CTR066197-COI.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

11/28/2023

(928) 757-7788 (928) 757-4576

18058

Kingman Aid to Abused People 1770 Airway Ave Kingman, AZ 86409

A 1,000,000

X X PHPK2502796 12/28/2022 12/28/2023 100,000

5,000

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

1,000,000A

X X PHPK2502796 12/28/2022 12/28/2023

1,000,000A

PHUB845823 12/28/2022 12/28/2023 1,000,000

10,000

A Sexual Abuse/Molesta PHPK2502796 12/28/2022 Each 1,000,000 A Professional Liabili PHPK2502796 12/28/2022 12/28/2023 Aggregate 2,000,000

Re: Contract CTR066197 The policy shall be endorsed, as required by written agreement to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees as additional insured with respect to liability arising out of the activities performed by or on behalf of the contractor.

Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of 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

SEE ATTACHED ACORD 101

The State of Arizona and Dept of Economic Security c/o myCOI 1075 Broad Ripple Ave, Suite 313 Indianapolis, IN 46220

KINGAID-01 DWEYERMILLER

The Mahoney Group - Kingman 1740 Beverly Avenue, #A Kingman, AZ 86409

Dora Weyermiller

Philadelphia Indemnity Ins. Co

12/28/2023

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.

The Mahoney Group - Kingman

KINGAID-01

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

Kingman Aid to Abused People 1770 Airway Ave Kingman, AZ 86409

SEE PAGE 1

DWEYERMILLER

Description of Operations/Locations/Vehicles:

contractor.

General Liability Additional Insured provided per policy form CG2026 04/13 and Waiver of Subrogation provided per policy form CG2404 10/93. Commercial Auto Additional Insured provided per policy form CA2048 10/13 and Waiver of Subrogation provided per policy form CA0444 03/10.

Professional Liability Coverage $2,000,000 each claim and $2,000,000 annual aggregate

Sexual Abuse and Molestation is included.

All insurance policies required of this contract, contractor's insurance shall not be permitted to expire, be suspended, be canceled, or be materially changed for any reason without thiryt (30) days prior written notice to the State of Arizona. Exception is a 10 day notice of cancel for non-payment.