Preview
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
9 Swiss Re
Corporate Solutions
November 18, 2014
FirstSpecialty Insurance Corporation
MR. RONALD SORG 5200 Metcalf Avenue
AMWINS BROKERAGE OF NEW JERSEY Overland Park KS 66202
110 FIELDCREST AVENUE USA
RARITAN PLAZA I
Telephone (913) 676-5200
EDISON, NJ 08837
www.swissre.com/corporatesolutions
Re: CACTUS HOLDINGS, INC.
Policy Number: IRA 2000002 02
Commission: 15.000%
Dear MR. RONALD SORG,
Attached is the policy for the above referenced insured. Please forward it to the insured and keep a copy for your file.
Please remember to stamp the Declarations Page of the policy with the appropriate Surplus Lines warning
language or complete the applicable surplus lines requirements for the insured's state of domicile.
to"
If you have not already done so, please forward the following "subject items that were listed on your binder. This
should include the following:
N/A
to"
All "subject items, endorsement requests and loss run reports should be submitted to one of the following
addresses:
USPS: E&S Casualty Mail
E-mail: FAX: 1-800-303-8415 P.O. Box 29129
ES CasualtyPriorityMail@swissre.com Shawnee Mission KS 66201
Please identify the policy number and underwriter name on all correspondence.
If you have questions regarding the policy, please contact the Underwriting Administrator, Sally Gustafson at
816-926-0610 or sally_gustafson@swissre.com. We appreciate the opportunity to be of service.
Sincerely,
Underwriting Services
attachment
06/14
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
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SP53690514
Insurance
Productsunderwrittenby WestportInsurance FirstSpecialtyinsurance
Corporation. NorthAmericanCapacityInsurance
Corporation. NorthAmericanSpecialty
Company.
[nsurance
Company. NorthAmericanEliteInsurance Washington
Company. International
Insurance
Company. orSwissReInternational
SE.
SwissReCorporate Solutionsoffersinnovative, high-qualityinsurance capacityforsingleandmulti-lineprogrammes worldwide.eitherona standalone basisoraspartofstructured
andtailor-madesolutions.[naddition.it providescustomised risktransfersolutionstomid-sizedand[arge.multinational
corporationsacrosstheglobetoassistin mitigatingtheirrisk
exposure.SwissReCorporate Solutions servesmorethan50000 customers acrossnearly40 officesworldwideandisbackedbythefinancialstrengthoftheSwissReGroup.Formore
information
aboutSwissReCorporate Solutions.pleasevisit.www.swissre.com/corporatesolutions
e2014SwissRe.
e2014SwissReAllnghts
All rightsreserved
reserved.
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
Policy Number: IRA 2000002 02
First Specialty Insurance Corporation
Renewal of Number: IRA 2000002 01
COMMON POLICY DECLARATIONS
Administrative Address: 5200 Metcalf Avenue, Overland Park, KS 66202
Domiciliary Address: 237 East High Street, Jefferson City, MO 65102
Item 1. Named Insured and Mailing Address Agent Name and Address
CACTUS HOLDINGS, INC. AMWINS BROKERAGE OF NEW JERSEY
47-05 METROPOLITAN AVE 110 FIELDCREST AVENUE
RIDGEWOOD, NY 11385 RARITAN PLAZA I
EDISON, NJ 08837
Item 2. Policy Period: From: November 15, 2014 To: November 15, 2015
at 12:01 A.M., Standard Time at your mailing address shown above
Item 3. Business Description: Grocery Stores
Form of Business: Corporation
Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the
insurance as stated in this policy.
This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no
coverage. This premium may be subject to adjustment.
Coverage Part(s) Premium
Commercial Property Coverage Part N/A
Commercial General Liability Coverage Part $601,200
Commercial Crime Coverage Part N/A
Commercial Inland Marine Coverage Part N/A
Commercial Auto (Business or Truckers) Coverage Part N/A
Liquor Liability Coverage Form $23,800
Garage Coverage Form N/A
Total Deposit Premium: $625,000
Minimum Earned Premium %: 35.0 Minimum Premium: $612,500
Item 5. Forms and Endorsements
Form(s) and Endorsement(s) made a part of this policy at time of issue: See Schedule of Forms and Endorsements
THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH THE COMMON POLICY CONDITIONS,
COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE-NUMBERED POLICY.
