2024-2-1_COI.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

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)

COMMERCIAL GENERAL LIABILITY

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

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

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 LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

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 any 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.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Social Service Contractors Indemnity

CopperPoint Casualty Ins Co

Hudson Excess Insurance Company

6/23/2023

USI Insurance Services LLC 2375 E. Camelback Rd, Suite 250 Phoenix, AZ 85016

Isai Gomez

Isai.Gomez@usi.com

Housing Solutions of Northern Arizona Inc PO Box 30134 Flagstaff, AZ 86003

NONE

13210 14484

A X X

X

X X 60029421 03/03/2023 02/01/2024 1,000,000 1,000,000 10,000 1,000,000 3,000,000 3,000,000

A

X X X

X X 60029421 03/03/2023 02/01/2024 1,000,000

A X X

X 10,000

60029431 03/03/2023 02/01/2024 1,000,000 1,000,000

B

Y

X 1019752 07/01/2023 07/01/2024 X 1,000,000

1,000,000 1,000,000

A C A

Crime Cyber Liabilty Prof Liab /SAM

60029421

CYB303083601

60029421

03/03/2023 02/01/2023 03/03/2023

02/01/2024 02/01/2024 02/01/2024

*See Description of Ops *See Description of Ops *See Description of Ops

Cyber Liability: $500,000 Each Claim, $500,000 Aggregate Retro date: 12-10-18 Employee Dishonesty: $25,000 Limit - Deductible: $1,000 Forgery & Alteration: $25,000 Limit - Deductible: $1,000 Professional Liability: $1,000,000 Each Occurrence / $3,000,000 Aggregate Sexual Abuse & Molestation: $1,000,000 Each Occurrence / $3,000,000 Aggregate (See Attached Descriptions)

The State of Arizona Department of Economic Security 1789 W. Jefferson Street Phoenix, AZ 85007

#S40500790/M40500276

HOUSISOL1Client#: 1273307

JXDJD

#S40500790/M40500276

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1)

RE: Contract: CTR066196 - Domestic Violence Statewide.

The General Liability and Automobile Liability policies includes an automatic Additional Insured endorsement that provides Additional Insured status to the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees, only when there is a written contract that requires such status, and only with regard to work performed by or on behalf of the named insured. The General Liability policy contains a special endorsement with Primary and Noncontributory wording, when required by written contract. The General Liability, Automobile Liability and Workers Compensation policies include a Waiver of Subrogation endorsement in favor of The 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. Sexual Abuse and Molestation coverage is included.

#S40500790/M40500276

Social Service Contractors Indemnity Pool

WHO IS AN INSURED - ADDITIONAL INSURED_SSCOMMAIAZ_08/21

SSCOMMAIAZ (08-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WHO IS AN INSURED - ADDITIONAL INSURED

Policy Number: 6002942-1 Effective Date: 03/03/2023 This endorsement modifies insurance provided under the following:

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION COVERAGE FORM

BUSINESS AUTO COVERAGE FORM (coverage applies to owned, leased, hired or borrowed vehicles) COMMERCIAL GENERAL LIABILITY COVERAGE FORM (including Products-Completed Operations Coverage)

Schedule:

Name Of Additional Insured Entities:

The State of Arizona, its departments, agencies, boards, commissions, and universities, and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the Contractor.

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

The section entitled “Who is an Insured” in each of the coverage forms set forth above is amended to include as an insured the person or organization shown in the schedule, but only with respect to liability for injury or damage resulting from your operations performed for that insured and caused by your acts or omissions.

All other terms and conditions remain unchanged.

Social Service Contractors Indemnity Pool

WAIVER OF TRANSFER RIGHTS OF RECOVERY_SSCOMMWOSAZ_08/21

SSCOMMWOSAZ (08-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER RIGHTS OF RECOVERY

Policy Number: 6002942-1 Effective Date:03/03/2023

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL ABUSE LIABILITY COVERAGE FORM

SCHEDULE

Name of Person or Organization: the State of Arizona, its departments, agencies, boards, commissions, universities and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the contractor.

1. The TRANSFER OF RIGHTS OF RECOVERY Condition (Section IV COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:

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 damages arising out of your ongoing operations or "your work" done under a contract for 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.

2. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) is amended by the addition of the following:

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 damages for “bodily injury” or “property damage” to which this insurance applies.

3. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV PROFESSIONAL LIABILITY CONDITIONS) is amended by the addition of the following:

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 “damages” resulting from a “wrongful act” to which this insurance applies.

4. The TRANSFER OF RIGHTS OF RECOVERY Condition (Section D., SEXUAL OR PHYSICAL ABUSE OR MOLESTATION CONDITIONS) is amended by the addition of the following:

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 damages due to “abuse” to which this insurance applies.

All other terms and conditions remain unchanged.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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 1019752Policy No. Endorsement No.

Housing Solutions Of Northern ArizonaInsured Premium $

CopperPoint Casualty Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

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 State Blanket/Schedule/State AZ The State of Arizona, Department of Economic Security.

The 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.

jenn.decker Typewritten text 07/01/2023

Job 1: The State of Arizona