Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Community Resource Center; 2020-09-10;
1 CA 05/25/2016 AGREEMENT BETWEEN THE CITY OF CARLSBAD AND COMMUNITY RESOURCE CENTER FOR FEDERAL COMMUNITY DEVELOPMENT BLOCK GRANT FUNDS THIS AGREEMENT (“Agreement”) made and entered into as of this __10th_ day of _ 20____ by and between the CITY OF CARLSBAD ("City") and COMMUNITY RESOURCE CENTER, a California non-profit corporation ("Subrecipient"). RECITALS WHEREAS, the City has applied for and received funds from the United States Government under Title I of the Housing and Community Development Act of 1974, Public Law 93-383 as amended to fund eligible activities which benefit persons of low and moderate income under Catalog of Federal Domestic Assistance number 14.218; and, WHEREAS, the City wishes to provide assistance to non-profit public service providers who offer services for lower income Carlsbad residents; and, WHEREAS, the Subrecipient can provide these basic services for lower income households with some assistance from the City; and, WHEREAS, the City has determined that the services offered by the Subrecipient are exempt from environmental review under 24 CFR Section 58.34(a)(4); and, WHEREAS, the U.S. Department of Housing and Urban Development has approved the City’s Annual Consolidated Plan for Community Development Block Grant funds (hereinafter referred to as the “Annual Consolidated Plan”). NOW, THEREFORE, in consideration of these recitals and the mutual covenants contained herein, City and Subrecipient agree as follows: 1.STATEMENT OF WORK The City has allocated federal community development block grant (“CDBG”) funds, in the amount of twenty thousand dollars ($20,000) to the Subrecipient for provision of services through their offices located at 650 Second Street, Encinitas, CA for the period beginning July 1, 2020 and ending April 30, 2021. The Subrecipient agrees to use all federal funds provided by the City to the Subrecipient pursuant to the provisions of this Agreement, the Scope of Work, attached hereto as Exhibit “A”, and in accordance with the terms of the Annual Consolidated Plan. Every effort shall be made by the Subrecipient to expend the allocated funds in their entirety by April 30, 2021. If the Subrecipient will be unable to expend all of the funds allocated to the project by the noted date, the Subrecipient shall request an extension from the City for continued use of the funds on the approved project based on progress made by the Subrecipient towards completing the subject project. The City may agree to grant the extension or notify the DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 September 20 2 CA 05/25/2016 Subrecipient that, in its sole discretion, the funds must be reallocated to another eligible activity due to slow project progress. 2. DISBURSEMENT OF FUNDS The City shall reimburse the Subrecipient with CDBG funds for necessary and reasonable costs related to the provision of services for eligible residents of Carlsbad for the term of this Agreement. The reimbursements for costs shall not exceed a total of $20,000. However, no more than 90 percent of the total agreed upon compensation will be paid during the performance of this Agreement. The balance due (remaining 10 percent) shall be paid upon final certification by the City that Subrecipient has administered the services and activities in compliance with all applicable Federal, state, and local rules and regulations governing these funds, and in a manner satisfactory to the City. Payment for eligible expenses shall be made in accordance with budget information provided in Exhibit “B” and in accordance with performance. Subrecipient represents that the budget includes only allowable costs and an accurate analysis of costs applicable to the CDBG funds pursuant to 24 CFR Section 570.502. Subrecipient shall submit a "Request for Reimbursement" to the City for compensation of eligible and actual expenses incurred. The City shall not provide any payments/reimbursements in advance of actual expenditures by the Subrecipient. Subrecipient may request reimbursements anytime after this Agreement is approved by the City Council and continue until the expiration date, or amended expiration date, of this Agreement. Each request for reimbursement shall include documentation to verify expenditure of funds are consistent with this Agreement, the Statement of Work, the Annual Consolidated Plan, and with all applicable Federal, state, and local rules and regulations governing these funds. Payroll records, receipts, paid invoices including an itemized statement of all costs are samples of appropriate methods of reimbursement documentation. 3. PROGRAM INCOME The Subrecipient shall report, to the City, any interest, or other income, earned as a direct result of the use of federal CDBG funds for the program outlined within this Agreement. All reported program income may be retained by the Subrecipient for costs related to the subject program activities. However, the program income, retained by the Subrecipient, must be expended before additional funds are requested from the City. The requirements are set forth in 24 CFR Section 570.504 which is incorporated herein by reference. 