The URL can be used to link to this page

Home My WebLink AboutInterfaith Community Services Inc; 2023-04-28; PSA23-2169ENVPSA23-2169ENV City Attorney Approved Version 12/28/2022 1 AGREEMENT BETWEEN THE CITY OF CARLSBAD AND INTERFAITH COMMUNITY SERVICES FOR EDIBLE FOOD RECOVERY SERVICES – EQUIPMENT This Agreement is made and entered into as of the ______________ day of __________________, 2023, by and between the City of Carlsbad, California, a municipal corporation (“City”) and Interfaith Community Services, Inc., a California non-profit corporation (“Contractor”). RECITALS City has received grant funding through the CalRecycle SB 1383 Local Assistance Grant Program (OWR1)- FY2021-2022 (“Grant”); and To fully utilize the Grant funds, City requires the services of an edible food recovery program provider to increase edible food recovery in the City; and Contractor has the necessary experience in providing these services, has submitted a proposal to City and has affirmed its willingness and ability to perform such work; and NOW, THEREFORE, in consideration of these recitals and the mutual covenants contained herein, City and Contractor agree as follows: 1. SCOPE OF WORK City retains Contractor to perform, and Contractor agrees to render, those Services (the “Services”) that are defined in Exhibit “A,” attached and incorporated by this reference in accordance with the terms and conditions set forth in this Agreement. 2. TERM Unless otherwise terminated in accordance with the terms of this Agreement, this Agreement will be effective for a period of three (3) years from the date first above written (the “Agreement Term”). 3. COMPENSATION During the Term of the Agreement, Contractor shall have the benefit of using the City-owned the food recovery equipment and supplies identified in Exhibit “B,” which is attached and incorporated herein by reference, and which have a total value of $6,218.97 (the “Equipment”), in accordance with the terms of this Agreement. At the end of the Agreement Term, the City shall pay the Contractor for performance of all Services rendered in accordance with this Agreement by conveying ownership of the Equipment to Contractor. City shall not owe any monies or further consideration to Contractor for performance of the Services. 4. STATUS OF CONTRACTOR Contractor will perform the Services as an independent contractor and in pursuit of Contractor’s independent calling, and not as an employee of City. Contractor will be under the control of City only as to the results to be accomplished. DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE 28th April PSA23-2169ENV City Attorney Approved Version 12/28/2022 2 5. INDEMNIFICATION Contractor agrees to indemnify and hold harmless the City and its officers, officials, employees and volunteers from and against all claims, damages, losses and expenses including attorneys fees arising out of the performance of the work described herein caused by any negligence, recklessness, or willful misconduct of the Contractor, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable. The parties expressly agree that any payment, attorney’s fee, costs or expense City incurs or makes to or on behalf of an injured employee under the City’s self-administered workers’ compensation is included as a loss, expense or cost for the purposes of this section, and that this section will survive the expiration or early termination of this Agreement. 6. INSURANCE Contractor will obtain and maintain policies of commercial general liability insurance, automobile liability insurance, a combined policy of workers' compensation, employers liability insurance, and professional liability insurance from an insurance company authorized to transact the business of insurance in the State of California which has a current Best's Key Rating of not less than "A-:VII"; OR with a surplus line insurer on the State of California’s List of Approved Surplus Line Insurers (LASLI) with a rating in the latest Best’s Key Rating Guide of at least “A:X”; OR an alien non- admitted insurer listed by the National Association of Insurance Commissioners (NAIC) latest quarterly listings report, in an amount of not less than one million dollars ($1,000,000) each, unless otherwise authorized and approved by the Risk Manager or the City Manager. Contractor will obtain per occurrence coverage, excluding Professional Liability, which will be written as claims-made coverage. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location or the general aggregate limit shall be twice the required occurrence limit. Workers' Compensation limits shall be as required by the California Labor Code. Workers' Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. The insurance will be in force during the life of this Agreement and will not be canceled without thirty (30) days prior written notice to the City by certified mail. City will be named as an additional insured on General Liability which shall provide primary coverage to the City. The full limits available to the named insured shall also be available and applicable to the City as an additional insured. Contractor will furnish certificates of insurance to the Contract Department, with endorsements to City prior to City’s execution of this Agreement. /// /// /// /// /// /// /// /// DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENV City Attorney Approved Version 12/28/2022 3 7. NOTICES The name of the persons who are authorized to give written notice or to receive written notice on behalf of City and on behalf of Contractor under this Agreement. For City (Agreement Administrator) For Contractor Name Avecita Jones Name Vannessa Marshall Title Senior Program Manager Title Program Manager Department Environmental Sustainability Address 5731 Palmer Way, Ste. A City of Carlsbad Carlsbad, CA 92010 Address 1635 Faraday Avenue, Phone No. 760-489-6380 Carlsbad, CA 92008 Email vmarshall@interfaithservices.org Phone No. 442-339-2646 Email. FoodRecovery@carlsbadca.gov Each party will notify the other immediately of any changes of address that would require any notice or delivery to be directed to another address. 