ACCEPTED CTR069053 GL, AL, WC 6.29.23 - 6.29.24.pdf
PDF 3 MB Posted
- Attached to
- Master Agreement AZ|CTR069053
- Contract number
- CTR069053
- Issued by
- Arizona
About this file
This document is a Workers' Compensation and Employers' Liability Insurance Policy issued by The Hartford Insurance Group to WCD Enterprises LLC, a janitorial services company based in Scottsdale, Arizona. The policy covers operations in multiple states including Arizona, Oklahoma, Delaware, and Texas, with various state-specific endorsements. The policy involves additional insureds such as the Arizona Department of Transportation, City of Richardson, and other governmental and commercial entities.
The policy provides workers' compensation insurance with an estimated annual premium of $1,937, covering approximately 23 employees performing janitorial and commercial cleaning services. The policy period runs from January 13, 2024 to January 13, 2025, with coverage limits of $1,000,000 for bodily injury by accident, bodily injury by disease policy limit, and bodily injury by disease per employee. The premium is based on payroll classifications including janitorial services, lawn maintenance, and clerical office employees, with an experience rating modification factor applied. The policy includes provisions for audit, potential premium adjustments, and various state-specific requirements such as alcohol and drug-free workplace credit programs.
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Text version
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
DATE (MM/DD/YYYY)
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
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 RENTED
CLAIMS-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 AGG $JECT
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 LIMIT $DESCRIPTION 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.
The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE 2/07/2024
JESSICA DELGADO
602-993-1010COPPER SILVER INSURANCE AGENCY
13321 W INDIAN SCHOOL RD 108 Jessica@csiforyou.com 85340
602-993-2717
11738
COPPER SILVER INSURANCE AGENCY
LITCHFIELD PARK
INFINITY COMMERCIAL AUTO
WCD ENTERPRISES, LLC
DBA: DESERT COMMERCIAL SERVICES
28150 N.ALMA SCHOOL PKWY SUITE 103-452
SCOTTSDALE, AZ 85262
502414952745001
A
7/06/2023 1,000,000 7/06/2024
X
X X
X
X
Additional Insured Names: State of Arizona, and its departments,agencies, boards, commissions, universities, officers, officials,agents, and employees
Waiver of Subrogation applies to: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees
INSURANCE APPLIES TO ANY AND ALL WORK PERFORMED FOR OR ON BEHALF OF THE STATE OF ARIZONA/ADOT
The State of Arizona/ADOT
206 S. 17TH AVE
PHOENIX,AZ 85007
JESSICA DELGADO
UM/UIM
e6906 Accepted
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
02/07/2024 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
INTEGRA INSURANCE GROUP
59304509
13350 N 94TH DRIVE SUITE B
PEORIA AZ 85381
CONTACT NAME:
PHONE
(A/C, No, Ext):
(623) 322-5955 FAX
(A/C, No):
E-MAIL ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC#
INSURER A : Sentinel Insurance Company Ltd. 11000
INSURED
WES DRYDEN WCD ENTERPRISES LLC
28150 N ALMA SCHOOL PKWY STE 103-452
SCOTTSDALE AZ 85262-8133
INSURER B : Hartford Fire and Its P&C Affiliates 00914
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
A
COMMERCIAL GENERAL LIABILITY
X X 59 SBA PI1952 06/29/2023 06/29/2024
EACH OCCURRENCE $1,000,000
CLAIMS-MADE X OCCUR DAMAGE TO RENTED
PREMISES (Ea occurrence) $1,000,000
X General Liability MED EXP (Any one person) $10,000
PERSONAL & ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY X PRO-
JECT
LOC PRODUCTS - COMP/OP AGG $2,000,000
OTHER:
A
AUTOMOBILE LIABILITY
59 SBA PI1952 06/29/2023 06/29/2024
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000 ANY AUTO BODILY INJURY (Per person)
ALL OWNED
AUTOS
SCHEDULED
AUTOS BODILY INJURY (Per accident)
X HIRED
AUTOS X NON-OWNED
AUTOS
PROPERTY DAMAGE
(Per accident)
A
X UMBRELLA LIAB
EXCESS LIAB
X OCCUR
CLAIMS-
MADE 59 SBA PI1952 06/29/2023 06/29/2024
EACH OCCURRENCE $5,000,000
AGGREGATE $5,000,000
DED X RETENTION $ 10,000
B
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 59 WEC AL4NPT 01/13/2024 01/13/2025
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
A EMPLOYMENT PRACTICES
LIABILITY
59 SBA PI1952 06/29/2023 06/29/2024 Each Claim Limit Aggregate Limit
$10,000 $10,000
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. Applies to any and all work performed for or on behalf of the State of Arizona / ADOT.
CERTIFICATE HOLDER CANCELLATION
The State of Arizona/ADOT
206 S 17TH AVE
PHOENIX AZ 85007
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 e6906 GL Only e6906 WC Only
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
INTEGRA INSURANCE GROUP
NAMED INSURED
WES DRYDEN WCD ENTERPRISES LLC
28150 N ALMA SCHOOL PKWY STE 103-45
SCOTTSDALE AZ 85262-8133
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
Certificate holder is an additional insured per the Business Liability Coverage Form SS0008 attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy.
