certificate of liability insurance - mover's … · cancellation certificate of liability...

CERTIFICATE HOLDER

© 1988-2010 ACORD CORPORATION. All rights reserved.ACORD 25 (2010/05)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE

LOCJECTPRO-POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

GENERAL LIABILITY

PREMISES (Ea occurrence) $DAMAGE TO RENTEDEACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

INSRLTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF(MM/DD/YYYY)

POLICY EXP(MM/DD/YYYY) LIMITS

WC STATU-TORY LIMITS

OTH-ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

$

$

$

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe underDESCRIPTION OF OPERATIONS below

(Mandatory in NH)OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTOALL OWNED SCHEDULED

HIRED AUTOSNON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)PROPERTY DAMAGE $

$

$$

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE 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.

INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement(s).

The ACORD name and logo are registered marks of ACORD

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE(A/C, No, Ext):

PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.

1/14/2014

Paul Hanson Partners1319 First StreetNapa CA 94559

CERTIFICATE SAMPLES-ZURICH

American Guarantee & Liability InsuZurich American Insurance CompanyZurich American Insurance Company oAmerican Zurich Insurance Company

26247

2785540142

16535

insert broker contact person707-252-5900 707-252-5905

broker's email

ZUICERT

335494784

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X

X HPDComp$100d X HPDColl$1000d

CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000

1,000,000A Cargo Liabilty

WLL

ZUR987654 1/1/2013 1/1/2014 Per Unit/OccurrenceDeductibleLOC#`

$250,000/$500,000$1,000$1,000,000

Y

Allied Van Lines, Inc. is added as additional insured with respect to General Liability, Auto Liability, Warehouse Legal Liability and CargoLiability for contract with insured; subject to all policy terms and provisions and legal liability established in the agent agreement. MOTORCARRIER.(If WC coverage is written through our office add: Allied Van Lines, Inc. is named as an alternate employer per attached endorsement.Coverage includes all states coverage and casual labor is included for all states except for the monopolistic states: OH, ND, WA and WY.)

See Attached...

ALLIED VAN LINES, INCSIRVA World HeadquartersOne Parkview PlazaOakbrook Terrace IL 60181

ACORD 101 (2008/01)The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:1. If the insured is affiliated with Allied Van Line, issue cert with this wording; if not, issue the cert with ongoing move wording2. Verify that Allied Van Lines is included on the PKG & TRK policies.3. Do not attach any additional insured endorsements. For WC attach the alternate employer endorsement and verify that this endorsement isincluded in the WC policy.4. Charge whichever is less for GL A/I: Method A - 5% of GL policy premium; Method B - $100 each.5. List all the locations on both PKG & WC policies. For the locations with WLL coverage, please also list the limit and deductible for eachlocation.6. Van Lines certs need to be issued before policy renewal date.

11


ZUICERT

Paul Hanson Partners

25 CERTIFICATE OF LIABILITY INSURANCE

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

A. In the performance of your ongoing operations; or B. In connection with your premises owned by or

rented to you.

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 07 04

CG 20 26 07 04

© ISO Properties, Inc., 2004

Page 1 of 1

CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1



ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

A. Section II – Who Is An Insured is amended to

include as a n additional insured the person(s) or organization(s) shown in the Sche dule, but only with respect to liability for "bodily inju ry", "property damage" or "personal and advertising injury" caused, in whole or in part, by your act s or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of yo ur ongoing operations;

or 2. In connection with your premise s owned by or

rented to you.

However: 1. The insurance afforded to such additional

insured only applies to th e extent permitted by law; and

2. If coverage provided to the additional insured is required by a contra ct or agree ment, the insurance afforded to su ch additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: If coverage provide d 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: 1. Required by the contract or agreement; or 2. Available under the ap plicable Limits of

Insurance shown in the De clarations; whichever is less.

This endorsement shall not incre ase the applicable Limits of Insuran ce shown in the Declaration.

Name Of Additional Insured Person(s) Or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

POLICY NUMBER: COMMERCIAL AUTO CA 20 48 02 99


DESIGNATED INSURED

This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indi-cated below.

Endorsement Effective: Countersigned By:

Named Insured:

(Authorized Representative)

SCHEDULE

Name of Person(s) or Organization(s) :

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 © Insurance Services Office, Inc., 1998

©Insurance Services Office, Inc.

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/14/2014




26247

2785540142

16535


broker's email

ZUICERT

267349888

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Y

North American Van Lines is added as additional insured with respect to (general liability per CG2026), (auto liability), (WLL) and (cargoliability) for contract with insured; subject to all policy terms and provisions and legal liability established in the agent agreement. MOTORCARRIER. It is further agreed that North American Van Lines shall be given thirty (30) days written notice of policy cancellation and/ornonrenewal with such notice being mailed to certificate holder. In the event of non payment of premium ten (10) days written notice ofcancellation shall apply.(If WC coverage is written through our office add: North American Van Lines, Inc. is named as an alternate employer per attachedSee Attached...

North American Van Lines, Inc.SIRVA World HeadquartersOne Parkview PlazaOakbrook Terrace IL 60181




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

endorsement. Coverage includes all states coverage and casual labor is included for all states except for the monopolistic states: OH, ND,WA and WY.)

BROKER NOTES:1. If the insured is affiliated with North American Van Line, issue cert with this wording; if not, issue the cert with ongoing move wording2. Verify that North American Van Lines is included on the PKG & TRK policies. If not, submit change request to add it.3. Do not attach any additional insured endorsements.4. For WC attach the alternate employer endorsement and verify that this endorsement is included in the WC policy.5. Charge whichever is less for GL A/I: Method A - 5% of GL policy premium; Method B - $100 each.6. List all the locations on both PKG & WC policies. For the locations with WLL coverage, please also list the limit and deductible for eachlocation.7. Van Lines certs need to be issued before policy renewal date.

11


ZUICERT







SCHEDULE




rented to you.


CG 20 26 07 04


Page 1 of 1







SCHEDULE




rented to you.











DESIGNATED INSURED




Named Insured:


SCHEDULE




CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/12/2014




26247

2785540142

16535


broker's email

ZUICERT

1854682239

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Y

Unigroup, Inc. is added as additional insured with respect to general liability per CG2026 07 04, auto liability per CA2048 02 99, warehouselegal liability and cargo liability per U-CIM-199-A-CW, for contract with insured; subject to all policy terms and provisions and legal liabilityestablished in the agent agreement. 30-day notice of cancellation provided per attached form U-GU-298A-CW (02/92). (If WC coverage iswritten through our office, add: Coverage includes all states coverage and casual labor is included for all states except for themonopolistic states: OH, ND, WA and WY. 30-day notice of cancellation provided per attached form WC 990633)

See Attached...

UNIGROUP CG2026 GL AI/CA2048 TRK AIU-CIM-199-AUW APPROVAL REQUIRED LH EXPOSUREPO Box 881639San Diego CA 92168




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:1. If a Van Line certificate request is received, but the insured is not affiliated with Unigroup, issue the cert with on-going move wording andissue CG2026 Form.2.. For UNIGROUP, show up to $3M CSL on GL and AL.3. Attach CG2026, CA2048, U-CIM-199-A, 3U-GU-298A-CW (and WC990633 if WC coverage is written through our office with Zurich orAmturst)4. Submit a change request if the policy does not currently include the CA2048. CG 2026 carries a minimum of 5% of GL premium and aminimum of $100 check to see if the policy was issued with it and request it, if not issued Attach CG2026 to certificate5. If there is WLL coverage for multiple locations, list all locations and WLL coverage and deductible limit.6. If there are locations on PKG & WC policies without WLL info, list the specific locaitons on van line cert.7. Van Lines certs need to be issued before policy renewal date.

