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19-052 Plan-it GEO LLC, Software-as-a-ServiceTECHNOLOGY SOFTWARE-AS-A-SERVICE (SaaS} AGREEMENT AGREEMENT BETWEEN THE CITY OF CUPERTINO AND Plan-it GEO FOR SOFTWARE-AS-A-SERVICE THIS AGREEMENT, by and between the CITY OF CUPERTINO, a California municipal corporation ("City"), and plan-it GEO a LLC corporation whose address is 7878 Wadsworth Blvd, Suite 340 Arvada, Colorado ( "Software Provider") (collectively referred to as the "Patties"). RECITALS: The following Recitals are a substantive portion of this Agreement: A.City is a municipal corporation duly organized and validly existing under the laws of the State of California. B.Software Provider is specially trained, experienced and competent to perform the special services which will be required by this Agreement. C.City and Software Provider desire to enter into an agreement for Software Provider's provision of software-as-a-service (SaaS) pertaining to City's online systems. Through this Agreement, Software Provider shall provide to City an easy to use web application to view the tree ecosystem benefits on an individual or City-wide basis. Using the iTree software, a state-of-the-art, peer-reviewed software suite from the USDA Forest Service that provides urban and rural forestry analysis and benefits assessment tools, - Benefits include overall monetary, stormwater monetary benefits, runoff prevention in gallons, property value total, energy savings, natural gas savings, heat prevention, air quality monetary benefit, pollutants removed, and carbon monetary benefit. The application will also allow the resident to view the trees maintenance history as a whole City-wide or on an individual basis. Work order and inspection history viewed in a dashboard setting. relating to the City's network. The full scope of services covered by this agreement is described in the attached Exhibit A: Service Level Agreement (the "SLA"). NOW, THEREFORE, the Parties mutually agree as follows: 1.TERM The term of this Agreement shall c01mnence on March 11, 2019 and end March 11, 2020_. The tenn of this Agreement is subject to the City's option to renew for one year tenns, unless the Agreement is terminated prior thereto under the provisions of Section 16, below. 2.SCOPE OF SERVICES AND CONDITIONS THEREOF 090517 Subject to the terms and conditions set forth in this Agreement, Software Provider shall perfonn each and every service to the schedule of perfonnance set forth in the SLA (collectively "Services"), as described below. Page 1 of 13 A.Resp onsibilities of Software Provider. Software Provider shall provide the software services as further described in the SLA. The Services provided under this Agreement shall include (a) any software, plug-ins or extensions related to the Services or upon which the Services are based including any and all updates, upgrades, bug fixes, dot releases, version upgrades or any similar changes that may be made available to the Software Provider from time to time (the "Software"), (b) any and all technical documentation necessary or use of the Services, in hard copy fonn or online (the "Documentation"), (c) regular maintenance of Software Provider's system, and (d) other technology, user interfaces, know-how and other trade secrets, techniques, designs, inventions, data, images, text, content, APis, and tools provided in conjunction with the Services. B.Equipment. If necessary to enable Software Provider to fulfill its obligations under the SLA, Software Provider shall, at its sole cost and expense, furnish all facilities, personnel and equipment to City necessary to provide the Services (the "Equipment"). City agrees, if necessary, to install the Equipment at the location(s) and in the manner specified by Software Provider and as directed by Software Provider. Any Equipment installed by City is a part of the Service and loaned to City by Software Provider, not sold. City agrees to return the Equipment to Software Provider at the tennination of this Agreement in an undamaged condition, less ordinary wear and tear. c.Registration. Prior to using the Services, City shall identify the administrative users for its account ("Administrators"). Each Administrator will be provided an administrator ID and password. D.License Grant. Software Provider hereby grants City a license to use the Software and the Documentation for the permitted purpose of accessing the Services. E.Reservation of Rights and Data Ownership. City shall own all right, title and interest in its data that is related to the services provided by this contract. Software Provider shall not access City user accounts or City data, except (1) as essential to fulfillment of the objectives of this Agreement, (2) in response to service or technical issues, or (3) at City's written request. F.Data Protection. In carrying out the Services, Software Provider shall endeavor to protect the confidentiality of all confidential, non-public City data ("City Data") as follows: 1.Implement and maintain appropriate security measures to safeguard against unauthorized access, disclosure or theft of City Data in accordance with recognized industry practice. 2.City Data shall be encrypted at rest and in transit with controlled access. Unless otherwise stipulated, Software Provider is responsible for encryption of the City Data. 3.Software Provider shall not use any City Data collected by it in connection with the Service for any purpose other than fulfilling the obligations under this Agreement. G.Software Ownership. Software Provider owns the Services, Software, Documentation, and any underlying infrastructure provided by Service Provider in connection with this Agreement. City acknowledges and agrees that (a) the Services, any Software and Documentation are protected by United States and Page 2 of 13 international copyiight, trademark, patent, trade secret and other intellectual property or proprietary rights laws, (b) Software Provider retains all right, title and interest (including, without limitation, all patent, copyright, trade secret and other intellectual property rights) in and to the Services, the Software, any Documentation, any other deliverables, any and all related and underlying technology and any derivative works or modifications of any of the foregoing, including, without limitation, (c) the Software and access to the Services are licensed on a subscription basis, not sold, and City acquires no ownership or other interest in or to the Services, the Software or the Documentation other than the license 1ights expressly stated herein, and (d) the Services are offered as an on-line, hosted solution, and that City has no right to obtain a copy of the Services. H.Restrictions. City agrees not to, directly or indirectly: (i) modify, translate, copy or create derivative works based on the Service or any element of the Software, (ii) interfere with or disrupt the integrity or perfo1mance of the Services or the data contained therein or block or disrupt any use or enjoyinent of the Services by any third party, (iii) attempt to gain unauthmized access to the Services or their related systems or networks or (iv) remove or obscure any prop1ietary or other notice contained in the Services, including on any reports or data printed from the Services. 1.Security Incident. In the event a data breach occurs with respect to City Data, Software Provider shall ilmnediately notify the appropriate City contact by telephone in accordance with the agreed upon security plan or security procedures if it reasonably believes there has been a security incident. Software Provider shall (1)cooperate with City to investigate and resolve the data breach, (2) promptly implement necessary remedial measures, if necessary, and (3) document responsive actions taken related to the data breach, including any post-incident review of events and actions taken to make changes in business practices in providing the services, if necessary. J.Notification of Legal Requests. Software Provider shall contact City upon receipt of any electronic discovery, litigation holds, discovery searches and expert testimonies related to City Data. Software Provider shall not respond to subpoenas, service of process and other legal requests related to City without first notifying City, unless prohibited by law from providing such notice. K.Access to Security Logs and Reports. Software Provider shall provide reports to City in a fo1mat as specified in the SLA agreed to by both Software Provider and City. Reports shall include latency statistics, user access, user access IP address, and user access history and secmity logs for all City files related to this Agreement. Software Provider will provide the City the application google analytics link so the City can monitor the application site visits. L.Responsibilities and Uptime Guarantee. Software Provider shall be responsible for the acquisition and operation of all hardware, software and network support related to the services being provided. The technical and professional activities required for establishing, managing and maintaining the enviromnents are the responsibilities of Software Provider. The system shall be available for City's use on a 24/7/365 basis (with agreed-upon maintenance downtime). M.Subcontractor Disclosure. Software Provider shall identify all of its strategic Page 3 of 13 business partners related to services provided under this Agreement, including all subcontractors or other entities or individuals who may be a party to a joint venture or similar agreement with Software Provider, and who shall be involved in any application development and/or operations. N.Business Continuity and Disaster Recovery. Software Provider shall provide to City a written business continuity and disaster recovery plan prior to or at the time of execution of this agreement and shall ensure that it meets City's recovery time objective (RTO) of four (4) hours or less. o.Compliance with Accessibility Standards. Software Provider shall comply with and adhere to the Americans with Disabilities Act of 1990 (42 U.S.C. § 12101). P.Web Services. Software Provider shall use Web services exclusively to interface with City Data on a nightly basis. Q.Encryption of Data at Rest. Software Provider shall ensure hard drive encryption consistent with validated cryptography standards as referenced in FIPS 140-2, Security Requirements for Cryptographic Modules for all personal data, unless City approves the storage of personal data on Software Provider's portable device in order to accomplish work as defined in the statement of work. 3.COMPENSATION TO SOFTWARE PROVIDER Software Provider shall be compensated for services performed pursuant to this Agreement in a total amount not to exceed xxxx dollars ($xxxx.OO). The payments specified in this section shall be the only payments to be made to Software Provider for services rendered pursuant to this Agreement. Software Provider shall invoice City according to the following schedule of milestones/ deliverables: Upon execution of this Agreement $0 Upon completion of Application $9000 configuration for Cupertino -Landing Page, Cupertino Tree Data Integration, Individual Tree Pop-up, Eco Benefits Calculator Upon completion of 311 Integration $4000 City shall pay Contractor within thirty (30) days after receipt of Service Provider's invoice. City shall return to Contractor any payment request determined not to be a proper payment request as soon as practicable, but not later than seven (7) days after receipt, and shall explain in writing the reasons why the payment request is not proper. 4.TIME IS OF THE ESSENCE 5. Software Provider and City agree that time 1s of the essence regarding the perfonnance of this Agreement. LICENSES; PERMITS; ETC. Software Provider represents and wairnnts to City that it has all licenses, pennits, qualifications, and approvals of whatsoever nature which are legally required to carry out the purposes of this Agreement. Page 4 of 13 6.ASSIGNMENTS. Software Provider may assign, sublease, or transfer this Agreement, or any interest therein, to a third paiiy with the p1ior w1itten consent of City. Such consent shall not be umeasonably withheld. City's withholding of consent shall be deemed reasonable if it appears that the intended assignee in question is not financially or technically capable of perfonning Software Provider's obligations under this Agreement, or if City has reason to conclude that the proposed assignee is otherwise incapable of fulfilling Software Provider's duties hereunder. 