DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY …

1 No other option is available with this insurerNo changes madeYes andGL policy (including endorsements) does not cover the additional insured for claims involving injury to employees of the named insured orsubcontractors (not workers' compensation) other option is available with this insurerNo changes madeYes and" insured contract" exception to the employers LIABILITY exclusion is removed or modified (GL policy) other option is available with this insurerNo changes madeYes andBlanket contractual LIABILITY located in the " insured contract" definition (Section V, Number 9, Item f. in the ISO CGL policy) is removed other option is available with this insurerNo andYesAdditional insured will receive advance notice if insurer cancels (GL policy) other option is available with this insurerNo andYesAccording to the terms of this GL policy, the additional insured has primary and noncontributory :#:CG 20 38CG 20 37CG 20 33CG 20 32CG 20 26 Other:CG 20 10 additional insured endorsement (GL policy)D.

2 [see attached endorsement][see attached declarations / endorsement]Designated workClassificationsBuilding height:Type of construction:Location:Specific operations excluded or restricted (GL policy) / ISO modifiedGeneral LIABILITY (GL) policy line or free trade zoneAdmitted / to ACORD 25 ACORD 855 NY (2014/05) 2014 ACORD CORPORATION. All rights ACORD name and logo are registered marks of ACORDREVISION NUMBER: CERTIFICATE NUMBER:ADDENDUM INFORMATIONEFFECTIVE DATENAMED insured (S)POLICY NUMBERNAIC CODECARRIERAGENCYNEW YORK CONSTRUCTIONAGENCY CUSTOMER ID:THIS ADDENDUM SUMMARIZES SOME OF THE POLICY PROVISIONS IN THE REFERENCED INSURANCE POLICIES AND IS ISSUED AS AMATTER OF INFORMATION ONLY; IT CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. ALL TERMS, EXCLUSIONS AND CONDITIONSIN THE ACTUAL POLICY SHOULD BE CONSULTED FOR A MORE DETAILED ANALYSIS OF COVERAGE, AS THIS ADDENDUM DOES NOTAFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE OF LIABILITY INSURANCE ADDENDUMDATE (MM/DD/ yyyy )Page 2 of 2 DATE (MM/DD/ yyyy )AUTHORIZED REPRESENTATIVE SIGNATUREno other option is available with this insurerNo andYes, by endorsementYes, by specific policy provisionExcess / umbrella policy is primary and non-contributory for additional other option is available with this insurerNo changes madeYes andProperty damage to work performed by subcontractors (exception to the "damage to your work" exclusion in the ISO CGL policy) is excludedor other option is available with this insurerNo changes madeYes andInsured vs.

3 insured suits (cross LIABILITY in the ISO CGL policy) are excluded or restricted (other than named insured vs. named insured ) other option is available with this insurerNo changes madeYes andEarth movement, excavation or explosion / collapse / underground property damage is excluded or restricted (GL policy) INFORMATION (continued)AGENCY CUSTOMER ID:ACORD 855 NY (2014/05)ACORD 855 NY (2014/05) - New York Construction CERTIFICATE of LIABILITY Insurance AddendumACORD 855 NY, New York Construction CERTIFICATE of LIABILITY Insurance Addendum, may be used to supplement ACORD 25, CERTIFICATE of LiabilityInsurance, in the state of New York, to provide more information about the policy's coverage when required by the CERTIFICATE holder. It is notintended to answer specific coverage questions, but merely to indicate areas of coverage where the solicitation of more details may be expedient( , examination of the actual policy forms).

4 Form Page 1 Section NameField NameDescriptionIDENTIFICATION SECTIONA gency Customer IDEnter identifier: The customer's identification number assigned by the producer ( , agency orbrokerage).IDENTIFICATION SECTIONDateEnter date: The date on which the form is completed. (MM/DD/ yyyy )IDENTIFICATION SECTIONA gencyEnter text: The full name of the producer / SECTIONP olicy NumberEnter identifier: The identifier assigned by the insurer to the policy, or submission, beingreferenced exactly as it appears on the policy, including prefix and suffix symbols. If required forself-insurance, the self- insured license or contract SECTIONE ffective DateEnter date: The effective date of the policy. The date that the terms and conditions of the policycommence. (MM/DD/ yyyy )IDENTIFICATION SECTIONN amed insured (s)Enter text: The named insured (s) as it / they will appear on the policy declarations SECTIONC arrierEnter text: The insurer's full legal company name(s) as found in the file copy of the policy.

