CTR056092_-_Certification_of_Insurance_2.6.2023_WC_exp_1.1.2023.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 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 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

4/4/2022

(480) 924-1200 (480) 924-1211

18058

Graham County Rehabilitation Center Inc PO Box 870 Safford, AZ 85548

13210

A 1,000,000

X X PHPK2372013 2/6/2022 2/6/2023 100,000

5,000

1,000,000

2,000,000

2,000,000

SEXUAL ABUSE OR 1,000,000

1,000,000A

X X PHPK2372013 2/6/2022 2/6/2023

4,000,000A

PHUB800854 2/6/2022 2/6/2023 4,000,000

10,000 B

X 1009754 1/1/2022 1/1/2023 1,000,000

1,000,000

1,000,000

A Abuse PHPK2372013 2/6/2022 includes molestation 1,000,000

A Prof Liability Aggr PHPK2372013 2/6/2022 2/6/2023 $1,000,000 Ea Claim 2,000,000

Re: CTR056092 - Pre-Employment Transition Services (Pre-ETS) SOCIAL SERVICES ORGANIZATION-ALL EMPLOYEES & SALESPERSONS; STORES-CLOTHING/DRY GOODS-RETAIL

Waiver of Subrogation and Additional Insured status applies with respect to General Liability and Auto Liability in favor of the State of Arizona, its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees' losses arising from work performed by or on behalf of the contractor if required by written contract.

SEE ATTACHED ACORD 101

State of Arizona Department of Economic Security 1789 W Jackson Street Mail Drop #1222 Phoenix, AZ 85007

GRAHCOU-03 WALBR1

Southwest Risk Management, LLC 4801 E McKellips Mesa, AZ 85215 service@southwestrisk.com

Philadelphia Indemnity Insurance Company CopperPoint Casualty Insurance Co

X

2/6/2023

X 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.

Southwest Risk Management, LLC

GRAHCOU-03

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

Graham County Rehabilitation Center Inc PO Box 870 Safford, AZ 85548 Graham

SEE PAGE 1

WALBR1

Description of Operations/Locations/Vehicles:

Waiver of Subrogation status applies with respect to Workers Comp in favor of the State of Arizona, its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees' losses arising from work performed by or on behalf of the contractor if required by written contract.

Sexual Abuse and Molestation Coverage is included.

PI-HS-004D (07/04)

Includes copyright material of the Insurance Services Office, Inc. used with its permission.

PHILADELPHIA INDEMNITY INSURANCE COMPANY

HUMAN SERVICES ORGANIZATION PROFESSIONAL LIABILITY COVERAGE PART

DECLARATIONS

CLAIMS MADE COVERAGE

POLICY NO. Effective date:

12:01 A.M. Standard Time

LIMITS OF INSURANCE

AGGREGATE LIMIT $

EACH PROFESSIONAL INCIDENT LIMIT $

RETROACTIVE DATE

This Insurance Does Not Apply to “Damages” Resulting from a “Professional Incident” Which Occurred Before the Retroactive Date, If Any, Shown Here

(Enter Date or “None” if No Retroactive Date Applies)

BUSINESS DESCRIPTION

Form of Business:

Business Description:

PREMIUM:

FORMS AND ENDORSEMENTS (Other than Applicable Forms and Endorsements Shown Elsewhere in the Policy)

Forms and Endorsements Applying to this Coverage Part and Made Part of this Policy at Time of Issue:

THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.

Includes Copyrighted Material of the Insurance Service Office, Inc Used with its Permission.

PHPK2372013

CORPORATION

Non Prof it Organizat ion

02/ 06/ 2022

$ 13,250.00

04/ 22/ 1994

1,000,000

2,000,000

POLICY CHANGE DOCUMENT

POLICY NO.:

CHANGE EFFECTIVE CHANGE # REVISION #

DESCRIPTION

PHPK2372013

102/06/2022

04/04/2022____________________ Issue Date

Added:

Additional Insured CA0444-Waiver of Subrogation CG2404-Waiver of Subrogation With respects to The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees [as additional insureds] with respect to liability arising out of the activities performed by or on behalf of the Contractor

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees [as additional insureds] with respect to liability arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor.

