CTR048038_COI_GL__Auto__WC__PL_Exp_4-1-23.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

Willis Towers Watson Insurance Services West, Inc.

c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA

Inter Tribal Council of Arizona, Inc.

2214 N. Central Avenue, #100 Phoenix, AZ 85004

Re: Contract Number CTR048038

SEE ATTACHED

State of Arizona

DES-DAAS

Attn: Lei Ronda Golden-Grady 1789 W. Jefferson Street, SC950A Phoenix, AZ 85007

04/01/2022

1-877-945-7378 1-888-467-2378 certificates@willis.com

Philadelphia Indemnity Insurance Company 18058

AmTrust Insurance Company 15954

W24449105

A

1,000,000

100,000

1,000

1,000,000

3,000,000

3,000,000

Y Y PHPK2379440 04/01/2022 04/01/2023

A

1,000,000

04/01/202304/01/2022Y Y PHPK2379440

WWC3580409

B Y

1,000,000 Yes 04/01/2022 04/01/2023

1,000,000

1,000,000

A Crime - Employee Dishonesty Limit:PHPK2379440 04/01/2022 04/01/2023

Ded. Per Occ.:

247227122413554SR ID: BATCH:

$2,500

$250,000

Willis Towers Watson Certificate Center

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:

Inter Tribal Council of Arizona, Inc.

2214 N. Central Avenue, #100 Phoenix, AZ 85004

The State of Arizona and the Department of Economic Security are included as Additional Insureds as respects to General Liability and Auto Liability.

General Liability policy shall be Primary to any other insurance in force for or which may be purchased by Additional Insureds.

Waiver of Subrogation applies in favor of the State of Arizona, its departments, agencies, boards, commissions, and its officers, officials, agents, and employees with respects to General Liability, Auto Liability, and Workers’ Compensation as permitted by law.

INSURER AFFORDING COVERAGE: Philadelphia Indemnity Insurance Company NAIC#: 18058

POLICY NUMBER: PHPK2257918 EFF DATE: 04/01/2022 EXP DATE: 04/01/2023

TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:

Professional Liability Per Occurrence $1,000,000

Aggregate $3,000,000 Retention $0

2 2

Willis Towers Watson Insurance Services West, Inc.

See Page 1

See Page 1 See Page 1 See Page 1

25 Certificate of Liability Insurance

W24449105CERT:2472271BATCH:22413554SR ID:

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

PHPK2379440

D010372 Sticky Note Auto and GL are under a single policy so they share the same policy number.

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

PHPK2379440

WWC3580409

D010372

Auto and GL are under a single policy so they share the same policy number.

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

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 anyone not named in the Schedule.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 04-84)

Schedule

Any person or organization as required by written contract

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 4/1/2022 Policy No. WWC3580409 Endorsement No. 0 Insured Inter Tribal Council of Arizona Premium $ 12,551 Insurance Company Wesco Insurance Company

Countersigned by

WC 00 03 13

(Ed. 04-84)

D010372

See above schedule for State Language. Language is also included on page 2 of the Acord form.