2025-01-01 COI WC.pdf

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

01/05/2024 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 be endorsed. If SUBROGATIONIS 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).

PRODUCER

AP INTEGO INSURANCE GROUP LLC

76250846

375 WOODCLIFF DRIVE STE 103

FAIRPORT NY 14450

CONTACT NAME:

PHONE

(A/C, No, Ext):

(888) 289-2939 FAX

(A/C, No):

E-MAIL ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

INSURER A : Hartford Fire and Its P&C Affiliates 00914

INSURED

CTC & ASSOCIATES LLC

2323 WOODSCREST AVE

LINCOLN NE 68502-3962

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

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.

INSR

LTR

TYPE OF INSURANCE ADDL

INSR

SUBR

WVD

POLICY NUMBER POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/Y YYY)

LIMITS

COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE

CLAIMS-MADE OCCUR DAMAGE TO RENTED

PREMISES (Ea occurrence) MED EXP (Any one person)

PERSONAL & ADV INJURY

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE

POLICY PRO-

JECT

LOC PRODUCTS - COMP/OP AGG

OTHER:

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT

(Ea accident)

ANY AUTO BODILY INJURY (Per person)

ALL OWNED

AUTOS

SCHEDULED

AUTOS BODILY INJURY (Per accident)

HIRED

AUTOS

NON-OWNED

AUTOS

PROPERTY DAMAGE

(Per accident)

UMBRELLA LIAB

EXCESS LIAB

OCCUR

CLAIMS-

MADE

EACH OCCURRENCE

AGGREGATE

DED RETENTION $

A

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY

PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

N/ A X 76 WEG AV5SEZ 01/01/2024 01/01/2025

X PER

STATUTE

OTH-

ER

Y/N E.L. EACH ACCIDENT $1,000,000

E.L. DISEASE -EA EMPLOYEE $1,000,000

E.L. DISEASE - POLICY LIMIT $1,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

Those usual to the Insured's Operations. Waiver of Subrogation applies in favor of the Certificate Holder per Waiver of our Right to Recover from Others Endorsement WC000313, attached to this policy.

CERTIFICATE HOLDER CANCELLATION

The State of Arizona/ADOT

206 S 17TH AVE

PHOENIX AZ 85007-3213

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED

BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED

IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

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

F0950 WC Only

Form WC 99 03 68 Printed in U.S.A.

Process Date: 11/21/23 Policy Expiration Date: 01/01/25

EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS

Policy Number: 76 WEG AV5SEZ Endorsement Number:

Effective Date: 01/01/24 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: CTC & Associates LLC

2323 WOODSCREST AVE

LINCOLN NE 68502

Item 3.D. of the Information Page is completed to include the following endorsements:

G-4119-0 POLICYHOLDER NOTICE-PAYROLL BILLING

WC000000C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

WC000001A.1 INFORMATION PAGE

WC000001A.2 INFORMATION PAGE

WC000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

WC000403 EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT

WC000404 PENDING RATE CHANGE ENDORSEMENT

WC000414A 90-DAY REPORTING REQUIREMENT- NOTIFICATION OF CHANGE IN OWNERSHIP

ENDORSEMENT

WC000419 PREMIUM DUE DATE ENDORSEMENT

WC000419A PART FIVE - PREMIUM AMENDATORY ENDORSEMENT

WC000421F CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM

ENDORSEMENT

WC000422C TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE

ENDORSEMENT

WC000424 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT

WC020401C ARIZONA ALCOHOL AND DRUG-FREE WORKPLACE PREMIUM CREDIT

ENDORSEMENT

WC020601C Arizona Cancellation and Nonrenewal Endorsement

WC020603A ARIZONA AMENDATORY ENDORSEMENT

WC050402 COLORADO CLASSIFICATION ENDORSEMENT

EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS

Policy Number: 76 WEG AV5SEZ Endorsement Number:

Effective Date: 01/01/24 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: CTC & Associates LLC

2323 WOODSCREST AVE

LINCOLN NE 68502

Item 3.D. of the Information Page is completed to include the following endorsements:

WC050403 COLORADO PREMIUM CREDIT FOR CERTIFIED RISK MANAGEMENT PROGRAMS

ENDORSEMENT

WC260601C NEBRASKA CANCELLATION AND NON RENEWAL ENDORSEMENT

WC280402A NEW HAMPSHIRE CERTIFIED MANAGED CARE ENDORSEMENT

WC280405 NEW HAMPSHIRE AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT

WC280601 NEW HAMPSHIRE SOLE REPRESENTATIVE ENDORSEMENT

WC280604 NEW HAMPSHIRE AMENDATORY ENDORSEMENT

WC440601 VERMONT LAW ENDORSEMENT

WC440602C VERMONT CANCELLATION AND NON RENEWAL ENDORSEMENT

WC480601C WISCONSIN LAW ENDORSEMENT

WC480606B WISCONSIN CANCELLATION AND NONRENEWAL ENDORSEMENT

WC990001K Signature/Copyright

WC990002 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY BUSINESS INSURANCE

POLICY

WC990005 SCHEDULE OF OPERATIONS

WC990069 AMENDATORY ENDORSEMENT - COLORADO

WC990300B WORKERS' COMPENSATION BROAD FORM ENDORSEMENT

WC990302B WORKERS COMPENSATION BROAD FORM ENDORSEMENT

WC990322 VERMONT CHANGES: PROPERTY/CASUALTY - CIVIL UNION ENDORSEMENT

EXTENSION OF THE INFORMATION PAGE - ITEM 3.D - ENDORSEMENTS

Policy Number: 76 WEG AV5SEZ Endorsement Number:

Effective Date: 01/01/24 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: CTC & Associates LLC

2323 WOODSCREST AVE

LINCOLN NE 68502

Item 3.D. of the Information Page is completed to include the following endorsements:

WC990358B AMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT -

EMPLOYERS LIABILITY STOP GAP COVERAGE

WC990359B AMENDMENT TO WORKERS COMPENSATION BROAD FORM ENDORSEMENT -

EMPLOYERS LIABILITY STOP GAP COVERAGE

WC990366 EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER WORKPLACES

WC990367 EXTENSION OF THE INFORMATION PAGE - ITEM 3.A - STATES COVERED

WC990368 EXTENSION OF THE INFORMATION PAGE - ITEM 3.D. - ENDORSEMENTS

WC990371A ARIZONA COUNTERSIGNATURE EXCLUSION ENDORSEMENT

WC990689 GOODS AND SERVICES ENDORSEMENT

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Countersigned by Authorized Representative

Form WC 00 03 13 Printed in U.S.A.

Process Date: 11/21/23 Policy Expiration Date: 01/01/25

WAIVER OF OUR RIGHT TO RECOVER

FROM OTHERS ENDORSEMENT

Policy Number: 76 WEG AV5SEZ Endorsement Number:

Effective Date: 01/01/24 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: CTC & Associates LLC

2323 WOODSCREST AVE

LINCOLN NE 68502

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 shall not operate directly or indirectly to benefit anyone not named in the Schedule.

SCHEDULE

The State of Arizona, insured doing government contract work with the department of transportation

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