CTR066207-WCCOIandEndorsements.pdf
PDF 2 MB Posted
- Attached to
- Master Agreement AZ|CTR066207
- Contract number
- CTR066207
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by CopperPoint Indemnity Insurance Company for Verde Valley Sanctuary Inc, located in Sedona, Arizona. The certificate is for a policy covering the State of Arizona, specifically the Department of Economic Security (ADES), with a contract ID of CTR066207. The insurance policy includes commercial general liability and workers' compensation coverage, with Heffernan Insurance Brokers serving as the producer.
The policy provides liability coverage with limits of $1,000,000 for each occurrence, general aggregate, and personal and advertising injury. The workers' compensation policy covers employees with $1,000,000 limits for each accident, disease per employee, and disease policy limit. The insurance is effective from May 1, 2024, to May 1, 2025, and includes a waiver of subrogation for the State of Arizona, its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. The certificate holder is the State of Arizona and Department of Economic Security, with a 30-day notice of cancellation provision attached to the policy.
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Text version
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
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
4/29/2024
(HD) Heffernan Insurance Brokers 1350 Carlback Avenue Walnut Creek CA 94596
Shannon Davison 925-934-8500 925-934-8278 shannond@heffins.com
License#: 0564249 CopperPoint Indemnity Insurance Company 13928
VERDVAL-02
Verde Valley Sanctuary Inc PO Box 595 Sedona AZ 86339
1073813659
A X
N
Y 1016058 5/1/2024 5/1/2025
1,000,000
1,000,000
1,000,000
Division Name: ADES.
- Contract ID: CTR066207 Waiver of Subrogation applies to: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees.
30 days notice of cancellation is attached. No proprietor/partner/executive/officer/member is excluded
The State of Arizona and Dept of Economic Security C/O: myCOI 1075 Broad Ripple Ave, Suite 313 Indianapolis IN 46220
1 of 1WC 00 99 06 29 | Doc Type: POLEND 07 | 22
CopperPoint Indemnity Insurance Company
CARRIER CODE 93107
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
05/01/2024 1016058
AMENDING POLICY NUMBER AUTHORIZED REPRESENTATIVEMO DAY YEAR
04/08/2024
ENDORSEMENT NO
Counter signed at Phoenix, Arizona
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