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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 />Docusign Envelope ID: 64CB58D5-D017-49AC-85D7-20BCCED1A57F