ADOA_WC_COI_22-23.pdf

This document is an ACORD Certificate of Liability Insurance issued by Marsh Affinity, a division of Marsh USA LLC, on behalf of New Hampshire Insurance Co. The certificate involves ADP TotalSource CO XXIII, Inc. and Safe Site Utility Services, LLC, with the Arizona Department of Administration listed as the certificate holder. The insurance policy covers worksite employees of Safe Site Utility Services, LLC who are paid under ADP TotalSource, Inc.'s payroll.

The Workers' Compensation insurance policy (Policy Number WC 053416556 AZ) is effective from 07/01/2022 to 07/01/2023, with coverage limits of $2,000,000 for each accident, disease per employee, and disease policy limit. The document includes a Waiver of Subrogation in favor of the certificate holder for jobs performed by Safe Site Utility Services, LLC, as required by written contract. The policy is specifically for worksite employees in Arizona, with the insured locations being 5800 Windward Parkway in Alpharetta, GA, and 7623 N 73rd Dr in Glendale, AZ.