2022-07-01 COI.pdf

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

E-MAIL

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

7/30/2021

Arthur J. Gallagher & Co.

Insurance Brokers of CA.Inc LIC #0726293 18201 Von Karman Ave Suite 200 Irvine CA 92612

Nasreen Kopecky 949-349-9857 nasreen_kopecky@ajg.com

Arizona Counties Insurance Pool

ARIZCOU-01

Mohave County Attn: Risk Management Department P O Box 7000 Kingman AZ 86402

1904851673

A X 1,000,000 X Included

X Pub Offls' E&O Not Covered X Misc Med Mal E&O 1,000,000

2,000,000 X

Y Y ACIP070121 7/1/2021 7/1/2022

2,000,000

Errors & Omissions 1,000,000 A 1,000,000

X

X X X Comprehensiv X Collison

Y Y ACIP070121 7/1/2021 7/1/2022

Comp/Coll Deductibles $2,500/$2,500

A X

N

Y ACIPWC070121 7/1/2021 7/1/2022

1,000,000

1,000,000

1,000,000 A Incidental Medical Malpractice

Sexual Abuse N N ACIP070121 7/1/2021 7/1/2022 Per Incident/Agg

Per Claim/Agg $1M / $3M $250,000/ $500,000

Re: Contract #CTR050596 – Health Start Program.

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, agents, and employees are included as Additional Insureds as respects General Liability and Auto Liability policies, pursuant to and subject to the policy's terms, definitions, conditions and exclusions. Waiver of Subrogation applies to additional insureds, as respects General Liability, Auto Liability and Workers Compensation policies, pursuant to and subject to the policy's terms, definitions, conditions and exclusions.

State of Arizona Department of Health Services 150 N 18th Avenue, Suite 530 Phoenix, AZ 85007

ACIP MOC POLICY NUMBER ACIP070121

ENDORSEMENT NO. 11 – Additional Insured – INSURED

CONTRACT

THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER SECTION I,

COMPREHENSIVE GENERAL LIABILITY. PLEASE READ IT CAREFULLY.

1. The following is added to SECTION I COMPREHENSIVE GENERAL

LIABILITY:

Any person(s), entity(ies), or organization(s) to whom the NAMED MEMBER is obligated by virtue of an INSURED CONTRACT to provide coverage solely with respect to BODILY INJURY and PROPERTY DAMAGE and arising out of:

a. PREMISES leased, rented, used or occupied by you;

b. AUTOMOBILES leased or rented by you;

c. Equipment owned, leased, rented, maintained or used by you; or

d. Mortgagees of a NAMED MEMBER.

However, this insurance under this endorsement does not apply to:

1) Any OCCURRENCE which takes place prior to or after you cease to occupy the PREMISES as stated in the INSURED

CONTRACT.

2) Any structural alteration, new construction or demolition operations performed by or on behalf of the additional insured.

3) Any WRONGFUL ACT, EMPLOYMENT PRACTICES VIOLATION, or NEGLIGENT ACT, ERROR, OR OMISSION.

The limits of Coverage afforded under this endorsement will be limited to the Limits of Insurance required within the terms of the INSURED CONTRACT or the Limits of Coverage of this MOC, whichever is less, and will apply in excess of any underlying insurance or your Member Deductible shown in the Declarations. We will not be obligated for Limits of Insurance shown in the INSURED CONTRACT that are greater than the Limits of Coverage of this MOC.

ACIP MOC POLICY NUMBER ACIP070121

ENDORSEMENT NO. 11 – Additional Insured – INSURED CONTRACT (Continued)

DEFINITIONS

INSURED CONTRACT means:

1. A contract for PREMISES leased, rented or loaned to you. However, that portion of the contract for a lease of PREMISES that indemnifies any person or organization for damage by fire to PREMISES while rented to you or temporarily occupied by you with permission of the owner is not an INSURED

CONTRACT;

2. A sidetrack agreement;

3. Any easement or license agreement, except in connection with construction or demolition operations on or within 50 feet of a railroad;

4. An obligation, as required by ordinance;

5. An elevator maintenance agreement;

6. That part of any other contract or agreement pertaining to your business under which you assume the tort liability to pay for BODILY INJURY or PROPERTY DAMAGE to a third person or organization. Tort liability means a liability that would be imposed by law in the absence of any contract or agreement.

INSURED CONTRACT does not include an agreement to indemnify the following:

1. A railroad for construction or demolition operations within 50 feet of railroad property and affecting any railroad bridge or trestle, tracks, roadbeds, tunnel, underpass, or crossing;

2. An architect, engineer, or surveyor for their professional services.

Except as amended in this Endorsement, this coverage is subject to all coverage terms, clauses and conditions in the policy to which this Endorsement is attached.