will be done on a time-and- material basis according to the attached Schedule of Standard Rates. • Town of Hillsborough Site Plan & Zoning Permits o SUMMIT will provide the required information for the Site/Zoning Permit application as required by the Town of Hillsborough. These are the only Site Design permits anticipated at this time. If during the review process it is determined that other permits will be required, we will provide those services according to our Schedule of Standard Rates or per an approved Change Order. Task 4—Construction Administration: Construction Administration services during the construction phase of the project including intermittent site inspections (up to 4 inspections total), answer miscellaneous questions from the contractor, review materials submittals from the contractor, coordinate as needed with the Town of Hillsborough and answer questions from the owner/client. This task will be done on a time- and-material, not to exceed, basis according to the attached Schedule of Standard Rates. Any additional work will be approved via Change Order. DocuSign Envelope ID:35DE8770-E58E 4C2C-927C 2DA561B203BF Ww ASSUMPTIONS & EXCLUSIONS 1. No bidding assistance is provided. 2. No liability is assumed for the accuracy of other consultant's work or information provided by the Owner used in the production of our documents. 3. The Owner will pay all regulatory application/permitting/filing/recording fees, either directly or as reimbursable expense. These fees are not included in this proposal. 4. All utility design other than domestic water, sanitary sewer and stormwater shall be designed by others. ADDITIONAL SERVICES Any item not contained in the scope of services or items as exclusions will be deemed as Additional Services. Additional Services will be provided if requested by the Client for a negotiated lump sum fee or at our Standard Hourly Billing Rates. CLIENT RESPONSIBILITIES It shall be the responsibility of the Client to provide the following items: 1. Access to the site. 2. Any other electronic information that has been obtained or developed for the site, including all survey and environmental information PDF and AutoCAD versions as applicable. 3. Payment of all required permit and review fees 4. Decisions on critical design issues as necessary in a timely manner. 5. Payment of all invoices per Conditions of the Agreement. Note: Please see attached separate documentation from Power Solutions for the Generator and Automatic Power Switch specifications and fee proposal for the installation of the unit. (Fee quote of$294,782.60) DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF COMPENSATION SUMMIT agrees to provide professional services as outlined above in the Scope of Services. Our fee proposal is based on man-hour projections and applicable billing rates for the scope of work and schedule as described and anticipated for this project. SUMMIT proposes a lump sum fee to be invoiced monthly on a percent complete basis with payment due upon receipt. SCOPE OF SERVICES FEE TASK 1— Design Development Site Plans $6,520 TASK 2 —Town Review Process $2,500 TASK 3 — Permitting $2,500 TASK 4—Construction Administration and Inspections $3,750 (T&M) TOTAL FEES FOR SUMMIT DESIGN AND ENGINEERING $15,270 Reimbursable expenses shall be paid in accordance with the Rate Schedule and General Conditions, as attached hereto. CONCLUSION This document may serve as an Owner-Consulting Engineers Agreement. Included in the agreement are the standard Hourly Rate Schedule and Conditions of the Agreement. If this proposal is acceptable, please execute and return a copy of the Agreement to this office. Do not hesitate to contact us if you have any questions regarding our proposal. Please give us the opportunity to clarify any details of this proposal or to revise this proposal if it appears that we misunderstood some portion of the scope of services. Respectfully submitted: SUMMIT DESIGN AND ENGINEERING SERVICES, PLLC Timothy A. Smith, PLS, PE Senior Project Manager Attachments: Power Solutions Scope and Fee Proposal Power Solutions Submittal Specifications DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF 704/05/2021 E(MM/DD/YYYY) AC®R®® CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Scott LaNier NAME: Colonial Insurance Agency Hillsborough AICNN EXt: (919)732-2191 A/C No): (919)732-2192 103 Millstone Dr. Suite A E-MAIL scoff colonial-a en ADDRESS: C� g GY.com Po Box 490 INSURER(S)AFFORDING COVERAGE NAIC# Hillsborough NC 27278 INSURER ; Starr Surplus Lines Ins.Co. 13604 INSURED INSURER B Summit Design And Engineering Services, PLLC INSURER C 320 Executive Court INSURER D INSURER E Hillsborough NC 27278 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DDIYYYY Y MM/DD/Y Y LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TTE CLAIMS-MADE OCCUR PREM SESOE.olccurence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO ❑ LOC PRODUCTS-COMP/OPAGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE F ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 0FFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Professional, E&O Contractors Occurence 5,000,000 A Pollution Liability N N SLSL-PRO-262380-21 04/02/2021 04/02/2022 Aggregate 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Asset Management Services ACCORDANCE WITH THE POLICY PROVISIONS. PO Bmc 8181 AUTHORIZED REPRESENTATIVE '}' Hillsborough NC 27278 Fax: Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF DATE(MM/DDNYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 04/28/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Crystal Perry NAME: Business Insurers of Carolinas aCC Ext: (919)968-4611 AIX No): (919)968-8991 501 Eastowne Drive,Suite 250 E-MAIL c er business-insurers.com ADDRESS: p ry@ PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515 INSURERA: Travelers Indemnity 25658 INSURED INSURER B: Travelers Property Cas Cc of America 36161 Summit Design and Engineering Services PLLC INSURER C: Accident Fund General Ins Cc 12304 320 Executive Court INSURER D: INSURER E: Hillsborough NC 27278 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2132331060 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PRIM