APPROVED 05.17.2021 - 05.17.2022.pdf

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):

E-MAIL

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

72SBAAL7V78 05/17/202105/17/2022

AAI010085-02 04/22/202104/22/2022 $2,000,000 EACH CLAIM

$2,000,000 AGGREGATE

PROFESSIONAL LIABILITYB

A

A

05/18/2021

REAL ESTATE APRPAISERS / SALESPERSONS PROFESSIONAL AND COMMERCIAL GENERAL LIABILITY INSURANCE STATE OF ARIZONA AND ARIZONA DEPARTMENT OF TRANSPORTATION ARE NAMED AS ADDITIONAL INSURED WITH

RESPECTS TOTHE COMMERCIAL GENERAL LIABILITY POLICY

FOR ANY AND ALL WORK PERFORMED IN ADOT'S RIGHT-OF-WAY

72SBAAL7V78 05/17/202105/17/2022

XX

10,000

1,000,000

1,000,000 1,000,000

1,000,000

2,000,000 2,000,000

X X

STATE OF ARIZONA AND/OR

ARIZONA DEPARTMENT OF TRANSPORTATION

C/O ADOT PROCUREMENT OFFICE

1739 W JACKSON MODULAR A MAILDROP: 100P

PHOENIX AZ 85007

SOUTHWESTERN AG SERVICES, LLC

PO BOX 1857

HIGLEY, AZ 85236

ID# 170596

X

ASPEN AMERICAN INSURANCE COMPANY

HARTFORD UNDERWRITERS INS. CO.

LIA ADMINISTRATORS & INSURANCE

SERVICES

PO BOX 1319

SANTA BARBARA, CA 93102-1319 30104

43460

Y

Y Y

Y

Y

DANA DAMICO

805-963-6624 805-962-0652

DANA@LIABILITY.COM

DocuSign Envelope ID: E2E1E30A-2D2F-4BA3-8594-1DFBB1824BC2DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

ACCEPTED

ADOT Risk Management

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Form SL 30 32 10 18 Page 1 of 3 © 2018, The Hartford

(May include copyrighted material of Insurance Services Office, Inc., with its permission)

BLANKET ADDITIONAL INSURED BY CONTRACT

This endorsement modifies insurance provided under the following:

BUSINESS LIABILITY COVERAGE FORM

Except as otherwise stated in this endorsement, the terms and conditions of the Policy apply.

A. The following is added to Section C. WHO IS AN INSURED:

Additional Insureds When Required By Written Contract, Written Agreement Or Permit The person(s) or organization(s) identified in Paragraphs a. through f. below are additional insureds when you have agreed, in a written contract or written agreement, or when required by a written permit issued by a state or governmental agency or subdivision or political subdivision that such person or organization be added as an additional insured on your Coverage Part, provided the injury or damage occurs subsequent to the execution of the contract or agreement, or the issuance of the permit.

A person or organization is an additional insured under this provision only for that period of time required by the contract, agreement or permit.

However, no such person or organization is an additional insured under this provision if such person or organization is included as an additional insured by any other endorsement issued by us and made a part of this Coverage Part.

The insurance afforded to such additional insured will not be broader than that which you are required by the contract, agreement, or permit to provide for such additional insured.

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

The limits of insurance that apply to additional insureds are described in Section D. LIABILITY AND MEDICAL EXPENSES LIMITS OF INSURANCE. How this insurance applies when other insurance is available to an additional insured is described in the Other Insurance Condition in Section E. LIABILITY AND MEDICAL EXPENSES

GENERAL CONDITIONS.

a. Vendors

Any person(s) or organization(s) (referred to below as vendor), but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business and only if this Coverage Part provides coverage for "bodily injury" or "property damage" included within the "products-completed operations hazard".

