CTR061004_Certificate_of_Insurance.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

PHOENIX AZ 85007

1789 W JEFFERSON ST

State of Arizona Department of Economic Security

Contract Number: CTR061004 applies.

Sexual Abuse and Molestation Coverage is included.

Senior In Home Care LLC dba A Country Retreat is listing the The State of Arizona Department of Economic Security as Additional Insured per Contractual Requirements.

Waivers of Subrogation are in effect.

Senior In Home Care LLC dba A Country Retreat holds harmless : The STATE OF ARIZONA, its departments, agencies, boards, commissions, universities and all officers, officials, agents, and employees of these entities for losses arising from work performed by or on behalf of the Contractor.

3,000,000General Aggregate

1,000,000Each Occurrence

08/01/202308/01/20226002659-1 Professional Liability

A

1,000,000

1,000,000

1,000,000

06/30/202306/30/2022WCAZ000066500YYB

1,000,000

1,000,000

08/01/202308/01/20226002660-1Y✘

✘A

1,000,000

08/01/202308/01/20226002659-1YY✘A

3,000,000

3,000,000

1,000,000

10,000

1,000,000

1,000,000

08/01/202308/01/20226002659-1YY

Sexual Abuse and Molestation✘

A

12262Pennsylvania Manufacturers' Association Insurance Co

14329Social Services Contractor Indemnity Pool

86005-8829AZFLAGSTAFF

412 OLD MUNDS HWY

Senior In Home Care LLC dba A Country Retreat jimcoegoodnews@gmail.com

928 527 7506(928) 527-4179

Jim Coe

86004AZFlagstaff

2708 E Rt. 66

Good News Ins & Fin'l Svcs Inc. AZ

8/22/2022

Social Service Contractors Indemnity Pool

WHO IS AN INSURED - ADDITIONAL INSURED_SSCOMMAIAZ_08/21

SSCOMMAIAZ (08-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WHO IS AN INSURED - ADDITIONAL INSURED

Policy Number: 6002659-1 Effective Date: 08/01/2022 This endorsement modifies insurance provided under the following:

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION COVERAGE FORM

BUSINESS AUTO COVERAGE FORM (coverage applies to owned, leased, hired or borrowed vehicles) COMMERCIAL GENERAL LIABILITY COVERAGE FORM (including Products-Completed Operations Coverage)

Schedule:

Name Of Additional Insured Entities:

The State of Arizona, its departments, agencies, boards, commissions, and universities, and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the Contractor.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The section entitled “Who is an Insured” in each of the coverage forms set forth above is amended to include as an insured the person or organization shown in the schedule, but only with respect to liability for injury or damage resulting from your operations performed for that insured and caused by your acts or omissions.

All other terms and conditions remain unchanged.

Social Service Contractors Indemnity Pool

WAIVER OF TRANSFER RIGHTS OF RECOVERY_SSCOMMWOSAZ_08/21

SSCOMMWOSAZ (08-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER RIGHTS OF RECOVERY

Policy Number: 6002659-1 Effective Date:08/01/2022

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL ABUSE LIABILITY COVERAGE FORM

SCHEDULE

Name of Person or Organization: the State of Arizona, its departments, agencies, boards, commissions, universities and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the contractor.

1. The TRANSFER OF RIGHTS OF RECOVERY Condition (Section IV COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:

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 damages arising out of your ongoing operations or "your work" done under a contract for 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.

2. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) is amended by the addition of the following:

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 damages for “bodily injury” or “property damage” to which this insurance applies.

3. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV PROFESSIONAL LIABILITY CONDITIONS) is amended by the addition of the following:

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 “damages” resulting from a “wrongful act” to which this insurance applies.

4. The TRANSFER OF RIGHTS OF RECOVERY Condition (Section D., SEXUAL OR PHYSICAL ABUSE OR MOLESTATION CONDITIONS) is amended by the addition of the following:

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 damages due to “abuse” to which this insurance applies.

All other terms and conditions remain unchanged.

8/26/22, 9:40 AM State of Arizona Mail - FW: SENIOR IN HOME CARE LLC WCAZ000066500 https://mail.google.com/mail/u/0/?ik=0ff9c9de1d&view=pt&search=all&permthid=thread-f%3A1741988374865847830&simpl=msg-f%3A1741988374865847830 1/2

Virginia Dominguez <vdominguez@azdes.gov>

FW: SENIOR IN HOME CARE LLC WCAZ000066500

1 message jimcoegoodnews@gmail.com <jimcoegoodnews@gmail.com> Tue, Aug 23, 2022 at 2:19 PM To: Virginia Dominguez <vdominguez@azdes.gov>, jfajardo@ades.gov, info@seniorinhomecarellc.com

Workers Comp Wording.

Please see below.

This is from the company.

Thanks, Jim Coe

Property & Caualty Agent

Commercial and Personal Lines

Good News Insurance and Financial Services inc.

2708 E Route 66

Flagstaff, AZ 86004

928 527 4179

928 527 7506 fax

928 853 0101 cell jimcoegoodnews@gmail.com

From: Pederson, Letisha <lpederson@ormarks.com>

Sent: Tuesday, August 23, 2022 2:12 PM https://www.google.com/maps/search/2708+E+Route+66++Flagstaff,+AZ+86004?entry=gmail&source=g https://www.google.com/maps/search/2708+E+Route+66++Flagstaff,+AZ+86004?entry=gmail&source=g mailto:jimcoegoodnews@gmail.com mailto:lpederson@ormarks.com

8/26/22, 9:40 AM State of Arizona Mail - FW: SENIOR IN HOME CARE LLC WCAZ000066500 https://mail.google.com/mail/u/0/?ik=0ff9c9de1d&view=pt&search=all&permthid=thread-f%3A1741988374865847830&simpl=msg-f%3A1741988374865847830 2/2

To: 'Jim Coe' <jimcoegoodnews@gmail.com>

Subject: SENIOR IN HOME CARE LLC WCAZ000066500

Good afternoon Jim, We received your request to add wording to the State of Arizona waiver of subrogation (“wos”). Please be advised, we cannot include the additional wording as it is not approved/allowed in the workers compensation ARP. In short, it “assumes” a blanket wos to which is not approved/allowed.

Thank you

Please submit all responses, requests, inquires, etc. to policyservices@ormarks.com to avoid delays

Letisha Pederson

Underwriting Technician: AZ & DE

O: (877) 347-3596 Fax: (612) 902-9241 lpederson@ormarks.com

Old Republic Residual Market Services ‘ORMARKS’

400 2nd Avenue South, Ste 250 Minneapolis, MN 55401-2499 www.ormarks.com

Policy Change Requests: Policyservices@ormarks.com

Attention:

The information contained in this message and or attachments is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and delete the material from any system and destroy any copies. (ORI) mailto:jimcoegoodnews@gmail.com mailto:policyservices@ormarks.com mailto:lpederson@ormarks.com http://www.ormarks.com/ mailto:Policyservices@ormarks.com