11


ZUICERT







SCHEDULE




rented to you.


CG 20 26 07 04


Page 1 of 1







SCHEDULE




rented to you.











DESIGNATED INSURED




Named Insured:


SCHEDULE




Additional Insured

U-CIM-199-A CW. (06-11) Page 1 of 1

Includes copyrighted material of Insurance Services Office, Inc. with its permission.

Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add’l. Prem Return Prem.

Named Insured / Mailing Address:

Producer:


This endorsement modifies insurance provided under the:

MOVING AND STORAGE COVERAGE FORM

SCHEDULE


Unigroup, Inc., and subsidiaries One Premier Drive Fenton, MO 63026

It is hereby agreed and understood that the entity identified in the Schedule is listed as an Additional Insured under the above policy, but only as it pertains to claims arising out of the operations of the First Named Insured and subsidiaries for shipments not on United/Mayflower authority.

All other terms, conditions, provisions and exclusions of this policy remain the same.

U-GU-298-A CW (2/92) Page 1 of 1

Cancellation By Us

Policy No. Exp. Date of Pol. Eff. Date of End. Agency No. Addl. Prem. Return Prem.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: Address (including ZIP Code): This endorsement modifies insurance provided under the: Boiler and Machinery Coverage Part Commercial Auto Coverage Part Commercial Crime Coverage Part Commercial General Liability Coverage Part Commercial Inland Marine Coverage Part Commercial Property Coverage Part Farm Coverage Part Liquor Liability Coverage Part Pollution Liability Coverage Part Products/Completed Operations Liability Coverage

SCHEDULE Number of Days’ Notice ____30______

(If no entr y appears above, inform ation required to complete this Schedule will be shown in t he Declarations as applicable to this endorsement.) For any statutorily permitted reason other than nonpay ment of premium, the number of days required for notice of cancellation, as provi ded in paragraph 2. of either t he CANCELLATION Common Policy Condition or as amended by an applicable state cance llation endorsement, is increased to t he number of days shown in the Schedule above. Countersigned: Authorized Representative

WC 99 06 33 (Ed. 05-10)Includes copyrighted material of National Council on Compensation Insurance, Inc. with its permission.Page 1 of 1

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 33

NOTIFICATION TO OTHERS OF CANCELLATION ENDORSEMENT

This endorsement is used to add the following to Part Six of the policy.

PART SIX CONDITIONS

A. If we cancel this policy by written notice to you for any reason other than nonpayment of premium, we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below. Notification to such person or organization will be provided at least 10 days prior to the effective date of the cancellation, as advised in our notice to you, or the longer number of days notice if indicated in the Schedule below.

B. If we cancel this policy by written notice to you for nonpayment of premium, we will mail or deliver a copy of

such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation.

C. If notice as described in Paragraphs A. or B. of this endorsement is mailed, proof of mailing will be sufficient

proof of such notice.

SCHEDULE Name and Address of Other Person(s) /

Organization(s): Number of Days Notice: UniGroup, Inc. & subsidiaries c/o Ebix BPO 30

P.O. Box 881639, San Diego CA 92168-1639

All other terms and conditions of this policy remain unchanged.

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 Policy No. Endorsement No. Insured: Premium $ Insurance Company:

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/14/2014




26247

2785540142

16535


broker's email

ZUICERT

554346624

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Y

Atlas Van Lines are added as additional insured with respect to general liability per CG2026, auto liability per CA2312, warehouse legalliability and cargo liability for contract with insured; subject to all policy terms and provisions and legal liability established in the agentagreement. It is further agreed that Atlas Van Lines and its subsidiaries shall be given thirty (30) days written notice of policy cancellationand/or nonrenewal with such notice being mailed to certificate holder. In the event of nonpayment of premium ten (10) days written notice ofcancellation shall apply.(If WC coverage is written through our office add: Coverage includes all states coverage and casual labor is included for all states except forSee Attached...

ATLAS VAN LINESCG2026 GL AI/CA2312 TRK AI ATLAS BLUE FORMLONG HAUL EXPOSUREEVANSVILLE IN 47711




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

the monopolistic states: OH, ND, WA and WY.)

BROKER NOTES:1. If the insured is affiliated with Atlas Van Line, has long haul and Atlas blue form, issue cert with this wording; if the insured is affiliatedwith Atlas Van Line, but no long haul or Atlas blue form, issue the cert wiht the wording for "EXCEPT UNIGROUP/ATLAS OR NAVL"; if notaffiliated with Atlas, issue the cert with ongoing move wording.2. Policy must be endorsed and properly rated for long haul exposure. Submit a change request if the policy does not currently include theCA2312.3. CG 2026 carries a minimum of 5% of GL premium and a minimum of $100 check to see if the policy was issued with it and if not, submit achange request to add.4. No need to release endorsement together with cert.5. If there is WLL coverage for multiple locations, list location and WLL coverage and deductible limit.6. If there are locations on PKG & WC policies without WLL info, list the specific locaitons on van line cert.7. Van Lines certs need to be issued before policy renewal date.

11


ZUICERT







SCHEDULE




rented to you.


CG 20 26 07 04


Page 1 of 1







SCHEDULE




rented to you.











CA 23 12 12 93 Copyright, Insurance Services Office, Inc., 1993 Page 1 of 1

TRUCKERS – NAMED LESSEE AS INSURED This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi-fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective

Named Insured Countersigned By


SCHEDULE Name of Lessee: Address: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The Lessee named in the Schedule is an "insured" for the use of a covered "auto" you own or hire, subject to the following provisions: 1. Covered "auto" must be used pursuant to operat-

ing rights granted to the lessee by a public authori-ty.

2. The covered "auto" must be leased in writing and in accordance with a written hold harmless agreement between you and the lessee.

3. The LIABILITY COVERAGE CONTRACTUAL Exclusion does not apply to the lease agreement between you and the lessee.

4. LIABILITY COVERAGE is primary for the lessee. 5. If the Coverage Form is written on a gross receipts

basis, the term "gross receipts" in the Declarations is changed to include the actual remuneration re-ceived from leasing the covered "autos" to the les-see.

6. If we cancel the policy or reduce the LIABILITY COVERAGE LIMIT OF INSURANCE we will give the lessee 30 days advance notice.

POLICY NUMBER: COMMERCIAL AUTO



TRUCKERS – NAMED LESSEE AS INSURED This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM TRUCKERS COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective

Named Insured Countersigned By


SCHEDULE Name of Lessee: Address:

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The Lessee named in the Schedule is an "insured" for the use of a covered "auto" you own or hire, subject to the following provisions: 1. Covered "auto" must be used pursuant to operat-

ing rights granted to the lessee by a public authori-ty.

2. The covered "auto" must be leased in writing and in accordance with a written hold harmless agreement between you and the lessee.

