CTR056103__-_Renewal_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

3/27/2024

(480) 730-4920 (480) 730-4929

18058

The Opportunity Tree 3146 E. Windsor Ave.

Phoenix, AZ 85008

13928

A 1,000,000

X X PHPK2547494 5/1/2023 5/1/2024 100,000

Professional Liab 5,000

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

1,000,000A

X X PHPK2547494 5/1/2023 5/1/2024

5,000,000A

PHPK2547494 5/1/2023 5/1/2024

10,000 B

X 1014567 4/1/2024 4/1/2025 1,000,000 1,000,000 1,000,000

A Sex & Physical Abuse PHPK2547494 5/1/2023 Occurence 1,000,000 A Sex & Physical Abuse PHPK2547494 5/1/2023 5/1/2024 Aggregate 3,000,000

Re: Contract # CTR055503/CTR056103 Social Services Organization; Group Homes - All Employees & Salespersons, Drivers - Subject to policy limitations and exclusions.

The State of Arizona and the Department of Economic Security shall be named as Additional Insureds with respect to General Liability arising out of the activities performed by or on behalf of the Contractor, as required by written contract.

The State of Arizona and the Arizona Department of Economic Security shall be named as Additional Insureds with respect to Auto Liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles

SEE ATTACHED ACORD 101

State of Arizona Department of Economic Security Rehabilitation Services Admin 1789 W. jefferson St 2nd Flr NW Mail Drop 53C1 Phoenix, AZ 85007

THEOPPO-01 PEVANS

The Mahoney Group - Mesa 1835 South Extension Road Mesa, AZ 85210

Philadelphia Indemnity Ins. Co CopperPoint Indemnity Insurance Company

X

5/1/2024

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.

The Mahoney Group - Mesa

THEOPPO-01

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

The Opportunity Tree 3146 E. Windsor Ave.

Phoenix, AZ 85008

SEE PAGE 1

PEVANS

Description of Operations/Locations/Vehicles:

owned, leased, hired or borrowed by the Contractor, as required by written contract.

Policy shall contain a waiver of subrogation 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 or on behalf of the Contractor.

Umbrella Extends to Professional Liability in Order to Satisfy $2Million Occurrence/ $2Million Aggregate Requirement

Sexual and physical abuse is not excluded

MANUSCRIPT (06/11)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – STATE OF ARIZONA

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

HUMAN SERVICES ORGANIZATION PROFESSIONAL LIABILITY COVERAGE FORM

ABUSIVE CONDUCT LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

SCHEDULE

The following provisions are added to the policy:

1. WHO IS AN INSURED is amended to include as an insured the person or organization shown in the above SCHEDULE, but only with respect to their liability for activities performed by you or on your behalf relating to the conduct of your business;

2. The coverage provided by this endorsement includes the assumption of liability in a written or oral contract between the named insured and the person or organization shown in the above SCHEDULE for work performed by you or on your behalf relating to the conduct of your business;

3. The coverage provided by this endorsement only is primary. Any other applicable insurance will apply as excess; and

4. We agree to waive any right of subrogation against the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees” for losses arising from work performed by or on behalf of Subcontractor

Name of Person or Organization: State of Arizona, Department of Economic Security, 1789 W Jefferson, Phoenix, AZ 85007 The State of Arizona, its departments, agencies, boards commissions, universities and its officers, officials, agents, and employees and the Department of Economic Security for losses arising out of the work performed by or on behalf of the Contractor

Policy #PHPK2547494

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

State Blanket/Schedule/State

AZ STATE

State Waiver: State of Arizona, its departments, agencies, boards, commissions, universities, and its officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

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.)

Policy No. 1014567 Endorsement No. 20 Endorsement Effective 04/01/2024 Insured The Opportunity Tree Premium $ 100

Insurance Company CopperPoint Indemnity Insurance Company Countersigned by

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.