2025-04-30_COI_CTR051357_MedImpact.pdf

H o ld e r Id e n ti fi e r

77777

77707 07070

00777 63616

06555 33307

73725 77703

65557 07662

00774 16353

00072 66144

61543 11130

74262 67572

56776 00776

04115 34472

13007 74605

51722 14570

07340 01571

22347 10077

64617 73427

45500 77727

25202 57731

10777 77770

70007 07007

66666

66606 06060

00626 06466

20444 62006

22020 42620

40022 06222

20426 02600

22060 22224

06206 22220

60000 26060

26222 20622

20060 60040

00206 22220

40422 40202

06222 00604

22402 20060

22224 04202

26200 66646

06224 06644

40666 66660

60006 06006

C e rt if ic a te N o

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

05/01/2024

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.

PRODUCER

Aon Risk Insurance Services West, Inc.

Los Angeles CA Office 707 Wilshire Boulevard Suite 2600 Los Angeles CA 90017-0460 USA

PHONE

(A/C. No. Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

(866) 283-7122

INSURED Travelers Casualty and Surety Company of AmericaINSURER A:

26883AIG Specialty Insurance CompanyINSURER B:

Federal Insurance CompanyINSURER C:

ACE American Insurance Company INSURER D:

INSURER E:

INSURER F:

FAX

(A/C. No.):

(800) 363-0105

CONTACT

NAME:

MedImpact Holdings, Inc 10181 Scripps Gateway Court San Diego CA 92131-5152 USA

COVERAGES CERTIFICATE NUMBER: 570103880401 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. Limits shown are as requested

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

(MM/DD/YYYY)

SUBR

WVD

INSR

LTR

ADDL

INSD POLICY NUMBER TYPE OF INSURANCE LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY LOC

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

X

X

X

GEN'L AGGREGATE LIMIT APPLIES PER:

$1,000,000

$1,000,000

$10,000

$1,000,000

$2,000,000

$2,000,000

C 04/30/2024 04/30/202536085140

PRO-

JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

SCHEDULED

AUTOS

HIRED AUTOS

ONLY

NON-OWNED

AUTOS ONLY

BODILY INJURY ( Per person)

PROPERTY DAMAGE

(Per accident)

X

BODILY INJURY (Per accident)

$1,000,000C 04/30/2024 04/30/2025 COMBINED SINGLE LIMIT

(Ea accident) 73641749

EXCESS LIAB

X OCCUR

CLAIMS-MADE AGGREGATE

EACH OCCURRENCE

DED

$10,000,000

$10,000,000

04/30/2024

UMBRELLA LIAB

C 04/30/202556721432

RETENTION

X

E.L. DISEASE-EA EMPLOYEE

E.L. DISEASE-POLICY LIMIT

E.L. EACH ACCIDENT $1,000,000

X OTH-

ER

PER STATUTED 04/30/2024 04/30/2025

$1,000,000

Y / N

(Mandatory in NH)

ANY PROPRIETOR / PARTNER / EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / AN

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

If yes, describe under DESCRIPTION OF OPERATIONS below

$1,000,000

71840064

Aggregate Limit108040508 04/30/2024 04/30/2025 Claims Made

Managed Care LiabilityA

SIR applies per policy terms & conditions

$5,000,000

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

RE: Contract #CTR051357 - 012311 Pharmacy Benefits Management. The State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents and employees are included as Additional Insured in accordance with the policy provisions of the General Liability policy. A Waiver of Subrogation is granted in favor of Certificate Holder in accordance with the policy provisions of the General Liability policy. General Liability policy evidenced herein is Primary and Non-Contributory to other insurance available to an Additional Insured, but only in accordance with the policy's provisions.Cyber Liability policy includes: Technology Errors & Omissions coverage. Umbrella Liability is excess and sits above the General Liability policy.

CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVEState of Arizona Arizona Dept. of Administration 100 N. 15th Ave., #103 Phoenix AZ 85007-0000 USA

ACORD 25 (2016/03)

©1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

POLICY PROVISIONS.

AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE

LOC #:

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY

See Certificate Number:

See Certificate Number:

570103880401

570103880401

Aon Risk Insurance Services West, Inc.

570000076284

ADDITIONAL POLICIES

If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits.

INSURER

INSURER

INSURER

INSURER

INSURER(S) AFFORDING COVERAGE

Page _ of _

NAIC #

MedImpact Holdings, Inc

TYPE OF INSURANCE

POLICY NUMBER LIMITS

OTHER

B Cyber Liability 061845373 . 04/30/2024 04/30/2025 Limit $10,000,000 Claims Made

ADDL

INSD

INSR

LTR

SUBR

WVD

POLICY

EFFECTIVE DATE

(MM/DD/YYYY)

POLICY

EXPIRATION

DATE

(MM/DD/YYYY)

SIR applies per policy terms & conditions

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

E Managed Care Liability Excess 0314-2637 04/30/2024 04/30/2025 Limit $5,000,000

: E - Allied World Specialty Insurance Company