CTR057909_COI_11.01.2025.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

7/18/2025

Arthur J. Gallagher Risk Management Services, LLC 101 S Main St Ste 200 Decatur IL 62523

Christina Larson 217-233-3315 217-428-0865 christina_larson@ajg.com

Selective Insurance Company of SC 19259 SILVBIR-03 United Wisconsin Insurance Company 29157

3rd and Indian School Assisted Living Facility, LLC Solterra 3rd Indian School Operations, LLC 4000 N 3rd Ave.

Phoenix AZ 85013

Columbia Casualty Company 31127

305892374

C X 1,000,000 X 100,000

100,000

1,000,000

3,000,000 X

Y Y PLC8033139020 8/1/2025 8/1/2026

1,000,000

A 1,000,000

X

X X

Y Y S 2546678-03 8/1/2025 8/1/2026

C X 5,000,000 X

UMB8033328069 8/1/2025 8/1/2026

B XY 100084926 11/1/2024 11/1/2025

1,000,000

1,000,000

1,000,000 C Professional Liability Y PLC8033139020 8/1/2025 8/1/2026 Per Claim

Aggregate $1,000,000 $3,000,000

RE: Contract #: CTR057909 | Description: Assisted Living Facility

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 are listed as Additional Insured with respects to General Liability, Automobile Liability and Professional Liability. A waiver of subrogation applies to the General Liability, Automobile Liability and Workers Compensation. Sexual Abuse and Molestation coverage is not excluded.

Both General Liability and Professional Liability are written on a claims-made basis. Contractor warrants that any retroactive date under both the General See Attached...

The State of Arizona Department of Economic Security c/o myCOI P.O. Box 501970 8710 Bash Street Indianapolis, IN 46256

USA

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:

SILVBIR-03

1 1

Arthur J. Gallagher Risk Management Services, LLC 3rd and Indian School Assisted Living Facility, LLC Solterra 3rd Indian School Operations, LLC 4000 N 3rd Ave.

Phoenix AZ 85013

25 CERTIFICATE OF LIABILITY INSURANCE

Liability and Professional Liability policy shall precede the effective date of this Contract; and that either continuous coverage will be maintained or an extended discovery period will be exercised for a period of two (2) years beginning at the time work under this Contract is completed.

LTC.P.019 (5.08 ed.) Page: 1 of 1

IRONSHORE SPECIALTY INSURANCE COMPANY

175 Berkeley Street Boston, MA 02116

Toll Free: (877) IRON411

Endorsement # 29

Policy Number: HC7CACKG5B003 Effective Date of Endorsement: February 01, 2025 Insured Name: Silver Birch Living, LLC

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED ENDORSEMENT

In consideration of the premium charged:

1. The term “Insured,” as defined in the Policy, shall be deemed to include each person or entity listed below (each an “Additional Insured”), but only with respect to liability of any such Additional Insured that is based on or arises out of a Claim for which coverage would otherwise be afforded to the original Insured under this Policy.

Additional Insured(s):

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

2. It is understood and agreed that each Additional Insured listed above is being afforded coverage under this Policy for any liability incurred solely as a result of the acts, errors or omissions of the original Insured. No coverage will be available under this Policy for any Claim based on or arising out of any actual or alleged independent or direct liability of any Additional Insured.

3. The Insurer will provide the Additional Insured(s) identified above with at least ten (10) days’ written notice of cancellation or non-renewal of this Policy if such cancellation or non-renewal is for non-payment of premium, or sixty (60) days’ written notice of cancellation or non-renewal if such cancellation or non-renewal is for any other reason.

ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS OF THIS POLICY REMAIN UNCHANGED.

LTC.P.068 (03/09 Ed.) Page 1 of 1

175 Berkeley Street Boston, MA 02116

Toll Free: (877) IRON411

Endorsement # 30

Policy Number: HC7CACKG5B003 Effective Date of Endorsement: February 01, 2025 Insured Name: Silver Birch Living, LLC

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF SUBROGATION RIGHTS FOR GENERAL LIABILITY PAYMENTS

In consideration of the premium charged, the Ins agrees to waive its right to be subrogated to the extent of any payment s under INSURING AGREEMENT (B) of this Policy to rights of recovery of the Insured against the following third party(ies):

Third Party(ies):

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

GENERAL CONDITION (K) will be deemed amended to effect the purpose and intent of this endorsement.

ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS OF THIS POLICY REMAIN UNCHANGED.

LTC.P.012 (03/09 Ed.) Page 1 of 1

175 Berkeley Street Boston, MA 02116

Toll Free: (877) IRON411

Endorsement # 32

Policy Number: HC7CACKG5B003 Effective Date of Endorsement: March 01, 2025 Insured Name: Silver Birch Living, LLC

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

AMEND DEFINITION OF “NAMED INSURED” TO INCLUDE ADDITIONAL

ENTITIES

In consideration of the premium charged, the term “Named Insured,” as defined in Section II DEFINITIONS of the Policy, is amended to include each of the following entities, but solely with respect to Wrongful Acts committed or allegedly committed, or Occurrences happening, on or after the Retroactive Date:

Additional Named Insured(s)

Silver Birch Midtown Manager, LLC Silver Birch Midtown GP, LLC 3rd and Indian School Assisted Living Facility, LLC

All other terms, conditions and limitations of this Policy shall remain unchanged.

Aging Services Healthcare Primary

Insured Name

SILVER BIRCH LIVING, LLC

121 W WACKER DR STE 400

CHICAGO, IL 60601-1781

Policy Number

PLC 8033139020

Policy Period

08/01/2025 to 08/01/2026

PolicyChange

Producer Information

RISK PLACEMENT SERVICES INC

300 S RIVERSIDE PLZ STE 1500

CHICAGO, IL 60606-6637

Producer Processing Code

977-021440

CNA Branch

CHICAGO

151 N. Franklin Street Chicago, IL 60606

Thank you for choosing CNA!

With your Aging Services Healthcare Primary policy, you have insurance coverage tailored to meet the needs of your business. The international network of insurance professionals and the financial strength of CNA, rated "A" by A.M. Best, provide the resources to help you manage the daily risks of your organization so that you may focus on what’s most important to you.

Claim Services

To file a claim contact us at:

Email: HPReports@CNA.com

Fax#: 800-446-8632

Mailing Address: Aging Services CNA Claims Reporting P.O. Box 8317 Chicago, IL 60680-8317

Please send endorsement requests on this policy to CNA at: ciet@cna.com.

© Copyright CNA All Rights Reserved.

Policy Schedule

AMENDMENT OF FORMS AND ENDORSEMENTS SCHEDULE

ADDITION OR DELETION OF ENDORSEMENTS

It is understood and agreed as follows:

I. ADDITION OF FORMS OR ENDORSEMENTS

The Forms and Endorsements Schedule is amended to add the following forms or endorsements effective as of the date set forth in such form or endorsement.

Endorsement Number

Form or Endorsement Name Form Number Edition Date

29 AMENDMENT OF FORMS AND ENDORSEMENTS

SCHEDULE ADDITION OR DELETION OF

ENDORSEMENTS

CNA62673XX 01-2016

30 AMENDMENT OF SCHEDULE ON SPECIFIED

ENDORSEMENT

CNA62656XX 09-2012

II. DELETION OF FORMS OR ENDORSEMENTS

The Forms and Endorsements Schedule is amended to delete the following forms or endorsements effective as of the “deletion date” indicated below.

The net premium change, if any, for the above endorsements in Sections I. and II. is: $0

Surcharge Taxes and Fees changes are (Please note that surcharges and fees are not applicable in New York State):

Total change is: $0

All other terms and conditions of the policy remain unchanged.

This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below.

PLC 8033139020

Endorsement No: 29; Page: 1 of 1 Underwriting Company: Columbia Casualty Company, 151 N Franklin St, Chicago, IL 60606

Form No: CNA62673XX (01-2016) Endorsement Effective Date:

Policy No:

Policy Effective Date: 08/01/2025Endorsement Expiration Date:

Policy Endorsement

AMENDMENT OF SCHEDULE ON SPECIFIED ENDORSEMENT

SCHEDULE

Endorsement Number Specified Endorsements Name Specified Form Number

25 ADDITIONAL INSURED - DESIGNATED PERSON OR

ORGANIZATION ENDORSEMENT

CNA84727XXC

In consideration of the premium paid for this Policy, it is agreed that the endorsements specified above are amended as follows:

A. The following entries are added to the Schedules set forth in the above specified Endorsements:

SCHEDULE

Name Of Additional Insured Person Or Organization

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

All other terms and conditions of the policy remain unchanged.

This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below.

PLC 8033139020

Endorsement No: 30; Page: 1 of 1 Underwriting Company: Columbia Casualty Company, 151 N Franklin St, Chicago, IL 60606

Form No: CNA62656XX (09-2012) Endorsement Effective Date:

Policy No:

Policy Effective Date: 08/01/2025Endorsement Expiration Date: