CGI_Certificate_of_Insurance_-_Epires_6-1-2025_Part_6.pdf
PDF 25 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 00 03 13 (00) - 025) issued by Travelers Insurance for the State of Arizona. The endorsement specifically involves the State of Arizona, its departments, agencies, boards, commissions, universities, officials, agents, and employees, with the State of Arizona Department of Administration's State Procurement Office identified as the primary organizational entity.
The endorsement relates to a Waiver of Right to Recover from Others, referencing Contract Award No. CTR061240 for the Human Resources Information System (HRIS) Replacement. The document outlines the insurance carrier's agreement to waive subrogation rights against the designated organizations, with a specific note that for work performed in Missouri, the waiver does not apply to certain construction classification groups. The policy number is UB-4P332787-24-51-K, and the date of issue is 05-14-24, indicating a current or upcoming contractual arrangement.
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Text version
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-4P332787-24-51-K
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:
DATE OF ISSUE: PAGEST ASSIGN: OF
Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual.
05-14-24 1 1
MLBERUBE
Typewriter STATE OF ARIZONA, AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES.
STATE OF ARIZONA, DEPARTMENT OF ADMINISTRATION, STATE PROCUREMENT OFFICE
100 N 15TH AVENUE, PHOENIX, AZ 85007
REFERENCE: CONTRACT AWARD NO. CTR061240, HUMAN RESOURCES INFORMATION SYSTEM (HRIS)
REPLACEMENT
File details come from the government source that posted it. Updated .