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):

E-MAIL

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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A2.3,-.-1:/.0U;A.2-1/0.-,?/@4.0�/-<2.0@AA>,9@U>.

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

E-MAIL

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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