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HomeMy Public PortalAboutC-18-012 - SC FUELS AMENDMENT NO. 1 2023 JULY 1AMENDMENT NO. 1 TO AGREEMENT FOR CONTRACT SERVICES THIS AMENDMENT TO THE AGREEMENT FOR CONTRACT SERVICES ("Amendment No. 1") by and between the CITY OF CARSON, a California municipal corporation ("City") and SOUTHERN COUNTIES OIL CO., a California Limited Partnership, dba/SC Fuels ("Consultant") is effective as of the 1st day of July, 2023, except as otherwise provided herein. City and Consultant are sometimes hereinafter individually referred to as "Party" and hereinafter collectively referred to as the "Parties." RECITALS A. City and Consultant entered into that certain Agreement for Contract Services dated 'r*d July 9, 2018, ("Agreement") whereby Consultant agreed to provide on-call services related to bulk fuel purchasing of gasoline and diesel fuel and Cardlock fuel cards for a five (5) year term commencing on July 1, 2018, and ending June 30, 2023, for a total not -to -exceed Contract Sum of One Million Two Hundred Fifty Thousand Dollars ($1,250,000.00), unless additional compensation is approved pursuant to Section 1.8. B. In approving the Agreement, the City Council concurrently approved inclusion of an administrative option to extend the Agreement term for a two-year period, to be taken in one- year increments. C. City and Consultant now desire to amend the Agreement to increase the contract sum by Fifty Thousand Dollars ($50,000.00) to fund the services needed for the initial five (5) year term. This increases the Agreement's total Contract Sum for the initial five (5) year term to One Million Three Hundred Thousand Dollars ($1,300,000.00). D. City and Consultant additionally desire to amend the Agreement to extend the term by one (1) year, through June 30, 2024 (unless earlier terminated pursuant to Article 7 of the Agreement), at the same Pricing Methodology specified in the Agreement (except with respect to applicable tax rates as provided below), and to provide funding for the Services during this one- year extension period in an amount not to exceed Three Hundred Fifty Thousand Dollars ($350,000.00), bringing the total Contract Sum over the six-year term to One Million Six Hundred Fifty Thousand Dollars ($1,650,000.00), with one remaining City option to extend the term of the Agreement for an additional one-year period thereafter. E. City and Consultant additionally desire to amend the Agreement, effective retroactively as of the commencement date of the Agreement, to remove the language in Section II of Exhibit "C" (Schedule of Compensation) stating the following, which was originally included in the Agreement in error: "A retention of ten percent (10%) shall be held from each payment as a contract retention to be paid as part of the final payment upon satisfactory completion of services." TERMS 1. Contract Changes. The Agreement is amended as provided herein (new text is identified in bold italics, deleted text in stFike *ugh): 01007.0006/897609.3 follows: A. Section 2.1 (Contract Sum) is hereby amended to read in its entirety as "2.1 Contract Sum. 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 One *, ilhe., Two Hundred fifty Theusand Dollars and No Cents (S , One Million Six Hundred Fifty Thousand Dollars and No Cents ($1,650,000.00) (the "Contract Sum"), unless additional compensation is approved pursuant to Section 1.8." B. Section 3.4 (Term) is hereby amended to read in its entirety as follows: "3.4 Term. Unless earlier terminated in accordance with Article 7 of this Agreement, this Agreement shall continue in full force and effect until completion of the services but not exceeding six (6) five (5) years commencing July 1, 2018, and terminating June 30, 2024 Awe 30, City may, in its sole discretion, extend the term of the Agreement for one additional one-year extension period, from July 1, 2024 through June 30, 2025." C. The "Excise Tax Rates Per Gallon" table in Section I of Exhibit "C" (Schedule of Compensation) is hereby amended as follows: "Excise Tax Rates Per Gallon: RATE A. Gasoline (Motor vehicle fuel) $0.417 $0.539 B. Diesel $4:36 $0.41" D. The "Cardlocks for Fleet Per Gallon' table in Section I of Exhibit "C" (Schedule of Compensation) is hereby amended as follows: "Cardlocks for Fleet Per Gallon (offsite fueling sites): RATE OPIS Contract Average A. Gasoline (Motor vehicle fuel) $0.15 $4.04 $0.055 B. Diesel $0.15 $4:44 $0.055" E. The "California Sales and Use Tax Rate (per gal)" table in Section I of Exhibit "C" (Schedule of Compensation) is hereby amended as follows: "California Sales and Use Tax Rate (Carsonlper): 2 01007.0006/8976093 RATE A. Gasoline (Motor vehicle fuel) 2.250% 5.25% B. Diesel 13.00-07 0 12.0625%" F. The "Federal Oil Spill Fee (per gal)" table in Section I of Exhibit "C" (Schedule of Compensation) is hereby amended as follows: "Other Taxes (per jeal) (Includes Federal Oil Spill Fee per gal) : RATE A. Diesel .^0'�,; $0.03711 B. Gasoline $0.03551" G. Effective July 1, 2018, Section II of Exhibit "C" (Schedule of Compensation) is hereby deleted as follows: "II. [Reserved]re�ti�:t *' r *en pereent (1004) shallheld he eld fro eeem.h paymefA as a eentr-aet r-etenfien te be paid as part of the final payment zupen safisfaGtei.�Y ,.let•., ofs " H. Section IV of Exhibit "C" (Schedule of Compensation) is hereby amended to read in its entirety as follows: "IV. The total compensation for the Services shall not exceed $1,650,000 $1,250,00 as provided in Section 2.1 of this Agreement." 2. Continuing Effect of Agreement. Except as amended by this Amendment No. 1, all provisions of the Agreement shall remain unchanged and in full force and effect. From and after the date of this Amendment No. 1, whenever the term "Agreement" appears in the Agreement, it shall mean the Agreement, as amended by this Amendment No. 1 to the Agreement. 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. 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. Each party represents and warrants to the other that the Agreement is currently an effective, valid, and binding obligation. Consultant represents and warrants to City that, as of the date of this Amendment No. 1, 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. 01007.0006/897609.3 City represents and warrants to Consultant that, as of the date of this Amendment No. 1, 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. 1. 5. Authority. The persons executing this Amendment No. 1 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. 1 on behalf of said party, (iii) by so executing this Amendment No. 1, such party is formally bound to the provisions of this Amendment No. 1, and (iv) the entering into this Amendment No. 1 does not violate any provision of any other agreement to which said party is bound. [SIGNATURES ON FOLLOWING PAGE] 4 01007.0006/897609.3 IN WITNESS WHEREOF, the parties hereto have executed this Amendment No. 1 on the date(s) and year(s) set forth below, with express intent that this Amendment No. 1 shall be effective as of the date first -above written. A EST: . . B -r Dr. Kha eah R. Bradshaw, City Clerk APPROVED AS TO FORM: ALESHIRE & WYNDER, LLP Sunny K. Soltani, City Attorney [br3 01007.0006/897609.3 CITY: Cl Y F CARSON, a municipal corporation PulaDavis-Holmes, Mayor Date: CONSULTANT: SOUTHERN COUNTIES OIL CO., a California Limited Partnership, dba/SC Fuels By: --� N nie: obert W. Bollar Title: Corporate Secretary 4_qd Vice President r►f O$ - B. .......... .. Name: Edward A. Wondergem Title: CFO -Treasurer, and \'its' l'rc i&:iii Address: 1800 W. Katella Ave., Suite 400 P.O. Box 4159 Orange, CA 92863-4159 Date: IN WITNESS WHEREOF, the parties hereto have executed this Amendment No. 1 on the date(s) and year(s) set forth below, with express intent that this Amendment No. 1 shall be effective as of the date first -above written. ATTEST: Dr. Khaleah R. Bradshaw, City Clerk APPROVED AS TO FORM: ALESHIRE & WYNDER, LLP Sunny K. Soltani, City Attorney [brj] CITY: CITY OF CARSON, a municipal corporation Lula Davis -Holmes, Mayor Date: CONSULTANT: SOUTHERN COUNTIES OIL CO., a California Limited Partnership, dba1SC Fuels By: Ame'7kobert W. Bollar Title: Corporate Secretary and Vice President of OP B Name: Edward A. Wondergem Title: CFO. Treasurer. and Vise President Address: 1800 W. Katella Ave., Suite 400 P.O. Box 4159 Orange, CA 92863-4159 Date: 5 01007.00061897609.3 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy or validity of that document. STATE OF CALIFORNIA COUNTY OF ORANGE On June 27, 2023 before me, Xuan Huong Morales, Notary Public, personally appeared Robert W. Bollar and Edward A. Wondergem, proved to me on the basis of satisfactory evidence to be the person(s) whose names(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 California that the foregoing paragraph is true and correct. WITNESS my hand and offs al seal.