CERTIFICATE OF LIABILITY INSURANCE (222)�
�`�O � CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYVYY)
8/16/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement s.
PRODUCER NAME: PBt�ICIa BI�f1C0 __.___ __,
lames C. Jenkins Insurance Service, II1C. PHONE F,ox ---
_icense #0545478 c r,o �t :916-576-1517 _ tac r,o>:g16-583-7613 _ _
E-MAIL
'O Box 13847 nooRess: bianco 'enkinsins rou .com
3acramento CA 95853-3847 INSURER(S) AFFORDING COVERAGE NAIC M
iNSUrteRq:Wausau lJndPrwritPr� �
INSURED
DKS Associates
1970 Broadway, Suite 740
Oakland CA 94612
COVERAGES
DKSAS-1
CERTIFICATE NUMBER: 1833122687
D:
E:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR 7ypE OF INSURANCE ADDL SUBR POLICY EFF POUCY ERP LIMITS �
LTR INSR NND POLICY NUMBER MMIDDIYYYY MMIDD/YYYY
A GENERAL LIABILITY VJZ91459167 1 /1/2013 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY '°�E PREM SES Ea occur ence 5300,000
CLAIMS-MADE � OCCUR MED EXP (Any one person) $0
AUG2 p�p�� FERSONAL & ADV INJURY $1,000,000
-GENERALAGGREGATE _�$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: [c q� PRODUCTS - COMP/OP AGG $2,000,000 ._ _...__
PRO- 1-fIC�/'y6 (� �" �
POI.ICY X T n LOC �v�% — ''
A AU70MOBILE LIABILITY ASJZ914591 �£ I/1/2013 Ea accident $1,000,000
— —___ _—
� ANY AUTO I, BODILY INJURY (Per person) $
ALLOWNED SCHEDULEC� �'� �� --------- ��-��--�--�---- -T---� -
AUTOS AUTOS i � BODiLY INJURY (Per accident) $
X X NON-OWNED � I PROPERTY DAMAGE —� -
HIRED AUTOS AUTOS Per accident _ _
X No Owned Aut $
UMBRELLA LIAB OCCUR EACH OCCURRENCE �$
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
g WORKERS COMPENSATION 57WEHO6750 I1I2012 /1/2013 X WC STATU- OTH-
AND EMPLOYERS' LIABILITY _. TORY LIMITS ER _.._
ANY PROPRIETOR/PARTNER/EXECUTIVE � E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? N I A ���. --�����— —
(Mandatory in NH) ' E.L. DISEASE - EA EMPLOYE $1,000,000 __
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000
C Errors and Omissions B0738SP005280G /1/2012 /1/2013 Per Claim $1,000,000
Claims Made Aggregate $1,000,000
Deductible $50,000
DESCRIPTION OP OPERATIONS 1 LOCATIONS I VEHICLES (Attaeh ACORD 101, Additional Remarks Schedule, if more space is required)
RE: RFQ 16-12. City of Clearwater is and Additional Insured as respects General Liability and Automobile Liability per the attached forms.
Primary wording and Waiver of Subrogation applies to General Liability and Automobile Liability per the attached forms.
CERTIFICATE HOLDER
City of Clearwater
Attn: City Clerk
P.O. Box 4748
Clearwater FL 33758-4748
ACORD 25 (2070/05)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEIIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
,�''��r��' � � � '-�'�.' _..., ..
f,..
�..�'� .=�`�,� u'" �'.1'� ;. t''`�� °--°
O 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
LIBERTI' DirectSolutions for Professional Services
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILIT'Y COVERAGE PART
This endoxsement modifies insurance by broadening the insuxance provided by CG 00 01.
Index of modified items:
Item 1– REASONABI.E FORCE
Item 2. - NON-OWNED WATERCRAFT EXTENSION
Item 3. - ALIENATED PREMISES
Item 4. - DAMAGE TO BORROWED EQUIPMENT
Item 5. - PROPERTY IN YOUR CARE, CUSTODY OR CONTROL
Item 6. - DAMAGE TO PREMISES RENTED TO YOU - EXPANDED COVERAGE
Item 7. - BODILY INJURY TO CO-EMPLOYEES
Item 8. - HEALTH CARE PROFESSIONALS AS INSUREDS
Item 9. - NEWLY FORMED OR ACQUIRED ENTITIES
Item 10. - BLANKET ADDITIONAL INSURED AND WAIVER OF SUBROGATION—MANAGERS OR LESSORS
OF PREMISES
Item 11. - BLANKET ADDITIONAL INSURED AND WAIVER OF SUBROGATION – PERSON OR
ORGANIZATION
Item 12. - ADDITIONAL INSURED – STATE, MUNICIPALITY OR POLITICAL SUBDIVISION - PERMITS
Item 13. - ADDITIONAL INSURED AND WAIVER OF SUBROGATION – LESSOR OF LEASED EQUIPMENT
Item 14. - KNOWLEDGE OF OCCURRENCE
Item 15. - UNINTENTIONAL ERRORS AND OMISSIONS
Item 1G. - BODILY INJURY REDEFINITION
Item 17. - MOBILE EQUIPMENT REDEFINITION
Item 18. - SUPPLEMENTARY PAYMENTS
Item 19. - LIBERAI.IZATION
These changes broaden the policy sections described unless differing language is separately endorsed to the coverage
part.
Item 1. - REASONABLE FORCE
Exclusion a. of Coverage A is teplaced by the following:
a. Expected or Intended Injury
"Bodily injury" or "property damage" expected ox intended from the standpoint of the insured. This exclusion
does not apply to "bodily injury" or "property damage° resulung from the use of reasonable force to protect
persons or property.
Item 2. - NON-OWNED WATERCRAFT EXTENSION
Subparagraph g.(2) of Exclusion g. of Coverage A(Secuon I- Coverages) is replaced by the following:
(2) A watercraft you do not own that is:
(a) Less than 55 feet long; and
(b) Not being used for public txansportation or as a common caxrier.
Item 3. - ALIENATED PREMISES
Subparagraph j.(2) of Exclusions of Section I– Coverages – Bodily Injury And Pxoperty Damage Liability is
replaced by the following:
(2) Premises you sell, give away, ot abandon, if the "property damage" axises out of any part of those premises, and
occurs from hazards that were known by you, ot should have reasonably been known by you, at the time the
property- was transferred or abandoned.
LG 32 38 09 07 Page 1 of 7
Item 4. - DAMAGE TO BORROWED EQUIPMENT
A. Exclusion j. of Coverage A(Secuon I— Covexages) is amended to add the following
Paxagraphs (3) and (4) do not apply to "property damage" to borrowed equipment either loaned to pou or in }�our cate,
custody or contxol.
B. Subject to Paragraphs 2., 3., and 5. of Section III — Limits Of Insurance, the most we will pa5� for damages under this
endorsement is $35,000 for all "occurrences" during the policy period.
The insuxance provided by this endoxsement is excess ovex an}� other valid and collectible pxopert�� insurance (inclucling
any deductible portion thereo fl available to the insured whether primary, excess, contingent or on any other basis.
Item 5. - PROPERTY IN YOUR CARE, CUSTODY OR CONTROL
1. Subpaxagraphs (3) and (4) of exclusion j. of coverage A. do not apply except to
(a) borrowed equipment, or
(b) "property damage" to propert}� in your care, custody and control while in transit.
This insurance does not apply to any poruon of a loss for which the insured has available any other valid and collectible
insurance, whether primary, excess, contingent, or on any other basis, unless such other insurance was specifically
purchased by the insured to apply in excess of this policy.
2. Limits of Insurance
Subject to Paragraphs 2., 3., and 5.
provided bp paragraph 1., above is:
$10,000 Each Occurxence Limit
$25,000 Agp,regate Limit
of Secuon III — Limits Of Insurance, the most we will pay fox insutance
The Each Occurrence Limit for this coverage applies to all damages as a result of any one "occurrence" regardless
of the number of persons ox organizations who sustain damage because of that "occurxence."
The Aggregate Limit is the most we will pay for the sum of all occurrences covered by this provision.