SP 2 207 0711 Page 1 of1
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
First Specialty Insurance Corporation Number IRA 2000002 02
Policy
SCHEDULE OF FORMS AND ENDORSEMENTS
Named Insured Effective Date: November 15, 2014
12:01 A.M., Standard Time
CACTUS HOLDINGS, INC.
Agent Name: Agent No. 1008776
AMWINS BROKERAGE OF NEW JERSEY
Policy Form Description Form Number Edition Date
Common Policy Declarations SP 2 207 07-11
Schedule of Forms and Endorsements SP 2 174 06-11
Claims Reporting Procedures SP 3 291 06-11
Surplus Lines Warning Message SLN0001NY 02-13
Service of Suit Clause Endorsement FSIC 3371 06-11
Common Policy Conditions IL 00 17 11-98
Commercial General Liability Coverage Part Declarations SP 3 550 07-12
Amendment of Conditions SP 4 546 06-11
Bases of Premium Clarification Endorsement SP 4 547 06-11
Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 00 21 09-08
Total Lead Exclusion SP 4 040 06-11
Asbestos Exclusion SP 3 549 06-11
Fungi or Bacteria Exclusion CG 21 67 12-04
Silica or Silica-Related Dust Exclusion CG 21 96 03-05
Acts of Discrimination Exclusion SP 3 559 04-14
International Trade Controls SP 5 400 11-11
Signature Page SP 3 881 03-07
Commercial General Liability Coverage Form CG 00 01 12-07
Employment-Related Practices Exclusion CG 21 47 12-07
Exclusion - Coverage C - Medical Payments CG 21 35 10-01
Self-Insured Retention Endorsement (TPA-Administered - Defense Costs Included) SP 5 436 12-11
Cap on Losses from Certified Acts of Terrorism CG 21 70 01-08
Exclusion of Punitive Damages Related to a Certified Act of Terrorism CG 21 76 01-08
Disclosure Pursuant to Terrorism Risk Insurance Act IL 09 85 01-08
Employee Benefits Liability Coverage CG 04 35 12-07
Additional Insured - Managers or Lessors of Premises CG 20 11 01-96
Additional Insured - Vendors CG 20 15 07-04
Additional Insured - Vendors CG 20 15 07-04
Additional Insured - or Receiver CG 20 18 11-85
Mortgagee, Assignee,
Exclusion - Designated Professional Services CG 21 16 07-98
Waiver of Transfer of Rights of Recovery Against Others to Us CG 24 04 05-09
Unintentional Errors or Omissions FSIC 33537 06-11
Cross Suits Liability Exclusion FSIC 3392 06-11
Amendment - Aggregate Limits of Insurance (Per Location - with SP 2 388 06-11
Policy Cap)
New York Owners and Contractors Endorsement SP 2 930 06-11
Knowledge and Notice of Occurrence SP 4 563 06-11
SP 2 174 0611 Page 1 of2
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
First Specialty Insurance Corporation Number IRA 2000002 02
Policy
SCHEDULE OF FORMS AND ENDORSEMENTS
Named Insured Effective Date: November 15, 2014
12:01 A.M., Standard Time
CACTUS HOLDINGS, INC.
Agent Name: Agent No. 1008776
AMWINS BROKERAGE OF NEW JERSEY
Policy Form Description Form Number Edition Date
Broad Form Named Insured Endorsement SP 5 086 04-12
Liquor Liability Coverage Part Declarations SP 2 189 07-11
Liquor Liability Coverage Form CG 00 33 12-07
Assault and Battery Exclusion - Liquor SP 3 892 06-11
Liability
Deductible Liability Insurance CG 03 05 01-96
SP 2 174 0611 Page 2 of2
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
First Specialty Insurance Corporation
CLAIMS REPORTING PROCEDURES
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
In the event of a claim or potential claim, please immediately complete and forward a First Notice of Loss on an
ACORD Loss Form, along witha copy of the Policy Declarations Page and any policy-specific, manuscripted
endorsements to one of the following addresses:
By Mail: E&S Casualty Claims, P.O. Box 2976, Overland Park, Kansas 66201
By Fax: Send to the attention of E&S Casualty Claims at (866) 487-8755
By e-mail: ES_CasualtyClaims@SwissRe.com
By Special Delivery (Fed Ex, UPS): E&S Casualty Claims
5200 Metcalf
Overland Park, Kansas 66202
All other terms and conditions of this policy shall remain unchanged.
This endorsement forms a part of the policy to which attached, effective on the inception date of the policy unless
otherwise stated herein.
Policy Number:
Named Insured:
Endorsement Effective Date:
SP 3 291 0611 Page 1 of 1
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
First Specialty Insurance Corporation
THE INSURER(S) NAMED HEREIN IS (ARE) NOT LICENSED BY THE STATE OF NEW YORK,
NOT SUBJECT TO ITS SUPERVISION, AND IN THE EVENT OF THE INSOLVENCY OF THE
INSURER(S), NOT PROTECTED BY THE NEW YORK STATE SECURITY FUNDS. THE POLICY
MAY NOT BE SUBJECT TO ALL OF THE REGULATIONS OF THE INSURANCE DEPARTMENT
PERTAINING TO POLICY FORMS.
SLN0001NY 0213 Page 1 of1
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
First Specialty Insurance Corporation
SERVICE OF SUIT CLAUSE ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Service of process in any lawsuit, or mandated alternative dispute resolution (ADR) proceeding instituted against
the Company may be made upon:
General Counsel
First Specialty Insurance Corporation
5200 Metcalf
Overland Park, Kansas 66201
The above party is authorized
and directed to accept service of process on behalf of the Company in any suit or
ADR proceeding, and/or, upon the request of the insured, agrees to give a written undertaking to the insured that
he will enter a general appearance upon the Company's behalf should a lawsuit, or ADR proceeding be instituted.
Further, pursuant to any law of any state, the District of Columbia, territory, or protectorate of the United States
which makes provision therefore, the Company hereby designates the Superintendent, Commissioner, Director of
Insurance, deputy, or department employee specified as attorney or agent for receipt of lawful service of process or
ADR proceeding, in the law, instituted by or on behalf of the insured or any beneficiary within this contract, the
above is hereby authorized as the company's designee upon whom the service of process may be served.
Nothing contained herein shall limit or abridge the right to serve any process, notice or demand upon the company
in any other manner permitted or required by law.
All other terms and conditions of this policy shall remain unchanged.
This endorsement forms a part of the policy to which attached, effective on the inception date of the policy unless
otherwise stated herein.
Policy Number:
Named Insured:
Endorsement Effective Date:
FSIC 3371 0611 Page 1 of 1
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018
NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018
IL 00 17 11 98
COMMON POLICY CONDITIONS
All Coverage Parts included in this policy are subject to the following conditions.
A. Cancellation b. Give you reports on the conditions we
find; and
1. ~ The first Named Insured shown in the Dec-
larations may cancel this policy by mailing or c. Recommend changes.
delivering to us advance written notice of .
2. We are not obligated to make
any inspections,
cancellation.
surveys, reports or recommendations and any
2. We cancel this or de- such actions we do undertake relate to
may policy by mailing only
livering to the first Named Insured written insurability and the premiums to be charged.
notice of cancellation at least: We do not make safety inspections. We do
not undertake to perform the duty of any
a. 10 days before the effective date of can-
person or organization to provide for the
cellation if we cancel for nonpayment of
health or safety of workers or the public. And
premium; or
we do not warrant that conditions:
b. 30 days before the effective date of can-
a. Are safe or healthful; or
cellation if we cancel for any other
reason. b. Comply with laws, regulations, codes or
standards.
3. We will mail or deliver our notice to the first
Named Insured's last mailing address known 3. Paragraphs 1. ~ and 2. of this condition apply
to us. not to us, but also to rating, ad-
only any
. . visory, rate service or similar organization
4. Notice of cancellation will state the effective
which makes insurance inspections, surveys,
date of cancellation. The policy period will
reports or recommendations.
end on that date.
. 4. Paragraph 2. of this condition does not apply
5. If this
policy is cancelled, we will send the recom-
to any inspections, surveys, reports or
first Named Insured any premium refund due.
mendations we make relative to certifi-
may
If we cancel, the refund will be pro rata. If the or-
cation, under state or municipal statutes,
first Named Insured cancels, the refund may dinances or
regulations, of boilers, pressure
be less than pro rata. The cancellation will be
Preview
FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 9 Swiss Re Corporate Solutions November 18, 2014 FirstSpecialty Insurance Corporation MR. RONALD SORG 5200 Metcalf Avenue AMWINS BROKERAGE OF NEW JERSEY Overland Park KS 66202 110 FIELDCREST AVENUE USA RARITAN PLAZA I Telephone (913) 676-5200 EDISON, NJ 08837 www.swissre.com/corporatesolutions Re: CACTUS HOLDINGS, INC. Policy Number: IRA 2000002 02 Commission: 15.000% Dear MR. RONALD SORG, Attached is the policy for the above referenced insured. Please forward it to the insured and keep a copy for your file. Please remember to stamp the Declarations Page of the policy with the appropriate Surplus Lines warning language or complete the applicable surplus lines requirements for the insured's state of domicile. to" If you have not already done so, please forward the following "subject items that were listed on your binder. This should include the following: N/A to" All "subject items, endorsement requests and loss run reports should be submitted to one of the following addresses: USPS: E&S Casualty Mail E-mail: FAX: 1-800-303-8415 P.O. Box 29129 ES CasualtyPriorityMail@swissre.com Shawnee Mission KS 66201 Please identify the policy number and underwriter name on all correspondence. If you have questions regarding the policy, please contact the Underwriting Administrator, Sally Gustafson at 816-926-0610 or sally_gustafson@swissre.com. We appreciate the opportunity to be of service. Sincerely, Underwriting Services attachment 06/14 FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. 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NorthAmericanCapacityInsurance Corporation. NorthAmericanSpecialty Company. [nsurance Company. NorthAmericanEliteInsurance Washington Company. International Insurance Company. orSwissReInternational SE. SwissReCorporate Solutionsoffersinnovative, high-qualityinsurance capacityforsingleandmulti-lineprogrammes worldwide.eitherona standalone basisoraspartofstructured andtailor-madesolutions.[naddition.it providescustomised risktransfersolutionstomid-sizedand[arge.multinational corporationsacrosstheglobetoassistin mitigatingtheirrisk exposure.SwissReCorporate Solutions servesmorethan50000 customers acrossnearly40 officesworldwideandisbackedbythefinancialstrengthoftheSwissReGroup.Formore information aboutSwissReCorporate Solutions.pleasevisit.www.swissre.com/corporatesolutions e2014SwissRe. e2014SwissReAllnghts All rightsreserved reserved. FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 Policy Number: IRA 2000002 02 First Specialty Insurance Corporation Renewal of Number: IRA 2000002 01 COMMON POLICY DECLARATIONS Administrative Address: 5200 Metcalf Avenue, Overland Park, KS 66202 Domiciliary Address: 237 East High Street, Jefferson City, MO 65102 Item 1. Named Insured and Mailing Address Agent Name and Address CACTUS HOLDINGS, INC. AMWINS BROKERAGE OF NEW JERSEY 47-05 METROPOLITAN AVE 110 FIELDCREST AVENUE RIDGEWOOD, NY 11385 RARITAN PLAZA I EDISON, NJ 08837 Item 2. Policy Period: From: November 15, 2014 To: November 15, 2015 at 12:01 A.M., Standard Time at your mailing address shown above Item 3. Business Description: Grocery Stores Form of Business: Corporation Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment. Coverage Part(s) Premium Commercial Property Coverage Part N/A Commercial General Liability Coverage Part $601,200 Commercial Crime Coverage Part N/A Commercial Inland Marine Coverage Part N/A Commercial Auto (Business or Truckers) Coverage Part N/A Liquor Liability Coverage Form $23,800 Garage Coverage Form N/A Total Deposit Premium: $625,000 Minimum Earned Premium %: 35.0 Minimum Premium: $612,500 Item 5. Forms and Endorsements Form(s) and Endorsement(s) made a part of