CTR052592_Certificate_of_Insurance_Exp_7.1.23.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)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

6/29/2022

Crest Insurance Group, LLC 5285 E. Williams Circle Suite 4500 Tucson AZ 85711

Jynessa Shaffer 520-784-7617 520-618-3948 jshaffer@crestins.com

Philadelphia Indemnity Ins Co 18058 COMMFOO-01 CopperPoint Indemnity Insurance Company 13928

Community Food Bank, Inc.

3003 S. Country Club Road Tucson AZ 85713

127421574

A X 1,000,000 X 100,000

5,000

1,000,000

3,000,000 X

Y Y PHPK2433639 7/1/2022 7/1/2023

3,000,000

A 1,000,000

X

X X

Y PHPK2433639 7/1/2022 7/1/2023

A X X 5,000,000PHUB821722 7/1/2022 7/1/2023

5,000,000 X 10,000

B XY 1018212 7/1/2022 7/1/2023

1,000,000

1,000,000

1,000,000 A Products Liability

Sexual/Physical Abuse or Molestat

PHPK2433639 7/1/2022 7/1/2023 1,000,000/3,000,000

1,000,000/3,000,000

RE: Contract #CTR052592 - RFP #BPM001904 Hunger Relief Program - Commodity Senior Food Program (CSFP). State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

Certificate holder and others when required in a written contract or agreement are Additional Insured (General Liability). Coverage is Primary & Non-Contributory (General Liability). Waiver of Subrogation (General Liability & Workers Compensation) applies. This form is subject to all policy forms, terms, endorsements, conditions definitions & exclusions. 30 Day Notice of Cancellation applies.

Arizona Department of Economic Security Division of Aging and Adult Services 1789 W. Jefferson Street Mail Drop 57C1 Phoenix AZ 85007

CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART.

SCHEDULE

Name of Person or Organization:

(If no entry appears above, information required to complete this endorsement will be shown in the Declara-tions as applicable to this endorsement.)

The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV -- COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard".

This waiver applies only to the person or organization shown in the Schedule above.

POLICY SHALL CONTAIN A WAIVER OF SUBROGATION ENDORSEMENT, AS REQUIRED BY THIS

WRITTEN AGREEMENT,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

1789 W JEFFERSON ST

MAIL DROP 5112

PHOENIX, AZ 85007-3202

GA 4397 09 17

ADDITIONAL INSURED - DESIGNATED PERSON

OR ORGANIZATION (VICARIOUS LIABILITY)

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name of Person(s) or Organization(s) (Additional Insured):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II - Who Is An Insured is amended to include as an insured the person or organiza-tion shown in the Schedule, but only with re-spect to liability caused by your acts or omis-sions.

However, if coverage provided to the addition-al insured is required by a contract or agree-ment, the insurance afforded to such addition-al insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is add-ed to Section III - Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional in-sured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the appli-cable Limits of Insurance shown in the Decla-rations.

THE POLICY SHALL BE ENDORSED, AS REQUIRED BY THIS WRITTEN AGREEMENT, TO INCLUDE

THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES,BOARDS,COMMISSIONS,

UNIVERSITIES AND ITS OFFICERS, OFFICIALS,AGENTS AND EMPLOYEES AS ADDITIONAL

INSUREDS WITH RESPECT TO LIABILITY ARISING OUT OF THE ACTIVITIES PERFORMED BY

OR ON BEHALF OF THE CONTRACTOR

1789 W JEFFERSON ST

AA 4004 03 06

ADDITIONAL INSURED - DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

The person or organization named in the following schedule is an "insured" to the extent of their liability for the conduct of another "insured" as provided in SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who is an Insured, Paragraph c.

Schedule

Additional Insured

Address:

07-01-2020 ETA 044 41 04

COMMUNITY FOOD BANK INC

THE POLICY SHALL BE ENDORSED, AS REQUIRED BY THIS WRITTEN AGREEMENT, TO INCLUDE

THE STATE OF ARIZONA, ITS

DEPARTMENTS,AGENCIES,BOARDS,COMMISSIONS,UNIVERSITIES,OFFICERS,OFFICIALS,AGENTS

& EMPLOYEES AS ADDITIONAL INSUREDS WITH RESPECT TO LIABILITY ARISING OUT OF

ACTIVITIES PERFORMED BY OR ON BEHALF OF THE CONTRACTOR INVOLVING AUTOS OWNED,

HIRED AND/OR NON-0WNED BY CONTRACTOR

1789 W JEFFERSON ST

AA 4195 01 07

WAIVER OF SUBROGATION - AUTO

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

This endorsement changes the policy effective on the inception date of the policy unless another date is indi-cated below.

Endorsement Effective: Policy Number:

Named Insured:

Countersigned by:

(Authorized Representative)

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

SCHEDULE

Name of person(s) or organization(s):

Job location: Job and/or Contract Number:

1. Waiver of Subrogation

SECTION IV - BUSINESS AUTO CONDI-

TIONS, A. Loss Conditions, 5. is amended by the addition of the following:

With regard to the person(s) or organiza-tion(s), job location, and job and / or contract number shown in the Schedule of this en-dorsement, we waive any right of recovery we may have against any person or organization because of payments we make for "bodily in-jury" or "property damage" arising out of the operation of a covered "auto" when you have assumed liability for such "bodily injury" or "property damage" under an "insured con-tract", provided the "bodily injury" or "property damage" occurs subsequent to the execution of the "insured contract".

07-01-2020 ETA 044 41 04

COMMUNITY FOOD BANK INC

POLICY SHALL CONTAIN A WAIVER OF SUBROGATION ENDORSEMENT, AS REQUIRED BY THIS

WRITTEN AGREEMENT,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

1789 W JEFFERSON ST

MAIL DROP 5112

PHOENIX, AZ 85007-3202

1789 W JEFFERSON ST ADES17- 174140

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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.

Schedule State Blanket/Schedule/State

AZ State of Arizona. 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.

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.)

07/01/2020Endorsement Effective 1018212Policy No. 18Endorsement No.

Community Food Bank IncInsured 100 Premium $

CopperPoint General Insurance CompanyInsurance Company Countersigned by