7.INDEPENDENT PARTIES City and Software Provider intend that the relationship betweerr them created by this Agreement is that of independent contractor. No civil service status or other right of employment will be acquired by virtue of Software Provider's services. None of the benefits provided by City to its employees, including but not limited to, unemployment insurance, workers' compensation plans, vacation and sick leave are available from City to Software Provider, its employees or agents. Software Provider is not a "public official" for purposes of Government Code §§ 87200 et seq. 8.IMMIGRATION REFORM AND CONTROL ACT (IRCA) Software Provider assumes any and all responsibility for verifying the identity and employment authorization of all of his/her employees perfonning work hereunder, pursuant to all applicable IRCA or other federal or state rules and regulations. Software Provider shall indemnify and hold City hannless from and against any loss, damage, liability, costs or expenses arising from any noncompliance of this provision by Software Provider. 9.NON-DISCRIMINATION Consistent with City's policy prohibiting harassment and discrimination, Software Provider agrees that neither it nor its employee or subcontractors shall harass or discriminate against a job applicant, a City employee, or a citizen on the basis of race, religious creed, color, national 01igin, ancestry, handicap, disability, marital status, pregnancy, sex, age, sexual orientation, or any other protected class status. Software Provider agrees that any and all violations of this provision shall constitute a material breach of this Agreement. 10.INTELLECTUAL PROPERTY INDEMNIFICATION Software Provider agrees to, at its expense, defend and/or settle any claim made by a third party against City alleging that the City's use of the Services infringes such third party's United States patent, copyright, trademark or trade secret (an "IP Claim"), and pay those amounts finally awarded by a court of competent jurisdiction against City with respect to such IP Claim. 11.DUTY TO INDEMNIFY AND HOLD HARMLESS Software Provider shall indemnify, defend, and hold hannless City and its officers, Page 5 of 13 090517 officials, agents, employees and volunteers from and against any and all liability, claims, actions, causes of action or demands whatsoever against any of them, including for any injury to or death of any person or damage to property or other liability of any nature, whether physical, emotional, consequential or otherwise, arising out, pe1iaining to, or related to the perfonnance of this Agreement by Software Provider or Software Provider's employees, officers, officials, agents or independent contractors, except where such liability arises solely as a result of the active negligence or tortious conduct of City or its agent. Such costs and expenses shall include reasonable attorneys' fees of counsel of City's choice, expert fees and all other costs and fees of litigation. The provisions of this Section survive the completion of the Services or tennination of this Contract. 12.INSURANCE: A.General Requirements. On or before the cmmnencement of the term of this Agreement, Software Provider shall furnish City with certificates showing the type, amount, class of operations covered, effective dates and dates of expiration of insurance coverage in compliance with the requirements listed in Exhibit "B". Software Provider shall maintain in force at all times dming the perfonnance of this Agreement all appropriate coverage of insurance required by this Agreement. B.Subrogation Waiver. Software Provider agrees that in the event ofloss due to any of the perils for which it has agreed to provide comprehensive general and automotive liability insurance, Software Provider shall look solely to its insurance for recovery. Software Provider hereby grants to City, on behalf of any insurer providing comprehensive general and automotive liability insurance to either Software Provider or City with respect to the services of Software Provider herein, a waiver of any right to subrogation which any such insurer of said Software Provider may acquire against City by virtue of the payment of any loss under such msurance. 13.RECORDS Software Provider shall maintain internal records reflecting that the Services were performed by Software Provider hereunder in accordance with customary recordkeeping practices in the software development industry. Software Provider shall provide free access to such records to the representatives of City or its designee's at all reasonable and proper times, and gives City the right to examine and audit same, and to make transcripts therefrom as necessary. No such examination and audit shall give City the right to access records relating to other Software Provider customers. Such records shall be maintained for a period of three (3) years after Software Provider receives final payment from City for all services required under this agreement. 14.NONAPPROPRIATION This Agreement is subject to the fiscal provisions of the Cupertino Municipal Code and Agreement will terminate without any penalty (a) at the end of any fiscal year in the event that funds are not approp1iated for the following fiscal year, or (b) at any time within a fiscal year in the event that funds are only appropriated for a portion of the fiscal year and funds for this Agreement are no longer available. This Page 6 of l3 Section shall take precedence in the event of a conflict with any other covenant, tenn, condition, or provision of this Agreement. 15.NOTICES All notices, demands, requests or approvals to be given under this Agreement shall be given in writing and conclusively shall be deemed served when delivered personally or on the second business day after deposit in the U.S. Mail, postage prepaid, addressed as hereinafter provided. All notices, demands, requests, or approvals shall be addressed as follows: TO CITY: City of Cupe1iino 10300 Torre Ave. Cupertino CA 95014 Attention: Bill Mitchell Copy to: Heather Minner, Esq. City Attorney, City of Cupertino 20410 Town Center Lane, Suite 210 Cupertino, CA 95014-3255 TO SOFTWARE PROVIDER: plan-it GEO 7878 Wadsw01ih Blvd, Suite 340 Arvada, Colorado 80003 Attention: Evan Sims 16.TERMINATION A.Basis for Termination. In the event Software Provider fails or refuses to perfonn any of the provisions hereof at the time and in the manner required hereunder, Software Provider shall be deemed in default in the perfonnance of this Agreement. If Software Provider fails to cure the default within the time specified and according to the requirements set forth in City's written notice of default, and in addition to any other remedy available to the City by law, the City Manager may tenninate the Agreement by giving Software Provider written notice thereof, which shall be effective immediately. The City Manager shall also have the option, at its sole discretion and without cause, of tenninating this Agreement by giving seven (7)calendar days' prior written notice to Software Provider as provided herein. Upon receipt of any notice of te1mination, Software Provider shall immediately discontinue perfonnance. B.Pro Rata Payments. City shall pay Software Provider for services satisfactorily perfonned up to the effective date of te1mination. In such event, a calculation of the amounts due shall be deemed correct as computed on a pro rata basis with compensation provided for the period of service paid as a percentage of the total contract amount. Page 7 of 13 C.Handling of City Data. In the event of a tennination of this Agreement, Software Provider shall implement an orderly return of City data in a CSV or another mutually agreeable fonnat at a time agreed to by the paiiies and the subsequent secure disposal of City data. During any period of service suspension, Software Provider shall not take any action to intentionally erase any City data for a period of30 days after the effective date of tennination, unless authorized by City. City shall be entitled to any post-tennination assistance generally made available with respect to the Services; unless a unique data retrieval arrangement has been established as part of the SLA. Software Provider shall securely dispose of all requested data in all of its fonns, such as disk, CD/ DVD, backup tape and paper, when requested by City. Data shall be permanently deleted and shall not be recoverable, according to National Institute of Standards and Technology (NIST) approved methods. Certificates of destruction shall be provided to City. 17.WARRANTY AN D WARR ANTY DISCLAIMER Software Provider warrants that, (i) the services shall be provided in a diligent, professional, and workmanlike manner in accordance with industry standards, (ii) the services provided under this agreement do not infringe or misappropriate any intellectual prope1iy rights of any third party, and (iii) the services shall substantially perfonn in all material respects as described in the SLA in the event of any breach of section (iii), above, Software Provider shall, as its sole liability and your sole remedy, repair or replace the services that are subject to the warranty claim at no cost to City or if Software Provider is unable to repair or replace, then it will refund any pre-paid fees for services not rendered. Except for the warranty described in this section, the services are provided without warranty of any kind, express or implied including, but not limited to, the implied warranties or conditions of design, merchantability, fitness for a particular purpose, and any warranties of title and non-infringement. 18.COMPLIAN CE Software Provider shall comply with all state or federal laws and all ordinances, rules, policies and regulations enacted or issued by City. 19.CONFLICTOFLAW This Agreement shall be interpreted under, and enforced 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 suits brought pursuant to this Agreement shall be filed with the Superior Court for the County of Santa Clara, State of California. 20.ADVERTISEMENT Software Provider shall not post, exhibit, display or allow to be posted, exhibited, displayed any signs, advertising, show bills, lithographs, posters or cards of any kind pertaining to the services perfo1med under this Agreement unless prior written approval has been secured from City to do otherwise. 21.INTEGRATED CONTRACT This Agreement, including all appendices, represents the full and complete Page 8 of 13 understanding of every kind or nature whatsoever between the Parties, and all preliminary negotiations and agreements of whatsoever kind or nature are merged herein. No verbal agreement or implied covenant shall be held to vary the provisions hereof. Any modification of this Agreement will be effective only by written execution signed by both City and Software Provider. In the event that any Service Level Agreement, Exhibit, associated instrument or agreement executed by the Parties in conjunction with this Agreement or prior thereto contains a term that conflicts with the terms of this Agreement, the terms of this Agreement shall govern and supersede any other document or Exhibit. 22.AUTHORITY The individual(s) executing this Agreement represent and warrant that they have the legal capacity and authority to do so on behalf of their respective legal entities. IN WITNESS WHEREOF, the parties have caused this Agreement to be executed. SOFTWARE PROVIDER Plan-it GEO LLC B7 /� ;1.,, S', i+oo,1 Title Ceo -+ 1-c1y,0 il,;- Date 1../ � I.{ • 19 CITY OF CUPERTINO A Municipal Corporation By Title Chief Technology Officer Date April 8, 2019 D Over $175,000-Council Approval Required D Over $45,000-Department Head Approval Required D Up to $45,000-Designated Supervisor Approval Required RECOMMENDED FOR APPROVAL �JO Name. Title Page 9 of 13 APPROVED AS TO FORM: City Attorney Heather M. Minner ATTEST: .... �<gL4ktt City Clerk y 1 (� 7 090517 Exhibit A: Service Level Agreement (SLA) tan-·it G€0 Terms of Service Updated June 2018 For our web-based platform including Tree Plotter, Parks Plotter, Work Order Management, Canopy Planner products and custom apps, services, add-on modules, and related services. By using Plan-It Geo's web-based platform and related services, you accept and agree to these terms: 1)Our Services: Plan-It Geo provides a web-based software platform for mapping, GIS, and data tracking and management. Clients who have separate contracts with Plan-It Geo for subscription-based access to our services are additionally required to follow any terms and provisions in those contracts, as is Plan-It Geo. 2)Expected and Authorized Use: Anyone can use our platform to view and interact with the public-facing, read-only portions of various map-based applications and related content. Members of the general public are expected to use the application in the way intended -to view, explore, and interact with web-based map data. Any other use or reproduction of our platform, lawful or otherwise, is prohibited. Clients with accounts are bound by the same terms. They can additionally login to the application with their account, and are able to upload, manage, export, and modify their data according to their permissions. Account owners are entirely responsible for their own actions on the platform, including any changes they make to data intentionally or otherwise, and are responsible for using their own account, and not letting others login with their credentials, or sharing account information. Clients are responsible for the actions of their users on the platform to the extent that it affects their data, and individual account-holders are responsible for their own actions on the site. Clients who can grant new accounts are expected to act responsibly in providing and manage those accounts to new users. Clients who allow members of the general public to register for accounts on their site will approve those accounts at their own discretion, and are expected to monitor the activity of those users to a reasonable extent, and notify Plan-It Geo of any problems with the actions of those users or those accounts. All users of the platform are prohibited from hacking the platform, reverse-engineering any aspect of our platform, attempting to subvert any security or permissions-related code, or doing anything else other than what the platform is intended for, which is generally interacting with web-based maps and related data. 3)Customer Service and Service Level Agreement: We strive to keep our platform available continuously, especially during standard business hours in client time zones, with the exception of scheduled down-time. However, we make no guarantees about this availability due to the various factors that can affect our service. We are not \. 833.TreeMap � info@planitgeo.com www.planitgeo.com 9 7878 Wadsworth Boulevard, Suite 3L,O Arvada, Colorado 80003 lan-itG€0 responsible for addressing non-availability of the platform resulting from factors outside of our control, such as a firewall or internet service provider specif ic to a user or client. Historically, we have less than 1% down-time during business hours. Customer service is available 8 am - 8 pm Eastern Standard Time, Monday to Friday, generally with a one hour response time. For weekends, non-business hours, and U.S. holidays, use our emergency contact number. See the website for detail. We also regularly work with customers outside of regular business hours, and provide phone and email contact information to all clients. Members of the general public may email support@planitgeo.com with questions or for help, and can generally expect a reply within one or two business days. Our software platform is not free of bugs and will continue to have bugs, and sometimes those bugs will affect a user's ability to interact with our services and data in the platform in expected ways. Our processes to identify, prioritize, and address those bugs is something we are always working to improve. Data-related bugs are often resolved the day they are received and code-related bugs within 1-2 days. Users of our service are invited to communicate bugs to us using support channels, and are always welcome to provide suggestions for improvements and new features. Upgrades and bug fixes to the platform are performed regularly, and new code and features are introduced periodically. Plan-It Geo will typically communicate these changes to one or all clients depending on the nature of the change (i.e. global or local). especially when the changes are expected to affect the user experience of the platform. 4)Data Policy: All data added, entered, uploaded, or managed by clients, whether web-based map data or otherwise, is their own. Data collected in public-facing sites also belongs to the client responsible for that site. You are welcome to export data using the platform's tools to which you have access. You can also request that Plan-It Geo provide custom mass updates or exports of data, though a fee may be associated. With client permission, Plan-It Geo may use your site (and to some limited extent the data in it) for marketing, educational, and other purposes in the following ways: we might use a client site in web-based or in-person demonstrations, during marketing webinars or industry-related seminars, or during educational or other presentations. We won't provide access to your site or data inappropriately, and will ask for permission to use your site or data in ways not covered here (e.g. printed materials, publications, etc.). You can access and export your data if you plan to close an account or stop using our services, as long as you have paid for the service and have access to your account. Otherwise, we will provide the data for you, though in some cases a fee may be associated, for example if the account has been already closed for non-payment of services. � pian-1tG€O 5)Data Protection: Plan-It Geo currently backs up user databases and other user content nightly. A client's site can be restored to the time of one of these backups if necessary. Depending on the circumstances of a request to recover, restore, or explore backed-up data, fees may be associated for our services. We do not monitor changes to data made by the general public (where permitted). by you, or by account holders in your organization, and you are responsible for changes to data in your site by account-holding users. It is the responsibility of clients to understand the implications of account access they provide to their application, especially with respect to tools that can create, modify or delete data. 6)Time Span of Terms: These terms are valid for the public-facing parts of our platform and client's sites without time restriction. Terms related to client sites (including backups) are in effect as long as the client is in good standing with respect to their contract, generally identified by Start and End dates in their contract or in communication with Plan-It Geo during the setup of their account. 7)Fees and Payments: Fees and payments are determined for clients in individual contracts or subscription agreements. Other clients will pay according to subscription packages identified on our websites, or other documents. Payment is required by the time due in their agreement, and non-payment will result in loss of access to our services. 8)Privacy Policy: Map-based and other data placed in the platform and accessed through our services belongs to the clients that provided the data. We will not intentionally share client data, map-based or otherwise, without client permission, with the exception of some terms identif ied in our Terms of Services data policy. Public-facing sites have data that the public can view, and different accounts can be setup to access different sets of data on a client site. Limits to access are determined by the client in these cases, sometimes with the help of Plan-It Geo. It is the client's responsibility to control access according to their choices and to understand the implications of the access they give to account holders. Contract No. --- Exhibit B: Insurance Requirements and Proof of Insurance Proof of insurance coverage described below is attached to this Exhibit, with City named as additional insured. 1.MINIMUM SCOPE AND LIMITS OF REQUIRED INSURANCE POLICIES Additional Insureds: City, its City Council, boards and cmmnissions, officers, employees and volunteers shall be named as additional insureds under all insurance coverages, except any professional liability insurance, required by this Agreement. The naming of an additional insured shall not affect any recovery to which such additional insured would be entitled under this policy if not named as such additional insured. An additional insured named herein shall not be held liable for any premium, deductible portion of any loss, or expense of any nature on this policy or any extension thereof. Any other insurance held by an additional insured shall not be required to contribute anything toward any loss or expense covered by the insurance provided by this policy. Workers' Compensation: Statutory coverage as required by the State of California and Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. General Liability: Commercial general liability coverage in the following minimum limits: Bodily Injury: $1,000,000 each occurrence $1,000,000 aggregate -all other Property Damage: $500,000 each occmTence $1,000,000 aggregate If submitted, combined single limit policy with aggregate limits in the amounts of $2,000,000 will be considered equi valent to the required minimum limits shown above. 2.ABSENCE OF INSURANCE COVERAGE. City may direct Software Provider to i1mnediately cease all activities with respect to this Agreement if it detem1ines that Software Provider fails to carry, in full force and effect, all insurance policies with coverages at or above the limits specified in this Agreement. At the City's discretion, under conditions of lapse, City may purchase appropriate insurance and charge all costs related to such policy to Software Provider. 3.PROOF OF INSURANCE COVERAGE AND COVERAGE VERIFICATION. A Ce1iificate of Insurance, on an Accord fonn, and completed coverage verification shall be provided to City by each of Software Provider's insurance companies as evidence of the stipulated coverages prior to the Cmmnencement Date of this Agreement, and annually thereafter for the te1m of this Agreement. All of the insurance companies providing insurance 12 Marilyn Monreal From: Sent: To: Subject: HI Teri! Sony for the delay. cyber requirement. Thanks for following up. Joe Joe Costamagna Costa mag na, Joseph <joseph.costamag na@yorkrisk.com > Tuesday, March 19, 2019 7:59 AM Teri Gerhardt Re: FVV:Cyberlnsurance Yes, based on the risk and the i nfounation provided, I think it is fine to waive the Senior Consllltant, Litigation Management m. 415.407.4157 o. 916.290.4614 1750 Creekside Oaks Drive, Suite 200 Sacramento, CA 95833 YORKRISK.COM Notes and suggestions contained in this communication are made by York staff for the purpose of recommending best risk management practices and enhancing the risk management decisions made by York clients and member agencies. NOTHING CONTAINED IN THIS EMAIL IS INTENDED TO BE, NOR SHOULD BE CONSTRUED AS, LEGAL ADVICE. York clients and member agencies are encouraged to seek appropriate counsel with legal professionals to address legal questions. On Tue, Mar 19, 2019 at 7:27 AM Teri Gerhardt <TeriG@cupe1iino.org> wrote: Hi Joe, I wanted to following up on the email I sent you below. Can we waive the cyber insurance ' for this project? , Regards, 1 n • CUPERTINO From: Teri Gerhardt Teri Gerhardt GIS -Manager Innovation Technology TeriG@cupertino.org (408)777-33119f)000@)0 Sent: Wednesday, March 13, 2019 8:26 AM To: 'J costamagna@bickmore.net' <J costamagna@bickmore.net> 1 Subject: Cyber Insurance Hi Joe, 1 We are contracting with a company to configure an application highlighting the ecosystem value of our City forest or on an individual tree basis, so a property owner or interested citizen can see how much value their tree or the forest as a whole brings to the City or the property owner as an individual. In Cupertino 311, Cupertino's public service request system, tree requests are the City's most common request types. Cupertino residents are interested in what is happening with their trees. This application will also give the home owner their tree's maintenance history at their fingertips. They can see the last time the tree was pruned, inspected, plant date and so on. Insurance. The company we are contracting with has cyber liability coverage up to $SOOK currently. The questions is do we need cyber insurance at all in this scenario? The application will only be consuming public data on trees (data that is already in our open data portal exportable by anyone from the public) in one direction (meaning the application is not altering the data in anyway just displaying), and no sensitive info (personal/medical/legal etc.). Can you clarify if this limit applies to our specific scope of work? Thanks, 2 THE� HARTFORD CITY CLERK THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BL VD 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 April 4, 2019 tO 't Contact Us Business Service Center Business Hours: Monday -Friday (7 AM -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 AC� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) �-04/04/2019 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: STANTON INSURANCE LLC/PHS 34340017 PHONE (866) 467-8730 I FAX (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: 7878 WADSWORTH BLVD STE 340 INSURER C: ARVADA CO 80003-2146 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 A TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY -� CLAIMS-MADE0 OCCUR X General Liability GEN'L AGGREGATE LIMIT APPLIES PER: � POLICY D PRO-JECT OTHER: AUTOMOBILE LIABILITY -X ANY AUTO QLoc -ALL OWNED � SCHEDULED AUTOS AUTOS -HIRED >--NON-OWNED X AUTOS X AUTOS ->-- ..x UMBRELLA LIAB 4 OCCUR EXCESS LIAB CLAIMS-MADE DEDJ X J RETENTION $ 1 0, 000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY Y/N PROPRIETOR/PARTNER/EXECUTIVE [ OFFICER/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 LIMITS WVD IMMIDDNYYY\ IMMIDDN YYY\ EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED PREMISES tEa nccurrence\ $1,000,000 MED EXP (Any one person) $10,000 X 34 SBAAA8144 01/16/2019 01/16/2020 PERSONAL & ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 PRODUCTS -COMP/OP AGG $4,000,000 COMBINED SINGLE LIMIT $1,000,000 lE!:! �rcidenfl BODILY INJURY (Per person) X 34 UEC ID3036 01/16/2019 01/16/2020 BODILY INJURY (Per accidenl) PROPERTY DAMAGE (Per accident) EACH OCCURRENCE $2,000,000 34 SBA AA8144 01/16/2019 01/16/2020 AGGREGATE $2,000,000 IPER I STATUTE IOTH-ER E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE E.L. DISEASE -POLICY LIMIT $500,000 34 SBA AA8144 01/16/2019 01/16/2020 $50,000 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. Please see Additional Remarks Schedule Acord Form 101 attached. CERTIFICATE HOLDER CANCELLATION CITY CLERK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED CITY OF CUPERTINO BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 10300 TORRE AVE IN ACCORDANCE WITH THE POLICY PROVISIONS. CUPERTINO CA 95014-3202 AUTHORIZED REPRESENTATIVE 6Uem/) of. Ca..a� © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOG#:�� ADDITIONAL REMARKS SCHEDULE Page _2_ of 2 AGENCY NAMED INSURED POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM FORM NUMBER: FORM TITLE: ACORD 101 (2014/01) © 2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD WLTR005 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 March 27, 2019 CITY CLERK CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014-3202 Account Information: Policy Holder Details :PLAN-IT GEO LLC 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 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 03/27/2019 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 STANTON INSURANCE LLC/PHS 34340017 The Hartford Business Service Center 3600 Wiseman Blvd San Antonio, TX 78265 CONTACT NAME: PHONE (A/C, No, Ext): (866) 467-8730 FAX (A/C, No): (888) 443-6112 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED PLAN-IT GEO LLC 7878 WADSWORTH BLVD STE 340 ARVADA CO 80003-2146 INSURER A : The Sentinel Insurance Company 11000 INSURER B :Hartford Fire and Its P&C Affiliates 00914 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 TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/Y YYY)LIMITS A COMMERCIAL GENERAL LIABILITY X X 34 SBA AA8144 01/16/2019 01/16/2020 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence)$1,000,000 X General Liability MED EXP (Any one person)$10,000 PERSONAL & ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $4,000,000 POLICY PRO- JECT X LOC PRODUCTS - COMP/OP AGG $4,000,000 OTHER: C AUTOMOBILE LIABILITY X X 34 UEC ID3036 01/16/2019 01/16/2020 COMBINED SINGLE LIMIT (Ea accident)$1,000,000 X ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) X HIRED AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS- MADE X 34 SBA AA8144 01/16/2019 01/16/2020 EACH OCCURRENCE $2,000,000 AGGREGATE $2,000,000 DED X RETENTION $ 10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/ A 34 WEC IB0462 06/29/2018 06/29/2019 PER STATUTE X OTH- ER Y/N E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 A DATA BREACH - DEFENSE & LIAB COVG 34 SBA AA8144 01/16/2019 01/16/2020 $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured'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 CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014-3202 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD SCPHS017 THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 May 22, 2018 PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Policy Information: Policy Number:34 WEC IB0462 Renewal Date:06/29/18 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 Thank you for being a loyal customer of The Hartford. 1. Your Hartford Policy 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? Welcome Letter SC USAA and NON USAA (Continued) SCPHS017 ·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 Form 100722 11th Rev.Printed in U.S.A. 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 97485 16th Rev.Printed in U.S.A.Page 1 of 6 Process Date:05/22/18 Policy Expiration Date:06/29/19 Policy Number 34 WEC IB0462 Policy Effective Date 06/29/18 PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 Dear Hartford Insured, 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.Page 2 of 6 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 3 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 4 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 5 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 6 of 6 To The Hartford’s Risk Engineering Department: Yes – I am interested in obtaining information concerning: General Topics Business Continuity Construction Accident Analysis Business Travel Safety Construction Site Consultation Accident Investigations Contingency Planning Overview Construction Equipment Hazards Establishing a Risk Engineering Program Emergency/Disaster Response Hazard Communication Hazard Recognition Emergency Evacuation Drills Ladders & Scaffolds Safety Committees Emergency Preparedness Planning Trenching & Evacuation Fall Protection Ergonomics Industrial Hygiene Property Back Injury Prevention Hazard Communication Automatic Sprinkler System Computer Workstation Industrial Hygiene (general)Flammable Liquids Cumulative Trauma Disorders Indoor Air Quality Fire Prevention and Protection Ergo Train-the-Trainer Noise Exposures Fire Drill and Evacuation Telecommuting Respiratory Protection Hot Work Permit Program Transportation Workers’ Compensation Other Topics 3-D Driver Training Bloodborne Pathogens Business Risk Management Driving Defensively Drug Screening General Liability Investigations Fleet Newsletter Machine Safeguarding Product Liability Programs Guide to Successful Driver Mgmt Return to Work Programs Safety Training School Bus Driving Tips Slip and Falls Security/Terrorism Name Company Policy # Address City & State Zip Code Email Address:Telephone 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 One Hartford Plaza, T-7 Hartford, CT 06155 Form 98456 5th Rev. 12-13 Printed in U.S.A.Page 1 of 2 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:Wages,bonuses,commissions, overtime,*sick pay,vacation pay,*tool allowances,contributions to individual retirement accounts,employee contributions to employee benefit plans. Payments on basis of:Piece work, incentive plans, profit sharing. The value of:Housing furnished to employees,*meals furnished to employees,*store certificates, merchandise and other dollar substitutes. 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. Form 98456 5th Rev. 12-13 Printed in U.S.A.Page 2 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 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. Form WC 66 03 37 H Printed in U.S.A.Page 1 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. 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 Form WC 66 03 37 H Printed in U.S.A.Page 2 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 01 49 F Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 Date Signature and Title PLAN-IT GEO LLC Agent Name Date Signature INSURANCE CENTER OF AMERICA/PHS Return to Issuing Office:THE HARTFORD BUSINESS SERVICE CENTER Address:3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 02 65 O Printed in U.S.A. Process Date:05/22/18 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 IB0462 Employer Name Date Signature and Title PLAN-IT GEO LLC Agent Name Date Signature INSURANCE CENTER OF AMERICA/PHS Return this form to Issuing Office:THE HARTFORD BUSINESS SERVICE CENTER Address:3600 WISEMAN BLVD SAN ANTONIO TX 78251 SOUTH CAROLINA - APPLICATION FOR DRUG- AND ALCOHOL-FREE WORKPLACE PREMIUM CREDIT PROGRAM Form WC 66 02 85 B Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 Name of Employer:PLAN-IT GEO LLC Policy 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 Signature* *Application must be signed by an officer, partner, sole proprietor, LLC member or owner. Title Notary public’s signature Date Exp. Of commission Form WC 66 02 81 C Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 34 WEC IB0462 Issuing Office THE HARTFORD BUSINESS SERVICE CENTER Issuing Office Address 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 03 06 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 WORKERS’ COMPENSATION COST CONTAINMENT CERTIFICATION DISCLOSURE STATEMENT Cost Containment Certification is available from the Colorado Workers’Compensation Cost Containment Board.If you obtain certification, your policy will be subject to a premium credit which will be shown separately on your policy. PLEASE CHECK ONE (1) OF THE FOLLOWING BOXES BASED UPON YOUR BUSINESS ENTITY QUALIFICATION: ☐I am aware if my business does qualify for experience and/or schedule rating under my workers’compensation insurance policy and my business has implemented a certified workers’compensation risk management program,my policy is subject to a 5%premium credit if the loss experience has improved since the last renewal date of workers’ compensation insurance.This 5% premium credit is in addition to any schedule rating for which i may qualify. or, ☐I am aware if my business does not qualify for experience and/or schedule rating under my workers’compensation insurance policy and my business entity has implemented a certified workers’compensation risk management program, my policy is subject to the following premium credit: Premium Dividend Dividend Criteria 10%If my business has been loss free for at least the last year immediately preceding the effective date of the premium credit. 8%If my business had one medical loss exceeding $250 in the last year immediately preceding the effective date of the premium credit. 6%If my business had two medical losses,each exceeding $250,in the last year immediately preceding the effective date of the premium credit. 4%If my business had three medical losses,each exceeding $250,in the last year immediately preceding the effective date of the premium credit. 2%If my business 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. 