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19-073 Plan-It Geo, LLC, Tree Canopy Assessment
CITY OF a DESIGN PROFESSIONAL SERVICES AGREEMENT (SINGLE) WITH Plan-it GEO, LLC CUPERTINO 1.PARTIES This Agreement is made and entered into as of _0_4/_2_2_/2_0_1_9 _______________ _ ("Effective Date"), by and between the City of Cupe11ino, a municipal corporation ("City"), and Plan-it GEO LLC ("Consultant"), a�C�o�r=-p-=-ot�·a=ti�o�n� ____ for Tree Canopy Assessment _________________________________ ("Project"). 2.SERVICES 2.1 Basic Services. Consultant agrees to provide the Basic Services for the Project, which are set fo11h in detail in the Scope of Services, attached here and incorporated as Exhibit A, and as fu11her specified in Consultant's written Proposal as approved by City, except for any provision in the Proposal which conflicts or is inconsistent with this Agreement and the Exhibits hereto, or as otherwise expressly rejected by City. 2.2 Additional Services. City may request at any time during the Contract Time that Consultant provide additional services for the Project, which are not already encompassed, expressly or implicitly, in the Agreement, the Scope of Services, or the Proposal ("Additional Services"). Additional Services must be authorized in writing by City and Consultant will not be paid for unauthorized Additional Services rendered. Additional Services are subject to all the provisions applicable to Basic Services, except and only to the extent otherwise specified by City in w1iting. All references to "Services" in the Agreement include Basic Services and Additional Services, unless otherwise stated in writing. The Services may be divided into separate sequential tasks, as fu11her specified in this Agreement, the Scope of Services, and Consultant's Proposal. Consultant is solely responsible for its en-ors and omissions and those of its subconsultants, and must promptly c01Tect them at its sole expense. Consultant must take appropriate measures to avoid or mitigate any delay, liability, and costs resulting from its e1rnrs or omissions. 3.TIME OF PERFORMANCE 3.1 Term. This Agreement begins on the Effective Date and ends on _�D�V?�l_3_D�\ _6)-_0_1�-- unless te1minated earlier as provided herein ("Contract Time"). 3.2 Schedule of Performance. All Services must be provided within the times specified in Exhibit B, Schedule of Perfo1mance, attached and incorporated here. Consultant must promptly notify City of any actual or potential delay in providing the Services as scheduled to afford the Parties adequate opp011unity to address or mitigate delays. If the Services are divided by tasks, Consultant must begin work on each separate task upon receiving City's Notice to Proceed (''NTO"), and must complete each task within the time specified in Exhibit B. City Project Tree Canopy Assessment Design Professional Agreement (single) /Rev. J'vfay. 2018 Page I of IO 3.3 Time is of the essence for the performance of all the Services. Consultant must have sufficient time, resources, and qualified staff to deliver the Services on time. 4.COMPENSATION 4.1 Maximum Compensation. City will pay Consultant for satisfactory performance of the Basic Services and Additional Services, if approved, a cumulative total amount that will be capped so as not to exceed $33,500 ("Contract Price"), as specified in Exhibit C, Co mpensation, attached and incorporated here. The Contract Price includes all expenses and reimbursements and will remain in place even if Consultant's actual costs exceed the capped amount. No extra work or payment is permitted in excess of the Contract Price. 4.2 Basic Services. City will pay Consultant$ 33,500 ("Lump Sum Price") for the complete and satisfactory performance of the Basic Services in accordance with Exhibit C. The Lump Sum Price is inclusive of all time and expenses, including, but not limited to, subConsultant's costs, materials, supplies, equipment, travel, taxes, overhead and profit. If the Basic Services are not fully completed, Consultant will be compensated a percentage of the Lump Sum Price proportionate to the percentage of Basic Services that were completed to City's reasonable satisfaction. 4.3 Additional Services. City has the discretion, but not the obligation, to authorize Additional Services up to an amount not to exceed $ 0 . Additional Services provided to City's reasonable satisfaction will be compensated on a lump sum basis or based on time and expenses, in accordance will the Hourly Rates and Reimbursable Expenses Schedules included in Exhibit C. If paid on an hourly basis, Consultant will be compensated for actual costs only of normal business expenses and overhead, with no markup or surcharge ("Reimbursable Expenses"). Consultant will not be entitled to reimbursement for copying, printing, faxes, telephone charges, employee ove1time, or travel to City offices or to the Project site. 4.4 Invoices and Payments. Monthly invoices must describe the Services completed and the amount due for the preceding month. City will pay Consultant within 30 days following receipt of a properly submitted and approved invoice for Services. The invoice must separately itemize and provide subtotals for Basic Services and Additional Services, and must state the percentage of completion for each task, as specified in Exhibit C. City will notify Consultant in writing of any disagreements with the invoice or the stated percentage of completion of tasks. If the disagreement is unresolved, City will pay Consultant only for the undisputed po1tion of the Services. Disputed amounts shall be subject to the Dispute Resolution provision of this Agreement. a.Time and Expenses. For Additional Services provided on an hourly basis, each invoice must also include, for each day of Services provided: (i) name and title of each person providing Services; (ii) a succinct summary of the Services performed by each person; (iii) the time spent per person, in 30 minute increments; (iv) the hourly billing rate or Sub Consultant charge and payment due; and (v) an itemized list with amounts and explanation for all permitted reimbursable expenses. City Project Tree Canopy Assessment Page 2 of I 0 Design Professional Agreement (single) /Rev. May. 2018 b.Rates and Receipts. All hourly rates and reimbursable expenses must conform to the City approved rates set fo1th in Exhibit C, which will be in effect for the entire Contract Time. Each invoice must attach legible, dated receipts for Reimbursable Expenses. 5.INDEPENDENT CONTRACTOR 5.1 Status. Consultant is an independent Consultant and not an employee, partner, or joint venture of the City. Consultant is solely responsible for the means and methods of performing the Services and shall exercise full control over the employment, direction, compensation and discharge of all persons assisting Consultant in performing the Services. Consultant is not entitled to health benefits, worker's compensation, retirement, or any City benefit. 5.2 Qualifications and Standard of Care. Consultant represents on behalf of itself and its subConsultants that they have the qualifications and skills to perform the Services in a competent and professional manner, as exercised by design professionals performing similar services in the San Francisco Bay Area. Services may only be performed by qualified and experienced personnel or subconsultants who are not employed by City and do not have any contractual relationship with City excepting this Agreement. All Services must be performed as specified to City's reasonable satisfaction. 5.3 Permits and Licenses. Consultant warrants on behalf of itself and any subConsultants that they are properly licensed, registered, and/or certified to perform the Services, as required by law, and that they have procured a valid City Business License. 5.4 SubConsultants. Unless prior written approval from City is obtained, only Consultant's employees and subConsultants whose names are included in this Agreement and incorporated Exhibits may provide Services under this Agreement. Consultant must require all subConsultants to furnish proof of insurance for workers' compensation, commercial liability, auto, and professional liability in reasonable conformity to the insurance required of Consultant. The terms and conditions of this Agreement shall be binding on all subConsultants relative to the portion of their work. 5.5 Tools, Materials and Equipment. Consultant will supply and shall be responsible for all tools, materials and equipment required to perform the Services under this Agreement. 5.6 Payment of Taxes. Consultant must pay income taxes on the money earned under this Agreement. Upon City's request, Consultant will provide proof of payment and will indemnify City for any violations pursuant to the indemnity provision of this Agreement. 5.7 Errors and Omissions. Consultant is solely responsible for its errors and omissions and those of its SubConsultants, and must take prompt measures to avoid, mitigate, and correct them at its sole expense. 6.PROPRIETARY/CONFIDENTIAL INFORMATION During the Contract Time Consultant may have access to private or confidential information owned or controlled by the City, which may contain proprietary or confidential details, the disclosure of which to third parties may be damaging to City. Consultant shall hold in confidence all City information and use City Project Tree Canopy Assessment Design Professional Agreement (single) /Rev. 1\lfay. 2018 Page 3 of IO it only to perform this Agreement. Consultant shall exercise the same standard of care to protect City information as a reasonably prudent Consultant would use to protect its own proprietary data. 7.OWNERSHIP OF MATERIALS 7.1 Property Rights. Subject to City meeting its payment obligations for the Services, any interest (including copyright interests) of Consultant in any product, memoranda, study, report, map, plan, drawing, specification, data, record, document, or other information or work, in any medium, prepared by Consultant under this Agreement ("Work Product"), will be the exclusive property of the City and shall not be shown to a third-party without prior written approval by City 7.2 Copyright. To the extent permitted by Title 17 of U.S. Code, all copyrights to the Work Product prepared/created by Consultant and its SubConsultants and all copyrights in such Work Product shall constitute City propetiy. If it is determined under federal law that the Work Product is not "works for hire", Consultant and SubConsultants hereby assign to City all copyrights to the Work Product when and as created. Consultant may retain copyrights to its standard details, but hereby grants City a perpetual, non-exclusive license to use such details. 7.3 Patents and Licenses. Consultant must pay royalties or license fees required for authorized use of any third party intellectual property, including but not limited to patented, trademarked, or copyrighted intellectual property if incorporated into the Services or Work Product of this Agreement. 7.4 Re-Use of Work Product. Unless prohibited by law and without waiving any rights, City may use or modify the Work Product of Consultant and its SubConsultants to execute or implement any of the following, but Consultant shall not be responsible or liable for City's re-use of Work Product: (a)For work related to the original Services for which Consultant was hired; (b)To complete the original Services with City personnel, agents or other Consultants; ( c)To make subsequent additions to the original Services; and/or ( d)For other City projects. 7.5 Deliverables and Format. Electronic and hard copies of the Work Product constitute part of the Deliverables required under this Agreement, which shall be provided to City on recycled paper and copied on both sides, except for one single-sided original. Large-scale architectural plans and similar items must be in CAD and PDF formats, and unless otherwise specified, other documents must be in Microsoft Office applications and PDF formats. 8.RECORDS 8.1 Consultant must maintain complete, accurate, and detailed accounting records relating to the Services and Compensation, in accordance with generally accepted accounting principles and procedures. The records must include detailed information about Consultant's performance, benchmarks and deliverables. The records and supporting documents must be kept separate from other files and maintained for a period of four years from the date of City's final payment. 8.2 Consultant will provide City full access to Consultant's books and records for review and audit, to make transcripts or copies, and to conduct a preliminary examination of all the work, data, documents, proceedings, and activities related to this Agreement. If a supplemental examination or City Project Tree Canopy Assessment Design Professional Agreement (single) !Rev. lvlay. 2018 Page 4 of 10 audit of Consultant's records discloses non-compliance with appropriate internal financial controls, a contract breach, or a failure to act in good faith, City will be entitled to recover from Consultant the costs of the supplemental examination. If this is a lump sum fee Agreement, City will be provided access to records of reimbursable expenses and the instruments of service/deliverables for review and audit. This Section survives the expiration/termination of this Agreement. 9.ASSIGNMENT Consultant shall not assign, sublease, hypothecate, or transfer this Agreement, or any interest therein, directly or indirectly, by operation of law or otherwise, without prior written consent of City. Any attempt to do so will be null and void. Any changes related to the financial control or business nature of Consultant as a legal entity will be considered an Assignment subject to City approval, which shall not be unreasonably withheld. For purposes of this provision, control means 50% or more of the voting power of the business entity. This Agreement binds Consultant, its heirs, successors and assignees. 10.PUBLICITY / SIGNS Any publicity generated by Consultant for the project under this Agreement, during the term of this Agreement and for one year thereafter, will reference the City's contributions in making the project possible. The words "City of Cupertino" will be displayed in all pieces of publicity, including flyers, press releases, posters, brochures, public service announcements, interviews and newspaper a1iicles. No signs may be posted, exhibited or displayed on or about City prope1iy, except signage required by law or this Agreement, without prior written approval from the City. 11.INDEMNIFICATION 11.1 To the fullest extent allowed by law and except for losses caused by the sole or active negligence or willful misconduct of City personnel, Consultant agrees to indemnify, defend, and hold harmless the City, its City Council, boards and commissions, officers, officials, employees, agents, servants, volunteers and consultants ( collectively, "lndemnitees"), as follows: a.Indemnity Obligations Subject to Civil Code Section 2782.8. With respect to the Services performed in connection with the Agreement, Consultant shall indemnify, defend, and hold harmless Indemnitees from and against any and all liability, claims, actions, causes of action, demands or charges whatsoever against any Indemnitee, including any injury to or death of any person or damage to property or other liability of any nature (collectively, "Liability"), that arise out of, pe1iain to, or relate to the negligence, recklessness, or willful misconduct of Consultant, its officers, officials, employees, agents or SubConsultants. Such costs and expenses shall include reasonable attorney fees for legal counsel of City's choice, expe1i fees, and all other costs and fees of litigation. In addition to its indemnity obligations, Design Professional will provide its immediate and active cooperation and assistance to the City, at no additional cost to the City, in analyzing, defending, and resolving such Liability. b.Claims Involving Intellectual Property. Consultant shall indemnify, defend, and hold ha1mless Indemnitees from and against any claim involving intellectual property, infringement or violation of a United States patent right or copyright, trade secret, trademark, or service mark or other proprietary or intellectual property rights, which arises out of, pertains to, or relates to Consultant's City Project Tree Canopy Assessment Design Professional Agreement (single) /Rev. i\l[ay. 2018 Page 5 of 10 negligence, recklessness, or willful misconduct. Such costs and expenses will include reasonable attorney fees for legal counsel of City's choice, expert fees and all other costs and fees of litigation. c.Claims for Other Liability. For all other liabilities not included in provisions "a" and "b" above, Consultant shall indemnify, defend, and hold harmless the Jndernnitees against any and all liability, claims, actions, causes of action or demands whatsoever, including any injury to or death of any person or damage to property, or other liability of any nature arising out of, pertaining to, or relating to the performance of this Agreement by Design Professional, its employees, officers, officials, agents or subconsultants, including liability based on breach of contract, obligations, or warranties, or any unauthorized use or disclosure of City's confidential and proprietary information. 11.2 Consultant will assist City, at no additional cost, in the defense of any claim, dispute or lawsuit arising out of this Agreement. Consultant's duties herein are not limited to or subject to the Contract Price, to Workers' Compensation claims, or to the Insurance or Bond limits and provisions. Nothing in this Agreement shall be construed to give rise to an implied right of indemnity in favor of Consultant against any Indemnitee. 11.3 If this Agreement is entered into or amended on or after January 1, 2018, Consultant's duty to pay for any of Indemnitees' defense related costs will be limited to its proportionate share of fault, as determined by final decision by a court of competent jurisdiction, subject to any applicable exceptions in Civil Code section 2782.8. 11.4 Consultant agrees to pay the reasonable costs City may incur in enforcing this provision related to Consultant's indemnification duties, including reasonable attorney fees, fees for legal counsel acceptable to City, expert fees, and all other costs and expenses related to a claim or counterclaim, a purchase order, another transaction, litigation, or dispute resolution. Without waiving any rights, City may deduct money from Consultant's payments to cover moneys due to City. Section 11 survives expiration or termination of this Agreement. 12.INSURANCE On or before the Contract Time commences, Consultant shall furnish City with proof of compliance with City Insurance Requirements, attached and incorporated here as Exhibit D. City will not execute the Agreement until Consultant has submitted and City has reasonably approved receipt of satisfactory certificates of insurance and endorsements evidencing the type, amount, class of operations covered, and the effective and expiration dates of coverage. Alternatively, City may terminate this Agreement or in its sole discretion purchase insurance at Consultant's expense and deduct costs from payments to Consultant. 13.COMPLIANCE WITH LAWS 13.1 General Laws. Consultant shall comply with all laws and regulations applicable to this Agreement. Consultant will promptly notify City of changes in the law or other conditions that may affect the Project or Consultant's ability to perform. Consultant is responsible for verifying the employment authorization of employees performing the Services, as required by the Immigration Reform and Control Act, or other federal or state law, rule or regulation. City Project Tree Canopy Assessment Design Professional Agreement (single) /Rev. May. 2018 Page 6 of 10 13.2 Labor Laws. Consultant shall comply with all labor laws applicable to this Agreement. If the Services include a "public works" component, Consultant must comply with prevailing wage laws under Labor Code Section 1720 and other labor laws. To the extent applicable, Consultant must comply with City's Labor Compliance Program and with state labor laws pettaining to working days, overtime, payroll records and DIR Registration and Oversight. If the Contract Price is $30,000 or more, Consultant must comply with the apprenticeship requirement in Labor Code Section 1777.5. 13.3 Discrimination Laws. Consultant shall not discriminate on the basis of race, religious creed, color, ancestry, national origin, ethnicity, handicap, disability, marital status, pregnancy, age, sex, gender, sexual orientation, gender identity, Acquired-Immune Deficiency Syndrome (AIDS), or any other protected classification. Consultant shall comply with all anti-discrimination laws, including Government Code Section 12900 and 11135, and Labor Code Section. 1735, 1777 and 3077.5. Consistent with City policy prohibiting, Consultant understands that harassment and discrimination by Consultant or any of its subConsultants toward a job applicant, an employee, a City employee, or any other person is strictly prohibited. 13.4 Conflicts oflnterest. Consultant shall comply with all conflict of interest laws and regulations applicable to this Agreement and must avoid any conflict of interest. Consultant warrants that no public official, employee, or member of a City board or commission who might have been involved in the making of this Agreement, has or will receive a direct or indirect financial interest in this Agreement in violation of California Government Code Section 1090 et seq. Consultant may be required to file a conflict of interest form if Consultant makes certain governmental decisions or serves in a staff capacity, as provided in Section 18700 of the California Code of Regulations and other laws. Services may only be performed by persons who are not employed by City and who do not have any contractual relationship with City, with the exception of this Agreement. Consultant is familiar with and agrees to abide by the City's rules governing gifts to public officials and employees. 13.5 Remedies. A violation of this Section constitutes a material breach and may result in City suspending payments, requiring reimbursement, or terminating this Agreement. City reserves all its rights and remedies under law and this Agreement, including the right to seek indemnification under Section 11. Consultant agrees to indemnify, defend, and hold City harmless from and against any loss, liability, and expenses arising from noncompliance with this Section. 14.PROJECT COORDINATION 14.1 City Project Manager. The City's Project Manager for all purposes under this Agreement will be Teri Gerhardt , who shall have the authority to manage this Agreement and oversee the progress and performance of the Services. City in its sole discretion may substitute another Project Manager at any time and will advise Consultant of the new representative. 14.2 Consultant Project Manager. Subject to City's reasonable approval, Consultant's Project Manager for all purposes under this Agreement will be _Ia_n_H_a_n_o_u _____________ . who shall be the single representative for Consultant with the authority to manage compliance with this Agreement and oversee the progress and performance of the Services. This includes responsibility for coordinating and scheduling the Services in accordance with City instructions, service orders, and the Schedule of Performance, and providing regular updates to the City's Project Manager on the Project status, progress, and any delays. City written approval is required prior to Consultant substituting a new Project Manager, which shall result in no additional costs to City or Project delays. City Project Tree Canopy Assessment Design Professional Agreement (single) /Rev. May. 2018 Page 7 of IO 15.ABANDONMENT OF PROJECT City may abandon or postpone the Project with thirty (30) calendar days written notice to Consultant. Consultant will be compensated for satisfactory Services performed through the date of abandonment and will be given reasonable time to assemble the work and close out the Services. No close out work shall be conducted without City reasonable approval of closure costs, which may not exceed ten percent (10%) of the total time expended to the date of abandonment. All charges including job closure costs will be paid in accordance with the provisions of this Agreement and within thirty (30) days of Consultant's final invoice reasonably approved by the City. 16.TERMINATION City may terminate this Agreement for cause or without cause at any time, following reasonable written notice to Consultant at least thirty (30) calendar days prior to the termination date. Consultant will be paid for satisfactory Services rendered through the date of termination, but final payment will not be made until Consultant closes out the Services and delivers all Work Product to City. All charges approved by City including job closure costs will be paid within 30 days of Consultant's final invoice. 17.GOVERNING LAW, VENUE AND DISPUTE RESOLUTION This Agreement is governed by the laws of the State of California, excepting any choice of law rules which may direct the application of laws of another jurisdiction. Any lawsuits filed related to this Agreement must be filed with the Superior Court for the County of Santa Clara, State of California. Consultant must comply with the claims filing requirements under the Government Code prior to filing a civil action in court against City. The Agreement and obligations of the patties are subject to all valid laws, orders, rules, and regulations of the authorities having jurisdiction over this Agreement ( or the successors of those authorities). lf a dispute arises, Consultant must continue to provide the Services pending resolution of the dispute. If the Parties elect arbitration, the arbitrator's award must be supported by law and substantial evidence and include detailed written findings of law and fact. 18.ATTORNEY FEES If City initiates legal action, files a complaint or cross-complaint, or pursues arbitration, appeal or other proceedings to enforce its rights or a judgment in connection with this Agreement, the prevailing party will be entitled to reasonable attorney fees and costs. This Section survives the expiration/termination of this Agreement. 19.THIRD PARTY BENEFICIARIES There are no intended third patty beneficiaries of this Agreement. 20.WAIVER Neither acceptance of the Services nor payment thereof shall constitute a waiver of any contract provision. City's waiver of any breach shall not be deemed to constitute waiver of another term, provision, covenant or condition, or a subsequent breach, whether of the same or a different character. City Project Tree Canopy Assessment Design Professional Agreement (single) /Rev. May. 2018 Page 8 of 10 21.ENTIRE AGREEMENT This Agreement and all its Sections represent the full and complete understanding of the Parties, of every kind or nature, and supersedes any and all other agreements and understandings, either oral or written, between them. Any modification of this Agreement will be effective only if in writing and signed by each Patty's authorized representative. No verbal agreement or implied covenant will be valid to amend or abridge this Agreement. If there is any inconsistency between this main Agreement and the attachments or exhibits thereto, the text of the main Agreement shall prevail. 22. INSERTED PROVISIONS Each contractual provision or clause that may be required by law is deemed to be included and will be inferred in this Agreement. Either party may request an amendment to cure any mistaken insertion or omission of a required provision. 23.HEADINGS The headings in this Agreement are for convenience only, are not a part of the Agreement and in no way affect, limit, or amplify the terms or provisions of this Agreement. 24.SEVERABILITY /PARTIAL INVALIDITY If any term or provision of this Agreement, or their application to a particular situation, is found by the court to be void, invalid, illegal or unenforceable, such term or provision shall remain in force and effect to the extent allowed by such ruling. All other terms and provisions of this Agreement or their application to specific situations shall remain in full force and effect. 25.SURVIVAL All provisions which by their nature must continue after the Agreement ends, including without limitation those referenced in specific Sections herein, survive this Agreement and shall remain in full force and effect. 26.NOTICES All notices, requests and approvals must be sent to the persons below in writing to the persons below, and will be considered effective on the date of personal delivery, the delivery date confirmed by a reputable overnight delivery service, on the fifth calendar day after deposit in the United States Mail, postage prepaid, registered or ce11ified, or the next business day following electronic submission: To City of Cupet1ino 10300 Torre Ave. Cupertino CA 95014 Attention: Teri Gerhardt Email: Terig@cupertino.org City Project Tree Canopy Assessment To Consultant: Plan-it GEO -------------7878 Wadsworth Blvd, Suite 340 Arvada Colorado 80003 Attention: Ian Hanou '-'-'-----'-"-'-"-'------------Em ail: Ianhanou@planitgeo.com Design Professional Agreement (single) /Rev. May. 2018 Page 9 of I 0 27.VALIDITY OF CONTRACT This Agreement is valid and enforceable only if it complies with the contract provisions of Cupertino Municipal Code Chapters 3.22 and 3.23, is signed by the City Manager or authorized designee, and is approved for form by the City Attorney's Office. 28.EXECUTION ·The person executing this Agreement on behalf of Consultant represents and waITants that Consultant has the right, power, and authority to enter into this Agreement and cany out all actions herein, and that he or she is authorized to execute this Agreement, which constitutes a legally binding obligation of Consultant. This Agreement may be executed in counterparts, each one of which is deemed an original and all of which, taken together, constitute a single binding instrument. IN WITNESS WHEREOF, the parties have caused the Agreement to be executed on the Effective ·Date stated earlier in this Agreement. CONSULTANTPlan-it GEO, LLC ·Title CEO & Founder Date L/ {)..L \ I °l, 11Taxl.D. No.: 1,./S--L/!ij YbGJ<j . APPROVED AS TO FORM: HEATHER M. MINNER Cupertino City Attorney ATTEST: ·Gµ�l1A�GRACE SCHMIDT � -/I.{--/J City Clerk Citv Projecl Tree Canopy Assessment CITY OF CUPERTINO A Munici9ail Corporation "---I./ ,, By_ . . ,,,,---cf__---F Name Teri Gerbardt Title GlS Manacrer Date 04/22/20 l 9 Design Pn)/'essional Agreement (�inglc) /Rev. May. 2018 CITY OF CUPERTINO Project Summary INNOVATION AND TECHNOLOGY DEPARTMENT CITY HALL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 TELEPHONE: (408) 777-3223 • FAX: (408) 777-3366 CUPERTINO.ORG Tree Canopy Assessment: SCOPE OF WORK January 28, 2019 Cupertino is looking to contract with a consultant to provide a tree canopy assessment, for Cupertino's 11.31 square miles, that will help guide diverse and strategic tree planting, policy, and management planning by collecting, analyzing, and summarizing baseline tree canopy data. We would like a canopy change analysis performed using Cupertino's 2006 and 2016 LIDAR data and 3inch aerials for the same timeframes. As well as a priority planning analysis to identify optimal locations for future plantings based on need and specific criteria. Business Reasons: Amount of tree canopy coverage is typically a reflection of a variety of factors - including intentional planning and investment. Studies throughout the United States have repeatedly shown that most communities are losing tree canopy due to a wide range of threats, including insects, disease, natural disasters and development. An Urban Tree Canopy [UTC) Assessment can help a community measure, monitor, and improve tree cover over time, and combat threats that can lead tree canopy loss. The aim of the Urban Tree Canopy (UTC) Assessment is to help decision makers understand their urban forest resources, particularly the amount of tree canopy that currently exists and the amount that could exist at multiple scales. The information from this assessment will be used to inform UTC goals, prioritize locations for tree planting efforts, establish urban forestry master plans, understand patterns of environmental justice, inform sustainability plans, and justify budget increases for urban forestry programs. Customers: Cupertino staff and citizens Customer Benefits: Urban Tree Canopy (UTC) refers to the layer of tree leaves, branches, and stems that provide tree coverage of the ground when viewed from above. Today, many communities are planting trees in an effort to become more sustainable and livable. Improving a city's urban tree canopy can have numerous benefits, including reducing summer peak temperatures and air pollution, enhancing property values, providing wildlife habitat, providing aesthetic benefits, and improving social ties among neighbors. A robust tree canopy can also attract businesses and residents. Scientists now have the ability to qualify and quantify the benefits of urban tree canopy, using the Urban Tree Canopy (UTC) Assessment suite of tools. An increase in urban tree canopy brings an associated increase in the tree benefits listed above. Give Cupertino Tree Division the information to inform UTC goals, prioritize locations for tree planting efforts, establish urban forestry master plans, understand patterns of environmental justice, inform sustainability plans, and justify budget increases for urban forestry programs. Cupertino Tree Data https://gis-cupertino.opendata.arcgis.com/datasets?q=tree Let me know if you have any questions, otherwise please send a proposal, with a cost breakdown, to my email below. Be sure to include references and details on the project completed for the client. Sincerely, Teri Gerhardt GIS -Manager Innovation Technology TeriG@cupertino.org (408)777-3311 PLANITGEO' CUPERTINO mopping o greener future Ian S. Hanou CEO/Founder and Senior Project Manager, Plan-It Geo, LLC ianhanou@planitgeo.com I (303) S03-4846 CO NTE NTS PROJECT UNDERSTANDING TEAM SKILL SET & EXPERIENCE ........................................................................................... STAFF BIOS ......................... . ....................... PROJECT REFERENCES . .................................................... .STAFF EXPER IENCE PROJECT APPROACH & METHODOLOGY 12 ......................... . ........ PROJECT MANAGEMENT, INITI ATION,AND COMMUNICATIONS 12 .. . . ........ URBAN TREE CANOPYASSESSMENT TREE PLOTTER & DECISION SUPPORT PROJECT PRICING TIMELINE & SCHEDULE TREE CANOPY ASSESSMENT I CUPERTINO, CA APRIL2019 U ND ERST AND ING APRIL 2019 TREE CANOPY ASSE SSMENT I CUPERTINO, CA 5 Ian Hanou, Founder, Owner, and Senior Reviewer Jeremy Cantor, Director of Geospatial Services and Project Co-Manager Maegan Blansett, GIS & Natural Resource Specialist Ben Wittman, GIS Specialist & Software Technician Carrie Asselmeier GIS & Natural Resources Technician TREE CANOPY ASSESSMENT I CUPERTINO, CA APRIL 2019 Project References Report: https://issuu.com/planitgeoissu u/docs/bellevue wa -tree canopy assessmen Canopy Planner: https://pg-cloud.com/KinqCD-Cities/ Report: https://issuu.com/planitgeoissuu/docs/jacksonville urban tree canopy repo Canopy Planner: https://pg-cloud.com/JacksonvilleFL/ Report: https://issuu.com/planitgeoissuu/docs/colorado springs co -tree canopy a Canopy Planner: https://pg-cloud.com/ColoradoSpringsCO/ Canopy Planner: https://pg-cloud.com/DDOTUFA/ Report: https://issuu.com/planitgeoissuu/docs/grand rapids utc assessment report Canopy Planner: https://pq-cloud.com/michiqan/ APRIL 2019 TREE CANOPY ASSESSMENT I CUPERTINO, CA CEO & Founder Ian has 18 years of experience applying innovative geospatial, software, and business solutions in forestry, urban forestry, planning, natural resources, and water resources. His work involves human resources, GIS, ecosystem services, technical writing, software design, and business development with all levels of government agencies, private sector, nonprofits and universities. He has presented at 100+ conferences on the use of technology for urban forestry, mapping, and green infrastructure. He is prof icient in contract administration, spatial analysis, training, public speaking, marketing, employee development, and project management. EDUCATION Bachelor of Science in Forest Management, GIS & Remote Sensing Minor I Colorado State University, 2001 PROFESSIONAL AFFILIATIONS Society of American Foresters I Front Range Urban Forestry Council I GIS Colorado URBAN TREE/FOREST CANOPY ASSESSMENTS AND PROJECTS Washington State Urban Tree Canopy {UTC} Assessments Since 2007, managed GIS/RS canopy studies in Seattle, Kirk land, Vancouver, Thurston County, Shoreline, Bothell, Snoqualmie, Issaquah, and others, including canopy change analysis, reporting, Council presentation, and i-Tree. Calgary, Alberta: Tree Canopy Assessment Managed a GIS/RS assessment of canopy and priority planting areas analysed for 292 communities, 67 land use types, and 300,000 parcels; developed a GIS-based suitability model to prioritize tree planting. Mississauga, Ontario: Mississauga Urban Forest Canopy Re-Assessment 2007-2074 and City Council Presentation Managed a follow-up UTC to a 2007 study Mapped updated land cover and urban forest canopy distribution for 2014, and evaluated canopy cover changes over time, as well as historical canopy trends since 1992. Included data analysis, custom maps and tools, and broad recommendations for setting and achieving canopy objectives. Oakville, Ontario: Canopy Assessment, EAB Risk Management Mapping, and Goal Setting Scenarios Managed multiple UFC analysis and scenario planning studies since 2010. Included a hyperspectral imaging analysis of ash/EAB risk management and mapping of current canopy and available planting area town-wide, by communities, and by land use types. Lead GIS/RS consultant on a team to re-analyze Oakville's canopy in 201S/2016. Columbus, OH: Urban Tree Canopy Assessment, i-Tree Hydro Analysis, and Custom Canopy Planner Tool Managed this 250 square mile study, created planting prioritization and scenario tools, and provided training. Treasure Valley, Idaho: Urban Tree Canopy Assessment, i-Tree Eco Analysis, and Scenario Tool Development Conducted a 265 square mile study and created planting prioritization and scenario tools using CommunityViz (Esri land use planning extension) and i-Tree Eco data values. Classif ied land cover using remote sensing, summarized data at a variety of assessment scales, analysed ecosystem services, and reported all methods and findings. Provided training in Boise to 30+ attendees from the region (planners, GIS, foresters, park managers, etc.). TREE CANOPY ASSESSMENT I CUPERTINO, CA Director of Geospatial Services Jeremy contributes to GIS modeling, remote sensing analysis of multispectral and LiDAR imagery, data production, IT, cartography, task management within the geospatial team, Urban Tree Canopy (UTC) assessment reports and delivery, and web/mobile mapping app design. Prior to joining Plan-It Geo in 2016, Jeremy worked in the Ocean & Coastal Resources Branch of the National Park Service Water Resources Division for seven years focusing on coastal systems, geospatial analysis, and website design/online mapping applications. EDUCATION Master of Natural Resources Stewardship in Spatial Information Systems I Colorado State University, 2010 Bachelor of Arts in Geography; Economics Minor I University of Vermont, 2006 GEOSPATIAL PROJECTS Urban Tree Canopy Assessments APRIL 2019 Jeremy has led and managed accurate and comprehensive analyses to assess the current status of tree canopy and available planting space. Tasks managed included remote sensing classification, canopy analysis, GIS mapping, tree planting prioritization, summary reports, and web-map design. Communication, training, and presentations of project deliverables were provided throughout the project and upon completion. Project locations include: West Palm Beach, FL (58 mi 2, 2019); Charlotte, NC (308 mi 2, 2018); Colorado Springs, CO (194 mi2, 2018); King County, WA (12 cities, 170 mi2, 2018); Richmond Hill, ON (39 mi 2, 2018); Wichita, KS (160 mi2, 2018); Snake River Valley, ID (15 cities, 160 mi 2, 2017); Jacksonville, FL (508 mi 2, 2017); Snoqualmie, WA (7 mi2, 2016); Washington, DC (62 mi2, 2016); and Denton, TX (115 mi2 , 2016). Million Trees Miami: Miami-Dade County Canopy Action Plan and Interactive Online Tree Tool Served as a GIS analyst and web designer to provide an online engagement tool for the public and tree managers to view existing canopy, plan priority reforestation efforts based on envi ronmental, health, and socioeconomic data, and track newly planted trees as a means to achieve local and regional canopy goals. (https://pg-cloud com/MillionTreesMiami/) Denver, Colorado: South Platte River Urban Waters Partnership Natural Capital Grant Project Served as a GIS analyst to map and evaluate the regional network of green infrastructure in Colorado's South Platte River watershed (6,000 square miles). Derived spatial data were used to develop a tool to prioritize key areas for conservation and restoration based on the ecosystem services that the natural resources provide (https://pg-cloud.com/NaturalCapital/). Washington, D.C.: Community Forestry Resource Guide, Canopy Strategy, and Management Handbook Contributed textual content, graphics, and styling to this document which provided a strategy for managing the region's urban forest and a handbook to guide Metro Washington Council of Government's ap proach to community engagement and outreach as it relates to education and encouraging tree planting, protection, and engagement strategies. The handbook also included an i-Tree demonstration project and user guide for i-Tree Canopy. Mesa, Arizona Parks and Recreation Strategic Plan Contributed to the plan by analysing environmental justice and the level of service provided by Mesa's parks and recreation facilities. Several subsets of Mesa's population were studied to determine how access for vulnerable residents (elderly or young) and residents living in poverty compare to that of the overall population. PLAN IT GE0- mopp,roy a ljlrt:Umu, Cuh•tO APRIL 2019 TREE CANOPY ASSESSMENT I CUPERTINO, CA CIS and Natural Resources Specialist Maegan graduated from the University of California, Santa Barbara with a Master's in Environmental Science and Management, where she specialized in Conservation Planning and Strategic Environmental Communications. She has a Bachelor's in Physical Geography with a minor in Forestry and Natural Resources from the University of California, Berkeley. Maegan supports Plan-It Geo's urban tree canopy assessment swith data management, spatial analysis, QA/QC of remote sensing products, client communication, reporting, 9 proposals, and task management. Prior to joining the geospatial services team, she coordinated a water quality testing program at the Goleta Water District in Southern California and served a year as an AmeriCorps member focused on expanding urban gardens at public housing communities in New York City. EDUCATION M.E.S.M. in Conservation Planning, University of California -Santa Barbara, 2017 BA in Geography, Minor in Forestry & Natural Resources, University of California -Berkeley, 2014 GEOSPATIAL PROJECTS Urban Tree Canopy Assessment and Change Analysis, Colorado Springs, Colorado Provided a baseline and benchmark of the City's tree canopy and possible planting areas for the first time, and also assessed canopy cover at two past time periods using a point-based sampling method. High resolution aerial imagery from three time periods was utilized to map current tree canopy cover and perform a change analysis. Performed the change analysis, designed a public opinion survey to launch the project, and assisted with data preparation and analy .sis, project management, reporting, public presentations, and client communications Urban Tree Canopy Assessments and ,Tree Hydro study, King County, Washington Provided an updated baseline and benchmark of tree canopy and other land cover types for over a dozen municipalities in the county, as well as three additional pilot communities' tree canopy as it relates to stormwater benefits. High resolution aerial imagery and LiDAR was utilized to map current tree canopy cover, as well as perform a change analysis from a previous year's study where municipalities had previous study data available. Contributed to data gathering, QA/QC of remote sensing products, project management/client communications, and all reporting. Urban Tree Canopy Assessment and Data Preparation, Snake River Valley, ID This assessment of five study areas throughout the state of Idaho provided a benchmark of tree canopy and other land cover types, identified areas suitable for future tree plantings, and prioritiz ed planting sites based on a number of environmental and social criteria in order to update the state's existing Canopy Planner software app with the most recent canopy and planting space metrics. Performed the planting site suitability analysis and assisted with reporting, metadata, and delivery of final products. Urban Tree Canopy Assessment and Change Analysis, Shoreline, Washington Provided an updated baseline and benchmark of the City's tree canopy and other land cover types using remote sensing of high-resolution 2017 imagery and LiDAR, and compared changes in canopy since a previous study conducted in 2010. Assisted with QA/QC of remote sensing products, change analysis, accuracy assessment, project management, client communications, and report writing. TREE CANOPY ASSESSMENT I CUPERTINO, CA CIS Natural Resources Specialist APRIL 2019 EDUCATION GEOSPATIAL PROJECTS Urban Tree Canopy Assessments SOFTWARE PROJECTS Tree Plotter applications Canopy Planner applications APRIL 2019 TREE CANOPY ASSESSMENT I CUPERTINO, CA CARRIE ASSELMEIER G/5 & Natural Resources Technician Carrie has a background in ArcGIS analysis, urban forestry, i-Tree tools, natural resources, and conservation. Carrie joined Plan-It Geo in 2017 to assist with urban tree canopy assessments by performing quality assurance/quality control (QA/QC) on remote sensing land cover classification data, GIS analysis, hydrology modeling, map making, and report writing Most recently, Carrie has contributed most of her time at Plan-It Geo to a large stormwater management and analysis project for the Puget Sound region in Washington State. 11 Prior to Plan-It Geo, Carrie interned with Chicago Wilderness working on conservation issues and GIS. Most recently, she worked for Cherry Creek State Park to educate park visitors and prevent the spread of aquatic nuisance species. EDUCATION Bachelor of Arts in Geographical and Sustainbility Science I University of Iowa, 2014 GEOSPATIAL PROJECTS Puget Sound Urban Tree Canopy and Stormwater Analysis As Plan-IT Geo's primary point of contact and GIS analyst for this comprehensive, multi-city project, Carrie conducted background research, collected data, performed hydrological modeling, and contributed to the technical report and handbook. Carrie Modeled six tree canopy scenarios in four pilot communities (Kent, Kirkland, Snohomish and Tacoma, WA) in i-Tree Hydro at 4 different scales. Both i-Tree Hydro and a local hydrological modeling program (Western Washington Hydrology Model, or WWHM) were used to estimate the amount of stormwater runoff present in various land cover change scenarios across a six-year time span. The results of the modelling were then used to create both a technical report of the findings and a handbook designed to provide advice to communities wishing to make use of these tools. Other Urban Tree Canopy Assessments As a GIS Technician, Carrie has performed a variety of different tasks for urban tree canopy assessment projects across the U.S. and Canada, such as land cover classif ication quality control, data/spreadsheet analysis, cartography, ESRI ArcGIS spatial analysis, canopy change analysis, socioeconomic impact analysis, technical report writing, metadata, and delivery of final data to clients. Project locations included: Downtown Denver (l mi 2, 2018) and Colorado Springs (195 mi2, 2019), CO Dallas County (966 mi2, 2019) and Rowlett (20 mi2, 2017), TX King County (203 mi 2, 2018) and Shoreline (11.5 mi 2, 2017), WA Jacksonville (588 mi 2, 2017) and West Palm Beach (58 mi2, 2017). FL Richmond Hill (40 mi 2, 2017) and Cambridge (44 mi 2, 2018), Ontario, Canada Snake River Valley, ID (80 mi2 , 2017) Wichita, KS (165 mi 2 , 2018) Charlotte, NC (308 mi 2, 2019) 12 TREE CANOPY ASSESSMENT I CUPERTINO, CA METHODOLOGY Project Management, Initiation, and Communications APRIL 2019 Data Collection Urban Tree Canopy Assessment APRIL 2019 TREE CANOPY ASSESSMENT I CUPERTINO, CA Land Cover Mapping Plan-It Geo is an industry leader in spectral and spatial remote sensing analysis, particularly using object based image analysis (OBIA) for various urban land cover classifications. This is a critical technique for accurately and cost-effectively mapping the region's tree canopy and plantable spaces. We utilize Feature Analyst software vS.2 for the OBIA classification which uses spectral and texture analysis and pattern recognition through an iterative machine-learning approach. High resolution (l-meter). multi-spectral (4 -band) 2018 NAIP imagery (U.S. Department of Agriculture National Agriculture Imagery Program) will be used when it becomes available in the coming months. The City has stated that it possesses aerial imagery and LiDAR data collections from 2006 and 2016 in the study area. These datasets will be evaluated to determine whether the resolution, quality, and collection dates meet our requirements Plan-It Geo will assist the City in selecting which imagery will be the best fit for this project We employ a statistically and functionally rigorous protocol for classif ication and quality assessment and control (QA/QC) Our technicians will manually correct errors in the automated classification at a scale of l:l,250, repeating until targeted accuracies are reached. We have budgeted to achieve at least 92% overall mapping accuracy, with at least 94% user's accuracy specifically for tree canopy with a minimum mapping unit (MMU) of 3x4 meters. The canopy layer will be provided for review and acceptance prior to other steps in the project. FGDC-compliant metadata will be provided for all spat ial datasets created. Land Cover Classes Urban tree canopy mapping will include all vegetation generally greater than 10-15' tall, based on multispectral imagery, LiDAR height, and object-oriented classif ication techniques. Imagery will be used in an OBIA classification technique using spatial and spectral information (visible and near-infrared bands). textural analysis (shadowing). and pattern recognition. On-the-ground images from Google Street View will be used for training of the remote sensing classification inputs and for verif ication/ ref inement of the classification outputs. It may be useful to obtain photos from the local communities of any areas that cannot be identified. The City's existing city owned tree inventory may also be included in the mapping process as reference for small/newly planted trees. Other (non-canopy} vegetation will include shrub/scrub vegetation, turf grass, and open space. Following the remote sensing classification and final QA/QC of the tree canopy data layer, the output will be used as a mask to extract all other types of vegetation using a Normalized Difference Vegetation Index (NDVI) analysis or similar technique. Results will represent all areas of healthy grass cover, based on the time of imagery capture, with a focus towards plantable areas for the purpose of this study and intended use of the data. If useful, we can incorporate land use or zoning data to separate open space areas that are residential (plantable) vs. agricultural (not plantable). The results will be at an individual pixel level and will be smoothed and aggregated to a reasonable size for urban forestry and other planning applications (water conservation and supply planning). No specific MMU is proposed as the patch size can be easily adjusted at the end and incorporated along with the other land cover classes. lmpervio ussurfaceswill comprise all paved surfaces and hardscapesand be broken out (sub-categorized) using existing data that the City is able to provide. These sub-categories can include streets, parking lots, buildings, sidewalks, and "other impervious areas" such as patios, driveways, and other miscellaneous hardscape surfaces (to be discussed at the project kickoff meeting). These digitized impervious surface polygons (and any buffered point or line features for buildings, roads, etc.) will be incorporated into the land cover classification by overlaying "on top of" the impervious surface areas that are extracted via automated image classification procedures. This will also be valuable when merged with all other impervious layers to account for tree canopy overhang of built-up surfaces. TREE CANOPY ASSESSMENT I CUPERTINO, CA APRIL 2019 Bare soil will include barren soil, gravel pits, exposed dirt/open construction, rock, and sand as well as dry (non-photosynthetic) vegetation. The MMU will be 5x5 meters with individual class accuracy of at least 92%. Water will be mapped from the base imagery and available hydrologic features such as lakes, rivers, ponds, and streams. The MMU will be 5x5 meters with individual class ac curacy of at least 92%. After remote sensing automation and QA/QC of all land cover classes, we will conduct a point-based accuracy assessment. The result will be a standard error (confusion) matrix which we have included routinely on land cover and UTC assessments. Once the tree canopy layer has 94% user's accuracy or higher and overall accuracy for all classes reaches 92%, we will send samples of the results to the City for review and approval before proceeding with the GIS-based modeling of land cover and UTC metrics. The estimated National Map Accuracy Standard for the horizontal (positional) accuracy of the land cover data will be dependent upon the accuracy of the imagery as all data will be derived from it. The following land cover raster layers will be produced: 5-class (tree canopy, other vegetation, impervious, bare soil, and water) and all-class (separate impervious classes for building, road, parking, and "other" impervious background areas that are provided) In addition, separate raster and vector files will be delivered for tree canopy and all impervious surfaces. The final land cover products will be delivered in vector and raster Format (shapefile and TIFF) in the UTM Zone lON coordinate system and meet the Federal Geographic Data Committee (FGDC) metadata guidelines. Assessment and Prioritization of Potential Plantable Space As part of our land cover mapping process, we will digitize areas that are unsuitable for tree planting to ensure that the plantable spaces presented to the City are accurate and realistic. These areas include, but are not limited to, above-ground utility corridors, recreation fields, golf course playing areas (tees, fairways, greens), and other features desired by the City. We refer to this as Possible Planting Area -Vegetation, while parking lots, sidewalks, and driveways, sub-types of total imperv ious where slight modification of the landscape could result in plantable space with enhanced ecosystem benefits, is called Possible Planting Area -Impervious. 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ASSESSMENT BOUNDARIES TN:r,s1w,-iutWn!r.MIGl'llpt(VTC).1nd�kt pbn11ng �t&.x (PP,t,j at multi� Q"°Jlilphlc: =I.is 1n orck• lO pro,11(111 xton;;tilril lnfoim•uon to :;i dMlfl;a rar,v11 o, � 8"/ IOl!nn�ng wN1 ,a:uces. •nd oooortunite;a,,gtum..s8K.1M.thOCtycanbllr'nOlll p,wctJW in 1/""QI, ilPPl�h to Pl'OUICI. and o��nd tha<.1rb,m1rwc-nopy M•111e,.,.,-erogaNrau1C1 illtnci lo!k:M1ng O(iO!;lr;phlc 1:1::al;1s:1hllcny.\1C» bcund;11yD): ceyccuncn dt.trlCU (61: w:ito�s ru� ZIP cooos (211t n11ir)hbo/00Cdi (77): consir. Cib:k g,otJi::r;; pgs): CIIMu, blocb{lO.BSJ�bndllll!r.,p!i"S[non-iQ91QOiwd l7J.6. a111"Jreg;�61�¥1dJ)i(CilsflS73"li RECOMMENDATIONS ll"IQr�t11$ol\l"IIS,an�5c;nbllir...Kl10oolWboa oori1nt11"1!] r,lan ilna 5trat.,gy to p,t",CIICI ;ird 11'<"!Mnd thGurtwl/ol",1'1,tl"IColor;tdc:15p1ri�TilllLJTC.1rd&1eit. me1ncs should be uSw<J a; a QUtda to �rerm1n11 v.nare lNO'rjtu;�RJCCIIWU!lnprutli'CtlOQ;md0-p,;rdr11] IU. vrban for� rt>SO..Wca. .... hllr.l! al!D ta,�ung arms to cono.nu;tefuure1N�l'n!Jnteflortsb.s;;c1on� t•n...tn.s, •nd ........ :;;� pl.1nt1ng sp:;ica c:olor�o S0M9s C41lU:;.Jthos.ow..tlltttDtom ;c)uCatothoCOOVT"U"l'C'/ ato.A: th11 1mpo,unca ot 1hlil urtun felli51 �nd cmwra lhH oollc:IZ ;nd m.ln:ii;i;1rn;in1 pr;xo;;� CClltlfl\/,) IC po:i1101ii m; IN\/ll11n.1na;,, r.;a•I\ �ndgro,,.th m< URBAHTRE:E CANOPY 32% IMPERVIOUS SUR!=ACE: 29% POSSIBLE PLANTING AREA F1p4Ke l. J Based en on an�""UI of20 rs h/gh-rMoludcn ltn09"')\ cobTJdo Sp,lngli canttllnr 17':'ii u .. conopy. .nK Ql"\IUl.thotcolidsvppounmopyt, ih11/vtun,, and J29'rcnollmi,9rv.buson,aL. APRIL 2019 TREE CANOPY ASSESSMENT I CUPERTINO, CA 17 TREE PLOTTER & DECISION SUPPORT Plan-It Geo specializes in building cost-effective, spatially aware, decision support and operational productivity tools with a specialty in integrating GIS with science-based ecosystem benefit models and forestry/natural resources data. Our suite of software tools includes Tree Plotter, Parks Plotter, Work Order Management, and Canopy Pia nne1·, as well as a dozen or more custom web browser mapping applications. We have more than 70 software clients (see https://treeplottercom/clien ts/) with more than 250 users through statewide or regional tools in Colorado, Idaho, Iowa, Mississippi, Missouri, Nebraska, New Mexico, Pennsylvania, and Wisconsin, and large cities such as Saskatoon, Saskatchewan. Upon completion of land cover mapping, UTC assessment, and planting prioritization, we propose developing a powerful yet easy to use web-based decision support and prioritization tool for planners, resource managers, and arborists. This Canopy Planner tool can be seamlessly integrated with an existing Tree Plotter application to allow the City to dynamically view areas of canopy cover and plantable space, prioritize planting areas based on environmental, socioeconomic, and demographic factors, run hypothetical canopy growth scenarios, and map out tree planting sites based on this information. Canopy Planner Online Software Canopy Planner can provide many benefits to the City of Cupertino and increase the value, accessibility, and usage of the tree canopy assessment data by city staff, partners, and community members. It is a web-based interactive map of tree canopy and plantable space, accessible to the public and city departments, that allows users to explore existing canopy and planting areas data, prioritize planting spaces, and interactively create "grow out" scenarios. Three tools are included: l.The View' tool component of Canopy Planner allows users to easily choose a geographic scale (e.g. land use, census boundaries) and display% metrics or filter data with slider bars. 2.The 'Plan' tool is a GIS-based prioritization tool that requires GIS analysis and data preparation. We suggest 7-8 criteria be included. Weights from low to high are then set by the user for each criterion to see the thematic map update with priority areas based on the ranks and weights applied for specific objectives. Examples include existing tree canopy, plantable space, urban heat islands, stormwater management, air quality improvement, wildlife habitat connectivity and enhancement, and socioeconomic and demographic indicators. 3.The 'Grow' tool allows users to simulate future canopy cover in relationship to planting goals. Additionally, ecosystem benefits provided by modeled canopy scenarios are shown using i-Tree values on air quality and carbon sequestration and storage. Examples of current Canopy Planner software applications include: Jacksonville, Florida -https//pg-cloud com/JacksonvilleFL/ King Conservation District, Washington -https//pg-cloud com/KingCD-Cities/ Denton, Texas -ht tps//pg-cloud com/Denton TX/ 18 TREE CANOPY ASSESSMENT J CUPERTINO, CA 00 Home Tools View 00 SUIS Canopy Dita Plan Grow Uu tM slld;1 t;a;s �low to make ma.05 Gt Hlst!ng UrNf\ Tree Canopy aoaJor Poss,b'f Fl anti no Arus � Siel!!'cl a G�graphy J Census Block Groups ·I Urban TrH Clnopy '\ o n 9--------� ,0 .. Average;ll 60 BO Tot• Possl»a Pi.rtlng AIH" � 0 83 9----.-,� 20 40 60 80 ,oo HM?MPMI See the distribution of tree canopy and planting space. t�UM?i Launch View Tool Weight and prioritize criteria to determine suitability for planting. • � UMfi?i Launch Plan Tool Evaluate potential tree canopy goals and tree numbers to reach goals, fo recast future benefits, and compare scenarios. C� UMfi?i Launch Grow Tool Wichita, KS • Tree Plotter and Canopy Planner APRIL2019 ..... Canopy !I Urban TtH Cl.nopy '\ n APRIL 2019 TREE CANOPY ASSESSMENT I CUPERTINO, CA 19 PROJECT----P RI Cl NG We propose the following tasks be performed to provide Cupertino with a comprehensive assessment of their tree canopy. Each proposed task is described below with an associated cost. Individual tasks can be selected or omitted in order to best align with City goals. ,'ih:1!3 -� II -:l.."1'"41•1H•JII ''- l.UTC Assessment of Classify all tree canopy and land cover using LiDAR and high- Cupertino, CA (11 mi2}resolution (l m} 2018 NAIP imagery or city provided multispectral -- (4-band} imagery from 2016 la. Tree canopy 1-class raster (.tif} and/or vector (.shp) with 94% accuracy and $4,500 classification minimum mapping unit of 3x4 m2. 5-10-class raster GIS data with 92% accuracy overall: -Tree canopy lb. Wall-to-wall land -Other vegetation cover classification -Impervious (based on image analysis and merged with existing $4,000 (* Requires la} data for buildings, roads, parking lots, etc.} -Soil/ Dry vegetation -Water 3-class raster GIS data: le. Possible planting -Urban tree canopy -Possible planting area Vegetationarea assessment -Possible planting area Impervious (requires impervious sub-$1,000 (* Requires la and/or types from lb)lb) -Unsuitable areas (based on available data and manual digitizing of ball fields, golf courses, airports, etc.) ld. Assessment Includes assessment of three geographies plus the main area boundaries of interest (city boundary), GIS data, maps, and an assessment $3,500 spreadsheet for each assessment boundary. Delineation of tree canopy in a previous year using historic aerial imagery and same methods as with current time period to locate 2. Canopy change specific areas of change. Includes change metrics and maps for $6,500 analysis all assessment boundaries. Assumes use of city-provided imagery or free NAIP imagery. Otherwise, added cost for historical high- resolution satellite imagery. 3. Priority planting Identify optimal locations for future plantings based on need and $3,000 analysis other criteria. Includes maps and GIS data layers. 4.Ecosystem services Quantify the economic benefits of the City's canopy using i-Tree $1,500 analysis tools. Inclusion in report. 5. Project report Includes 2 drafts and l final. $8,000 6.Summary fact sheet Includes 2 drafts and 1 final. $1,000 7.Incorporation of The City will be able to display and interact with layers canopy assessment showing existing canopy, possible planting areas, and planting data in existing Canopy prioritization. Price discounted heavily based on existing Tree $500 Planner software for 1 Plotter software application. Annual renewal required at same year cost. .. ' � •. ,·J· :·.; · . ,' " c··.e .. · .·,., � ,. ·"' .· TREE CANOPY ASSESSMENT J CUPERTINO, CA APRIL 2019 Kickoff meeting to confirm deliverables, methods, and required data sets. Urban tree canopy and land cover mapping and assessment, possible planting area assessment. Mid-project meeting to review land cover mapping upon completion. Canopy change, priority planting, ecosystem services analyses Report and Fact Sheet Final delivery of all data April 2019 May 2019 May 2019 June 2019 June 2019 PLAN IT GEO" CUPERTINO mapping o greener fulure � ACC>RC::l' CER TIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) ..___., 05/07/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).PRODUCER CONTACT NAME: STA NTON INSURANCE LLC/PHS 34340017 PHONE (866) 467-8730 IFAX (888)443-6112(A/C, No, Ext): (A/C, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78265 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A: The Sentinel Insurance Company 11000 PLAN-IT GEO LLC INSURER B: Hartford Fire and Its P&C Affiliates 00914 7878 WA DSWORTH BLVD STE 340 ARVADA CO 80003-2146 INSURER C: INSURER D: 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. INSR LTR .A A A B TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY D CLAIMS-MADE 0 OCCUR x General Liability GEN'L AGGREGATE LIMIT APPLIES PER: � POLICY D PRO-JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO @Loe -ALL OWNED -SCHEDULED - X - ..x AUTOS AUTOS -HIRED NON-OWNED AUTOS X AUTOS - UMBRELLA LIAB n OCCUR EXCESS LIAB CLAIMS-MADE DEDJ X I RETENTION $ 1 0, 000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY Y/N PROPRIETOR/PARTNER/EXECUTIVE COFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below DATA BREACH -DEFENSE & LIAB COVG ADDL INSR X X X N/A SUBR POLICY NUMBER POLICY EFF POLICY EXP WVD IMMIDD"'""'" IMMIDDN YYYI X 34 SBA AA8144 01/16/2019 01/16/2020 X 34 UEC ID3036 01/16/2019 01/16/2020 34 SBA AA8144 01/16/2019 01/16/2020 34 WEC 180462 06/29/2018 06/29/2019 34 SBA AA8144 01/16/2019 01/16/2020 LIMITS EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence\ MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS -COMP/OP AGG COMBINED SINGLE LIMIT I /Ea accident\ BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) EACH OCCURRENCE AGGREGATE JPER IX JOTH-STATUTE -ER E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE E.L. DISEASE -POLICY LIMIT $2,000,000 $1,000,000 $10,000 $2,000,000 $4,000,000 $4,000,000 $1,000,000 $2,000,000 $2,000,000 $1,000,000 $1,000,000 $1,000,000 $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Those usual to the lnsured's Operations. City, its City Council, boards and commissions, officers, employees and volunteers shall be named as additional insureds. Coverage provided is primary/non-contributory per form SS0008 attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy. CERTIFICATE HOLDER CANCELLATION CITY CLERK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED CITY OF CU PERTINO BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 10300 TORRE AVE IN ACCORDANCE WITH THE POLICY PROVISIONS. CUPERTINO CA 95014-3202 AUTHORIZED REPRESENTATIVE 6 U&.?UJ £ Ca:1� © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD t- THEt1 HARTFORD CITY CLERK THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014-3202 Account Information: J Policy Holder Details : J PLAN-IT GEO LLC May 7, 2019 tO 'it Contact Us Business Service Center Business Hours: Monday -Friday (7 AM -7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: aqency.services@thehartford.com Website: https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 POLICY NUMBER: 34 SBA AA8144' CHANGE NUMBER: 003 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): CITY, ITS CITY COUNCIL, BOARDS AND COMMISSIONS, OFFICERS, EMPLOYEES AND Location(s) Of Covered Operations: VOLUNTEERS. 10300 TORRE AVEO CUPERTINO CA 95014-3202 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.Section C. -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omissions; or 2.The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. Form SS 41700611 Process Date: 04/04/19 B.With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Page 1 of 1 Policy Expiration Date: 01/16/20 © 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission) POLICY CHANGE (Continued) Policy Number: 34 SBA AAB144 Policy Change Number: 003 FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: ss 41 70 06 11 IH12001185 ADDITIONAL INSURED -OWNER, LESSEES OR CONTRACTOR IH12001185 WAIVER OF SUBROGATION FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: ss 41 71 06 11 Form SS 12110405 T Process Date: 04/04/19 Page 002 Policy Effective Date: 01/16/19 Policy Expiration Date: 01/16/20 POLICY NUMBER: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section C. -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 "bodi ly injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- completed operations hazard". Form 55 41 71 06 11 Process Date: © 2011, The Hartford Page 1 of 1 Policy Expiration Date: (Includes copyrighted material of Insurance Services Office, Inc., with its permission) POLICY NUMBER: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Form IH 12 00 11 85 T SEQ. NO. Printed in U.S.A. Page Process Date: Expiration Date: POLICY NUMBER: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Form IH 12 00 11 85 T SEQ. NO. Printed in U.S.A. Page Process Date: Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 00 03 13 Process Date: SCHEDULE Policy Expiration Date: INSURANCE ENDORSEMENT ATTACHED *** PLEASE REVIEW THE CHANGE*** The Hartford Har tford Fire Insurance Company and its Affiliates One Hartford Plaza, Hartford, Connec ticut 06155 l THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 34 SBA AA8144 DX Named Insured and Mailing Address; PLAN-IT GEO LLC 7878 WADSWORTH BLVD STE 340 ARVADA CO 80003 Policy Change Effective Date: 03/28/19 Policy Change Number: 003 Agent Name: STANTON INSURANCE LLC/PHS Code: 340017 POLICY CHANGES: Effective hour is the same as stated in the Declarations Page of the Policy. SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT. IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED ADDITIONAL INSURED IS CHANGED TO READ: LOCATION 001 BUILDING 001 ADDITIONAL INSURED #1 -OWNERS, LESSEE OR CONTRACTORS IS REVISED FORM NAME ADDRESS SS4170 SS4171 CITY, ITS CITY COUNCIL, BOARDS AND COMMISSIONS, OFFICERS, EM PLOYEES AND VOLUNTEERS. 10300 TORRE AVEO CUPERTINO CA 95014-3202 PRO RATA FACTOR: 0. 806 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12110405 T Process Date: 04/04/19 Page 001 (CONTINUED ON NEXT PAGE) Policy Effective Date: 01/16/19 Policy Expiration Date: 01/16/20 COMMERCIAL LINES 11.UTOMAT!ON -SPECTRffi.i SUMM.ll.R.Y POLICY INFORMATION NAMED INSURED: PLJI..N-IT GEO, LLC AGeNT CODE AND NAMJ:!: 310017 STANTON N'SURANCE LLC/PHS PAGE COMPA..NY CODE AND NAME: A SENTINEL INSURANCE COMP� .. NY, LIMITED EFFEC1.'XVE DATE: 01/16/19 RXPIR.ll .. TION DATE: 01/16/20 . AUDIT PERIOD: NON-AUDITABLE POLICY AUTOMATICALLY BOOKED REPL.ll .. CEMENT COST APPLIES TO BPP SPECTRUM r-'ROPE:RTY DEDUCTIBLE: $500 Sl?ECTRTJM DATA BRE:ACP. RESPONSE EXPENS£ DEDUCTIBLE: $2,500 SPECTRUM DATA BREACH DEFENSE 11..ND LIABILITY DEDUCTIBLE: COVERAGES LIMITS OF LIABILITY POLICY 8ASE PREMIUM BvSINESS PERSON/1 .. L PROPERTY BUSINESS INCOME/EXTRA EXPENSE EQUIPME'N1' BREAKDOWN BUSINESS LIABILITY PREMISES/OPERATIONS PRODUCTS/COMPLETED OPERATIONS DAMAGES TO PRii:MISES RENTED TO YOU ANY ONE PREMISES FUNGI LIMITED COVERAGE FUNGI LIMITED ausnr.Ess INTERRUPTION MONEY .AND SECURITIES INSIDE-PREMISES OUTSIDE-PREMISES �tAIVER OF SUBROGATION UMBRELLA PREMISES/O?ER.!\,l'IONS ffi.fBRELLA PRODUCTS/COMPLETED Ol>ERATION IDENTITY RECOVERY INTERNATIONAL s·rRET(:H EMPI.tOYMENT PRACTICES LIABILITY DATA l;!REACH -RESPONSE EXPENSE DATA BREACH -DEFENSE & LIABILITY UMBRELLA AUTO LIABILITY STRETCH ENDORSEMEm 'l'ERRORISM COVERAGE $10,000/ UMBRELLA LIABILITY MINIMUM PREM DIFf DIRECT l,CCOUNT BILL UMBER -13616530 $52,300 INCLUDED ,�2 I 000, QQO $2,000,000 $1,000,000 $50,000 30 DAYS $10,000 $5,000 $2,000,000 $2,000,000 $1:>, 000 $l0,000 $50,000 $500,000 INCLUDED TOTAL $0 PREMIUMS $59.00 $134.00 $11. 00 $7.00 $14 .. 00 $1.. 00 INCLUDED INCLUDED I CLUDED INCLUDED $85 .. 00 $3 .. 00 $1. 00 INCLUDED $200.00 INCLUDED $105.00 $569.00 $168 .. 00 $102 .. 00 $29 .. 00 $948.00 $2,436.00 5 POLICY # 34SBAAA8144 OX CONTROL ;ij 001 '!ERM ID R054V8GA PROCESS DATE l2/20/1S OPER INITIALS AC AAR PREV POL # 34SBAPL4737 , I . I PRODUCER' S FACT SHEET (CONTINUED) POL#: 34 $BA ��8114 DX ss 0,1 75 03 16 ss 04 80 03 00 ss 04 86 03 00 ss 40 18 07 OS ss 40 93 07 05 ss 41 12 12 17 ss 41 51 10 09 ss 41 63 06 11 ss 41 82 03 16 IH 10 01 09 86 s.s 05 09 07 00 ss 05 47 09 lS ss 51 ll 03 17 (;-3416-0 IH 12 00 11 85 't;,i(IH 12 00 11 85 M_IH 12 00 11 85 IH 12 00 1l 85 l?C-371-0 ss 09 01 12 14 ss 09 53 10 08 ss 09 67 09 1'l SS 09 70 12 H ss 09 71 12 14 ss 09 73 12 14 88 12 12 03 9?. �� �� i� gf �� 100722RV11 ss 00 46 03 16 ss 00 47 03 16 ss 00 48 0.3 16 !H 99 •10 04 09 IH 99 41 04 09 sx 80 01 06 97 sx 80 04 10 08 sx 80 02 04 05 sx 02 06 10 08 s.x 21 04 06 97 sx 21 05 06 97 sx 21 67 10 08 sx 21 71 03 00 sx 21 82 10 08 sx 21 94 03 17 sx 23 15 12 15 sx 24 01 01 01 s.x 24 33 06 10 INTERNATIONAL STRETCH CRIME COMMON CONDITIONS AND EXCLUSIO�S FORGERY COVERAGE OFF-PREMISES U'I'!LI'l.'Y SERVICES -DIRECT DAM..11..GE LIMITEl) FUNGI, BACTERIA OR VIRUS COVERAGE ID·ENTITY RECOVERY COVERAGE FOR BUS INESSOWNERS AND EMPLOYEES BUILDING LIMIT-AUTOMATIC INCREASE REVISION AME'.NDMENT -DEFINITION OF INSURED CONTRACT BUSINESS INCOME EX'l'E�S:tON FOR OFF-PREMISES OPERATIONS PERILS SPECIFIC11..LLY EXCEPTED EXCLUSION -TESTING OR CONSULTING ERRORS .<\ND OMISSIONS EXCLUSION -NUCLEAR ENERGY LIABILITY EXCLUSION -UNM!.NNED AIRCRJ.I..FT ( PROPERTY} PROOUC8R COMPENSATION NOTIC!:! ADDITIONAL INSURED -PERSON-ORGANIZATION ADDI'I'IONAt INSlffiEO -OWNER, LESSEES OR CONTRACTOR WA VER OF SUBROGATION ADDITIONAL INSURED -LESSORS OF LAND IMPORTANT NOTICE TO POLICYHOLDERS EMPLOYMENT PRACTICES LIABILITY COVERAGE FORM ( CLAIMS MADE) COLORADO CHANGES -EMPLOYMlWT PRJ\CTICES LIABILI1''{ WJI_GE .Z:LlolD HOUR CLAIMS EXPENSES -EMPLOYMENT PRP.CTICES LIABILITY THIRD l?AR'rY LIABn�rTI ENDORSEMENT -EMPLOYMENT PRACTICES LIABILITY RETROACTIVE DATE ENDORSEMENT -EMPLOYMENT PRACTICES LIABILITY COLORla"\DO CHANGES -EMPLOYME:N'J' PRACTICES LIP..BILITY LOSS PAYABLE PROVISIONS WAIVER OF SUBROGATION CAP ON LOSSES :PROM CERTIFIED ACTS OF TERRORISM INSURANCE POLICY BILLING INFORMJ\TION DATA BREACH COVER..l\.GE DECT..AAATIONS DATA BREACH COVER..l\.GE -RESPONSE EXPENSES DATA BREACH COVERAGE - DEFENSE AND LIABILITY (CL�.IMS MJU)E) U.S. DEPT OF THE TREASURY, OFFICE! OF FOREIGN ASSETS CONTROL ("OFAC") ADVISORY NO'tIC.E TO l?OLlCYHOLDERS TRADE OR ECONOMIC SA!."l"CTIONS ENDORSEMENT UMBRELLA LI.ABILITY S0l?l?L£M.SNTAL CONTRACT -POLICY DECLARATIONS PAGE EXTENSION SCHEDULE OF UNDERLYING INSURANCE POLICIES UMBRELLA LI1'..BILITY POLICY PROVISIONS AMENDMENT OF CONDITION$ -COLORADO EXCLUSION -CARE, CUSTODY OR CONTROL OF PERSONAL PROPERTY EXCLUSION -CARE, CUSTODY OR CONTROL OF REAL J?ROPERTI EXCLUSION -TEST NG OR CONSULTING ERRORS .�m OMISSIONS EXCLUSION -PROGRAMMING _zrnsOLU'I'E LEAD EXCLUSION EXCLUSION -UNMANNED AIRCRAFT EXCLUSION -ACCESS OR DISCLOSURE: Of:c CONFIDENTIAL OR PERSONAL INFORMATION AND DATA RELATED LIABILITY WITH FOLLOWING F'ORM ENDORSEMENT -AUTOMOBILE LrJ>.BILITY FOLLOWING FORM ENDORSEMENT -PERSONAL & ADVER'IISING IN.TORY PRODUCER' S FACT SH�ET PAGE 2 12/20/18 34 SBA AA6l11. DX (01/16/20) THE1 HARTFORD PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Policy Information: Policy Number: 34 WEC IB0462 Renewal Date: 06/29/18 Thank you for being a loyal customer of The Hartford. 1.Your Hartford Policy May 22, 2018 tO 'it Contact Us Business Service Center Business Hours: Monday -Friday (7AM -7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: agency.services@thehartford.com Website: www.thehartford.com Enclosed are renewal documents for your policy, which is scheduled to renew on 06/29/18. Along with a new Declarations Page, which details the coverages provided by your policy, we are enclosing important policy documents. Please be aware that you will receive an invoice separately for this new policy term approximately 30 days prior to the renewal date; no action is required now. To ensure the premium you paid for this past policy term was accurate, we may contact you by letter, phone or email to conduct a premium audit. If contacted, we will advise what information is needed to complete the audit. 2.Your Business Insurance Coverage Checkup Now is a great time to complete a business insurance coverage checkup with a Hartford Insurance Professional. Because you wear so many hats each day, you may not be thinking about how changes to your business can impact the type and amount of insurance coverage needed to protect it. Together we will evaluate how your needs may have changed over the past year. Examples include: •Has your mailing address and/or the physical location of your business changed? •Has there been any increase/decrease in the amount of business property/equipment you own? SCPHS017 Welcome Letter SC USAA and NON USAA (Continued) •Has there been any increase/decrease in your company's payroll or sales? •Have you added or eliminated any vehicles used in your business operations? •Are the bill plan and deductible on your policy right for your business? During the review we may make coverage recommendations, provide peace of mind solutions, and possibly reduce your costs. Here is all you need to do: •Contact us and select our renewal review service option any weekday and request your business insurance check-up. •To best serve you, please have your Policy Number or Account Number and a Copy of your current Renewal Policy in hand when you call. 3.Servicing Your Needs To login or register for our Online Business Service Center, go to www.thehartford.com/servicecenter where any time, day or night you can: •Pay your bill, view payment history and enroll in Auto Pay •Request Auto ID Cards and Certificates of Insurance •View electronic copies of billing and policy documents and sign up for paperless delivery 4.If You've Had A Loss or Accident. .. Report It Immediately To Report a Claim or Loss, Call 800-327-3636. Representatives are available 24 hours a day, 365 days a year. On behalf of INSURANCE CENTER OF AMERICA/PHS and The Hartford, we appreciate the opportunity to have been of service to you this past year and look forward to serving your business insurance needs for the upcoming year. Sincerely, Your Hartford Service Team SCPHS017 Insurance Policy Billing Information Thank you for selecting The Hartford for your business insurance needs. Shortly, you will receive your first bill from us. You are receiving this Notice so you know what to expect as a valued customer of The Hartford. Should you have any questions after reviewing this information, please contact us at 866-467-8730, and we will be happy to assist you. o Your total policy premium will appear on your policy's Declarations Page. You will be billed based on the payment plan you selected. o You may pay the "minimum due" as it appears on your insurance bill or pay the policy balance in full. o An installment service fee is added to each installment. A late fee will also be applied if the "minimum due" is not received by the due date shown on your bill. Service and late payment fees do not apply in all states. o If you selected installment billing, any credit or additional premium due as the result of a change made to your policy, will be spread over the remaining billing installments. Additional premium due as a result of an audit will be billed in full on your next bill date following the completion of the audit. o If you elected Electronic Funds Transfer (EFT), policy changes may result in changes to the amount automatically withdrawn from your bank account. The invoice you receive following a policy change will include future withdrawal amounts. If you need to adjust or stop your next scheduled EFT withdrawal, please contact us at least 3 days prior to the scheduled withdrawal date at the telephone number shown below. o If you selected installment billing and pay the premiums for your first policy term on time, at renewal, your account may qualify for our "Equal Installment" feature. This means that the percentage due for each installment, including the initial renewal installment, will be the same throughout the policy term -helping you better manage cash flow. Equal installments will continue as long as you pay your premiums on time and no cancellation notices are issued for any policy on your account. If you no longer qualify for Equal Installments, future renewals will be billed based on the payment plan you selected, which includes a higher initial installment amount. o If your policy is eligible for renewal, your bill for the upcoming policy term will be sent to you approximately 30 days prior to your policy's renewal date. If your insurance needs change, please contact us at least 60 days prior to your renewal date so we can properly address any adjustments needed. o One bill convenience --you have the option of combining all eligible Hartford policies on one single bill allowing you to make one payment for all policies on your account as payments are due. You're In Control In addition to selecting a bill plan option that best meets your budget, you have the flexibility to decide how your payments are made ... o Repetitive EFT: Sign up for Repetitive EFT payments and have payments automatically withdrawn from your bank account. This option saves you money by reducing the amount of the installment service fee. o Pay Online: Register at www.thehartford.com/servicecenter. Online Bill Pay is Quick, Easy and Secure! o Pay by Check: Send a check with your remittance stub in the envelope provided with your bill. o Pay by Phone: Call toll-free 1-866-467-8730. Should you have any questions about your bill, please call Customer Service toll-free number: 1-866-467-8730 -7AM -7PM CST. We look forward to being of service to you. Form 100722 11th Rev. Printed in U.S.A. .. Policy Number 34 WEC IB0462 PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Dear Hartford Insured, THEJ fliRTFORD Policy Effective Date 06/29/18 Re: An Important Message to Workers Compensation Policyholders The control of workplace accidents and injuries should be among the highest priorities of your firm. Each accident wastes precious human and financial resources, and introduces inefficiencies into your operations. From a practical standpoint, the control of accidents, and their inevitable costs, simply makes good business sense. An effective risk engineering program can save you money and aggravation, can positively impact your loss experience (and thus your premium), and most importantly, can help you maintain solid control of your operations. As a service to you, our valued customer, the Risk Engineering Department of The Hartford in cooperation with your independent agent, can assist you in establishing risk engineering strategies. If you would like assistance, please complete and return to us the reply portion of this brochure, or contact your independent agent. Services Available The following is a description of some of the services that we provide. The types of services that may be appropriate for your business depend upon the nature and size of your operations and the specific risk engineering services you have requested. The cost of risk engineering services may or may not be a part of your insurance premium. This depends on the extent of the requested services, agreements stated in your insurance policy and program, and statutory regulations that may require us to provide risk engineering services. 1)Reference Materials -Information about risk engineering topics that can be provided or made available to you to help you to enhance your risk engineering program. 2)Telephone Consultation -We can hold a teleconference with you to help you to evaluate your risk engineering program, identify areas for improvement, and recommend ways to implement such improvements. 