COI_1.6.2026.pdf
PDF 1 MB Posted
- Attached to
- Master Agreement AZ|CTR076215
- Contract number
- CTR076215
- Issued by
- Arizona
About this file
This Certificate of Liability Insurance documents coverage for Las Palmas Assisted Living LLC and Las Palmas Assisted Living 2 LLC under Contract #CTR076215 with the State of Arizona and the Department of Economic Security. The coverage is underwritten through the Social Service Contractors Indemnity Pool, with THE PIE INS CO serving as the primary insurer. The certificate is issued by J A Knapp Agency and is effective January 6, 2025, through January 6, 2026. The State of Arizona, its departments, agencies, boards, commissions, universities, and their officers, officials, agents, and employees are named as additional insureds and certificate holders.
The insurance package includes Commercial General Liability with limits of $1,000,000 each occurrence and $2,000,000 general aggregate; Business Auto Liability with $1,000,000 combined single limit; Umbrella/Excess Liability with $1,000,000 each occurrence and $1,000,000 aggregate; Workers' Compensation with $1,000,000 each accident; and Professional Liability Claims Made coverage for an assisted living facility with Sexual Abuse and Molestation coverage limits of $2,000,000/$3,000,000 (each act/aggregate) and $1,000,000/$2,000,000 (each/aggregate). All policies include additional insured endorsements and waivers of subrogation in favor of the State of Arizona for losses arising from work performed by or on behalf of the contractor. No deductibles or retention amounts are specified in the certificate.
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Text version
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
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)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
6/18/2025
J A Knapp Agency
PO BOX 286
Sunbury OH 43074
Robin Johnston
(740) 913-0815 csr@jaknapp.com
Las Palmas Assisted Living LLC
Las Palmas Assisted Living 2 LLC
9443 E 3RD ST
TUCSON AZ 85710
SOCIAL SERVICE CONTRACTORS IND POOL 525190
THE PIE INS CO 21857
A
Y Y 6002323-4 01/06/2025 01/06/2026
1,000,000
1,000,000
10,000
1,000,000
2,000,000
2,000,000
A
✘ Y Y 6002323-4 01/06/2025 01/06/2026
1,000,000
A
Y Y 6002323-4 01/06/2025 01/06/2026
1,000,000
1,000,000
B N Y WC PI 1950903-000 01/06/2025 01/06/2026
1,000,000
1,000,000
1,000,000
A Professional Liability Claims Made
Abuse and Molestation 6002323-4 01/06/2025 01/06/2026
Each Act/Aggregate 2,000,000/3,000,000
Each/Aggregate 1,000,000/2,000,000
Contract # CTR076215 - Assisted Living Facility. Sexual Abuse and Molestation coverage is included. See attached additional remarks section
The State of Arizona and Dept of Economic Security C/O: myCOI
P.O. Box# 501970, 8710 Bash Street
Indianapolis IN 46256
EFFECTIVE DATE:
NAMED INSURED
POLICY NUMBER
NAIC CODECARRIER
AGENCY
LOC #:
AGENCY CUSTOMER ID:
ofPageADDITIONAL REMARKS SCHEDULE
ADDITIONAL REMARKS
FORM TITLE:FORM NUMBER:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
© 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORD 101 (2008/01)
J A Knapp Agency
6002323/WWC3689309
Social Service Contractors/PIE Insurance
Las Palmas Assisted Living 2 LLC
Mateo, Maria
9443 E 3rd St
Tucson, AZ 85710
01/06/2025
25 CERTIFICATE OF LIABILITY INSURANCE
Contract # CTR076215 - Assisted Living Facility
General Liability 6002323-4:
Page 31, Section 25.3.1.3 The policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.
Page 31, Section 25.3.1.4 Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, 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.
Business Auto Liability 6002323-4:
Page 32, Section 25.3.2.1 Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor.
Page 31, Section 25.3.2.2 Policy shall contain a waiver of subrogation endorsement as required by this written agreement 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.
Workers Compensation WC PI 1950903-000:
Waiver of Subrogation, per written agreement, 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
| CTR076215 - COI.pdf |
| CTR076215 - Additional Endorsement.pdf |
| CTR076215 - Endorsements.pdf |
| CTR076215 - WC WOS.pdf |
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