CTR066190_-_WC_Policy.pdf

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Policy Number:

Account Number:

1019020

5000024356

1 of 1P-799 | Doc Type: SFCOR 03 | 21

Phone: 602.631.2300 Toll Free: 1.800.231.1363

3030 N 3rd Street | Phoenix AZ 85012-3068 copperpoint.com

06/28/2023

Catholic Charities Community Services Inc 5151 N 19th Avenue Phoenix, AZ 85015

1019020Policy Number:

Dear Policyholder:

Thank you for renewing through CopperPoint Western Insurance Company. Enclosed please find your new Workers Compensation and Employers Liability Insurance Policy.

Total Premium Down Payment Installment Frequency or Payment Plan

$88,620.00 $9,006.00 Installment Plan - 10 Pay, 10% Down

As a reminder, helpful products and services are available on our website, copperpoint.com, where it is easy to create a registered account using your policy and account numbers located above.

Please visit the Customer Login page at ce.copperpoint.com to create your web account or call us at 1-800-231-1363 for assistance.

With your account, you’ll have 24/7 access to resources, such as:

• Fast claim filing

• Payroll reporting

• Account invoices and billing history

• Payment by electronic funds transfer (EFT)

• Exclusive safety videos

• Safety cards by industry and injury prevention

• Downloadable step-by-step safety plan template

• State-specific workplace compliance and safety posters

Again, we thank you for choosing CopperPoint Western Insurance Company, a premier provider of workers compensation and a leading advocate for workplace safety. “Put us to work for you.”

If you have any questions, please contact us at 602.631.2300 or 1.800.231.1363.

This document may have been uploaded to the CopperPoint Portal.

INFORMATION PAGE DOC TYPE: INFPG

Carrier Code 97046

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

ARIZONA

07/01/2023 - 07/01/2024

1 4747 N 7TH AVENUE, PHOENIX, AZ 85013

$110,467 0.040000 $44 8871 CLERICAL TELECOMMUTER EMPLOYEES

$1,661,409 0.880000 $14,620 8842 Group Homes-all Employees & Salespersons, Drivers

11,422,063 0.630000 $71,959 8864 SOCIAL SERVICES ORGANIZATION--ALL EMPLOYEES &

SALESPERSONS

$7,504,290 0.570000 $42,774 8869 CHILD DAY CAMP-ALL EMPLS INCL CLER/SLS

$2,282,093 0.070000 $1,597 8810 CLERICAL OFFICE EMPLOYEES-N.O.C.

2 736 N. MAIN STREET, COTTONWOOD, AZ 86326

3 2220 S. COUNTRY CLUB DR, MESA, AZ 85210

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

4 1135 E. CHANDLER BLVD, CHANDLER, AZ 85224

5 2101 N. 4TH STREET, FLAGSTAFF, AZ 86004

6 434 W. GURLEY STREET, PRESCOTT, AZ 86301

7 5104 E. THOMAS RD., PHOENIX, AZ 85018

8 6738 N 45TH AVE, GLENDALE, AZ 85301

9 525 E. HARRISON DR., AVONDALE, AZ 85323

10 113 E. CENTRE DR., BUCKEYE, AZ 85326

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

11 405 S. 7TH ST., BUCKEYE, AZ 85326

12 4801 W. MARYLAND AVE., GLENDALE, AZ 85301

13 7910 W. MARYLAND AVE., GLENDALE, AZ 85303

14 12397 W. THUNDERBIRD RD., EL MIRAGE, AZ 85335

15 6625 N. 56TH AVE., GLENDALE, AZ 85301

16 6600 W. MISSOURI AVE., GLENDALE, AZ 85301

17 6331 W. LAMAR RD., GLENDALE, AZ 85301

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

18 220 E. LA CANADA BLVD., AVONDALE, AZ 85323

19 5535 N. 67TH AVE., GLENDALE, AZ 85301

20 45 S. 3RD AVE., AVONDALE, AZ 85323

21 6242 N. 59TH AVE., GLENDALE, AZ 85301

22 10700 S. PALO VERDE RD., PALO VERDE, AZ 85343

23 11708 N. 80TH AVE., PEORIA, AZ 85345

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

24 4933 W. ORANGEWOOD AVE., GLENDALE, AZ 85301

25 9302 W. BADEN ST., TOLLESON, AZ 85353

26 7400 W OLIVE AVE, PEORIA, AZ 85258

27 1895 E DON CARLOS, TEMPE, AZ 85281

28 460-466 W BELLVIEW, MESA, AZ 85204

29 2422 W HOLLY STREET, PHOENIX, AZ 85009

30 5151 N 19TH AVENUE, PHOENIX, AZ 85015

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

31 5104 N. 16TH AVENUE, PHOENIX, AZ 85013

32 9261 W VAN BUREN STREET, TOLLESON, AZ 85353

33 5119 N 19TH AVE, PHOENIX, AZ 85015

34 1594 N. OATMAN ROAD, BULLHEAD CITY, AZ 86442

35 3834 S. 91ST AVENUE, TOLLESON, AZ 85353

36 1825 W. NORTHERN AVENUE, PHOENIX, AZ 85021

37 1252 S. AVONDALE, AVONDALE, AZ 85323

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

$130,994 Manual Premium

$0 0.020000 $100 0930 Waiver of Subrogation - Scheduled

$130,994 0.011000 $1,441 9812 Increased Limit Charge

$132,535 0.700000 ($39,761)9898 Experience modifier

22,980,322 0.007000 $1,609 9740 Terrorism

22,980,322 0.007000 $1,609 9741 Catastrophe (other than Certified Acts of Terrorism)

$92,774 0.081191 ($7,532)0063 Premium discount

$1 160 $160 0900 Expense constant

$88,620 ARIZONA Total Premium

Note:

This endorsement may be used to extend the information page by listing additional endorsements and schedules that are part of the policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 60

(Ed. 05/22)

WC 99 06 60

(Ed. 05/22)

© 1991 National Council on Compensation Insurance.

EXTENSION OF INFORMATION PAGE

Schedule of Forms

ITEM 3D

1019020POLICY NO:

Form Numbers Form Name Applicable States P-503 Independent Contractor Premium Advisory AZ

P-504.1 Out of State Coverage Advisory AZ

P-799 Policy Renewal Statement Letter AZ

WC 00 00 00 C Workers Compensation and Employers Liability Insurance Policy

AZ

WC 00 00 01 D Information Page Notes AZ

WC 99 04 19 Premium When Due Endorsement AZ

WC 99 06 17 Dividend Endorsement AZ

WC 99 06 18 Notification of Dividend AZ

P-531 Installment Plan Schedule AZ

WC 00 04 21 F Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement

AZ

WC 00 04 22 C Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement

AZ

WC 02 06 03 Arizona Amendatory Endorsement AZ

WC 00 99 03 22 Limited Other States Insurance Endorsement AZ

WC 00 99 06 23 Membership Endorsement AZ

WC 00 99 06 25 Schedule of Fees AZ

WC 02 04 01 C Arizona Alcohol & Drug Free Workplace Premium Credit Endorsement

AZ

WC 99 06 60 Extension of Information Page Item 3D Endorsement

AZ

WC 00 03 13 Waiver of Our Right to Recover from Others Endorsement

AZ

WC 00 04 04 Pending Rate Change Endorsement AZ

WC 00 04 14 A 90-Day Reporting Requirement—Notification of Change in Ownership Endorsement

AZ

WC 00 04 25 Experience Rating Modification Factor Revision Endorsement

AZ

Note:

This endorsement may be used to extend the information page by listing additional endorsements and schedules that are part of the policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 60

(Ed. 05/22)

WC 99 06 60

(Ed. 05/22)

© 1991 National Council on Compensation Insurance.

Form Numbers Form Name Applicable States WC 02 06 01 C Arizona Cancellation and NonRenewal

Endorsement

AZ

WC 99 06 22 Extension of Information Page Schedule of Named Insured

AZ

WC 00 03 10 Sole Proprietors Partners Officers and Others Coverage Endorsement

AZ

CopperPoint Western Insurance Company

CARRIER CODE 97046

POLICY ENDORSEMENT

Please attach this endorsement to your policy

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

MO DAY YEAR

EFFECTIVE

12:01 AM 07/01/2023

MO DAY YEAR

06/28/2023

AUTHORIZED REPRESENTATIVE

Counter signed at Phoenix, Arizona

1019020

AMENDING POLICY NUMBER

Catholic Charities Community Services Inc 5151 N 19th Avenue Phoenix, AZ 85015

1 of 1WC 99 06 22 | Doc Type: POLEND 05 | 15

EXTENSION OF INFORMATION PAGE

Schedule of Named Insured Item 1

Named Insured FEIN

N/A N/A

Doing Business As

N/A

Agency

Lockton Companies, LLC (Phoenix) 602-602-6002 14850 N Scottsdale Rd Suite 225 Scottsdale, AZ 85254

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C

(Ed. 01-15)

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows:

GENERAL SECTION

A. The Policy

This policy includes at its effective date the Infor-mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor-mation Page) and us (the insurer named on the In-formation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this poli-cy.

B. Who is Insured

You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an em-ployer of the partnership’s employees.

C. Workers Compensation Law

Workers Compensation Law means the workers or workmen’s compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen’s compensation law, any fed-eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits.

D. State

State means any state of the United States of America, and the District of Columbia.

E. Locations

This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such workplaces.

PART ONE

WORKERS COMPENSATION INSURANCE

A. How This Insurance Applies

This workers compensation insurance applies to bodily injury by accident or bodily injury by disease.

Bodily injury includes resulting death.

1. Bodily injury by accident must occur during the policy period.

2. Bodily injury by disease must be caused or ag-gravated by the conditions of your employment.

The employee’s last day of last exposure to the conditions causing or aggravating such bodily in-jury by disease must occur during the policy pe-riod.

B. We Will Pay

We will pay promptly when due the benefits required of you by the workers compensation law.

C. We Will Defend

We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in-vestigate and settle these claims, proceedings or suits.

We have no duty to defend a claim, proceeding or suit that is not covered by this insurance.

D. We Will Also Pay

We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend:

1. reasonable expenses incurred at our request, but not loss of earnings;

2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance;

3. litigation costs taxed against you;

4. interest on a judgment as required by law until we offer the amount due under this insurance;

and

5. expenses we incur.

E. Other Insurance

We will not pay more than our share of benefits and costs covered by this insurance and other

WC 00 00 00 C

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

insurance or self insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid.

F. Payments You Must Make

You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required be-cause:

1. of your serious and willful misconduct;

2. you knowingly employ an employee in violation of law;

3. you fail to comply with a health or safety law or regulation; or

4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law.

If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly.

G. Recovery From Others

We have your rights, and the rights of persons enti-tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them.

H. Statutory Provisions

These statements apply where they are required by law.

1. As between an injured worker and us, we have notice of the injury when you have notice.

2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du-ties under this insurance after an injury occurs.

3. We are directly and primarily liable to any per-son entitled to the benefits payable by this in-surance. Those persons may enforce our duties;

so may an agency authorized by law. Enforce-ment may be against us or against you and us.

4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law.

5. This insurance conforms to the parts of the workers compensation law that apply to:

a. benefits payable by this insurance;

b. special taxes, payments into security or oth-er special funds, and assessments payable by us under that law.

6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law.

Nothing in these paragraphs relieves you of your du-ties under this policy.

PART TWO

EMPLOYERS LIABILITY INSURANCE

A. How This Insurance Applies

This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death.

1. The bodily injury must arise out of and in the course of the injured employee’s employment by you.

2. The employment must be necessary or inci-dental to your work in a state or territory listed in Item 3.A. of the Information Page.

3. Bodily injury by accident must occur during the policy period.

4. Bodily injury by disease must be caused or ag-gravated by the conditions of your employment.

The employee’s last day of last exposure to the conditions causing or aggravating such bodily in-jury by disease must occur during the policy pe-riod.

5. If you are sued, the original suit and any related legal actions for damages for bodily injury by ac-cident or by disease must be brought in the United States of America, its territories or pos-sessions, or Canada.

B. We Will Pay

We will pay all sums that you legally must pay as damages because of bodily injury to your employ-ees, provided the bodily injury is covered by this Employers Liability Insurance.

The damages we will pay, where recovery is permit-ted by law, include damages:

1. For which you are liable to a third party by rea-son of a claim or suit against you by that third party to recover the damages claimed against

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

such third party as a result of injury to your em-ployee;

2. For care and loss of services; and

3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em-ployee; provided that these damages are the di-rect consequence of bodily injury that arises out of and in the course of the injured employee’s employment by you; and

4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer.

