2023-09-26 COI.pdf

CERTIFICATE HOLDER

© 1988-2010 ACORD CORPORATION. All rights reserved.

ACORD 25 (2010/05)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSR

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

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 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).

The ACORD name and logo are registered marks of ACORD

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

Ace Surface Maintenance, Inc.

3418 North 29th Avenue Phoenix, AZ 85017

Talanton Insurance Agency 6868 North 7th Avenue Suite 204 Phoenix, AZ 85013

Commercial Department 480-777-0080

Commercial@GoTalanton.com 602-888-9719

Y Y

Y Y

09/26/2022 09/26/2023

09/26/2022 09/26/2023

2,000,000 2,000,000

5,000 1,000,000

300,000 1,000,000

1,000,000

West Bend Mutual Insurance Company 15350

X

X X

X

X

03/29/2023

23850Tokio Marine Specialty Insurance Company

X X

PUB835059 09/26/2022 09/26/2023

2,000,000 2,000,000 2,000,000

B

A

A

B145459 00

B145459 00

Y Y

Project Description:

Project Address:

Y B145475 12/01/2022 09/26/2023A X

1,000,000 1,000,000 1,000,000

See Attached Acord 101

Y

ADOT Facilities Management & Support Group 1655 W. Jackson St., Suite 121, MD 123F Phoenix, Arizona 85007 a8812 Accepted

EFFECTIVE DATE:

NAMED INSURED

POLICY NUMBER

NAIC CODECARRIER

AGENCY

LOC #:

AGENCY CUSTOMER ID:

ofPageADDITIONAL REMARKS SCHEDULE

ADDITIONAL REMARKS

FORM TITLE:FORM NUMBER:

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

© 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

ACORD 101 (2008/01)

Certificate Holder is defined as an Additional Insured with respect to the General, Auto and Excess Liability policies, if required or agreed to in a written contract, subject to all provisions and limitations of the policy.

A Waiver of Subrogation in favor of the Certificate Holder applies to the General, Auto and Excess Liability and Worker's Compensation / Employer's Liabilit y policies if required or agreed to in a written contract, subject to all provisions and limitations of the policy.

Per Attached: WB 1482 0717, CG 24 53 12 19, CA 20 48 Z 10 13, CA 04 44 10 13, PIC-EXS-001 (05/13), PIC-EXS-084 (04/15), WC 00 03 13.

Ira Schwartz has elected to be excluded from WorkComp pursuant to A.R.S. #23 902(B)-(C).

Ace Surface Maintenance, Inc.

3418 North 29th Avenue Phoenix, AZ 85017

25 Certificate of Liability Insurance

Talanton Insurance Agency

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WB 1482 07 17 West Bend Mutual Insurance Company Page 1 of 2 West Bend, Wisconsin 53095

ADDITIONAL INSURED – CONTRACTOR'S BLANKET

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. WHO IS AN INSURED (Section II) is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract or written agreement.

The written contract or written agreement must be:

1. Currently in effect or becoming effective dur-ing the term of this policy; and

2. Signed by all parties to the written contract or written agreement prior to the "bodily injury," "property damage," "personal injury and ad-vertising injury."

B. The insurance provided to the additional insured is limited as follows:

1. That person or organization is only an addi-tional insured with respect to liability for "bodi-ly injury", "property damage' or "personal and advertising injury" caused in whole or in part, by:

a. Your premises; or

b. Your negligent acts or omissions in con-nection with "Your work" for that additional insured.

However:

a. The insurance afforded to such additional insured only applies to the extent permit-ted by law; and

b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the written contract or written agreement to provide such additional insured.

2. The Limits of Insurance applicable to the additional insured are those specified in the written contract or written agreement or in the Declarations for this policy, whichever is less.

These Limits of Insurance are inclusive and not in addition to the Limits of Insurance shown in the Declarations.

3. Except when required by written contract or written agreement, the coverage provided to the additional insured by this endorsement does not apply to:

a. "Bodily injury" or "property damage" oc-curring after:

(1) All work on the project (other than service, maintenance or repairs) to be performed by or on behalf of the addi-tional insured at the site of the covered operations has been completed; or

(2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than an-other contractor or subcontractor en-gaged in performing operations for a principal as part of the same project.

b. "Bodily injury" or "property damage" aris-ing out of acts or omissions of the addi-tional insured other than in connection with the general supervision of "your work."

4. The insurance provided to the additional insured does not apply to "bodily injury," "property damage," "personal injury and ad-vertising injury" arising out of an architect's, engineer's, or surveyor's rendering of or fail-ure to render any professional services in-cluding;

a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifica-tions; and

b. Supervisory, or inspection activities per-formed as part of any related architectural or engineering activities.

This exclusion applies even if the claims against any insured allege negligence or other wrongdo-ing in the supervision, hiring, employment, train-ing or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any profes-sional architectural, engineering or surveying services.

Page 2 of 2 West Bend Mutual Insurance Company WB 1482 07 17 West Bend, Wisconsin 53095

C. As respects the coverage provided under this endorsement, Paragraph 4.b. SECTION IV –

COMMERCIAL GENERAL LIABILITY CONDI-

TIONS is amended with the addition of the fol-lowing:

4. Other insurance

b. Excess insurance

This insurance is excess over:

Any other valid and collectible insurance procured by or on behalf of the additional insured whether primary, excess, contin-gent or on any other basis unless a written contract specifically requires that this in-surance be either primary or primary and noncontributing. Where required by writ-ten contract, we will consider any other in-surance procured by the additional in-sured for injury or damage covered by this endorsement to be excess and noncon-tributing with this insurance.

If no written contract specifically requires primary or noncontributory coverage, then this insurance is excess and as a condi-tion of coverage, the additional insured shall be obligated to tender the defense and indemnity of every claim or suit to all other insurers that may provide coverage to the additional insured, whether on a contingent, excess or primary basis.

When this insurance is excess, we will have no duty under Coverage A. and Coverage B. to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the in-sured's rights against all those other in-surers.

POLICY NUMBER: COMMERCIAL AUTO

CA 20 48 Z 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

West Bend Mutual Insurance Company West Bend, Wisconsin 53095

Contains material copyrighted by ISO, with its permission.

CA 20 48 Z 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi-fied by this endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

Name of Person(s) or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Each person or organization shown in the Sched-ule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or or-ganization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II – Covered Autos Liability Cover-age in the Business Auto and Motor Carrier Cov-erage Forms and Paragraph D.2. of Section I Covered Autos Coverages of the Auto Dealers Coverage Form.

B. The following is added to the Other Insurance Condition in the Business Auto and Auto Dealers Coverage Forms and the Other Insurance – Pri-mary And Excess Insurance Provisions in the Mo-tor Carrier Coverage Form and supersedes any provision to the contrary:

This Coverage Form's Covered Autos Liability Coverage is primary to and will not seek contribu-tion from any other insurance available to an "in-sured" shown in the schedule provided that:

1. Such "insured" is a Named Insured under such other insurance; and

2. You have agreed in writing in a contract or agreement that this insurance would be prima-ry and would not seek contribution from any other insurance available to such "insured".

B145459

Ace Surface Maintenance, Inc

09-26-2022

Any party for whom the insured is required to provide designated insured status.

POLICY NUMBER: COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

Name(s) Of Person(s) Or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

Any party with whom the insured agrees to waive subrogation in a written contract.

B145459

09-26-2022

Ace Surface Maintenance, Inc

POLICY NUMBER: PIC-EXS-084 (04/15)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF SUBROGATION FOLLOW FORM ENDORSEMENT

This endorsement modifies insurance provided under the following:

COMMERCIAL EXCESS LIABILITY COVERAGE FORM

The following is added to SECTION III – CONDITIONS:

This policy is intended to include Waiver of Transfer of Rights of Recovery Against Others to Us.

We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage to the extent the “controlling underlying insurance” also waives such right of recovery.

The coverage provided will follow the same provisions, exclusions and limitations that are contained in the “controlling underlying insurance” shown in the Schedule of Controlling Underlying Insurance unless otherwise directed by an endorsement to this policy.

To the extent such provisions differ or conflict, the provisions of this policy will apply. However, the coverage provided under this policy will not be broader than that provided by the “controlling underlying insurance.”

PUB835059

1983 National Council on Compensation Insurance.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

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.

Schedule

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.)

Endorsement Effective Policy No. Endorsement No.

Insured Premium

Insurance Company Countersigned by ___________________________________________

WC 00 03 13

(Ed. 4-84)

Any party with whom the insured agrees to waive subrogation in a written contract

Included Ace Surface Maintenance, Inc

B145475 12-01-2022