25-26_COI_-_The_State_of_Arizona_and_Dept_of_Economic_Security_1.28.25.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

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 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

2/5/2025

(520) 795-8511 (520) 795-8542

10677

Arizona Cooperative Therapies ACT Child & Family Services LLC Attn: Leo Huppert III 99 E. Virginia Avenue, Ste. 200 Phoenix, AZ 85004

13928

A 1,000,000

X X ETD 0371704 1/28/2025 1/28/2026 1,000,000

10,000

1,000,000 2,000,000 2,000,000

1,000,000A

X X ETA 0371704 1/28/2025 1/28/2026

1,000,000A

ETD 0371704 1/28/2025 1/28/2026 1,000,000

B

X 1023175 1/28/2025 1/28/2026 1,000,000 1,000,000 1,000,000

A Professional Liab ETD 0371704 1/28/2025 1,000,000 2,000,000 A Abuse/Molestation ETD 0371704 1/28/2025 1/28/2026 1,000,000 2,000,000

RE: Division Name: ADES. - Contract ID: CTR072525 & CTR070503 Certificate Holder includes Arizona Department of Economic Security Division of Developmental Disabilities, The State of Arizona, its departments, agencies, boards, commissions, universities & its officers, officials, agents & employees. General Liability Additional Insured, Waiver of Subrogation and Primary Non- Contributory per written contract, per attached. Auto Additional Insured, Waiver of Subrogation per written contract, per attached. Worker’s Compensation Waiver of Subrogation per written contract, per attached. Umbrella follows form of general liability, auto liability, workers compensation, professional liability & sex abuse & molestation. Sexual Abuse & Molestation coverage is included. WC Excluded: Amber Neubauer, Kristin Gier, Alicia Quintana. Does not visit job sites.

The State of Arizona and Dept of Economic Security C/O: myCOI 1075 Broad Ripple Ave, Suite 313 Indianapolis, IN 46220

ARIZCOO-01 JBROKAW

The Mahoney Group - Tucson 5330 N. La Cholla Blvd Tucson, AZ 85741

Cincinnati Insurance Company CopperPoint Indemnity Insurance Company

X

1/28/2026

X X

X

X X

X

X

X

GA 4397 09 17

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - DESIGNATED PERSON

OR ORGANIZATION (VICARIOUS LIABILITY)

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name of Person(s) or Organization(s) (Additional Insured):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II - Who Is An Insured is amended to include as an insured the person or organiza-tion shown in the Schedule, but only with re-spect to liability caused by your acts or omis-sions.

However, if coverage provided to the addition-al insured is required by a contract or agree-ment, the insurance afforded to such addition-al insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is add-ed to Section III - Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional in-sured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the appli-cable Limits of Insurance shown in the Decla-rations.

jprobst Text Box ARIZONA DEPARTMENT OF ECONOMIC SECURITY, DIVISION OF DEVELOPMENTAL DISABILITIES, IN FAVOR OF THE STATE OF ARIZONA AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED ON OR BEHALF OF THE CONTRACTOR

PO BOX 6123, SITE CODE 2HC3

PHOENIX, AZ 85006-6123

CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 24 04 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

ELECTRONIC DATA LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES

POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

RAILROAD PROTECTIVE LIABILITY COVERAGE PART

UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS

SCHEDULE

Name Of Person(s) Or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Sec-tion IV – Conditions:

We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above be-cause of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organi-zation(s) shown in the Schedule above.

jprobst_1 Text Box ARIZONA DEPARTMENT OF ECONOMIC SECURITY, DIVISION OF DEVELOPMENTAL DISABILITIES, IN FAVOR OF THE STATE OF ARIZONA AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED ON OR BEHALF OF THE CONTRACTOR

PO BOX 6123, SITE CODE 2HC3

PHOENIX, AZ 85006-6123

AA 4004 01 24 Page 1 of 1

ADDITIONAL INSURED - DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

The person or organization named in the following schedule is an "insured" to the extent of their liability for the conduct of another "insured" as provided in SECTION II - COVERED AUTOS LIABILITY COVERAGE, A.

Coverage, 1. Who is an Insured, Paragraph c.

Schedule

Additional Insured

Address:

jprobst_2 Text Box ARIZONA DEPARTMENT OF ECONOMIC SECURITY, DIVISION OF DEVELOPMENTAL DISABILITIES, IN FAVOR OF THE STATE OF ARIZONA AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED ON OR BEHALF OF THE CONTRACTOR jprobst_3

PO BOX 6123, SITE CODE 2HC3

PHOENIX, AZ 85006-6123

jprobst_4 Text Box 01-28-2025 jprobst_5 Text Box

ETD 0371704

jprobst_6

Arizona Cooperative Therapies

AA 4195 01 07

WAIVER OF SUBROGATION - AUTO

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indi-cated below.

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

SCHEDULE

Name of person(s) or organization(s):

Job location: Job and/or Contract Number:

1. Waiver of Subrogation

SECTION IV - BUSINESS AUTO CONDI-

TIONS, A. Loss Conditions, 5. is amended by the addition of the following:

With regard to the person(s) or organiza-tion(s), job location, and job and / or contract number shown in the Schedule of this en-dorsement, we waive any right of recovery we may have against any person or organization because of payments we make for "bodily in-jury" or "property damage" arising out of the operation of a covered "auto" when you have assumed liability for such "bodily injury" or "property damage" under an "insured con-tract", provided the "bodily injury" or "property damage" occurs subsequent to the execution of the "insured contract".

jprobst_7 Text Box ARIZONA DEPARTMENT OF ECONOMIC SECURITY, DIVISION OF DEVELOPMENTAL DISABILITIES, IN FAVOR OF THE STATE OF ARIZONA AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED ON OR BEHALF OF THE CONTRACTOR

PO BOX 6123, SITE CODE 2HC3

PHOENIX, AZ 85006-6123

jprobst_8 Text Box 01/28/2025 jprobst_9 Text Box

ETA 0371704

jprobst_10 Text Box Arizona Cooperative Therapies jprobst_11 Text Box

PO BOX 6123, SITE CODE 2HC3

PHOENIX, AZ 85006-6123

jprobst_12

ARIZONA DEPT

AA 4174 11 05

THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY

PRIMARY AND NONCONTRIBUTORY INSURANCE

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indi cated below

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement

1 Noncontributory Insurance

SECTION IV BUSINESS AUTO CONDI

TIONS, B General Conditions, 5 Other In surance is replaced by the following:

c Regardless of the provisions of Para graph a above, this Coverage Form’s Li ability Coverage is primary and we will not seek contribution from any other in surance for any liability assumed under an "insured contract" that requires liability to be assumed on a primary noncon tributory basis jprobst_13 Text Box 01-28-2025 jprobst_14 Text Box

ETA 0371704

jprobst_15

Arizona Cooperative Therapies