Item G. - DAMAGE TO PREMISES RENTED TO YOU - EXPANDED COVERAGE
A. Fire, Lightning Ox Explosion Damage
The last paragraph of 2. Exclusions under Section I— Coverage A is replaced by the following:
Exclusions c. through n. do not apply to damage to premises rented to you or temporarily occupied bj� you
with permission of the owner when the damage is caused by fire, lightning, or explosion or subsequent damages
resulting from such fire, lightning or explosion, including watex damage. A separate limit of insurance applies
to this coverage as described in Secuon III — Limits of Insurance.
B. Limits for Damage to Premises Rented to You
Paxagraph 6. of Section III — Limits of Insuxance is replaced by the following:
Subject to 5. above, the Damage to Premises Rented to You Limit is the most we will pay under Coverage A
for any combination of:
(a) damage caused by fire, lightning, or explosion or subsequent damages resulting fxom such fixe,
lightning or explosion, including water damage to premises rented to you, ox temporaxily occupied
by you with permission of the owner; and
(b) "property damage" (othex than damage bj� fire) to premises, including the contents of such
pxemises, rented to you fox a pexiod of 7 ox fewer consecutive days.
Item 7. - BODILY INJURY TO CO-EMPLOYEES
LG 32 38 09 07 Page 2 of 7
1. Subject to the Each Occurrence Limit and the General Ag�uxegate Limit, Paragraphs 2.a.(1)(a), (b) and (c) of
Section II – Who Is an Insured do not apply to your superoisary or management "employees" for "bodily injury"
only.
2. Subject to the Each Occurrence Limit and the General Aggregate Limit, Paxagxaphs 2.a.(1)(a), (b) and (c) of
Section II – Who Is an Insured do not apply to youx "employees" or "volunteer workexs" for "bodily injury"
arising out of a Good Samaritan act to a co-"employee" ox co-"volunteer worker." A Good Samaritan act means an
attempt to xescue or aid a pexson in imminent or serious peril, provided the attempt is not recklessly made.
Damages owed to an injured co-"employ�ee" or "volunteer worker" will be reduced by any amount paid or avaIlable to
the injured co-"employee" ar"volunteer woxker" under any other valid and collectible insurance.
Item 8. - HEALTH CARE PROFESSIONALS AS INSUREDS
Paragraph 2.a. (1) (d) of Section II – Who Is An Insuted is deleted unless:
(i) You are engaged in the occuparion or business of providing or offering medical, surg,ical, dental, x-ray ar nursing
services, treatment, advice or instruction; or
(u) The "emploj�ee" has any othex insuxance that would also cover claims axising under this provision, whethex the
other insurance is primary, excess, contingent or on any other basis.
Item 9. - NEWLY FORMED OR ACQUIRED ENTITIES
Paxagraph 3. of Section II – Who Is An Insured is replaced by- the following:
3. Anj� organizaaon, other than a joint venture, you newly acquire or form and over which you maintain majority
ownership or majorit�� interest, will qualify as a Named Insured if there is no other simIlar insurance available to
that organization.
a. Covexage undex this provision is afforded only until
i. the 180th da}� after you acquire or form the organizauon; or
ii. separate coverage is purchased for the organization; ox
iii. the end of the policy period,
whichevet is earlier.
b. Coverage A does not apply to "bodily injur�' or "properry damage" that occurred before you acquired or
foxmed the organization; and
c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before
you acquired or formed the organization.
No person or organization is an insured with respect to the conduct of any past parmership, current or past joint venture
or past limited liability company that is not shown as a Named Insured in the Declarations.
Item 10. - BLANKET ADDITIONAL INSURED AND WAIVER OF SUBROGATION—MANAGERS OR LESSORS
OF PREMISES
A. Section II – Who Is An Insured is amended to include as an insured any manager or lessor of premises leased bp you
in which the written lease agreement obligates you to pxocure additional insured coverage, pxovided that:
1. the "bodily injury", "propertt� damage" or "personal and advertising injury" giving rise to liability occurs
subsequent to the execution of the agreement; and
2. the written agreement is in effect at the dme of the "bodily injury", "properry damage", "personal and
advertising injury" fox which covexage is sought.
That person or organization shall be referred to as the additional insured.
The coverage afforded to the additional insured is limited to liability in connecuon with the ownership, maintenance or
use of the pxemises leased to you and caused, in whole or in part, by some negligent acts or omissions of you, your
employees, }�our agents, or your subcontractors. There is no coverage for the additional insured for "bodily injury",
"property damage" or "personal and advertising injury" arising out of the sole negligence of the addiuonal insured or by
those acting on behalf of the additional insured, except as provided below.
LG 32 38 09 07
Page 3 of 7
If the written agreement to indemnify an additional insuxed requires that you indemnify the additional insured fox its sole
negligence, then the coverage for the additional insured shall conform to that agreement; provided, however, that the
contractual indemnification language of the agxeement is valid under the law of the state where the agreement was
formed. If the written agreement provides that a paruculax state's law will apply, then such provision will be honoxed.
B. Waiver Of Subtogation
For any addiuonal insured that obtains insured status on this policy� through paragraph A., above, we waive any right of
recovery we may have against the additional insured because of payments we make for "bodily injury", "property
damage" or "personal and advertising injury" to which this insurance applies.
C. Exclusions
This insurance does not apply to:
1. An}• "occurrence" that takes place after }�ou cease to be a tenant in that premises.
2. Anj� construction, renovation, demolition or installation operations performed by or on behalf of the Additional
Insured.
3. An}' premises for which coverage is excluded by endorsement.
D. OtherInsurance
The insuxance provided by this endorsement applies only to coverages and limits of insurance required by written
a�eement, but in no event exceeds either the scope of coverage ox the limits of insurance available within this policy.
This insurance shall be excess over any other insuxance available to the additional insured, whether such insurance is on
an excess, contingent ox primary basis, unless you are obligated undex a written agreement to provide liability insuxance
for that additional insuxed on any othex basis. In that event, this polic}� will apply solely on the basis required by° such
written agreement.
To the extent that the additional insuxed has the right to pursue any other insurance caxrier for covexage, including a
defense, we shall share that right with the additional insured.
Item 11. - BLANKET ADDITIONAL INSURED AND WAIVER OF SUBROGATION — PERSON OR
ORGANIZATION
A. Section II — Who Is An Insured is amended to include as an additional insured an5� pexson or oxganization to whom
you axe obligated b}• a written agreement to procure additional insured coverage, but only with respect to liability fox
"bodily injury", "pxoperty damage" or "pexsonal and adverusing injury" caused, in whole or in part, by 5�our acts or
omissions or the acts ot omissions of those acting on youx behal£
1. In the pexformance of your ongoing opexauons; or
2. In connection with premises owned by you
provided that:
(a) the "bodily injury", "propert�� damage" or "personal and advertising injurp" giving rise to liability occurs
subsequent to the execution of the agreement; and
(b) the written agreement is in effect at the time of the "bodily injury", "property damage", "personal injury" or
"advertising injury" for which covexage is sought.
That person ot ocganization shall be xeferred to as the additional insured.
There is no coverage far the additional insured for "bodily injury", "propexty damage" ox "personal and advexusing
injur5�" arising out of the sole negligence of the addiuonal insured or by those acting on behalf of the additional insured,
except as provided below.
If the written agxeement to indemnify an additional insured requires that you indemnify the additional insured for its sole
negligence, then the coverage for the addirional insured shall confoxm to that agreement; provided, howevex, that the
contracrual indemnification language of the agreement is valid under the law of the state whexe the agreement was
foxmed. If the written agreement provides that a particular state's law will apply, then such pxovision will be honored.
B. Waiver Of Subrogation
LG 32 38 09 07 Page 4 of 7
For any additional insured that obtains insured status on this policy� through paragraph A., above, we waive any right of
recovery we may have against the addiuonal insured because of payments we make for "bodily injury", "property
damage" or "personal and advertising injury" to which this insurance applies.
C. Exclusions
This insuxance does not apply to:
1. Any pxemises or equipment leased to you.
2. Any construction, renovation, demolition or installation operations pexformed by or on behalf of you, or those
opexating on }�oux behalf.
D. Other Insurance
The insurance provided by this endorsement applies only to coverages and limits of insurance required by written
agreement, but in no event exceeds either the scope of coverage or the limits of insurance available within this policy.
