CTR066199_-_COI_and_Endorsements__2_.pdf

01/08/2025

AssuredPartners of Arizona, LLC 1760 E River Rd Suite 300

Tucson AZ 85718

Greg Sorensen

Greg.Sorensen@AssuredPartners.com

Mt Graham Safe House Inc, DBA: Mt Graham Safe House P.O. Box 1202

Safford AZ 85548

Social Services Contractors Indemnity Pool 52519 CopperPoint Insurance Company 14216- Arch Insurance Company 11150

25-26 master

A Y Y 6000420 01/01/2025 01/01/2026

1,000,000 500,000 10,000

INCLUDED

2,000,000 1,000,000

Professional Liability 1,000,000

A Y Y 6000420 01/01/2025 01/01/2026 1,000,000

Medical payments 5,000

A 6000474 01/01/2025 01/01/2026 1,000,000 1,000,000

B Y Y 1010953 01/01/2025 01/01/2026 1,000,000 1,000,000 1,000,000

C Directors and Officers

Y NFP0340043-00 06/24/2024 06/24/2025

D&O Annual Aggregate $1,000,000 Insured Person Liability $1,000,000 Organization Reimbursement

$1,000,000

Contract ADES17-178645, CTR062153, CTR066199-Domestic Violence and CTR066289-Housing Support Svcs Venture West Construction LLC The State of Arizona, its departments, agencies, boards, commissions, universitites and its officers, officials, agents and employees additional insured with waiver of subrogation as regards General Liability, Auto Liability, Professional Liability, and Sexual Abuse Liability per attached. General Liability and Auto liability are primary and non-contributory. Umbrella is follow form. SAM coverage may be sub-limited to no less than $500,000.

Workers Compensation Exclusion:

The State of Arizona and Dept of Economic Security c/o: myCOI 1075 Broad Ripple Ave STE 313 Phoenix AZ 85007

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

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

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

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

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Mt Graham Safe House Inc, DBA: Mt Graham Safe House

00033982

AssuredPartners of Arizona, LLC

25 Certificate of Liability Insurance

Paul David - Excluded (not on work sites) Arnold Lopez - Excluded (not on work sites) Edmund Lopez - Excluded (not on work sites) Jeanette Aston - Included (present at work sites)

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

Experience Mod Factor 1 EXP01

Experience Mod Factor 1 EXP01

ADDITIONAL COVERAGES

Ref # Description Edition DateForm No.Coverage Code

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Ref # Description Coverage Code Form No. Edition Date

Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium

Copyright 2001, AMS Services, Inc.OFADTLCV

Mt Graham Safe House

Mt. Graham Safe House

Doing Business As

Doing Business As

Additional Named Insureds

Other Named Insureds

OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC

Mt Graham Safe House Inc, DBA: Mt Graham Safe House

00033982

AssuredPartners of Arizona, LLC

25 Certificate of Liability Insurance: Notes

Note: Several policies reflect an extended term this year in order to unify their effective dates with that of the Workers Compensation coverage. There has been no lapse.

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

Social Service Contractors Indemnity Pool

EXCESS LIABILITY COVERAGE AGREEMENT DECLARATIONS_SSEDEC_01/21

SSEDEC (01-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 2

EXCESS LIABILITY COVERAGE AGREEMENT

DECLARATIONS

Policy # 6000474-6

Replaces Policy # 6000474-5

THIS DECLARATIONS PAGE AND THE ATTACHED EXCESS LIABILITY COVERAGE AGREEMENT COMPLETE THIS COVERAGE PART.

Item 1. "NAMED INSURED":

Mt. Graham Safe House, Inc.

P.O. Box 1202 Safford, AZ 85548

Item 2. CONTINOUS COVERAGE PERIOD:

12:01 A.M. Standard Time at Named Insured Mailing Address

Rating Period from: 12/15/2032 To: 1/1/2025

Item 3. LIMITS OF INSURANCE

Aggregate Limit of Liability

$ 1,000,000 $ 1,000,000

Item 4. EXCESS RETRO-ACTIVE DATE:

Professional (E & O): 12/15/1995

Employers Benefits Liability:

Item 5. SCHEDULE OF "UNDERLYING INSURANCE COVERAGE":

Excess coverage applies only to coverage for which underlying Limits of Coverage are shown.

