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HomeMy WebLinkAboutAlcal COI 23.09.29SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY Willis Towers Watson Insurance Services West, Inc.c/o 26 Century BlvdP.O. Box 305191Nashville, TN 372305191 USA [2122] Alcal Specialty Contracting, Inc.21402 84th Avenue SKent, WA 98032 RE: City of Bremerton Pump Station 14 Relocation ProjectSEE ATTACHED Prospect Construction, Inc.116 23rd Street SEPuyallup, WA 98372 02/01/2023 1-877-945-7378 1-888-467-2378 certificates@willis.com Liberty Surplus Insurance Corporation 10725 Safety National Casualty Corporation Allied World National Assurance Company 15105 10690 Berkley National Insurance Company 38911 W28014272 A 1,000,000 500,000 10,000SIR $100,000 1,000,000 2,000,000 2,000,000 Y Y 1000432451-03 09/29/2022 09/29/2023 B 3,000,000 09/29/202309/29/2022YYCAS4055739 C 10,000,000 10,000 0309-7989 09/29/2022 09/29/2023 10,000,000 LDC4053821BY 1,000,000No09/29/2022 09/29/2023 1,000,000 1,000,000 A Excess Liability $15,000,000 xs of1000487437-02 09/29/2022 09/29/2023 283644523696477SR ID:BATCH: $10,000,000 Willis Towers Watson Certificate Center Page 1 of 2 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: [2122] Alcal Specialty Contracting, Inc.21402 84th Avenue SKent, WA 98032 Prospect Construction, Inc., Contractor,Owner, and their affiliates, principals, officers, directors and managers shallbe added as Additional Insureds where required by written contract, but only to the extent any bodily injury orproperty damages arise out of the acts, errors or omission of Named Insured. The General Liability policy shall be Primary and Non-Contributory with any other insurance in force for or which maybe purchased by Additional Insureds. Waiver of Subrogation applies in favor of Additional Insureds with respects to General Liability, Business Auto andWorkers Compensation, as permitted by law. INSURER AFFORDING COVERAGE: Allied World National Assurance Company NAIC#: 10690POLICY NUMBER: 0312-0222 EFF DATE: 09/29/2021 EXP DATE: 09/29/2023 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:Contractors Pollution Liability Each Incident $5,000,000 Aggregate $5,000,000 Retention $25,000 INSURER AFFORDING COVERAGE: Berkley National Insurance Company NAIC#: 38911POLICY NUMBER: MIM-1045445-51 EFF DATE: 09/29/2022 EXP DATE: 09/29/2023 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:Leased/Rented Equipment Limit: $500,000 Deductible: $2,500 Deductible Crane: $10,000 2 2 Willis Towers Watson Insurance Services West, Inc. See Page 1 See Page 1 See Page 1 See Page 1 25 Certificate of Liability Insurance W28014272CERT:2836445BATCH:23696477SR ID: CG 20 10 07 04 © ISO Properties, Inc., 2004 1 1 LIBERTY SURPLUS INSURANCE CORPORATION (A New Hampshire Stock Insurance Company, hereinafter the "Company") ENDORSEMENT NO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. –– This endorsement modifies insurance provided under the following: SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy; Any other person or organization you are required to add as an additional insured under the contract or agreement described in the paragraph above. All locations of covered operations. (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 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to “bodily injury” or “property damage” occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of “your work” out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Policy Number:1000432451-03 Effective Date:09/29/2022                      ! "# $ %#%& '( ) '*'+     "   # " $ " %    & %  + ,,$"-,,", $../0 "   !!'' !  '( )*'+'( )''! ,'!,'  #/1$ #" $/ #","  /1 -/,/ / " /12,,,,,.",#".#3# /1#"4", ,,,,.",",  /,2, / 2- ..5,($-,   $4",.   ,".$ 2-..2  (.& '-.  '' !,,.",,,.", &/1&                                      6     1000432451-03 09/29/2022 CGL 10 11 01 03 1 2 LIBERTY SURPLUS INSURANCE CORPORATION (A New Hampshire Stock Insurance Company, hereinafter the "Company") THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SCHEDULE Designated Construction Project(s): All Covered Projects during the policy period (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the insured becomes legally obligated to pay as damages caused by “occurrences” under COVERAGE A (SECTION I), which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The overall Policy Aggregate Limit scheduled in the Declarations is the most we will pay for the sum of all Designated Construction Project General Aggregate Limits. 3. Subject to the Policy Aggregate Limit, the Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except damages because of “bodily injury” or “property damage” included in the “products-completed operations hazard”, regardless of the number of: a. Insureds; b. Claims made or “suits” brought; or c. Persons or organizations making claims or bringing “suits”. 4. Any payments made under COVERAGE A for damages shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Subject to the Policy Aggregate Limit, such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 5. The limits shown in the Declarations for Each occurrence continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit and Policy Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by “occurrences” under COVERAGE A (SECTION I), which cannot be attributed only to operations at a single designated construction project shown in the Schedule above: 1. Any payments made under COVERAGE A for damages shall reduce the amount available under the General Aggregate Limit or the Products-Completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Designated Construction Project General Aggregate Limit. Policy Number: 1000432451-03 Effective Date: 09/29/2022 CGL 10 11 01 03 2 2 C. When coverage for liability arising out of the “products-completed operations hazard” is provided, any payments for damages because of “bodily injury” or “property damage” included in the “products-completed operations hazard” will reduce the Products-Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit, Designated Construction Project General Aggregate Limit nor Policy Aggregate Limit. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Limits Of Insurance (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. CGL 10 31 04 03 1 1 LIBERTY SURPLUS INSURANCE CORPORATION (A New Hampshire Stock Insurance Company, hereinafter the "Company") THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. To the extent that this insurance is afforded to any additional insured under the policy, such insurance shall apply as primary and not contributing with any insurance carried by such additional insured, as required by written contract. Nothing herein contained shall be held to waive, vary, alter or extend any condition or provision of the policy other than as above stated. Policy Number: 1000432451-03 Effective Date: 09/29/2022 CG 24 04 05 09 © Insurance Services Office, Inc., 2008 1 1 LIBERTY SURPLUS INSURANCE CORPORATION (A New Hampshire Stock Insurance Company, hereinafter the "Company") ENDORSEMENT NO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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. Policy Number: 1000432451-03 Effective Date: 09/29/2022 As per written contract policy. As required by written contract signed by both parties prior to any “occurrence” in which coverage is sought under this Name Of Person Or Organization: SCHEDULE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SNCA 026 1111 Safety National Casualty Corporation Page 1 of 2 DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) or Organization(s): Person(s) or Organization(s) as required by written contract. Any individually scheduled Designated Additional Insured shall not be construed to override nor negate this blanket Designated Additional Insured. CHANGE The below language is added to Paragraph 1. Who Is An Insured of SECTION II –LIABILITY COVERAGE within each of the above referenced Coverage Forms except GARAGE COVERAGE FORM, or is added to Paragraph 3. Who Is An Insured of SECTION II –LIABILITY COVERAGE within the GARAGE COVERAGE FORM. The person(s) or organization(s) shown in the Schedule above with whom you have agreed in a written contract to provide insurance such as is afforded under this Coverage Form, is included as an Additional Insured subject to the below: (1)Insurance for such Additional Insured(s) scheduled above shall be afforded only to the extent that such Additional Insured is liable for “bodily injury” or “property damage” arising out of your operations and resulting from the ownership, maintenance or use of covered “autos” by you while the covered “autos” are on premises owned or leased by the above scheduled Additional Insured(s). (2)The insurance afforded under this Coverage Form to such Additional Insured(s) applies only: (a)If the “accident” takes place subsequent to the execution and effective date of such written contract: and, (b)While such written contract is in force, or until the end of the policy period, which ever occurs first. (3)How Limits Apply to Additional Insured(s) The most we will pay on behalf of the Additional Insured(s) scheduled above is the lesser of: (a)The limits of insurance specified in the written contract or written agreement; or, (b)The Limits of Insurance provided by the Coverage Form. The amount we will pay on behalf of such Additional Insured(s) shall be a part of, and not in addition to, the Limits of Insurance shown in the Coverage Form Declarations and described in this section. Such amount will thus not increase the Limits of Insurance shown for the Coverage Form. (4)Exclusions (a)This endorsement does not apply to liability of the Additional Insured which arises out of the ownership of transportation operating rights granted to the Additional Insured by public authority. (b)This endorsement does not apply to the liability of the owner or anyone else from whom you hire or borrow a covered auto. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 No. Named Insured PACIFIC COAST BUILDING PRODUCTS, INC.Premium $Included Insurance Company Safety National Casualty Corporation Countersigned By ________________________________ SNCA 026 1111 Safety National Casualty Corporation Page 2 of 2 (5) Obligations at the Additional Insured’s Own Cost No Additional Insured will, except at their own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent. The Additional Insured(s) scheduled above shall be subject to all other conditions set forth in the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. Endorsement Effective 09/29/2022 Policy No. CAS4055739 COMMON POLICY CHANGE ENDORSEMENT SAFETY NATIONAL CASUALTY CORP ST. LOUIS, MO 63146 (888) 995-5300 Effective Date Endorsement Number Named Insured and Address Agent PACIFIC COAST BUILDING PRODUCTS, INC. 10600 WHITE ROCK ROAD BLDG B STE 100 RANCHO CORDOVA, CA 95670 CHANGE DESCRIPTION IL 10 05 12 08 Page 1 of 2 At your request and as agreed to by us, your attached policy is hereby endorsed and amended as follows: This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Forms apply unless modified by this endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. ADDITIONAL INSURED – PRIMARY/NON-CONTRIBUTORY ENDORSEMENT Schedule of Additional Insured(s) As required by written contract executed prior to an “accident”. The below language is added to Paragraph 1. Who Is An Insured of SECTION II – LIABILITY COVERAGE. The person(s) or organization(s) shown in the Schedule above with whom you have agreed in a written contract to provide insurance such as is afforded under this Coverage Form, is included as an Additional Insured subject to the below: (1)Insurance for such Additional Insured(s) shall be afforded only to the extent that such Additional Insured(s) is liable for “bodily injury” or “property damage” arising out of your operations and resulting from the ownership, maintenance or use of covered “autos” by you while the covered “autos” are on premises owned or leased by the above scheduled Addition- al Insured(s). (2)The insurance afforded under this Coverage Form to such Additional Insured(s) applies only: (a)If the “accident” takes place subsequent to the execution and effective date of such written contract: and, (b)While such written contract is in force, or until the end of the policy period, which ever occurs first. (3)How Limits Apply to Additional Insured(s) The most we will pay on behalf of the Additional Insured(s) scheduled above is the lesser of: (a)The limits of insurance specified in the written contract or written agreement; or, (b)The Limits of Insurance provided by the Coverage Form. location 12:01 A.M. Standard Time at the described 09/29/2022 Telephone:(213) 607-6368 LOS ANGELES, CA 90071 300 SOUTH GRAND AVENUE SUITE 2000INC.WILLIS TOWERS WATSON INSURANCE SERVICES WEST, CAS4055739 Policy Number COMMON POLICY CHANGE ENDORSEMENT (Continued) SAFETY NATIONAL CASUALTY CORP ST. LOUIS, MO 63146 (888) 995-5300 Effective Date CHANGE DESCRIPTION IL 10 05 12 08 Page 2 of 2 The amount we will pay on behalf of such Additional Insured(s) shall be a part of, and not in addition to, the Limits of In- surance shown in the Coverage Form Declarations and described in this section. Such amount will thus not increase the Limits of Insurance shown for the Coverage Form. (4) Exclusions This endorsement does not apply to liability of the Additional Insured(s) that arises out of the ownership of transportation operating rights granted to the Additional Insured(s) by any public authority. (5)Obligations at the Additional Insured’s Own Cost No Additional Insured(s) will, except at their own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent. SECTION IV – BUSINESS AUTO CONDITIONS, B. General Conditions, is amended by adding the following to 5. Other In- surance but only with respect to insurance provided to the Additional Insured(s) shown in the above Schedule. If the scheduled Additional Insured(s) is the first named insured on other insurance applicable to the same loss then, regard- less of the provisions set forth in paragraphs a. and d. of this Item 5., if you have specifically agreed in a written contract with the Additional Insured(s) that this insurance be primary and non-contributory with such other insurance, then this insur- ance shall be primary and we will not seek contribution from such other insurance as long as all the provisions set forth in this endorsement are satisfied. location 12:01 A.M. Standard Time at the described 09/29/2022CAS4055739 Policy Number THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SNCA 027 1111 Safety National Casualty Corporation Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM SCHEDULE Name Of Person Or Organization: Person(s) or Organization(s) as required by written contract when such writtencontract is executed prior to an accident to which this endorsement applies. Any individually scheduled Waivers shall not be construed to override nor negatethis blanket Waiver. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CHANGE Paragraph 5. Transfer Of Rights Of Recovery Against Others To Us of the A. Loss Conditions section within the CONDITIONS section of each of the referenced Coverage Forms is amended to include the following: 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 “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”. This waiver applies only to the person or organization shown in the Schedule above. 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 No. Named Insured: PACIFIC COAST BUILDING PRODUCTS, INC. Premium $ Included Insurance Company Safety National Casualty Corporation Countersigned By ________________________________ Endorsement Effective: 09/29/2022 Policy No. CAS4055739 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE WHERE A WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS IS REQUIRED BY WRITTEN CONTRACT, SUCH ADDITIONAL ENTITIES SHALL BE CONSIDERED AUTOMATICALLY SCHEDULED BY THE COMPANY. INDIVIDUALLY SCHEDULED WAIVERS SHALL NOT BE CONSTRUED TO OVERRIDE NOR NEGATE THIS BLANKET WAIVER. 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 No. Insured PACIFIC COAST BUILDING PRODUCTS, INC. Premium $ Included (INCLUSIVE OF ALCAL SPECIALTY CONTRACTING, INC.) Insurance Company Safety National Casualty Corporation Countersigned By WC 00 03 13 (04 84) © 1983 National Council on Compensation Insurance. Page 1 of 1 Endorsement Effective 09/29/2022 Policy No. LDC4053821