Certificate_of_insurance_for_State_of_Arizona_Department_of_Child_Safety_2024_2025_Redacted.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

AUTHORIZED REPRESENTATIVE

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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 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 any rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Philadelphia Indemnity Insurance Co.

5/09/2024

USI Southwest 9811 Katy Freeway, Suite 500 Houston, TX 77024 855 874-1450

Suzie Rees 602-234-4127 suzie.rees@usi.com

Step Up Arizona LLC

18058

A X X

X X PHPK2638920 01/20/2024 01/20/2025 1,000,000

100,000 5,000 1,000,000 3,000,000 3,000,000

A X

X X

X X PHPK2638920 01/20/2024 01/20/2025 1,000,000

A Abuse/Molestation Professional Liability

PHPK2638920

PHPK2638920

01/20/2024 01/20/2024

01/20/2025 01/20/2025

$1,000,000

$1,000,000 -EA

$2,000,000 -AGG

RE: Solicitation No. BPM005892, Congregate Care.

The General Liability and Automobile Liability policies includes an automatic Additional Insured endorsement that provides Additional Insured status to The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees, only when there is a written contract that requires such status, and only with regard to work performed by or on behalf of the (See Attached Descriptions)

State of Arizona Department of Child Safety Office of Procurement & Contract 3003 N Central Avenue Site CodeCH010-20 Phoenix, AZ 85012

#S44729125/M44727096

STEPUP3Client#: 1845125

AXLZP

#S44729125/M44727096

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) named insured. The General Liability and Automobile Liability policies contain a special endorsement with Primary wording, when required by written contract. The General Liability, Automobile Liability and Workers Compensation policies provide a Blanket Waiver of Subrogation when required by written contract, except as prohibited by law.

#S44729125/M44727096