AZ_State_Parks_ACORD_Form_20230316-132726_Southern.pdf

03/16/2023

Banasky Insurance Inc 891 Baxter Drive

South Jordan UT 84095

Kristi Lawson

(801) 748-1009 (801) 748-0782 kristi@banasky.com

KP Ventures Well Drilling and Pump Company LLC KP Equipment Investments, LLC P.O. Box 2411 Cottonwood AZ 86326

The Phoenix Insurance Company 25623 The Charter Oak Fire Insurance Company 25615 Travelers Property Casualty Company of America 25674 Westchester Surplus Lines Ins Co 10172

2022*2023

A Contractual Liability

Leased/Rented Equipment

DT-CO-8P076521-PHX-22 04/11/2022 04/11/2023

1,000,000 500,000 10,000 1,000,000 2,000,000 2,000,000

Limit/Deductible 500,000/2,500

B 810-0N229275-22-26-G 04/11/2022 04/11/2023

1,000,000

Medical payments 5,000

C 10,000

CUP-8K406789-22-26 04/11/2022 04/11/2023

5,000,000 5,000,000

B N UB-3R811852-22-26-G 04/11/2022 04/11/2023

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

D Pollution Liability

G71129780 005 04/11/2022 04/11/2023 Per Occurrence Limit 1,000,000 Aggregate Limit 2,000,000 Deductible 5,000

RE: CONTRACT NO. CTR054550

Arizona State Parks and Trails Procurement Services 23751 North 23rd Ave., Ste 190

Phoenix AZ 85085

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

E-MAIL

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

KP Equipment Investments, LLC

KP Property Investments, LLC

Additional Named Insureds

Other Named Insureds

OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC

Uninsured motorist combined single limit UMCSL

1,000,000

Underinsured motorist combined single limit UNCSL

1,000,000

ADDITIONAL COVERAGES

Ref # Description Edition DateForm No.Coverage Code

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Copyright 2001, AMS Services, Inc.OFADTLCV

Stephanie Holland Typewritten text 04-06-2022

Stephanie Holland

DT-CO-8P076521-PHX-22

DT-CO-8P076521-PHX-22

Stephanie Holland

POLICY NUMBER:

POLICY NUMBER:

Stephanie Holland

DT-CO-8P076521-PHX-22

04-06-2022

Stephanie Holland

UB-3R811852-22-26-G

810-0N229275-22-26-G

Stephanie Holland

POLICY NUMBER: