COI_ADOA_-_Workers_Comp_-_Marlene_Imirzian.pdf

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

INSURER(S) AFFORDING COVERAGE NAIC #

PRODUCER

INSURED

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

COVERAGES

TYPE OF INSURANCE POLICY NUMBER LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

LOCPOLICY

OTHER:

EACH OCCURRENCE

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

AUTOMOBILE LIABILITY

ANY AUTO

OCCUR

CLAIMS-MADE

DED RETENTION $

EACH OCCURRENCE

AGGREGATE

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

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

CERTIFICATE HOLDER CANCELLATION

Y/N

CONTACT

NAME:

PHONE

(A/C, No, Ext):

E-MAIL

ADDRESS:

FAX

(A/C, No):

CERTIFICATE NUMBER: REVISION NUMBER:

UMBRELLA LIAB

EXCESS LIAB

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

INSURER F :

N/A

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

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.

INSR

LTR

ADDL

INSD

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

PRO-

JECT

DAMAGE TO RENTED

PREMISES (Ea occurrence)

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident)

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

PER

STATUTE

OTH-

ER

SUBR

WVD

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 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).

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

04/17/2025

PAYCHEX INSURANCE AGENCY INC

225 KENNETH DR

ROCHESTER, NY 14623

(877) 362-6785

(877) 362-6785 (877) 677-0447 paychex@travelers.com

MARLENE IMIRZIAN & ASSOCIATES,

LLC

8906 N CENTRAL AVE,

PHOENIX AZ 85020

THE TRAVELERS INDEMNITY COMPANY

984593343581701

A X UB-1N010970-24 06/04/2024 06/04/2025 X

1,000,000 1,000,000 1,000,000

AS RESPECTS TO WORKERS COMPENSATION COVERAGE, WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT, WC 00 03 13 (00), HAS BEEN ATTACHED TO THE POLICY. AN ENDORSEMENT HAS BEEN ADDED TO THE POLICY (OR POLICIES) THAT PROVIDES 30 DAY EARLIER NOTICE OF CANCELLATION, SUBJECT TO THE TERMS OF THAT ENDORSEMENT. RE: CONTRACT NO. CTR076530 FOR ADOA ON-CALL

ARCHITECTURAL SERVICES

ARIZONA DEPARTMENT OF ADMINISTRATION

GENERAL SERVICES DIVISION

1400 W. WASHINGTON, SUITE B200

PHOENIX, AZ 85007