ACCEPTED ANY_ALL WC 12.24.24-12.24.25.pdf

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSD

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

OTHER:

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 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:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

11/25/2024

EBACON CUSTOM BENEFITS

20815 N CAVE CREEK ROAD

PHOENIX, AZ 85024

KARINA LUGO

623 580 4900 623 580 4902

WC@EBACON.COM

AMTRUST NORTH AMERICA, INC.

SPECIALIZED OFFICE SYSTEMS, INC. DBA SOS

19235 N. CAVE CREEK RD. STE 100

Phoenix, AZ 85024

A

TWC4514843 12/24/2024 12/24/2025 X

1,000,000

ARIZONA DEPARTMENT OF TRANSPORTATION

1309 N. 21ST AVE

PHOENIX, AZ 85009

Eve Grikis Typewriter Y

Eve Grikis Typewriter Waiver of subrogation in favor of certificate holder when required by contract.

Eve Grikis Typewriter 424120

Cindy Lewis WC Only

WAIVER�OF�OUR�RIGHT�TO�RECOVER�FROM�OTHERS�ENDORSEMENT

We�have�the�right�to�recover�our�payments�from�anyone�liable�for�an�injury�covered�by�this�policy.�We�will�not�enforce our�right�against�the�person�or�organization�named�in�the�Schedule.�(This�agreement�applies�only�to�the�extent�that you�perform�work�under�a�written�contract�that�requires�you�to�obtain�this�agreement�from�us.)

This�agreement�shall�not�operate�directly�or�indirectly�to�benefit�anyone�not�named�in�the�Schedule.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 04-84)

Any�person�or�organization�as�required�by�written�contract

This�endorsement�changes�the�policy�to�which�it�is�attached�and�is�effective�on�the�date�issued�unless�otherwise�stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement�Effective 12/24/2024 Policy�No. TWC4514843 Endorsement�No. 0 Insured Specialized�Office�Systems,�Inc Premium�$ 5,708 Insurance�Company Technology�Insurance�Company,�Inc.

Countersigned�by

WC 00 03 13

(Ed.�04-84)