SES Ea oNcE ence $ 300,000 MED EXP(Any one person) $ 10,000 A Y 6304KO89149 01/01/2021 01/01/2022 PERSONAL&ADV INJURY $ 1,000,000 MOTHER LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED Y 810-2J958216 04/02/2021 04/02/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident X UMBRELLA LIAB M OCCUR EACH OCCURRENCE $ 6,000,000 B EXCESS LABCLAIMS-MADE CUP51<458639 01/01/2021 01/01/2022 AGGREGATE $ 6,000,000 DED I X1 RETENTION $ 10,000 $ WORKERS COMPENSATION X1 STATUTE X ER PERH AND EMPLOYERS'LIABILITY Y/N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ C OFFICER/MEMBEREXCLUDED? NIA Y WCV6179537 01/01/2021 01/01/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Excess/Umbrella over GL,AU,WC DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is included as Additional Insured with regards to General Liability and Auto Liability as required by written contract. Waiver of subrogation in favor of certificate holder as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Orange County Asset Management ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 AUTHORIZED REPRESENTATIVE Hillsborough NC 27278 n (� ©1988-20155 Attl��C..--O�ORRD1 CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF Additional Named Insureds Other Named Insureds Subtec Explorations Doing Business As Subtec Explorations Doing Business As Subtec Explorations Doing Business As OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA56lB203BF Policy 810-2J958216 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. BROAD FORM NAMED INSURED H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF B. BLANKET ADDITIONAL INSURED USE—INCREASED LIMIT C. EMPLOYEE HIRED AUTO I. PHYSICAL DAMAGE — TRANSPORTATION EXPENSES—INCREASED LIMIT D. EMPLOYEES AS INSURED J. PERSONAL PROPERTY E. SUPPLEMENTARY PAYMENTS — INCREASED K. AIRBAGS LIMITS L. NOTICE AND KNOWLEDGE OF ACCIDENT OR F. HIRED AUTO — LIMITED WORLDWIDE COV- LOSS ERAGE—INDEMNITY BASIS M. BLANKET WAIVER OF SUBROGATION G. WAIVER OF DEDUCTIBLE—GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS PROVISIONS A. BROAD FORM NAMED INSURED this insurance applies and only to the extent that The following is added to Paragraph A.1., Who Is person or organization qualifies as an "insured" An Insured, of SECTION II —COVERED AUTOS under the Who Is An Insured provision contained LIABILITY COVERAGE: in Section II. Any organization you newly acquire or form dur- C. EMPLOYEE HIRED AUTO ing the policy period over which you maintain 1. The following is added to Paragraph A.1., 50% or more ownership interest and that is not Who Is An Insured, of SECTION II — COV- separately insured for Business Auto Coverage. ERED AUTOS LIABILITY COVERAGE: Coverage under this provision is afforded only un- An "employee" of yours is an "insured" while til the 180th day after you acquire or form the or- operating an "auto" hired or rented under a ganization or the end of the policy period, which- contract or agreement in an "employee's" ever is earlier. name, with your permission, while performing duties related to the conduct of your busi- B. BLANKET ADDITIONAL INSURED ness. The following is added to Paragraph c. in A.1., 2. The following replaces Paragraph b. in B.5., Who Is An Insured, of SECTION II — COVERED Other Insurance, of SECTION IV — BUSI- AUTOS LIABILITY COVERAGE: NESS AUTO CONDITIONS: Any person or organization who is required under b. For Hired Auto Physical Damage Cover- a written contract or agreement between you and age, the following are deemed to be cov- that person or organization, that is signed and ered "autos" you own: executed by you before the "bodily injury" or (1) Any covered "auto" you lease, hire, "property damage" occurs and that is in effect rent or borrow; and during the policy period, to be named as an addi- (2) Any covered "auto" hired or rented by tional insured is an "insured" for Covered Autos your "employee" under a contract in Liability Coverage, but only for damages to which an "employee's" name, with your CA T3 53 02 15 ©2015 The Travelers Indemnity Company.All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office,Inc.with its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF COMMERCIAL AUTO permission, while performing duties (a) With respect to any claim made or "suit" related to the conduct of your busi- brought outside the United States of ness. America, the territories and possessions However, any "auto"that is leased, hired, of the United States of America, Puerto rented or borrowed with a driver is not a Rico and Canada: covered "auto". (i) You must arrange to defend the "in- D. EMPLOYEES AS INSURED sured" against, and investigate or set- tle any such claim or "suit" and keep The following is added to Paragraph A.1., Who Is us advised of all proceedings and ac- An Insured, of SECTION II —COVERED AUTOS tions. LIABILITY COVERAGE: Any "employee (ii) Neither you nor any other involved of yours is an Insured" while us- "insured" will make any settlement ing a covered "auto"you don't own, hire or borrow without our consent. in your business or your personal affairs. (iii)We may, at our discretion, participate E. SUPPLEMENTARY PAYMENTS — INCREASED in defending the "insured" against, or LIMITS in the settlement of, any claim or 1. The following replaces Paragraph A.2.a.(2), "suit". of SECTION II — COVERED AUTOS LIABIL- (iv)We will reimburse the "insured" for ITY COVERAGE: sums that the "insured" legally must (2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily cluding bonds for related traffic law viola- injury" or"property damage" to which tions) required because of an "accident" this insurance applies, that the "in- we cover. We do not have to furnish sured" pays with our consent, but these bonds. only up to the limit described in Para- 2. The following replaces Paragraph A.2.a.