3. The LIABILITY COVERAGE CONTRACTUAL Exclusion does not apply to the lease agreement between you and the lessee.

4. LIABILITY COVERAGE is primary for the lessee. 5. If the Coverage Form is written on a gross receipts

basis, the term "gross receipts" in the Declarations is changed to include the actual remuneration re-ceived from leasing the covered "autos" to the les-see.

6. If we cancel the policy or reduce the LIABILITY COVERAGE LIMIT OF INSURANCE we will give the lessee 30 days advance notice.

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/14/2014




26247

2785540142

16535


broker's email

ZUICERT

1757358463

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Y

(Insert Van Line Name) is added as additional insured with respect to general liability per CG2026, auto liability per CA2048, warehouse legalliability and cargo liability for contract with insured; subject to all policy terms and provisions and legal liability established in the agentagreement.(If WC coverage is written through our office, for Global, Interstate, Wheaton and Bekins Van Lines, add: XXX Van Lines is named as analternate employer per attached endorsement. Coverage includes all states coverage and casual labor is included for all states except forthe monopolistic states: OH, ND, WA and WY. For other Van Lines, add: Coverage includes all states coverage and casual labor is includedSee Attached...

EXCEPT UNIGROUP/ATLAS OR NAVLCG2026-GL ADDITIONAL INSDCA2048-AUTO ADDITIONAL INSDSan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

for all states except for the monopolistic states: OH, ND, WA and WY.)

BROKER NOTES:1. If the insured is affiliated with the Van Line, issue cert with this wording; if not, issue the cert with ongoing move wording2. If policy not currently endorsed to reflect Van Line affiliation, submit an acord change request with certificate to PHP.3. CG 2026 carries a minimum of 5% of GL premium and a minimum of $100. Check to see if the policy was issued with it and request it if notissued. Attach CG2026 to certificate.4. If 30 day notice of cancellation requested by Van Lines, add: It is further agreed that XXX Van Lines shall be given thirty (30) days writtennotice of policy cancellation and/or nonrenewal with such notice being mailed to certificate holder. In the event of non payment of premium ten(10) days written notice of cancellation shall apply.5. List all the locations on both PKG & WC policies. For the locations with WLL coverage, please also list the limit and deductible for eachlocation.6. Van Lines certs need to be issued before policy renewal date.

11


ZUICERT







SCHEDULE




rented to you.


CG 20 26 07 04


Page 1 of 1







SCHEDULE




rented to you.











DESIGNATED INSURED




Named Insured:


SCHEDULE




CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

25452800

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is added as additional insured with respect to general liability for move conducted by named insured per form CG2026;subject to all policy terms and provisions. (move date; shipper and shipper location)

See Attached...

ADDITIONAL INSUREDONE TIME MOVECG2026-ADDITIONAL INSDSan Fancisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:1. This certificate is issued to shippers; property management companies; landlords of premises the shipper is moving in to or buildingowners.2. CG 2026 carries a minimum of 5% of GL premium and a minimum of $100. Check to see if the policy was issued with it and request it if notissued. Attach CG2026 to certificate.3. Use the form version on policy. If policy is not available yet, choose the correct form version per the following rule:* Effective 9/1/2013, AL, AR, AZ, DC, GA, IA, ID, IN, KS, KY, MA, ME, MN, MS, MT, NE, NC, NV, OH, OK, OR, PA, RI, SC, SD, UT, VT,WA, WV, WY approved new edition 0413.* Effective 10/1/2013, AK, CO, LA, MI, NJ, NM, ND, TN, TX, VA, WI approved to use new edition 0413 * Effective 11/1/2013, CT, FL, IL, MD,MO, NH, NY approved to use new edition 0413.* For all other not approved states, select the old edition.4. IF AI IS NOT RELATED TO SHIPPER/PROP MGMT OR LANDLORD-SUBMIT THE FOLLOWING INFO FOR UW APPROVAL: 1). Who isthe additional insured? 2). Does the additional insured have an auto exposure and do they have the appropriate coverage in place? 3). Whatis their operation and how does it relate to the named insured? 4). Does the request for an additional insured fit with the named insured'soperations? 5). Is the request appropriate given the relationship between the parties? 6). What are the contractual agreements between thenamed insured and the additional insured? Do these agreements meet the definition of an ""Insured Contract""?

11


ZUICERT







SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) For shippers and landlords where moves are to occur per certificates on file with Program Administrator Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedul e, but only with resp ect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

A. In the performance of your ong oing operations; or B. In connection with your premises owned by or

rented to you.


CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1







SCHEDULE




rented to you.







Name Of Additional Insured Person(s) Or Organization(s): For shippers and landlords where moves are to occur per certificates on file with Program Administrator


CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

1967629823

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is added as additional insured with respect to general liability for ongoing moves conducted by named insured per formCG2026; subject to all policy terms and provisions.

See Attached...

ADDITIONAL INSUREDONGOING MOVESCG2026-ADDITIONAL INSDSan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:1. This certificate is issued to shippers; property management companies; landlords of premises the shipper is moving in to or buildingowners.2. CG 2026 carries a minimum of 5% of GL premium and a minimum of $100. Check to see if the policy was issued with it and request it if notissued. Attach CG2026 to certificate.3. Use the form version on policy. If policy is not available yet, choose the correct form version per the following rule:* Effective 9/1/2013, AL, AR, AZ, DC, GA, IA, ID, IN, KS, KY, MA, ME, MN, MS, MT, NE, NC, NV, OH, OK, OR, PA, RI, SC, SD, UT, VT,WA, WV, WY approved new edition 0413.* Effective 10/1/2013, AK, CO, LA, MI, NJ, NM, ND, TN, TX, VA, WI approved to use new edition 0413* Effective 11/1/2013, CT, FL, IL, MD, MO, NH, NY approved to use new edition 0413.* For all other not approved states, select the old edition.4. IF AI IS NOT RELATED TO SHIPPER/PROP MGMT OR LANDLORD-SUBMIT THE FOLLOWING INFO FOR UW APPROVAL: 1). Who isthe additional insured? 2). Does the additional insured have an auto exposure and do they have the appropriate coverage in place? 3). Whatis their operation and how does it relate to the named insured? 4). Does the request for an additional insured fit with the named insured'soperations? 5). Is the request appropriate given the relationship between the parties? 6). What are the contractual agreements between thenamed insured and the additional insured? Do these agreements meet the definition of an ""Insured Contract""?

11


ZUICERT







SCHEDULE




rented to you.



CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

137288704

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is added as additional insured with respect to general liability for move/on going moves conducted by named insured perform U-GL-1175; subject to all policy terms and provisions.

See Attached...

ADDITIONAL INSUREDCOMPLETED OPERATIONU-GL-1175-ADDITIONAL INSDSan Fancisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:1. Blanket form with charge

2. Check if U-GL-1175 is on policy or not. If not, contact UW to add U-GL-1175.

11


ZUICERT



Policy No.

Additional Insured -- Automatic - Owners, Lessees Or-- Contractors

Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. 64266000

Add' l. Prem 0

Return Prem. 0


Named Insured: Address (including ZIP Code):

This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part

A. Section II --- Who Is An Insured is amended to include as an additional insured any person or organization whom you- are required to add as an additional insured on this policy under a written contract or written agreement. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:

1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf,

However, the insurance afforded to such additional insured:

1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the written contract or written agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies:

This insurance does not apply to: "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:

The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or

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 the failure to render any professional architectural, engineering or surveying services.

in the performance of your ongoing operations or "your work" as included in the "products-completed operations hazard", which is the subject of the written contract or written agreement.

