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Insurance Certificates 2021/22 FIND Food BankINSURANCE REVIEW RE: Please list the Contracting Party / Vendor Name, type of agreement to be executed, including any change orders or amendments, and the type of services to be provided. Make sure to list any related Project No. and Project Name. Insurance certificates required per the Agreement: ACCORD Certificate dated 10-days prior or less _____________________________ enter ACCORD issue date Commercial General Liability Insurance: $1,000,000 per occurrence/$2,000,000 aggregate OR $2,000,000 per occurrence/$4,000,000 aggregate Additional Insured Endorsement naming City of La Quinta Primary and Non-Contributory Endorsement Automobile Liability: $1,000,000 combined single limit for bodily injury and property damage. Workers’ Compensation: Statutory Limits / Employer’s Liability $1,000,000 per accident or disease Workers’ Compensation Endorsement with Waiver of Subrogation Sole Proprietor Professional Liability (Errors and Omissions): Errors and Omissions Liability insurance with a limit of not less than $1,000,000 per claim Cyber Liability/Technology Errors and Omissions Liability Insurance: $1,000,000 per occurrence/loss Other: ________________________________________________________ List other insurance types such as – molestation, harassment, etc. Approved by: ________________________ Date: ________________________ Contract Services Agreement with FIND Food Bank to provide food distribution services to La Quinta residents in response to food insecurity due to the COVID-19 pandemic. ✔ ✔ ✔ ✔ ✔ ✔ ✔ Monika Radeva 5/3/2022 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. 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GALLAGHER RISK MANAGEME Find Food BankFood In Need of Distribution, Inc. MAILING ADDRESS PO Box 10080Indio, CA 92202-2507 POLICY PERIOD: FROM TO at 12:01 A.M. Standard Time at your mailing address shown above. Path ID 14454888 0.00 NO CHANGE COUNTERSIGNED BY (Date)(Authorized Representative) 12/15/2020 12/15/2021 In consideration of the premium reflected, the policy is amended as indicated below: Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $ Total Prorate NO CHANGE Insurance Policy POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page of ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): 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 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 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 III – Limits Of Insurance: 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. PHPK2215397 City of La Quinta and its officers, employees, agents and volunteers 11 PI-GL-005 (07/12) Page of Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Effective Date: Name of Person or Organization (Additional Insured): SECTION II – WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or relating to your negligence in the performance of “your work” for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or ”occurrence” we cover for this Additional Insured. The Additional Insured’s limits of insurance do not increase our limits of insurance, as described in SECTION III – LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. City of La Quinta, and its officers, employees, agents, and volunteers 78495 Calle Tampico La Quinta, CA 92253 04/30/2020 11 POLICY CHANGE DOCUMENT POLICY NO.: CHANGE EFFECTIVE CHANGE # REVISION # DESCRIPTION PHPK2151916 2402/09/2021 02/10/2021____________________ Issue Date 24 Added: Additional Insured: City of La Quinta and its officers, employees, agents, and volunteers Community Resources Department 78495 Calle Tampic La Quinta CA 92253 Form CG2026 Additional Insured - Designated Person or Organization Form PI-GL-005 Addl Insured Primary & Non-Contributory Insurance Per attached Page 1 of 1 Philadelphia Indemnity Insurance Company NAMED INSURED 2648 ARTHUR J. GALLAGHER RISK MANAGEME Food Bank of the Rockies MAILING ADDRESS 10700 E 45th AveDenver, CO 80239-2906 POLICY PERIOD: FROM TO at 12:01 A.M. Standard Time at your mailing address shown above. Path ID 14447496 0.00 NO CHANGE COUNTERSIGNED BY (Date)(Authorized Representative) 07/01/2020 07/01/2021 In consideration of the premium reflected, the policy is amended as indicated below: Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $ Total Prorate NO CHANGE Insurance Policy Page of Additional Insured Schedule Policy Number: Philadelphia Indemnity Insurance Company PHPK2151916 employees, agents, and volunteers Additional Insured Community Resources Department 78495 Calle Tampico First Citizens Bank & Trust Co La Quinta, CA 92253-2839 With respect to Food Distribution Additional Insured City of La Quinta and its officers, PO Box 29519Raleigh, NC 27626-0519 CG2026 - General Liability CA2001 - CO - Veh #24 2015 KENWORTH CONSTRUCTION - 2XKHAJ7X9FM461531 11 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page of ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): 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 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 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 III – Limits Of Insurance: 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. PHPK2151916 City of La Quinta and its officers, employees, agents, and volunteers Community Resources Department 11 PI-GL-005 (07/12) Page of Includes copyrighted material of Insurance Services Office, Inc., with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED PRIMARY AND NON-CONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Effective Date: Name of Person or Organization (Additional Insured): SECTION II – WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or relating to your negligence in the performance of “your work” for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule. This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization. This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or ”occurrence” we cover for this Additional Insured. The Additional Insured’s limits of insurance do not increase our limits of insurance, as described in SECTION III – LIMITS OF INSURANCE. All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged. City of La Quinta and its officers, employees, agents, and volunteers Community Resources Department 02/09/2021 11 3,*/ 3DJHRI ,QFOXGHVFRS\ULJKWHGPDWHULDORI,QVXUDQFH6HUYLFHV2IILFH,QFZLWKLWVSHUPLVVLRQ 7+,6(1'256(0(17&+$1*(67+(32/,&<3/($6(5($',7&$5()8//< $'',7,21$/,1685(' 35,0$5<$1'121&2175,%8725<,1685$1&( 7KLVHQGRUVHPHQWPRGLILHVLQVXUDQFHSURYLGHGXQGHUWKHIROORZLQJ &200(5&,$/*(1(5$//,$%,/,7<&29(5$*(3$57 6&+('8/( (IIHFWLYH'DWH 1DPHRI3HUVRQRU2UJDQL]DWLRQ$GGLWLRQDO,QVXUHG 6(&7,21,,±:+2,6$1,1685('LVDPHQGHGWRLQFOXGHDVDQDGGLWLRQDOLQVXUHGWKHSHUVRQVRU RUJDQL]DWLRQVVKRZQLQWKHHQGRUVHPHQW6FKHGXOHEXWRQO\ZLWKUHVSHFWWROLDELOLW\IRU³ERGLO\LQMXU\´ ³SURSHUW\GDPDJH´RU³SHUVRQDODQGDGYHUWLVLQJLQMXU\´DULVLQJRXWRIRUUHODWLQJWR\RXUQHJOLJHQFHLQWKH SHUIRUPDQFHRI³\RXUZRUN´IRUVXFKSHUVRQVRURUJDQL]DWLRQVWKDWRFFXUVRQRUDIWHUWKHHIIHFWLYHGDWH VKRZQLQWKHHQGRUVHPHQW6FKHGXOH 7KLVLQVXUDQFHLVSULPDU\WRDQGQRQFRQWULEXWRU\ZLWKDQ\RWKHULQVXUDQFHPDLQWDLQHGE\WKHSHUVRQRU RUJDQL]DWLRQ$GGLWLRQDO,QVXUHGH[FHSWIRUORVVUHVXOWLQJIURPWKHVROHQHJOLJHQFHRIWKDWSHUVRQRU RUJDQL]DWLRQ 7KLVFRQGLWLRQDSSOLHVHYHQLIRWKHUYDOLGDQGFROOHFWLEOHLQVXUDQFHLVDYDLODEOHWRWKH$GGLWLRQDO,QVXUHG IRUDORVVRU´RFFXUUHQFH´ZHFRYHUIRUWKLV$GGLWLRQDO,QVXUHG 7KH$GGLWLRQDO,QVXUHG¶VOLPLWVRILQVXUDQFHGRQRWLQFUHDVHRXUOLPLWVRILQVXUDQFHDVGHVFULEHGLQ 6(&7,21,,,±/,0,762),1685$1&( $OORWKHUWHUPVFRQGLWLRQVDQGH[FOXVLRQVXQGHUWKHSROLF\DUHDSSOLFDEOHWRWKLVHQGRUVHPHQWDQG UHPDLQXQFKDQJHG City of La Quinta, and its officers, employees, agents, and volunteers 78495 Calle Tampico La Quinta, CA 92253 04/30/2020 13 WC 00 00 01 A Ed. 1-17-2020 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Information Page Producer: PolicyNo. 