This insurance shall be excess over any other insurance available to the additional insured, whether such insuxance is on
an excess, contingent or primary basis, unless you are obligated under a written agreement to provide liability� insurance
fox that additional insured on any other basis. In that event, this polic}• will apply solely on the basis required by such
written agreement.
To the extent that the additional insured has the right to pursue any other insurance carxier for covexage, including a
defense, we shall share that right with the additional insured.
Item 12. - ADDITIONAL INSURED — STATE, MUNICIPALITY OR POLITICAL SUBDIVISION - PERMITS
Section II — Who Is An Insured is amended to include as an additional insured any state, municipality or political
subdivision with respect to any operations performed by you, or on pour behalf, for which the state, municipalit}� or
political subdivision has issued a pexmit
However, this insurance does not apply to:
1. "Bodily injury," "pxopexty damage" or "personal and advextising injury" axising out of operadons
performed for the state, municipality or political subdivision; or
2. Any "bodily injury" or "propertj� damage" included within the "pxoducts-completed operations hazaxd",
except when xequired by written contract or agreement initiated priox to loss; or
3. `Bodily injury," "property damage" or "personal and advextising injury," unless negligentlj� caused, in
whole or in part, by you or those acting on your behalf.
Item 13. - ADDITIONAL INSURED AND WAIVER OF SUBROGATION — LESSOR OF LEASED EQUIPMENT
A. Section II - Who Is An Insured is amended to include as an additional insured an5� person or organization from
whom you lease equipment when you and such person or organizauon have agreed in a wxitten ag,reement that such
person or organizadon be added as an addiuonal insured on your policy. Such person or organization is an insured
only with respect to liability for "bodilj• injur}�", "pxoperty damage" or "personal and advertising injury" caused, in
whole or in part, b}� j�our maintenance, operadon or use of equipment leased to pou by such person or otgaruzauon.
There is no coverage for the addiuonal insured far "bodily� injury", "properry damage" ox "personal and advertising
injur5" arising out of the sole negligence of the additional insured or by those acting on behalf of the additional
insured.
A persods or organization's status as an addiuonal insured undex this endorsement ends when the agreement with }•ou
fox such leased equipment ends.
B. Waiver of Subrogation
LG 32 38 09 07
Page 5 of 7
For any addirional insured that obtains insured status on this policy through paragraph A., above, we waive any right
of recovery we may have against the additional insured because of pa}�ments we make for "bodily injury", "property
damage" ox "personal and advertising injury" caused, in whole or in part, b}� your maintenance, opexation or use of
equipment leased to you by such person or oxganization.
C. OtherInsurance
This insurance shall be excess over any other insutance available to the additional insured, whethex such insurance is
on an excess, conungent or primar�� basis, uriless you are obligated under a written agreement to provide liabilit��
insurance for that additional insuxed on any othex basis. In that event, this policy will appl}� solely on the basis
required by such written agreement.
To the extent that the additional insuxed has the right to pursue any other insurance carrier fox coverage, including a
defense, we shall share that right with the addiuonal insured.
Item 14. - KNOWLEDGE OF OCCURRENCE
Subparagraph 2.a., b. and c. of Condition 2. Section IV — Commercial Genexal Liability Conditions are amended to add
the following:
As used in this paragraph, the word "you" refers to an"execudve officer", partner, member or legal representauve, and
any other "employee" with insurance or risk management responsibilities.
Item 15. - UNINTENTIONAL ERRORS AND OMISSIONS
Paragraph 6. of Section IV — Commexcial Genexal Liabilit�� Conditions is amended to add the following:
Any unintentional error or omission in the descxiption of, or failure to completely describe, any premises or
operauons intended to be covered by this policy will not invalidate or affect coverage for those premises ox
operations. Howevex, you must xeport such error or omission to us as soon as practicable after its discovery.
This provision does not affect our right to collect additional premium or exercise our right of cancellation or non-
renewal.
Item 16. - BODILY INJURY REDEFINITION
The defuuuon oE� "bodily injuxy" in Secdon V- Definiuons is xeplaced by the following:
`Bodily injury" means bodily injury, sickness or disease sustained by� a person. It includes death or mental anguish,
which xesults at any time from such physical harm, physical sickness ox physical disease. Mental anguish means any
type of inental ox emorional illness or distress.
