2022.03.31 COI.pdf

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07007 C er ti fi ca te N o

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

09/23/2021

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.

PRODUCER

Aon Risk Services Central, Inc.

Philadelphia PA Office One Liberty Place 1650 Market Street Suite 1000 Philadelphia PA 19103 USA

PHONE

(A/C. No. Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

(866) 283-7122

INSURED 22667ACE American Insurance CompanyINSURER A:

43575Indemnity Insurance Co of North AmericaINSURER B:

20702ACE Fire Underwriters Insurance Co.INSURER C:

AA1128623Lloyd's Syndicate No. 2623INSURER D:

31135Great American Security Ins CoINSURER E:

INSURER F:

FAX

(A/C. No.): (800) 363-0105

CONTACT

NAME:

American Medical Response 6363 Fiddlers Green Circle Suite 1400 Greenwood Village CO 80111 USA

COVERAGES CERTIFICATE NUMBER: 570089379792 REVISION NUMBER:

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. Limits shown are as requested

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

(MM/DD/YYYY)

SUBR

WVD

INSR

LTR

ADDL

INSD POLICY NUMBER TYPE OF INSURANCE LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY LOC

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

X

X

X

GEN'L AGGREGATE LIMIT APPLIES PER:

$2,750,000

$100,000

$2,750,000

$5,000,000

$2,750,000

$250,000SIR/Deductible

A 03/31/2021 03/31/2022Y Y

SIR applies per policy terms & conditions

XSLG7248194A

PRO-

JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

SCHEDULED

AUTOS

HIRED AUTOS

ONLY

NON-OWNED

AUTOS ONLY

BODILY INJURY ( Per person)

PROPERTY DAMAGE

(Per accident)

X BODILY INJURY (Per accident)

$10,000,000A 03/31/2021 03/31/2022 COMBINED SINGLE LIMIT

(Ea accident)

ISAH25545138

EXCESS LIAB

X OCCUR

CLAIMS-MADE AGGREGATE

EACH OCCURRENCE

DED

$10,000,000

$10,000,000

03/31/2021UMBRELLA LIABE 03/31/2022EXC3415145

RETENTION

X

E.L. DISEASE-EA EMPLOYEE

E.L. DISEASE-POLICY LIMIT

E.L. EACH ACCIDENT $1,000,000

X OTH-

ER

PER STATUTEB 03/31/2021 03/31/2022

AOS

WLRC67819251A 03/31/2021 03/31/2022

$1,000,000

Y / N

(Mandatory in NH)

ANY PROPRIETOR / PARTNER / EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / AN

CA, MA

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

If yes, describe under DESCRIPTION OF OPERATIONS below

$1,000,000

WLRC67819299

Per ClaimW1B173210601 03/31/2021 03/31/2022 Professional Liability $10,000,000Aggregate

SIR $3,000,000

E&O-PL-XSD

SIR applies per policy terms & conditions

$10,000,000

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

State of Arizona Department, Department, its agents, officials, employees, or the State of Arizona are included as additional insured with respects to the General Liability and Auto Liability policies. The coverage is primary and non-contributory. A Waiver of Subrogation applies 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: CTR053477 RURAL METRO CORP, CTR053486 SOUTHWEST AMBULANCE, CTR053478 PMT AMBULANCE GROUND, AND CTR049640 AMERICAN MEDICAL RESPONSE OF MARICOPA. EVIDENCE OF INSURANCE FOR THE FOLLOWING ADDITIONAL NAMED INSUREDS: RIVER MEDICAL, INC.

CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVEArizona Department of Health Services Bureau of Emergency Medical Services & Trauma System 150 N. 18th Ave, Suite 540 Phoenix AZ 85007 USA

ACORD 25 (2016/03)

©1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

POLICY PROVISIONS.

AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE

LOC #:

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY

See Certificate Number:

See Certificate Number:

570089379792

570089379792

Aon Risk Services Central, Inc.

570000073826

ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits.