4. LABOR, MATERIALS AND SUPPLIES: The Subrecipient shall furnish all labor, materials and services and bear all expenses necessary to provide the subject program as outlined in this agreement. Under this Agreement, the City's only financial obligation to the Subrecipient is to provide the CDBG funds of $20,000 maximum as allocated by the City Council for program year 2020-2021. DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 3 CA 05/25/2016 5. RECORDS AND REPORTS The Subrecipient shall maintain all records required by the Federal regulations specified in 24 CFR Section 570.506 that are pertinent to the activities to be funded under this Agreement. Such records shall include but not be limited to: a. Records providing a full description of each activity undertaken; b. Records demonstrating each activity undertaken meets one of the National Objectives of the CDBG program; c. Records required to determine the eligibility of activities; d. Records demonstrating compliance with 24 CFR Section 570.505 regarding change of use of real property acquired or improved with CDBG assistance; e. Records demonstrating compliance with the requirements in 24 CFR Section 570.606 regarding acquisition, displacement, relocation, and replacement housing; f. Records documenting compliance with the fair housing and equal opportunity components of the CDBG program; g. Documentation of all CDBG funds received from the City, eligible expenses incurred for administration of each activity, and other financial records as required by 24 CFR Section 570.502, and OMB (the United States Office of Management and Budget) Circular A-110; and, h. Any other related records as the City shall require to demonstrate compliance with applicable Federal, state, and local rules and regulations governing these funds. The Subrecipient shall submit quarterly "Progress Reports" within ten (10) calendar days of the end of each quarter for the full term of this Agreement. The final progress report is due no later than July 10, 2021. The report must include sufficient information to assist the City in monitoring the Subrecipient's performance. The Subrecipient must demonstrate satisfactory performance prior to reimbursement for expenditures. At a minimum, the performance reports shall include the following information: a. Total number of persons/households participating in the program during reported period; b. Total number of participants from Carlsbad; c. Number of low/moderate income Carlsbad persons/households participating in the program during the reporting period; d. Age and ethnic background of Carlsbad participants; and, e. Summary of program(s) provided to Carlsbad participants. f. Quarterly reports must be submitted by the following: October 10, January 10, April 10, and July 10. The Subrecipient shall maintain client data demonstrating client eligibility for services provided. Such data shall include at the minimum client name, address, ethnicity, income level or other basis for determining eligibility, and a description of the service provided. This data shall assist the Subrecipient in completing the required quarterly progress reports to be submitted to the DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 4 CA 05/25/2016 City. The Subrecipient shall maintain separate accounting records for the federal CDBG funds provided by the City. The City, Federal Grantor Agency, Comptroller General of the United States, or any of their duly-authorized representatives shall have access to all books, documents, papers and records maintained by the Subrecipient which directly pertain to the above project for the purpose of audit, examination, excerpts and transcriptions. Unless otherwise notified by the City, the Subrecipient shall retain all financial records, supporting documents and statistical reports related to the project identified under this Agreement for a period of five (5) years after the termination of all activities funded under this Agreement. All records subject to litigation, claims, audit findings, negotiations, or other actions must be retained for five (5) years from the date such action commenced or until completion of the action and resolution of all issues by the appropriate officials and verified by official written notice to the Subrecipient, whichever occurs later. If the Subrecipient shall receive more than $750,000 in total federal funds in one fiscal year from the City of Carlsbad and/or any other city or agency, the Subrecipient is required to submit a Single Audit Report. As required by the Federal Single Audit Act, the Subrecipient shall be required to submit, to the City, a comprehensive financial audit prepared by an independent, neutral third-party auditor. The audit shall cover financial operations of the Subrecipient for the term of this Agreement and is due not later than one year after expiration of the agreement. The Subrecipient shall also be required to submit a second audit for the following period covered under the fiscal year beginning July 1, 2020 and ending June 30, 2021 for any funds received in fiscal year 2020-2021 per this Agreement. 6. PROGRAM REQUIREMENTS The Subrecipient agrees to comply with the requirements of Title 24 of the Code of Federal Regulations, Part 570 (the Housing and Urban Development regulations concerning Community Development Block Grants). The Subrecipient also agrees to adhere to the terms of the City's CDBG Application and Subrecipient Agreement on file at the Housing and Redevelopment Department and with assurances and agreements made, by the City to the United States Department of Housing and Urban Development of which the Subrecipient is given notice. The Subrecipient shall comply with applicable Uniform Administrative Requirements as described in 24 CFR Section 570.502, the federal regulations for the CDBG Program; the federal requirements are set forth, and incorporated by reference herein, as a provision of this Agreement. The Subrecipient shall carry out all activities in compliance with all Federal laws and regulations as described in Subpart K of the CDBG Program Regulations, such as affirmatively furthering fair housing, labor standards (Davis Bacon Act), displacement, relocation and acquisition, and employment and contracting opportunities, except that: a. The Subrecipient will not assume the City's environmental responsibilities as DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 5 CA 05/25/2016 described in 24 CFR Section 570.604; and b. The Subrecipient will not assume the City's responsibility for initiating the review process required under the provisions of 24 CFR Section 52. The provisions of Subpart K, of the CDBG Program Regulations, incorporated herein by reference, are a condition of this Agreement. The Subrecipient shall comply with all federal regulations related to the use of CDBG funds by religious organizations, if applicable to this Agreement and the approved project outlined herein. 