2024-03-12-CGAWPol-_COI-Kary_Env.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 EXP

TYPE 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

KARYE-1 OP ID: SM

08/01/2023

Southwest Insurance Brokers

Southwest Insurance Brokers 14805 N 73rd St Scottsdale, AZ 85260 Southwest Insurance Brokers, 602-263-0777

Everest Indemnity Insurance Co Berkley Casualty Company

Kary Environmental Services, Inc.

641 S. Drew St Mesa, AZ 85210

Auto-Owners Insurance Ameritrust Insurance Company

A X 1,000,000

X X X EF4ML05578-231 03/12/2023 03/12/2024 50,000

X 5,000

X 03/12/2023 03/12/2024 1,000,000

2,000,000

X 2,000,000

1,000,000A

X X X EF4CA00321-231 03/12/2023 03/12/2024

X X

X MCS-90

XX 10,000,000

X

A

EF4CU00819-231 03/12/2023 03/12/2024 10,000,000

10,000X Follows Form*

XB

X AMWC380001 03/01/2023 03/01/2024 1,000,000

Y 1,000,000

1,000,000

A CLAIMS MADE 5/15/98 03/12/2023 03/12/2024 Occur/Agg $1mil/$2mil

A Contr Poll Liab * OCCURRENCE FORM 03/12/2023 03/12/2024 Occur/Agg $1mil/$2mil

Solicitation No. CTR065799

The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents and employees are continued page two:

ADEQ-02

Arziona Department of Environmental Quality 1110 W Washington Street Phoenix, AZ 85007

602-263-0777

10851 26727 18988

PER PRJ AGGR LMT $6000000

EF4ML05578-231

CPL Liab $1m/$2m

Prof Liab $1m/$2m

Professional Liab*

NOTEPAD

PAGE

INSURED'S NAME Date

OP ID: SM

hereby listed as Additional insured on a Primary/non contriburory basis including a Waiver of Subrogation and a Per Project Aggregate for the General Liability and Pollution sections of the policy and as an Additional Insured including a Waiver of Subrogation for the Commercial Auto. A Waiver of Subrogation applies for the Workers Compensation.

FORMS: ECG00595(12/21), ECG24671(08/18), ECG24669(08/18), ECG24673

(08/18), CA2048(10/13), ECA24503(02/14), ECA24509(04/14) and WC000313 (04/84).

Blanket Notice of Cancellation - 30 day per form EIL00734(09/18)

Umbrella is following form & extends over all underlying coverage including Pollution.

All forms apply where required by written contract.

KARYE-1

08/01/2023

Kary Environmental

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

The following statement only applies to policies or exposure in Missouri: Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual.

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)

1983 National Council on Compensation Insurance.

Kary Environmental Services Inc.

03/01/2023 AMWC380001

Berkley Casualty Company

Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation.