CTR052593-InsuranceRenewalCOI.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

DAMAGE TO RENTED

CLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-

POLICY LOC PRODUCTS - COMP/OP AGG $JECT

OTHER: $

COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED BODILY INJURY (Per accident) $

AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE $

AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N

N / A (Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

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

CERTIFICATE OF LIABILITY INSURANCE

Lockton Companies 8110 E. Union Avenue Suite 700 Denver CO 80237

(303) 414-6000

St. Mary's Food Bank Alliance 2831 North 31st Avenue Phoenix, AZ 85009

Philadelphia Indemnity Insurance Co. 18058 CopperPoint Indemnity Insurance Company 13928

X X

1,000,000 1,000,000 20,000 1,000,000 3,000,000 3,000,000

X

X Comp/Coll X $5000 Deductible

1,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X X

X 10,000

10,000,000 10,000,000

XXXXXXX

N

X

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

Sexual Abuse/Molestation

Professional Liability

$2M Agg $1M ea Abusive Conduct $3M Agg $1M ea Prof Incident

A PHPK2620722 10/31/2023 10/31/2024

A PHPK2620722 10/31/2023 10/31/2024

A PHPK2620722 10/31/2023 10/31/2024

A PHPK2620722 10/31/2023 10/31/2024

A PHUB888047 10/31/2023 10/31/2024

B 1001987 7/1/2023 7/1/2024

7/1/2024

1374066

Y Y

Y Y

N N

Y

10/31/2022

N N

12881858

12881858 XXXXXXX

State of Arizona and Dept of Economic Security c/o MyCOI 1075 Broad Ripple Ave, Suite 313 Indianapolis, IN 46220

RE: CTR061897, CTR052593, CTR052635. The State of Arizona and its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees are included as Additional Insureds if required by written contract with respect to General Liability and Auto Liability arising out of the activities performed by or on behalf of the Contractor, including those involving automobiles owned, leased, hired or borrowed by the Contractor.

CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required)

ACORD 25 (2016/03)

Waiver of Subrogation in favor of the State of Arizona and 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 Contractor as respects General Liability, Auto Liability, and Workers Compensation if required by written contract. Sexual Abuse and Molestation coverage is included. Where allowed by law and if required by written contract, General Liability and Auto Liability insurance is primary and non-contributory. If the General Liability policy is cancelled by the issuing company during the policy term, for other than nonpayment of premium, 30 days notice will be provided to the Certificate Holder named below.

Certificate Holder ID: 12881858