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Insurance Certificates 2024/25 Lozano's Painting, Inc - MISSING ALL ENDORSEMENTSACORD CERTIFICATE OF LIABILITY INSURANCE DATE 07-01-2024 () 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 Berkshire Hathaway Direct Insurance Company 1314 Douglas Street Suite 1400 Omaha, NE 68102 CONTACT NAME: PHONE 1-800-507-4495 FAX: 866-715-2764 (A/c, No, Ext): (JC, No): E-MAIL ADDRESS: service@threeinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Berkshire Hathaway Direct Insurance Company 10391 INSURED Lozano's Painting Inc. 33881 Pueblo Trl # A Cathedral City, CA 92234-4555 INSURER B : CP140209420P2 024 INSURER C : 06/14/2025 INSURER D : $ 1,000,000 INSURER E : $ 100,000 INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUB R WVD POLICY NUMBER POLICY EFF (MM/DD/Y YYY) POLICY EXP (MM/DD/YYYY ) LIMITS A X COMMERCIAL GENERAL LIABILITY CP140209420P2 024 06/14/2024 06/14/2025 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGGGRREEGATE $ 3,000,000 X POLICY JECT LOC PRODUCTS - COMP/OP AGG $ SEE GENERAL AGGREGATE OTHER: $ A AUTOMOBILE LIABILITY CP140209420 P2024 06/14/2024 06/14/2025 COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED AUTOS ONLY SCHEDULED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X HIRED AUTOS ONLY X NON -OWNED AUTOS ONLY HIRED AND NON - OWNED $1,000,000/3,000 ,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A CP211240209420 06/14/2024 06/14/2025 X SPER TATUT E X OTHER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 3,000,000 A OCCUR CP140209420 P202PerOccur/Aggregate 06/14/2024 06/14/2025 PerOccur/Aggregate $1,000,000 / 3,000,000 $1,000,000 / 3,000,000 ERRORS & OMISSIONS X CYBER X DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule may be attached if more space is required) City of La Qu'nta, 78-495 Calle Tampico, La Quinta, CA 92253 is an additional insured on the general liability policy only in regard to work performed by the insured, per ISO endorsements CG 20 37 04 13 and CG 20 10 04 13 and CG 20 01 04 13 and CG 20 12 05 09 and CG 20 29 or equivalent. The policy contains a blanket Additional Insured provision adding Additional Insured where required by a written contract with the insured prior to the start of work. The certificate holder is named an additional insured. Waiver of Subrogation and Blanket Additional Insured provisions are contained with Form 3PG 00 00-11/22. The insurer agrees to waive our right to recover from the certificate holder to the extent required by written contract. The certificate holder has waivers of subrogation as their interest may appear (ATIMA). The policy contains a blanket waiver of subrogation where required by a written contract with the insured prior to the start of work performed by insured, per ISO endorsements CG 20 10 11 85 and or equivalent. The policy is Primary as to the losses it covers, and the insurer will not seek contribution if there is a written contract requirement between the insured and the certificate holder. Completed and Ongoing operations regarding general liability are included subject to the Each Occurrence and General Aggregate in the Commercial General Liability section for policy CP140209420P2024. The insurer will provide at least 30 days before cancellation or 10 days if for nonpayment of premium prior to when the insurer cancels and non -renews. Policyholder has informed Insurer of its operations at/on Project Name/On-Call Painting and Refinishing Services. Policy does not have project or engagement specific exclusions. Excluded from Workers Compensation Jasmine Lozano - Excluded Jose Lozano - Excluded CERTIFICATE HOLDER CANCELLATION City of La Quinta Attn: Carley Escarrega, Administrative Technician 78-495 Calle Tampico La Quinta, CA 92253 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) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORDs provided by Forms Boss. www.FormsBoss.com; (c) Impressive Publishing 800-208-1977 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number POLICY NUMBER CP140209420P2024 POLICY CHANGES EFFECTIVE 07-02-2024 COMPANY Berkshire Hathaway Direct Insurance Company NAMED INSURED Lozano's Painting Inc. AUTHORIZED REPRESENTATIVE 2- COVERAGE PARTS AFFECTED CHANGES Add Insured Individual - City of La Quinta, 78-495 Calle Tampico, La Quinta, CA 92253 is an additional insured. No change in premium IL 12 01 11 85 Authorized Representative Signature Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 J THREE 3 Page Policy Summary (Declarations) Page BY