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CG 20 10 04 13 Page 1 of 2 <br />A0187554 <br />Middlesex Insurance Company <br />POLICY NUMBER: <br />© Insurance Services Office, Inc., 2012 <br />COMMERCIAL GENERAL LIABILITY <br />CG 20 10 04 13 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />ADDITIONAL INSURED - OWNERS, LESSEES OR <br />CONTRACTORS - SCHEDULED PERSON OR <br />ORGANIZATION <br />This endorsement modifies insurance provided under the following: <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART <br />SCHEDULE <br />Name Of Additional Insured Person(s) <br />Or Organization(s)Location(s) Of Covered Operations <br />Any person or organization you are required to add as <br />an <br />additional insured under a written contract or <br />agreement <br />in effect prior to any accident, injury, loss or damage. <br />All locations per written contract, agreement or <br />permit. <br />Description: <br />All jobs performed that have a written contract, <br />agreement, or permit. <br />Information required to complete this Schedule, if not shown above, will be shown in the Declarations. <br />A.Section II - Who Is An Insured is amended to <br />include as an additional insured the person(s) or <br />organization(s) shown in the Schedule, but only <br />with respect to liability for "bodily injury", <br />"property damage" or "personal and advertising <br />injury" caused, in whole or in part, by: <br />1.Your acts or omissions; or <br />2.The acts or omissions of those acting on your <br />behalf; <br />in the performance of your ongoing operations for <br />the additional insured(s) at the location(s) <br />designated above. <br />However: <br />1.The insurance afforded to such additional <br />insured only applies to the extent permitted by <br />law; and <br />2.If coverage provided to the additional insured <br />is required by a contract or agreement, the <br />insurance afforded to such additional insured <br />will not be broader than that which you are <br />required by the contract or agreement to <br />provide for such additional insured. <br />B.With respect to the insurance afforded to these <br />additional insureds, the following additional <br />exclusions apply: <br />This insurance does not apply to "bodily injury" or <br />"property damage" occurring after: <br />1.All work, including materials, parts or <br />equipment furnished in connection with such <br />work, on the project (other than service, <br />maintenance or repairs) to be performed by or <br />on behalf of the additional insured(s) at the <br />location of the covered operations has been <br />completed; or <br />2.That portion of "your work" out of which the <br />injury or damage arises has been put to its <br />intended use by any person or organization <br />other than another contractor or <br />subcontractor engaged in performing <br />operations for a principal as a part of the same <br />project. <br />A0187554003 <br />00001 0000000000 22047 0 N1 58c328ae-cc30-4fbb-b685-7ecb3405cdea58c328ae-cc30-4fbb-b685-7ecb3405cdea <br />Docusign Envelope ID: 67863BCC-80EA-4357-8D30-8E7498D8853E