2022-01-07 COI GL AL WC PL.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 EXP

TYPE 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

9/29/2021

(608) 257-3795 (608) 257-4324

10677

CTC & Associates LLC 4805 Goldfinch Dr Madison, WI 53714-3331

24319

A 1,000,000

X X EPP0057449 1/7/2021 1/7/2024 100,000

5,000

1,000,000

2,000,000

2,000,000

1,000,000A

X X EBA0057449 1/7/2021 1/7/2022

1,000,000A

EPP0057449 1/7/2021 1/7/2024 1,000,000

B Prof Liability 03062827 1/7/2021 Occurrence 2,000,000

B Prof Liability 03062827 1/7/2021 1/7/2022 Aggregate 2,000,000

REF: Contract No. CTR057382 / Technical Writing and Technical Editing Services

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees are additional insureds when required in written contract with respects to commercial general liability and hired and non owned auto liability arising out of activites performed by or on behalf of the contractor involving automobiles owned, leased, hired or borrowed.

Waivers of Subrogation apply to the commercial general liability and commercial auto policies.

A 30 day written notice to the State of Arizona applies with the exception of a 10 day notice of cancellation for non-payment of premium.

Arizona Department of Transportation Attn: Sharon L Tohtsoni 1739 West Jackson St Ste A, MD100P

Phoenix, AZ 85007

CTC&ASS-01 NHANSOHN

Hausmann-Johnson Insurance, Inc.

740 Regent Street 4th Floor PO Box 259408 Madison, WI 53725-9408

Cincinnati Insurance Company

Allied World Surplus Lines Ins

1/7/2022

X

X

X X

X X

X

X

X

ACCEPTED

ADOT Risk Management

Includes copyrighted material of Insurance GA 472 09 18 Services Office, Inc., with its permission. Page 1 of 3

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CONTRACTORS ADDITIONAL INSURED - AUTOMATIC STATUS

AND AUTOMATIC WAIVER OF SUBROGATION

WHEN REQUIRED IN WRITTEN CONTRACT, AGREEMENT,

PERMIT OR AUTHORIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. Additional Insured - Owners, Lessees Or Contractors - Automatic Status For Other Parties When Required In Written Contract Or Agreement With You

1. Section II - Who Is An Insured is amended to include as an additional in-sured any person or organization you have agreed in writing in a contract or agreement to add as an additional in-sured on this Coverage Part. Such per-son(s) or organization(s) is an additional insured only with respect to liability for:

a. "Bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by the performance of your ongoing opera-tions by you or on your behalf, under that written contract or written agreement. Ongoing operations does not apply to "bodily injury" or "proper-ty damage" occurring after:

(1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the loca-tion of the covered operations has been completed; or

(2) That portion of "your work" out of which the injury or damage aris-es has been put to its intended use by any person or organiza-tion other than another contrac-tor or subcontractor engaged in performing operations for a prin-cipal as a part of the same pro-ject; and

b. "Bodily injury" or "property damage" caused, in whole or in part, by "your work" performed under that written contract or written agreement and in cluded in the "products-completed operations hazard", but only if:

(1) The Coverage Part to which this endorsement is attached pro-vides coverage for "bodily injury" or "property damage" included within the "products-completed operations hazard"; and

(2) The written contract or written agreement requires you to pro-vide additional insured coverage included within the "products-completed operations hazard" for that person or organization.

If the written contract or written agreement requires you to provide additional insured coverage included within the "products-completed oper-ations hazard" for a specified length of time for that person or organiza-tion, the "bodily injury" or "property damage" must occur prior to the ex-piration of that period of time in order for this insurance to apply.

If the written contract or written agreement requires you to provide additional insured coverage for a person or organization per only ISO additional insured endorsement form number CG 20 10, without specifying an edition date, and without specifi-cally requiring additional insured coverage included within the “prod-ucts-completed operations hazard”, this Paragraph b. does not apply to that person or organization.

2. If the written contract or written agree-ment described in Paragraph 1. above specifically requires you to provide addi-tional insured coverage to that person or organization:

a. Arising out of your ongoing opera-tions or arising out of "your work"; or

GA 472 09 18 Services Office, Inc., with its permission. Page 2 of 3

b. By way of an edition of an ISO addi-tional insured endorsement that in-cludes arising out of your ongoing operations or arising out of "your work";

then the phrase caused, in whole or in part, by in Paragraph A.1.a. and/or Para-graph A.1.b. above, whichever applies, is replaced by the phrase arising out of.

3. With respect to the insurance afforded to the additional insureds described in Para-graph A.1., the following additional exclu-sion applies:

This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including:

a. The preparing, approving or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or draw-ings and specifications; or

b. Supervisory, inspection, architectural or engineering activities.

This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hir-ing, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "prop-erty damage", or the offense which caused the "personal and advertising inju-ry", involved the rendering of, or the fail-ure to render, any professional architec-tural, engineering or surveying services.

