2024-7-1_COI.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD 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)

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 RENTED

CLAIMS-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 AGG $JECT

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 LIMIT $DESCRIPTION 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.

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

CERTIFICATE OF LIABILITY INSURANCE

Lockton Companies 8110 E. Union Avenue Suite 700 Denver CO 80237

(303) 414-6000

Catholic Charities Community Services, Inc.

5151 N 19th Ave Phoenix, AZ 85015

Social Service Contractor's Indemnity Pool 0 CopperPoint American Insurance Company 13751

X X

1,000,000 1,000,000 10,000 1,000,000 3,000,000 3,000,000

X

X $500 comp X $500 coll

1,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X X X

5,000,000 5,000,000

XXXXXXX

N

X

1,000,000 1,000,000 1,000,000

See Attached See Attached

A 6000569 7/1/2023 7/1/2024

A 6000569 7/1/2023 7/1/2024

A 6000569 7/1/2023 7/1/2024

A 6000570 7/1/2023 7/1/2024

B 1019020 7/1/2023 7/1/2024

7/1/2024

1428315

Y Y

Y Y

N N

Y

10/25/2022

N N

19892632

19892632 XXXXXXX

The State of Arizona Department of Economic Security 1789 W. Jefferson Street Mail Drop 6271 Phoenix AZ 85007

Re: Contract #CTR062214, CTR066190 & CTR066282 for Domestic Violence - Statewide project. The State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees are included as Additional Insured with respect to liability arising out of the activities performed by or on behalf of the Named Insured as respect General Liability and Auto Liability, involving automobiles owned, hired and/or non-owned by the Contractor, where required by written contract. Waiver of Subrogation applies in favor of the State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees for

X

See Attachment

CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required)

ACORD 25 (2016/03)

losses arising from work performed by or on behalf of the Named Insured as respects General Liability, Auto Liability, and Workers’ Compensation where required by written contract as permitted by law. Sexual Abuse and Molestation coverage is included. The Excess Liability policy referenced above schedules General Liability, Automobile Liability, Employers' Liability (Occurrence) and Professional Liability (Claims Made, Retro Date 5/01/2013) as underlying insurance.

Certificate Holder ID: 19892632

Catholic Charities Community Services, Inc.

Policy: 6000569 Insurer: Social Services Contractor's Indemnity Pool Policy Term: 7/1/2023 – 7/1/2024

Other Coverages:

Professional Liability Claims Made Retro Date 5/1/2013

$3,000,000 Aggregate $1,000,000 Each Act

Sexual Abuse/Molestation Occurrence

$3,000,000 Aggregate $1,000,000 Each Act

Attachment Code: D593480 Master ID: 1428315, Certificate ID: 19892632

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adraper Text Box Policy Number: 6000569-6 Effective Date: 07/01/2023

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.)

07/01/2023Endorsement Effective 1019020Policy No. 9Endorsement No.

Catholic Charities Community Services IncInsured Premium $

CopperPoint Western 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. its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees for losses arising from work perfromed by or on behalf of the Contractor