BERKSHIRE HATHAWAY Policy Number: CP140209420P2024 Policy Period: 06/14/2024 to 06/14/2025 @12:01AM This Policy Issued By: Berkshire Hathaway Direct Insurance Company. A Nebraska Stock Insurance Company. Named Insured (Your Business): Lozano's Painting Inc. 33881 Pueblo Trl # A Cathedral City, CA, 92234-4555 Phone: 760-698-1150 Email: lozanospaintinginc@gmail.com What's insured & for how much: The table below shows the insured buildings, and the Deductible and Limit for each Coverage. We will pay up to the Limit after a loss is more than the Deductible. If your business has more than one loss, it must pay a separate Deductible for each loss. We will pay up to the Limit for each loss, except for Business Liability, where there is a Maximum Limit. After we have paid the Maximum Limit, we will no longer pay any amounts for Business Liability under this policy. COVERAGE FOR LIMIT DEDUCTIBLE Earthquake Damage (See California Supplement) Business Liability Business Interruption (Net Income) C ber Incident Res•onse Workers' Compensation $0 $1,000,000 per occurrence, $3,000,000 Maximum Up to 1 year, $0 $250,000 No deductible 3 day waiting period No deductible As required by law None All Other Property $0 $500 Estimated Premium: $6,441 (Subject to Audit When Permitted or Required by Law) Cancellation: Your business may cancel for any reason by written request for a future date. We may only cancel as allowed by CA law, at least 30 days before cancellation or 10 days if for nonpayment of premium. We will send a notice to the address above that explains the cancellation and the effective date. After cancellation, the premium will be adjusted proportionately based on the time the policy was in effect. Policy Forms & Endorsements: 3 Page Policy Form 3PG 00 00 – 11/22 California Workers Compensation Forms and Information: California Supplement 3PG CA 01 — 01/21 WC3PCADECA, WC040604A 3PG COVEX 01 - 11/22 JTHREE To Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com BY BERKSHIRE HATHAWAY 3PG 00 00-11/22 J THREE 3 Page Policy Summary (Declarations) Page (Extension) BY BERKSHIRE HATHAWAY Policy Number: CP140209420P2024 Policy Period: 06/14/2024 to 06/14/2025 @12:01AM This Policy Issued By: Berkshire Hathaway Direct Insurance Company. A Nebraska Stock Insurance Company. Named Insured (Your Business): Lozano's Painting Inc. 33881 Pueblo Trl # A Cathedral City, CA, 92234-4555 Additional Named Insured ADDITIONAL NAMED INSURED ADDRESS 1 & 2 N/A N/A Additional Insureds Phone: 760-698-1150 Email: lozanospaintinginc@gmail.com CITY, STATE, ZIP N/A PHONE N/A ADDITIONAL INSURED ADDRESS 1 & 2 CITY, STATE, ZIP BLANKET ADDITIONAL INSURED — AS REQUIRED BY WRITTEN CONTRACT City of La Quinta 78-495 Calle La Quinta, CA 92253 Tampico Additional Listed Buildings BUILDING N/A Additional Listed Vehicles VEHICLE N/A LIMIT DEDUCTIBLE N/A N/A LIMIT DEDUCTIBLE N/A N/A THREE BY BERKSHIRE HATHAWAY To Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com 3PG 00 00-11/22 I. The coverage we provide your business under this policy: This policy only covers your business for loss caused by occurrences during the policy period. An "occurrence" means an accident, including continuous or repeated exposure to substantially the same general harmful conditions that begin during the policy period. "Occurrence" also includes an error or omission by your business. Should any part of this policy, on its effective date, conflict with the laws of the state where your business is based, then that part of this policy will be automatically amended to meet the minimum requirements of those laws. For your business' property: We cover your business for theft of and physical damage to property your business owns or leases. As a direct result of a property loss we pay, your business may have increased operating expenses or lose net income. After the Waiting Period on the Summary, we will cover these amounts as Business Interruption until your business resumes normal operations (or until either Business Interruption limit on the Summary is reached). "Net income" means (i) net profit or loss before income taxes and (ii) continuing normal operating expenses, including payroll. Unauthorized modification of electronic data is physical damage to property. For your business' liability to others: We cover your business for amounts it is legally required to pay others as the result of an occurrence. We will provide legal counsel to defend any such claims. Employees of your business acting on its behalf and Additional Insureds working with