APPROVED CTR054972 WC 01.01.22-01.01.23.pdf
PDF 272 KB Posted
- Attached to
- Master Agreement AZ|CTR054972
- Contract number
- CTR054972
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance and Workers Compensation Policy issued by CopperPoint Insurance Companies for Sell & Associates Inc, with the Arizona Department of Transportation (ADOT) as the certificate holder. The policy covers Real Estate Appraisal and Valuation Services statewide, with an effective period from 01/01/2022 to 01/01/2023. The insurance includes workers compensation coverage with a state waiver for the State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents, and employees.
The policy provides workers compensation and employers liability insurance with statutory limits of $1,000,000 for each accident, each employee, and policy limit for disease. The total estimated annual premium is $1,022, with endorsements that include a waiver of subrogation rights for the State of Arizona. The job number CTR054972 is associated with statewide real estate appraisal and valuation services, specifically noted as "8721 - AZ - REAL ESTATE APPRAISAL CO-OUTSIDE EMP" in the document description.
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Text version
ACCEPTED
ADOT Risk Management
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
WC 00 03 13
(Ed. 4-84)
© 1983 National Council on Compensation Insurance.
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us).
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule State Blanket/Schedule/State
AZ STATE
State Waiver: State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
01/01/2022Endorsement Effective 1010128Policy No. 20Endorsement No.
Sell & Associates IncInsured 100 Premium $
CopperPoint Insurance CompanyInsurance Company Countersigned by
This document may have been uploaded to the CopperPoint Portal.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B
(Version 7/01)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
01/01/2022Endorsement Effective 1010128Policy No. 21Endorsement No.
Sell & Associates IncInsured $100Premium Cost Change
CopperPoint Insurance CompanyInsurance Company Countersigned by
This document may have been uploaded to the CopperPoint Portal.
WC 89 06 00 B
(Version 7/01)
© Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved.
POLICY INFORMATION PAGE ENDORSEMENT
The following item(s)
Insured’s Name (WC 89 06 01) Expiration Date (WC 89 06 04) Insured’s Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer’s Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured’s Legal Status (WC 89 06 10) Item 3.A. States (WC 89 06 11)
Item 3.B. Limits (WC 89 06 12) Item 3 .C. States (WC 89 06 13)
✔ Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4.* Class, Rate, Other (WC 89 04 15)
✔ Interim Adjustment of Premium (WC 89 04 16) Interstate/Intrastate Risk ID Number (WC 89 06 18) Issuing Agency/Producer Office Address (WC 89 06 25)
Is changed to read:
Total Estimated Annual Premium: $1,022
File details come from the government source that posted it. Updated .