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Park Use Permit - Pan Florida Bike RideCITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863 - 763 -3372 ext. 217 Fax: 863 - 763 -1686 e -mail: fdcr.l r� ciivofo;rkeechobe ,a;an Park Use Permit Permit Number: 010 Date(s) of Event: March 12, 2017 7AM -1 PM Permit Expiration: March 12, 2017 11:59AM Purpose of Request: Pan - Florida Challenge Bicycle Ride Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee State: Florida Zip Code: 34974 Applicant: Pan Florida Challenge Applicant's Address: 1400 Gulf Shore Blvd N #106, Naples, FL 34102 Phone Number: 863 - 467 -8748 Address of Project: Park #6 Current Zoning: P Subdivision: City of Okeechobee Restrictions /Remarks: All debris must be removed within 24 hours of expiration date. rh Public.: Works Director re (q a tS, -0Eie,ara -up gamy, e from the (even-it including e rotyirrig the trash cans in the park(s) used arbd placing clean trash c ira liner,: in cans after the event FLU Designation: Public ,.Ta c.2 e' March 7, 2017 General Services Secretary Date Page 1 of 3 Revised 11/4/16 CITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863 - 763 -3372 ext. 217 Fax: 863- 763 -1686 PARK USE AND /OR TEMPORARY STREET/ SIDEWALK CLOSING PERMIT APPLICATION Date Received: 3 - ► - ti Date Issued: 3- 7 -, 7 • Application No: 11. 010 Date(s) & Times of Event: Suu4ay , $l.arc'A 1,),..1t lai,,.. - iJ» Information: Organization: V - for i tic\ (,ova 1(Cvi q 2.. Mailing Address: ( '4'O Gi,+.(i t rp RlvkJ J■1 !o4./ h1t.pies 3 -Ji2a, Contact Name: 1`1`1 -'7( -c-v i S ,SU, lc f " E -Mail Address: ±r-x.vt' P. pa.w, Gr.4 .C,katj. vige, , 0, Telephone: Work: 5(4, j , a Li (,; .0a0 Home: Cell: 1 Summary of activities: 1c, Fe otii d-', c v`r —b ire., r tati1 IA; Hi, our VulufeerS 1 i , .! r "t ( -E5 pu,SSinci cAki sr, a cM_St (IAA, Se 1 ell +.1 iwo p)r .o. tellh S 114 51.1j `1'h C' We- vain i/vS e- cL pc r tilt te_ i t-, 5 ., ,�(.arct / y, l a S. ze A -bw cl -e S/'/d ju.iu A t it_e J ve i stn i`e,c.•• ft..., Y) c 0(; S Proceeds usage: Please check requested Parks: Flagler Parks: ❑ City Hall Park ❑ #1 Memorial Park ❑ #2 ❑ #3 ❑ #4 ❑ #5 [Park 3 is location of Gazebo. Park 4 is location of Bandstand] (If other private property used in conjunction with this Park Use Permit please provide the address and parcel number below along with notarized letter of authorization from property owner) Additional Addresses, if applicable Parcel ID: Page 2 of 3 Revised 11/4/16 TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (Street Closings require City Council approval. Meetings 1st & 3rd Tuesdays but subject to change) Address of Event: Street(s) to be closed: Date(s) to be closed: Time(s) to be closed: Purpose of Closing: Attachments Required for Use of Parks Attachments Required for Street /Sidewalk Closings / ■ Site Plan • Site Plan • Copy of liability insurance in the amount of / $1,000,000.00 with the City of Okeechobee as additional insured. • Copy of liability insurance in the amount of $1,000,000.00 with the City of Okeechobee and R.E. Hamrick Testamentary Trust as Additional Insured. • Proof of non -profit status (IRS Determination / Letter) • Original signatures of all residents, property owners and business owners affected by the closing. • State Food Service License if > 3 days. • State Food Service License if > 3 days. • Notarized letter of authorization from property owner, if applicable.* • State Alcoholic Beverage License, if applicable. ** * Required if private property used in conjunction ** Alcoholic beverages can be served only on private Parks, City streets or City sidewalks. See additional ❑ Please check if items will be sold on City streets Use Permit 667 along with the Street Closing application. with a Park Use application. property. Alcoholic beverages NOT ALLOWED in City note below. /sidewalks. Each business will need to apply for a Temporary streets or sidewalks. beverages are served on private Beverage License. Please note there are inside You must have the appropriate license(s). for delivering the appropriate barricades. a street for more than three (3) hours. Note: • Clean -up is required within 24 hours. • No alcoholic beverages permitted