2024.10.01_COI.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

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 EXPTYPE 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 RENTEDCLAIMS-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 AGGJECT

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 LIMITDESCRIPTION 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.ACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

10/24/2023

(602) 992-9750 (602) 992-9775

36897

Marshall Home for Men 3314 S. 16th Ave.

Tucson, AZ 85713

13928

A 1,000,000

X X 8223011417518 10/5/2023 10/5/2024 100,000 5,000

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

1,000,000A

X X 1523011417518 10/5/2023 10/5/2024

1,000,000B 6023011417518 10/5/2023 10/5/2024

C X 1006343 10/1/2023 10/1/2024 1,000,000

N 1,000,000 1,000,000

A Abuse/Molestation 8223011417518 10/5/2023 Occurrence 1,000,000 A Professional Liab 3823011417518 10/5/2023 10/5/2024 Occurrence 1,000,000

RE: Contract #CTR059105-Assisted Living. 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 for General Liability and Auto Liability. Waiver of subrogation General Liability and Auto Liability to the State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents, and employees for losses arising from work perfored by or on behalf of the contractor.

Sexual Abuse and Molestation coverage is included.

Policies contain 30 days Notice of Cancellation General and Auto Liability - Primary and Non-Contributory per attached endorsements Workers Compensation Excluded Officers: Doug Wolfe, David Livingston. No job sites apply

The State of Arizona and Dept of Economic Security C/O: my COI 1075 Broad Ripple Ave #313 Indianapolis, IN 46220

MARSHOM-01 BROCE1

AssuredPartners 14805 N 73rd St Scottsdale, AZ 85260

Manufacturers Alliance Insurance Company PA Manufacturers Assn Ins Co CopperPoint Indemnity Ins Co

X

10/5/2024

X X

X X X

X X

INSURED COPY

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 1 of 1

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.

152301-14-17-51-8

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.

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.)

10/01/2023Endorsement Effective 1006343Policy No. 4Endorsement No.

Marshall Home For Men IncInsured Premium $

CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

State Waiver: 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.

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 STATE

POLICY NUMBER: INTERLINE

IL 12 09 09 22

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

IL 12 09 09 22 Insurance Services Office, Inc., 2022 Page

ARIZONA POLICY CHANGES

Policy Change Number:

Policy Number: Company:

From: 12:01 AM Policy Changes Effective:

To: 12:01 AM

Authorized Representative:

Named Insured s Mailing Address:

Coverage Parts Affected:

Changes

822301-14-17-51-8

10/05/2023

10/05/2024

MARSHALL HOME FOR MEN, INC.

MANUFACTURERS ALLIANCE INSURANCE COMPANY

3314 S 16TH AVE

822301-14-17-51-8

TUCSON, AZ 85713-5899

RISK PLACEMENT SERVICES, INC. (RPS

NIPC)

P.O. BOX 4005

CLINTON IA 52733-4005

COMMERCIAL GENERAL LIABILITY

$ 389.00

A PREMISES/OPERATIONS ADDITIONAL INTEREST HAS BEEN ADDED IN FAVOR OF

THE FOLLOWING: THE 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 THE SUBCONTRACTOR, OR ON BEHALF OF

THE SUBCONTRACTOR OR CONTRACTOR.

THE FOLLOWING FORMS HAVE BEEN ADDED:

CG 20 01 12-19 PRIMARY AND NONCONTRIBUTORY - OTHER INSD

CG 20 10 12-19 ADDL INSD - OWNERS/LESSEES/CONTRACTORS

CG 20 37 12-19 ADDL INSD-OWNERS/LESSEES/CONTR-COMP OPS

ALL OTHER TERMS AND CONDITIONS REMAIN THE SAME

PCA AP 27 10 01

ENDORSEMENT

Policy Number

Named Insured Effective Date:

12:01 A.M., Standard Time

152301-14-17-51-8

10-05-23MARSHALL HOME FOR MEN, INC.

