CTR055523_COI_2022-10-19.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 Insurance Brokers, LLC 777 S. Figueroa Street, 52nd Fl.

CA License #0F15767 Los Angeles CA 90017

(213) 689-0065

Human Resource Training Inc.

1951 W Camelback Rd, Ste. 450 Phoenix AZ 85015

PYRHO01

American Zurich Insurance Company 40142

Illinois Union Insurance Company 27960 Zurich American Insurance Company 16535

X X

X $500,000 SIR

X $1M Abusive Act

1,000,000 50,000 See Below 1,000,000 3,000,000 1,000,000

X

X Scheduled PD Autos

2,000,000

XXXXXXX

XXXXXXX

XXXXXXX

Comp/Coll DED 5,000

X X X

5,000,000 5,000,000

XXXXXXX

N

X

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

Healthcare Prof Liab Claims Made 11/1/15

Each Medical Incident: $1,000,000 Aggregate: $3,000,000

SIR: $500,000

B BAP 2519669-03 10/19/2021 10/19/2022

A MLP G72547597 001 10/19/2021 10/19/2022

A XFL G72547603 001 10/19/2021 10/19/2022

A XFL G72547603 001 10/19/2021 10/19/2022

C WC 2519668-03 10/19/2021 10/19/2022

10/19/2022

1503305

Y Y

Y Y

N N

Y

1/11/2022

N N

18157279

18157279 XXXXXXX

Department of Child Safety Office of Procurement & Contracts 3003 N. Central Ave., C010-20 Phoenix AZ 85007

Auto Liability deductible is $350,000. Workers' Compensation Deductible is $250,000.

Sexual Abuse and Molestation coverage is included under the $1,000,000 Each Abusive Act Limit within the Professional Liability Policy.

GL Med Exp.:$5,000/$25K Agg. RE: Contract Numbers include: ADCS18-200036, ADCS17-174432, ADCS16-119255, CTR045636, ADCS15-094739, AZDCS18-00007646, ADCS19-206583,CTR055523. The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees are Additional Insured with respect to liability arising out of the operations of the insured and to the extent provided by the policy language or endorsement issued or approved by the insurance carrier. Waiver of Subrogation applies per attached endorsement(s) or policy language. Insurance provided to Additional Insured(s) is primary and non-contributory as per the attached endorsements or policy language.

X

See Attachments

Department of Child Safety Office of Procurement & Contracts

3003 N. Central Ave., C010-20

Phoenix, AZ 85007

To whom it may concern:

In our continuing effort to provide timely certificate delivery, Lockton Companies is transitioning to paperless delivery of Certificates of Insurance, thus, this is your final hard-copy delivery.

To ensure electronic delivery for future renewals of this certificate, we need your email address.

Please contact us via one of the methods below, referencing Certificate ID 18157279.

Email: PacificeDelivery@lockton.com Phone: (213) 689-2300

If you received this certificate through an internet link where the current certificate is viewable, we have your email and no further action is needed.

In the event your mailing address has changed, will change in the future, or you no longer require this certificate, please let us know using one of the methods above.

The above inbox and phone number below are for automating electronic delivery of certificates only. Please do NOT send future certificate requests to the above inbox or call into the number below.

Thank you for your cooperation and willingness in reducing our environmental footprint.

Lockton Insurance Brokers, LLC - Pacific Series

Lockton Insurance Brokers, LLC License #0F15767

777 S Figueroa Street, 52nd Fl / Los Angeles, CA 90017-5524

213-689-0065 / FAX: 213-689-0550

lockton.com

Attachment Code: D567517 Master ID: 1503305, Certificate ID: 18157279 mailto:PacificeDelivery@lockton.com

ADDITIONAL INSURED(S) ENDORSEMENT: WRITTEN CONTRACT, QUARTERLY REPORTING

ADDITIONAL INSURED(S) ENDORSEMENT: WRITTEN CONTRACT,

QUARTERLY REPORTING

Named Insured

Pyramid Health Holdings, LLC Endorsement Number

Policy Symbol

MLP

Policy Number

G72547597 001 Policy Period

10/19/2021 to 10/19/2022 Effective Date of Endorsement

10/19/2021 Issued By (Name of Insurance Company)

Illinois Union Insurance Company

THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies coverage under the following:

(Select Applicable Coverage Parts)

HEALTHCARE FACILITIES GENERAL LIABILITY COVERAGE PART (CLAIMS MADE)

X GENERAL LIABILITY COVERAGE PART (OCCURRENCE)

X HEALTHCARE FACILITIES PROFESSIONAL LIABILITY COVERAGE PART (CLAIMS

MADE)

It is agreed that:

1. The Who Is An Insured provision of the applicable Coverage Part(s) selected above shall be amended to include as “insured(s)” any natural person or organization with which the Named Insured has a written contract (i) in effect during the policy period and (ii) executed prior to the “bodily injury”, “property damage”, “personal or advertising injury” or “professional incident” occurring or being committed, if such written contract requires that this policy include such natural person or organization as an insured hereunder.