7. CHANGES IN USE OF FUNDS Changes in the use of CDBG funds must be approved by the City Council and the U.S. Department of HUD. If the Subrecipient desires a change in the use of the CDBG funds following approval of this Agreement, a written request must be submitted to the City for review by the City Council. No change in use of the CDBG funds will be permitted without prior written approval of the City Council. 8. NONDISCRIMINATION CLAUSE The Subrecipient shall comply with all state and federal laws regarding nondiscrimination in the provision of services and the equal opportunity employment of personnel. 9. SUSPENSION AND TERMINATION OF AGREEMENT In accordance with 24 CFR Sections 85.43 and 85.44, this Agreement may be suspended or terminated if the Subrecipient fails to comply with any term(s) of the award. 24 CFR Sections 85.43 and 85.44 are incorporated herein by reference, as provisions of this Agreement. 10. REVERSION OF ASSETS Upon expiration of the Agreement, the Subrecipient shall transfer to the City any CDBG funds on hand at the time of expiration and any accounts receivable attributable to the use of CDBG funds. The Subrecipient shall be required to use any real property under the Subrecipient's control that was acquired or improved in whole or in part with CDBG funds in excess of $25,000 to either be: a) Used to meet one of the national objectives in 24 CFR Section 570.208 of the federal regulations until five (5) years after expiration of the Agreement; or, b) Disposed of in a manner that results in the City being reimbursed in the amount of the current fair market value of the property less any portion of the value attributable to expenditures of non-CDBG funds for acquisition, or improvement to, the property. Reimbursement is not required after the period of time specified in paragraph (a) of this section. DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 6 CA 05/25/2016 11. HOLD HARMLESS AGREEMENT The City, its officers, and employees shall not be liable for any claims, liabilities, penalties, fines, or any damage to goods, or real or personal property of any person whatsoever, nor for personal injuries or death caused by, or claimed to have been caused by, or resulting from, any intentional or negligent acts, errors or omission of Subrecipient or Subrecipient's agents, employees, or representatives arising directly or indirectly out of performance of the project outlined in this Agreement. Subrecipient agrees to defend, indemnify, and hold free and harmless the City, its officers, employees and agents against any of the foregoing liabilities or claims of any kind and any cost or expenses incurred by the City including attorneys’ fees, on account of any of the foregoing liabilities, including liabilities or claims arising out of alleged defects in any plans or specifications for the project or facility. 12. ASSIGNMENT OF AGREEMENT The Subrecipient shall not assign this Agreement or any monies due thereunder without the prior written consent of the City Council. 13. SUCCESSORS OR ASSIGNS Subject to the provisions of this Subrecipient Agreement Paragraph 11, "Hold Harmless Agreement," all terms, conditions, and provisions hereof shall inure to and shall bind each of the parties hereto, and each of their respective heirs, executors, administrators, successors, and assigns. 14. INSURANCE If the Subrecipient shall receive more than $5,000 from the City in CDBG funds and/or other funds, the Subrecipient shall obtain and maintain policies of Commercial General Liability insurance and a combined policy of worker's compensation and employers liability insurance in an insurable amount of not less than one million dollars ($1,000,000) each, unless a lower amount is approved by the Risk Manager or the City Manager. The insurance will be obtained from an insurance carrier admitted and authorized to do business in the State of California. The insurance carrier is required to have a current Best's Key Rating of not less than "A-:VII" or have a surplus line insurer which is on the State of California’s List of Eligible Surplus Line Insurers with a current Best’s Key Rating of not less than “A:X”. The City shall be named as an additional insured on the Commercial General Liability Policy which shall provide primary coverage to the City. This insurance shall be in force during the term of this Agreement and shall not be canceled or materially changed without ten (10) days prior written notice to the City sent by certified mail. The Subrecipient shall furnish certificates of insurance and required endorsements to the Housing and Neighborhood Services Director before commencement of work. DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 7 CA 05/25/2016 SUBRECIPIENT: Community Resource Center By: John Van Cleef Chief Executive Officer Dated: By: Sarah Ferry Chief Operating Officer Dated: CITY OF CARLSBAD: By: Jeff Murphy Community Development Director Dated: ATTEST: _________________________________ Tamara R. McMinn for BARBARA ENGLESON City Clerk Dated: (Proper notarial acknowledgment of execution by Subrecipient must be attached. Chairman, president or vice-president and secretary, assistant secretary, CFO or assistant treasurer must sign for corporations. Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation.) APPROVED AS TO FORM: Celia A. Brewer, City Attorney By: Ron Kemp, Assistant City Attorney Dated: DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 9/3/2020 9/3/2020 9/9/2020 9/9/2020 9/10/2020 CA 8/13/2012 EXHIBIT “A” CITY OF CARLSBAD COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM SCOPE OF WORK Contract Term: July 1, 2020 to April 30, 2021 Subrecipient Name: Community Resource Center Address: 650 Second Street, Encinitas, CA 92024 Project Description: Community Resource Center Project Goals & Objectives: (Please Attach Additional Sheets As Necessary.) 1. CDBG funds will be used to fund the following activities in compliance with the project description outlined and in conformance with the Federal regulations for the CDBG program: (Please specify if CDBG funds will be used to fund costs associated with staffing, rents, utilities, supplies, etc.) Funds will be used to assist paying for facility operations including wages and salaries, and program expenses such as rental assistance, case management services, and evaluation (client assistance flex funds). 2. Project objectives to be accomplished during the contract period: (Please describe the specific services or activities to be provided to low/moderate income Carlsbad residents with the CDBG funds awarded. If applicable, please provide a target objective for the number of persons/households to benefit from the Subrecipient's services/project.) Approximately, 10 Carlsbad residents will be served. 3. Project objectives performance measures: a. Provide quarterly performance reports to the City of Carlsbad, Housing and Neighborhood Services Department on the CDBG Quarterly Performance Report form as provided. b. Maintain records, invoices, and relevant statistics supporting the quarterly reports. c. Provide a final performance report, including an evaluation report of the program’s success in meeting established goals, to the City of Carlsbad Housing and Neighborhood Services Department within 10 days of termination of the contract date on the CDBG Annual Performance Report form as provided. d. Provide notification to the City of any audits or investigations including results, findings, and/or liens. DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CA 8/13/2012 EXHIBIT “B” CITY OF CARLSBAD COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM BUDGET Contract Term: July 1, 2020 to April 30, 2021 Subrecipient Name: Community Resource Center Address: 650 Second Street, Encinitas, CA 92024 Project Description: Community Resource Center Cost Breakdown: Wages and Salaries $10,000 Program Expenses $10,000 Total $20,000 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTRINSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 6/23/2020 License # 0757776 (442) 244-6932 22136 Community Resource Center 650 Second St Encinitas, CA 92024 16691 26832 30120 A 1,000,000 X PAC220700904 10/15/2019 10/15/2020 100,000 5,000 1,000,000 3,000,000 3,000,000 1,000,000B X CAP 2207007 04 10/15/2019 10/15/2020 1,000,000C UMB220700604 10/15/2019 10/15/2020 10,000 1,000,000 D Z136665601 6/1/2020 6/1/2021 1,000,000 1,000,000 1,000,000 Certificate Holder is named additional insured as respects General Liability per CG8970 1114 (Form includes primary & non-contributory wording) and Auto Liability per CA8620 0516. All forms valid where required by written contract. City of Carlsbad 1200 Carlsbad Village Drive Carlsbad, CA 92008 COMMRES-10 JZHAO1 HUB International Insurance Services Inc. 1525 Faraday Avenue Suite 200 Carlsbad, CA 92008 Sandra Bao sandra.bao@hubinternational.com Great American Insurance Company of New York Great American Insurance Company Great American Alliance Insurance Company ZNAT Insurance Company Products/Comp X X X X X X X DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 1 of 12) CG 89 70 (Ed. 11/14) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SIGNATURE GENERAL LIABILITY BROADENING ENDORSEMENT This Endorsement modifies and is subject to the insurance provided under the following form: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following extension only applies in the event that no other specific coverage for the indicated lossexposure is provided under this Policy. If other specific coverage applies, the terms, conditions andlimits of that Coverage are the exclusive coverage applicable under this Policy,unless otherwise noted inthis Endorsement. This is a summary of the various additional coverages and coverage modificationsprovided by this Endorsement. For complete details on specific coverages, consult the actual policywording. Coverage Description Limit of Insurance Page Non-Owned Aircraft Included 2 Non-Owned Watercraft Included 2 Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Included 3 Medical Payments $ 20,000 3 Damage to Premises Rented to You $ 1,000,000 3 Supplementary Payments - Bail Bonds $ 3,000 4 Supplementary Payments - Loss of Earnings $ 1,000 per day 4 Newly Formed or Acquired Organizations Included 4 Unintentional Failure to Disclose Hazards Included 5 Knowledge of Occurrence,Claim or Suit Included 5 Property Damage Liability - Elevators Included 5 Property Damage Liability - Borrowed Equipment Included 5 Liberalization Clause Included 6 Amendment of Pollution Exclusion (Premises)Included 6 Limited Property Damage to Property of Others $ 5,000 6 Additional Insured - Manager or Lessor of Premises Included 7 *S1 * 10/22/2018 * PAC 2207009 03 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 2 of 12) Coverage Description Limit of