8. CONFLICT OF INTEREST Contractor shall file a Conflict of Interest Statement with the City Clerk in accordance with the requirements of the City of Carlsbad Conflict of Interest Code. The Contractor shall report investments or interests in all categories. Yes No 9. COMPLIANCE WITH LAWS Contractor will comply with all applicable local, state and federal laws and regulations prohibiting discrimination and harassment and will obtain and maintain a City of Carlsbad Business License for the term of this Agreement. Contractor shall comply with all applicable provisions of the Grant Procedures and Requirements, which are attached and incorporated herein as Exhibit “C,” including submission of a Reliable Contractor Declaration. Contractor shall also comply with all requests from City for documents or information necessary for City to comply with the Grant terms. 10. TERMINATION City or Contractor may terminate this Agreement at any time after a discussion, and written notice to the other party and in accordance with the provisions of this paragraph. 10.1 Equipment Reimbursement It is understood and agreed by the Parties that once the City-owned Equipment is used or installed by Contractor, returning the Equipment to City will become impractical and inefficient, and damages to the City in the event of a breach of contract by Contractor would be impossible to quantify. Therefore, the Parties agree that in the event Contractor breaches the terms of this Agreement, including by discontinuing business, or the Agreement is terminated, the Contractor shall reimburse the City for the cost of the Equipment as follows: DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE □ PSA23-2169ENV City Attorney Approved Version 12/28/2022 4 • Year 0 -1 o Months 0-6: 100% of Equipment value o Months 7-12: 80 % of Equipment value • Year 1 -2 o Months 13 – 18: 60% of Equipment value o Months 19 – 24: 50% of Equipment value • Year 2 -3 o Months 25 – 30 30% of Equipment value o Months 31 – 36: 20% of Equipment value • After Year 3: 0% of Equipment value Payment shall be made within ninety (90) days of City’s request. Upon payment to City of the remaining Equipment value, ownership of the Equipment shall be transferred to Contractor. 11. CLAIMS AND LAWSUITS By signing this Agreement, Contractor agrees it may be subject to civil penalties for the filing of false claims as set forth in the California False Claims Act, Government Code sections 12650, et seq., and Carlsbad Municipal Code Sections 3.32.025, et seq. Contractor further acknowledges that debarment by another jurisdiction is grounds for the City of Carlsbad to terminate this Agreement. 12. JURISDICTIONS AND VENUE Contractor agrees and stipulates that the proper venue and jurisdiction for resolution of any disputes between the parties arising out of this Agreement is the State Superior Court, San Diego County, California. 13. ASSIGNMENT Contractor may assign neither this Agreement nor any part of it, nor any monies due or to become due under it, without the prior written consent of City. 14. AMENDMENTS This Agreement may be amended by mutual consent of City and Contractor. Any amendment will be in writing, signed by both parties, with a statement of estimated changes in charges or time schedule. /// /// /// /// /// /// /// /// DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENV City Attorney Approved Version 12/28/2022 5 15. AUTHORITY The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. CONTRACTOR INTERFAITH COMMUNITY SERVICES, INC., a California non-profit corporation CITY OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) Paz Gomez, Deputy City Manager, Public Works, as authorized by the City Manager Dr. Kadri Webb, Chairman (print name/title) By: (sign here) Lisa Brinig, Secretary (print name/title) If required by City, proper notarial acknowledgment of execution by contractor must be attached. If a corporation, Agreement must be signed by one corporate officer from each of the following two groups. Group A Group B Chairman, Secretary, President, or Assistant Secretary, Vice-President CFO or Assistant Treasurer 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: CINDIE K. McMAHON, City Attorney BY: _____________________________ Assistant City Attorney DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENV 6 EXHIBIT “A” SCOPE OF SERVICES Background and Purpose: The City of Carlsbad (City) and Interfaith Community Services (Contractor), a non-profit organization, are proposing to expand food rescue from local commercial edible food generators through the implementation of the CalRecycle SB 1383 Local Assistance Grant Program (OWR1) FY2021-2022 (Grant) the City received. Based on the Eligible Costs and Metrics in Table 1 below, Contractor estimates that this Agreement will result in [total monthly pounds from Table 1] pounds per month of surplus edible food being recovered in Carlsbad and redistributed to the San Diego region’s food insecure population. Complete Table 1 below by filling in proposed additional edible food recovery per month in pounds (lbs) next to each equipment type being provided. The Grand Total is the total monthly pounds recovered (sum of proposed food recovery per month and the baseline monthly food recovery in Carlsbad) multiplied by the number active agreement months. Table 1. Eligible Costs and Metrics Equipment Metric for Measuring Edible Food Recovered Proposed Food Recovery (additional lbs per month) in Carlsbad Cold storage (freezers), sizes may vary* Monthly lbs of additional food rescued. Approximately 1 square foot per 28 lbs of solid food. Or throughput of additional meals rescued (must be converted to pounds [Average weight of a meal is 1.2 lbs]) 50 lbs. Cold storage (refrigerators), sizes may vary* Monthly lbs of additional food rescued. Approximately 1 square foot per 28 lbs of solid food. Or throughput of additional meals rescued (must be converted to pounds [Average weight of a meal is 1.2 lbs]) 50 lbs. Shelving/storage units Monthly lbs of additional food rescued. Approximately 1 square foot per 28 lbs of solid food. Or throughput of additional meals rescued (must be converted to pounds [Average weight of a meal is 1.2 lbs]) 43 lbs. Commercial Kitchen Equipment* •Food preparation and cooking items such as ovens, ranges, etc. •Produce wash stations •Counters and prep/storage space Monthly lbs of additional food rescued in pounds using new kitchen equipment. Or throughput of additional meals rescued and prepared (must be converted to pounds [Average weight of a meal is 1.2 lbs.]) DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENVExhibit "A" (Cont.) 7 Food safety supplies for temp control (e.g. thermal blankets and wraps, cambros, insulated boxes/coolers) Monthly lbs of additional food rescued by using equipment. Food rescue supplies (e.g. durable boxes/totes, crates, tote bags, etc.) Monthly lbs of additional food rescued. Approximately 1 square foot per 28 lbs of solid food. Packaging and portioning equipment* (i.e. equipment used to sort and/or separate from bulk, vacuum seal for freshness or freezing, meal separation) Monthly lbs of additional food rescued by using equipment. Total Additional Monthly Pounds Recovered: Sum: Proposed Food Recovery Baseline Monthly Food Recovery in Carlsbad (from the Application) Baseline Recovery Total Monthly Pounds Recovered 143 lbs. Grand Total: 1,716 lbs. As described herein, Contractor will provide the Services in exchange for the City's purchase and loan to Contractor of City- owned equipment and supplies to expand Contractor's food donation capacity in Carlsbad, increasing the number of donations they can accept, and in turn providing healthy food to the community. This will better equip the Contractor to receive, store, process, and distribute the new influx of recovered food. Contractor will prioritize using the Equipment to increase rescue of edible food from commercial edible food generators within the City of Carlsbad. Contractor responsibilities include: Contractor, at its sole expense, will receive, install, maintain, repair, and replace (if/as needed), all equipment and supplies related to this Agreement purchased by the City. Receiving includes physically receiving, verifying items delivered, and providing City with signed delivery receipt confirming all items were received. Contractor will meet site preparation expectations before installation •Power requirements •Prepare and clean space for equipment delivery Contractor will provide City with initial photo of installed equipment. Contractor will prioritize use of Equipment provided by the City to increase food rescue or distribution of surplus edible food from commercial edible food generators within the City of DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENV Exhibit "A" (Cont.) 8 Carlsbad. Activities may include collection, receiving, storage, processing, portioning and repackaging, preparing meals; and distribution of meals and rescued food items. Contractor will continue to operate its food rescue and distribution operations, located at [ENTER FULL ADDRESS]. Contractor shall maintain compliance with all federal, state, and local land use, regulatory, and permit requirements. Contractor will be required to obtain and maintain a valid business license with the City of Carlsbad during the service agreement. Contractor will recover edible food in Carlsbad, at minimum, the pounds identified in the Grand Total in the Eligible Metrics Exhibit “A,” Table 1. Contractor will weigh all donation items per donation site in Carlsbad and provide each one of them with the information in pounds recovered, including an inventory by category of items. Contractor will utilize its staff and collection vehicles to conduct food donation collection in this program. Contractor will work with each edible food generator to determine the best food donation collection system, including location, days, times to pick up the donation, and containers to store and transport the food being donated. Contractor will monitor and report the total food donated and distribution activities through the Agreement Term using the Progress Report form provided by the City. Contractor will submit Progress Reports on the schedule below documenting total pounds of food rescued in Carlsbad using the equipment and supplies. Contractor will communicate with City if there are organizational changes or if organization will be moving or closing within the Agreement Term. Contractor acknowledges that the Equipment purchased by the City will remain under the City's ownership and control during the Agreement Term. Once the Agreement Term has ended, ownership of the Equipment will be conveyed from City to the Contractor to continue the program. Progress Report # Covering Grant Activities from: Due Date to City Staff: #1 Grant start date through June 30, 2023 7/15/2023 #2 July 1, 2023, through Dec 31, 2023 1/15/2024 #3 Jan. 1, 2024, through March 31, 2024 4/15/2024 #4 April 1, 2024 through Dec 31, 2024 1/15/25 #5 Jan. 1, 2025 through Dec 31, 2025 1/15/26 #6 Jan. 1, 2026 through end of Agreement Term End of Agreement Term DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENV Exhibit "A" (Cont.) 9 City responsibilities include: City shall be responsible for coordinating assignments undertaken pursuant to this Agreement and will provide overall supervision of the progress and performance of this Agreement. City will purchase the items specified on an approved list of food rescue Equipment (Exhibit “B”), provided by Contractor or its designee, necessary to complete the obligations of the Scope of Work (Exhibit “A”) at a total cost of $6,218.97. City will ensure delivery of the Equipment to Contractor and will process and pay the invoice. The City will submit the invoice to CalRecycle for reimbursement by the Grant. The Equipment must be used for the Agreement activities described in this Scope of Work, but their use is not limited to just these activities. All Equipment purchased by the City will remain under City's ownership during the Agreement Term. At the end of the Agreement Term, ownership of the equipment and supplies will transfer to the Contractor. City will evaluate