APPROVED PL_11.23.2021 - 11.23.2022.pdf

WWC3bZ~ CERTIFICATE OF LIABILITY INSURANCE 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) ~

PRODUCER NAMF" PATRI CK CORAY

LIA ADMINISTRATORS 8 INSURANCE A/C No Ext:805 963 6624 A/c No 805-962-0652 SERVICES ADDREss: PATRICK L IAB I L I TY.COM

PO BOX 1319 INSURER(S) AFFORDING COVERAGE NAIC ¹

SANTA BARBARA, CA 93102-1319 INsURFR A. CAPITOL SPECIALTY INSURANCE

INSURED INSURER B:

SIGNVALUE, INC. INSURER C:

925 S. GILBERT RD., STE. 203 INSURER D:

MESA, AZ 85204 INSURER E:

INSURER F:

COVE RAG ES CERTIFICATE NUMBER: REVIS ION NUM BER:

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.

INSR ADDL SUBR POLICY EFF POLICY EXP

LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS

COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 8

DAMAGE TO RENTED

CLAIMS-MADE OCCUR PREMISES Ea occurrence

MED EXP (Any one person) 8

PERSONAL 8 ADV INJURY 8

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 8

POLICY ~ JFCT ~ LOC

~ PRO-

PRODUCTS - COMP/OP AGG 8

OTHER: 8

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 8Ea accident

ANY AUTO BODILY INJURY (Per person) 8

BODILY INJURY (Per accident) 8

HIRED NON-ON/NED PROPERTY DAMAGE

AUTOS ONLY AUTOS ONLY Per accident

UMBRELLA LIAB OCCUR EACH OCCURRENCE 8

EXCESS LIAB CLAIMS-MADE AGGREGATE 8

DED RETENTION 8 8

WORKERS COMPENSATION PER OTH-

AND EMPLOYERS'IABILITY Y/N

STATUTE ER

ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT 8

OFFICER/MEMBER EXCLUDED? N/A

(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE 8 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 8

A PROFESSIONAL LIABILITY SGC0010580-03 11/23/202111/23/202 $2,000,000 EACH C AIM

$2,000,000 AGGRE ATE

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

EVIDENCE OF INSURANCE IS PROVIDED TO BELOW LISTED CERTIFICATE HOLDER.

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

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

STATE OF ARIZONA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ARIZONA DEPARTMENT OF TRANSPORTATION

1739 W. JACKSON ST., SUITE A MD 100P

PHOENIX, AZ 85007

1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

ACCEPTED

ADOT Risk Management