your business are also covered the same way your business would be. Additional Insured automatically includes any required Additional Insured in a contract made before starting work. We also cover (i) claims of negligence, errors, or omissions in providing professional services, and (ii) claims against directors or officers of your business arising from their actions taken on behalf of your business. For these kinds of claims, if your business first learns about the claim during this policy, and previously had continuous insurance coverage that would have covered the claim, we will cover that claim even though it is not the result of an occurrence during this policy. For Auto: We cover damage to or accidents involving vehicles on the Summary the same way we cover property and liability claims, but with the Auto limits listed on the Summary. For Cyber: We provide your business with crisis management, data and system review and recovery services, breach notification, and credit monitoring, following a data breach or computer system hack. Workers' compensation insurance: Every state has workers' compensation laws that provide benefits for injured employees. We cover your business for and will promptly pay amounts required by state workers' compensation law. We will pay all installments of the compensation that may be awarded or agreed upon in connection with those injuries. II. If something goes wrong: If your business has a property loss from an occurrence, we will pay to repair the damaged property if possible, or replace it with something of similar capabilities. We only pay for buildings (which in this policy includes any part of a building) or vehicles that are on the Summary, up to the Limit for each. For all other property that is damaged by an occurrence (including exterior glass and improvements to a leased premises that your business is responsible for) we will pay up to the amount listed for Other Property on the Summary. Other Property also includes property (other than a building) that is in the care, custody, or control of your business, but Business Interruption is not available arising from damage or loss to that property. THREE To Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com ©V BERKSHIRE HATHAWAY 3PG 00 01-11/22 We will also pay necessary costs to keep your business going or to minimize the time it is out of business after a loss that we cover. We will pay these expenses until listed vehicles are repaired or replaced (or until the Limit for that damaged vehicle is reached) or your business has resumed at a permanent location (or until either limit for Business Interruption has been reached). For liability claims, we will have the right to decide how to prepare for and defend any potential claim, and to decide if a claim should be settled. The costs of defending do not count towards policy limits. For cyber claims, we provide cyber incident response and breach coach services through our selected vendors. If your business runs out of money (it is insolvent or in bankruptcy) or otherwise defaults after a person is injured by an occurrence, our obligation to pay will not be affected. III. What we do not cover: We do not cover any occurrence(s) that start or take place outside the policy period on the Summary. To be covered by any of this policy's Coverages, the damage, liability, or injury must be caused by or arise from an occurrence during the policy period on the Summary. For any claims that we do not cover, we will not provide legal counsel to defend those claims. We do not cover any company other than those named on the Summary, and we do not provide coverage that is personal to you (or anyone) independent of your business. We do not cover damage to any building your business owns, leases, occupies, or rents that is not listed on the Summary. We do not cover damage to, or accidents involving, any vehicle owned or leased by your business (or any of its owners or officers) that is not listed on the Summary. We do not cover any Additional Insured for any claims that are unrelated to your business. We do not cover any claims between any Named Insureds or additional Named Insureds. We do not cover any claims between your business and any Additional Insured that arises from a loss where this policy covers the Additional Insured. We do not cover any damage to property (or Business Interruption), nor any claim made against your business, that is caused by pollution, asbestos, or a nuclear event. Pollution means damage caused by the spreading or