CERT-186039463.pdf
PDF 5 MB Posted
- Attached to
- Master Agreement AZ|CTR055333
- Contract number
- CTR055333
- Issued by
- Arizona
About this file
This document is a comprehensive insurance certificate and policy endorsement package for DBA Construction, Inc., issued by Commercial West Insurance Agency and primarily underwritten by Phoenix Insurance Company, Travelers Property Casualty Company, and other insurers. The policy provides coverage for the State of Arizona and the Arizona Game and Fish Department, with the contract renewal identified as CTR55333, effective from January 1, 2024 to January 1, 2025.
The insurance coverage includes commercial general liability, automobile liability, umbrella liability, workers' compensation, pollution liability, and builder's risk policies. Key policy limits include $1,000,000 for general liability, $10,000,000 for umbrella liability, and $1,000,000 for workers' compensation. Additional specific coverages include a $750,000 limit for leased and rented equipment, a $5,000,000 pollution liability policy, and a blanket builder's risk policy. The policy provides additional insured status to the State of Arizona and the Arizona Game and Fish Department where required by written contract, with comprehensive coverage for potential risks associated with construction and related operations.
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The ACORD name and logo are registered marks of ACORD
CERTIFICATE HOLDER
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
AUTHORIZED REPRESENTATIVE
CANCELLATION
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE
LOCJECT
PRO-POLICY
GEN'L AGGREGATE LIMIT APPLIES PER:
OCCURCLAIMS-MADE
COMMERCIAL GENERAL LIABILITY
PREMISES (Ea occurrence) $
DAMAGE TO RENTED
EACH OCCURRENCE $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$RETENTIONDED
CLAIMS-MADE
OCCUR
AGGREGATE $
EACH OCCURRENCE $UMBRELLA LIAB
EXCESS LIAB
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
INSR
LTR TYPE OF INSURANCE POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
PER
STATUTE
OTH-
ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
ANY PROPRIETOR/PARTNER/EXECUTIVE
If yes, describe under DESCRIPTION OF OPERATIONS below
(Mandatory in NH)
OFFICER/MEMBER EXCLUDED?
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
HIRED AUTOS
NON-OWNED
AUTOS AUTOS
AUTOS
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE $
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.
INSD
ADDL
WVD
SUBR
N / A
(Ea accident)
(Per accident)
OTHER:
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 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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INSURED
PHONE
(A/C, No, Ext):
PRODUCER
ADDRESS:
FAX
(A/C, No):
CONTACT
NAME:
NAIC #
INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
INSURER(S) AFFORDING COVERAGE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
12/28/2023
Commercial West Insurance Agency 2152 South Vineyard, Suite 107 Mesa AZ 85210
Lori Spelde 480-961-5400 480-961-5401
Lori@trycwi.com
Phoenix Insurance Company 25623 DBACO-1 Travelers Property Casualty Co 25674
DBA Construction, Inc.
P.O. Box 63035 Phoenix AZ 85082-3035
Travelers Casualty & Surety 31194 Continental Casualty Co. 20443 Westchester Surplus Lines Ins 10172
186039463
A X 1,000,000 X 300,000
5,000
1,000,000
2,000,000
X
Y Y DT-CO-9D586889-PHX-24 1/1/2024 1/1/2025
2,000,000
B 1,000,000 X
Y Y 810-2L968980-24-26-G 1/1/2024 1/1/2025
B X X 10,000,000CUP-0K482811-24-26
10,000,000
1/1/2024 1/1/2025
C
N
Y UB-9J634648-24-26-G 1/1/2024 1/1/2025 X
1,000,000
1,000,000
1,000,000 D E
Leased & Rented Equipment Pollution Liability
6079982568 G70963620004
1/1/2024 1/1/2024
1/1/2025 1/1/2025
Limit/Deductible Limit/Ded
750,000/1,000 5,000,000/10,000
Work Comp applies to all states excluding monopolistic - ND, OH, WA, WY *Blanket Builder's Risk Policy #6079982568|Contienental Casualty Company| Effective 01/01/2024 to 01/01/2025 $1,000,000 Policy Limit* *Motor Truck Legal Liability #6079982568|Continenental Casualty Company| Effective 01/01/2024 to 01/01/2025 $500,000 All Vehicles-Any One Loss* RE: Contract Renewal CTR55333. State of Arizona and the Arizona Game and Fish Department are additional insured where required by written contract.
Arizona Game & Fish Department 5000 W. Carefree Hwy Phoenix AZ 85086 lspelde.comme53 Highlight lspelde.comme53_1 lspelde.comme53_2 lspelde.comme53_3
ENDORSEMENT WC 00 03 13 (00) -
POLICY NUMBER:
EMPLOYERS LIABILITY POLICY
AND
WORKERS COMPENSATION
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
ONE TOWER SQUARE
HARTFORD CT 06183
UB-9J634648-22-26-G
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule.
SCHEDULE
DESIGNATED ORGANIZATION:
DESIGNATED PERSON:
ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED
BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS
WAIVER.
INCLUDING:
THE STATE OF ARIZONA, ARIZONA DEPARTMENT OF TRANSPORTATION,
ITS DEPARTMENTS, ITS OFFICERS, OFFICIALS, AGENTS AND
EMPLOYEES.
DATE OF ISSUE: PAGEST ASSIGN: OF01-03-22 1 101/01/2024
UB-9J634648-24-26-G
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