U-GL-1175-F CW (04/13) Page 1 of 2

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV ---- Commercial General Liability Conditions:

The additional insured must see to it that: 1. We are notified as soon as practicable of an "occurrence" or offense that may result in a claim;

2. We receive written notice of a claim or " uit" as soon as practicable; ands

3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured if the written contract or written agreement requires that this coverage be primary and non-contributory.

D. For the purposes of the coverage provided by this endorsement:

1. The following is added to the Other Insurance Condition of Section IV -- Commercial General Liability Conditions--: Primary and Noncontributory insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured provided that: a. The additional insured is a Named Insured under such other insurance; and

b. You are required by written contract or written agreement that this insurance be primary and not seek contribution from any other insurance available to the additional insured.

This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by a written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis.

F. With respect to the insurance afforded to the additional insureds under this endorsement, the following is added to Section III --- Limits Of Insurance-:

The most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement; or 2. Available under the applicable Limits of Insurance shown in the Declarations,

whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.


E. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured.

2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV --- Commercial- General Liability Conditions:

U-GL-1175-F CW (04/13) Page 2 of 2


CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

331607296

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Except with respect to claims arising out of the sole negligence or willful misconduct of an additional insured, the general liability insurance isprimary, and non-contributory over any policy in the name of an additional insured; subject to all policy terms and provisions.

BROKER NOTE: This primary wording is used when NOT required by written contract. If primary coverage is required as part of a writtencontract requiring the additional insured endorsement, refer to certificate ""Primary & Non-Contributory"" for instructions.

PRIMARYNO CONTRACTINCL FOR ADDT'L INSDS $0 CHARGESan Francisco CA 12345

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

2030899711

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

General Liability insurance is primary insurance as respects our coverage to an additional insured person or organization, where the writtencontract or written agreement requires that general liability insurance be primary and non-contributory per form U-GL-1327 (add “ & CG2001”if use 0413 version per UW'ing Condition); subject to all policy terms and provisions.

BROKER NOTES:1. Attach Zurich forms - UGL1327 (and CG2001 if necessary per note below).See Attached...

PRIMARY PER CONTRACTUW APPROVAL REQUIRED IF NOT SHIPPER ORLANDLORDINCL IN ALL POLICIES U-GL-1327 or CG2001 PRIMARYSan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

2. IF NOT SHIPPER OR LANDLORD REFER FOR UW APPROVAL.3. Use the form version on policy. If policy is not available yet, choose the correct forms version per the following rule:* Effective 9/1/2013, AL, AR, AZ, DC, GA, IA, ID, IN, KS, KY, MA, ME, MN, MS, MT, NE, NC, NV, OH, OK, OR, PA, RI, SC, SD, UT, VT,WA, WV, WY approved new edition 0413.* Effective 10/1/2013, AK, CO, LA, MI, NJ, NM, ND, TN, TX, VA, WI approved to use new edition 0413* Effective 11/1/2013, CT, FL, IL, MD, MO, NH, NY approved to use new edition 0413.* For all other not approved states, select the old edition.

11


ZUICERT







SCHEDULE




rented to you.



Other Insurance Amendment -- Primary And Non-- Contributory

Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No.

Add' l. Prem

Return Prem.


This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part

1. The following paragraph is added to the Other Insurance Condition of Section IV --- CommercialGeneral Liability- Conditions:

This insurance is primary insurance to and will not seek contribution from any other insurance available to an additional insured under this policy provided that: a. The additional insured is a Named Insured under such other insurance; and

b. You are required by a written contract or written agreement that this insurance would be primary and would not seek contribution from any any other insurance available to the additional insured.

2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV --- Commercial- General Liability Conditions:

This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis.


U-GL-1327-B CW (04/13) Page 1 of 1


Named Insured: Address (including ZIP Code):

U-GL-1327-A CW (3/2007) Page 1 of 1

Other Insurance Amendment – Primary And Non-Contributory

Policy No. Exp. Date of Pol. Eff. Date of End. Agency No. Addl. Prem. Return Prem.


Named Insured: Address (including ZIP Code): This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part

SECTION IV. COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, is amended per the following:

1. The following paragraph is added under a. Primary Insurance:

This insurance is primary insurance as respects our coverage to an additional insured person or organization, where the written contract or written agreement requires that this insurance be primary and non-contributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured on which the additional insured person or organization is a Named Insured.

2. The following paragraph is added under b. Excess Insurance:

This insurance is excess over:

Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the ad ditional insured on our policy is also covered as an additional insured by attachment of an endorsement to another policy providing coverage for the same "occurrence", claim or "suit". Th is provision does not apply to any policy in which the additional insured is a Nam ed Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a prim ary and non-contributory basis.

Any provisions in this Coverage Part not changed by the terms and conditions of this endorsement continue to apply as written.

COMMERCIAL GENERAL LIABILITY CG 20 01 04 13



PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE CONDITION


COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

The following is adde d to the Other Insurance Condition and supersedes any provision to the contrary:

Primary And Noncontributory Insurance This insurance is primary to and will n ot seek contribution from any other insurance available to an additi onal 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 insuran ce would be primary and would not see k contribution from any oth er insurance available to the additional insured.

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

108097024

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Waiver of subrogation applies to general liability per CG2404 (or U-GL-925-B CW); subject to all policy terms and provisions.

BROKER NOTES:1. no charge2. Check to see if PKG policy currently includes endorsement CG2404 (or U-GL-925-B CW), if so, proceed. Attach certificate CG2404 (orU-GL-925-B CW). If not, issue certificate and CG2404 (or U-GL-925-B CW) but send in acord change request to have policy endorsed withSee Attached...

GL WAIVER OF SUBROGATIONCG2404 or U-GL-925-B CW$0 ChargeSan Francisco CA 12245




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

CG2404 (or U-GL-925-B CW).3. This is a blanket endorsement so it is not necessary to endorse the policy each time the CG2404 (or U-GL-925-B CW) is issued.

11


ZUICERT




CG 24 04 05 09 Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US


COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:


The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV ---- Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

CPO 9815778-00

ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/12/2014




26247

2785540142

16535


broker's email

ZUICERT

470223488

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is additional insured on auto liability if liable for the conduct of the insured but only to the extent of that liability is aninsured for auto liability.

See Attached...

AUTO AI PER CONTRACT UW APPROVAL REQUIREDIF NOT SHIPPER OR LANDLORD $0 CHARGESan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:1. IF NOT SHIPPER OR LANDLORD-SUBMIT THE FOLLOWING INFO FOR UW APPROVAL: 1). What is the nature of your relationship?2). What are you hauling? 3). Does the Additional Insured have an auto exposure and do they have appropriate coverages in place? 4). Willthe insured be using their bill of lading? 5). Will the insured be using or moving any vehicles of the certificate holder? 6). Will the insured beusing scheduled vehicles on their policy? 7). Will you be using scheduled vehicles on your policy?2. IF RELATED TO A SHIPPER - ISSUE WITH APPROVED WORDING NOTED ON SAMPLE If certificate holder requests verification thatcoverage is included in policy form - attach 'Who is an insured' item c. from Bus Auto Coverage

11


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of 12 Insurance Services Office, Inc., 2009 CA 00 01 03 10

19 Mobile Equip-ment Subject To Compulsory Or Financial Responsibility Or Other Motor Vehicle Insur-ance Law Only

Only those "autos" that are land vehicles and that would qualify under the definition of "mobile equipment" under this policy if they were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where they are licensed or principally garaged.