3)Onsite Consultation -This consists of visiting your premises and helping you to assess and remedy your risk engineering needs onsite. This level of service is usually only appropriate for larger, higher hazard operations. The following are examples of some of the services that could be provided onsite: o A review of your safety program to determine its adequacy and recommend modifications to that plan where needed. Form 97485 16th Rev. Printed in U.S.A. Process Date: 05/22/18 Page 1 of 6 Policy Expiration Date: 06/29/19 t- o Specific hazard evaluations, including ergonomics, industrial hygiene or material handling. o An initial survey and evaluation to address potential safety and health hazards. o Consultation to help management establish a comprehensive loss prevention Program. o Periodic summaries of accidents and analysis of causes. o Follow-up visits to check on progress and to provide continuing assistance when required. A Word About OSHA The Occupational Safety and Health Act of 1970 and similarly approved State Plans require employers to provide their employees with safe and healthful places to work. The Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor and similar State agencies enforce the regulations and apply penalties (civil and criminal) for non-compliance. New standards have been developed, and through application and interpretation, standards change. You should make yourself aware of the standards that are applicable to your operations, and assure yourself that reasonable efforts are made to be in compliance. Copies of the standards are available through most libraries, or can be obtained through OSHA or the U.S. Government Printing Office. You should know that neither The Hartford, nor any other party, can fulfill your obligations under the Law. Questions related to your legal obligations should be referred to your legal counsel. Some Safety Reminders from The Hartford: Have you considered: o The need to formalize your safety efforts to assure compliance and document your efforts? o The need to acquire Material Safety Data Sheets on all hazardous materials and the need for training on appropriate safety measures for your employees? o Requirements for record keeping of injuries, illnesses, and exposure to hazardous substances? o Assessing each job task to determine hazards and needed controls? o Measuring each exposure to hazardous substances to determine the need for control or personal protective equipment? o What mechanisms are in place to periodically verify that exposure controls (guards, ventilation systems, etc.) are still in place and working? o What specific training your employees and your supervisors need to avoid hazards in the workplace? o What specific OSHA standards apply to your business? Form 97485 16th Rev. Printed in U.S.A.Page 2 of 6 o What mechanism exists to promptly investigate all accidents and 'near-misses' to limit the chance of another occurrence? o The financial impact an injury or illness has on your business? o What resources are available to you to help prevent accidents and illnesses? Thank you for your business. Sincerely, The Hartford's Risk Engineering Department Form 97485 16th Rev. Printed in U.S.A.Page 3 of 6 THIS BROCHURE IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT INTENDED TO BE A SUBSTITUTE FOR A COMPLETE ON-SITE SAFETY INSPECTION CONDUCTED BY A QUALIFIED RISK ENGINEERING SPECIALIST. READERS ARE ENCOURAGED TO HAVE SUCH AN INSPECTION CONDUCTED BOTH TO PROMOTE WORKPLACE SAFETY AND TO COMPLY WITH APPLICABLE LAW. FOR ADDITIONAL INFORMATION OR ASSISTANCE, EITHER TELEPHONE OR MAIL THIS FORM TO YOUR HARTFORD AGENT OR NEAREST OFFICE OF THE HARTFORD NOTICE TO ARKANSAS POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain accident prevention services at no additional cost as required by ARK. Code Ann. §11-9-409(D) and Rule 32. If you would like more information, call The Hartford's Risk Engineering Department, One Hartford Plaza, T-7, Hartford, CT 06155 at 1-866-586-0467. If you have any questions about this requirement, call the Health and Safety Division, Arkansas Workers' Compensation Commission at 1-800-622-4472. NOTICE TO CALIFORNIA POLICYHOLDERS The Hartford is required by law to provide its policyholders with certain occupational safety and health risk engineering consultation services as required by the California Labor Code, §6354.5, at no additional charge. If you would like more information call The Hartford's Risk Engineering Department at 1-866-586- 0467 for occupational safety and health risk engineering consultation services. California Workers Compensation insurance policyholders may register comments about the insurer's risk engineering consultation service by writing to: State of California Department of Industrial Relations Division of Occupational Safety and Health P.O. Box 420603 San Francisco, California 94142 NOTICE TO PENNSYLVANIA POLICYHOLDERS The Hartford maintains and provides accident and illness prevention services as required by the nature of the policyholder's business or its operation, in accordance with the Pennsylvania Workers' Compensation Act. For more information about these services contact your Hartford Agent or nearest office of The Hartford. Form 97485 16th Rev. Printed in U.S.A. Page 4 of 6 NOTICE TO TEXAS POLICYHOLDERS Pursuant to Texas Labor Code §411.066, The Hartford is required to notify its policyholders that accident prevention services are available from The Hartford at no additional charge. These services may include surveys, recommendations, training programs, consultations, analyses of accident causes, industrial hygiene and industrial health services. The Hartford is also required to provide return-to-work coordination services as required by Texas Labor Code §413.021 and to notify you of the availability of the return-to-work reimbursement program for employers under Texas Labor Code §413.022. If you would like more information, contact The Hartford at 1-866-586-0467 and email contactriskengineering@thehartford.com for accident prevention services or 1-877-952-9222 and email CentralClaimCenter.WCEDM@thehartford.com for return-to-work coordination services. For information about these requirements call the Texas Department of Insurance, Division of Workers' Compensation (TDI-DWC) at 1-800-687-7080 or for information about the return-to-work reimbursement program for employers call the TDI-DWC at 1-512-804-5000. If The Hartford fails to respond to your request for accident prevention services or return-to-work coordination services, you may file a complaint with the TDI-DWC in writing at http://www.tdi.texas.gov or by mail to Texas Department of Insurance, Division of Workers' Compensation, MS-8, at 7551 Metro Center Drive, Austin, Texas 78744-1645. Form 97485 16th Rev. Printed in U.S.A. Page 5 of 6 To The Hartford's Risk Engineering Department: Yes - I am interested in obtaining information concerning: General Topics Accident Analysis Accident Investigations Establishing a Risk Engineering Program Hazard Recognition Safety Committees Ergonomics Back Injury Prevention Computer Workstation Cumulative Trauma Disorders Ergo Train-the-Trainer Telecommuting Transportation 3-D Driver Training Driving Defensively Fleet Newsletter Guide to Successful Driver Mgmt School Bus Driving Tips Business Continuity Business Travel Safety Contingency Planning Overview Emergency/Disaster Response Emergency Evacuation Drills Emergency Preparedness Planning Industrial Hygiene Hazard Communication Industrial Hygiene (general) Indoor Air Quality Noise Exposures Respiratory Protection Workers' Compensation Bloodborne Pathogens Drug Screening Machine Safeguarding Return to Work Programs Slip and Falls Policy# Name Company Address -------------------- ----------------------Zip Code City & State Email Address: -------------------Telephone Construction Construction Site Consultation Construction Equipment Hazards Hazard Communication Ladders & Scaffolds Trenching & Evacuation Fall Protection Property Automatic Sprinkler System Flammable Liquids Fire Prevention and Protection Fire Drill and Evacuation Hot Work Permit Program Other Topics Business Risk Management General Liability Investigations Product Liability Programs Safety Training Security/Terrorism For more information on the above, you can visit our website at https://www.thehartford .com/riskengineering Or you may forward your request to: Fax line: 1-860-723-4459 Or mail to: The Hartford Financial Services Group Risk Engineering Department Form 97485 16th Rev. Printed in U.S.A. One Hartford Plaza, T-7 Hartford, CT 06155 Page 6 of 6 MAINTAINING YOUR RECORDS FOR AUDIT PURPOSES WHAT IS A PREMIUM ADJUSTMENT? When your Workers' Compensation policy was issued you paid a deposit premium based on the nature of your business and estimates of your payroll. At the end of the policy period, we conduct an audit to compare the estimates against the actual figures and operations. Based on this comparison an adjustment is made. If the actual premium is less than what you already have paid, a refund will be made. If it's more, you will be billed for the difference. These adjustments are subject to any minimum premiums that apply. HOW WILL THE PREMIUM ADJUSTMENT BE MADE? On smaller, less complex operations we may e-mail you, call you, or mail you a request to ask you to provide the information via our online web-based portal, mail or telephone. If we require this information, we will provide an electronic link to, or a paper copy of, the necessary forms for you to complete. On larger, more complex operations one of our Premium Auditors will contact you for an appointment. You will be contacted either by e-mail, telephone or mail. If directed, the auditor will contact your accountant to obtain as much information as possible and contact you at a later time for additional information that may be needed. BASIS OF PREMIUM Remuneration (Payroll) in most states, includes: Payment of: Payments on basis of: The value of: Wages, bonuses, commissions, overtime,* sick pay, vacation pay,* tool allowances, contributions to individual retirement accounts, employee contributions to employee benefit plans. Piece work, incentive plans, profit sharing. Housing furnished to employees,* meals furnished to employees,* store certificates, merchandise and other dollar substitutes. Form 98456 5th Rev. 12-13 Printed in U.S.A. Remuneration does not include: a.Employer contributions to a group insurance or pension plan other than statutory plans of insurance. b.Special awards for individual inventions or discoveries. c.Overtime.* Subcontractors. In the absence of other insurance, most state laws hold a contractor responsible for injuries to employees of subcontractors. At the time of audit Certificates of Insurance must be available for subcontractors with employees, in order to avoid payment of premium. Independent Contractors, without employees, whose duties closely resemble those of an employee, will be considered your employee with the appropriate premium charged. The actual working relationship between you and the Independent Contractor is examined. Items such as, but not limited to: whether the work performed is an integral part of your operations, whether you have the right to control the details of the work, the method of payment, who supplied the materials used, does the person regularly work for others, whose regulatory authority did person operate under, whether the person is involved in a separate and distinct business offering the same services to the public. RECORDS As part of the policy conditions, we are allowed to examine your financial books and records to determine actual exposures and operations. We would appreciate your cooperation in making the needed records available for the auditor's inspection. What Records Will Be Needed? The records needed will vary. In most cases, the Premium Auditor will be able to obtain the necessary audit data from two or more of the following records: Journals, Ledgers, State and Federal Tax Reports, Individual Earning Cards, Checkbooks and Contracts. Page 1 of 2 How You Should Keep Your Records By maintaining your payroll records in accordance with the following guidelines, you might reduce your insurance costs. Overtime. In most states, the amount paid in excess of straight time pay can be deducted if it can be verified in your records. You must maintain your records to show pay separately by employee and in summary by classification of work. *Division of an employee's payroll to more than one classification is not allowed in most states. Exception: For construction, erection or stevedoring operations the payroll of an employee may be allocated to each type of work performed if proper records are kept. Your records must show the number of hours and amount of payroll for each type of work. If you do not keep such a breakdown, the full salary must be charged to the highest rated classification to which the employee is exposed. Executive Officers in most states are considered employees of their corporation and included in the Form 98456 5th Rev. 12-13 Printed in U.S.A. computation of premium. Their remuneration is assigned without division to the actual operation in which they are engaged. If their duties are the same as those of a worker, foreman or superintendent, their payroll is assigned to the classification that develops the highest payroll. Minimum and maximum payrolls apply to executive officers. Automated Records. If your records are automated or you plan to automate in the near future you can obtain maximum benefits by setting up your records to include insurance requirements. Our Premium Auditor will be pleased to assist you in setting up your records. Contact your Hartford Representative if you would like this assistance. NOTE: The contents of this publication are not intended to supersede any definitions or conditions of your policy, the Workers' Compensation Law or any legal rulings. *Your state may have specific rules or exceptions. Please contact your Hartford Representative for details that may apply and answer questions you may have. Page 2 of 2 IMPORTANT NOTICE TO POLICYHOLDERS DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT A.Disclosure Of Premium In accordance with the federal Terrorism Risk Insurance Act, as amended (TRIA), we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for "certified acts of terrorism" under TRIA. The charge for terrorism is shown in Item 4 of the Information Page or on the Schedule. The rate for terrorism will apply as of the effective date of your policy. The terrorism rates are subject to change at any time based on state regulatory action. B.The following definition is added with respect to the provisions of this endorsement: 1.A "certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in accordance with the provisions of TRIA, to be an act of terrorism under TRIA. The criteria contained in TRIA for a "certified act of terrorism" include the following: a.The act results in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to TRIA; and b.The act results in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of an United States mission; and c.The act is a violent act or an act that is dangerous to human life, property or infrastructure and is 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. Form WC 66 03 37 H Printed in U.S.A. C.Disclosure Of Federal Share Of Terrorism Losses Under TRIA The United States Department of the Treasury will reimburse insurers for a portion of such insured losses as indicated in the table below that exceeds the applicable insurer deductible: Calendar Year Federal Share of Terrorism Losses 2015 85% 2016 84% 2017 83% 2018 82% 2019 81% 2020 or later 80% However, if aggregate insured losses attributable to "certified acts of terrorism" under TRIA exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. The United States Government has not charged any premium for their participation in covering terrorism losses. D.Cap On Insurer Liability for Terrorism Losses Under TRIA If aggregate insured losses attributable to "certified acts of terrorism" under TRIA exceed $100 billion in a calendar year and we have met, or will meet, our insurer deductible under TRIA we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion. In such case, your coverage for terrorism losses may be reduced on a pro-rata basis in accordance with procedures established by the Treasury, based on its estimates of aggregate industry losses Page 1 of 2 and our estimate that we will exceed our insurer deductible. In accordance with Treasury procedures, amounts paid for losses may be subject to further adjustments based on differences between actual losses and estimates. E.All other terms and conditions remain the same. Form WC 66 03 37 H Printed in U.S.A. Page 2 of 2 IMPORTANT NOTICE COLORADO WORKERS' COMPENSATION INSURANCE MEDICAL AND INDEMNITY DEDUCTIBLE ELECTION FORM Colorado Workers' Compensation Law permits an employer to purchase workers' compensation insurance with a deductible. The deductible is for medical and indemnity benefits only. There are nine "Per Claim" deductible options available. They are: ( ) NONE ( ) $ 500 ( ) 1,000 ( ) 1,500 ( ) 2,000 ( ) 2,500 ( ) 5,000 ( ) 10,000 ( ) 13,500 ( ) 15,500 ( ) 16,000 ( ) 16,500 All medical and indemnity claims shall be paid by the company. In such case, the law requires that you reimburse the company for any deductible amounts so paid. If you have any questions, or desire one of these deductible amounts to apply to your coverage, please call your Agent for a quote. This offer is valid for thirty days after the effective date of the policy with which this notice is enclosed. Policy Number 34 WEC IB0462 Employer Name PLAN-IT GEO LLC Agent Name INSURANCE CENTER OF AMERICA/PHS Return to Issuing Office: Address: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 01 49 F Printed in U.S.A. Process Date: 05/22/18 Date Signature and Title Date Signature Policy Expiration Date: 06/29/19 IMPORTANT NOTICE SOUTH CAROLINA WORKERS' COMPENSATION INSURANCE MEDICAL AND INDEMNITY BENEFITS DEDUCTIBLE ELECTION FORM South Carolina Workers' Compensation law permits an employer to purchase workers' compensation insurance with a deductible. The deductible is for medical and indemnity benefits only. Please check the option which you have elected and return this form to the company prior to the effective date of your coverage. 1.I reject any deductible option and elect that the company pay all benefits due under my policy. 2.I elect one of the following deductibles to be applied to benefits under my workers' compensation insurance policy and each subsequent renewal. The premium reduction to be applied is shown below. PREMIUM REDUCTION HAZARD GROUP A B C D E F G ) $100 0.6% 0.5% 0.4% 0.3% 0.2% 0.1% 0.1% ( ) $200 1.1% 0.9% 0.8% 0.5% 0.4% 0.3% 0.2% ( ) $300 1.6% 1.2% 1.0% 0.8% 0.6% 0.4% 0.3% ( ) $400 1.9% 1.5% 1.3% 0.9% 0.7% 0.5% 0.5% ( ) $500 2.3% 1.8% 1.6% 1.1% 0.9% 0.6% 0.6% ( ) $1,000 3.5% 2.8% 2.5% 1.9% 1.4% 1.1% 1.0% ( ) $1,500 4.5% 3.7% 3.2% 2.4% 1.9% 1.5% 1.3% ( ) $2,000 5.3% 4.3% 3.9% 3.0% 2.4% 1.9% 1.6% ( ) $2,500 6.0% 5.0% 4.5% 3.4% 2.8% 2.2% 1.9% All claims shall be paid by the company. In such case, the law requires that you reimburse the company for any deductible amounts so paid. If you do not return this form promptly to the company, it will be construed to mean that we should pay in full all benefits due under your policy with no contribution on your part. If you have any questions, please call your Agent. Policy Number 34 WEC 180462 Employer Name PLAN-IT GEO LLC Agent Name INSURANCE CENTER OF AMERICA/PHS Return this form to Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER Address: 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 02 65 0 Printed in U.S.A. Process Date: 05/22/18 Date Signature and Title Date Signature Policy Expiration Date: 06/29/19 SOUTH CAROLINA - APPLICATION FOR DRUG-AND ALCOHOL-FREE WORKPLACE PREMIUM CREDIT PROGRAM Name of Employer: PLAN-IT GEO LLC ------------------------------Po Ii c y Number: 34 WEC 180462 ------------------------------Date Program Implemented: This form must be completed by you and returned to your carrier with a copy of applicable documentation as proof of compliance before the premium credit of 5% can be established and processed. A program must be certified during each year the employer receives credit. Failure to do so will remove you from eligibility for this credit. Following are the four minimum requirements necessary for a qualified employer workplace program. Please check the items below that apply. ( ) 1) Substance Abuse Policy Statement: By law, any policy must be designed to help employees who need substance abuse assistance while, at the same time, sending a clear message that the abuse of drugs and alcohol is not compatible with employment in that employer's workplace. The policy statement must evidence both the employer's respect for its employees and the employer's need to maintain a safe, productive, substance-abuse free environment. ( ) 2) Employee Notification: In order to protect the individual rights of each employee and to begin the employee education process necessary for a well-defined, well managed workplace drug and alcohol abuse prevention program, each existing employee and each new employee hired after program implementation must be given a clear, concise, readable notice of the program, the program's requirements, the policy statement, and the employer's expectations under the program. Notification should be, and should remain posted in employee common areas. In addition, each existing employee and each new employee must be given, by mail or by in-person delivery, a copy of the notice. Delivery may be accomplished by inclusion of the notice within the employee's paycheck package or any similarly important-to-the-employee correspondence or benefits delivery. ( ) 3) Testing Procedure: The testing procedure must include a provision for random sampling of all persons who receive wages and compensation in any form from the employer. If a second test is administered, the testing procedure may allow for a single sample to be split for use in the first and second tests. Positive test results must be provided in writing to the employee within 24 hours of the time the employer receives the test results. Each employer must keep records of each test for up to one year. ( ) 4) Test Results Confidentially Protocols: Test results, information, interviews, reports, statements, and memorandums received by the employer must be considered confidential but may be used or received in evidence, obtained in discovery, or disclosed in any civil or administrative proceeding. The burden to protect against unauthorized release is placed not only upon the employer and any laboratory, medical review officer, or rehabilitation program or their agents, but also upon the underwriting carrier. Employers, laboratories, medical review officers, carriers, drug or alcohol rehabilitation programs, and employer drug prevention programs, and their agents who receive or have access to information concerning test results must keep all information confidential. Release of such information under any other circumstance shall be solely pursuant to a written consent form signed voluntarily by the employee tested or their designee, unless the release is completed through disclosure by an agency of the state in a civil or administrative proceeding, an order of a court of competent jurisdiction, or the determination of a professional or occupational licensing board in a related disciplinary proceeding. The consent form must contain, at a minimum: (1)the name of the person who is authorized to obtain the information; (2)the purpose of the disclosure; (3) the precise information to be disclosed; (4)the duration of the consent; and (5) the signature of a person authorizing release of the information. Information on test results shall not be released for or used or admissible in any criminal proceeding against the employee. I certify that the above information is accurate. If it is determined that there is any misrepresentation of the established drug-and alcohol-free workplace premium credit program requirements, i may be subject to an additional premium charge. This is a true and factual depiction of my current program. Employer name Date *Application must be signed by an officer, partner, sole proprietor, LLC member or owner. Notary public's signature Form WC 66 02 85 B Printed in U.S.A. Process Date: 05/22/18 Date Signature* Title Exp. Of commission Policy Expiration Date: 06/29/19 I � WORKERS' COMPENSATION SELECTION OF DESIGNATED MEDICAL PROVIDER DISCLOSURE STATEMENT If you select two Designated Medical Providers meeting the following qualifications, a premium credit will be applied to your policy. For policies eligible for this credit as well as schedule rating, the combination of the 2.5% credit and the schedule modification cannot exceed +/-25%. A qualified Designated Medical Provider is a medical provider, who: 1)Has a knowledge of work injuries; 2)Is knowledgeable of fee schedules; 3)Is decisive on medical-maximum-improvement determinations; 4)Communicates with you, the employer on such issues as case management and wellness programs; 5)Is knowledgeable of the employers operations. The names of the providers must be posted and well publicized by you, the employer. ** SIGN AND RETURN ** I am aware of the availability of a premium credit of 2.5%, if I select two qualified Designated Medical Providers. For policies eligible for this credit as well as schedule rating, the combination of the 2.5% credit and the schedule modification cannot exceed +/-25%. Insured Signature Policy Number Issuing Office Issuing Office Address 34 WEC IB0462 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 02 81 C Printed in U.S.A. Process Date: 05/22/18 Policy Expiration Date: 06/29/19 WORKERS' COMPENSATION COST CONTAINMENT CERTIFICATION DISCLOSURE STATEMENT PLEASE CHECK ONE (1) OF THE FOLLOWING BOXES BASED UPON YOUR BUSINESS ENTITY QUALIFICATION: does qualify or, does not qualify Insured Signature Policy Number Issuing Office Issuing Office Address Premium Dividend Dividend Criteria ***PLEASE SIGN AND RETURN*** Form WC 66 03 06 Process Date: Policy Expiration Date: INSTRUCTIONS EMPLOYEE'S CLAIM FOR WORKERS' COMPENSATION BENEFITS it is not mandatory for the employee to complete it. after immediately DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: LossConnect (1-800-327-3636) Form WC 55 00 11 D Workers' Compensation and Employers' Liability Business Insurance Policy Form WC 99 00 02 (03/14) Page 1 of 1 (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: SEE ATTACHED ENDORSEMENT NCCI Company Number: 13161 Company Code: 9 POLICY NUMBER: Previous Policy Number: 1.Named Insured and Mailing Address: (No., Street, Town, State, Zip Code) FEIN Number: 45-4214699 PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 34 WEC IB0462 34 WEC IB0462 State Identification Number(s): See Schedule of Operations if applicable The Named Insured is: LLC Suffix LARS RENEWAL I I 2 Business of Named Insured: Administrative Management and General Management Consulting Services Other workplaces not shown above: See Endorsement -WC990366 2.Policy Period: Producer's Name: Producer's Code: Issuing Office: From 06/29/18 To 06/29/19 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. INSURANCE CENTER OF AMERICA/PHS 2055 ANGLO DRIVE, SUITE 200 COLORADO SPRINGS CO 80918 34342266 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8730 Total Estimated Annual Premium: $2,471 Deposit Premium: Policy Minimum Premium: $720 CA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Four Pay (30%Down+2@25%+1@20%) The policy is not binding unless countersigned by our authorized representative. Countersigned by Gum:l/J £ Cao� Authorized Representative Form WC 00 00 01 A (1)Printed in U.S.A. Process Date: 05/22/18 05/22/18 Date Page 1 (Continued on next page) Policy Expiration Date: 06/29/19 INFORMATION PAGE (Continued) Policy Number: 34 WEC IB0462 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: PA SEE ENDORSEMENT -WC 99 03 67 B.Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident Bodily injury by Disease Bodily injury by Disease $1,000,000 $1,000,000 $1,000,000 each accident policy limit each employee C.Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D.This policy includes these endorsements and schedule: SEE ENDORSEMENT-WC 99 03 68 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. Classifications Code Number and Description Total Standard Premium Expense Constant Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Catastrophe (Other Than Certified Acts Of Terrorism) Other Miscellaneous State Premiums Estimated Annual Premium (before Surcharges) Total Estimated Surcharges *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $2,471 Deposit Premium: Policy Minimum Premium: $720 CA (Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 541611 Labor Contractors Policy Number: SIC: 8748 Form WC 00 00 01 A (1)Printed in U.S.A.Page 2 Estimated Annual Premium $2,110 $230 $59 $49 $500 $2,448 $23 Process Date: 05/22/18 Policy Expiration Date: 06/29/19 EXTENSION OF THE INFORMATION PAGE -ITEM 1 -OTHER WORKPLACES Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 99 03 66 Process Date: Policy Expiration Date: EXTENSION OF THE INFORMATION PAGE -ITEM 3.A -STATES COVERED Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 99 03 67 Process Date: Policy Expiration Date: EXTENSION OF THE INFORMATION PAGE -ITEM 3.D -ENDORSEMENTS Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Item 3.D. of the Information Page is completed to include the following endorsements: G-2240-2DTwcooooooc WC000001A.1 WC000001A.2 WC000313 WC000403 WC000404 WC000414 WC000419 WC000421D WC000422B WC000424 WC040301BB WC040306 WC040360B WC040421 WC040422 BLANK ENDORSEMENT (COMPUTER PRODUCED) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE INFORMATION PAGE WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT PENDING RATE CHANGE ENDORSEMENT NOTIFICATION OF CHANGE IN OWNERSHIP PREMIUM DUE DATE ENDORSEMENT CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT POLICY AMENDATORY ENDORSEMENT -CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA EMPLOYERS LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA OPTIONAL PREMIUM INCRE ASE ENDORSEMENT -CALIFORNIA CALIFORNIA SHORT-RATE CANCELLATION ENDORSEMENT Form WC 99 03 68 Printed in U.S.A. Process Date: 05/22/18 Policy Expiration Date: 06/29/19 ,_ EXTENSION OF THE INFORMATION PAGE -ITEM 3.0 -ENDORSEMENTS Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 99 03 68 Process Date: Policy Expiration Date: EXTENSION OF THE INFORMATION PAGE -ITEM 3.D -ENDORSEMENTS Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 99 03 68 Process Date: Policy Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: THE SENTINEL INSURANCE COMPANY Company Code: A Policy Number: 34 WEC IB0462 Schedule Number: 01-04-01 Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: PLAN-IT GEO LLC 5265 SOLEDAD MOUNTAIN RD SAN DIEGO CA 92109 FEIN: 45-4214699 NAICS: 541611 SIC: 8748 NO. OF EMPL: 1 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. Classifications Code Number and Description 8742 SALESPERSONS -OUTSIDE Total State Summary Total Class Premium CA Territorial Differential Waiver of Subrogation Small Policy Credit Total Estimated Annual Standard Premium Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement CA User Fund CA Fraud CA Subsequent Injuries Benefit Trust Fund Assessments CA Occupational Safety & Health Fund CA Labor Enforcement & Compliance Fund CA Guarantee Fund Assessment Total Estimated Annual Premium Countersigned by Form WC 99 00 05 (1)Printed in U.S.A. Premium Basis Total Estimated Annual Remuneration 18,100.00 18,100.00 Rates Per $100 of Remuneration 0.8700 0.8500 6 0.0300 0.8146 0.2550 0.3559 0.2655 0.2150 2 Estimated Annual Premium 157 157 -24 250 -23 360 5 3 1 1 1 1 7 379 --------------------Authorized Representative Process Date: 05/22/18 Policy Expiration Date: 06/29/19 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: THE HARTFORD ACCIDENT AND INDEMNITY INSURANCE COMPANY Company Code: 5 Policy Number: 34 WEC IB0462 Schedule Number: 01-05-02 Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 FEIN: 45-4214699 NAICS: 541611 SIC: 8748 NO. OF EMPL: 4 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. Classifications Code Number and Description 8810 COMPUTER SYSTEM DESIGNERS OR PROGRAMMERS: EXCLUSIVELY OFFICE 8742 SALESPERSONS OR COLLECTORS -OUTSIDE 8810 CLERICAL OFFICE EMPLOYEES NOC Total State Summary Total Class Premium Waiver of Subrogation Emp liab increased limits Employer Liability Increase Limits balance to Minimum Premium Total Estimated Annual Standard Premium Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Catas trophe ( other than certified acts of terrorism) Total Estimated Annual Premium Countersigned by Form WC 99 00 05 (1)Printed in U.S.A. Premium Basis Total Estimated Annual Remuneration 47,000.00 79,900.00 75,300.00 202,200.00 202,200.00 Rates Per $100 of Remuneration 0.1800 0.3500 0.1800 0.0110 0.0060 0.0100 Estimated Annual Premium 85 280 136 501 250 6 103 860 12 20 892 -------------------Authorized Representative Process Date: 05/22/18 Policy Expiration Date: 06/29/19 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: THE HARTFORD ACCIDENT AND INDEMNITY INSURANCE COMPANY Company Code: 5 Policy Number: 34 WEC IB0462 Schedule Number: 01-37-03 Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: PLAN-IT GEO LLC 10789 JONESTOWN RD ONO PA 17077 FEIN: 45-4214699 NAICS: 541611 SIC: 8748 NO. OF EMPL: 0 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. Classifications Code Number and Description 0951 SALESPERSONS -OUTSIDE Total State Summary Total Class Premium Emp liab increased limits Merit Rating Total Estimated Annual Standard Premium Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Catastrophe (other than certified acts of terrorism) PA Assessment Surcharge Total Estimated Annual Premium Countersigned by Form WC 99 00 05 (1)Printed in U.S.A. Premium Basis Total Estimated Annual Remuneration 65,800.00 65,800.00 65,800.00 Rates Per $100 of Remuneration 0.5700 0.0140 0.9500 0.0400 0.0200 2.1700 Estimated Annual Premium 375 375 5 -19 361 26 13 9 409 --------------------Authorized Representative Process Date: 05/22/18 Policy Expiration Date: 06/29/19 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: THE HARTFORD CASUAL TY INSURANCE COMPANY Company Code: 3 Policy Number: 34 WEC IB0462 Schedule Number: 01-39-04 Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: PLAN-IT GEO LLC 518 SPRING LANDING DRIVE ROCK HILL SC 29730 FEIN: 45-4214699 NAICS: 541611 SIC: 8748 NO. OF EMPL: 0 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. Classifications Code Number and Description 8742 SALESPERSONS OR COLLECTORS -OUTSIDE Total State Summary Total Class Premium Emp liab increased limits Total Estimated Annual Standard Premium Expense constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Catastrophe ( other than certified acts of terrorism) Total Estimated Annual Premium Countersigned by Form WC 99 00 05 (1)Printed in U.S.A. Premium Basis Total Estimated Annual Remuneration 72,800.00 72,800.00 72,800.00 Rates Per $100 of Remuneration 0.7100 0.0110 0.0200 0.0200 Estimated Annual Premium 517 517 6 523 230 15 15 783 --------------------Authorized Representative Process Date: 05/22/18 Policy Expiration Date: 06/29/19 SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER: THE HARTFORD ACCIDENT AND INDEMNITY INSURANCE COMPANY Company Code: 5 Policy Number: 34 WEC 180462 Schedule Number: 01-48-05 Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: PLAN-IT GEO LLC NO SPECIFIC LOCATION IN STATE OF WI 00000 FEIN: 45-4214699 NAICS: 541611 SIC: 8748 NO. OF EMPL: 0 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. Classifications Code Number and Description 8871 CLERICAL TELECOMMUTER EMPLOYEES Total State Summary Total Class Premium Total Estimated Annual Standard Premium Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Catastrophe ( other than certified acts of terrorism) Total Estimated Annual Premium Countersigned by Form WC 99 00 05 (1)Printed in U.S.A. Premium Basis Total Estimated Annual Remuneration 5,300.00 5,300.00 5,300.00 Rates Per $100 of Remuneration 0.1100 0.0200 0.0100 Estimated Annual Premium 6 6 6 1 1 8 ------------,--,----,--�-----Authorized Representative Process Date: 05/22/18 Policy Expiration Date: 06/29/19 l I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY QUICK REFERENCE INFORMATION PAGE Beginning on Page 1 General Section.............................................................. 1 A. The Policy............................................................... 1 B.Who Is Insured....................................................... 1 C.Workers Compensation Law.................................. 1 D.State ....................................................................... 1 E.Locations................................................................ 1 PART ONE-WORKERS COMPENSATION INSURANCE ... 1 A.How This Insurance Applies................................... 1 B.We Will Pay............................................................ 1 C. We Will Defend....................................................... 1 D.We Will Also Pay .................................................... 1 E.Other Insurance ...................................................... 2 F.Payments You Must Make ...................................... 2 G.Recovery From Others ........................................... 2 H.Statutory Provisions................................................ 2 PART TWO -EMPLOYERS LIABILITY INSURANCE ...... 2 A.How This Insurance Applies................................... 2 B.We will Pay............................................................. 3 C.Exclusions.............................................................. 3 D.We Will Defend ....................................................... 3 E.We Will Also Pay.................................................... 4 F.Other Insurance ...................................................... 4 Beginning on Page PART TWO -Continued G.Limits of Liability ............................................ .. H.Recovery From Others ................................... .. I.Actions Against Us ......................................... .. PART THREE -OTHER STATES INSURANCE A.How This Insurance Applies ........................... .. B.Notice .............................................................. . PART FOUR -YOUR DUTIES IF INJURY OCCURS .... . PART FIVE -PREMIUM ............................................. .. A.Our Manuals ................................................... .. B.Classifications ................................................. . C.Remuneration .................................................. . D.Premium Payments ......................................... . E.Final Premium ................................................. . F.Records ........................................................... . G.Audit. .............................................................. .. PART SIX -CONDITIONS ...................................... . A.Inspection ....................................................... .. B.Long Term Policy ........................................... .. C.Transfer of Your Rights and Duties ................ .. D.Cancellation .................................................... . E.Sole Representative ....................................... .. 4 4 4 4 4 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 IMPORTANT: This Quick Reference is not part of the Workers Compensation and Employers Liability Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Policy itself for actual contractual provisions. PLEASE READ THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CAREF ULLY. Form WC 66 01 56 B Printed in U.S.A. Process Date: 05/22/18 Policy Expiration Date: 06/29/19 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 Information Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Information Page) and us (the insurer named on the Information 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 Insured 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 employer 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 federal 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 compensation 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 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. B.We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. Form WC 00 00 00 C Printed in U.S.A. Process Date: 05/22/18 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 investigate 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; Page 1 of 6 Policy Expiration Date: 06/29/19 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 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 entitled 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 duties under this insurance after an injury occurs. 3.We are directly and primarily liable to any person entitled to the benefits payable by this insurance. Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be 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 other 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 duties 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. Form WC 00 00 00 C Printed in U.S.A. 2.The employment must be necessary or incidental 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 aggravated by the conditions of your employment. The employee's last day of last Page 2 of 6 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. B.We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permitted by law, include damages: 1.For which you are liable to a third party by reason of a claim or suit against you by that third party to recover the damages claimed against such third party as a result of injury to your employee; 2.For care and loss of services; and 3.For consequential bodily injury to a spouse, child, parent, brother or sister of the injured employee; provided that these damages are the direct consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4.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 exclusion does not apply to a warranty that your work will be done in a workmanlike manner; 2.Punitive or exemplary damages because of bodily 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 com pensation, occupational disease, unemployment compensation, or disability benefits law, or any similar 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. Form WC 00 00 00 C Printed in U.S.A. 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, demotion, evaluation, reassignment, discipline, defamation, harassment, humiliation, dis crimination 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 Noappropriated 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. Sections 51 et seq.), any other federal laws obligating 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 damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11 . Fines or penalties imposed for violation of federal or state law; and 12.Damages payable under the Migrant and Seasonal 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 expense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceedings and suits. Page 3 of 6 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. F.Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other insurance or self-insurance. Subject to any limits of liability that 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 and self-insurance will be equal until the loss is paid. G.Limits of Liability Our liability to pay for damages is limited. Our limits 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 the 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 Injury 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 <;Jisease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease each employee" 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 disease 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 under 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 policy; 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 determine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obligations 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 Information Page. 2.If you begin work in any one of those states after the effective date of this policy and are not insured or are not self-insured for such work, all provisions of the policy will apply as though that state were Form WC 00 00 00 C Printed in U.S.A. listed in Item 3.A. of the Information Page. 3.We will reimburse you for the benefits required by the workers compensation law of that state 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 policy in any state not listed in Item 3.A. of the Page 4 of 6 Information 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 services 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 papers related to the injury, claim, proceeding or suit. 4.Cooperate with us and assist us, as we may request, in the investigation, settlement or defense of any claim, proceeding or suit. 5.Do nothing after an injury occurs that would interfere with our right to recover from others. 6.Do not voluntarily make payments, assume obligations 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 classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. B.Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifications. 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. Remuneration is the most common premium basis. This premium basis includes payroll and all other remuneration 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 Form WC 00 00 00 C Printed in U.S.A. 2.all other persons engaged in work that could make us liable under Part One (Workers Compensation Insurance) of this policy. If you do not have payroll records for these persons, the contract 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 employers 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 compensation 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, 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. Page 5 of 6 If this policy is cancelled, final premium will be determined 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 cancellation table and procedure. Final premium will not be less than the minimum premium. F.Records You will keep records of information needed to compute 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 ledgers, journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing and retrieving data. We may conduct the audits during regular business hours during the policy period and within three years after the policy 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. PART SIX -CONDITIONS A.Inspection We have the right, but are not obligated to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurability 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 organizations have the same rights we have under this provision. B.Long Term Policy If the policy period is longer than one year and sixteen 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 after your death, we will cover your legal representative as insured. Form WC 00 00 00 C Printed in U.S.A. D.Cancellation 1.You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. 2.We may cancel this policy. We must mail or deliver to you not less than ten days advance written notice stating when the cancellation 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 cancellation notice. 4.Any of these provisions that conflict with a law that controls the cancellation of the insurance in this policy is changed by this statement to comply with that 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 cancellation. Page 6 of 6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PREMIUM DUE DATE ENDORSEMENT Policy Number: 34 WEC 180462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Section D of Part Five of the policy is replaced by this provision: D.Premium is amended to read: PART FIVE PREMIUM You will pay all premium when due. You will pay the premium even if part or all of a workers compensation Counters igned by law is not valid. The due date for audit and retrospective premiums is the date of the billing. -------------------- Form WC 00 04 19 Printed in U.S.A. Process Date: 05/22/18 Authorized Representative Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT Policy Number: 34 WEC 180462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Part Five -Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is revised by adding the following: If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit information as requested, we may apply an Audit Noncompliance Charge. The method for determining the Audit Noncompliance Charge by state, where applicable, is shown in the Schedule below. If you allow us to examine and audit all of your records after we have applied an Audit Noncompliance Charge, we will revise your premium in accordance with our manuals and Part 5 -Premium, E. (Final Premium) of this policy. Failure to cooperate with this policy provision may result in the cancellation of your insurance coverage, as specified under the policy. State(s) AL, AR, CO, CT, DC, DE, GA, IA, ID, IL, KY, MD, ME, Ml, MN, MS, NE, NH, NM, OR, RI, SC, SD, TN, UT, VA, VT, WV AZ, HI, KS, OK, WI NC NV Form WC 00 04 24 Printed in U.S.A. Process Date: 05/22/18 Schedule Basis of Audit Noncompliance Charge Estimated Annual Premium Estimated Annual Premium Estimated Annual Premium Estimated Annual Premium Maximum Audit Noncompliance Charge Multiplier Up to two times Two times Up to three times Up to one times Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY AMENDATORY ENDORSEMENT-CALIFORNIA Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARV ADA CO 80002 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 California Labor 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 Form WC 04 03 01 BB Printed in U.S.A. Process Date: 05/22/18 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, we will 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 employee's exposure 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 policy by reason of the designation of California in Page 1 of 2 Policy Expiration Date: 06/29/19 Item 3 of the Information Page are subject to change if 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 consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written 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 money and 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 Form WC 04 03 01 BB Printed in U.S.A. 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. 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. Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EMPLOYERS' LIABILITY COVERAGE AMENDATORY END ORSEMENT -CALIFORNIA Policy Number: 34 WEC 160462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 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. Bodily 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. Form WC 04 03 60 B Printed in U.S.A. Process Date: 05/22/18 Countersigned by 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, defamation, harassment, humiliation, discrimination against or termination of any employee, termination 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. ---------------------Authorized Representative Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OPTIONAL PREMIUM INCREASE ENDORSEMENT -CALIFORNIA Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 04 04 21 Process Date: Page 1 of 1 Policy Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA SHORT-RATE CANCELATION ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 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: Extended Percent of Number of Full Policy Days Premium 1 ·········· 5% 2 ..........6% 3-4 ..........7% 5-6 ..........8% 7-8 ..........9% 9-10 ..........10% 11-12 ..........11% 13-14 ..........12% 15-16 ..........13% 17-18 ·········· 14% 19-20 ..........15% 21-22 ..........16% 23-25 ..........17% 26-29 ..........18% 30-32 (1 mo.) 19% 33-36 ..........20% 37-40 ..........21% 41-43 ..........22% 44-47 ..........23% 48-51 ..........24% 52-54 ..........25% 55-58 ..........26% 59-62 (2 mos.) 27% 63-65 ..........28% 66-69 ..........29% 70-73 ..........30% 74-76 ..........31% 77-80 ..........32% 81-83 ..........33% 84-87 ..........34% 88-91 (3 mos.) 35% 92-94 ..........36% Form WC 04 04 22 Printed in U.S.A. Process Date: 05/22/18 Extended Number of Days 95-98 .......... 99-102 .......... 103-105 .......... 106-109 .......... 110-113 .......... 114-116 .......... 117-120 .......... 121-124 (4 mos.) 125-127 . ......... 128-131 .......... 132-135 .......... 136-138 .......... 139-142 . ......... 143-146 .......... 147-149 .......... 150-153 (5 mos.) 154-156 ·········· 157-160 .......... 161-164 . ......... 165-167 .......... 168-171 .......... 172-175 . ......... 176-178 ·········· 179-182 (6 mos.) 183-187 ·········· 188-191 . ......... 192-196 .......... 197-200 .......... 201-205 .......... 206-209 .......... 210-214 (7 mos.) 215-218 . ......... Percent of Extended Percent of Full Policy Number of Full Policy Premium Days Premium 37% 219-223 . .........69% 38% 224-228 . .........70% 39% 229-232 . .........71% 40% 233-237 .......... 72% 41% 238-241 .......... 73% 42% 242-246 (8 mos.) 74% 43% 247-250 .......... 75% 44% 251-255 ..........76% 45% 256-260 ·········· 77% 46% 261-264 . .........78% 47% 265-269 ·········· 79% 48% 270-273 (9 mos.) 80% 49% 274-278 .......... 81% 50% 279-282 ..........82% 51% 283-287 ..........83% 52% 288-291 ..........84% 53% 292-296 ..........85% 54% 297-301 ..........86% 55% 302-305 (10 mos.) 87% 56% 306-310 . .........88% 57% 311-314 .......... 89% 58% 315-319 ·········· 90% 59% 320-323 ..........91% 60% 324-328 ..........92% 61% 329-332 ..........93% 62% 333-337 (11 mos.) 94% 63% 338-342 ..........95% 64% 343-346 ..........96% 65% 347-351 ·········· 97% 66% 352-355 . .........98% 67% 356-360 .......... 99% 68% 361-365 (12 mos.) 100% Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA CANCELLATION ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancellation condition in Part Six (Conditions) of the policy is replaced by these conditions: Cancellation 1.You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation 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 cancellation 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 Item (g) through (1), we will give you 30 days advance written notice; however, we agree that in the event of cancellation 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 cancellation notice. Countersigned by: Form WC 04 06 01 A Printed in U.S.A. Process Date: 05/22/18 Authorized Representative Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO CLASSIFICATION ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies only to the insurance provided by Part One (Workers Compensation Insurance) because Colorado is shown in Item 3.A. of the Information Page. Section B. Classifications of Part Five (Premium) is amended by adding the following: The assignment of a proper classification resulting in higher premium is allowed only if the misclassification was caused by your failure to provide accurate or complete data. If your operation changes during the policy term, you must notify us within ninety days of the change. Failure to notify us will be considered a failure to provide accurate or complete data. Section E. Final Premium of Part Five is amended by adding this sentence at the end of the first paragraph: Payments to us or to you based on improper classification may be collected or refunded during the term of the policy and for twelve months after the term. Form WC 05 04 02 Printed in U.S.A. Process Date: 05/22/18 Countersigned by Authorized Representative Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PENNSYLVANIA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARV ADA CO 80002 Part Five -Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is revised by adding the following: If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit information as requested, we may apply an Audit Noncompliance Charge (ANC). The charge is determined by applying the ANC Multiplier to the ANC Basis shown in the table below: ANC Basis ANC Multiplier Estimated Annual Premium Two times If you allow us to examine and audit all of your records after we have applied an ANC, we will remove the ANC and revise your premium in accordance with our manuals and Part 5 -Premium, E. (Final Premium) of this policy. The application of the ANC is subject to the following conditions: a)Carriers must comply with all applicable state laws and/or regulations related to audits of workers compensation insurance policies. b)The Audit Noncompliance Charge Endorsement is optional. When used, the Audit Noncompliance Charge Endorsement and/or applicable state-specific endorsement must be attached to the policy at inception of the policy term being audited. c)The carrier must make two attempts to obtain the audit information and/or complete the audit. At each attempt, the carrier must notify the employer regarding the specific required records and the amount of the ANC to be applied if the employer continues to refuse to comply with the audit. d)The carrier must adequately document the audit file regarding the above attempts to obtain the required audit information. These ANC conditions apply to mail/email, telephone, computer (remote access), and physical audits, unless otherwise provided by state law. Form WC 37 04 01 Printed in U.S.A. Process Date: 05/22/18 Page 1 of 2 Policy Expiration Date: 06/29/19 If an ANC is applied and the employer ... Then the carrier ... not not not Form WC 37 04 01 Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SPECIAL PENNSYLVANIA ENDORSEMENT - INSPECTION OF MANUALS Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 37 06 01 Process Date: Policy Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PENNSYLVANIA NOTICE Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 An Insurance Company, its agents, employees or service contractors acting on its behalf, may provide services to reduce the likelihood of injury, death or loss. These services may include any of the following or related services incident to the application for, issuance, renewal or continuation of, a policy of insurance: 1.surveys; 2.consultation or advice; or 3.inspections. The "Insurance Consultation Services Exemption Act" of Pennsylvania provides that the Insurance Company, its agents, employees or service contractors acting on its behalf, is not liable for damages from injury, death or loss occurring as a result of any act or omission by any person in the furnishing of or the failure to furnish these services. The Act does not apply: 1.if the injury, death or loss occurred during the actual performance of the services and was caused by the negligence of the Insurance Company, its agents, employees or service contractors; 2.to consultation services required to be performed under a written service contract not related to a policy of insurance; or 3.if any acts or omissions of the Insurance Company, its agents, employees or service contractors are judicially determined to constitute a crime, actual malice, or gross negligence. Form WC 37 06 02 Printed in U.S.A. Process Date: 05/22/18 Countersigned by ---------------------Authorized Representative Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PENNSYLVANIA ACT 86-1986 ENDORSEMENT NONRENEWAL, NOTICE OF INCREASE OF PREMIUM, AND RETURN OF UNEARNED PREMIUM Policy Number: 34 WEC 180462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies only to the insurance provided by the policy because Pennsylvania is shown in Item 3.A. of the Information Page. The policy conditions are amended by adding the following regarding nonrenewal, notice of increase in premium, and return of unearned premium. Nonrenewal 1.We may elect not to renew the policy. We will mail each named insured, by first class mail, not less than 60 days advance notice stating when the nonrenewal will take effect. Mailing that notice to you at your mailing address last known to us will be sufficient to prove notice. 2.Our notice of nonrenewal will state our specific reasons for not renewing. 3.If we have indicated our willingness to renew, we will not send you a notice of nonrenewal. However, the policy will still terminate on its expiration date if: a.you notify us or the agent or broker who procured this policy that you do not want the policy renewed; or b.you fail to pay all premiums when due; or c.you obtain other insurance as a replacement of the policy Form WC 37 06 03 A Process Date: 05/22/18 Notice of Increase in Premium 1.We will provide you with not less than 30 days advance notice of an increase in renewal premium of this policy, if it is our intent to offer such renewal. 2.The above notification requirement will be satisfied if we have issued a renewal policy more than 30 days prior to its ef fective date. 3.If a policy has been written or is to be written on a retrospective rating plan basis, the notice of increase in premium provision of this endorsement does not apply. Return of Unearned Premium 1.If this policy is canceled and there is unearned premium due you: a.If the Company cancels, the unearned premium will be returned to you within 10 business days after the effective date of cancellation. b.If you cancel, the unearned premium will be returned within 30 days after the effective date of cancellation. Page 1 of 2 Policy Expiration Date: 06/29/19 2.Because this policy was written on the basis of an estimated premium and is subject to a premium audit, the unearned premium specified in 1 a. and 1 b. above, if any, shall be returned on an estimated basis. Upon our completion of computation of the exact premium, an additional return premium or charge will be made to you within 15 days of the final computation. Countersigned by Form WC 37 06 03 A 3.These return or unearned premium provisions shall not apply if this policy is written on a retrospective rating plan basis. ----------------------Authorized Representative Page 2 of 2 .. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WISCONSIN LAW ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies only to the insurance provided by the policy because Wisconsin is shown in Item 3.A. of the Information Page. This policy is amended to reflect the following changes and/or additions to clarify or comply with Wisconsin Law: I.If our agent has knowledge of a change in or a violation of a policy condition, this will be considered our knowledge and will not void the policy or defeat a recovery for a claim. II."Workers Compensation Law" means Chapter 102, Wisconsin Statutes. It does not include and Form WC 48 06 01 C Printed in U.S.A. Process Date: 05/22/18 Countersigned by this policy does not apply to any obligation under Chapter 40, Wisconsin Statutes, or Section 66.191, Wisconsin Statutes, or any amendment to these laws. Il l. Any language involving "Actions Against Us" is replaced and amended to provide that no legal action may be brought against us until there has been full compliance with all terms of this policy. IV.If an injury occurs that may be covered by this insurance, the policy is amended to provide that you must notify us of that injury as soon as reasonably possible. ---------------------Authorized Representative Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WISCONSIN CANCELLATION AND NONRENEWAL ENDORSEMENT Policy Number: 34 WEC 180462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies only to the insurance provided by the policy because Wisconsin is shown in Item 3.A. of the Information Page. The Cancellation Section (D) of the Part Six -Conditions is deleted and replaced by the following: A.Cancellation 1.You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancellation is to take effect. If you purchase replacement insurance, the cancellation becomes effective on the date the new coverage becomes effective. If no replacement coverage is purchased, the cancellation will be effective thirty (30) days after receipt of written notice by the Wisconsin Compensation Rating Bureau. 2.We may cancel the policy for any reason if the policy has been in effect for less than sixty (60) days. If the policy is issued for a term longer than one year or for an indefinite term, we may cancel the policy for any reason on an annual anniversary of the policy effective date. We may cancel the policy at any other time for the following reasons: a.you fail to pay all premiums when due, however, we must deliver or mail, first Form WC 48 06 06 B Printed in U.S.A. Process Date: 05/22/18 class, not less than thirty (30) days advance written notice stating when the cancellation is to take effect; b.a material misrepresentation; c.a substantial breach of the obligations, conditions or warranties under the policy; or d.a substantial change in the risk we assumed under the policy unless it was reasonable for us to foresee the change or expect the risk when we issued the policy. 3.If we cancel for any permissible reason other than nonpayment of premium when due, we must deliver or mail, first class, not less than* thirty (30) days notice stating when the cancellation 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. 4.The policy period will end on the day and hour stated in a notice of cancellation. B.Nonrenewal 1.You have the right to have the insurance renewed unless we deliver or mail to you not less than* sixty (60) days advance written notice stating our intention not to renew this policy. Page 1 of 2 Policy Expiration Date: 06/29/19 l I t * 2.We do not have to renew the insurance if you do not pay the renewal premium billing by the due date or if you accept replacement insurance, are insured elsewhere, requested or agree to nonrenewal, or if the policy is expressly designated as being nonrenewable. 3.If we renew the insurance, we may use the policy forms, rates and rating plans we are then using for similar risks. We may limit the policy to a term equivalent to the term of the expiring policy or one year, whichever is less. 4.If we offer to renew the insurance on less favorable terms, we will mail or deliver written notice of the new terms by first class mail to you, the policy holder, at least sixty (60) days prior to the renewal date. The definition of "terms" does not include manual rates, experience modification factors, or classification of risks. If we provide such notice within sixty (60) days prior to the renewal date, the new terms will not take effect until sixty (60) days after the notice is mailed or delivered, in which case, you, the policy holder, may elect to cancel the renewal policy at any time during the sixty (60) day period. The notice will include a statement of your right to cancel. If you elect to cancel the renewal policy during the sixty (60) day period, the return premium or additional premium charges shall be calculated proportionally on the basis of the old premiums. We need not mail or deliver this notice if the only change adverse to you is a premium increase that; (a) is less than 25%; or, (b) results from a change based on your action that alters the nature and extent of the risk insured against, including, but not limited to, a change in the classifications for the business. Any written agreement attached to and made a part of the policy, between the insurance carrier and policyholder which extends the cancellation or nonrenewal notification timeframe, will supercede the aforementioned notification requirements found in items A.3., and B.1., respectively. Countersigned by ----------------------Authorized Representative Form WC 48 06 06 B Printed in U.S.A. Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 99 00 69 Process Date: Policy Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. KNOWLEDGE OF OCCURRENCE ENDORSEMENT Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 99 03 52 A Process Date: Policy Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies only to the insurance provided because California is shown in Item 3.A. of the Information Page. A service fee of $7.00 is charged for each installment Form WC 99 03 75 Printed in U.S.A. Process Date: 05/22/18 when your premium is paid in installments. The service fee is $5.00 per withdrawal when you select an electronic fund transfer payment plan. The service fee will be added to the premium amount shown on your premium billing statement. Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT PROGRAMS ENDORSEMENT Policy Number: 34 WEC 180462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies to Part One (Workers Compensation Insurance) because Colorado is listed in Item 3.A of the Information Page. The Colorado Workers Compensation Cost Containment Board has determined that a premium differential shall be provided on all policies when you have selected a designed medical provider. If you qualify for experience and/or schedule rating and you have implemented a certified workers compensation risk management program or service, we must al.low a 5% premium credit if your loss experience has improved since your last renewal date. The Schedule below will indicate if you qualify for this credit. If you do not qualify for experience and/or schedule rating on your workers compensation insurance and you have implemented a certified workers compensation risk management program or service, we must offer premium credits as follows: Premium Credit 10% 8% 6% 4% 2% 0% Credit Criteria If you have been loss free for at least the last year immediately preceding the effective date of the premium credit. If you have had one medical loss exceeding $250 in the last year immediately preceding the effective date of the premium credit. If you have had two medical losses, each exceeding $250 within the last year immediately preceding the effective date of the premium credit. If you have had three medical losses, each exceeding $250 within the last year immediately preceding the effective date of the premium credit. If you have had three medical losses, each exceeding $250, and one claim for loss of time in the last year immediately preceding the effective date of the premium credit. If you have had more than three medical losses and one claim for loss time in the last year immediately preceding the effective date of the premium credit. Countersigned by Authorized Representative Form WC 05 04 03 Printed in U.S.A. Process Date: 05/22/18 Page 1 of 2 Policy Expiration Date: 06/29/19 Schedule % Premium Credit Certified Risk Management Program/Designated Medical Provider Form WC 05 04 03 Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an endorsement to show the proper factor, if different from the factor shown, when it is calculated. Form WC 00 04 03 Printed in U.S.A. Process Date: 05/22/18 Countersigned by Authorized Representative Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PENNSYLVANIA MERIT RATING PLAN ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement applies to the insurance provided by this policy because Pennsylvania is shown in Item 3.A. of the Information Page. The premium for this insurance may be subject to merit rating because your premium may be less than the amount necessary to be eligible for the uniform Experience Rating Plan. The following premium discount or surcharge will be applied to your manual premium based on your claims during the most recent two year period for which statistics are available. Form WC 37 04 05 Printed in U.S.A. Process Date: 05/22/18 Countersigned by 1.A 5% credit (discount) will be applied if you had no compensable employee lost-time injuries Statistical Code 9885. 2.No credit or debit will be applied if you had one (1) compensable employee lost-time injury --Statistical Code 9884. 3.A 5% debit (surcharge) will be applied if you had two (2) or more compensable employee lost-time injuries --Statistical Code 9886. --------------------Authorized Representative Policy Expiration Date: 06/29/19 t- THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PENDING RATE CHANGE ENDORSEMENT Policy Number: Endorsement Number: Effective Date: Named Insured and Address: State Form WC 00 04 04 Process Date: SCHEDULE Policy Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WORKERS' COMPENSATION BROAD FORM ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section Ill of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: SUBJECT SECTION I PAGE 2 PARTS ONE and TWO 01 We Will Also Pay PART-THREE 02 How This Insurance Works PART-SIX 03 Transfer of Your Rights and Duties 04 Liberalization SECTION II VOLUNTARY COMPENSATION INSURANCE 05 Voluntary Compensation Insurance A.How This Insurance Applies B.We will Pay C.Exclusions D.Before We Pay E.Recovery From Others F.Employers' Liability Insurance EMPLOYERS' LIABILITY STOP GAP COVERAGE 06 Employers' Liability Stop Gap Coverage 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 A.Stop Gap Coverage Limited Montana, North Dakota, Ohio, Washington, West 3 Virginia and Wyoming B.Part One does not Apply C.Application of Coverage D.Additional Exclusions E.West Virginia SECTION Ill 07 Schedule of Covered States Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) Process Date: 05/22/18 © 2000, The Hartford 3 3 3 3 4 4 Page 1 of 4 Policy Expiration Date: 06/29/19 PARTS ONE and TWO 1.WE WILL ALSO PAY D.We Will Also Pay of Part One (WORKERS' COMPENSATION INSURANCE); and E.We Will Also Pay of Part Two (EMPLOYERS' LIABILITY INSURANCE) is replaced by the following: 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, INCLUDING 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 law; and 5.expenses we incur. VOLUNTARY COMPENSATION AND EMPLOYERS' LIABILITY COVERAGE 5.Voluntary Compensation Insurance A.How This Insurance Applies This insurance applies to bodily mJury by accident or bodily injury by disease. Bodily injury includes resulting death. 1.The bodily injury must be sustained by any officer or employee not subject to the workers' compensation law of any state shown in Item 3.A. of the Information Jage. 2.The bodily injury must arise out of and in the course of employment or incidental Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) SECTION I PART THREE 2.How This Insurance Applies Paragraph 4. of A. How This Insurance Applies of Part 3 (Other States Insurance) is replaced by the following: 4.If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within sixty days. PART SIX 3. Transfer Of Your Rights and Duties C.Transfer Of Your Rights and Duties of Part 6 (Conditions) is replaced by the following: Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within sixty days after your death, we will cover your legal representative as insured. 4.Liberalization SECTION II If we adopt a change in this form that would broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. to work in a state shown in Item 3.A. of the Information Page. 3.The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen, or otherwise legal resident, and legally employed, in the United States or Canada and temporarily away from those places. 4.Bodily injury by accident must occur during the policy period. 5.Bodily injury by disease must be caused or aggravated by the conditions of the officer's or employee's employment. Page 2 of 4 The officer's or employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B.We Will Pay We will pay an amount equal to the benefits that would be required of you as if you and your employees were subject to the workers' compensation law of any state shown in Item 3.A. of the Information Page. We will pay those amounts to the persons who would be entitled to them under the law. C.Exclusion This insurance does not cover: 1.any obligation imposed by workers' compensation or occupational disease law or any similar law. 2.bodily injury intentionally caused or aggravated by you. 3.officers or employees who have elected not to be subject to the state workers' compensation law. 4.partners or sole proprietors not covered under the Standard Sole Proprietors, Partners, Officers and Others Coverage Endorsement. D.Before We Pay Before we pay benefits to the persons entitled to them, they must: 1.Release you and us, in writing, of all responsibility for the injury or death. 2.Transfer to us their right to recover from others who may be responsible for the injury or death. 3.Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E.Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F.Employers' Liability Insurance Part Two (Employers' Liability Insurance) applies to bodily injury covered by this endorsement as though the State of Employment was shown in Item 3.A. of the Information Page. This provision 5. does not apply in New Jersey or Wisconsin. EMPLOYERS' LIABILITY STOP GAP COVERAGE 6.Employers' Liability Stop Gap Coverage A.This coverage only applies in Montana, North Dakota, Ohio, Washington, West Virginia and Wyoming. B.Part One (Workers' Compensation Insurance) does not apply to work in states shown in Paragraph A above. C.Part Two (Employers' Liability Insurance) applies in the states, shown in Paragraph A., as though they were shown in Item 3.A. of the Information Page. D.Part Two, Section C. Exclusions is changed by adding these exclusions. This insurance does not cover; 5.bodily inJury intentionally caused or aggravated by you or in Ohio bodily injury resulting from an act which is determined by an Ohio court of law to have been committed by you with the belief than an injury is substantially certain to occur. However, the cost of defending such claims or suits in Ohio is covered. 13.bodily injury sustained by any member of the flying crew of any aircraft. 14.any claim for bodily injury with respect to which you 'are deprived of any defense or defenses or are otherwise subject to penalty because of default in premium under the provisions of the workers' compensation law or laws of a state shown in Paragraph A. E.This insurance applies to damages for which you are liable under West Virginia Code Annot. S 23- 4-2. Page 3 of4 SECTION Ill 7.SCHEDULE OF COVERED STATES A.This endorsement only applies in the states listed in this Schedule of Covered States. C.Schedule of Covered States: CO, CA Countersigned by Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00) B.If a state, shown in Item 3.A. of the Information Page, approves this endorsement after the effective date of this policy, this endorsement will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. ---------------,-----,-------Authorized Representative Page 4 of 4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WORKERS' COMPENSATION BROAD FORM ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section Ill of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: INDEX SUBJECT PAGE SECTION I 2 PARTS ONE and TWO 2 01 We Will Also Pay 2 PART-THREE 2 02 How This Insurance Works 2 PART-SIX 2 03 Transfer of Your Rights and Duties 2 04 Cancellation 2 05 Liberalization 2 SECTION II 2 VOLUNTARY COMPENSATION INSURANCE 2 06 Voluntary Compensation Insurance 2 A.How This Insurance Applies 2 B.We will Pay 3 C.Exclusions 3 D.Before We Pay 3 E.Recovery From Others 3 F.Employers' Liability Insurance 3 EMPLOYERS' LIABILITY STOP GAP COVERAGE 3 07 Employers' Liability Stop Gap Coverage 3 A.Stop Gap Coverage Limited to North Dakota, Ohio, Washington, and 3 Wyoming B.Part One does not Apply 3 C.Application of Coverage 3 D.Additional Exclusions 3 SECTION Ill 4 08 Schedule of Covered States 4 Form WC 99 03 19 D Printed in U.S.A. Page 1 of 4 © 2008, The Hartford Process Date: 05/22/18 Policy Expiration Date: 06/29/19 SECTION I PARTS ONE and TWO 1.WE WILL ALSO PAY D.We Will Also Pay of Part One (WORKERS' COMPENSATION INSURANCE); and E.We Will Also Pay (EMPLOYERS' LIABILITY replaced by the following: We Will Also Pay of Part Two INSURANCE) is 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, INCLUDING 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 law; and 5.expenses we incur. PART THREE 2.How This Insurance Applies Paragraph 4. of A. How This Insurance Applies of Part 3 (Other States Insurance) is replaced by the following: 4.If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within sixty days. PART SIX 3.Transfer Of Your Rights and Duties C.Transfer Of Your Rights and Duties of Part 6 (Conditions) is replaced by the following: Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within sixty days after your death, we will cover your legal representative as insured. 4.Cancellation Paragraph 2. · of D. Cancellation of Part 6 (Conditions) is replaced by the following: 2.We may cancel this policy for non-payment of premium. We must mail or deliver to you not less than 15 business days advance written notice stating when the cancellation 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. 5.Liberalization If we adopt a change in this form that would broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS' LIABILITY COVERAGE 6.Voluntary Compensation Insurance A.How This Insurance Applies This insurance applies to bodily 1nJury by accident or bodily injury by disease. Bodily injury includes resulting death. 1.The bodily injury must be sustained by any officer or employee not subject to the workers' compensation law of any state shown in Item 3.A. of the Information Page. Form WC 99 03 19 D Printed in U.S.A. 2.The bodily injury must arise out of and in the course of employment or incidental to work in a state shown in Item 3.A. of the Information Page. 3.The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen, or otherwise legal resident, and legally employed, in the United States or Canada and temporarily away from those places. Page 2 of4 4.Bodily injury by accident must occur during the policy period. 5.Bodily injury by disease must be caused or aggravated by the conditions of the officer's or employee's employment. The officer's or employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B.We Will Pay We will pay an amount equal to the benefits that would be required of you as if you and your employees were subject to the workers' compensation law of any state shown in Item 3.A. of the Information Page. We will pay those amounts to the persons who would be entitled to them under the law. C.Exclusion This insurance does not cover: 1.any obligation imposed by workers' compensation or occupational disease law or any similar law. 2.bodily injury intentionally caused or aggravated by you. 3.officers or employees who have elected not to be subject to the state workers' compensation law. 4.partners or sole proprietors not covered under the Standard Sole Proprietors, Partners, Officers and Others Coverage Endorsement. D.Before We Pay Before we pay benefits to the persons entitled to them, they must: 1.Release you and us, in writing, of all responsibility for the injury or death. 2.Transfer to us their right to recover from others who may be responsible for the injury or death. 3.Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. Form WC 99 03 19 D Printed in U.S.A. E.Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F.Employers' Liability Insurance Part Two (Employers' Liability Insurance) applies to bodily injury covered by this endorsement as though the State of Employment was shown in Item 3.A. of the Information Page. EMPLOYERS' LIABILITY STOP GAP COVERAGE 7.Employers' Liability Stop Gap Coverage A.This coverage only applies in North Dakota, Ohio, Washington and Wyoming. B.Part One (Workers' Compensation Insurance) does not apply to work in states shown in Paragraph A above. C.Part Two (Employers' Liability Insurance) applies in the states, shown in Paragraph A., as though they were shown in Item 3.A. of the Information Page. D.Part Two, Section C. Exclusions is changed by adding these exclusions. This insurance does not cover; 5.bodily injury intentionally caused or aggravated by you or in Ohio bodily injury resulting from an act which is determined by an Ohio court of law to have been committed by you with the belief that an injury is substantially certain to occur. However, the cost of defending such claims or suits in Ohio is covered. 13.bodily injury sustained by any member of the flying crew of any aircraft. 14.any claim for bodily injury with respect to which you are deprived of any defense or defenses or are otherwise subject to penalty because of default in premium under the provisions of the workers' compensation law or laws of a state shown in Paragraph A. Page 3 of 4 SECTION Ill 8.SCHEDULE OF COVERED STATES A.This endorsement only applies in the states listed in this Schedule of Covered States. C.Schedule of Covered States: PA Form WC 99 03 19 D Printed in U.S.A. B. If a state, shown in Item 3.A. of the Informati on Page, approves this endorsement after the effective date of this policy, this endorsement will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. Page 4 of 4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT TO WORKERS' COMPENSATION BROAD FORM ENDORSEMENT-EMPLO YERS' LIABILITY STOP GAP COVERAGE Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement changes the Workers' Compensation Broad Form Endorsement - Employers' Liability Stop Gap Coverage 6.Employers' Liability Stop Gap Coverage Form WC 99 03 58 B Printed in U.S.A (Ed. 7/08) Process Date: 05/22/18 A.This coverage only applies in North Dakota, Ohio, Washington, and Wyoming E.This paragraph is removed. Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT TO WORKERS' COMPENSATION BROAD FORM ENDORSEMENT-EMPLOYERS' LIABILITY STOP GAP COVERAGE Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 This endorsement changes the Workers' Compensation Broad Form Endorsement Employers' Liability Stop Gap Coverage 7.Employers' Liability Stop Gap Coverage Form WC 99 03 59 B Printed in U.S.A. Process Date: 05/22/18 A.This coverage only applies in North Dakota, Ohio, Washington, and Wyoming. E.This paragraph is removed. Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WORKERS' COMPENSATION BROAD FORM ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section Ill of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: INDEX SUBJECT PAGE SECTION I 2 PARTS ONE and TWO 2 01 We Will Also Pay 2 PART-THREE 2 02 How This Insurance Works 2 PART -SIX 2 03 Transfer of Your Rights and Duties 2 04 Cancellation 2 05 Liberalization 2 SECTION II 2 VOLUNTARY COMPENSATION INSURANCE 2 06 Voluntary Compensation Insurance 2 A.How This Insurance Applies 2 B.We will Pay 3 C.Exclusions 3 D.Before We Pay 3 E.Recovery From Others 3 F.Employers' Liability Insurance 3 EMPLOYERS' LIABILITY STOP GAP COVERAGE 3 07 Employers' Liability Stop Gap Coverage 3 A.Stop Gap Coverage Limited Montana, North Dakota, Ohio, Washington,3 West Virginia and Wyoming B.Part One does not Apply 3 C.Application of Coverage 3 D.Additional Exclusions 3 E.West Virginia 3 SECTION Ill 4 08 Schedule of Covered States 4 Form WC 99 03 00 B Printed in U.S.A. (Ed. 8/00) Page 1 of 4 Process Date: 05/22/18 Policy Expiration Date: 06/29/19 © 2000, The Hartford SECTION I PARTS ONE and TWO 1.WE WILL ALSO PAY D.We Will Also Pay of Part One (WORKERS' COMPENSATION INSURANCE); and E.We Will Also Pay of Part Two (EMPLOYERS' LIABILITY INSURANCE) is replaced by the following: 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, INCLUDING 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 law; and 5.expenses we incur. PART THREE 2.How This Insurance Applies Paragraph 4. of A. How This Insurance Applies of Part 3 (Other States Insurance) is replaced by the following: 4.If you have work on the effective date of this policy in any state not listed in Item 3.A. of the Information Page, coverage will not be afforded for that state unless we are notified within sixty days. PART SIX 3.Transfer Of Your Rights and Duties C. Transfer Of Your Rights and Duties of Part 6 (Conditions) is replaced by the following: Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within sixty days after your death, we will cover your legal representative as insured. 4.Cancellation Paragraph 2. of D. Cancellation of Part 6 (Conditions) is replaced by the following: 2.We may cancel this policy. We must mail or deliver to you not less than 15 days advance written notice stating when the cancellation 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. 5.Liberalization If we adopt a change in this form that would broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS' LIABILITY COVERAGE 6.Voluntary Compensation Insurance A.How This Insurance Applies This insurance applies to bodily mJury by accident or bodily injury by disease. Bodily injury includes resulting death. 1.The bodily injury must be sustained by any officer or employee not subject to the workers' compensation law of any state shown in Item 3.A. of the Information Page. Form WC 99 03 00 B Printed in U.S.A. (Ed. 8/00) 2.The bodily injury must arise out of and in the course of employment or incidental to work in a state shown in Item 3.A. of the Information Page. 3.The bodily injury must occur in the United States of America, its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen, or otherwise legal resident, and legally employed, in the United States or Canada and temporarily away from those places. Page 2 of 4 4.Bodily injury by accident must occur during the policy period. 5.Bodily injury by disease must be caused or aggravated by the conditions of the officer's or employee's employment. The officer's or employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B.We Will Pay We will pay an amount equal to the benefits that would be required of you as if you and your employees were subject to the workers' compensation law of any state shown in Item 3.A. of the Information Page. We will pay those amounts to the persons who would be entitled to them under the law. C.Exclusion This insurance does not cover: 1 . any obligation imposed by workers' compensation or occupational disease law or any similar law. 2.bodily injury intentionally caused or aggravated by you. 3.officers or employees who have elected not to be subject to the state workers' compensation law. 4.partners or sole proprietors not covered under the Standard Sole Proprietors, Partners, Officers and Others Coverage Endorsement. D.Before We Pay Before we pay benefits to the persons entitled to them, they must: 1.Release you and us, in writing, of all responsibility for the injury or death. 2.Transfer to us their right to recover from others who may be responsible for the injury or death. 3.Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this insurance fail to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E.Recovery From Others If we make a recovery from others, we will keep Form WC 99 03 00 B Printed in U.S.A. (Ed. 8/00) an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F.Employers' Liability Insurance Part Two (Employers' Liability Insurance) applies to bodily injury covered by this endorsement as though the State of Employment was shown in Item 3.A. of the Information Page. This provision 6. does not apply in New Jersey or Wisconsin. EMPLOYERS' LIABILITY STOP GAP COVERAGE 7.Employers' Liability Stop Gap Coverage A.This coverage only applies in Montana, North Dakota, Ohio, Washington, West Virginia and Wyoming. B.Part One (Workers' Compensation Insurance) does not apply to work in states shown in Paragraph A above. C.Part Two (Employers' Liability Insurance) applies in the states, shown in Paragraph A., as though they were shown in Item 3.A. of the Information Page. D.Part Two, Section C. Exclusions is changed by adding these exclusions. This insurance does not cover; 5.bodily 1nJury intentionally caused or aggravated by you or in Ohio bodily injury resulting from an act which is determined by an Ohio court of law to have been committed by you with the belief than an injury is substantially certain to occur. However, the cost of defending such claims or suits in Ohio is covered. 13.bodily injury sustained by any member of the flying crew of any aircraft. 14.any claim for bodily injury with respect to which you are deprived of any defense or defenses or are otherwise subject to penalty because of default in premium under the provisions of the workers' compensation law or laws of a state shown in Paragraph A. E.This insurance applies to damages for which you are liable under West Virginia Code Annot. S 23-4-2. Page 3 of 4 t- SECTION Ill 8.SCHEDULE OF COVERED STATES A.This endorsement only applies in the states listed in this Schedule of Covered States. SC C. Schedule of Covered States: Countersigned by Form WC 99 03 00 B Printed in U.S.A. (Ed. 8/00) B.If a state, shown in Item 3.A. of the Information Page, approves this endorsement after the effective date of this policy, this endorsement will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. ------------,-----,-----------Authorized Representative Page 4 of 4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 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 2015. 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 2015. Form WC 00 04 22 B Printed in U.S.A. Process Date: 05/22/18 "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, 2015, and ending on December 31, 2020, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year. Page 1 of 2 Policy Expiration Date: 06/29/19 Limitation of Liability 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 exceed: a.$100,000,000, with respect to such Insured Losses occurring in calendar year 2015, the United States Government would pay 85% of our Insured Losses that exceed our Insurer Deductible. b.$120,000,000, with respect to such Insured Losses occurring in calendar year 2016, the United States Government would pay 84% of our Insured Losses that exceed our Insurer Deductible. c.$140,000,000, with respect to such Insured Losses occurring in calendar year 2017, the United States Government would pay 83% of our Insured Losses that exceed our Insurer Deductible. d.$160,000,000, with respect to such Insured Losses occurring in calendar year 2018, the United States Government would pay 82% of our Insured Losses that exceed our Insurer Deductible. e.$180,000,000, with respect to such Insured Losses occurring in calendar year 2019, the United States Government would pay 81% of our Insured Losses that exceed our Insurer Deductible. f.$200,000,000, with respect to such Insured Losses occurring in calendar year 2020, 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. Schedule State Rate Premium See Attached Schedule Form WC 00 04 22 B Printed in U.S.A. Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number: 34 WEC 180462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 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 B), attached to this policy. For purposes of this endorsement, the following definitions apply: o 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. o Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. o Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary State PA SC WI Form WC 00 04 21 D Printed in U.S.A. Process Date: 05/22/18 of 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. o 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. Schedule Rate Premium 0.0200 0.0200 0.0100 $13 $15 $1 Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number: 34 WEC IB0462 Endorsement Number: Effective Date: 06/29/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 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 B), attached to this policy. For purposes of this endorsement, the following definitions apply: o 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. o Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. o Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary State co Form WC 00 04 21 D Printed in U.S.A. Process Date: 05/22/18 of 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. o 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. Schedule Rate Premium 0.0100 $20 Policy Expiration Date: 06/29/19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 00 0414 Process Date: Policy Expiration Date: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WISCONSIN REAL ESTATE SALESPERSONS ENDORSEMENT Policy Number: Endorsement Number: Effective Date: Named Insured and Address: Form WC 48 03 04 Process Date: Policy Expiration Date: POLICY ADJUSTMENT NOTICE The premium we charged for your enclosed Hartford policy was based, in part, on estimates and assumptions related to items such as payroll, sales revenue, and the nature of business operations for the policy period shown. When your coverage period expires, a premium audit will be conducted to ensure the premium you paid for your insurance was accurate. In order to complete the premium audit, when your policy coverage period expires you may receive, via e-mail or US Postal mail, a request to complete an "lnsured's Report of Exposure" Form. Alternatively, you may receive notice that a Premium Audit representative will be contacting you to review your records and discuss your business operations over the phone or in person. The purpose of the statement, phone call or visit is for the Premium Audit Department to collect the information required to ensure that the premium you paid for your coverage was accurate. Once the audit is complete, you will receive a Statement of Premium Adjustment which will reflect the amount of your policy auditable premium, and will indicate whether you are owed a refund or if additional premium is due for the policy period shown. If we owe you a return premium, The Hartford will apply the refund amount to any current account balance. If your account is paid in full, or if your refund amount is greater than the current account balance, we will issue you a refund check. You can expect to receive this check within the next 30 days. If you owe us an additional premium, the entire amount will appear as due and payable on your next bill. This amount will appear as "Premium Audit" on your bill. If you have any questions regarding the Premium Audit process, please call your insurance agent. Thank you for doing business with The Hartford. Form G-3058-1 Printed in U.S.A. WISCONSIN NOTICE OF RIGHT TO FILE A COMPLAINT KEEP THIS WITH YOUR INSURANCE PAPERS PR OBLEMS WITH YOUR INSURANCE? -If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem. THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8730 You can also contact the OFFICE OF THE COMMISSI ONER OF INSURANCE, a state agency which enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by writing to: Office of the Commissioner of Insurance Complaints Department P. 0. Box 7873 Madison, WI 53707-7873 or you can call 1-800-236-8517 outside of Madison or 266-0103 in Madison, and request a complaint form. Form G-3143-0 Printed in U.S.A. Process Date: 05/22/18 Expiration Date: 06/29/19 PRODUCER COMPENSATION NOTICE You can review and obtain infor mation on The Hartford's producer compensation practices at www.TheHartford.com or at 1-800-592-5717. Form G-3418-0 POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I.Information Available to You A.Information Available from Us -The Sentinel Insurance Company (1)General questions regarding your policy should be directed to your Hartford Agent or THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Telephone: (866) 467-8730 www.thehartford.com (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 (WCIRB) 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). Contact information for the WCIRB is: WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Customer Service. You may also contact WCIRB Customer Service at 1-888-229-2472, by fax at 415-778-7272, or via the Internet at the WCIRB's website: http://www.wcirb.com. The regulations contained in the USRP and the ERP are available for public viewing through the WCIRB's website. (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, California 94612, Attention: Custodian of Records. The Custodian of Records can be reached by telephone at 415- 777-0777 and by fax at 415-778-7272. Form PN 04 99 01 F Printed in U.S.A. Process Date: 05/22/18 Page 1 of 3 Policy Expiration Date: 06/29/19 (3)Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form free of charge by completing a Policyholder Rate Sheet Request Form on the WCIRB's website at http://www.wcirb.com/ratesheet. The Experience Rating Form 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. A.Our Dispute Resolution Process. 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: The Sentinel Insurance Company One Pointe Drive, Suite 200, Brea, CA 92821; Telephone (714) 674-1200; Fax (714) 674-1477. 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 commissioner as described in paragraph 11.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 14 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, California 94612, Attention: Customer Service. Customer Service can be reached by telephone at 1-888-229-2472, and by fax at 415-778-7272 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 11.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Complaints and Reconsiderations. The WCIRB's telephone number is 1-888-229-2472, and the fax number is 415-371-5204. Form PN 04 99 01 F Printed in U.S.A. Page 2 of 3 C.California Department of Insurance -Appeals to the Insurance Commissioner. If, after you follow the appropriate dispute resolution process described above, we or the WCIRB decline to review your request, if you are dissatisfied with the decision upon review, or if 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, Sections 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, California 94105 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. Ill. 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, California 94612, Attention: Policyholder Ombudsman. The policyholder ombudsman can be reached by telephone at 415-778-7159 and by fax at 415-371-5288. B.California Department of Insurance -Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 1-800-927-HELP (4357) or http://www.insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph 11.C. This notice does not change the policy to which it is attached. Form PN 04 99 01 F Printed in U.S.A. Page 3 of 3 POLICYHOLDER NOTICE CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 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 after public hearing that our rates might jeopardize our ability to pay claims or 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 Form PN 04 99 02 B (Ed. 5-02) Printed in U.S.A. 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. Page 1 of 2 CALIFORNIA WORKERS' COMPENSATION INSURANCE 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 non renewal 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. Form PN 04 99 02 B (Ed. 5-02) Printed in U.S.A. 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 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. Page 2 of 2 POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged, "CA Surcharge" or "CA Surcharge (CIGA Surcharge)" with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. Form PN 04 99 04 Printed in U.S.A. POLICYHOLDER NOTICE PAYROLL RECORD AND AUDIT REQUIREMENTS FOR DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Your policy includes one or more construction or erection classifications. Dual wage classifications are pairs of classifications that describe the same construction or erection operation yet are assigned based upon whether the employee's hourly wage is above or below a specified threshold. Each pair of dual wage classifications contains one "high wage" classification that is assignable to payrolls earned by employees whose regular hourly wage equals or exceeds a specified wage threshold and one "low wage" classification that is assignable to payrolls earned by employees whose regular hourly wage is less than the specified threshold. Payroll Record Requirements The assignment of a high wage classification to any non-salaried employee is contingent on verifying that the employee's hourly wage equals or exceeds the specified wage threshold. The determination of the regular hourly wage must be supported by one of the following sources: o Original time cards or time book entries for each employee. Original records must include the operations performed, the total hours worked each day and the times the employee started and ended each work period throughout the workday. At job locations where all of the employer's operations cease for a uniform unpaid meal period, recording the start and stop times of the uniform break period is not required. o A valid collective bargaining agreement that shows the regular hourly wage rate by job classification of a worker. If using a collective bargaining agreement, the records must include an employee roster by job classification that permits the reconciliation of individual employees to the job classifications set forth in the collective bargaining agreement. The non-salaried employee's regular hourly wage shall be determined by dividing that employee's total remuneration by the hours worked during the pay period, irrespective of whether the employee is paid on an hourly, piecework, production or commission basis. The payroll earned by any non-salaried employees for whom the records specified above are not maintained and/or made available will be assigned to the low wage classification that describes the operations performed. The regular hourly wage of salaried employees is determined by dividing the total annual remuneration by 2000 hours. If an employee is salaried for less than 12 months, the regu.lar hourly wage for the salaried period is calculated on a prorated basis. Audit Requirements If your policy produces a final premium of $13,000 or more, a physical audit is required at least once a year. If your policy produces a final premium of less than $13,000 and payroll is developed under a high wage classification, a physical audit of the policy is required unless the policy is a renewal and a physical audit was completed for one of the two immediately preceding policy periods. A "physical audit" is defined as an audit of payroll, whether conducted at the policyholder's location or at a remote site, that is based upon an auditor's examination of the policyholder's books of accounts and original payroll records (in either electronic or hard copy form) as necessary to determine and verify the exposure amounts by classification. If you hold a C-39 Roofing Contractor license from the California Contractors State License Board, a physical audit is required on the complete policy period of each policy regardless of the amount of final premium. See California Insurance Code Section 11665(a) for additional requirements regarding the audit of C-39 license holders. Form PN 04 99 06 C Printed in U.S.A. POLICYHOLDER NOTICE JANUARY 1, 2015 AUDIT REQUIREMENTS FOR POLICIES WITH FINAL PREMIUM OF LESS THAN $13,000 THAT DEVELOP PAYROLL IN HIGH WAGE DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Dual wage classifications are pairs of classifications that describe the same construction or erection operation yet are assigned based upon whether the employee's hourly wage is above or below a specified threshold. Each pair of dual wage classifications contains one "high wage" classification that is assignable to payrolls earned by employees whose regular hourly wage equals or exceeds a specific wage threshold and one "low wage" classification that is assignable to payrolls earned by employees whose regular hourly wage is less than the specified threshold. If your policy effective on or after January 1, 2015 produces a final premium of less than $13,000 and develops payroll in a high wage classification, a physical audit of the policy is required unless the policy is a renewal and a physical audit was completed for one of the two immediately preceding policy periods. If your policy produces a final premium of $13,000 or more, a physical audit is required at least once a year. A "physical audit" is defined as an audit of payroll, whether conducted at the policyholder's location or at a remote site, that is based upon an auditor's examination of the policyholder's books of accounts and original payroll records (in either electronic or hard copy form) as necessary to determine and verify the exposure amounts by classification. Form PN 04 99 07 A Printed in U.S.A. CALIFORNIA NOTICE Form WC WORKERS' COMPENSATION DISCLOSURE FORM IMPORTANT NOTICE TO POLICYHOLDERS 1.NOTICE OF CHANGE IN RATE BY CLASSIFICATION If you desire information whenever there is a change in your workers' compensation insurance rate by classification, you must request such information from your insurer. This request for information must be in writing. 2.NOTICE OF POLICYHOLDER'S RIGHT TO APPEAL CLASSIFICATION Your insurer can charge and collect any additional amount of money not included in the initial premium charged as a result of job misclassification. If you have any questions regarding the employee classification assigned to calculate your workers' compensation insurance premium, you need to direct your questions to your insurer or the insurer's authorized representative within either thirty (30) days after the anniversary date of the policy or the date of receipt by you of notice of a change in job classification. Within thirty (30) days after receipt of your request for information, your insurer or the insurer's authorized representative must explain to you why a particular employee classification was used. If you disagree with your insurer or the insurer's authorized representative on the employee classification assignment, you may appeal to the Workers' Compensation Classification Appeal Board by filing written notice with said board within thirty (30) days after you have exhausted all appeal review procedures provided by the insurer. Your request should be sent to the Secretary of the Colorado Workers' Compensation Classification Appeals Board, Michael Craddock, c/o National Council on Compensation Insurance, 901 Peninsula Corporate Circle, Boca Raton, FL 33487. Written instructions for your appearance before the Colorado Workers' Compensation Classification Appeals Board will be furnished by the Secretary of the board. The board will render a decision as to whether a misclassification has occurred. A decision by the board is final and not subject to appeal unless you, the insurer or Pinnacol Assurance provides written notice of appeal within thirty (30) days after the board's decision to the office of the Commissioner of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202. The Commissioner shall review any decision of the board properly appealed. 3.NOTICE OF AVAILABILITY OF MEDICAL CASE MANAGEMENT SERVICES On appropriate cases, staff Health Service Representatives (R.N.'s) or outside vendors are assigned for medical case management to insure quality medical care and rehabilitation at a reasonable cost. The use includes, but is not limited to, coordinating with qualified medical providers, monitoring the rehabilitation process and working with employers to return the injured party to their regular or a modified position. Form WC 66 00 89 B Printed in U.S.A. TO OUR POLICYHOLDERS: Form WC 66 01 20 IMPORTANT NOTICE COLORADO WORKERS' COMPENSATION INSURANCE MEDICAL AND INDEMNITY DEDUCTIBLE ELECTION FORM Colorado Workers' Compensation Law permits an employer to purchase workers' compensation insurance with a deductible. The deductible is for medical and indemnity benefits only. There are nine "Per Claim" deductible options available. They are: ( ) NONE ( ) $ 500 ( ) 1,000 ( ) 1,500 ( ) 2,000 ( ) 2,500 ( ) 5,000 ( ) 10,000 ( ) 13,500 ( ) 15,500 ( ) 16,000 ( ) 16,500 All medical and indemnity claims shall be paid by the company. In such case, the law requires that you reimburse the company for any deductible amounts so paid. If you have any questions, or desire one of these deductible amounts to apply to your coverage, please call your Agent for a quote. This offer is valid for thirty days after the effective date of the policy with which this notice is enclosed. Policy Number 34 WEC IB0462 Employer Name PLAN-IT GEO LLC Agent Name INSURANCE CENTER OF AMERICNPHS Return to Issuing Office: Address: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 01 49 F Printed in U.S.A. Process Date: 05/22/18 Date Signature and Title Date Signature Policy Expiration Date: 06/29/19 NOTICE TO POLICYHOLDER CALIFORNIA WORKERS' COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers' compensation rating laws applicable to new and renewal policies with policy effective dates on and after January 1, 1995. 1.The laws requiring all insurers to charge the same minimum rate uniformly to all employers within a given classification has been repealed. Beginning January 1, 1995, we will establish our own rates for workers' compensation. Our rates will not be applicable prior to the first normal policy effective date of a policy incepting on or after January 1, 1995. 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 has determined after public hearing that our rates might jeopardize our ability to pay claims or 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 classification, he may order an increase in the rates applicable to outstanding policies. 3.Rating organizations may develop pure premium rates which 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 sue 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 developed by the insurance rating organization designated by the Insurance commissioner is subject to the approval of the Insurance Commissioner. 5.A standard classification system developed by the insurance rating or ganization designated by the Insurance Commissioner is subject to approval of 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 that we can report the payroll, expenses and other costs of claims in a way which is consistent with 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 will require 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. Form WC 66 02 05 A Printed in U.S.A. IMPORTANT NOTICE SOUTH CAROLINA WORKERS' COMPENSATION INSURANCE MEDICAL AND INDEMNITY BENEFITS DEDUCTIBLE ELECTION FORM South Carolina Workers' Compensation law permits an employer to purchase workers' compensation insurance with a deductible. The deductible is for medical and indemnity benefits only. Please check the option which you have elected and return this form to the company prior to the effective date of your coverage. 1.I reject any deductible option and elect that the company pay all benefits due under my policy. 2.I elect one of the following deductibles to be applied to benefits under my workers' compensation insurance policy and each subsequent renewal. The premium reduction to be applied is shown below. PREMIUM REDUCTION HAZARD GROUP A B C D E F G ( ) $100 0.6% 0.5% 0.4% 0.3% 0.2% 0.1% 0.1% ( ) $200 1.1% 0.9% 0.8% 0.5% 0.4% 0.3% 0.2% ( ) $300 1.6% 1.2% 1.0% 0.8% 0.6% 0.4% 0.3% ( ) $400 1.9% 1.5% 1.3% 0.9% 0.7% 0.5% 0.5% ( ) $500 2.3% 1.8% 1.6% 1.1% 0.9% 0.6% 0.6% ( ) $1,000 3.5% 2.8% 2.5% 1.9% 1.4% 1.1% 1.0% ( ) $1,500 4.5% 3.7% 3.2% 2.4% 1.9% 1.5% 1.3% ( ) $2,000 5.3% 4.3% 3.9% 3.0% 2.4% 1.9% 1.6% ( ) $2,500 6.0% 5.0% 4.5% 3.4% 2.8% 2.2% 1.9% All claims shall be paid by the company. In such case, the law requires that you reimburse the company for any deductible amounts so paid. If you do not return this form promptly to the company, it will be construed to mean that we should pay in full all benefits due under your policy with no contribution on your part. If you have any questions, please call your Agent. Policy Number 34 WEC IB0462 Employer Name PLAN-IT GEO LLC Agent Name INSURANCE CENTER OF AMERICA/PHS Return this form to Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER Address: 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 02 65 0 Printed in U.S.A. Process Date: 05/22/18 Date Signature and Title Date Signature Policy Expiration Date: 06/29/19 PENNSYLVANIA WORKERS' COMPENSATION REFORM Act 57 of the Pennsylvania law lengthens the period of time during which you may require an injured employee to seek treatment from a health care provider designated by the employer. Effective August 23, 1996, the period was lengthened from 30 days to 90 days after the date of the first visit to a designated health care provider. Under the terms of the law, you MAY NOT DIRECT an injured worker to a health care provider during such 90 day period UNLESS first obtaining written acknowledgment from the employee indicating that the employee has been informed of and understands his or her rights and obligations under the provisions of section 306 (F .1 )(1 )(1) of the Workers' Compensation Act. If you fail to obtain such written acknowledgment, an injured employee is entitled to treatment from a medical care provider of his or her choice. The Hartford will be responsible for paying the cost of such treatment. However, because such treatment will be more expensive, you should be advised that it could adversely impact your future insurance cost. Attached is a sample of a FORM WHICH WE ENCOURAGE YOU TO USE to inform employees of their rights and obligations under the law and which can be used to obtain their written acknowledgment of such rights and responsibilities. IF YOU HAVE NOT ESTABLISHED A PANEL OF PHYSICIANS, WE CAN BE OF ASSISTANCE. The Hartford currently utilizes FIRST HEAL TH as their medical network for the state of Pennsylvania. FIRST HEAL TH is one of the nation's largest preferred provider organizations offering a network of Workers' Compensation focused providers and comprehensive array of services, industrial medical clinics and work hardening centers. You may contact The Hartford's Network Referral Unit directly at 1-800-327-3636, option 4, to obtain a list of treating physicians. We appreciate your cooperation and encourage you to utilize our Hartford LossConnect reporting system. (1-800-327-3636) to report your losses with 24 hours. Form WC 66 02 67 A Printed in U.S.A. IMPORTANT NOTICE This Notice shall service to advise you of your rights and responsibilities under the Pennsylvania Workers' Compensation Act. If you sustain a work-related injury requiring medical treatment, you are required to first treat with a doctor who is on a list of six (6) providers identified below. You are required to treat with that provider for ninety (90) days from the first visit. However, if invasive surgery is recommended by the designated physician, then you are allowed a second opinion by a physician of your choice. If the second opinion differs from the first, you have the right to determine which course of treatment to follow, provided that the second opinion provides a specific and detailed course of treatment. If you choose to follow the procedures designated in the second opinion, such procedures shall be performed by one of the physicians or other health care providers so designated by the employer for a period of ninety (90) days from the date of the second opinion visit. Treatment with your own medical provider in violation of the above may result in your medical bills being unpaid for the prescribed period. Upon expiration of the prescribed period, if you select a medical provider not on the panel below, you must notify your employer of your choice of providers within five (5) days of the first visit or risk non payment of those medical bills until proper notice is given. Your employer's approved providers are: 1. 2. 3. The name of your employer's insurance carrier is: The Hartford P.O. Box 4771 Syracuse, NY 13221 1-877 -469-9222 4. 5. 6. Please sign where indicated to verify that you understand the rights and responsibility outlined in this Notice. I, -------------------'--have read the above and understand the rights and responsibilities explained to me therein. Signature of Employee/Date Witness/Date Form WC 66 02 68 A Printed in U.S.A. We're protected by WORKERS' COMPENSATION Follow safety rules and you'll be protected from injury. But if you are injured at work, you're protected by benefits. PREVENT THE ABUSE OF WORKERS' COMPENSATION CLAIMS We Help Employers Fight Fraud If you suspect a claim is fraudulent, or that it abuses the system, work with your insurance carrier to prepare evidence of the alleged fraud. Then Report the case to: Workers' Compensation Fraud Unit 201 E. Washington Avenue P.O. Box 7901 Madison, WI 53707-7901 For quick help, call the Fraud Hotline: (608) 261-8486 What We Can Do to Help The Workers' Compensation Division is authorized by Wisconsin Statute 102.125 to work with employers and insurers to report, investigate, and prosecute allegations of Workers' Compensation fraud. Here's what we do: o Work with you and your insurance carrier to determine if there is enough evidence to take the case to court. o Refer the case to the local District Attorney's Office for prosecution if there is sufficient evidence of fraud. Cooperation from the Justice Department and District Attorneys has been excellent. They will prosecute! PROVE IT! Conviction of a fraudulent claim requires proof beyond a reasonable doubt of an intentional misrepresentation to secure benefits. Only the best documented cases succeed. Prevention Is the Best Defense A well-designed loss control program and the serious threat of legal action are very effective deterrents to abusive claims. Fraud Prevention Tips 1.Develop a first-class safety program. Claims are less likely to mushroom if injuries are prevented and employees feel that management is genuinely concerned about their safety. You can do that by establishing and practicing clear and comprehensive safety policies. 2.Establish strong accident investigation procedures. Injured employees and witnesses should be interviewed in person about the accident as soon as possible. Document all statements. Get a signed statement from the claimant. 3.Send the Supervisor with the injured worker to the medical provider. Show concern for getting first-class medical evaluations and treatments. 4.Establish procedures for a clear understanding of essential information. Make sure the treating physician understands the nature of the job. Make sure the supervisor understands return-to work limitations. -5. Make sure employees understand that false claims can be punished by termination and criminal prosecution. o You don't need a lawyer to get benefits o You won't get in trouble for reporting an injury or making a truthful claim. Report injuries to your supervisor immediately. o Your supervisor will help you start your claim. o Don't make a Workers' Compensation claim unless it's legitimate. You risk jail, a fine or job loss. Call the Fraud Hotline if you know about a false claim, (608) 261-8486. Or you can reach the Fraud Unit on the World Wide Web at http://www.dwd.state.wi.us/wc. Save everyone the added insurance costs and a possible reduction in wage increases. Fraud hurts us all. The Department of Workforce Development does not discriminate on the basis of disability in the provision of services or in employment. If you need this printed material interpreted or in a different form, or if you need assistance in using this service, please contact the Fraud Unit. Deaf and hearing or speech impaired callers may reach the Fraud Unit through the Wisconsin TRS. WKC-10539-P(N.09/96). Form WC 66 02 72 Printed in U.S.A. WORKERS' COMPENSATION SELECTION OF DESIGNATED MEDICAL PROVIDER DISCLOSURE STATEMENT If you select two Designated Medical Providers meeting the following qualifications, a premium credit will be applied to your policy. For policies eligible for this credit as well as schedule rating, the combination of the 2.5% credit and the schedule modification cannot exceed +/-25%. A qualified Designated Medical Provider is a medical provider, who: 1)Has a knowledge of work injuries; 2)Is knowledgeable of fee schedules; 3)Is decisive on medical-maximum-improvement determinations; 4)Communicates with you, the employer on such issues as case management and wellness programs; 5)Is knowledgeable of the employers operations. The names of the providers must be posted and well publicized by you, the employer. ** SIGN AND RETURN ** I am aware of the availability of a premium credit of 2.5%, if I select two qualified Designated Medical Providers. For policies eligible for this credit as well as schedule rating, the combination of the 2.5% credit and the schedule modification cannot exceed +/-25%. Insured Signature Policy Number Issuing Office Issuing Office Address 34 WEC IB0462 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 02 81 C Printed in U.S.A. Process Date: 05/22/18 Policy Expiration Date: 06/29/19 SOUTH CAROLINA -APPLICATION FOR DRUG-AND ALCOHOL-FREE WORKPLACE PREMIUM CREDIT PROGRAM Name of Employer: PLAN-IT GEO LLC ------------------------------Po Ii c y Number: 34 WEC IB0462 ------------------------------Date Program Implemented: This form must be completed by you and returned to your carrier with a copy of applicable documentation as proof of compliance before the premium credit of 5% can be established and processed. A program must be certified during each year the employer receives credit. Failure to do so will remove you from eligibility for this credit. Following are the four minimum requirements necessary for a qualified employer workplace program. Please check the items below that apply. ( ) 1) Substance Abuse Policy Statement: By law, any policy must be designed to help employees who need substance abuse assistance while, at the same time, sending a clear message that the abuse of drugs and alcohol is not compatible with employment in that employer's workplace. The policy statement must evidence both the employer's respect for its employees and the employer's need to maintain a safe, productive, substance-abuse free environment. ( ) 2) Employee Notification: In order to protect the individual rights of each employee and to begin the employee education process necessary for a well-defined, well managed workplace drug and alcohol abuse prevention program, each existing employee and each new employee hired after program implementation must be given a clear, concise, readable notice of the program, the program's requirements, the policy statement, and the employer's expectations under the program. Notification should be, and should remain posted in employee common areas. In addition, each existing employee and each new employee must be given, by mail or by in-person delivery, a copy of the notice. Delivery may be accomplished by inclusion of the notice within the employee's paycheck package or any similarly important-to-the-employee correspondence or benefits delivery. ( ) 3) Testing Procedure: The testing procedure must include a provision for random sampling of all persons who receive wages and compensation in any form from the employer. If a second test is administered, the testing procedure may allow for a single sample to be split for use in the first and second tests. Positive test results must be provided in writing to the employee within 24 hours of the time the employer receives the test results. Each employer must keep records of each test for up to one year. ( ) 4) Test Results Confidentially Protocols: Test results, information, interviews, reports, statements, and memorandums received by the employer must be considered confidential but may be used or received in evidence, obtained in discovery, or disclosed in any civil or administrative proceeding. The burden to protect against unauthorized release is placed not only upon the employer and any laboratory, medical review officer, or rehabilitation program or their agents, but also upon the underwriting carrier. Employers, laboratories, medical review officers, carriers, drug or alcohol rehabilitation programs, and employer drug prevention programs, and their agents who receive or have access to information concerning test results must keep all information confidential. Release of such information under any other circumstance shall be solely pursuant to a written consent form signed voluntarily by the employee tested or their designee, unless the release is completed through disclosure by an agency of the state in a civil or administrative proceeding, an order of a court of competent jurisdiction, or the determination of a professional or occupational licensing board in a related disciplinary proceeding. The consent form must contain, at a minimum: (1) the name of the person who is authorized to obtain the information; (2)the purpose of the disclosure; (3)the precise information to be disclosed; (4)the duration of the consent; and (5)the signature of a person authorizing release of the information. Information on test results shall not be released for or used or admissible in any criminal proceeding against the employee. I certify that the above information is accurate. If it is determined that there is any misrepresentation of the established drug-and alcohol-free workplace premium credit program requirements, i may be subject to an additional premium charge. This is a true and factual depiction of my current program. Employer name Date *Application must be signed by an officer, partner, sole proprietor, LLC member or owner. Notary public's signature Form WC 66 02 85 B Printed in U.S.A. Process Date: 05/22/18 Date Signature* Title Exp. Of commission Policy Expiration Date: 06/29/19 l WORKERS' COMPENSATION COST CONTAINMENT CERTIFICATION DISCLOSURE STATEMENT ***PLEASE SIGN AND RETURN*** Reporting a Work-Related Injury is Time Sensitive! Call The Hartford's LossConnect immediately to report a claim. 1-800-327-3636 Available 24 hours a day, 365 days a year. The Benefits of Timely Loss Reporting: Research has shown that faster loss reporting significantly affects loss costs. The sooner we are notified, the sooner we can investigate the accident and coordinate with you, the injured employee, and the medical team to ensure the fastest possible return to health and work. The Effect of Timely Reporting on Controlling the Cost of Your Loss: Average Loss for Closed Claims (Accident Years 2002-2005) Report Lag in Days Percent Change in Loss Costs Compared to First Week Report Incident Day -6% Week 1 0% Week 2 13% Week 3 or 4 16% 1 Month or Later 24% Statutory requirements also necessitate the prompt initial reporting of the accident causing injury or death. Failure to comply may result in a fineable offense by the State. Information You'll Need Company Information o Account Number o Location Code (if applicable) o Parent Company (or program name) o Policy Number Worker Information o Name, DOB, Address, Phone o Social Security Number o Age, Gender o Marital Status, Number of Dependants o Hire Date, Years in Current Position o Wage Information Network Providers Incident Information o Type of injury (burn, cut, etc.)? o Exact body par t injured? o What caused the accident? o Any reason to question the injury? o Any witnesses? o Address where injury occurred? o Where was the injured employee treated? (Provide name, address, phone of medical provider.) o When was the accident reported to you and by whom (date, time)? A listing of more than 400,000 network providers qualified to treat work-related injuries is available online at www.talispoint.com/hartext or by calling our Network Referral Unit at 1-800-327-3636 (select 4 at the prompt). Since network referrals are often impacted by state specific rules, please call to learn how to maximize our network capabilities on behalf of your employees. Form WC 66 03 84 Printed in U.S.A. Customer Privacy Notice The Hartford Financial Services Group, Inc. and Affiliates* (herein called "we, our, and us") This Privacy Policy applies to our United States Operations We value your trust. We are committed to the responsible: a)management; b)use; and c)protection; of Personal Information. This notice describes how we collect, disclose, and protect Personal Information. We collect Personal Information to: a)service your Transactions with us; and b)support our business functions. We may obtain Personal Information from: a)You; b)your Transactions with us; and c)third parties such as a consumer-reporting agency. Based on the type of product or service You apply for or get from us, Personal Information such as: a)your name; b)your address; c)your income; d)your payment; or e)your credit history; may be gathered from sources such as applications, Transactions, and consumer reports. To serve You and service our business, we may share certain Personal Information. We will share Personal Information, only as allowed by law, with affiliates such as: a)our insurance companies; b)our employee agents; c)our brokerage firms; and d)our administrators. As allowed by law, we may share Personal Financial Information with our affiliates to: a)market our products; or b)market our services; to You without providing You with an option to prevent these disclosures. We may also share Personal Information, only as allowed by law, with unaffiliated third parties including: a)independent agen�; b)brokerage firms; Form WC 66 03 30 J Printed in U.S.A. c)insurance companies; d)administrators; and e)service providers; who help us serve You and service our business. When allowed by law, we may share certain Personal Financial Information with other unaffiliated third parties who assist us by performing services or functions such as: a)taking surveys; b)marketing our products or services; or c)offering financial products or services under a joint agreement between us and one or more financial institutions. We, and third parties we partner with, may track some of the pages You visit through the use of: a)cookies; b)pixel tagging; or c)other technologies; and currently do not process or comply with any web browser's "do not track" signal or other similar mechanism that indicates a request to disable online tracking of individual users who visit our websites or use our services. For more information, our Online Privacy Policy, which governs information we collect on our website and our affiliate websites, is available at https://www.thehartford.com/online-privacy-policy. We will not sell or share your Personal Financial Information with anyone for purposes unrelated to our business functions without offering You the opportunity to: a)"opt-out;" or b)"opt-in;" as required by law. We only disclose Personal Health Information with: a)your proper written authorization; or b)as otherwise allowed or required by law. Our employees have access to Personal Information in the course of doing their jobs, such as: a)underwriting policies; b)paying claims; c)developing new products; or d)advising customers of our products and services. Page 1 of 2 We use manual and electronic security procedures to maintain: a)the confidentiality; and b) the integrity of; Personal Information that we have. We use these procedures to guard against unauthorized access. Some techniques we use to protect Personal Information include: a)secured files; b)user authentication; c)encryption; d)firewall technology; and e)the use of detection software. We are responsible for and must: a)identify information to be protected; b)provide an adequate level of protection for that data; c)grant access to protected data only to those people who must use it in the performance of their job related duties. Employees who violate our privacy policies and procedures may be subject to discipline, which may include termination of their employment with us. We will continue to follow our Privacy Policy regarding Personal Information even when a business relationship no longer exists between us. As used in this Privacy Notice: Application means your request for our product or service. Personal Financial Information means financial information such as: a)credit history; b)income; c)financial benefits; or d)policy or claim information. Personal Financial Information may include Social Security Numbers, Driver's license numbers, or other government-issued identification numbers, or credit, debit card, or bank account numbers. Personal Health Information means health information such as: a)your medical records; or b)information about your illness, disability or injury. Personal Information means information that identifies You personally and is not otherwise available to the public. It includes: a)Personal Financial Information; and b)Personal Health Information. Transaction means your business dealings with us, such as: a)your Application; b)your request for us to pay a claim; and c)your request for us to take an action on your account. You means an individual who has given us Personal Information in conjunction with: a)asking about; b)applying for; or c)obtaining; a financial product or service from us if the product or service is used mainly for personal, family, or household purposes. This Customer Privacy Policy is being provided on behalf of The Hartford Financial Services Group, Inc. and its affiliates, to the extent required by the Gramm-Leach-Bliley Act and implementing regulations. 1stAGChoice, Inc.; Access CoverageCorp, Inc.; Access CoverageCorp Technologies, Inc.; American Maturity Life Insurance Company; Archway 60 R, LLC; Business Management Group, Inc.; OMS R, LLC; First State Insurance Company; Fountain Investors I LLC; Fountain Investors II LLC; Fountain Investors Ill LLC; Fountain Investors IV LLC; FP R, LLC (Delaware); FTC Resolution Company LLC; Hart Re Group L.L.C.; Hartford Accident and Indemnity Company; Hartford Administrative Services Company; Hartford Casualty General Agency, Inc.; Hartford Casualty Insurance Company; Hartford Financial Services, LLC; Hartford Fire General Agency, Inc.; Hartford Fire Insurance Company; Hartford Funds Distributors, LLC; Hartford Funds Management Company, LLC; Hartford Funds Management Group, Inc.; Hartford Group Benefits Holding Company; Hartford Holdings, Inc.; Hartford HLS Series Fund II, Inc.; Hartford Insurance Company of Illinois; Hartford Insurance Company of the Midwest; Hartford Insurance Company of the Southeast; Hartford Integrated Technologies, Inc.; Hartford International Life Reassurance Corporation; Hartford Investment Management Company; Hartford Life and Accident Insurance Company; Hartford Life and Annuity Insurance Company; Hartford Life Insurance Company; Hartford Life, Inc.; Hartford Life International Holding Company; Hartford Life Private Placement, LLC; Hartford Lloyd's Corporation; Hartford Lloyd's Insurance Company; Hartford of Texas General Agency, Inc.; Hartford Residual Market, L.C.C.; Hartford Securities Distribution Company, Inc.; Hartford Series Fund, Inc.; Hartford Specialty Insurance Services of Texas, LLC; Hartford Strategic Investments, LLC; Hartford Underwriters General Agency, Inc.; Hartford Underwriters Insurance Company; Hartford Comprehensive Employee Benefit Service Company; HOC R, LLC; Heritage Holdings, Inc.; HIMCO Distribution Services Company; HIMCO Variable Insurance Trust; HLA LLC; HL Investment Advisors, LLC; Horizon Management Group, LLC; HRA Brokerage Services, Inc.; Lanidex Class B, LLC; Lanidex R, LLC (Delaware); Lattice Strategies LLC; Maxum Casualty Insurance Company; Maxum Indemnity Company; Maxum Specialty Services Corporation; MPC Resolution Company LLC; New England Insurance Company; New England Reinsurance Corporation; Northern Homelands Company; Nutmeg Insurance Agency, Inc.; Nutmeg Insurance Company; Pacific Insurance Company, Limited; Property and Casualty Insurance Company of Hartford; Sentinel Insurance Company, Ltd.; Trumbull Flood Management, L.L.C.; Trumbull Insurance Company; Twin City Fire Insurance Company. Form WC 66 03 30 J Printed in U.S.A. Page 2 of 2 34 WEC IB0462 Our President and Secretary have signed this policy. Where required by law, the Information Page has been countersigned by our duly authorized representative. Lisa Levin, Secretary Douglas Elliot, President Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. © 2000 National Council on Compensation Insurance. DELAWARE: Delaware forms have been copyrighted by the Delaware Compensation Rating Bureau or the Pennsylvania Compensation Rating Bureau. NEW JERSEY: New Jersey forms have been copyrighted by the Compensation Rating and Inspection Bureau. NEW YORK: New York forms have been copyrighted by the New York Compensation Insurance Rating Board. PENNSYLVANIA: Pennsylvania forms have been copyrighted by the Pennsylvania Compensation Rating Bureau or the Delaware Compensation Rating Bureau. POLICY NUMBER: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization{s): Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.Section C. -Who Is An Insured ls 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 whote or in part, by: 1.Your acts or omissions; or 2.The acts o.r omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured{s) at the location(s) designated above. Form SS 41700611 Process Date: B.With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1.All work, including materials, parts or equipment furnished in connection with such work, on the project (other than seNice, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the cove.red operations has been completed; or 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in perfomiing operations for a principal as a part of the same project Page 1 of 1 Policy Expiration Date: © 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its perm ission) �Jr' fJ. THIS ENOORSEJI/ENT CHANGES T1-E POUCY. PLEASE READ rT CAREfll.L Y. WAIVER OF SUBROGATION / This endorsement modifies insurance provided under the fctlO'wing: BUStESS l...lABUIY COVERAGE FORM We waive any right of rect::NBry we may have against 1.Any person or organization shown in the Declarations, or 2.Any peraon or organizatiori witt'l whom you have a contract that requires such waiver. Form SS 1215 03 00 © 2000, The Hartford Page 1 of 1 I I THE� HARTFORD CITY CLERK THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014-3202 Account Information: I Policy Holder Details: I PLAN-IT GEO LLC March 27, 2019 tO 'it Contact Us Business Service Center Business Hours: Monday -Friday (7AM -7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: agency.services@thehartford.com Website: https://business.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005