2024-07-01_GDAT_WC.pdf
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- Attached to
- Master Agreement AZ|CTR049354
- Contract number
- CTR049354
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance and Waiver of Subrogation issued by Marsh Affinity, a division of Marsh USA LLC, on behalf of New Hampshire Insurance Co. The policy covers ADP TotalSource III, Inc. and Gordon-Darby Arizona Testing, Inc., with the Arizona Department of Environmental Quality named as a key stakeholder. The insurance certificate is specifically for Workers' Compensation and is valid from 07/01/2023 to 07/01/2024, with a policy number of WC 034276319 AZ.
The insurance provides coverage for all worksite employees of Gordon-Darby Arizona Testing, Inc. who are paid through ADP TotalSource's payroll. The policy includes a waiver of subrogation in favor of the Arizona Department of Environmental Quality and the State of Arizona, covering losses arising from work performed by or on behalf of the contractor. The policy has limits of $2,000,000 for each accident, disease-each employee, and disease-policy limit. The scope of work encompasses all operations subject to federal, state, or local government statutes, ordinances, regulations, or licensing requirements.
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Text version
04/17/2023
Marsh Affinity a division of Marsh USA LLC.
PO BOX 14404
Des Moines, IA 50306-9686
Marsh Affinity
800-743-8130
ADPTotalSource@marsh.com
New Hampshire Insurance Co. 23841
A 07/01/2023 07/01/2024 2,000,000
2,000,000
2,000,000
ADP TotalSource III, Inc.
5800 Windward Parkway Alpharetta, GA 30005 L/C/F:
Gordon-Darby Arizona Testing, Inc.
3001 S. 35TH STREET
Suite 4 Phoenix, AZ 850340000
WC 034276319 AZX
All worksite employees working for GORDON-DARBY ARIZONA TESTING, INC., paid under ADP TOTALSOURCE, INC's payroll, are covered under the above stated policy.WAIVER OF SUBROGATION IN FAVOR OF ARIZONA DEPT. OF ENVIRONMENTAL QUALITY AND , THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES AND ITS OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED BY OR ON BEHALF OF THE CONTRACTOR AS RESPECTS OF JOB PERFORMED BY GORDON-DARBY ARIZONA TESTING, INC. AS REQUIRED BY WRITTEN CONTRACT.Ref Project: All operations subject to federal, state or local government statute ordinance regulation or licensing
Arizona Dept. of Environmental Quality 1110 W. Washington St.
Phoenix, AZ 85007
X
07/01/2023 WC 034276319 AZ
ADP TotalSource III, Inc.
5800 Windward Parkway Alpharetta, GA 30005 L/C/F:
Gordon-Darby Arizona Testing, Inc.
3001 S. 35TH STREET
Suite 4 Phoenix, AZ 850340000
New Hampshire Insurance Co.
WAIVER OF SUBROGATION IN FAVOR OF ARIZONA DEPT. OF ENVIRONMENTAL QUALITY AND , THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES AND ITS OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED BY OR ON BEHALF OF THE CONTRACTOR AS RESPECTS OF JOB PERFORMED BY Gordon-Darby Arizona Testing, Inc. AS
REQUIRED BY WRITTEN CONTRACT.
Ref Project: All operations subject to federal, state or local government statute ordinance regulation or licensing
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