CTR054969_Certificate_of_Insurance.pdf

© 1988-2015 ACORD CORPORATION. All rights reserved.

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

CERTIFICATE HOLDER CANCELLATION

Arizona Department of Transportation and/or State of Arizona ADOT Procurement Office 1739 W Jackson Modular A Maildrop: 100 Phoenix, AZ 85007

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

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

05/18/2021 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).

PRODUCER

CS&S/GENERAL SOUTHWEST INS. AGCY INC

PO BOX 958489

LAKE MARY, FL 32746-8989

Phone - 877-724-2669 Fax - 877-763-5122

CONTACT

NAME:

PHONE

(A/C, No, Ext):

FAX

(A/C, No):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : Continental Casualty Company 20443

INSURED

NAGY PROPERTY CONSULTANTS, INC.

2415 E CAMELBACK RD STE 700

PHOENIX, AZ 85016

INSURER B :

INSURER C :

INSURER D :

INSURER E : The Continental Insurance Company 35289

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

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 TYPE OF INSURANCE

ADDL

INSD

SUBR

WVD POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

A

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY PRO-

JECT LOC

OTHER

Y Y 6021260676 09/23/2020 09/23/2021

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

$ 2,000,000 $ 300,000 $ 10,000 $ 2,000,000 $ 4,000,000 $ 4,000,000

A

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

Y Y 6021260676 09/23/2020 09/23/2021

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident)

$ 1,000,000

UMBRELLA LIAB OCCUR

EXCESS LIAB CLAIMS-MADE

DED RETENTION $

EACH OCCURRENCE

AGGREGATE

E

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

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

Y/N N Y 6021327373 11/15/2020 11/15/2021

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

$ 1,000,000

$ 1,000,000

$ 1,000,000

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

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees is added as an additional insured with respect to liability arising out of the activities performed by or on behalf of the Contractor as the named insured, for any and all work performed in ADOT's right of way. Waiver of Subrogation is Included in the Blanket Additional Insured Form, 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 and on behalf of the Contractor.

ACCEPTED

ADOT Risk Management

WC 6021327373[

Policy No: 6021327373 Policyy Effective Date:11/15/2019

Form No: CNA79829

© Copyright CNA All Rights Reserved.

SCHEDULE

List of Persons or Organizations

ADC_Waiver of Subrogation Name of Person or Organization

It is understood and agreed that the COMMON CONDITIONS, the section entitled SUBROGATION is amended to add the following: Arizona Department of Transportation and/or The State of Arizona

The Insurer has the right to recover its payments from anyone liable for an injury covered by this policy. The Insurer agrees not to enforce this right of subrogation against any person or organization named in the Schedule, but this agreement not to subrogate applies only to the extent that at the time of the loss, the Named Insured is performing work under a written contract that requires the Named Insured to obtain from the Insurer an agreement not to subrogate.

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

All other terms and conditions of the policy remain unchanged.

This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below.

WAIVER OF SUBROGATION AGAINST DESIGNATED PERSONS OR ORGANIZATIONS ENDORSEMENT

SCHEDULE

List of Persons or Organizations

ADC_Waiver of Subrogation Name of Person or Organization

It is understood and agreed that the COMMON CONDITIONS, the section ennttitltled SUBRB OGATION isis amended to add the following: Arizona Department of Transportation and/orr ThThee State of AArizizona

The Insurer has the right to recover its payments from anyone liable foro ann injuryry covoverered bby thisis policcyy. The Insurer agrees not to enforce this right of subrogation against any y peperson or oorganizazation namedd iinn the Schedule, but this agreement not to subrogate applies only to thhe exxtent that atat the ttime of thehe llooss, the Named Insured is performing work under a written contract thatt requiireres the Namemed Innsus reedd toto obtain from the Insurer an agreement not to subrogate.

This agreement shall not operate directly or indirectly to benefit anynyoonee not nan med in tthhe Schedule.