Insurance Page Additional Insured - Funding Sources Included 7 Additional Insured - By Contract Included 8 Primary and Non-Contributory Additional Insured Extension Included 10 Additional Insureds - Protection of Your Limits Included 10 Blanket Waiver of Transfer of Rights of Recovery Against Others Includedto Us (Subrogation)11 Property Damage Extension With Voluntary Payments $ 1,000/$ 5,000 11 Who Is An Insured - Fellow Employee Extension - Management IncludedEmployees 12 Broadened Personal and Advertising Injury Included 12 A. Non-Owned Aircraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, exclusion g. Aircraft,Auto or Watercraft does not apply to an aircraft provided: 1.it is not owned by any insured; 2.it is hired, chartered or loaned with a trained paid crew; 3.the pilot in command holds a currently effective certificate, issued by the duly constitutedauthority of the United States of America or Canada, designating him or her a commercial orairline pilot; and 4.it is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the Insuredother valid and collectible insurance, whether primary, excess (other than insurance written to applyspecifically in excess of this Policy), contingent or on any other basis, that would also apply to the loss covered under this provision. B. Non-Owned Watercraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraph (2)of exclusion g. Aircraft,Auto or Watercraft is replaced by the following: This exclusion does not apply to: (2)A watercraft you do not own that is: (a)less than 60 feet long; and * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 3 of 12) (b)not being used to carry persons or property for a charge. C. Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Under SECTION V - DEFINITIONS, Definition 3.is replaced by the following: 3. "Bodily Injury"means physical injury, sickness, or disease, including death of a person. "BodilyInjury" also means mental injury, mental anguish, humiliation, or shock if directly resulting fromphysical injury, sickness, or disease to that person. D. Medical Payments If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided bythis Policy are amended as follows: The Medical Expense Limit in paragraph 7.of SECTION III - LIMITS OF INSURANCE is replaced bythe following Medical expense Limit: The Medical Expense Limit provided by this Policy shall be the greater of: a.$ 20,000; or b.the amount shown in the Declarations for Medical Expense Limit This provision 7.is subject to all the terms of SECTION III - LIMITS OF INSURANCE. E. Damage to Premises Rented to You If Damage to Premises Rented to You is not otherwise excluded from this Coverage Part: 1.Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: 3.The last paragraph of paragraph 2. Exclusions is deleted in its entirety and replaced by thefollowing: Exclusions c.through n.do not apply to damage by fire, lightning, explosion, smoke,leakage from an automatic fire protection system or water to premises while rented to youor temporarily occupied by you with permission of the owner. A separate Limit ofInsurance applies to this coverage as described in SECTION III - LIMITS OF INSURANCE. However, this insurance does not apply to damage to premises while rented to you, or temporarily occupied by you with the permission of the owner, caused by: i.rupture, bursting, or operation of pressure relief devices; ii.rupture or bursting due to expansion or swelling of the contents of any building orstructure, caused by or resulting from water; iii.explosion of steam boilers, steam pipes, steam engines, or steam turbines; or iv.flood 2.Paragraph 6.Under SECTION III - LIMITS OF INSURANCE is deleted in its entirety andreplaced with the following: * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 4 of 12) 6.Subject to paragraph 5.above, 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 caused by fire, lightning, explosion, smoke, leakage from automatic fire protection system or water while rented to you or temporarily occupied by you with the permission of the owner, for all such damage caused by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water proximately caused by the same event,whether such damage results from fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water or any combination of the six, is the higher of $1,000,000 or the amount shown in the Declarations for the Damage to Premises Rented to You Limit. 3.Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, subsection 4.Other Insurance, paragraph b.Excess Insurance where the words "Fire insurance"appear they are changed to "insurance for fire, lightning, explosion, smoke, leakage from an automatic fire protection system or water." 4.As regards coverage provided by this provision I. Damage to Premises Rented to You - paragraph 9.a.of Definitions is replaced with the following: 9. a.a contract for a lease of premises.However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water to premises while rented to you or temporarily occupied by you with the permission of the owner is not an "insured contract"; F. Supplementary Payments 1.In the Supplementary Payments - Coverages A and B provision, paragraph 1.b.is replaced with: b.Up to $ 3,000 for the 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. 2.Paragraph 1.d.is replaced by the following: d.All reasonable expenses incurred by the Insured at our request to assist us in the investigation or defense of the claim or "suit," including actual loss of earnings up to $ 1,000 a day because of time off work. G. Newly Formed or Acquired Organizations Paragraph 3.of SECTION II - WHO IS AN INSURED is replaced by the following: 3.Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a named insured if there is no other similar insurance available to that organization.However: a.coverage under this provision is afforded only until the expiration of the policy period inwhich the entity was acquired or formed by you; b.coverage A does not apply to "bodily injury" or property damage that occurred before you acquired or formed the organization; and c.coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 5 of 12) d.records and descriptions of operations must be maintained by the first named insured. No person or organization is an insured with respect to the conduct of any current or pastpartnership, joint venture or limited liability company that is not shown as a named insured in the Declarations or qualifies as an insured under this provision. H. Unintentional Failure to Disclose Hazards Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 6. Representations: Failure of the Insured to disclose all hazards existing as of the inception date of this Policy shall not prejudice the insurance with respect to the coverage afforded by this Policy, provided such failure or omission is not intentional on the part of the Insured. I. Knowledge of Occurrence, Claim or Suit Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 2. Duties in the Event of Occurrence,Offense,Claim or Suit: Knowledge of any occurrence, claim, or suit by any agent, servant or employee of the Named Insured does not in itself constitute knowledge by the Insured unless notice of such injury, claim or suit shall have been received by: 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. J. Property Damage Liability - Elevators 1.Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraphs (3),(4)and (6)of exclusion j. Damage to Property do not apply if such property damage results from the use of elevators. 2.The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 4. Other Insurance, paragraph b. Excess Insurance: The insurance afforded by this provision of this Endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. K. Property Damage Liability - Borrowed Equipment 1.Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraph (4)of exclusion j. Damage to Property does not apply to "property damage" to borrowed equipment while not being used to perform operations at a jobsite. 2.The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY Conditions, Condition 4. Other Insurance, paragraph b. Excess Insurance: The insurance afforded by this provision of this Endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 6 of 12) L. Liberalization Clause If we revise this Signature General Liability Broadening Endorsement to provide more coveragewithoutadditional premium charge, your policy will automatically provide the coverage as of the date the revision is effective in your state. M. Amendment of Pollution Exclusion (Premises) 1.The following is added to paragraph (1)(a)of Exclusion f.of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: (iv)"Bodily injury" or "property damage" arising out of the actual discharge, dispersal, seepage, migration, release or escape of "pollutants." As used in this Endorsement, the actual discharge, dispersal, seepage, migration, release or escape of pollutants must: (aa)commence on a clearly identifiable day during the policy period; and (bb)end, in its entirety, within seventy-two (72)hours of the commencement of the discharge, dispersal, seepage, migration, release or escape of "pollutants"; and (cc)be discovered and reported to us within fifteen (15) days of the clearly identifiable day that the discharge, dispersal, seepage, migration, release or escape of "pollutants" commences; and (dd)be neither expected nor intended from the standpoint of any insured; and (ee)be unrelated to any previous discharge, dispersal, seepage, migration, release or escape; and (ff)not originate at or from a storage tank or other container, duct or piping which: a.is below the surface of the ground or water; or b.at any time has been buried under the surface of the ground or water and then is subsequently exposed. 2.For the purposes of this coverage, the following is added to the definition of "property damage" of SECTION V - DEFINITIONS and applies only as respects this coverage: Land or water,whether below ground level or not, is not tangible property. 3.Coverage provided hereunder does not apply to any discharge, dispersal, seepage, migration, release or escape that is merely threatened or alleged rather than shown to have actually occurred. N. Limited Property Damage to Property of Others The following is added under SECTION I - SUPPLEMENTARY PAYMENTS - COVERAGES A and B: 3.We will pay up to $ 5,000 for loss to personal property of others while in the temporary care,custody or control of an insured caused by any person participating in your organized activities. For the purpose of this supplementary payment, loss shall mean damage or destruction but does not include mysterious disappearance or loss of use. In the event of a theft, a police report must be filed. This supplementary payment does not apply if: a.coverage is otherwise provided by the Property Coverage part (if any) of this Policy; or * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 7 of 12) b.the loss is covered by any other insurance you have or by any insurance of such person who causes such loss. These payments will not reduce the Limits of Insurance. O. Additional Insured - Manager or Lessor of Premises 1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any personor organization from whom you lease or rent property and which requires you to add such person or organization as an additional insured on this Policy under: (a)a written contract; or (b)an oral agreement or contract where a Certificate of Insurance showing that person or organization as an additional insured has been issued; but the written or oral contract or agreement must be an "insured contract," and, (i)currently in effect or become effective during the term of this Policy; and (ii)executed prior to the "bodily injury," "property damage," "personal and advertising injury." 