ACCEPTED CTR062471 GL,AL,WC,PROFESSIONAL 08.29.23-08.29.24.pdf
PDF 1 MB Posted
- Attached to
- Master Agreement AZ|CTR062471
- Contract number
- CTR062471
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance for CivTech, Inc., issued by Professional Insurance Brokers, Inc. on 08/29/23. The certificate covers multiple insurance policies from various insurers including RLI Insurance Company, Nutmeg Insurance Company, Hartford Accident & Indemnity Co, and Hartford Fire Insurance Company. The certificate holder is the Arizona Department of Transportation (ADOT), located in Phoenix, Arizona.
The insurance policies provide comprehensive coverage for CivTech, Inc., including Commercial General Liability ($1,000,000 per occurrence), Automobile Liability ($1,000,000), Umbrella Liability ($4,000,000), Workers Compensation, and Professional Liability ($2,000,000). The policies are effective from 08/29/23 to 08/29/24 and include additional insured status for the State of Arizona, its departments, officials, and employees on a primary and non-contributory basis. The certificate is associated with a TSMO (Transportation Systems Management and Operations) On-call contract, with a 30-day cancellation notice provision and a waiver of subrogation for all listed policies.
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Text version
08/29/23
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).
PRODUCER: WENDI S REED
PROFESSIONAL INSURANCE BROKERS, INC. 623 465-5300 623 465-5933
PMB 857, 515 E. CAREFREE HWY
wendi@pibinc.com
PHOENIX, ARIZONA 85085-8839
R L I INSURANCE COMPANY, INC. 13056
CIVTECH, INC. NUTMEG INSURANCE COMPANY 39608
10605 N. HAYDEN ROAD HARTFORD ACCIDENT & INDEMNITY CO 22357
BUILDING G, SUITE 140 HARTFORD FIRE INSURANCE COMPANY 19682
SCOTTSDALE, ARIZONA 85260
COVERAGES: CERTIFICATE NUMBER: 463 REVISION NUMBER: 1-8/18/23
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.
CO
LTR LIMITS
A X COMMERCIAL GENERAL LIABILITY $ 1,000,000
CLAIMS MADE X X X PSB0001543 08/29/23 08/29/24 $ 1,000,000
X $ 10,000
X CONTRACTUAL LIABILITY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: $ 2,000,000
X LOC $ 2,000,000
OTHER
B AUTOMOBILE LIABILITY $ 1,000,000
X ANY AUTO SCHEDULED X X 59UECBC6952 08/29/23 08/29/24
AUTOS $
NON $
OWNED $
AUTOS
A X UMBRELLA LAB X X PSE0001351 08/29/23 08/29/24 EACH OCCURRENCE $ 4,000,000
X AGGREGATE $ 4,000,000
DED RETENTION $ $
C
Y/N
N N/A X 59WECAS5XPV 08/29/23 08/29/24 $ 1,000,000
$ 1,000,000
$ 1,000,000
OTHER EACH CLAIM / AGGREGATE
D X PROFESSIONAL LIABILITY X 08/29/23 08/29/24 2,000,000 / 2,000,000
A X VALUABLE PAPERS PSB0001543 08/29/23 08/29/24 $100,000
CTR062471 TSMO On-call
As required by the written contract, the State of Arizona, its departments, officials, officers, employees, and agents are Additional Insured, on a primary and non-contributory basis, as respects the General and Automobile Liability coverages only, as per Endorsement
Forms PPB040212 and HA99161221 attached. Umbrella follows form. Waiver of Subrogation applies to all listed policies as per written contract. Workers Compensation Blanket waiver form WC000313 attached. 30 day notices of cancellation applies.
CERTIFICATE HOLDER CANCELLATION
A D O T
STATE OF ARIZONA
MAIL DROP 100
1655 W. JACKSON ST.
PHOENIX, ARIZONA 85007
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD.
A C O RD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
CONTACT
NAME:
PHONE
(A/C.No. Ext):
FAX (A/C
No)
ADDRESS:
PRODUCER
CUSTOMER ID:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED: INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
INSURER F:
POLICY EXP.
DATE(MM/DD/YY) DATE(MM/DD/YY)
EACH OCCURRENCE
OCCUR DAMAGE TO RENTED PREMISES
(Ec occurrence)
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVO
POLICY NUMBER
POLICY EFF.
BROAD FORM PROPERTY DAMAGE MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
POLICY PROJECT PRODUCTS.COMP/OP AGG
COMBINED SINGLE LIMIT (Ec
Accident)
ALL
OWNED
AUTOS
BODILY INJURY (Per person)
X
BODILY INJURY (Per accident)
X
HIRED
AUTOS
PROPERTY DAMAGE (Per accident)
EXCESS LIAB OCCUR
CLAIMS-MADE
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY ANY
PROPRIETOR/PARTNER EXECUTIVE
OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION
OF OPERATIONS BELOW
X PER STATUTE
OTHER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
AUTHORIZED REPRESENTATIVE
E.L. DISEASE - POLICY LIMIT
OH 03987192301
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
a8812 Accepted
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