Signed Contract_Premier Bank/Iowa Street Revocable License Copyrighted
December 17, 2018
City of Dubuque Consent Items # 22.
ITEM TITLE: Signed Contract(s)
SUMMARY: Amendment to Staffing Agreement with Dubuque
Initiatives; Revocable License with Premier Bank
Revocable License for lowa St. Parkway. I IW, P.C. for
DICW/McFadden Project Engineering Services
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File
ATTACHMENTS:
Description Type
AmendmenttoStaffingAgreementwithDubuque SupportingDocumentation
Initiati�s
Premier Bank Revocable License for lowa St. Parkway Supporting Documentation
IIW - McFadden ProjectAgreement Supporting Documentation
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TO: Michael C. Van Milligen, City Manager �
FROM: Gus Psihoyos, City Engineer _
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DATE: December 3, 2018
RE: Revocable License — Premier Bank Proposed lowa St Parkway Improvements ,
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INTRODUCTION ,�
This is in response to a request from Premier Bank, who is requesting permission to encroach Ij
on the public right of way for parkway improvements in the lowa Street Right-of-Way between II
8tn and 9t" Street. '��
DISCUSSION �
lowa Street has varying right of way, at 9t" Street it starts at 97 feet and then widens to 125 feet �
at 8t" Street. Leaving a public right of way behind the curbing from 13 feet and widening to 35 ii
feet. II
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The proposed improvements include complete removal of existing locust trees; removal and
installation of new concrete sidewalks, new landscaping materials, decorative iron fencing and
three flag poles. '
City staff reviewed the request with respect to the proposed encroachments and would
recommend approval, with the condition that the City will not be responsible for replacing �
improvements (encroachments)when maintaining infrastructure above or below ground.
All the required documents have been received which include the License Application, signed I
Acceptance of Terms, and Certificate of Insurance. Engineering has reviewed the request and
documents and have found them to be acceptable.
BUDGETIMPACT
The payment of the $250.00 application fee will be recorded as part of the CIP 10055400-42170
revenue.
ACTION STEP
The requested action is for review of the attached materials submitted by Premier Bank for the
encroachment of parkway improvements in the public right of way. Your approval, denial or
approval with conditions will be forwarded to Premier Bank by the City Engineering Department.
cc: Kyle Kritz, Associate Planner
Nate Kieffer, PLS
Kerry Bradley, Engineering Asst
F:\JANE SMITH\ROW�ROWENCR\LICENSE REQUEST12018
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Doc ID: 010215960007 Type: GEN
Kind: MISCELLANEOUS
Recorded: 12/05/2018 at 02:03:03 PM
Fee Amt: $47.00 Paqe 1 of 7
Dubuque Cauntv Iowa
John Murphy Recorder
File20i8-00014332 �
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Prepared by: Gus Psihoyos,City Engineer,City of Dubuque,50 W. 13th Street,Dubuque, IA 52001 (563 589-4270) �
Return to: Gus Psihoyos,City Engineer,City of Dubuque,50 W.13`h Street,Dubuque, IA 52001 (563 589-4270) �
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REVOCABLE LICENSE +
AUTHORIZING p�'em��c'" �c���
TO�CONSTRUCT �.arn����ra���`�q. � i
ON PUBLIC RIGHT-OF- 'VAY �
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Section 1. �'��i�r�� ��.v�� as the owner of the premises, �
(business) (�icensee), known as I�t� �+J, �`�^ ��, in i`;
DUbUqUe, IOWa, and legally described as Part of the Iowa Street Right of Way: between �j
be and is hereby granted a Revocable License and authority to construct and maintain 9th & W8th �
� �� � r, S as s�own attc
' (Encroachment) see atta�hmentrf�o�r I
location under t e erms and conditions et forth in this License.
Secfion 2. The permission herein granted is expressly conditioned on
Licensee's agreement ta: ;;
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a. Assume any and all liability for damages to persons or property which may
result from the existence, location, installation, construction or
maintenance of said Encroachment;
b. Procure and maintain in force during the term of this License a policy of
liability insurance as set forth in the attached Insurance Schedule or �
private policy of liability insurance which covers your encroachment of the "
public right of way; as required by the City Manager
c. Pay on behalf of the City of Dubuque, all sums which the City of Dubuque
shall become obligated to pay by reason of the liability imposed upon the
City of Dubuque for damages of any kind resulting from the location,
installation, existence, construction or maintenance of said Encroachment
sustained by any person or persons, caused by accident or otherwise to
defend at its own expense and on behalf of said City any claim against the
City of Dubuque arising ouf of the location, installation, existence,
construction or maintenance of Encroachment and to pay reasonable
attorney fees therefor; and
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d. Indemnify, defend and hold the City of Dubuque firee and harmless from
any and all claims, including but not limited to damages, loss, liability and
expense for death and/or injuries to third persons or damages to property
of third persons, or for damage to any property of the City of Dubuque
which may occur as a result of or in connection with the location, �
installation, existence, construction, maintenance and repair of �
Encroachment. �
e. Any special conditions as set forth for this License as identified: I�
,
The City will not be responsible for replacing improvements(encroachments)when maintaining infrastructure
above or below ground.
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Section 3. The Encroachment shall be maintained in accordance with all ,j
applicable state and federal laws and regulations, and the Ordinances of the City of a
Dubuque. ��
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Section 4. The permission herein granted is expressly conditioned upon '�
Licensee's further agreement that should the right and privilege herein granted be j,
rescinded or revoked by the City Manager, with or without cause, Licensee, shall within I�
ten (10) days after receipt of written notice from the City Manager; so to do, at its own �
expense, remove said Encroachment at Licensee's expense and dispose of the same,
and Licensee shall have no claim against the City ar its officers, agents, or employees j
for damages resulting from the removal of said Encroachment.
Secfiion 5. Licensee covenanfis and agrees that the Revocable License herein a
granted does not constitute an approval of the design, erection, location, construction, �
repair or maintenance of said Encroachment and Licensee hereby covenants and �
agrees not to assert such claim or defense against the City of Dubuque in the event of 9
claim asserted for death, personal injuries and/or property damage against Licensee y
arising out of or in any way connected with the location, installation, construction, y
design, repair and maintenance of the Encroachment.
Section 6. This Revocable License shall become effective and the rights
hereunder accrue to Licensee when this License has been approved by the City
Manager and the terms and condifiions thereof accepted by Licensee by acceptance
endorsed on this L'tcense. This Revocable License is not assignable or�tr.ansferable to
another location. Tf�is license is for this property only. `•
Section 7. The City Clerk shall file a copy of this Cicense at Licensee's
expense in the Office of the Recorder in and for Dubuque Counfiy, lowa.
2
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Section 8. lowa One-Call registration may be required by the Code of lowa.
When applicable Licensee shall submit documentation to the City Engineer of lowa i
One-Call registration membership. ,
Signed this �� day of ���-���� , 20�
Michael C. Van Milligen, City Manager {
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Attest: �
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Kevi . Firnsta , ity Clerk ilf
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� State of lowa )
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County of Dubuque )
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On this day of � , ���� , before me, the
undersigned, a Notary Public in and for the State of lowa, personally appeared Michael
C. Van Milligen and Kevin S. Firnstahl, to me personally known, who, being by me duly '��
sworn, did say that they are the City Manager and City Clerk, respectively, of the City of
Dubuque, lowa, a municipal corporation, that the seal affixed to the foregoing ''
instrument is the corporate seal of the corporation, and that the instrument was si ned �
and seal on b 1�alf of the cor oration, "„ ���+h„��+" „f ,+� �;+„ �,,,,r.-,�, on the � �
day of ,� , �Z �' �, and Michael C. Van Milligen and Kevin S. Firnstahl �
acknow edged the execution of the instrument to be their v�a ntary act and deed.
, � �C.. ,,,�
Notary Public' and for said State
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ACCEPTANCE OF TERMS AND CQNDITIONS OF LICENSE
Th r i n in I riz i A n n h fi f �
e unde � g ed, be g du y autho ed fio execute th s ccepta ce o be al o ,,
'�'�^�,�►� ��:�►�, , and having read and being familiar with the terms �
and conditions of the Revocable License, accepts the same and agrees to be bound by
the terms and conditians herein.
LICENS .
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Signature
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Title: ���.�r c���n`� � �-� I�
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Dated: �'! ��-� � �-0�� i�
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Signature requires notary— Use "All Purpose Acknowledgement" on next page ii
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ALL PURPOSE ACKNOWLEDGMENT
STATE OF IOWA )
COUNTY OF DUBUQUE ) �
On this ��� day of �s� . , 200$, befor me the undersigned, a i�
Notary Public in and for said State, personally appeared���`'�� %� ��.�-�-�' "
(NAME/S) to me personally known, OR proved to me on the basis of �
satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within ,
instrument and acknowledged to me that he/she/they executed the same in his/her/their �
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s) acted, executed the instrument. !
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(Notary Seal) I'�
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Notary Public in and for State of lowa ,I
CAPACITY CLAIMED BY SIGNER II
INDIVIDUAL � � � ��
CORPORATE OFFICER(S) (Title) �;
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(CORP SEAL)
AFFIXED
NO SEAL PROCURED i
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PARTNER(S) LIMITED GENERAL i
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ATTORN EY-I N-FACT '
TRUSTEE(S) �
GUARDIAN/CONSERVATOR �
OTHER �
SIGNER IS REPRESENTING:
Name of Person(s) or Entity(ies):
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DESCRIPTION OF OPERATIONS!LUCATIONS(yEHIGLES{ACpRD i01,Addidonal Remarks Schodule,may be atfacNed if more space Is�equlred� �
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50 W�3#h Street
Dubuque IA 52D01 AUTHORI2EDR�P�IV�
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THIS ENDC3RSEMENT CH,�►NGES THE POLICY. PL�ASE READ rT CAREFULI.Y. ; �
COMMERCIAL CE�ERAL LIABlLITY EXTENDED I �
ENDC?RSEMENT ' �
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This endor��mpnt mn�ifiPs insur�ncp �rat�;�+ed �;nder th�f�llow:�ng. �
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CO�VIMERC�AL GENERq,L LIASILITY CQVE{�AGE PART I C
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A. Endarsement-Table of Contents: i �
Correraae• � �
Begins on Paae: + �
1. �mplayee Benefit Liability Coverage"... ................................................................,,,,.......... ,3 ' '{
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! 62. Unintentional Failure To Disclose Hazards.............................................................................9 ; �
3. parnage 7o P'remises Rented To You, ,g
4. Supplernentary Payrnents................................................................�.,...�....,..........,,. ,.,. ........�� I
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5. '180 Day Coverage For Newly Farmed Or Acquired Organizations ...................................10 ' �
f. Wai�er Of Subrogatian........................................ . .... ...................�..,,.,.,.,.......,......, ,.,., 9p ;
. . ., . ..,....
7. Automatic Additio�nal Insured -Specified Re#ationships: ......................,,,........... ,,,,..,...,..91 '�
• Managers Or Lessors Of Premises; ' �
• Lessor Qf Leaser� Equipment; ��
• Vend4rs;
• State Or Governmental Agency Or Subdivision Or Political Sut�div�sion - Permits
Or Authariza#ians ReEating To Premises; and ��
• Martgagee,Assignee Or Receiver
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8. Properly Damage T'o Barrowed �'qu�pment.................... .....,..,,,,..,..,.,74 �
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9. Employees As Insureds - Specified Health Gare 5ervices And Good Samaritan � ��
Services. .............................................................................................................�.,,.,.,....,.. 15 � ��
'l0. Braadened Notice Of Occuerence.......................................�,.,,,.....,......,,.,................,...,,,.....15 � 4
11. Nonawned Aircra�Ft...................... qg I
12. Badily Injury Redefined................................................................................. .........�..,...,,.....,15 �
.,, , ................ h
13. Ex�ected Qr Intended Injury Rede�ned ,., .�5
14. Former�mployees As Insureds............................................................................................'15 �
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B. Limits Qf Insurance:
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The Corr�mercial General Liability �imits of Insurance apply to tha insurance provided by this endorse- ' 'I
menC, except as pravided belaw: �
1. �mp{ayee Benefik Liability Ca�erage � �
Each Employee Limit: $1,QOO,Q00 �
Aggregate Limit; $3,4p0,0pp
Deductible Amount: $ 1,400 ;
3. Damage To Premises Rented To You
7he lesser o�: �
a, The �ach �ccurrence Limit shown 3n the beclarations; or i
b. $500,000 unless otherwise skated$ i
4. Supplementary Payrrrents i
a. �aif Bonds, �2,500 �
b. Ross df Earnings: $ 500 f
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Includes copyrighted rnaterial af lnsurance
GA 227 0917 Services OfFice, Inc„ wi�h its permission. p��,� 1 v{�5
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8. Property Damage Ta Borrowed �quipment �
Each �ccurrence Limit: $10,D00 ; �
Deductible Amount: $ 2S0 ; ;
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GA 227 09 17 Services C►ffice, Inc., with its permission. Paga 2 of 15
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C. Coverages � �
2) Qccurred prlar ta the
'I. �mployee Benefit Liability Coverage "first effective date" of � �
a, 7he following is added to Sec#ion I - this endorsemant pro- i ;
vided: � �
Coverages: �
�mployee Bene�t Liability Cover- �� knowe�dgeQt fiav� � 'ti
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��� claim ar°suit'"on or !
{1) Insuring Agreement befare the "first ef- �
fective date" of this °
(a) We will pay those sums that endarsement. �
the insured becames legally � �
obligated to pay as damag- Yau will be . �
es caused by any act, error deemed to have
ar omission of the insured, knawledge of a �
or of any o�her person for claim ar "suit° ; �4�
whose acts the insured is when any "author- ii
IegaEly ]iable, to which this ized representa- � �
insurance applies, We will tive'; ! ,�
have the right and duty to i} Re ports all, c�r
defend the insured against any part,of the � g
any "suit" seeking thase act, error or i
damages, Ffowever, we will �
have no duty to defend omission to us ,�
against any "suit" seeking or any other
damages to which this ir�-
insurer,
surance does not apply. We ii) Receives a
may, at aur discretion, in- wrikten or ver- "
vestigate any report of an bal demand or � f�
act, errnr or amission and c{aim for dam- F
settle any clalm ar"suit°` that ages because i�,
may result. gu#: of the act, er- ;
'!) The amaunt we will pay ror ar omis- '
far damages is limited sion; and t,
as described in Sect�on b) There is no aCher �
III - �imiRs t7f Insur- applicable insur-
ance; and ance, �
2) Our right and duty to (2) Exckusians �
defend ends when we �
have used up the appli- This insurance does nat apply to;
cable limit of insurance (a) Bodily Injury, Praperty
in the payment of judg- Damage Or Personal And
ments or settlements. Ad�ertising Injury
No ather obligation or liabil- "Bodily injury" "'p p y �
ity to pay sums or perForm damage" ar "personal and
acfs or services is covered advertising injury". j
unless explicitly pravid�d for
under Supplementary (b) Dishanest, Fraudulent, �
payments. Criminal Or Malicious Act �
(b� This insurance applies ta bamages arising out af any i
damages only if the act, er- intentional, dishonesk, �
ror or omission, is negligent- fraudulenk, criminal or mafi- �
ly committed in the "a�min- cious act, errar or omission, j
istratian" of your "employee committed by any insured, i
bene�t program"; and including th� wiilful or reck-
'1) Clccurs during the palicy less violation of ar�y stakute, li
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period; or
Includes copyrighted materiai a#Insurance ?
