MARSHALL STREET INFLUENT PUMP STATION REPAIR PROJECT - 16-0038-UT - CERTIFICATE OF LIABILITY INSURANCE - 16-0038-UT (2)��r� � DATE(MM/DD/YYYY)
A� ° CERTIFICATE OF LIABILITY INSURANCE 06/23/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
AOII RlSk 521'V1C25 Central , IIIC. NAME:
Chi cago IL Offi ce (A��NN . Ext): C866) 283-7122 �� No :(800) 363-0105
200 EdSt Randol ph E-MAIL
ChiCdgO IL 60601 USA ADDRESS:
PCL Construction, Inc.
3810 Northdale Boulevard
Suite 160
Tamoa FL 33624 U5A
COVERAGES
INSURER A
INSURER B:
INSURER C:
INSURER D:
INSURER E:
INSURER F:
CERTIFICATE NUMBER: 570067187849
INSURER(S) AFFORDING COVERAGE
American Zurich Ins Co
Zurich American Ins Co
Indian Harbor Insurance Company
REVISION NUMBER:
NAIC #
40142
16535
36940
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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. Limits shown are as requested
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
B X COMMERCIAL GENERAL LIABILITY GLO EACH OCCURRENCE S S, 000, 000
CLAIMS-MADE X❑ OCCUR PREMISES Ea occurrence � 5, 000 , 000
MED EXP (Any one person) �10, 000
PERSONAL&ADVINJURY $5,000,000 �
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 510, 000, 000 �
POLICY X❑ PE � ❑X LOC PRODUCTS - COMP/OP AGG S10 , 000 , 000 �
0
OTHER: o
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B BAP 2090771-19 07/O1/2017 07/Ol/2018 COMBINEDSINGLE LIMIT `n
AUTOMOBILE LIABILITY $2 , 000, 000
Ea accident
X ANY AUTO BODILY INJURY ( Per person) �
OWNED SCHEDULED BODILY INJURY (Per accident) d
AUTOS ONLY AUTOS
X HIREDAUTOS X NON-OWNED PROPERTYDAMAGE R
ONLY AUTOSONLY Peraccident w
�
N
� UMBRELLALIAB X OCCUR CPX742008704 07/O1/2017 07/Ol/2018 EACHOCCURRENCE 520,000,000 V
X EXCESS LIAB CLAIMS-MADE AGGREGATE $20, 000, 000
DED RETENTION
A WORKERSCOMPENSATIONAND WC209077220 07/O1/2017 07/Ol/2018 X PER OTH-
EMPLOYERS' LIABILITY
STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE Y❑ E.L.EACH ACCIDENT $Z�OOO�OOO
OFFICER/MEMBER EXCLUDED? N N/ A
(Mandatory in NH) E.L. DISEASE-EA EMPLOYEE $2 , 000, 000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $2 , 000, 000 -
�
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DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) �'
Re: Marshall St. Influent Pump Station Repair, Project #16-0038-UT, Project location: 1605 Harbor Drive, Clearwater, FL 33755, �
Project duration: 07/OS/2017 - O1/04/2018. see attached. �
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CERTIFICATE HOLDER CANCELLATION �c=.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE -
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
Cl ty Of Cl earwater AUTHORIZED REPRESENTATIVE
100 5. Myrtle Ave
Clearwater FL 33756 U5A �`�� r�,�� i����
'r7li_ O C�/
J�u�c �.J
01 988-201 5 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
AC�R��
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AGENCY CUSTOMER ID: 570000034016
LOC #:
ADDITIONAL REMARKS SCHEDULE
AGENCY NAMEDINSURED
Aon Risk Services Central, Inc. PCL Construction, Inc.
POLICY NUMBER
see Certificate Number: 570067187849
CARRIER NAIC CODE
see Ce rti fi cate Numbe r: 570067187849 EFFECTIVE DATE:
ADDITIONAL REMARKS
Page _ of _
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: BAP 2090771-19
COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER 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" for Covered Autos Liability Coverage
under the Who Is An Insured provision 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 indicated
below.
Named InSUred: PCL Construction Enterprises, Inc.
Endorsement Effective Date: 07/O1/2017
SCHEDULE
Name Of Person(s) Or Organization(s):
Any person or organization with whom you have agreed , through written contract, agreement or permit, executed prior to
the loss, to provide additional insured coverage.
Information reauired to complete this Schedule, if not shown above, will be shown in the Declarations.
Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies
as an "insured" under the Who Is An Insured
provision contained in Paragraph A.1. of Section II —
Covered Autos Liability Coverage in the Business
Auto and Motor Carrier Coverage Forms and
Paragraph D.2. of Section I— Covered Autos
Coverages of the Auto Dealers Coverage Form.