COMMERCIAL GENERAL LIABILITY LIMITS (OCCURRENCE)

Underlying Insurer:

Underlying Policy Number:

Policy Period:

SSCIP

6000420

From: 12/15/2023 General Liability – Aggregate $ 2,000,000 General Liability – Each Occurrence $ 1,000,000

AUTOMOBILE LIABILITY LIMITS (OCCURRENCE)

SSEDEC (01-21) Includes wording © ISO Properties, Inc., used with permission Page 2 of 2

Underlying Insurer:

Underlying Policy Number:

Policy Period:

SSCIP

6000420

From: 12/15/2023 Bodily Injury Liability - Each Accident Limit $ 1,000,000 Property Damage Liability -Each Accident Limit $ 1,000,000

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION (OCCURRENCE)

Underlying Insurer:

Underlying Policy Number:

Policy Period:

SSCIP

6000420

From: 12/15/2023 Each Act of Abuse Limit: $ 1,000,000 Aggregate Limit: $ 2,000,000

EMPLOYERS LIABILITY (CLAIMS MADE)

Underlying Insurer:

Underlying Policy Number:

Policy Period:

SSCIP

6000420

From: 12/15/2023 Bodily Injury - By Accident Limit $ Not Covered Bodily Injury By Disease - Each Employee Limit $ Not Covered Bodily Injury By Disease - Policy Limit $ Not Covered

PROFESSIONAL LIABILITY (E & O) (CLAIMS MADE)

Underlying Insurer:

Underlying Policy Number:

Policy Period:

SSCIP

6000420

From: 12/15/2023 Errors and Omissions - Each Claim $ 1,000,000 Errors and Omissions - Aggregate $ 2,000,000

EMPLOYEE BENEFITS LIABILITY (CLAIMS MADE)

Underlying Insurer:

Underlying Policy Number:

Policy Period:

Employee Benefits - Each Incident $ Not Covered Employee Benefits - Aggregate $ Not Covered

Item 6. PREMIUM: $ 2,490

Item 7. COVERAGE FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE:

SSECOV (01/21) SSECON (01/21)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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 State Waiver:

Cert Holder Name: State of Arizona

Verbiage: State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees' losses arising from work performed by or on behalf of the Contractor.

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.)

1010953Policy No.Endorsement Effective 01/01/2024 Insured Mt Graham Safe House Inc

Endorsement No.

Premium $ 0.00

CopperPoint Mutual Insurance CompanyInsurance Company Countersigned by

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WC 00 03 13

(Ed. 4-84)

© 1983 National Council on Compensation Insurance.

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.)

1010953Policy No. 7Endorsement No.Endorsement Effective 01/01/2024 Insured Mt Graham Safe House Inc Premium $

CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

Blanket Waiver: Anyone for whom you have agreed to provide this Waiver subject to the terms of this endorsement

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 State Blanket/Schedule/State

AZ BLANKET

WAIVER OF TRANSFER RIGHTS OF RECOVERY_SSCOMMWOSAZ_08/21

SSCOMMWOSAZ (08-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER RIGHTS OF RECOVERY

Policy Number: 6000420-6 Effective Date:12/15/2023

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL ABUSE LIABILITY COVERAGE FORM

SCHEDULE

Name of Person or Organization: the State of Arizona, its departments, agencies, boards, commissions, universities and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the contractor.

1. The TRANSFER OF RIGHTS OF RECOVERY 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 damages arising out of your ongoing operations or "your work" done under a contract for 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.

2. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO 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 damages for “bodily injury” or “property damage” to which this insurance applies.

3. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV PROFESSIONAL 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 “damages” resulting from a “wrongful act” to which this insurance applies.

4. The TRANSFER OF RIGHTS OF RECOVERY Condition (Section D., SEXUAL OR PHYSICAL ABUSE OR MOLESTATION 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 damages due to “abuse” to which this insurance applies.

All other terms and conditions remain unchanged.

WHO IS AN INSURED - ADDITIONAL INSURED_SSCOMMAIAZ_08/21

SSCOMMAIAZ (08-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WHO IS AN INSURED - ADDITIONAL INSURED

Policy Number: 6000420-6 Effective Date: 12/15/2023 This endorsement modifies insurance provided under the following:

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION COVERAGE FORM

BUSINESS AUTO COVERAGE FORM (coverage applies to owned, leased, hired or borrowed vehicles) COMMERCIAL GENERAL LIABILITY COVERAGE FORM (including Products-Completed Operations Coverage)

Schedule:

Name Of Additional Insured Entities:

The State of Arizona, its departments, agencies, boards, commissions, and universities, and all officers, officials, agents, and employees of these entities, for losses arising from work performed by or on behalf of the Contractor.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The section entitled “Who is an Insured” in each of the coverage forms set forth above is amended to include as an insured the person or organization shown in the schedule, but only with respect to liability for injury or damage resulting from your operations performed for that insured and caused by your acts or omissions.

All other terms and conditions remain unchanged.