BUILDING_DREAMS_REVISED_COI_RR_12132024.pdf
PDF 17 KB Posted
- Attached to
- Master Agreement AZ|CTR077297
- Contract number
- CTR077297
- Issued by
- Arizona
About this file
This document is an ACORD Certificate of Liability Insurance for Building Dreams LLC, located in Phoenix, Arizona. The insurance is provided by Liberty State Insurance (DBA Copper Silver Insurance) and involves multiple insurers including Hartford Insurance Company, United Financial/Progressive, and Travelers. The certificate is issued for the Child Welfare Licensing Unit / Office of Licensing and Regulation at the Department of Child Safety, with the certificate dated 12/13/2024.
The insurance coverage includes Commercial General Liability with a $1,000,000 each occurrence limit, $2,000,000 general aggregate, and $25,000 property damage. Automobile liability is also included, covering scheduled and non-owned autos. Workers' Compensation is provided with $1,000,000 limits for each accident and disease. The policy includes additional coverage for Sexual Abuse/Molestation and Professional Liability, with a $1,000,000/$3,000,000 limit. The policies are effective from 09/23/2024 to 09/23/2025, with a waiver of subrogation applying to Commercial General Liability and Workers Compensation policies. The Department of Child Safety is listed as an additional insured with a 30-day notice requirement for any material changes or cancellation.
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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
12/13/2024
Liberty State insurance DBA: Copper Silver insurance PHX 27035 N 35th Ave
Phoenix AZ 85083
Gavin Michael Moritomo 623-587-5750 mike@csivegas.insure
Building Dreams LLC 1415 E Baseline Rd
Phoenix AZ 85042
Hartford Insurance Company United Financial / Progressive Travelers
A
A 59SBARV6705-000 09/23/2024 09/23/2025
1,000,000 500,000 1,000,000 2,000,000 2,000,000
Property 25,000
B ✖ B 00591221-0 09/23/2024 09/23/2025
1,000,000
INCL
INCL
INCL
C Y WCV066282801 09/23/2024 09/23/2025
1,000,000 1,000,000 1,000,000
A
SEXUAL ABUSE/MOLESTATION
PROFESSIONAL LIABILITY A 59SBARV6705-000 09/23/2024 09/23/2025
500,000 1,000,000 /3000000
WAIVER OF SUBROGATION APPLIES TO COMMERCIAL GENERAL LIABILITY AND WORKERS COMPENSATION POLICIES. DEPARTMENT OF CHILD SAFETY ARE LISTED AS ADDITIONAL INSUREDS. 30 DAY NOTICE OF MATERIAL CHANGE, NON RENEWAL, OR CANCELLATION APPLIES. SEXUAL ABUSE AND MOLESTATION IS INCLUDED AND
NOT EXCLUDED.
Ashley Lawrence
AND REGULATION. DEPARTMENT OF CHILD SAFETY
3003 N CENTRAL AVEUE
PHOENIX AZ 85012
CHILD WELFARE LICENSING UNIT / OFFICE OF LICENSING
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