COI - ADHS Well Woman VWH.pdf

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

E-MAIL

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)

© 1988-2016 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

AZ

24988

UAZ0000127 15,000,000

12/01/2024 X

N/A

Medical Prof Liab Claims Made

CN101622780-STND-GAWP-23-24

1,000,000

11860

12/01/2024

LOS-002741256-01

12/01/2023

X

02/27/2024

15,000,000& GL/Umbrella Occurrence Aggregate

1,000,000 1,000,000

A

12/01/2023

12/01/2023

N/A

9018935002

Each Incident/Occurrence

9018935001

Deductible: 500,000

XS of $2M/$2M Buffer XS $2M SIR

The placements for Automobile Policy # 901893502 and Workers Compensation policies #901893501 and 901893503 were made by Lovitt-Touche. Marsh USA Inc. has only acted in the role of a consultant to the client with respect to these placements, which are indicated here for your convenience.

RE: Well Woman Health Check Program RFP: BPM005681; CTR 070059��

District� Maricopa County Special Health Care�

Phoenix, AZ 85008 2601 E. Roosevelt�

Sentry Insurance A Mutual Co

2325 E. Camelback Road�

MARSH USA LLC.�

Phoenix, AZ 85016�� Suite 600�

Attn: healthcare.accountscss@marsh.com Fax: 212-948-1307

Copic Insurance Company

N

150 N. 18th Avenue, Suite 530� Phoenix, AZ 85007

Arizona Department of Health Services�

(RFP - BPM005681: CTR070059)�

AZ

A

1,000,000

B

12/01/2024

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

MARSH USA LLC.�

Policy Dates: 12/01/2023 - 12/01/2024�

Expiration Date: 12/01/24�

States: AZ� Policy Number: 9018935003 �

Effective Date: 12/01/23�

Additional Workers Comp: �

Policy Dates: 12/01/2023 0 12/01/2024�

Employers Liability Each Accident: $1,000,000 �

Policy Number: UHE5000070-00�

Limits: $10M xs $30M�

Phoenix

Certificate of Liability Insurance

Excess Layers�

The Workers Compensation placements were made by Lovitt-Touche (Workers Compensation Policies 9018935001 and 9018935003). Marsh USA Inc. has only acted in the role of

Limits: $10M xs $40M�

Endurance American Specialty Ins. Co.�

Employers Liability Disease-Policy Limit: $1,000,000 �

Sentry Casualty Company � a consultant to the client with respect to these placements, which is indicated here for your convenience. �

Employers Liability Disease-Each Employee: $1,000,000 �

District� Maricopa County Special Health Care�

2601 E. Roosevelt�

Arch Specialty Insurance Co.�

CN101622780

Phoenix, AZ 85008

Policy Number: HHF30049060200