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Insurance Certificates 2023/24 - GameTimeAC � " ® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 03/14/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Justin Llizo MARSH USA, LLC. FAX Two Alliance Center AICNNo Ext : (202) 258-5895 A/C No), E-MAIL ADDRESS: Justin.Llizo@marsh.com 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 Attn: Atlanta.Cer Request@marsh.com / Fax: 212-948-4321 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Evanston Insurance Company 35378 CN102326389-CAS-GAUWX-23-24 INSURED PlayCore Wisconsin, Inc. INSURER B : Continental Casualty Company 20443 INSURER C : American Casualty Company Of Reading, Pa 20427 Dba GameTime INSURER D : Transportation Insurance Cc 20494 150 PlayCore Drive SE Fort Payne, AL 35967 INSURER E : N/A N/A INSURER F : The COnt nental Insurance COMDanv 35289 COVERAGES CERTIFICATE NUMBER: ATL-005713001-01 REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY X MKLV2PBC002028 08/01/2023 08/01/2024 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE X� OCCUR DA AGE To TED PREMIS lccurrrence)$ SES (E. occurrence) 100,000 X MED EXP (Any one person) $ 10,000 SIR $250,000 Per Occ. PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY JE� LOC PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY AGGREGATE $ 10,000,000 OTHER: B AUTOMOBILE LIABILITY X BUA 7039895527 08/01/2023 08/01/2024 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Comp./Coll. Ded.: $1,000 $ F X UMBRELLALIAB X OCCUR 7039984806 08/01/2023 08/01/2024 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE RETENTION Umb Catastrophe $25,000 DED X RETENTION $ 0 $ C C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑N (Mandatory in NH) N/A X WC 7 39895530 WC 7 39895544 WC 7 39918871 08/01/2023 08/01/2023 08/01/2023 08/01/2024 08/01/2024 08/01/2024 X STATUTE OERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 C If yes, describe under DESCRIPTION OF OPERATIONS below WC 7 39929062 08/01/2023 08/01/2024 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Project No 2023-26 - LQ Park Fitness Equipment City of La Quinta, its officers, and employees are listed as additional insured in regards to services performed by the Insured, on a primary and non-contributory basis on the General Liability via CG 2010 & CG 2037 (04/13 form) and Automobile Liability via CA 2048 policies, when required by written contract. A Waiver of Subrogation applies in favor of the additional insureds on the Workers Compensation policy, when required by written contract. CERTIFICATE HOLDER CANCELLATION City of La Quinta SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 78495 Calle Tampico THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN La Quinta, CA 92253 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA LLC @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102326389 LOC #: Atlanta ACCOR " ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA, LLC. PlayCore Wisconsin, Inc. Dba GameTime POLICY NUMBER 150 PlayCore Drive SE Fort Payne,AL 35967 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers' Compensation (Continued): Carrier: Transportation Insurance Company Policy Number: WC 7039918885 Dates: 08/01/2023 - 08/01/2024 WC 7 39895530 - AL,CO,FL,GA,ID,IL,IN,KS,KY,ME,MD,MI,MN,MO,MT,NV,NY,NC,OK,OR,PA,SC,TN,TX,UT,VA WC 7 39895544 - CA WC 7 39918871 - AZ, OR, WI WC 7039918885- OH, ND, WY, WA ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CNA Workers Compensation And Employers Liability Insurance Information Page WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INFORMATION PAGE Coverage Provided By Policy Number American Casualty Company of Reading, Pennsylvania Policy Number: WC 7 39895530 a Stock Insurance Company Renewal of: New Policy 151 N Franklin St Chicago, IL 60606 NCCI Carrier Code: 10030 Item 1 Named Insured and Mailing Address Producer Information PLAYCORE GROUP, INC 544 CHESTNUT ST CHATTANOOGA, TN 37402-4906 MARSH USA LLC 3560 LENOX RD NE STE 2400 TWO ALLIANCE CTR ATLANTA, GA 30326-4266 Type of Entity: Corporation (Not Otherwise Classified) Producer Processing Code: 620-077696 FEIN Number: 82-2297804 Interstate ID No.: 910227165 If there are other Named Insureds: See Name and Address Schedule attached. If there are other work places not shown above: See Name and Address Schedule attached. Item 2 Policy Period , —1 1W 08/01 /2023 to 08/01 /2024 at 12:01 a.m. Standard Time at the Named Insured's mailing address shown above. Anniversary Rating Date: NONE 1111111 Item 3 A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: CO,States: AL, • OK, 'A Item 3 B. Employers Liability Insurance: Part Two of this policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease WC000001 $1,000,000 1 each accident $1,000,000 1 policy limit $1,000,000 1 each employee Form No: P-33398-E (06-1987) Policy No: WC 7 39895530 Information Page; Page: 1 of 2 Policy Effective Date: 08/01 /2023 Underwriting Company: American Casualty Company of Reading, Pennsylvania, 151 N Franklin St, Policy Page: 114 of 298 Chicago, IL 60606 ° Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. CNA Workers Compensation And Employers Liability Insurance Information Page policy� I Item 3 C. Other States Insurance: Part Three of this [States: All states except ND, OH, WA, WY and states designated in Item 3A of the Information Page Item 3 D. This policy includes these endorsements Schedule of Operations, Class Description Summary Page, Endorsement Schedule, Named Insured Schedule and Name and Address Schedule All information required below is subject to verification and change by audit. Adjustment of Premium shall be made: At Policy Expiration Classification of Operations: See Schedule of Operations Attached Minimum Premium Deposit Premium Account Number: 3042688303 Date of Issuance: 09/01 /2023 Policy Issuance Office: ATLANTA Chairman of the Board WC000001 Estimated Annual Premium Premium Discount Expense Constant Terrorism Premium Catastrophe (O/T Cert Acts of Terror) Total Estimated Annual Premium Total State Taxes/Assessments/Surcharges Total Estimated Cost Countersigned: Date: By: Authorized Agent Secretary Form No: P-33398-E (06-1987) Policy No: WC 7 39895530 Information Page; Page: 2 of 2 Policy Effective Date: 08/01 /2023 Underwriting Company: American Casualty Company of Reading, Pennsylvania, 151 N Franklin St, Policy Page: 115 of 298 Chicago, IL 60606 ° Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. CNA 1 Product Name Workers' Compensation V We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule "Any person or organization whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss" The premium charge for the endorsement is reflected in the Schedule of Operations. All other terms and conditions of the policy remain unchanged. This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below. Form No: WC 00 03 13 (04-1984) Policy No: W739895530; WC739895544; Endorsement Effective Date: 08/01 /2023 Endorsement Expiration Date:07/31 /2024 WC739918871; WC739929062 Endorsement No: TBD; Page: TBD Policy Effective Date: 08/01 /2023 Underwriting Company: AMERICAN CASUALTY COMPANY OF READING PENNSYLVANIA; Policy Page: TBD TRANSPORTATION INSURANCE COMPANY opyright 1983 National Council on Compensation Insurance. POLICY NUMBER: MKLV2PBC002028 EFFECTIVE: AUGUST 1, 2023 EXPIRES: AUGUST 1, 2024 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations As required by written contract executed by both All locations parties prior to loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section 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. © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 37 04 13 POLICY NUMBER: MKLV2PBC002028 EFFECTIVE: AUGUST 1, 2023 EXPIRES: AUGUST 1, 2024 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations As required by written contract executed by both All locations parties prior to loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section 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. © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 37 04 13 EFFECTIVE: AUGUST 1, 2023 EXPIRES: AUGUST 1, 2024 POLICY NUMBER: MKLV2PBC002028 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 01 04 13 Product Name CNA 1iusinesstxuto DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: P1ayCore Group, Inc. Endorsement Effective Date: 8/1/2023 SCHEDULE Name Of Person(s) Or Organization(s): "Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss." Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. Form No: CA 20 48 10 13 Policy No: BUA 703895527 Endorsement Effective Date: 08/01/2023 Policy Effective Date: 08/01/2023 Endorsement No: TBD; Page: TBD Policy Page: TBD Underwriting Company: CONTINENTAL CASUALTY COMPANY ° Copyright Insurance Services Office, Inc., 2011