0%If my business had more than three medical losses and one claim for loss of time in the last year immediately preceding the effective date of the premium credit. ***PLEASE SIGN AND RETURN*** Insured Signature Policy Number 34 WEC IB0462 Issuing Office THE HARTFORD BUSINESS SERVICE CENTER Issuing Office 3600 WISEMAN BLVD Address SAN ANTONIO TX 78251 Form WC 55 00 11 D Printed in U.S.A. INSTRUCTIONS EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS As of January 1,1990,California employers are required by law to furnish a claim form to an injured worker within one working day of knowledge of a work-related injury or illness (other than First Aid).While it is mandatory for the employer to furnish the claim form to the employee,it is not mandatory for the employee to complete it. The employer should complete sections 9-17,with the exception of section 13 (which reads,"Date employer received claim form").This is to be completed after the claimant has completed his or her portion of the claim form and returned it to you, at which time section 13 should be immediately filled out or date stamped. Penalties can be invoked if employers fail to provide an injured employee an EMPLOYEE’S CLAIM FOR COMPENSATION BENEFITS form or if employers fail to report the claim to the workers’compensation insurance carrier. DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: Whether or not the employee completes the EMPLOYEE’S CLAIM FOR WORKER’S COMPENSATION BENEFITS,please contact The Hartford’s LossConnect (1-800-327-3636)to report every occupational injury or illness which results in lost time beyond the date of the incident or requires medical treatment beyond First Aid. Form WC 99 00 02 (03/14)Page 1 of 1 Workers’ Compensation and Employers’ Liability Business Insurance Policy (Policy Provisions:WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Form WC 00 00 01 A (1)Printed in U.S.A.Page 1 (Continued on next page) Process Date:05/22/18 Policy Expiration Date:06/29/19 INSURER:SEE ATTACHED ENDORSEMENT NCCI Company Number:13161 Company Code:9 Suffix LARS RENEWAL POLICY NUMBER:34 WEC IB0462 2 Previous Policy Number:34 WEC IB0462 1.Named Insured and Mailing Address: (No., Street, Town, State, Zip Code) PLAN-IT GEO LLC 5690 WEBSTER ST ARVADA CO 80002 FEIN Number:45-4214699 State Identification Number(s):See Schedule of Operations if applicable The Named Insured is:LLC Business of Named Insured:Administrative Management and General Management Consulting Services Other workplaces not shown above:See Endorsement - WC990366 2.Policy Period:From 06/29/18 To 06/29/19 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer’s Name:INSURANCE CENTER OF AMERICA/PHS 2055 ANGLO DRIVE, SUITE 200 COLORADO SPRINGS CO 80918 Producer’s Code:34342266 Issuing Office: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 05/22/18 Authorized Representative Date INFORMATION PAGE (Continued)Policy Number:34 WEC IB0462 Form WC 00 00 01 A (1)Printed in U.S.A.Page 2 Process Date:05/22/18 Policy Expiration Date:06/29/19 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 $1,000,000 each accident Bodily injury by Disease $1,000,000 policy limit Bodily injury by Disease $1,000,000 each employee C. Other States Insurance:Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT 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 Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Total Standard Premium $2,110 Expense Constant $230 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $59 Catastrophe (Other Than Certified Acts Of Terrorism)$49 Other Miscellaneous State Premiums $500 Estimated Annual Premium (before Surcharges)$2,448 Total Estimated Surcharges $23 *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 99 03 66 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES 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 1 of the Information Page is completed to include other workplaces of the named insured: 5265 SOLEDAD MOUNTAIN RD, SAN DIEGO, CA 92109 10789 JONESTOWN RD, ONO, PA 17077 518 SPRING LANDING DRIVE, ROCK HILL, SC 29730 NO SPECIFIC LOCATION IN STATE OF WI 00000 Form WC 99 03 67 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED 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.A. of the Information Page is completed to include the following states: Pennsylvania PA South Carolina SC Wisconsin WI Colorado CO California CA 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.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-2240-2DT BLANK ENDORSEMENT (COMPUTER PRODUCED) WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC000001A.1 INFORMATION PAGE WC000001A.2 INFORMATION PAGE WC000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT WC000404 PENDING RATE CHANGE ENDORSEMENT WC000414 NOTIFICATION OF CHANGE IN OWNERSHIP WC000419 PREMIUM DUE DATE ENDORSEMENT WC000421D CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT WC000422B TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC040301BB POLICY AMENDATORY ENDORSEMENT - CALIFORNIA WC040306 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA WC040360B EMPLOYERS LIABILITY COVERAGE AMENDATORY ENDORSEMENT - CALIFORNIA WC040421 OPTIONAL PREMIUM INCREASE ENDORSEMENT - CALIFORNIA WC040422 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.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: WC040601A CALIFORNIA CANCELLATION ENDORSEMENT WC050402 COLORADO CLASSIFICATION ENDORSEMENT WC050403 COLORADO PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT PROGRAMS ENDORSEMENT WC370401 PENNSYLVANIA AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT WC370405 PENNSYLVANIA MERIT RATING PLAN ENDORSEMENT WC370601 SPECIAL PENNSYLVANIA ENDORSEMENT - INSPECTION OF MANUALS WC370602 PENNSYLVANIA NOTICE WC370603A PENNSYLVANIA ACT 86-1986 ENDORSEMENT WC480304 WISCONSIN REAL ESTATE SALESPERSONS ENDORSEMENT WC480601C WISCONSIN LAW ENDORSEMENT WC480606B WISCONSIN CANCELLATION AND NONRENEWAL ENDORSEMENT WC550011D Employees Claim for Workers compensation Benefits WC880400I Notice to Employees - Injuries Caused By Work (TITLE IN SPANISH) WC880401I Notice to Employees - Injuries Caused By Work WC990001I Signature/ Copyright WC990002 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE POLICY WC990005 SCHEDULE OF OPERATIONS 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.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: WC990069 AMENDATORY ENDORSEMENT - COLORADO WC990300B WORKERS COMPENSATION BROAD FORM ENDORSEMENT WC990302B WORKERS COMPENSATION BROAD FORM ENDORSEMENT WC990319D WORKERS COMPENSATION BROAD FORM ENDORSEMENT WC990352A KNOWLEDGE OF OCCURRENCE WC990358B AMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT - EMPLOYERS LIABILITY STOP GAP COVERAGE WC990359B AMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT - EMPLOYERS LIABILITY STOP GAP COVERAGE WC990366 EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES WC990367 EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED WC990368 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS WC990375 CALIFORNIA INSTALLMENT FEE DISCLOSURE ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form G-2240-2DT Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 POLICY IS AMENDED TO PROVIDE TO PROVIDE COVERAGE BY THE FOLLOWING INSURERS IN THE FOLLOWING JURISDICTIONS: INSURER NAIC JURISDICTION The Sentinel Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 11000 CA The Hartford Accident and Indemnity Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 22357 CO WI PA The Hartford Casualty Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 29424 SC THE COVERAGE PROVIDED IN EACH JURISDICTION IS WITH RESPECT TO THE LOCATIONS OF THE NAMED INSURED IN THAT JURISDICTION IN ACCORDANCE WITH THE WORKERS’COMPENSATION LAW OF THAT JURISDICTION.AS USED IN THIS POLICY,“COMPANY,”“WE,’”“US”AND “OURS”MEAN THE MEMBER INSURANCE COMPANIES OF THE HARTFORD INSURANCE GROUP COLLECTIVELY PROVIDING THIS INSURANCE. Nothing herein contained shall be held to vary,waive,alter,or extend any of the terms,conditions,agreements or information of the policy, other than as herein stated. This endorsement shall not be binding unless countersigned by a duly authorized agent of the company,provided that if this endorsement takes effect as of the effective date of the policy and,at issue of said policy,forms a part thereof, countersignature on the Information Page of said policy by a duly authorized agent of the company shall constitute valid countersignature of this endorsement. 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 NAICS:541611 FEIN:45-4214699 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 Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 8742 SALESPERSONS - OUTSIDE 18,100.00 0.8700 157 Total State Summary Total Class Premium 157 CA Territorial Differential 0.8500 -24 Waiver of Subrogation 250 Small Policy Credit 6 -23 Total Estimated Annual Standard Premium 360 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 18,100.00 0.0300 5 CA User Fund 0.8146 3 CA Fraud 0.2550 1 CA Subsequent Injuries Benefit Trust Fund Assessments 0.3559 1 CA Occupational Safety & Health Fund 0.2655 1 CA Labor Enforcement & Compliance Fund 0.2150 1 CA Guarantee Fund Assessment 2 7 Total Estimated Annual Premium 379 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 NAICS:541611 FEIN:45-4214699 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 Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 8810 COMPUTER SYSTEM DESIGNERS OR PROGRAMMERS: EXCLUSIVELY OFFICE 47,000.00 0.1800 85 8742 SALESPERSONS OR COLLECTORS - OUTSIDE 79,900.00 0.3500 280 8810 CLERICAL OFFICE EMPLOYEES NOC 75,300.00 0.1800 136 Total State Summary Total Class Premium 501 Waiver of Subrogation 250 Emp liab increased limits 0.0110 6 Employer Liability Increase Limits balance to Minimum Premium 103 Total Estimated Annual Standard Premium 860 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 202,200.00 0.0060 12 Catastrophe (other than certified acts of terrorism)202,200.00 0.0100 20 Total Estimated Annual Premium 892 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 NAICS:541611 FEIN:45-4214699 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 Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 0951 SALESPERSONS - OUTSIDE 65,800.00 0.5700 375 Total State Summary Total Class Premium 375 Emp liab increased limits 0.0140 5 Merit Rating 0.9500 -19 Total Estimated Annual Standard Premium 361 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 65,800.00 0.0400 26 Catastrophe (other than certified acts of terrorism)65,800.00 0.0200 13 PA Assessment Surcharge 2.1700 9 Total Estimated Annual Premium 409 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 CASUALTY 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 NAICS:541611 FEIN:45-4214699 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 Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 8742 SALESPERSONS OR COLLECTORS - OUTSIDE 72,800.00 0.7100 517 Total State Summary Total Class Premium 517 Emp liab increased limits 0.0110 6 Total Estimated Annual Standard Premium 523 Expense constant 230 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 72,800.00 0.0200 15 Catastrophe (other than certified acts of terrorism)72,800.00 0.0200 15 Total Estimated Annual Premium 783 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:01-48-05 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 NAICS:541611 FEIN:45-4214699 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 Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 8871 CLERICAL TELECOMMUTER EMPLOYEES 5,300.00 0.1100 6 Total State Summary Total Class Premium 6 Total Estimated Annual Standard Premium 6 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 5,300.00 0.0200 1 Catastrophe (other than certified acts of terrorism)5,300.00 0.0100 1 Total Estimated Annual Premium 8 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 QUICK REFERENCE Beginning Beginning on Page on Page INFORMATION PAGE PART TWO - Continued 1 G.Limits of Liability ..............................................4 General Section..............................................................1 H.Recovery From Others.....................................4 A.The Policy...............................................................1 I.Actions Against Us...........................................4 B.Who Is Insured.......................................................1 C.Workers Compensation Law..................................1 PART THREE - OTHER STATES INSURANCE 4 D.State.......................................................................1 A.How This Insurance Applies.............................4 E.Locations................................................................1 B.Notice...............................................................5 PART ONE - WORKERS COMPENSATION INSURANCE...1 PART FOUR - YOUR DUTIES IF INJURY OCCURS.....5 A.How This Insurance Applies...................................1 B.We Will Pay............................................................1 PART FIVE - PREMIUM...............................................5 C.We Will Defend.......................................................1 A.Our Manuals.....................................................5 D.We Will Also Pay....................................................1 B.Classifications..................................................5 E.Other Insurance......................................................2 C.Remuneration...................................................5 F.Payments You Must Make......................................2 D.Premium Payments..........................................5 G.Recovery From Others...........................................2 E.Final Premium..................................................5 H.Statutory Provisions................................................2 F.Records............................................................6 G.Audit.................................................................6 PART TWO - EMPLOYERS LIABILITY INSURANCE......2 A.How This Insurance Applies...................................2 PART SIX - CONDITIONS.......................................6 B.We will Pay.............................................................3 A.Inspection.........................................................6 C.Exclusions..............................................................3 B.Long Term Policy.............................................6 D.We Will Defend.......................................................3 C.Transfer of Your Rights and Duties..................6 E.We Will Also Pay....................................................4 D.Cancellation.....................................................6 F.Other Insurance......................................................4 E.Sole Representative.........................................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 CAREFULLY. Form WC 00 00 00 C Printed in U.S.A.Page 1 of 6 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. 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; Form WC 00 00 00 C Printed in U.S.A.Page 2 of 6 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. 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 Form WC 00 00 00 C Printed in U.S.A.Page 3 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. 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. Form WC 00 00 00 C Printed in U.S.A.Page 4 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 disease,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 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 Form WC 00 00 00 C Printed in U.S.A.Page 5 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 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. Form WC 00 00 00 C Printed in U.S.A.Page 6 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. 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. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 00 04 19 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 PREMIUM DUE DATE 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 D of Part Five of the policy is replaced by this provision: PART FIVE PREMIUM D.Premium is amended to read: 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.The due date for audit and retrospective premiums is the date of the billing. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 00 04 24 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 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. Schedule State(s)Basis of Audit Noncompliance Charge Maximum Audit Noncompliance Charge Multiplier AL,AR,CO,CT,DC,DE,GA,IA, ID,IL,KY,MD,ME,MI,MN,MS, NE,NH,NM,OR,RI,SC,SD,TN, UT, VA, VT, WV Estimated Annual Premium Up to two times AZ, HI, KS, OK, WI Estimated Annual Premium Two times NC Estimated Annual Premium Up to three times NV Estimated Annual Premium Up to one times THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 04 03 01 BB Printed in U.S.A.Page 1 of 2 Process Date:05/22/18 Policy Expiration Date:06/29/19 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 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: 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 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 Form WC 04 03 01 BB Printed in U.S.A.Page 2 of 2 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 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. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 04 03 60 B Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 EMPLOYERS' LIABILITY COVERAGE 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 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. 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. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 04 04 21 Printed in U.S.A.Page 1 of 1 Process Date:05/22/18 Policy Expiration Date:06/29/19 OPTIONAL PREMIUM INCREASE 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 ARVADA CO 80002 You must provide us,or our authorized representative, access to records necessary to perform a payroll verification audit.If you fail to provide access within 90 days after expiration of the policy,you are liable to pay a total premium equal to 3 times our current estimate of the annual premium for your policy.In addition,if you fail to provide access after our third request within a 90 day or longer period,you are also liable for our costs in attempting to perform the audit unless you provide a compelling business reason for your failure. We will contact you to schedule appointments during normal business hours. We will notify you of your failure to provide access by mailing a certified,return-receipt document stating the increased premium and the total amount of our costs incurred in our attempt(s)to perform an audit.In addition to any other obligations under this contract,30 days after you receive the notification,you will be obligated to pay the total premium and costs referenced above.If, thereafter,you provide access to your records within three years after the policy expires,or within another mutually agreed upon time,and we succeed in performing the audit to our satisfaction,we will revise your total premium and the costs due to reflect the results of the audit. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 04 04 22 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 Number of Days Percent of Full Policy Premium Extended Number of Days Percent of Full Policy Premium Extended Number of Days Percent of Full Policy Premium 1 ..........5%95-98 ..........37%219-223 ..........69% 2 ..........6%99-102 ..........38%224-228 ..........70% 3-4 ..........7%103-105 ..........39%229-232 ..........71% 5-6 ..........8%106-109 ..........40%233-237 ..........72% 7-8 ..........9%110-113 ..........41%238-241 ..........73% 9-10 ..........10%114-116 ..........42%242-246 (8 mos.)74% 11-12 ..........11%117-120 ..........43%247-250 ..........75% 13-14 ..........12%121-124 (4 mos.)44%251-255 ..........76% 15-16 ..........13%125-127 ..........45%256-260 ..........77% 17-18 ..........14%128-131 ..........46%261-264 ..........78% 19-20 ..........15%132-135 ..........47%265-269 ..........79% 21-22 ..........16%136-138 ..........48%270-273 (9 mos.)80% 23-25 ..........17%139-142 ..........49%274-278 ..........81% 26-29 ..........18%143-146 ..........50%279-282 ..........82% 30-32 (1 mo.)19%147-149 ..........51%283-287 ..........83% 33-36 ..........20%150-153 (5 mos.)52%288-291 ..........84% 37-40 ..........21%154-156 ..........53%292-296 ..........85% 41-43 ..........22%157-160 ..........54%297-301 ..........86% 44-47 ..........23%161-164 ..........55%302-305 (10 mos.)87% 48-51 ..........24%165-167 ..........56%306-310 ..........88% 52-54 ..........25%168-171 ..........57%311-314 ..........89% 55-58 ..........26%172-175 ..........58%315-319 ..........90% 59-62 (2 mos.)27%176-178 ..........59%320-323 ..........91% 63-65 ..........28%179-182 (6 mos.)60%324-328 ..........92% 66-69 ..........29%183-187 ..........61%329-332 ..........93% 70-73 ..........30%188-191 ..........62%333-337 (11 mos.)94% 74-76 ..........31%192-196 ..........63%338-342 ..........95% 77-80 ..........32%197-200 ..........64%343-346 ..........96% 81-83 ..........33%201-205 ..........65%347-351 ..........97% 84-87 ..........34%206-209 ..........66%352-355 ..........98% 88-91 (3 mos.)35%210-214 (7 mos.)67%356-360 ..........99% 92-94 ..........36%215-218 ..........68%361-365 (12 mos.)100% THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by: Authorized Representative Form WC 04 06 01 A Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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; l.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 (l),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. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 05 04 02 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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. Countersigned by Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 37 04 01 Printed in U.S.A.Page 1 of 2 Process Date:05/22/18 Policy Expiration Date:06/29/19 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 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 (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.Page 2 of 2 The scenarios listed below may occur and are treated as follows: If an ANC is applied and the employer…Then the carrier… Pays the ANC and later allows the audit o Performs the final audit and determines the final policy premium based on the results of the audit; and o Refunds the ANC to the employer,or applies the ANC amount to any outstanding balance on the policy Submits a unit statistical correction report to remove the ANC from the previously reported Unit Statistical data. Does not pay the ANC but later allows the audit Performs the final audit and determines the final policy premium based on the results of the audit Pays the ANC but does not later allow the audit Does not change the previously reported: o Unit Statistical data o Noncompliance transactionsDoes not pay the ANC and does not later allow the audit. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 37 06 01 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 SPECIAL PENNSYLVANIA ENDORSEMENT - INSPECTION OF MANUALS 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 manuals of rules,rating plans,and classifications are approved pursuant to the provisions of Section 654 of the Insurance Company Law of May 17,1921,P.L.682,as amended,and are on file with the Insurance Commissioner of the Commonwealth of Pennsylvania. Countersigned by Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 37 06 02 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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. Countersigned by Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 37 06 03 A Page 1 of 2 Process Date:05/22/18 Policy Expiration Date:06/29/19 PENNSYLVANIA ACT 86-1986 ENDORSEMENT NONRENEWAL, NOTICE OF INCREASE OF PREMIUM, AND RETURN OF UNEARNED PREMIUM 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 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 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 effective 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. Form WC 37 06 03 A Page 2 of 2 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 1a.and 1b. 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. 3.These return or unearned premium provisions shall not apply if this policy is written on a retrospective rating plan basis. Countersigned by Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 48 06 01 C Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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. ll.“Workers Compensation Law”means Chapter 102, Wisconsin Statutes. It does not include and 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. III.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. Countersigned by Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 48 06 06 B Printed in U.S.A.Page 1 of 2 Process Date:05/22/18 Policy Expiration Date:06/29/19 WISCONSIN CANCELLATION AND NONRENEWAL 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. 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 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. Form WC 48 06 06 B Printed in U.S.A.Page 2 of 2 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 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 99 00 69 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 AMENDATORY ENDORSEMENT COLORADO 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 this policy covers all employees of the insured,including statutory employees,and covers all business operations of the insured in any lawful endeavors,whether naturally connected or not,with respect to compensation and other benefits required of the insured by the Workers Compensation Law. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 03 52 A Printed in U.S.A. (Ed. 08/04) Process Date:05/22/18 Policy Expiration Date:06/29/19 KNOWLEDGE OF OCCURRENCE 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 knowledge of an occurrence by the agent,servant,or employee of the insured shall not,in itself, constitute knowledge to the insured unless an executive officer of the insured corporation or other persons employed in a managerial capacity shall have received such notice. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 03 75 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 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. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 05 04 03 Printed in U.S.A.Page 1 of 2 Process Date:05/22/18 Policy Expiration Date:06/29/19 COLORADO PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT PROGRAMS 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 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 allow 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 Credit Criteria 10%If you have been loss free for at least the last year immediately preceding the effective date of the premium credit. 8%If you have had one medical loss exceeding $250 in the last year immediately preceding the effective date of the premium credit. 6%If you have had two medical losses,each exceeding $250 within the last year immediately preceding the effective date of the premium credit. 4%If you have had three medical losses,each exceeding $250 within the last year immediately preceding the effective date of the premium credit. 2%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. 0%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. Form WC 05 04 03 Printed in U.S.A.Page 2 of 2 If you have selected a designated medical provider,we must allow a credit 0f 2.5%.If you are eligible for schedule rating, the 2.5% credit must be included in the total schedule credit or debit, subject to the 25% maximum limitation. If you are not eligible for experience or schedule rating,the 2.5%credit will be applied,in addition to the premium credit applicable.The combined premium credit and the 2.5%credit for selection of a designated medical provider shall not exceed 12.5% Schedule % Premium Credit Certified Risk Management Program/Designated Medical Provider THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 00 04 03 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 37 04 05 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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. 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. Countersigned by Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 00 04 04 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 PENDING RATE CHANGE 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 A rate change filing is being considered by the proper regulatory authority.The filing may result in rates different from the rates shown on the policy.If it does, we will issue an endorsement to show the new rates and their effective date. If only one state is shown in Item 3.A.of the Information Page,this endorsement applies to that state.If more than one state is shown there, this endorsement applies only in the state shown in the Schedule. SCHEDULE State SC THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 03 02 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 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 III 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 Liberalization 2 SECTION II 2 VOLUNTARY COMPENSATION INSURANCE 2 05 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 06 Employers’ Liability Stop Gap Coverage 3 A.Stop Gap Coverage Limited Montana, North Dakota, Ohio, Washington, West Virginia and Wyoming 3 B.Part One does not Apply 3 C.Application of Coverage 3 D.Additional Exclusions 3 E.West Virginia 3 SECTION III 4 07 Schedule of Covered States 4 Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00)Page 2 of 4 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.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 5.Voluntary Compensation Insurance A.How This Insurance Applies This insurance applies to bodily injury 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. 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. 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. Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00)Page 3 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. 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. Countersigned by Authorized Representative Form WC 99 03 02 B Printed in U.S.A. (Ed. 8/00)Page 4 of 4 SECTION III 7.SCHEDULE OF COVERED STATES A.This endorsement only applies in the states listed in this Schedule of Covered States. 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. C.Schedule of Covered States: CO,CA THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. 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 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 III 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 Wyoming 3 B.Part One does not Apply 3 C.Application of Coverage 3 D.Additional Exclusions 3 SECTION III 4 08 Schedule of Covered States 4 Form WC 99 03 19 D Printed in U.S.A.Page 2 of 4 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 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 injury 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. 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. Form WC 99 03 19 D Printed in U.S.A.Page 3 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 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. Form WC 99 03 19 D Printed in U.S.A.Page 4 of 4 SECTION III 8.SCHEDULE OF COVERED STATES A.This endorsement only applies in the states listed in this Schedule of Covered States. 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. C. Schedule of Covered States: PA THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 03 58 B Printed in U.S.A (Ed. 7/08) Process Date:05/22/18 Policy Expiration Date:06/29/19 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 6.Employers’Liability Stop Gap Coverage A.This coverage only applies in North Dakota, Ohio, Washington, and Wyoming E.This paragraph is removed. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 99 03 59 B Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 A.This coverage only applies in North Dakota, Ohio, Washington, and Wyoming. E.This paragraph is removed. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. 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 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 III 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, West Virginia and Wyoming 3 B.Part One does not Apply 3 C.Application of Coverage 3 D.Additional Exclusions 3 E.West Virginia 3 SECTION III 4 08 Schedule of Covered States 4 Form WC 99 03 00 B Printed in U.S.A. (Ed. 8/00)Page 2 of 4 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 injury 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. 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. Form WC 99 03 00 B Printed in U.S.A. (Ed. 8/00)Page 3 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 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 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. Form WC 99 03 00 B Printed in U.S.A. (Ed. 8/00)Page 4 of 4 SECTION III 8.SCHEDULE OF COVERED STATES A.This endorsement only applies in the states listed in this Schedule of Covered States. 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. C.Schedule of Covered States: SC Countersigned by Authorized Representative THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 00 04 22 B Printed in U.S.A.Page 1 of 2 Process Date:05/22/18 Policy Expiration Date:06/29/19 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. "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. Form WC 00 04 22 B Printed in U.S.A.Page 2 of 2 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 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 00 04 21 D Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 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 State Rate Premium PA 0.0200 $13 SC 0.0200 $15 WI 0.0100 $1 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 00 04 21 D Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 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 State Rate Premium CO 0.0100 $20 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 00 04 14 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 NOTIFICATION OF CHANGE IN OWNERSHIP 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 Experience rating is mandatory for all eligible insureds.The experience rating modification factor,if any,applicable to this policy,may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes.Change in ownership includes sales,purchases,other transfers,mergers, consolidations,dissolutions,formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change.Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 48 03 04 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 WISCONSIN REAL ESTATE SALESPERSONS 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. You have elected to name as an employee real estate salesperson(s)who are engaged in performing services as part of your real estate business. This election only applies where the election with regard to such real estate salesperson(s) is evidenced in writing. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 00 03 13 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 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 We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE THE CORPORATION OF THE TOWN OF RICHMOND HILL PO BOX 300, 225 EAST BEAVER CREEK ROAD RICHMOND HILL,ONTARIO L4C 4Y5-ATTN: RISK MANAGEMENT BRANCH 002 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 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 ARVADA CO 80002 We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule.(This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5 %of the California workers'compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description CITY OF CLAREMONT RE: CALFIRE URBAN FOREST PROJECTS. URBAN FOREST MANAGEMENT PLAN 1616 MONTE VISTA AVE CLAREMONT, CA 91711- WRITING A MANAGEMENT PLAN 001 Form G-3058-1 Printed in U.S.A. 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 "Insured'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-3143-0 Printed in U.S.A. Process Date:05/22/18 Expiration Date:06/29/19 WISCONSIN NOTICE OF RIGHT TO FILE A COMPLAINT KEEP THIS WITH YOUR INSURANCE PAPERS PROBLEMS 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 COMMISSIONER 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. O. 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-3418-0 PRODUCER COMPENSATION NOTICE You can review and obtain information on The Hartford’s producer compensation practices at www.TheHartford.com or at 1-800-592-5717. Form PN 04 99 01 F Printed in U.S.A.Page 1 of 3 Process Date:05/22/18 Policy Expiration Date:06/29/19 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.Page 2 of 3 (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 II.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 II.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 3 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. III.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 II.C. This notice does not change the policy to which it is attached. Form PN 04 99 02 B (Ed. 5-02)Printed in U.S.A.Page 1 of 2 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 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. Form PN 04 99 02 B (Ed. 5-02)Printed in U.S.A.Page 2 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 nonrenewal in any of the following situations: 1.Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2.The policy was extended for 90 days or less and the required notice was given prior to the extension. 3.You obtained replacement coverage or agreed,in writing,within 60 days of the termination of the policy, to obtain that coverage. 4.The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5.You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6.We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A)If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy,we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date.The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code 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. Form PN 04 99 04 Printed in U.S.A. 