on City property, • No donations can be requested if any type of alcoholic property/business unless you possess a State Alcoholic consumption and outside consumption licenses. ► The Department of Public Works will be responsible • Dumpsters and port -o -lets are required when closing Applicant must meet any insurance coverage and of other governmental regulatory agencies. The applicant code compliance requirements of the City and other regulations will be responsible for costs associated with the event, the applicant agrees and shall hold the City harmless for out of applicant's use of location for such event, and shall including attorney fees. The applicant shall be subject to incurred by the City pertaining to the event including, but not expenses. The City reserves the right to require from in the sum approximated by the City to be incurred in providing be refunded to the applicant of this Park Use /Street Closing including damage of property. By receipt of this permit, any accident, injury, claim or demand whatever arises indemnify and defend the City for such incident, demand for, and payment of, all of the actual costs limited to, Police, Fire, Public Works or other departmental an applicant a cashier's check or advance deposit City services. Any such sum not incurred shall Permit. Page 3 o r 3 Revised I'416 hereby acknowledge that I have read and completed this application, the attached Resolutions No.(s) 03-8 and 04-03. concerning the use and the rules of using City property., that the information is correct, and that I am the duly authorized agent of the organization. 1 agree to contbrin with, abide by and obey all the rules and regulations, which may be lawfully prescribed by the City Council of the City of Okeechobee, or its officers, for the issuance Certificate of Insurance must name City of Okeechobee as Additional Insured as well as R.E. Hamrick Testamentary Trust if closing streets or sidewalks. Applicant Signature Staff Review Date ""OFFICE USE ONLY"" Fire Department: Buildin. Official: Public Works: IAD lir; "7411, ir 1)ate: 1 al Attz-.20/ / , Date: 3.7' 17 i--------- Date: Date: Date: Date: 3— 7 7 7 Police _ Department: BTR Department: .11 .' i //1.1 4— city Administrator: City Clerk: 1 --1/4..±,• , , 'it t, Date: , NOTE: APPLICATION AND INSURANCE CERTIFICATE MUST BE COMPLETED AND RETURNED TO THE GENERAL SERVICES DEPARTMENT THIRTY (30) DAYS PRIOR TO EVENT FOR PERMITTING. Temporary Street and Sidewalk Closing submitted for review by City Council on Date Teniporary Street and Sidewalk Closing reviewed by City Council and approved Date 2 ec 1'1 sat z 1 ACO DR THIS TIFICATE 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. CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 3/1/2017 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 Lutgert Insurance - Fort Myers 12660 World Plaza Lane Bldg 73 Fort Myers FL 33907 INSURED Pan Florida Challenge, Inc. 1400 Gulf Shore Blvd N, # 160 Naples FL 34102 PANFLOR -01 CONTACT NAME: Mildred Kraujalis PHONE (ALC No Ext) 239- 4182114 FAX 239- 936 -8288 -- - _ 'LAIC Nol_ AooRS: mkraujalis @lutgertinsurance.com INSURER(S) AFFORDING COVERAGE_ NAIC # INSURER A :Philadelphia Indemnity Ins Co _ 18058 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : • bO V t KAt# Ca \'GU% 111- II,A I G IIIVIVILJLIN. •• -�' - - -- 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 LTR TYPE OF INSURANCE ADDL INSD SUBRJ WVD ■ POLICY NUMBER POLICY EFF POLICY EXP (MM /DD/YYYY) (MM /DD /YYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I X j OCCUR PHPK1560226 10/1/2016 10/1/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 MED EXP (Any one person) PERSONAL & ADV INJURY $5 000 GEN'L X $1,000,000 $2,000,000 GENERAL AGGREGATE PRODUCTS - COMP/OP AGG AGGREGATE LIMIT APPLIES PER: POLICY r J PRO r LOC OTHER: $2,000,000 AUTOMOBILE - --1 -- -- LIABILITY ANY AUTO AUTOS HIRED AUTOS — — AWNED CHEDULED NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) $ $ $ $ _ $ PROPERTY DAMAGE - (Per accident) - - - - -- A X UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE PHUB558957 10/1/2016 10/1/2017 EACH OCCURRENCE AGGREGATE $5,000,000 $5,000,000 $ DED X 1 RETENTION $10,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N / A PER OTH- STATUTE j 1 ER , E.L. EACH ACCIDENT $ I E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Date Of Event; March 12th, 2017 The City of Okeechobee is listed as an Additional Insured with respect to General Liability. t,tK I 'rrt./A 1C nvr-vcr City of Okeechobee 55 SE Third Avenue Okeechobee FL 34974 . ----- ---- --- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Exempt Organizations Select Check IRS Page 1 of 1 Exempt Organizations Select Check Exempt Organizations Select Check Horne Organizations Eligible to Receive Tax - Deductible Charitable Contributions (Pub. 78 data) - Search Results The following list includes tax - exempt organizations that are eligible to receive tax - deductible charitable contributions. Click on the "Deductibility Status" column for an explanation of limitations on the deductibility of contributions made to different types of tax - exempt organizations. Results are sorted by EIN. To sort results by another category, click on the icon next to the column heading for that category. Clicking on that icon a second time will reverse the sort order. Click on a column heading for an explanation of information in that column. 1 -1 of 1 results EIN . Legal Name (Doing Business As) 47- 2993766 Pan Florida Challenge Inc. Return to Search I Results Per Page L25 vi € OK I . ,f « Prev I 1 -1 I Nei* State Country l Deductibility Status City ■ Naples FL United States 1 PC Pre -1 I Next https: / /apps.irs.gov /app /eos /pub78Search.do ?ein 1 =47- 2993 766 &names = pan +florida +challe... 3/2/2017 INTERNAL REVENUE SERVICE P. 0. BOX 2508 CINCINNATI, OH 45201 DEC 03 2015 PAN FLORIDA CHALLENGE INC C/0 AARON A FARMER 999 VANDERBILT BEACH RD STE 503 NAPLES, FL 34108 Dear Applicant: DEPARTMENT OF THE TREASURY EMPloyer Identification Number: 47-2993766 DLN: 17053274318045 Contact Person: MITCHELL P STEELE Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170(b) (1) (A) (vi) Form 990/990-EZ/990-N Required: Yes Effective Date of Exemption: December 10, 2014 Contribution Deductibility: Yes Addendum Applies: No ID# 31360 Were pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests, devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your exempt status. Please keep it for your records. Organizations exempt under IRC Section 501(c)(3) are further classified as either public charities or private foundations. We determined you're a public charity under the IRC Section listed at the top of this letter. If we indicated at the top of this letter that you're required to file Form 990/990-EZ/990-N, our records show you're required to file an annual information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard). If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked. If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter "4221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c)(3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 947 Jackie Dunham From: Jackie Dunham Sent: Thursday, March 02, 2017 12:29 PM To: Herb Smith; Chief Peterson Cc: Patty Burnette Subject: Upcoming Bike Ride 3 -12 -17 7A -2P Attachments: Upcoming Bike Ride 3- 12.pdf Attached is the first page of the application 1 received late yesterday and the site plan for the Pan Florida Challenge bike ride which will be coming through our City of Okeechobee on Sunday, March 12th. This is the same weekend as the Speckled Perch festival. This organization will be using Park 6 to set up a water station for the participants as well as their own port-o -lets. I have the certificate of insurance for the organization but I am waiting on the COI for the company providing the port-o -lets. Just wanted to give you an idea of what the group is doing. It's very basic and I don't think it will be a problem for your department. The biggest worry would be if a bicyclist was injured while going through the City. I have the permit application at my desk. If you are able to stop by my desk to review and approve I would appreciate it. Thank you for your help. Jacki p fz-f c Ci Yea -7-711_S• , _t_)1%Ifl r EL 3/ I Z J ii ® ��� CERTIFICATE OF LIABILITY INSURANCE DAT (MM /D2017YYY) 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 Aon