B. Owned Autos You Acquire After The Policy Begins

1. If Symbols 1, 2, 3, 4, 5, 6 or 19 are entered next to a coverage in Item Two of the Declarations, then you have coverage for "autos" that you acquire of the type described for the remainder of the policy period.

2. But, if Symbol 7 is entered next to a coverage in Item Two of the Declarations, an "auto" you acquire will be a covered "auto" for that cover-age only if:

a. We already cover all "autos" that you own for that coverage or it replaces an "auto" you previously owned that had that cover-age; and

b. You tell us within 30 days after you acquire it that you want us to cover it for that cover-age.

C. Certain Trailers, Mobile Equipment And Temporary Substitute Autos

If Liability Coverage is provided by this coverage form, the following types of vehicles are also cov-ered "autos" for Liability Coverage:

1. "Trailers" with a load capacity of 2,000 pounds or less designed primarily for travel on public roads.

2. "Mobile equipment" while being carried or towed by a covered "auto".

3. Any "auto" you do not own while used with the permission of its owner as a temporary substi-tute for a covered "auto" you own that is out of service because of its:

a. Breakdown;

b. Repair;

c. Servicing;

d. "Loss"; or

e. Destruction.

SECTION II ---- LIABILITY COVERAGE

A. Coverage

We will pay all sums an "insured" legally must pay as damages because of "bodily injury" or "property damage" to which this insurance applies, caused by an "accident" and resulting from the ownership, maintenance or use of a covered "auto".

We will also pay all sums an "insured" legally must pay as a "covered pollution cost or expense" to which this insurance applies, caused by an "acci-dent" and resulting from the ownership, mainte-nance or use of covered "autos". However, we will only pay for the "covered pollution cost or ex-pense" if there is either "bodily injury" or "property damage" to which this insurance applies that is caused by the same "accident".

We have the right and duty to defend any "insured" against a "suit" asking for such damages or a "covered pollution cost or expense". However, we have no duty to defend any "insured" against a "suit" seeking damages for "bodily injury" or "prop-erty damage" or a "covered pollution cost or ex-pense" to which this insurance does not apply. We may investigate and settle any claim or "suit" as we consider appropriate. Our duty to defend or settle ends when the Liability Coverage Limit of Insurance has been exhausted by payment of judgments or settlements.

1. Who Is An Insured

The following are "insureds":

a. You for any covered "auto".

b. Anyone else while using with your permis-sion a covered "auto" you own, hire or bor-row except:

(1) The owner or anyone else from whom you hire or borrow a covered "auto".

This exception does not apply if the covered "auto" is a "trailer" connected to a covered "auto" you own.

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CA 00 01 03 10 Insurance Services Office, Inc., 2009 Page 3 of 12

(2) Your "employee" if the covered "auto" is owned by that "employee" or a member of his or her household.

(3) Someone using a covered "auto" while he or she is working in a business of selling, servicing, repairing, parking or storing "autos" unless that business is yours.

(4) Anyone other than your "employees", partners (if you are a partnership), members (if you are a limited liability company) or a lessee or borrower or any of their "employees", while moving property to or from a covered "auto".

(5) A partner (if you are a partnership) or a member (if you are a limited liability company) for a covered "auto" owned by him or her or a member of his or her household.

c. Anyone liable for the conduct of an "in-sured" described above but only to the ex-tent of that liability.

2. Coverage Extensions

a. Supplementary Payments

We will pay for the "insured":

(1) All expenses we incur.

(2) Up to $2,000 for cost of bail bonds (in-cluding bonds for related traffic law vio-lations) required because of an "acci-dent" we cover. We do not have to fur-nish these bonds.

(3) The cost of bonds to release attach-ments in any "suit" against the "insured" we defend, but only for bond amounts within our Limit of Insurance.

(4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $250 a day be-cause of time off from work.

(5) All court costs taxed against the "in-sured" in any "suit" against the "insured" we defend. However, these payments do not include attorneys’ fees or attorneys’ expenses taxed against the "insured".

(6) All interest on the full amount of any judgment that accrues after entry of the judgment in any "suit" against the "in-sured" we defend, but our duty to pay interest ends when we have paid, of-fered to pay or deposited in court the part of the judgment that is within our Limit of Insurance.

These payments will not reduce the Limit of Insurance.

b. Out-of-state Coverage Extensions

While a covered "auto" is away from the state where it is licensed we will:

(1) Increase the Limit of Insurance for Li-ability Coverage to meet the limits speci-fied by a compulsory or financial re-sponsibility law of the jurisdiction where the covered "auto" is being used. This extension does not apply to the limit or limits specified by any law governing motor carriers of passengers or prop-erty.

(2) Provide the minimum amounts and types of other coverages, such as no-fault, required of out-of-state vehicles by the jurisdiction where the covered "auto" is being used.

We will not pay anyone more than once for the same elements of loss because of these extensions.

B. Exclusions

This insurance does not apply to any of the follow-ing:

1. Expected Or Intended Injury

"Bodily injury" or "property damage" expected or intended from the standpoint of the "in-sured".

2. Contractual

Liability assumed under any contract or agreement.

But this exclusion does not apply to liability for damages:

a. Assumed in a contract or agreement that is an "insured contract" provided the "bodily injury" or "property damage" occurs subse-quent to the execution of the contract or agreement; or

b. That the "insured" would have in the ab-sence of the contract or agreement.

3. Workers’ Compensation

Any obligation for which the "insured" or the "insured’s" insurer may be held liable under any workers’ compensation, disability benefits or unemployment compensation law or any similar law.

susand

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susand

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CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/12/2014




26247

2785540142

16535


broker's email

ZUICERT

1775999871

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Transfer of Rights of Recovery Against Others applies to auto liability - If any person or organization to or for whom we make payment underthis Coverage Form has rights to recover damages from another, those rights are transferred to us. That person or organization must doeverything necessary to secure our rights and must do nothing after accident/loss to impair them.

BROKER NOTES:1. IF NOT SHIPPER OR LANDLORD-SUBMIT THE FOLLOWING INFO FOR UW APPROVAL: 1). What is the nature of your relationship?See Attached...

AUTO WAIVER OF SUBROGATION UW APPROVALREQUIREDIF NOT SHIPPER OR LANDLORD $0 CHARGESan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

2). What are you hauling? 3). Does the Additional Insured have an auto exposure and do they have appropriate coverages in place? 4). Willthe insured be using their bill of lading? 5). Will the insured be using or moving any vehicles of the certificate holder? 6). Will the insured beusing scheduled vehicles on their policy?2. IF RELATED TO A SHIPPER - issue certificate. If certificate holder requests verification that coverage is included in policy form - attachSection IV from Bus Auto Coverage item 5.

11


ZUICERT



of 12 Insurance Services Office, Inc., 2009 CA 00 01 03 10

SECTION IV ---- BUSINESS AUTO CONDITIONS

The following conditions apply in addition to the Common Policy Conditions:

A. Loss Conditions

1. Appraisal For Physical Damage Loss

If you and we disagree on the amount of "loss", either may demand an appraisal of the "loss". In this event, each party will select a competent appraiser. The two appraisers will select a competent and impartial umpire. The appraisers will state separately the actual cash value and amount of "loss". If they fail to agree, they will submit their differences to the umpire. A decision agreed to by any two will be binding. Each party will:

a. Pay its chosen appraiser; and

b. Bear the other expenses of the appraisal and umpire equally.

If we submit to an appraisal, we will still retain our right to deny the claim.

2. Duties In The Event Of Accident, Claim, Suit Or Loss

We have no duty to provide coverage under this policy unless there has been full compli-ance with the following duties:

a. In the event of "accident", claim, "suit" or "loss", you must give us or our authorized representative prompt notice of the "acci-dent" or "loss". Include:

(1) How, when and where the "accident" or "loss" occurred;

(2) The "insured’s" name and address; and

(3) To the extent possible, the names and addresses of any injured persons and witnesses.

b. Additionally, you and any other involved "insured" must:

(1) Assume no obligation, make no payment or incur no expense without our consent, except at the "insured’s" own cost.

(2) Immediately send us copies of any re-quest, demand, order, notice, summons or legal paper received concerning the claim or "suit".

(3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit".

(4) Authorize us to obtain medical records or other pertinent information.

(5) Submit to examination, at our expense, by physicians of our choice, as often as we reasonably require.

c. If there is "loss" to a covered "auto" or its equipment you must also do the following:

(1) Promptly notify the police if the covered "auto" or any of its equipment is stolen.

(2) Take all reasonable steps to protect the covered "auto" from further damage. Al-so keep a record of your expenses for consideration in the settlement of the claim.

(3) Permit us to inspect the covered "auto" and records proving the "loss" before its repair or disposition.

(4) Agree to examinations under oath at our request and give us a signed statement of your answers.

3. Legal Action Against Us

No one may bring a legal action against us un-der this coverage form until:

a. There has been full compliance with all the terms of this coverage form; and

b. Under Liability Coverage, we agree in writ-ing that the "insured" has an obligation to pay or until the amount of that obligation has finally been determined by judgment af-ter trial. No one has the right under this pol-icy to bring us into an action to determine the "insured’s" liability.

4. Loss Payment ---- Physical Damage Coverages

At our option we may:

a. Pay for, repair or replace damaged or stolen property;

b. Return the stolen property, at our expense. We will pay for any damage that results to the "auto" from the theft; or

c. Take all or any part of the damaged or sto-len property at an agreed or appraised val-ue.

If we pay for the "loss", our payment will in-clude the applicable sales tax for the damaged or stolen property.

5. Transfer Of Rights Of Recovery Against Others To Us

If any person or organization to or for whom we make payment under this coverage form has rights to recover damages from another, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident" or "loss" to impair them.

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susand

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CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

267117824

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is included as additional insured with respect to auto liability per CA2048 and loss payee per CA9944 with respect to (listyear, make, model, VIN & value); subject to all policy terms and provisions.

See Attached...

AUTO ADDITIONAL INSUREDLONG TERM LEASE/PURCHASE/BANKCA2048-ADDITIONAL INSD CA9944-LOSS PAYEESan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:1. Submit acord change request with certificate to schedule vehicle on the policy, if not currently scheduled on policy.2. If the AI/LP is not currently listed on the policy, submit acord change request to add.3. no need to include forms when releasing cert.

11


ZUICERT





DESIGNATED INSURED




Named Insured:


SCHEDULE




COMMERCIAL AUTO CA 99 44 12 93



LOSS PAYABLE CLAUSE This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi-fied by the endorsement. A. We will pay, as interest may appear, you and the

loss payee named in the policy for "loss" to a cov-ered "auto".

B. The insurance covers the interest of the loss pay-ee unless the "loss" result s from conversion, se-cretion or embezzlement on your part.

C. We may cancel the policy as allowed by the CAN-CELLATION Common Policy Condition.

Cancellation ends this agreement as to the loss payee's interest. If we c ancel the policy we will mail you and the loss payee the same advance notice.

D. If we make any payments to the loss payee, we will obtain his or her rights against any other party.

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

2115029503

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is added as additional insured with respect to auto liability per CA2048 and loss payee per CA9944 with respect to allvehicles rented, leased or borrowed by named insured from certificate holder; subject to all policy terms and provisions. (SHORT TERMLEASE ONLY - 30 days or less)

See Attached...

AUTO ADDITIONAL INSUREDSHORT TERM LEASECA2048-ADDITIONAL INSD CA9944-LOSS PAYEESan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

BROKER NOTES:

1. If an insured is leasing an auto for less than 30 days then the auto does not need to be on the schedule, however the insured must havehired auto liability and hired auto physical damage coverage on the policy and the lessor would also be added to the policy with from CA2048(examples are Penske, Ryder and other car leasing companies). Submit an acord change request to add the additional insured with yourcertificate to PHP.

2. no need to include forms when releasing cert.

11


ZUICERT





DESIGNATED INSURED




Named Insured:


SCHEDULE




CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/12/2014




26247

2785540142

16535


broker's email

ZUICERT

1335509887

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is added as additional insured per CG2011 with respect to general liability for premises leased by named insured located at:(insert property location); subject to all policy terms and provisions.

BROKER NOTES:1. If certificate holder is not currently endorsed on the policy submit an acord change request.2. specific, up to $100 flat charge for each cert holder.See Attached...

RENTED/LEASED PREMISESCG2011San Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

3. Use the form version on policy. If policy is not available yet, choose the correct form version per the following rule:* Effective 9/1/2013, AL, AR, AZ, DC, GA, IA, ID, IN, KS, KY, MA, ME, MN, MS, MT, NE, NC, NV, OH, OK, OR, PA, RI, SC, SD, UT, VT,WA, WV, WY approved new edition 0413.* Effective 10/1/2013, AK, CO, LA, MI, NJ, NM, ND, TN, TX, VA, WI approved to use new edition 0413 * Effective 11/1/2013, CT, FL, IL, MD,MO, NH, NY approved to use new edition 0413.* For all other not approved states, select the old edition.

11


ZUICERT






ADDITIONAL INSURED – MANAGERS OR LESSORS OF PREMISES



SCHEDULE

Designation Of Premises (Part Leased To You):

Name Of Person(s) Or Organization(s) (Additional Insured):

Additional Premium: $

Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to

include as an additional insured the person(s) or organization(s) shown in t he Schedule, but only with respect to liability ari sing out of the ownership, maintenance or use of that part of the premises leased to you and sho wn in the Schedule and subject to the followin g additional exclusions: This insurance does not apply to:

1. Any "occurrence" which takes place after you cease to be a tenant in that premises.

2. Structural alterations, new construction or demolition operations performed by or on behalf of th e person(s) or organi zation(s) shown in the Schedule.


insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contra ct or ag reement, the insurance afforded to such additional insured will not be broader than t hat which you are required by the contract or agreem ent to provide for such additional insured.

B. With respect to the insu rance 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 in sured is the amount of insurance:

1. Required by the contract or agreement; or 2. Available under the a pplicable Limits of

Insurance shown in the Declarations; whichever is less. This endorsement shall not incre ase the applicable Limits of In surance shown in the Declarations.



CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1

ADDITIONAL INSURED – MANAGERS OR LESSORS OF PREMISES



SCHEDULE 1. Designation of Premises (Part Leased to You): 2. Name of Person or Organization (Additional Insured): 3. Additional Premium: (If no entry appears above, the informati on required to complete this endorsement will be shown in the Declara-tions as applicable to this endorsement.) WHO IS AN INSURED (Sec tion II) is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any "occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construc tion or demolition operations perform ed by or on behalf of the person or

organization shown in the Schedule.

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

1825961983

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

(certificate holder) is added as additional insured with respect to general liability per CG2026 regarding Insured’s premise located at: (insertproperty location); subject to all policy terms and provisions. Ref Loan#___.

BROKER NOTES:1. If certificate holder is not currently endorsed on the policy submit an acord change request.2. $100 flat charge for each cert holder.

A/I request for EOP holder - Mortgagee, Assignee, orReceiverCG2026San Francisco CA 12345





SCHEDULE




rented to you.


CG 20 26 07 04


Page 1 of 1







SCHEDULE




rented to you.









CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

1224897791

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

(certificate holder) is added as additional insured with respect to general liability per CG2026 regarding Insured’s premise located at: (insertproperty location); subject to all policy terms and provisions. Ref Loan#___.

BROKER NOTES:1. If certificate holder is not currently endorsed on the policy submit an acord change request.2. $100 flat charge for each cert holder.

Lessor of Leased EquipmentCG2026San Francisco CA 12345





SCHEDULE




rented to you.


CG 20 26 07 04


Page 1 of 1







SCHEDULE




rented to you.









CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

81997824

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

Certificate holder is added as additional insured with respect to auto liability per CA2048 and loss payee per CA9944 with respect to:(insert year, make, model, VIN); owned and operated by (insert contractor name); subject to all policy terms and provisions.

BROKER NOTE: If the cert request indicates the vehicle is for an owner/operator, verify that the owner/operator is listed on the driver list andthe vehicle is scheduled on the policy. If not, send customer the 'agreement to add sub-hauler' form to complete. Submit this completed formwith acord change request to add the driver and AI/LP, add vehicle and finance company as AI/LP. Please note, the OO will not be added asSee Attached...

OWNER/OPERATORCA2048-ADDITIONAL INSUREDCA9944-LOSS PAYEESan Francisco CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

an AI/LP without a completed signed sub-hauler agreement. If the above criteria can be verified, issue the certificate to the certificateholder. Submit a copy of the 'agreement to add sub-hauler' with your certificate.

11


ZUICERT





DESIGNATED INSURED




Named Insured:


SCHEDULE




CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

1030853632

A Y ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B Y

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

All water and rail carriers participating in the UIIA are named as additional insured on the auto and trailer interchange per CA2317; generalliability per CG2026 where required by written contract. *See attached list

BROKER NOTES:1. If SCAC & Motor Carrier Insurance Agent Code is available, issue cert online. If not, issue paper cert with this wording. 2. 30 day noticemust be provided to UIIA if the policy cancelsSee Attached...

UIIA-PORT SHIPMENTS UW APPROVAL REQUIREDADDTL PREMIUM CHARGECA2317-INTERMODAL INTERCHANGE CG2026-AI/GLCalverton MD 20705




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

3. VERIFY POLICY INCLUDES TRAILER INTERCHANGE COVERAGE4. SUBMIT THE FOLLOWING INFORMATION TO UNDERWRITER FOR APPROVAL: Number of trailers used for intermodal contract.WHEN APPROVED-issue certificate with approved wording; submit certificate with provider list and accord form to endorse policy with formCA2317 and CG2026. CG 2026 carries a minimum of 5% of GL premium and a minimum of $100 check to see if the policy was issued with itand request it if not issued.5. Attach CG2026 & CA2317 to certificate

11


ZUICERT







SCHEDULE




rented to you.


CG 20 26 07 04


Page 1 of 1







SCHEDULE




rented to you.











CA 23 17 03 06 © ISO Properties, Inc., 2005 Page 1 of 2

TRUCKERS – UNIFORM INTERMODAL INTERCHANGE ENDORSEMENT FORM UIIE – 1


BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi-fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured:

Endorsement Effective Date:

Countersignature Of Authorized Representative Name:

Title:

Signature:

Date:

It is agreed that such insurance as is afforded by the policy for Auto Bodily Injury and Property Damage Liability applies to liability assumed by the named insured, as "Motor Carrier Participant", under Section F.4. of the Uniform Intermodal Interchange and Facili-ties Access Agreement, and any subsequent amendments thereto:

F.4. Indemnity a. Subject to the exceptions set forth in Sub-

section (b) below, Motor Carrier agrees to defend, hold harmless, and fully indemnify the Indemnitees (without regard to whether the Indemnitees' liability is vicarious, im-plied by law, or as a result of the fault or negligence of the Indemnitees), against any and all claims, "suits", loss, damage or lia-bility, for "bodily injury", death and/or "prop-erty damage", including reasonable attor-ney fees and costs incurred in the defense against a claim or "suit", or incurred be-cause of the wrongful failure to defend against a claim or "suit", or in enforcing Section F.4. (collectively, the "Damages"), caused by or resulting from the Motor Car-rier's: use or maintenance of the Equipment during an Interchange Period; and/or pres-ence on the Facility Operator's premises.

of 2 © ISO Properties, Inc., 2005 CA 23 17 03 06

b. Exceptions The foregoing indemnity provision shall not apply to the extent Damages: (i) occur dur-ing the presence of the Motor Carrier on the Facility Operator's premises and are caused by or result from the negligent or in-tentional acts or omissions of the Indem-nitees, their agents, "employees", vendors or third party invitees (excluding Indemni-tor); or (ii) are caused by or result from de-fects to the Equipment with respect to items other than those set forth in Exhibit A, un-less such defects were caused by or result-ed from the negligent or intentional acts or omissions of the Motor Carrier, its agents, "employees", vendors, or subcontractors during the Interchange Period.

Subject to the following provisions: 1. The limit of the company's liability under this

policy for damages because of "bodily injury" and "property damage" arising out of the use, operation, maintenance or possession of inter-change equipment shall be the applicable amount stated below and designated by an "x" unless a greater amount is otherwise stated in the policy as applicable to such "bodily injury" or "property damage".

Single Limit "Bodily Injury" And "Property Damage" (Or the Equivalent)

$Each "Accident"

2. The company shall: a. Upon issuance of this endorsement, furnish

to the President, The Intermodal Associa-tion of North America, 11785 Beltsville Drive, 11th Flr., Beltsville, MD 20705, a properly executed Certif icate of Insurance which carries the notation that the company has issued to the named insured Motor Carrier a policy of liability insurance; and

b. Upon cancellation or termination of the policy of which this endorsement forms a part, furnish a notice of such cancellation or termination NOT LESS THAN 30 DAYS prior to the effective date of such cancella-tion or termination, such notice to be mailed to said President at the above address.

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



1/12/2014




26247

2785540142

16535


broker's email

ZUICERT

1679917183

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

XB

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000


WLL


$250,000/$500,000$1,000$1,000,000

No language added to certificate, check per project/location on GL section.