Coverage is primary and noncontributory per the Business Liability Coverage Form SS0008, attached to this policy. 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.
AGENCY NAMED INSURED
POLICY NUMBER
CARRIER NAIC CODE
EFFECTIVE DATE:
AGENCY CUSTOMER ID:
LOC #:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: FORM TITLE:
ADDITIONAL REMARKS
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Page ofADDITIONAL REMARKS SCHEDULE
WCDAZDEC
COPPER SILVER INSURANCE WCD ENTERPRISES, LLC
DBA: DESERT COMMERCIAL SERVICES
28150 N.ALMA SCHOOL PKWY SUITE 103-452
SCOTTSDALE, AZ 85262
INFINITY COMMERCIAL AUTO 11738 / /
25 Ceritificate of Liability Insurance
�" The policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.
�" Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.
Additional Insured Names: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees
Waiver of Subrogation applies to: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employee
02/05/24 06/29/23
06/29/24
59 SBA PI1952 SC
WES DRYDEN WCD ENTERPRISES LLC
28150 N ALMA SCHOOL PKWY STE103-452
SCOTTSDALE AZ 85262
02/05/24
INTEGRA INSURANCE GROUP
304509
SENTINEL INSURANCE COMPANY, LIMITED
ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING
STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK
ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS.
THIS IS NOT A BILL.
NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE
PROPERTY OPTIONAL COVERAGES APPLICABLE TO ALL LOCATIONS ARE ADDED
COMPUTERS AND MEDIA COVERAGE
FORM SS 04 41
DEDUCTIBLE: $ 1,000
FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE:
IH12001185 ADDITIONAL INSURED - OWNER, LESSEES OR CONTRACTOR
PRO RATA FACTOR: 1.000
THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN.
Form SS 12 11 04 05 T Page Process Date: Policy Effective Date:
Policy Expiration Date:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGE
This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below:
Policy Number:
Named Insured and Mailing Address;
Policy Change Effective Date: Effective hour is the same as stated in the Declarations Page of the Policy.
Policy Change Number:
Agent Name:
Code:
POLICY CHANGES:
59 SBA PI1952
ADDITIONAL INSURED - OWNER, LESSEES OR CONTRACTOR
LOC 001 BLDG 001
USM, INC., AN EMCOR COMPANY
1700 MARKLEY STREET SUITE 100,
NORRISTOWN, PA 19401
NUMBER OF JOB LOCATIONS: 1
RE: CLEANING SEVICES
ONGOING AND COMPLETED OPERATIONS-SS4171, CG2037
CBRE,INC.
C/O GRMS
5271 CALIFORNIA AVE SUITE 29
IRVING, CA 92617
STATE OF ARIZONA/ ADOT
206 S 17TH AVE
PHOENIX, AZ 85007
005 001
02/05/24 06/29/24
POLICY NUMBER:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Form IH 12 00 11 85 T SEQ. NO. Printed in U.S.A. Page
Process Date: Expiration Date:
Form SS 00 01 03 14 Page 1 of 1
Business Owner’s Policy
Form G-3418-0
PRODUCER COMPENSATION NOTICE
You can review and obtain information on The Hartford’s producer compensation practices at www.TheHartford.com or at 1-800-592-5717.
$144.00
THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN
RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK
INSURANCE ACT.
DISCLOSURE/CAP ON LOSSES - TERRORISM
RISK INSURANCE ACT
POLICY NUMBER:
A. Disclosure Of Premium In accordance with the federal Terrorism Risk Insurance Act, as amended (TRIA), we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for "certified acts of terrorism" under TRIA. The portion of your premium attributable to terrorism coverage is shown in the above Schedule of this endorsement.
B. The following definition is added with respect to the provisions of this endorsement:
1. A "certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in accordance with the provisions of TRIA, to be an act of terrorism under TRIA. The criteria contained in TRIA for a "certified act of terrorism" include the following:
a. The act results in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to TRIA; and
b. The act results in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of an United States mission; and
c. The act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals as part of an effort to coerce the civilian population of the
United States or to influence the policy or affect the conduct of the United States Government by coercion
C. Disclosure Of Federal Share Of Terrorism Losses
The United States Department of the Treasury will reimburse insurers for 80% of insured losses attributable to "certified acts of terrorism" under TRIA that exceeds the applicable insurer deductible.
However, if aggregate industry insured losses attributable to "certified acts of terrorism" under TRIA exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. The United States government has not charged any premium for their participation in covering terrorism losses.
D. Cap On Insurer Liability for Terrorism Losses
If aggregate industry insured losses attributable to "certified acts of terrorism" under TRIA exceed $100 billion in a calendar year and we have met, or will meet, our insurer deductible under TRIA, we shall not be liable for the payment of any portion of the amount of such losses that exceed $100 billion. In such case, your coverage for terrorism losses may be reduced on a pro-rata basis in accordance with procedures established by the Treasury, based on its estimates of aggregate industry losses and our estimate that we will exceed our insurer deductible.