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 06 C 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 regular 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 07 A 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 WC 66 00 15 A Printed in U.S.A. CALIFORNIA NOTICE CALIFORNIA LABOR CODE 3551 PROVIDES THAT EVERY EMPLOYER SUBJECT TO THE COMPENSATION PROVISIONS OF THIS CODE,EXCEPT EMPLOYERS OF EMPLOYEES DEFINED IN SUBDIVISION (d)OF SECTION 3351,SHALL GIVE EVERY NEW EMPLOYEE,EITHER AT THE TIME OF HIRE,OR BY THE END OF THE FIRST PAY PERIOD, WRITTEN NOTICE OF THE INFORMATION CONTAINED IN SECTION 3550. CALIFORNIA LABOR CODE 3550 PROVIDES THAT EVERY EMPLOYER SUBJECT TO THE COMPENSATION PROVISIONS OF THIS DIVISION SHALL POST AND KEEP POSTED IN A CONSPICUOUS LOCATION FREQUENTED BY EMPLOYEES,AND WHERE THE NOTICE MAY BE EASILY READ BY EMPLOYEES DURING THE HOURS OF THE WORKDAY,A NOTICE WHICH SHALL STATE THE NAME OF THE CURRENT COMPENSATION INSURANCE CARRIER OF THE EMPLOYER,OR WHEN SUCH IS THE FACT,THAT THE EMPLOYER IS SELF-INSURED,AND WHO IS RESPONSIBLE FOR CLAIMS ADJUSTMENT. Form WC 66 00 89 B Printed in U.S.A. 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 01 20 Printed in U.S.A. TO OUR POLICYHOLDERS: Colorado House Bill 1212 requires that companies providing Workers'Compensation Coverage in Colorado make available their risk management services in order that all insureds may establish a formal risk management program.If your company is interested in establishing such a program,please contact your independent agent and they will see to it that this material is provided to you. Form WC 66 01 49 F Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 Date Signature and Title PLAN-IT GEO LLC Agent Name Date Signature INSURANCE CENTER OF AMERICA/PHS Return to Issuing Office:THE HARTFORD BUSINESS SERVICE CENTER Address:3600 WISEMAN BLVD SAN ANTONIO TX 78251 Form WC 66 02 05 A Printed in U.S.A. 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 organization 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 65 O Printed in U.S.A. Process Date:05/22/18 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 IB0462 Employer Name Date Signature and Title PLAN-IT GEO LLC Agent Name Date Signature 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 67 A Printed in U.S.A. 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 HEALTH as their medical network for the state of Pennsylvania. FIRST HEALTH 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 68 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: 1.4. 2.5. 3.6. The name of your employer’s insurance carrier is: The Hartford P.O. Box 4771 Syracuse, NY 13221 1-877-469-9222 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 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. 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. Form WC 66 02 81 C Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 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 34 WEC IB0462 Issuing Office THE HARTFORD BUSINESS SERVICE CENTER Issuing Office Address 3600 WISEMAN BLVD SAN ANTONIO TX 78251 SOUTH CAROLINA - APPLICATION FOR DRUG- AND ALCOHOL-FREE WORKPLACE PREMIUM CREDIT PROGRAM Form WC 66 02 85 B Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 Name of Employer:PLAN-IT GEO LLC Policy 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 Signature* *Application must be signed by an officer, partner, sole proprietor, LLC member or owner. Title Notary public’s signature Date Exp. Of commission Form WC 66 03 06 Printed in U.S.A. Process Date:05/22/18 Policy Expiration Date:06/29/19 WORKERS’ COMPENSATION COST CONTAINMENT CERTIFICATION DISCLOSURE STATEMENT Cost Containment Certification is available from the Colorado Workers’Compensation Cost Containment Board.If you obtain certification, your policy will be subject to a premium credit which will be shown separately on your policy. PLEASE CHECK ONE (1) OF THE FOLLOWING BOXES BASED UPON YOUR BUSINESS ENTITY QUALIFICATION: ☐I am aware if my business does qualify for experience and/or schedule rating under my workers’compensation insurance policy and my business has implemented a certified workers’compensation risk management program,my policy is subject to a 5%premium credit if the loss experience has improved since the last renewal date of workers’ compensation insurance.This 5% premium credit is in addition to any schedule rating for which i may qualify. or, ☐I am aware if my business does not qualify for experience and/or schedule rating under my workers’compensation insurance policy and my business entity has implemented a certified workers’compensation risk management program, my policy is subject to the following premium credit: Premium Dividend Dividend Criteria 10%If my business has been loss free for at least the last year immediately preceding the effective date of the premium credit. 8%If my business had one medical loss exceeding $250 in the last year immediately preceding the effective date of the premium credit. 6%If my business had two medical losses,each exceeding $250,in the last year immediately preceding the effective date of the premium credit. 4%If my business had three medical losses,each exceeding $250,in the last year immediately preceding the effective date of the premium credit. 2%If my business 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. 0%If my business had more than three medical losses and one claim for loss of time in the last year immediately preceding the effective date of the premium credit. ***PLEASE SIGN AND RETURN*** Insured Signature Policy Number 34 WEC IB0462 Issuing Office THE HARTFORD BUSINESS SERVICE CENTER Issuing Office 3600 WISEMAN BLVD Address SAN ANTONIO TX 78251 Form WC 66 03 84 Printed in U.S.A. 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 Incident Information o Type of injury (burn, cut, etc.)? o Exact body part 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)? Network Providers 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 30 J Printed in U.S.A.Page 1 of 2 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 agents; b)brokerage firms; 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. Form WC 66 03 30 J Printed in U.S.A.Page 2 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.;DMS R,LLC;First State Insurance Company;Fountain Investors I LLC; Fountain Investors II LLC;Fountain Investors III 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;HDC 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. POLICY NUMBER:34 WEC IB0462 Form WC 99 00 01 I (Signature/Copyright) Our President and Secretary have signed this policy.Where required by law,the Information Page has been countersigned by our duly authorized representative. 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. Select Customer Insurance Center 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 Policyholder, please call us at: ( 8 6 6) 4 6 7 -8 7 3 o Agent, please call us at: ( 866) 46 7-8 73 o SERVICE.TX@THEHARTFORD.COM INSURANCE ENDORSEMENT ATTACHED *** PLEASE REVIEW THE CHANGE*** Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes: Policyholder, please call us at: ( 8 6 6) 4 6 7 -8 7 3 o Agent, please call us at: (866) 467-8730 between 7 A.M. and 7 P.M. CST . The premium billing will be mailed to you separately. You can expect to receive it soon. Thank you for allowing us to service your business needs. THE HARTFORD SELECT CUSTOMER INSURANCE CENTER The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza, Hartford, Connecticut 06155 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 12 11 04 05 T Process Date: 04/04/19 Page 001 (CONTINUED ON NEXT PAGE) Policy Effective Date: 01/16/19 Policy Expiration Date: 01/16/20 POLICY CHANGE (Continued) Policy Number: 34 SBA AA8144 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 12 11 04 05 T Process Date: 04/04/19 Page 002 Policy Effective Date: 01/16/19 Policy Expiration Date: o 1 / 16 / 2 o POLICY NUMBER: 34 SBA AA8144 CHANGE NUMBER : 0 0 3 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 COMMISSI ONS, 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 417006 11 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 NUMBER: 34 SBA AAB144 CHANGE NUMBER: 003 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): CITY, ITS CITY COUNCIL, BOARDS AND COMMISSIONS, OFFICERS, EMPLOYEES AND Location And Description Of Completed 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. 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" 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 SS 41 71 0611 Process Date: 04/04/19 © 2011, The Hartford Page 1 of 1 Policy Expiration Date: 01/16/20 (Includes copyrighted material of Insurance Services Office, Inc., with its permission) POLICY NUMBER: 34 SBA AA8144 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNER, LESSEES OR CONTRACTOR THE CORPORATION OF THE TOWN OF RICHMOND HILL PO BOX 300, 225 EAST BEAVER CREEK ROAD RICHMOND HILL, ONTARIO L4C 4Y5 ATTN: RISK MANAGEMENT BRANCH CITY, ITS CITY COUNCIL, BOARDS AND COMMISSIONS, OFFICERS, EMPLOYEES AND VOLUNTEERS 10300 TORRE AVE CUPERTINO CA 95014-3202 Form IH 12 00 11 85 T SEQ. NO. 002 Printed in U.S.A. Page 001 Process Date: 04/04/19 Expiration Date: 01/16/20 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: Select Customer Insurance Center 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 Policyholder, please call us at: ( 8 6 6) 4 6 7 -8 7 3 o Agent, please call us at: (866) 467-8730 SERVICE.TX@THEHARTFORD.COM INSURANCE ENDORSEMENT ATTACHED *** PLEASE REVIEW THE CHANGE*** Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes: Policyholder, please call us at: ( 8 6 6) 4 6 7 -8 7 3 o Agent, please call us at: (866) 467-8730 between 7 A.M. and 7 P.M. CST . The premium billing will be mailed to you separately. You can expect to receive it soon. Thank you for allowing us to service your business needs. STANTON INSURANCE LLC/PHS THE HARTFORD SELECT CUSTOMER INSURANCE CENTER The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza, Hartford, Connecticut 06155 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 Decla rations 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 SS4170 SS4171 FORM NAME CITY, ITS CITY COUNCIL, BOARDS AND COMMISSIONS, OFFICERS, EM PLOYEES AND ADDRESS 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 12 11 04 05 T Process Date: 04/04/19 Page 001 (CONTINUED ON NEXT PAGE) Policy Effective Date: 01/16/19 Policy Expiration Date: 01/16/20 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 12 11 04 05 T Process Date: 04/04/19 Page 002 Policy Effective Date: 01/16/19 Policy Expiration Date: 01/16/20 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 NUMBER: 34 SBA AA8144 CHANGE NUMBER: 0 0 3 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): CITY, ITS CITY COUNCIL, BOARDS AND COMMISSIONS, OFFICERS, EMPLOYEES AND Location And Description Of Completed 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. 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" 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 SS 41 71 0611 Process Date: 04/04/19 © 2011, The Hartford Page 1 of 1 Policy Expiration Date: o 1 / 16 / 2 o (Includes copyrighted material of Insurance Ser vices 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 120011 85 T SEQ. NO. Printed in U.S.A. Page Process Date: Expiration Date: THIS ENDORSBvl:NT CHANGES THE POLICY. PLEASE READ IT CAREAJlL Y. WAIVER OF SUBROGATION This endorsement modifies insurance provided under the fallowing: v;/c waive any right of recovery we may have against0.Any person ororganitatioo shown in the Dedaralions, or 2.My person or organiza.1ion with whom you have a contract that requires such W",,Jver. Form SS 1215 03 00 © 2000, The Har1furd Page 1 of 1 POLICY NUMBER: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFUL.LY. ADDITIONAL INSURED -OWNERS, LE SSEE S OR CONTRACTORS -SCHEDULED PERSQ,N OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organizalion(s); Location(s) Of Covered OperaUons 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 organ12ation(s) shown in the Schedule, but only with respect to Ii.ability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1.Your acts or omis sions; 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 Jocation(s) designated above. Form SS 417006 11 Process Date: 8.With respect to the insurance afforded to these additional insur eds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1.All work, induding 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: © 2011 , Toe Hartford (Jnctudes copyrighted material of Insurance Services Office, Inc., with its permission)