5 Usethe actual name of the company within the group to which the policy has been issued. This isnot the insurer's group name or trade SECTIONNAIC CodeEnter code: The identification code assigned to the insurer by the INFORMATIONC ertificate NumberEnter identifier: The producer assigned number for the INFORMATIONR evision NumberEnter number: The producer assigned revision number for the INFORMATIONA. Insurer - Admitted /Authorized (check box)Check the box (if applicable): Indicates that this is a group of insurers that is admitted orauthorized in the state of New 855 NY (2014/05) released 04-29-2014 Page 1 of 11 ADDENDUM INFORMATIONE xcess Line or Free TradeZone (check box)Check the box (if applicable): Indicates that this a group of insurers (known as surplus lines inother states) that are not authorized in the state of New York, but are included on the stampinglist of approved unauthorized insurers maintained by the Excess Line Association of New coverage implications are that these insurers are exempt from filing their rate and formswith the Department of Financial Services.

6 Significant variance in the language of forms andendorsements should be expected with these policies. In addition, policies written byunauthorized insurers are not afforded by the insolvency protection of the Property / CasualtyInsurance Security Trade Zone refers to regulatory exemptions for ''special risks" that may be written byauthorized insurers having a special FTZ license. FTZ provisions allow these insurers anexemption from rate and form filing requirements so they may effectively compete with excessline insurers in the "special risks" market. They are authorized insurers, so the Property /Casualty Insurance Security Fund is applicable to policies written by INFORMATIONB. General LIABILITY (GL)Policy Form - ISO / ISOM odified (check box)Check the box (if applicable): Indicates that the Insurance Service Office, Inc develops standardinsurance forms for use by its member insurers.

7 The ISO CG 00 01 Commercial GeneralLiability Coverage Form is often used to insure construction risks. With access to the list offorms on the declarations, the extent of coverage can be determined from these standard forms,which are generally available from policyholders and industry representatives. Another benefitin using standard forms is that the language has undergone years of judicial interpretation,which gives the determination of coverage more certainty. However, it is not uncommon forinsurers to modify the basic ISO CGL form with language preferred by the INFORMATIONO ther (check box)Check the box (if applicable): Indicates that insurers have filed proprietary forms of their own,which makes comparisons with standard forms more difficult and language interpretation 855 NY (2014/05) released 04-29-2014 Page 2 of 11 ADDENDUM INFORMATIONC.

8 Specific OperationsExcluded or Restricted (GLPolicy) - Location (checkbox)Check the box (if applicable): Indicates that specific operations are excluded or restricted on theGL policy. While the unendorsed ISO CG 00 01 Commercial General LIABILITY Coverage Formdoes not limit its coverage to any specific location, three standard ISO endorsements exist thatcan be used to restrict coverage by location:CG 21 00 Exclusion - All Hazards In Connection With Designated PremisesThis endorsement allows the insurer to describe a location of premises where coverage isexcluded. For example it may exclude all work conducted in New York 21 34 Exclusion - Designated WorkThis endorsement excludes the completed operations LIABILITY exposure for work shown in theschedule, which could be a project or designated work at a specific location. More likely, itwould exclude work of a specific type and/or during a specific time period.

9 Ongoing operationsremain 21 53 Exclusion - Designated Ongoing OperationsThis endorsement excludes the ongoing operations LIABILITY exposure of a specific type. Theexcluded operation also can be specific to a location. Completed operations remain endorsements may restrict coverage to a specific location eliminating all INFORMATIONL ocationEnter text: The specific description of the location being excluded if applicable or indicate if thelocation is for a project or designated work at a specific INFORMATIONType of Construction (checkbox)Check the box (if applicable): Indicates that the specific operations are excluded or restricted bytype of construction on a GL policy. However, there is no standard endorsement for thispurpose. While the unendorsed ISO CG 00 01 Commercial General LIABILITY Coverage Formdoes not limit its coverage to any specific type of construction, nonstandard endorsements maydesignate residential, single-family, apartment, condominium, townhome, track home,habitational or commercial construction as restricted or INFORMATIONType of ConstructionEnter text: The description of the building's occupancy.

10 As used here, indicates the type ofconstruction and indicates the location is occupied as either a residential, single family,apartment, condominium, townhouse, track home, habitational or commercial INFORMATIONB uilding Height (check box)Check the box (if applicable): Indicates that the specific operations are excluded or restricted bytype of building height on a GL policy. However, there is no standard endorsement for thispurpose. While the unendorsed ISO CG 00 01 Commercial General LIABILITY Coverage Formdoes not limit its coverage to any specific building height, nonstandard endorsements maydesignate the number of floors / stories that are either covered or INFORMATIONB uilding HeightEnter number: The number of stories or floors for this building not including any INFORMATIONC lassifications (check box)Check the box (if applicable): Indicates that the specific operations are excluded or restricted bytype of classifications on a GL policy.