INSURER

INSURER

INSURER

INSURER

INSURER(S) AFFORDING COVERAGE

Page _ of _

NAIC #

American Medical Response

TYPE OF INSURANCE

POLICY NUMBER LIMITS

WORKERS COMPENSATION

C SCFC67819330 03/31/2021 03/31/2022

A WCUC67819378 03/31/2021 03/31/2022

WI Paid Loss Retro

OH-SIR

N/A

N/A

ADDL

INSD

INSR

LTR

SUBR

WVD

POLICY

EFFECTIVE

DATE

(MM/DD/YYYY)

POLICY

EXPIRATION

DATE

(MM/DD/YYYY)

SIR applies per policy terms & conditions

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

DBA LIFE LINE AMBULANCE 415 EL CAMINO WAY LAKE HAVASU CITY, AZ 85403 (CON 94) RURAL/METRO CORPORATION (PIMA) 3759 N. COMMERCE DR. TUCSON, AZ 85705 (CON 55) RURAL/METRO CORPORATION (PINAL) DBA TRI-CITY MED DBA LIFE LINE AMBULANCE 3759 N. COMMERCE DR. TUCSON, AZ 85705 (CON 87) RURAL/METRO CORPORATION (YUMA) DBA RURAL/METRO AMBULANCE SERVICE 2029 S ARIZONA AVE, YUMA AZ 85364 (CON 65) SOUTHWEST AMBULANCE OF SOUTHEASTERN ARIZONA, INC. DBA SOUTHWEST AMBULANCE OF SAFFORD DBA LIFE LINE AMBULANCE 3759 N. COMMERCE DR. TUCSON, AZ 85705 (CON 63). ABC AMBULANCE LLC 3118 E. MCDOWELL RD. PHOENIX, AZ 85008 (CON 139), AMERICAN MEDICAL RESPONSE OF COCHISE

COUNTY LLC 4266 INDUSTRY DRIVE, STE 3, SIERRA VISTA, AZ 85635 (CON 120).

FORM TITLE:FORM NUMBER:

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

ADDITIONAL REMARKS

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

Aon Risk Services Central, Inc.

NAMED INSUREDAGENCY

LOC #:

570000073826AGENCY CUSTOMER ID:

© 2008 ACORD CORPORATION. All rights reserved.

See Certificate Number:

See Certificate Number:

The ACORD name and logo are registered marks of ACORD

570089379792

570089379792

ACORD 25 Certificate of Liability Insurance Additional Description of Operations / Locations / Vehicles:

ACORD 101 (2008/01)

ADDITIONAL REMARKS SCHEDULE Page _ of _

American Medical Response

Additional Remarks

AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE

LOC #:

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY

See Certificate Number:

See Certificate Number:

Aon Risk Services Central, Inc.

570000073826

570089379792

570089379792

Page _ of _

American Medical Response

Professional Medical Transport, Inc. dba Life Line Ambulance dba PMT Ambulance dba ComTrans Ambulance Inc.

dba ComTrans Ambulance Service dba Promed Transport dba American ComTrans dba American Medical Response dba AMR 8465 N. Pima Rd. Scottsdale, AZ 85258 (CON 71) American Medical Response of Maricopa, LLC dba American Medical Response dba AMR dba SW General, Inc. dba Southwest Ambulance dba Southwest Ambulance of Casa Grande, Inc. dba Southwest Ambulance and Rescue of Arizona 617 E Main Street Mesa, AZ 85201 (CON 136) Rural/Metro Corporation (Maricopa) dba Rural/Metro Ambulance Service dba Arizona Medical Transport dba AMT 8465 N. Pima Rd. Scottsdale, AZ 85258 (CON 109) Southwest Ambulance of Tucson, Inc. dba Kord's Southwest dba American Medical Response, dba AMR 3759 N. Commerce Dr. Tucson, AZ 85705 (CON 54) Life Line Ambulance, Inc. 1099 W Iron Springs Road Prescott, AZ 85258 (CON 62) R/M Arizona Holdings, Inc. dba Canyon State Ambulance dba Payson Medical Transport dba LifeStar EMS dba Life Line Ambulance 8465 N. Pima Road Scottsdale, AZ 85258 (CON 58) Southwest Ambulance of Casa Grande, Inc. dba Southwest Ambulance of Casa Grande, dba American Medical Response dba AMR 3759 N. Commerce Dr. Tucson, AZ 85705 (CON 85).

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD