Loading...
HomeMy Public PortalAboutC-19-019 - KOA Corporation Amendment No. 2, On-Call Engineering ServicesAMENDMENT NO.2 TO AGREEMENT FOR CONTRACT SERVICES THIS AMENDMENT TO THE AGREEMENT FOR CONTRACT SERVICES 1 ("Amendment No. 2") by and between the City of Carson, a California municipal corporation ("City") and KOA Corporation, a California corporation ("Consultant") is effective as of the 6`�' day of October, 2020. U RECITALS A. City and Consultant entered into that certain Agreement for Contractual Services dated April 2, 2019 ("Agreement") whereby Consultant agreed to provide On -Call Engineering Services. B. City and Consultant amended the Agreement on April 26, 2019 ("Amendment No. P) to decrease the Contract Sum from Five Hundred Thousand Dollars ($500,000.00) to Two Hundred Fifty Thousand Dollars ($250,000.00). C. City and Consultant now desire to again amend the Agreement to increase the Contract Sum from Two Hundred Fifty Thousand Dollars ($250,000.00) to Seven Hundred Fifty Thousand Dollars (750,000.00), and to extend the term by one (1) additional year until June 30, 2022. TERMS 1. Contract Changes. The Agreement is amended as provided herein (new text in bold italics and deleted text in ��ugh). A. Section 2. 1, "Contract Sum," of the Agreement, is hereby amended to read in its entirety as follows: "Subject to any limitations set forth in this Agreement, City agrees to pay Consultant the amounts specified in the "Schedule of Compensation" attached hereto as Exhibit "C" and incorporated herein by this reference. The total compensation, including reimbursement for actual expenses, shall not exceed Seven Hundred Fifty Thousand Dollars ($750,000.00) (the "Contract Sum"), unless additional compensation is approved pursuant to Section 1.8." B. Exhibit B, Section II, amending Section 2. 1, "Contract Sum," of the Agreement, is hereby amended to read in its entirety as follows: "Subject to any limitations set forth in this Agreement, City agrees to pay Consultant the amounts specified in the "Schedule of Compensation" attached hereto as Exhibit "C" and incorporated herein by this reference. The total 01007000&672011 1 compensation, including reimbursement for actual expenses, shall not exceed Two Seven Hundred Fifty Tlrousand Dollars ($750,000) (the "Contract Sum"), unless additional compensation is approved pursuant to Section I.8 or subsequently approved by the City Council." C. Exhibit C, Section IX, of the Agreement, is hereby amended to read in its entirety as follows: "The total compensation for the Services shall not exceed $250,099 -$750,000 for the term of this Agreement, as provided in Section 2.1 of this Agreement, and as amended in Exhibit B." D. Exhibit D, Section I, of the Agreement is hereby amended to read in its entirety as follows: "From April 2, 2019 through june 30, 204 June 30, 2022, Consultant shall provide Services on an on-call basis as set forth in Exhibit A." 2. Continuing Effect of Agreement. Except as amended by this Amendment No. 2, all provisions of the Agreement and Amendment No. 1 shall remain unchanged and in full force and effect. From and after the date of this Amendment No. 2, whenever the term "Agreement" appears in the Agreement, it shall mean the Agreement, as amended by this Amendment No. 2 and Amendment No. 1. 3. Affirmation of Agreement; Warranty Re Absence of Defaults. City and Consultant each ratify and reaffirm each and every one of the respective rights and obligations arising under the Agreement and Amendment No. 1. Each party represents and warrants to the other that there have been no written or oral modifications to the Agreement other than as provided herein and Amendment No. 1. Each party represents and warrants to the other that the Agreement, as amended by Amendment No. 1 and this Amendment No. 2, is currently an effective, valid, and binding obligation. Consultant represents and warrants to City that, as of the date of this Amendment No. 2, City is not in default of any material term of the Agreement and that there have been no events that, with the passing of time or the giving of notice, or both, would constitute a material default under the Agreement. City represents and warrants to Consultant that, as of the date of this Amendment No. 2, Consultant is not in default of any material term of the Agreement and that there have been no events that, with the passing of time or the giving of notice, or both, would constitute a material default under the Agreement. 4. Adequate Consideration. The parties hereto irrevocably stipulate and agree that they have each received adequate and independent consideration for the performance of the obligations they have undertaken pursuant to this Amendment No. 2. -2- 01007 00061672011 1 5. Authority. The persons executing this Amendment No. 2 on behalf of the parties hereto warrant that (i) such party is duly organized and existing, (ii) they are duly authorized to execute and deliver this Amendment No. 2 on behalf of said party, (iii) by so executing this Amendment No. 2, such party is formally bound to the provisions of this Amendment No. 2, and (iv) the entering into this Amendment No. 2 does not violate any provision of any other agreement to which said party is bound. [SIGNATURES ON FOLLOWING PAGE] 43_ 01007 0006/672011 1 11hr 1 ligt-a n. c1:1 it I-A.A HI.[ : CA mwe - of [w MIF Y#���n[ R nlnl Ekmxsia Gause-.4Jdans, Cit Cleo APPROVIM AS TO FORM: ALES1 AIRF & WYNrDM LLP 6 -4 Sunni K- Sohani, City Attemey [1J1) NJ III CONSULTAN-f- KOA CORPORAUON By: Name: Jimmy Lin 1 By- Name: Juav4b Title: Chief FintceOfficer Address: I100 Corporate Center Drive, Suite 201 Monterey Park CA 91754 Two corporate officer signatures required when Consultant is a corporation, with one signature required from each of the following groups: 1) Chairman of the Board, President or any Vice President; and 2) Secretary, any Assistant Secretary, Chief Financial Officer or any Assistant Treasurer. CONSULTANT'S SIGNATURES SHALL BE DULY NOTARIZED, AND APPROPRIATE ATTESTATIONS SHALL BE INCLUDED AS MAY BE REQUIRED BY THE BYLAWS, ARTICLES OF INCORPORATION, OR OTHER RULES OR REGULATIONS APPLICABLE TO CONSULTANT'S BUSINESS ENTITY. _4 01007 00061673011 1 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE A notary public or other officer completing this certificate verifies only the identity of the individual who signed the _ document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. i State of California County of Los _ C� nAtLS On 0(A k ► % Ute__ before me, Niktak Uud , WTta4m PiAblic , Date Here Insert Name and Titg of the Officer personally appeared JYMM4 (�YN , ltk _ lmerra Names) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of Califomia that the foregoing paragraph is true and correct. NIKITACHot WITNESS my hand and official seal. Notary Public - Califomia Los Angeles County E `( )& L Commission N 219E1531 Si1.gnature My Comm. Expires Apr 9, 2021 Signature of Notary Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: �exwn f�cna�+n+rC_ �1_k 2_ l��eC Document Date: 0 � Number of Pages: Signer(s) Other Than NdneA Above: Capacity(ies) Claimed by Signer(s) Signer's Name: kimMo LM ®"Corporate Officer -- T e(s): ❑ Partner — ❑ Limited ❑ General J fyeCxCttiG ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: _WrAseg Signer's Name: TA n et (cejre. ZrCorporate Officer — Title(s): C tO ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attomey in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: imS-e 02016 National Notary Association - www.NationaiNotary.org • 1 -800 -US NOTARY (1-800-876-6827) Item #5907 es ACOR��DATE CERTIFICATE OF LIABILITY INSURANCE (MM/DD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. 9/3/2020 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME Dealey, Renton & Associates PHONE FAX ilvc..x9-EM510-485-3090 No 790 E Colorado Blvd #460 ADDRESS_ Certificates@Dealeyrenton.com Pasadena, CA 91101 License #0020739 INSURERM AFFORDING COVERAGE MAIC I INSURER A XL.Specialty Insurance Co. 37885 INSURER B Travelers PropertV Casualty Company of America 25674 INSURED KOACORPOR KOA Corporation — 1100 Corporate Center Drive #201 INSURER C INSURER D Monterey Park, CA 91754 (323) 2604703 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 233377436 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 Public Works I Engineering Division WV0 POLICY EFF POLICYNUMeERMMIDDIYYYY POLICY EXP MMIDOIYYYY LIMITS B Y Y 680BH966428 311312020 311312021 EACHOCCURRENCE $2.000000 [tXCOhMMERCIALGFNERALUA131UTY CLAIMS -MADE X OCCUR I AMAGE TO 11 PR MIS o r nce $1 000000 MED EXP (Any one rson) S 10 ODD fn ictual4ah X I XCU Ind ded _ PERSONAL 6 ADV INJURY s 2.OD0,000 T- AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S4,000.000 POLICY E JEST ❑ LOG MOTHER: PRODUCTS -COMPIOPAGG S4,000,000 $ B AUTOMODILELWBILITY Y Y BAZA439560 3/13/2020 3113/2021 COMBINED SIN LELIMIr SS.00D000 _jEa_jfcadert0 