C. Exclusions

This insurance does not cover:

1. Liability assumed under a contract. This exclu-sion does not apply to a warranty that your work will be done in a workmanlike manner;

2. Punitive or exemplary damages because of bodily injury to an employee employed in viola-tion of law;

3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers;

4. Any obligation imposed by a workers compensa-tion, occupational disease, unemployment com-pensation, or disability benefits law, or any simi-lar law;

5. Bodily injury intentionally caused or aggravated by you;

6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries;

7. Damages arising out of coercion, criticism, de-motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina-tion against or termination of any employee, or any personnel practices, policies, acts or omis-sions;

8. Bodily injury to any person in work subject to the Longshore and Harbor Workers’ Compensation Act (33 U.S.C. Sections 901 et seq.), the Non-appropriated Fund Instrumentalities Act (5 U.S.C.

Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651–1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901– 944), any other federal workers or workmen’s compensation law or other federal occupational disease law, or any amendments to these laws;

9. Bodily injury to any person in work subject to the Federal Employers’ Liability Act (45 U.S.C.

Sections 51 et seq.), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws;

10. Bodily injury to a master or member of the crew of any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law;

11. Fines or penalties imposed for violation of feder-al or state law; and

12. Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued there under, and any amendments to those laws.

D. We Will Defend

We have the right and duty to defend, at our ex-pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed-ings and suits.

We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance.

E. We Will Also Pay

We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend:

1. Reasonable expenses incurred at our request, but not loss of earnings;

2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance;

3. Litigation costs taxed against you;

4. Interest on a judgment as required by law until we offer the amount due under this insurance; and

5. Expenses we incur.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

F. Other Insurance

We will not pay more than our share of damages and costs covered by this insurance and other in-surance or self-insurance. Subject to any limits of li-ability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is ex-hausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid.

G. Limits of Liability

Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below.

1. Bodily Injury by Accident. The limit shown for “bodily injury by accident—each accident” is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident.

A disease is not bodily injury by accident unless it results directly from bodily injury by accident.

2. Bodily Injury by Disease. The limit shown for “bodily injury by disease—policy limit” is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis-ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for “bodily injury by disease—each em-ployee” is the most we will pay for all damages because of bodily injury by disease to any one employee.

Bodily injury by disease does not include dis-ease that results directly from a bodily injury by accident.

3. We will not pay any claims for damages after we have paid the applicable limit of our liability un-der this insurance.

H. Recovery From Others

We have your rights to recover our payment from anyone liable for an injury covered by this insurance.

You will do everything necessary to protect those rights for us and to help us enforce them.

I. Actions Against Us

There will be no right of action against us under this insurance unless:

1. You have complied with all the terms of this poli-cy; and

2. The amount you owe has been determined with our consent or by actual trial and final judgment.

This insurance does not give anyone the right to add us as a defendant in an action against you to deter-mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga-tions under this Part.

PART THREE

OTHER STATES INSURANCE

A. How This Insurance Applies

1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor-mation Page.

2. If you begin work in any one of those states after the effective date of this policy and are not in-sured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page.

3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them.

4. If you have work on the effective date of this pol-icy in any state not listed in Item 3.A. of the In-formation Page, coverage will not be afforded for that state unless we are notified within thirty days.

B. Notice

Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page.

PART FOUR

YOUR DUTIES IF INJURY OCCURS

Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here.

1. Provide for immediate medical and other ser-vices required by the workers compensation law.

2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need.

3. Promptly give us all notices, demands and legal

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

papers related to the injury, claim, proceeding or suit.

4. Cooperate with us and assist us, as we may re-quest, in the investigation, settlement or defense of any claim, proceeding or suit.

5. Do nothing after an injury occurs that would in-terfere with our right to recover from others.

6. Do not voluntarily make payments, assume obli-gations or incur expenses, except at your own cost.

PART FIVE—PREMIUM

A. Our Manuals

All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifica-tions. We may change our manuals and apply the changes to this policy if authorized by law or a gov-ernmental agency regulating this insurance.

B. Classifications

Item 4 of the Information Page shows the rate and premium basis for certain business or work classifi-cations. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy.