(4), graph C., Limits Of Insurance, of of SECTION II — COVERED AUTOS LIABIL- SECTION II — COVERED AUTOS ITY COVERAGE: LIABILITY COVERAGE. (4) All reasonable expenses incurred by the (v) We will reimburse the "insured" for "insured" at our request, including actual the reasonable expenses incurred loss of earnings up to $500 a day be- with our consent for your investiga- cause of time off from work. tion of such claims and your defense of the "insured" against any such F. HIRED AUTO — LIMITED WORLDWIDE COV- "suit", but only up to and included ERAGE—INDEMNITY BASIS within the limit described in Para- The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of graph B.7., Policy Period, Coverage Territory, SECTION II — COVERED AUTOS of SECTION IV — BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in TIONS: addition to such limit. Our duty to (5) Anywhere in the world, except any country or make such payments ends when we jurisdiction while any trade sanction, em- have used up the applicable limit of bargo, or similar regulation imposed by the insurance in payments for damages, United States of America applies to and pro- settlements or defense expenses. hibits the transaction of business with or (b) This insurance is excess over any valid within such country or jurisdiction, for Cov- and collectible other insurance available ered Autos Liability Coverage for any covered to the "insured" whether primary, excess, "auto" that you lease, hire, rent or borrow contingent or on any other basis. without a driver for a period of 30 days or less (c) This insurance is not a substitute for re- and that is not an auto" you lease, hire, rent or borrow from any of your "employees", quired or compulsory insurance in any country outside the United States, its ter- partners (if you are a partnership), members ritories and possessions, Puerto Rico and (if you are a limited liability company) or Canada. members of their households. Page 2 of 4 ©2015 The Travelers Indemnity Company.All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office,Inc.with its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF COMMERCIAL AUTO You agree to maintain all required or (2) In or on your covered "auto". compulsory insurance in any such coun- This coverage applies only in the event of a total try up to the minimum limits required by theft of your covered "auto". local law. Your failure to comply with No deductibles apply to this Personal Property compulsory insurance requirements will coverage. not invalidate the coverage afforded by this policy, but we will only be liable to the K. AIRBAGS same extent we would have been liable The following is added to Paragraph B.3., Exclu- had you complied with the compulsory in- sions, of SECTION III — PHYSICAL DAMAGE surance requirements. COVERAGE: (d) It is understood that we are not an admit- Exclusion 3.a. does not apply to "loss" to one or ted or authorized insurer outside the more airbags in a covered "auto" you own that in- United States of America, its territories flate due to a cause other than a cause of "loss" and possessions, Puerto Rico and Can- set forth in Paragraphs A.1.b. and A.1.c., but ada. We assume no responsibility for the only: furnishing of certificates of insurance, or a. If that "auto" is a covered "auto" for Compre- for compliance in any way with the laws hensive Coverage under this policy; of other countries relating to insurance. b. The airbags are not covered under any war- G. WAIVER OF DEDUCTIBLE—GLASS ranty; and The following is added to Paragraph D., Deducti- c. The airbags were not intentionally inflated. ble, of SECTION III — PHYSICAL DAMAGE We will pay up to a maximum of $1,000 for any COVERAGE: one 'loss". No deductible for a covered "auto" will apply to L. NOTICE AND KNOWLEDGE OF ACCIDENT OR glass damage if the glass is repaired rather than LOSS replaced. The following is added to Paragraph A.2.a., of H. HIRED AUTO PHYSICAL DAMAGE — LOSS OF SECTION IV—BUSINESS AUTO CONDITIONS: USE—INCREASED LIMIT Your duty to give us or our authorized representa- The following replaces the last sentence of Para- tive prompt notice of the "accident" or 'loss" ap- graph A.4.b., Loss Of Use Expenses, of SEC- plies only when the "accident" or 'loss" is known TION III—PHYSICAL DAMAGE COVERAGE: to: However, the most we will pay for any expenses (a) You (if you are an individual); for loss of use is $65 per day, to a maximum of (b) A partner(if you are a partnership); $750 for any one "accident'. I. PHYSICAL DAMAGE — TRANSPORTATION (c) ember (if you are a limited liability com- pan Y): EXPENSES—INCREASED LIMIT (d) An executive officer, director or insurance The following replaces the first sentence in Para- manager(if you are a corporation or other or- graph A.4.a., Transportation Expenses, of ganization); or SECTION III — PHYSICAL DAMAGE COVER- (e) Any "employee" authorized by you to give no- AGE: tice of the "accident' or"loss". We will pay up to $50 per day to a maximum of M. BLANKET WAIVER OF SUBROGATION $1,500 for temporary transportation expense in- The following replaces Paragraph A.5., Transfer curred by you because of the total theft of a cov- Of Rights Of Recovery Against Others To Us, ered "auto"of the private passenger type. of SECTION IV — BUSINESS AUTO CONDI- J. PERSONAL PROPERTY TIONS: The following is added to Paragraph A.4., Cover- 5. Transfer Of Rights Of Recovery Against age Extensions, of SECTION III — PHYSICAL Others To Us DAMAGE COVERAGE: We waive any right of recovery we may have Personal Property against any person or organization to the ex- tent required of you by a written contract We will pay up to $400 for 'loss" to wearing ap- signed and executed prior to any "accident' parel and other personal property which is: or"loss", provided that the "accident' or"loss" (1) Owned by an "insured"; and arises out of operations contemplated by CA T3 53 02 15 ©2015 The Travelers Indemnity Company.All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance Services Office,Inc.with its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF COMMERCIAL AUTO such contract. The waiver applies only to the The unintentional omission of, or unintentional person or organization designated in such error in, any information given by you shall not contract. prejudice your rights under this insurance. How- N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col- The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of cealment, Misrepresentation, Or Fraud, of cancellation or non-renewal. SECTION IV— BUSINESS AUTO CONDITIONS: Page 