APPROVED WC ONLY 04.08.22-04.08.23.pdf

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

INSURER(S) AFFORDING COVERAGE NAIC #

PRODUCER

INSURED

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

COVERAGES

TYPE OF INSURANCE POLICY NUMBER LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

LOCPOLICY

OTHER:

EACH OCCURRENCE

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

AUTOMOBILE LIABILITY

ANY AUTO

OCCUR

CLAIMS-MADE

DED RETENTION $

EACH OCCURRENCE

AGGREGATE

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

Y/N

CONTACT

NAME:

PHONE

(A/C, No, Ext):

E-MAIL

ADDRESS:

FAX

(A/C, No):

CERTIFICATE NUMBER: REVISION NUMBER:

UMBRELLA LIAB

EXCESS LIAB

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

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

INSURER F :

N/A

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

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

LTR

ADDL

INSD

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

PRO-

JECT

DAMAGE TO RENTED

PREMISES (Ea occurrence)

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident)

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

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

PER

STATUTE

OTH-

ER

SUBR

WVD

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).

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

03/15/2022

AUTOMATIC DATA PROCESSING INSURANCE AGCY INC

1 ADP BLVD MS 625

ROSELAND, NJ 07068

(877) 677-0428

(877) 677-0428 (877) 677-0430 spcbicadp@travelers.com

KEEN INDEPENDENT RESEARCH LLC

100 FILLMORE ST. 5TH FL.

DENVER, CO 80206

THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT

954047113451960

A X UB-9M740535-22 04/08/2022 04/08/2023 X

1,000,000 1,000,000 1,000,000

AS RESPECTS TO WORKERS COMPENSATION COVERAGE, WC 00 03 13 (00), WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS HAS BEEN ATTACHED TO THE POLICY IN REGARD TO THE STATE OF ARIZONA OR ADOT.

THE STATE OF ARIZONA OR ADOT

1324 N. 22ND AVE

PHOENIX, AZ 85009

a8812 Accepted

ENDORSEMENT WC 00 03 13 (00) -

POLICY NUMBER:

EMPLOYERS LIABILITY POLICY

AND

WORKERS COMPENSATION

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

ONE TOWER SQUARE

HARTFORD CT 06183

UB-9M740535-22-42-G

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 any one not named in the Schedule.

SCHEDULE

DESIGNATED ORGANIZATION:

DESIGNATED PERSON:

ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED

BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS

WAIVER.

INCLUDING:

THE STATE OF ARIZONA OR ADOT, 1324 N. 22ND AVE., PHOENIX, AZ

85009

DATE OF ISSUE: PAGEST ASSIGN: OF02-25-22 1 1