CTR057909_Certificate_of_Insurance_exp._08.03.2023.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

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)

COMMERCIAL GENERAL LIABILITY

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

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

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 LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

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 any 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.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Illinois Union Ins.Co.-NON-ADMITTED

CopperPoint General Insurance Company

Federal Insurance Co

11/02/2022

MJ Insurance, Inc.

3900 E. Camelback Road, Suite 225 Phoenix, AZ 85018 602 772-3300

Kimberly Shedd 317 805-7500 3178057515 certificate@mjinsurance.com

3rd and Indian School Assisted Living Facility, LLC **SEE NAMED INSURED BELOW* 14650 N. 78th Way Bldg B Scottsdale, AZ 85260

27960 13043 20281

A X X

DED $25,000

HPLG71836745 11/01/2022 11/01/2023 1,000,000

50,000 5,000 1,000,000 3,000,000 1,000,000

C X

X X

73619159 11/01/2022 11/01/2023 1,000,000

A X X XHLG71836757 11/01/2022 11/01/2023 5,000,000

5,000,000

B

N

1022049

3A INC: AZ

3C-STATES EXCL:

ALL OTHER STATES

08/03/2022 08/03/2023 X 1,000,000

1,000,000 1,000,000

A

A

PROFESSIONAL

LIABILITY

ABUSE & MOLESTAT

HPLG71836745

DED: $25,000

HPLG71836745

11/01/2022

11/01/2022

11/01/2023

11/01/2023

$1,000,000 PER CLAIM

$3,000,000 AGGREGATE

$1,000,000 AGGREGATE

NAMED INSUREDS INCLUDE: BRIDGEWATER ASSISTED LIVING MIDTOWN; SOLTERRA 3RD INDIAN SCHOOL DEVELOPMENT, LLC;

SOLTERRA 3RD INDIAN OPERATIONS, LLC; SOLTERRA 3RD INDIAN SCHOOL, LLC; INDIAN SCHOOL ASSISTED LIVING FACILITY, LLC; THIRD INDIAN, LLC; SOLTERRA DEER VALLEY DEVELOPMENT, LLC; SOLTERRA DEER VALLEY OPERATIONS, LLC; SOLTERRA DEER VALLEY, LLC; DEER VALLEY ASSISTED LIVING FACILITY, LLC; BRIDGEWATER AVONDALE

OPERATIONS,LLC; AVONDALE VAN BUREN ALF, LLC

(See Attached Descriptions)

Arizona Department of Economic Security 1789 W Jefferson St, Mail drop Phoenix, AZ 85007

#S1466357/M1466348

SOLTSENClient#: 13723

KLK1

#S1466357/M1466348

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1)

Named Insured: Avondale Van Buren ALF, LLC; Bridgewater Avondale Operations, LLC; Bridgewater La Cholla, LLC; Bridgewater La Cholla Holdings, LLC; Bridgewater La Cholla Operations, LLC; Deer Valley Assisted Living Facility, LLC; J-Bar Investments, LLC Two; Solterra 3rd Indian School Operations, LLC;

Solterra At White Mountains Two Ops; Solterra At White Mountains Two, LLC; Solterra Deer Valley Operations, LLC; Solterra La Cholla Operations, LLC; Solterra Management Group, LLC; Solterra Of Arizona, LLC Dba:

Solterra Senior Living; Solterra Team Services, LLC; Third & Indian School Assisted Living Facility, LLC

Holder Cont: Office of Procurement

30 Days Notice of Cancellation, with 10 Days Notice for non-payment of premium, applies to the General Liability, Automobile Liability, Workers Compensation, and Umbrella Liability subject to the terms, conditions and exclusions on the policy(ies).

Sexual abuse and molestation is not excluded

Commercial General Liability: 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.

Business Auto Liability: 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

Contract # CTR057909

#S1466357/M1466348