ACCEPTED ANY_ALL AL 06.25.25-06.25.26 (1).pdf
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- Attached to
- Master Agreement AZ|CTR077172
- Contract number
- CTR077172
- Issued by
- Arizona
About this file
This document is a Business Auto Insurance Policy issued by Midvale Indemnity Company for Prime Collision LLC, located in Gilbert, Arizona. The policy is effective from 06/25/2025 to 06/25/2026 and involves the Arizona Department of Transportation (ADOT) as an additional insured and waiver of subrogation. The policy is underwritten by American Family Insurance and specifically covers a 2001 Ford Ranger with policy number CA00055366.
The policy provides comprehensive auto insurance coverage with a $1,000,000 combined single limit for liability, $10,000 medical payments per person, and $1,000,000 for uninsured and underinsured motorist coverage. The vehicle is insured with a $500 deductible for comprehensive and collision, includes full glass coverage, and offers rental reimbursement at $35 per day up to 30 days with a maximum of $1,050. Additional endorsements include Arizona-specific changes and provisions. The total policy premium is $3,502, with a multi-product discount applied. The policy does not include hired or non-owned auto liability coverage.
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Text version
BID CA 1001 AZ 01 20 Page 1 of 4
American Family Insurance - Business Insurance Underwritten by: Midvale Indemnity Company
A Wisconsin Stock Company
PO Box 5316 Lucas Shafer Binghamton, NY 13902
(866) 908-0626
1717 E BELL RD STE 7
PHOENIX,AZ 85022
(602) 788-5359
Information Effective as of: 06/25/2025
POLICY DECLARATIONS
This document and your policy contract define our insuring agreement. In return for payment of premium and subject to all the terms of this policy, we agree to provide you insurance as stated in the policy.
Policy Information
Named Insured: Prime Collision LLC Policy Number: CA00055366
Policy Type: Business Auto Policy
Policy Period: 06/25/2025 to 06/25/2026 12:01 A.M. Standard Time at Primary Location
E-mail Address: primecollisionaz@gmail.com Phone: 6026259860
Form of Business: Limited Liability Company
Policy Forms and Endorsements
CA 00 01 10 13 BUSINESS AUTO COVERAGE FORM
CA 01 75 10 13 ARIZONA CHANGES
CA 04 44 10 13
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST
OTHERS TO US
CA 21 39 05 24 ARIZONA UNINSURED MOTORISTS COVERAGE
CA 21 40 05 24 ARIZONA UNDERINSURED MOTORISTS COVERAGE
CA 23 84 10 13 EXCLUSION OF TERRORISM
CA 23 94 10 13
SILICA OR SILICA-RELATED DUST EXCLUSION FOR COVERED
AUTOS EXPOSURE
CA 74 01 01 20 TOWING AND EMERGENCY ROADSIDE SERVICE
CA 74 02 01 20 PERSONAL TRAILER LIABILITY COVERAGE ENDORSEMENT
CA 79 01 01 99 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
CA 99 03 10 13 AUTO MEDICAL PAYMENTS COVERAGE
IL 00 17 11 98 COMMON POLICY CONDITIONS
IL 00 21 09 08
NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (BROAD
FORM)
IL 75 02 06 99 PUNITIVE DAMAGE EXCLUSION
IL 75 40 03 16 NON-STACKING OF LIMITS
Cindy Lewis Accepted
BID CA 1001 AZ 01 20 Page 2 of 4
Schedule of Coverages and Covered Autos
This policy provides only those coverages where a symbol is shown in the covered autos column below. Each of these coverages will apply only to those “autos” shown as covered “autos”. “Autos” are shown as covered “autos” for a particular coverage by the entry of one or more of the symbols from the Covered Auto Section of the Business Auto Coverage Form next to the name of the coverage.
Coverages
Covered Autos (Entry of one or more of the symbols from the Covered
Autos Section of the Business Auto Coverage of the Business Auto Coverage Form shows which autos are covered autos.)
Liability 7, 19
Auto Medical Payments 7
Uninsured Motorist 7
Underinsured Motorist 7
Physical Damage Other Than Collision 7
Collision 7
Towing and Labor 7
BID CA 1001 AZ 01 20 Page 3 of 4
Vehicle Coverage and Endorsements
Vehicle #1
Vehicle Description 2001 FORD RANGER VIN Number 1FTYR14V71PB10282
Cost New $15905 Gross Vehicle Weight Less than or equal to 10,000 lbs
Garaged at Location
764 E Morgan Dr Gilbert, AZ 85295
Limit of Insurance Deductible
Liability
Combined Single Limit $1,000,000
Medical Payments - Each Person $10,000
Uninsured Motorist – Bodily Injury Combined Single Limit $1,000,000
Underinsured Motorist – Bodily Injury Combined Single Limit $1,000,000
Comprehensive Full Glass Coverage
$500
Collision $500 Rental Reimbursement Any One Day $35 per day Number of Days 30 days Any One Period $1,050 maximum
Towing And Labor $500
Vehicle Forms and Endorsements
CA 73 02 05 00 ARIZONA CHANGES - COMMERCIAL VEHICLE FULL GLASS
CA 99 23 10 13 RENTAL REIMBURSEMENT COVERAGE
Hired Auto Liability Coverage
Limit of Insurance Deductible
Hired Auto Liability No Coverage
Hired Auto Liability – Physical Damage No Coverage
Non-Owned Auto Liability Coverage
Non-Owned Auto Liability No Coverage
BID CA 1001 AZ 01 20 Page 4 of 4
Third Party Interest
Vehicle Type Name and Address Loan Number
Additional Insured Designated Person Or Organization
Arizona Department of Transportation 1655 W Jackson St MD100P Phoenix, AZ 85007
Waiver of Transfer of Rights of Recovery Against Others to Us
Arizona Department of Transportation 1655 W Jackson St MD 100P Phoenix, AZ 85007
Policy Premium $3,502
Discounts Applied to This Policy
Multi-Product Discount
In witness whereof, we have caused this policy to be signed by our authorized officers.
Home Office Midvale Indemnity Company 6000 American Parkway Madison, WI 53783
(866) 908-0626
Tony Desantis, Jr Lauren K. Powell President Secretary
Carolyn Gilb
CA 79 01 01 99 Includes Copyrighted material of Insurance Services Office, Inc., with its permission Copyright, Insurance Services Office, Inc., 1993
POLICY NUMBER: CA00055366 COMMERCIAL AUTO
CA 79 01 01 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Named Insured Prime Collision LLC
Countersigned by Lucas Shafer
Endorsement Effective 06/25/2025
SCHEDULE
Additional Insured / Address:
Arizona Department of Transportation 1655 W Jackson St/MD100P,Phoenix,AZ,85007
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
Section II - Liability Coverage, A.1., Who Is An Insured, is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability coverage for a covered "auto ", as stated in Coverage Form.
POLICY NUMBER: CA00055366 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Named Insured: Prime Collision LLC
Endorsement Effective Date: 06/25/2025
SCHEDULE
Name(s) Of Person(s) Or Organization(s):
Arizona Department of Transportation
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.
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