CTR057399_COI_Exp_2021.12.1.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)

© 1988-2016 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Deductible: 500,000

LOS-002563248-03

1,000,000

AZ,CO,FL,IL,TX,NV,MO,MI,MN,TN,UT

27960

AggregateXS $2MM Retained Limit

Phoenix, AZ 85016

N

X12/01/2020

12/01/2021

12/01/2020

24988

901893502

Medical Prof Liab Claims Made

D

N/A Illinois Union Insurance Co

1,000,000

X

B

10/19/2021

15,000,000

15,000,000

RE: Contract CT057399, BPM003737, Refugee Program – Health Promotion. State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are Additional Insureds on a primary basis, (Except Workers Compensation) as required by written contract and subject to policy terms and conditions. Waiver of Subrogation applies in favor of State of Arizona, and

Phoenix, AZ 85007

ADES

Sentry Insurance A Mutual Co its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. Notice of Cancellation applies per attached forms. Sexual Abuse and Molestation coverage is not excluded.

N/A

CN101622780-STND-AWXE-20-21

Each Incident/Occurrence

12/01/2021

1,000,000

& GL/Umbrella Occurrence

N/A

1,000,000

12/01/2021

901893501

2325 E. Camelback Road Marsh USA Inc.

Suite 600

Attn: healthcare.accountscss@marsh.com Fax: 212-948-1307

District Maricopa County Special Health Care

Phoenix, AZ 85008 2601 E. Roosevelt

XHLG46842169003

12/01/2020

1789 W Jefferson

D

N/A

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 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:

your convenience. The Workers Compensation placements were made by Lovitt-Touche (Workers Compensation Policies 901893501 and 901893503). Marsh USA Inc. has only acted in the role of a consultant

Employers Liability Disease-Policy Limit: $1,000,000 �

Employers Liability Each Accident: $1,000,000 �

Phoenix

Policy Number: 901893503 �

Sentry Casualty Company �

States: OK and WI�

Additional Workers Comp: �

Certificate of Liability Insurance

CN101622780

Employers Liability Disease-Each Employee: $1,000,000 ��

The Automobile placement was made by Lovitt-Touche (Auto Policy 901893502). Marsh USA Inc. has only acted in the role of a consultant to the client with respect to this placement, which is indicated here for to the client with respect to these placements, which is indicated here for your convenience. ��

Marsh USA Inc.� District� Maricopa County Special Health Care�

Phoenix, AZ 85008 2601 E. Roosevelt