Form SS 83 76 12 20 Page 1 of 2 2020, The Hartford
(Includes copyrighted material of Insurance Services Office, Inc., with its permission)
SCHEDULE
Terrorism Premium:
In accordance with the Treasury's procedures, amounts paid for losses may be subject to further adjustments based on differences between actual losses and estimates.
E. Application of Other Exclusions
The terms and limitations of any terrorism exclusion, the inapplicability or omission of a terrorism exclusion, or the inclusion of terrorism coverage, do not serve to create coverage for any loss which would otherwise be excluded under this Coverage Form, Coverage Part or Policy, such as losses excluded by any pollution, pathogenic, nuclear hazard or war exclusions which may be included on this Policy.
F. All other terms and conditions remain the same
Page 2 of 2 Form SS 83 76 12 20
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Form SS 12 23 06 11 Page 1 of 1 © 2011, The Hartford
NOTICE OF CANCELLATION TO CERTIFICATE HOLDER(S)
This policy is subject to the following additional Conditions:
A. If this policy is cancelled by the Company, other than for non-payment of premium, notice of such cancellation will be provided at least thirty (30) days in advance of the cancellation effective date to the certificate holder(s) with mailing addresses on file with the agent of record or the Company.
B. If this policy is cancelled by the company for non-payment of premium, or by the insured, notice of such cancellation will be provided within ten (10) days of the cancellation effective date to the certificate holder(s) with mailing addresses on file with the agent of record or the Company.
If notice is mailed, proof of mailing to the last known mailing address of the certificate holder(s) on file with the agent of record or the Company will be sufficient proof of notice.
Any notification rights provided by this endorsement apply only to active certificate holder(s) who were issued a certificate of insurance applicable to this policy’s term.
Failure to provide such notice to the certificate holder(s) will not amend or extend the date the cancellation becomes effective, nor will it negate cancellation of the policy. Failure to send notice shall impose no liability of any kind upon the Company or its agents or representatives.
Form SS 90 30 06 18 Page 1 of 1 © 2018, The Hartford
IMPORTANT NOTICE TO POLICYHOLDERS
ERISA - EMPLOYEE DISHONESTY
You are receiving this notice because your renewal policy contains ERISA-EMPLOYEE DISHONESTY.
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets rules and standards of conduct for private sector employee benefit plans and those that invest and manage their assets. One of ERISA's requirements is that people who handle plan funds and other property must be covered by a fidelity bond to protect the plan from losses due to fraud or dishonesty.
Please be advised that on or before the beginning of each plan year, the plan administrator or other plan fiduciary must ensure that the plan has the legally required bonding amount for the individuals who will handle the plan's funds and other property. If necessary, the plan administrator or other plan fiduciary may need to obtain appropriate adjustments or additional protection to ensure that the coverage will be in compliance for the new plan year.
If you wish to adjust the amount of your ERISA fidelity bond, please reach out to your agent or Hartford representative.
Form PC-374-0 Printed in U.S.A.
IMPORTANT NOTICE TO POLICYHOLDERS
To help your insurance keep pace with increasing costs, we have increased your amount of insurance . . . giving you better protection in case of either a partial, or total loss to your property.
If you feel the new amount is not the proper one, please contact your agent or broker.
IMPORTANT NOTICE TO POLICYHOLDERS
PREMIUM DETERMINATION FOR SUBCONTRACTORS
As a contractor some of your operations may be performed by a subcontractor. In order to minimize your premium charge for subcontracted work, the subcontractor must carry adequate insurance.
PLEASE READ THE FOLLOWING CAREFULLY TO UNDERSTAND:
What is an Adequately Insured Subcontractoro
How we determine your premium for an Adequately Insured Subcontractoro
How we determine your premium for an Inadequately Insured Subcontractoro
What records we require you to maintaino
The role of a Hartford Premium Auditoro
I. WHAT IS AN ADEQUATELY INSURED III. HOW WE DETERMINE YOUR PREMIUM FOR AN
SUBCONTRACTOR INADEQUATELY INSURED SUBCONTRACTOR
Unless otherwise specified by us at inception, the When a subcontractor is inadequately insured, the subcontractor will be considered to be adequately subcontractors' payroll records are necessary to insured (for purposes of premium computation only) if determine your premium charge. In such cases your the subcontractor, during the period of time that the premium will be based on the payroll of that work is performed for you, carries limits equal to: subcontractor.
A. Your occurrence, general aggregate and If we cannot determine the subcontractors' payroll, products/completed operations aggregate limits, or your premium charge for the inadequately insured subcontractor will be based on the following:B. $300,000 per occurrence, $300,000 general aggregate, and $300,000 products/completed A. 50% of the subcontractor price will be considered operations aggregate limits; payroll if the subcontract is for labor and material.
whichever is lower. B. 90% of the subcontract price will be considered payroll if the subcontract is for labor only.When requested, you must furnish us with satisfactory evidence of subcontractors' insurance (i.e., certificates IV. WHAT RECORDS WE REQUIRE YOU TO MAINTAIN of insurance).
It's essential that you keep clear and accurate records II. HOW WE DETERMINE YOUR PREMIUM FOR AN with a breakdown of payrolls and subcontract costs by
ADEQUATELY INSURED SUBCONTRACTOR type of work performed.
When a subcontractor is adequately insured, we will V. THE ROLE OF A HARTFORD PREMIUM AUDITOR charge a premium for the subcontracted work to
The Hartford auditor is permitted by the policy determine your total premium. The premium for provisions to make a complete audit of the records subcontracted work will be based on 100% of the price needed to establish the proper premium for your of subcontracted work. The rate used to determine policy. This includes, but is not limited to, an this premium is discounted to recognize that adequate examination of your cash journals, general ledgers, insurance is carried by the subcontractors.
payroll records, subcontractor records, income tax, In order to meet this requirement, satisfactory social security reports, unemployment insurance evidence of subcontractors' insurance (i.e., certificates reports, checkbooks and contracts.
of insurance) showing adequate limits must be available at the time of audit.
Form SS 83 03 10 01 Printed in U.S.A. (NS)
© 2000, The Hartford
We appreciate your cooperation in making these records premium quickly and efficiently. If you have any available for the auditor's inspection. These records will questions please contact your agent or the Hartford enable the auditor to determine your auditor for details that apply to your policy.
Page 2 of 2 Form SS 83 03 10 01 Printed in U.S.A. (NS)
001 (CONTINUED ON NEXT PAGE)
05/15/23 06/29/24
PI
SBA
SENTINEL INSURANCE COMPANY, LIMITED
ONE HARTFORD PLAZA, HARTFORD, CT 06155
A
59 SBA PI1952 SC
WES DRYDEN WCD ENTERPRISES LLC
28150 N ALMA SCHOOL PKWY STE103-452
SCOTTSDALE AZ 85262
06/29/23 06/29/24 1 YEAR
INTEGRA INSURANCE GROUP
304509
59 SBA PI1952
LIMITED LIAB CORP
ANNUAL
SPECIAL
$7,358
IN RECOGNITION OF THE MULTIPLE COVERAGES INSURED WITH THE HARTFORD, YOUR
POLICY PREMIUM INCLUDES AN ACCOUNT CREDIT.
05/15/23
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
This Spectrum Policy consists of the Declarations, Coverage Forms, Common Policy Conditions and any other Forms and Endorsements issued to be a part of the Policy. This insurance is provided by the stock insurance company of The Hartford Insurance Group shown below.
INSURER:
COMPANY CODE:
Policy Number:
SPECTRUM POLICY DECLARATIONS
Named Insured and Mailing Address:
(No., Street, Town, State, Zip Code)
Policy Period: From To 12:01 a.m., Standard time at your mailing address shown above. Exception: 12 noon in New Hampshire.
Name of Agent/Broker:
Code:
Previous Policy Number:
Named Insured is:
Audit Period:
Type of Property Coverage:
Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy, we agree with you to provide insurance as stated in this policy.
TOTAL ANNUAL PREMIUM IS:
Countersigned by Authorized Representative Date
002 (CONTINUED ON NEXT PAGE)
59 SBA PI1952
001 001
9215 E PRESERVE WAY
SCOTTSDALE AZ 85262
Janitorial Services - Commercial
$ 500 PER OCCURRENCE
NO COVERAGE
$ 8,100
NO COVERAGE
MONEY AND SECURITIES
INSIDE THE PREMISES
OUTSIDE THE PREMISES
$ 10,000 $ 5,000
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER:
Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premises as designated by Number below.
Location: Building:
Description of Business:
Deductible:
BUILDING AND BUSINESS PERSONAL PROPERTY LIMITS OF INSURANCE
BUILDING
BUSINESS PERSONAL PROPERTY
REPLACEMENT COST
PERSONAL PROPERTY OF OTHERS
REPLACEMENT COST
003 (CONTINUED ON NEXT PAGE)
59 SBA PI1952
001 001
JANITORIAL SERVICES STRETCH
FORM: SS 04 67
THIS FORM INCLUDES MANY ADDITIONAL
COVERAGES AND EXTENSIONS OF
COVERAGES. A SUMMARY OF THE
COVERAGE LIMITS IS ATTACHED.
LIMITED FUNGI, BACTERIA OR VIRUS
COVERAGE:
FORM SS 40 93
THIS IS THE MAXIMUM AMOUNT OF
INSURANCE FOR THIS COVERAGE,
SUBJECT TO ALL PROPERTY LIMITS
FOUND ELSEWHERE ON THIS
DECLARATION.
INCLUDING BUSINESS INCOME AND EXTRA
EXPENSE COVERAGE FOR:
$ 50,000
30 DAYS
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER:
Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premises as designated by Number below.
Location: Building:
PROPERTY OPTIONAL COVERAGES APPLICABLE LIMITS OF INSURANCE
TO THIS LOCATION
004 (CONTINUED ON NEXT PAGE)
59 SBA PI1952
BUSINESS INCOME AND EXTRA EXPENSE
COVERAGE
COVERAGE INCLUDES THE FOLLOWING
COVERAGE EXTENSIONS:
ACTION OF CIVIL AUTHORITY:
EXTENDED BUSINESS INCOME:
EQUIPMENT BREAKDOWN COVERAGE
COVERAGE FOR DIRECT PHYSICAL LOSS
DUE TO:
MECHANICAL BREAKDOWN,
ARTIFICIALLY GENERATED CURRENT
AND STEAM EXPLOSION
THIS ADDITIONAL COVERAGE INCLUDES
THE FOLLOWING EXTENSIONS
HAZARDOUS SUBSTANCES
EXPEDITING EXPENSES
MECHANICAL BREAKDOWN COVERAGE ONLY
APPLIES WHEN BUILDING OR BUSINESS
PERSONAL PROPERTY IS SELECTED ON
THE POLICY
IDENTITY RECOVERY COVERAGE
FORM SS 41 12
COMPUTERS AND MEDIA COVERAGE
FORM SS 04 41
DEDUCTIBLE: $ 1,000
12 MONTHS ACTUAL LOSS SUSTAINED
30 DAYS
30 CONSECUTIVE DAYS
$ 50,000 $ 50,000
$ 15,000
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER:
PROPERTY OPTIONAL COVERAGES APPLICABLE LIMITS OF INSURANCE
TO ALL LOCATIONS
$1,000,000
$ 10,000
$1,000,000
$1,000,000
$2,000,000
$2,000,000
FORM SS 09 01
$ 10,000
NOT APPLICABLE
$ 10,000
06292013
$1,000,000
BUSINESS LIABILITY OPTIONAL
COVERAGES
HIRED/NON-OWNED AUTO LIABILITY
UMBRELLA LIABILITY - SEE
SCHEDULE ATTACHED
005 (CONTINUED ON NEXT PAGE)
06/29/2405/15/23
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER:
BUSINESS LIABILITY LIMITS OF INSURANCE
LIABILITY AND MEDICAL EXPENSES
MEDICAL EXPENSES - ANY ONE PERSON
PERSONAL AND ADVERTISING INJURY
DAMAGES TO PREMISES RENTED TO YOU
ANY ONE PREMISES
AGGREGATE LIMITS
PRODUCTS-COMPLETED OPERATIONS
GENERAL AGGREGATE
EMPLOYMENT PRACTICES LIABILITY
COVERAGE:
EACH CLAIM LIMIT
DEDUCTIBLE - EACH CLAIM LIMIT
AGGREGATE LIMIT
RETROACTIVE DATE:
This Employment Practices Liability Coverage contains claims made coverage. Except as may be otherwise provided herein, specified coverages of this insurance are limited generally to liability for injuries for which claims are first made against the insured while the insurance is in force. Please read and review the insurance carefully and discuss the coverage with your Hartford Agent or Broker.
The Limits of Insurance stated in this Declarations will be reduced, and may be completely exhausted, by the payment of "defense expense" and, in such event, The Company will not be obligated to pay any further "defense expense" or sums which the insured is or may become legally obligated to pay as "damages".
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
006 (CONTINUED ON NEXT PAGE)
59 SBA PI1952
WAIVER OF SUBROGATION:
FORM SS 12 15
LOCATION: 001 BUILDING: 001
SEE FORM IH 12 00
CYBERFLEX COVERAGE
FORM SS 40 26
UNMANNED AIRCRAFT LIABILITY
IS EXCLUDED
SEE FORM: SS 42 06
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER:
BUSINESS LIABILITY OPTIONAL COVERAGES LIMITS OF INSURANCE
(Continued)
007 (CONTINUED ON NEXT PAGE)
59 SBA PI1952
LOCATION 001 BUILDING 001
TYPE PERSON ORGANIZATION
NAME SEE FORM IH 12 00
TYPE LEASED EQUIPMENT
NAME SEE FORM IH 12 00
TYPE OWNER, LESSEES OR CONTRACTORS
NAME SEE FORM IH 12 00
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER:
ADDITIONAL INSUREDS: THE FOLLOWING ARE ADDITIONAL INSUREDS FOR BUSINESS
LIABILITY COVERAGE IN THIS POLICY.
59 SBA PI1952
SS 00 01 03 14 SS 00 05 10 08 SS 00 07 07 05 SS 00 08 04 05
SS 00 38 04 04 SS 00 60 09 15 SS 00 61 07 19 SS 00 64 09 16
SS 84 09 09 07 SS 41 70 06 11 SS 41 71 12 19 SS 01 54 06 21
SS 42 06 03 17 SS 04 19 04 09 SS 04 22 07 05 SS 04 24 10 09
SS 04 26 03 00 SS 04 30 07 05 SS 04 33 04 05 SS 04 38 09 09
SS 04 39 07 05 SS 04 41 03 18 SS 04 42 03 17 SS 04 44 07 05
SS 04 45 07 05 SS 04 46 09 14 SS 04 47 04 09 SS 04 67 09 07
SS 04 80 03 00 SS 04 86 03 00 SS 40 18 07 05 SS 40 26 03 17
SS 40 93 07 05 SS 41 12 06 22 SS 41 51 10 09 SS 41 63 06 11
IH 10 01 09 86 SS 05 47 09 15 SS 50 04 06 04 SS 50 57 04 05
SS 51 11 03 17 SS 05 71 04 05 IH 12 05 02 21 SS 09 01 12 14
SS 09 03 12 14 SS 09 67 09 14 SS 09 70 12 14 SS 09 71 12 14
SS 12 15 03 00 IH 99 40 04 09 IH 99 41 04 09 SX 80 01 06 97
SS 83 76 12 20 SS 89 93 07 16 SS 12 23 06 11
IH 12 00 11 85 ADDITIONAL INSURED - PERSON-ORGANIZATION
IH 12 00 11 85 WAIVER OF SUBROGATION
IH 12 00 11 85 ADDITIONAL INSURED - VENDOR
IH 12 00 11 85 ADDITIONAL INSURED - OWNER, LESSEES OR CONTRACTOR
IH 12 00 11 85 ADDITIONAL INSURED - LEASED EQUIPMENT
Form SS 00 02 12 06 Page Process Date: Policy Expiration Date:
SPECTRUM POLICY DECLARATIONS (Continued)
POLICY NUMBER:
Form Numbers of Forms and Endorsements that apply:
001 (CONTINUED ON NEXT PAGE)
59 SBA PI1952
LOC/BLDG NO: 001/001 TERR: 024
LOCATION: 9215 E PRESERVE WAY
SCOTTSDALE AZ 85262
CLASSIFICATION CODE NUMBER 73451
DESCRIPTION:
Janitorial Services - Commercial
COVERAGE DESCRIPTION: PREMISES/OPERATIONS COVERAGE
REFER TO: BUSINESS LIABILITY COVERAGE PART FORM SS 00 08
RATING BASIS: PAYROLL PER 1000
EXPOSURE: 104,743
FINAL RATE: 26.388
ADVANCE PREMIUM: $2,764.00
COVERAGE DESCRIPTION: PRODUCTS/COMPLETED OPERATIONS COVERAGE
REFER TO: BUSINESS LIABILITY COVERAGE PART FORM SS 00 08
RATING BASIS: PAYROLL PER 1000
EXPOSURE: 104,743
FINAL RATE: 12.220
ADVANCE PREMIUM: $1,280.00
COVERAGE DESCRIPTION: BUSINESS INCOME & EXTRA EXPENSE - ACTUAL LOSS
SUSTAINED
REFER TO: SPECIAL PROPERTY COVERAGE PART FORM SS 00 07
RATING BASIS: PAYROLL PER 1000
EXPOSURE: 104,743
FINAL RATE: 0.143
ADVANCE PREMIUM: $15.00
Form SS 00 38 04 04T Page Process Date: Policy Expiration Date:
Spectrum Supplemental Schedule of Auditable Coverages
This schedule reflects only those locations that have classes and/or coverages that are subject to audit.
Policy Number:
Entries herein, except as specifically provided elsewhere in this policy, do not modify any of the other provisions of this policy.
59 SBA PI1952
TOTAL ADVANCE PREMIUM $4,059.00 DOES NOT INCLUDE TERRORISM OR
FOR AUDITABLE COVERAGES ANY APPLICABLE STATE SURCHARGES OR FEES OR
MINIMUM PREMIUMS
Form SS 00 38 04 04T Page Process Date: Policy Expiration Date:
Spectrum Supplemental Schedule of Auditable Coverages (Continued)
Policy Number:
Form SS 84 09 09 07 Page 1 of 2 © 2007, The Hartford
JANITORIAL SERVICES STRETCH SUMMARY
SUMMARY OF COVERAGE LIMITS
This is a summary of the Coverages and the Limits of Insurance provided by the Janitorial Services Stretch Coverage form SS 04 67 which is included in this policy. No coverage is provided by this summary. Refer to coverage form SS 04 67 to determine the scope of your insurance protection.
