2024-04-30_COI_CTR051357_MedImpact.pdf

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Id e n ti fi e r

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66666 66606 06060 00626 06466 20444 62006 02200 62622 42000 06222 02404 20402 00062 22024 04224 00220 60220 06262 24002 00600 22242 40062 22206 22200 62422 40200 06222 20606 20622 00060 00006 04222 24200 66646 06224 06644 40666 66660 60006 06006

C e rt if ic a te

N o

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

05/08/2023

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.

PRODUCER

Aon Risk Insurance Services West, Inc.

Los Angeles CA Office 707 Wilshire Boulevard Suite 2600 Los Angeles CA 90017-0460 USA

PHONE

(A/C. No. Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

(866) 283-7122

INSURED 27960Illinois Union Insurance CompanyINSURER A:

26883AIG Specialty Insurance CompanyINSURER B:

11126Sompo America Insurance CompanyINSURER C:

11551Endurance Assurance CorporationINSURER D:

24988Sentry Insurance CompanyINSURER E:

INSURER F:

FAX

(A/C. No.):

(800) 363-0105

Endurance American Specialty Ins Co. 41718

CONTACT

NAME:

MedImpact Holdings, Inc 10181 Scripps Gateway Court San Diego CA 92131-5152 USA

COVERAGES CERTIFICATE NUMBER: 570099360272 REVISION NUMBER:

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. Limits shown are as requested

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

(MM/DD/YYYY)

SUBR

WVD

INSR

LTR

ADDL

INSD POLICY NUMBER TYPE OF INSURANCE LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY LOC

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

X

X

X

GEN'L AGGREGATE LIMIT APPLIES PER:

$1,000,000

$1,000,000

$5,000

$1,000,000

$2,000,000

$2,000,000

F 04/30/2023 04/30/2024MGP30001121101

PRO-

JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

SCHEDULED

AUTOS

HIRED AUTOS

ONLY

NON-OWNED

AUTOS ONLY

BODILY INJURY ( Per person)

PROPERTY DAMAGE

(Per accident)

X

BODILY INJURY (Per accident)

$1,000,000C 04/30/2023 04/30/2024 COMBINED SINGLE LIMIT

(Ea accident)

MTP30036919500

EXCESS LIAB

X OCCUR

CLAIMS-MADE AGGREGATE

EACH OCCURRENCE

DED

$10,000,000

$10,000,000

$10,000

04/30/2023UMBRELLA LIABD 04/30/2024MUP30019210701

RETENTIONX

X

E.L. DISEASE-EA EMPLOYEE

E.L. DISEASE-POLICY LIMIT

E.L. EACH ACCIDENT $1,000,000

X OTH-

ER

PER STATUTEE 04/30/2023 04/30/2024

AOS

9020557002E 04/30/2023 04/30/2024

$1,000,000

Y / N

(Mandatory in NH)

ANY PROPRIETOR / PARTNER / EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / AN

OH, HI, ND, OK, WA, WI

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

If yes, describe under DESCRIPTION OF OPERATIONS below

$1,000,000

9020557001

Aggregate LimitMSPG27169855012 04/30/2023 04/30/2024 Claims Made

Managed Care LiabilityA

SIR applies per policy terms & conditions

$10,000,000

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

RE: Contract #CTR051357 - 012311 Pharmacy Benefits Management. The State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents and employees are included as Additional Insured in accordance with the policy provisions of the General Liability policy. A Waiver of Subrogation is granted in favor of Certificate Holder in accordance with the policy provisions of the General Liability policy. General Liability policy evidenced herein is Primary and Non-Contributory to other insurance available to an Additional Insured, but only in accordance with the policy's provisions.Cyber Liability policy includes: Technology Errors & Omissions coverage.

CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVEState of Arizona Arizona Dept. of Administration 100 N. 15th Ave., #103 Phoenix AZ 85007-0000 USA

ACORD 25 (2016/03)

©1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

POLICY PROVISIONS.

AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE

LOC #:

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY

See Certificate Number:

See Certificate Number:

570099360272

570099360272

Aon Risk Insurance Services West, Inc.

570000076284

ADDITIONAL POLICIES

If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits.

INSURER

INSURER

INSURER

INSURER

INSURER(S) AFFORDING COVERAGE

Page _ of _

NAIC #

MedImpact Holdings, Inc

TYPE OF INSURANCE

POLICY NUMBER LIMITS

OTHER

B Cyber Liability 061845373 04/30/2023 04/30/2024 Limit $10,000,000 Claims Made

ADDL

INSD

INSR

LTR

SUBR

WVD

POLICY

EFFECTIVE

DATE

(MM/DD/YYYY)

POLICY

EXPIRATION

DATE

(MM/DD/YYYY)

SIR applies per policy terms & conditions

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD