Certificate_of_Insurance_exp_8.1.2022.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

A

1,000,000

3605-58-59 WCE

X

NYC-011188382-04

10,000,000

X

20346

10,000,000

SIR:

N

08/01/2022

08/01/2020

08/01/2022

(21)7360-54-64

Managed Care E&O

2,000,000

1,000,000

X

25445 Pacific Indemnity Company

C

X contributory as required by contract.

09/20/2021

150,000

08/01/2021

10,000,000

RE: Contract Number: CTR50520 - Mercy Care DCS CHP

The State of Arizona & Department of Economic Security are named as Additional Insured with respect to General Liability, Automobile Liability and the E&O Liability policy above. A waiver of subrogation applies in

**See Acord 101

X

Subject to Gen. Aggr.

3003 N. Central, Suite 2000

Site Code C010-20

Arizona Department of Child Safety

Phoenix, AZ 85012 favor of the additional insured to the extent required by written contract as allowed by applicable law with respect to General Liability and Automobile Liability. General Liability & Auto Liability are primary & non-

A

Ironshore Specialty Insurance Company

CN102074033--GAUMC-20-21

Limit:

5,000

1,000,000

7818-80-91

See Below

20281

1,000,000

11/01/2021

99 HIGH STREET

MARSH USA, INC.

BOSTON, MA 02110

4500 E. Cotton Center Blvd.

Mercy Care

Phoenix, AZ 85040

001995106

08/01/2021

Office of Contracts

08/01/2021

B

08/01/2022

Federal Insurance Company

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:

actual or alleged direct liability for any "Sexual Activity".��

Limit: $5,000,000 xs $10,000,000��

Boston

Carrier: Illinois Union Insurance Company�

Policy Period: 08/01/2020 - 11/01/2021� Policy # XMS G71163568 003�

EXCESS MANAGED CARE E&O POLICY:�

Certificate of Liability Insurance

CN102074033

Sexual Abuse and Molestation coverage is provided on a vicarious liability basis, to the extend that the Managed Care E&O Liability policy terms, definitions and conditions apply. "Sexual Activity" is defined in the sexual abuse, sexual harassment, sexual exploitation or any sexual act. Actual or alleged "sexual activity" is considered a "wrongful act" under the policy, however a "wrongful act" does not include "Insured's"

MARSH USA, INC.�

4500 E. Cotton Center Blvd.� Mercy Care�

Phoenix, AZ 85040 policy as any conduct, physical acts, gestures or spoken or written words of a sexual nature, including without limitation sexual intimacy (even if consensual), sexual molestation, sexual assault, sexual battery,