Contractor's progress reports and provide necessary feedback to make sure it is meeting the terms of this Agreement, Grant goals and reporting requirements. City will schedule regular check-in meetings between Contractor and City. DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENV 10 EXHIBIT “B” EQUIPMENT LIST – Interfaith Equipment Item Name Equipment Link/URL Equipment Total Cost, including tax and delivery Norpole 27.6 cu. ft. Double Door Commercial Reach-In Refrigerator in Stainless Steel (x1 items @ $3,379) https://www.homedepot.com/p/ Norpole-27-6-cu-ft-Double-Door- Commercial-Reach-In- Refrigerator-in-Stainless-Steel- NE35R/319060951? $3,379.00 Food Pantry Storage Solutions: Seville Classics Extra-Wide 7- Tier NSF 21-Bin Rack, 48" W x14" D x56" H (x 3 items @ $279.99 each) https://www.sevilleclassics.com/ products/web560?variant=39489 483505822&currency=USD&utm _medium=product_sync&utm_s ource=google&utm_content=sag _organic&utm_campaign=sag_or ganic&utm_campaign=gs-2021- 11- 08&utm_source=google&utm_m edium=smart_campaign&gclid=E AIaIQobChMIrNbd74i6_QIVCxmt Bh39NAE2EAQYByABEgIksPD_Bw E $839.97 Pantry Floor Repairs N/A $2,000.00 Grand Total $ 6,218.97 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE PSA23-2169ENV 11 EXHIBIT “C” CALRECYCLE GRANT TERMS DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE Table 1, Budget Examples Budciet Cateciorv Na me Examples (This is not an all-inclusive list) Indirect' Costs associated with operating and maintaining facilities, utilities, background checks and certification fees, permitting fees, all types of insurance, travel and mileage for personal vehicles used for food recovery or prevention activities, indirect supervision/management and consultant fees, etc. Construction Electrical, plumbing, engineering costs, site preparation, installation, kitchen design and construction/improvement, etc. Education and Outreach' Materials such as fliers, brochures, signs, etc. Note: Salaries covering personnel to conduct education and outreach activities should be listed under Personnel. EquipmentJ Equipment includes the following subcategories: • Food preparation and kitchenware • Materials (packaging, crates/bins for food storage, gloves, boxes, liners, GPS, PPE, etc.) • Refrigeration, freezers, refrigeration systems, etc . • Software such as food waste online exchange/logistics and source reduction platforms, etc. • Vehicl es and vehicle wraps or identification Maintenance Service or repair of grant-funded equipment and vehicles, vehicle modification for storage and shelving, fuel and/or ri,ileage [at State rate for travel reimbursements (https://www.calhr.ca.gov/emp loyees/Pages/travel- reimbursements.aspx0] for grant-f unded vehicles, etc. Personnel4 Salaries including: staff conducting outreach and education efforts, technical assistance for software support 1 Indirect costs are capped at 10 percent of total requested grant amount, see Indirect Costs section under Grant Cycle Overvi ew. 2 Public education and outreach may not exceed 10 percent of the applicant's req uested grant amount. 3 Software (food waste online exchange/logistic and source reduction platforms) may not exceed 25 percent of the applicant's requested grant amount, and it may not exceed $50,000. 4 Salaries may not exceed 65 percent of the applica nt's requested grant amount. Grant- funded jobs must be related to the proposed project and may not exceed $75 per hour. Applications Guidelines and Instructions Ed ible Food Recovery Grant Program, EFR1 (FY 2021 -22 and FY 2022-23) 16 PSA23-2169ENV Exhibit "C" (Cont.) 12 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE Budget Category Name Examples (This is not an all-inclusive list) or program development, food rescue drivers, warehouse workers, kitchen staff, etc. Transportation Services Food recovery transportation servi ces provided by third- party providers (i nvoices must be submitted). Eligible Costs Grantees may incur eligible costs only during the Grant Term, which starts when the grantee receives a Notice to Proceed from CalRecycle and ends on April 3, 2024. See "Grant Term" for additional information. Al l grant expenditures must be for activities, products, and costs specifically included in the approved Work Plan and approved Budget. To be eligible for reimbursement, costs must be incurred and fully paid (payments must be cleared), and all grant-funded items must be received by the grantee, after receiving a Notice to Proceed and before the end of the Grant Term. All services must be provided and goods received during this period in order to be eligible costs. Invoices for goods and services must be paid by the grantee prior to the inclusion of those goods or services on a payment request. Eligible costs include, but are not limited to the following: • Refrigerators, freezers, and refrigeration systems. • Vehicl es such as refrigerated trucks. • Transportation such as third party food transportation services. • Storage and co llection infrastructure such as food crates and bins. • Materials and equipment related to health and safety such as Personal Protective Equipment (masks, gloves, sanitation, etc.). • Food preparation and cooking items such as ovens, ranges, etc. • Salaries up to 65 percent of the applicant's requested grant amount (all grant- funded jobs must relate to the proposed project and hourly wages shall not exceed $75 per hour for direct personnel costs). • Public education and outreach costs up to ten percent of the applicant's requested grant amount. PSA23-2169ENVExhibit "C" (Cont.) 13 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE Ineligible Costs Any costs not specifically included in the approved Budget and not directly related to food recovery or food waste prevention and the approved grant project are ineligible for reimbursement. The grantee should contact the Grant Manager if clarification is needed. Ineligible costs include, but are not limited to: • Costs incurred prior to the date that Cal Recycle sends the Notice to Proceed email or after April 3, 2024. • Indirect Costs exceeding ten percent of the applicant's