2025.12.19 CGL AL WC PL CL.pdf
PDF 29 KB Posted
- Attached to
- Master Agreement AZ|CTR050598
- Contract number
- CTR050598
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance for Native American Community Health Center Inc., located in Phoenix, Arizona, involving multiple insurance providers including Cincinnati Insurance Co., Sequoia Insurance Company, Lexington Insurance Co., and Philadelphia Insurance Co. The certificate is issued to cover various insurance policies and is specifically tied to a contract with the Arizona Department of Health Services (Contract #CTR050598-Health Start).
The insurance coverage includes Commercial General Liability ($1,000,000 per occurrence), Automobile Liability ($1,000,000), Umbrella Liability ($6,000,000), Workers' Compensation, Professional Liability ($1,000,000 per claim), and Cyber Liability ($2,000,000). The policies are effective from December 1, 2024, to December 1, 2025, with the Arizona Department of Health Services named as an additional insured. The certificate covers liability for the health center's operations, including automobiles owned, leased, hired, or borrowed, and provides comprehensive insurance protection for the organization's activities under the state contract.
View the file
Other files
Show all 24
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER POLICY EFF POLICY EXPTYPE 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 RENTEDCLAIMS-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 AGGJECT
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 LIMITDESCRIPTION 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.ACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
The ACORD name and logo are registered marks of ACORD
8/4/2025
(573) 651-0509 (573) 651-4456
10677
Native American Community Health Center Inc 4041 N Central Ave Phoenix, AZ 85012
23850
A 1,000,000
X X ETD 0560395 12/1/2024 12/1/2025 500,000
5,000
1,000,000 3,000,000 3,000,000
1,000,000A
X X ETA 0560395 12/1/2024 12/1/2025
6,000,000A
ETD 0560395 12/1/2024 12/1/2025 6,000,000
B
X QWC1415717 12/1/2024 12/1/2025 1,000,000
N 1,000,000 1,000,000
C Professional Liabili 6799131 1/3/2025 Per Claim 1,000,000 D Cyber Liability PHSD1841798 12/19/2024 12/19/2025 Limit 2,000,000
Contract #CTR050598-Health Start. AZ Dept of Health Services & State of Arizona its departments, agencies, boards, commissions, universities, and officers, officials, agents, and employees shall be named additional insured with respect to automobile (including autos owned, leased, hired, or borrowed by the contractor) liability arising out of
Arizona Dept of Health Services 150 N 18th Ave Ste 530 Phoenix, AZ 85007
NATIHEA-01 CCOLE
Midwest Risk DBA Arnold Ins 875 N Kingshighway St Cape Girardeau, MO 63701 info@myarnoldteam.com
Cincinnati Insurance Co.
Sequoia Insurance Company Lexington Insurance Co.
PHILADELPHIA INSURANCE CO
X
1/3/2026
X X
X
X
X X
File details come from the government source that posted it. Updated .