CTR055525_2022-07-1_COI.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

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 EXPTYPE 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 RENTEDCLAIMS-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 AGGJECT

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 LIMITDESCRIPTION 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.ACORD 25 (2016/03)

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

The ACORD name and logo are registered marks of ACORD

6/30/2021

10328

Casa De Los Ninos, Inc.

1120 N. 5th Avenue Tucson, AZ 85705

19100

11074

A 1,000,000

HS20212433-01 7/1/2021 7/1/2022 100,000

20,000

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

1,000,000B

ACP3009789796 7/1/2021 7/1/2022

5,000,000A

HS20212434-01 7/1/2021 7/1/2022 5,000,000

C 1003495 7/1/2021 7/1/2022 1,000,000

Y 1,000,000 1,000,000

A Professional Liabili HS20212433-01 7/1/2021 See Remarks D Crime ACP3009789796 7/1/2021 7/1/2022 SEE REMARKS

The State of Arizona, and its Departments, Agencies, Boards, Commissions, Universities, Officers, Agencies and Employees are included as additional insured with a waiver of subrogation with respect to General Liability, Auto Liability arising out of the activities performed on or on behalf of the contractor.

Blanket Waiver of Subrogation applies on the Workers Compensation.

Regarding Pending Contracts - FC, NPP, SENSE.

The State of Arizona, and its Departments, Agencies, Boards, Commissions, Universities, Officers, Agencies and Employees are included as additional insured with a waiver of subrogation with respect to General Liability, Auto Liability arising out of the activities performed on or on behalf of the contractor;

Policy form CGL461 and CCA207. Blanket Waiver of Subrogation applies on the Workers Compensation.

State of Arizona, Dept of Child Safety Office of Procurement & Contracts 30003 N Central Ave 20th Floor Phoenix, AZ 85012

CASADEL-17 FORTIZ

Tucson, AZ-The Clements Agency-HUB International Insurance Services

(NMX)

6245 E Broadway Blvd Suite 310 Tucson, AZ 85711

Faith Ortiz faith.ortiz@hubinternational.com

Capitol Specialty Insurance Corporation AMCO Insurance Company CopperPoint Indemnity Insurance Company Selective Insurance Company of New Jersey

X

7/1/2022

X X

X

X

X X

FORM NUMBER:

EFFECTIVE DATE:

The ACORD name and logo are registered marks of ACORD

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE

FORM TITLE:

Page of

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

ACORD 101 (2008/01)

AGENCY CUSTOMER ID:

LOC #:

AGENCY NAMED INSURED

POLICY NUMBER

CARRIER NAIC CODE

© 2008 ACORD CORPORATION. All rights reserved.

Tucson, AZ-The Clements Agency-HUB International Insurance Services (NMX)

CASADEL-17

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

Casa De Los Ninos, Inc.

1120 N. 5th Avenue Tucson, AZ 85705 Pima

SEE PAGE 1

FORTIZ

Professional Professional Liability - Claims Made $1,000,000 - Each Wrongful Act $3,000,000 - Aggregate 09/14/1988 - Claims Made Retro Date

Scheduled professionals should read as follows:

- Dr Howard Lin

- Dr. Wenhui Cai

Nurse Practitioner Christine Reynolds

Independently Licensed Professionals Jessica Barnes Sari Emami Laura Epperson Catherine Horton Lourdes Lopez-Escobar Shawna McKee Farrah Sanchez Bruce Kahler Cassaundra Loller Sean Seeba Ruben Aroz Letha Grady Odessa Hancock Jennifer Key Cathleen Phelan Kristin Burns

Crime $1,000,000 - Employee Theft $10,000 – Deductible

Sexual or Physical Abuse Liability - Claims Made $1,000,000 - Each Wrongful Act $3,000,000 - Aggregate 09/14/1988 - Claims Made Retro Date

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 BLANKET

Blanket Waiver: Anyone for whom you have agreed to provide this Waiver subject to the terms of this endorsement

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.)

07/01/2021Endorsement Effective 1003495Policy No. 7Endorsement No.

Casa De Los NinosInsured Premium $

CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.