COI_2023-02-01.pdf

3/23/2022

Powers-Leavitt Insurance Agency, Inc.

111 E Monroe Ave, Suite 200

PO Box 125

Buckeye AZ 85326

Darlene Terry

(623)386-4452 (866)836-5280 darlenet@leavitt.com

Amazing Grace Arizona Families LLC

1945 Desert Vista Trail #74

Phoenix AZ 85085

Philadelphia Indemnity Company 018058

NGM Insurance Company 14788

CopperPoint General Insurance 13043

22/23

A

X

X

X

X Y PHPK2358459 2/1/2022 2/1/2023

1,000,000

100,000

5,000

1,000,000

3,000,000

3,000,000

Abusive Conduct Liability 1,000,000

B

X

X

X X Y B1P3764R 2/1/2022 2/1/2023

1,000,000

C 1021567 2/1/2022 2/1/2023

X

1,000,000

1,000,000

1,000,000

A Sexual/Phys Abuse/Molestation PHPK2358459 2/1/2022 2/1/2023 $1,000,000 Agg/ $1,000,000 Ea Inc

Professional Liability PHPK2358459 2/1/2022 2/1/2023 $3,000,000 Agg/ $1,000,000 Ea Inc

RE: Family Connections & Nurturing Parenting Sexual Abuse and Molestation coverage is included. The State of Arizona Department of Child Safety (ADCS), Office of Procuement & Contracts & Geena Salzman and its departments, agencies, boards,commissions,universities,officers, officials,agents,and employees are additional insured per written contract with respect to liability arising out of the activities performed by or on behalf of the Contractor as per form PI-GLD-HS 1011 &

CG2402 0509.

State of Arizona Department of Child Safe Office of Procurement & Contracts 3003 N Central Avenue Phoenix, AZ 85012

Jay Broadbent/KRLUCI

Y

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSD

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

OTHER:

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 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).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

The State of Arizona Department of Child Safety (ADCS), Office of Procuement & Contracts & Geena Salzman, and its departments, agencies, boards,commissions,universities,officers, officials,agents,and employees are additional insured per written contract with respect to liability arising out of the activities performed by or on behalf of the Contractor involving automobiles owned, leased, hired or borrowed by the contractor per form 64K290 0418.

Waiver of Subrogation applies in favor of the State of Arizona Department of Child Safety (ADCS), Office of Procuement & Contracts & Geena Salzman, its departments, agencies, boards, commissions, universities and its officers, officials, agents, employees for losses arising from work performed by or on behalf of the contractor per forms CG2404 0509, 64K290 0418 and WC000313 0484 per written contract.

COMMENTS/REMARKS

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