20220701 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

Cert_Renewal

07/01/21

CIRTS_Support@jacobs.com

1,000,000

Marsh Risk & Insurance Services

1,000,000

2,000,000

07/01/22 07/01/22

07/01/22

1739 W. Jackson St., Suite A, MD100P

Phoenix, AZ 85007-3276

Jacobs Engineering Group Inc.

1,000,000

LIC #0437153

1,000,000

A

A

07/01/21

A

ACE AMER INS CO

WCU C67817588 (OH)*

Los Angeles, CA 90017

SCF C6781762A (WI)

ISA H25545631

WLR C67817540 (AOS)

07/01/21

1-212-948-1306

5,000

X

1-212-948-1306

C/O Global Risk Management 1000 Wilshire Blvd., Suite 2100

X

1,000,000

633 W. Fifth Street

06/07/2021

07/01/21

07/01/21

07/01/21

07/01/22A

Los Angeles, CA 90071

A

X or on behalf of the Contractor involving automobiles owned, leased, hired or borrowed by the Contractor for auto and employees shall be named as additional insureds with respect to liability arising out of the activities performed by The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, respect to liability arising out of the activities performed by or on behalf of the contractor for general liability.

and the public entity and its officers, officials, agents, and employees shall be named as additional insureds with and all work performed in ADOT's right of way. The State of Arizona, its departments, agencies, boards, commissions, OFFICE LOCATION: Phoenix, AZ. PROJECT MGR: Jeanne Work. CONTRACT MGR: Connie Hodes. SECTOR: Public. RE: For any

22667

07/01/22

Arizona Department of Transportation

1,000,000

State of Arizona

PROFESSIONAL LIABILITY

1,000,000

HDO G72493503

500,000

07/01/22

2,000,000

A

N

PER CLAIM/PER AGG

X CONTRACTUAL LIABILITY

X

USA

X

EON G21655065 012

62420007

62420007

ACCEPTED

ADOT Risk Management

SUPP (05/04)

SUPPLEMENT TO CERTIFICATE OF INSURANCE

DATE

NAME OF INSURED:

Additional Description of Operations/Remarks from Page 1:

Additional Information:

06/07/2021

*$2,000,000 SIR FOR STATE OF: OHIO

CONTRACT.*

INSURANCE WILL NOT EXCEED OR BROADEN IN ANY WAY THE TERMS, CONDITIONS, AND LIMITS AGREED TO UNDER THE APPLICABLE insurance is excess and non-contributory. *THE TERMS, CONDITIONS, AND LIMITS PROVIDED UNDER THIS CERTIFICATE OF performed by or on behalf of the Contractor for GL, AL & WC. Coverage is primary and certificate holder's boards, commissions, universities and its officers, officials, agents, and employees for losses arising from work liability. Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies

Jacobs Engineering Group Inc.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Named Insured

Jacobs Engineering Group Inc.

Endorsement Number

Policy Symbol

EON

Policy Number Policy Period to Effective Date of Endorsement

Issued By (Name of Insurance Company)

ACE American Insurance Company

NOTICE TO OTHERS ENDORSEMENT – SCHEDULE

. If We cancel or non-renew the Policy prior to its expiration date by notice to You for any reason other than nonpayment of premium, We will endeavor, as set out below, to send written notice of cancellation or non-renewal via such electronic or other form of notification as We determine, to the persons or organizations listed in the schedule that You or Your representative provide or have provided to Us (the Schedule). You or Your representative must provide Us with both the physical and e-mail address of such persons or organizations, and We will utilize such e-mail address and/or physical address that You or Your representative provided to Us on such Schedule.

. The Schedule must be initially provided to Us within 30 days after:

i. The beginning of the Policy Period, if this endorsement is effective as of such date; or

ii. This endorsement has been added to the Policy, if this endorsement is effective after the Policy Period commences.

. The Schedule must be in a format that is acceptable to Us and must be accurate.

. Our delivery of the notification as described in Paragraph A of this endorsement will be based on the most recent Schedule in Our records as of the date the notice of cancellation or non-renewal is mailed or delivered to You.

. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation or non-renewal date applicable to the Policy.

. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation or non-renewal of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation or non-renewal to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon Us, Our agents or representatives, will not extend any Policy cancellation or non-renewal date and will not negate any cancellation or non-renewal of the Policy.

. We are not responsible for verifying any information provided to Us in any Schedule, nor are We responsible for any incorrect information that You or Your representative provide to Us. If You or Your representative does not provide Us with a Schedule, We have no responsibility for taking any action under this endorsement. In addition, if neither You nor Your representative provides Us with e-mail address and/or physical address information with respect to a particular person or organization, then We shall have no responsibility for taking action with regard to such person or entity under this endorsement.

. With respect to this endorsement Our, Us or We means the stock insurance company listed in the Declarations, and You or Your means the insured person or entity listed in Item 1 of the Declarations page.

All other terms and conditions of this Policy remain unchanged.

MS-36362 (04/19)

Authorized Representative