3-Attachment 7 - Supplement Insurance.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

PartnerRe Insurance Solutions Bermuda

Endurance American Specialty Ins Co

Endurance American Specialty Ins Co

National Liability & Fire Insurance Co.

2/11/2025

USI Insurance Services LLC 9910 Dupont Circle Dr. E Suite 120 Fort Wayne, IN 46825

260 432-3400

USA Up Star, LLC 1760 Industrial Dr Greenwood, IN 46143

NONAIC

00914 41718 20052

A X X

X BI/PD Ded:25000

X

X VCP202413501 05/07/2024 05/07/2025 1,000,000

50,000 5,000 1,000,000 2,000,000 2,000,000

D

X

73APB008640 05/07/2024 05/07/2025 1,000,000

A X X

VCX202411001 05/07/2024 05/07/2025 1,000,000

1,000,000

B

N

131080424331351685 11/30/2024 11/30/2025 X 1,000,000

1,000,000 1,000,000

B A

2nd Layer Excess Pollution Liab

ELD30067651600

VCP202413501

09/01/2024 05/07/2024

05/07/2025 05/07/2025

$4,000,000 $2,000,000 Agg

Arizona Department of Administration is listed as an Additional Insured

Arizona Department of Administration 100 N 15th Ave. Ste 302 Phoenix, AZ 85007

#S48092345/M47191369

USAUPSTAClient#: 1949740

LXRAM