Arizona_Department_COI_18386208_BPM004541__Base_Liab_.pdf

Endorsement Effective

Countersigned by

Policy No.

Premium $Insured

Insurance Company

Endorsement No.

All other terms and conditions of this policy remain unchanged.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

TO DESIGNATED PERSONS OR ORGANIZATIONS

NOTICE OF CANCELLATION

POLICY NUMBER:

ENDORSEMENT WC 99 06 R3 (00) -

EMPLOYERS LIABILITY POLICY

AND

WORKERS COMPENSATION

Notice Of Cancellation To Designated Persons Or Organizations

Name and Address of Designated Persons or Organizations: Number of Days Notice

The following is added to PART SIX – CONDITIONS :

SCHEDULE

If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organiza-tion before the cancellation is to take effect.

You are responsible for providing us with the information necessary to accurately complete the Schedule below.

If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation.

ONE TOWER SQUARE

UB-9R137340-22-I3-G

HARTFORD CT 06183 007

DEPARTMENTS, AGENCIES, BOARDS,

100 N 15TH AVENUE

PHOENIX AZ 85007

STATE OF ARIZONA, AND ITS

Page ofDATE OF ISSUE: ST ASSIGN:

© 2013 The Travelers Indemnity Company. All rights reserved.

10-06-22 11

COMMERC GENERAL L ITYIAL IABIL

POLICY : ISSUE D :NUMBER ATE

This endorsement i ies insurance pro ided under t folmod f v he lowing:

COMMERC GENERAL L ITY VERA P RTIAL IABIL CO GE A

SCHEDULE

Name of Perso or izati :n Organ on

(I no entry appears above required to comp th endorsement will be shown in the Declarationsf lete is as applicable is endorsement.)to th

A. Sectio – Who Is An n is a to such work, on the projec (other than semended t r-include as an insured the person or v ce, ma or repairs) to be per-i intenance shown in the Schedule, but only with respect to by or on behal o the f f liab li f your ongoing operations per- insured(s) at the site o the co ered op-i ty arising out o f v for ed for i sured. erations has been completed;m that n or

B. (2)respect to the insurance to these That o "your out o whichf f additiona insureds, the fol wing is the injury or arises has been putl lo added: to its in use by any person or tended ganization other than another contractor2. Exclusions or subcontractor engaged in

This insurance does not apply to in- operations for a princ as a part of theipal same project.

(1) Al work, includ parts orl ing equipment f in connect withurnished ion

CG 20 10 10 01 Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

© ISO Properties Inc., 2000

, information exclusion

II Insured organization

With

"bodily jury" or "property damage" occurring after:

materials, performing damage portion or-additionalformed afforded work"

POLICY NUMBER: GENERAL PURPOSE ENDORSEMENT

PageIL T8 05 1

CHANGE EFFECTIVE DATE: 10-01-22

CHANGE ENDORSEMENT NUMBER: 0016

POLICY NUMBER: ISSUE DATE:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED PERSON OR ORGANIZATION – NOTICE OF

CANCELLATION PROVIDED BY US

This endorsement modifies insurance provided under the following:

ALL COVERAGE PARTS INCLUDED IN THIS POLICY

CANCELLATION:

SCHEDULE

Number of Days Notice:

PERSON OR

ORGANIZATION:

PROVISIONS

IL T4 05 05 19 © 2019 The Travelers Indemnity Company. All rights reserved. Page 1 of 1

If we cancel this policy for any legally permitted reason other than nonpayment of premium, and a number of days is shown for Cancellation in the Schedule above, we will mail notice of cancellation to the person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for Cancellation in such Schedule before the effective date of cancellation.

10-06-22

STATE OF ARIZONA, AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS,

UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES

100 N 15TH AVENUE

PHOENIX, AZ 85007

ADDRESS:

H-810-9P782425-TIL-22

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED PERSON OR ORGANIZATION – NOTICE OF

CANCELLATION PROVIDED BY US

This endorsement modifies insurance provided under the following:

ALL COVERAGE PARTS INCLUDED IN THIS POLICY

SCHEDULE

CANCELLATION: Number of Days Notice:

PERSON OR

ORGANIZATION:

ADDRESS:

PROVISIONS

If we cancel this policy for any legally permitted reason other than nonpayment of premium, and a number of days is shown for Cancellation in the Schedule above, we will mail notice of cancellation to the person or organization shown in such Schedule. We will mail such notice to the address shown in the Schedule above at least the number of days shown for Cancellation in such Schedule before the effective date of cancellation.

IL T4 05 05 19 © 2019 The Travelers Indemnity Company. All rights reserved. Page 1 of 1

POLICY NUMBER: ISSUE DATE: