ACCEPTED CTR062477 WC 07.01.24-07.01.25.pdf
PDF 182 KB Posted
- Attached to
- Master Agreement AZ|CTR062477
- Contract number
- CTR062477
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance and Waiver of Subrogation issued by Marsh Affinity, a division of Marsh USA LLC, for ADP TotalSource FL XVII, Inc. The insurance policy is underwritten by New Hampshire Insurance Co. and covers OZ Engineering, LLC, with the certificate holder being the State of Arizona, Arizona Department of Transportation. The policy is specifically related to contract CTR062477 and provides workers' compensation insurance.
The workers' compensation insurance policy is effective from 07/01/2024 to 07/01/2025, with coverage limits of $2,000,000 for each accident, disease-each employee, and disease-policy limit. The policy covers all worksite employees of OZ Engineering, LLC who are paid through ADP TotalSource, Inc.'s payroll. A waiver of subrogation is included in favor of the State of Arizona, Arizona Department of Transportation, as required by the written contract. The policy includes provisions for proprietors, partners, executive officers, and members, who are not excluded as long as they are on the ADP TotalSource payroll or have completed the SEI Participation Addendum.
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Text version
03/19/2025
Marsh Affinity a division of Marsh USA LLC.
PO BOX 14404
Des Moines, IA 50306-9686
Marsh Affinity
800-743-8130
ADPTotalSource@marsh.com
New Hampshire Insurance Co. 23841
A N 07/01/2024 07/01/2025 2,000,000
2,000,000
2,000,000
ADP TotalSource FL XVII, Inc.
5800 Windward Parkway
Alpharetta, GA 30005 L/C/F:
OZ Engineering, LLC
1711 W GREENTREE DRIVE
Suite 205 Tempe, AZ 852840000
WC 088409059 AZX
All worksite employees working for OZ Engineering, LLC paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. Proprietor/Partner/Executive Officer/Member are not excluded as long as they are in the ADPTS payroll or have completed the SEI Participation Addendum.
WAIVER OF SUBROGATION IN FAVOR OF State of Arizona, Arizona Department of Transporation AS RESPECTS OF JOB PERFORMED BY OZ Engineering, LLC AS REQUIRED BY WRITTEN CONTRACT. RE: CTR062477
State of Arizona, Arizona Department of Transporation 1739 W Jackson Street Suite A MD 100P Phoenix, AZ 85007
X
Cindy Lewis WC Only
07/01/2024 WC 088409059 AZ
ADP TotalSource FL XVII, Inc.
5800 Windward Parkway
Alpharetta, GA 30005 L/C/F:
OZ Engineering, LLC
1711 W GREENTREE DRIVE
Suite 205 Tempe, AZ 852840000
New Hampshire Insurance Co.
WAIVER OF SUBROGATION IN FAVOR OF State of Arizona, Arizona Department of Transporation AS RESPECTS OF JOB PERFORMED BY OZ Engineering, LLC AS REQUIRED BY WRITTEN CONTRACT.
RE: CTR062477
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