03.01.22-03.01.23 WC GL CoI.pdf
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- Attached to
- Master Agreement AZ|CTR059324
- Contract number
- CTR059324
- Issued by
- Arizona
About this file
This document is a comprehensive insurance certificate and related endorsements for Sands Motor Company, an automotive dealership located in Glendale, Arizona. The insurance is provided by multiple insurers, including Charter Oak Fire Insurance Company and Travelers Property Casualty Insurance Company, with Trans City Casualty Insurance Agency as the producer. The certificate names the State of Arizona or Arizona Department of Transportation (ADOT) as the certificate holder, and covers multiple Sands Motor Company entities including Sands Chevrolet, Sands Imports, Sands Properties, and various real estate subsidiaries.
The insurance coverage includes commercial general liability, automobile liability, umbrella liability, and workers' compensation, with policy periods from March 1, 2022 to March 1, 2023. Key coverage limits include $1,000,000 for general liability, $1,000,000 for automobile liability, and $10,000,000 for umbrella liability. The policies cover new and used vehicle sales, parts, repairs, and general maintenance services across multiple locations including Sands Motor Company Inc., Sands Chevrolet Surprise, Sands Kia Surprise, and Sands Collision Center. The endorsements specifically include additional insured provisions for the State of Arizona and ADOT, with the insurance being primary and non-contributory for certain liability coverages.
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ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $
DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT
OTHER: $
COMBINED SINGLE LIMIT
$(Ea accident)
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED
BODILY INJURY (Per accident) $AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
$AUTOS ONLY AUTOS ONLY (Per accident)
OCCUR EACH OCCURRENCE
CLAIMS-MADE AGGREGATE $
DED RETENTION $
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below
INSURER(S) AFFORDING COVERAGE NAIC #
COMMERCIAL GENERAL LIABILITY
Y / N N / A
(Mandatory in NH)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
The ACORD name and logo are registered marks of ACORD
4/5/2022
(602) 992-9750 (602) 992-9775
25615
SANDS MOTOR COMPANY
PO Box 95 Glendale, AZ 85311
36161
A 1,000,000
X X Y-630-9P976926-COF-22 3/1/2022 3/1/2023 300,000
5,000
1,000,000 2,000,000 2,000,000
DEALERS INSURAN 1,000,000
1,000,000A
X X AD-0S318840-21CAG 3/1/2022 3/1/2023
10,000,000B
CUP-0S445908-22-14 3/1/2022 3/1/2023 10,000,000
100,000 10,000,000
A Garagekeepers AD-0S318840-21CAG 3/1/2022 Policy Aggregate 3,000,000
Additional Named Insureds:
SANDS MOTOR COMPANY
SANDS PROPERTIES LLC
SANDS CHEVROLET LLC
SANDS SURPRISE REAL ESTATE CHEVY LLC
SANDS IMPORTS LLC
SANDS SURPRISE REAL ESTATE KIA LLC
SEE ATTACHED ACORD 101
The State of Arizona or ADOT 1324 N 22nd Ave MD 128A Phoenix, AZ 85009
SANDMOT-01 PJOHNSON
AssuredPartners 7500 N. Dreamy Draw Dr., Ste. 100 Phoenix, AZ 85020
Charter Oak Fire Ins. Co.
Travelers Prop. Cas. Ins. Co.
Product-Comp/OP
3/1/2023
X X
X
X
X
X
X a8812 Accepted
FORM NUMBER:
EFFECTIVE DATE:
The ACORD name and logo are registered marks of ACORD
ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE
FORM TITLE:
Page of
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
ACORD 101 (2008/01)
AGENCY CUSTOMER ID:
LOC #:
AGENCY NAMED INSURED
POLICY NUMBER
CARRIER NAIC CODE
© 2008 ACORD CORPORATION. All rights reserved.
AssuredPartners
SANDMOT-01
SEE PAGE 1
SEE PAGE 1
ACORD 25 Certificate of Liability Insurance
SEE P 1
SANDS MOTOR COMPANY
PO Box 95 Glendale, AZ 85311 Maricopa
SEE PAGE 1
PJOHNSON
Description of Operations/Locations/Vehicles:
BELL ROAD HOLDINGS LLC
LOUIS SANDS IV REAL ESTATE LLLP
SANDS INSURANCE AGENCY LLC
SANDS MOTOR COMPANY 401K PROFIT SHARING PLAN
LS IV H20 LLC LS
IV MANAGEMENT CO.
Products and Work You Performed Aggregate of $2,000,000 applies to the Garage Liability.
Additional Insured: Primary and Non Contributory Conditions apply per form CA T6 18 01 18 The cert holder is Additional Insured to the garage liability policy for this insured.
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A :
NAIC #
NAME:
CONTACT
(A/C, No):
FAX
ADDRESS:
PRODUCER
(A/C, No, Ext):
PHONE
INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
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).
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.
OTHER:
(Per accident)
(Ea accident)
N / A
SUBR
WVD
ADDL
INSD
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.
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOSAUTOS ONLY
NON-OWNED
SCHEDULEDOWNED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-
STATUTE
PER
LIMITS(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
OCCUR
CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE
DAMAGE TO RENTED
$PREMISES (Ea occurrence)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY
PRO-
JECT LOC
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
a8812 Accepted
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
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
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective Date: Policy No.: Endorsement No.
11:
Premium:
Countersigned by:
Insured:
Insurance Company:
Trans City Casualty Insurance Company
WC 00 03 13 (Ed. 4-84)
© 1983 National Council on Compensation Insurance
| Form_EditionIdentifier_A: ACORD 0025 2016-03 Acroform |
| ISSUE DATE: 03/11/2022 |
| Producer_FullName_A: TRANS CITY CASUALTY INSURANCE AGENCY |
| Producer_MailingAddress_LineOne_A: 7500 E. MCDONALD DRIVE SUITE 600 |
| Producer_MailingAddress_LineTwo_A: SCOTTSDALE AZ 85250 |
| Producer_MailingAddress_CityName_A: |
| Producer_MailingAddress_StateOrProvinceCode_A: |
| Producer_MailingAddress_PostalCode_A: |
| Producer_ContactPerson_FullName_A: DAN HULSEY VP MARKETING |
| Producer_ContactPerson_PhoneNumber_A: 480-4893-4322 |
| Producer_FaxNumber_A: 480-483-0324 |
| Producer_ContactPerson_EmailAddress_A: DHULSEY@TRANSCITYINS.COM GMESA@TRANSCITYINS.COM |
| NamedInsured_MailingAddress_LineOne_A: (ALL CHAPMAN AUTO DEALERS/COLLISION CENTERS - AZ) |
| NamedInsured_MailingAddress_LineTwo_A: 7455 W. ORCHID LANE. |
| NamedInsured_MailingAddress_CityName_A: CHANDLER AZ, 85226 |
| NamedInsured_MailingAddress_StateOrProvinceCode_A: |
| NamedInsured_MailingAddress_PostalCode_A: |
| Insurer_FullName_A: TRANS CITY CASUALTY INSURANCE COMPANY |
| Insurer_NAICCode_A: 34002 |
| WorkersCompensationEmployersLiability_InsurerLetterCode_A: A |
| WorkersCompensationEmployersLiability_AnyPersonsExcludedIndicator_A: |
| WS19: Y |
| EXPIRATION DATE: 01/01/2023 |
| WorkersCompensationEmployersLiability_WorkersCompensationStatutoryLimitIndicator_A: 1 |
| WorkersCompensationEmployersLiability_OtherCoverageIndicator_A: Off |
| WorkersCompensationEmployersLiability_OtherCoverageDescription_A: |
| WorkersCompensationEmployersLiability_EmployersLiability_EachAccidentLimitAmount_A: 1,000,000 |
| WorkersCompensationEmployersLiability_EmployersLiability_DiseaseEachEmployeeLimitAmount_A: 1,000,000 |
| WorkersCompensationEmployersLiability_EmployersLiability_DiseasePolicyLimitAmount_A: 1,000,000 |
| REMARK 19: NEW AND USED VEHICLE SALES, PARTS, REPAIRS AND GENERAL MAINTENENACE SERVICES. |
Contract #: CTR059324 Locations:
SANDS MOTOR COMPANY INC., SANDS CHEVROLET SURPRISE, SANDS KIA SURPRISE, SANDS COLLISION CENTER
| CH120D: |
| CertificateHolder_MailingAddress_StateOrProvinceCode_A: |
| CertificateHolder_MailingAddress_PostalCode_A: |
| INSURED: SANDS MOTOR COMPANY INC./CHEVROLET/KIA/COLLISION CENTER |
| PREMIUM ANNIV: |
| EFFECTIVE DATE: 01/01/2022 |
| POLICY NO: WC0166,180,003-22 |
| CH20A: The State of Arizona or Arizona department of Transportation |
| CH20B: 1324 N. 22nd Ave MD 128A |
| CH20C: Phoenix, AZ 85009 |
| CH20D: |
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