ACORD_Forms.pdf

5/22/2024

First International Insurance 6025 W Chandler Blvd

Chandler AZ 85226

Sheri Anderson 701-757-6503 sanderson@firstintlins.com

Independence Low Vision LLC 632 E Silver Fox Way

Phoenix AZ 85048-0189

Fidelity & Guaranty Insurance Co 35386 Progressive Sentinel Insurance Company, LTD 11000 Travelers Burns & Wilcox

CL2412618746

A

X

X

X

X Optometrists/Opticians

X BIP2S009159 10/15/2023 10/15/2024

2,000,000

300,000

5,000

2,000,000

4,000,000

4,000,000

Professional Liability -INCL-

B X 978706068 03/14/2024 03/14/2025

1,000,000

Medical payments 5,000

C Y

59WECAT0APA 6/24/2024 6/24/2025

X

1,000,000

1,000,000

1,000,000

D Cyber Liability 0107527498 10/15/2023 10/15/2024 Occurrence $1,000,000/Aggregate $2,000,000

E Abuse & Molestation Coverage B0621PELIZ001924 01/26/2024 01/26/2025 Limit/Deductible $5,000 $500,000

State of Nevada is included as an additional insured with respects to general liability arising out of the activities performed by, or on behalf of the Contractor and State of Nevada. We hereby waive our right of subrogation against the certificate holder because of payment we may under the workers compensation only when required by written contract.

There is no specific coverage exclusion included in the policy for abuse or molestation coverage. Limits are up to the General Liability policy coverage limits.

State of Nevada, Purchasing Division 515 E Musser St Suite 300 Carson City, NV 89701 purchasinginsurance@admin.nv.gov

Terrie Kolker/MIRIAH

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)

Empl Practices Liab Ins EPL-1

100,000 2,500

RLECR RLECR

25,000

DEENC DEENC

XNUCL XNUCL

Total Pollution Exclusion XPOLU

Waiver of Subrogation WVSUB

$250.00

Expense constant EXCNT

$1.00

Expense constant EXCNT

$160.00

Increased employer's liability INEL

$3.00

Additional Prem to Equal Inc Limits AILMP

$117.00

ADDITIONAL COVERAGES

Ref # Description Edition DateForm No.Coverage Code

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

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