2025.07.06_COI.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD 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)

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 RENTED

CLAIMS-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 AGG $JECT

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 LIMIT $DESCRIPTION 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.

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

CERTIFICATE OF LIABILITY INSURANCE

Lockton Companies, LLC 8110 E. Union Avenue Suite 700 Denver CO 80237

(303) 414-6000

Aid to Adoption of Special Kids/Arizona 2320 North 20th Street Phoenix, AZ 85006

Social Service Contractor's Indemnity Pool 0 CopperPoint General Insurance Company 13043

X X

1,000,000 1,000,000 10,000 1,000,000 3,000,000 3,000,000

X X

1,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X X 1,000,000 1,000,000

XXXXXXX

N

X

1,000,000 1,000,000 1,000,000

Professional Liab.

Claims Made Retro Date 7/6/88

Per Claim: $1,000,000

Aggregate: $3,000,000

A 6000167-7 7/6/2024 7/6/2025

A 6000167-7 7/6/2024 7/6/2025

A 6000167-7 7/6/2024 7/6/2025

A 6000168-7 7/6/2024 7/6/2025

B 1001754 7/6/2024 7/6/2025

7/6/2025

1413832

Y Y

Y Y

N N

Y

11/5/2024

N N

21126247

21126247 XXXXXXX

Arizona Department of Health Services 150 N. 15 Avenue, Suite 530 Phoenix AZ 85007

Sexual Abuse and Molestation coverage is not excluded. The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are included as Additional Insureds as respects General Liability and Auto Liability, if required by written contract. Waiver of Subrogation applies in favor of The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as respects General Liability, Auto Liability and Workers Compensation if required by written contract, when permissible by law.

X

See Attachment

CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required)

ACORD 25 (2016/03)

Coverage is Primary and Non-Contributory. If General Liability, Auto Liability or Workers Compensation are cancelled by the issuing company during the policy term, for other than non-payment of premium, 30 days’ notice will be provided to the Certificate Holder named below and 10 days’ notice for non-payment of premium.

Certificate Holder ID: 21126247

Sexual Abuse/Molestation

Carrier: Social Service Contractors Indemnity Pool

Policy#: 6000167-7

Policy Term: 7/6/2024 - 7/6/2025

Limits: $1,000,000 Each Act $3,000,000 Aggregate

Attachment Code: D607729 Master ID: 1413832, Certificate ID: 21126247