2024.4.1 GL AL WC UL PL.pdf

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

3/30/2023

Brown & Brown Insurance of AZ, Inc 2800 N. Central Ave., #1100 P.O. Box 2800 Phoenix AZ 85004

Maria Rosaortega, CIC, CISR 602-664-7067

Maria.Rosaortega@bbrown.com

Argonaut Insurance Company 19801 00438864 CopperPoint Insurance Company 14216

Concentric Healthcare Solutions, LLC dba Concentric Healthcare Staffing 4250 N. Drinkwater Blvd #100 Scottsdale AZ 85251

Philadelphia Indemnity Insurance Company 18058 Accredited Specialty Insurance Company 16835

570681122

C X 2,000,000 X 100,000

10,000

2,000,000

4,000,000 X

X Stop Gap:

Y Y PHPK2536155 4/1/2023 4/1/2024

4,000,000

OH, ND, WA, WY 1,000,000

C 1,000,000

X X

Y Y PHPK2536155 4/1/2023 4/1/2024

C X 8,000,000 X

Y PHUB857508 4/1/2023Y 4/1/2024

8,000,000 X 0

B A

X

N

Y 1014656

WC 928978358184

4/1/2023 4/1/2023

4/1/2024 4/1/2024

1,000,000

1,000,000

1,000,000 C D C

Prof Liability (Medical E&O) Cyber Crime incl. 3rd Party

Y Y Y

Y PHPK2536155

2-CIA-AZ-17-S0106093-01

PHPK2536155

4/1/2023 4/1/2023 4/1/2023

4/1/2024 4/1/2024 4/1/2024

See Below for Limits See Below for Limits See Below for Limits

Employee Theft including Client Premises (3rd Party): Limit $3,000,000. Retention $25,000

Professional Liability - including Medical E&O: $2,000,000 each Claim/$4,000,000 aggregate. $25,000 deductible applies. Retro-date: 03/07/2005.

Indiana Professional Liability (policy #PHPK2536243): $500,000 each Occurrence/$1,500,000 Aggregate. $10,000 deductible applies. Retro-date: 04/01/2023

Sexual Misconduct Liability: $1,000,000 each Claim/$2,000,000 aggregate. $10,000 deductible applies. Retro-date: 03/07/2005

See Attached...

Arizona State Hospital 2500 E Van Buren St Phoenix AZ 85008

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

00438864

1 1

Brown & Brown Insurance of AZ, Inc Concentric Healthcare Solutions, LLC dba Concentric Healthcare Staffing 4250 N. Drinkwater Blvd #100 Scottsdale AZ 85251

25 CERTIFICATE OF LIABILITY INSURANCE

Cyber Liability: $5,000,000 each claim/$5,000,000 aggregate. $25,000 deductible applies. Retroactive Date – Full Prior Acts

Employment Practices Liability - including 3rd Party: $2,000,000 each Claim/$2,000,000 aggregate. $25,000 deductible applies. Retro-date: 03/04/2006

Additional Insured applies on a blanket basis to the General Liability per attached from CG2026 0413; coverage is Primary & Non-contributory on a blanket basis per attached form PI-GLD-TS 1115 and blanket Waiver of Subrogation applies per attached form CG2404 0509. Additional Insured on a Primary and Non-Contributory basis with a Waiver of Subrogation applies on a blanket basis to the Professional Liability per attached form PI-TS-MANU. Additional Insured and Primary/Non-Contributory applies on a blanket basis to the Auto Liability per attached form PI-MANU-1 0100 (CA2048 1013) with blanket Waiver of Subrogation per attached form PI-MANU-1 0100 (CA0444 1013). Blanket Waiver of Subrogation applies to Workers' Compensation per attached form WC000313, WC430305. Blanket 30 Day Notice of Intent to Cancel applies per attached form PI-MANU-1 0906 (PI-CANXAICH-002). General Liability, Professional Liability and Auto Liability limits are not shared. Additional Insured applies to the Cyber Liability where required by written contract per policy.

Umbrella underlying schedule includes: General Liability, Professional Liability; Employers' Liability; Employee Benefits Liability and Automobile Liability.

Umbrella Policy follows form. Separation of Insureds applied to the General Liability per attached page 13 of the CG0001 0413 and to the Professional Liability per attached page 10 of the PI-TS-003 1211. *VA Professional Liability limits apply with regards to § 8.01-581.15 of the Code of Virginia per attached form

PI-MANU-1 0100.

WC Policy # 1014656 applies to AZ, CO, NM, NV, UT WC Policy # WC 928978358184 applies to all other non-monopolistic states RE: Solicitation No.: BPM001022, Registry Staffing Services for the Arizona State Hospital Additional Insured: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees where required by written contract.