4. This Paragraph A. does not apply to addi-tional insureds described in Paragraph B.

B. Additional Insured - State Or Governmental Agency Or Subdivision Or Political Subdi-vision - Automatic Status When Required In Written Permits Or Authorizations

1. Section II - Who Is An Insured is amended to include as an additional in-sured any state or governmental agency or subdivision or political subdivision you have agreed in writing in a contract, agreement, permit or authorization to add as an additional insured on this Coverage Part. Such state or governmental agency or subdivision or political subdivision is an additional insured only with respect to op-erations performed by you or on your be-half for which the state or governmental agency or subdivision or political subdivi-sion issued, in writing, a contract, agree-ment, permit or authorization.

2. With respect to the insurance afforded to the additional insureds described in Para-graph B.1., the following additional exclu-sions apply:

This insurance does not apply to:

a. "Bodily injury", "property damage" or "personal and advertising injury" aris-ing out of operations performed for the federal government, state or mu-nicipality; or

b. "Bodily injury" or "property damage" included within the "products-completed operations hazard."

C. The insurance afforded to additional insureds described in Paragraphs A. and B.:

1. Only applies to the extent permitted by law; and

2. Will not be broader than that which you are required by the written contract, writ-ten agreement, written permit or written authorization to provide for such addition-al insured; and

3. Does not apply to any person, organiza-tion, state, governmental agency or sub-division or political subdivision specifically named as an additional insured for the same project in the schedule of an en-dorsement added to this Coverage Part.

D. With respect to the insurance afforded to the additional insureds described in Paragraphs A. and B., the following is added to Section III

- Limits Of Insurance:

The most we will pay on behalf of the addi-tional insured is the amount of insurance:

1. Required by the written contract, written agreement, written permit or written au-thorization described in Paragraphs A.

and B.; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the appli-cable Limits of Insurance shown in the Decla-rations.

E. Section IV - Commercial General Liability Conditions is amended to add the following:

Automatic Additional Insured Provision

This insurance applies only if the "bodily inju-ry" or "property damage" occurs, or the "per-sonal and advertising injury" offense is com-mitted:

1. During the policy period; and

GA 472 09 18 Services Office, Inc., with its permission. Page 3 of 3

2. Subsequent to your execution of the writ-ten contract or written agreement, or the issuance of a written permit or written au-thorization, described in Paragraphs A.

and B.

F. Except when G. below applies, the following is added to Section IV - Commercial General Liability Conditions, 5. Other Insurance, and supersedes any provision to the contrary:

When Other Additional Insured Coverage Applies On An Excess Basis

This insurance is primary to other insurance available to the additional insured described in Paragraphs A. and B. except:

1. As otherwise provided in Section IV - Commercial General Liability Condi-tions, 5. Other Insurance, b. Excess In-surance; or

2. For any other valid and collectible insur-ance available to the additional insured as an additional insured by attachment of an endorsement to another insurance policy that is written on an excess basis. In such case, this insurance is also excess.

G. The following is added to Section IV - Com-mercial General Liability Conditions, 5.

Other Insurance, and supersedes any provi-sion to the contrary:

Primary Insurance When Required By Writ-ten Contract, Agreement, Permit Or Au-thorization

Except when wrap-up insurance applies to the claim or "suit" on behalf of the additional in-sured, this insurance is primary to any other insurance available to the additional insured described in Paragraphs A. and B. provided that:

1. The additional insured is a Named In-sured under such other insurance; and

2. You have agreed in writing in a contract, agreement, permit or authorization de-scribed in Paragraph A. or B. that this in-surance would be primary to any other in-surance available to the additional in-sured.

As used in this endorsement, wrap-up insur-ance means any insurance provided by a con-solidated (wrap-up) insurance program.

Primary And Noncontributory Insurance When Required By Written Contract, Agreement, Permit Or Authorization

Except when wrap-up insurance applies to the claim or "suit" on behalf of the additional in-sured, this insurance is primary to and will not seek contribution from any other insurance available to the additional insured described in Paragraphs A. and B. provided that:

1. The additional insured is a Named In-sured under such other insurance; and

2. You have agreed in writing in a contract, agreement, permit or authorization de-scribed in Paragraph A. or B. that this in-surance would be primary and would not seek contribution from any other insur-ance available to the additional insured.

As used in this endorsement, wrap-up insur-ance means any insurance provided by a con-solidated (wrap-up) insurance program.

H. Section IV - Commercial General Liability Conditions, 9. Transfer Of Rights Of Re-covery Against Others To Us is amended by the addition of the following:

We waive any right of recovery we may have against any additional insured under this en-dorsement against whom you have agreed to waive such right of recovery in a written con-tract, written agreement, written permit or writ-ten authorization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a written contract, written agreement, written permit or written authorization. However, our rights may only be waived prior to the "occur-rence" giving rise to the injury or damage for which we make payment under this Coverage Part. The insured must do nothing after a loss to impair our rights. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce those rights.

GA 4094 09 17

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRIMARY/NONCONTRIBUTORY - OTHER INSURANCE

CONDITION SCHEDULED PERSON

OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name of Person or Organization:

The following is added to the Other Insurance Condition and supercedes any provision to the con-trary:

Primary and Noncontributory Insurance

This insurance is primary to and will not seek contribution from any other insurance available to an additional insured described in the Schedule of this endorsement provided that:

(1) The additional insured is a Named In-sured under such other insurance; and

(2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured.

THE STATE OF ARIZONA AND ITS DEPARTMENTS AGENCIES BOARDS COMMISSIONS

UNIVERSITIES OFFICERS OFFICIALS AGENTS AND EMPLOYEES

C/O: ARIZONA DEPARTMENT OF TRANSPORTATION PROCUREMENT GROU

1739 W JACKSON ST STE B

MD100P ATTN: PAMELA VEAL

PHOENIX, AZ 85007

CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART.

SCHEDULE

Name of Person or Organization:

(If no entry appears above, information required to complete this endorsement will be shown in the Declara-tions as applicable to this endorsement.)

The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US 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 damage arising out of your ongoing operations or "your work" done under a contract with 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.

STATE OF ARIZONA ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, AND THE PUBLIC

ENTITY AND ITS OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES

C/O: ARIZONA DEPARTMENT OF TRANSPORTATION

1739 W JACKSON ST STE A

PHOENIX, AZ 85007-3218

AA 4195 01 07

WAIVER OF SUBROGATION - AUTO

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indi-cated below.

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

SCHEDULE

Name of person(s) or organization(s):

Job location: Job and/or Contract Number:

1. Waiver of Subrogation

SECTION IV - BUSINESS AUTO CONDI-

TIONS, A. Loss Conditions, 5. is amended by the addition of the following:

With regard to the person(s) or organiza-tion(s), job location, and job and / or contract number shown in the Schedule of this en-dorsement, we waive any right of recovery we may have against any person or organization because of payments we make for "bodily in-jury" or "property damage" arising out of the operation of a covered "auto" when you have assumed liability for such "bodily injury" or "property damage" under an "insured con-tract", provided the "bodily injury" or "property damage" occurs subsequent to the execution of the "insured contract".

01-07-2021 EBA 005 74 49

CTC & ASSOCIATES LLC

ARIZONA DEPT TRANSPORTATION

AA 4004 03 06

ADDITIONAL INSURED - DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

The person or organization named in the following schedule is an "insured" to the extent of their liability for the conduct of another "insured" as provided in SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who is an Insured, Paragraph c.

Schedule

Additional Insured

Address:

01-07-2021 EBA 005 74 49

CTC & ASSOCIATES LLC

STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, AND THE

PUBLIC ENTITY OF ITS OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES

C/O: ARIZONA DEPARTMENT OF TRANSPORTAION

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

INSURER(S) AFFORDING COVERAGE NAIC #

PRODUCER

INSURED

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

COVERAGES

TYPE OF INSURANCE POLICY NUMBER LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

LOCPOLICY

OTHER:

EACH OCCURRENCE

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

AUTOMOBILE LIABILITY

ANY AUTO

OCCUR

CLAIMS-MADE

DED RETENTION $

EACH OCCURRENCE

AGGREGATE

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

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

CERTIFICATE HOLDER CANCELLATION

Y/N

CONTACT

NAME:

PHONE

(A/C, No, Ext):

E-MAIL

ADDRESS:

FAX

(A/C, No):

CERTIFICATE NUMBER: REVISION NUMBER:

UMBRELLA LIAB

EXCESS LIAB

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

INSURER F :

N/A

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

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.

INSR

LTR

ADDL

INSD

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

PRO-

JECT

DAMAGE TO RENTED

PREMISES (Ea occurrence)

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident)

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

PER

STATUTE

OTH-

ER

SUBR

WVD

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).

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

09/29/2021

PAYCHEX INSURANCE AGENCY INC

150 SAWGRASS DR

ROCHESTER, NY 14620

(877) 362-6785

(877) 362-6785 (877) 677-0447 paychex@travelers.com

CTC & ASSOCIATES LLC

4805 GOLDFINCH DR

MADISON, WI 53717

THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT

114079229581272

A X UB-3L741408-21 01/07/2021 01/07/2022 X

1,000,000 1,000,000 1,000,000

AS RESPECTS TO WORKERS COMPENSATION COVERAGE, WC 00 03 13 00 - WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS HAS BEEN ATTACHED TO THE POLICY IN REGARD TO STATE OF ARIZONA, AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES.

RE: ARIZONA DOT CONTRACT NO. CTR057382 / TECHNICAL WRITING AND TECHNICAL EDITING SERVICES

ARIZONA DEPARTMENT OF TRANSPORTATION

1655 W. JACKSON STREET,

MD 111F

PHOENIX, AZ 85007

ACCEPTED – WC Only

ADOT Risk Management