2023-05-01_COI_Lohman.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

1/6/2023

Lohman Helicopter, LLC 406 Burrell Ave Hangar N23 P.O. Box 976 Lewiston, ID 83501

1,000,000A

01-CA-064597471-9 5/1/2022 5/1/2023

B 100 0003829 9/1/2022 9/1/2023 2,000,000

2,000,000 2,000,000

See attached Additional Insured - Where Required under Contract or Agreement and Limited Waiver of Rights of Recovery Against Others clause (form no.

102093 1-14).

As respects coverage B - see attached Waiver of our Right to Recover from Others endorsement (form no. WC 00 03 13).

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees Arizona Game and Fish Department attn: Purchasing 5000 W Carefree Hwy Phoenix, AZ 85086

LOHMHEL-01 SFIELD

Pik West Insurance Agency, LLC P.O. Box 2003 Renton, WA 98059

New Hampshire Insurance Company Starr Indemnity & Liability Company

X

X

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

(Ed. 04-84)

WC 00 03 13

Schedule

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Any person or organization to whom you become obligated to waive your rights of recovery against, under any contract or agreement you enter into prior to the occurrence of loss.

Endorsement Effective: Policy No.: Endorsement No.:

Insured: Premium:

Insurance Company: Countersigned by:

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

WC 00 03 13

(Ed. 04-84) Page 1 of 1

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Pik West Insurance Agency, LLC P.O. Box 2003 Renton, WA 98059 Phone: 206-914-7493 CA License #6000825

CERTIFICATE OF INSURANCE

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(s) 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. This Certificate cancels and supersedes all previously issued certificates.

Certificate Holder: Named Insured:

The State of Arizona, and its departments, agencies, boards, commissions, Lohman Helicopter, LLC universities, officers, officials, agents, and employees 406 Burrell Ave, N23 Arizona Game and Fish Dept. Attn: Purchasing Lewiston, ID 83501 5000 W Carefree Hwy Phoenix, AZ 85086

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 of condition of any contract or other document with respect to which this Certificate may be issued or may pertain. The insurance afforded by the policy(s) described herein is subject to all terms, exclusions, and conditions of such policies. Limits shown may have been reduced by paid claims.

Policy Type: Aircraft Hull and Liability / Commercial General Liability Policy Period: 5/1/2022 to 5/1/2023 Both days as of 12:01 A.M. Standard Time at the address of the Named Insured shown above Insurer(s): Starr Indemnity Insurance Company through Starr Aviation, Inc. (45% lead line) and following markets as held on file Lead Policy No(s): SASICOM60063522-09 / SASICOM60063822-09

Aircraft Physical Damage Coverage Aircraft Covered: All aircraft owned and/or operated by the Named Insured Insured Values:

Not In Motion In Motion / Ingestion / Moored Deductibles:

Aircraft Liability Coverage Liability Coverages: Limits of Liability:

Flight Coverage - Combined Single Limit Bodily Injury and Property Damage Aircraft Liability Including Passenger Liability $10,000,000 each occurrence

Aviation Commercial General Liability Coverage Premises Covered: All premises necessary and/or incidental to the aviation operations of the Named Insured Liability Coverages: Limits of Liability:

Aviation General Liability including Premises Liability, Personal & Advertising Injury (Aggregate), and Products/Completed Operations (Aggregate) $2,000,000 each occurrence except where aggregate limits apply

Certificate Provisions

With respect to Aircraft Liability, it is understood and agreed the Certificate Holder(s) shall be included as Additional Insured(s) solely with respect to the aviation operations of the Named Insured. It is specifically agreed the inclusion of more than one Insured shall not operate to increase the Limits of Liability and it limited to those coverages provided by these policies. The policy does not provide coverage for the Certificate Holder(s) for bodily injury or property damage which arises from the design, manufacture, modification, repair, sale, or servicing of aircraft by the Certificate Holder(s).

With respect to hull coverage provided by the above described policy(s), the Insurer(s) hereby waives its rights of subrogation against the Certificate Holder(s), excluding gross negligence and/or willful misconduct by the Certificate Holder(s). This waiver shall not prejudice its right of recourse for damages arising from the design, manufacture, modification, repair, sale, supplier, or servicing of the aircraft by the Certificate Holder(s).

The Insurer(s) listed above will provide for 30 days (except 10 days as respects non-payment and 7 days or less as respects war coverage), written notice to you in the event of cancellation of the above described policy(s). Except as otherwise stated in this certificate, the Insurer(s) assume no legal responsibility for any failure to do so.

Pik West Insurance Agency, LLC P.O. Box 2003 Renton, WA 98059 Phone: 206-914-7493 CA License #6000825

Insurer(s) agree that as to the interest of the Certificate Holder(s), the insurance shall be primary insurance without any right of contribution from any other insurance which may be carried by the Certificate Holder(s).

Certificate No.: LOHMHEL-112 Date: 1/6/2023 Authorized Representative