2023-10-21-_CGAWPro-Dominion_Env.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.

WC0871895

Phoenix, AZ 85007-2935

X

X

1,000,000

68924518

68924518

5,000

1,000,000 is added to the General Liability, Auto Liability and Workers Compensation in favor of the additional insureds.

insurance available to the additional insured(s) under any other third party liability policy. A waiver of subrogation The coverage provided by the additional insured endorsement shall be primary and not contributing with any other liability arising out of the activities performed by or on behalf of Dominion Environmental Consultants.

employees are named as additional insureds with respect to the Commercial General Liability and Auto Liability for The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and Re: Asbestos and Lead Consultant and Abatement Services / Contract No. CTR065792

X

USA

LIC #124221

LIC #124221

X

Mesa, AZ 85275-1644

Mesa, AZ 85275-1644

X

X

10/21/22 10/21/23

(866) 829-4369

(866) 829-4369

20045 N. 19th Avenue, Bldg. 7

20045 N. 19th Avenue, Bldg. 7

N

X

Melanie Tyson

Melanie Tyson

A

X

UCW Insurance Agency, Inc.

UCW Insurance Agency, Inc.

Professional Liability

Contractors Pollution

X

Melanie C. Tyson

Melanie C. Tyson

10/21/22 10/21/23 mtyson@ucwinsurance.com mtyson@ucwinsurance.com

Contracts and Procurement Arizona Department of Environmental Quality

50,000

1-866-829-4368

1-866-829-4368

Dominion Environmental Consultants, Inc.

Dominion Environmental Consultants, Inc.

Phoenix, AZ 85027

Phoenix, AZ 85027

10/21/23

4,000,000

1,000,000

1110 W Washington Street

X

06/09/2023

06/09/2023

PO Box 31644

PO Box 31644

X

X

X

EF4CU01660-221

EF4CA00482-221B

1,000,000

1,000,000

X

STAR INS CO

STAR INS CO

Everest Denali Insurance Company

Everest Denali Insurance Company

EVEREST IND INS CO

EVEREST IND INS CO

X

C

EF4ML06620-221

mtyson

1,000,000

1,000,000

A

1,000,000

4,000,000

X

18023

18023

16044

16044

10851

10851

(866) 829-4368

(866) 829-4368

10/21/22

03/28/23 03/28/24