2022_12_01_COI_AL_WC_UL.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)

© 1988-2016 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Deductible: 500,000

LOS-002563248-04

1,000,000

AZ

27960

AggregateXS $2MM Retained Limit

Phoenix, AZ 85016

N

X12/01/2021

12/01/2022

12/01/2021

24988

901893501

Medical Prof Liab Claims Made

D

N/A Illinois Union Insurance Co

1,000,000

X

B

12/06/2021

15,000,000

15,000,000

RE: Contract CT057399, BPM003737, Refugee Program – Health Promotion.

Phoenix, AZ 85007

ADES

Sentry Insurance A Mutual Co N/A

CN101622780-STND-AWXE-21-22

Each Incident/Occurrence

12/01/2022

1,000,000

& GL/Umbrella Occurrence

AZ

N/A

1,000,000

12/01/2022

901893501

2325 E. Camelback Road

Marsh USA Inc.

Suite 600

Attn: healthcare.accountscss@marsh.com Fax: 212-948-1307

District

Maricopa County Special Health Care

Phoenix, AZ 85008 2601 E. Roosevelt

XHLG46842169005

12/01/2021

1789 W Jefferson

D

N/A

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

Employers Liability Disease-Each Employee: $1,000,000 �

Excess Layer:�

National Fire & Marine Ins. Co. � for your convenience. The Workers Compensation placements were made by Lovitt-Touche (Workers Compensation Policies 901893501 and 901893503). Marsh USA Inc. has only acted in the role of a

Expiration Date: 12/01/22�

Expiration Date: 12/01/22� Effective Date: 12/01/21�

Phoenix

Policy Number: 901893503 � Sentry Casualty Company �

States: AZ�

Additional Workers Comp: �

Certificate of Liability Insurance

CN101622780

Employers Liability Disease-Policy Limit: $1,000,000 �

Policy Number: EN017975 � consultant to the client with respect to these placements, which is indicated here for your convenience. ��

The Automobile placement was made by Lovitt-Touche (Auto Policy 901893502). Marsh USA Inc. has only acted in the role of a consultant to the client with respect to this placement, which is indicated here

Limits: $20,000,000 XS of $30MM �

Marsh USA Inc.� District� Maricopa County Special Health Care�

Phoenix, AZ 85008 2601 E. Roosevelt�

Effective Date: 12/01/21�

Employers Liability Each Accident: $1,000,000 �

11/8/21, 8:39 AM State of Arizona Mail - Re: URGENT: CTR057399 Maricopa Special Health Care District DBA Valleywise Health https://mail.google.com/mail/u/0/?ik=a38cb5e5bf&view=pt&search=all&permthid=thread-f%3A1715549482974251151%7Cmsg-f%3A17156113482156… 1/2

Frances Rubio <frubio@azdes.gov>

Re: URGENT: CTR057399 Maricopa Special Health Care District DBA Valleywise Health

1 message

Judy Leung <jleung@azdes.gov> Fri, Nov 5, 2021 at 10:47 AM To: James Abdo <james.abdo@azdoa.gov>, Frances Rubio <frubio@azdes.gov>

Thank you, James!

On Fri, Nov 5, 2021 at 9:47 AM James Abdo <james.abdo@azdoa.gov> wrote:

Hi Judy, The endorsements do indicate sufficient GL coverage to meet the contract requirements.

James Abdo

Senior Insurance Analyst

ADOA – Risk Management Division | State of Arizona

100 North 15th Avenue, Suite 301, Phoenix, AZ 85007 Mailing Address: 1802 W. Jackson Street #93, Phoenix, Arizona 85007 p: 602 542 2016 | james.abdo@azdoa.gov https://doa.az.gov/

---------- Forwarded message ---------

From: PL Insurance - ADOA <plinsurance@azdoa.gov>

Date: Fri, Nov 5, 2021 at 8:41 AM

Subject: Fwd: URGENT: CTR057399 Maricopa Special Health Care District DBA Valleywise Health

To: James Abdo <james.abdo@azdoa.gov>

---------- Forwarded message ---------

From: Judy Leung <jleung@azdes.gov>

Date: Thu, Nov 4, 2021 at 6:24 PM

Subject: URGENT: CTR057399 Maricopa Special Health Care District DBA Valleywise Health

To: PL Insurance - ADOA <plinsurance@azdoa.gov>

Cc: Frances Rubio <frubio@azdes.gov>

Hi PL, Please review the Certificate of Insurance and endorsements, the COI does not indicate CGL, however the endorsement pages do. Does the COI and endorsements meet the Insurance requirements? I understand that this would normally be an IGA, but the contract was awarded through a RFP.

Regards, Frances and Judy

Judy Leung

Procurement Project Manager

Office of Procurement

Division of Financial Operations

Cell: (480) 435-8139 des.az.gov

NOTICE: This e-mail (and any attachments) may contain PRIVILEGED OR CONFIDENTIAL information and is intended only for the use of the specific individual(s) to whom it is addressed. It may contain information that is privileged and confidential under state and federal law. This information may be used or disclosed only in accordance with law, and you may be subject to penalties under law for improper use or further disclosure of the information in this e-mail and its attachments. If you have received this e-mail in error, please immediately notify the person named above by reply e-mail, and then delete the original e-mail.

NOTICE: This e-mail (and any attachments) may contain PRIVILEGED OR CONFIDENTIAL information and is intended only for the use of the specific individual(s) to whom it is addressed. It may contain information that is privileged and confidential under state and federal law. This information may be used or disclosed only in accordance with law, and you may be subject to penalties under law for improper use or further disclosure of the information in this e-mail and its attachments. If you have received this e-mail in error, please immediately notify the person named above by reply e-mail, and then delete the original e-mail. Thank you.

Judy Leung mailto:james.abdo@azdoa.gov https://www.google.com/maps/search/100+North+15th+Avenue,+Suite+301,+Phoenix,+AZ+85007?entry=gmail&source=g https://www.google.com/maps/search/1802+W.+Jackson+Street+%2393,+Phoenix,+Arizona+85007?entry=gmail&source=g mailto:james.abdo@azdoa.gov https://doa.az.gov/ mailto:plinsurance@azdoa.gov mailto:james.abdo@azdoa.gov mailto:jleung@azdes.gov mailto:plinsurance@azdoa.gov mailto:frubio@azdes.gov http://des.az.gov/

11/8/21, 8:39 AM State of Arizona Mail - Re: URGENT: CTR057399 Maricopa Special Health Care District DBA Valleywise Health https://mail.google.com/mail/u/0/?ik=a38cb5e5bf&view=pt&search=all&permthid=thread-f%3A1715549482974251151%7Cmsg-f%3A17156113482156… 2/2

Procurement Project Manager

Office of Procurement

Department of Economic Security

1789 W. Jefferson Street

Phoenix, AZ 85007

Mail Drop: 1222

Cell: (480) 435-8139

JLeung@azdes.gov des.az.gov

NOTICE: This e-mail (and any attachments) may contain PRIVILEGED OR CONFIDENTIAL information and is intended only for the use of the specific individual(s) to whom it is addressed. It may contain information that is privileged and confidential under state and federal law. This information may be used or disclosed only in accordance with law, and you may be subject to penalties under law for improper use or further disclosure of the information in this e-mail and its attachments. If you have received this e-mail in error, please immediately notify the person named above by reply e-mail, and then delete the original e-mail. Thank you.

https://www.google.com/maps/search/1789+W.+Jefferson+Street+Phoenix,+AZ+85007?entry=gmail&source=g https://www.google.com/maps/search/1789+W.+Jefferson+Street+Phoenix,+AZ+85007?entry=gmail&source=g mailto:JLeung@azdes.gov http://des.az.gov/