*my XUAN NUONG MORALES Notary Public - CaliforniaOranle ounty K. Signature. missio #236� tommisslon N 2368530 Comm. Expires Jul 20, 2025 r�+rw OPTIONAL Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER ❑ INDIVIDUAL ® CORPORATE OFFICER Corporate Secretary and Vice President/ CFO, Treasurer, and Vice President 01007.0006/897609.3 DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT SIGNER(S) OTHER THAN NAMED ABOVE TITLE(S) ❑ PARTNER(S) ❑ LIMITED ❑ GENERAL ❑ ATTORNEY-IN-FACT ❑ TRUSTEE(S) ❑ GUARDIAN/CONSERVATOR ❑ OTHER SIGNER IS REPRESENTING: (NAME OF PERSON(S) OR ENTITY(IES)) 01007.0006/897609.3 DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT SIGNER(S) OTHER THAN NAMED ABOVE A,IC"R o® CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE DATE TYPE OF INSURANCE ADDL THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: MARSH USA, INC. PHONE TWO ALLIANCE CENTER (A& No E • aC No): 3560 LENOX ROAD, SUITE 2400 E-MAIL ATLANTA, GA 30326 ADDRESS: GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PES F—] LOC OTHER: GENERAL AGGREGATE $ 10,000,000 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: National Fire & Marine Insurance Co 20079 CN 1 02393196-w/end-GAWUX-22- INSURED Southern Counties Oil Co., INSURER B: ACE American Insurance Company 22667 INSURER C : NIA N/A a California Limited Partnership; SC Commercial, LLC; Cardlock Fuels System LLC dba SC Fuels 09/01/2022 P.O. Box 4159 INSURER D : INSURER E: Orange, CA 92867 INSURER F: $ COVERAGES CERTIFICATE NUMBER- ATL -005422525-10 REVISION NUMBFR- 3 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 SU D POLICY NUMBER MM/DD/YYrr MWDD� LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR X X XSLG4729874A 09/01/2022 09/01/2023 EACH OCCURRENCE $ 1,000,000 DAPREMMAISESSGE(RENTED Ea occurrence) $ 100,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PES F—] LOC OTHER: GENERAL AGGREGATE $ 10,000,000 PRODUCTS -COMP/OPAGG $ 1,000,000 $ B AUTOMOBILE IXX LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY MCS -90 X X ISAH10690481 09/01/2022 09/01/2023 CEOMaBIINdEeDDSINGLELIMIT $ 5,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE 42UM030858304 09/01/2022 09/01/2023 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I X I RETENTION s25,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED7 7 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A X WLRC50670041 09/01/2023 X PER oTH- -STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) City of Carson, its elected and appointed officers, employees, volunteers and agents is/are included as Additional Insured with respect to the General and Auto Liability policies where required by written contract. Waiver of subrogation is applicable where required by written contract and subject to policy terms and conditions. This insurance is primary and non-contributory over any existing insurance and limited to liability arising out of the operations of the named insured subject to policy terms and conditions. %,rm I Iri%,A I e rIULUMM GAN"LLA 1 IUN City of Carson SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 701 E. Carson St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Carson, CA 90745 INSURANCE APPROVED ACCORDANCE WITH THE POLICY PROVISIONS. j/ - �- AUTHORIZED REPRESENTATIVE 5/3/2023 of Marsh USA Inc ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2 NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Endorsement Number Pilot Travel Centers LLC 5 Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G4729874A 09/01/2022 to 09/01/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder ofthe information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY Scher Oraanization Additional Insured Endorsement Any additional insured with whom you have agreed to provide such non- contributory insurance, pursuant to and as required under a written contract executed prior to the date of loss (lf no information is filled in, the schedule shall read. "All persons or entities added as additional insureds through an endorsement with the term "Additional Insured" in the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to Section IVA: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured") for a loss we cover under this policy, this insurance will apply to such loss and is primary (subject to satisfaction of the "retained limit"), meaning that we will not seek contribution from the other insurance available to the Additional Insured. Your "retained limit" still applies to such loss, and we will only pay the Additional Insured for the "ultimate net loss" in excess of the "retained limit" shown in the Declarations of this policy. Authorized Representative XS -20288a (05/14) ©Chub. 2016. All lights reserved. Page 1 of 1 ADDITIONAL INSURED — DESIGNATED PERSONS OR ORGANIZATIONS Named Insured Southern Counties Oil Co., a California Endorsement Number Limited Partnership 6 Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA IH10690481 09/01/2022 To 09/01/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder ofthe information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM AUTO DEALERS COVERAGE FORM MOTOR CARRIER COVERAGE FORM EXCESS BUSINESS AUTO COVERAGE FORM Additional Insured(s): Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. A. For a covered "auto," Who Is Insured is amended to include as an "insured," the persons or organizations named in this endorsement. However, these persons or organizations are an "insured" only for "bodily injury" or "property damage" resulting from acts or omissions of: 1. You. 2. Any of your "employees" or agents. 3. Any person operating a covered "auto" with permission from you, any of your "employees" or agents. B. The persons or organizations named in this endorsement are not liable for payment of your premium. Authorized Representative DA 9U74c (03/16) Page 1 of 1 NOTICE TO OTHERS ENDORSEMENT — SCHEDULE NOTICE BY INSUREDS REPRESENTATIVE it Co., a 5 Limited Partnership Policy Symbol IPolicy Number Policy Period Effective Date ISA IH10690481 109/01/2022 To 09/01/2023 ssued By (Name of Insurance Company) 4CE American Insurance Company Insert the. policy number. The remainder of the information is to be completed only when this an THIS issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel this Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, asset out in this endorsement, to send written notice of cancellation, to the persons or organizations listed in the schedule that you or your representative create or maintain (the "Schedule") by allowing your representative to send such notice to such persons or organizations. This notice will be in addition to our notice to you or the first Named Insured, and any other party whom we are required to notify by statute and in accordance with the cancellation provisions of the Policy. B. The notice referenced in this endorsement as provided by your representative is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). The failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule will impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. C. We are not responsible for verifying any