CA 20 48 10 13 O Insurance Services Office, Inc., 2011 Page 1 of 1
Wolters Kluwer Financial Services � Uniform Formsr""
Policy Number
GLO 2090773-19
ENDORSEMENT
ZURICH AMERICAN INSURANCE COMPANY
Named Insured PCL CONSTRUCTION ENTERPRISES, Effective Date: 07—01-17
12:01 A.M., Standard Time
Agent Name AON RI SK SERV I CE S CENTRAL INC Agent No. 3 0 3 8 0— 0 0 0
BROAD FORM ADDITIONAL INSURED COVERAGE—OWNERS, LESSEES OR CONTRACTORS
SCHEDULED PERSON OR ORGANIZATION
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
INSURED ANY PERSON OR ORGANIZATION WHO YOU ARE REQUIRED TO
ADD AS AN ADDITIONAL INSURED ON THIS POLICY UNDER A WRITTEN
CONTRACT OR WRITTEN AGREEMENT.
B. THE INSURANCE PROVIDED TO THE ADDITIONAL INSURED APPLIES ONLY
TO ��BODILY INJURY", "PROPERTY DAMAGE" OR "PERSONAL AND
ADVERTISING INJURY" COVERED UNDER SECTION I— COVERAGE A,
BODILY INJURY AND PROPERTY DAMAGE LIABILITY AND SECTION I—
COVERAGE B, PERSONAL AND ADVERTISING INJURY LIABILITY, BUT
ONLY WITH RESPECT TO LIABILITY FOR "BODILY INJURY",
"PROPERTY DAMAGE" OR "PERSONAL AND ADVERTISING INJURY" CAUSED:
l. IN WHOLE OR IN PART, BY YOUR ACTS OR OMISSIONS OR THE ACTS
OR OMISSIONS OF THOSE ACTING ON YOUR BEHALF; OR
2. SOLELY BY ACTS OR OMISSIONS OF THE ADDITIONAL INSURED, IF
COVERAGE FOR SOLE ACTS OR OMISSIONS OF THE ADDITIONAL
INSURED IS REQUIRED BY WRITTEN CONTRACT OR WRITTEN
AGREEMENT, AND RESULTING FROM:
A. YOUR ONGOING OPERATIONS; OR
B. ��YOUR WORK" COMPLETED AS INCLUDED IN THE "PRODUCTS—
COMPLETED OPERATIONS HAZARD", PERFORMED FOR THE
ADDITIONAL INSURED AT THE LOCATION DESIGNATED AND
DESCRIBED IN THE SCHEDULE.
C. HOWEVER, REGARDLESS OF THE PROVISIONS OF PARAGRAPHS A. AND B.
ABOVE:
l. WE WILL NOT EXTEND ANY INSURANCE COVERAGE TO THE ADDITIONAL
INSURED PERSON OR ORGANIZATION:
A. THAT IS NOT PROVIDED TO YOU IN THIS POLICY; OR
B. THAT IS ANY BROADER COVERAGE THAN YOU ARE REQUIRED
TO PROVIDE TO THE ADDITIONAL INSURED PERSON OR
OR ORGANIZATION IN THE WRITTEN CONTRACT OR WRITTEN
AGREEMENT; AND
2. WE WILL NOT PROVIDE LIMITS OF INSURANCE TO THE ADDITIONAL
INSURED PERSON OR ORGANIZATION THAT EXCEED THE LOWER OF:
A. THE LIMITS OF INSURANCE PROVIDED TO YOU IN THIS POLICY;
OR
B. THE LIMITS OF INSURANCE YOU ARE REQUIRED TO PROVIDE IN
THE WRITTEN CONTRACT OR WRITTEN AGREEMENT.
D. THE INSURANCE PROVIDED TO THE ADDITIONAL INSURED DOES NOT APPLY
T0:
l. ��BODILY INJURY", ��PROPERTY DAMAGE" OR "PERSONAL AND
ADVERTISING INJURY" ARISING OUT OF THE RENDERING OR
U-GL-1114A CW (10/02)
Policy Number
GLO 2090773-19
ENDORSEMENT
ZURICH AMERICAN INSURANCE COMPANY
Named Insured PCL CONSTRUCTION ENTERPRISES,
AgentName AON RISK SERVICES CENTRAL INC
FAILURE TO RENDER ANY PROFESSIONAL ARCHITECTURAL,
ENGINEERING OR SURVEYING SERVICES INCLUDING:
Effective Date: 0 7— 01-17
12:01 A.M., Standard Time
Agent No. 30380-000
A. THE PREPARING, APPROVING, OR FAILING TO PREPARE OR
APPROVE MAPS, SHOP DRAWINGS, OPINIONS, REPORTS,
SURVEYS, FIELD ORDERS, CHANGE ORDERS OR DRAWINGS
AND SPECIFICATIONS; AND
B. SUPERVISORY, INSPECTION, ARCHITECTURAL OR ENGINEERING
ACTIVITIES.
E. THE ADDITIONAL INSURED MUST SEE TO IT THAT:
l. 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 ��SUIT" AS SOON AS
PRACTICABLE; AND
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 IN WHICH THE ADDITIONAL INSURED IS A
NAMED INSURED, IF THE WRITTEN CONTRACT OR AGREEMENT
REQUIRES THAT THIS INSURANCE BE PRIMARY AND
NON—CONTRIBUTORY.
F. FOR THE COVERAGE PROVIDED BY THIS ENDORSEMENT:
l. THE FOLLOWING PARAGRAPH IS ADDED TO 4. OTHER INSURANCE OF
SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS,
UNDER A. PRIMARY INSURANCE:
THIS INSURANCE IS PRIMARY INSURANCE AS RESPECTS OUR COVERAGE TO THE
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 TO 4. OTHER INSURANCE OF
SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 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
ADDITIONAL 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".
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-1114A CW (10/02)
U-GL-1114A CW (10/02)
Policy Number
GLO 2090773-19
ENDORSEMENT
ZURICH AMERICAN INSURANCE COMPANY
Named Insured: PCL CONSTRUCTION ENTERPRISES,
Agent Name: AON RISK SERVICES CENTRAL INC
Effective Date: 07-01-2017
12:01 A.M., Standard Time
Agent No. 30380-000
BLANKET NOTIFICATION TO OTHERS OF CANCELLATION
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. IF WE CANCEL TffiS COVERAGE PART (S) BY WRITTEN NOTICE TO THE FIRST NAMED INSURED FOR ANY
REASON OTHER THAN NONPAYMENT OF PREMIUM, WE WILL MAIL OR DELIVER A COPY OF SUCH WRITTEN
NOTICE OF CANCELLATION:
1. TO THE NAME AND ADDRESS CORRESPONDING TO EACH PERSON OR ORGANIZATION SHOWN IN THE
SCHEDULE BELOW; AND
2. AT LEAST 10 DAYS PRIOR TO THE EFFECTIVE DATE OF THE CANCELLATION, AS ADVISED IN OUR NOTICE
TO THE FIRST NAMED INSURED, OR THE LONGER NUMBER OF DAYS NOTICE IF INDICATED IN THE
SCHEDULE BELOW.
B. IF WE CANCEL TffiS COVERAGE PART (S) BY WRITTEN NOTICE TO THE FIRST NAMED INSURED 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.
D. NAME AND ADDRESS OF OTHER PERSONS OR ORGANIZATIONS:
ALL CERTIFICATE HOLDERS WHERE NOTICE OF CANCELLATION IS REQUIRED BY WRITTEN CONTRACT WITH
THE NAMED INSURED SUBJECT TO THE FOLLOWING PROCEDURES:
WE WILL MAIL OR DELIVER NOTIFICATION THAT SUCH COVERAGE PART HAS BEEN CANCELLED TO EACH
PERSON OR ORGANIZATION SHOWN IN AN ACCURATE SCHEDULE PROVIDED TO US BY THE FIRST NAMED
INSURED AT INCEPTION OF THE POLICY OR AS PERIODICALLY UPDATED. NOTICE WILL BE MAILED OR
DELIVERED AS SOON AS PRACTICABLE AFTER AN ACCURRATE LIST OF NAMES AND ADDRESS IS PROVIDED TO
US BY THE FIRST NAMED INSURED IN RESPONSE TO OUR REQUEST.
NUMBER OF DAYS NOTICE: 120 DAYS
ALL OTHER TERMS AND CONDITIONS OF TffiS POLICY REMAIN UNCHANGED.
