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HomeMy WebLinkAboutA9051 - TOUR DE PALM SPRINGSCONTRACT ABSTRACT DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F AGREEMENT FOR EVENT PROMOTION RECITALS WHEREAS, WHEREAS, WHEREAS, WHEREAS, WHEREAS, WHEREAS, NOW, THEREFORE, IT IS AGREED AS FOLLOWS: 1.0 EVENT DATE AND LOCATION DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 2.0 PRESENTING SPONSOR 3.0 SPONSORSHIP TERMS FOR THE CITY DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F received, final costs to produce the Event, and a detailed breakdown of the specific uses of the City's funding. 4.0 SERVICES TO BE PROVIDED BY PROMOTER As the producer of the Event, Promoter will provide production services, including, but not limited to, the following and will accept all financial responsibility for such services: 4.1 Securing the necessary venues for the Event and related activities, including VIP party, use of parking lots and other possible special attractions as approved by City. 4.2 Developing and submitting a schedule and list of exhibitors and sponsors participating in Event to City's SEPT at least ten (10) days prior to the Event; coordinating Event routing, signs, delineation and staging with SEPT and providing an accurate count to date of registered Event participants no less than forty-eight (48) hours prior to start of bike event. 4.3 Contracting and paying for all service vendors and technical support, including, but not limited to, sound, including a public address system, lighting, electricity, canopies, tents, bleachers, and security services at related activities described in Section 4.1, and reimbursing City for any expenses incurred by the City pursuant to Section 4.2 in excess of the City's in-kind contribution. 4.4 Recruiting, coordinating, and supervising volunteers and all their activities. 4.5 Obtaining certificates of insurance and liability release forms from all entries, volunteers and vendors participating in Event. 4.6 Promoter shall be responsible for all promotional activities related to the Event including: a. Preparing press releases and marketing materials to promote the Event. City logo to be included in all printed promotional materials; b.Coordinating with the Palm Springs Bureau of Tourism to promote Event; and c.Promoting Event through personal appearances and/or the distribution of collateral materials. 5.0 CONTRIBUTION AND SUPPORT SERVICES PROVIDED BY CITY 3 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 6.0 TERM OF AGREEMENT, BREACH AND REIMBURSEMENT DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F a.Promoter loses its tax-exempt status under Section 501 (c) (4) and 170 (c) (2) of the Internal Revenue Code; or b.The dissolution of Promoter; or c.Promoter terminates or attempts to terminate this Agreement for any reason other than City's failure to make payments as provided hereunder; or d.Promoter fails to fulfill the responsibilities, duties, and obligations set forth herein. 7.NO LIABILITY, NONDISCRIMINATION, AND OTHER PROVISIONS 7 .1 No Personal Liability. No officer or employee of the City shall be personally liable for any civil or financial damages to the Promoter, or any successor-in-interest, in the event of any City default or breach under this Agreement. 7 .2 No Director/Officer Liability. No individual director or officer of the Promoter shall be personally liable for any civil or financial damages to the City in the event of any Promoter default or breach under this Agreement. 7.3 Covenant against Discrimination. In connection with its performance under this Agreement, Promoter shall not discriminate against any employee or applicant for employment because of actual or perceived race, religion, color, sex, age, marital status, ancestry, national origin (i.e., place of origin, immigration status, cultural or linguistic characteristics, or ethnicity), sexual orientation, gender identity, gender expression, physical or mental disability, or medical condition (each a "prohibited basis"). Promoter shall ensure that applicants are employed, and that employees are treated during their employment, without regard to any prohibited basis. As a condition precedent to City's lawful capacity to enter this Agreement, and in executing this Agreement, Promoter certifies that its actions and omissions hereunder shall not incorporate any discrimination arising from or related to any prohibited basis in any Promoter activity, including but not limited to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship; and further, that Promoter is in full compliance with the provisions of Palm Springs Municipal Code Section 7.09.040, including without limitation the provision of benefits, relating to non-discrimination in city contracting. 7 .3 No Financial Interest. Promoter acknowledges that no officer or employee of the City has or shall have any direct or indirect financial 5 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F interest in this Agreement, nor shall Promoter enter into any Agreement of any kind with any such officer or employee during the term of this Agreement and for one year thereafter. Promoter warrants that Promoter has not paid or given, and will not pay or given, any third party any money or other consideration in exchange for obtaining this Agreement. 7 .4 Political Use/Lobbying. Promoter covenants that the funds provided by City pursuant to this Agreement will not be used for political advocacy or lobbying purposes. 8.MUTUAL INDEMNIFICATION. 8.1 Promoter shall indemnify, hold harmless, and defend the City and its officers, agents and employees from any and all loss, cost, damage, injury, liability, and claims thereof for injury to or death of a person, including employees of Promoter or loss of or damage to property, arising directly or indirectly from Promoter's performance of this Agreement. Promoter shall indemnify, hold harmless and defend the City as a result of the negligent acts of Promoter regardless of whether the facilities or equipment is provided by City or others, and regardless of whether liability without fault is imposed or sought to be imposed on City. However, to the extent that such indemnity is void or otherwise unenforceable under applicable law in effect on, or validly retroactive to the date of this Agreement, and except where such loss, damage, injury, liability or claim is the result of the active negligence or willful misconduct of City, and is not contributed to by any act of, or by any omission to perform some duty imposed by law or this Agreement on Promoter, its subcontractors or either's agents or employees, Promoter shall not be required to indemnify, hold harmless or defend the City. The foregoing indemnity shall include, without limitation, reasonable fees of attorneys, consultants and experts and related costs, and City's costs of investigating any claims against the City. In addition to Promoter's obligation to indemnify City, Promoter specifically acknowledges and agrees that it has an immediate and independent obligation to defend City from any claim which actually or potentially falls within this indemnification provision, even if the allegations are or may be groundless, false or fraudulent, which obligation arises at the time such claim is tendered to Promoter by City and continues at all times thereafter. Promoter shall indemnify and hold City harmless from all loss and liability, including attorneys' fees, court costs and all other litigation expenses for any infringement of the patent rights, copyright, trade secret or any other proprietary right or trademark, and all other intellectual property claims of any person or persons in consequence of the use by City, or any of its officers or agents, of articles or services to be supplied in the performance of this Agreement. 6 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 8.2 City shall indemnify, hold harmless, and defend the Promoter and its officers, agents and employees from any and all loss, cost, damage, injury, liability, and claims thereof for injury to or death of a person, including employees of Promoter or loss of or damage to property, arising directly or indirectly from the City's active negligence in support of the Promoter's Event. However, to the extent that such indemnity is void or otherwise unenforceable under applicable law in effect on, or validly retroactive to the date of this Agreement, and except where such loss, damage, injury, liability or claim is the result of the negligence or willful misconduct of Promoter, and is not contributed to by any act of, or by any omission to perform some duty imposed by law or agreement on City's part, its management or employees, City shall not be required to indemnify, hold harmless or defend the Promoter. The foregoing indemnity shall include, without limitation, reasonable fees of attorneys, consultants and experts and related costs, and Promoter's costs of investigating any claims against Promoter. 9.INSURANCE. Promoter will deliver to the City, not less than thirty (30)days prior to the first scheduled date of the Event, a certificate of insurance showing the City as an additional insured in a policy or policies issued by a company approved by the Risk Manager for the City, with coverage and limits of insurance acceptable to the Risk Manager, not subject to cancellation except upon thirty (30) days' written notice to the City. City's insurance requirements are further reflected in Exhibit "C," attached hereto and incorporated by this reference herein. 10.GENERAL PROVISIONS 10.1. Inspection. City shall have the right to inspect all production services and promoter records arising from and related to this Agreement. 10.2 Complete Agreement. This Agreement contains all the terms and conditions agreed upon by the parties. No other understandings, oral or otherwise, regarding the subject matter of this Agreement shall be deemed to exist or to bind any of the parties hereto. This Agreement supersedes all previous agreements, if any, between the parties. 10.3 Amendments. Any alterations, variations, modifications or waivers of provisions to this Agreement shall be valid only when reduced to writing duly signed and attached to the original of this Agreement. 10.4 City Representation. Promoter shall work closely with the City's Special Events Manager, who shall be designated the "Liaison Representative of City." Promoter principals shall provide regular updates to the Liaison Representative of City to keep the City currently advised on the status of the Event. 7 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F CITY: 10.5 Compliance with Laws. Promoter shall comply with all applicable federal, state, and local laws, ordinances and regulations. 10.6 Standard of Care. City relies upon the professional ability of Promoter as a material inducement to entering into this Agreement. Promoter agrees to use reasonable care and diligence in rendering services under this Agreement. Promoter agrees that the acceptance of its work by City shall not operate as a waiver or release of said obligation of Promoter. The absence, omission, or failure to include in this Agreement, items which are normally considered to be a part of generally accepted professional procedure or which involve professional judgment shall not be used as a basis for submission of inadequate work or incomplete performance. 10.7 Demand for Assurance. Each party to this Agreement undertakes the obligation that the other's expectation of receiving due performance will not be impaired. When reasonable grounds for insecurity arise with respect to the performance of either party, the other may in writing demand adequate assurance of due performance and until he/she receives such assurance may, if commercially reasonable, suspend any performance for which the agreed return has not been received. "Commercially reasonable" includes not only the conduct of a party with respect to performance under this Agreement but also conduct with respect to other agreements with parties to this Agreement or others. After receipt of a justified demand, failure to provide within a reasonable time, but not exceeding ten (10) days, such assurance of due performance as is adequate under the circumstances of the particular case is a repudiation of this Agreement. Acceptance of any improper delivery, service, or payment does not prejudice the aggrieved party's right to demand adequate assurance of future performance. 10.8 Third Party Beneficiaries. Nothing contained in this Agreement shall be construed to create and the parties do not intend to create any rights in third parties. 10.9 Notices. Communications among the parties hereto shall be addressed as follows: PROMOTER: C.V. Spin, Inc. TOUR DE PALM SPRINGS, Aftab Dada, President 74854 Velie Way, Suite 9 Palm Desert, CA 92260 (760)674-4700 CITY OF PALM SPRINGS Justin Clifton, City Manager 8 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F P.O. Box 2743 Palm Springs, CA 92262 (760)322-8336 FAX (760) 323-8207 7.7 CITY REPRESENTATION. Promoter shall work closely with the City's Special Events Manager, who shall be designated the "Liaison Representative of City." Promoter's principals shall provide regular updates to the Liaison Representative of City to keep the City currently advised on the status of the Event. 7.8 COMPLIANCE WITH LAWS. Promoter shall comply with all applicable federal, state, and local laws, ordinances and regulations. 7.9 STANDARD OF CARE. City relies upon the professional ability of Promoter as a material inducement to entering into this Agreement. Promoter agrees to use reasonable care and diligence in rendering services under this Agreement. Promoter agrees that the acceptance of its work by City shall not operate as a waiver or release of said obligation of Promoter. The absence, omission, or failure to include in this Agreement items that are normally considered to be a part of generally accepted professional procedure or that involve professional judgment shall not be used as a basis for submission of inadequate work or incomplete performance. 7.10 DEMAND FOR ASSURANCE. Each party to this Agreement undertakes the obligation that the other's expectation of receiving due performance will not be impaired. When reasonable grounds for insecurity arise with respect to the performance of either party, the other may in writing demand adequate assurance of due performance and until he/she receives such assurance may, if commercially reasonable, suspend any performance for which the agreed return has not been received. "Commercially reasonable" includes not only the conduct of a party with respect to performance under this Agreement but also conduct with respect to other agreements with parties to this Agreement or others. After receipt of a justified demand, failure to provide within a reasonable time, but not exceeding ten (10) days, such assurance of due performance as is adequate under the circumstances of the particular case is a repudiation of this Agreement. Acceptance of any improper delivery, service, or payment does not prejudice the aggrieved party's right to demand adequate assurance of future performance. 7.11 THIRD PARTY BENEFICIARIES. Nothing contained in this Agreement shall be construed to create and the parties do not intend to create any rights in third parties. 8.0 Covenant Against Discrimination. In connection with its performance under this Agreement, Contractor shall not discriminate against any employee or applicant for employment because of actual or perceived 9 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F i.e., [SIGNATURE BLOCK NEXT PAGE] 10 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 00 llllt II rn11@a11 U1 11 m11 111 1 1111 111 1 iUJ1H 010011 11111111:a 11 111u O 11111 &011111 2 Jl!JC 3 3 J J § A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California . I } County of ,{'1 Ytr.S/tle On c/ d/1 {1,t!_/'1 .3/ #;;before me, /f4t711/f(� M. h�/4;-db /4.-y A, .64;e Oat He e Insert Name and Title of the Officer personally appeared J>ebr� �ri{lilb Name(s) of Signer(s) who 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), or the entity upon behalf of which the person(s) acted, executed the instrument. Place Notary Seal and/or Stomp Above I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. OPTIONAL Completing this information con deter alteration of the document or fraudulent reattachment of this form to on unintended document. Description of ched Document Title or Type of Docu Document Date: _______ .,._ ____________ Number of Pages: ___ _ Signer(s) Other Than Named Above: ------------------------­ Capacity(ies) Claimed by Signer(s) Signer's Name: ___________ _ □Corporate Officer -Title(s): ______ _□Partner -□ Limited □ General□Individual □Attorney in Fact□Trustee □Guardian of Conservator□Other:Signer is Representing: _________ _ ©2017 National Notary Association Si r's Name: ___________ _ □Corp te Officer -Title(s): ______ _□Partner -□General□Attorney in Fact□Trustee □Guardian of Conservator□Other: DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above ATTEST: By: _________ _ Anthony J. Mejia, MMC City Clerk APPROVED AS TO FORM CITY ATTORNEY CITY OF PALM SPRINGS, a California charter city and municipal corporation By:--------- � Justin Clifton City Manager C.V. Spin, Inc •. , a California nonprofit public benefit corporation 11 A9051 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 2/10/2022 Exhibit "A" SCOPE OF SERVICES Promoter shall organize, manage, and produce the 2022 Tour De' Palm Springs Event for the City scheduled February 11 & 12, 2022, to include a bicycle ride and walk, entertainment, and vendor expo. Production of the Event will include, but is not limited to, the following: 1.Promoter is responsible for organizing, planning, managing, coordinating, staging and otherwise producing the Event on February 11 & 12, 2022 upon designated streets within the City. 2.Promoter is responsible for developing the schedule of activities, site map and travel routes, traffic delineation and signs, rest stations, and Event layout to the satisfaction and requirements of SEPT. 3.Promoter is responsible for all onsite security through the use of a qualified security company approved by the City, and all volunteer and/or paid staff as needed to man and stage the Event on various streets throughout Palm Springs as required by SEPT review. A copy of the security contract must be provided to SEPT by February 1, 2022. 4.All electrical and lighting required to stage the Event will be the responsibility of the Promoter. City shall provide electrician to facilitate hookup to city power in the Downtown, if needed. 5.All amplified sound equipment and lighting is to be directed away from all adjacent residential and business housing. 6.Dumpsters shall be placed in locations approved by SEPT. Promoter shall provide recycling containers for the Event. 7.All trash pickup throughout the Event site will be the responsibility of the Promoter with support from paid city staff. All marking of concrete walks, streets and parking lots shall be done with a water-soluble paint or chalk and shall be removed by Promoter within twenty-four (24) hours of the conclusion of the Event. Promoter will handle all cleaning of restrooms to include ample portable toilets in locations approved by SEPT. 8.All food vendor applications will be submitted to Riverside County Department of Environmental Health no later than January 28, 2020. All food vendors will be required to comply with Riverside County Environmental Health Codes for the Event. 9.Should the promoter decide to have create a "beer or wine garden" at the event. The promoter shall submit an application to the Department of Alcohol and Beverage Control no later than January 28, 2022. 12 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 10.All vendors will be required to have the appropriate City business licenses as determined through the SEPT review process. Business licenses must be displayed on or within vendor booths throughout the Event. VillageFest licenses are not considered acceptable as a City business license. All vendor permits must be submitted no later than January 28, 2022. All vendors must submit a valid Sellers Permit with the City of Palm Springs listed issued by the State Board of Equalization. 11.A first aid station shall be required on the Event site. Two (2) Palm Springs Fire Department Emergency Medical Technicians shall be on site throughout the Event as determined by SEPT. Additionally, two (2) fire marshals shall be required on site during the ride. 12.Promoter will provide bike routes as needed and approved by SEPT. Promoter will coordinate staging and lineup of all participant entries, pre­ and post-stage traffic delineation and staging as approved by SEPT. No changes will be made to routes without the consent of SEPT. 13.Promoter will provide portable toilets in various locations at the pre-stage area and other locations as determined by SEPT. Promoter will be responsible for the delivery, cleaning and pickup of portable toilets and is required to obtain permission of the property owners for placement on private property, all portable restrooms will removed from downtown Palm Springs before 8:00 a.m. on Monday February 14. 14.Promoter shall be responsible for attending a Palm Springs Neighborhood meeting and reviewing all routes that will impact Palm Springs neighborhoods. The promoter shall mark the routes at least 3 days in advance notifying the public that the streets will be utilized for Tour de Palm Springs and identify the date of the event. 15.The Promoter shall also attend a Main Street meeting to review any impact the Palm Springs Merchants. The promoter will also hand delivery notices to all the business affected by the ride and road closures. The promoter may also be asked to attend other stakeholder meetings and shall be required to attend. 16.City police officers shall be required at the Event site on Friday, February 11 and Saturday, February 12. City's Police Department shall coordinate required staffing for the event, consisting of motor officers, marked units and foot beat officers. 17.Expo shall be set up on designated streets (Approved by SEPT) closing at 6:00 a.m. by City Streets Department. Departure of all bike rides will be off Palm Canyon Drive and Tahquitz Canyon Drive. All riders and walkers will have departed by 11: 15 a.m. Palm Canyon Drive will reopen to vehicular traffic by 7:00 p.m. on Saturday February 12. Vendor is responsible to have all tenting, tables, staging etc ... off the street by 7:00 p.m. 13 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 18.Expo event hours shall be the following: Friday February 11 from 12:00 p.m. -9:00 p.m.; Saturday February 2 from 9:00 a.m. -5:00 p.m. All vendors and expo materials will be completely removed from the street by 7:00p.m. 19.Traffic Plan for all routes within the City of Palm Springs shall be submitted to SEPT. 20.Traffic Message Boards shall be displayed at E. Racquet Club/Farrell and Southbound N. Gene Autry North of the railroad bridge. Messages should advise motorists of heavy bicycle traffic traveling on roadways. Additional message boards may be required for public safety by SEPT. 21.SEPT will assign additional staffing as needed. 22.Event layout must be reviewed and approved by the Palm Springs Fire Marshall and the Events Manager by Friday January 28, 2022. No changes may be made without written consent from city staff. FIRE DEPARTMENT CONDITIONS FID 1 Fire Department Fees - A $793.00 fee (Operational Permit + FBRx3 hours) is required at the time of submittal for site-plan review and site compliance inspection. These fees are established by resolution of the Palm Springs City Council, if applicable. FID 2 Site Plan -Aerial site plan (Google Map overlay) shall be submitted to the Fire Department in PDF format. Information shall include: Event name and date(s); dimensions of enclosure, booths, bars, tents, stages, beer trailers, etc.; expected number of attendees; vendor booth locations; identification of any cooking booths using open flame devices; fences; exits. FID 3 Fire Apparatus Access Roads -(public streets, private streets, parking lot lanes and access roadways) shall not be obstructed in any manner including the parking of vehicles that will reduce the fire department access road to a width of less than 20 feet. FID 4 Fire Hydrants -No person shall stop, park, or leave standing any vehicle, or place a vendor booth or display, within 15 feet (7.5 feet on either side) of a fire hydrant. FID 5 Food Vendors -All food vendors utilizing open flame cooking devices (grills, barbeques, stoves, ovens, woks, kettles, deep-fryers, etc., shall be required to have the appropriate fire extinguisher with a current State Fire Marshal service tag attached (serviced within the past 12 months). A 2A-10B:C minimum rated dry chemical fire extinguisher is required. In 14 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 7 All Vendors 8 Tent Permits 9 Medical Standby 15 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F Exhibit "B" ESTIMATE SCHEDULE OF COMPENSATION AND DESCRIPTION OF CITY SERVICE COSTS $ $ $ $ $ $ TOTAL ESTIMATED COST: 73,500.00 City Sponsorship: $ 50,000.00 Total Due to City: $23,500.00 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F Exhibit "C" INSURANCE REQUIREMENTS INSURANCE. The Contractor shall procure and maintain, at its sole cost and expense, in a form and content satisfactory to City, during the entire term of the Agreement, including any extension thereof, the following policies of insurance: (a)Commercial General Liability Insurance. A policy of commercial general liability insurance written on a per occurrence basis with a combined single limit of at least $2,000,000 bodily injury and property damage, including coverages for contractual liability, personal injury, independent contractors, broad form property damage, products and completed operations. The Commercial General Liability Insurance shall name the City, its officers, employees and agents as additional insured. (b)Workers' Compensation Insurance. A policy of workers' compensation insurance in any amount which fully complies with the statutory requirements of the State of California and which includes $1,000,000 employer's liability. The insurer shall waive all rights of subrogation and contribution it may have against the City, its officers, employees and agents, and their respective insurers. (c)Business Automobile Insurance: A policy of business automobile liability insurance written on a per occurrence basis with a single limit liability in the amount of $1,000,000 bodily injury and property damage. The Business Automobile Insurance shall name the City, its officers, employees, and agents as additional insured. No work or services under this Agreement shall commence until the Contractor has provided the City with Certificates of Insurance, endorsements or appropriate insurance binders evidencing the above insurance coverages and said Certificates of Insurance, endorsements or binders are approved by the City. The contractor agrees that the provisions of contained herein shall not be construed as limiting in any way the extent to which the Contractor may be held responsible for the payment of damages to any persons or property resulting from the Contractor's activities or the activities of any person or persons for which the Contractor is otherwise responsible. In the event the Contractor subcontracts any portion of the work in compliance with this Agreement the contract between the Contractor and such subcontractor shall require the subcontractor to maintain the same policies of insurance that the Contractor is required to maintain pursuant to this Section. 17 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F � USACYCL-22 MRODRlmIEZ ACORD" CERTIFICATE OF LIABILITY INSURANCE I DA TE (MM/DD/YYYY) � 1/31/2022 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 £2'1.I�cT Fairly Group Certificates Fairly Consulting Group, LLC PHONE I FAX 1800 S. Washln¥ton, Suite 400 (A/C, No, Ext): (A/C, No): Amarillo, TX 79 02 ltM}Jbi::i::• certs<wfairlygroup.com INSURERISI AFFORDING COVERAGE NAIC# INSURER A: HDI Global Specialty SE INSURED INSURER B: USA Cycling, Inc. INSURER C: 210 USA Cycling Point INSURER D: Colorado Springs, CO 80919 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER· 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. ·�� A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY -D CLAIMS-MADE 00 OCCUR ---GEN'L AGGREGATE LIMIT APPLIES PER: Fxi POLICY □ �ra □ LOC OTHER: Per Event AUTOMOBILE LIABILITY ,___ ANY AUTO ,__ OWNED -SCHEDULED ,__ AUTOS ONLY ,__ AUTOS ,__ �L'W:PsoNLY ,__ �8f:tI��tK� UMBRELLA LIAB ,___ EXCESS LIAB H OCCUR CLAIMS-MADE OED I I RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE □ �r��ird�i��m EXCLUDED? �m:�rtfi�� o�'6PERATIONS below �.Pk X N/A W9� POLICY NUMBER POLICY EFF POLICY EXP LIMITS . .. EACH OCCURRENCE $ 1,000,000 HDGL003700597 12/31/2021 12/31/2022 DAMAGE TO RENTED D�S::MIC::S::C::/S::,. $ 1,000,000 MED EXP /Anv one oerson\ $ Excluded PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 $ COMBINED SINGLE LIMIT (Ea ::ir-.r.irient\ $ BODILY INJURY (Per person\ $ BODILY INJURY (Per accident\ $ PROPERTY DAMAGE /Per accident) $ $ EACH OCCURRENCE $ AGGREGATE $ $ I �ffrnrE I I ��H- E.L. EACH ACCIDENT 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) Job 2022-4198 RMGL 03 09 02 18 SCHEDULE OF NAMED INSUREDS: Event Organizers and/or Promoters are Named Insureds. It shall be a condition of coverage that all organizers/promoters for whom coverage is afforded under this policy execute a USAC Event Permit Application and coverage will be afforded only for the specific event and date(s) on the permit. Event Number: 2022-4198 Event Name: Tour de Palm Springs SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Palm Springs, its officials, employees and agents THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 3200 E Tahquitz Canyon Way Palm Springs, CA 92262 AUTHORIZED REPRESENTATIVE I � ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F AGENCY CUSTOMER ID: USACYCL-22 MRODRIGUEZ ------------------- LO C #: � ACORD .,ADDITIONAL REMARKS SCHEDULE AGENCY N AME D IN SURED USA C_ycling, Inc. airly Consulting Group, LLC 210 USA C_ycling Point 1- P - 0 - LI - CY _ N _ U _ M _ BE - R -----------------------lcolorado Springs, co 80919 EE PAGE 1 EE PAGE 1 ADDITIONAL REMARKS NA ICC0DE SEEP 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: Event Location: Palm Springs, CA Event Date(s): 02/12/2022 E FFECTIVE DATE : Page 1 of 1 The City of Palm Springs, its officials, employees and agents are named as an additional insured per attached endorsement. This insurance is primary and non-contributory over any insurance or self-insurance the City may have for any and all work performed with the City per attached endorsement. Should any of the above described policies be canceled before the expiration date thereof, the issuing company will mail 30 days written notice to the Certificate Holder named per attached endorsement. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F POLICY NUMBER:HDGL003700597 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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): The City of Palm Springs, its officials, employees and agents 3200 E Tahquitz Canyon Way Palm Springs, CA 92262 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. B.With respect to the insurance afforded to these additional insureds, the following is added to Section Ill -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 theamount 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. CG 20 26 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F This Endorsement changes the Policy. Please read it carefully. Amendment -Primary and Non-Contributory - RMGL 15 50 02 18 Policy Amendment -Commercial General Liability This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person(s) Or Organization(s): The City of Palm Springs, its officials, employees and agents 3200 E Tahquitz Canyon Way Palm Springs, CA 92262 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) I.The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to the Person(s) or Organization(s) shown in the Schedule applicable to this endorsement provided that: (1)such Person(s) or Organization(s) is/are a Named Insured under such other insurance; and (2)you have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such Person(s) or Organization(s). II.This Endorsement is otherwise subject to all the terms, conditions, exclusions, limitations, and provisions of the policy to which it is attached. RMGL 15 50 02 18 Page 1 of 1 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F This Endorsement changes the Policy. Please read it carefully. Manuscript Endorsement -RMGL 03 09 02 18 Policy Amendment -Commercial General Liability It is hereby understood and agreed upon that the following is added to this Policy: Subject to the cancellation provisions of the Coverage Form to which this endorsement is attached, we will not: 1.Cancel; or, 2.Nonrenew; this Coverage Form, for any statutorily permitted reason other than nonpayment of premium, until we provide at least 30 days written notice of such cancellation or nonrenewal. Written notice will be to the person or organization named in the Schedule. This notification of cancellation or nonrenewal to the person or organization named in the Schedule is intended as a courtesy only. Our failure to provide such notification will not: 1.Extend any Coverage Form cancellation date; 2.Negate the cancellation as to any insured or any certificate holder; 3.Provide any additional insurance that would not have been provided in the absence of this endorsement; or 4.Impose liability of any kind upon us. This endorsement does not entitle the person or organization named in the Schedule to any benefits, rights or protection under this Coverage Form. SCHEDULE Name Of Person Or Organization & Mailing Address The City of Palm Springs, its officials, employees and agents 3200 E Tahquitz Canyon Way Palm Springs, CA 92262 RMGL 03 09 02 18 Page 1 of 1 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F December 16, 2020 C.V.S.P.I.N. Policy Term: Policy Limit: Premium: .. J . Ii; . , <.'/�.; Annual DIRECTORS AND OFFICERS LIABILITY PREMIUM QUOTATION License No. 0G80261 LIABILITY Underwritten by U. S. Liability Insurance Company (Admitted A++) $1,000,000 Directors and Officers Liability. $0 Retention $1,000,000 Employment Practices Liability $5,000 Retention Defense costs are outside the Limits on Liability Data and Security Endorsement is included Human Resources consulting services included $ 1,522.00 12. ;�.( /·L '-. The attached application needs to be completed, signed and returned with premium check prior to expiration of current coverage. Sincerely; a� 1407 Foothill Blvd. #228, La Verne, CA 91750 •866.866.7090 • ed@hcmeventinsurance.com • DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F USU.COM 888-523-5545 Check Out Your New Employment Practices Liability Risk Management Toolkit from PeopleSystems Free Employment Practices Liability (EPL) Helpline 1-888-811-4182 (8 a.m. to 7:30 p.m. Eastern Time) If a human resource consulting firm offered you their time and expertise for free, would you lock their phone number and email address in a drawer and never cal? Of course not! Do you have questions such as: What are the current federal and state employment laws I need to know? What are "wage and hour" regulations? What does �exempt" versus "non-exempr mean? How should I handle terminating . suspending or warning an employee? What type of human resources policies should I have in place? How should I property document performance issues and disciplinary actions in an employee's fde? What are appropriate and inappropriate questions to ask during an employment interview? What guidelines should I use to investigate a complaint of discrimination or harassment? PeopleSyst�ms Is just a free phon� call or email aw-dy! Online Human Resources Center www.peoplesystems.com/USLI To access the USU policyholder features, chck on '·Request for dient login" and complete with your information. Please take a moment to become fam�iar with the new PeopleSystems Resource Center's information. Helpline to email your human resource questions: Now you can email your questions via this web portal. Human resource news center and recent employment law changes:The news center keeps you up-to-date with recent changes in state and federal employment laws and what they mean to you as wen as pertinent articles on employment issues you need to know about Human resource manual and employment fonns: You will find '"Best Practices'" helpful for handling common human resource issues. Issues may include conducting employee evaluations and understanding employment laws such as FLSA, FMLA and COBRA. Human resource recommendations; You will also find sample human resource policies regarding discrimination, harassment. employment at-will and electronic communications. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F USU.COM 888-523-5545 Directors and Officers and Employment Practices Liability for Nonprofit Organizations As a director or officer of a non profit orga nization, are you immune from liability? Immunity does not prevent an organization from being sued Immunity typically applies to volunteers. not to paid employees or the organization itself Employment.related laws are the same for any type of organization Over 90 percent of the claims against nonprofit organizations are employment practices-related These employment practices claims may include wrongful termination, third party sexual harassment, and third party discrimination Nearly 85 percent of nonprofits have an annual budget that is less than the average cost to defend a dairn dosed by litigation Why you should purchase the Nonprofit Director s and Officers and Employment Practices Liability policy: COVERAGE FEATURES USLI COMPETITORS Separate limits of liability for O&O and EPL claims (O&O limit not eroded by employement daims) Defense outside the limit of liability on all claims Punitive damages, where insurable by law, included automatically In most states. Third-party sexual harassment and third-party discrimination coverage Lifetime occurrence reporting provision (Occurrence feature for former D&Os) Coverage for both monetary and non-monetary claims Coverage for outside directorship liability Risk management services -Free unlimited employement practices consultation via a toll free helpline supported by the ability to ask questions online In the new EPL Risk Management Toolkit from PeopleSystems. The toolkit also contains a helpful news center, how-to guide for writing an employment manual and sample HR policies and employment forms. Fair Labor standards Act (FLSA) $100,000 sublimit for defense and settlement (avaffable in most states) Optional Standard Form option: combined D&O and EPL limit, defense inside the limit. excludes helpline and FLSA DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F USU.COM 888-523-5545 Nonprofit Management Liability Product For nearly 25 years, USU has provided nonprofits and those who serve them with critical protection against unforeseen and cosdy management liability daims. Nonprofits are often asked to do more with less, and we in turn strive to provide them with more coverage at an affordable cosl Applicants can depend on the following coverage features to protect them and their missions: Directors and Officers Liability $1 mllion additional Side A coverage included on all policies Full severability Employed lalNYers, personal injury and publishers liability included Retention forgiveness included at no charge Lifetime Occurrence Reporting Provision Broad definitionofdaim 80/20 hammer Comprehensive subsidiary coverage Broad Insured vs. Insured carve backs Full prior acts induded Defense outside the limit Employment Practices Liability Employmentpracticesliability induding express social media coverage Retaliation carve backs Separate limits ofliability for directors and officers and employmentpractices liability claims FairlaborStandardsAct(FLSA)$1O0,00Osublimit fordefense costs and loss (ava�able in mosljurisdictions) Thir�party harassment and third-party discrimination coverage Product Advantages Data & Security+ endorsement -$50,000 sublimit each for data breach. identity theft, workplace violence and kidnap expenses, plus free identity theft services for directors and officers Risk management services -Free human resource consultation helpline service with unlimited calls and no time limits, plus an online HR resource center See reverse side for common eligible classes Additional Advantages Direct Bill available Ava0able for web quoting Financial stability of a carrier rated A++ by A.M. Best Policyholders have access to many free and discounted services through our Business Resource Center that wiU assist in growing and protecting their business ,. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F Common Classes Target Classes Foundations United Way centers Social/Human Services Assistance centers Court-appointed special advocates Food banks Homeless shelters Community Exhibitions (auto shows, fairs, festivals) Historical societies/Preservation Humane societies Libraries/Museums Performing arts organizations Edu�ation Preschools/Kindergartens/Day cares Montessori schools Boarding/Private high schools Community/Junior colleges Vocational training Ease of Doing Business Minimum information to quote: •Name •State •Annual revenues •Description of operations Ability to quote: •Over the phone •Off of competitor applications •Online Religious Organizations Churches Temp les Synagogues Ministry organizations Govemment Related Convention centers Community/Civic centers Economic development corporations Public broadcasting Regional planning commissions Visitors/Tourist bureaus Zoos Shared Property Cemeteries Condo/Homeowners associations Low-income housing Property owners associations Water associations Membership Organiutions Fraternal clubs Service clubs Country dubs -dining dubs (golf, swimming, tennis, yacht dubs) USU.COM 888-523-5545 Promotion of Business Chambers of commerce Lending organizations Private industry councils Professional associations Research organizations Trade associations Youth Organizations At-risk youth facilities Big Brother/Sister Boys and Girls Clubs Scouting organizations Youth sports associations YMCAsN'WCAs Health Mental health centers Substance abuse centers Counseling/Referral/Crisis services/ Developmentally disabled facilities Health care providers/clinics Assisted living/Retirement/Nursing hom&s/Hospice DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F business resource center As a pclicyholder through USU or Devon Park Specialty, you have access to many free and discounted serv;ces through the Business Resource Center that will assist you in operating. growing ano protecting your business. Consider the following services and assoc:ated cost savings when deciding where to place your insurance! HUMAN RESOURCES »Free human resources consultation hotline to be used for personnel issues, including harassment and discriminatior., the Family and Medical Leave Act disability, wage and hours regulations and more »Online library with information. forms ar.d articles pertaining to human resources »Discounted sexual harassment training and more »Resources for recruiting and training as well as termination and administration PRE-EMPLOYMENT AND TENANT SCREENINGS »Discounted background ct,ecks. incl..iding multi-court criminal da:abase searct-.es, county criminal searches and more (tirst background ct--eck is free) »Best prac:ices for performing a background check >>Discounted tenant and drug screenings and motor vehicle reports (MVRs) PAYROLL AND TAXES »Discountec! payroll processing and tax services lallored for either a small or large business CYBER RISK »Materials about securing personal and payment caro ·ntormation aa El• Try our cost-savings calculator to see how much you could save! »Complimentary access to tools and resources tha. will help you understand your expos1.1re to a data breact, and the importance of a response pl�n MARKETING »Suggested free and paid services. including email campa;gns. photo editing. file management and more. for web marketing for your business )> Sugge:;ted free and paid services for socia, Media plattorms. development. management and more »Discountec! promotional items. giveaways and signaqe SAFETY »Free 011-site safety and occupational healtl� consultation for your business »Free personal credit report »Disaster and emerge1cy preparedress resources »Discounted illcohol and food server safety training for your staff and servers »Discounted CPR and 4rst aid tra·ning »Youth resources for concussion training. waivers of liability, recognizing the signs and symptoms of child abuse, and mere :-2 :/1·,�-:?t._.;,�'t'_. .. �.:.,,Lt; :�;;�. 'L ;:-: ': :-, .. r;:.··, . .,_ 1:�_�, . :••,\··-r•_ :. �'i;·:;��l ··;. ·:··� �,-.;:•?�� -�:�· . .!/ ; ·� :: �, • •,,\". , r:c ' .. �. -;,, ;�• <r': !4':. · .. '"?\ h, afidl� �� �nctffl, .dis� ·aftel·n'"�,_ vldt1 bilre.low-cecenter.com. , .:;·;-,>-:;1�-;:_�-:;t�:<·-:-;,<ir·��:.\.:·:�-Yi� ·_, .-.:�-�-,r·: __ ���, /-.. ·\\).i_:�-.-_:.:.�'�::-����':---� .. -.. :,_ ... ·, ·· .��-�,--��f_?�*�\:�r�i DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F K&K INSURANCE Insuring the wortd's fun! 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN 46801-2338 1-877-783-1161 Fax 1-260-459-5870 www.kandkinsurance.com CA# 0334819 DIRECTORS' AND OFFICERS' Including Employment Practices Llablllty Insurance Appllcatlon For Not-For-Profit Entities Enrollment Form Rates Available Through 2128/15 Notice: The policy for which this enrollment form is made applies, subject to its terms, only to any "Claim" first made against the "Insureds" during the certificate coverage period.This fonn must be completed and returned with your payment. Rates shown are available until February 28, 2015. The submission of this enrollment form does not guarantee coverage. Completion of this enrollment form confirms your desire to obtain insurance through the Sports, Leisure and Entertainment Risk Purchasing Group. An RPG provides group purchasing power for similar risks resulting in potential advantageous coverage terms, competitive rates, risk management bulletins, and rewards for favorable group loss experience. An RPG membership fee may be charged. The expiration date is one full year from the effective date. Read the entire brochure and enrollment form carefully before signing. This is a claims-made coverage.. . . ; . ( ._. -h ,. - , . , . \ .•· . 1'l-.. ., r 'l -t � ' c. '· . c • Name of organization: l, V �JP\ t0 ·-,-'-!c.:.. ,i,/-.v'\ .>, '·1··1"?. ':::��. 1-n.:.r<.t.·,·� , N c:. · .b rJ 1 · '-' l-. 1 Date of indorporation: ,4 c; St Mailing address: _, <... • 0,, J< 1 , � City: L; ,.\ ·n-n:l) be� t.- C , ,--Y State: {''. � Zip: cy 2. 2- -.; .--_:;-· Contact person: 'l)t:,.12_-�_,\'----·-'--....::...;_,,_��'_,_;-_;._. ---'''-'----'-=-·_\':--__________ Phone: ( ?c:;.-L.-) � 7 'i -'f ? c .... • •I ,-,..;..---;�., 1_1,,':,;'-r•, E-mail:_.L.\L..? c :: �. ·, c "'"Y;:,. ;-:, i..." 1' � '-'"\ ..... 1 1'Web site: 1.,v..;._...�-�>...s .), '••x, �"T"l_Fax no: ( ) ______ _ \ f "i. �,. (.C.:,. v, Please provide a complete description of your operations and events. -=-·��;;. ... 1;;==-· --'-A._·�..:...A..;:..,,:;.4:""""s1"'""1,;._·--v=, .... • _________ _ --'/ Number of full time compensated employees (over 30 hours a week for 12 months): __ ::_.\ __________ _ Number of part time compensated employees (under 30 hours a week or less than 12 months): _l,;_: _______ _ Number of volunteers: _L_.}_,_,.,1 .... · ______ _Is the organization a not-for-profit entity? � Yes □ No Tax ID No. ; -� - L.-,� -� L. L· -7 .2 Financial Information Total organization's annual gross revenue (gross revenue indudes all receipts from fees, sponsorships, fundraisers, membership, ticket sales) $ 3-37 7'-1 ;· --- Total organization's assets on the financial statement $ G: Cc::::-c.:.- · Total organization's liabilities on the financial statement $ '3 ·J-2 1 � I - If more than $5 million for any one category, please subm it cu1Tent fi nancial statement. Does the organization currently have D&O coverage in force? □No -�Yes (If yes, please provide the follow ing:) ... , I Carrier: n-' lL-A 'l:,:·L·?,� ,� 1\J !:, c...:. Limit: i cc l .. ,: , Premium: H (t•Pt Retentio n: ____ Exp date: , }-Q 1,,, Desired effective date: Check one. □Start my covera�e on the �te my enro llment form and payment arTreceived.□Start my coverage on this date: - , __ / __ -l,.. '-"--c:..: r£ ,; ,-.; L '{ ,.., ., f-rt ) ,!_> ·n ,v,... � Note: Coverage will not be made effec tive prior to the date that the en rollment form and pa yment are received and approved by K&K. Past Activities No claim that would fall within the scope of the proposed insuranc e has been made against any person or entity proposed for this insurance (including without limi tation any claim against such person or entity for any employment practice, as described in the proposed insurance, or any complaint against any such person or entity before the Equal Employment Opportunity Commission or any similar state or local authority), except as follows (include loss payment and defense costs): If so, explain. __ ��-tt..,�eou-�� If none, check here □ No person or entity proposed for this insurance is cognizant of any fact, circumstance or situation (including without limitation any suspected or threatened claim against any such person or entity for any employment practice, as described in the proposed insurance, or any suspected or threatened complaint against any such person or entity before the Equal Employment Opportunity Commission or any similar state or local authority) which might afford grounds for any claim that would fall within the scope of the proposed insurance, except as tallows: If none, check here □ Page3 1281-Sports-D&O 11/13 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F K&K I nsu ranee Directors & Officers Application/Supplemental information Complete description of your operations and events: CVSPIN, Inc. dba: Tour de Palm Springs and Patriot Ride for our Heroes is a non-profit entity whose main purpose is to raise funds for local charities. Two separate bike rides/walks are organized for February (Tour de Palm Springs) and November (Patriot Ride for our Heroes). CVSPIN, Inc. works with the cities involved in the bike rides obtaining necessary permits, insurance, and police/department of transportation support to provide a safe and fun event. Participants pay a fee to ride in the rides. Those funds along with any sponsorships are then used to pay for event costs and the remaining balance of funds is distributed to local charities. 2/10/2018 Tour de Palm Springs -a death occurred from injuries sustained while participating in the Tour de Palm Springs event and serious injuries occurred to another rider during the same incident. Both parties were hit by a driver who was speeding and intoxicated at the time of the event. This event currently has a lawsuit filed. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F PHILADELPHIA INDEMNITY INSURANCE COMPANY 1-877-438-7 459 ONE BALA PLAZA, SUITE 100 BALA CYNWYD, PA 19004 IMPORTANT NOTICE NOTICE OF POLICY RENEWAL October 14, 2020 C.V.5.P.I.N., Inc.PO Box 1718 Cathedral City, CA 92235-1718 POLICY NUMBER: PHSD1511911 EFFECTIVE DATE OF RENEWAL: 1/8/2021 NAME OF PRODUCER· nesert Cornerstone Insurance Service. Inc. This notice is to advise that we are agreeable to renewing the above policy subject to the changes as described below. Please contact your agent listed above or call our toll-free number if you have any questions concerning this Notice. Important Note: This Notice does not apply if a notice of nonrenewal or cancellation has been or is subsequently issued on the policy. If such a notice has been issued, it supersedes this Notice. NOTICE OF REDUCTION IN COVERAGE This is a summary of the major changes to your policy form and endorsements. No coverage is provided by this summary nor can it be construed to replace any provisions of your policy. You should read your policy and review your Declarations page for complete information on the coverages you are provided. If there is any conflict between the policy and this summary, THE PROVISIONS OF THE POLICY SHALL PREVAIL. PI-NPD 27 (11/19) -ABUSE EXCLUSION WITH WORKPLACE HARASSMENT CARVEBACK PI-NPD 27 (11/19) ABUSE EXCLUSION WITH WORKPLACE HARASSMENT CARVEBACK will be attached to your policy at renewal. If Pl PI-NPD 27 (10/11) -SEXUAL ABUSE EXCLUSION was attached to your policy, it will be replaced by PI-NPD-27 (11/19) ABUSE EXCLUSION WITH WORKPLACE HARASSMENT CARVEBACK and will be attached to your renewal policy, please read the following: This exclusion clarifies our intent in regard to Abuse coverage. This endorsement will exclude abusive acts as defined by this endorsement and clarifies that this coverage does not exist and was never intended to be covered by this Policy. Note: If you are an Illinois insured, the following applies instead of the above: PI-NPD 27 (11/19) ABUSE EXCLUSION WITH WORKPLACE HARASSMENT CARVEBACK will be attached to your policy at renewal. If Pl PI-NPD 27 IL (10/11) -SEXUAL ABUSE EXCLUSION was attached to your policy, it will be replaced by PI-NPD-27 (11/19) ABUSE EXCLUSION WITH WORKPLACE HARASSMENT CARVEBACK and will be attached to your renewal policy, please read the following: Pl-FF NOTICE (11/19) ·--�Page 1 of 2 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F 24290000 Y BR04 EMPLOYERS P.O. Box 539003 Henderson, NV 89053-9003 C.V.S.P.I.N., INC.SUITEE77971 WILDCAT DRIVEINDIO CA 92201MLRINC Policy Number: EIG 4930643 00 INSURED COPY DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F IENIPUJVERIT Welcome to EMPLOYERS i Thank you for the trust you have placed in EMPLOYERS. As a leading provider of workers' compensation insurance for America's small businesses, EMPLOYERS is focused on making premiums affordable, as well as helping our policyholders reduce the long-term costs associated with workplace injuries and illnesses. Verify Important Policv Information Enclosea you will find your EMPLOY�RS Workers' Compensation and Employers Liability Policy. Please take a moment to review it to make sure that all of the information is correct. If any information is inaccurate or needs to be updated, please contact your insurance agent immediately. 1.Mailing Address Please verify that the mailing address on the Policy is correct. Important notices will be mailed to this address. 2.Named Insureds Please review each Named Insured and corresponding Federal Employer Identification Number (FEIN) shown on the Policy to make sure the proper employer(s) are listed. This Policy does not provide coverage for any business or legal entity not listed on the Policy declarations page or as an additional named insured on the Named Insured Schedule endorsement. Only legally combinable Named Insureds (legal entities with common majority ownership) may be provided coverage on the same policy. 