CTR065779_COI_EXP_2025-7-5_CGAUWPro.pdf
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- Attached to
- Master Agreement AZ|CTR065779
- Contract number
- CTR065779
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance for Adams and Wendt, Inc., issued by LeBaron & Carroll LLC, with insurance coverage provided by Beasley Insurance Company and Secura Insurance A Mutual Company. The certificate is issued for a contract with the Arizona Department of Environmental Quality, with reference to Solicitation No. BPM004287 and Contract No. CTR065779. The insurance policies cover commercial general liability, automobile liability, umbrella liability, workers' compensation, professional liability, and pollution liability, with various coverage periods effective from 5/7/2024 to 5/7/2025.
The insurance policies provide comprehensive coverage with significant limit amounts, including $3,000,000 for each occurrence in commercial general liability, $1,000,000 for automobile liability, $4,000,000 for umbrella liability, and $1,000,000 for workers' compensation. The State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are included as additional insured parties. The policies include waivers of subrogation for general liability, auto liability, and workers' compensation when required by written contract. The insurance covers ongoing operations and completed operations, with specific provisions for pollution liability and professional liability.
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ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
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
6/10/2024
(480) 464-3438 (480) 844-9866
Adams and Wendt, Inc.
461 N. Gilbert Rd Suite 1 Mesa, AZ 85203
22543
A 3,000,000
X X ENC001133-01 5/7/2024 5/7/2025 100,000
Professional & Pollu 10,000
3,000,000 5,000,000 5,000,000
See Forms & Endorsements for D PROF POLL EA OC 3,000,000 1,000,000B
X X 20-A3225248-14 5/7/2024 5/7/2025
4,000,000B
20-CU003225250-14 5/7/2024 5/7/2025 4,000,000
10,000 B
X 20WC00322524914 5/7/2024 5/7/2025 1,000,000
Y 1,000,000
1,000,000 A Pollution Liability ENC001133-01 5/7/2024 Ea Pollution Cond. 3,000,000 A Professional Liabili ENC001133-01 5/7/2024 5/7/2025 Ea wrongful act 3,000,000
RE: Solicitation No. BPM004287; Contract No. CTR065779 The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are included as additional insured with respect to General Liability when required by written contract per attached form(s). Auto Liability additional insured is included when required by written contract per attached form(s). Waiver of Subrogation applies with respect to General Liability, Auto Liability and Worker's Compensation when required by written contract per attached form(s).
Arizona Department of Environmental Quality 1110 W Washington St Phoenix, AZ 85007
STRACOM-01 SQUERNEMOEN
LeBaron & Carroll LLC 1350 E Southern Avenue Mesa, AZ 85204
Julianna Arnett julianna@lebaroncarroll.com
Beasley Insurance Company Secura Insurance A Mutual Company
X
5/7/2025
X X
X
X X
X
X
X
X
CG 20 37 07 04 ©Insurance Services Office, Inc. Page 92
Effective Date: 5/7/2024 PolicyNumber: ENC001133-01
Endorsement Number: 8
ADDITIONAL INSURED – OWNERS, LESSORS OR CONTRACTORS – COMPLETED OPERATIONS
In consideration of a premium change of , this endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
All other terms and conditions of this Policy remain unchanged.
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Location And Description Of Completed Operations
Any person(s) or organization(s) where this endorsement is required by contract.
All project locations where this endorsement is required by contract.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".
CG 20 10 07 04 ©Insurance Services Office, Inc. Page 86
Endorsement Number: 5
ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – SCHEDULED PERSON OR
ORGANIZATION
In consideration of a premium change of , this endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
All other terms and conditions of this Policy remain unchanged.
SCHEDULE
Name of Additional Insured Person(s) Or Organization(s):
Location(s) of Covered Operations
Any person(s) or organization(s) where this endorsement is required by contract.
All project locations where this endorsement is required by contract.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to "bodily injury" or "property damage" occurring after:
CG 20 10 07 04 ©Insurance Services Office, Inc. Page 87
1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or
2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.
CPP208 12/2016 Page 102
Effective Date: 5/7/2024 PolicyNumber:ENC001133-01
Endorsement Number: 17
OTHER INSURANCE – PRIMARY WITHOUT RIGHT OF CONTRIBUTION
This endorsement modifies insurance provided under all coverages applicable to this policy.
All other terms and conditions of this Policy remain unchanged.
In consideration of the premium charged for the Policy, it is hereby understood and agreed that Clause XIV. OTHER INSURANCE is deleted in its entirety and replaced with the following:
XIV. OTHER INSURANCE
Subject to Clause VII. and VIII., where other valid and collectible insurance is available to the Insured for any Pollution Condition or Claim, this insurance shall apply as primary insurance versus any other valid and collectable insurance, and the Underwriters will have no right of contribution against any other insurance company providing insurance for a Pollution Condition or a Claim on a primary basis.
CG 24 04 10 93 ©Insurance Services Office, Inc. Page 95
Endorsement Number: 11
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
All other terms and conditions of this Policy remain unchanged.
SCHEDULE
Name of Person or Organization:
Any person(s) or organization(s) where this endorsement is required by contract.
All Person(s) Or Organization(s) where this endorsement is required by contract.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US 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 damage arising out of your ongoing operations or "your work" done under a contract with 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.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
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
This endorsement changes the policy to which it is attached 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 05/07/2024 Policy No.
20-WC-003225249-14 Endorsement No. 000
Insured Straightway Company Inc Premium $ Insurance Company Countersigned by
SECURA Insurance Company
WC 00 03 13
(Ed. 4-84)
1983 National Council on Compensation Insurance.
State Entity Name Contract or Project Number Description of Work
Waiver Premium Waiver Type
AZ Blanket Waiver of Subrogation No specific address
Mesa, AZ 85203
Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.
$250 BLANKET
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