GA 227 09'l7 Services Office, Inc,,with its permission. Page 3 of 15 �
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(c) Failure To Perform A Con� effork and cooperatian ofi the �
tract insured, from the applicable � �
funds accrued ar other co!- �
Damages arising out of fail- lectible insurance. ' �
ure of perFormance af con- � !,I
tract by any insurer, (i) Taxes, Fines Qr Penalties '
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(dy Insufficiency Of Funds Taxes,finas or pena{tias, in- ��
cluding those imposed un- 7
Damage.� arisir� �ut c� a�� der the Internal Revenue ��
insufficiency of funds to Code ar any similar state or � �
meet any abligations under i �
any plan included in the ``�G�� iaw' i y
employee benefit pragram . (j) �mployment-Related Prac- ' `
tices 'I �
(e) Inadequacy 4f PerFor- �,l
mance �f Invest- Any liabiliky arising out of �
menTlAdvice Gi�en With any. li
Respect To Participation ; �
{1) Refusal to amploy; ;
Any claim 6ased upon; (2) Terminatian af employ- il
1} �ailure of any invest- ment; !I,
ment to perfprm; u�
(3} Coercion, dernotion,
2) Errors in pro�iding in- evaluation, reassign- �_
farmation on past per- ment, discipline, defa� q
formance of investment mation, harassment, ; I
vehicles; or humiliation, discrimina- I;i
tian or Qther employ- 'H
3) Advice given to any ��
person with respect to ment- related practices, �i
that person's decision ta acts or amissions;or il
parkicipata or not ta par- (4) Consequential liability ii
ticipate in �ny plan in- as a result of (1}, (Z} or
cluded �n the"employee (3)al�ove. �
benefik program". � �
This exclusian applies i
(f} Workers" Comperosation whether the insured may be
And Similar Laws held lia�le as an emplayer �
Any claim arising out of your or in any other capacity and �
failure ta camply with the tiQ �nY obligatian to share h
mar�datory provisions of any damages with or repay �
workers' compensaCion, un- someone else who musk pay ;;
damages because of Che in- �
emplayment compensation �ury
insurance, social securi#y or
disability benefits law or any (3) Supplementary Payments �
simifar law. �
Section I - Caverag�s, Sup- �
{g} ERISA �lemen,�ary Payments - Cov�er-
Damages far which any in- ages A And B alsa apply to this
sured is liable because of li- Coverage, ,
ability imposed on a fiduci- b. Who Is An Insured
ary by the Employee Re- As res ecks Em la ee Benefit Lia- �
tirement Income Security p � Y
Act af 1974, as now ar bility Caverage, Section II - Who Is
hereafter arnended, or by An Insured is replaced by the fallow- '
any similar federal, state ar ing: ;
lacal laws, (�) If you are designated in ihe DecT !
(h) Available 8enefits larations as; j
Any claim for benefiks to the (a) An individual, you and your �
ex#ent that such benefits are spouse are insureds, but on- �
available, with reasonable ly with respect to the con- �
lncludes copyrighted material af Insurance �
GA 227 49 17 Services�ffice, Inc.,with its perrnissian. Page 4 of 1S I
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duct of a business of which liability company, and over which �
you are the sole awner, you maintain awnership or majar- ! �
(b} A partnership or joint ven- ity interest, wil! qualify as a ,�
Named Insured if no okher similar ;
ture, you are an insured, insurance applies to that organi- �
Your rnembers, your part- zation, Hawever, coverage under
ners, and their spouses are this provisian: i
also insureds but only �vith
respect #o the conduct af (a) Is afforded only until the ��
yaur business. 180th day after you acquire ' iJ
� or form the organization ar '
(c) A limited liability company, the end of the policy period, �
you are an insured. Your whichever is earlier; and ��
members are also insureds, �
but anly vrith respeck to the (b) baes not apply to any a�t, i ,�
conduck af your business, error or amission that was I i�
Your managers are in- cornmitted before you ac- ��
sureds, but only with respect quired or formed the organi- ! �
to their duties as your man� zation, I
agers. �
c, Limits C?f Insurance �
{d) An organization ather than a ��
partnership, joint venture or As respects Emplayee Benefit �ia� :�
li�rtited liability campany, you bi{itY Coverage, Sectian lfl � Limits
are an insured.Your°execu- �f 4nsurance is replaced by the fol- �
tive ofificers" and dir�ctvrs lowing; � �
are insureds, but only with (�) The l�imiCs af Insurance s�own in
respect to their duties as Seckion B, Limits Of Insurance, � �
yaur officers ar directors, �
Your stockholders are alsa 1, �mployee Benefit Liability , �
insureds, but only wifih re- Caverage and the rules below fix , ,I
the most we will pay regardless
spect to their liability as af the number of: ;
stockhalders. ;i
Insureds; ;
(e) A trust, you are an insured. {ay , i
Your trustees are also in- (k�) Claims made or "suits°
sureds, but only with respecC . braught;
to their duties as trustees. .
(c) Persons or organizations
(2) �acf� of the following is also an rnaking claims or bringing i
insured: "suits"; '
(a) Each of your "employees"' {d) Acts, errars or omissior�s;or ��
who is or was authorized to
administar your "empioyee (e) Benefits included in yaur �
benefit pragram'; "employee benefit program". �
(b) Any persons, organizations (2) The Aggregate Limit shown in
or °emplayees" having prap- 5ectian 8. Limits Of Insurance, �
er temporary authorization 1. �mployee Benefit Liability �
ta administer your "emplay- Ca�erage of this endorsernent is �
ee bene�t program" if you the most we will pay for all dam�
die, but only until your legal ages because of acts, errors or ,
representative is appointed; omissions negligently committed i
Qr in the "administration" of your '
"employee benefit prograrn". �
(c) Your legal representative if '
yau die, but only with re- (3) Subjeck to the limit described in I
2 above, the �ach Empioyee i
spect to duties as such. That Limit shawn in Section B. Lirnits
representative will have all '
your rights and duties under (7f Insurance, 1. �mployee
this Coverage Part. Benefit Liability Co�erage of j
this endorsement is the mosk we
(3) Any organization you newly ac- will pay for all damages sus-
qu�re or farm, other than a part- tained by any one "ernployee", ,
nership, joint v�nture ar iimit�d including damages sustained by I
Includes capyrighted material of Insurance
GA 227 Q9"17 Services affice, Inc., wfth its permission. Page 5 a#1 S `
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such "employee's" dependents (d) We may pay any part or all
and beneficiaries, as a result af: of the Deductible Amount ta
effect settlement of any
(a) An ack, error or amission; or claim or °suit° and, upon na- 'I
(b) A series of related acts, er�
tificaCion of the action taken, ' '�h
rors or amissions, regard- you shall promptly reim- �, �
less af the amounk of time burse us for such part of the ; ;�
thak lapses between such beductible Amount as we �
acts, errors or omiss�ons, �a�� P�i�• ?