escape or presence of any contaminant (whether it is solid, liquid or gas), including chemicals and waste. Asbestos means the presence or escape of any asbestos at all. Nuclear means nuclear reaction or radiation or radioactive contamination, however caused. For property (including Business Interruption) claims, we do not cover, (i) lost or misplaced property, money, securities, or stock certificates; (ii) any property that is illegal or damaged during illegal transportation; (iii) land or water or things growing on or in them like crops; (iv) animals; or (v); any damage to property or losses caused by a law, ordinance, order, or other legal requirement, which includes any zoning change, shutdown order, or other government action. We also do not cover (i) ordinary wear and tear; or (ii) deterioration that happens because the property is old or not maintained properly, or (iii) equipment, machinery, or listed vehicles that stop working without being involved in an accident as these are not occurrences. For liability claims, we do not cover claims (i) from damage or occurrences that were expected or intended (in other words, it was not accidental); (ii) solely arising from a contract; (iii) for warranty; (iv) from any promise of financial performance or return, or (v) arising out of damage to any property in the care, custody, or control of your business. THREE To Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com ©V BERKSHIRE HATHAWAY 3PG 00 01-11/22 IV. Deductibles and limits: Except for workers' compensation, which is governed by your business' state's laws, each coverage has a limit and may have a deductible. Your business is responsible for any deductible. We are responsible for loss above any deductible, up to the limit. The type of loss determines the limit, the deductible amount, and when it is paid. We will never pay more than the limit that applies less any deductible. The Summary lists the deductible (if any) and the limit for (i) any one occurrence to listed buildings, (ii) any one occurrence to Other Property; (iii) net income and business interruption expenses ; (iv) any one liability occurrence and in aggregate for any and all liability occurrences; (v) for the repair (and any related expenses) of listed vehicles; (vi) any one occurrence for liability arising from accidents in which listed vehicles are involved, and (vii) for cyber incident services for any one occurrence involving data breaches or hacking of computer systems. For liability claims, we will pay the deductible portion and bill your business for it later, since we need to appoint counsel right away in order to protect your business. V. What your business needs to do: You expect us to be fair in meeting your business' needs. For us to best meet our responsibilities under this policy, we need your business to meet certain requirements as well. First, we need openness and honesty about all the information provided to us in connection with this policy. We will rely upon that information to give a premium estimate, and we also use it to protect ourselves in the event of fraud or efforts to abuse our policy and the promises we make in it. Second, we need your business to report to us as quickly as possible about anything that could give rise to claims, and cooperate with our requests. We ask that your business take all reasonable steps to protect itself and its property after a loss. Your business must file a police report following a theft. If you have any questions or concerns, the earlier you report to us, the faster we can act to cover your business. We may need to ask additional questions to process claims, and your business must answer those promptly and truthfully. After your business reports a claim to us, we will promptly investigate, and will promptly pay claims when liability has become clear and your business has provided us with proof of loss. Your business cannot give up claims it might have against others for the losses covered by this policy without our permission, except, if required by contract before starting work, your business may make this policy primary and waive our rights of subrogation or contribution. Third, keep us updated. If any of the information given to us changes, such as adding a new property to the business, let us know so that we can keep our records up to date. Some information we may seek to confirm in any event. For example, after this policy expires, we will likely ask for confirmation of payroll so we can confirm workers' compensation data. For this and any other information requests relating to this insurance, we will be relying on your business to provide accurate information. These requests may include audits of books or physical inspection of your business' operations. We will also use the information to adjust the premium (up or down) so it accurately reflects your business' risks. All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifications. We may change our manuals and apply the changes to this policy if authorized by law or a governmental agency regulating this insurance. If your business does not meet its obligations to us, your business may lose some or all coverage under this policy. J THREE To Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com BY BERKSHIRE HATHAWAY 3PG 00 01-11/22 3 J THREE Y BERKSHIRE HATHAWAY PagePolicy3 Supplement California Su lement B We have tried to make our policy as simple and short as possible. Because the law of insurance is set by each state, we must include some additional terms to meet the requirements of California Iaw.We have included this section because California requires it. Parties: This policy is an agreement between your business (listed on the Summary) and Berkshire Hathaway Direct Insurance Company. Coverage for Earthquake Losses: For damage caused directly or indirectly by an earthquake to listed buildings and Other Property, the deductible and limit may vary based on the coverage selected by your business as reflected on the Summary. If your business did not purchase earthquake coverage, the limit for earthquake damage is $0. If your business did purchase earthquake coverage, buildings and Other Property have the same limits they would have for non -earthquake damage. For each earthquake loss to buildings or Other Property, the deductible is changed to a percentage (the one listed for Earthquake Damage on the Summary) of the limit that applies to that loss. Damages caused by a fire that results from an earthquake are not considered "caused directly or indirectly by an earthquake." All earthquake shocks that occur within any single 168 -hour period are considered a single earthquake. For this policy, all damage from an earthquake happens at the time the earthquake starts. This means there is no coverage for an earthquake that begins before this policy's start time, but coverage is available for the damage caused by an earthquake that begins before this policy's end time and continues afterwards. If there is a total loss due to earthquake, and either i) as a result of the earthquake deductible applying your business is unable to pay the full amount of the deductible, or ii) as a result of unrepaired damage to land, a building cannot be repaired or replaced, we may satisfy our obligations to your business by providing a payment of the full limit (less the earthquake deductible) that applies to the loss. Property & Premium Breakdown: California law requires the follow disclosure of premiums, and of property insured but not owned by your business: Schedule of Non -Owned Property No Non -Owned Property Listed Coverage For Other Property Premium $4 Property (Taxes & Surcharges) Business Liability, including Cyber (Data Breach and Computer System Hacks) Vehicle Auto (Other charges) $0 $3,014 No Listed Vehicles Direct Actions by Judgment Creditors: A creditor that has secured a judgment against your business in an action based upon bodily injury, death, or property damage, may bring an action against us on this policy subject to its terms and limitations, to recover on the judgment. Exclusion of Fines, Penalties and Punitive Damages: This policy does not cover fines, penalties, or restitution as prohibited by Cal. Ins. Code § 533.5. THREETo Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com 3PG CA 01-01/21 BY BERKSHIRE HATHAWAY Uninsured Motorist Coverage: This policy provides uninsured and underinsured motorist coverage as broad as required by Cal. Ins. Code § 11580.2. The limit that applies to this coverage is the Auto (Liability) limit that appears on the Summary. Execution Requirement — California law requires the following signatures: Peter Shelley President Bruce J. Byrnes Secretary THIS TEXT REPLACES THE "WORKERS COMPENSATION" PARAGRAPH OF THE POLICY: Workers Compensation and Employers Liability: A separate policy has been issued to your business that covers Workers Compensation and Employers Liability. This policy does not cover any claims resulting from bodily injury to your business's employees that are covered under the Workers