CTR066193_DES_COI_Liability_25-26_exp6.20.26.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

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 EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

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

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

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 LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

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 any 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.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Great American Assurance Company

Great American Alliance Insurance Co.

6/24/2025

USI Insurance Services LLC 2375 E. Camelback Road, Suite 740 Phoenix, AZ 85016 877 468-6516

Kim Martin 602 749-4148 610 537-2283 kim.martin@usi.com

Chrysalis Shelter for Victims of Domestic Violence, Inc.

2055 W. Northern Ave Phoenix, AZ 85021

26344 26832

A X X

PAC429677410 06/20/2025 06/20/2026 1,000,000

100,000 10,000 1,000,000 3,000,000 3,000,000

B X

X X

CAP267176807 06/20/2025 06/20/2026 1,000,000

B X

X EXC429677512 06/20/2025 06/20/2026 5,000,000

5,000,000

A A

Professional Liab Abuse/Molestation

PAC429677410

PAC429677410

06/20/2025 06/20/2025

06/20/2026 06/20/2026

$1,000,000/$3,000,000 $1,000,000/$2,000,000

Re: Contract #CTR066193

The State of Arizona its departments, agencies, boards, commissions, universities its officers, officials, agents & employees are additional insureds with regard to General Liability with respect to liability arising out of the activities performed by or on behalf of the Contractor when required by a written (See Attached Descriptions)

The State of Arizona and Department of Economic Security c/o myCOI PO Box #501970, 8710 Bash St.

Phoenix, AZ 85007

#S49745655/M49732049

CHRYSSHEClient#: 2046868

SECZP

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) agreement or permit per attached form. The State of Arizona its departments, agencies, boards, commissions, universities its officers, officials, agents & employees are additional insureds under the Automobile 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 when required by a written agreement or permit per attached form.

Waiver of Subrogation applies in favor of the State of Arizona, and its departments, agencies, boards, commission, universities, officers, officials, agents, and employees as it relates to General Liability and Auto Liability when required by a written contract or written agreement. Coverage is primary and non contributory as respects to General Liability when required in writing in a contract or agreement.

Umbrella Liability follows form to General Liability, Automobile Liability, Professional Liability & Abuse/Molestation. Subject to policy terms and conditions.

#S49745655/M49732049

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

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 EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

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

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

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 LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

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 any 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.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Great American Assurance Company

Great American Alliance Insurance Co.

6/24/2025

USI Insurance Services LLC 2375 E. Camelback Road, Suite 740 Phoenix, AZ 85016 877 468-6516

Kim Martin 602 749-4148 610 537-2283 kim.martin@usi.com

Chrysalis Shelter for Victims of Domestic Violence, Inc.

2055 W. Northern Ave Phoenix, AZ 85021

26344 26832

A X X

PAC429677410 06/20/2025 06/20/2026 1,000,000

100,000 10,000 1,000,000 3,000,000 3,000,000

B X

X X

CAP267176807 06/20/2025 06/20/2026 1,000,000

B X

X EXC429677512 06/20/2025 06/20/2026 5,000,000

5,000,000

A A

Professional Liab Abuse/Molestation

PAC429677410

PAC429677410

06/20/2025 06/20/2025

06/20/2026 06/20/2026

$1,000,000/$3,000,000 $1,000,000/$2,000,000

Division Name: ADES Contract ID: CTR066193

The State of Arizona its departments, agencies, boards, commissions, universities its officers, officials, agents & employees are additional insured.

(See Attached Descriptions)

The State of Arizona, Department of Economic Security 1789 W Jefferson St Mail Drop 6271 Phoenix, AZ 85007

#S49745656/M49732049

CHRYSSHEClient#: 2046868

SECZP

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1)

Sexual Abuse & Molestation coverage is included at $1,000,000 per occurrence limit / $2,000,000 aggregate limits. Umbrella liability limits extends over the General Liability, Automobile Liability, Professional Liability & Abuse/Molestation limits.

#S49745656/M49732049