2024_04_01_COI_CL_AL_WC_Crime_SAM.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

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

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2016 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Willis Towers Watson Insurance Services West, Inc.

c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA

Inter Tribal Council of Arizona, Inc.

2214 N. Central Avenue, #100 Phoenix, AZ 85004

Re: Contract Number CTR048038

Abusive Conduct Liability - Sexual Abuse & Molestation (SAM) Liability:

Aggregate Limit: $500,000 Each Abusive Conduct Limit: $500,000

SEE ATTACHED

State of Arizona

DES-DAAS

Attn: Lei Ronda Golden-Grady 1789 W. Jefferson Street, SC950A Phoenix, AZ 85007

08/07/2023

1-877-945-7378 1-888-467-2378 certificates@willis.com

Philadelphia Indemnity Insurance Company 18058

AmTrust Insurance Company 15954

W29812882

A

1,000,000

100,000

1,000

1,000,000

3,000,000

3,000,000

Y Y PHPK2519586 04/01/2023 04/01/2024

A

1,000,000

04/01/202404/01/2023Y Y PHPK2519586

A 2,000,000

10,000

PHUB851965 04/01/2023 04/01/2024 2,000,000

WWC3643330

B Y

1,000,000 Yes 04/01/2023 04/01/2024

1,000,000

1,000,000

A SAM Coverage:

Abusive Conduct Liability

See belowPHPK2519586 04/01/2023 04/01/2024

308215224515748SR ID: BATCH:

Willis Towers Watson Certificate Center

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

Inter Tribal Council of Arizona, Inc.

2214 N. Central Avenue, #100 Phoenix, AZ 85004

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as Additional Insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor are included as Additional Insureds as respects to General Liability and Auto Liability

Waiver of Subrogation applies in favor of 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 with respects to General Liability, Auto Liability and Workers Compensation as permitted by law.

INSURER AFFORDING COVERAGE: Philadelphia Indemnity Insurance Company NAIC#: 18058

POLICY NUMBER: PHPK2519586 EFF DATE: 04/01/2023 EXP DATE: 04/01/2024

TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:

Crime Limit: See Below

ADDITIONAL REMARKS:

Crime Coverages:

Employee Dishonesty: $250,000 Money & Securities Inside/Outside: $100,000 Computer Fraud: $100,000 Forgery or Alteration: $100,000

INSURER AFFORDING COVERAGE: Philadelphia Indemnity Insurance Company NAIC#: 18058

POLICY NUMBER: PHPK2519586 EFF DATE: 04/01/2023 EXP DATE: 04/01/2024

TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:

Professional Liability Per Occurrence $1,000,000 ���������������������� Aggregate $3,000,000

2 2

Willis Towers Watson Insurance Services West, Inc.

See Page 1

See Page 1 See Page 1 See Page 1

25 Certificate of Liability Insurance

W29812882CERT:3082152BATCH:24515748SR ID:

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 24 04 05 09

CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

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

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

PHPK2519586

State of Arizona, its departments, agencies, boards, commissions, universities officers, officials, agents, and employees as additional insureds *Full name is listed on the attached manuscript endorsement*

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 24 04 05 09

CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

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

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

PHPK2519586

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses (See Manuscript)

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

The following is added to the Schedule of CG2026-Additional Insured-Designated Person or Organization (attached to this policy):

The State of Arizona, its departments, agencies, boards commissions, universities and its officers, officials, agents and employees and the Depart of Economic Security for losses arising out of the work performed by or on behalf of the Contractor Attn: Arizona Department of Economic Security, Division of Aging and Adult Services 1789 W Jefferson St, Phoenix, AZ 85007

Addl Insured CG2026: The State of Arizona

The following is added to the Schedule of CG2404 Waiver of Transfer of Rights of Recovery Against Others To Us (attached to this policy):

The State of Arizona, its departments, agencies, boards commissions, universities and its officers, officials, agents and employees and the Depart of Economic Security for losses arising out of the work performed by or on behalf of the Contractor Attn: Arizona Department of Economic Security, Division of Aging and Adult Services 1789 W Jefferson St, Phoenix, AZ 85007 RE: A contract and requirements for the State

CG2404 Waiver of Transfer of Rights Complete Name: The State of Arizona

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 of

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.

PHPK2519586

05/05/2023 Inter Tribal Council of AZ, Inc

The State of Arizona, its departments, agencies, boards commissions, universities and its officers, officials, agents and employees and the Depart of Economic Security for losses arising out of the work performed by or on behalf of the Contractor

1 2

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 of

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.

PHPK2519586

05/05/2023 Inter Tribal Council of AZ, Inc

State of Arizona, and its departments, agencies, boards, commissions, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor (See Manuscript)

2 2

The following is added as an Additional Insured per forms

Form CA2048-Additional Insured-Designated Insured Form CA0444 Waiver of Subrogation

State of Arizona, its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor

Attn: Arizona Department of Economic Security, Division of Aging and Adult Services 1789 W Jefferson St, Phoenix, AZ 85007

Full Name for AI State of Arizona, et al

The following is added to the Schedule of CG2026-Additional

Insured-Designated Person or Organization (attached to this policy):

The State of Arizona, its departments, agencies, boards commissions, universities and its officers, officials, agents and employees and the

Depart of Economic Security for losses arising out of the work performed by or on behalf of the Contractor

Attn: Arizona Department of Economic Security, Division of Aging and Adult Services

1789 W Jefferson St, Phoenix, AZ 85007

Addl Insured CG2026: The State of Arizona

The following is added to the Schedule of CG2404 Waiver of Transfer of

Rights of Recovery Against Others To Us (attached to this policy):

The State of Arizona, its departments, agencies, boards commissions, universities and its officers, officials, agents and employees and the

Depart of Economic Security for losses arising out of the work performed by or on behalf of the Contractor

Attn: Arizona Department of Economic Security, Division of Aging and Adult Services

1789 W Jefferson St, Phoenix, AZ 85007

RE: A contract and requirements for the State

CG2404 Waiver of Transfer of Rights Complete Name: The State of Arizona

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.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 04-84)

Schedule

State of Arizona Dept of Economic Security Division of Child Care 1789 West Jefferson, Mail Drop 85V1 Phoenix, AZ. 85007

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

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 4/1/2023 Policy No. WWC3643330 Endorsement No. 3 Insured Inter Tribal Council of Arizona Premium $ 11,393 Insurance Company Wesco Insurance Company

Countersigned by

WC 00 03 13

(Ed. 04-84)