2023-10-1_COI.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

6/23/2023

(480) 214-2709 (480) 730-4929

18058

Area Agency On Aging 1366 E. Thomas Rd. #108 Phoenix, AZ 85014

13928

A 1,000,000

X X PHPK2483416 11/5/2022 11/5/2023 100,000

10,000

1,000,000 3,000,000 3,000,000

1,000,000A

X X PHPK2483416 11/5/2022 11/5/2023

10,000,000A

PHUB838868 11/5/2022 11/5/2023 10,000,000

10,000 B

X 1009539 10/1/2022 10/1/2023 1,000,000 Y 1,000,000

1,000,000 A Abuse & Molestation PHPK2483416 11/5/2022 Occurrence Limit 1,000,000 A Professional Liab PHPK2483416 11/5/2022 11/5/2023 Incident Limit 1,000,000

Contract No: CTR066189 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.

Sexual Abuse and Molestation coverage is included - $1,000,000 Each Abusive Conduct, $3,000,000 Aggregate Professional Liability coverage is included - $1,000,000 Each Professional Incident, $3,000,000 Aggregate The following policies are scheduled under the Umbrella policy: Employers Liability, General Liability, Auto Liability, Employee Benefits Liability, Abusive Conduct Liability and Professional Liability 30 day notice of cancellation provided to the State of Arizona, 10 days notice for non-payment of premium

State of Arizona 1789 W. Jefferson Street Mail Drop 6271 Phoenix, AZ 85007

AREAAGE-01 CCOMPTON

The Mahoney Group - Mesa 1835 South Extension Road Mesa, AZ 85210

Connie Compton ccompton@mahoneygroup.com

Philadelphia Indemnity Ins. Co CopperPoint Indemnity Insurance Company

X

11/5/2023

X X

X

X X X

X

X

X

Note:

This endorsement may be used to extend the information page by listing additional endorsements and schedules that are part of the policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 60

(Ed. 05/22)

WC 99 06 60

(Ed. 05/22)

© 1991 National Council on Compensation Insurance.

EXTENSION OF INFORMATION PAGE

Schedule of Forms

ITEM 3D

1009539POLICY NO:

Form Numbers Form Name Applicable States P-799 Policy Renewal Statement Letter AZ

WC 00 00 01 D Information Page Notes AZ

P-503 Independent Contractor Premium Advisory AZ

WC 99 06 17 Dividend Endorsement AZ

P-504.1 Out of State Coverage Advisory AZ

WC 00 00 00 C Workers Compensation and Employers Liability Insurance Policy

AZ

WC 99 04 19 Premium When Due Endorsement AZ

WC 99 06 18 Notification of Dividend AZ

WC 02 04 01 C Arizona Alcohol & Drug Free Workplace Premium Credit Endorsement

AZ

WC 99 06 60 Extension of Information Page Item 3D Endorsement

AZ

WC 00 03 13 Waiver of Our Right to Recover from Others Endorsement

AZ

WC 00 99 03 22 Limited Other States Insurance Endorsement AZ

WC 00 04 21 F Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement

AZ

WC 00 04 22 C Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement

AZ

WC 02 06 03 Arizona Amendatory Endorsement AZ

WC 00 99 06 23 Membership Endorsement AZ

WC 00 99 06 25 Schedule of Fees AZ

WC 00 04 04 Pending Rate Change Endorsement AZ

WC 00 04 14 A 90-Day Reporting Requirement—Notification of Change in Ownership Endorsement

AZ

WC 00 04 25 Experience Rating Modification Factor Revision Endorsement

AZ

WC 02 06 01 C Arizona Cancellation and NonRenewal Endorsement

AZ

Note:

This endorsement may be used to extend the information page by listing additional endorsements and schedules that are part of the policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 60

(Ed. 05/22)

WC 99 06 60

(Ed. 05/22)

© 1991 National Council on Compensation Insurance.

Form Numbers Form Name Applicable States WC 99 06 22 Extension of Information Page Schedule of

Named Insured

AZ

WC 00 03 10 Sole Proprietors Partners Officers and Others Coverage Endorsement

AZ

WC 89 06 00 B Policy Information Page Endorsement AZ

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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.)

12/21/2022Endorsement Effective 1009539Policy No. 20Endorsement No.

Area Agency on Aging Region One IncInsured 100 Premium $

CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

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 State Blanket/Schedule/State

AZ 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"

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B

(Version 7/01)

WC 89 06 00 B

(Version 7/01)

© Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved.

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.)

12/21/2022Endorsement Effective 1009539Policy No. 19Endorsement No.

Area Agency on Aging Region One IncInsured 61,909 Premium $

CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

POLICY INFORMATION PAGE ENDORSEMENT

The following item(s)

Insured’s Name (WC 89 06 01) Expiration Date (WC 89 06 04) Insured’s Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer’s Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured’s Legal Status (WC 89 06 10) Item 3.A. States (WC 89 06 11)

Item 3.B. Limits (WC 89 06 12) Item 3 .C. States (WC 89 06 13)

✔ Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4.* Class, Rate, Other (WC 89 04 15)

✔ Interim Adjustment of Premium (WC 89 04 16) Interstate/Intrastate Risk ID Number (WC 89 06 18) Issuing Agency/Producer Office Address (WC 89 06 25)

Is changed to read:

Total Estimated Annual Premium: $61,909