4 of 4 ©2015 The Travelers Indemnity Company.All rights reserved. CA T3 53 02 15 Includes copyrighted material of Insurance Services Office,Inc.with its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF Policy 6304KOB9149 COMMERCIAL GENERAL LIABILITY THIS ENDORSMENT CHANGES THE POLCY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY-CONTRACTORS COVERAGE PART 1) WHO IS AN INSURED — (Section II) is drawings, opinions, reports, surveys, amended to include any person or ffeld orders, change orders, or drawings organization you are required to include as an and specifications;and additional insured on this policy by a written contract or written agreement In effect during ii) Supervisory or inspection activities this policy period and signed and executed by performed as part of any related you prior to the loss for which coverage is architectural or engineering activities. sought. The person or organization does not qualify,as an additional insured with respect to c) This insurance does not apply to "bodily the independent acts or omissions of such injury' or "property damage" caused by person or organization. The person or "your work" included in the "products- organization is only an additional insured with completed operations hazard" unless you respect to liability caused by "your work" for are required to provide such coverage for that additional Insured. the additional insured by a written contract or written agreement in effect during this 2) The insurance provided to the additional policy period and signed and executed by insured is limited as follows: you prior to the loss for which coverage is sought and then only for the period of time a) In the event that the limits of liability stated required by such contract or agreement and in the policy exceed the limits of liability in no event beyond the expiration date of the required by a written contract or written policy. agreement In effect during this policy period and signed and executed by you 3) Subpart (1)(a) of the Pollution exclusion under prior to the loss for which coverage is Paragraph 2., Exclusions of Bodily Injury and sought, the insurance provided by this Property Damage Liability Coverage(Section I— endorsement shall be limited to the limits Coverages) does not apply to you If the 'bodily of liability required by such contract or injury" or "property damage" arises out of"your agreement. This endorsement shall not work' performed on premises which are owned increase the limits stated in Section III- or rented by the additional insured at the time LIMITS OF INSURANCE. "your work"is performed. b) The insurance provided to the additional 4) Any coverage provided by this endorsement to insured does not apply to"bodily injury"or an additional insured shall be excess over any "advertising Injury" arising out of an other valid and collectible insurance available to architect's, engineer's or surveyor's the additional insured whether primary, excess, rendering of or failure to render any contingent or on any other basis unless a written professional services Including: contract or written agreement in effect during this policy period and signed and executed by €) The preparing, approving or failing to you prior to the loss for which coverage is prepare or approve maps, shop sought specifically requires that this insurance Copyright,The Travelers Indemnity Company, 2002 CG D2 46 10 02 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF apply on a primary or non-contributory basis. c) Tender the defense and Indemnity of any When this insurance is primary and there is claim or "suit" to any other insurer which other insurance available to the additional insured also Insures against a loss we cover under from any source, we will share with that other this endorsement. This includes, but is not insurance by the method described in the policy. limited to, any insurer which has issued a policy of insurance in which the additional 5) As a condition of coverage, each additional insured qualifies as an insured. For insured must: purposes of this requirement, the term "insures against"refers to any self-insurance and to any insurer which issued a policy of a) Give us prompt written notice of an insurance that may provide coverage for the "occurrence" or offences which may result loss, regardless of whether the additional In a claim and prompt written notice of insured has actually requested that the "suit". insurer provide the additional insured with a defense and/or indemnity under that policy b) Immediately forward all legal papers to us, of insurance. cooperate in the investigation or settlement of the claim or defense against d) Agree to make available any other insurance the "suit," and otherwise comply with that the additional insured has for a loss we policy conditions. cover under this endorsement. Copyright,The Travelers Indemnity Company, 2002 CG D2 46 10 02 DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF Policy 6304KO89149 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTEND ENDORSEMENT FOR COMMERCIAL INDUSTRIES This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE—This endorsement broadens coverage.However,coverage for any injury, damage or medical expenses described In any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part,and these coverage broadening provisions do not apply to the extent that coverage Is excluded or limited by such an endorsement.The following listing Is a general cover- age description only.Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights,duties,and what is and is not covered. A. Broadened Named Insured J. Bodily Injury To Co-Employees And Co-Volunteer B. Blanket Additional Insured—Broad Form Vendors Workers C. Damage To Premises Rented To You K. Aircraft Chartered With Crew • Perils of fire, explosion, lightning, smoke, L. Non-Owned Watercraft—Increased From 25 Feet water To 50 Feet • Limit increased to$300,000 M. Increased Supplementary Payments D. Blanket Waiver Of Subrogation • Cost of bail bonds increased to$2,500 E. Blanket Additional Insured — Owners, Managers • Loss of eamings increased to$500 per day Or Lessors Of Premises F. Blanket Additional Insured — Lessors Of Leased N. Medical Payments-Increased Limit Equipment O. Knowledge And Notice Of Occurrence Or Offense G. Incidental Medical Malpractice P. Unintentional Omission H. Personal injury—Assumed By Contract Q. Reasonable Force — Bodily Injury Or Property I. Amended Bodily Injury Definition Damage PROVISIONS B. BLANKET ADDITIONAL INSURED — BROAD A. BROADENED NAMED INSURED FORM VENDORS 1. The following Is added to SECTION II—WHO The following is added to SECTION II —WHO IS IS AN INSURED: AN INSURED: Any organization, other than a partnership or Any person or organization that is a vendor and joint venture,over which you maintain owner- that you have agreed in a written contract or ship or majority Interest on the effective date agreement to include as an additional insured on of the policy qualifies as a Named Insured. this Coverage Part is an Insured,but only with re- However, coverage for any such organization spect to liability for 'bodily injury' or "property will cease as of the date during the policy pa- damage"that: riod that you no longer maintain ownership of, a. Is caused by an'occurrence'that takes place or majority interest In,such organization. after you have signed and executed that con- 2. The following replaces Paragraph 4.a. of tract or agreement;and SECTION 11—WHO IS AN INSURED: a. Coverage under this provision is afforded b. Arises out of 'your products' which are dis- only until the 180th day after you acquire tributed or sold in the regular course of such or form the organization or the end of the vendor's business. policy period,whichever is earlier, unless The Insurance provided to such vendor Is subject reported in writing to us within 180 days. to the following provisions: CG D4 56 0713 0 2013 The Travelers Indemnity Company.All rights reserved. Page 1 of 7 Includes copyrighted material of Insurance services Office,Inc,with its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA56lB203BF COMMERCIAL GENERAL LIABILITY a. The limits of insurance provided to such ven- JURY AND PROPERTY DAMAGE LIABIL- dor will be the limits which you agreed to pro- ITY: vide in the written contract or agreement, or Exclusions c.through n.do not apply to dam- the limits shown In the Declarations of this age to premises while rented to you, or tem- Coverage Part,whichever are less. poradly occupied by you with permission of b. The insurance provided to such vendor does the owner,caused by: not apply to: a. Fire; (1) 'Bodily injury" or 'property damage" for b. Explosion; which the vendor Is obligated to pay c. Lightning; damages by reason of the assumption of liability in a contract or agreement. This d. Smoke resulting from such fire,explosion, exclusion does not apply to liability for or lightning;or damages that the vendor would have in e. Water. the absence of the contract or agreement; A separate limit of insurance applies to such (2) Any express warranty unauthorized by damage to premises as described in Para- you; graph 6.of Section III—Limits Of Insurance. (3) Any physical or chemical change in'your This Insurance does not apply to damage to products° made Intentionally by such premises while rented to you, or temporarily vendor, occupied by you with permission of the (4) Repackaging, unless unpacked solely far owner,caused by- the purpose of Inspection,demonstration, a. Rupture, bursting, or operation of pres- testing, or the substitution of parts under sure relief devices; Instructions from the manufacturer, and then repackaged in the original container, b. Rupture or bursting due to expansion or (S) Any failure to make such Inspections,ad- swelling of the contents of any building or structure, caused by or resulting from wa- justments, tests or servicing as vendors ter; agree to perform or normally undertake to perform in the regular course of business, c. Explosion of steam boilers, steam pipes, in connection with the distribution or sale steam engines,or steam turbines. of'your products% 2. The following replaces Paragraph 6. of SEC- (6) Demonstration, installation, servicing or TION III—LIMITS OF INSURANCE: repair operations, except such operations Subject to 5. above, the Damage To Prem- performed at such vendor's premises in Ises Rented To You Limit is the most we will connection with the sale of "your prod- pay under Coverage A for damages because ucts';or of "property damage" to any one premises (7) 'Your products'which,after distribution or while rented to you, or temporarily occupied sale by you, have been labeled or rela- by you with permission of the owner, caused beled or used as a container, part or in- by fire; explosion; lightning smoke resulting gredient of any other thing or substance from such fire, explosion, or lightning; or wa- by or for such vendor. ter. The Damage To Premises Rented To Coverage under this provision does not apply to: You Limit will apply to all damage proximately a. Any person or organization from whom you caused by the same "occurrence', whether have acquired 'your products', or any ingre- such damage results from fire; explosion; dient, part or container entering into, accom- lightning; smoke resulting from such fire, ex- panying or containing such products;or plosion, or lightning; water, or any combina- b. Any vendor for which coverage as an addi- tion of any of these. tonal insured specifically is scheduled by en- The Damage To Premises Rented To You dorsement Limit will be the higher of: C. DAMAGE TO PREMISES RENTED TO YOU a. $300,000;or 1. The following replaces the last paragraph of b. The amount shown on the Declarations of Paragraph 2., Exclusions, of SECTION I — this Coverage Part for Damage To Prem- COVERAGES—COVERAGE A BODILY IN- Ises Rented To You Limit Page 2 of 7 ®2013 The Travelers Indemnity Company.All rights reserved. CG D4 58 07 13 Includes copyrighted material of Insurance services Office,Inc.with Its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF COMMERCIAL GENERAL LIABILITY 3. The following replaces Paragraph a, of the a. is"bodily injury'or"property damage"caused definition of'Insured contract' in the DEFINI- by an "occurrence" that takes place, or"per- TIONS Section: sonal injury"or"advertising injury"caused by a. A contract for a lease of premises. How- an offense that is committed, after you have ever, that portion of the contract for a signed and executed that contract or agree- lease of premises that Indemnifies any ment;and person or organization for damage to b. Arises out of the ownership, maintenance or premises while rented to you, or tempo- use of that part of any premises leased to racily occupied by you with permission of you. the owner,caused by: The insurance provided to such premises owner, (1) Fire; manager or lessor is subject to the following pro- visions: (2) Explosion; a. The limits of insurance provided to such (3) Lightning; premises owner, manager or lessor will be (4) Smoke resulting from such fire, ex- the limits which you agreed to provide in the plosion,or lightning;or written contract or agreement, or the limits (5) Water. shown on the Declarations of this Coverage Part,whichever are less. is not an"insured contract'; b. The Insurance provided to such premises 4. The following replaces Paragraph 4.b.(1)(b) owner,manager or lessor does not apply to: of SECTION IV—COMMERCIAL GENERAL (1) "Bodily injury" or "property damage" LIABILITY CONDITIONS: caused by an "occurrence" that takes (b) That is Insurance for premises rented to place, or"personal injury" or "advertising you, or temporarily occupied by you with injury'caused by an offense that is com- the permission of the owner, miffed, after you cease to be a tenant In D. BLANKET WAIVER OF SUBROGATION that premises;or The following is added to Paragraph 8., Transfer (2) Structural alterations, new construction ordemolition operations performed by or on Of Rights Of Recovery Against Others To Us, behalf of such premises owner, manager of SECTION IV— COMMERCIAL GENERAL LI- or lessor. ABILITY CONDITIONS: c. The insurance provided to such premises We waive any right of recovery we may have owner, manager or lessor is excess over any against any person or organization because of valid and collectible other insurance available payments we make for injury or damage arising to such premises owner, manager or lessor, out of premises owned or occupied by or rented unless you have agreed in a written contract or loaned to you; ongoing operations performed for this insurance to apply on a primary or by you or on your behalf, done under a contract contributory basis. with that person or organization; "your work"; or F. BLANKET ADDITIONAL INSURED—LESSORS "your products". We waive this right where you OF LEASED EQUIPMENT have agreed to do so as part of a written contract, The following is added to SECTION 11—WHO IS executed by you prior to loss. AN INSURED: E. BLANKET ADDITIONAL INSURED—OWNERS, Any OR LESSORS OF PREMISES lessor person or organization that is an equipment lessor and that you have agreed in a written con- The following is added to SECTION II—WHO IS tract or agreement to include as an additional in- AN INSURED: sured on this Coverage Part is an insured, but Any person or organization that is a premises only with respect to liability for `bodily injury. (property damage", "personal injury' or "advertis- owner, manager or lessor and that you have agreed in a written contract or agreement to ng injury"that name as an additional Insured on this Coverage a. Is'bodily injury" or"property damage'caused Part is an insured, but only with respect to liability by an 'occurrence' that takes place, or"per- for "bodily Injury", 'property damage', "personal sonal injury" or"advertising injury"caused by Injury"or'advertising Injury"that: an offense that is committed, after you have CG D4 58 0713 020113 The Travelers Indemnity Company.All rights reserved. Page 3 of 7 Includes copyrighted material of Insurance Services Office,Inc.with Its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA56lB203BF COMMERCIAL GENERAL LIABILITY signed and executed that contract or agree- 3. The following is added to Paragraph 2.a.(1)of ment;and SECTION II—WHO IS AN INSURED: b. Is caused, In whole or in part,by your acts or Unless you are In the business or occupation emissions in the maintenance, operation or of providing professional health care services, use by you of equipment leased to you by Paragraphs (1)(a), (b), (c) and (d) above do such equipment lesson not apply to any "bodily Injury' arising out of The insurance provided to such equipment lessor any providing or failing to provide 'Incidental medical services"by any of your"employees', is subject to the following provisions: other than an employed doctor. Any such a. The limits of Insurance provided to such "employees" providing or falling to provide equipment lessor will be the limits which you 'incidental medical services'during their work agreed to provide in the written contract or hours for you will be deemed to be acting agreement, or the limits shown on the Decla- within the scope of their employment by you rations of this Coverage Part, whichever are or performing duties related to the conduct of less. your business. b. The insurance provided to such equipment 4. The following exclusion is added to Para- lessor does not apply to any"bodily Injury"or graph 2., Exclusions, of SECTION I—COV- "property damage°caused by an'occurrence" ERAGES—COVERAGE A BODILY INJURY that takes place, or "personal Injury' or 'ad- AND PROPERTY DAMAGE LIABILITY: vertising injury' caused by an offense that is Sale Of Pharmaceuticals committed,after the equipment lease expires. "Bodily injury" or 'property damage' arising c. The Insurance provided to such equipment out of the willful violation of a penal statute or lessor is excess over any valid and collectible ordinance relating to the sale of pharmaceut- other insurance available to such equipment Gals committed by, or with the knowledge or lessor, unless you have agreed in a written consent of,the insured. contract for this insurance to apply on a pri- S. The following is added to Paragraph 5. of mary or contributory basis. SECTION III—LIMITS OF INSURANCE: G. INCIDENTAL MEDICAL MALPRACTICE For the purposes of determining the applica- 1. The following Is added to the definition of'oc- ble Each Occurrence Limit, all related acts or omissions committed in the providing or fail- currence'in the DEFINITIONS Section: ing to provide'incidental medical services"to Unless you are in the business or occupation any one person will be considered one "oc- of providing professional health care services, currence'. 