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AC 84 23 08 11 © 2010, Liberty Mutual Group of Companies. All rights reserved.Page 1 of 1 <br />Includes copyrighted material of Insurance Services Office, Inc., <br />with its permission. <br />Policy Number: <br />Issued by: <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />DESIGNATED INSURED - NONCONTRIBUTING <br />This endorsement modifies insurance provided under the following: <br />BUSINESS AUTO COVERAGE FORM <br />GARAGE COVERAGE FORM <br />MOTOR CARRIERS COVERAGE FORM <br />TRUCKERS COVERAGE FORM <br />With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless <br />modified by this endorsement. <br />This endorsement identifies person(s)or organization(s)who are "insureds"under the Who Is An Insured <br />Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage form. <br />Schedule <br />Name of Person(s) or Organizations(s): <br />Regarding Designated Contract or Project: <br />Each person or organization shown in the Schedule of this endorsement is an "insured"for Liability Coverage,but <br />only to the extent that person or organization qualifies as an "insured"under the Who Is An Insured Provision <br />contained in Section II of the Coverage Form. <br />The following is added to the Other Insurance Condition: <br />If you have agreed in a written agreement that this policy will be primary and without right of contribution <br />from any insurance in force for an Additional Insured for liability arising out of your operations,and the <br />agreement was executed prior to the "bodily injury"or "property damage",then this insurance will be <br />primary and we will not seek contribution from such insurance. <br />"4 <br />Liberty Insurance Corp. <br />Any person or organization whom you have agreed in writing to a dd as an <br />additional insured, but only to coverage and minimum limits of insurance <br />required by the written agreement, and in no event to exceed ei ther the scope of <br />coverage or the limits of insurance provided in this policy. <br />Docusign Envelope ID: 60EE15FB-6306-4EE2-AF99-E2DF4E4D420C