1.TheInsured: Mailing Address: Renewal of: Individual Partnership Corporationor FederalEmployerID#: Inter/Intrastate Risk I.D.# Other I.D.# Otherworkplacesnotshownabove: 2.Policy Period: From to 12:01A.M. standard time at the insured’s mailingaddress. 3.A.WorkersCompensationInsurance:PartOne ofthepolicyappliestothe WorkersCompensationLaw ofthestatelisted here: B.Employers Liability Insurance: PartTwo ofthe policy applies toworkineach state listed initem3.A. The limitsofour liabilityunderPartTwoare: Bodily InjurybyAccident $ _eachaccident Bodily InjurybyDisease $ _policylimit Bodily InjurybyDisease $ _ eachemployee C.Other State Insurance:PartThree ofthe policyappliestothestates, ifany,listed here: D.Thispolicyincludestheseendorsementandschedules: 4.Thepremiumforthispolicywillbe determinedbyourManualsofRules,Classifications,RatesandRating Plans. Allinformation requiredbelow issubjecttoverificationandchangebyaudit. Premium Basis Rate Per Code Total Estimated $100 of Estimated Classification No.Annual remuneration Remuneration Annual Premium [SEE ATTACHED SCHEDULE] Experience Modification SEE SCHEDULE Total Estimated Standard Annual Premium Expense Constant MinimumPremium Deposit Premium Premium Adjustment Period: Counter Signed by: Servicing and Issuing Office: Date Produced: Copyright 1987 National Council of Compensation Insurance. WC 00 00 01 A Ed. 1‐17‐2020 SATIS0022501 07/06/2021 SERVICE AMERICAN INDEMNITY COMPANY, a stock company PO Box 26850 AUSTIN, TEXAS 78755 NCCI # 38369 Food in Need of Distribution, Inc. Po Box 10080 Indio, CA 92202 See Schedule Tangram Insurance Services, Inc. TAN0001 140 2nd Street Suite 230 Petaluma CA 94952 Service American Indemnity Co, TX X See Item 4. Extension WC 00 00 01A For Rating & Assessments See Schedule All states except states designated in Item 3A, of the Information Page and the states of: ID, MN, ND, NY,OH, WA, WY See Schedule SATIS0022500 07/01/2021 07/01/2022 Annual 43,771 1,000,000 1,000,000 1,000,000 3132758 45,503 200 1,000 CA WC 00 00 01 A Insured: Policy Number: Effective Date: EXTENSION OF INFORMATION PAGE Administrative Office: PO Box 26850 Austin, TX 78755 Telephone Number: (833)294‐0968 IN WITNESS WHEREOF; Service American Indemnity Company has caused this policy to be signed by its President and Secretary at Austin, Texas. _______________________ _______________________ President Secretary SATIS0022501 Food in Need of Distribution, Inc. 07/01/2021 Insured: Policy Number: Item Schedule of Named Insureds Extension Schedule1 Food in Need of Distribution, Inc. SATIS0022501 Effective Date:07/01/2021 001-001-00 FEIN: 33-0006007 Food in Need of Distribution, Inc. Item 3.D. Insured: Policy Number: Form Number:Description:Edition: CA Independent Contractors Workers Compensation and Employers Liability Insurance Policy CA Signature Page Information Page Item 4 - Extension of Information Page Pending Rate Change Endorsement Premium Due Date Endorsement Catastrophe (Other Than Certified Acts Of Terrorism) Premium Endorsement Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Policy Amendatory Endorsement - California Waiver of Our Right to Recover From Others Endorsement California Short-Rate Cancelation Endorsement California Cancelation Endorsement COVID-19 Reporting Requirement Endorsement - California PN 04 99 08 WC 00 00 00 C WC 00 00 01 A (CA SIG) WC 00 00 01 A (Ed. 1-17-20) WC 00 00 01 EXT WC 00 04 04 WC 00 04 19 WC 00 04 21 E WC 00 04 22 C WC 04 03 01 D WC 04 03 06 WC 04 04 22 WC 04 06 01 A WC 04 06 04 12-19 1-15 1-20 1-20 1-90 4-84 1-01 1-21 1-21 2-18 4-84 1-12 12-93 9-20 SATIS0022501 Extension Schedule Schedule of Forms and Endorsements Food in Need of Distribution, Inc. Effective Date:07/01/2021 CODE NO. Rates Per $100 of Remun- eration Estimated Annual Premiums Subject to Modification Estimated Total Annual Remuneration POLICY NO. All Other SATIS0022501WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFORMATION PAGE ITEM 4. CONTINUED CLASSIFICATION OF OPERATIONS PAGE NO._____________________________1 WC 00 00 01A CA-4 Intrastate ID:3132758 LOC. 1 Employees: 1 NAICS: 485999 83775 Citrus Ave Indio, (Riverside) CA 92201 001-001-00 Food in Need of Distribution, Inc. FEIN: 33-0006007 From 07/01/2021 To 07/01/2022 BUS, SHUTTLE VAN OR LIMOUSINE OPERATIONS - all employees SALESPERSONS - Outside CLERICAL OFFICE EMPLOYEES - N.O.C. STORES - wholesale - N.O.C. Waiver of Rights to Recover Employer's Liability (in 000's) Limit: 1,000/1,000/1,000 TOTAL UNMODIFIED PREMIUM Experience Modification Final TOTAL MODIFIED PREMIUM Schedule debit/credit STANDARD PREMIUM Territory Modification Premium Discount 7382 8742 8810 8018 0930 9812 9898 9887 9135 0063 10.48 0.54 0.35 8.65 0.011 1.480 0.660 1.100 149,807 656,962 271,294 262,441 15,700 3,548 950 22,701 800 472 44,171 21,202 65,373 -22,227 43,146 4,315 -4,158 CODE NO. Rates Per $100 of Remun- eration Estimated Annual Premiums Subject to Modification Estimated Total Annual Remuneration POLICY NO. All Other Expense Constant Terrorism Catastrophe (other than Certified Acts of Terrorism) California Assessment 0.0226460 Fraud Assessment 0.0047340 CIGA Premium Surcharge SIBA Premium Surcharge 0.0065790 UEBT Fund Surcharge 0.0007750 OSHF Fund Assessment 0.0025840 LECF Assessment 0.0022720 TOTAL ESTIMATED PREMIUM TOTAL ASSESSMENTS TOTAL CA ESTIMATED PREMIUM TOTAL CA ASSESSMENTS 0900 9740 9741 200 134 134 SATIS0022501WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY EXTENSION OF INFORMATION PAGE ITEM 4. CONTINUED CLASSIFICATION OF OPERATIONS PAGE NO._____________________________2 WC 00 00 01A CA-4 Intrastate ID:3132758 LOC. 1 Employees: 1 NAICS: 485999 83775 Citrus Ave Indio, (Riverside) CA 92201 0.0100 0.0100 991.00 207.00 0.00 288.00 34.00 113.00 99.00 43,771 1,732.00 43,771 1,732.00 Page 1 of 6 ¤¤ Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Infor- mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor- mation Page) and us (the insurer named on the In- formation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an em- ployer of the partnership’s employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen’s compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen’s compensation law, any fed- eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such workplaces. PART ONE WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in- vestigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other Page 2 of 6 ¤¤ Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du- ties under this insurance after an injury occurs. 