CTR061004_COI_2025-6-30_GL_AL_WC_PL_SAM.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

3/4/2025

Good News Ins & Fin'l Svcs Inc. AZ

2708 E Rt. 66

Flagstaff AZ 86004

Jim Coe

(928) 527-3852 928 527 7506 jimcoegoodnews@gmail.com

Senior In Home Care LLC dba A Country Retreat

412 OLD MUNDS HWY

FLAGSTAFF AZ 86005-8829

Social Services Contractor Indemnity Pool 14329

Pennsylvania Manufacturers' Association Insurance Co. 12262

A

Y Y 6002659-3 08/01/2023 08/01/2025

1,000,000

1,000,000

10,000

1,000,000

3,000,000

3,000,000

A

Y Y 6002659-3 08/01/2023 08/01/2025

1,000,000

A ✘ ✘ Y Y 6002660-3 08/01/2024 08/01/2025

1,000,000

1,000,000

A Y Y WCAZ000066502 06/30/2024 06/30/2025

1,000,000

1,000,000

1,000,000

A Professional Liability

Y Y 6002659-3 08/01/2023 08/01/2025

Each Occurrence 1,000,000

General Aggregate 3,000,000

Senior In Home Care LLC dba A Country Retreat is listing the State of Arizona, and its Departments, Agencies, Boards, Commissions, Universities, Officers, Officials, Agents, and Employees as Additional Insured per Contractual Requirements.

The State of Arizona and Dept of Economic Security

C/O: myCOI

1075 Broad Ripple Ave STE 313

Indianapolis IN 46220

CERTIFICATE OF INSURANCE ISSUE

DATE:09/02/2024

AGENT:

Good News Insurance and Financial Services Inc.

2708 E Route 66 Flagstaff, AZ 86004

Social Service Contractors Indemnity Pool

COMPANIES AFFORDING COVERAGE

COMPANY

LETTER A SOCIAL SERVICE CONTRACTORS INDEMNITY POOL (SSCIP)

MEMBER/INSURED:

Senior In Home Care LLC dba A Country Retreat 412 Old Munds Highway Flagstaff, AZ 86005

POLICY NUMBER: 6002659-3 / 6002660-3

POLICY EFFECTIVE DATE: 08/01/2024-08/01/2025

STATE DIVISION: AZDES - DDD

STATE CONTRACT NUMBER: CTR061004

COVERAGES

THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT WHICH THIS CERTIFICATE MAY BE ISSUED OR PERTAIN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HERE IN IS SUBJECT TO ALL

TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES.

TYPE OF INSURANCE FORM NUMBER OTHER POLICY LIMITS

COMMERCIAL GENERAL LIABILITY

OCCURRENCE TRIGGER

SSGLCOV

EACH OCCURENCE

PROD COMP/OPS AGGR

GENERAL AGGREGATE

PERSONAL & ADV INJURY

DAMAGE-RENTED PREM

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

AUTOMOBILE LIABILITY

OWNED, LEASED,HIRED OR NON-OWNED

SSACOV

SYMBOLS

7, 8 & 9

COMBINED SINGLE LIMIT $1,000,000

EXCESS LIABILITY

SSECOV

EACH WRONGFUL ACT

AGGREGATE

$1,000,000 $1,000,000

PROFESSIONAL LIABILITY-

CLAIMS MADE TRIGGER

SSPLCOV

RETRO DATE:

08/01/2022

EACH WRONGFUL ACT

AGGREGATE

SEXUAL ABUSE AND MOLESTATION-

OCCURRENCE TRIGGER

SSPSAMCOV OCCURRENCE

TRIGGER

EACH OCCURRENCE $1,000,000

AGGREGATE $3,000,000

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS

STATE ADDITIONAL INSURED ENDORSEMENT SSCOMMAZAI INCLUDES:

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

ADDITIONAL INSURED COVERAGE TO THE STATE FOR GENERAL LIABILITY, AUTOMOBILIE LIABILITY, PROFESSIONAL LIABILITY AND SEXUAL ABUSE MOLESTATION LIABILITY

WAIVER OF SUBROGATION FOR GENERAL LIABILITY, AUTOMOBILE LIABILITY, PROFESSIONAL LIABILITY AND SEXUAL ABUSE AND

MOLESTATION LIABILITY

PRIMARY NON-CONTRIBUTORY LANGUAGE FOR GENERAL LIABILITY, AUTOMOBILE LIABILITY, PROFESSIONAL LIABILITY AND SEXUAL

ABUSEAND MOLESTATION LIABILITY

BUSINESS AUTO COVERAGE FORM APPLIES TO OWNED AND LEASED (SYMBOL 7) AND HIRED OR BORROWED VEHICLES

(SYMBOL 8 AND 9)

OTHER INFORMATION:

SIGNATURE