APPROVED CTR054974 WC 07.01.22-07.01.23.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

Jeff Jones

Tucson

Jeff Jones Farmers Insurance

Jeff Jones Insurance Agency 520-885-5700

03/22/2023

520-885-1163 jjones19@farmersagent.com 7613 E Speedway Blvd

AZ 85710-8832

TUCSON

Truck Insurance Exchange 21709

Farmers Insurance Exchange 21652

SOUTHWEST APPRAISAL ASSOCIATES, INC

Mid Century Insurance Company 21687

PO BOX 16156

AZ 85732

A

2,000,000

1,000,000

10,000

Y 2,000,000

4,000,000

Y 602144225 05/01/2022 05/01/2023

2,000,000

A

2,000,000

Y Y 602144225 05/01/2023

B

1,000,000

Y Y 602788115 05/01/2022 05/01/2023

C Y Y B15078329

1,000,000

1,000,000

1,000,000

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

ADOT contract # CTR054974-2

STATE OF ARIZONA

ARIZONA DEPT OF TRANSPORTATION

1324 N 22ND AVE MD 128A

PHOENIX AZ 85009

05/01/2022

07/01/202307/01/2022

ACCEPTED – WC Only

ADOT Risk Management

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

Effective Date Policy Number

This endorsement modifies insurance provided under the following:

BUSINESSOWNERS COMMON POLICY CONDITIONS - BP 00 09

SCHEDULE

Name of Person or Organization:

(If no entry appears above, information required to complete this Endorsement must be shown in the Declarations as applicable to this endorsement.)

The provisions of the Businessowners Common Policy Conditions are modified by this endorsement as follows:

Condition K. Transfer Of Rights Of Recovery Against Others To Us in the Businessowners Common Policy Conditions is amended by the addition of the following:

3. We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your work done under a contract with that person or organization and included in the products-completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above.

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.

E3306-ED1 6-97 Includes Copyrighted Material of Insurance Services Office, Inc., with its permission. Page 1 of 1 91-3306 E3306101

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

E3306 1st Edition

602144225

STATE OF ARIZONA ARIZONA DEPT OF TRANSPORTATION

03/22/2023