(1) The insurance afforded to the vendor is subject to the following additional exclusions:

This insurance does not apply to:

(a) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement;

(b) Any express warranty unauthorized by you;

(c) Any physical or chemical change in the product made intentionally by the vendor;

(d) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container;

(e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products;

(f) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product;

(g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or

Policy # 72SBAAL7V78DocuSign Envelope ID: E2E1E30A-2D2F-4BA3-8594-1DFBB1824BC2DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

Form SL 30 32 10 18 Page 2 of 3 © 2018, The Hartford

(May include copyrighted material of Insurance Services Office, Inc., with its permission)

(h) "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to:

(i) The exceptions contained in Paragraphs (d) or (f); or

(ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products.

(2) This insurance does not apply to any insured person or organization from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products.

b. Lessors Of Equipment

(1) Any person or organization from whom you lease equipment; but only with respect to their liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization.

(2) With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after you cease to lease that equipment.

c. Lessors Of Land Or Premises

(1) Any person or organization from whom you lease land or premises, but only with respect to liability arising out of the ownership, maintenance or use of that part of the land or premises leased to you.

(2) With respect to the insurance afforded to these additional insureds, this insurance does not apply to:

(a) Any "occurrence" which takes place after you cease to lease that land or be a tenant in that premises; or

(b) Structural alterations, new construction or demolition operations performed by or on behalf of such person or organization.

d. Architects, Engineers Or Surveyors

(1) Any architect, engineer, or surveyor, 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:

(a) In connection with your premises; or

(b) In the performance of your ongoing operations performed by you or on your behalf.

(2) With respect to the insurance afforded to these additional insureds, the following additional exclusion applies:

(a) 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 services, including:

(i) The preparing, approving, or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders, designs or drawings and specifications; or

(ii) Supervisory, surveying, inspection, architectural or engineering activities.

This exclusion applies even if the claims allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by an insured, if the “bodily injury”, “property damage”, or “personal and advertising injury” arises out of the rendering of or the failure to render any professional service.

(b) This insurance does not apply to "bodily injury" or "property damage" included within the "products-completed operations hazard”.

e. State Or Governmental Agency Or Subdivision Or Political Subdivision Issuing Permit

(1) Any state or governmental agency or subdivision or political subdivision, but only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit.

(2) With respect to the insurance afforded to these additional insureds, this insurance does not apply to:

(a) "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or

DocuSign Envelope ID: E2E1E30A-2D2F-4BA3-8594-1DFBB1824BC2DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

Form SL 30 32 10 18 Page 3 of 3 © 2018, The Hartford

(May include copyrighted material of Insurance Services Office, Inc., with its permission)

(b) "Bodily injury" or "property damage" included within the "products-completed operations hazard".

f. Any Other Party

(1) Any other person or organization who is not in one of the categories or classes listed above in Paragraphs a.

through e. above, 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:

(a) In the performance of your ongoing operations performed by you or on your behalf;

(b) In connection with your premises owned by or rented to you; or

(c) In connection with "your work" and included within the "products-completed operations hazard", but only if:

(i) The written contract, written agreement or permit requires you to provide such coverage to such additional insured; and

(ii) This Coverage Part provides coverage for "bodily injury" or "property damage" included within the

"products-completed operations hazard".

(2) With respect to the insurance afforded to these additional insureds, the following additional exclusion applies:

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:

(a) The preparing, approving, or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders, designs or drawings and specifications; or

(b) Supervisory, surveying, inspection, architectural or engineering activities.

This exclusion applies even if the claims allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by an insured, if the “bodily injury”, “property damage”, or “personal and advertising injury” arises out of the rendering of or the failure to render any professional service described in Paragraphs f.(2)(a) or f.(2)(b) above.

DocuSign Envelope ID: E2E1E30A-2D2F-4BA3-8594-1DFBB1824BC2DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

Form SL 00 00 10 18 Page 18 of 22 © 2018, The Hartford

(May include copyrighted material of Insurance Services Office, Inc., with its permission)

If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer’s share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers.

7. Transfer Of Rights Of Recovery Against Others To Us

a. Transfer Of Rights Of Recovery

If the insured has rights to recover all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. This condition does not apply to Medical Expenses Coverage.

b. Waiver Of Rights Of Recovery (Waiver Of Subrogation) If the insured has waived any rights of recovery against any person or organization for all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, we also waive that right, provided the insured waived their rights of recovery against such person or organization in a contract, agreement or permit that was executed prior to the injury or damage.