'occurrence' also means an act or omission 6. The following is added to Paragraph 4.b., Ex- committed in providing or failing to provide cess Insurance, of SECTION IV — COM- 'incidental medical services'to a person. MERCIAL GENERAL LIABILITY CONDI- 2, The following is added to the DEFINITIONS TIONS: Section: This insurance is excess over any valid and "Incidental medical services"means: collectible other insurance, whether primary, excess,contingent or on any other basis,that a. Medical,surgical,dental,laboratory,x-ray is ava€table to any of your "employees' for or nursing service or treatment, advice or "bodily injury' that arises out of providing or instruction, or the related furnishing of failing to provide"incidental medical services" food or beverages; to any person to the extent not subject to b. The furnishing or dispensing of drugs or Paragraph 2.a.(1) of SECTION II —WHO IS medical, dental, or surgical supplies or AN INSURED. appliances; H. PERSONAL INJURY — ASSUMED BY CON- c. First aid;or TRACT d. "Good Samaritan services". 1. The following replaces Exclusion e.,Contrac- tual Liability, in Paragraph 2. of SECTION I 'Good Samaritan services" means any emer- — COVERAGES — COVERAGE B PER- gency medical services for which no compen- SONAL AND ADVERTISING INJURY LI- sation is demanded or received. ABILITY: Page 4 of 7 ®2013 The Travelers Indemnity Company.All rights reserved. CG D4 58 07 13 Includes copyrighted material of Insurance Services Office,Inc.with its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF COMMERCIAL GENERAL LIABILITY e. Contractual Liability the insured and the interests of the in- 'Personal Injury"or"advertising injury"for demnitee; which the insured is obligated to pay 4. The following replaces the first subparagraph damages by reason of the assumption of of Paragraph f. of the definition of "insured liability in a contract or agreement. This contract'in the DEFINITIONS Section: exclusion does not apply to: f. That part of any other contract or agree- (1) Liability for damages that the Insured ment pertaining to your business (includ- would have in the absence of the €ng an Indemnification of a municipality in contract or agreement;or connection with work performed for a (2) Liability for damages because of municipality)under which you assume the tort liability of another party to pay for "personal injury" assumed in a can- "bodily Injury,""property damage"or"per- tract or agreement that is an "Insured sonal injury"to a third person or organiza- contracr, provided that the"personal don. Tort liability means a liability that Injury" is caused by an offense com- would be imposed by law In the absence mitted subsequent to the execution of of any contract or agreement the contract or agreement. Solely for 1. AMENDED BODILY INJURY DEFINITION the purposes of liability assumed in an "insured contracf, reasonable at- The following replaces the definitlon of"bodily€n- torneys fees and necessary litigation jury"in the DEFINITIONS Section: expenses incurred by or for a party "Bodily Injury" means bodily Injury, mental an- other than an insured will be deemed guish, mental injury, shock, fright, disability, hu- to be damages because of"personal millation, sickness or disease sustained by a per- injury",provided that: son,Including death resulting from any of these at (a) Liability to such party for, or for any time. the cost of, that party's defense J. BODILY INJURY TO CO-EMPLOYEES AND has also been assumed in the CO-VOLUNTEER WORKERS same"insured contract';and The following is added to Paragraph 2.a.(1) of (b) Such attorney fees and litigation SECTION II—WHO IS AN INSURED: expenses are for defense of that Paragraph (1)(a) above does not apply to "bodily party against a civil or altemative injury"to a co-"employee"in the course of the co- dispute resolution proceeding in "employee's" employment by you or performing which damages to which this in- duties related to the conduct of your business, or surance applies are alleged. to"bodily injury" to your other"volunteer workers" 2. The following replaces the third sentence of while performing duties related to the conduct of Paragraph 2. of SUPPLEMENTARY PAY- your business. MENTS—COVERAGES A AND B: K. AIRCRAFT CHARTERED WITH CREW Notwithstanding the provisions of Paragraph The following is added to Exclusion g., Aircraft, 2.b.(2)of Section 1—Coverage A—Bodily In- Auto Or Watercraft,in Paragraph 2.of SECTION jury And Property Damage Liability or Para- I —COVERAGES — COVERAGE A BODILY IN- graph 2.e. of Section I —Coverage B — Per- JURY AND PROPERTY DAMAGE LIABILITY: sonal and Advertising Injury Liability, such This exclusion does not apply to an aircraft that payments will not be deemed to be damages Is: because of"bodily injury", "property damage" (a) Chartered with crew to any Insured; or "personal Injury", and will not reduce the (b) Not owned by any Insured;and limits of insurance. (c) Not being used to cant' any person or prop- 3. The following replaces Paragraph 2.d. of erty for a charge. SUPPLEMENTARY PAYMENTS — COVER- L. NON-OWNED WATERCRAFT AGES A AND B: 1. The following replaces Paragraph (2) of Ex- d. The allegations in the "suit" and the in- clusion g., Aircraft, Auto Or Watercraft, in formation we know about the "occur- Paragraph 2. of SECTION I—COVERAGES rence"or offense are such that no conflict — COVERAGE A BODILY INJURY AND appears to exist between the interests of PROPERTY DAMAGE LIABILITY: CG D4 58 07 13 ®2013 The Travelers Indemnity Company.All rights reserved. Page 5 of 7 Includes copyrighted material of Insurance Services Office,Inc.with Its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA56lB203BF COMMERCIAL GENERAL LIABILITY (2) A watercraft you do not own that is: e. The following provisions apply to Paragraph (a) Fifty feet long or less;and a. above, but only for the purposes of the in- (b) Not being used to carry any person or surance provided under this Coverage Part to property for a charge. you or any insured listed in Paragraph 1.or 2. of Secticn II—Who Is An Insured: 2. The following Is added to Paragraph 2. of (1) Notice to us of such "occurrence" or of- SECTION 11—WHO IS AN INSURED: fense must be given as soon as practica- Any person or organization that,with your ex- ble only after the °occurrence" or offense press or Implied consent,either uses or is re- is known to you(if you are an individual), sponsible for the use of a watercraft that you any of your partners or members who is do not own that is: an Individual (if you are a partnership or (1) Fifty feet long or less;and joint venture), any of your managers who (2) Not being used to carry any person or is an Individual(if you are a limited liability property for a charge. company), any of your trustees who is an M. INCREASED SUPPLEMENTARY PAYMENTS Individual (if you are a trust), any of your "executive officers"or directors(if you are 1. The following replaces Paragraph 1.b. of an organization other than a partnership, SUPPLEMENTARY PAYMENTS — COVER- joint venture, limited liability company or AGES A AND B of SECTION I — COVER- trust) or any "employee° authorized by AGES: you to give notice of an "occurrence' or b. Up to $2,500 for cost of bail bands re- offense. quired because of accidents or traffic law (2) If you are a partnership,joint venture,lim- violations arising out of the use of any ited liability company or trust,and none of vehicle to which the Bodily Injury Liability Coverage applies.We do not have to fur- your parsers, joint venture members, Wish these bonds. managers or trustees are individuals, no- t. The followingfaces Paragraph i.d. of tice to us of such occurrence or offense replaces g p must be given as soon as practicable only SUPPLEMENTARY PAYMENTS — COVER- after the"occurrence"or offense is known AGES A AND B of SECTION I — COVER- by: AGES: (a) Any individual who is: d. All reasonable expenses incurred by the Insured at our request to assist us in the (i) A parser or member of any part- Investigation or defense of the claim or nership or joint venture; "suit", including actual loss of earnings up (11) A manager of any limited liability to $500 a day because of time off from company-, work. (111)A trustee of any trust;or N. MEDICAL PAYMENTS—INCREASED LIMIT (iv)An executive officer or director of The following replaces Paragraph 7. of SECTION any other organization; 111—LIMITS OF INSURANCE: that Is your parser, joint venture 7. Subject to 5. above, the Medical Expense member,manager or trustee;or Limit is the most we will pay under Coverage C. for all medical expenses because of"bod- (b) Any "employee" authorized by such ily Injury' sustained by any one person, and partnership, joint venture, limited li- will be the higher of ability company, trust or other organi- (a) $10,000;or zat€on to give notice of an "occur- rence"or offense. (b) The amount shown on the Declarations of (3) Notice to us of such "occurrence" or of- this Coverage Part for Medical Expense fense will be deemed to be given as soon Limit as practicable if it is given in good faith as O. KNOWLEDGE AND NOTICE OF OCCUR- soon as practicable to your workers' RENCE OR OFFENSE compensation insurer.This applies only if The following is added to Paragraph 2., Duties In you subsequently give notice to us of the The Event of Occurrence, Offense, Claim or "occurrence"or offense as soon as prac- Suit, of SECTION IV — COMMERCIAL GEN- ticabie after any of the persons described ERAL LIABILITY CONDITIONS: In Paragraphs e.(1) or (2) above discov- Page 6 of 7 ®2013 The Travelers Indemnity Company.All rights reserved. CG D4 58 07 13 Includes copyrighted material of Insurance Services Office,Inc.with Its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA56lB203BF COMMERCIAL GENERAL LIABILITY ers that the °occurrence" or offense may your rights under this insurance. However, this result in sums to which the insurance provision does not affect our right to collect addi- provided under this Coverage Part may tonal premium or to exercise our rights of cancel- apply. lation or nonrenewal in accordance with applica- However, if this policy includes an endorse- ble insurance laws or regulations. ment that provides limited coverage for'bod- Q. REASONABLE FORCE — BODILY INJURY OR ily injury' or 'property damage' or pollution PROPERTY DAMAGE costs arising out of a discharge, release or escape of 'pollutants' which contains a re- The following replaces Exclusion a.,Expected Or quirement that the discharge, release or es- Intended Injury,in Paragraph 2.of SECTION I— cape of "pollutants' must be reported to us COVERAGES — COVERAGE A BODILY IN- wlthln a specific number of days after its JURY AND PROPERTY DAMAGE LIABILITY: abrupt commencement, this Paragraph e. does not affect that requirement. a. Expected or Intended Injury or Damage P. UNINTENTIONAL OMISSION "Bodily injury'or'prop"damage"expected The following is added to Paragraph 6., Repre- or intended from the standpoint of the In- sentatlons, of SECTION IV — COMMERCIAL sured. This exclusion does not apply to'bod- GENERAL LIABILITY CONDITIONS: ily injury"or"property damage'resuiling from The unintentional omission of, or unintentional er- the use of reasonable force to protect any ror in, any information provided by you which we person or property. relied upon In Issuing this policy will not prejudice CG D4 58 07 13 ®2013 The Travelers Indemnity Company.All rights reserved. Page 7 of 7 Includes copyrighted material of Insurance Services Office,Inc.with Its permission. DocuSign Envelope ID:35DE8770-E58E-4C2C-927C-2DA561B203BF WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Any person or organization that you perform work for that is liable for an injury, covered by this policy, that prior to the injury has written contract requiring a waiver of our right to recover from them. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 1/1/2021 Policy No. WCV6179537 Endorsement No. Insured r miumS Summit Design and Engineering Services PLLC I l \ Insurance Company Countersigned by Accident Fund General Ins Co WC000313 (Ed. 4-84) Copyright 1983 National Council on Compensation Insurance.