2021-09-01_GL_SAM_AL_U_WC_PL.pdf

7/12/2021

AssuredPartners of Arizona, LLC 4544 E Camp Lowell Dr Ste 110

Tucson AZ 85712-1282

Joshua Parra (520)571-7737 (520)571-9115 joshua.parra@assuredpartners.com

DK Advocates Inc, ANB Services LLC 23335 N 18th Dr

STE B-124

Phoenix AZ 85027

Social Services Contractor Ind Southwest Risk Services, Inc CopperPoint General Insurance Company

20.21 MASTER

A X

X X Sexual Abuse & Molestation included

X

X 60005273 9/1/2020 9/1/2021

1,000,000 500,000 10,000

1,000,000 3,000,000 1,000,000

A X X

X 60005273 9/1/2020 9/1/2021

1,000,000

B X X

60005483 9/1/2020 9/1/2021 1,000,000 1,000,000

C 1019971 9/1/2020 9/1/2021

X 1,000,000 1,000,000 1,000,000

A Professional Liability 60005273 9/1/2020 9/1/2021 Per Occurence/Aggregate $1mil/$3mil A Employee Dishonesty 60005273 9/1/2020 9/1/2021 Aggregate/Deductible $250k/$1k

Sexual abuse & Molestation included in General Liability limit RE: CTR049897 Career Exploration; ADES13-044254 Work Adjustment Training; ADES13-050738 Job Training;

ADES15-097167 Disability Related Employment Services; CTR055496 Extended Supportive Employment;

ADES13-044214 Work Adjustment Training; ADES14-071723 for RIS (Various Disabilities); CTR056087 Employment Related Services - Pre- Employment Transition Services (Pre-ETS)

ADES/RSA Insurance Monitor P.O. Box 6123, Site Code 930A Phoenix, AZ 85005-6123

RSAContractsUnitInsurance@azd

D Lovitt Jr, CLU/JOSH

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSD

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

OTHER:

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 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:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

General and Auto Liability contain additional insured and waivers of subrogation in favor of The State of Arizona, its departments, agencies, boards, commissions, and universities, and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the Contractor.

COMMENTS/REMARKS

COPYRIGHT 2000, AMS SERVICES INC.OFREMARK

Social Service Contractors Indemnity Pool

EXCESS LIABILITY COVERAGE AGREEMENT DECLARATIONS_SSEDEC_08/17

SSEDEC (08-17) Includes wording © ISO Properties. Used with Permission Page 1 of 2

EXCESS LIABILITY COVERAGE AGREEMENT

DECLARATIONS

Policy # 6000548-3

Replaces Policy # 6000548-

2SSCE

THIS DECLARATIONS PAGE AND THE ATTACHED EXCESS LIABILITY COVERAGE AGREEMENT COMPLETE THIS COVERAGE PART.

Item 1. "NAMED INSURED":

DK Advocates Inc 23335 N 18th Drive Suite B-124 Phoenix, AZ 85027

Item 2. CONTINOUS COVERAGE PERIOD:

12:01 A.M. Standard Time at Named Insured Mailing Address

Rating Period from: 09/01/2020 To: 09/01/2021

Item 3. LIMITS OF INSURANCE

Aggregate Limit of Liability

$ 1,000,000 $ 1,000,000

Item 4. EXCESS RETRO-ACTIVE DATE:

Professional: 09/01/2018

Employers Benefits Liability:

Item 5. SCHEDULE OF "UNDERLYING INSURANCE COVERAGE":

Excess coverage applies only to coverage for which underlying Limits of Coverage are shown.

COMMERCIAL GENERAL LIABILITY LIMITS (OCCURRENCE)

Underlying Insurer: SSCIP Underlying Policy Number: 6000527-3 Policy Period: From: 09/01/2020 General Liability/Sexual Abuse & Molestation – If applicable Aggregate $ 3,000,000 General Liability/Sexual Abuse & Molestation – If applicable Each Occurrence $ 1,000,000 Products - Completed Operations - Occurrence/Aggregate $ 3,000,000

SSEDEC (08-17) Includes wording © ISO Properties. Used with Permission Page 2 of 2

Personal Advertising Injury $ 1,000,000

AUTOMOBILE LIABILITY LIMITS (OCCURRENCE)

Underlying Insurer: SSCIP Underlying Policy Number: 6000527-3 Policy Period: From: 09/01/2020 Bodily Injury Liability - Each Accident Limit $ 1,000,000 Property Damage Liability -Each Accident Limit $ 1,000,000

EMPLOYERS LIABILITY (OCCURRENCE)

Underlying Insurer:

Underlying Policy Number:

Policy Period:

Bodily Injury - By Accident Limit $ Not Covered Bodily Injury By Disease - Each Employee Limit $ Not Covered Bodily Injury By Disease - Policy Limit $ Not Covered

PROFESSIONAL LIABILITY (CLAIMS MADE)

Underlying Insurer: SSCIP Underlying Policy Number: 6000527-3 Policy Period: From: 09/01/2020 Errors and Omissions - Each Claim $ 1,000,000 Errors and Omissions - Aggregate $ 3,000,000

EMPLOYEE BENEFITS LIABILITY (CLAIMS MADE)

Underlying Insurer:

Underlying Policy Number:

Policy Period:

Employee Benefits - Each Incident $ Not Covered Employee Benefits - Aggregate $ Not Covered

Item 6. PREMIUM: $ 1,250

Item 7. COVERAGE FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE:

SSECOV (08/17) SSECON (08/17)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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 State Blanket/Schedule/State

AZ STATE

State Waiver: State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

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.)

09/01/2020Endorsement Effective 1019971Policy No. 17Endorsement No.

DK Advocates IncInsured 100 Premium $

CopperPoint General Insurance CompanyInsurance Company Countersigned by

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B

(Version 7/01)

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.)

09/01/2020Endorsement Effective 1019971Policy No. 16Endorsement No.

DK Advocates IncInsured $100Premium Cost Change

CopperPoint General Insurance CompanyInsurance Company Countersigned by

WC 89 06 00 B

(Version 7/01)

© Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved.

POLICY INFORMATION PAGE ENDORSEMENT

The following item(s)

Insured’s Name (WC 89 06 01) Expiration Date (WC 89 06 04) Insured’s Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer’s Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured’s Legal Status (WC 89 06 10) Item 3.A. States (WC 89 06 11)

Item 3.B. Limits (WC 89 06 12) Item 3 .C. States (WC 89 06 13) Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4.* Class, Rate, Other (WC 89 04 15) Interim Adjustment of Premium (WC 89 04 16) Interstate/Intrastate Risk ID Number (WC 89 06 18) Issuing Agency/Producer Office Address (WC 89 06 25)

Is changed to read:

Total Estimated Annual Premium: $3,595

SSCOMMAIAZ (01/21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WHO IS AN INSURED – ADDITIONAL INSURED

This insurance modifies insurance provided under the following:

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION COVERAGE FORM

BUSINESS AUTO COVERAGE FORM (coverage applies to owned, leased, hired or borrowed vehicles) COMMERCIAL GENERAL LIABILITY COVERAGE FORM (including

Products-Completed Operations Coverage)

SCHEDULE

Name Of Additional Insured Entities:

The State of Arizona, its departments, agencies, boards, commissions, and universities, and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the Contractor.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The section entitled “Who is an Insured” in each of the coverage forms set forth above is amended to include as an insured the person or organization shown in the schedule, but only with respect to liability for injury or damage resulting from your operations performed for that insured and caused by your acts or omissions.

All other terms and conditions remain unchanged.

Policy #: 6000527-3

WAIVER OF TRANSFER RIGHTS OF RECOVERY_SSCOMMWOSAZ_01/21

SSCOMMWOSAZ (01-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER RIGHTS OF RECOVERY

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL ABUSE LIABILITY COVERAGE FORM

SCHEDULE

Name of Person or Organization: the State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees

The TRANSFER OF RIGHTS OF RECOVERY Condition (Section IV COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damages arising out of your ongoing operations or "your work" done under a contract for that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) is amended by the addition of the following:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damages for “bodily injury” or “property damage” to which this insurance applies.

The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV PROFESSIONAL LIABILITY CONDITIONS) is amended by the addition of the following:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for “damages” resulting from a “wrongful act” to which this insurance applies.

The TRANSFER OF RIGHTS OF RECOVERY Condition (Section D., SEXUAL OR PHYSICAL ABUSE OR MOLESTATION CONDITIONS) is amended by the addition of the following:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damages due to “abuse” to which this insurance applies.

All other terms and conditions remain unchanged.