APPROVED 05.01.2021 - 05.01.2022.pdf

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

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 certifi cate 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 certifi cate does not confer rights to the certifi cate holder in lieu of such endorsement(s).

PRODUCER CONTACT

NAME:

PHONE

(A/C, NO, EXT):

FAX

(A/C, NO):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

INSURED INSURER A:

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 NAME 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

ADDTL

INSD

SUBR

WVD

POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

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 PROJECT LOC PRODUCTS - COMP/OP AGG $

OTHER: $

AUTOMOBILE LIABILITY

COMBINED SINGLE LIMIT

(Ea accident)

ANY AUTO BODILY INJURY (Per person) $

OWNED AUTOS

ONLY

SCHEDULED

AUTOS

BODILY INJURY (Per accident) $

HIRED AUTOS

ONLY

NON-OWNED

AUTOS ONLY

PROPERTY DAMAGE

(Per accident)

UMBRELLA LIAB OCCUR EACH OCCURRENCE $

EXCESS LIAB CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

WORKERS COMPENSATION

AND EMPLOYERS ‘ LIABILITY

N/A

PER

STATUTE

OTHER $

ANY PROPRIETOR/PARTNER/

EXECUTIVE OFFICER/MEMBER

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

Y/N E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

E.L. DISEASE - POLICY LIMIT $

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

CERTIFICATE HOLDER CANCELLATION

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

The ACORD name and logo are registered marks of ACORD

ACORD 25 (2016/03)

31-1769 11-15

Randy Jones

Tucson

Randy Jones Farmers Insurance

Randy Jones Insurance Agency Inc 520-885-5700

05/11/2021

520-885-1163 rjones1@farmersagent.com 7613 E Speedway Blvd

AZ 85710-8832

TUCSON

Truck Insurance Exchange 21709

Farmers Insurance Exchange 21652

SOUTHWEST APPRAISAL ASSOCIATES

Mid Century Insurance Company 21687

PO BOX 16156

AZ 85732

A

2,000,000

75,000

5,000

Y 2,000,000

4,000,000

Y 602144225 05/01/2021 05/01/2022

2,000,000

A

2,000,000

Y Y 602144225 05/01/2022

B

1,000,000

Y Y 602788115 05/01/2021 05/01/2022

B Y Y B15078329

1,000,000

1,000,000

1,000,000

Contract # CTR054974 and for any and all work performed in ADOT’s right-of-way

Arizona Department of Transportation

State Procurement Office

1739 W Jackson St. Ste A, MD 100P

PHOENIX AZ 85007

05/01/2021

07/01/202207/01/2021

ACCEPTED

ADOT Risk Management

Randy Jones

07/01/2020

Southwest Appraisal Associates

Truck Insurance Exchange

State of Arizona

Truck Insurance Exchange

Southwest Appraisal Associates

07/01/2021

Randy Jones

State of Arizona

10/30/12 60214-42-25

ARIZONA DEPT OF TRANSPORTATION PROCUREMENT GROUP SEE E0002

ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

BUSINESSOWNERS LIABILITY COVERAGE FORM

BUSINESSOWNERS COVERAGE FORM

APARTMENTOWNERS LIABILITY COVERAGE FORM

CONDOMINIUM LIABILITY COVERAGE FORM

SCHEDULE

A. The following is added to Paragraph C. Who Is An Insured of the applicable Coverage Form:

Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your ongoing operations or in connection with your premises owned by or rented to you.

However:

a. The insurance afforded to such additional insured only applies to the extent permitted by law; and

b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Paragraph D. Liability And Medical Expenses Limits Of Insurance of the applicable Coverage Form:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits Of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits Of Insurance shown in the Declarations.

Name Of Additional Insured Person(s) Or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

J7238-ED1 02-19 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 937238 J7238101

POLICY NUMBER: J7238

1st Edition

This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all the terms of the policy.

602144225

STATE OF ARIZONA ARIZONA DEPT OF TRANSPORTATION

ACCEPTED

ADOT Risk Management