MANUFACTURERS ALLIANCE INSURANCE COMPANY

COMMERCIAL BUSINESS AUTO COVERAGE PART

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ENDORSEMENT FORM PCA 05 07 04 14 - ADDITIONAL INSURED COVERAGE

REQUIRED BY INSURED CONTRACT, WRITTEN AGREEMENT OR PERMIT IS AMENDED

TO INCLUDE THE FOLLOWING AS ADDITIONAL INSURED TO THE POLICY:

THE STATE OF ARIZONA AND ITS DEPARTMENTS, AGENCIES, BOARDS,

COMISSIONS, UNIVERSITIES, OFFICERS, OFFICALS, AGENTS, AND EMPLOYEES

AS ADDITIONAL INSUREDS WITH RESPECT TO LIABILITY ARISING OUT OF THE

ACTIVITIES PERFORMED BY, OR ON BEHALF OF, THE CONTRACTOR INVOLVING

AUROMOBILES OWNED, HIRED AND/OR NON-OWNED BY THE CONTRACTOR.

COMMERCIAL AUTO

PCA 05 07 04 14

PCA 05 07 04 14 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission

The PMA Insurance Group, 2014

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED COVERAGE REQUIRED BY INSURED CONTRACT,

WRITTEN AGREEMENT OR PERMIT

This endorsement modifies coverage provided under the following:

BUSINESS AUTO COVERAGE FORM

AUTO DEALERS COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

The following are added as �insureds� under Covered Autos Liability Coverage, Who is an Insured:

d. Any person, organization, trustee, estate or governmental entity with respect to the operation, maintenance, or use of a covered auto if:

1) You are obligated to add that person, organization, trustee, estate or governmental entity as an additional insured to this policy by:

a) an expressed provision of an insured contract or written agreement; or

b) an expressed condition of a written permit issued to you by a governmental or public authority.

2) The bodily injury or property damage is caused by an accident which takes place after:

a) you executed the insured contract or written agreement; or

b) the permit has been issued to you.

POLICY NUMBER: INTERLINE

IL 12 09 09 22

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

IL 12 09 09 22 Insurance Services Office, Inc., 2022 Page

ARIZONA POLICY CHANGES

Policy Change Number:

Policy Number: Company:

From: 12:01 AM Policy Changes Effective:

To: 12:01 AM

Authorized Representative:

Named Insured s Mailing Address:

Coverage Parts Affected:

Changes

152301-14-17-51-8

10/05/2023

10/05/2024

MARSHALL HOME FOR MEN, INC.

MANUFACTURERS ALLIANCE INSURANCE COMPANY

3314 S 16TH AVE

152301-14-17-51-8

TUCSON, AZ 85713-5899

RISK PLACEMENT SERVICES, INC. (RPS

NIPC)

P.O. BOX 4005

CLINTON IA 52733-4005

COMMERCIAL AUTOMOBILE

THE FOLLOWING FORM(S) HAS BEEN ADDED:

CA 04 49 11-16 PRIMARY NONCONTRIBUTORY - OTHER INS COND

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)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

9/13/2023

(HD) Heffernan Insurance Brokers 1350 Carlback Avenue Walnut Creek CA 94596

Shannon Davison 925-934-8500 925-934-8278 shannond@heffins.com

License#: 0564249 CopperPoint Indemnity Insurance Company 13928

MARSHOM-02

Marshall Home For Men Inc 3314 S 16th Ave Tucson AZ 85713

1815784791

A XY 1006343 10/1/2023 10/1/2024

1,000,000

1,000,000

1,000,000

Waiver of Subrogation is included on the Workers Compensation policy per the attached endorsement, if required.

Division Name: ADES.

- Contract ID: CTR059105.

The State of Arizona and Dept of Economic Security C/O: myCOI 1075 Broad Ripple Ave, Suite 313 Indianapolis, IN 46220

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.)

10/01/2023Endorsement Effective 1006343Policy No. 8Endorsement No.

Marshall Home For Men IncInsured Premium $

CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

State Waiver: 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.

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 STATE