total requested amount. • Food waste dehydrators (https://www.calrecycle.ca .gov/organics/food/commercial/dehydrators) and liquefiers (https://www.calrecycle.ca.gov/organics/food/commercial/liquefiers). • Activities or equipment already funded by other agencies using California Climate Investments funds. • Environmental review for project permitting, including the preparation of Environmental Impact Reports or related documents. • Purchase, rent, or lease of land or buildings. • Compost bins and composting equipment. • Cardboard balers. Indirect Costs Indirect costs can be claimed by the grantee. The following guidelines must be used when claiming these costs. • Total indirect costs shall not exceed ten percent of the applicant's total requested amount. o These costs are expenditures not capable of being assigned or not read ily itemized to a particu lar project or activity, but considered necessary for the operation of the organization and the performance of the program. o Examples of indirect costs include, but are not limited to: the costs of operating and maintaining facilities, accounting services, admi nistrative sa laries (management not directly working on the grant project), all types of insurance, roadside assistance, utilities, background checks, safe food handling certification, and travel expenses are examples of indirect costs. • All indirect costs charged to the grant must be associated with grant activities as shown in the approved Budget. • Personnel costs associated w ith supervision performed by managers and supervisors is an indirect cost. However, if a manager or supervi sor performs an activity that is directly related to the execution of the grant (not supervising staff working on the project), costs associated with th is activity may be included as a direct charge. Such activity must be clearly supported by appropriate documentation and shall not be charged to the grant as an ind irect cost. • Tile grantee must maintain organized and accurate records that follow generally accepted accounting principles and leave an audit trail. The grantee must provide access to all documents related to the grant program and fiscal operation of the grant program as deemed necessary by Cal Recycle. PSA23-2169ENVExhibit "C" (Cont.) 14 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE • Tax preparation. • Food. o This grant will not reimburse for the purchase of food of any kind. • Costs deemed unreasonable or not related to the grant project by the Grant Manager. 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 1/11/2023 License # 0C32169 (619) 937-0164 (619) 937-0168 18058 Interfaith Community Services, Inc. 550 W Washington Ave B Escondido, CA 92025 13269 A 1,000,000 X X PHPK2446847 8/1/2022 8/1/2023 100,000 5,000 1,000,000 3,000,000 3,000,000 1,000,000A PHPK2446847 8/1/2022 8/1/2023 10,000,000A PHUB826564 8/1/2022 8/1/2023 10,000,000 10,000 B X M1302802 7/1/2022 7/1/2023 1,000,000 1,000,000 1,000,000 A Professional Liab.PHPK2446847 8/1/2022 Agg $3M, Occ $1M Ded 0 A Abuse & Molestation PHPK2446847 8/1/2022 8/1/2023 Agg $2M, Occ $1M Ded 0 RE: OPERATIONS OF THE NAMED INSURED AS CERTIFICATE HOLDERS INTEREST MAY APPEAR. THE CITY OF CARLSBAD, HOUSING SERVICES DIVISION, ITS OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WITH REGARDS TO THE GENERAL LIABILITY PER ATTACHED FORMS. PRIMARY AND NON-CONTRIBUTORY WORDING APPLIES WITH REGARDS TO THE GENERAL LIABILITY PER THE ATTACHED FORMS. WAIVER OF SUBROGATION APPLIES WITH REGARDS TO THE GENERAL LIABILITY AND WORKERS COMPENSATION POLICIES PER THE ATTACHED FORMS.(cpp) CITY OF CARLSBAD/CMWD 1200 CARLSBAD VILLAGE DRIVE CARLSBAD, CA 92008 INTECOM-02 CERTT3 Rancho Mesa Insurance Services, Inc. 250 Riverview Parkway Santee, CA 92071 Philadelphia Indemnity Ins Co Zenith Insurance Company 2 X 8/1/2023 X X X X X X X X X DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE ACORD" I ~ I ~ □ □ ~ ~ ~ □ □ ~ ~ ~ ~ ~ ~ ~ ~ H I I I I I □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±([WHQGHG5HSRUWLQJ3HULRG\HDUV $WKOHWLF$FWLYLWLHV$PHQGHG 6XSSOHPHQWDU\3D\PHQWV±%DLO%RQGV 6XSSOHPHQWDU\3D\PHQW±/RVVRI(DUQLQJVSHUGD\ (PSOR\HH,QGHPQLILFDWLRQ'HIHQVH&RYHUDJH .H\DQG/RFN5HSODFHPHQW±-DQLWRULDO6HUYLFHV&OLHQW&RYHUDJHOLPLW $GGLWLRQDO,QVXUHG±1HZO\$FTXLUHG7LPH3HULRG$PHQGHG $GGLWLRQDO,QVXUHG±0HGLFDO'LUHFWRUVDQG$GPLQLVWUDWRUV,QFOXGHG $GGLWLRQDO,QVXUHG±0DQDJHUVDQG6XSHUYLVRUVZLWK)HOORZ (PSOR\HH&RYHUDJH ,QFOXGHG $GGLWLRQDO,QVXUHG±%URDGHQHG1DPHG,QVXUHG,QFOXGHG $GGLWLRQDO,QVXUHG±)XQGLQJ6RXUFH,QFOXGHG $GGLWLRQDO,QVXUHG±+RPH&DUH3URYLGHUV,QFOXGHG $GGLWLRQDO,QVXUHG±0DQDJHUV/DQGORUGVRU/HVVRUVRI3UHPLVHV,QFOXGHG $GGLWLRQDO,QVXUHG±/HVVRURI/HDVHG(TXLSPHQW,QFOXGHG $GGLWLRQDO,QVXUHG±*UDQWRURI3HUPLWV,QFOXGHG $GGLWLRQDO,QVXUHG±9HQGRU,QFOXGHG $GGLWLRQDO,QVXUHG±)UDQFKLVRU,QFOXGHG $GGLWLRQDO,QVXUHG±:KHQ5HTXLUHGE\&RQWUDFW,QFOXGHG $GGLWLRQDO,QVXUHG±2ZQHUV/HVVHHVRU&RQWUDFWRUV,QFOXGHG $GGLWLRQDO,QVXUHG±6WDWHRU3ROLWLFDO6XEGLYLVLRQV,QFOXGHG $GGLWLRQDO,QVXUHG ±1HZO\$FTXLUHG 7LPH3HULRG $PHQGHG $GGLWLRQDO,QVXUHG ±0HGLFDO'LUHFWRUVDQG$GPLQLVWUDWRUV ,QFOXGHG $GGLWLRQDO,QVXUHG ±0DQDJHUVDQG6XSHUYLVRUV ZLWK)HOORZ,QFOXGHG (PSOR\HH&RYHUDJHS\ J $GGLWLRQDO,QVXUHG ±%URDGHQHG1DPHG,QVXUHG ,QFOXGHG $GGLWLRQDO,QVXUHG ±)XQGLQJ6RXUFH ,QFOXGHG $GGLWLRQDO,QVXUHG ±+RPH&DUH3URYLGHUV,QFOXGHG $GGLWLRQDO,QVXUHG ±0DQDJHUV/DQGORUGVRU/HVVRUVRI3UHPLVHV ,QFOXGHG $GGLWLRQDO,QVXUHG ±/HVVRURI/HDVHG(TXLSPHQW,QFOXGHG $GGLWLRQDO,QVXUHG ±*UDQWRURI3HUPLWV ,QFOXGHG $GGLWLRQDO,QVXUHG±9HQGRU ,QFOXGHG $GGLWLRQDO,QVXUHG ±)UDQFKLVRU ,QFOXGHG $GGLWLRQDO,QVXUHG ±:KHQ 5HTXLUHGE\&RQWUDFW ,QFOXGHG $GGLWLRQDO,QVXUHG ±2ZQHUV/HVVHHVRU&RQWUDFWRUV ,QFOXGHG $GGLWLRQDO,QVXUHG ±6WDWHRU3ROLWLFDO 6XEGLYLVLRQV ,QFOXGHG POLICY NUMBER: PHPK2446847 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE L J l J u L J l J u ~ J l J u ~ L J l J u L J l J u l J t j u l J l J u L J l J u l J l J u C J l J u l J J u l ) ( J u l ) l J u l J l J u 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ 'XWLHVLQWKH(YHQWRI2FFXUUHQFH&ODLPRU6XLW,QFOXGHG 8QLQWHQWLRQDO)DLOXUHWR'LVFORVH+D]DUGV,QFOXGHG 7UDQVIHURI5LJKWVRI5HFRYHU\$JDLQVW2WKHUV7R8V&ODULILFDWLRQ /LEHUDOL]DWLRQ,QFOXGHG %RGLO\,QMXU\±LQFOXGHV0HQWDO$QJXLVK,QFOXGHG 3HUVRQDODQG$GYHUWLVLQJ,QMXU\±LQFOXGHV$EXVHRI3URFHVV 'LVFULPLQDWLRQ ,QFOXGHG $ ([WHQGHG3URSHUW\'DPDJH 6(&7,21,±&29(5$*(6&29(5$*($%2',/<,1-85<$1'3523(57<'$0$*( /,$%,/,7<6XEVHFWLRQ([FOXVLRQV3DUDJUDSKDLVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGE\WKH IROORZLQJ D([SHFWHGRU,QWHQGHG,QMXU\ ³%RGLO\LQMXU\´RUSURSHUW\GDPDJH´H[SHFWHGRULQWHQGHGIURPWKHVWDQGSRLQWRIWKHLQVXUHG 7KLVH[FOXVLRQGRHVQRWDSSO\WR³ERGLO\LQMXU\´RU³SURSHUW\GDPDJH´UHVXOWLQJIURPWKHXVHRI UHDVRQDEOHIRUFHWRSURWHFWSHUVRQVRUSURSHUW\ % /LPLWHG5HQWDO/HDVH$JUHHPHQW&RQWUDFWXDO/LDELOLW\ 6(&7,21,±&29(5$*(6&29(5$*($%2',/<,1-85<$1'3523(57<'$0$*( /,$%,/,7<6XEVHFWLRQ([FOXVLRQV3DUDJUDSKE&RQWUDFWXDO/LDELOLW\LVDPHQGHGWRLQFOXGHWKH IROORZLQJ %DVHGRQWKHQDPHGLQVXUHG¶VUHTXHVWDWWKHWLPHRIFODLPZHDJUHHWRLQGHPQLI\WKH QDPHGLQVXUHGIRUWKHLUOLDELOLW\DVVXPHGLQDFRQWUDFWRUDJUHHPHQWUHJDUGLQJWKHUHQWDO RUOHDVHRIDSUHPLVHVRQEHKDOIRIWKHLUFOLHQWXSWR7KLVFRYHUDJHH[WHQVLRQ RQO\DSSOLHVWRUHQWDOOHDVHDJUHHPHQWV7KLVFRYHUDJHLVH[FHVVRYHUDQ\UHQWHU¶V OLDELOLW\LQVXUDQFHRIWKHFOLHQW & 1RQ2ZQHG:DWHUFUDIW 6(&7,21,±&29(5$*(6&29(5$*($%2',/<,1-85<$1'3523(57<'$0$*( /,$%,/,7<6XEVHFWLRQ([FOXVLRQV3DUDJUDSKJLVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGE\WKH IROORZLQJ $ZDWHUFUDIW\RXGRQRWRZQWKDWLV D /HVVWKDQIHHWORQJDQG E 1RWEHLQJXVHGWRFDUU\SHUVRQVRUSURSHUW\IRUDFKDUJH 7KLVSURYLVLRQDSSOLHVWRDQ\SHUVRQZKRZLWK\RXUFRQVHQWHLWKHUXVHVRULVUHVSRQVLEOHIRU WKHXVHRIDZDWHUFUDIW7KLVLQVXUDQFHLVH[FHVVRYHUDQ\RWKHUYDOLGDQGFROOHFWLEOH LQVXUDQFHDYDLODEOHWRWKHLQVXUHGZKHWKHUSULPDU\H[FHVVRUFRQWLQJHQW ' 'DPDJHWR3URSHUW\<RX2ZQ5HQWRU2FFXS\ 6(&7,21,±&29(5$*(6&29(5$*($%2',/<,1-85<$1'3523(57<'$0$*( 7UDQVIHURI5LJKWVRI5HFRYHU\$JDLQVW2WKHUV7R8V &ODULILFDWLRQ DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE l J l J u 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ /,$%,/,7<6XEVHFWLRQ([FOXVLRQV3DUDJUDSKM'DPDJHWR3URSHUW\,WHPLVGHOHWHGLQLWV HQWLUHW\DQGUHSODFHGZLWKWKHIROORZLQJ 3URSHUW\\RXRZQUHQWRURFFXS\LQFOXGLQJDQ\FRVWVRUH[SHQVHVLQFXUUHGE\\RXRU DQ\RWKHUSHUVRQRUJDQL]DWLRQRUHQWLW\IRUUHSDLUUHSODFHPHQWHQKDQFHPHQW UHVWRUDWLRQRUPDLQWHQDQFHRIVXFKSURSHUW\IRUDQ\UHDVRQLQFOXGLQJSUHYHQWLRQRILQMXU\ WRDSHUVRQRUGDPDJHWRDQRWKHU¶VSURSHUW\XQOHVVWKHGDPDJHWRSURSHUW\LVFDXVHGE\ \RXUFOLHQWXSWRDOLPLW$FOLHQWLVGHILQHGDVDSHUVRQXQGHU\RXUGLUHFWFDUH DQGVXSHUYLVLRQ ('DPDJHWR3UHPLVHV5HQWHGWR<RX ,IGDPDJHE\ILUHWRSUHPLVHVUHQWHGWR\RXLVQRWRWKHUZLVHH[FOXGHGIURPWKLV&RYHUDJH3DUW WKHZRUG³ILUH´LVFKDQJHGWR³ILUHOLJKWQLQJH[SORVLRQVPRNHRUOHDNDJHIURPDXWRPDWLFILUH SURWHFWLYHV\VWHPV´ZKHUHLWDSSHDUVLQ D 7KHODVWSDUDJUDSKRI6(&7,21,±&29(5$*(6&29(5$*($%2',/<,1-85<$1' 3523(57<'$0$*(/,$%,/,7<6XEVHFWLRQ([FOXVLRQVLVGHOHWHGLQLWVHQWLUHW\DQG UHSODFHGE\WKHIROORZLQJ ([FOXVLRQVFWKURXJKQGRQRWDSSO\WRGDPDJHE\ILUHOLJKWQLQJH[SORVLRQVPRNHRU OHDNDJHIURPDXWRPDWLFILUHSURWHFWLYHV\VWHPVWRSUHPLVHVZKLOHUHQWHGWR\RXRU WHPSRUDULO\RFFXSLHGE\\RXZLWKSHUPLVVLRQRIWKHRZQHU$VHSDUDWHOLPLWRILQVXUDQFH DSSOLHVWRWKLVFRYHUDJHDVGHVFULEHGLQ6(&7,21,,,±/,0,762),1685$1&( E 6(&7,21,,,±/,0,762),1685$1&(3DUDJUDSKLVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHG E\WKHIROORZLQJ 6XEMHFWWR3DUDJUDSKDERYHWKH'DPDJH7R3UHPLVHV5HQWHG7R<RX/LPLWLVWKH PRVWZHZLOOSD\XQGHU&RYHUDJH$IRUGDPDJHVEHFDXVHRISURSHUW\GDPDJHWRDQ\ RQHSUHPLVHVZKLOHUHQWHGWR\RXRULQWKHFDVHRIGDPDJHE\ILUHOLJKWQLQJH[SORVLRQ VPRNHRUOHDNDJHIURPDXWRPDWLFILUHSURWHFWLYHV\VWHPVZKLOHUHQWHGWR\RXRU WHPSRUDULO\RFFXSLHGE\\RXZLWKSHUPLVVLRQRIWKHRZQHU F 6(&7,219±'(),1,7,2163DUDJUDSKDLVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGE\WKH IROORZLQJ $FRQWUDFWIRUDOHDVHRISUHPLVHV+RZHYHUWKDWSRUWLRQRIWKHFRQWUDFWIRUDOHDVHRI SUHPLVHVWKDWLQGHPQLILHVDQ\SHUVRQRURUJDQL]DWLRQIRUGDPDJHE\ILUHOLJKWQLQJ H[SORVLRQVPRNHRUOHDNDJHIURPDXWRPDWLFILUHSURWHFWLYHV\VWHPVWRSUHPLVHVZKLOH UHQWHGWR\RXRUWHPSRUDULO\RFFXSLHGE\\RXZLWKSHUPLVVLRQRIWKHRZQHULVQRWDQ LQVXUHGFRQWUDFW 6(&7,21,9±&200(5&,$/*(1(5$//,$%,/,7<&21',7,2166XEVHFWLRQ2WKHU ,QVXUDQFH3DUDJUDSKE([FHVV,QVXUDQFHDLLLVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGE\ WKHIROORZLQJ 7KDWLVLQVXUDQFHIRUILUHOLJKWQLQJH[SORVLRQVPRNHRUOHDNDJHIURPDXWRPDWLFILUH SURWHFWLYHV\VWHPVIRUSUHPLVHVUHQWHGWR\RXRUWHPSRUDULO\RFFXSLHGE\\RXZLWKSHUPLVVLRQ RIWKHRZQHU 7KH'DPDJH7R3UHPLVHV5HQWHG7R<RX/LPLWVHFWLRQRIWKH'HFODUDWLRQVLVDPHQGHGWRWKH JUHDWHURI DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ D RU E7KHDPRXQWVKRZQLQWKH'HFODUDWLRQVDVWKH'DPDJHWR3UHPLVHV5HQWHGWR<RX/LPLW 7KLVLVWKHPRVWZHZLOOSD\IRUDOOGDPDJHSUR[LPDWHO\FDXVHGE\WKHVDPHHYHQWZKHWKHUVXFK GDPDJHUHVXOWVIURPILUHOLJKWQLQJH[SORVLRQVPRNHRUOHDNVIURPDXWRPDWLFILUHSURWHFWLYH V\VWHPVRUDQ\FRPELQDWLRQWKHUHRI ) +,3$$ 6(&7,21,±&29(5$*(6&29(5$*(%3(5621$/$1'$'9(57,6,1*,1-85</,$%,/,7< LVDPHQGHGDVIROORZV 3DUDJUDSK,QVXULQJ$JUHHPHQWLVDPHQGHGWRLQFOXGHWKHIROORZLQJ :HZLOOSD\WKRVHVXPVWKDWWKHLQVXUHGEHFRPHVOHJDOO\REOLJDWHGWRSD\DVGDPDJHVEHFDXVH RID³YLRODWLRQV´RIWKH+HDOWK,QVXUDQFH3RUWDELOLW\DQG$FFRXQWDELOLW\$FW+,3$$:HKDYH WKHULJKWDQGWKHGXW\WRGHIHQGWKHLQVXUHGDJDLQVWDQ\³VXLW´³LQYHVWLJDWLRQ´RU³FLYLOSURFHHGLQJ´ VHHNLQJWKHVHGDPDJHV+RZHYHUZHZLOOKDYHQRGXW\WRGHIHQGWKHLQVXUHGDJDLQVWDQ\³VXLW´ VHHNLQJGDPDJHV³LQYHVWLJDWLRQ´RU³FLYLOSURFHHGLQJ´WRZKLFKWKLVLQVXUDQFHGRHVQRWDSSO\ 3DUDJUDSK([FOXVLRQVLVDPHQGHGWRLQFOXGHWKHIROORZLQJDGGLWLRQDOH[FOXVLRQV 7KLVLQVXUDQFHGRHVQRWDSSO\WR D,QWHQWLRQDO:LOOIXORU'HOLEHUDWH9LRODWLRQV $Q\ZLOOIXOLQWHQWLRQDORUGHOLEHUDWH³YLRODWLRQV´E\DQ\LQVXUHG E&ULPLQDO$FWV $Q\³YLRODWLRQ´ZKLFKUHVXOWVLQDQ\FULPLQDOSHQDOWLHVXQGHUWKH+,3$$ F2WKHU5HPHGLHV $Q\UHPHG\RWKHUWKDQPRQHWDU\GDPDJHVIRUSHQDOWLHVDVVHVVHG G&RPSOLDQFH5HYLHZVRU$XGLWV $Q\FRPSOLDQFHUHYLHZVE\WKH'HSDUWPHQWRI+HDOWKDQG+XPDQ6HUYLFHV 6(&7,219±'(),1,7,216LVDPHQGHGWRLQFOXGHWKHIROORZLQJDGGLWLRQDOGHILQLWLRQV D ³&LYLOSURFHHGLQJ´PHDQVDQDFWLRQE\WKH'HSDUWPHQWRI+HDOWKDQG+XPDQ6HUYLFHV++6 DULVLQJRXWRI³YLRODWLRQV´ E ³,QYHVWLJDWLRQ´PHDQVDQH[DPLQDWLRQRIDQDFWXDORUDOOHJHG³YLRODWLRQV´E\++6+RZHYHU ³LQYHVWLJDWLRQ´GRHVQRWLQFOXGHD&RPSOLDQFH5HYLHZ F ³9LRODWLRQ´PHDQVWKHDFWXDORUDOOHJHGIDLOXUHWRFRPSO\ZLWKWKHUHJXODWLRQVLQFOXGHGLQWKH +,3$$ DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ *0HGLFDO3D\PHQWV±/LPLW,QFUHDVHGWR([WHQGHG5HSRUWLQJ3HULRG ,I&29(5$*(&0(',&$/3$<0(176LVQRWRWKHUZLVHH[FOXGHGIURPWKLV&RYHUDJH3DUW 7KH0HGLFDO([SHQVH/LPLWLVFKDQJHGVXEMHFWWRDOORIWKHWHUPVRI6(&7,21,,,/,0,762) ,1685$1&(WRWKHJUHDWHURI