information in any Schedule, nor are we responsible for any incorrect information that you or your representative may use. D. We will only be responsible for sending such notice to your representative, and your representative will in turn send the notice to the persons or organizations listed in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. E. This endorsement does not apply in the event that you cancel the Policy. All other terms and conditions of this Policy remain unchanged. Authorized Representative ALL -32686 (01/11) Page 1 of 1 NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Named Insured Southern Counties Oil Co., a California Endorsement Number Limited Partnership 7 Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA H10690481 109/01/2022 To 09/01/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM Schedule Orctanization Additional Insured Endorsement Any additional insured with whom you have agreed to provide such non- contributory insurance, pursuant to and as required under a written contract executed prior to the date of loss. (If no information is filled in, the schedule shall read. "All persons or entities added as additional insureds through an endorsement with the term Additional Insured" in the title) For organizations that are listed in the Schedule above that are also an Additional Insured under an endorsement attached to this policy, the following is added to the Other Insurance Condition under General Conditions: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the 'Additional Insured") for a loss we cover under this policy, this insurance will apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured. Authorized Representative DA -21886b (06/14) Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS Named Insured Southern Counties Oil Co., a California Endorsement Number Limited Partnership 8 Policy Symbol IPolicy Number Policy Period Effective Date of Endorsement ISA IH10690481 109101/2022 To 09/01/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder ofthe information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This Endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIERS COVERAGE FORM AUTO DEALERS COVERAGE FORM We waive any right of recovery we may have against the person or organization shown in the Schedule below because of payments we make for injury or damage arising out of the use of a covered auto. The waiver applies only to the person or organization shown in the SCHEDULE. SCHEDULE Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. Authorized Representative DA -13115a (06/14) Page 1 of 1 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Named Insured Endorsement Number Pilot Travel Centers LLC 2 Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G4729874A 09/01/2022 to 09/01/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name of Person or Organization: Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this policy. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. All Other Terms And Conditions Remain Unchanged. Authorized Representative XS-6W34a (02/20) Page i of i 2 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Named Insured Endorsement Number Pilot Travel Centers LLC 3 Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G4729874A I 09/01/2022 to 09/01/2023 Issued By (Name of Insurance Company) ACE American Insurance Company insert the policy number. The remainderot the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name of Person or Organization: Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. A. Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted bylaw; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance And Retained Limit: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Authorized Representative XS-6W25b (04/13) Incudes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 2 ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — COMPLETED OPERATIONS Named Insured Endorsement Number Pilot Travel Centers LLC 4 Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G4729874A 09/01/2022 to 09/01/2023 above will be shown in the Declarations. Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder ofthe information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This Endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Any person or organization whom you have agreed to All locations where you perform work for such additional include as an additional insured under a written insured pursuant to any such written contract. contract, provided such contract was executed prior to the date of loss. Information required to complete this Schedule, if not shown above will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organiza- tions) 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 endorse- ment performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section 111 — Limits Of Insurance And Retained Limit: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance_ 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Authorized Representative XS -21164a (04/13) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 2 NOTICE TO OTHERS ENDORSEMENT SCHEDULE NOTICE BY INSURED'S REPRESENTATIVE Named Insured pilot Travel Centers LLC Endorsement Number 1 Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL IG4729874A 109/01/2022 To 09/01/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel this Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out in this endorsement, to send written notice of cancellation, to the persons or organizations listed in the schedule that you or your representative create or maintain (the "Schedule") by allowing your representative to send such notice to such persons or organizations. This notice will be in addition to our notice to you or the first Named Insured, and any other party whom we are required to notify by statute and in accordance with the cancellation provisions of the Policy. B. The notice referenced in this endorsement as provided by your representative is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). The failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule will impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. C. We are not responsible for verifying any information in any Schedule, nor are we responsible for any incorrect information that you or your representative may use. D. We will only be responsible for sending such notice to your representative, and your representative will in tum send the notice to the persons or organizations listed in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. E. This endorsement does not apply in the event that you cancel the Policy. AH other terms and conditions of this Policy remain unchanged. Authorized Representative ALL -32686 (01/11) Page 1 of 1 rl POLICY NUMBER: ISA H10690481 Endorsement Number. 