Per attached

Philadelphia Indemnity Insurance Company

NAMED INSURED

25816 Southwest Risk Management, LLC

Graham County Rehabilitation Center

MAILING ADDRESS PO Box 870 Safford, AZ 85548-0870

POLICY PERIOD: FROM TO at

12:01 A.M. Standard Time at your mailing address shown above.

Path ID 15548743

0.00

NO CHANGE

COUNTERSIGNED BY

(Date) (Authorized Representative)

02/06/2022 02/06/2023

In consideration of the premium reflected, the policy is amended as indicated below:

Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $

Total Prorate

NO CHANGE

Insurance Policy

Page of

$GGLWLRQDO ,QVXUHG Schedule

Policy Number:

Philadelphia Indemnity Insurance Company

PHPK2372013

Div of Developmental Disabilities

Additional Insured

1789 W Jefferson St Site code 791A

B&M Carl Williams Inc, an Arizona, Phoenix, AZ 85007-3202

Phoenix, AZ 85007-3202

Commercial Automobile of Arizona 5875 Castle Creek Parkway, Suite 400

Additional Insured

Indianapolis, IN 46250

AZ Dept of Economic Security

Commercial Automobile

Limited Liability Company 2111 W 1st St

CG2026 - General Liability

Knowledge Services & The State

Thatcher, AZ 85552

Additional Insured

CG2018 - AZ - Loc #2

Kenneth Stroud and Nina Stroud

Additional Insured

2204 N Maple Ave Huachuca City, AZ 85616-8119

AZ Dept of Economic Security Div of Developmental Disabilities

AZ - Loc #5

1789 W Jefferson St Site code 791A

Additional Insured

1 3

Policy Number:

Philadelphia Indemnity Insurance Company

PHPK2372013

and employees [as additional insureds] with respect to liability arising out of

Additional Insured activities performed by or on behalf of the Contractor 1789 W Jackson St

Knowledge Services & The State

Mail Drop 1222

CG2018 - AZ - Loc #6

Additional Insured

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent of Arizona

Phoenix, AZ 85007-3218

5875 Castle Creek Parkway, Suite 400 Indianapolis, IN 46250

CG2026 - General Liability

CG2026 - General Liability

Additional Insured

Christopher Cleland 123 Main St Stafford, AZ 85546

2 3

Policy Number:

Philadelphia Indemnity Insurance Company

PHPK2372013

Additional Insured

The State of Arizona, and its department agencies, boards, commissions, universities, officers, officials, agent and employees [as additional insureds] with respect to liability arising out of activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor 1789 W Jackson St Mail Drop 1222 Phoenix, AZ 85007-3218

CA2048 - AZ - Veh #0 - MANUSCRIPT ENDORSEMENT - AUTO

3 3

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 26 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page of

ADDITIONAL INSURED – DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

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

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

1. In the performance of your ongoing operations;

or

2. In connection with your premises owned by or rented to you.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

PHPK2372013

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

The State of Arizona, and its departmentV agencies, boards, commissions, universities, officers, officials, agentV DQG HPSOR\HHV

3 3

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 24 04 05 09

CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Person Or Organization:

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

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above.

PHPK2372013

The State of Arizona, and its departments, agencies, boards, commissions, officers officials, agents, and employees with respect to liability arising out activities performed by or on behalf of the Contractor

POLICY NUMBER: COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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

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:

Endorsement Effective Date:

SCHEDULE

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

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.

PHPK2372013

02/06/2022

Graham County Rehabilitation Center

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers,officials, agents, and employees with respect to arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor.

1 1

POLICY NUMBER: COMMERCIAL AUTO

CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

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 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:

Endorsement Effective Date:

SCHEDULE

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

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 the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I – Covered Autos Coverages of the Auto Dealers Coverage Form.

PHPK2372013

02/06/2022

Graham County Rehabilitation Center

The State of Arizona, and its departmentV agencies, boards, commissions, universities, officers, officials, agentV DQG HPSOR\HHV

1 1

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

The following is added as additional insured CA2048 and CA0444-Waiver of

Subrogation:

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees [as additional insureds] with respect to liability arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or non-owned by the Contractor.

Addl Insured-The State of Arizona