BROKER NOTES:1. $250 charge for each cert holder

2. UW's approval is requiredSee Attached...

PER PROJECT/LOCATION$250 flat chargeCG2053/CG2054 CA 12345




ADDITIONAL REMARKS



AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

3. If UW approves, issue certificate with "per project" or "per loc" checked.

4.Submit acord change request to add "per project" or "per loc" with certificate to PHP.

11


ZUICERT






DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT



SCHEDULE

Designated Construction Project(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becom es legally

obligated to pay as damages caused by "occur-rences" under Section I – Coverage A, and for all medical expenses caused by a ccidents under Section I – Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in th e Schedule above:

1. A separate Designated Construction Project General Aggregate Limit applies to each des-ignated construction project, and that l imit is equal to the amount of the General Aggregate Limit shown in the Declarations.

2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all d amages under Coverage A, ex-cept damages because of "bodily injury" or "property damage" included in the "produ cts-completed operations hazard", and for medi-cal expenses under Coverage C regardless of the number of:

a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or

bringing "suits".

3. Any payments made under Coverage A for damages or unde r Coverage C for m edical expenses shall reduce the Designated Con-struction Project General Aggregate Limit for that designated construction project. Such payments shall not redu ce the G eneral Ag-gregate Limit shown in th e Declarations nor shall they reduce any other Designated Con-struction Project General Aggregate Limit for any other d esignated construction project shown in the Schedule above.

4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Decla-rations, such limits will be subject to the appli-cable Designated Construction Project Gen-eral Aggregate Limit.

of 2 © Insurance Services Office, Inc., 2008 CG 25 03 05 09

B. For all sums which the insured becom es legally obligated to pay as damages caused by "occur-rences" under Section I – Coverage A, and for all medical expenses caused by a ccidents under Section I – Coverage C, which cannot be at-tributed only to ongoing operations at a singl e designated construction project shown in the Schedule above:

1. Any payments made under Coverage A for damages or unde r Coverage C for m edical expenses shall reduce the amount available under the G eneral Aggregate Limit o r the Products-completed Operations Aggregate Limit, whichever is applicable; and

2. Such payments shall not reduce any Desig-nated Construction Project General Aggre-gate Limit.

C. When coverage fo r liability arising out of the "products-completed operations hazard" is pro-vided, any p ayments for damages because of "bodily injury" or "p roperty damage" included in the "products-completed operations hazard" will reduce the Products-completed Operations Ag-gregate Limit, and not re duce the Ge neral Ag-gregate Limit nor the De signated Construction Project General Aggregate Limit.

D. If the applica ble designated construction project has been abandoned, delayed, or a bandoned and then restarted, or if the authorized contract-ing parties deviate from plan s, blueprints, de-signs, specifications or timetables, the project will still be deemed to be the same construction pro-ject.

E. The provisions of Se ction III – Limits Of Insur-ance not otherwise modified by this endorsement shall continue to apply as stipulated.




DESIGNATED LOCATION(S) GENERAL AGGREGATE LIMIT



SCHEDULE

Designated Location(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becom es legally

obligated to pay as damages caused by "occur-rences" under Section I – Coverage A, and for all medical expenses caused by a ccidents under Section I – Coverage C, which can be attributed only to op erations at a single designated "loca-tion" shown in the Schedule above:

1. A separate Designated Location General Aggregate Limit applies to ea ch designated "location", and that limit is eq ual to the amount of the Gen eral Aggregate Limit shown in the Declarations.

2. The Designated Location General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damag-es because of "bodily injury" or " property damage" included in the "products-completed operations hazard", and for medical expenses under Coverage C regardless of the numbe r of:

a. Insureds;

b. Claims made or "suits" brought; or c. Persons or organizations making claims or

bringing "suits". 3. Any payments made under Coverage A for

damages or unde r Coverage C for m edical expenses shall reduce the Designated Loca-tion General Aggregate Limit for that desig-nated "location". Such payments shall not re-duce the Ge neral Aggregate Limit sho wn in the Declarations nor shall they redu ce any other Designated Location General Aggre-gate Limit for any other designated "location" shown in the Schedule above.

4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Decla-rations, such limits will be subject to the appli-cable Designated Location General Aggre-gate Limit.

of 2 © Insurance Services Office, Inc., 2008 CG 25 04 05 09

B. For all sums which the insured becom es legally obligated to pay as damages caused by "occur-rences" under Section I – Coverage A, and for all medical expenses caused by a ccidents under Section I – Coverage C, which cannot be at-tributed only to operations at a single de signated "location" shown in the Schedule above:

1. Any payments made under Coverage A for damages or unde r Coverage C for m edical expenses shall reduce the amount available under the G eneral Aggregate Limit o r the Products-completed Operations Aggregate Limit, whichever is applicable; and

2. Such payments shall not reduce any Desig-nated Location General Aggregate Limit.

C. When coverage fo r liability arising out of the "products-completed operations hazard" is pro -vided, any p ayments for damages because of "bodily injury" or " property damage" included in the "products-completed operations hazard" will reduce the Products-completed Operations Ag-gregate Limit, and not re duce the Ge neral Ag-gregate Limit nor the Designated Location Gen-eral Aggregate Limit.

D. For the purposes of this endorsement, the Defi-nitions Section is amended by the a ddition of the following definition: "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a stre et, roadway, waterway or right-of-way of a railroad.

E. The provisions of Se ction III – Limits Of Insur-ance not otherwise modified by this endorsement shall continue to apply as stipulated.

CERTIFICATE HOLDER



CANCELLATION


LOCJECTPRO-POLICY


OCCURCLAIMS-MADE


GENERAL LIABILITY




GENERAL AGGREGATE $


$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $


EXCESS LIAB






OTH-ER

E.L. EACH ACCIDENT



$

$

$








AUTOS AUTOS

AUTOS




$

$$


INSRADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)




INSURED


PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :



12/14/2013




26247

2785540142

16535


broker's email

ZUICERT

1809379583

A ZUR987654 1/1/2013 1/1/2014 1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

X

X

X

B

X

X X


CPO456789 1/1/2013 1/1/2014 2,000,000

C X X UMB123456 1/1/2013 1/1/2014 4,000,000

4,000,000

D WC 91-234567 1/1/2013 1/1/2014 X

1,000,000

1,000,000

1,000,000

Y

A Cargo Liabilty

WLL


$250,000/$500,000$1,000$1,000,000

Blanket Waiver of Subrogation applies with respect to workers compensation per WC 04 03 06 (or WC000313, or WC420304 or WC430305per state).

BROKER NOTES: Check policy to see if currently endorsed with Waiver. a. If Zurich Blanket WC Waiver of Subrogation is included, issuethe cert with the sample wording directly. b. If Zurich Blanket WC Waiver of Subrogation is not included, 1) submit request to underwriter forapproval. 2) If UW approves, issue certificate with approved wording on sample. 3) Submit acord change request to add waiver withcertificate to PHP.

WORKERS COMPENSATIONWAIVER OF SUBROGATIONSan Francisco CA 12345

Insured Copy

WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Page 1 of 1

WORKERS’ COMPENSATION AND EMPLOYERS’ LIABILITY INSURANCE POLICY WC 04 03 06

(Ed. 4-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT------CALIFORNIA

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule.

The additional premium for this endorsement shall be % of the California workers’ compensation pre-mium otherwise due on such remuneration.

Schedule

Person or Organization Job Description

ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US

certificate of liability insurance - mover's … · cancellation certificate of liability...

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