The Limit of Insurance for the following Additional Coverages are in addition to any other limit of insurance provided under this policy:
Coverage Limit Accounts Receivable – On/Off-Premises $ 25,000 Brands and Labels Up to Business Personal Property Limit Claims Expense $ 10,000 Computer Fraud $ 5,000 Computers and Media $ 50,000 Contractors Equipment $10,000 /$500 Min per Item Contractors Tools $1,000 /$500 Max per Item Debris Removal $ 25,000 Employee Dishonesty (including ERISA) $ 25,000 Fine Arts $ 10,000 Forgery $ 25,000 Laptop Computers – Worldwide Coverage $ 5,000 Lost Keys $ 25,000 Off Premises Service – Direct Damage $ 25,000 Outdoor Signs Full Value Pairs and Sets Up to Business Personal Property Limit Personal Property of Others $ 25,000 Property at Other Premises $ 10,000 Salespersons’ Samples $ 10,000 Sewer and Drain Back Up Included up to Covered Property Limits Sump Overflow or Sump Pump Failure $ 15,000 Temperature Change $ 25,000 Tenant Building and Business Personal Property Coverage - Required by Lease
$20,000
Transit Property in the Care of Carriers for Hire $ 10,000 Unauthorized Business Card Use $ 2,500 Valuable Papers and Records – On/Off-Premises $ 50,000
The Limits of Insurance for the following Coverage Extensions are a replacement of the Limit of Insurance provided under the Standard Property Coverage Form or the Special Property Coverage Form, whichever applies to the policy:
Coverage Limit Newly Acquired or Constructed Property – 180 Days
Building $1,000,000 Business Personal Property $ 500,000 Business Income and Extra Expense $ 500,000
Outdoor Property $ 20,000 aggregate/ $1,000 per item Personal Effects $ 35,000 Property Off-Premises $ 15,000
Page 2 of 2 Form SS 84 09 09 07
The following changes apply only if Business Income and Extra Expense are covered under this policy. The Limits of Insurance for the following Business Income and Extra Expense Coverages are in addition to any other Limit of Insurance provided under this policy:
Coverage Limit Business Income Extension for Off-Premises Utility Services $ 25,000 Business Income Extension for Web Sites $ 10,000/7 days Business Income from Dependent Properties $ 25,000
The following Limit of Insurance for the following Business Income Coverage is a replacement of the Limit of Insurance provided under the Standard Property Coverage Form or the Special Property Coverage Form, whichever applies to the policy:
Coverage Limit Extended Business Income 60 Days
The following changes apply to Loss Payment Conditions:
Coverage Limit Valuation Changes
Commodity Stock Included "Finished Stock" Included Mercantile Stock - Sold Included
The following changes apply only if Business Liability Coverage is covered under this policy:
Coverage Limit Damage To Property (Care, Custody or Control Exception) Included in Business Liability Limit Extended Property Damage Coverage $25,000
THE CITY OF CORINTH
3300 CORINTH PKWY, DENTON TX 76208
POLICY NUMBER:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Form SS 41 70 06 11 Process Date:
Policy Expiration Date:
© 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission)
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Location(s) Of Covered Operations:
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section C. – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to "bodily injury" or "property damage" occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or
2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.
ARIZONA GAME AND FISH
5000 W CAREFREE HIGHWAY PHOENIX, AZ 85086
POLICY NUMBER:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Form SS 41 70 06 11 Process Date:
Policy Expiration Date:
© 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission)
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Location(s) Of Covered Operations:
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section C. – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to "bodily injury" or "property damage" occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or
2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor
KELLERMEYER BERGENSONS SERVICES, LLC
3605 OCEAN RANCH BOULEVARD, SUITE 200 OCEANSIDE, CA 92056
POLICY NUMBER:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Form SS 41 70 06 11 Process Date:
Policy Expiration Date:
© 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission)
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Location(s) Of Covered Operations:
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section C. – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to "bodily injury" or "property damage" occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or
2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor
THE CITY OF CORINTH
3300 CORINTH PKWY, DENTON TX 76208
59 SBA PI1952
05/15/23 06/29/24
POLICY NUMBER :
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Location And Description Of Completed Operations:
Section C. – Who Is An Insured is amended to include the following:
a. The person(s) or organization(s) shown in the Schedule on the Declarations is also an additional insured, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" and at the location designated and described in the Location And Description Of Completed Operations Schedule in the Declarations performed for that additional insured and included in the "products-completed operations hazard".
b. With respect to the insurance afforded to these additional insureds, this insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including:
(1) The preparing, approving, editing of or failure to prepare or approve, shop drawings, maps, opinions, reports, surveys, change orders, field orders, designs, drawings, specifications, warnings, recommendations, permit applications, payment requests, manuals or instructions;
(2) Supervisory, inspection, quality control, architectural, engineering or surveying activities or services;
(3) Maintenance of job site safety, construction administration, construction contracting, construction management, computer consulting or design software development or programming service, or selection of a contractor or programming service;
(4) Monitoring, sampling, or testing service necessary to perform any of the services included in (1), (2) or (3) above;
(5) Supervision, hiring, employment, training or monitoring of others who are performing any of the services included in (1), (2) or (3) above;
c. The insurance afforded to these additional insureds only applies to the extent permitted by law.
Form SS 41 71 12 19 Page 1 of 1 Process Date: Policy Expiration Date:
© 2019, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission)
ARIZONA GAME AND FISH
5000 W CAREFREE HIGHWAY PHOENIX, AZ 85086
59 SBA PI1952
05/15/23 06/29/24
POLICY NUMBER :
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Location And Description Of Completed Operations:
Section C. – Who Is An Insured is amended to include the following:
a. The person(s) or organization(s) shown in the Schedule on the Declarations is also an additional insured, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" and at the location designated and described in the Location And Description Of Completed Operations Schedule in the Declarations performed for that additional insured and included in the "products-completed operations hazard".
b. With respect to the insurance afforded to these additional insureds, this insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including:
(1) The preparing, approving, editing of or failure to prepare or approve, shop drawings, maps, opinions, reports, surveys, change orders, field orders, designs, drawings, specifications, warnings, recommendations, permit applications, payment requests, manuals or instructions;
(2) Supervisory, inspection, quality control, architectural, engineering or surveying activities or services;
(3) Maintenance of job site safety, construction administration, construction contracting, construction management, computer consulting or design software development or programming service, or selection of a contractor or programming service;
(4) Monitoring, sampling, or testing service necessary to perform any of the services included in (1), (2) or (3) above;
(5) Supervision, hiring, employment, training or monitoring of others who are performing any of the services included in (1), (2) or (3) above;
c. The insurance afforded to these additional insureds only applies to the extent permitted by law.