negligently commikted in the d• Addttionas Canditions i
"administration" af your "employ- As res ects Em lo ee Bene�t Lia-
ee benefit ra
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p grar� . bility C�verage, Section IV - Com-
Mowever, the amount paid under rnercial General Liability Condi- ;
this endarsement shall not ex- tions is amended as follaws; ; �
ceed, and wiEl be subject to the (1y Item 2, Duties In �'he Event Of ';
fimits and restrictions that apply Occurrence, Offense, Claim Or �
to the payrnent of benefits in any g�;t is repEaced by the fallowing: �
plan included in the "emplayee a
benefit program:' 2. Duties In The Event Of An ii
(4) Deductii�le Arnaunt Act, Error �r Om(ssion, Or ; ;;
Claim t,�r Suit y
(a) �ur abligation to pay dam- a, You must see to it that ! I�
ages on behaff of the in- we are notified as saon ;i,
sured applies only ta the as practicable of an act, (i
amount af damages in ex- error or omission which i
cess of the Deductible rrtay result in a claim. �'�
Arnaunt stated in the Decia- Ta the extent possibEe, '
rati�ns as applicabfe ta notice should include: �
Each Employee. The lirnits
of insurance shalf not be re- (1) What the ack, errar I;
duced by the amount of this or amissian w�s ;J
deductible. and when it ac� �
(b� The beductible Amount curred; and
Sk�k2d in the Declaratians {�} The names and Y
applies ta all damages sus- addresses of any- �
tained by any one "emplay- one wha may suf- j�
ee", including such "employ- fer damages as a �
ee's" depandents and bene� result af the act,
ficiaries, because of aU acts, error ar omissian, ,y
errars ar omissions to which �, If a claim is made or s
this insurance applies. "suit" is braught against �
(c) The terms af this insurance, any insured, you must: � ��
including those with respect N
ko: (1) Immediately record
the specifics af the
1y Our right and dury to claim ar "suit" and
defer�d the insured the date received;
against any "suits" and
s�eeking those damag-
es;and (2) Notify us as soon
as practicable,
�) Your duties, and khe du-
ties af any other in- You must see to it that .
valved insured, in the we receive written na-
event of an act, error or tice af the clairn or"suit"
amission,or claim; as saan as prackicable, �
apply irrespective of the ap� c. You and any other in- �
plication af the Deductible valved insured must: i
Amount
1 a
lncludes copyrighted material of Insurance �
GA 227 p9 '17 Services Office, Inc.,with its permission, Page 6 of 15
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(1) �mmediately send b. Mefihad C1f Sharing i
us copies of any If ali of the other insur- �
dernands, natices, i
summonses or le- ance permits cantribu- , i�
ga{ papers re- tion by equal shares, ,
ceived in connec- we will foflow t�is meth- , �
tion with #he claim �d aisa, lJnder this ap- �
or"suit"; ontributes�Gh in�sq ai ;
(2) Authorize us to ob- amounts until it has �
tain records and paid its applicable limit ' �
other information; af insurance or none of � �
the loss remains,
{3) Cooperate with us whichever comes flrsk. �
in the investigatian ; �
or settlement of the If any af the other ir�- �
claim or defense surance does nat permit ' �
a ainsk the "suit'; 'I
g contributian by equal ;
and shares, we will contrib- ' ;
ute by limits, Under this �
(4) Assist us; upon aur method, each insurer's 'i
request, �� the en- share is based on the 'a
forcemenC af any ratio of iks appficable �
right against any limi� af insurance ka the � �
person or organi- tatal applicable limits of '
zation which may insurance o# all insur- I�
be liable to the in- ers,
sured because of �i
an act, error or c. No Coverage !!I
omissian to which This insurance shall not �
this insurance may �i
alsa a�ply. cav�r any koss for which �,
the insured is entitled to �
d. No insured will, except recovery under any '�
at that insured's own ather insurance in force 15
cast, voluntarily make a pre�ious to the effecti�e �i
payment, assume. any date of this Coverage �
obligation, ar incur any Part.
expense without aur '
consent. e, Additianal Definiticns �
(2} Item 5, Other insurance is re- As respects Empfoyee Benefit Lia- ;9
placed by the fallowing: bility Caverage, Section V- De�ni• '�
tions is amended as follows: �
5, Other Insurance t�� The following definitions are '�
If other valid and collectit�le added: I�
insurance is availabie to the �
insured far a loss we caver 1. "Administration"means:
under this Coverage Part, �, Providing information to I �
our abligations are limited as °employees", including i g
follows; their dependenEs and i
a. Primary Insurance beneficiaries, with re- �
sped ta eligibility for ar �
This insurance is prima- scope of "emplayee
ry except when c, befow benefit pragrams";
applies. kf this insurance
is primary, our obliga- b. Interpreting the "em-
tions are not affected playee benefit pro- i
unless any of the r�ther grams"; �
insurance is also prima- �, Handling recQrds in �
ry. Then, we will share !
connec#ian with the
with all that other insur� "employee benefit pro-
ance by the methfld de- grams";ar I
scribed in b, below. i
Includes copyrighted material of lnsurance �
GA 227 09 '17 Services Office, ]nc.,with its permission. Page 7 of 15 �
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d, �ffacting, continuing or ees" who are eligible � �
terminating any "'em- under the pfan for such �
. ployee's" participation in bene�ts; , �
any bene�t included in ;
th� "employee benefit c. Unemplayment Insur- !
}t ance, social security �
program .
benefits, workers' cam-
Hawever, "administration" pensation and disability
daes not include: benefits: and '
a. Handling payroll deduc- d. Uacation plans, includ- �
tions; or ing buy and sell pro- ; ;
kr, The failure to effect or grams; leave of ab- �
maintain any insurance sence pro�rams, includ-
ing military, maternity, '
or adequate limits of family, and civil leave; �
coverage of insurance, tujtion assistance plans; ' II
including but not limited transpartation and �
to unemployment insur- health club subsidies, �
ance, social security ' ;;
�enefits, workers' com� d, °First effeekive date" means ' N
pensation and disability the date upan which cover- ;�
benefits, age was first effected in a ''
2, "Cafeteria plans" means series of uninterrupted re- ; �
newafs af insurance cover-
plans authorized by applica- ag� �
ble law to a11ow"emplayaes" ,'�
to elect to pay far cer#ain (�} The following definitians are de-
benefits with pre-tax dallars, leted in their entirety and re- � I;,
3, Emplayee benefit pro� placed by the following, i
grams" means a program 8, "Employee" means a persan ;I,
providing some af all af the actively employed, formarly i;
fallawing benefits to "em- employed, an leave of ab-
pfuyees", whether provided sence or disabled,or retired, I
thraugh a "cafeteria plan" or "Employee" includes a �
otherwise; "leased worker", "Employee" II
a. Group iife insurance; does nat include a "tempo- �
grou p accident or health rary worker . �
insurance; dental, vision 21. "Suit" means a civil proceed- ;y
and hearing plans; and ing in which money damag- �
flexible spending ac- es because of an act, error
counts; pravided that no or omission to which this in- �
ane other than an "em- surance applies are alleged,
ployee" may subscribe "Suit" includes,
ta such benefits and
such benefits are made a. An arbitratian proceed-
gener�lly available to ing in which such dam-
those "emplqyees" who ages are claimed and to
sakisfy the plan's eligibil- which the insured must ;
ity requirements; submit or does submit
with our consent; i
b. Profit sharing plans, i
emplayee savings b. Any nther alternative �
plans, employee skock di�pute resofut�on pro- i
awnership plans, pen- ceeding in which such �.
sion plans and stock damages are claimed �
subscription plans, pro- and to which the in- �
vided that na one other sured subrnits with our
than an "employee" consent; or
may subscribe to such �, An appea! of a civil pro-
benefits and such bene- ceeding.
fits are made generally
available to all "employ-
includes copyrighted material of Insurance '
GA 227 0917 5ervices afFice, Inc,,with its permission, Page 8 of 15
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Z. Unintentional Failure Ta pisclose Haz� 2) Rust or other cor-
ards rosion, decay, de- � �I�
#erioration, hidden
Sectian IV- Commerciaf General Liabil- ar latent defect ar °
ity Conditlans, 7. Rep�resentations is any quafity in �
amended by the addikian of the following: property that caus- �
Based an our dapendence upon your rep- es it to damage or ,
resentations as to existing hazards, if un� destroy ikself; {
intenfionaiiy yau should faii to disclose all � ;
such hazards at the inceptian date of yaur 3� Sm°g' !
policy, we wiN not reject coverage under 4) Mechanical break- ; ��
this Caverage Part based solely an such down, including j ,I
failure, rupture or �ursting
3. Damage To premises Rented To You
caused 6y cenkri�-
ugalforce; i i
a, The last Paragraph af 2, Exclusians 5j 5ettling, cracking, � �
under Section I � Coverage A� Bod� shrinking nr ex- ;
ily Injury And Property �amage Li- �
ability is replaced by the following, pansian; `�
Exclusions c, through q, do nok apply 6} Nesting ar infesta- i
tion, oC discharge �I
ta "property damage" by fire, expfa- or release of waste ;
sion, lightning, smoke or soat ta praducts or secre- �
premises while rented to you or tem- tions, by insects,
porarily occupied by yau with permis- birds, rc�dents or ' ,I
sion of the nwner, for which the other animals; ar
amount we will pay is li�nited to the I
Damage TQ Premises Rented To 7) Presence, growth, �
Yc�u Limit as described in Section III proliferation, ;
-Limits Of Insurance. spread ar any ac-
tiviiy of fungus, in- �
b. The insurance provided under Sec- cluding mold or j
tion I - Coverage A - Bodily Injury mildew, and any I
And Property Damage l.iability ap- �
plies to "praperty damage"arising out
mycotoxins,
o f w a t e r d a m a g e t o p r e m i s e s t h a t a r e spares, scents or �
both rented to and occupied by you, byprodu�ts pro� ,i
duced or releas�d �
(1j As respects Water Damage Le- by fungi. ;
gal Liability, as provided in Para- ��� �°property damage" caused �
graph 3.b,above: directly or indirectly by any � �
The exclusions under Section i - of the following;
Coverage A- Bodily fnjury And (i) Earthqualcs, volcanic
praperky Darnage Liability, 2. aruption, landslide or k
Exclusions, other than i. War any ather earth move- '�
and the Nuclear Energy L'rabil- ment;
ity Exctusion (Brc�ad Forma, are N
deleted and the following are (ii) Water that backs up or
added: overflows ar is other-
wise discharged from a
This insurance does nat apply to, sewer, drain, sump,
(a) "Praperky damage"; sump pump or related i
equipment; ,
(i} Assumed in any con- � �
tract or agreemant; or (iii) Water under the ground
surface pressing on, ar
{ii) Caused by ar resulting flowing or seeping j �
frorn any of the fofiaw through:
�n�� 1) Foundations, walls,
1) Wear and tear; floors or paved �
surFaces; +
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lncludes copyrighted materiaf o�Insurance
GA 227 0917 Services�ffice, Inc,,with its permission. Page 9 af 15
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2) Basements, you with permission of i I�
whether paved ar the awner; � �
not; ar '
b. In the case af damage �
3) �aors, windaws ar by �re, explosion, light- � �
ather openi�gs. ning, smake or sovt,
while rented to yau; or
(c) "Property damage" caused � �
by or resulting from water � c, In the case of damage �
ihai leaks ��• fibws �r�rn by water, while renked ; �
p�umbing, heating, air condi- to and occupied by you. ; 4
tianing, fire pratec#ion sys- *
tems, ar ather equipment, (2} ��� most we will pay is limited as
caused by or resulting from described in Section B. Limits i �
freezing, unless; Of Insurance, 3, pamage 'Fo �
Premises Rented 7a You of#his j
(i) You did your best to � endarsement. ;
rnaintain heat in the i ;
building ar structure; ar �• Supplerr►entary Payments i
ij
(pi} Yau drained the equip- Under Sectian I - Supplementary Pay�
ment and shut dff #he ments�Coverages A And B; '�
water supply if the heat �, Paragraph 2, is replaced by the fol- I
was nnt maintained, lowing;
i�
(d) °Property damage"#o; Up to the limit shawn in Sectian B. '!
(i) Plumbing, heating, air Limits �f Insurance, 4,a. Bafl Bonds ;j
canditioning,fire protec� of this endarsement for eost of bail ;�
tion systems, or aCher bonds required beca�se af accidents �
equipment or applianc� or traffic law violations arisfng aut of ;
es; ar the use of any vehicle to which the i
Bodily injury Liabil�ty Coverage ap� ',�
(ii) The {nteriar af any plies, We do nat have to furnish these i
building or structur�, or bands. � ;
ta persanal praperty in
th�building ar struckure, b, Paragraph .4, is replaceci by the faf- I�
cau�ed by or resulting lowing: �
from rain, snow, sleet ar Ali reasonable expenses incurred by ;
ice, whether driven by the insured ak our request to assist us
� wind or nr�k, in the investigation or defense o� the
c. Limit Of Insurance claim or"suit", including actual loss of
earnings up to the IEmit shawn in Sec- ';
With respect to the insurance afFord- tion B. Limits �f Insurance, 4.b. '�
ed in Paragraphs�,a. and 3.b,above, Loss Of�arnings of this endorsement
the Damage To Premises Rented per day because of time off fram ;�
To Yvu Limit as shown in the Decla- work, �
rations is amended as follows:
5. 180 aay Caverage Far Newly �ormed p
(1} Paragraph 6. af Section III - Or Acqutred Organiza#ions �
Limits Of Insurance is replaced �
by the following: Section II - Who Is An Insured is , -
amended as follows:
6. Subject to Paragraph 5, �ub ara ra h
above, the Damage To ���ed bg the follow n��ragraph 3, is re- i
Premises Rented Ta Yau p y ��
Lirr+it is the most we wifl pay �, Insurance under this provi$ion is af- �
under Coverage A - Bodily forded only until the 180th day after i
Injury And Property Dam- you acquire or form the organization �
age Liability for damages or the end of �he policy period, � �
because of "praperty dam- whichever is earlier; I
age ta any one premises: �
a, While rented ta yau, or �� �aiver of Subragation 3
temporarily occupied by Section IV- Commercial General Liabil-
, ity Conditians, 9, Transfer Of Rights 4f
Includes copyrighted material of fnsurance
GA 227 09 17 Services Office, Inc., with its permfssion, page 10 of 15
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Recoue A a�nst Others To Us is �
ry g ' (i) Any "occurrence° which �
amended by the additian of the foflowing: takes place after you
cease to be a tenant in '
We waive any right of recavery we may that premises;
have against any persan or organizakion
against whom yau have agreed to waive (ii) Struckural alteratians, i ;�
such right af recovery in a written con#ract new construction or ,{
ar agreement because of payments we demolition operakions y
rnake far injury or dama�e arisin� out of performec{ by or on be- ; �
your ongoing operatians or "your work" half of such additional � �
done under a written conkract ar agree- insured. ��
ment with that person or organizatian and :
inciuded in the "products-completed aper- (b) l.essor Of l,eased Equip- I ,
ations hazard". Hawever, our rights may rnent i�
only be waived prior ko the "occurrence" Any persan or arganization ,�
giving rise to t�e injury or darnage for from wham you lease
which we make payment under this Cvv- '
erage Part. The insured must do nothing equipment when you and
after a lass to impair aur rights. At our re- such person(s} or organiza- ,
tion(s) have agreed per Par�
quest, khe insured will bring '"suit"' or trans� agraph 7,a.(1) o� this en- �
fer thase rights to us and heip us enforce darsement to provide insur- '!
those rights, y
ance. 5uch persan(s) vr or- �
7. Automatic Additianal Insured - Speci- ganizakion{s) are insureds ii
�ed Rerationshfps only with respect to liability p
for "bodily injury", "property ;I
a. The followjng is added to Sectivn MI - damage" ar "personal and ;�
Who Is An Insured. advertising injury"caused, in
(1) Ar�y parson(s) or organization(s} whale or in part, by your
maintenance, operation Qr
cfescribed in Paragraph 7.a.(2) of use af equipment leased to �
this endorsement (hereinafter re- you by such}�ersan(s} ar or-
ferred to as addi�ional insured) ganization{s). A person's ar i
wham you are required to add as organizaklan's status as an
an additional insured under this� additional insured under this '
Coverage Part by reason of a endorsement ends when �
written cantract, written agree- their contract ar agreement j
ment, written permit or written with yau for such leased '.j
authorization. equipmenk ends, However, �i
(2} fJnly the #ollowing persons or or- this insurance does not ap- '
ganizations are additional in- ply ta any "occurrence" ; �
sureds under this endorsement, which talces place after the ,�
and insurance coverage provided equipment lease expires. I�
to such additional insureds is lim- {c) Vendors �
ited as provided herein; ;
� Any person ar organizatinn �
(a) Managers �r Lessars Of (referred to below as ven-
Premises dor) with wham you have
The manager or lessor of a agreed per Paragraph
premises leased to you with 7,a,(1} af this endorsement
wharn you have agreed per to provide insurance, but on- ;
Paragraph 7,a.{1j af this en- ly with respect to "bodily in- �
dorsement to prcrvide insur- jury" or "property damage"'
ance, but only with respect arising out of"your products"
ta liability �arising out af the which are distributed ar sald
ownership, maintenance or in the regular co�arse af the '
use of that part of the prem- vandor's business, subject I
ises leased to you, subject ta the following additionaf
to the foflawing additional exclusians: �
exclusions: The insurance afforded �
��)
This insurance daes not ap- the vendar does not
ply ta: apply to; I
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Includes copyrighted material of I�surance I
GA 227 0917 Services Office, Inc„ with its permission. pag� �� �{�� I
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1} "Bodily injury" or 7} Products which, af- �
"property damage" ter distribution or ' u
for which the ven- sale by you, hava ' ;
dor is abligated to been labeled or re- �
pay damages by labeled ar used as ;
reasan of the as- a container, part ar ;
sumption of liability ingredient af any ;
in a cantract or ather thing ar sub- �
�gr��r�en#. Tt�is s�ane� by�r fio�fhe I
excfusion does not vendar; or � �
apply to fiability for ' �
damages that the 8) "'�odily injury" or , '�
vendor would have "property damage" �
in the absence of arlsirtg out of the
the cantract or sole negligence af
agreement; the vendor far its �
own acts or omis- �
2) Any express war� sions or thase of '�
ranty unautharized its employees or '�
by you; anyone else acting �i
3} Any physical ar on its behalf, How- i�
chemical change in ever, this exclusivn i
daes not apply to; � �
the product made � �
intentianalty by the a) The excep-
vendor; tions contained '�
4) Repackaging, ex- in Paragraphs ,
cept when un- �c) (i) 4) or sy ,,
of this en- '
packed salely for darsemenk; ar
the purpose of in-
spection, demon- b) Such inspec- ;�
stration, testing, or tians, adjusk- �i
the substitution of inents, tests or �
parts under in- servicing as 'i
structions from the the vendar has �
manufacturer, and agreed ta a
then repackaged in make or nor-
the original con- mafly under-
tainer; takes to make �I�I
5) Any failure to make in the usual ',
course of '�
such inspactions, business, in �
adjustments, tests cannectian �
or servicing as the with the distri- �
vendor has agreed bution or sale
to make or normal- of the prtid-
ly underfiakes to ucts. y
make in the usual e
course of busi- {ii) This insurance does nat �
ness, in connectian apply to any insured �
wi#h the distribution person ar organization:
or sale o# the �
products; 1) �rom whom you
have acquired
8) Demonstratian, in- such products, or ;
stallatian, servicing any ingredient, par� j
or repair opera- or co�kainer, enter- ,
tions, except such ing into, accompa-
operations per- nying ar containing ; �
formed at the ven- such products; or I
dar's premises in
cannection with the 2) When lia�ility in-
sale of the praduct; cluded within the
„products-
Includes copyrighted makerial of lnsuranee
GA 227 09 17 Services OfFice, Inc.,with its permiss�on, p�g,� ��Qf�g
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completed opera- ceiver and arising out of the �
tions hazard" has ownership, maintenance, ar �
been axcluded un- use af the premises by you. �
d�r this Coverage However, this insurance � �
Park with respect to does not apply to structural ;
such producks. a{terakions, new constrwction � i
and demolition operations ; �
(d) State Or Governmental performed by or for that per- �
Agency Or Suladivision Or son c�r ecg��izati�n. `
Political Subdivisian - ' �
Permits Or Authorizations (3) The insurance afforded to addi- ; I
Relating To Premises tional insurads described in Par- ; �'
Any state or gavernrnental a9raph 7.a.41) of khis endorse-
ment: j �
agency or subdivision or pa- � ,
litical subdivision with which (a) �nly appli�s to the extent ';',
you have agreed per Para- permitted by law; and "
graph 7,a.{1) of this en- � �
dorsement ta provide insur- (by Will not be broader than that �
ance, subject to the fallow- which you are required by ;i
ing additianal pravision; the vuritten cantract, written ;;
agreement, written permit ar w
This insurance applies only written authorization ko pra- !i
with respect tc� the following vide for such additianal in- !
hazards for which the state sured;and i
or governmentel agency or il
subdivision or political sub� (c) boes nok apply to any per-
division has issued a permiC son, �r�anization, vendor, �
or auEhorizatian in connec- state, governmental agency ;;
Cion with premises you awn, � or subdivision or political
rent ar control and ko which subdivision, specifically �
this insurance applies: named as an additional in-
sured under any ather provi- �
ti) The existence, mainte- sion of, or endorsement '
nance, repair, construc� added to, this Coverage � �
tion, erection ar removal Part, provided such ather ii
of adverkisin si ns, ''
g g provisian or endorsement
awnings, canopi�s, cel- covers the injury or darnage i
lar entrances, coal for which this insurance ap- !
holes, driveways, man- p1ies. ;
holes, marquees, hoist ; i
away openings, side- b. With respect ta the insurance afford- �
walk vaults, street ban- ed to the additional insureds de- ;�
ners or decarations and scribed in Paragraph 7.a.(1) of this
sim9lar exposures; or endorsement, #he following is added �'
to Section 1{I-Limits Of Insurance: u
(ii} The construction, erec- '
tian ar removal of e[eva- The most we wiil pay on behalf of the �
tors;ar additional insured is the amount of in-
surance: � �
(iii) The ownership, mainte� ; �
nance or use of any el- (1) Required by the written contract, �
evators cavered by this written agreemer�t, written permit
insurance. or written authorizatian described
in Raragraph 7.a,(1} of this en- ;
(e} Martgagae, Assignee C?r dorsemeni; or
Receiver
(2} Available under the applicable
Any person ar organization Limits of Insurance shown in the a
with wh�m yau have agreed Declaratiqns; I
per Paragraph 7,a.{1) af this whichever is less.
endarsemant to provide in- 'i
surance, but anly with re- This endorsernent shall nat increase
spect to their liability as the app�icable Limits of Insurance
mortgagee, assignee, or re- shown in the Declarations.