3. We are directly and primarily liable to any per- son entitled to the benefits payable by this in- surance. Those persons may enforce our duties; so may an agency authorized by law. Enforce- ment may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or oth- er special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your du- ties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee’s employment by you. 2. The employment must be necessary or inci- dental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee’s last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by ac- cident or by disease must be brought in the United States of America, its territories or pos- sessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employ- ees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permit- ted by law, include damages: 1. For which you are liable to a third party by rea- son of a claim or suit against you by that third party to recover the damages claimed against Page 3 of 6 ¤¤ Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) such third party as a result of injury to your employee; 2. For care and loss of services; and 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em- ployee; provided that these damages are the di- rect consequence of bodily injury that arises out of and in the course of the injured employee’s employment by you; and 4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclu- sion does not apply to a warranty that your work will be done in a workmanlike manner; 2. Punitive or exemplary damages because of bodi- ly injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. Any obligation imposed by a workers compensa- tion, occupational disease, unemployment com- pensation, or disability benefits law, or any simi- lar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, de- motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina- tion against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers’ Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonap- propriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651–1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901– 944), any other federal workers or workmen’s compensation law or other federal occupational disease law, or any amendments to these laws; 9. Bodily injury to any person in work subject to the Federal Employers’ Liability Act (45 U.S.C. Sec- tions 51 et seq.), any other federal laws obligat- ing an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10. Bodily injury to a master or member of the crew of any vessel, and does not cover punitive dam- ages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11. Fines or penalties imposed for violation of federal or state law; and 12. Damages payable under the Migrant and Sea- sonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued thereunder, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our ex- pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed- ings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our request, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgment as required by law until we offer the amount due under this insurance; and 5. Expenses we incur. Page 4 of 6 ¤¤ Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other in- surance or self-insurance. Subject to any limits of li- ability that apply, all shares will be equal until the loss is paid. If any insurance or self -insurance is ex- hausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for “bodily injury by accident—each accident” is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for “bodily injury by disease—policy limit” is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis- ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for “bodily injury by disease—each em- ployee” is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include dis- ease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability un- der this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this poli- cy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to deter- mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga- tions under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor- mation Page. 2. If you begin work in any one of those states after the effective date of this policy and are not in- sured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this pol- icy in any state not listed in Item 3.A. of the In- formation Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other ser- vices required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal Page 5 of 6 ¤¤ Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may re- quest, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would in- terfere with our right to recover from others. 6. Do not voluntarily make payments, assume obli- gations or incur expenses, except at your own cost. PART FIVE—PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifica- tions. We may change our manuals and apply the changes to this policy if authorized by law or a gov- ernmental agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifi- cations. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remu- neration is the most common premium basis. This premium basis includes payroll and all other remu- neration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com- pensation Insurance) of this policy. If you do not have payroll records for these persons, the con- tract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the em- ployers of these persons lawfully secured their workers compensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensa- tion law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premi- um basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the bal- ance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be de- termined in the following way unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short-rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to com- pute premium. You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledg- ers, journals, registers, vouchers, contracts, tax re- ports, payroll and disbursement records, and pro- grams for storing and retrieving data. We may con- duct the audits during regular business hours during the policy period and within three years after the pol- icy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. Page 6 of 6 ¤¤ Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) PART SIX—CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurabil- ity of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organiza- tions have the same rights we have under this provision. B. Long Term Policy If the policy period is longer than one year and six- teen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days af- ter your death, we will cover your legal representa- tive as insured. D. Cancelation 1. You may cancel this policy. You must mail or de- liver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or de- liver to you not less than ten days advance writ- ten notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com- ply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 04 (Ed. 4-84) PENDING RATE CHANGE ENDORSEMENT A rate change filing is being considered by the proper regulatory authority. The filing may result in rates different from the rates shown on the policy. If it does, we will issue an endorsement to show the new rates and their effective date. If only one state is shown in Item 3.A. of the Information Page, this endorsement applies to that state. If more than one state is shown there, this endorsement applies only in the state shown in the Schedule. Schedule State 1983 National Council on Compensation Insurance. WC 00 04 04 (Ed. 4-84) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date: c Page of to Premium $ Insured: DBA: Countersigned by Applies to all states listed in 3.A. with the exception of CA, IL, NM, MN, MO & TX (if those states are included in 3.A.) SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 WC 00 04 19WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-01) 2000 National Council on Compensation Insurance, Inc.C WC 00 04 19 (Ed. 1-01) PREMIUM DUE DATE ENDORSEMENT This endorsement is used to amend: Section D. of Part Five of the policy is replaced by this provision. PART FIVE PREMIUM D.Premium is amended to read: You will pay all premium when due. You will pay the premium even if part or all of a workers compensation law is not valid.The due date for audit and retrospective premiums is the date of the billing. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 E (Ed. 01-21) Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism).This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 C), attached to this policy. For purposes of this endorsement, the following definitions apply: •Catastrophe (Other Than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. •Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. •Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of the Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a.It is an act that is violent or dangerous to human life, property, or infrastructure; b.The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c.It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. •Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium © Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. Endorsement Effective Date: Policy Effective Date: Insured: DBA: Carrier Name / Code: WC 00 04 21 E (Ed. 01-21) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Policy No. to Endorsement No. Premium $ Countersigned by See Schedule Page of SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2019. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. “Act” means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2019. “Act of Terrorism” means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, as meeting all of the following requirements: a.The act is an act of terrorism. b.The act is violent or dangerous to human life, property, or infrastructure. c.The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d.The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. “Insured Loss” means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. “Insurer Deductible” means, for the period beginning on January 1, 2021, and ending on December 31, 2027, an amount equal to 20% of our direct earned premiums during the immediately preceding calendar year. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 C (Ed. 01-21) Page of© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved.12 Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1.Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses occurring in any calendar year exceed $200,000,000, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. 2.Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3.The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. Schedule State Premium Page of© Copyright 2020 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 04 22 C (Ed. 01-21) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Rate See Schedule Endorsement Effective Date: Policy Effective Date: Insured: DBA: Carrier Name / Code: WC 00 04 22 C (Ed. 01-21) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Policy No. to Endorsement No. Premium $ Countersigned by SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 22 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 01 D (Ed. 02-18) POLICY AMENDATORY ENDORSEMENT CALIFORNIA It is agreed that, anything in the policy to the contrary notwithstanding, such insurance as is afforded by this policy by reason of the designation of California in Item 3 of the Information Page is subject to the following provisions: 1.Minors IllegallyEmployed Not Insured.This policy does not cover liability for additional compensation imposed on you under Section 4557, Division IV, Labor Code of the State of California, by reason of injury to an employee under sixteen years of age and illegally employed at the time of injury. 2.Punitive or Exemplary Damages Uninsurable.This policy does not cover punitive or exemplary damages where insurance of liability therefor is prohibited by law or contrary to public policy. 3.Increase in Indemnity Payment Reimbursement.You are obligated to reimburseus for the amount of increase in indemnity payments made pursuant to Subdivision (d) of Section 4650 of the California Labor Code, if the late indemnity payment which gives rise to the increase in the amount of payment is due less than seven (7) days after we receive the completed claim form from you. You are obligated to reimburse us for any increase in indemnity payments not covered under this policy and will reimburse us for any increase in indemnity payment not covered under the policy when the aggregate total amount of the reimbursement payments paid in a policy year exceeds one hundred dollars ($100). If we notify you in writing, within 30 days of the payment, that you are obligated to reimburse us, we will bill you for the amount of increase in indemnity payment and collect it no later than the final audit. You will have 60 days, following notice of the obligation to reimburse, to appeal the decision of the insurer to the Department of Insurance. 4.Application of Policy.Part One, "WorkersCompensation Insurance",A, "How This Insurance Applies", is amended to read as follows: This workers compensation insurance applies to bodily injury by accident or disease, including death resulting therefrom. 8. 5.Rate Changes.The premium and rates with respect to the insurance provided by this policy by reason of the designation of California in Item 3 of the Information Page are subject to change if ordered by the Insurance Commissioner of the State of California pursuant to Section 11737 of the California Insurance Code. 6.Long Term Policy.If this policy is writtenfor a period longer than one year, all the provisions of this policy shall apply separately to each consecutive twelve-month period or, if the first or last consecutive period is less than twelve months, to such period of less than twelve months, in the same manner as if a separate policy had been written for each consecutive period. 7.Statutory Provision.Your employee has a firstlien upon any amount which becomes owing to you by us on account of this policy, and in the case of your legal incapacity or inability to receive the money and pay it to the claimant, we will pay it directly to the claimant. Part Five, "Premium", E, "Final Premium", is amended to read as follows: The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the balance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be determined in the following way unless our manuals provide otherwise: a. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. b. If you cancel, final premium may be more than pro rata; it will be based on the time this policy was in force, and may be increased by our short-rate cancelation table and procedure. Final premium will not be less than the pro rata share of the minimum premium. Page Bodily injury by accident must occur during the policy period. Bodily injury by disease must be caused or aggravated by the conditions of your employment.Your employee's exposure to those conditions causing or aggravating such bodily injury by disease must occur during the policy period. of12 WC 04 03 01 D WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 02-18) It is further agreed that this policy, including all endorsements forming a part thereof, constitutes the entire contract of insurance. No condition, provision, agreement, or understanding not set forth in this policy or such endorsements shall affect such contract or any rights, duties, or privileges arising therefrom. WC 04 03 01 D (Ed. 02-18) Page of (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 22 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA Wehave the right to recover our payments from anyoneliable for an injury covered by this policy. We will not enforce our right against the person or organizationnamed in the Schedule. (This agreement applies only to the extent that you per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be ____________ % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WC 04 03 06 (Ed. 4-84) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 See Below Specific Waiver is $200 Flat Charge FIND Food Bank FINDFoodBank CityofLaQuinta,78495CalleTampico,LaQuinta,CA 92253anditsofficers,employees,agents,and volunteers Concerningacontracttodistributefood. AllOperati WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA Wehave the right to recover our payments from anyoneliable for an injury covered by this policy. We will not enforce our right against the person or organizationnamed in the Schedule. (This agreement applies only to the extent that you per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be ____________ % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WC 04 03 06 (Ed. 4-84) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 See Below Specific Waiver is $200 Flat Charge The City of Indio, HUD, their agents, officers, and employee 100 Civic Center Mall Indio CA 92201 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA Wehave the right to recover our payments from anyoneliable for an injury covered by this policy. We will not enforce our right against the person or organizationnamed in the Schedule. (This agreement applies only to the extent that you per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be ____________ % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WC 04 03 06 (Ed. 4-84) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 See Below Specific Waiver is $200 Flat Charge City of Palm Springs 3200 E. Tahquitz Canyon Way, Palm Springs, CA 92262 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA Wehave the right to recover our payments from anyoneliable for an injury covered by this policy. We will not enforce our right against the person or organizationnamed in the Schedule. (This agreement applies only to the extent that you per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be ____________ % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WC 04 03 06 (Ed. 4-84) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 See Below Specific Waiver is $200 Flat Charge San Francisco Unified School District 135 Van Ness Street, Room 102 San Francisco, CA 94102 Specific Waiver is $200 Flat Charge San Francisco Unified School District, its Board, officers and employe WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) CALIFORNIA SHORT-RATE CANCELATION ENDORSEMENT If you cancel the policy and a disclosure was provided in accordance with Section 481(c) of the California Insurance Code, finalpremium will be based on the time this policy was in force and increased by the short-rate cancelation table below: It is agreed that, anything in the policy to the contrary not withstanding, such insurance as is afforded by this policy by reason ofthe designation of California in Item 3 of the Information Page is subject to the following provisions: SHORT RATE CANCELATION TABLE Factor to Apply to Earned Premium for Period Policy in Effect Factor to Apply to Earned Premium for Period Policy in Effect Factor to Apply to Earned Premium for Period Policy in Effect Short Rate Percentages Short Rate Percentages Short Rate Percentages Days in Policy Period Days in Policy Period Days in Policy Period 1 5% 18.2482 46 23% 1.8250 91 35% 1.4038 2 6 10.9489 47 23 1.7861 92 36 1.4283 3 7 8.5158 48 24 1.8250 93 36 1.4129 4 7 6.3869 49 24 1.7877 94 36 1.3979 5 8 5.8394 50 24 1.7520 95 37 1.4216 6 8 4.8662 51 24 1.7176 96 37 1.4068 7 9 4.6924 52 25 1.7548 97 37 1.3923 8 9 4.1058 53 25 1.7216 98 37 1.3781 9 10 4.0552 54 25 1.6899 99 38 1.4010 10 10 3.6496 55 26 1.7255 100 38 1.3870 11 11 3.6496 56 26 1.6947 101 38 1.3733 12 11 3.3455 57 26 1.6650 102 38 1.3598 13 12 3.3689 58 26 1.6362 103 39 1.3820 14 12 3.1283 59 27 1.6704 104 39 1.3688 15 13 3.1630 60 27 1.6425 105 39 1.3557 16 13 2.9653 61 27 1.6156 106 40 1.3774 17 14 3.0056 62 27 1.5895 107 40 1.3645 18 14 2.8386 63 28 1.6222 108 40 1.3519 19 15 2.8818 64 28 1.5969 109 40 1.3395 20 15 2.7377 65 28 1.5723 110 41 1.3605 21 16 2.7812 66 29 1.6038 111 41 1.3482 22 16 2.6547 67 29 1.5799 112 41 1.3362 23 17 2.6980 68 29 1.5566 113 41 1.3243 24 17 2.5856 69 29 1.5341 114 42 1.3447 25 17 2.4821 70 30 1.5643 115 42 1.3330 26 18 2.5270 71 30 1.5423 116 42 1.3215 27 18 2.4334 72 30 1.5208 117 43 1.3414 28 18 2.3465 73 30 1.5000 118 43 1.3301 29 18 2.2656 74 31 1.5291 119 43 1.3189 30 19 2.3117 75 31 1.5087 120 43 1.3079 31 19 2.2371 76 31 1.4888 121 44 1.3273 32 19 2.1672 77 32 1.5169 122 44 1.3164 33 20 2.2121 78 32 1.4974 123 44 1.3057 34 20 2.1471 79 32 1.4785 124 44 1.2951 35 20 2.0857 80 32 1.4600 125 45 1.3140 36 20 2.0278 81 33 1.4870 126 45 1.3036 37 21 2.0716 82 33 1.4689 127 45 1.2933 38 21 2.0171 83 33 1.4512 128 46 1.3117 39 21 1.9654 84 34 1.4774 129 46 1.3016 40 21 1.9162 85 34 1.4600 130 46 1.2916 41 22 1.9585 86 34 1.4430 131 46 1.2817 42 22 1.9119 87 34 1.4264 132 47 1.2996 43 22 1.8674 88 35 1.4517 133 47 1.2899 44 23 1.9079 89 35 1.4354 134 47 1.2802 45 23 1.8655 90 35 1.4194 135 47 1.2708 Page of Copyright 2011 by the Workers Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation C Insurance Forms Manual 2001 C C C 14 SHORT RATE CANCELATION TABLE (cont'd) Factor to Apply to Earned Premium for Period Policy in Effect Factor to Apply to Earned Premium for Period Policy in Effect Factor to Apply to Earned Premium for Period Policy in Effect Short Rate Percentages Short Rate Percentages Short Rate Percentages Days in Policy Period Days in Policy Period Days in Policy Period 136 48% 1.2882 181 60% 1.2099 226 70% 1.1305 137 48 1.2788 182 60 1.2033 227 70 1.1255 138 48 1.2696 183 61 1.2167 228 70 1.1206 139 49 1.2867 184 61 1.2101 229 71 1.1317 140 49 1.2775 185 61 1.2035 230 71 1.1267 141 49 1.2684 186 61 1.1970 231 71 1.1219 142 49 1.2595 187 61 1.1906 232 71 1.1170 143 50 1.2762 188 62 1.2037 233 72 1.1279 144 50 1.2674 189 62 1.1974 234 72 1.1231 145 50 1.2586 190 62 1.1910 235 72 1.1183 146 50 1.2500 191 62 1.1848 236 72 1.1136 147 51 1.2663 192 63 1.1977 237 72 1.1089 148 51 1.2578 193 63 1.1914 238 73 1.1195 149 51 1.2493 194 63 1.1853 239 73 1.1149 150 52 1.2653 195 63 1.1792 240 73 1.1102 151 52 1.2569 196 63 1.1732 241 73 1.1056 152 52 1.2487 197 64 1.1858 242 74 1.1161 153 52 1.2405 198 64 1.1798 243 74 1.1115 154 53 1.2562 199 64 1.1739 244 74 1.1070 155 53 1.2481 200 64 1.1680 245 74 1.1025 156 53 1.2401 201 65 1.1804 246 74 1.0980 157 54 1.2554 202 65 1.1745 247 75 1.1083 158 54 1.2475 203 65 1.1687 248 75 1.1038 159 54 1.2396 204 65 1.1630 249 75 1.0994 160 54 1.2319 205 65 1.1573 250 75 1.0950 161 55 1.2469 206 66 1.1694 251 76 1.1052 162 55 1.2392 207 66 1.1638 252 76 1.1008 163 55 1.2316 208 66 1.1582 253 76 1.0964 164 55 1.2241 209 66 1.1526 254 76 1.0921 165 56 1.2388 210 67 1.1645 255 76 1.0878 166 56 1.2313 211 67 1.1590 256 77 1.0979 167 56 1.2240 212 67 1.1535 257 77 1.0936 168 57 1.2384 213 67 1.1481 258 77 1.0893 169 57 1.2311 214 67 1.1428 259 77 1.0851 170 57 1.2238 215 68 1.1544 260 77 1.0810 171 57 1.2167 216 68 1.1491 261 78 1.0908 172 58 1.2308 217 68 1.1438 262 78 1.0866 173 58 1.2237 218 68 1.1385 263 78 1.0825 174 58 1.2167 219 69 1.1500 264 78 1.0784 175 58 1.2097 220 69 1.1448 265 79 1.0881 176 59 1.2236 221 69 1.1396 266 79 1.0840 177 59 1.2167 222 69 1.1345 267 79 1.0800 178 59 1.2098 223 69 1.1294 268 79 1.0759 179 60 1.2235 224 70 1.1406 269 79 1.0719 180 60 1.2167 225 70 1.1356 270 80 1.0815 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) Copyright 2011 by the Workers Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation C Insurance Forms Manual 2001 C C Page of C 24 SHORT RATE CANCELATION TABLE (cont'd) Factor to Apply to Earned Premium for Period Policy in Effect Factor to Apply to Earned Premium for Period Policy in Effect Factor to Apply to Earned Premium for Period Policy in Effect Short Rate Percentages Short Rate Percentages Short Rate Percentages Days in Policy Period Days in Policy Period Days in Policy Period 271 80% 1.0775 316 90% 1.0396 361 100% 1.0111 272 80 1.0735 317 90 1.0363 362 100 1.0083 273 80 1.0696 318 90 1.0330 363 100 1.0055 274 81 1.0790 319 90 1.0298 364 100 1.0027 275 81 1.0751 320 91 1.0380 365 100 1.0000 276 81 1.0712 321 91 1.0347 277 81 1.0673 322 91 1.0315 278 81 1.0635 323 91 1.0283 279 82 1.0728 324 92 1.0364 280 82 1.0689 325 92 1.0332 281 82 1.0651 326 92 1.0301 282 82 1.0614 327 92 1.0269 283 83 1.0705 328 92 1.0238 284 83 1.0667 329 93 1.0318 285 83 1.0630 330 93 1.0286 286 83 1.0593 331 93 1.0255 287 83 1.0556 332 93 1.0224 288 84 1.0646 333 94 1.0303 289 84 1.0609 334 94 1.0272 290 84 1.0572 335 94 1.0242 291 84 1.0536 336 94 1.0211 292 85 1.0625 337 94 1.0181 293 85 1.0589 338 95 1.0259 294 85 1.0553 339 95 1.0229 295 85 1.0517 340 95 1.0198 296 85 1.0481 341 95 1.0169 297 86 1.0569 342 95 1.0139 298 86 1.0534 343 96 1.0216 299 86 1.0498 344 96 1.0186 300 86 1.0463 345 96 1.0156 301 86 1.0429 346 96 1.0127 302 87 1.0515 347 97 1.0203 303 87 1.0480 348 97 1.0174 304 87 1.0446 349 97 1.0145 305 87 1.0411 350 97 1.0116 306 88 1.0497 351 97 1.0087 307 88 1.0462 352 98 1.0162 308 88 1.0429 353 98 1.0133 309 88 1.0395 354 98 1.0105 310 88 1.0361 355 98 1.0076 311 89 1.0445 356 99 1.0150 312 89 1.0412 357 99 1.0122 313 89 1.0379 358 99 1.0094 314 89 1.0346 359 99 1.0065 315 90 1.0429 360 99 1.0038 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) Page of Copyright 2011 by the Workers Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation C Insurance Forms Manual 2001 C C C 34 Copyright 2011 by the Workers Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation C Insurance Forms Manual 2001 C C WC 04 04 22 (Ed. 01-12) Page of (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 04 22 (Ed. 01-12) SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 44 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 01 A (Ed. 12-93) CALIFORNIA CANCELATION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. The cancelation condition in Part Six (Conditions) of the policy is replaced by these conditions: You may cancel this policy. You must mail or deliver advance written notice to us stating when the cancelation is to take effect. Cancelation We may cancel this policy for one or more of the following reasons: Non-payment of premium; b. Failure to permit us to audit payroll as required by the terms of this policy or of a previous policy issued by us; Failure to pay any additional premium resulting from an audit of payroll required by the the terms of this policy or any previous policy issued by us; 1. 2. 3. 4. Material misrepresentation made by you or your agent; Failure to cooperate with us in the investigation of a claim; g. The occurrence of a material change in the ownership of your business; c. d. e. i. If we cancel your policy for any of the reasons listed in (a) through (f), we will give you 10 days advance written notice, stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in item 1 of the Information Page will be sufficient to prove notice. If we cancel your policy for any reasons listed in items (g) through (l), we will give you 30 days advance written notice; however, we agree that in the event of cancelation and reissuance of a policy effective upon a material change in ownership or operations, notice will not be provided. The occurrence of any change in your business or operation which contemplates an activity excluded by our reinsurance treaties; l. The policy period will end on the day and hour stated in the cancelation notice. Failure to report payroll; f. h. a. Failure to comply with Federal or State safety orders; The occurrence of any change in your business or operations that materially increases the hazard for frequency or severity of loss; Failure to comply with written recommendations of our designated loss control representatives; j. k.The occurrence of any change in your business or operation that requires additional or different classification for premium calculation; WC 04 06 01 A (Ed. 12-93) (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement No.Endorsement Effective Date: Policy No. Carrier Name / Code: Policy Effective Date:to Premium $ Insured: DBA: Countersigned by Page of SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 11 WC 04 06 04 (Ed. 09-20) 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. Reporting COVID-19 Positive Tests from July 6, 2020 to September 17, 2020 Pursuant to California Labor Code Section 3212.88(k)(2), if you are aware of an employee testing positive for COVID-19 on or after July 6, 2020 and prior to September 17, 2020, you must report to your claims administrator in writing via electronic mail or facsimile within 30 business days of September 17, 2020, 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 each of the employee’s specific places of employment on any given work day between July 6, 2020 and September 17, 2020 Reporting COVID-19 Positive Tests from September 17, 2020 to January 1, 2023 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, 2023, 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. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 06 04 (Ed. 09-20) Page of12 (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. Note: This endorsement is only applicable until January 1, 2023, unless the repeal date of California Labor Code Section 3212.88 is extended. WC 04 06 04 (Ed. 09-20) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Page of 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.) Policy No. to Endorsement No. Premium $ Countersigned by Endorsement Effective Date: Policy Effective Date: Insured: DBA: Carrier Name / Code: WC 04 06 04 (Ed. 09-20) SATIS0022501 Service American Indemnity Company Food in Need of Distribution, Inc. 07/01/2021 07/01/2021 07/01/2022 22 PN 04 99 01 H (Ed. 05-20) PN 04 99 01 H 1 of 2 (Ed. 05-20) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I. Information Available to You A. Information Available from Us – Service American Indemnity Company (1) General questions regarding your policy should be directed to: Service American Indemnity Company P.O. Box 26850 Austin, TX 78755 833-294-0968 www.serviceamerican.com (2)Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non- payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3)Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers’ Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim. The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers’ Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner’s