F. LIABILITY AND MEDICAL EXPENSES DEFINITIONS

1. "Advertisement" means a notice that is broadcast or published to the general public or specific market segments about your goods, products or services for the purpose of attracting customers or supporters. For the purpose of this definition:

a. Notices that are published include material placed on the Internet or on similar electronic means of communication; and

b. Regarding web sites, only that part of a web site that is about your goods, products or services for the purpose of attracting customers or supporters is considered an advertisement.

2. "Advertising idea" means any idea for an "advertisement".

3. "Asbestos hazard" means an exposure or threat of exposure to the actual or alleged properties of asbestos and includes the mere presence of asbestos in any form.

4. "Auto" means:

a. A land motor vehicle, trailer or semi-trailer designed for travel on public roads, including any attached machinery or equipment; or

b. Any other land vehicle that is subject to a compulsory or financial responsibility law or other motor vehicle insurance or motor vehicle registration law where it is licensed or principally garaged.

However, "auto" does not include "mobile equipment".

5. "Bodily injury" means physical:

a. Injury;

b. Sickness; or

c. Disease sustained by a person and, if arising out of the above, mental anguish or death at any time.

6. "Coverage territory" means:

a. The United States of America (including its territories and possessions), Puerto Rico and Canada;

b. International waters or airspace, but only if the injury or damage occurs in the course of travel or transportation between any places included in a. above;

c. All other parts of the world if the injury or damage arises out of:

(1) Goods or products made or sold by you in the territory described in a. above;

(2) The activities of a person whose home is in the territory described in a. above, but is away for a short time on your business; or

Policy # 72SBAAL7V78

DocuSign Envelope ID: E2E1E30A-2D2F-4BA3-8594-1DFBB1824BC2DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

Form SL 00 00 10 18 Page 17 of 22 © 2018, The Hartford

(May include copyrighted material of Insurance Services Office, Inc., with its permission)

(2) Premises Rented To You That is fire, lightning or explosion insurance for premises rented to you or temporarily occupied by you with permission of the owner;

(3) Tenant Liability That is insurance purchased by you to cover your liability as a tenant for "property damage" to premises rented to you or temporarily occupied by you with permission of the owner;

(4) Aircraft, Auto Or Watercraft If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of Section B. Exclusions.

(5) Property Damage To Borrowed Equipment Or Use Of Elevators If the loss arises out of "property damage" to borrowed equipment or the use of elevators to the extent not subject to Exclusion k. of Section B. Exclusions.

(6) When You Are Added As An Additional Insured To Other Insurance That is other insurance available to you covering liability for damages arising out of the premises or operations, or products and completed operations, for which you have been added as an additional insured by that insurance; or

(7) When You Add Others As An Additional Insured To This Insurance That is other insurance available to an additional insured.

However, the following provisions apply to other insurance available to any person or organization who is an additional insured under this Coverage Part:

(a) Primary Insurance When Required By Contract

This insurance is primary if you have agreed in a written contract, written agreement or permit that this insurance be primary. If other insurance is also primary, we will share with all that other insurance by the method described in c. below.

(b) Primary And Non-Contributory To Other Insurance When Required By Contract If you have agreed in a written contract, written agreement or permit that this insurance is primary and non-contributory with the additional insured's own insurance, this insurance is primary and we will not seek contribution from that other insurance.

Paragraphs (a) and (b) do not apply to other insurance to which the additional insured has been added as an additional insured.

When this insurance is excess, we will have no duty under this Coverage Part to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers.

When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of:

(1) The total amount that all such other insurance would pay for the loss in the absence of this insurance;

and

(2) The total of all deductible and self-insured amounts under all that other insurance.

We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part.

c. Method Of Sharing If all the other insurance permits contribution by equal shares, we will follow this method also. Under this approach, each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first.

Policy # 72SBAAL7V78

DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

WORKERS’ COMPENSATION WAIVER

SOLE PROPRIETOR / INDEPENDENT CONTRACTOR

Revised 08.13.18

THIS FORM IS APPROVED FOR ADOT USE ONLY. IT IS NOT INTENDED FOR USE BY EMPLOYERS IN

THE CONSTRUCTION INDUSTRY THAT USE A CONTRACTOR.

This is a written agreement under the compulsory Workers' Compensation laws of the State of Arizona, A.R.S. § 23-901 (et. seq.), A.R.S. § 23-902 (C), (D), and A.R.S. § 23-961(M) that a “sole proprietor” or “independent contractor” relationship exists between the Arizona Department of Transportation (ADOT) and the “sole proprietor” or “independent contractor” signed below, here in after referred to together as the parties. The parties agree that the “sole proprietor” or “independent contractor" is independent of the "ADOT" in the execution of the work and not subject to the rule or control of the "ADOT" but is engaged only in the performance of a definite job or piece of work and is subordinate to the "ADOT" only in effecting a result in accordance with the "ADOT" design(s). The parties also agree that the "ADOT" does not have the authority to supervise or control the actual work of the "sole proprietor” or “independent contractor" or the "independent contractor's" employees. Furthermore, it is understood and agreed that the “sole proprietor”, “independent contractor” or the "independent contractor's" employees are not entitled to workers' compensation benefits from the "ADOT”.

I am a “sole proprietor” or “independent contractor”. I am performing work as an independent contractor for the “ADOT” and therefore, for workers' compensation purposes, I am not entitled to workers' compensation benefits from the “ADOT”.

I understand that if I have any employees working for me, I must maintain workers' compensation insurance on them.

The written agreement shall be null and void and create no presumption of a “sole proprietor’ or “independent contractor” relationship if the consent of either party is obtained through misrepresentation, false statements, fraud or intimidation, coercion or duress.

DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

WORKERS’ COMPENSATION WAIVER

SOLE PROPRIETOR / INDEPENDENT CONTRACTOR

Revised 08.13.18

I THE UNDERSIGNED AGREE THAT THE "ADOT":

• Does not require the independent contractor to perform work exclusively for the business. This paragraph shall not be construed as conclusive evidence that an individual who performs services primarily or exclusively for another person is an employee of that person.

• Does not provide the independent contractor with any business registrations or licenses required to perform the specific services set forth in the contract.

• Does not pay the independent contractor a salary or hourly rate instead of an amount fixed by contract.

• Will not terminate the independent contractor before the expiration of the contract period, unless the independent contractor breaches the contract, violates the laws of this state, or funds are not appropriated or allocated for the fulfillment of the contract.

• Does not provide tools to the independent contractor.

• Does not dictate the time of performance.

• Pays the independent contractor in the name appearing on the written agreement.

• Will not combine business operations with the person performing the services rather than maintaining these operations separately.

NAME OF SOLE PROPRIETOR/

INDEPENDENT CONTRACTOR: ____________________________________________________________

STREET ADDRESS / P.O. BOX: _______________________________________________________

CITY: __________________________________, STATE: ____________ ZIP: __________

SIGNATURE OF

SOLE PROPIETOR/

INDEPENDENT CONTRACTOR: __________________________________ DATE: ___________

ADOT CONTRACTING DIVISION: __________________________________________________

SIGNATURE OF ADOT

CONTRACT ADMINISTRATOR: __________________________________________________

CONTRACT IDENTIFICATION: __________________________________________________

ADOT Risk Management:

Southwestern Ag Services, LLC

PO Box 1857

Higley AZ 85236

5/24/21

Digitally signed by Steven D Pendleton DN: cn=Steven D Pendleton, o=Southwestern Ag Services, ou, email=steve@swaservices.com, c=US Date: 2021.05.24 15:18:31 -07'00'

DocuSign Envelope ID: 4EE7B659-CCE8-4937-9E5E-B126DA4CD1C6

CTR054975

Arizona Department of Transportation-Procurement

ACCEPTED

ADOT Risk Management