Compensation and Employers Liability policy, and this policy does not cover any claims resulting from bodily injury to the owners or officers of your business. All references to "you" in any documents related to the Workers Compensation and Employers Liability policy shall mean "your business." THREE BY BERKSHIRE HATHAWAY To Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com 3PG CA 01-01/21 2 J THREE 3 Page Policy Coverage Extensions BY BERKSHIRE HATHAWAY Damage to Premises Rented To Your Business: The limit for this coverage is $100,000 per building. We will pay up to this amount for fire damage to a building if 1) your business is occupying the building with the permission of its owner (and the owner is not a named insured); and 2) your business is legally liable for causing the fire damage. The most we will pay for any one building is the limit listed above. We will pay up to this amount for damage, other than fire damage, to a building (and its contents) that has been rented to your business for seven or fewer consecutive days. The most we will pay for any one building (and its contents) is the limit listed above. The amounts we pay under this coverage count towards that occurrence's limit for Business Liability, and towards the Maximum Limit for Business Liability. Once we have paid the Maximum Limit, we will not pay any amounts under this coverage. Medical Expenses: The limit for this coverage is $5,000 per person. We will pay the expenses below, regardless of fault, for bodily injury caused by an accident that happens during the policy period 1) at a building your business owns or leases; or 2) on the ways next to a building your business owns or leases; or 3) because of the operations of your business. This coverage is subject to the same exclusions as liability claims under this policy. In addition, this coverage is not available to anyone: 1) that is an insured under this policy; or 2) that has been hired to perform work for any insured under this policy or the tenant of any insured under this policy; or 3) that is injured in a location that they normally occupy; or 4) if benefits for the bodily injury are payable under workers compensation, disability benefit, or any other similar law; or 5) injured while practicing, instructing, or participating in any physical exercises or games, sports, or athletic contests; or 6) if the bodily injury arises from work your business has completed for a third party, or products your business has sold or provided to a third party. This coverage is not available for accidents that occur outside the policy period. We will pay reasonable expenses for: 1) first aid administered at the time of an accident; 2) necessary medical, surgical, x-ray and dental services, including prosthetic devices; and 3) necessary ambulance, hospital, professional nursing and funeral services. We will only pay these expenses if they are incurred and reported to us within one year of the date of the accident. To make a claim for reimbursement of these expenses, a claimant must agree to submit to examination (at our expense) by physicians of our choice, as often as we reasonably require. The amounts we pay under this coverage count towards that occurrence's limit for Business Liability, and towards the Maximum Limit for Business Liability. Once we have paid the Maximum Limit, we will not pay any amounts under this coverage. THREE To Report a Claim or For Questions: Call 1-800-507-4495 or Log On www.threeinsurance.com BY BERKSHIRE HATHAWAY 3PG COVEX 01— 11/22 1 Berkshire Hathaway Direct Insurance Company A Stock Company 1. Named Insured and Mailing Address: Lozano's Painting Inc. 33881 Pueblo Trl # A Cathedral City, CA, 92234-4555 Policy Number: CP140209420P2024 New Policy Renewal of Policy Information Page Federal Employer's ID: 92-3838723 Risk ID Number: Business Description: Painting - Both Inside and Outside of Buildings - 3 stories or less 2. Policy Period: From June 14, 2024 12:01 AM, to June 14, 2025 12:01 AM, standard time at the insured's mailing address listed on the Summary. 