2022-05-01_COI_GL_PL_AL_UL_WC_SAM.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

7/29/2021

(480) 730-4920 (480) 730-4929

19100

The Opportunity Tree 3146 E. Windsor Ave.

Phoenix, AZ 85008

23787 14216

A 1,000,000

X X ACP3019715631 5/1/2021 5/1/2022 100,000

Prof Liability 5,000

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

1,000,000B

X X ACP3019715631 5/1/2021 5/1/2022

5,000,000A

ACP3019715631 5/1/2021 5/1/2022

10,000 C

X 1014567 4/1/2021 4/1/2022 1,000,000 1,000,000 1,000,000

A Sexual Abuse & Moles ACP3019715631 5/1/2021 Occurence 1,000,000 A Sexual Abuse & Moles ACP3019715631 5/1/2021 5/1/2022 Aggregate 3,000,000

Re: Contract # CTR056103 Social Services Organization; Group Homes - All Employees & Salespersons, Drivers - Subject to policy limitations and exclusions.

The State of Arizona and the Department of Economic Security shall be named as Additional Insureds with respect to General Liability arising out of the activities performed by or on behalf of the Contractor, as required by written contract.

The State of Arizona and the Arizona Department of Economic Security shall be named as Additional Insureds with respect to Auto Liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles owned, leased, hired or borrowed by the Contractor, as required by written contract.

SEE ATTACHED ACORD 101

State of Arizona Department of Economic Security Rehabilitation Services Admin 1789 W. Jefferson St, 2nd Flr NW Mail Drop 53C1 Phoenix, AZ 85007

THEOPPO-01 PEVANS

The Mahoney Group - Mesa 1835 South Extension Road Mesa, AZ 85210

AMCO Insurance Company

NATIONWIDE MUTUAL INSURANCE COMPANY

CopperPoint Insurance Company

5/1/2022

X X

X

X

X

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.

The Mahoney Group - Mesa

THEOPPO-01

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

The Opportunity Tree 3146 E. Windsor Ave.

Phoenix, AZ 85008

SEE PAGE 1

PEVANS

Description of Operations/Locations/Vehicles:

Policy shall contain a waiver of subrogation 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.

Umbrella Extends to Professional Liability in Order to Satisfy $2Million Occurence/ $2Million Aggregate Requirement

Sexual and physical abuse is not excluded

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 37 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s)

Or Organization(s) Location And Description Of Completed Operations

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

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable limits of insurance;

whichever is less.

This endorsement shall not increase the applicable limits of insurance.

The State of Arizona and its departments, agencies, boards commission, universities, officers, officials, agents, agents and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor

ACP30197155631

ACP3019715631 COMMERCIAL GENERAL LIABILITY

CG 24 04 05 09

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIO NS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization: The State of Arizona and its departments, agencies, boards, commission, universities, officers, officials, agents and employees as additional insureds with respect to liability arising out of the activities 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 following is added to Paragraph 8. Transfer Of

Rights Of Recovery Against Others To Us of Section

IV — Conditions:

We waive any r ight 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.

All terms and conditions of this policy apply unless modified by this endorsement.

CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1

ACP GLA03009597414 74KA 20009 INSURED COPY 46 0010263

POLICY NUMBER: ACP3019715631 COMMERCIAL GENERAL LIABILITY

CG 20 26 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s): The State of Arizona and its departments, agencies, boards, commission, universities, officers, officials, agents and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

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

A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

1. In the performance of your ongoing operations; or

2. In connection with your premises owned by or rented to you.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

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

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

All terms and conditions apply unless modified by this endorsement.

CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1

ACP GLA03009597414 74KA 20009 INSURED COPY 46 0010252

ACP3019715631 COMMERCIAL AUTO CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

SCHEDULE

Name(s) Of Person(s) Or Organization(s): The State of Arizona and its departments, agencies, boards, commission, universities, officers, officials, agents and employees as additional insureds with respect to liability arising out of the activities 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 Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

ACP BA 30-0-9597414 74KA 20008 INSURED COPY CA0444101300 0200 46 0010427

COMMERCIAL AUTO

CA 20 48 10 13

ACP3019715631

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

SCHEDULE

Name Of Person(s) Or Organization(s):The State of Arizona and its departments, agencies, boards, commission, universities, officers, officials, agents and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

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

Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form.

CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

ACP BA 30-0-9597414 74KA 20008 INSURED COPY CA2048101300 0100 46 0010428

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The State of Arizona, it's departments, agencies, Boards, commissions, universities and it's Officers, officials, agents, and employees as additional insureds with liability arising out of the activities performed on or on behalf of the contractor.

sknaub Typewritten text

OF ARIZONA - DEPARTMENT OF ECONOMIC SECURITY

UMB 1 (12-98)

DECLARATIONS

COMMERCIAL UMBRELLA LIABILITY

RENEWAL INSURANCE POLICY

AMCO INSURANCE COMPANY

1100 LOCUST ST DEPT 1100

DES MOINES IA 503912000

Policy Number: ACP CAA 3019715631

ITEM 1

Named Insured: THE OPPORTUNITY TREE

ITEM 2 ARIZONA FOUNDATION FOR THE HANDICAPPED

Address: 3146 E WINDSOR AVE

PHOENIX AZ 850081135

Agent: THE MAHONEY GROUP Address: MESA AZ 85210 46 02 60491 0027

PRODUCER: NICHALAS C FLORES

ITEM 3

Policy Period : From 12:01 A.M., 05/01/21 to 12:01 A.M., 05/01/22

ITEM 4

Schedule of Underlying Insurance: See Endorsement No. UMB 00 01

ITEM 5

Retained Limit Aggregate: NONE

ITEM 6

Limits of Insurance: a) $5,000,000Each Occurrence

b) $5,000,000 Products - Completed Operations Aggregate

c) $5,000,000Other Aggregate

ITEM 7

Coverage IX A - Excess Follow Form Liability Insurance

B - Umbrella Liability Insurance

ITEM 8

Premium :

$22,213.00

ITEM 9

Endorsements: UMB0001 0309 UMB0002 0413 UMB0052 0115 UMB0064 0120 UMB0200 0112

UMB0201 0413 UMB7010 0514 UMB0095 0311 UMB0085 0310 UMB7011 1213

Amount

Renewal or Replacement No. ACP CAA 3009715631

Countersigned By Authorized Representative

UMB 1 (12-98)

DIRECT BILL I.22K 21126 INSURED 48 46 07097

-L L

SO

- G

O E

1.-d

-M

N

AMCO INSURANCE COMPANY

IN WITNESS WHEREOF the Company has caused this policy to be signed by its president and secretary and countersigned on the declarations page by a duly authorized representative of the company.

SECRETARY PRESIDENT

SP 00 02 09 16 Page 1 of 1

ACP CAA 3019715631 INSURED 46 0007098

AMCO INSURANCE COMPANY

COMMERCIAL UMBRELLA LIABILITY

FORMS AND ENDORSEMENTS SUMMARY

Number: ACP CAA 3019715631 Period:

From 05/01/21 To 05/01/22

FORM/ENDORSEMENT DATE TITLE

UMB0001

UMB0002

UMB0052

UMB0064

UMB0085

UMB0095

UMB0200

UMB0201

UMB7010

UMB7011

0309 SCHEDULE OF UNDERLYING INSURANCE

0413 COMMERCIAL UMBRELLA LIABILITY POLICY

0115 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM

0120 CONDITIONAL EXCLUSION OF TERRORISM (RELATING TO DISPOSITION

0310 ABUSE OR MOLESTATION

0311 EXCLUSION ENDORSEMENT - CRISIS RESPONSE AND LOST WAGES - COV

0112 ARIZONA CHANGES - CANCELLATION AND NONRENEWAL

0413 ARIZONA CHANGES - REPRESENTATIONS OR FRAUD

0514 EXCLUSION-ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL I

1213 ABUSE OR MOLESTATION AGGREGATE

LB2K 21121 INSURED 46 07099

UMB 00 01 03 09

Policy Number: ACP CAA 3019715631 Policy Period: 05/01/21 to 05/01/22

ITEM 4.

Schedule Of Underlying Insurance (as identified by the entry of a company name, policy number, policy period and limits):

X Commercial General Liability or Businessowners Liability

AMCO

Policy Number: ACP GLAO 3019715631 Policy Period: 05/01/21 to 05/01/22

Limits ($) 3000000 3000000 1000000 1000000

General Aggregate Products-Completed Operations Aggregate Personal and Advertising Injury Each Occurrence

Commercial Auto Liability

NATIONWIDE MUTUAL INS CO

Policy Number: ACP BA 3019715631 Policy Period: 05/01/21 to 05/01/22

Limits ($) 1000000 Each Accident

Employer's Liability or Stop Gap Liability

Policy Number:

Policy Period: to

Limits ($)

Bodily Injury by Accident - Each Accident Bodily Injury by Disease— Each Employee Bodily Injury by Disease— Policy Limit

Policy Number:

Policy Period: to

Limits ($)

Policy Number:

Policy Period: to

Limits ($)

Policy Number:

Policy Period: to

Limits ($)

Policy Number:

Policy Period: to

Limits ($)

IMPORTANT NOTICE: RESTRICTIONS, LIMITATIONS AND EXCLUSIONS TO THE ABOVE SCHEDULED

UNDERLYING INSURANCE (OR ANY REPLACEMENTS THEREOF) WILL ACT AS RESTRICTIONS,

LIMITATIONS AND EXCLUSIONS TO COVERAGE A OF THIS POLICY.

UMB 00 01 03 09

ACP CAA 3019715631 INSURED

Page of 46 0007100