2022-03-01 COI.pdf
PDF 758 KB Posted
- Attached to
- Master Agreement AZ|CTR050592
- Contract number
- CTR050592
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by Selective Insurance Company of America and Republic Indemnity Company of California, with Lovitt & Touché A Marsh and McLennan Agency, LLC serving as the insurance producer. The certificate is for Adelante Healthcare, Inc., located in Phoenix, Arizona, and names the Arizona Department of Health Services as the certificate holder. The policy covers the Health Start Program under Contract #CTR050592, with coverage effective from March 1, 2021 to March 1, 2022.
The insurance provides commercial general liability, automobile liability, umbrella liability, and workers' compensation coverage. Key coverage limits include $1,000,000 for each occurrence of bodily injury and property damage, $3,000,000 general aggregate, $1,000,000 for automobile liability, and $7,000,000 umbrella liability. The policy includes additional insured provisions for the State of Arizona, its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. A notable feature is the waiver of subrogation in favor of the state and its entities for losses arising from work performed by or on behalf of the contractor.
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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
7/23/2021
Lovitt & Touché A Marsh and McLennan Agency, LLC 1050 W Washington Street, Suite 233 Tempe AZ 85281
Jasmine Loesch 602-792-2329 602-956-2258 jloesch@lovitt-touche.com
Selective Insurance Co of America 12572 ADELA-1 Republic Indemnity Company of Californi 43753
Adelante Healthcare, Inc.
3033 N. Central Ave, Ste 145, 140, 200 Phoenix AZ 85012
254020455
A X 1,000,000 X 500,000
15,000
1,000,000
3,000,000 X X X
Y Y S230452001 3/1/2021 3/1/2022
3,000,000
A 1,000,000
X
X X
Y Y S230452001 3/1/2021 3/1/2022
A X X 7,000,000S230452001 3/1/2021 3/1/2022
7,000,000 X 0
B X18285111 3/1/2021 3/1/2022
1,000,000
1,000,000
1,000,000 A Sexual Abuse/Molestation S230452001 3/1/2021 3/1/2022 Each Claim
Aggregate 1,000,000 3,000,000
With respects to General Liability and Auto Liability coverage:
The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees will be named as Additional Insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.
Subrogation is waived in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.
RE: Contract #CTR050592 | HEALTH START PROGRAM
Arizona Department of Health Services 150 N. 18th Avenue, Suite 530 Phoenix AZ 85007
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