D RU E 7KH0HGLFDO([SHQVH/LPLWVKRZQLQWKH'HFODUDWLRQVRIWKLV&RYHUDJH3DUW 6(&7,21,±&29(5$*(&29(5$*(&0(',&$/3$<0(1766XEVHFWLRQ,QVXULQJ $JUHHPHQWDELVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGE\WKHIROORZLQJ E7KHH[SHQVHVDUHLQFXUUHGDQGUHSRUWHGWRXVZLWKLQWKUHH\HDUVRIWKHGDWHRIWKH DFFLGHQW + $WKOHWLF$FWLYLWLHV 6(&7,21,±&29(5$*(6&29(5$*(&0(',&$/3$<0(1766XEVHFWLRQ([FOXVLRQV 3DUDJUDSKH$WKOHWLF$FWLYLWLHVLVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGZLWKWKHIROORZLQJ H$WKOHWLF$FWLYLWLHV 7RDSHUVRQLQMXUHGZKLOHWDNLQJSDUWLQDWKOHWLFV , 6XSSOHPHQWDU\3D\PHQWV 6(&7,21,±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±&29(5$*(66833/(0(17$5<3$<0(176±&29(5$*(6$$1'%WKH IROORZLQJLVDGGHG :HZLOOSD\RQ\RXUEHKDOIGHIHQVHFRVWVLQFXUUHGE\DQ³HPSOR\HH´LQDFULPLQDOSURFHHGLQJ RFFXUULQJLQWKHFRXUVHRIHPSOR\PHQW 7KHPRVWZHZLOOSD\IRUDQ\³HPSOR\HH´ZKRLVDOOHJHGWREHGLUHFWO\LQYROYHGLQDFULPLQDO SURFHHGLQJLVUHJDUGOHVVRIWKHQXPEHUVRI³HPSOR\HHV´FODLPVRU³VXLWV´EURXJKWRU SHUVRQVRURUJDQL]DWLRQVPDNLQJFODLPVRUEULQJLQJ³VXLWV DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ . .H\DQG/RFN5HSODFHPHQW±-DQLWRULDO6HUYLFHV&OLHQW&RYHUDJH 6(&7,21,±&29(5$*(66833/(0(17$5<3$<0(176±&29(5$*(6$$1'%LV DPHQGHGWRLQFOXGHWKHIROORZLQJ :HZLOOSD\IRUWKHFRVWWRUHSODFHNH\VDQGORFNVDWWKH³FOLHQWV´SUHPLVHVGXHWRWKHIWRURWKHU ORVVWRNH\VHQWUXVWHGWR\RXE\\RXU³FOLHQW´XSWRDOLPLWSHURFFXUUHQFHDQG SROLF\DJJUHJDWH :HZLOOQRWSD\IRUORVVRUGDPDJHUHVXOWLQJIURPWKHIWRUDQ\RWKHUGLVKRQHVWRUFULPLQDODFWWKDW \RXRUDQ\RI\RXUSDUWQHUVPHPEHUVRIILFHUV³HPSOR\HHV´³PDQDJHUV´GLUHFWRUVWUXVWHHV DXWKRUL]HGUHSUHVHQWDWLYHVRUDQ\RQHWRZKRP\RXHQWUXVWWKHNH\VRID³FOLHQW´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±:+2,6$1,1685('LVDPHQGHGDVIROORZV ,IFRYHUDJHIRUQHZO\DFTXLUHGRUIRUPHGRUJDQL]DWLRQVLVQRWRWKHUZLVHH[FOXGHGIURPWKLV DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ &RYHUDJH3DUW3DUDJUDSKDLVGHOHWHGLQLWVHQWLUHO\DQGUHSODFHGE\WKHIROORZLQJ D&RYHUDJHXQGHUWKLVSURYLVLRQLVDIIRUGHGXQWLOWKHHQGRIWKHSROLF\SHULRG (DFKRIWKHIROORZLQJLVDOVRDQLQVXUHG D0HGLFDO'LUHFWRUVDQG$GPLQLVWUDWRUV±<RXUPHGLFDOGLUHFWRUVDQGDGPLQLVWUDWRUVEXW RQO\ZKLOHDFWLQJZLWKLQWKHVFRSHRIDQGGXULQJWKHFRXUVHRIWKHLUGXWLHVDVVXFK6XFK GXWLHVGRQRWLQFOXGHWKHIXUQLVKLQJRUIDLOXUHWRIXUQLVKSURIHVVLRQDOVHUYLFHVRIDQ\SK\VLFLDQ RUSV\FKLDWULVWLQWKHWUHDWPHQWRIDSDWLHQW E0DQDJHUVDQG6XSHUYLVRUV±<RXUPDQDJHUVDQGVXSHUYLVRUVDUHDOVRLQVXUHGVEXW RQO\ZLWKUHVSHFWWRWKHLUGXWLHVDV\RXUPDQDJHUVDQGVXSHUYLVRUV0DQDJHUVDQG VXSHUYLVRUVZKRDUH\RXU³HPSOR\HHV´DUHDOVRLQVXUHGVIRU³ERGLO\LQMXU\´WRDFR ³HPSOR\HH´ZKLOHLQWKHFRXUVHRIKLVRUKHUHPSOR\PHQWE\\RXRUSHUIRUPLQJGXWLHV UHODWHGWRWKHFRQGXFWRI\RXUEXVLQHVV 7KLVSURYLVLRQGRHVQRWFKDQJH,WHPDDDVLWDSSOLHVWRPDQDJHUVRIDOLPLWHG OLDELOLW\FRPSDQ\ F%URDGHQHG1DPHG,QVXUHG±$Q\RUJDQL]DWLRQDQGVXEVLGLDU\WKHUHRIZKLFK\RXFRQWURODQG DFWLYHO\PDQDJHRQWKHHIIHFWLYHGDWHRIWKLV&RYHUDJH3DUW+RZHYHUFRYHUDJHGRHVQRW DSSO\WRDQ\RUJDQL]DWLRQRUVXEVLGLDU\QRWQDPHGLQWKH'HFODUDWLRQVDV1DPHG,QVXUHGLI WKH\DUHDOVRLQVXUHGXQGHUDQRWKHUVLPLODUSROLF\EXWIRULWVWHUPLQDWLRQRUWKHH[KDXVWLRQRI LWVOLPLWVRILQVXUDQFH G)XQGLQJ6RXUFH±$Q\SHUVRQRURUJDQL]DWLRQZLWKUHVSHFWWRWKHLUOLDELOLW\DULVLQJRXWRI 7KHLUILQDQFLDOFRQWURORI\RXRU 3UHPLVHVWKH\RZQPDLQWDLQRUFRQWUROZKLOH\RXOHDVHRURFFXS\WKHVHSUHPLVHV 7KLVLQVXUDQFHGRHVQRWDSSO\WRVWUXFWXUDODOWHUDWLRQVQHZFRQVWUXFWLRQDQGGHPROLWLRQ RSHUDWLRQVSHUIRUPHGE\RUIRUWKDWSHUVRQRURUJDQL]DWLRQ H+RPH&DUH3URYLGHUV±$WWKHILUVW1DPHG,QVXUHG VRSWLRQDQ\SHUVRQRURUJDQL]DWLRQ XQGHU\RXUGLUHFWVXSHUYLVLRQDQGFRQWUROZKLOHSURYLGLQJIRU\RXSULYDWHKRPHUHVSLWHRU IRVWHUKRPHFDUHIRUWKHGHYHORSPHQWDOO\GLVDEOHG I0DQDJHUV/DQGORUGVRU/HVVRUVRI3UHPLVHV±$Q\SHUVRQRURUJDQL]DWLRQZLWKUHVSHFW WRWKHLUOLDELOLW\DULVLQJRXWRIWKHRZQHUVKLSPDLQWHQDQFHRUXVHRIWKDWSDUWRIWKHSUHPLVHV OHDVHGRUUHQWHGWR\RXVXEMHFWWRWKHIROORZLQJDGGLWLRQDOH[FOXVLRQV 7KLVLQVXUDQFHGRHVQRWDSSO\WR $Q\³RFFXUUHQFH´ZKLFKWDNHVSODFHDIWHU\RXFHDVHWREHDWHQDQWLQWKDWSUHPLVHVRU 6WUXFWXUDODOWHUDWLRQVQHZFRQVWUXFWLRQRUGHPROLWLRQRSHUDWLRQVSHUIRUPHGE\RURQ EHKDOIRIWKDWSHUVRQRURUJDQL]DWLRQ J /HVVRURI/HDVHG(TXLSPHQW±$XWRPDWLF6WDWXV:KHQ5HTXLUHGLQ/HDVH$JUHHPHQW :LWK<RX±$Q\SHUVRQRURUJDQL]DWLRQIURPZKRP\RXOHDVHHTXLSPHQWZKHQ\RXDQGVXFK SHUVRQRURUJDQL]DWLRQKDYHDJUHHGLQZULWLQJLQDFRQWUDFWRUDJUHHPHQWWKDWVXFKSHUVRQRU RUJDQL]DWLRQLVWREHDGGHGDVDQDGGLWLRQDOLQVXUHGRQ\RXUSROLF\6XFKSHUVRQRU DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ RUJDQL]DWLRQLVDQLQVXUHGRQO\ZLWKUHVSHFWWROLDELOLW\IRU³ERGLO\LQMXU\´³SURSHUW\GDPDJH´RU ³SHUVRQDODQGDGYHUWLVLQJLQMXU\´FDXVHGLQZKROHRULQSDUWE\\RXUPDLQWHQDQFHRSHUDWLRQ RUXVHRIHTXLSPHQWOHDVHGWR\RXE\VXFKSHUVRQRURUJDQL]DWLRQ $SHUVRQ¶VRURUJDQL]DWLRQ¶VVWDWXVDVDQDGGLWLRQDOLQVXUHGXQGHUWKLVHQGRUVHPHQWHQGV ZKHQWKHLUFRQWUDFWRUDJUHHPHQWZLWK\RXIRUVXFKOHDVHGHTXLSPHQWHQGV :LWKUHVSHFWWRWKHLQVXUDQFHDIIRUGHGWRWKHVHDGGLWLRQDOLQVXUHGVWKLVLQVXUDQFHGRHVQRW DSSO\WRDQ\³RFFXUUHQFH´ZKLFKWDNHVSODFHDIWHUWKHHTXLSPHQWOHDVHH[SLUHV K*UDQWRUVRI3HUPLWV±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±2QO\ZLWKUHVSHFWWR³ERGLO\LQMXU\´RU³SURSHUW\GDPDJH´DULVLQJRXWRI³\RXU SURGXFWV´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ocuSign Envelope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±$Q\SHUVRQRURUJDQL]DWLRQZLWKUHVSHFWWRWKHLUOLDELOLW\DVWKHJUDQWRURID IUDQFKLVHWR\RX N$V5HTXLUHGE\&RQWUDFW±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±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ocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE 3,*/'+6 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 3KLODGHOSKLD,QGHPQLW\,QVXUDQFH&RPSDQ\ P6WDWHRU3ROLWLFDO6XEGLYLVLRQV±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±&200(5&,$/*(1(5$//,$%,/,7<&21',7,2163DUDJUDSKLVDPHQGHGDV IROORZV DLVDPHQGHGWRLQFOXGH 7KLVFRQGLWLRQDSSOLHVRQO\ZKHQWKH³RFFXUUHQFH´RURIIHQVHLVNQRZQWR <RXLI\RXDUHDQLQGLYLGXDO $SDUWQHULI\RXDUHDSDUWQHUVKLSRU $QH[HFXWLYHRIILFHURULQVXUDQFHPDQDJHULI\RXDUHDFRUSRUDWLRQ ELVDPHQGHGWRLQFOXGH 7KLVFRQGLWLRQZLOOQRWEHFRQVLGHUHGEUHDFKHGXQOHVVWKHEUHDFKRFFXUVDIWHUVXFKFODLPRU³VXLW´ LVNQRZQWR <RXLI\RXDUHDQLQGLYLGXDO $SDUWQHULI\RXDUHDSDUWQHUVKLSRU $QH[HFXWLYHRIILFHURULQVXUDQFHPDQDJHULI\RXDUHDFRUSRUDWLRQ 1 8QLQWHQWLRQDO)DLOXUH7R'LVFORVH+D]DUGV 6(&7,21,9±&200(5&,$/*(1(5$//,$%,/,7<&21',7,2165HSUHVHQWDWLRQVLV DPHQGHGWRLQFOXGHWKHIROORZLQJ ,WLVDJUHHGWKDWEDVHGRQRXUUHOLDQFHRQ\RXUUHSUHVHQWDWLRQVDVWRH[LVWLQJKD]DUGVLI\RX