Form SS 41 71 12 19 Page 1 of 1 Process Date: Policy Expiration Date:
KELLERMEYER BERGENSONS SERVICES, LLC
3605 OCEAN RANCH BOULEVARD, SUITE 200 OCEANSIDE, CA 92056
59 SBA PI1952
05/15/23 06/29/24
POLICY NUMBER :
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
BUSINESS LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Location And Description Of Completed Operations:
Section C. – Who Is An Insured is amended to include the following:
a. The person(s) or organization(s) shown in the Schedule on the Declarations is also an additional insured, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" and at the location designated and described in the Location And Description Of Completed Operations Schedule in the Declarations performed for that additional insured and included in the "products-completed operations hazard".
b. With respect to the insurance afforded to these additional insureds, this insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including:
(1) The preparing, approving, editing of or failure to prepare or approve, shop drawings, maps, opinions, reports, surveys, change orders, field orders, designs, drawings, specifications, warnings, recommendations, permit applications, payment requests, manuals or instructions;
(2) Supervisory, inspection, quality control, architectural, engineering or surveying activities or services;
(3) Maintenance of job site safety, construction administration, construction contracting, construction management, computer consulting or design software development or programming service, or selection of a contractor or programming service;
(4) Monitoring, sampling, or testing service necessary to perform any of the services included in (1), (2) or (3) above;
(5) Supervision, hiring, employment, training or monitoring of others who are performing any of the services included in (1), (2) or (3) above;
c. The insurance afforded to these additional insureds only applies to the extent permitted by law.
Form SS 41 71 12 19 Page 1 of 1 Process Date: Policy Expiration Date:
COMMON POLICY CONDITIONS
Form SS 00 05 10 08 © 2008, The Hartford
QUICK REFERENCE - SPECTRUM POLICY
DECLARATIONS
and
COMMON POLICY CONDITIONS
Form SS 00 05 10 08
I. DECLARATIONS
Named Insured and Mailing Address Policy Period Description and Business Location Coverages and Limits of Insurance
II. COMMON POLICY CONDITIONS Beginning on Page
A. Cancellation 1
B. Changes 1
C. Concealment, Misrepresentation Or Fraud 2
D. Examination Of Your Books And Records 2
E. Inspections And Surveys 2
F. Insurance Under Two Or More Coverages 2
G. Liberalization 2
H. Other Insurance - Property Coverage 2
I. Premiums 2
J. Transfer Of Rights Of Recovery Against Others To Us 2
K. Transfer Of Your Rights And Duties Under This Policy 3
L. Premium Audit 3
All coverages of this policy are subject to the following conditions.
A. Cancellation
1. The first Named Insured shown in the Declarations may cancel this policy by mailing or delivering to us advance written notice of cancellation.
2. We may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least:
a. 5 days before the effective date of cancellation if any one of the following conditions exists at any building that is Covered Property in this policy:
(1) The building has been vacant or unoccupied 60 or more consecutive days. This does not apply to:
(a) Seasonal unoccupancy; or
(b) Buildings in the course of construction, renovation or addition.
Buildings with 65% or more of the rental units or floor area vacant or unoccupied are considered unoccupied under this provision.
(2) After damage by a Covered Cause of Loss, permanent repairs to the building:
(a) Have not started; and
(b) Have not been contracted for, within 30 days of initial payment of loss.
(3) The building has:
(a) An outstanding order to vacate;
(b) An outstanding demolition order; or
(c) Been declared unsafe by governmental authority.
(4) Fixed and salvageable items have been or are being removed from the building and are not being replaced.
This does not apply to such removal that is necessary or incidental to any renovation or remodeling.
(5) Failure to:
(a) Furnish necessary heat, water, sewer service or electricity for 30 consecutive days or more, except during a period of seasonal unoccupancy; or
(b) Pay property taxes that are owing and have been outstanding for more than one year following the date due, except that this provision will not apply where you are in a bona fide dispute with the taxing authority regarding payment of such taxes.
b. 10 days before the effective date of cancellation if we cancel for nonpayment of premium.
c. 30 days before the effective date of cancellation if we cancel for any other reason.
3. We will mail or deliver our notice to the first Named Insured's last mailing address known to us.
4. Notice of cancellation will state the effective date of cancellation. The policy period will end on that date.
5. If this policy is canceled, we will send the first Named Insured any premium…
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