Certificate_of_Insurance_12.1.2024.pdf

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)

© 1988-2016 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Willis Towers Watson Northeast, Inc.

c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA

General Parts, LLC 11311 Hampshire Ave S Bloomington, MN 55438

SEE ATTACHED

Arizona Department of Economic Security Office of Procurement 1789 W. Jefferson St, Site Code 805Z Phoenix, AZ 85007

11/22/2023

1-877-945-7378 1-888-467-2378 certificates@willis.com

Arch Insurance Company 11150

Travelers Property Casualty Company of Ame

Arch Indemnity Insurance Company

25674

30830

W31158787

A

1,000,000

1,000,000

5,000

5,000,000

5,000,000

5,000,000

Y 11GPP1080600 12/01/2023 12/01/2024

A

5,000,000

12/01/202412/01/2023Y 11CAB1080600

B 10,000,000

10,000

CUP-3X981000-23-NF 12/01/2023 12/01/2024 10,000,000

11WCI1080600

A 1,000,000

12/01/2023 12/01/2024 1,000,000

1,000,000

C Workers Compensation and

Employers Liability

E.L. EACH ACCIDENT14WCI1080700 12/01/2023 12/01/2024

E.L. DISEASE - EA EMP

Per Statute EL DISEASE - POL LMT

322179824996986SR ID: BATCH:

$1,000,000

$1,000,000

$1,000,000

Willis Towers Watson Certificate Center

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

General Parts, LLC 11311 Hampshire Ave S Bloomington, MN 55438

RE: Contract #CTR054655. The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are additional insureds for general liability and auto liability with respect to liability arising out of the activities performed by or on behalf of the Contractor (General Parts, LLC) if required by written contract . Waiver of Subrogation applies in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor (General Parts, LLC) for general liability, auto liability and workers compensation if required by written contract .

INSURER AFFORDING COVERAGE: Arch Insurance Company NAIC#: 11150

POLICY NUMBER: 11CAB1080700 EFF DATE: 12/01/2023 EXP DATE: 12/01/2024

TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:

Auto Liability - Any Autos Combined Single Limit $5,000,000

(MA)

2 2

Willis Towers Watson Northeast, Inc.

See Page 1

See Page 1 See Page 1 See Page 1

25 Certificate of Liability Insurance

W31158787CERT:3221798BATCH:24996986SR ID: