CTR055535_2022-06-15_COI.pdf
PDF 911 KB Posted
- Attached to
- Master Agreement AZ|CTR055535
- Contract number
- CTR055535
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance for MileMarkers Therapy, Inc., issued by Philadelphia Insurance Company, with S. Wolf & Associates, Inc. as the producer. The certificate covers multiple entities, including MileMarkers Therapy, the State of Arizona, the Arizona Department of Economic Security, the Division of Developmental Disabilities, and Lake Havasu City. The insurance policy is effective from June 15, 2021, to June 15, 2022, and includes multiple types of coverage such as Commercial General Liability, Automobile Liability, Umbrella Liability, Workers' Compensation, Professional Liability, and Abuse Molestation coverage.
The policy provides various coverage limits, including $2,000,000 for General Aggregate and Each Occurrence, $1,000,000 for Umbrella Liability, and $3,000,000 for Professional Liability. The insurance is specifically tied to contract CTR055535 and references QVA #05951 and RFPQVA DDD710000. The policy includes additional insured provisions for the State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. Sexual Abuse and Molestation coverage is included, and the policy provides a waiver of transfer of rights of recovery against the specified organizations, ensuring comprehensive protection for the insured parties during the contract period.
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Text version
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
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
8/25/2021
(773) 754-0849
MileMarkers Therapy, Inc.
1515 Lake Havasu Ave N Ste 100 Lake Havasu City, AZ 86404
A 2,000,000
X X PHPK2289073 6/15/2021 6/15/2022 100,000
5,000
2,000,000 2,000,000 2,000,000
100,000A
X X PHPK2289073 6/15/2021 6/15/2022
1,000,000A
PHUB772754 6/15/2021 6/15/2022 1,000,000
B
R2WC216559 2/20/2021 2/20/2022 1,000,000
1,000,000 1,000,000
A Professional Liab. X PHPK2289073 6/15/2021 Ea. 3MIL Agg 3MIL 3,000,000 A Abuse Molestation PHPK2289073 6/15/2021 6/15/2022 Ea 2MIL AGG 4MIL
The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to general & auto liability arising out of the activities performed by or on behalf of the Contractor.Sexual Abuse and Molestation coverage in included.
QVA #05951 and RFPQVA DDD710000 Contract# CTR055535.
State of Arizona Dept of State of Arizona Dept of State of Arizona Dept of PO Box 6123 Phoenix, AZ 85005
MILETHE-01 JBROWN
S. Wolf & Associates, Inc.
2338 W. Morse 1.C Chicago, IL 60645 info@swolfandassociates.com
Philadelphia Insurance Company Berkshire Hathaway GUARD Insurance Companies
X
6/15/2022
X
X
X
X X
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