CTR066200_-_COI_and_Endorsements__1_.pdf

9/10/2024

Powers-Leavitt Insurance Agency, Inc.

111 E Monroe Avenue, Suite 200

Buckeye AZ 85326

April Tuzon (623)386-4452 (866)836-5280 april-tuzon@leavitt.com

New Life Center P.O. Box 5005

Goodyear AZ 85338

Philadelphia Indemnity Company 018058 CopperPoint Indemnity Insuranc 13928

24/25

A

X

X

X

X Y PHPK2606161 9/15/2024 9/15/2025

1,000,000

100,000

5,000

1,000,000

3,000,000

3,000,000

A X

PHPK2606161 9/15/2024 9/15/2025

1,000,000

A

X X

X 10,000

PHUB882800 9/15/2024 9/15/2025

2,000,000

2,000,000

B N

1024845 9/1/2024 9/1/2025

X

1,000,000

1,000,000

1,000,000

A Sexual Abuse/Molestation PHSD1815427 9/15/2024 9/15/2025 Occurrence / Aggregate $1M / $3M

Professional Liability 9/15/2024 9/15/2025 Occurrence / Aggregate $1M / $3M

Re: DES-SVSF-06 & CTR066200.

Sexual Abuse & Molestation is included as coverage is listed above.

Professional Liability is scheduled on the Umbrella policy, per the attached schedule of underlying per form PI-CXL-002 (05/19)

The State of Arizona and Department of Economic Security c/omyCOI 1075 Broad Ripple Ave Suite 313 Indianapolis, IN 46220 must be uploaded

Tyler Woodruff/APTUZO

Y

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

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

LOCJECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSD

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

OTHER:

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 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:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

Re: DES-SVSF-06 & CTR066200.

The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor are included as Additional Insureds including Waiver of Subrogation, if a written contract is in effect for each, as required by form PI-GLD-HS (10/11) with regard to General Liability.

Coverage is subject to policy terms, conditions, limitations, and exclusions.

Waiver of Subrogation if a written contract is in effect for each, as required by attached form with regard to Auto Liability, per form CA 04 11 10 13.

Waiver of Subrogation, if a written contract is in effect, as required by attached form WC 00 03 13 with regard to Workers Compensation.

COMMENTS/REMARKS

COPYRIGHT 2000, AMS SERVICES INC.OFREMARK

PI-CXL-002 (05/19)

POLICY NUMBER:

PI-CXL-002 (05/19)

Includes copyrighted material of Insurance Services Office, Inc., with permission.

SCHEDULE OF UNDERLYING INSURANCE

Employers' Liability Company:

Policy Number:

Policy Period:

Minimum Applicable Limits

Bodily injury by accident $ Each Accident

Bodily injury by disease $ Each Employee

Bodily injury by disease $ Policy Limit

Commercial General Liability Occurrence Claims-Made

Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits:

General Aggregate $

Products-Completed Operations Aggregate ����$

Personal And Advertising Injury $

Each Occurrence $

Commercial Auto Liability Company:

Policy Number:

Policy Period:

Minimum Applicable Limits

Garage Aggregate Limit For Other Than Autos (if applicable) $

Each Accident $

Professional Liability Occurrence Claims-Made

Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

PHUB833018

WWC3487038

Wesco Insurance Company

09/15/2022 09/15/2023

1,000,000

1,000,000 1,000,000

PHPK2466024

Philadelphia Indemnity Insurance Company

09/15/2022 09/15/2023

Not Applicable

X

1,000,000

1,000,000

3,000,000

3,000,000

PHPK2466024

Philadelphia Indemnity Insurance Company

09/15/2022 09/15/2023

Not Applicable

1,000,000

PHPK2466024

Philadelphia Indemnity Insurance Company

09/15/2022 09/15/2023 09/15/2004

Each Professional Incident 1,000,000

Aggregate 3,000,000

X

POLICY NUMBER: COMMERCIAL AUTO

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page of

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

Name(s) Of Person(s) Or Organization(s):

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

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

PHPK2466024

09/15/2022

New Life Center

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

1 1

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

HUMAN SERVICES ORGANIZATION PROFESSIONAL LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

SCHEDULE

Name of Person or Organization:

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds 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 by the Contractor.

The following provisions are added to the policy:

1. WHO IS AN INSURED is amended to include as an insured the person or organization shown in the above SCHEDULE, but only with respect to their liability for activities performed by you or on your behalf relating to the conduct of your business;

2. The coverage provided by this endorsement includes the assumption of liability in a written or oral contract between the named insured and the person or organization shown in the above SCHEDULE for work performed by you or on your behalf relating to the conduct of your business;

3. The coverage provided by this endorsement only is primary. Any other applicable insurance will apply as excess; and

4. We agree to waive any right of recovery we may have against the

ADDITIONAL INSURED - STATE OF ARIZONA

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

person or organization shown in the above SCHEDULE because of payments we make for injury or damage arising out of your ongoing operations or "your work" performed under a contract with that person or organization.

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.)

12/23/2022Endorsement Effective 1024845Policy No. 21Endorsement No.

New Life CenterInsured 100 Premium $

CopperPoint Indemnity Insurance CompanyInsurance Company Countersigned by

This document may have been uploaded to the CopperPoint Portal.

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