CTR061004_COI_2026-06-30_AL_GL_PEO_SAM_WC.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

8/14/2025

Good News Ins & Fin'l Svcs Inc. AZ

2708 E Rt. 66

Flagstaff AZ 86004

Jim Coe

(928) 527-4179 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 Contractors Indemnity Pool 14329

Accident Insurance Company `11573

A Y Y 6002659-4 08/01/2025 08/01/2026

1,000,000

1,000,000

10,000

1,000,000

3,000,000

3,000,000

A Y Y 6002659-4 08/01/2025 08/01/2026

1,000,000

A Y Y 6002660-4 08/01/2025 08/01/2026

1,000,000

1,000,000

B N Y WCV 0302140 01 06/30/2025 06/30/2026

1,000,000

1,000,000

1,000,000

A Professional Liability

Including Sexual Abuse and Molestation Y Y 6002659-4 08/01/2025 08/01/2026

Each Occurrence 1,000,000

General Aggregate 3,000,000

Division Name: ADES.

- Contract ID: CTR061004.

Senior In Home Care LLC is listing the State of Arizona and its Departments, Agencies, Boards, Commissions, Universities, Officers, Officials, Agents, and Employees as

Additional Insured per Contractual Requirements.

Contract NR: CTR-061004 dated 05/12/2025. Waivers of Subrogation are in effect and Insurance is primary and non-contributory.

The State of Arizona and Dept of Economic Security c/o myCOI

PO Box 501970

8710 Bash ST

Indianapolis IN 46256

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

WC 00 03 13

(Ed. 04/84)

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

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

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy)

Endorsement Effective: 06/30/25 File No.: 002000002137025 Carrier Policy No.: WCV 0302140 01 Premium: $ 2,280.00

Insured: SENIOR IN HOME CARE LLC Carrier No.: 51401

A COUNTRY RETREAT

Agency: APPALACHIAN UNDERWRITERS/ 2 Insurance Company: Accident Insurance Company Inc

WC 00 0313

Ed. 04/84 © Copyright 1984 National Council on Compensation Insurance

Countersigned by:

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