Arizona_Department_of_Environmental_Quality_120_Water__Inc._25-26_GL_AUTO_EXCESS_PROF_6-26-2025.pdf
PDF 1 MB Posted
- Attached to
- Master Agreement AZ|CTR065767
- Contract number
- CTR065767
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance for 120 Water, Inc., issued by Alliant Insurance Services, Inc. in Boston, MA, with primary coverage from Homeland Insurance Company and Cincinnati Insurance Company. The certificate is specifically for a contract with the Arizona Department of Environmental Quality (ADEQ) located in Phoenix, AZ, with policy number CTR065767.
The insurance coverage includes Commercial General Liability, Automobile Liability, Umbrella Liability, and Professional Liability with various policy limits. Specifically, the policy provides $1,000,000 per occurrence for general liability, $5,000,000 in umbrella liability, and $1,000,000 each for Professional Liability and Contractors Pollution Liability. The policies are effective from 6/30/2025 to 6/30/2026, with additional insured provisions and waivers of subrogation. The automobile policy includes a $1,000,000 Combined Single Limit for bodily injury and property damage, covering additional interests, hired and non-owned vehicles, and includes blanket waiver of subrogation.
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Text version
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A :
NAIC #
NAME:
CONTACT
(A/C, No):
FAX
ADDRESS:
PRODUCER
(A/C, No, Ext):
PHONE
INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
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).
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.
OTHER:
(Per accident)
(Ea accident)
N / A
SUBR
WVD
ADDL
INSD
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.
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOSAUTOS ONLY
NON-OWNED
SCHEDULEDOWNED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-
STATUTE
PER
LIMITS(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
OCCUR
CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE
DAMAGE TO RENTED
$PREMISES (Ea occurrence)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY
PRO-
JECT LOC
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
6/26/2025
Alliant Insurance Services, Inc.
125 High St. Ste. 2205 Boston MA 02110
Paulina Lipinski
Paulina.Lipinski@alliant.com
License#: 0C36861 Homeland Insurance Company of 34452 Cincinnati Insurance Company 10677
120 Water, Inc.
P.O. Box 604 Zionsville IN 46077-0604
805677896
A X 1,000,000 X 100,000
10,000
1,000,000
2,000,000 X
Y Y 793-01-34-30-0001 6/30/2025 6/30/2026
2,000,000
B 1,000,000
X X
Y Y EBA 0499915 6/7/2025 6/30/2026
A X 5,000,000 X
793-01-34-31-0001 6/30/2025 6/30/2026
5,000,000
A A
Professional Liability Contractors Pollution Liability
793-01-34-30-0001 793-01-34-30-0001
6/30/2025 6/30/2025
6/30/2026 6/30/2026
Per Occur/Aggreg Each Poll Condition Subject to Policy Agg
$1,000,000 $1,000,000 $2,000,000
Contract # CTR065767
See the attached endorsements/policy forms for applicable requirements
Arizona Department of Environmental Quality 1110 W. Washington Street Phoenix AZ 85007
AA 4172 09 09
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF SUBROGATION - AUTO
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
This endorsement changes the policy effective on the inception date of the policy unless another date is indi-cated below.
Endorsement Effective: Policy Number:
Named Insured:
Countersigned by:
(Authorized Representative)
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.
1. Blanket Waiver of Subrogation
SECTION IV - BUSINESS AUTO CONDI-
TIONS, A. Loss Conditions, 5. Transfer of Rights of Recovery Against Others to Us is amended by the addition of the following:
We waive any right of recovery we may have against any person or organization because of payments we make for "bodily injury" or "prop-erty damage" arising out of the operation of a covered "auto" when you have assumed liabil-ity for such "bodily injury" or "property damage" under an "insured contract", provided the "bod-ily injury" or "property damage" occurs subse-quent to the execution of the "insured con-tract".
06-07-2025 EBA 049 99 15
120 WATER AUDIT, INC.
AUTOMOBILE SCHEDULE
ITEM
Attached to and forming a part of Policy Number , effective
The insurance afforded for any automobile is only with respects to such and so many of the coverages as are indicated by specific premium charge or charges indicated.
POLICY LIMITS
State:
Bodily Injury: Property Damage:
THREE
EBA 049 99 15 06-07-2025
IN
1,000,000 CSL INCLUDED
Veh.
No. Vehicle Information
Class: Territory Coll Ded:
BI PD MP OTC COLL UM
ADDITIONAL INTEREST - ADDITIONAL INSURED BY CONTRACT
OTC-COMP DED: N/A N/A
336 INCL
TOTAL
Class: Territory Coll Ded:
BI PD MP OTC COLL UM
ADDITIONAL INTEREST - DESIGNATED PERSON OR ORGANIZATION
OTC-COMP DED: N/A N/A
25 INCL
TOTAL
Class: Territory Coll Ded:
BI PD MP OTC COLL UM
BLANKET WAIVER OF SUBROGATION
OTC-COMP DED: N/A N/A
150 INCL
TOTAL
Class: Territory Coll Ded:
BI PD MP OTC COLL UM
HIRED AND NON-OWNED
OTC-COMP DED: N/A N/A
222 INCL N/A
TOTAL
Class: Territory Coll Ded:
BI PD MP OTC COLL UM
NONCONTRIBUTORY INSURANCE
OTC-COMP DED: N/A N/A
100 INCL
TOTAL
AA 4183 02 06 Page of 1 2 plipinski Highlight
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