CGI_Certificate_of_Insurance_-_Epires_6-1-2025_Part_5.pdf
PDF 65 KB Posted
- Attached to
- Master Agreement AZ|CTR061240
- Contract number
- CTR061240
- Issued by
- Arizona
About this file
This document is a Workers Compensation and Employers Liability Policy Endorsement (WC 99 06 R3 (00) - 024) issued by Travelers Insurance for the State of Arizona. The policy endorsement provides a Notice of Cancellation to Designated Persons or Organizations, specifically involving the State of Arizona, its agencies, boards, commissions, universities, officers, agents, and employees, with a focus on losses arising from work performed by or on behalf of the contractor (referenced as AZ Financial Information System or AFIS Replacement Solicitation).
The endorsement outlines the terms for policy cancellation notification, requiring a 30-day notice period if the policy is cancelled for reasons other than non-payment of premium. The policy number is UB-4P332787-24-51-K, and the document emphasizes the insured's responsibility to provide accurate information for the notification schedule. The endorsement maintains all other existing policy terms and conditions, with the effective date being the date of issuance (05-15-24), as indicated on the document.
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Text version
Endorsement Effective
Countersigned by
Policy No.
Premium $Insured
Insurance Company
Endorsement No.
All other terms and conditions of this policy remain unchanged.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
TO DESIGNATED PERSONS OR ORGANIZATIONS
NOTICE OF CANCELLATION
POLICY NUMBER:
ENDORSEMENT WC 99 06 R3 (00) -
EMPLOYERS LIABILITY POLICY
AND
WORKERS COMPENSATION
Notice Of Cancellation To Designated Persons Or Organizations
Name and Address of Designated Persons or Organizations: Number of Days Notice
The following is added to PART SIX – CONDITIONS :
SCHEDULE
If we cancel this policy for any reason other than non-payment of premium by you, we will provide notice of such cancellation to each person or organization designated in the Schedule below. We will mail or deliver such notice to each person or organization at its listed address at least the number of days shown for that person or organiza-tion before the cancellation is to take effect.
You are responsible for providing us with the information necessary to accurately complete the Schedule below.
If we cannot mail or deliver a notice of cancellation to a designated person or organization because the name or address of such designated person or organization provided to us is not accurate or complete, we have no responsibility to mail, deliver or otherwise notify such designated person or organization of the cancellation.
ONE TOWER SQUARE
HARTFORD CT 06183
Page ofDATE OF ISSUE: ST ASSIGN:
© 2013 The Travelers Indemnity Company. All rights reserved.
MLBERUBE
Typewriter
UB-4P332787-24-51-K
MLBERUBE
Typewriter
THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS,
COMMISSIONS, UNIVERSITIES AND ITS OFFICERS, OFFICIALS,
AGENTS, AND EMPLOYEES FOR LOSSES ARISING FROM WORK PERFORMED
BY OR ON BEHALF OF THE CONTRACTOR. RE: AZ FINANCIAL
INFORMATION SYSTEM (AFIS) REPLACEMENT SOLICIATION NO.
ADSPO13-043465
MLBERUBE
Typewriter
MLBERUBE
Typewriter 05-15-24
File details come from the government source that posted it. Updated .