this policy at time of issue: See Schedule of Forms and Endorsements THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE-NUMBERED POLICY. SP 2 207 0711 Page 1 of1 FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 First Specialty Insurance Corporation Number IRA 2000002 02 Policy SCHEDULE OF FORMS AND ENDORSEMENTS Named Insured Effective Date: November 15, 2014 12:01 A.M., Standard Time CACTUS HOLDINGS, INC. Agent Name: Agent No. 1008776 AMWINS BROKERAGE OF NEW JERSEY Policy Form Description Form Number Edition Date Common Policy Declarations SP 2 207 07-11 Schedule of Forms and Endorsements SP 2 174 06-11 Claims Reporting Procedures SP 3 291 06-11 Surplus Lines Warning Message SLN0001NY 02-13 Service of Suit Clause Endorsement FSIC 3371 06-11 Common Policy Conditions IL 00 17 11-98 Commercial General Liability Coverage Part Declarations SP 3 550 07-12 Amendment of Conditions SP 4 546 06-11 Bases of Premium Clarification Endorsement SP 4 547 06-11 Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 00 21 09-08 Total Lead Exclusion SP 4 040 06-11 Asbestos Exclusion SP 3 549 06-11 Fungi or Bacteria Exclusion CG 21 67 12-04 Silica or Silica-Related Dust Exclusion CG 21 96 03-05 Acts of Discrimination Exclusion SP 3 559 04-14 International Trade Controls SP 5 400 11-11 Signature Page SP 3 881 03-07 Commercial General Liability Coverage Form CG 00 01 12-07 Employment-Related Practices Exclusion CG 21 47 12-07 Exclusion - Coverage C - Medical Payments CG 21 35 10-01 Self-Insured Retention Endorsement (TPA-Administered - Defense Costs Included) SP 5 436 12-11 Cap on Losses from Certified Acts of Terrorism CG 21 70 01-08 Exclusion of Punitive Damages Related to a Certified Act of Terrorism CG 21 76 01-08 Disclosure Pursuant to Terrorism Risk Insurance Act IL 09 85 01-08 Employee Benefits Liability Coverage CG 04 35 12-07 Additional Insured - Managers or Lessors of Premises CG 20 11 01-96 Additional Insured - Vendors CG 20 15 07-04 Additional Insured - Vendors CG 20 15 07-04 Additional Insured - or Receiver CG 20 18 11-85 Mortgagee, Assignee, Exclusion - Designated Professional Services CG 21 16 07-98 Waiver of Transfer of Rights of Recovery Against Others to Us CG 24 04 05-09 Unintentional Errors or Omissions FSIC 33537 06-11 Cross Suits Liability Exclusion FSIC 3392 06-11 Amendment - Aggregate Limits of Insurance (Per Location - with SP 2 388 06-11 Policy Cap) New York Owners and Contractors Endorsement SP 2 930 06-11 Knowledge and Notice of Occurrence SP 4 563 06-11 SP 2 174 0611 Page 1 of2 FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 First Specialty Insurance Corporation Number IRA 2000002 02 Policy SCHEDULE OF FORMS AND ENDORSEMENTS Named Insured Effective Date: November 15, 2014 12:01 A.M., Standard Time CACTUS HOLDINGS, INC. Agent Name: Agent No. 1008776 AMWINS BROKERAGE OF NEW JERSEY Policy Form Description Form Number Edition Date Broad Form Named Insured Endorsement SP 5 086 04-12 Liquor Liability Coverage Part Declarations SP 2 189 07-11 Liquor Liability Coverage Form CG 00 33 12-07 Assault and Battery Exclusion - Liquor SP 3 892 06-11 Liability Deductible Liability Insurance CG 03 05 01-96 SP 2 174 0611 Page 2 of2 FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 First Specialty Insurance Corporation CLAIMS REPORTING PROCEDURES THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. In the event of a claim or potential claim, please immediately complete and forward a First Notice of Loss on an ACORD Loss Form, along witha copy of the Policy Declarations Page and any policy-specific, manuscripted endorsements to one of the following addresses: By Mail: E&S Casualty Claims, P.O. Box 2976, Overland Park, Kansas 66201 By Fax: Send to the attention of E&S Casualty Claims at (866) 487-8755 By e-mail: ES_CasualtyClaims@SwissRe.com By Special Delivery (Fed Ex, UPS): E&S Casualty Claims 5200 Metcalf Overland Park, Kansas 66202 All other terms and conditions of this policy shall remain unchanged. This endorsement forms a part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein. Policy Number: Named Insured: Endorsement Effective Date: SP 3 291 0611 Page 1 of 1 FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 First Specialty Insurance Corporation THE INSURER(S) NAMED HEREIN IS (ARE) NOT LICENSED BY THE STATE OF NEW YORK, NOT SUBJECT TO ITS SUPERVISION, AND IN THE EVENT OF THE INSOLVENCY OF THE INSURER(S), NOT PROTECTED BY THE NEW YORK STATE SECURITY FUNDS. THE POLICY MAY NOT BE SUBJECT TO ALL OF THE REGULATIONS OF THE INSURANCE DEPARTMENT PERTAINING TO POLICY FORMS. SLN0001NY 0213 Page 1 of1 FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 First Specialty Insurance Corporation SERVICE OF SUIT CLAUSE ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Service of process in any lawsuit, or mandated alternative dispute resolution (ADR) proceeding instituted against the Company may be made upon: General Counsel First Specialty Insurance Corporation 5200 Metcalf Overland Park, Kansas 66201 The above party is authorized and directed to accept service of process on behalf of the Company in any suit or ADR proceeding, and/or, upon the request of the insured, agrees to give a written undertaking to the insured that he will enter a general appearance upon the Company's behalf should a lawsuit, or ADR proceeding be instituted. Further, pursuant to any law of any state, the District of Columbia, territory, or protectorate of the United States which makes provision therefore, the Company hereby designates the Superintendent, Commissioner, Director of Insurance, deputy, or department employee specified as attorney or agent for receipt of lawful service of process or ADR proceeding, in the law, instituted by or on behalf of the insured or any beneficiary within this contract, the above is hereby authorized as the company's designee upon whom the service of process may be served. Nothing contained herein shall limit or abridge the right to serve any process, notice or demand upon the company in any other manner permitted or required by law. All other terms and conditions of this policy shall remain unchanged. This endorsement forms a part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein. Policy Number: Named Insured: Endorsement Effective Date: FSIC 3371 0611 Page 1 of 1 FILED: NEW YORK COUNTY CLERK 08/02/2018 03:16 PM INDEX NO. 652336/2018 NYSCEF DOC. NO. 11 RECEIVED NYSCEF: 08/02/2018 IL 00 17 11 98 COMMON POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions. A. Cancellation b. Give you reports on the conditions we find; and 1. ~ The first Named Insured shown in the Dec- larations may cancel this policy by mailing or c. Recommend changes. delivering to us advance written notice of . 2. We are not obligated to make any inspections, cancellation. surveys, reports or recommendations and any 2. We cancel this or de- such actions we do undertake relate to may policy by mailing only livering to the first Named Insured written insurability and the premiums to be charged. notice of cancellation at least: We do not make safety inspections. We do not undertake to perform the duty of any a. 10 days before the effective date of can- person or organization to provide for the cellation if we cancel for nonpayment of health or safety of workers or the public. And premium; or we do not warrant that conditions: b. 30 days before the effective date of can- a. Are safe or healthful; or cellation if we cancel for any other reason. b. Comply with laws, regulations, codes or standards. 3. We will mail or deliver our notice to the first Named Insured's last mailing address known 3. Paragraphs 1. ~ and 2. of this condition apply to us. not to us, but also to rating, ad- only any . . visory, rate service or similar organization 4. Notice of cancellation will state the effective which makes insurance inspections, surveys, date of cancellation. The policy period will reports or recommendations. end on that date. . 4. Paragraph 2. of this condition does not apply 5. If this policy is cancelled, we will send the recom- to any inspections, surveys, reports or first Named Insured any premium refund due. mendations we make relative to certifi- may If we cancel, the refund will be pro rata. If the or- cation, under state or municipal statutes, first Named Insured cancels, the refund may dinances or regulations, of boilers, pressure be less than pro rata. The cancellation will be