2025.04.13 COI WC.pdf

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

07/24/2024 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

HEFFERNAN INSURANCE BROKERS

57141990

1820 GATEWAY DR SUITE 330

SAN MATEO CA 94404

CONTACT NAME:

PHONE

(A/C, No, Ext):

(650) 842-5200 FAX

(A/C, No):

E-MAIL ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

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

INSURED

BIOLYTICAL LABORATORIES, INC.

PO BOX 5007

FERNDALE WA 98248-5007

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 57 WEC KU6689 04/13/2024 04/13/2025

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.

CERTIFICATE HOLDER CANCELLATION

Arizona Department of Health Services

150 N 18TH AVE

PHOENIX AZ 85007

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

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