3. Coverage: A. Workers' Compensation Insurance — Part One of this policy applies to the Workers' Compensation Law of the following states: All States Except Monopolistic States B. Employer's Liability Insurance — Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: • Bodily Injury by Accident — each accident: $1,000,000 • Bodily Injury by Disease — each employee: $1,000,000 • Bodily Injury by Disease — policy limit: $3,000,000 C. Other States Insurance — Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: • WC 000000C — STANDARD POLICY • WC 3P CA DEC A — INFORMATION • Additional Forms: WC040604A 4. Premium: The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page.) Total Estimated Policy Premium: $3,229.00 Total Surcharges / Assessments: $194.00 Total Estimated Cost: $3,423.00 Issuing Office: 1314 Douglas Street, Suite 1400, Omaha, NE 68102-1944 WC 3P CA DEC A - 2 20 1 Berkshire Hathaway Direct Insurance Company A Stock Company Premium (cont.): CA Classification Policy Number: CP140209420P2024 New Policy Renewal of Code Premium Basis: Rate per $100 Estimated Annual Policy Totals Manual Premium Total Estimated Annual Remuneration Remuneration rremium Effective: 06-14-2024 - 06-14-2025 $6.00 ELlncreased Limits PAINTING OR WALLPAPER INSTALLATION-- INCLUDING SHIP, YARD OR STORAGE OPERATIONS --EMPLOYEES WHOSE REGULAR HOURLY WAGE DOES NOT EQUAL OR EXCEED $31.00 PER HOUR--N.O.C. (5474) 5474 $30,000 9.55 $2,865.00 PAINTING OR WALLPAPER INSTALLATION-- INCLUDING SHOP, YARD OR STORAGE OPERATIONS --EMPLOYEES WHOSE REGULAR HOURLY WAGE EQUALS OR EXCEEDS $31.00 PER HOUR--N.O.C. (5482) 5482 If Any 5.8 $0.00 CLERICAL OFFICE EMPLOYEES (8810) 8810 If Any 0.28 $0.00 Total Est. Premium: 06-14-2024 - 06-14-2025 Catastrophe $6.00 $3,423.00 Experience Modification $3,229.00 Revolving Fund $0.00 Subsequent Injury Fund $51.00 Insurance Guaranty Association Minimum Premium: Uninsured Employers Fund $5.00 $0.00 Total Est. Standard Premium for CA $23.00 State Fraud $2,871.00 Policy Totals Manual Premium $2,865.00 Employers Liability $6.00 ELlncreased Limits 1000/1000/3000 Subject Premium $2,871.00 Modified Premium $2,871.00 Standard Premium $2,871.00 Expense Constant CA: $340.00 Terrorism $12.00 Catastrophe $6.00 Total Est. Annual Premium $3,229.00 Revolving Fund $79.00 Subsequent Injury Fund $51.00 Insurance Guaranty Association $0.00 Uninsured Employers Fund $5.00 Occupational Safety and Health Fund $23.00 State Fraud $13.00 Labor Enforcement and Compliance Fund $23.00 Total Est. Cost for:CP140209420P2024 $3,423.00 Issuing Office: 1314 Douglas Street, Suite 1400, Omaha, NE 68102-1944 WC3PCADECA-220 2 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 04 A (Ed. 01-23) COVID-19 REPORTING REQUIREMENT ENDORSEMENT — CALIFORNIA In addition to the requirements under Part 4, "Your Duties if Injury Occurs" of your policy, if you have five or more employees and an employee that is not described in California Labor Code section 3212.87 tests positive for COVID-19, you are required to report the following information as provided below. Pursuant to California Labor Code Section 3212.88(i), when you know, or reasonably should know, that an employee has tested positive for COVID-19 between September 17, 2020 and January 1, 2024, you must report to your claims administrator in writing via electronic mail or facsimile within 3 business days all of the following: (1) An employee has tested positive. For purposes of this reporting, do not provide any personally identifiable information regarding the employee who tested positive for COVID-19 unless the employee asserts the infection is work related or has filed a claim form pursuant to California Labor Code Section 5401. (2) The date that the employee tests positive, which is the date the specimen was collected for testing. (3) The specific address or addresses of the employee's specific place of employment during the 14 -day period preceding the date of the employee's positive test. (4) The highest number of employees who reported to work at the employee's specific place of employment in the 45 -day period preceding the last day the employee worked at each specific place of employment. Labor Code Section 3212.88(j) states that the intentional submission of false or misleading information or the failure to report the above information as required may subject you to a civil penalty in the amount of up to $10,000 to be assessed by the Labor Commissioner. For the purposes of these reporting requirements, California Labor Code Section 3212.88(m) provides the following: (1) "COVID-19" means the 2019 novel coronavirus disease. (2) "Test" or "testing" means a PCR (Polymerase Chain Reaction) test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA. "Test" or "testing" does not include serologic testing, also known as antibody testing. "Test" or "testing" may include any other viral culture test approved for use or approved for emergency use by the United States Food and Drug Administration to detect the