C. Remuneration

Premium for each work classification is determined by multiplying a rate times a premium basis. Remu-neration is the most common premium basis. This premium basis includes payroll and all other remu-neration paid or payable during the policy period for the services of:

1. all your officers and employees engaged in work covered by this policy; and

2. all other persons engaged in work that could make us liable under Part One (Workers Com-pensation Insurance) of this policy. If you do not have payroll records for these persons, the con-tract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the em-ployers of these persons lawfully secured their workers compensation obligations.

D. Premium Payments

You will pay all premium when due. You will pay the premium even if part or all of a workers compensa-tion law is not valid.

E. Final Premium

The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premi-um basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the bal-ance. If it is less, we will refund the balance to you.

The final premium will not be less than the highest minimum premium for the classifications covered by this policy.

If this policy is canceled, final premium will be de-termined in the following way unless our manuals provide otherwise:

1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force.

Final premium will not be less than the pro rata share of the minimum premium.

2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short-rate cancelation table and procedure. Final premium will not be less than the minimum premium.

F. Records

You will keep records of information needed to com-pute premium. You will provide us with copies of those records when we ask for them.

G. Audit

You will let us examine and audit all your records that relate to this policy. These records include ledg-ers, journals, registers, vouchers, contracts, tax re-ports, payroll and disbursement records, and pro-grams for storing and retrieving data. We may con-duct the audits during regular business hours during the policy period and within three years after the pol-icy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

PART SIX—CONDITIONS

A. Inspection

We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurabil-ity of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organiza-tions have the same rights we have under this provi-sion.

B. Long Term Policy

If the policy period is longer than one year and six-teen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force.

C. Transfer of Your Rights and Duties

Your rights or duties under this policy may not be transferred without our written consent.

If you die and we receive notice within thirty days af-ter your death, we will cover your legal representa-tive as insured.

D. Cancelation

1. You may cancel this policy. You must mail or de-liver advance written notice to us stating when the cancelation is to take effect.

2. We may cancel this policy. We must mail or de-liver to you not less than ten days advance writ-ten notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice.

3. The policy period will end on the day and hour stated in the cancelation notice.

4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com-ply with the law.

E. Sole Representative

The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation.

1 of 1WC 99 04 19 | Doc Type: POLEND 03 | 22

Catholic Charities Community Services Inc 5151 N 19th Avenue Phoenix, AZ 85015

CopperPoint Western Insurance Company

CARRIER CODE 97046

POLICY ENDORSEMENT

Please attach this endorsement to your policy

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

MO DAY YEAREFFECTIVE 12:01AM

AT THE MAILING

ADDRESS OF THE

INSURED

07/01/2023 1019020

AMENDING POLICY NUMBER AUTHORIZED REPRESENTATIVEMO DAY YEAR

06/28/2023

ENDORSEMENT NO

Counter signed at Phoenix, Arizona

PREMIUM WHEN DUE ENDORSEMENT

Payment of all "premium when due" includes payment of any outstanding workers compensation premium obligation or other monetary obligation (e.g. deductible) on any previous workers compensation policy from a subsidiary or affiliate of the insurer named on the information page.

"Premium when due" also includes payment of final premium based upon audit. If you do not complete an audit as requested, final premium will be determined based upon an estimated audit. The due date for audit and retrospective premiums is the date indicated on the billing statement.

We may credit payments received to the oldest amounts due.

5151 N 19th Avenue Phoenix, AZ 85015

1 of 1WC 00 99 06 23 | Doc Type: POLEND 03 |22

CopperPoint Western Insurance Company

CARRIER CODE 97046

POLICY ENDORSEMENT

Please attach this endorsement to your policy

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

MO DAY YEAREFFECTIVE 12:01AM

AT THE MAILING

ADDRESS OF THE

INSURED

07/01/2023 1019020

AMENDING POLICY NUMBER AUTHORIZED REPRESENTATIVEMO DAY YEAR

06/28/2023

ENDORSEMENT NO

Counter signed at Phoenix, Arizona

MEMBERSHIP ENDORSEMENT

The employer named in Item 1 of the Information Page is a member of CopperPoint Mutual Insurance Holding Company with all the rights and obligations of such membership and shall remain a member so long as this policy remains in force.

5151 N 19th Avenue Phoenix, AZ 85015

1 of 1WC 00 99 06 25 | Doc Type: POLEND 04 | 18

CopperPoint Western Insurance Company

CARRIER CODE 97046

POLICY ENDORSEMENT

Please attach this endorsement to your policy

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

MO DAY YEAR

EFFECTIVE

12:01 AM 07/01/2023

MO DAY YEAR

06/28/2023

AUTHORIZED REPRESENTATIVE

Counter signed at Phoenix, Arizona

1019020

AMENDING POLICY NUMBER

SCHEDULE OF FEES ENDORSEMENT

You may be subject to the following fees.

