CTR064872_2025-26_COI_renewal_CGL_Auto_SAM_PL_exp11.10.26_WC_exp12.1.26.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT

OTHER: $

COMBINED SINGLE LIMIT

$(Ea accident)

ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED

BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE

$AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE

CLAIMS-MADE AGGREGATE $

DED RETENTION $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N N / A

(Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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 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).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

11/21/2025

License # 0757776

22292

Arizona Community Action Association dba Wildfire 340 E Palm Lane, Suite 315 Phoenix, AZ 85004

A 1,000,000

X X OH4H076826 11/10/2025 11/10/2026 300,000

5,000

1,000,000 2,000,000 2,000,000

1,000,000A

X X OH4H076826 11/10/2025 11/10/2026

1,000,000A

X X OH4H076826 11/10/2025 11/10/2026 1,000,000

A

WH4H076822 12/1/2025 12/1/2026 1,000,000

N 1,000,000 1,000,000

Contract ID: CTR064872 The certificate holder is included as an additional insured if required by an executed written contract or agreement for General Liability. Coverage is on a primary and non-contributory basis.

A waiver of subrogation in favor of certificate holder applies to the for General Liability.

Thirty (30) days’ notice of cancellation with ten (10) days’ notice for non-payment of premium is provided to certificate holder.

SEE ATTACHED ACORD 101

The State of Arizona and Dept of Economic Security c/o myCOI P.O. Box# 501970, 8710 Bash Street Indianapolis, IN 46256

ARIZCOM-02 MSMYERS

Scottsdale, AZ-Priority Insurance-HUB International Insurance Services

(SOW)

8777 N Gainey Center Dr. Suite 100 Scottsdale, AZ 85258

Misty Smyers misty.smyers@hubinternational.com

Hanover Insurance Company

X

X X

X

X X

X X

FORM NUMBER:

EFFECTIVE DATE:

The ACORD name and logo are registered marks of ACORD

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE

FORM TITLE:

Page of

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

ACORD 101 (2008/01)

AGENCY CUSTOMER ID:

LOC #:

AGENCY NAMED INSURED

POLICY NUMBER

CARRIER NAIC CODE

© 2008 ACORD CORPORATION. All rights reserved.

Scottsdale, AZ-Priority Insurance-HUB International Insurance Services (SOW)

ARIZCOM-02

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

License # 0757776

SEE P 1

Arizona Community Action Association dba Wildfire 340 E Palm Lane, Suite 315 Phoenix, AZ 85004

SEE PAGE 1

MSMYERS

Description of Operations/Locations/Vehicles:

Additional Insured Names: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees under the General Liability, Automobile Liability and Workers Compensation policies.

The policies are Primary and Non-Contributory.

Waiver of Subrogation endorsement is included on all policies, as required by written agreement in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees.

There are NO company owned Vehicles. Symbol 1 is not allowed. Hired & Non-Owned Auto is included

WH4-H076822-06