Item 17. - MOBILE EQUIPMENT REDEFINITION
Paragraph 12. f.(1) (a), (b) and (c) of Secrion V— Definitions does not appl}� to self-propelled vehicles of less than 1000
pounds gross vehicle weight.
Item 18. - SUPPLEMENTARY PAYMENTS
Section I- Covetages, Supplementary Payments - Coverages A and B, item 1. b. and 1. d., respectively, are replaced
with:
b. Up to $2,500 for cost of bail bonds requixed because of accidents or traffic law violations arising out of the use
of any vehicle to which the Bodily InjurS� Liability Covexage applies. We do not have to furnish these bonds.
d. All xeasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the
claim or "suit" including substantiated loss of eaxnings up to $500 a day because of time off fxom woxk.
Item 19. - LIBERALIZATION
Section IV - Commexcial General Liability Conditions is amended to add the following:
LG 32 38 09 07 Page 6 of 7
10. Liberalization
If we adopt a change in our foxms or rule which would btoaden your coverage without an extra charge, the
broader coverage will apply to this policy. This extension is effective upon the approval of such broader
coverage in your state.
This endorsement is executed bp the
Premium $
EffectiveDate 5�1�12
For attachment to Policy No.
Audit Basis Annual
Issued To DI{S Associates
Issued
LG 32 38 09 07
ExpirationDate 5/1�13
YVJZ914591G7
Countersigned by
Sales Office and No.
1�,�C�' �• �� �'""i�'��
�s;erirf�+tav i�no.xrra�'s�
Authoiized Repzesentative � �
End. Serial No.
Page 7 of 7
POLICY NUMBER: ASJZ91459167
COMMERCIAL AUTO
CA 20 48 02 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
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: 5/1/12
Named Insured: DKS Associates
SCHEDULE
Name of Person(s) or Organization(s):
Any person or organization where the named insured has agreed by written contract to include such
person or organization as designated insured.
(If no entry appears above, information required to complete this endorsement will be shown in the Decfarations
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 Copyright, Insurance Services Office, Inc., 1998
Page 1 of 1
❑�
�
PO�ICj/ #ASJZ91459167
b. Return the stolen property, at our ex-
pense. 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
stolen property at an agreed or appraised
value.
If we pay for the "loss", our payment will in-
clude the applicable sales tax for the dam-
aged 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
"accidenY' or "loss" to impair them.
B. General Conditions
1. Bankruptcy
Bankruptcy or insolvency of the "insured" or
the "insured's" estate will not relieve us of any
obligations underthis coverage form.
2. Concealment, Misrepresentation Or Fraud
This coverage form is void in any case of
fraud by you at any time as it relates to this
coverage form. It is also void if you or any
other "insured", at any time, intentionally con-
ceal or misrepresent a material fact concern-
ing:
a. This coverage form;
b. The covered "auto";
c. Your interest in the covered "auto"; or
d. A claim under this coverage form.
3. Liberalization
If we revise this coverage form to provide
more coverage without additional premium
charge, your policy will automatically provide
the additional coverage as of the day the re-
vision is effective in your state.
4. No Benefit To Bailee — Physical Damage
Coverages
We will not recognize any assignment or
grant any coverage for the benefit of any per-
son or organization holding, storing or trans-
porting property for a fee regardless of any
other provision of this coverage form.
COMMERCIAL AUTO
5. Other Insurance
a. For any covered "auto" you own, this
coverage form provides primary insur-
ance. For any covered "auto" you don't
own, the insurance provided by this cov-
erage form is excess over any other col-
lectible insurance. However, while a cov-
ered "auto" which is a"trailer" is con-
nected to another vehicle, the Liability
Coverage this coverage form provides for
the "trailer" is:
(1) Excess while it is connected to a mo-
tor vehicle you do not own.
(2) Primary while it is connected to a
covered "auto" you own.
b. For Hired Auto Physical Damage Cover-
age, any covered "auto" you lease, hire,
rent or borrow is deemed to be a covered
"auto" you own. However, any "auto" that
is leased, hired, rented or borrowed with
a driver is not a covered "auto".
c. Regardless of the provisions of Para-
graph a. above, this coverage form's Li-
�� ability Coverage is primary for any liability
assumed under an "insured contracY'.
d. When this coverage form and any other
coverage form or policy covers on the
same basis, either excess or primary, we
will pay only our share. Our share is the
proportion that the Limit of Insurance of
our coverage form bears to the total of
the limits of all the coverage forms and
policies covering on the same basis.
6. Premium Audit
a. The estimated premium for this coverage
form is based on the exposures you told
us you would have when this policy be-
gan. We will compute the final premium
due when we determine your actual ex-
posures. The estimated total premium will
be credited against the final premium due
and the first Named Insured will be billed
for the balance, if any. The due date for
the final premium or retrospective pre-
mium is the date shown as the due date
on the bill. If the estimated total premium
exceeds the final premium due, the first
Named Insured will get a refund.
b. If this policy is issued for more than one
year, the premium for this coverage form
will be computed annually based on our
rates or premiums in effect at the begin-
ning of each year of the policy.
CA 00 01 03 10 (Rev. 02-��) OO Insurance Services Office, Inc., 2009 Page 9 of 12
Policy �IUENQA4977
17. TWO OR MORE QEDUCTtBLES
Under Paragraph D. - DEDUCTIBLE - of SECTION
III - PHYSICAL DAMAGE COVERAGE, the
follawing is added:
If another Hartford Financial Services Group, Inc.
company policy or coverage form that is not an
automobile policy or coverage form applies to the
same "accidenY', the following applies:
(1) If the deductible under this Business Auta
Cover�ge Form is the smaller (or smallest)
deductible, it will be waived;
(2) If the deductible under this Business Auto
Coverage Form is not the smaller (.or smallest)
deductibie, it wili be reduced by the amount of
the smaller (or smallest) deductible.
12. AMENDED DUTIES IN THE EVEN.T OF
ACCIDENT, CLAIM, SUIT OR LOSS
The requirement in LOSS GONDITIONS 2.a. -
DUTIES IN THE EVENT �F ACCIDENT, CLAIM.
SUIT OR LOSS - af SECTION IV - BUSINESS
AU70 CONDITIONS that you must notify us of an
'accidenY applies only when the 'accident' is
known to:
(1) You. if you are an individual;
(2} A partner, if you are a partnership;
(3} A member, if you are a limited liability
company; or
(4) An executive officer or insurance manager, if
you are a corporation.
13. UNINTENTIONAL FAILURE TO DISCLOSE
HAZARDS
If you unintentionally fail to disclose any hazards
existing at the inception date of your policy, we will
not deny coverage under this Coverage Form
because of such failure.
Form HA 99 1S 03 02
14. HIRED AUTO - COVERAGE TERRffORY
Paragraph e. of GENERAL CONDITIONS 7. -
POLICY PERIOD, COVERAGE TERRITORY - of
SECTION IV - BUSINESS AUTO CONDITIONS is
replaced by the following:
e. For short-term hired 'autos", the coverage
territory with respect to Liability Coverage is
anywhere in the world provided that if the
''insured's" responsibility to pay damages for
'bodily injury' or 'property damage° is
determined in a'suit,' the 'suit" is brought in
#he United States of America, the territories
and possessions of the United States of
America, Pue�to Rico or Canada or in a
settlement we agree to.
15. WAIVEA OF SUBROGATION
TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US - of SECTION IV -
BUSINESS AUTO CONDITIONS is amended by
adding the following:
We waive any right of recovery we may have
against any person or organization with whom you
have a written contract that requires such waiver
because of. payments we make for damages under
this Coverage Form.
76. RESULTANT MENTAL ANGUISH COVERAGE
The definition of �'bodily injury' in SECTION V-
DEFINITIONS is replaced by the following:
'Badily injury" means bodily injury, sickness or
disease sustained by any person; including mental
anguish or death resulting frorn any of these.
17. EXTENDED CANCELLATION CONDITION
Paragraph 2, of the COMMON POUCY
CONDITIONS - GANCELLATION - applies except
as follows:
If we cancel for any reason other than nonpayment
of premium, we will mail or delivsr to the first
Named Insured written notice of canceflation at
least 60 days before the effective date of
cancellation.
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