CTR059105_-_Certificate_of_Insurance_Expires_10.5.2025.pdf

10/02/2024

AssuredPartners of Arizona, LLC 14805 N 73rd Street

Scottsdale AZ 85260

Celeste Brooks celeste.brooks@assuredpartners.com

Marshall Home for Men Inc 3314 S. 16th Ave.

Tucson AZ 85713

Manufacturers Alliance Insurance Company 36897 Pennsylvania Manufacturers' Association Insurance Company

12262 CopperPoint Indemnity Insurance Company 13928

24-25 GL/PL/EXS/AUTO/

WC

A Y Y 8224011417518 10/05/2024 10/05/2025

1,000,000 100,000 5,000 1,000,000 3,000,000 3,000,000

Employee Benefits 1,000,000

A Y Y 1524011417518 10/05/2024 10/05/2025

1,000,000

B 6024011417518 10/05/2024 10/05/2025 1,000,000

XS over PL

C Y Y 1006343 10/01/2024 10/01/2025 1,000,000 1,000,000 1,000,000

A Abuse/Molestation #8224011417518 Professional Liab #3824011417518 See Policy Numbers to the Left 10/05/2024 10/05/2025

Abuse Occurrence 1,000,000 Prof Occurrence 1,000,000 Prof Aggregate 3,000,000

RE: Divison Name: ADES; Contract ID: CTR059105-Assisted Living. 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 for General Liability and Auto Liability. Waiver of subrogation General Liability and Auto Liability to 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.

Sexual Abuse and Molestation coverage is included.

Policies contain 30 days Notice of Cancellation Workers Compensation: Excluded Officers: Doug Wolfe, David Livingston.

The State of Arizona and Dept of Economic Security C/O: my COI 1075 Broad Ripple Ave Ste #313 Indianapolis IN 46220

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

ΗΜΡΤΘ∆Χ ΒΝΟΞ

ΟΝΚΗΒΞ ΜΤΛΑ∆Θ9 ΒΝΛΛ∆ΘΒΗ≅Κ ≅ΤΣΝ

Β≅ /3 33 0/ 02

ΣΓΗΡ ∆ΜΧΝΘΡ∆Λ∆ΜΣ ΒΓ≅ΜΦ∆Ρ ΣΓ∆ ΟΝΚΗΒΞ− ΟΚ∆≅Ρ∆ Θ∆≅Χ ΗΣ Β≅Θ∆ΕΤΚΚΞ−

Β≅ /3 33 0/ 02 Ηµρτθµβδ Ρδθυηβδρ Νεεηβδ+ Ηµβ−+ 1/00 Οφδ 0 νε 0 ς≅ΗΥ∆Θ ΝΕ ΣΘ≅ΜΡΕ∆Θ ΝΕ ΘΗΦΓΣΡ ΝΕ Θ∆ΒΝΥ∆ΘΞ ≅Φ≅ΗΜΡΣ ΝΣΓ∆ΘΡ ΣΝ ΤΡ ∋ς≅ΗΥ∆Θ ΝΕ ΡΤΑΘΝΦ≅ΣΗΝΜ(

Σγηρ δµχνθρδλδµσ λνχηεηδρ ηµρτθµβδ οθνυηχδχ τµχδθ σγδ ενκκνϖηµφ9

≅ΤΣΝ Χ∆≅Κ∆ΘΡ ΒΝΥ∆Θ≅Φ∆ ΕΝΘΛ

ΑΤΡΗΜ∆ΡΡ ≅ΤΣΝ ΒΝΥ∆Θ≅Φ∆ ΕΝΘΛ

ΛΝΣΝΘ Β≅ΘΘΗ∆Θ ΒΝΥ∆Θ≅Φ∆ ΕΝΘΛ

ςησγ θδροδβσ σν βνυδθφδ οθνυηχδχ αξ σγηρ δµχνθρδλδµσ+ σγδ οθνυηρηνµρ νε σγδ Βνυδθφδ Ενθλ οοκξ τµκδρρ λνχηεηδχ αξ σγδ δµχνθρδλδµσ−

Σγηρ δµχνθρδλδµσ βγµφδρ σγδ ονκηβξ δεεδβσηυδ νµ σγδ ηµβδοσηνµ χσδ νε σγδ ονκηβξ τµκδρρ µνσγδθ χσδ ηρ ηµχηβσδχ αδκνϖ−

Μλδχ Ηµρτθδχ9

∆µχνθρδλδµσ ∆εεδβσηυδ Χσδ9

ΡΒΓ∆ΧΤΚ∆

Μλδ∋ρ( Νε Οδθρνµ∋ρ( Νθ Νθφµηψσηνµ∋ρ(9

Ηµενθλσηνµ θδπτηθδχ σν βνλοκδσδ σγηρ Ρβγδχτκδ+ ηε µνσ ργνϖµ ανυδ+ ϖηκκ αδ ργνϖµ ηµ σγδ Χδβκθσηνµρ−

Σγδ Σθµρεδθ Νε Θηφγσρ Νε Θδβνυδθξ ≅φηµρσ Νσγδθρ Σν Τρ βνµχησηνµ χνδρ µνσ οοκξ σν σγδ οδθρνµ∋ρ( νθ νθφµηψσηνµ∋ρ( ργνϖµ ηµ σγδ Ρβγδχτκδ+ ατσ νµκξ σν σγδ δωσδµσ σγσ ρταθνφσηνµ ηρ ϖηυδχ οθηνθ σν σγδ ��ββηχδµσ�� νθ σγδ ��κνρρ�� τµχδθ βνµσθβσ ϖησγ σγσ οδθρνµ νθ νθφµηψσηνµ−

0412/0,03,06,40,7

ΣΓ∆ ΡΣ≅Σ∆ ΝΕ ≅ΘΗΨΝΜ≅ ≅ΜΧ ΗΣΡ Χ∆Ο≅ΘΣΛ∆ΜΣΡ+ ≅Φ∆ΜΒΗ∆Ρ+ ΑΝ≅ΘΧΡ+

ΒΝΛΛΗΡΡΗΝΜΡ+ ΤΜΗΥ∆ΘΡΗΣΗ∆Ρ+ ΝΕΕΗΒ∆ΘΡ+ ΝΕΕΗΒΗ≅ΚΡ+ ≅Φ∆ΜΣΡ ≅ΜΧ

∆ΛΟΚΝΞ∆∆Ρ ΕΝΘ ΚΝΡΡ∆Ρ ≅ΘΗΡΗΜΦ ΕΘΝΛ ςΝΘϑ Ο∆ΘΕΝΘΛ∆Χ ΑΞ ΝΘ ΝΜ Α∆Γ≅ΚΕ

ΝΕ ΣΓ∆ ΒΝΜΣΘ≅ΒΣΝΘ−

POLICY NUMBER: 822301-14-17-51-8 COMMERCIAL GENERAL LIABILITY

CG 20 2612 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED- DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

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

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.

Information will be shown in the Declarations.

A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

B. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits Of Insurance:

1. In the performance of your ongoing operations;

or

2. In connection with your premises owned by or rented to you.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable limits of insurance;

whichever is less.

This endorsement shall not increase the applicable limits of insurance.

CG 20 2612 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

INSURED COPY

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AZDES COI.pdf