All other terms and conditions of the policy remmaiainn unnchc angeed.d

This endorsement, which forms a part ooff andd is for attacchmhment to tthehe ppoolicy issued by the designated Insurers, takes effect on the Policy Effective datatee ofof saiidd policy at thhee hoh ur stated in said policy, unless another effective date (the Endorsement EfEffef ctive Daatet ) isis shown belowow, anandd expires concurrently with said policy unless another expiration date is s sshowwn below.

WAIVER OF SUBROGATION AGAINST DESIGNATED PERSONS OR ORGANIZATIONS ENDORSEMENT

APPRAISAL, VALUATION AND PROPERTY SERVICES

PROFESSIONAL LIABILITY INSURANCE POLICY

THIS IS A CLAIMS MADE AND REPORTED POLICY. COVERAGE IS LIMITED TO LIABILITY FOR ONLY THOSE

CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND THEN

REPORTED TO THE COMPANY IN WRITING NO LATER THAN SIXTY (60) DAYS AFTER EXPIRATION OR

TERMINATION OF THIS POLICY, OR DURING THE EXTENDED REPORTING PERIOD, IF APPLICABLE, FOR A

WRONGFUL ACT COMMITTED ON OR AFTER THE RETROACTIVE DATE AND BEFORE THE END OF THE

POLICY PERIOD. PLEASE READ THE POLICY CAREFULLY.

DECLARATIONS

AAI002198-05AAI002198-067/22/2020

Previous Policy NumberPolicy NumberDate Issued

Aspen American Insurance Company (Referred to below as the "Company")

590 Madison Avenue, 7th Floor

New York, NY 10022

877-245-3510

1. Customer ID:

Named Insured:

2. Policy Period: From: To:

12:01 A.M. Standard Time at the address stated in 1 above.

3. Deductible: Each Claim

4. Retroactive Date:

5. Inception Date:

6. Limits of Liability: A.

B.

Each Claim

Aggregate

7.

103469

NAGY PROPERTY CONSULTANTS, INC

Steven Nagy, President

Phoenix, AZ 85016

07/20/2020 07/20/2021

$5000

07/20/1986

07/20/2015

$2,000,000

$2,000,000

2415 E. Camelback Rd., Ste. 700

Subpoena Response:

Pre-Claim Assistance:

Disciplinary Proceeding:

$5,000 Supplemental Payment Coverage

Loss of Earnings:

$5,000 Supplemental Payment Coverage

$12,500 Supplemental Payment Coverage

$500 per day Supplemental Payment Coverage

Covered Professional Services (as defined in the Policy and/or by Endorsement):

Real Estate Appraisal and Valuation:

Residential Property:

Commercial Property:

Bodily Injury and Property Damage Caused

During Appraisal Inspection ($100,000 Sub-Limit):

Right of Way Agent and Relocation:

Machinery and Equipment Valuation:

Personal Property Appraisal:

Real Estate Sales/Brokerage:

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

(If "yes", added by endorsement)

(If "yes", added by endorsement)

(If "yes", added by endorsement)

X

X

X

X

X

X

X

X

Page 1 of 2Aspen American Insurance Company

LIA001 (04/19)

ACCEPTED

ADOT Risk Management

Report Claims to: LIA Administrators & Insurance Services, 800-334-0652, P.O. Box 1319, 1600 Anacapa St, Santa Barbara, California 93101

9. Annual Premium:

10. Forms attached at issue: LIA002 (04/19) LIA AZ (05/19) LIA012 (05/19) LIA018 (05/19) LIA020 (05/19) LIA112

(05/19) LIA164 (05/19) LIA165 (05/19)

$3,145.00

8.

This Declarations Page, together with the completed and signed Policy Application including all attachments and exhibits thereto, and the Policy shall constitute the contract between the Named Insured and the Company.

Date

07/22/2020 By ______________________________________________________________

Authorized Representative

Cust ID: 103469

LIA001 (04/19)

Aspen American Insurance Company Page 2 of 2