designated statistical agent. As such, the WCIRB is responsible for administering the California Workers’ Compensation Uniform Statistical Reporting Plan— 1995 (USRP) and the California Workers’ Compensation Experience Rating Plan—1995 (ERP). WCIRB contact information is: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service; 888.229.2472 (phone); 415.778.7272 (fax); and customerservice@wcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB’s website at wcirb.com. (2)Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Custodian of Records. The Custodian of Records can be reached at 415.777.0777 (phone) and 415.778.7272 (fax). (3)Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB’s website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet will include a Loss-Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium, or by the application of our rating system to your workers’ compensation insurance, you may dispute these matters with us. If you are dissatisfied with the outcome of the initial dispute with us, you may send us a written Complaint and Request for Action as outlined below.] You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written Complaints and Requests for Action should be forwarded to: Service American Indemnity Company Phone: 833-294-0968 P.O. Box 26850 Austin, TX 78755 Website: www.serviceamerican.com PN 04 99 01 H (Ed. 05-20) PN 04 99 01 H 2 of 2 (Ed. 05-20) After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether or not your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice@wcirb.com (email). If you are dissatisfied with the WCIRB’s decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB’s contact information is 888.229.2472 (phone), 415.371.5204 (fax) and customerservice@wcirb.com (email). C. California Department of Insurance – Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 1901 Harrison Street, 3rd Floor Oakland, CA 94612 415.538.4243 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (fax) and ombudsman@wcirb.com (email). B. California Department of Insurance – Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. PN 04 99 02 B (Ed. 05-02) 1 of 2 POLICYHOLDER NOTICE CALIFORNIA WORKERS’ COMPENSATION INSURANCE RATING LAWS Pursuant to Section 11752.8 of the California Insurance Code, we are providing you with an explanation of the California workers’ compensation rating laws. 1. We establish our own rates for workers’ compensation. Our rates, rating plans, and related information are filed with the insurance commissioner and are open for public inspection. 2. The insurance commissioner can disapprove our rates, rating plans, or classifications only if he or she has determined after public hearing that our rates might jeopardize our ability to pay claims or might create a monopoly in the market. A monopoly is defined by law as a market where one insurer writes 20% or more of that part of the California workers’ compensation insurance that is not written by the State Compensation Insurance Fund. If the insurance commissioner disapproves our rates, rating plans, or classifications, he or she may order an increase in the rates applicable to outstanding policies. 3. Rating organizations may develop pure premium rates that are subject to the insurance commissioner’s approval. A pure premium rate reflects the anticipated cost and expenses of claims per $100 of payroll for a given classification. Pure premium rates are advisory only, as we are not required to use the pure premium rates developed by any rating organization in establishing our own rates. 4. We must adhere to a single, uniform experience rating plan. If you are eligible for experience rating under the plan, we will be required to adjust your premium to reflect your claim history. A better claim history generally results in a lower experience rating modification; more claims, or more expensive claims, generally result in a higher experience rating modification. The uniform experience rating plan, which is developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. 5. A standard classification system, developed by the insurance rating organization designated by the insurance commissioner, is subject to approval by the insurance commissioner. The standard classification system is a method of recognizing and separating policyholders into industry or occupational groups according to their similarities and/or differences. We can adopt and apply the standard classification system or develop and apply our own classification system, provided we can report the payroll, expenses, and other costs of claims in a way that is consistent with the uniform statistical plan or the standard classification system. 6. Our rates and classifications may not violate the Unruh Civil Rights Act or be unfairly discriminatory. 7. We will provide an appeal process for you to appeal the way we rate your insurance policy. The process requires us to respond to your written appeal within 30 days. If you are not satisfied with the result of your appeal, you may appeal our decision to the insurance commissioner. California Workers’ Compensation Insurance Notice of Nonrenewal Section 11664 of the California Insurance Code requires us, in most instances, to provide you with a notice of nonrenewal. Except as specified in paragraphs 1 through 6 below, if we elect to nonrenew your policy, we are required to deliver or mail to you a written notice stating the reason or reasons for the nonrenewal of the policy. The notice is required to be sent to you no earlier than 120 days before the end of the policy period and no later than 30 days before the end of the policy period. If we fail to provide you the required notice, we are required to continue the coverage under the policy with no change in the premium rate until 60 days after we provide you with the required notice. PN 04 99 02 B (Ed. 05-02) 2 of 2 We are not required to provide you with a notice of nonrenewal in any of the following situations: 1. Your policy was transferred or renewed without a change in its terms or conditions or the rate on which the premium is based to another insurer or other insurers who are members of the same insurance group as us. 2. The policy was extended for 90 days or less and the required notice was given prior to the extension. 3. You obtained replacement coverage or agreed, in writing, within 60 days of the termination of the policy, to obtain that cov erage. 4. The policy is for a period of no more than 60 days and you were notified at the time of issuance that it may not be renewed. 5. You requested a change in the terms or conditions or risks covered by the policy within 60 days prior to the end of the policy period. 