Includes copyrighted material of Insurance
GA 227 0917 Services Office, Inc.,with its permission. Page 13 of 15 �
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c. Section IV � Comrnerciai Gerreral ment, the following additional provi-
Liability Canditions is atnanded tv sions apply.
include the faliowing: ; �
(1) The l.imits of lnsurance shawn in ;�
Automatic Additional Insured Pro- the peclarativns are replaced by � �
visian the limits designated in Section �
B. Limits Of Insurance, 8. I �
This insurance applies oniy if the Property Damage T'o Barrowed
"badily injury" or "property damage" ���R�;���t �fi thi� e�rodorsement � �
occurs, or the "parsanal and advertis- with respect to coverage provid- � �
ing injs�ry"afFense is commitked: ed by this endorsement. These I '
(1) During khe poficy periQd; and limits are tnclusive of and not in i '�
additian to the firnits being re- j
(2) 5ubsequent to your execution of placed. The Limits of fnsurance ' ,�
the writtan cantrack or written shown in Sectian B, Limits Of � �
agreement, or the issuance of a Insurance, 8. Praperty bamage �
written perrnit or written auChori- To Bvrrowed Equiprnent of this ' �
zation, described in Paragraph endorsement fix the most we wili ' �
7.a.(1). pay in any one "accurrence" ra- ' ;
gardless af the nurnber of; '
d. Section IV - Cornmerciat Genera� �
Liability Conditians is amended as (a) Insureds;
ft�llows:
{b) Claims made or "suits" �
Car�dition 5. [t#her Insurance is braught; or
arnended ta include;
(e) Persorts or organizations �
Primary And Noncontributory In- making claims or bringing �
Slir$11C� ��SUItS", ';I
,,
7his insurance is primary to and will (2} beductible Ciause I
noC seek contributian fram any other :
insurance available to an additional (a) Our �bligation ta pay dam- ',I
insured per Paragraph 7.a,(1) of this ages an your hehalf applies
endarsemant provided that; onEy ta the amount of darn- I,�
ages far eaCh "occurrence"
(1) The additional insured is a which ara in exces5 of t�e
Named Insured under such ather Deductible Amount stated in � i
insurance; and Seckion B. Limits 1]f tnsur- �
{2) You have agreed in writing in a ����• 8. Praperty Damage J
contract, agreement, permit or Tp Borrnwed Equipment of ,
this endorsernent, Tha limits �
authorization described fn 7,a.(2) of insurance will not be re�
of this endorsement that this in- duced by the ap�iication of
surance wauld be primary and such deductible amaunt.
would nak seek contribution from
any other insurance available to {b) Section IV - Comrnercial
the additional insured. General k.iability Candf-
tians, 2. Du#ies tn The
8. Praperty Damage 1"o Borrowed Equip� E�vent Of Occurr�nc�, Of- i ��
ment fense, Claim Or Suit, ap-
a. The folfowing is added to Exciusion pGes to each claim or "suit° �
2.j.Damage To Properly under Sec- irrespective of the�mount. �
tion I - Caverage A - Bodily Injury (G) We may pay any part or all '
And Praperty pamage Liahility: of the deductible amount to ;
Paragraphs (3) and (4) af this exclu- effect settlement of any I
sian da nat apply ta taols or equip- claim ar "suit" and, upon no- i
tification of the action taken, '
ment loaned ko you, provided they are ou shall rom tf reim- t
not being used to perForm oparativns burse us forsuch�a '
at the time of loss. P � QF���
cteduttible amaunt as has
b. With respect to the insurance provid- been paid by us.
ed by this section af the endorse- �
4ncfudes copyrighted material of Insurance �
GA 227 09 �7 Services�ffice, Inc„with its permission. Page '14 of'15
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Ct}MI��RCI,AL G�I��RAL I,IABi[.IT'Y � �, 'I
CG�0 01 Ck��3 ;
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TH�S ENDORSEM�NT C�.AI�GES THE P4tCCY, P�.EASE F�EAD tT CAR��'#JL,LY, I �
. y
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�������� ��� ��������������� � ! �
o�rHER ir�suR�r��E �ar�a�-�Non� �, ��
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This endc�rsement modifies insurance provided under the iollowing; � I
G
�C7MMERCfAL G�N�RAL LIA�ILITYCC}VERAG� PART i I�
PRODUCTS/CQMPLET��OF'�RATIQN$LiA�ILITYCOVERAGE PART �
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The fplfowing (s added to the pthel� {rlsur�rlCe (1,� The �ddi#ional fnsured is a �larned �
Condition arx� supersec(es ar+y provision ta the lnsured under such atMer Insurance; ,h
cantrary: and � ;
Primary Artd Noncontr�autory insurance (2) You have agreed in wri8ng in a � �
This insurance is ry Contract ar agreemerrt that this � '
prima ta and will nat �
seek canfribufion fram ar�y oth�r insurance �n�r�noe wauid be primary and would 3
available ta an aclditional insured under r�ot seek contributlon from any other � ,
Insurance avallah(e tt� the additianal # � !
yaur�olfcy provicied that: � , y
_ _ insured. ,�
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9. �mployees As Insureds - Specified This exclusion does not apply to an air- �
Health Care Services And Good Sar►tar- craft you da not own, provided that: � `
itan services
a, The pilat in cammand halds a current �
Paragraph 2,a.(1)(d) under Section II - effec#ive certificate, issuad by a duly
Who Is An Insured does nat apply to: constikuted authority of the Uni#ed
States of America or Canada, desig-
a. Your "employ�es" who pravide pro- nating that person as a cammercial or I'1
fessional health care services on yaur airli�e t�'�n�p�a�t pif�t; � �
behaif as a duiy licensed nurse, � �
emergency medical technician or b. The aircraft is rented wikh a trained, j
paramedic in the jurisdictian where an paid crew; and �
"occurrence" or affense ta which this ' �
irtsurance applies takes place; or c. The aircraft daes not transport per- , �
sons or carga for a charge, j ,
b. Your"employees" or "volunkeer work- -I�
ers", other than an employed or vol- '�z, Bodily In�ury Redefined ' i
unteer dactor, providing first aid or Sectian V - De�nitians, 4. "Badily injury" i
goad samaritan senrices during their is replaced by th�fallowing: '{
work hours for you will be deerned to �
be acting within the scape of their 4, "Bodily injury" tneans bodily harm or ;
employrnent by you or performing du- injury, sicknass, disease, disability, � 7
ties related to the conduct of your humiliation, shock, fright, m�nta) an- I!
business. guish ar mental injury, including care, I,I
I055 af serviees or death resulting �
'1U, Broadened Notice Of�ccurrence from any of these at any time. � i
Paragraph a. af Conditian 2, Duties In 13. �xpected Or lntended Injury Redefined ' I
7he Event Of Occurrence� Offense, � �
Claim Or Suit under Section IV - Com� The last sentence of Exelusian 2.a. �x-
mercial General Liability Conditions is pected 4r Intended lnjury under Sec-
replaced by the follawing: tion I - Caverage A , Bod ily injury And i ;I
Property Damage Liabitity is replaced by ; Ij
a. You must see ko it that we are notified the following,
as soon as practicable �f an 'bccur�
rence° ar an affense which may result This exclusion does not apply to "bodily
in a claim. Ta the extent passible, na- injury" or°property damage" resulting from -
tice shauld include: the use of reasonable force to protect per- '!
(�) How, when and where the '"oc-
sons or property. 1
currence"ar of€ense tr�vk pface; 14. Forrner Employees As Insureds '
(2) The names and .addresses of 7he following is added to Paragraph 2. �I
any injured persons and wit- under Section II r Who Is An Insured: ,I�
nesses; and
2. Each of the following is alsa an in- ;
{3) The nature and locatian of any sured; � ;
• injury or damage arising ouk of
the'bccurrence"or offense. Any of your former "employees", di-
rectars, managers, members, part-
This requirement applies anly when ners ar "executive officers", including
the 'bccurrence" ar offer�se is knawn but not lirnited kn retired, disabled or
to an "au#horized representative". those on leave af absence, but only � i
1'E. Nonowned Aircraft for acts within the scope of their em-
ployment by y�u or for duties related
The fallowing is added to Exclusian 2.g. ta t�e conduct of your business. �
Aircraft, Auto Or Watercraft under Sec-
tidn 1 - Caverage A - Bodily Injury And
Praperty Damage Liabllity: ;
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Includes capyrighted material of Insurance
GA Z27 0917 Services 4ffice, Inc„ with its permission. Page 15 of 1S
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THIS END4RSEMENT CHANGLS THE PfJLICY. PLEASE REA,D IT CAREFULLY. . I�
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�4V�RNMENTAL �MMUNITY � �
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This endorsement modl�ies ir�urance provided under the fallowing; � �
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COMIVI�RCIAL.G�N�RAI.LIABILIIY CCJVERAGE PART ;
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SCHEDk�LE � �
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Name of Organization: ; �
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CITY 0�' DT7BUQUE, 50 W 1.3th S�reet, Dubuque, IA 520Q1 ; �iil
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SEC7101V IV-COMM�RCIAL GENERAL LfAB1L4TY COh1DITIONS is arnended to add the iollowing: ;�
Nonwaiver af Govemment Irrmunity :
The purchase af this pdiey and naming of the organization sha�wn in the Schedule as an additional insured 'I
does not waive any of tha defenses of go�ernmental immuniiy available ta the organization sho�wn in the �'
Schedule under Code of lowa 5ectian fi70.4 as it now exists and as lt may be amended from time to time, �
Claims Goverage �
This policy shall cover only those daims not subject to the defense of governmental immuniky under the Code �I'
of lowa Secfion 670.4 as it now e�isfs and as it may be amended fr`om time to time. �I
Assertian of Gavemment Immunity ��
The organizatifln shawn in the Schedule shal!be responsible for asserting any defense of governmental immu- �
nity,and may do so.at any time and sha11 do so upon fhe timelywri�ten raques#of the insurance carrier. '
ii
Nan-Denial of Co�erage for Governmenta#Immuni�y � ��
We shall nat deny coverage or deny any of the rights and benefiks accx�uing to the organization shawn in the r!
