ADOAStateProcurementOffice_StateofArizona_W36358679__1_.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

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

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2016 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Willis Towers Watson Northeast, Inc.

c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA

Matheson Tri-Gas, Inc.

3 Mountainview Road, 3rd Floor Warren, NJ 07059

RE: ADSPO17-00007105

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are included as Additional Insureds as respects to General Liability and Automobile Liability.

General Liability policy shall be Primary and Non-contributory with any other insurance in force for or which may be

ADOA - State Procurement Office | State of Arizona Attn: Margie Silva 100 North 15th Avenue Suite 201 Phoenix, AZ 85007

11/25/2024

1-877-945-7378 1-888-467-2378 certificates@willis.com

Tokio Marine Specialty Insurance Company 23850

National Union Fire Insurance Company of P

AIU Insurance Company

19445

19399

W36358679

A

1,000,000

1,000,000

10,000

1,000,000

10,000,000

5,000,000

Y Y GLS 4300661-02 12/01/2024 12/01/2025

SIR 2,000,000

B

1,000,000

10/01/202510/01/2024Y Y 7620253

14111834 C Y

1,000,000 No 10/01/2024 10/01/2025

1,000,000

1,000,000

371773026813392SR ID: BATCH:

Willis Towers Watson Certificate Center

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

Matheson Tri-Gas, Inc.

3 Mountainview Road, 3rd Floor Warren, NJ 07059 purchased by Additional Insureds.

Waiver of Subrogation applies in favor of Additional Insureds with respects to General Liability, Automobile Liability and Workers Compensation, as permitted by law.

Coverage for Contractual Liability and Broad Form Property damage is provided under General Liability policy.

2 2

Willis Towers Watson Northeast, Inc.

See Page 1

See Page 1 See Page 1 See Page 1

25 Certificate of Liability Insurance

W36358679CERT:3717730BATCH:26813392SR ID:

10.0.2.20120224.1.869952

c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA

3 Mountainview Road, 3rd Floor Warren, NJ 07059

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are included as Additional Insureds as respects to General Liability and Automobile Liability.

General Liability policy shall be Primary and Non-contributory with any other insurance in force for or which may be

INSURED:

ADOA - State Procurement Office | State of Arizona Attn: Margie Silva 100 North 15th Avenue Suite 201 Phoenix, AZ 85007