CTR056121_Certificate_of_Insurance_2023-04-01.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

3/24/2022

Lovitt & Touché A Marsh and McLennan Agency, LLC 1050 W Washington Street, Suite 233 Tempe AZ 85281

Lindsey Brundage 602-385-0535 602-956-2258 lbrundage@lovitt-touche.com

AMCO Insurance Company 19100 CENTE-9 Nationwide Mutual Insurance Company 23787

The Centers for Habilitation The Centers for Habilitation Enterprises, LLC dba ASDD 215 W. Lodge Drive Tempe AZ 85283

CopperPoint General Insurance Company 13043

1161116925

B X 1,000,000 X 1,000,000

20,000

1,000,000

3,000,000 X

Y Y ACP3039178513 4/1/2022 4/1/2023

3,000,000

B 1,000,000

X

Y Y ACPBA3039178513 4/1/2022 4/1/2023

A X X 5,000,000ACPCAA3039178513 4/1/2022 4/1/2023

5,000,000 X 0

C XY 1015685 4/1/2022 4/1/2023

1,000,000

1,000,000

1,000,000 B

Professional Liability Sexual Abuse & Molestation

ACP3039178513 4/1/2022 4/1/2023 Per Claim $1,000,000 $1,000,000

Per Aggregate $3,000,000 $3,000,000

The above-indicated Additional Insured and Waiver of Subrogation are provided with respects to General Liability when required in a written and executed contract.

The above-indicated Additional Insured is provided with respects to Automobile Liability when required in a written and executed contract.

Umbrella Liability, $5,000,000 is excess of General Liability, Automobile Liability, Employers Liability, Professional Liability and Sexual Abuse & Molestation.

Re: Contract Numbers ADES16-099585 and ADES17-191574 See Attached...

State of Arizona Department of Economic Security 1789 W. Jefferson St. 2nd FL, NW, Mail Drop 53C1 Phoenix AZ 85007

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY)

3/24/2022

(AIC,

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).

PRODUCER

Lovitt & Touché A Marsh and McLennan Agency, LLC 1050 W Washington Street, Suite 233 Tempe AZ 85281

CONTACT .

NAME: Lindsey Brundage

PHONE

No, Ext): 602-385-0535 602-956-2258 FAX (A/C, No):

E-MAIL

ADDRESS: Ibrundage@Iovitt-touche.com

INSURER(S) AFFORDING COVERAGE NAIC #

INSURERA: AMCO Insurance Company 19100

INSURED

The Centers for Habilitation The Centers for Habilitation Enterprises, LLC dba ASDD 215 W. Lodge Drive Tempe AZ 85283

CENTE 9 INSURER B : Nationwide Mutual Insurance Company 23787 INSURERCI Copperpoint General Insurance Company 13043

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: 1161116925 REVISION NUMBER:

TYPE OF INSURANCE LIMITS POLICY NUMBER

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.

ADDL$UBR POLICY EFF POLICY EXP

INSD WVD (MM/DD/YYYY) (MM/DD/YYYY)

ADDL

INSD

SUBR

WVD

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

B COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

PRO-

JECT POLICY

OTHER:

LOC

B AUTOMOBILE LIABILITY

ANY AUTO

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

A X UMBRELLA LIAB

EXCESS LIAB

X OCCUR

CLAIMS-MADE

DED X RETENTION $ n

Y Y ACP3039178513 4/1/2022 4/1/2023

Y Y ACPBA30391 78513 4/1/2022 4/1/2023

ACPCAA3039178513 4/1/2022 4/1/2023

C WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y I N

ANYPROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBEREXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

N I A

Y 1015685 4/1/2022 4/1/2023

EACH OCCURRENCE $ 1 ,000,000

DAMAGE TO RENTED

PREMISES (Ea occurrence) $ 1 ,000,000 MED EXP (Any one person) $20,000

PERSONAL & ADV INJURY $ 1 ,000,000

GENERAL AGGREGATE $ 3,000,000

PRODUCTS - COMP/OP AGG $ 3,000,000

COMBINED SINGLE LIMIT

(Ea accident) $ 1 ,000,000 BODILY INJURY (Per person) $

BODILY INJURY (Per accident) $

PROPERTY DAMAGE

(Per accident) $

EACH OCCURRENCE

AGGREGATE

$ 5,000,000

$ 5,000,000

X PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT $ 1,000,000

E.L. DISEASE - EA EMPLOYEE $ 1,000,000

E.L. DISEASE - POLICY LIMIT $ 1,000,000

B

Professional Liability Sexual Abuse & Molestation

ACP3039178513 4/1/2022 4/1/2023 Per Claim $1 000,000 $1 000,000

Per Aggregate $3 000,000 $3 000,000

DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

The above-indicated Additional Insured and Waiver of Subrogation are provided with respects to General Liability when required in a written and executed contract.

The above-indicated Additional Insured is provided with respects to Automobile Liability when required in a written and executed contract.

Umbrella Liability, $5,000,000 is excess of General Liability, Automobile Liability, Employers Liability, Professional Liability and Sexual Abuse & Molestation.

Re: Contract Numbers ADES16-099585, and ADES17-191574 See Attached...

CERTIFICATE HOLDER CANCELLATION

State of Arizona Department of Economic Security 1789 W. Jefferson St. 2nd FL, NW, Mail Drop 53C 1 Phoenix AZ 85007

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

al t5»~/

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights resewed.

The ACORD name and logo are registered marks of ACORD and CTR056121

ACORD 101 (2008/01)

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

CENTE-9

1 1

Lovitt & Touché A Marsh and McLennan Agency, LLC The Centers for Habilitation The Centers for Habilitation Enterprises, LLC dba ASDD 215 W. Lodge Drive Tempe AZ 85283

25 CERTIFICATE OF LIABILITY INSURANCE

General Liability:

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

Policy contains a waiver of subrogation in favor of the 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.

Automobile Liability:

The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees are named additional insured with respect to liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles owned, hired or borrowed by the Contractor.

Policy contains a waiver of subrogation in favor of the 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.

Worker's Compensation:

Policy contains a waiver of subrogation in favor of the 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.

AGENCY CUSTOMER ID:

LOC #:

CENTE-9

® w ACOR ADDITIONAL REMARKS SCHEDULE Page of 1 1

AGENCY

Lovitt & Touché A Marsh and McLennan Agency, LLC

NAMED INSURED

The Centers for Habilitation The Centers for Habilitation Enterprises, LLC dba ASDD 215 W. Lodge Drive Tempe AZ 85283

POLICY NUMBER

CARRIER NAIC CODE

EFFECTIVE DATE:

ADDITIONAL REMARKS

25 CERTIFICATE OF LIABILITY INSURANCE

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

General Liability:

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

Policy contains a waiver of subrogation in favor of the 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.

Automobile Liability:

The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees are named additional insured with respect to liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles owned, hired or borrowed by the Contractor.

Policy contains a waiver of subrogation in favor of the 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.

Worker's Compensation:

Policy contains a waiver of subrogation in favor of the 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.

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights resewed.

THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS,

COMMISSIONS, UNIVERSITIES AND ITS OFFICERS, OFFICIALS,

AGENTS, AND EMPLOYEES ARE NAMED ADDITIONAL INSURED WITH

TO LIABILITY ARISING OUT OF THE ACTIVITIES PERFORMED BY OR

ON BEHALF OF THE CONTRACTOR.

ACP GLO 3039178513 LO78 22158 INSURED COPY 46 0001046

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 24 04 05 09

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 OPERATIO NS 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.

All terms and conditions of this policy apply unless modified by this endorsement.

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

ACP GLO 3039178513 LO78 22087 INSURED COPY 46 0008841

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.

COMMERCIAL AUTO

AC 20 41 03 16

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – PRIMARY AND

NON-CONTRIBUTORY ENDORSEMENT

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

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

SCHEDULE

THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS

COMMISSIONS, UNIVERSITIES AND ITS OFFICERS, OFFICIALS,

AGENTS, AND EMPLOYEES ARE NAMED ADDITIONAL INSURED WITH

SEE BLANK FORM

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.)

A. d for PWho Is An Insure COVERED AUTOS rimary And Noncontributory Insurance LIABILITY COVERAGE is amended to include as

This insurance is primary to and will not seekan “insured” for Covered Autos Liability Coverage:

contribution from any other insurance available to

Each person or organization shown in the the person or organization named in the Schedule Schedule, but only to the extent that person or under your policy provided that:

organization qualifies as an “insured”. The (1) The person or organization is a Named “accident” must arise out of ongoing operations insured under such other insurance; and performed for the Named Insured.

(2) You have agreed in writing in a contract or agreement that this insurance would beB. Changes in CONDITIONS primary and would not seek contribution from any other insurance available to them.The following is added to the Other Insurance

Condition and supersedes any provision to the contrary:

AC 20 41 03 16 Page 1 of 1Includes copyrighted material of Insurance Services Office, Inc., with its permission.

ACP BA 30-3-9178513 LE9P 22095 INSURED COPY AC2041031600 0220 46 0002655

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.

SCHEDULE

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

STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARD

S, COMMISSIONS, UNIVERSITIES AND ITS OFFICERS, OFF

ICIALS, AGENTS, AND EMPLOYEES FOR LOSSES ARISING

SEE BLANK FORM

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 Page 1 of 1© Insurance Services Office, Inc., 2011

ACP BA 30-3-9178513 LE9P 22095 INSURED COPY CA0444101300 0200 46 0002656

GU 207 (06-78)

ENDORSEMENT

The policy is changed as follows:

COMPLETE NAME OF ADDITIONAL INSURED

RE: AC2041

THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS,

UNIVERSITIES AND ITS OFFICERS, OFFICIALS, AGENTS, AND EMPLOYEES ARE NAMED

ADDITIONAL INSURED WITH RESPECT TO LIABILITY ARISING OUT OF THE ACTIVITIES

PERFORMED BY OR ON BEHALF OF THE CONTRACTOR, INVOLVING AUTOMOBILES OWNED,

HIRED OR BORROWED BY THE CONTRACTOR.

ACP BA 30-3-9178513 LE9P 22095 INSURED COPY GU207 067800 2496 46 0002657

ENDORSEMENT

The policy is changed as follows:

COMPLETE NAME OF ADDITIONL INSUED

RE: CA0444

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

ACP BA 30-3-9178513 LE9P 22095 INSURED COPY GU207 067800 2496 46 0002658

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.

State Schedule

Blanket/Schedule/State

AZ State of Arizona. Policy contains a waiver of subrogation in favor of the 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.

This document may have been uploaded to the CopperPoint Portal.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 04/01/2022 Insured The Centers for Habilitation

Policy No. 1015685 Endorsement No. 19 Premium $ 100

Insurance Company CopperPoint Indemnity Insurance Company Countersigned by

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B

(Version 7/01)

POLICY INFORMATION PAGE ENDORSEMENT

The following item(s)

Insured’s Name (WC 89 06 01) Expiration Date (WC 89 06 04) Insured’s Mailing Address (WC 89 06 05) Experience Modification (WC 89 04 06) Producer’s Name (WC 89 06 07) Change in Workplace of Insured (WC 89 06 08) Insured’s Legal Status (WC 89 06 10) Item 3.A. States (WC 89 06 11)

Item 3.B. Limits (WC 89 06 12) Item 3 .C. States (WC 89 06 13)

✔ Item 3.D. Endorsement Numbers (WC 89 06 14) Item 4.* Class, Rate, Other (WC 89 04 15)

✔ Interim Adjustment of Premium (WC 89 04 16) Interstate/Intrastate Risk ID Number (WC 89 06 18) Issuing Agency/Producer Office Address (WC 89 06 25)

Is changed to read:

Total Estimated Annual Premium: $74,093

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

This document may have been uploaded to the CopperPoint Portal.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 04/01/2022 Insured The Centers for Habilitation

Policy No. 1015685 Endorsement No. 18 Premium $ 74,093

Insurance Company CopperPoint Indemnity Insurance Company Countersigned by

WC 89 06 00 B

(Version 7/01)

© Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved.