ACCEPTED_ANY_ALL_GL_AL_WC_CONTRACTORS_POLL_05.01.25-05.01.26.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

5/28/2025

License # 0757776

(505) 828-4000 (866) 487-3972

23663

Riley Industrial Services, Inc.

PO Box 2014 Farmington, NM 87499

20044

A 1,000,000

X X OP53511030 5/1/2025 5/1/2026 300,000

10,000

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

Ltd Pollution 1,000,000 1,000,000A

X X OP53511030 5/1/2025 5/1/2026

5,000,000A

X X OU43761030 5/1/2025 5/1/2026 5,000,000

B

X RIWC637005 5/1/2025 5/1/2026 1,000,000

N 1,000,000 1,000,000

For any and all work performed in ADOT's right-of-way.

SEE ATTACHED ACORD 101

Arizona Department of Transportation PO Box 2100 Mall Drop 527M Phoenix, AZ 85001-2100

RILEIND-01 AFORAKER1

HUB International Insurance Services (SOW) 6565 Americas Parkway Suite 720 Albuquerque, NM 87110

National American Insurance Company (OK) Berkshire Hathaway Homestate Insurance Company

X

X X

X

X

X X

X X

Cindy Lewis Accepted

FORM NUMBER:

EFFECTIVE DATE:

The ACORD name and logo are registered marks of ACORD

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE

FORM TITLE:

Page of

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

ACORD 101 (2008/01)

AGENCY CUSTOMER ID:

LOC #:

AGENCY NAMED INSURED

POLICY NUMBER

CARRIER NAIC CODE

© 2008 ACORD CORPORATION. All rights reserved.

HUB International Insurance Services (SOW)

RILEIND-01

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

License # 0757776

SEE P 1

Riley Industrial Services, Inc.

PO Box 2014 Farmington, NM 87499

SEE PAGE 1

AFORAKER1

Description of Operations/Locations/Vehicles:

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees is included as Additional Insured with regard to the General Liability and Auto Liability policies on a Primary and Non-Contributory basis as required by written contract with Named Insured. Waiver of Subrogation in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees with regard to the General Liability, Auto Liability and Workers Compensation policies as required by written contract with Named Insured. Umbrella on a follow form basis that extends coverage over General Liability, Automobile Liability, and Employer's Liability. 30 Day Notice of Cancellation (10 Days for Non-Payment) applies to the General Liability, Auto Liability, and Workers' Compensation policies.

Umbrella follows form.

The General liability policy is endorsed with limited pollution coverage. The General Liability policy's blanket Additional Insured and Waiver of Subrogation endorsments also apply to that limited pollution coverage.

Highlight fiHowever, provides such coverage.otherwise his Coverage Parttsuch coverage and you to provide the additional insured "written contract" requireshetifbut only

";completed operations hazard-"products included in theadvertising injury" or "personal and","property damage

",contract" but only for "bodily injury "Your work" specified in the "writtenb.

contract"; or operations specified in the "written in the performance of your ongoing omissions of those acting on your behalf, Your acts or omissions, or the acts ora.

by:

advertising injury" caused in whole or in part injury," "property damage," or "personal and insured only with respect to liability for "bodily The person or organization is an additional1.

is limited as follows:

The insurance provided to the additional insuredB.

.Coverage Part contract" to add as an additional insured on this organization whom you are required by "written person ornyainclude as an additional insured is amended toWho Is An Insured-Section IIA.

as follows:PART COMMERCIAL GENERAL LIABILITY COVERAGEIt is understood and agreed that this endorsement amends the

REQUIRED IN A WRITTEN CONTRACT

AUTOMATIC STATUS WHEN-OPERATIONS COVERAGE

COMPLETED-WITH PRODUCTS-CONTRACTORS

OWNERS, LESSEES OR-ADDITIONAL INSURED

.THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

NATIONAL AMERICAN INSURANCE COMPANY

12 23NA CG 16

COMMERCIAL GENERAL LIABILITYPOLICY NUMBER:

of 21Page with its permission.

Includes Copyrighted Material of Insurance Services Office, Inc.,2 231NA CG 16

The rendering of, or the failure to render,a.

advertising injury" arising out of:

"property damage," or "personal and insured does not apply to "bodily injury," The insurance provided to the additional.4 a Named Insured.

insurance on which the additional insured is to, but only with respectcontributory -this insurance will be primary and non contributory,-contract" to be primary and non basis. But if required by the "written on a primary, excess, contingent or any other additional insured whetheranyavailable to this insurance is excess of all other insurance

,IV)(Section4. Other InsuranceCondition Notwithstanding anything to the contrary in.3 whichever is less.

That afforded to you under this policy,.b orThat required by the "written contract";.a of insurance than:

provide the additional insured any higher limit will notWepermitted by applicable law.

policy and applies only to the extent provisions, conditions and exclusions of this insured is subject to all of the terms, The insurance provided to the additional.2 by' are replaced by the words 'arising out of '.

above, the words 'caused in whole or in part B.1.then in paragraphdescribed in 1.b., operations described in 1.a. and "your work" ., or arising out of both your ongoingb1.

or "your work" described in.described in 1.a arising out of your ongoing operations damage", or "personal and advertising injury" contract" for "bodily injury" "property described or identified in the "written for another party, person or entitycoverage insuredadditionalobtainrequires you to the "written contract" specifically ordrawings and specifications;

field orders, change orders or drawings, opinions, reports, surveys, to prepare or approve maps, shop The preparing, approving, or failing(1)

:but not limited toincluding engineering, or surveying services, architectural,,any professional

OP53511030

Named Insured.

on which the additional insured is a provision (4) does not apply to insurance contributory, this-primary and non contract" requires this insurance to be Coverage Part. But if the "written cover under thismayto a loss we insurer whose policy or program applies claim or "suit" to any other insurer or self Tender the defense and indemnity of any(4) settlement of the claim or "suit"; and us in the investigation, defense, or received, and otherwise cooperate with Send us copies of all legal papers(3) provide us with proof of such notice;

andcover under this Coverage Part mayadditional insured has for a loss we thecarrierany other insuranceoffense to

Provide notice of s uch an "occurrence" or(2) claim or "suit" that does result;

or "suit" under this insurance, and of any or an offense which may result in a claim Give us written notice of an "occurrence"(1) will as soon as practicable:

An additional insured under this endorsement insured:

conditions applicable to the additional amended to add the following additional condition isOffense, Claim or Suit Duties In The Event of Occurrence,The1.

is amended as follows:LIABILITY CONDITIONS

COMMERCIAL GENERAL-SECTION IVC.

Coverage Part.

another endorsement attached to this on, by name,an additional insured additional insured is specifically listed as or work for which thelocationAnyb.

activities ; or architectural or engineeringcontrol, , quality, inspectionionSupervis(2) of 22Page with its permission.

Includes Copyrighted Material of Insurance Services Office, Inc.,2 231NA CG 16

.the same All other terms and conditions of the Policy remain coverage under this Coverage Part.

for which the additional insured seeks and advertising injury," The offenses that caused the "personalb.

or The "bodily injury" or "property damage";a.

Was executed prior to:2.

during the term of this policy; and Is currently in effect or becomes effective1.

agreement:

this Coverage Part, provided the contract or person or organization an additional insured on written agreement that requires you to make a tten contract" means a written contract or"Wri amended to add the following definition:

isDEFINITIONS-SECTION Vthis endorsement, Only for the purpose of the insurance provided byD.

above conditions.

additional insured has satisfied all of the and thewritten notice of a claim or "suit," until we receive from the additional insured additional insured under this endorsement We have no duty to defend or indemnify an waiver of subrogation.

aa written contract when such contract requires for whom the insured is operating underorganization person orwe waive our right to recovery against any

TO US, in the event of any payment under this policy, OF RIGHTS OF RECOVERY AGAINST OTHERS

LIABILITY CONDITIONS (Section IV), TRANSFER contrary in Paragraph 8 of COMMERCIAL GENERAL It is agreed that notwithstanding anything to the policy remain unchanged.

indicated. All other terms and conditions of this It is agreed that this policy is hereby amended as

COMMERCIAL GENERAL LIABILITY COVERAGE PART

This endorsement modifies insurance provided under the follow ing:

REQUIRED IN A WRITTEN CONTRACT

AUTOMATIC STATUS WHEN-AGAINST OTHERS TO US

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

.THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

NATIONAL AMERICAN INSURANCE COMPANY

01 17GL2017

COMMERCIAL GENERAL LIABILITYPOLICY NUMBER:

1of1Page01 17GL2017

OP53511030

.additional insured theother insurance available toanyfrom primary and would not seek contribution agreement that this insurance would be ou have agreed in writing in a contract orY(2) under such other insurance; and The additional insured is a Named Insured)1( that:

ured under your policy providedan additional ins contribution from any other insurance available to insurance is primary to and will not seekThis

InsuranceontributorycNonAndPrimary contrary:

and supersedes any provision to theCondition Other InsurancetheThe following is added to

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

COMMERCIAL GENERAL LIABILITY COVERAGE PART

This endorsement modifies insurance provided under the follow ing:

ITIONOTHER INSURANCE COND

PRIMARY AND NONCONTRIBUTORY -

1of1Page© Insurance Services Office, Inc., 2018CG 20 01 12 19

LY.EASE READ IT CAREFULNGES THE POLICY. PLTHIS ENDORSEMENT CHA

CG 20 01 12 19

COMMERCIAL GENERAL LIABILITY

POLICY NUMBER: OP53511030

All other terms and conditions of this policy remain unchanged.

insureds" but only to the extent of that liability."they are also " "insured" arising out of the ownership, maintenance or use of a covered auto under the above policy, To the extent that the person(s) or organization(s) shown in the schedule is liable for the conduct of an of Person or Organization:Name

SCHEDULE

ISSUE DATE:POLICY NUMBER:

ENDORSEMENT NO.:NAMED INSURED:

indicated below:

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

TOR CARRIER COVERAGE FORMMO

TRUCKERS COVERAGE FORM

COMMERCIAL AUTO COVERAGE PART

This endorsement modifies insurance provided under the following:

ADDITIONAL INSURED ENDORSEMENT

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

NATIONAL AMERICAN INSURANCE COMPANY

1 of1Page25 (Ed. 5/2007)-NAICO

RILEY INDUSTRIAL

OP53511030 05/01/2025

AUTOMATIC STATUS WHEN REQUIRED BY WRITTEN CONTRACT

Prior to the "accident" or the "loss".B.

(s); andorganizationperson(s) or with suchact or agreementrnder a written contUA.

subrogation is waived:

orm, but only to the extent thatFoverageCunder this subrogation with respect to the coverage provided to waiverequiredyou arewhomfororganization(s) to any person(s) ortion does not applyondiCTo Us

Transfer Of Rights Of Recovery Against OthersThe by the endorsement.

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

MOTOR CARRIER COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

AUTO DEALERS COVERAGE FORM

This endorsement modifies insurance provided under the following:

OR AGREEMENTCONTRACT

AUTOMATIC WHEN REQUIRED BY WRITTEN

AGAINST OTHERS TO US (WAIVER OF SUBROGATION) -

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

1of1Page© Insurance Services Office, Inc., 2022CA 04 43 12 23

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 04 43 12 23

COMMERCIAL AUTO

POLICY NUMBER: OP53511030

Highlight