6. We made a written offer to you to renew the policy at a premium rate increase of less than 25 percent. (A) If the premium rate in your governing classification is to be increased 25 percent or greater and we intend to renew the policy, we shall provide a written notice of a renewal offer not less than 30 days prior to the policy renewal date. The governing classification shall be determined by the rules and regulations established in accordance with California Insurance Code Section 11750.3(c). (B) For purposes of this Notice, “premium rate” means the cost of insurance per unit of exposure prior to the application of individual risk variations based on loss or expense considerations such as scheduled rating and experience rating. This notice does not change the policy to which it is attached. PN 04 99 04 (Ed. 12-01) POLICYHOLDER NOTICE CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) SURCHARGE Companies writing property and casualty insurance business in California are required to participate in the California Insurance Guarantee Association. If a company becomes insolvent, the California Insurance Guarantee Association settles unpaid claims and assesses each insurance company for its fair share. California law requires all companies to surcharge policies to recover these assessments. If your policy is surcharged, “CA Surcharge” or “CA Surcharge (CIGA Surcharge)” with an amount will be displayed on your premium notice. This notice does not change the policy to which it is attached. PN 04 99 06 D (Ed. 01-20) POLICYHOLDER NOTICE PAYROLL RECORD AND AUDIT REQUIREMENTS FOR DUAL WAGE CONSTRUCTION OR ERECTION CLASSIFICATIONS Your policy includes one or more construction or erection classifications. Dual wage classifications are pairs of classifications that describe the same construction or erection operation yet are assigned based upon whether the employee’s hourly wage is above or below a specified threshold. Each pair of dual wage classifications contains one “high wage” classification that is assignable to pay rolls earned by employees whose regular hourly wage equals or exceeds a specified wage threshold and one “low wage” classification that is assignable to payrolls earned by employees whose regular hourly wage is less than the specified threshold. Payroll Record Requirements The assignment of a high wage classification is contingent on verifying that the employee’s hourly wage equals or exceeds the specified wage threshold. The determination of the regular hourly wage for any non-salaried employee must be supported by one of the following sources: x Original time cards or time book entries for each employee. Original records must include the operations performed, the total hours worked each day and the times the employee started and ended each work period throughout the workday. At job locations where all of the employer’s operations cease for a uniform unpaid meal period, recording the start and stop times of the uniform break period is not required. x A valid collective bargaining agreement that shows the regular hourly wage rate by job classification of a worker. If using a collective bargaining agreement, the records must include an employee roster by job classification that permits the reconciliation of individual employees to the job classifications set forth in the collective bargaining agreement. The non-salaried employee’s regular hourly wage shall be determined by dividing that employee’s total remuneration by the hours worked during the pay period, irrespective of whether the employee is paid on an hourly, piecework, production or commission basis. The payroll earned by any non-salaried employees for whom the records specified above are not maintained and/or made available will be assigned to the low wage classification that describes the operations performed. The regular hourly wage of salaried employees is determined by dividing the total annual remuneration by 2000 hours. If an employee is salaried for less than 12 months, the regular hourly wage for the salaried period is calculated on a prorated basis. Audit Requirements If your policy has an effective date on or after January 1, 2020 and produces a final premium of $10,500 or more, a physical audit is required at least once a year; if it produces a final premium of less than $10,500 and develops payroll in a high wage classification, a physical audit of the policy is required unless the policy is a renewal and a physical audit was completed for one of the two immediately preceding policy periods. A “physical audit” is defined as an audit of payroll, whether conducted at the policyholder’s location or at a remote site, that is based upon an auditor’s examination of the policyholder’s books of accounts and original payroll records (in either electronic or hard copy form) as necessary to determine and verify the exposure amounts by classification. If you hold a C-39 Roofing Contractor license from the California Contractors State License Board, a physical audit is required on the complete policy period of each policy regardless of the amount of final premium. See California Insurance Code Section 11665(a) for additional requirements regarding the audit of C-39 license holders. PN 04 99 08 (Ed. 12-19) POLICYHOLDER NOTICE CALIFORNIA ASSEMBLY BILL NO. 5, INDEPENDENT CONTRACTORS Summary of Assembly Bill No. 5 (AB 5) For the purposes of wages, workers’ compensation and other benefits, AB 5 creates a presumption that an entity’s workers are employees unless the hiring entity can show that the worker meets three conditions, known as the “ABC Test”. With respect to workers’ compensation, AB 5 goes into effect on July 1, 2020 and applies to policies issued on or after July 1, 2020, as well as policies in force as of July 1, 2020. The bill adds Section 2750.3 to the California Labor Code, which provides in pertinent part: 2750.3. (a)(1) For purposes of the provisions of this code and the Unemployment Insurance Code, and for the wage orders of the Industrial Welfare Commission, a person providing labor or services for remuneration shall be considered an employee rather than an independent contractor unless the hiring entity demonstrates that all of the following conditions are satisfied: (A) The person is free from the control and direction of the hiring entity in connection with the performance of the work, both under the contract for the performance of the work and in fact. (B) The person performs work that is outside the usual course of the hiring entity’s business. (C) The person is customarily engaged in an independently established trade, occupation, or business of the same nature as that involved in the work performed. (2) Notwithstanding paragraph (1), any exceptions to the terms “employee,” “employer,” “employ,” or “independent contractor,” and any extensions of employer status or liability, that are expressly made by a provision of this code, the Unemployment Insurance Code, or in an applicable order of the Industrial Welfare Commission, including, but not limited to, the definition of “employee” in subdivision 2(E) of Wage Order No. 2, shall remain in effect for the purposes set forth therein. (3) If a court of law rules that the three-part test in paragraph (1) cannot be applied to a particular context based on grounds other than an express exception to employment status as provided under paragraph (2), then the determination of employee or independent contractor status in that context shall instead be governed by the California Supreme Court’s decision in S.G. Borello & Sons, Inc. v. Department of Industrial Relations (1989) 48 Cal.3d 341. AB 5 also provides an extensive list of occupations that are exempt from the application of Section 2750.3(a)(1). These exemptions are subject to revision. In addition, AB 5 amends Section 3351 of the California Labor Code and Sections 606.5 and 621 of the Unemployment Insurance Code. The pertinent sections of the California Labor Code and Unemployment Insurance Code may be accessed at http://leginfo.legislature.ca.gov. You may also access the California Labor & Workforce Development Agency webpage at https://www.labor.ca.gov/employmentstatus/ for more information. This notice does not change the policy to which it is attached. PN 04 99 08