X ANY AUTO BODILY INJURY (Per person) S IAUTOS OWNED SCHEDULED BODILY INJURY (Per aoptlenl) S AUTOS ONLY AUTOS X HIRED X NON -OWNED PROPERTY DAMAGE S ONLY AUTOS ONLY Lpq aca0enl) I IS B X UMSRELLALIAB I X OCCUR CUP6464YO33 31312020 3/13/2021 ~• I EACHOCCURRENCE 55,000,000 i AGGREGATE I S 5.000,00D EXCESS LIAR CLAIMS -MADE; S DED I X I RETENTIONS n I B WORKERS COMPENSATIONY AND EMPLOYERS' LIABILITY Y 1 N ANYPROPRIETORIPARTNERIEXECUTIVE r -1N U1321.459350 9119/2020 9/19/2021 X I PER H- TATUTE ER E.L. EACH ACCIDENT $1.000,000 OFFICER(MEMBEREXCLUDED7 1 A E.L. DISEASE - EA EMPLOYE $1,000,000 (Mandatary In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 A Prolessionaltiability DPR9957134 3113/2020 3/13/2021 Per Claim 2,000,000 Pollution Liability Included Annual Aggregale 4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1ACORD 101. Additional Remarks Schedule, may be attached It mars apace is required) AM Best's Rating on all policies above A/XII or greater. Umbrella Liability policy Is follow -form to its underlying Policies: General Liability/Auto Liability/Employers Liability. Re: JB91071 Carson Civil Engineering On -Call City of Carson, its officers, employees and agents are Additional Insured as respects to General & Auto Liability as required per written contract or agreement. Insurance coverage includes waiver of subrogation per the attached CERTIFICATE HOLDER CANCELLATION 30 Dav Notice of Cancellation ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD �O✓ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Carson THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Public Works I Engineering Division Attn: Raymond Velasco 701 East Carson Street Carson CA 90745 q AUTHORIZED REft RESENTATIVE , ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6808H966428 COMMERCIAL GENERAL LIABILITY ISSUED DATE: 9/3/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Any person or organization that you agree in a written contract to include as an additional insured on this Coverage Part for "bodily injury" or "property damage" included in the "products - completed operations hazard", provided that such contract was signed and executed by you before, and is in effect when, the bodily injury or property damage occurs. Location And Description Of Completed Operations Any project to which an applicable contract described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section 11 — Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" 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 in- sured and included in the "products -completed opera- tions hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 COMMERCIAL GENERAL LIABILITY POLICY NUMBER 6808H966428 ISSUED DATE 9/3/2020 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Names of Additional Insured Person(s) or Organization(s): Any person or organization that you agree in a written contract, on this Coverage Part, provided that such written contract was signed and executed by you before, and is in effect when the "bodily injury" or "property damage" occurs or the "personal injury" or "advertising injury" offense is committed. Location of Covered Operations: Any project to which an applicable written contract with the described in the Name of Additional Insured Person(s) or Organization(s) section of this Schedule applies. (information required to complete this Schedule, if not shown above, will be shown in the Declarations,) A. Section II — Who Is An Insured is amended to in- clude 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", "personal injury" or "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) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring, or "personal injury" or "advertising injury" arising out of an offense committed, after: 1. All work, including materials, parts or equip- ment furnished in connection with such work. on the project (other than service, mainte- nance or repairs) to be performed by or on behalf of the additional insured(s) at the loca- tion of the covered operations has been com- pleted; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG D3 6103 05 Copyright 2005 The St. Paul Travelers Companies, Inc. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. NAMED INSURED: KOA Corporation COMMERCIAL GENERAL LIABILITY COVERAGE POLICY NUMBER: 68081-1966428 ADDITIONAL COVERAGES BY WRITTEN CONTRACT OR AGREEMENT This Is a summary of the coverages provided under the following forms (complete forms available) Excerpt from COMMERCIAL GENERAL LIABILITY COVERAGE (FORM #CG T1 00 02 19) SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS 4. OTHER INSURANCE - d. PRIMARY AND NON-CONTRIBUTORY INSURANCE IF REQUIRED BY WRITTEN CONTRACT; If you specifically agree in a written contract or agreement that the insurance afforded to an insured under this Coverage Part must apply on a primary basis_ or a primary and non-contributory basis, this insurance is primary to other insurance that is available to such insured which covers such insured as a named insured, and we will not share with that other insurance, provided that: (1) The "bodily injury" or "property damage" for which coverage is sought occurs; and (2) The "personal and advertising injury" for which coverage is sought is caused by an offense that is committed; subsequent to the signing of that contract or agreement by you. Excerpt from XTEND ENDORSEMENT FOR ARCHITECTS, ENGINEERS AND SURVEYORS (FORM #CG D3 79 02 19) PROVISION M. - BLANKET WAIVER OF SUBROGATION - WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT: If the insured has agreed in a written contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: a. "Bodily injury" or "property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed, subsequent to the signing of that contract or agreement. Page 1 COMMERCIAL AUTO POLICY NUMBER: 6A2A439568 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following. AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage pro- vided in the Coverage Form. SCHEDULE Name Of Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION THAT YOU ARE REQUIRED TO INCLUDE AS ADDITIONAL INSURED ON THE COVERAGE FORM IN A WRITTEN CONTRACT OR AGREEMENT THAT IS SIGNED AND EXECUTED BY YOU BEFORE THE BODILY INJURY OR PROPERTY DAMAGE OCCURS AND THAT IS IN EFFECT DURING THE POLICY PERIOD. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provi- sion contained in Paragraph A.1. of Section II — Cov- ered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 Q Insurance Services Office, Inc., 2011 Page 1 of 1 Policy No. BA2A439568 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY WITH OTHER INSURANCE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM PROVISIONS 1. The following is added to Paragraph A.1.c., Who Is An Insured, of SECTION 11 — COVERED AUTOS LIABILITY COVERAGE: This includes any person or organization who you are required under a written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to name as an additional insured for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured". 2. The following is added to Paragraph B.5., Other Insurance of SECTION IV — BUSINESS AUTO CONDITIONS: Regardless of the provisions of paragraph a. and paragraph d. of this part 5. Other Insurance, this insurance is primary to and non-contributory with applicable other insurance under which an additional insured person or organization is the first named insured when the written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, requires this insurance to be primary and non-contributory. CA T4 74 0216 ® 2016 The Travelers Indemnity Company. All rights reserved Page 1 of 1 Includes copyrighted material of Insurance Services Office. Inc with its permission. Policy # BA2A439568 X918Tlul; U-NL1>1 U111111115e7 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following replaces Paragraph A.5., Transfer of required of you by a written contract executed Rights Of Recovery Against Others To Us, of the prior to any "accident" or "loss", provided that the CONDITIONS Section: "accident" or "loss" arises out of the operations 5. Transfer Of Rights Of Recovery Against Oth- contemplated by such contract. The waiver ap- ers To Us plies only to the person or organization desig- We waive any right of recovery we may have nated in such contract. against any person or organization to the extent CA T3 40 02 15 ® 2015 The Travelers Indemnity Company All rights reserved. Page 1 of i Includes copyrighted material of Insurance Services Office, Inc wilh its permission. TRAVELERS J k WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 99 03 76 ( A) - 001 POLICY NUMBER: UB -2L459350 -19-47-G WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be 2.00 % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR ALL LOCATIONS WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No Endorsement No. Insured Premium Insurance Company Countersigned by ST ASSIGN: Page 1 of 1