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HomeMy WebLinkAboutMichels Pipeline Construction 2019-01-31COU No. l g' I ct i l 'l January 31, 2019 Access Agreement between City of Ukiah And Michels Corporation This Access Agreement (the "Agreement") is entered on �,,,.� tv., 2019 ("Effective Date"), in Ukiah, California between the City of Ukiah ("City), a general law municipal corporation, and Michels Pipeline Construction, a corporation duly incorporated under and in compliance with the laws of the State of Wisconsin and registered to conduct business in the State of California ("Michels"). Collectively, City and Michels may be referred to herein as the "Parties." RECITALS. 1. The City owns property in the City of Ukiah known as Mendocino County Assessor's Parcel Numbers ("APNs")180-110-12-00, 180-120-04-00, 184-080-01-00, 180-110-01-40 ("the Property"). 2. Michels seeks the right of ingress and egress across the Property in order to better or more easily perform work or services at a nearby job site, said work consisting of l�4\\� � M14:'iz,n c•.rt C. c. ("the Work"). 3. The purpose of this Agreement is to allow Michels access to the Property for the purpose of performing the Work on the adjacent job site. 4. This Agreement allows for the Michels to enter the Property as reasonably necessary to perform the Work, subject to the terms and conditions of this Agreement. AGREEMENT In consideration of the above -recited facts and the terms and conditions as further stated herein, the parties agree as follows: 1. Right of Entry. During the Term of this Agreement, City hereby grants Michels, as may be reasonably necessary, a right of access and use to enter the Property in order to perform the Work on the adjacent job site. In 1 exercising this right of entry, Michels shall not unreasonably interfere with City's use of the Property or cause any damage to the Property. 2. Term. The term of this Agreement begins on the Effective Date and continues until 3-ul 1s4 , 2019, unless earlier terminated as provided in paragraph 10, below. 3. Work to be Performed. The Parties acknowledge and agree that Michels is performing the Work for its benefit and for the benefit of PG&E. The Work does not benefit the City and the City is providing Michels with access to the Property solely as an accommodation to Michels and PG&E. 4. Applicable Law and Regulations. In exercising its rights under this Agreement, the Michels will comply with all applicable laws, statutes, regulations, ordinances, or directives of whatsoever nature with respect to its access to and use of the Property, including, without limitation, all health, safety, and environmental laws, directives, ordinances, regulations, or statutes applicable to such work. 5. Restoration. Michaels shall use its best efforts to avoid interfering with City's use of the Property. Upon completion of the Work, tMichels shall immediately repair and restore all affected areas of the Property to its original condition existing before commencement of Michels having access to the Property. 6. Indemnification. Michels shall indemnify, defend and hold City harmless for, and from, any and all claims, demands, liabilities, costs, damages, and/or expenses, however characterized, arising out of andfor in connection with the Michels's (including without limitations its employees, agents, subcontractors, assigns, transferees, successors, or otherwise) access to or use of the Property and/or the restoration of the Property pursuant to this Agreement, whether such claims, demands, liabilities, costs, damages, and/or expenses are caused by Michels, its employees, agents, subcontractors, assigns, transferees, successors, or otherwise, excepting only that portion of such injury or harm to the extent the same is caused by City's active negligence. Michels shall indemnify and defend City, including, but not limited to, payment of all attorney's fees, costs, damages, and/or expenses incurred by City, and/or such awards against it, associated with or founded upon the aforementioned claims, demands, liabilities, costs, damages, and/or expenses. At all times during the Term of this Agreement, Michels shall maintain and shall provide proof of comprehensive general or commercial liability insurance of at least two million dollars ($2,000,000.00), and provide City with a policy declaration, naming City as additionally insured. Michels shall provide City with written notice of any cancellation of coverage and shall renew insurance certificates as they expire. 7. Entire Understanding. This Agreement sets forth the entire understanding between the City and Michels with respect to the subject matter of this Access Agreement and supersedes all prior negotiations and dealings pertaining to this Agreement. 2 8. Modification. No change in, addition to, or waiver of any of the provisions of this Agreement shall be binding upon either party unless it is established in writing and signed by each party. 9. Termination. With not less than ten (10) days' notice, this Agreement may be terminated by the City or Michels. However such termination will not release Michels from its obligations under Sections 4-6 of this Agreement or any other obligation under this Agreement that arose prior to the termination of the Agreement. 