Installment Fee (Per Invoice) $5.00

Late Fee (Per Month) Greater of 1.5% of the past due balance or $10.00

Payment Plan Processing Fee (Per Payment Plan Installment) $8.00

Payment Reversal Fee (Per Reversal) $20.00

Reinstatement Fee (Per Policyholder Requested Reinstatement) $50.00

Reporting Fee (Per Payroll Report) $7.00

Fees will be shown at amounts approved at time of policy issuance.

Phone: 602.631.2300 Toll Free: 1.800.231.1363

3030 N 3rd Street | Phoenix AZ 85012-3068

CopperPoint Western Insurance Company copperpoint.com

1 of 1P-504.1 | Doc Type: SCFOR 05 | 18

06/28/2023

Catholic Charities Community Services Inc 5151 N 19th Avenue Phoenix, AZ 85015

IMPORTANT NOTICE

Coverage Advisory for Out-of-State Injuries

Workers’ compensation benefits for a work-related injury to one of your employees while temporarily in another state doing work for you will be paid in accordance with applicable law and the Limited Other States Endorsement that is part of your policy.

Workers’ compensation laws vary from state to state and the performance of work in another state, even temporarily, may subject your business to the workers’ compensation laws of the other state, including a requirement that your employees be covered by a workers’ compensation insurance policy issued in the other state. Information about purchasing coverage in other states is available from your insurance agent or broker.

Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission.

© Copyright 1996 National Council on Compensation Insurance, Inc. All Rights Reserved.

WC 00 99 03 22 (10/2018)

PART THREE OTHER STATES INSURANCE

A. How This Insurance Applies

1. We will pay promptly when due the benefits required of you by the workers compensation law of any state not listed in Item 3.A. of the Information Page if all of the following conditions are met:

a. The employee claiming benefits was either hired under a contract of employment made in a state listed in Item 3.A. of the Information Page or was, at the time of injury, regularly employed in a state listed in Item 3.A. of the Information Page; and

b. The employee claiming benefits is not claiming benefits in a state where, at the time of injury, (i) you have other workers compensation insurance coverage, or (ii) you were, by virtue of the nature of your operations in that state, required by that state’s law to have obtained separate workers compensation insurance coverage in that state, or (iii) you are an authorized self-insurer or participant in a self-insured group plan;

and

c. The duration of the job or contract requiring the work being performed in the state for which the employee is claiming benefits does not exceed one hundred eighty (180) continuous days.

2. If we are not permitted to pay the benefits directly to persons entitled to them and all of the conditions above apply, we will reimburse you for the benefits required to be paid.

3. This insurance does not apply to fines or penalties arising out of your failure to comply with the requirements of the workers compensation law.

4. This insurance applies only to accidental injuries and/or death occurring outside of the states listed in Item 3.A. of the Information Page to workers who are otherwise entitled to the benefits as though the workers were injured within a state listed in Item 3.A. of the Information Page.

B. Notice Tell us at once if you begin work or hire any employees in any state not listed in Item 3.A. of the Information Page.

IMPORTANT NOTICE!

If you hire any employees outside those states listed in Item 3.A. on the Information Page or begin operations in any such state, you should do whatever may be required under that state’s law, because this endorsement may not satisfy the requirements of that state’s workers’ compensation law.

LIMITED OTHER STATES INSURANCE ENDORSEMENT

“Part Three — Other States Insurance” of the policy is replaced by the following:

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.)

07/01/2023Endorsement Effective 1019020Policy No. 4Endorsement No.

Catholic Charities Community Services IncInsured Premium $

CopperPoint Western Insurance CompanyInsurance Company Countersigned by

3030 N 3rd Street | Phoenix AZ 85012-3068

CopperPoint Western Insurance Company copperpoint.com

1 of 1P-503 | Doc Type: SFCOR 08 | 22

06/28/2023

Catholic Charities Community Services Inc 5151 N 19th Avenue Phoenix, AZ 85015

Important Notice – Contractor Advisory

If you engage contractors, you may be responsible for…