Schedule under thfs policy for reasons of gavemmental fmmunity unless and uritil a court af competent jurisdic- ii
tion has ruled in Favor of the defense(s)of govemmenfal immunity assarted by the organization shcwvn in the i�
Schedule. �
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GA 4217 W 05 03 �
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POI,fCY NUMB�i�: EPP0506139 COMM�RCfAL G�IV�RAL i.�ABl�t'fiY � i �
CQ 25 d�4 Q5 Q9 � , '�
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THIS ENDQRSENI6NT CHANCES 7HE pd1�ICY",pLEqSE R�'qp �T CAREFU�.�.Y. � ; ��
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G�NERAL AG�R�GATE M.�M�T i '
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This enc�arsement madlfies Ir�surance provfde�ur►der the fallov�fng� � �
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COMMEFiCIAL GE�}�RAl.E.IABILiTY CpV�RACE pqRT � ;
SCI�EC}Lil.� � I�,i
Designafecf Lpcat"ran(s); � a
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When r�quired �ex Wx�itten cantrae�. � j
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Information re uired io cpm Iete this Sohedu[a if riot shawn abnva,will be shown in the psc�arations, } ,;
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A. For all sums which the insured beaarnes I�- �4r��y°t������►�nated"lacatlor�"shown ' ',
in the Schedule above, �
ga[fy obligated io pay as damages caused by � '�'
acourrences under Sect€an 1 � Coverage A, 4, The limits shown in #he peclarat€ons ior � �
and for all medicai expens�s ca.use�b acci�
y ��.CI� OCGUt't'QIlG6, i3amage Ta Pramises � ?
dents under Sectian i - Caverage C, whioh �enta� To Yc�u ,and Mealical �xpense ��
oan be a�rlbuted only tb operations at a single cantinus ko apply. Hoyrev�r, instead of � `
desigr�a#ed "focatian" shcawn (ri the Schedule b�ing subjeot ko the Ceneral Aggregate j
above. L.Imit shown in the psnlara#ions,such lim- '
'f. A separate pesignated L.pcafinn General ���►�ill be subject to#he appficable besig� �
Aggregate Limit appties �o each desig- �$��d�.00atian Genaral Aggregate Limit. '!
nated"lacatian", arid that Ifmit ls equal to B, For all sums which the insured becames le- j
#he amaunt a€ tf�� Cen�ral Aggregate gally o�ligated to pay as damages caused by �
Limit shown in the peclarahons, "oc�currenaes" urrder 5eotlan I � Caverage A, ; ,�
2. The Dasignated Lacation Ge n e r a l A g g r e- �n�for ail medlcai expensas caus�d b y acc i• �
gate Lirrslt is the most we wi{I pay f�r the dents uncEer Section 1 - Caverage C, wh[ah ; ij
sum aE all damages under Caverage A, �an�pt be attrlbufed anly toM operabons a# a ' !
excepf �amages because of "b�dily in- single de�ignated lacation shawn In tna � ,�
�ury"or"property damagg"included 1n the 5chedule above: �
°pra�ucts-complete8 operations hazard", 1, Any payments macfe under C�verage A i y
and far mediaal expenses ur�der Cover- � far damages or under Caveraga C for ;
a ge C re g a r d f a ss a f t he num�er o f; m�diaal �xpenses shall raduce the
a, Insureds; amount available under the Qeneral Ag- ! �
gregats l.lmft or the Produots-compEeted
b. Cfaims made or�suits"brough#;or aperatians Aggregate Lfmit, whiohever is ; �
c. Persans or ar�anizations making applicable,and ,
, claims or bringing "sulfs". 2. 8uch payments shail not reduoe any I �
Designated Location General A re ate �
3. Any paymenta made under Gaverage A �;���, �� g �
far damages or under Cov�rage C for
med(ca� expenses shall red�tce the pes- � C. W'hert ooveraga f�r kiabillty arising nut of tha � ,
ignated Location GaneraE Agg�egate Limit "praducts-oompleted operations hazard" is
for that designatecf "lacatian". �uch �ay- prQvided, any payments for damagas �e-
ments shall nat reduce the G�neral Ag- cause�f"bodily inJury" or "property damage"
gregate Limlt shown in the �7acfaratlans included Pn the °products-com,pleted opera_
nor shafl they r�duae any ather Desig- tions hazard" wiil reduce the Products-
nated l,ocation Gerreraf Aggragate Limit aompleted D�aratians Aggregate Llmit, and
not reduo� the General Ag�regate Limit nar �
CG 2a 0�05 09 UG lrtsc�r�nce Servlces Of€fce,ino.,2008 R�ge 1 of 2 � �
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the Designated Loca#ion General Aggregat� connec��n is Interrup#ed only by a st�eet, �
l.imit, roadway, wa#arway or righ#-of-way of a rail- � i �
road,
D. For the purposes of this enc�arser�ent, #ha 1 ;�
Deflnitian� Section is amended by the addi- �. The provislons af Sectivn Itt-Limits Of Insur- � �j
tion af#he Poliowtng de(initian: ance ndt ptherwias.modified by#his endarse- i s
W „ ment shall cantinue to apply as stipulatad, ' � 9
Lacat(an means premises involving the j ,�
�ame �r �or�,r,2�tPr,g Ic�ts; c�i �rei�l��� wi�ose i
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CG 25 04 05 09 cO Insuranoe 5erv�aes Qffice, fn�,,2008 Page 2 of 2 ❑ �
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WpRKERS Cbr+MP�NSATl01�ANp EM�LOY�RS �IABILITY II�SUftANC� P�I.ICY � �
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WAIVER C}� UVR RtGHT T4 RECt7VER FRQM OTHERS �
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ENDQRSEMENT �
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We have the righk to recover our payments from anyona liable for an injury covered by this policy. We wilf not
enforce aur right against t4�e person ar organizatian named in the Schedule.
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This agreement shali not operate directly or indirectly to banefit anyone not named in the Schedule, i
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Schedule i
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Ci�y a� bubuque, 50 W J.3th Stree�., Dubuque, IA� 52C}O1 -
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This endarsement changes the policy to which it is atta�hed and is effective on the data issued unless other- �
wise statad.
(The informatian below is required anly when th[s endarsement is issued subsequent to preparaGon of the policy.)
Endorsement Effective Policy No. Endorsement Na. �
insured
Insurance Cornpany Premium $
Cauntersigned by �
WC 00 03 73
, OO 7983 National Council on Compensation insurance,
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