presence of viral RNA which has the same or higher sensitivity and specificity as the PCR test. (3) "A specific place of employment" means the building, store, facility, or agricultural field where an employee performs work at the employer's direction. "A specific place of employment" does not include the employee's home or residence, unless the employee provides home health care services to another individual at the employee's home or residence. Once the Employer knows or `reasonably should know' that an employee has tested positive for COVID-19, the employer must do all of the following: 1) Report a claim to us in writing: REPORT NEW CLAIMS Fax: 1-203-989-2652 Email: claims(a�biberk.com Online: https://www.biberk.com/policyholders/claims/ 2) If an Employee believes they contracted COVID-19 at work, Employers will be required to report this as a Workers' Compensation claim to us and provide the Employee with a DWC-1 Claim Form. 3) If an Employer or an Employee believes the COVID-19 infection was not the result of workplace exposure, the Employer will still be required to report this occurrence. When making the report, do not include any personally identifiable information for Employee(s) who have not alleged a workplace exposure. We will record this information on a report only basis. WC 04 06 04 A (Ed. 01-23) WC 04 06 04 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 01-23) 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 07-02-2024 Policy No. CP140209420P2024 Endorsement No. Insured Insurance Company Lozano's Painting Inc. Berkshire Hathaway Direct Insurance Company Countersigned By WC 04 06 04 A (Ed. 01-23) III THREE BY BERKSHIRE HATHAWAY 7/3/2024 Re: THREE policy coverage under Policy No. CP 140209420P2024 We are providing this letter to confirm the proper interpretation of the THREE policy from Berkshire Hathaway Direct Insurance Company (BHDIC) issued to Lozano's Painting Inc. The THREE policy form is novel — it's three pages long and does away with much standard insurance industry jargon. It grants coverage across multiple lines, and does not contain many of the standard exclusions. As such, many endorsements that are needed to "add back" coverage are unnecessary as those items are never excluded in the first place from the grant of coverage. The policy is available for review on our website (https://threeinsurance.com/the-policy) and we would be happy (with permission) to provide you a copy of actual policy issued to our insured. We understand you have previously rejected a certificate of insurance stating THREE's equivalence to certain industry -standard forms. We are providing this letter, on BHDIC/THREE letterhead to make clear that alternative interpretations of the THREE policy are erroneous and that the coverage is adequate to meet the needs listed. We ask that you re -review the policy in light of this letter. In reviewing a THREE policy, you should be aware that the policy's "Summary Page" is legally equivalent to a "Declarations Page" and is part of our policy form. THREE is sold on an admitted basis, and if it would assist in giving you comfort as to the scope of coverage, we can provide a list of the state filing numbers in SERFF for you to review the actual questions from and responses to various state insurance regulators regarding the scope of THREE's coverage and the proper interpretation of the policy. The THREE policy does not contain an other insurance clause, and thus is always primary. The policy's coverage is also non-contributory as required by written contract and a waiver of subrogation is included when required equivalent to CG 20 10 04 13 and CG 24 04 10 93 and WC 00 03 13. The policy form 3PG 00 01-01/21 contains an automatic waiver of subrogation provision. If there is a written agreement/contract signed by our insured prior to the commencement of work that requires a waiver of subrogation, waiver of subrogation is granted on a blanket basis equivalent to WC 00 03 13. To the extent this letter does not address your concern, we would appreciate you providing a written explanation in response, along with the contact information for a senior compliance or legal individual that we can have one of our senior legal resources reach out to, in the hopes of facilitating a direct resolution of any remaining issues. We believe that once you are comfortable with the THREE policy, you will agree that it provides a more straightforward way of knowing exactly what is covered. We are happy to assist with additional explanations.