ACCEPTED CTR066171 GL, AL, WC, pL 01.01.23 - 01.01.24.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 EXP

TYPE 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

CTCAS-1 OP ID: SH

06/20/2023

Sheryl Homer Copple Insurance Agency, Inc.

1640 L Street, Suite A Lincoln, NE 68508- Sheryl Homer

402-475-3213 402-475-6842 sheryl@coppleinsurance.com

Cincinnati Insurance Company Underwriters at Lloyd's

CTC & Associates LLC c/o Brian Hirt 2323 Woodcrest Ave Lincoln, NE 68502

A X 1,000,000

X X X EPP0675090 01/01/2023 01/01/2024 100,000

5,000

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

1,000,000A

X X EPP0675090 01/01/2023 01/01/2024

X X

XX 1,000,000A

EPP0675090 01/01/2023 01/01/2024 1,000,000

NoneX

B PSL0039592373 01/01/2023 01/01/2024 Occurrenc 2,000,000

B Prof Liability PSL0039592373 01/01/2023 01/01/2024 Aggregate 2,000,000

Ref: ADOT Contract No. CTR066171. See page 2 for continued insurance coverages.

The State of Arizona or ADOT 1324 N. 22nd Ave.

Phoenix, AZ 85009

402-475-3213

10677

Prof Liability e6906 Accepted

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

06/22/2023 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 SUBROGATIONIS 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

AP INTEGO INSURANCE GROUP LLC

76250846

375 WOODCLIFF DRIVE STE 103

FAIRPORT NY 14450

CONTACT NAME:

PHONE

(A/C, No, Ext):

(888) 289-2939 FAX

(A/C, No):

E-MAIL ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

INSURER A : Hartford Fire and Its P&C Affiliates 00914

INSURED

CTC & ASSOCIATES LLC

2323 WOODSCREST AVE

LINCOLN NE 68502-3962

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

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.

INSR

LTR

TYPE OF INSURANCE ADDL

INSR

SUBR

WVD

POLICY NUMBER POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/Y YYY)

LIMITS

COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE

CLAIMS-MADE OCCUR DAMAGE TO RENTED

PREMISES (Ea occurrence) MED EXP (Any one person)

PERSONAL & ADV INJURY

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE

POLICY PRO-

JECT

LOC PRODUCTS - COMP/OP AGG

OTHER:

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT

(Ea accident)

ANY AUTO BODILY INJURY (Per person)

ALL OWNED

AUTOS

SCHEDULED

AUTOS BODILY INJURY (Per accident)

HIRED

AUTOS

NON-OWNED

AUTOS

PROPERTY DAMAGE

(Per accident)

UMBRELLA LIAB

EXCESS LIAB

OCCUR

CLAIMS-

MADE

EACH OCCURRENCE

AGGREGATE

DED RETENTION $

A

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY

PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

N/ A X 76 WEG AV5SEZ 01/01/2023 01/01/2024

X PER

STATUTE

OTH-

ER

Y/N E.L. EACH ACCIDENT $1,000,000

E.L. DISEASE -EA EMPLOYEE $1,000,000

E.L. DISEASE - POLICY LIMIT $1,000,000

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

Those usual to the Insured's Operations.

CERTIFICATE HOLDER CANCELLATION

Arizona Department of Transportation

1324 N 22ND AVE

PHOENIX AZ 85009-3715

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED

BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED

IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

Date

HOLDER CODE

INSURED'S NAME

PAGE

NOTEPAD:

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are additional insureds when required in written contract with respect to Commercial General Liability Policy and Commercial Auto Policy (Hired and Non-owned Auto Liability) arising out of activites performed by or on behalf of the contractor involving automobiles leased, hired or borrowed.

Comercial General Liability and Commercial Auto Policies are primary and non-contributory.

Waivers of Subrogation apply to the Commercial General Liability and Commercial Auto Policies.

A 30 day written notice to the State of Arizona applies with the exception of a 10 day notice of cancellation for non-payment of premium.

CTC & Associates LLC 06/20/2023

CTCAS-1

OP ID: SH

IA 4087 09 17

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION OR NONRENEWAL BY US

NOTIFICATION TO A DESIGNATED ENTITY

This endorsement modifies insurance provided under the following:

BUSINESSOWNERS PACKAGE POLICY

CLAIMS-MADE EXCESS LIABILITY COVERAGE PART

COMMERCIAL AUTO COVERAGE PART

COMMERCIAL GENERAL LIABILITY COVERAGE PART

COMMERCIAL UMBRELLA LIABILITY COVERAGE PART

DENTIST'S PACKAGE POLICY

ELECTRONIC DATA LIABILITY COVERAGE PART

EXCESS LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART

POLLUTION LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS COVERAGE PART

PRODUCT WITHDRAWAL COVERAGE PART

PROFESSIONAL LIABILITY COVERAGE PART

PROFESSIONAL UMBRELLA LIABILITY COVERAGE PART

PROFESSIONAL UMBRELLA LIABILITY COVERAGE PART - CLAIMS-MADE

RAILROAD PROTECTIVE LIABILITY COVERAGE PART

UNDERGROUND STORAGE TANK POLICY

SCHEDULE

Name and mailing address of person(s) or organization(s):

Number of days notice (other than nonpayment of premium):

A. If we cancel or nonrenew this policy for any statutorily permitted reason other than nonpayment of premium we will mail notice to the person or organization shown in the Schedule. We will mail such notice at least the number of days shown in the Schedule before the effective date of cancellation or nonrenewal.

B. If we cancel this policy for nonpayment of premium, we will mail notice to the person or organization shown in the Schedule. We will mail such notice at least 10 days before the effective date of cancellation.

C. If notice is mailed, proof of mailing to the mailing address shown in the Schedule will be sufficient proof of notice.

D. In no event will coverage extend beyond the actual expiration, termination or cancellation of the policy.

sheryl Typewritten Text sheryl Typewritten Text sheryl Typewritten Text sheryl Typewritten Text sheryl Typewritten Text sheryl Typewritten Text sheryl Typewritten Text

STATE OF ARIZONA OR ADOT

1324 N 22ND AVE

PHOENIX AZ 85009

sheryl Typewritten Text

GA 4094 09 20 Page 1 of 1

PRIMARY/NONCONTRIBUTORY - OTHER INSURANCE

CONDITION - SCHEDULED PERSON

OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

The following is added to the Other Insurance Condition and supercedes any provision to the con-trary:

Primary And Noncontributory Insurance

This insurance is primary to and will not seek con-tribution from any other insurance available to an additional insured described in the Schedule of this endorsement provided that:

(1) The additional insured is a Named Insured under such other insurance; and

(2) You have agreed in writing in a contract or agreement that this insurance would be prima-ry and would not seek contribution from any other insurance available to the additional in-sured.

sheryl Typewritten Text sheryl Typewritten Text

THE STATE OF ARIZONA AND ITS DEPARTMENTS AGENCIES BOARDS COMMISSIONS

UNIVERSITIES OFFICERS OFFICIALS AGENTS AND EMPLOYEES

C/O ARIZONA DEPARTMENT OF TRANSPORTATION

1324 N 22ND AVE

PHOENIX AZ 85009

sheryl Typewritten Text

AA 4004 03 06

ADDITIONAL INSURED - DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

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

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

The person or organization named in the following schedule is an "insured" to the extent of their liability for the conduct of another "insured" as provided in SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who is an Insured, Paragraph c.

Schedule

Additional Insured

Address:

sheryl Typewritten Text 01-01-2023 sheryl Typewritten Text

EBA 067 50 90

sheryl Typewritten Text

CTC & ASSOCIATES LLC

sheryl Typewritten Text

THE STATE OF ARIZONA AND ITS DEPARTMENTS AGENCIES BOARDS COMMISSIONS

UNIVERSITIES OFFICERS OFFICIALS AGENTS AND EMPLOYEES

sheryl Typewritten Text

AA 4195 01 07

WAIVER OF SUBROGATION - AUTO

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indi-cated below.

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

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

SCHEDULE

Name of person(s) or organization(s):

Job location: Job and/or Contract Number:

1. Waiver of Subrogation

SECTION IV - BUSINESS AUTO CONDI-

TIONS, A. Loss Conditions, 5. is amended by the addition of the following:

With regard to the person(s) or organiza-tion(s), job location, and job and / or contract number shown in the Schedule of this en-dorsement, we waive any right of recovery we may have against any person or organization because of payments we make for "bodily in-jury" or "property damage" arising out of the operation of a covered "auto" when you have assumed liability for such "bodily injury" or "property damage" under an "insured con-tract", provided the "bodily injury" or "property damage" occurs subsequent to the execution of the "insured contract".

sheryl Typewritten Text 01-01-2023 sheryl Typewritten Text

EBA 067 50 90

sheryl Typewritten Text

CTC & ASSOCIATES LLC

sheryl Typewritten Text

THE STATE OF ARIZONA AND ITS DEPARTMENTS AGENCIES BOARDS COMMISSIONS

UNIVERSITIES OFFICERS OFFICIALS AGENTS AND EMPLOYEES

WLTR005

THE HARTFORD

BUSINESS SERVICE CENTER

3600 WISEMAN BLVD

SAN ANTONIO TX 78251 June 22, 2023

Arizona Department of Transportation

1324 N 22ND AVE

PHOENIX AZ 85009-3715

Account Information:

Policy Holder Details : CTC & Associates LLC Contact Us

Need Help?

Chat online or call us at

(866) 467-8730.

We're here Monday - Friday.

Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns.

Sincerely, Your Hartford Service Team

ACORD 101 (2014/01) © 2014 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

AGENCY CUSTOMER ID:

LOC# :

ADDITIONAL REMARKS SCHEDULE Page 2 of 2

AGENCY

AP INTEGO INSURANCE GROUP LLC

NAMED INSURED

CTC & ASSOCIATES LLC

2323 WOODSCREST AVE

LINCOLN NE 68502-3962

POLICY NUMBER

SEE ACORD 25

CARRIER

SEE ACORD 25

NAIC CODE

EFFECTIVE DATE: SEE ACORD 25

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM

FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE

Those usual to the Insured's Operations. Waiver of Subrogation applies in favor of the Certificate Holder per WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC000313, attached to this policy.RE;State job is performed in: AZ Payroll for job to support waiver (Work Comp): 30,000 Do we need to add this amount to the estimated payroll on the policy (Work Comp)?: No Job Description/Contract Number: ADOT Contract CTR066171

CHANGE IN INFORMATION PAGE (Continued)

Policy Number: 76 WEG AV5SEZ

Form WC 99 00 06 A (1) Printed in U.S.A. Page 2 Process Date: 06/22/23 Policy Expiration Date: 01/01/24

Policy is amended to add the following condition(s):

Waiver of Our Right to Recover from Others Endorsement

Policy is amended to add the following Endorsement Forms reflecting the changes made to your policy.

WC000313

WC020601C

WC990371A

WC990006A(.2)

WC880206A

WC880205B

WC880200D

WC660248

WC880204B

WC020401C

WC020603A

Policy is amended to revise the following Endorsement Forms reflecting the changes made to your policy.

WC990300B

G-4119-0

WC990005

WC990006A(.1P)

WC660440

WC990367

Countersigned by Authorized Representative

Form WC 00 03 13 Printed in U.S.A.

Process Date: 06/22/23 Policy Expiration Date: 01/01/24

WAIVER OF OUR RIGHT TO RECOVER

FROM OTHERS ENDORSEMENT

Policy Number: 76 WEG AV5SEZ Endorsement Number: 2 Effective Date: 06/22/23 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: CTC & Associates LLC

2323 WOODSCREST AVE

LINCOLN NE 68502

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

SCHEDULE

The State of Arizona, insured doing government contract work with the department of transportation

00000000