2024.10.21_COI_GL_AL_WC_PL_CL.pdf
PDF 941 KB Posted
- Attached to
- AZ|CTR070563
- Contract number
- CTR070563
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by Chastain & Associates Insurance on 06/14/2024, covering MediaLab Parent LLC and related entities (MediaLab Intermediate LLC, MediaLab Buyer LLC, MediaLab Solutions LLC) for various insurance policies. The certificate holder is the Arizona Department of Health Services, located in Phoenix, AZ. The insurance is provided by multiple carriers, including Philadelphia Indemnity Insurance Company, Allmerica Financial Benefit, and Mt. Vernon Fire Insurance Company.
The insurance coverage includes Commercial General Liability with a $2,000,000 each occurrence limit, Automobile Liability with a $2,000,000 combined single limit, Umbrella/Excess Liability with a $3,000,000 each occurrence limit, Workers' Compensation with statutory limits, Professional Liability, and Cyber Liability with a $5,000,000 each claim limit. The policies are effective from 12/30/2023 to 12/30/2024, with additional endorsements providing primary and non-contributory insurance and a waiver of subrogation rights. The certificate includes provisions for additional insured status and includes various states in its coverage, including DE, FL, GA, IL, MN, NC, and PA.
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Text version
06/14/2024
Chastain & Associates Ins P.O. Box 1908
Athens GA 30603
Julie Taylor
(706) 543-2575 (706) 543-4847 jtaylor@chastain-assoc.com
MediaLab Parent LLC, MediaLab Intermediate LLC, MediaLab Buyer LLC, and, DBA: MediaLab Solutions LLC dba MediaLabLLC, and MediaLab Solutions LLC, LabCE, LLC dba MediaLab 1745 N Brown Rd Suite 300 Lawrenceville GA 30043
Philadelphia Indemnity Insurance Company 23850 Allmerica Financial Benefit 41840 Mt. Vernon Fire Ins 26522
CL23122941907
A Y PHPK2632752 12/30/2023 12/30/2024
2,000,000 100,000 5,000 2,000,000 4,000,000 4,000,000
A Y PHPK2632752 12/30/2023 12/30/2024
2,000,000
A 10,000
Y PHUB892424 12/30/2023 12/30/2024
3,000,000 3,000,000
B Y W2AJ61361900 12/30/2023 12/30/2024
1,000,000 1,000,000 1,000,000
C Professional Liability Cyber Liability Y DPS4003244 10/21/2023 10/21/2024
Each Claim $5,000,000 Aggregate $5,000,000 Deductible $10 000
Arizona Department of Health Services 150 North 18th Ave
Phoenix AZ 85007
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
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
PI-GL-005 (07/12)
Page of Includes copyrighted material of Insurance Services Office, Inc., with its permission.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
PRIMARY AND NON-CONTRIBUTORY INSURANCE
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Effective Date:
Name of Person or Organization (Additional Insured):
SECTION II – WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the endorsement Schedule, but only with respect to liability for “bodily injury,” “property damage” or “personal and advertising injury” arising out of or relating to your negligence in the performance of “your work” for such person(s) or organization(s) that occurs on or after the effective date shown in the endorsement Schedule.
This insurance is primary to and non-contributory with any other insurance maintained by the person or organization (Additional Insured), except for loss resulting from the sole negligence of that person or organization.
This condition applies even if other valid and collectible insurance is available to the Additional Insured for a loss or ”occurrence” we cover for this Additional Insured.
The Additional Insured’s limits of insurance do not increase our limits of insurance, as described in
SECTION III – LIMITS OF INSURANCE.
All other terms, conditions, and exclusions under the policy are applicable to this endorsement and remain unchanged.
any person or organization as required by contract.
12/30/2023
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| Insurance Policy |
| Policy Change Document |
| Cancellation Notice To Sched Addl Insd Or Cert Holder |
| Insurance Policy |
| Policy Change Document |
| Additional Insured Primary And Non-Contributory Ins |
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