However, coverage for such “insured” under this endorsement is limited as follows:

a. If the Limits of Insurance stated in the Declarations exceed the limits of insurance required by such contract, the insurance provided by this endorsement shall be limited to the limits of insurance required by such written contract. This endorsement shall not increase the Limits of Insurance stated in the Declarations.

b. If Professional Liability coverage is selected above, such natural person or organization is an “insured” only for liability arising solely out of “healthcare professional services” performed by you or on your behalf for such “insured” and within the scope of your written contract with such “insured”.

c. If General Liability coverage is selected above, such natural person or organization is an “insured” only for “bodily injury”, “property damage” or “personal or advertising injury” caused by an “occurrence” or offense that was caused solely by:

i. you or your “employees” acting on your behalf; and

ii. performed on behalf of such “insured” and within the scope of your written contract with such “insured”.

d. Where no coverage shall apply herein for the Named Insured, no coverage or defense shall be afforded to such “insured”.

e. It is a condition precedent to coverage hereunder that all such organizations and written contracts be reported in writing to us on a quarterly basis during each calendar year.

2. If the General Liability Coverage Part is indicated by a check mark above, the Additional Exclusions section of the General Liability Coverage Part is amended by adding the following directly following paragraph 2b of the Contractual Liability exclusion:

PF-50055 (03/18) Page 1 of 2 Primary FAC (216056)

Attachment Code: D556818 Certificate ID: 18157279

3. Assumed in a contract reported to us on a quarterly basis pursuant to the Additional Insured(s) Endorsement: Written Contract, Quarterly Reporting, Form No.: PF-50055.

3. If the Professional Liability Coverage Part is indicated by a check mark above, the Additional Exclusions section of the Professional Liability Coverage Part is amended by adding the following directly following paragraph 2b of the Contractual Liability exclusion:

3. Assumed in a contract reported to us on a quarterly basis pursuant to the Additional Insured(s) Endorsement: Written Contract, Quarterly Reporting, Form No.: PF-50055.

All other terms and conditions of this policy remain unchanged.

Authorized Representative

PF-50055 (03/18) Page 2 of 2 Primary FAC (216056)

Attachment Code: D556818 Certificate ID: 18157279

POLICY NUMBER: BAP 2519669-03 COMMERCIAL AUTO

CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVEARGE

This endorsement modifies insurance provided under the following:

AUTO DELEARS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

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

Named Insured: Pyramid Health Holdings, LLC

Endorsement Effective Date: 10/19/2021

SCHEDULE

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

Only those organizations required by written contract

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

Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in teh Business Auto and Motor Carrier Coverage Forms Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form.

CA 20 48 10 13 Copyright, Insurance Services Office, Inc., 2011 Page 1 of 1

Attachment Code: D557359 Certificate ID: 18157279

POLICY NUMBER: BAP 2519669-03 COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US

(WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

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

Named Insured: PYRAMID HEALTH HOLDINGS, LLC

Endorsement Effective Date: 10/19/2021

SCHEDULE

Name(s) Of Person(s) Or Organization(s):

ONLY THOSE PERSONS OR ORGANIZATIONS FOR WHOM YOU ARE REQUIRED TO WAIVE YOUR RIGHTS

OF RECOVERY UNDER THE TERMS OF A WRITTEN CONTACT.

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

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

Attachment Code: D557035 Certificate ID: 18157279

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

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

ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT, OR

AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT

WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY

YOU FOR THAT PERSON AND/OR ORGANIZATION

WC 00 03 13 1983 National Council on Compensation Insurance.

(Ed. 4-84) U3024a Policy# WC 2519668-02

WC 00 03 13

(Ed. 4-84) © 1983 National Council on Compensation Insurance.

Attachment Code: D557036 Certificate ID: 18157279