2025-01-01 COI GL AL PL.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 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 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

CTCAS-1 OP ID: LM

01/26/2024

Sheryl Homer Copple Insurance Agency, Inc.

1640 L Street, Suite A Lincoln, NE 68508- Sheryl Homer

402-475-3213 402-475-6842 sheryl@coppleinsurance.com

Cincinnati Insurance Company Underwriters at Lloyd's

CTC & Associates LLC c/o Brian Hirt 2323 Woodcrest Ave Lincoln, NE 68502

A X 1,000,000

X X X EPP0675090 01/01/2024 01/01/2025 100,000

5,000

1,000,000 2,000,000 2,000,000

1,000,000A

X X EPP0675090 01/01/2024 01/01/2025

X X

XX 1,000,000A

EPP0675090 01/01/2024 01/01/2025 1,000,000

NoneX

B PSM0139843361 01/01/2024 01/01/2025 Occurrenc 2,000,000 Aggregate 2,000,000

For any and all work performed for or on behalf of the State of Arizona/ADOT Please see notes (page 2) for additional information

The State of Arizona/ADOT 206 S 17 Ave Phoenix, AZ 85007

402-475-3213

10677

Prof Liability

F0950 Accepted

Date

HOLDER CODE

INSURED'S NAME

PAGE

NOTEPAD:

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees are additional insureds when required in written contract with respects to commercial general liability and hired and non-owned auto liability arising out of activites performed by or on behalf of the contractor involving automobiles owned, leased, hired or borrowed.

Waivers of Subrogation apply to the commercial general liability and commercial auto policies.

A 30 day written notice to the State of Arizona applies with the exception of a 10 day notice of cancellation for non-payment of premium.

*Please note the following for information and NAIC (Alien ID) #s for Underwriters at Lloyd's sydnicates and other companies that are insurers for the Professional Liability coverage on Policy #PSM0139843361:

Lloyd's Syndicates:

AXL 2003 1.00% ID# AA-1128003 // ARG 2121 1.25% ID# AA-1128121 // AFB 5623

2.75% ID# 1120213 // QPS 5555 3.75% ID# AA-1120065 // MKL 3000 3.75% ID#

AA1129000 // ASP4711 7.5% ID# AA-1120090 // WSM 1200 8.25% ID# AA-1127200

// CGM 2488 11.00% ID# AA-1128488 // CNP 4444 11.25% ID# AA-1126004 //

CFC1988 27.25% ID# AA-1120203

Other Insurers:

HDI Global Specialty SE (UK Branch) 3.00% ID# AA-1340041 // Everest Insurance (Ireland) DAC 3.25% ID# AA-1780124 // Zurich Insurance Company

16.00% ID# AA-1460190

CTC & Associates LLC 01/26/2024

CTCAS-1

OP ID: LM