Arizona_-_Icom_America_Certificates_of_Insurance_25MAR18.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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 any rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

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

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Federal Insurance Company

Lloyd's of London

12/10/2024

USI Insurance Services NW CL 601 Union Street, Suite 1000 Seattle, WA 98101

Sheliah Massoth 206 441-6300 610-362-8530 sheliah.massoth@usi.com

Icom America, Inc.

12421 Willows Rd. NE Kirkland, WA 98034

20281

SURPLU

A X X

X

X X 57624957 12/01/2024 12/01/2025 1,000,000 1,000,000 15,000 1,000,000 2,000,000

EXCLUDED

A X

X X

73647206 12/01/2024 12/01/2025 1,000,000

A X X X X 56725842 12/01/2024 12/01/2025 4,000,000 4,000,000

A

N

71842545 12/01/2024 12/01/2025 X 1,000,000

1,000,000 1,000,000

B TECH E&O

CYBER LIABILITY

TRICE2377 12/01/2024 12/01/2025 $5,000,000 PER CLAIM

$5,000,000 AGGREGATE

$250,000 RETENTION

RE: Contract #CTR046821 The State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are named as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Insured. Waiver of Subrogation applies in favor of The State of Arizona as required by written agreement. 60 days' notice of cancellation will be provided for reasons other than nonpayment; 10 days' notice of cancellation will be provided for nonpayment of premium.

State of Arizona 100 North Fifteenth Avenue, Suite 402 Phoenix, AZ 85007-0000

#S47285898/M47284538

ICOMAMEClient#: 1537116

MLKZP

#S47285898/M47284538