3.Worksites Make sure that your Policy correctly identifies each state and location where you currently have work. This information is shown in item 3 .A of the Policy declarations page and on the Site Location Schedule endorsement. 4.Officers, Sole Proprietors, Members and/or Partners (or others) Coverage If the Policy contains any endorsement documenting an individual's rejection of statutory coverage, please confirm it is accurate. Eligibility to reject workers' compensation coverage varies by state. Any changes will require written documentation. If the Policy contains any endorsement documenting the election of statutory coverage by an individual not otherwise subject to the Workers Compensation Act, please confirm it is accurate. Eligibility to elect varies by state. Any changes will require written documentation. America's small business insurance specialist· EMPLOYERS® and America's small business insurance specialist® are registered trademarks of Employers Insurance Company of Nevada. Insurance is offered through Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company, and Employers Assurance Company. EIG Services, Inc. (in California, dba EIG Insurance Services) is an affiliated agency and adjuster. Not all insurers do business in all jurisdictions. CM_0016L T _US Rev 03/2018 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:MPUJVERIT Report a Claim Immediate reporting is a major step in cost and time containment of any claim and is beneficial to all parties involved. Any delays in the reporting of claims can result in delayed access to medical care, which in some instances may lead to further injury, resulting in the need for additional treatment subsequently leading to higher medical costs. EMPLOYERS® offers two convenient phone numbers that are available 24/7 to report a claim with less paperwork. * Both numbers are staffed with individuals fluent in both English and Spanish, with accommodations for other languages. 1.Injured Employee Hotline -855-365-6010•Reporting of a new work-related injury or illness when the injured/ill employee has not yet received medical treatment. -Access to registered nurses who are specially trained to provide nurse triage and medical guidance. 2.Customer Support-888-682-6671•Reporting of a new work-related injury or illness when the injured/ill employee has already received medical treatment. -Injured employees who have not yet sought medical treatment will be transferred to our Injured Employee Hotline (IEH) and provided the IEH phone number. *For all injuries or illnesses that require immediate assistance from Emergency Services please call 911. Download a Claim Kit As an employer, you are required to print and post certain workers' compensation notices. We have compiled these documents and made them available to print at https://www.employers.com/claims-services/state-claim-kits/. Please select your state and follow the instructions to ensure your business is compliant with applicable state laws. Some states have additional requirements that cannot be printed, including posters and forms. If required, EMPLOYERS will mail them to you sepa rately. Policyholders can request a printed copy of our claims kit by contacting us by phone at 888-682-6671 or e-mail at customersupport@employers.com. Medical Info Call 888-682-6671 or email customersuppor t@employers.com to obtain a medical provider list or check the status of a medical bill. America's small business insurance specialist· EMPLOYERS® and America's small business insurance specialist® are registered trademarks of Employers Insurance Company of Nevada. Insurance is offered through Employers Compensation Insurance Company, Employers Insurance Company of Nevada, Employers Preferred Insurance Company, and Employers Assurance Company. EIG Services, Inc. (in California, dba EIG Insurance Services) is an affiliated agency and adjuster. Not all insurers do business in all jurisdictions. CM_0017L T _us Rev0J/2018 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F IENIPLIJYER!T FACTS WHAT DOES EMPLOYERS® DO WITH YOUR PERSONAL INFORMATION? Why? This privacy notice is for individuals who are policyholders or applicants for our products and services. In this notice, "you" refers to these individuals. Insurance companies choose how they collect and share your personal information. Applicable laws give consumers the right to limit some but not all sharing. We want you to know how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. What? The types of personal information we collect and share depend on the product or service you have with us. This information can include: -Social Security number and insurance claim history -transaction history or loss history -employment information and income -medical information (only in connection with claims) When you are no longer our customer, we continue to share your information as described in this notice. How? All insurance companies need to share customers' personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customers' personal information; the reasons EMPLOYERS chooses to share; and whether you can limit this sharing. Reasons we can share your personal information Does EMPLOYERS share? Can you limit this sharing? For our everyday business purposes- such as to administer policies and claims, comply with laws or regulations, respond to court orders, legal investigations, YES NO and government agencies, or otherwise as required or permitted by law For our affiliates' everyday business purposes-YES NO information about your transactions and experiences For our marketing purposes- with nonaffiliated service providers we use to market our YES NO products and services to existing and prospective policyholders For our affiliates (excluding Cerity Services, Inc.) to market to you-YES NO to offer our products and services to existing and prospective policyholders For nonaffiliates to market to you NO We do not share For joint marketing with other financial companies NO We do not share For our affiliates' everyday business purposes-We do not collect or share We do not collect or share information about your personal creditworthiness Question sf? Please contact EMPLOYERS, Attn: Compliance, 10375 Professional Circle, Reno, Nevada 89521-4802, or go to www.emglo�ers.com. We believe that the information we have about our customers is accurate. If you would like access or request correction of your information, please forward a written request to the above address. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F Who we are Who is providing this notice? What we do How does EMPLOYERS protect my personal information? How does EMPLOYERS collect my personal information? Why can't I limit all sharing? -Definitions Affiliates Nonaffiliates Joint marketing 1' Other important information -·· ·-- - - -.. Employers Holdings, Inc. and its affiliates. .. -- - - .. .. -- -· - Page2 To protect your personal information from unauthorized access and use, we use security measures that comply with applicable law. These measures include physical, electronic and procedural safeguards. Nonaffiliates that perform services for us are contractually bound to keep this information confidential. Our employees are informed of the requirements to maintain the confidentiality of this information. We collect your personal information, for example, when you •file an insurance application or claim•provide your income, employment, or contact information•provide account information We also collect your personal information from others, such as your employer and its insurance producer, insu rance support organizations, our affiliates, medical providers or other companies as permitted by law. Insurance support organizations may retain information and disclose it to others. Insurance companies need to share personal information to run their everyday business. Generally, applicable laws give you the right to limit only certain types of sharing, such as •sharing information about your personal creditworthiness for affiliates'• everyday business purposes sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharinq. --.. Companies related by common ownership or control. They can be financial and nonfinancial companies . •Employers Holdings, Inc. affiliates are financial companies. Companies not related by common ownership or control. They can be financial and nonfinancial companies . •Examples include reinsurance companies, computer service providers, independent auditors, independent claims personnel, independent insurance agents, and insurance support organizations. A formal agreement between nonaffiliated financial companies that together market financial products or services to you . •EMPLOYERS does not share for joint marketing purposes. -- Employers Holdings, lnc.'s affiliates include: Employers Group, Inc., Employers Insurance Company of Nevada, Employers Compensation Insurance Company, Employers Preferred Insurance Company, Employers Assurance Company, Elite Insurance Services, Inc., dba Employers Elite Insurance Services and EIG Services, Inc. dba California EIG Insurance Services. CERITY is a trade name for the following companies. Cerity Group, Inc., cerity Services, Inc., and Cerity Insurance Company, which are also subsidiaries of Employers Holdings, Inc. Copyright© 2020 EMPLOYERS. All rights reserved. EMPLOYERS ®, America's small business insurance specialist1& . EACCESS ®. PrecisePay1& and Employers Insurance Company of Nevada® are registered trademarks of EIG Services, Inc. Employers Holdings, Inc. is a holding company with subsidiaries that are specialty providers of workers' compensation insurance and services focused on select, small businesses engaged in low-to-medium hazard industries. The Company operates throughout the United States, with the exception of four states that are served exclusively by their state funds. Insurance is offered through Employers Insurance Company of Nevada, Employers Compensation Insurance Company, Employers Preferred Insurance Company, Employers Assurance Company and Cerity Insurance Company. all rated A-(Excellent) by the A.M. Best Company. Not all insurers do business in all jurisdictions. See www.employers.com and www.cerity.com for coverage availability. LE_PH_001.1_US Rev 07 /2020 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:II/IPUJYERIT CALIFORNIA EMPLOYERS BILL OF RIGHTS As a workers' compensation policyholder in California, you have the right to information about claims filed against your company. In addition, there are specific actions you are required to take if you wish to dispute a claim. The following is a summary of your rights and responsibilities under California Labor Code Sections 3761 and 3762: Notification of Claims Filed -EMPLOYERS shall notify you within 15 days of any claim filed directly with EMPLOYERS for which you have not timely submitted a report of occupational injury or occupational illness. Reserves -At your request, EMPLOYERS shall provide a written report of the reserve amount established for any claim. Premium -EMPLOYERS shall discuss with you all non-privileged elements of the claim file that affect your premium and shall supply copies of the non-privileged documents pertaining thereto. Note: EMPLOYERS is prohibited from sharing medical information about an employee who has filed a workers' compensation claim, except as follows: 1.Diagnosis of the mental or physical condition for which workers' compensation is claimed and the treatment provided for this condition. 2.Medical information regarding the injury for which workers' compensation is claimed that is necessary for the policyholder to have in order to modify the employee's work duties. Disputed Claims EMPLOYERS reserves the right to investigate all claims and to decide whether or not to contest or settle claims. However, the California Labor Code affords policyholders a right to voice their position on proposed settlements. What to do if you dispute the validity of a claim: You must notify EMPLOYERS, in writing, of your knowledge of any facts that would tend to disprove any aspect of the employee's workers' compensation claim. You may also write the Workers' Compensation Appeals Board (WCAB) to request notification of any proposed settlement of the disputed claim. Upon receipt of your written dispute, EMPLOYERS will notify you within 15 days of any scheduled WCAB hearing during which a settlement of the disputed claim is to be approved. Settlements -If EMPLOYERS complies with the notification requirements outlined above, the Workers' Compensation Appeals Board may approve a claim settlement without a hearing or further proceedings. America's small business insurance specialist· Copyright© 2019 EMPLOYERS. All rights reserved. In California, insurance is offered through Employers Assurance Company, Employers Compensation Insurance Company and Employers Preferred Insurance Company. EIG Services, Inc. (in California, dba EIG Insurance Services) is an affiliated agency and adjuster. Not all insurers do business in all jurisdictions CL_PH_018_CA 05/2019 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I.Information Available to You A.Information Available from Us (1)General questions regarding your policy should be directed to: EMPLOYERS PREFERRED INS. CO. 10375 Professional Circle Reno, NV 89521-4802 1-888-682-6671 www.employers.com PN 04 99 01 G (Ed. 3-19) (2)Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non-payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3)Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California {WCI RB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B.Information Available from the Workers' Compensation Insurance Rating Bureau of California (1)The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan-1995 (USRP) and the California Workers' Compensation Experience Rating Plan-1995 (ERP). WCIRB contact information is: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415. 778.7272 (fax); and customerservice@wcirb.com (email). The regulations conta ined in the USRP and ERP are available for public viewing through the WCIRB's website at wcirb.com. (2)Policyholder Information. Pursuant to California Insurance Code {CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). (3)Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss-Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II.Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. PN 04 99 01 G (Ed. 3-19) Page 1 of 3 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F A.Our Dispute Resolution Process . PN 04 99 01 G (Ed. 3-19) If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers' compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below. You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: EMPLOYERS PREFERRED INS. CO. Office of General Counsel 500 N. Brand Blvd., Suite 700 Glendale, CA 91203, phone: 1-888-682-6671 fax: 775-886-1818 or visit our website at www.employers.com. After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether or not your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissi oner as described in paragraph I1.C., below. B.Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice@wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph I1.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerservice@wcirb.com (email). PN 04 99 01 G (Ed. 3-19) Page 2 of 3 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F PN 04 99 01 G (Ed. 3-19) C.California Department of Insurance -Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 45 Fremont Street, 22nd Floor San Francisco, CA 94105 415.538.4102 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. Resources Available to You in Obtaining Information and Pursuing Disputes A.Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at415. 778. 7159 (phone), 415.371.5288 (fax) and ombudsman@wcirb.com (email). B.California Department of Insurance -Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP(4357) or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph I1.C. This notice does not change the policy to which it is attached. PN 04 99 01 G (Ed. 3-19) Page 3 of 3 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:MPLIJVER!i® POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 117 52. 8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws. 1.We establish our own rates for workers' compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2.The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined a fter public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers' compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. 3.Rating organizations may develop pure premium rates that are subject to the insurance commissioner's approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4.We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. 5.A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6.Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7.We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. PN 04 99 02 B (Ed. 05-13) UW_PH_DAP _0006_CA_V2_0513 1 of 2 www.employers.com DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:MPLOVER!J® NOTICE OF NONRENEWAL Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. We are not required to provide you with a notice of nonrenewal in any of the following situations: 1.Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2.The policy was extended for 90 days or less and the required notice was given prior to the extension. 3.You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that coverage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, "premium rate" means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. PN 04 99 02 B (Ed. 05-13) UW_PH_DAP_0006_CA_V2_0513 2 of 2 www.employers.com DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE If If PN 04 99 04 (Ed. 12-01) www.employers.com DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:MPUJYERIJ® Important Notice Regarding Your Workers' Compensation Insurance TO OUR CALIFORNIA WORKERS' COMPENSATION POLICYHOLDERS: EIG Services, Inc. In Californ ia, dba EIG Insurance Services Re: Occupational Safety and Health Loss Control Consultation Services Section 6354.5 of the California Labor Code requires all Workers' Compensation Insurers to provide Occupational Safety and Health Consultation Services to all insured employers who require such services for operations in the State of California. As an EMPLOYERS® policyholder you have an extensive array of professional safety and health resources available to you at no additional charge, including: A.Evaluation of existing Injury and Illness Prevention Programs (IIPP) B.Identification and evaluation of work site hazards, materials, personal protective equipment, work methods, processes and facilities C.Safety Training programs addressing identified exposures and needed control measures D.Access to claims history reports (loss runs) and accident trend analyses, consisting of a review of reported workers' compensation injuries and identification of causal factors E.Written safety program Employer Guides F.Consultation and recommendations with respect to possible workplace safety improvement measures G.Follow-up services to items listed above For assistance in any of these areas, or for any other occupational safety or health-related questions, please contact EMPLOYERS at: Loss Control Department EMPLOYERS PO Box 539003 Henderson, NV 89053-9003 Loss Control Telephone: (800) 588-5200 E-Mail: losscontrol@employers.com Note: Workers' Compensation Insurance Policyholders may register comments about an insurer's Loss Control consultation services by writing to State of California, Department of Industrial Relations, Division of Occupational Safety & Health, 455 Golden Gate Avenue, San Francisco, California, p4102, or you can call the Loss Control Coordinator, with the Commission on Health, Safety and Workers' Compensation at (510) 622-3959. America's small business insurance specialist ® Tel 888 682-6671 I PO Box 32036 I Lakeland, FL 32036 I www.employers.com EIG Services, Inc., an affiliated agency and adjuster Employers Preferred Insurance Company I Employers Assurance Company Employers Compensation Insurance Company I Employers Insurance Company of Nevada LCNOT_CA_V2 I Rev 07/19 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:MPUJVERIT Workers' Compensation and Employers Liability Insurance Policy EMPLOYERS PREFERRED INS. CO. Policy Number Policy Period1 From oA Stock Company EIG 4930643 00 01/24/2022 01/24/2023 I �i�9Wa�'s1a��W�r�W1e at the address of the Transaction POLICY DECLARATIONS NCCI Carrier #31283 WCIRB CARRIER# 00920 PRIOR POLICY NUMBER NEW 1.Named Insured and Address Agent C.V.S.P.I.N., INC.DESERT CORNERSTONE INS SVCS 2429000 TOUR DE PALM SPRINGS IN COACHE 81713 US HIGHWAY 111 STE E SUITE E INDIO, CA 92201 77971 WILDCAT DRIVEINDIO CA 92201 Telephone: 7603477723 Customer# I Carrier# I FEIN# I Risk ID# I Entity of Insured 31283 330836672 ALL OTHER Additional Locations: 2.The Policy Period is from 01/24/2022 to 01/24/2023 12:01 a.m. Standard Time at the lnsured's mailing address. 3.A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: CA B.Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C.Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states listed in item 3.A. D.This policy includes these endorsements and schedules: See attached schedule. 4.The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Minimum Premium $ Assessments and Taxes $ SEE EXTENSION OF INFORMATION PAGE 500 Expense Constant Premium Discount Total Estimated AnnualPremium □This is a Three Year Fixed Rate Policy Premium Adjustment Period: !xi Annual; D Semiannual; D Quarterly; D Monthly Countersigned this Day of r. $ $ $ Issued Date: 01/24/2022 Authorized Representative Issuing Office EMPLOYERS PREFERRED INS. co. P.O. BOX 539003 HENDERSON, NV 89053-9003 Issued Date 01/24/2022 WC990630 (5/98 Ed.) INSURED COPY Page 1 of 4 160 588 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:MPUJYERIJ® EMPLOYERS PREFERRED INS. CO. A Stock Company P.O. BOX 539003 HENDERSON, NV 89053-9003 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 49 3064 3 00 Named Insured: C.V.S.P.I.N., INC. Agent: DESERT CORNERSTONE INS SVCS EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Code No. California Classification Description Rating Period: 01/24/2022 through 01/24/2023 Site 00001 8742 SALESPERSONS-OUTSIDE Site 00001 Total Total of Sites for Rating Period Rating Period Total Rating Period: 01/24/2022 through 01/24/2023 0930 WAIVER OF SUBROGATION 0900 EXPENSE CONSTANT 0936 STATE W.C. FRAUD ASSESSMENT 0935 STATE W.C. ADMINISTRATIVE ASSESSMENT 0937 CA INSURANCE GUARANTY 0938 CA UNINSURED EMPLOYERS FUND 0939 CA SUBSEQUENT INJURY FUND 0940 OSHF ASSESSMENT 0943 LABOR ENFORCEMENT & COMPLIANCE 9741 CATASTROPHE PREMIUM 9740 TERRORISM PREMIUM Rating Period Total State Total Policy Total Issued Date 01/24/2022 WC990 630 (5/98 Ed.) INSURED COPY Page 2 of 4 Premium Basis Total Est. Annual Remuneration 30,000 129 554 554 554 554 554 554 554 30,000 30,000 Rate Per $100 of Remuneration 0.430000 $ $ $ 0.020000 0.004856 0.019277 0.001455 0.017451 0.009177 0.007102 0.020000 0.030000 $ $ $ 2429000 Estimated Annual Premium 129.00 129.00 129.00 129.00 250.00 160.00 3.00 11. 00 1.00 10.00 5.00 4.00 6.00 9.00 459.00 588.00 588.00 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:II/IPUJYERIT EMPLOYERS PREFERRED INS. CO. A Stock Company P.O. BOX 539003 HENDERSON, NV 89053-9003 State CA C.V.S.P.I.N., INC.77971 WILDCAT DRIVE, SUITE EPALM DESERT CA 92211 Issued Date: 01/24/2022 WC990410 (7/06 Ed.) 1 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 4930643 00 Named Insured: C.V.S.P.I.N., INC. Aqent: DESERT CORNERSTONE INS SVCS SITE LOCATION SCHEDULE INSURED COPY Page 3 of 4 2429000 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F l:MPUJVERI> EMPLOYERS PREFERRED INS. CO. A Stock Company P.O. BOX 539003 HENDERSON, NV 89053-9003 State Form Nbr. CA wcooooooc CA WC000406A CA WC000419 CA WC000421E CA WC000422C CA WC040301D CA WC040306 CA WC040310 CA WC040360B CA WC040421 CA WC040422 CA WC040601A CA WC990405A Issued Date: 01/24/2022 WC990633 (5/98 Ed.) Ed. Date (1/15) (7 /95) (1/01) (1/21) (1/21) (2/18) (4/84) (1/95) (1/15) (1/08) (1/12) (12/93) (3/07) WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 4930643 00 Named Insured: C.V.S.P.I.N., INC. Agent: DESERT CORNERSTONE INS SVCS ENDORSEMENT SCHEDULE Description WC/EL INS. POLICY FORM BOOKLET PREMIUM DISCOUNT ENDORSEMENT PREMIUM DUE DATE ENDORSEMENT CATASTROPHE PREMIUM ENDORSE TERRORISM RISK INSURANCE PROG CA POLICY AMENDATORY END CA WAIVER OUR RIGHT TO RECOVER DUTY TO DEFEND CA ELL AMENDATORY ENDORSEMENT OPTIONAL PREM INCREASE ENDT SHORT RATE PENALTY CANCELLATION ENDORSEMENT INSTALLMENT PAYMENT ENDORSE INSURED COPY Page 4 of 4 2429000 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wcoooo ooc (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A.The Policy This policy includes at its effective date the Infor­ mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor­ mation Page) and us (the insurer named on the In­ formation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B.Who is lnsured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an em­ ployer of the partnership's employees. C.Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any fed­ eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D.State State means any state of the United States of America, and the District of Columbia. E.Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such workplaces. PART ONE WORKERS COMPENSATION INSURANCE A.How This Insurance Applies This workers comp ensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1.Bodily injury by accident must occur during the policy period. 2.Bodily injury by disease must be caused or ag­ gravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily in­ jury by disease must occur during the policy pe­ riod. B.We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C.We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in­ vestigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D.We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1 . reasonable expenses incurred at our request,but not loss of earnings; 2.premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3.litigation costs taxed against you; 4.interest on a judgment as required by law until we offer the amount due under this insurance; and 5.expenses we incur. E.Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other wcoo oo ooc (Ed. 1-15) 1 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wcoo oo ooc (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F.Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because:1 . of your serious and willful misconduct; 2.you knowingly employ an employee in violation of law; 3.you fail to comply with a health or safety law or regulation; or 4.you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G.Recovery From Others We have your rights, and the rights of persons enti­ tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H.Statutory Provisions These statements apply where they are required by law. 1.As between an injured worker and us, we have notice of the injury when you have notice. 2.Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du­ ties under this insurance after an injury occurs. 3.We are directly and primarily liable to any per­ son entitled to the benefits payable by this in­ surance. Those persons may enforce our duties; so may an agency authorized by law. Enforce­ ment may be against us or against you and us.4.Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5.This insurance conforms to the parts of the workers compensation law that apply to: a.benefits payable by this insurance; b.special taxes, payments into security or oth­ er special funds, and assessments payable by us under that law. 6.Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your du­ ties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A.How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death.1.The bodily injury must arise out of and in the course of the injured employee's employment by you. 2.The employment must be necessary or inci­ dental to your work in a state or territory listed in Item 3.A. of the Information Page. 3.Bodily injury by accident must occur during the policy period. 4.Bodily injury by disease must be caused or ag­ gravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily in­ jury by disease must occur during the policy period. 5.If you are sued, the original suit and any related legal actions for damages for bodily injury by ac­ cident or by disease must be brought in the United States of America, its territories or pos­ sessions, or Canada. B.We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employ­ ees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permit­ ted by law, include damages:1.For which you are liable to a third party by rea­ son of a claim or suit against you by that third party to recover the damages claimed against wcoo oo ooc (Ed. 1-15) 2 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wcoo oo ooc (Ed. 1-15) such third party as a result of injury to your em­ ployee; 2.For care and loss of services; and 3.For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em­ ployee; provided that these damages are the di­ rect consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and4.Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C.Exclusions This insurance does not cover:1.Liability assumed under a contract. This exclu­ sion does not apply to a warranty that your work will be done in a workmanlike manner; 2.Punitive or exemplary damages because of bodi­ ly injury to an employee employed in violation of law; 3.Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers;4.Any obligation imposed by a workers compensa­ tion, occupational disease, unemployment com­ pensation, or disability benefits law, or any simi­ lar law; 5.Bodily injury intentionally caused or aggravated by you; 6.Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7.Damages arising out of coercion, criticism, de­ motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina­ tion against or termination of any employee, or any personnel practices, policies, acts or omissions;8.Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonap­ propriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901- 944), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9.Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sec­ tions 51 et seq.), any other federal laws obligat­ ing an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10.Bodily injury to a master or member of the crew of any vessel, and does not cover punitive dam­ ages related to your duty or oblication to provide transportation, wages, maintenance, and cure under any applicable maritime law;11.Fines or penalties imposed for violation of feder­ al or state law; and 12.Damages payable under the Migrant and Sea­ sonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D.We Will Defend We have the right and duty to defend, at our ex­ pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed­ ings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E.We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1 . Reasonable expenses incurred at our request, but not loss of earnings; 2.Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3.Litigation costs taxed against you;4.Interest on a judgment as required by law until we offer the amount due under this insurance; and 5.Expenses we incur. wcoo oo ooc (Ed. 1-15) 3 of 6 c Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wcoo oo ooc (Ed. 1-15) F.Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other in­ surance or self-insurance. Subject to any limits of li­ ability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is ex­ hausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G.Limits of Liability Our liability to pay for damages is limited. Our li�its of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1.Bodily Injury by Accident. The limit shown for "bodily injury by accident-each accident" is th�most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2.Bodily lrijury by Disease. The limit shown for "bodily injury by disease-policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis­ ease, regardless of the number of employees who sustain bodily irijury by disease. The limit shown for "bodily injury by disease-each em­ ployee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include dis­ ease that results directly from a bodily injury by accident. 3.We will not pay any claims for damages after we have paid the applicable limit of our liability un­ der this insurance. H.Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I.Actions Against Us There will be no right of action against us under this insurance unless: 1.You have complied with all the terms of this poli­ cy; and 2.The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to deter­ mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga­ tions under this Part. PART THREE OTHER STATES INSURANCE A.How This Insurance Applies 1.This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor­ mation Page. 2.If you begin work in any one of those states after the effective date of this policy and are not in­ sured or are not self-insured for such work, all provisions of the policy will apply as though t�at state were listed in Item 3.A. of the Information Page. 3.We will reimburse you for the benefits required by the workers compensation law of t�at �tate if we are not permitted to pay the benefits directly to persons entitled to them. 4.If you have work on the effective date of this pol­ icy in any state not listed in Item 3.A. of the In­ formation Page, coverage will not be afforded for that state unless we are notified within thirty days. B.Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1.Provide for immediate medical and other ser­ vices required by the workers compensation law. 2.Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3.Promptly give us all notices, demands and legal wcoo oo ooc (Ed. 1-15) 4 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wcoo oo ooc (Ed. 1-15) papers related to the injury, claim, proceeding or suit. 4.Cooperate with us and assist us, as we may re­ quest, in the investigation, settlement or defense of any claim, proceeding or suit. 5.Do nothing after an injury occurs that would in­ terfere with our right to recover from others. 6.Do not voluntarily make payments, assume obli­ gations or incur expenses, except at your own cost. PART FIVE-PREMIUM A.Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifica­ tions. We may change our manuals and apply the changes to this policy if authorized by law or a gov­ ernmental agency regulating this insurance. B.Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifi­ cations. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C.Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remu­ neration is the most common premium basis. This premium basis includes payroll and all other remu­ neration paid or payable during the policy period for the services of:1 . all your officers and employees engaged in work covered by this policy; and 2.all other persons engaged in work that could make us liable under Part One (Workers Com­ pensation Insurance) of this policy. If you do not have payroll records for these persons, the con­ tract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the em­ ployers of these persons lawfully secured their workers compensation obligations. D.Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensa­ tion law is not valid. E.Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premi­ um basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the bal­ ance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be de­ termined in the following way unless our manuals provide otherwise: 1.If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2.If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short-rate cancelation table and procedure. Final premium will not be less than the minimum premium. F.Records You will keep records of information needed to com­ pute premium. You will provide us with copies of those records when we ask for them. G.Audit You will let us examine and audit all your records that relate to this policy. These records include ledg­ ers, journals, registers, vouchers, contracts, tax re­ ports, payroll and disbursement records, and pro­ grams for storing and retrieving data. We may con­ duct the audits during regular business hours during the policy period and within three years after the pol­ icy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. wcoo oo ooc (Ed. 1-15) 5 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY wcoo oo ooc (Ed. 1-15) PART SIX-CONDITIONS A.Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurabili­ ty of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organiza­ tions have the same rights we have under this provision. B.Long Term Policy If the policy period is longer than one year and six­ teen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C.Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days af­ ter your death, we will cover your legal representa­ tive as insured. D.Cancelation 1 . You may cancel this policy. You must mail or de­ liver advance written notice to us stating when the cancelation is to take effect. 2.We may cancel this policy. We must mail or de­ liver to you not less than ten days advance writ­ ten notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3.The policy period will end on the day and hour stated in the cancelation notice. 4.Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com­ ply with the law. E.Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. Your Workers' Compensation and Employers Liability Insurance Coverage afforded by this policy is provided by the Company named on the policy Information Page. In witness thereof, the Company has caused this policy to be executed, attested and countersigned by a duly authorized representative of the Company President and Chief Operating Officer wcoo oo ooc (Ed. 1-15) 6 of 6 � Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INS URANCE POLICY WC00 0406A (Ed. 7-95) PREMIUM DISCOUNT ENDORSEMENT The premium for this policy and the policies, if any, listed in Item 3 of the Schedule may be eligible for a discount. This endorsement shows your estimated discount in Items 1 or 2 of the Schedule. The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit. Premium subject to retrospective rating is not subject to premium discount. 1.State CALIFORNIA 2.Average percentage discount: 3.Other policies: First $5,000 0.0% Schedule Next $90,000 10.9% Next $305,000 12.6% Balance Over $400, 000 14.4% Refer to the Extension of Information Page 4.If there are no entries in Items 1, 2 and 3 of the Schedule, see the Premium Discount Endorsement attached to your policy number: This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective Policy No. Issued to Premium at 12:01 AM standard time, forms a part of Ofthe Carrier Code Endorsement No. Countersigned at __________ on _____ _ By:----------­Authorized Representative WC 00 0406A (Ed. 7-95) © National Council on Compensation Insurance, Inc. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. D.Premium is amended to read: PART FIVE PREMIUM WC 00 0419 (Ed.1-01) You will pay all premium when due. You will pay the premium even if part or all of a workers com pensa­ tion law is not valid. The due date for audit and retrospective premiums is the date of the billing. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective Policy No. Issued to Premium at 12:01 AM standard time, forms a part of Of the Carrier Code Endorsement No. Countersigned at ___________ on _____ _ By:----------­Authorized Representative WC 00 0419 (Ed. 1-01) © National Council on Compensation Insurance, Inc. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement WC 00 04 21 E (Ed. 01-2021) This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 C), attached to this policy. For purposes of this endorsement, the following definitions apply: •Catastrophe (Other Than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million.•Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity.•Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of the Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a.It is an act that is violent or dangerous to human life, property, or infrastructure; b.The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c.It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.•Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. State CALIFORNIA Schedule Rate 0.020000 Premium $6.00 This endorseme nt changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company WC 00 04 21 E (Ed. 01-2021) Policy No. Endorsement No. Premium Countersigned by ________________ _ 1 of 1 © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC00 0422C (Ed. 01-2021) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements: a.The act is an act of terrorism. b.The act is violent or dangerous to human life, property or infrastructure. c.The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d.The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year. 1 of 2 © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Limitation of Liability WC 00 04 22 C (Ed. 01-2021) The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1.Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2.Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3.The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. State CALIFORNIA Schedule Rate 0.030000 Premium $9.00 This endorseme nt changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Insurance Company WC00 0422C (Ed. 01-2021) Policy No. Endorsement No. Premium Countersigned by _________________ _ 2 of 2 © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY POLICY AMENDATORY ENDORSEMENT-CALIFORNIA WC 04 03 01 D (Ed. 02-18) It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1 . Minors Illegally Employed -Not Insured. This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2.Punitive or Exemplary Damages -Uninsurable. This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3.Increase in Indemnity Payment -Reimbursement. You are obligated to reimburse us for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the CaliforniaLabor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, wewill bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Department of Insurance. 4.Application of Policy. Part One, "Workers Compensation Insurance", A, "How This Insurance Applies",is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment. Your emplo yee'sexposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5.Rate Changes. The premium and rates with respect to the insurance provided by this Rolicy by reason of the designation of California in Item 3 of the Information Page are subject to change 1f ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6.Long Term Policy. If this policy is written for a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutiveperiod is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been wr itten for each consecutive period. 7.Statutory Provision. Your employee has a first lien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the moneyand pay it to the claimant, we will pay it directly to the claimant. 8.Part Five, "Premium", E, "Final Premium", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. WC040301 D (Ed. 02-18) Page 1 of 2 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 02-18) If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: a.If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b.If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short-rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective Policy No. Issued to Premium at 12:01 AM standard time, forms a part of Of the Carrier Code Endorsement No. Countersigned at __________ on _____ _ By:----------­Authorized Representative WC 04 03 01 D (Ed. 02-18) Page 2 of 2 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA Person or Organization Job Description This policy is subject to a minimum charge of $250 for the issuance of waivers of subrogation (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Authorized Representative WC 04 03 06 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 0310 DUTY TO DEFEND-CALIFORNIA "We Will Defend", WE WILL DEFEND (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Authorized Representative WC 04 0310 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 60 B (Ed. 01-15) EMPLOYERS' LIABILITY COVERAGE AMENDATORY ENDORSEMENT -CALIFORNIA The insurance afforded by Part Two (Employers' Liability Insurance) by reason of designation of California in item 3 of the information page is subject to the following provisions: A."How This Insurance Applies," is amended to read as follows: A.How This Insurance Applies This employers' liability insurance applies to bodily injury by accident or bodily injury by disease. Bodi­ ly injury means a physical injury, including resulting death. 1.The bodily injury must arise out of and in the course of the injured employee's employment by you. 2.The employment must be necessary or incidental to your work in California. 3. Bodily injury by accident must occur during the policy period. 4.Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. 5.If you are sued, the original suit and any related legal actions for damages for bodily injury by acci­dent or by disease must be brought in the United States of America, its territories or possessions,or Canada. C.The "Exclusions" section is modified as follows (all other exclusions in the "Exclusions" section remain as is): 1.Exclusion 1 is amended to read as follows: 1 . liability assumed under a contract. 2.Exclusion 2 is deleted. 3.Exclusion 7 is amended to read as follows: 7.damages arising out of coercion, criticism, demotion, evaluation, reassignment, discipline, def­ amation, harassment, humiliation, discrimination against or termination of any employee, ter­ mination of employment, or any personnel practices, policies, acts or omissions. 4.The following exclusions are added: 1.bodily injury to any member of the flying crew of any aircraft. 2.bodily injury to an employee when you are deprived of statutory or common law defenses or are subject to penalty because of your failure to secure your obligations under the workers' compensation law(s) applicable to you or otherwise fail to comply with that law. 3.liability arising from California Labor Code Section 2810.3 which relates to labor contracting. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective Policy No. Issued to Premium at 12:01 AM standard time, forms a part of Of the Carrier Code Endorsement No. Countersigned at __________ on _____ _ By:----------­Authorized Representative WC 04 03 60 B (Ed. 01-15) © 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY OPTIONAL PREMIUM INCREASE ENDORSEMENT -CALIFORNIA WC 04 04 21 (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) By:----------­ Authorized Representative WC 04 04 21 © National Council on Compensation Insurance, Inc. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 1-12) CALIFORNIA SHORT-RATE CANCELATION ENDORSEMENT It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: If you cancel the policy and a disclosure was provided in accordance with Section 481 (c) of the California Insurance Code, final premium will be based on the time this policy was in force and increased by the short-rate cancelation table below: Short Rate Cancelation Table Extended Per Cent of Extended Per Cent of Extended Per Cent of Number Full Policy Number Full Policy Number Full Policy of days Premium of days Premium of days Premium 1 ............. 5% 95-98 ............. 37% 219-223 . ............ 69% 2 ............. 6% 99-102 ............. 38% 224-228 . ............ 70% 3-4 ............. 7% 103-105 ............. 39% 229-232 . ............ 71% 5-6 ............. 8% 106-109 . ............ 40% 233-237 . ............ 72% 7-8 ............. 9% 110-113 . ............ 41% 238-241 . ............ 73% 9-10 ............. 10% 114-116 . ............ 42% 242-246 (8 mos.) 74% 11-12 ............. 11% 117-120 ............. 43% 247-250 . ............ 75% 13-14 ............. 12% 121-124 (4 mos.) 44% 251-255 . ............ 76% 15-16 ............. 13% 125-127 ............. 45% 256-260 . ............ 77% 17-18 ............. 14% 128-131 ............. 46% 261-264 ............. 78% 19-20 ............. 15% 132-135 . ............ 47% 265-269 . ............ 79% 21-22 ............. 16% 136-138 . ............ 48% 270-273 (9 mos.) 80% 23-25 ............. 17% 139-142 ............. 49% 274-278 . ............ 81% 26-29 ............. 18% 143-146 ............. 50% 279-282 . ............ 82% 30-32 (1 mo.) 19% 147-149 ............. 51% 283-287 ............. 83% 33-36 ............. 20% 150-153 (5 mos.) 52% 288-291 . ............ 84% 37-40 ............. 21% 154-156 . ............ 53% 292-296 . ............ 85% 41-43 .............22% 157-160 . ............ 54% 297-301 . ............ 86% 44-47 ............. 23% 161-164 ............. 55% 302-305 (10 mos.) 87% 48-51 ............. 24% 165-167 ............. 56% 306-310 . ............ 88% 52-54 ............. 25% 168-171 ............. 57% 311-314 . ............ 89% 55-58 ............. 26% 172-175 ............. 58% 315-319 . ............ 90% 59-62 (2 mos.) 27% 176-178 ............. 59% 320-323 ............. 91% 63-65 ............. 28% 179-182 (6 mos.) 60% 324-328 . ............ 92% 66-69 ............. 29% 183-187 ............. 61% 329-332 . ............ 93% 70-73 ............. 30% 188-191 ............. 62% 333-337 (11 mos.) 94% 74-76 ............. 31% 192-196 ............. 63% 338-342 . ............ 95% 77-80 ............. 32% 197-200 . ............ 64% 343-346 . ............ 96% 81-83 ............. 33% 201-205 ............. 65% 347-351 . ............ 97% 84-87 ............. 34% 206-209 ............. 66% 352-355 . ............ 98% 88-91 (3 mos.) 35% 210-214 (7 mos.) 67% 356-360 ............. 99% 92-94 ............. 36% 215-218 ............. 68% 361-365 (12 mos.) 100% This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective Policy No. Issued to Premium at 12:01 AM standard time, forms a part of Of the Carrier Code Endorsement No. Countersigned at ___________ on _____ _ By:----------­Authorized Representative WC 04 04 22 (Ed. 1-12) © Workers' Compensation Insurance Rating Bureau of California. All rights reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY CALIFORNIA CANCELATION ENDORSEMENT WC 04 06 01 A (Ed. 12-93) This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six {Conditions) of the policy is replaced by these conditions: Cancelation: 1.You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. 2.We may cancel this policy for one or more of the following reasons: a.Non-payment of premium; b. Failure to report payroll; c.Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; d.Failure to pay any additional premium resulting from an audit of payroll required by the terms of this policy or any previous policy issued by us; e.Material misrepresentation made by you or your agent; f. Failure to cooperate with us in the investigation of a claim; g.Failure to comply with Federal or State safety orders; h.Failure to comply with written recommendations of our designated loss control representatives; i.The occurrence of a material change in the ownership of your business; j.The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; k.The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; I.The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties. 3.If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any of the reasons listed in Items (g)through (I), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. 4.The policy period will end on the day and hour stated in the cancelation notice. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective Policy No. Issued to Premium at 12:01 AM standard time, forms a part of Of the Carrier Code Endorsement No. Countersigned at ___________ on _____ _ By:----------­Authorized Representative WC 04 06 01 A (Ed. 12-93) © Workers' Compensation Insurance Rating Bureau of California. All rights reserved. DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 9904 05A INSTALLMENT PAYMENT ENDORS EMENT Installment Number Date Due Amount (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) By:----------­Authorized Representative WC 99 04 05 A DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F A�RD8 CERTIFICATE OF LIABILITY INSURA NCE I DATE (MM/DD/YYYY) 01/28/2022 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($), 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 endorsernent(s). PRODUCER CONTACT Sanae Martin NAME: Desert Cornerstone Insurance Service, Inc. ��gNNEo Extl: (760) 347-7723 I FAX (A/C Nol: (760) 347-7725 CA License #0F15709 E-MAIL sanae@desertcornerstoneins.com ADDRESS: 81713 Hwy 111, Ste E INSURER(S) AFFORDING COVERAGE Indio CA 92201 INSURER A: Employers Preferred Insurance Co. INSURED INSURER B: C.V.S.P.I.N., Inc. INSURERC: Tour De Palm Springs in Coachella Valley INSURER D: 77971 Wildcat Drive, Suite E INSURERE: Indio CA 92201 INSURERF: COVERAGES CERTIFICATE NUMBER: CL2212814378 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR A TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY -D CLAIMS-MADE □ OCCUR- GEN'L AGGREGATE LIMIT APPLIES PER: � □PRO-POLICY JECTOTHER: AUTOMOBILE LIABILITY -ANY AUTO □LOC -O\NNED -SCHEDULED -AUTOS ONLY -AUTOS HIRED N ON-OWNED -AUTOS ONLY -AUTOS ONLY UMBRELLA LIAB -EXCESS LIAB H OCCUR CLAIMS-MADE OED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PA RTNER/EXECUTIVE □ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below POLICYEFF POLICY EXP INSD WW POLICY NUMBER IM M/DD/YYYYI IMM/DD/YYYYI N/A y EIG493064300 01/24/2022 01/24/2023 DESCRIP TION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) LIMITS EACH OCCURRENCE UAMA�t: TO �t:N I t:U P REMISES /Ea occurrence\ MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS -COMP/OP AGG COMBINED SINGLE LIMIT(Ea accident\ BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPER TY DAMAGE (Per accident) EACH OCCURRENCE AGGREGATE XI �ffrnTE I I OTH-ER E.L EACH ACCIDENT E.L DISEASE - EA EM PLOYEE E.L DISEASE - POLICY LIMIT Vendor Requirement -Waiver of Subrogation in favor of City, its elected officials, Officers, employees, agents and volunteers applies per attached when required by written contract. CERTIFICATE HOLDER CANCELLATION $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ NAIC# 10346 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Palm Springs ACCORDANCE WITH THE POLICY PROVISIONS. 3200 E. Tahquitz Canyon Way AUTHORIZED REPRESENTATIVE Palm Springs CA 92262 1//lttil&; Li� I © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA Person or Organization Job Description This policy is subject to a minimum charge of $250 for the issuance of waivers of subrogation (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Authorized Representative WC 04 03 06 DocuSign Envelope ID: E37BAD4D-B753-4CE4-B807-BA447C82516F