CTR062833_COI_CGL__AL__PL__7-1-23__WC_1-1-24.pdf

1/24/2023

Powers-Leavitt Insurance Agency, Inc.

111 E. Monroe Avenue, Suite 200

Buckeye AZ 85326

JoAnn Zohner

(623)386-4452 (866)836-5280 joann-zohner@leavitt.com

Native American Connections, Inc.

4520 N Central Ave., Suite 600

Phoenix AZ 85012

Philadelphia Indemnity Company 018058

CopperPoint Western Insurance Company 13209

2022/2023

A

X

X

X $0 Deductible

X

X Y PHPK2429579 7/1/2022 7/1/2023

1,000,000

100,000

5,000

1,000,000

3,000,000

3,000,000

A X

X Y PHPK2429579 7/1/2022 7/1/2023

1,000,000

A

X X

X 10,000 PHUB820024 7/1/2022 7/1/2023

10,000,000

10,000,000

B 1010536 1/1/2023 1/1/2024

X

1,000,000

1,000,000

1,000,000

A Prof Liab: Sexual Abuse & PHSD1723297 7/1/2022 7/1/2023 Each Claim $1,000,000

Molestations - Claims made Aggregate $3,000,000

Re: Contract # ADES18-206223; CTR062833; DES-HMLS-2A15; DES-HMLS-2B20

***See Notes**

Coverage is subject to policy terms, conditions, limitations and exclusions.

The State of Arizona Department of Economic Security 1789 W. Jefferson Street Mail Drop 6271 Phoenix, AZ 85007 fplakstis@azdes.gov

C Woodruff/SHNGUY

Y

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSD

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

OTHER:

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.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

Re: Contract # ADES18-206223; CTR062833; DES-HMLS-2A15; DES-HMLS-2B20

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, if a written contract is in effect, as required by CG2020 (0413).

Waiver of Subrogation endorsement applies to The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor, with respect to general liability, if a written contract is in effect, as required by form CG2404 (0509).

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 involving automobiles owned, hired and/or non-owned by the Contractor, if a written contract is in effect, as required by CA2048 (10/13).

Waiver of Subrogation endorsement applies to The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor, with respect to auto liability, if a written contract is in effect, as required by form CA0444 (10/13).

Waiver of Subrogation endorsement applies to The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor, with respect to workers compensation, if a written contract is in effect, as required by form WC000313 (04/84).

Sexual Abuse and Molestation coverage is not excluded.

Coverage subject to policy terms, conditions, exclusions and limitations. Revised 01/27/23

COMMENTS/REMARKS

COPYRIGHT 2000, AMS SERVICES INC.OFREMARK

POLICY NUMBER: COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page of

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

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

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

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

PHPK2429579

07/01/2022

NATIVE AMERICAN CONNECTIONS

Arizona Department of Economic Security, Division of Aging and Adult Services (See Manuscript)1789 W Jefferson St, Phoenix, AZ 85007

1 1

POLICY NUMBER: COMMERCIAL AUTO

CA 20 48 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page of

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

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

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

Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II – Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I – Covered Autos Coverages of the Auto Dealers Coverage Form.

PHPK2429579

07/01/2022

NATIVE AMERICAN CONNECTIONS

Arizona Department of Economic Security, Division of Aging and Adult Services (See Manuscript)

1 1

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

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 involving automobiles owned, hired and/or non-owned by the Contractor

Arizona Department of Economic Security, Division of Aging and Adult

Services

1789 W Jefferson St

Phoenix, AZ 85007

Form CA2048/CA0444 -Arizona Department of Economic Security

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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.)

07/01/2022Endorsement Effective 1010536Policy No. 20Endorsement No.

Native American Connections IncInsured 100 Premium $

CopperPoint Western Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

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 Blanket/Schedule/State

AZ Arizona Department of Economic Security. Division of Aging and Adult Services, Other Address: 1789 W Jefferson Street, Mail Drop 6271, Phoenix, AZ 85007

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

PI-CXL-002 (05/19)

POLICY NUMBER:

PI-CXL-002 (05/19)

Includes copyrighted material of Insurance Services Office, Inc., with permission.

COMMERCIAL UMBRELLA LIABILITY INSURANCE

POLICY DECLARATIONS

NAMED INSURED:

MAILING ADDRESS:

POLICY PERIOD: FROM TO AT 12:01 A.M. STANDARD

TIME AT YOUR MAILING ADDRESS SHOWN ABOVE

IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS

POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.