3 FORM MCS -90 OMB No-: 2126-0008 Expiration: 0513112024 USDOT Number: Date Received: Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this form with the Office of Management and Budget. This requirement to collect information as requested on this form does not expire. For questions, please contact the Office of Registration and Safety Information, Registration, Licensing, and Insurance Division. A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0008. Public reporting for this collection of information is estimated to be approximately 2 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC -RRA, Washington, D.C. 20590. United States Department of Transportation 11 Federal Motor Carrier Safety Administration Endorsement for Motor Carrier Policies of Insurance for Public Liability under Sections 29 and 30 of the Motor Carrier Act of 1980 FORM MCS -90 Issued to SC Commercial. LLC of Q (Motor Carrier name) (Motor Carrier state or province) Dated at Wilmington, DE 19803 on this 11th day of August 120 22. Amending Policy Number: ISA H10690481 Effective Date: 09/01/2022 Name of Insurance Company: ACE American Insurance Company 5 JOHN -L LUPIGI Prm.,6.wmt Countersigned by: (arahorized company representative) The policy to which this endorsement is attached provides primary or excess insurance, as Indicated for the limits shown (check only orte): NThis insurance is primary and the company shall not be liablefor amounts in excess of $ 5,000,000 for each accident. FThis insurance is excess andthe company shall not be liable for amounts in ercers of for each accident in excess of the w0erlring limit ojS far each accident Whenever required by the Federal Motor Carrier Safety Administration (FMCSA), the company agrees to furnish the FMCSA a duplicate of said policy and all its endorsements. The company also agrees, upon telephone request by an authorized representative of the FMCSA, to verify that the policy is in force as of a particular date. The telephone number to Cali is: 215 - 640 - 4555. Cancellation of this endorsement may be effected by the company or the insured by giving (1) thirty-five (35) days notice in writing to the other party (said 35 days notice to commence from the date the notice is mailed, proof of mailing shall be sufficient proof of notice), and (2) if the insured is subject to the FMCSA's registration requirements under 49 U.S.C. 13901, by providing thirty (30) days notice to the FMCSA (said 30 days notice to commence from the date the notice is received by the FMCSA at its office in Washington, DC). Filings must be transmitted online via the Internet at httpJ/www.fmcsa.dot.aov/urs. (continued on next page) FORM MCS -90 Page 1 of 3 Rev 6/3/2021 MC1622y (06-21) Wolters Kluwer I Uniform Forms FORM MCS -90 DEFINITIONS AS USED IN THIS ENDORSEMENT Accident includes continuous or repeated exposure to conditions or which results in bodily injury, property damage, or environmental damage which the insured neither expected nor intended. Motor Vehicle means a land vehicle, machine, truck, tractor, trailer, or semitrailer propelled or drawn by mechanical power and used on a highway for transporting property, or any combination thereof. Bodily Injury means injury to the body, sickness, or disease to any person, including death resulting from any of these. Property Damage means damage to or loss of use of tangible property. The insurance policy to which this endorsement is attached provides automobile liability insurance and is amended to assure compliance by the insured, within the limits stated herein, as a motor carrier of property, with Sections 29 and 30 of the Motor Carrier Act of 1980 and the rules and regulations of the Federal Motor Carrier Safety Admi nistration (FMCSA). In consideration of the premium stated in the policy to which this endorsement is attached, the insurer (the company) agrees to pay, within the limits of liability described herein, any final judgment recovered against the insured for public liability resulting from negligence in the operation, maintenance or use of motor vehicles subject to the financial responsibility requirements of Sections 29 and 30 of the Motor Carrier Act of 1980 regardless of whether or not each motor vehicle is specifically described in the policy and whether or not such negligence occurs on any route or in any territory authorized to be served by the insured or elsewhere. Such insurance as is afforded, for public liability, does not apply to injury to or death of the nsured's employees while engaged in the course of their employment, or property transported by the insured, designated as cargo. It is understood and agreed that no condition, provision, stipulation, or limitation contained in the policy, this endorsement, or any other endorsement thereon, MC1622y (06-21) OMB No.: 2126.0008 Expiration: 05/31/2024 Environmental Restoration means restitution for the loss, damage, or destruction of natural resources arising out of the accidental discharge, dispersal, release or escape into or upon the land, atmosphere, watercourse, or body of water, of any commodity transported by a motor carrier. This shall include the cost of removal and the cost of necessary measures taken to minimize or mitigate damage to human health, the natural environment, fish, shellfish, and wildlife. Public Liability means liability for bodily injury, property damage, and environmental restoration. or violation thereof, shall relieve the company from liability or from the payment of any final judgment, within the limits of liability herein described, irrespective of the financial condition, insolvency or bankruptcy of the insured. However, all terms, conditions, and limitations in the policy to which the endorsement is attached shall remain in full force and effect as binding between the insured and the company. The insured agrees to reimburse the company for any payment made by the company on account of any accident, claim, or suit involving a breach of the terms of the policy, and for any payment that the company would not have been obligated to make under the provisions of the policy except for the agreement contained in this endorsement. It is further understood and agreed that, upon failure of the company to pay any final judgment recovered against the insured as provided herein, the judgment creditor may maintain an action in any court of competent jurisdiction against the company to compel such payment. The limits of the company's liability for the amounts prescribed in this endorsement apply separately to each accident and any payment under the policy because of anyone accident shall not operate to reduce the liability of the company for the payment of final judgments resulting from any other accident_ FORM MCS -90 Page 2 of 3 (continued on next page) FORM MCS -90 SCHEDULE OF LIMITS — PUBLIC LIABILITY OMB No.: 2126-0008 Expiration: 05/31/2024 Type of carriage Commodity transported January 1, 1985 (1) For -hire (in interstate orforeign commerce, with a Property (nonhazardous) $750,000 gross vehicle weight rating of 10,001 or more pounds). hazardous materials, and hazardous substances (2) For -hire and Private (in interstate, foreign, or Hazardous substances, as defined in 49 CFR 171.8, $5,000,000 intrastate commerce, with a gross vehicle weight rating transported in cargo tanks, portable tanks, or of 10,001 or more pounds). hopper -type vehicles with capacities in excess of commerce, with a gross vehicle weight rating of less 3,500 water gallons; or in bulk Division 1.1, 1.2, and than 10,001 pounds). 1.3 materials, Division 2.3, Hazard Zone A, or Division 6.1, Packing Group I, Hazard Zone A material; in bulk Division 2.1 or 2.2; or highway route controlled quantities of a Class 7 material, as defined In 49 CFR 173.403. (3) For -hire and Private (in interstate or foreign Oil listed in 49 CFR 172.101; hazardous waste, $1,000,000 commerce, in any quantity; or in intrastate commerce, hazardous materials, and hazardous substances in bulk only; with a gross vehicle weight rating of defined in 49 CFR 171.8 and listed in 49 CFR 10,001 or more pounds). 172.101, but not mentioned in (2) above or (4) below. (4) For -hire and Private (In interstate or foreign Any quantity of Division 1.1, 1.2, or 1.3 material; any $5,000,000 commerce, with a gross vehicle weight rating of less quantity of a Division 2.3, Hazard Zone A, or Division than 10,001 pounds). 6.1, Packing Group I, Hazard Zone A material; or highway route controlled quantities of a Class 7 material as defined in 49 CFR 173.403. "The schedule of limits shown does not provide coverage. The limits shown in the schedule are for information purposes only FORM MCS -90 Page 3 of 3 MC1622y (06-21) POLICY NUMBER: ISA H10690481 FORM MCS -90 6 Endorsement Number: 2 OMB No.: 2126-0008 Expiration: 0513112024 USDOT Number: Date Received: Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this form with the Office of Management and Budget. This requirement to collect information as requested on this form does not expire. For questions, please contact the Office of Registration and Safety Information, Registration, Licensing, and Insurance Division. A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0008. Public reporting for this collection of information is estimated to be approximately 2 minutes perresponse, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC -RRA, Washington, D.C. 20590. United States Department of Transportation it Federal Motor Carrier Safety Administration Endorsement for Motor Carrier Policies of Insurance for Public Liability under Sections 29 and 30 of the Motor Carrier Act of 1980 FORM MCS -90 Issued to SC Retail. LLC of Q (Motor Carrier name) (.lfotor Carrier state or province) Dated at Wilmington, DE 19803 on this 11th day of August .20 22. Amending Policy Number: ISA H10690481 Effective Date: 09/01/2022 Name of Insurance Company: ACE American Insurance Company 531C*FiN 1 LiIPIC!'t_ Prat,dent Countersigned by: (awhorL-cd mntpanr, reglre.nvnative) The policy to which this endorsement Is attached provides primary or excess Insurance, as Indicated for the limits shown (check only one): 7 This insurance is primary am/ the company shall not be liableforamounts in excess of $ 5,000,000 for each accident FThis insurance Is excess andthe campanyshall not be liable for amounts in excess of S for each accident in excess ofthe underlying limit of$ for each accident Whenever required by the Federal Motor Carrier Safety Administration (FMCSA), the company agrees to furnish the FMCSA a duplicate of said policy and all its endorsements. The company also agrees, upon telephone request by an authorized representative of the FMCSA, to verify that the policy is in force as of a particular date. The telephone number to call is: 215 - 640 - 4555. Cancellation of this endorsement may be effected by the company or the insured by giving (1) thirty-five (35) days notice In writing to the other party (said 35 days notice to commence from the date the notice is mailed, proof of mailing shall be sufficient proof of notice), and (2) if the insured is subject to the FMCSA's registration requirements under 49 U.S.C. 13901, by providing thirty (30) days notice to the FMCSA (said 30 days notice to commence from the date the notice is received by the FMCSA at its office in Washington, DC). Filings must be transmitted online via the Internet at httpJ/www.fmcsa.dot.izov/urs. (continued on next page) FORM MCS -90 Page 1 of 3 Rev 6/3/2021 MC1622y (06-21) Wolters Kluwer I Uniform Forms FORM MCS -90 OMB No.: 2126-0008 Expiration: 0513112024 DEFINITIONS AS USED IN THIS ENDORSEMENT Accident includes continuous or repeated exposure to conditions or which results in bodily injury, property damage, or environmental damage which the insured neither expected nor intended. Motor Vehicle means a land vehicle, machine, truck, tractor, trailer, or semitrailer propelled or drawn by mechanical power and used on a highway for transporting property, or any combination thereof. Bodily Injury means injury to the body, sickness, or disease to any person, including death resulting from any of these. Property Damage means damage to or loss of use of tangible grope rty. The insurance policy to which this endorsement is attached provides automobile liability insurance and is amended to assure compliance by the insured, within the limits stated herein, as a motor carrier of property, with Sections 29 and 30 of the Motor Carrier Act of 1980 and the rules and regulations of the Federal Motor Carrier Safety Administration (FMCSA). In consideration of the premium stated in the policy to which this endorsement is attached, the insurer (the company) agrees to pay, within the limits of liability described herein, any final judgment recovered against the insured for public liability resulting from negligence in the operation, maintenance or use of motor vehicles subject to the financial responsibility requirements of Sections 29 and 30 of the Motor Carrier Act of 1980 regardless of whether or not each motor vehicle is specifically described in the policy and whether or not such negligence occurs on any route or in any territory authorized to be served by the insured or elsewhere. Such insurance as is afforded, for public liability, does not apply to injury to or death of the insured's employees while engaged in the course of their employment, or property transported by the insured, designated as cargo. It is understood and agreed that no condition, provision, stipulation, or limitation contained In the policy, this endorsement, or any other endorsement thereon, Environmental Restoration means restitution for the loss, damage, or destruction of natural resources arising out of the accidental discharge, dispersal, release or escape into or upon the land, atmosphere, watercourse, or body of water, of any commodity transported by a motor carrier. This shall include the cost of removal and the cost of necessary measures taken to minimize or mitigate damage to human health, the natural environment, fish, shellfish, and wildlife. Public Liability means liability for bodily injury, property damage, and environmental restoration. or violation thereof, shall relieve the company from liability or from the payment of any final judgment, within the limits of liability herein described, irrespective of the financial condition, insolvency or bankruptcy of the insured. However, all terms, conditions, and limitations in the policy to which the endorsement is attached shall remain in full force and effect as binding between the insured and the company. The insured agrees to reimburse the company for any payment made by the company on account of any accident, claim, or suit involving a breach of the terms of the policy, and for any payment that the company would not have been obligated to make under the provisions of the policy except for the agreement contained in this endorsement. It is further understood and agreed that, upon failure of the company to pay any final judgment recovered against the insured as provided herein, the judgment creditor may maintain an action in any court of competent jurisdiction against the company to compel such payment. The limits of the company's liability for the amounts prescribed in this endorsement apply separately to each accident and any payment under the policy because of anyone accident shall not operate to reduce the liability of the company for the payment of final judgments res utting from any other accident_ (continued on next page) FORM MCS -90 Page 2 of 3 MCI 622y (06-21) FORM MCS -90 SCHEDULE OF LIMITS - PUBLIC LIABILITY OMB No.: 2126-0008 Expiration: 0513112024 Type of carriage Commodity transported January 1, 1985 (1) For -hire (in interstate or foreign commerce, with a Property (nonhazardous) $750,000 gross vehicle weight rating of 10,001 or more pounds). (2) For -hire and Private (in interstate, foreign, or Hazardous substances, as defined in 49 CFR 171.8, $5,000,000 intrastate commerce, with a gross vehicle weight rating transported in cargo tanks, portable tanks, or of 10,001 or more pounds). hopper -type vehides with capacities in excess of 3,500 water gallons; or in bulk Division 1.1, 1.2, and 1.3 materials, Division 2.3, Hazard Zone A, or Division 6.1, Packing Group I, Hazard Zone A material, in bulk Division 2.1 or 2.2; or highway route controlled quantities of a Class 7 material, as defined in 49 CFR 173.403. (3) For -hire and Private (in interstate or foreign Oil listed in 49 CFR 172.101; hazardous waste, $1,000,000 commerce, in any quantity; or in intrastate commerce, hazardous materials, and hazardous substances in bulk only; with a gross vehicle weight rating of defined in 49 CFR 171.8 and listed in 49 CFR 10,001 or more pounds). 172.101, but not mentioned in (2) above or (4) below. (4) For -hire and Private (In interstate or foreign Any quantity of Division 1.1, 1.2, or 1.3 material; any $5,000,000 commerce, with a gross vehicle weight rating of less quantity of a Division 2.3, Hazard Zone A, or Division than 10,001 pounds). 6.1, Packing Group I, Hazard Zone A material; or highway route controlled quantities of a Class 7 material as defined in 49 CFR 173.403. `The schedule of limits shown does not provide coverage. The limits shown in the schedule are for information purposes only FORM MCS -90 Page 3 of 3 MC1622y (06-21) 4", POLICY NUMBER: ISA H10690481 Endorsement Number. 1 FORM MCS -90 OMB No.: 2126-0008 Expiration: 05/3112024 USDOT Number: Date Received: Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this form with the Office of Management and Budget. This requirement to coiled information as requested on this form does not expire. For questions, please contact the Office of Registration and Safety Information, Registration, Licensing and Insurance Division. A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0008. Public reporting for this collection ofinformation is estimated to be approximately 2 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC -RRA, Washington, D.C. 20590. y United States Department of Transportation !t Federal Motor Carrier Safety Administration Endorsement for Motor Carrier Policies of Insurance for Public Liability under Sections 29 and 30 of the Motor Carrier Act of 1980 FORM MCS -90 Issued to Southern Counties Oil Co.. a Calffornia limited Partnership of Q (.Vator Carrier twine) (14foror Cartier state or province) Dated at Wilmington, DE 19803 on this 11th day of August .20 22. Amending Policy Number: ISA H10690481 Effective Date: 09101/2022 Name of Insurance Company: ACE American Insurance Company 10HN Li RC�A- -1RreanCattt Countersigned by: (urithori cd contpanv rerresenkrtive) The policy to which this endorsement is attached provides primary or excess Insurance, as indicated for the limits shown (check only one): 1771 This insurance is priman, onei the company shall not be liablefor amounts in excess of S 5,000,000 for each accident EIThis insurance is excess andthe compam• shall not be liablefor amounts in excess of S for each accidem in excess ofthe unclerhing limit of S for each accident Whenever required by the Federal Motor Carrier Safety Administration (FMCSA), the company agrees to furnish the FMCSA a duplicate of said policy and all its endorsements. The company also agrees, upon telephone request by an authorized representative of the FMCSA, to verify that the policy is in force as of a particular date. The telephone number to call is: 215 - 640 - 4555. Cancellation of this endorsement may be effected by the company or the insured by giving (1) thirty-five (35) days notice in writing to the other party (sa id 35 days notice to commence from the date the notice is mailed, proof of mailing shall be sufficient proof of notice), and (2) if the insured is subject to the FMCSA's registration requirements under 49 U.S.C. 13901, by providing thirty (30) days notice to the FMCSA (said 30 days notice to commence from the date the notice is received by the FMCSA at its office in Washington, DC). Filings must be transmitted online via the Internet at http:/lwww.hncsa.dat.kroy/urs. (continued on next page) FORM MCS -90 Page 1 of 3 Rev 6/3/2021 MC1622y (06-21) Wolters Kluwer I Uniform Forms FORM MCS -90 DEFINITIONS AS USED IN THIS ENDORSEMENT Accident includes continuous or repeated exposure to conditions or which results in bodily injury, property damage, or environmental damage which the insured neither expected nor intended. Motor Vehicle means a land vehicle, machine, truck, tractor, trailer, or semitrailer propelled or drawn by mechanical power and used on a highway for transporting property, or any combination thereof. Bodily Injury means injury to the body, sickness, or disease to any person, including death resulting from any of these. Property Damage means damage to or loss of use of tangible property. The insurance policy to which this endorsement is attached provides automobile liability insurance and is amended to assure compliance by the insured, within the limits stated herein, as a motor carrier of property, with Sections 29 and 30 of the Motor Carrier Act of 1980 and the rules and regulations of the Federal Motor Carrier Safety Administration (FMCSA). In consideration of the premium stated in the policy to which this endorsement is attached, the insurer (the company) agrees to pay, within the Hmits of liability described herein, any final judgment recovered against the insured for public liability resulting from negligence in the operation, maintenance or use of motor vehicles subject to the financial responsibility requirements of Sections 29 and 30 of the Motor Carrier Act of 1980 regardless of whether or not each motor vehicle is specifically described in the policy and whether or not such negligence occurs on any route or in any territory authorized to be served by the insured or elsewhere. Such insurance as is afforded, for public liability, does not apply to injury to or death of the insured's employees while engaged in the course of their employment, or property transported by the insured, designated as cargo. It is understood and agreed that no condition, provision, stipulation, or limitation contained in the policy, this endorsement, or any other endorsement thereon, MCI 622y (06-21) OMB No.: 2126-0008 Expiration: 05/31/2024 Environmental Restoration means restitution for the loss, damage, or destruction of natural resources arising out of the accidental discharge, dispersal, release or escape into or upon the land, atmosphere, watercourse, or body of water, of any commodity transported by a motor carrier. This shall include the cost of removal and the cost of necessary measures taken to minimize or mitigate damage to human health, the natural environment, fish, shellfish, and wildlife. Public Liability means liability for bodily injury, property damage, and environmental restoration. or violation thereof, shall relieve the company from liability or from the payment of any final judgment, within the limits of liability herein described, irrespective of the financial condition, insolvency or bankruptcy of the insured. However, all terms, conditions, and limitations in the policy to which the endorsement is attached shall remain in full force and effect as binding between the insured and the company. The insured agrees to reimburse the company for any payment made by the company on account of any accident, claim, or suit involving a breach of the terms of the policy, and for any payment that the company would not have been obligated to make under the provisions of the policy except for the agreement contained in this endorsement. It is further understood and agreed that, upon failure of the company to pay any final judgment recovered against the insured as provided herein, the judgment creditor may maintain an action in any court of competent jurisdiction against the company to compel such payment. The limits of the company's liability for the amounts prescribed in this endorsement apply separately to each accident and any payment under the policy because of anyone accident shall not operate to reduce the liability of the company for the payment of final judgments resulting from any other accident. FORM MCS -90 Page 2 of 3 (continued on next page) FORM MCS -90 OMB No.: 2126-0008 Expiration: 05/31/2024 SCHEDULE OF LIMITS - PUBLIC LIABILITY Type of carriage Commodity transported January 1, 1985 (1) For -hire (in interstate orforeign commerce, with a Property (nonhazardous) $750,000 gross vehicle weight rating of 10,001 or more pounds). hazardous materials, and hazardous substances (2) For -hire and Private (in interstate, foreign, or Hazardous substances, as defined in 49 CFR 171.8, $5,000,000 intrastate commerce, with a gross vehicle weight rating transported in cargo tanks, portable tanks, or of 10,001 or more pounds). hopper -type vehicles with capacities in excess of commerce, with a gross vehicle weight rating of less 3,500 water gallons; or in bulk Division 1.1, 1.2, and than 10,001 pounds). 1.3 materials, Division 2.3, Hazard Zone A, or Division 6.1, Packing Group 1, Hazard Zone A material; in bulk Division 2.1 or 2.2; or highway route controlled quantities of a Class 7 material, as defined In 49 CFR 173.403. (3) For -hire and Private (in interstate or foreign Oil listed in 49 CFR 172.101; hazardous waste, $1,000,000 commerce, in any quantity; or in intrastate commerce, hazardous materials, and hazardous substances in bulk only; with a gross vehicle weight rating of defined in 49 CFR 171.8 and listed in 49 CFR 10,001 or more pounds). 172.101. but not mentioned in (2) above or (4) below. (4) For -hire and Private (In interstate or foreign Any quantity of Division 1.1, 1.2, or 1.3 material; any $5,000,000 commerce, with a gross vehicle weight rating of less quantity of a Division 2.3, Hazard Zone A, or Division than 10,001 pounds). 6.1, Packing Group I, Hazard Zone A material; or highway route controlled quantities of a Class 7 material as defined In 49 CFR 173.403. *The schedule of limits shown does not provide coverage. The limits shown in the schedule are for information purposes only FORM MCS -90 Page 3 of 3 MC1622y (06-21) POLICY NUMBER: ISA H10690481 FORM MCS -90 8 Endorsement Number. 4 OMB No.: 2126-0008 Expiration: 05131/2024 USDOT Number: Date Received: Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this form with the Office of Management and Budget. This requirement to collect information as requested on this form does not expire. For questions, please contact the Office of Registration and Safety Information, Registration, Licensing, and Insurance Division. A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0003. Public reporting for this collection of information is estimated to be approximately 2 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC -RRA, Washington, D.C. 20590. United States Department of Transportation Federal Motor Carrier Safety Administration Endorsement for Motor Carrier Policies of Insurance for Public Liability under Sections 29 and 30 of the Motor Carrier Act of 1980 FORM MCS -90 Issued to Southern Counties Oil Co of (.Motor Carrier name) (.1fotor Carrier state or proviwe) Dated at Wilmington, DE 19803 on this 11th day of August .20 22. Amending Policy Number: ISA H10690481 Effective Date: 09/01/2022 Name of Insurance Company: ACE American Insurance Company .ltlAU � t..tIFtICl1, P*eanBan=1 Countersigned by: (authorLedcomp nvrcrre.wnkttive) The policy to which this endorsement Is attached provides primary or excess insurance, as indicated for the limits shown (check only one): This insurance is primary aml the rampant• shall not be hablefor amorous in excess of $ 5,000,000 for each acezient aThis insurance is excess andthe company shall not be liablefor amounts in ercess of 5 for each accidem in excess of the utulerlring limit of s for each acciclew Whenever required by the Federal Motor Carrier Safety Administration (FMCSA), the company agrees to furnish the FMCSA a duplicate of said policy and all its endorsements. The company also agrees, upon telephone request by an authorized representative of the FMCSA, to verify that the policy is in force as of a particular date. The telephone number to call is: 215 - 640 - 4555. Cancellation of this endorsement may be effected by the company or the insured by giving (1) thirty-five (35) days notice In writing to the other party (said 35 days notice to commence from the date the notice is mailed, proof of mailing shall be sufficient proof of notice), and (2) if the insured is subject to the FMCSA's registration requirements under 49 U.S.C. 13901, by providing thirty (30) days notice to the FMCSA (said 30 days notice to commence from the date the notice is received by the FMCSA at its office in Washington, DC). Filings must be transmitted online via the Internet at htto://www.fmcsa.dot.izov/urs. (continued on next page) FORM MCS -90 Page 1 of 3 Rev 6/3/2021 MC1622y (06-21) Wolters Kluwer ( Uniform Forms FORM MCS -90 DEFINITIONS AS USED IN THIS ENDORSEMENT Accident includes continuous or repeated exposure to conditions or which results in bodily injury, property damage, or environmental damage which the insured neither expected nor intended. Motor Vehicle means a land vehicle, machine, truck, tractor, trailer, or semitrailer propelled or drawn by mechanical power and used on a highway for transporting property, or any combination thereof. Bodily injury means injury to the body, sickness, or disease to any person, including death resulting from any of these. Property Damage means damage to or loss of use of tangible property. The insurance policy to which this endorsement is attached provides automobile liability insurance and is amended to assure compliance by the insured, within the limits stated herein, as a motor carrier of property, with Sections 29 and 30 of the Motor Carrier Act of 1980 and the rules and regulations of the Federal Motor Carrier Safety Administration (FMCSA). In consideration of the premium stated in the policy to which this endorsement is attached, the insurer (the company) agrees to pay, within the limits of liability described herein, any final judgment recovered against the insured for public liability resulting from negligence in the operation, maintenance or use of motor vehicles subject to the financial responsibility requirements of Sections 29 and 30 of the Motor Carrier Act of 1980 regardless of whether or not each motor vehicle is specifically described in the policy and whether or not such negligence occurs on any route or in any territory authorized to be served by the insured or elsewhere. Such insurance as is afforded, for public liability, does not apply to injury to or death of the insured's employees while engaged in the course of their employment, or property transported by the insured, designated as cargo. It is understood and agreed that no condition, provision, stipulation, or limitation contained in the policy, this endorsement, or any other endorsement thereon, OMB No.: 2126-0008 Expiration: 05/3112024 Environmental Restoration means restitution for the loss, damage, or destruction of natural resources arising out of the accidental discharge, dispersal, release or escape into or upon the land, atmosphere, watercourse, or body of water, of any commodity transported by a motor carrier. This shall include the cost of removal and the cost of necessary measures taken to minimize or mitigate damage to human health, the natural environment, fish, shellfish, and wildlife. Public Liability means liability for bodily injury, property damage, and environmental restoration. or violation thereof, shall relieve the company from liability or from the payment of any final judgment, within the limits of liability herein described, irrespective of the financial condition, insolvency or bankruptcy of the insured. However, all terms, conditions, and limitations in the policy to which the endorsement is attached shall remain in full force and effect as binding between the insured and the company. The insured agrees to reimburse the company for any payment made by the company on account of arty accident, claim, or suit involving a breach of the terms of the policy, and for any payment that the company would not have been obligated to make under the provisions of the policy except for the agreement contained in this endorsement. It is further understood and agreed that, upon failure of the company to pay any final judgment recovered against the insured as provided herein, the judgment creditor may maintain an action in any court of competent jurisdiction against the company to compel such payment. The limits of the company's liability for the amounts prescribed in this endorsement apply separately to each accident and any payment under the policy because of anyone accident shall not operate to reduce the liability of the company for the payment of final judgments resulting from any other accident_ (continued on next page) FORM MCS -90 Page 2 of 3 MC1622y (06-21) FORM MCS -90 SCHEDULE OF LIMITS - PUBLIC LIABILITY OMB No.: 2126-0008 Expiration: 0 5131 120 24 Type of carriage Commodity transported January 1, 1985 (1) For -hire (in interstate or foreign commerce, with a Property (nonhazardous) $750,000 gross vehicle weight rating of 10,001 or more pounds). (2) For -hire and Private (in interstate, foreign, or Hazardous substances, as defined in 49 CFR 171.8, $5,000,000 intrastate commerce, with a gross vehicle weight rating transported in cargo tanks, portable tanks, or of 10,001 or more pounds). hopper -type vehicles with capacities in excess of 3,500 water gallons; or in bulk Division 1.1, 1.2, and 1.3 materials, Division 2.3, Hazard Zone A, or Division 6.1, Packing Group I, Hazard Zone A material; in bulk Division 2.1 or 2.2; or highway route controlled quantities of a Class 7 material, as defined In 49 CFR 173.403. (3) For -hire and Private (in interstate or foreign Oil listed in 49 CFR 172.101; hazardous waste, $1,000,000 commerce, in any quantity; or in intrastate commerce, hazardous materials, and hazardous substances in bulk only; with a gross vehicle weight rating of defined in 49 CFR 171.8 and listed in 49 CFR 10,001 or more pounds). 