10. Successors and Assigns. This Agreement is binding upon and inures to the benefit of the Parties' successors, transferees, and assigns. 11. Notice. The person authorized to give and receive notices and information on behalf of each party and the address and email number for that person is set forth below. A decision communicated by the authorized representative of each party shall constitute the decision of the party, unless the other party has received prior notice, as provided herein, that the authorized representative's decision is not the decision of the party. Whenever notice or other communication is permitted or required by this Agreement, it shall be deemed given when personally delivered or when received, if delivered by ovemight courier or email, with acknowledgment of receipt of the email, or 48 hours after it is deposited in the United States Mail with proper first class postage affixed thereto and addressed as follows: City of Ukiah Sage Sangiacomo, City Manager Ukiah Civic Center 300 Seminary Ave. Ukiah, CA. 95482 Email: asangiacomonacityofukiah.com Michels Corporation Tyler Freeman, Assistant Project Manager 9245 Laguna Springs Dr. Suite 320 Elk Grove, CA 95758 Ukiah, CA 95482 Email: tfreemannamichels.us 12. Access Agreement. Subject to the terms and conditions stated herein, including payment, this signed Access Agreement is effective as of the Effective Date By executing this Agreement, the following persons represent they maintain actual authority to act, including the act of executing this Agreement and for the matters set 3 forth herein, on behalf of the entity for whom said persons execute this Agreement. CITY OF UKIAH Sage9dngiaco Date City Manage , City of Ukiah Michels Corporation 4 Date Page 1 of 1 � CERTIFICATE OF LIABILITY INSURANCE A�oRoDATE (MMIDDM'W) 01/28/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Willis Towers Watson Midwest, Inc. fka Willis of Minnesota, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA CONTACT NAME: PHONE 1-877-945-7378 FAX 1-888-467-2378 (A/C. No. EMI: (A/C, No): E-MAIL ADDRESS: certificates@willis.com INSURER(S) AFFORDING COVERAGE NAICN INSURERA: Greenwich Insurance Company 22322 INSURED Michela Pipeline, a Division of Michels Corporation 9245 Laguna Springs Dr., Suite 320 Elk Grove, CA 95758 USA INSURERB: XL Insurance America Inc 24554 INSURERC: XL Specialty Insurance Company 37885 INSURER D : $ 3,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE NUMBER: W9989656 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR W POLICY NUMBER POLICY EFF (MM/Y /DDYYY) POLICY EXPVD IMM/DD/YYWI LIMITS A X COMMERCIAL GENERAL LIABILITY Y CGD740955302 02/01/2019 02/01/2020 EACH OCCURRENCE $ 3,000,000 CLAIMS -MADE X OCCUR D DAMAGE TO (a occurrence) PREMISES (Ea occunence) $ 1,000,000 MED EXP (Any one person) $ PERSONAL&ADV INJURY $ 3,000,000 GEN'LAGGREGATE POLICY OTHER: X LIMIT APPLIESPER: 78. -LOC GENERAL AGGREGATE $ 6,000,000 PRODUCTS-COMP/OPAGG $ 6,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY CAD740955402 02/01/2019 02/01/2020 COMBINED SINGLE LIMIT (Ea accident) $ 3,000,000 BODILY INJURY (Per person) $ BODILYINJURY(Peraccident) $ PROPERTY DAMAGE (Per accident) $ $ B — )( UMBRELLA LIAB EXCESSLIAB X OCCUR CLAIMS -MADE US00077661LI19A 02/01/2019 02/01/2020 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED7 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N No N/A CWD740955102 02/01/2019 02/01/2020 X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000 ,000 C Workers Compensation - WI and Employers Liability Work Comp: Per Statute CWR740955202 02/01/2019 02/01/2020 EL EA Accident EL Disease - EA Empl EL Disease - Limit $1,000,000 $1,000,000 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: ID -95-06, D-982, 74021521; APN: 180-110-12-00, 180-120-04-00, 184-080-01-00, 180-110-01-40. City of Ukiah is an Additional Insureds with respect to the General Liability coverage and the work performed by the Named Insured when required by written contract, agreement or permit executed prior to loss. CERTIFICATE HOLDER CANCELLATION City of Ukiah 300 Seminary Ave. Ukiah, CA 95482 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 174- y//� %- l ��� ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID 17956383 BATCH: 1044178 ENDORSEMENT # This endorsement, effective 12:01 a.m., February 1, 2019, forms a part of Policy No. CGD740955302 issued to M10, INC. by Greenwich Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. [XI 405 0910 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission. ENDORSEMENT # This endorsement, effective 12:01 a.m., February 1, 2019, forms a part of Policy No.CAD740955402 issued to M10, INC. by Greenwich Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. 'XI 405 0910 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 57 (Ed. 12/10) ENDORSEMENT # This endorsement, effective 12:01 a.m., February 1, 2019 forms a part of Policy No. CWD740955102 issued to M10, INC. by XL Specialty Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT This endorsement modifies insurance provided under the following: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. 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 February 1, 2019 Policy No. CWD7409551-02 Endorsement No. Insured M10, INC. Premium 5�, - �Z Insurance Company Countersigned by XL Specialty Insurance Company WC 99 06 57 Ed. 12/10 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 57 (Ed. 12/10) ENDORSEMENT # This endorsement, effective 12:01 a.m., February 1, 2019 forms a part of Policy No. CWR7409552-02 issued to M10, INC. by XL Specialty Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT This endorsement modifies insurance provided under the following: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. 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 February 1, 2019 Policy No. CWR7409552-02 Endorsement No. Insured M10, INC. Premium Insurance Company Countersigned by XL Specialty Insurance Company WC 99 06 57 Ed. 12/10 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission. Page 1 of 1 AC RD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 01/28/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Willis Towers Watson Midwest, Inc. fka Willis of Minnesota, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA CONTACT NAME: PHONE 1-877-945-7378 FAX 1-888-467-2378 UVC. No. Ertl: (AIC, No): p DRESS: certificates@willis.com INSURER(S)AFFORDINGCOVERAGE NAIC# INSURER A: Greenwich Insurance Company 22322 INSURED Michels Pipeline, a Division of Michels Corporation 9245 Laguna Springs Dr., Suite 320 Elk Grove, CA 95758 INSURER B: National Fire & Marine Insurance Company 20079 INSURER C• XL Specialty Insurance Company 37885 INSURER D: $ 1,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE NUMBER: W9989657 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD LI POCYNUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y CGD740955301 02/01/2018 02/01/2019 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE POLICY OTHER: X LIMIT APPLIES JE C PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY CAD740955401 02/01/2018 02/01/2019 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIAB EXCESSLIAB X — OCCUR CLAIMS -MADE 42-XSF-100139-05 02/01/2018 02/01/2019 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICEJMEMB ANYPROPRIETOR/PARTNERJEXECUTIVEE OFFICER/MEMBEREXCLUDED7 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/N No N/A CWD740955101 02/01/2018 02/01/2019 X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 C Workers Compensation - WI and Employers Liability Work Comp: Per Statute CWR740955201 02/01/2018 02/01/2019 EL EA Accident EL Disease - EA Empl EL Disease - Limit $1,000,000 $1,000,000 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: ID -95-06, 0-982, 79021521; APN: 180-110-12-00, 180-120-04-00, 184-080-01-00, 180-110-01-40. City of Ukiah is an Additional Insureds with respect to the General Liability coverage and the work performed by the Named Insured when required by written contract, agreement or permit executed prior to loss. CERTIFICATE HOLDER CANCELLATION City of Ukiah 300 Seminary Ave. Ukiah, CA 95482 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID 17956383 BATCH: 1049178 ENDORSEMENT # This endorsement, effective 12:01 a.m., February 1, 2018, forms a part of Policy No. CGD740955301 issued to M10, INC. by Greenwich Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. IX! 405 0910 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission. ENDORSEMENT # This endorsement, effective 12:01 a.m., February 1, 2018, forms a part of Policy No.CAD740955401 issued to M10, INC. by Greenwich Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. IX! 405 0910 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 57 ENDORSEMENT # (Ed. 12/10) This endorsement, effective 12:01 a.m., February 1, 2018 forms a part of Policy No. CWD740955101 issued to M10, INC. by XL Specialty Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT This endorsement modifies insurance provided under the following: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. 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 February 1, 2018 Policy No. CWD740955101 Endorsement No. Insured M10, INC. Premium Insurance Company Countersigned by XL Specialty Insurance Company WC 99 06 57 Ed. 12/10 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 57 (Ed. 12/10) ENDORSEMENT # This endorsement, effective 12:01 a.m., February 1, 2018 forms a part of Policy No. CWR740955201 issued to M10, INC. by XL Specialty Insurance Company. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION NOTIFICATION TO OTHERS ENDORSEMENT This endorsement modifies insurance provided under the following: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY In the event coverage is cancelled for any statutorily permitted reason, other than nonpayment of premium, advanced written notice will be mailed or delivered to person(s) or entity(ies) according to the notification schedule shown below: Name of Person(s) or Entity(ies) Mailing Address: Number of Days Advanced Notice of Cancellation: As per schedule on file with company 30 All other terms and conditions of the Policy remain unchanged. 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 February 1, 2018 Policy No. CWR740955201 Endorsement No. Insured M10, INC. Premium Insurance Company Countersigned by XL Specialty Insurance Company WC 99 06 57 Ed. 12/10 © 2010 X.L. America, Inc. All Rights Reserved. May not be copied without permission.