U-GL-1114-A CW (10/02)
Insurance for this coverage part provided by:
ZURICH AMERICAN INSURANCE COMPANY
ENDORSEMENT
Polic Number
BAl'�2o90771-19
Renewal of Number
BAP 2090771-18
BLANKET NOTIFICATION TO OTHERS OF CANCELLATION
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE:
COMMERCIAL AUTOMOBILE COVERAGE PART
A. IF WE CANCEL THIS COVERAGE PART(S) BY WRITTEN NOTICE TO THE FIRST
NAMED INSURED FOR ANY REASON OTHER THAN NONPAYMENT OF PREMIUM, WE
WILL MAIL OR DELIVER A COPY OF SUCH WRITTEN NOTICE OF
CANCELLATION:
1. TO THE NAME AND ADDRESS CORRESPONDING TO EACH PERSON OR
ORGANIZATION SHOWN IN THE SCHEDULE BELOW; AND
2. AT LEAST 10 DAYS PRIOR TO THE EFFECTIVE DATE OF THE CANCELLATION,
AS ADVISED IN OUR NOTICE TO THE FIRST NAMED INSURED, OR THE LONGER
NUMBER OF DAYS NOTICE IF INDICATED IN THE SCHEDULE BELOW.
B. IF WE CANCEL THIS COVERAGE PART(S) BY WRITTEN NOTICE TO THE FIRST
NAMED INSURED 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
NAME AND ADDRESS OF OTHER PERSON(S) ORGANIZATION(S):
ALL CERTIFICATE HOLDERS WHERE NOTICE OF CANCELLATION IS REQUIRED BY
WRITTEN CONTRACT WITH THE NAMED INSURED SUBJECT TO THE FOLLOWING
PROCEDURES:
WE WILL MAIL OR DELIVER NOTIFICATION THAT SUCH COVERAGE PART HAS BEEN
CANCELLED TO EACH PERSON OR ORGANIZATION SHOWN IN AN ACCURATE
SCHEDULE PROVIDED TO US BY THE FIRST NAMED INSURED AT INCEPTION
OF THE POLICY OR AS PERIODICALLY UPDATED.
NOTICE WILL BE MAILED OR DELIVERED AS SOON AS PRACTICABLE AFTER AN
ACCURATE LIST OF NAMES AND ADDRESSES IS PROVIDED TO US BY THE FIRST
NAMED INSURED IN RESPONSE TO OUR REQUEST.
NUMBER OF DAYS NOTICE: 120 DAYS
ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.
U-CA 388-A (07-94)
ENDORSEMENT
Insurance for this coverage part provided by:
AMERICAN ZURICH INSURANCE COMPANY
This end orsement changes the insurance as is afforded by the policy relating to the following:
Named Insured Policy Number
PCL CONSTRUCTION ENTERPRISES, WC 2090772-20
BLANKET NOTIFICATION TO OTHERS OF CANCEL
ITHIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ITHIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE:
I�n70RKERS COMPENSATION
A. IF WE CANCEL THIS COVERAGE PART(S) BY WRITTEN NOTICE TO
THE FIRST NAMED INSURED FOR ANY REASON OTHER THAN NONPAYMENT OF
PREMIUM,WE WILL MAIL OR DELIVER A COPY OF SUCH WRITTEN NOTICE
OF CANCELLATION:
1. TO THE NAME AND ADDRESS CORRESPONDING TO EACH PERSON
OR ORGANIZATION SHOWN IN THE SCHEDULE BELOW; AND
2. AT LEAST 10 DAYS PRIOR TO THE EFFECTIVE DATE OF THE
CANCELLATION, AS ADVISED IN OUR NOTICE TO THE FIRST NAMED
INSURED, OR THE LONGER NUMBER OF DAYS NOTICE IF INDICATED
IN THE SCHEDULE BELOW.
B. IF WE CANCEL THIS COVERAGE PART(S) BY WRITTEN NOTICE TO THE
FIRST NAMED INSURED 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
ENDORSEMENTIS MAILED, PROOF OF MAILING WILL BE SUFFICIENT
PROOF OF SUCH NOTICE.
NAME AND ADDRESS OF OTHER PERSONS OR ORGANIZATIONS:
ALL CERTIFICATE HOLDERS WHERE NOTICE OF CANCELLATION IS
REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED SUBJECT TO
THE FOLLOWING PROCEDURES:
WE WILL MAIL OR DELIVER NOTIFICATION THAT SUCH COVERAGE PART
HAS BEEN CANCELLED TO EACH PERSON OR ORGANIZATION SHOWN IN AN
ACCURATE SCHEDULE PROVIDED TO US BY THE FIRST NAMED INSURED AT
INCEPTION OF THE POLICY OR AS PERIODICALLY UPDATED.
NOTICE WILL BE MAILED OR DELIVERED AS SOON AS PRACTICABLE
AFTER AN ACCURATE LIST OF NAMES AND ADDRESSES IS PROVIDED TO
US BY THE FIRST NAMED INSURED IN RESPONSE TO OUR REQUEST.
NUMBER OF DAYS NOTICE: 120 DAYS
IALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.
U-WG332�4 (07-94)
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