Risk Services Northeast, Inc. Boston MA Offi ce One Federal Street Boston MA 02110 USA CONTACT NAME: PHONE FAX (NC. No. Ext): (866) 283 -7122 (A/C. No.): (800) 363 -0105 E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED United Site Services Northeast, Inc. 31 East Belcher Road Foxboro MA 02035 USA INSURER A: XL Specialty Insurance Co 37885 INSURER B: Safety National casualty Corp 15105 INSURER C: 11/03/2017 INSURER D: $1,000,000 INSURER E: $1,000,000 INSURER F: CERTIFICATE NUMBER: 570065658583 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM /DD /YYYY POLICY EXP 5lMM /DD /YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY GL4055896 General Liability SIR applies per policy terms 11/03/2016 & conditions 11/03/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $1,000,000 CLAIMS -MADE I X (OCCUR MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $10,000,000 GEN'L AGGREGATE POLICY X OTHER LIMIT APPLIES PRO- JECT PER LOC PRODUCTS - COMP /OPAGG $2,000,000 B AUTOMOBILE X X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY — _ SCHEDULED AUTOS NON -OWNED AUTOS ONLY CAS4047369 ALAI) 11/03/201611/03 /2017 COMBINED SINGLE LIMIT (Ea accident) $2,000,000 BODILY INJURY ( Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) '0' X UMBRELLA LIAB EXCESS LIAB X — OCCUR CLAIMS -MADE US00076933L116A Umbrella 11/03/2016 11/03 /2017 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED X RETENTION 510 000 B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR / PARTNER / EXECUTIVE I I OFFICER /MEMBER EXCLUDED, N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A LDS4047370 workers Comp 11/03/2016 11/03/2017 X IPER I IOTH- STATUTE ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E . DISEASE - POLICY LIMIT 81, 000, 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) city Of Okeechobee is included as Additional Insured in accordance with the policy provisions of the General L ability policy. CERTIFICATE HOLDER City Of Okeechobee Attn: Travis Suit 55 SE Third Ave. Okeechobee FL 34974 USA CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ,S4 ‘ fc ft.r.icsd c/loti ,na Holder Identifier : Certificate No : 570065658583 ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: GL 4055896 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations As required by written contract or agreement when such written contract or agreement is executed prior to an occurrence, offense or loss to which this endorsement applies, but only for the limits agreed to in such contract or the Limits of Liability provided by this policy, whichever is less. Any individually scheduled additional insureds shall not be construed to override nor negate this blanket additional insured. All Locations of Insured's Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury ", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 04 13 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: GL 4055896 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations As required by written contract or agreement when such written contract or agreement is executed prior to an occurrence, offense or loss to which this endorsement applies, but only for the limits agreed to in such contract or the Limits of Liability provided by this policy, whichever is less. Any individually scheduled additional insureds shall not be construed to override nor negate this blanket additional insured. All Locations of Insured's Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard ". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 04 13 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: GL 4055896 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): As required by written contract or agreement when such written contract or agreement is executed prior to an occurrence, offense or loss to which this endorsement applies, but only for the limits agreed to in such contract or the Limits of Liability provided by this policy, whichever is less. Any individually scheduled additional insureds shall not be construed to override nor negate this blanket additional insured. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 04 13 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 Page 1 of 1