172.101, but not mentioned in (2) above or (4) below. (4) For -hire and Private (In interstate or foreign Any quantity of Division 1.1, 1.2, or 1.3 material; any $5,000,000 commerce, with a gross vehicle weight rating of less quantity of a Division 2.3, Hazard Zone A, or Division than 10,001 pounds). 6.1, Packing Group I, Hazard Zone A material; or highway route controlled quantities of a Class 7 material as defined In 49 CFR 173.403. `The schedule of limits shown does not provide coverage. The limits shown in the schedule are for information purposes only FORM MCS -90 Page 3 of 3 MC1622y (06-21) Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number PILOT TRAVEL CENTERS LLC P.O. BOX 10146 Policy Number KNOXVILLE, TN 37939 Symbol: WLR Number: C5 0 67 0 0 4 1 Policy Period Effective Date of Endorsement 09/01/2022 TO 09/01/2023 09/01/2.022 Issued By (Name of Insurance Company) ACE AFRICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. ALTERNATE EMPLOYER ENDORSEMBff This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance afforded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule. Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benefits required by the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them. The insurance afforded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not file evidence of this insurance on behalf of the alternate employer with any government agency. We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement. Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer. The policy may be canceled according to its terms without sending notice to the alternate employer. Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six. Schedule 1. Alternate Employer Address IF ANY DOES NOT APPLY TO ANY EMPLOYEE LEASE CONTRACT/ARRANGEMENT 2. State of Special or Temporary Employment ANY STATE SHOWN IN ITEM 3A OF THE INFORMATION PAGE 3• Contract or Project For the state of HI, MI, OK refer to state specific endorsements. This endorsement is not applicable in AK. Authorized Agent WC 00 03 01A (Ed. 2-89) Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number PILOT TRAVEL CENTERS LLC P.O. BOX 10146 Policy Number KNOXVILLE, TN 37939 Symbol: WLR Number: 050670041 Policy Period Effective Date of Endorsement 09/01/2022 TO 09/01/2023 09/01/2022 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the Information is to be completed only When this endorsement is Issued subsequent to the preparation of the policy, NOTICE TO OTHERS ENDORSEMENT— SCHEDULE NOTICE BY INSURED'S REPRESENTATIVE A. If we cancel this Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment of premium, we will endeavor, as set out in this endorsement, to send written notice of cancellation, to the persons or organizations listed in the schedule that you or your representative create or maintain (the "Schedule") by allowing your representative to send such notice to such persons or organizations. This notice will be in addition to our notice to you or the first Named Insured, and any other party whom we are required to notify by statute and in accordance with the cancellation provisions of the Policy. B. The notice referenced in this endorsement as provided by your representative is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage.' We have no legal obligation of any kind to any such person(s) or organization(s). The failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule will impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. C. We are not responsible for verifying any information in any Schedule, nor are we responsible for any incorrect information that you or your representative may use. D. We will only be responsible for sending such notice to your representative, and your representative will in turn send the notice to the persons or organizations listed in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. E. This endorsement does not apply in the event that you cancel the Policy. All other terms and conditions of this Policy remain unchanged. Authorized Representative WC 99 03 69 (01/11) Page 1 of 1 Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number PILOT TRAVEL CENTERS LLC P.O. BOX 10146 Policy Number KNOXVILLE, TN 37939 Symbol: WLR Number: C50670041 Policy Period Effective Date of Endorsement 09/01/2022 TO 09/01/2023 09/01/2022 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, UT, TX, refer to state specific endorsements. This endorsement is not applicable in KY. NH, and NJ. The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications. For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program. Authorized Representative WC 00 03 13 (11/05) Ptd. U.S.A. Copyright 1982-83, National Council on Compensation Workers' Compensation and Employers' Liability Policy Named Insured EndorsementNumber PILOT TRAVELS CENTER LLC P.O. BOX 10146 Policy Number KNOXVILLE, TN 37939 SymboI:WLR Number: 050670041 Policy Period Effective Date of Endorsement 09/01/2022 TO 09/01/2023 09/01/2022 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Texas is shown in item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the schedule. Schedule Specific Waiver Name of person or organization: ( X ) Blanket W aiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: ALL TEXAS OPERATIONS 3. Premium: The premium charge for this endorsement shall be 2.0 percent of the premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Advance Premium: $0 9 � Authorized Representative WC 42 03 04B (06/14) © Copyright 2014 National Council on Compensation Insurance, Inc. All Rights Reserved. WorkeFs' Compensation and Employers' Liability Policy Named Insured Endorsement Number PILOT TRAVEL CENTERS LLC P.O. BOX 10146 Policy Number KNOXVILiE, TN 37939 Symbol: WLR Number: C50670041 Policy Period Effective Date of Endorsement 09/01/2022 TO 09/01/2023 09/01/2022 Issued By (Name of Insurance Companv) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. UTAH WAIVER OF SUBROGATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Utah is shown in Item 3.A. of the Information Page. 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the schedule. Our waiver of rights does not release your employees' rights against third parties and does not release our authority as trustee of claims against third parties. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. Authorized Agent WC 43 03 05 (10/00) Ptd. in U.S.A. 1 Workers' Compensation and Employers' Liability Policy PILOT TRAVEL CENTERS LLC P.O. BOX 10146 KNOXVILLE, TN 37939 um Number: C50670041 09/01/2022 TO 09/01/2023 ( 09/01/2022 ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. ( ) Specific Waiver Name of person or organization: (X) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: ALL OPERATIONS CONDUCTED BY AN INSURED PURSUANT TO SUCH WRITTEN CONTRACT 3. Premium: The premium charge for this endorsement shall be 1.0 percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: $0 Authorized Representative WC 90 03 75 (05118)