VKRXOGXQLQWHQWLRQDOO\IDLOWRGLVFORVHDOOVXFKKD]DUGVSULRUWRWKHEHJLQQLQJRIWKHSROLF\SHULRGRI WKLV&RYHUDJH3DUWZHVKDOOQRWGHQ\FRYHUDJHXQGHUWKLV&RYHUDJH3DUWEHFDXVHRIVXFKIDLOXUH 2 7UDQVIHURI5LJKWVRI5HFRYHU\$JDLQVW2WKHUV7R8V 6(&7,21,9±&200(5&,$/*(1(5$//,$%,/,7<&21',7,2167UDQVIHURI5LJKWVRI DocuSign Envelope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¶VULJKWVRIUHFRYHU\SULRUWRWKHRFFXUUHQFHRID ORVVSURYLGHGWKHZDLYHULVPDGHLQDZULWWHQFRQWUDFW 3 /LEHUDOL]DWLRQ 6(&7,21,9±&200(5&,$/*(1(5$//,$%,/,7<&21',7,216LVDPHQGHGWRLQFOXGHWKH IROORZLQJ ,IZHUHYLVHWKLVHQGRUVHPHQWWRSURYLGHPRUHFRYHUDJHZLWKRXWDGGLWLRQDOSUHPLXPFKDUJHZH ZLOODXWRPDWLFDOO\SURYLGHWKHDGGLWLRQDOFRYHUDJHWRDOOHQGRUVHPHQWKROGHUVDVRIWKHGD\WKH UHYLVLRQLVHIIHFWLYHLQ\RXUVWDWH 4%RGLO\,QMXU\±0HQWDO$QJXLVK 6(&7,219±'(),1,7,2163DUDJUDSK,VGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGE\WKHIROORZLQJ ³%RGLO\LQMXU\´PHDQV D %RGLO\LQMXU\VLFNQHVVRUGLVHDVHVXVWDLQHGE\DSHUVRQDQGLQFOXGHVPHQWDODQJXLVK UHVXOWLQJIURPDQ\RIWKHVHDQG E ([FHSWIRUPHQWDODQJXLVKLQFOXGHVGHDWKUHVXOWLQJIURPWKHIRUHJRLQJ,WHPDDERYHDWDQ\ WLPH 5 3HUVRQDODQG$GYHUWLVLQJ,QMXU\±$EXVHRI3URFHVV'LVFULPLQDWLRQ ,I&29(5$*(%3(5621$/$1'$'9(57,6,1*,1-85</,$%,/,7<&29(5$*(LVQRW RWKHUZLVHH[FOXGHGIURPWKLV&RYHUDJH3DUWWKHGHILQLWLRQRI³SHUVRQDODQGDGYHUWLVLQJLQMXU\´LV DPHQGHGDVIROORZV 6(&7,219±'(),1,7,2163DUDJUDSKELVGHOHWHGLQLWVHQWLUHW\DQGUHSODFHGE\WKH IROORZLQJ E 0DOLFLRXVSURVHFXWLRQRUDEXVHRISURFHVV 6(&7,219±'(),1,7,2163DUDJUDSKLVDPHQGHGE\DGGLQJWKHIROORZLQJ 'LVFULPLQDWLRQEDVHGRQUDFHFRORUUHOLJLRQVH[DJHRUQDWLRQDORULJLQH[FHSWZKHQ D 'RQHLQWHQWLRQDOO\E\RUDWWKHGLUHFWLRQRIRUZLWKWKHNQRZOHGJHRUFRQVHQWRI $Q\LQVXUHGRU $Q\H[HFXWLYHRIILFHUGLUHFWRUVWRFNKROGHUSDUWQHURUPHPEHURIWKHLQVXUHG E 'LUHFWO\RULQGLUHFWO\UHODWHGWRWKHHPSOR\PHQWIRUPHURUSURVSHFWLYHHPSOR\PHQW WHUPLQDWLRQRIHPSOR\PHQWRUDSSOLFDWLRQIRUHPSOR\PHQWRIDQ\SHUVRQRUSHUVRQVE\DQ LQVXUHG DocuSign Envelope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ocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 PRIMARY AND NONCONTRIBUTORY –OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1)The additional insured is a Named Insuredunder such other insurance; and (2)You have agreed in writing in a contract oragreement that this insurance would beprimary and would not seek contributionfrom any other insurance available to theadditional insured. POLICY NUMBER: PHPK2446847 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE ,/ ,/&RS\ULJKW,QVXUDQFH6HUYLFHV2IILFH,QF3DJHRI &2002132/,&<&21',7,216 $OO&RYHUDJH3DUWVLQFOXGHGLQWKLVSROLF\DUHVXEMHFWWRWKHIROORZLQJFRQGLWLRQV $ &DQFHOODWLRQ 7KHILUVW1DPHG,QVXUHGVKRZQLQWKH'HFODUD WLRQVPD\FDQFHOWKLVSROLF\E\PDLOLQJRUGH OLYHULQJWRXVDGYDQFHZULWWHQQRWLFHRIFDQFHO ODWLRQ :HPD\FDQFHOWKLVSROLF\E\PDLOLQJRUGHOLY HULQJWRWKHILUVW1DPHG,QVXUHGZULWWHQQRWLFH RIFDQFHOODWLRQDWOHDVW DGD\VEHIRUHWKHHIIHFWLYHGDWHRIFDQFHO ODWLRQLIZHFDQFHOIRUQRQSD\PHQWRISUH PLXPRU EGD\VEHIRUHWKHHIIHFWLYHGDWHRIFDQFHO ODWLRQLIZHFDQFHOIRUDQ\RWKHUUHDVRQ :HZLOOPDLORUGHOLYHURXUQRWLFHWRWKHILUVW 1DPHG,QVXUHG VODVWPDLOLQJDGGUHVVNQRZQWR XV 1RWLFH RI FDQFHOODWLRQ ZLOO VWDWH WKH HIIHFWLYH GDWHRIFDQFHOODWLRQ7KHSROLF\SHULRGZLOOHQG RQWKDWGDWH ,IWKLVSROLF\LVFDQFHOOHGZHZLOOVHQGWKHILUVW 1DPHG,QVXUHGDQ\SUHPLXPUHIXQGGXH,IZH FDQFHOWKHUHIXQGZLOOEHSURUDWD,IWKHILUVW 1DPHG ,QVXUHG FDQFHOV WKH UHIXQG PD\ EH OHVVWKDQSURUDWD7KHFDQFHOODWLRQZLOOEHHI IHFWLYHHYHQLIZHKDYHQRWPDGHRURIIHUHGD UHIXQG ,IQRWLFHLVPDLOHGSURRIRIPDLOLQJZLOOEHVXI ILFLHQWSURRIRIQRWLFH % &KDQJHV 7KLVSROLF\FRQWDLQVDOOWKHDJUHHPHQWVEHWZHHQ \RX DQG XV FRQFHUQLQJ WKH LQVXUDQFH DIIRUGHG 7KH ILUVW 1DPHG ,QVXUHG VKRZQ LQ WKH 'HFODUD WLRQVLVDXWKRUL]HGWRPDNHFKDQJHVLQWKHWHUPV RIWKLVSROLF\ZLWKRXUFRQVHQW7KLVSROLF\ VWHUPV FDQEHDPHQGHGRUZDLYHGRQO\E\HQGRUVHPHQW LVVXHGE\XVDQGPDGHDSDUWRIWKLVSROLF\ & ([DPLQDWLRQ2I<RXU%RRNV$QG5HFRUGV :HPD\H[DPLQHDQGDXGLW\RXUERRNVDQGUHF RUGVDVWKH\UHODWHWRWKLVSROLF\DWDQ\WLPHGXULQJ WKHSROLF\SHULRGDQGXSWRWKUHH\HDUVDIWHUZDUG ' ,QVSHFWLRQV$QG6XUYH\V :HKDYHWKHULJKWWR D0DNHLQVSHFWLRQVDQGVXUYH\VDWDQ\WLPH E*LYH\RXUHSRUWVRQWKHFRQGLWLRQVZHILQG DQG F5HFRPPHQGFKDQJHV :HDUHQRWREOLJDWHGWRPDNHDQ\LQVSHFWLRQV VXUYH\VUHSRUWVRUUHFRPPHQGDWLRQVDQGDQ\ VXFKDFWLRQVZHGRXQGHUWDNHUHODWHRQO\WRLQ VXUDELOLW\DQGWKHSUHPLXPVWREHFKDUJHG:H GRQRWPDNHVDIHW\LQVSHFWLRQV:HGRQRWXQ GHUWDNHWRSHUIRUPWKHGXW\RIDQ\SHUVRQRU RUJDQL]DWLRQWRSURYLGHIRUWKHKHDOWKRUVDIHW\ RIZRUNHUVRUWKHSXEOLF$QGZHGRQRWZDUUDQW WKDWFRQGLWLRQV D$UHVDIHRUKHDOWKIXORU E&RPSO\ ZLWK ODZV UHJXODWLRQV FRGHV RU VWDQGDUGV 3DUDJUDSKV DQG RI WKLV FRQGLWLRQ DSSO\ QRWRQO\WRXVEXWDOVRWRDQ\UDWLQJDGYLVRU\ UDWH VHUYLFH RU VLPLODU RUJDQL]DWLRQ ZKLFK PDNHVLQVXUDQFHLQVSHFWLRQVVXUYH\VUHSRUWV RUUHFRPPHQGDWLRQV 3DUDJUDSKRIWKLVFRQGLWLRQGRHVQRWDSSO\ WRDQ\LQVSHFWLRQVVXUYH\VUHSRUWVRUUHFRP PHQGDWLRQVZHPD\PDNHUHODWLYHWRFHUWLILFD WLRQ XQGHU VWDWH RU PXQLFLSDO VWDWXWHV RUGL QDQFHVRUUHJXODWLRQVRIERLOHUVSUHVVXUHYHV VHOVRUHOHYDWRUV ( 3UHPLXPV 7KH ILUVW 1DPHG ,QVXUHG VKRZQ LQ WKH 'HFODUD WLRQV ,VUHVSRQVLEOHIRUWKHSD\PHQWRIDOOSUHPLXPVDQG :LOOEHWKHSD\HHIRUDQ\UHWXUQSUHPLXPVZH SD\ ) 7UDQVIHU2I<RXU5LJKWV$QG'XWLHV8QGHU 7KLV3ROLF\ <RXUULJKWVDQGGXWLHVXQGHUWKLVSROLF\PD\QRW EHWUDQVIHUUHGZLWKRXWRXUZULWWHQFRQVHQWH[FHSW LQ WKH FDVH RI GHDWK RI DQ LQGLYLGXDO QDPHG LQ VXUHG ,I \RX GLH \RXU ULJKWV DQG GXWLHV ZLOO EH WUDQV IHUUHGWR\RXUOHJDOUHSUHVHQWDWLYHEXWRQO\ZKLOH DFWLQJZLWKLQWKHVFRSHRIGXWLHVDV\RXUOHJDOUHS UHVHQWDWLYH8QWLO\RXUOHJDOUHSUHVHQWDWLYHLVDS SRLQWHGDQ\RQHKDYLQJSURSHUWHPSRUDU\FXVWRG\ RI\RXUSURSHUW\ZLOOKDYH\RXUULJKWVDQGGXWLHV EXWRQO\ZLWKUHVSHFWWRWKDWSURSHUW\ POLICY NUMBER: PHPK2446847 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY BLANKET 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 any person or organization with whom you have a written contract that requires you to obtain this agreement from us. The additional premium for this endorsement shall be 2.00% of the California workers compensation premium otherwise due. Minimum Premium: $0 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 07/01/2022 Insured INTERFAITH COMMUNITY SERVICES Policy No. M1302802 CA Policy Period 07/01/2022 To 07/01/2023 Issued On 06/23/2021 WC-99-04-258 (Ed. 10-07) ZENITH INSURANCE COMPANY - 13145 At San Diego, CA Endorsement No. 16 DocuSign Envelope ID: AAAF6F58-E51D-4263-88E5-2E654704B8DE