CTR050597_COI_through_1.1.2021.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)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

8/5/2020

Lovitt & Touché, a Marsh & McLennan Agency, LLC 7202 E Rosewood Drive, Suite 200 Tucson AZ 85710

Julie Reed 520-722-7114 jreed@lovitt-touche.com

New York Marine and General Insurance Co 16608 MARICOM-C3 Philadelphia Indemnity Insurance Co 18058

Mariposa Community Health Center 825 N. Grand Ave., Suite 100 Nogales AZ 85621

389503177

B X 1,000,000 X 500,000

10,000

1,000,000

2,000,000 X

PHPK2080399 1/1/2020 1/1/2021

2,000,000

B 1,000,000

X

PHPK2080399 1/1/2020 1/1/2021

A XWC202000018650 1/1/2020 1/1/2021

1,000,000

1,000,000

1,000,000

Coverage subject to all policy terms, definitions, conditions and exclusions.

RFP No. BPM002372 /Health Start Program /Contract number CTR050597

Commercial General Liability: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are additional insureds with respect to liability arising out of activities performed by or on behalf of the Contractor.

Business Automobile Liability: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees See Attached...

Arizona Department of Health Services Office of Procurement 150 N. 18th Avenue, Ste. 260 Phoenix AZ 85007

THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE

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:

MARICOM-C3

1 1

Lovitt & Touché, a Marsh & McLennan Agency, LLC Mariposa Community Health Center 825 N. Grand Ave., Suite 100 Nogales AZ 85621

25 CERTIFICATE OF LIABILITY INSURANCE

are 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 nonowned by the Contractor.

Commercial General Liability, Business Automobile Liability, and Workers' Compensation and Employers' Liability: Policy contains a waiver of subrogation 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.

30 Notice of cancellation provided per attached forms. Insurance afforded by the Contractor shall be primary insurance.

INTERLINE

IL 83 27 12 14

NOTICE OF CANCELLATION TO THIRD PARTIES_IL 83 27_12/14

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

IL 83 27 12 14 Includes copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1

NOTICE OF CANCELLATION TO THIRD PARTIES

This endorsement modifies insurance provided under the following:

ABUSE OR MOLESTATION LIABILITY COVERAGE FORM

COMMERCIAL AUTOMOBILE COVERAGE PART

COMMERCIAL CRIME COVERAGE PART

COMMERCIAL EXCESS LIABILITY COVERAGE PART

COMMERCIAL GENERAL LIABILITY COVERAGE PART

COMMERCIAL INLAND MARINE COVERAGE PART

COMMERCIAL LIABILITY UMBRELLA COVERAGE PART

COMMERCIAL OUTPUT PROGRAM

COMMERCIAL PROPERTY COVERAGE PART

PROFESSIONAL LIABILITY COVERAGE FORM

SCHEDULE

Schedule of Person(s) or Organization(s):

The Arizona Dept of Health Services & The State of Arizona its Departments, Agencies, Boards, Commissions, Universities and its Officers, Officials, Agents, and Employees for losses arising from work performed by or on behalf of the Grantee 1470 W Adams St, Room 303 Phoenix, AZ 85007

Number of Days Notice: 30 (If no entry appears above, information required to complete this Schedule will be shown in the Declarations as applicable to this endorsement.)

Common Policy Conditions Condition A, Cancellation, is amended to include the following:

Notice of cancellation will be also be provided to the person(s) or organization(s) listed in the schedule above.

WC 00 03 13

(Ed. 4-84)

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 Insured

Insurance Company

Policy No. Endorsement No.

Premium

Countersigned by ___________________________________________

The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents and employees

All Operations of the Named Insured as requested by the certholder.

Mariposa Community Health Center, Inc.

WC202000018650

01-01-2020

New York Marine and General Insurance Company / 28746