2.With respect to the insurance afforded to the Additional Insured identified in paragraph 1.above, the following additional provisions apply: (a)This insurance applies only with respect to the liability arising out of the ownership,maintenance or use of that part of the premises leased to you. (b)The Limits of Insurance applicable to the Additional Insured are the lesser of thosespecified in the written contract or agreement or in the Declarations for this Policy and subject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. (c)In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. (d)Coverage provided herein is excess over any other valid and collectible insurance available to the Additional Insured whether the other insurance is primary, excess, contingent or on any other basis unless a written contractual arrangement specifically requires this insurance to be primary. (e)This insurance applies only to the extent permitted by law. 3.This insurance does not apply to: (a)Any "occurrence" or offense which takes place after you cease to be a tenant in that premises. (b)Structural alterations, new construction or demolition operations performed by or on behalf of the Additional Insured. P. Additional Insured - Funding Sources 1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any Funding Source which requires you in a written contract to name the Funding Source as an additional insured but only with respect to liability arising out of: * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 8 of 12) a.your premises; or b."your work" for such additional insured; or c.acts or omissions of such additional insured in connection with the general supervision of"your work" and only to the extent set forth as follows: a.The Limits of Insurance applicable to the Additional Insured are the lesser of thosespecified in the written contract or agreement or in the Declarations for this Policy andsubject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. b.The insurance afforded to the Additional Insured only applies to the extent permitted by law c.If coverage provided to the Additional Insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. d.In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. Q. Additional Insureds - By Contract 1. SECTION II - WHO IS AN INSURED is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of: a.your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the Additional Insured that are subject of the written contract or written agreement provided that the "bodily injury" or "property damage occurs, or the "personal and advertising injury" is committed,subsequent to the signing of such written contract or written agreement; or b.the maintenance,operation or use by you of equipment rented or leased to you by such person or organization; or c.the Additional Insureds financial control of you; or d.operations performed by you or on your behalf for which the state or political subdivision has issued a permit However: 1.the insurance afforded to such additional insured only applies to the extent permitted by law; and 2.if coverage provided to the Additional Insured is required by contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide such additional insured. With respect to paragraph 1.a.above, a person's or organization's status as an additional insured under this Endorsement ends when: * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 9 of 12) (1)all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2)that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. With respect to paragraph 1.b.above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this Endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage." We have no duty to defend an additional insured under this Endorsement until we receive written notice of a "suit" by the Additional Insured as required in paragraph b.of Condition 2. Duties in the Event of Occurrence,Offense,Claim or Suit under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITION. 2.With respect to the insurance provided by this Endorsement, the following are added to paragraph 2. Exclusions under SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: This insurance does not apply to: a."Bodily injury" or "property damage" that occurs prior to your commencing operations at the location where such "bodily injury" or "property damage" occurs. b."Bodily injury," "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural,engineering or surveying services, including: (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. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that Insured, if the "occurrence" which caused the "bodily injury" or "property damage," or the offense which caused the "personal and advertising injury," involved the rendering of, or failure to render, any professional architectural,engineering or surveying services. c."Bodily injury" or "property damage" occurring after: (1)all work, including materials, parts or equipment furnished in connection with suchwork, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2)that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 10 of 12) d.Any person or organization specifically designated as an additional insured for ongoing operations by a separate additional insured endorsement issued by us and made part of this Policy. 3.With respect to the insurance afforded to these Additional Insureds, the following is added to SECTION III - LIMITS OF INSURANCE: If coverage provided to the Additional Insured is required by a contract or agreement, the most we will pay on behalf of the Additional Insured is the amount of insurance: 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. R. Primary and Non-Contributory Additional Insured Extension This provision applies to any person or organization who qualifies as an additional insured under anyform or endorsement under this Policy. Condition 4. Other Insurance of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: a.The following is added to paragraph a. Primary Insurance: This insurance is primary to and will not seek contribution from any other insurance available toan additional insured under your policy provided that: (1)the Additional Insured is a named insured under such other insurance; and (2)you have agreed in writing in a contract or agreement that this insurance would be primaryand would not seek contribution from any other insurance available to the Additional Insured. b.The following is added to paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the Additional Insured is designated as a named insured. Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the Additional Insured has been added as an additional insured on other policies. S. Additional Insureds - Protection of Your Limits This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this Policy. 1.The following is added to Condition 2. Duties in the Event of Occurrence,Offense,Claim or Suit: An additional insured under this Endorsement will as soon as practicable: * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 11 of 12) a.give written notice of an "occurrence" or an offense that may result in a claim or "suit" under this insurance to us; b.tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the Additional Insured; and c.agree to make available any other insurance which the Additional Insured has for a loss we cover under this Coverage Part. d.we have no duty to defend or indemnify an additional insured under this Endorsement until we receive written notice of a "suit" by the Additional Insured. 2.The Limits of Insurance applicable to the Additional Insured are those specified in a written contract or written agreement or the Limits of Insurance stated in the Declarations of this Policy and defined in SECTION III - LIMITS OF INSURANCE of this Policy, whichever are less. These limits are inclusive of and not in addition to the Limits of Insurance available under this Policy. T. Blanket Waiver of Transfer of Rights of Recovery Against Others to Us (Subrogation) Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 8. Transfer of Rights of Recovery Against Others to Us: If required by a written contract or written agreement, we waive any right of recovery we may have against a person or organization because of payment we make for injury or damage arising out of your ongoing operations or "your work" done under a contract for that person or organization and included in the "products-completed operations hazard" provided that the injury or damage occurs subsequent to the execution of the written contract or written agreement. U. Property Damage Extension with Voluntary Payments 1.The following is added to paragraph 1. Insuring Agreement of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: At your request we will pay for "loss" to property of others caused by your business operations for which this Policy provides liability insurance. Such payment will be made without regard to your legal obligation to do so. The "loss" must occur during the policy period and must take place in the "coverage territory." 2.With respect to the coverage afforded under paragraph 1.above, paragraph 2. Exclusions of SECTION I - COVERAGES A - Bodily Injury and Property Damage Liability is amended as follows: Exclusions j.(3),j.(4),j.(5)and j.(6)are deleted. 3.As respects coverage afforded by this coverage,SECTION III - LIMITS OF INSURANCE is replaced by the following: Regardless of the number of insureds, claims made or "suits" brought or persons or organizations making claims or bring "suits": 1.Subject to 2.Below, the most we will pay for one or more "loss" arising out of any one"occurrence" is $1,000. 2.The aggregate amount we will pay for the sum of all "loss" in an annual period is $ 5,000.This aggregate amount is part of and not in addition to the General Aggregate Limit described in paragraph 2.of SECTION III - LIMITS OF INSURANCE. * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 CG 89 70 (Ed. 11/14)(Page 12 of 12) V. Who Is an Insured - Fellow Employee Extension - Management Employees 1.The following is added to paragraph 2.a.(1)of SECTION II - WHO IS AN INSURED: Paragraph (a)and (b)above do not apply to "bodily injury" or "personal and advertising injury"caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, including the direct supervision of other "employee" of yours.However,none of these "employees" are insureds for "bodily injury" or "personal and advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury" or "personal and advertising injury," caused in whole or in part by their intoxication by liquor or controlled substances. This coverage is excess over any other valid and collectable insurance available to your "employee." W. Broadened Personal and Advertising Injury 1.Unless "Personal and Advertising Injury" is excluded from this Policy, the following is added to SECTION V - DEFINITIONS Item 14.: h.mental injury, mental anguish, humiliation, or shock, if directly resulting from Items 14.a. through 14.e. * S1 * 10/22/2018 * PAC 2207009 02 GREAT AMERICAN INS CO OF NY *D/B* 744108371 0253858 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952 DocuSign Envelope ID: 1FE83D4B-947C-450A-BBA2-67D2CA2B0952