2020-11-07 COI WC.pdf

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

JHAINES

11/05/2019

CMACONS-01

A 7110109640011

A 7110109640011

A 4060241100011

A 7110109640011

1,000,000 1,000,000

1,000,000

10,000 10,000,000 10,000,000

2,000,000

1,000,000 2,000,000

10,000 1,000,000 1,000,000

1,000,000

X

X

X

X

X

X X

X X

11/07/2019 11/07/2020

11/07/2019 11/07/2020

11/07/2019 11/07/2020

11/07/2019 11/07/2020

RE: Contract No. CTR045033 See Remarks

State of Arizona, its departments, agencies, boards, commissions, officers, universities, officials, and employees are additional insured to general liability only as required by written contract with respect to liability arising out of activities performed by or on behalf of the contractor. State of Arizona, its departments, agencies, boards, commissions, officers, universities, officials, and employees are additional insured to auto liability with respect to liability arising out of activities performed by or on behalf of the contractor involving automobiles owned, leased, hired or borrowed by the contractor. Waiver of

SEE ATTACHED ACORD 101

Rose & Kiernan, Inc.

99 Troy Road East Greenbush, NY 12061

(518) 244-4262(518) 244-4245

Arizona Department of Health Services 1740 W Adams Suite 303 Phoenix, AZ 85007

CMA Consulting Services Currier McCabe & Assoc Inc 700 Troy-Schenectady Road Latham, NY 12110

OneBeacon America Ins Co. 20621

X

X

N

X

X

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.

Rose & Kiernan, Inc.

CMACONS-01

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

CMA Consulting Services Currier McCabe & Assoc Inc 700 Troy-Schenectady Road Latham, NY 12110 AlbanySEE PAGE 1

JHAINES

Description of Operations/Locations/Vehicles:

subrogation applies to general liability and workers compensation against the State of Arizona, its departments, agencies, boards, commissions, officers, universities, officials, and employees with respect to losses arising out of work performed by or on behalf of the contractor per noted policy forms

General Liability Policy contains form VCG761 NY 0205 that includes the following;

Additional Insured - Broad Form Vendors Additional Insured - By Contract, Agreement or Permit relating to work performed by you. Premises you own, rent, lease or occupy, equipment you lease. This insurance is primary & non-contributory if that is required in writing by the Contract, Agreement or Permit.

Blanket Waiver of Subrogation when required by contract