2025.04.01_COI.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

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)

COMMERCIAL GENERAL LIABILITY

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

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

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 LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

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 any 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.

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

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Philadelphia Indemnity Insurance Co.

11/08/2024

CBIZ Insurance Services, Inc.

2255 Glades Road Suite 321A Boca Raton, FL 33431

Megan Dawson 561 278-0448

Megan.Dawson@cbiz.com

Easterseals Blake Foundation 7750 E. Broadway Blvd. Suite A200 Tucson, AZ 85710

18058

24-25 GL, Auto, UMB

A X X

X

X X PHPK267114 04/01/2024 04/01/2025 1,000,000

100,000 5,000 1,000,000 3,000,000 3,000,000

A X

X X PHPK267114 04/01/2024 04/01/2025 1,000,000

A X X

X 10,000

PHUB905927 04/01/2024 04/01/2025 3,000,000

3,000,000

A Professional Liab PHPK2671144 04/01/2024 04/01/2025 Ea. Incident $1,000,000 Agg. $3,000,000

RFP # is BPM006057 Contract # is CTR074348 Arizona Department of Health Services, State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are additional insured on a primary and non-contributory basis with respect to General Liability and Auto Liability if required by written contract.

(See Attached Descriptions)

Arizona Department of Health Services 150 North 18th Ave, Suite 530

PHOENIX, AZ 85007

#S4309588/M4276867

EASTBLAClient#: 203124

80MD2

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) Waiver of Subrogation applies in favor of the additional insureds with respect to General Liability and Auto Liability. 30 days notice of cancellation applies, except for 10 days non-payment of premium to the certificate holder, as it pertains to General Liability, Auto Liability, Professional Liability. Sexual Abuse and molestation is not excluded.

Abusive Conduct Liability - Each Conduct Limit : $1,000,000 / Aggregate: $3,000,000 Insurance Company: Letter A - Philadelphia Indemnity Insurance Co.

Policy Term: 04/01/24 - 04/01/25 Policy Number: PHPK2671144

#S4309588/M4276867

Job 1: Arizona Department of Health