LIMITS OF INSURANCE

EACH OCCURRENCE LIMIT

(LIABILITY COVERAGE) $

PERSONAL & ADVERTISING INJURY LIMIT $ Any one person or organization

PRODUCTS COMPLETED OPERATIONS AGGREGATE LIMIT $

GENERAL AGGREGATE LIMIT (LIABILITY COVERAGE) (except with respect to Auto Liability and Products Completed Operations) $

RETAINED LIMIT

RETAINED LIMIT: $

Philadelphia Indemnity Insurance Company

PHUB820024

30537

(623)386-4452

07/01/2023

Native American Connections and per Named Insured Schedule

Powers-Leavitt Insurance Agency P.O. Box 125 Buckeye, AZ 85326

07/01/2022

4520 N Central Ave Ste 600 Phoenix, AZ 85012-1848

10,000,000

10,000,000

10,000

10,000,000

10,000,000

PI-CXL-002 (05/19)

Includes copyrighted material of Insurance Services Office, Inc., with permission.

PREMIUM

PREMIUM SUBTOTAL

STATE TAXES, FEES, SURCHARGES (if applicable)

PREMIUM TOTAL (including Taxes, Fees, Surcharges)

AUDIT PERIOD: NOT APPLICABLE ANNUALLY SEMI-ANNUALLY QUARTERLY MONTHLY

SEE ATTACHED SCHEDULE

ENDORSEMENTS ATTACHED TO THIS POLICY

DESCRIPTION OF BUSINESS

FORM OF BUSINESS:

BUSINESS DESCRIPTION:

PHUB820024

NON PROFIT ORGANIZATION

X

Non-Profit Umbrella

$ 45,893.00

$ 45,893.00

Not Applicable

PI-CXL-002 (05/19)

Includes copyrighted material of Insurance Services Office, Inc., with permission.

SCHEDULE OF UNDERLYING INSURANCE

Employers' Liability Company:

Policy Number:

Policy Period:

Minimum Applicable Limits

Bodily injury by accident $ Each Accident Bodily injury by disease $ Each Employee Bodily injury by disease $ Policy Limit

Commercial General Liability Occurrence Claims-Made Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits:

General Aggregate $ Products-Completed Operations Aggregate $ Personal And Advertising Injury $ Each Occurrence $

Commercial Auto Liability Company:

Policy Number:

Policy Period:

Minimum Applicable Limits

Garage Aggregate Limit For Other Than Autos (if applicable) $ Each Accident $

Professional Liability Occurrence Claims-Made Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

PHUB820024

Need dec page

01/01/2022 01/01/2023

1,000,000

1,000,000 1,000,000

PHPK2429579

Philadelphia Indemnity Insurance Company

07/01/2022 07/01/2023

Not Applicable

X

1,000,000

1,000,000

3,000,000

3,000,000

PHPK2429579

Philadelphia Indemnity Insurance Company

07/01/2022 07/01/2023

Not Applicable

1,000,000

PHPK2429579

Philadelphia Indemnity Insurance Company

07/01/2022 07/01/2023 07/01/1993

Each Professional Incident 1,000,000

Aggregate 3,000,000

X

PI-CXL-002 (05/19)

Includes copyrighted material of Insurance Services Office, Inc., with permission.

Employee Benefits Liability Occurrence Claims-Made Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

Abusive Conduct Liability Occurrence Claims-Made Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

Directors & Officers Liability Occurrence Claims-Made Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

Liquor Liability Occurrence Claims-Made Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

PHUB820024

PHPK2429579

Philadelphia Indemnity Insurance Company

07/01/2022 07/01/2023 07/01/1998

Each Claim 1,000,000

Aggregate 3,000,000

PHPK2429579

Philadelphia Indemnity Insurance Company

07/01/2022 07/01/2023 07/01/1993

Each Abusive Conduct 1,000,000

Aggregate 3,000,000

PI-CXL-002 (05/19)

Includes copyrighted material of Insurance Services Office, Inc., with permission.

Watercraft Liability Occurrence Claims-Made Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

Other Coverages Not Included in Above Occurrence Claims-Made

Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

THESE DECLARATIONS, TOGETHER WITH THE COMMON POLICY CONDITIONS AND COVERAGE

FORM(S) AND ANY ENDORSEMENT(S), COMPLETE THE ABOVE NUMBERED POLICY.

Countersigned: By:

(Date) (Authorized Representative)

IN WITNESS WHEREOF, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative.

Secretary John W. Glomb, Jr.

President & CEO

PHUB820024