CTR066209_-_COI_and_Endorsements__1_.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 EXP

TYPE 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

3/4/2025

License # L077730

24319

WestCare Arizona I, Inc.

PO Box 94738 Las Vegas, NV 89193-4738

44768 20044

A 1,000,000

X X 5088087805 7/1/2024 7/1/2025 100,000

20,000

1,000,000

3,000,000

3,000,000

ABUSE SEE REMA 2,000,000

1,000,000B

X X 5091019305 7/1/2024 7/1/2025

2,000,000A 5090022305 7/1/2024 7/1/2025

10,000 C

X WEWC621460 3/1/2025 3/1/2026 1,000,000

1,000,000

1,000,000

A Professional Liabili 5088087805 7/1/2024 Aggregate 3,000,000

A Professional Liabili 5088087805 7/1/2024 7/1/2025 Occurrence 1,000,000

Contract ID: CTR066209 State of Arizona, and its departments, agencies, boards, commission, universities, officers, officials, agents and employees are included as Additional Insureds as respects to General Liability where required by written contract.

State of Arizona, and its departments, agencies, boards, commission, universities, officers, officials, agents and employees are included as Additional Insureds as respects to liability arising out of the activities performed by or on behalf of the contractor involving Automobiles Owned, Hired and/or Non-owed by the contractor, where required by written contract.

Waiver of Subrogation applies in favor of Additional Insureds as respects to General Liability, Auto Liability and Workers Compensation as permitted by law, SEE ATTACHED ACORD 101

The State of Arizona, Department of Economic Security C/O: myCOI 1075 Broad Ripple Ave, Suite 313 Indianapolis, IN 46220

WESTFOU-01 SE72DWILLIAMS

AssuredPartners, Lake Mary 300 Colonial Center Parkway, Suite 270 Lake Mary, FL 32746

Deidre Williams deedee.williams@assuredpartners.com

Allied World Surplus Lines Insurance Company

Vantapro Specialty Insurance Company Berkshire Hathaway Homestate

X

7/1/2025

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.

AssuredPartners, Lake Mary

WESTFOU-01

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

License # L077730

SEE P 1

WestCare Arizona I, Inc.

PO Box 94738 Las Vegas, NV 89193-4738

SEE PAGE 1

SE72DWILLIAMS

Description of Operations/Locations/Vehicles:

where required by written contract.

Coverage is Primary and non-contributory where required by written contract.

Umbrella Extends over Professional Liability.

Sexual Abuse & Molestation Liability included as per attached form NPSS GL0000500.

Sexual Abuse and Molestation coverage is included.

Additional Coverages:

Coverage: Excess Umbrella INSURER AFFORDING COVERAGE: MSIG Specialty USA

POLICY NUMBER: PPA0000027 EFF DATE: 07/01/2024 EXP DATE: 07/01/2025

TYPE OF INSURANCE: $1,000,00 EXCESS OVER $2,000,000 PRIMARY UMBRELLA, EXCESS OVER General & Professional Liability CLAIMS MADE -- Retro Date: 07/01/2024 LIMIT DESCRIPTION: $1,000,000 each claim / $1,000,000 Aggregate

Coverage: Abuse & Molestation INSURER AFFORDING COVERAGE: Allied World Surplus Lines Insurance Company

POLICY NUMBER: 5088-0878-05 EFF DATE: 07/01/2024 EXP DATE: 07/01/2025

TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:

Abuse & Molestation Per Occurrence $1,000,000 Aggregate $3,000,000

Coverage: Cyber Liability INSURER AFFORDING COVERAGE: Houston Casualty Company

POLICY NUMBER: H23NGP21077103 EFF DATE: 07/01/2024 EXP DATE: 07/01/2025

TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:

Network Security Liability Per Claim: $5,000,000 Aggregate: $5,000,000

Coverage: Executive Risk/Management Liability INSURER AFFORDING COVERAGE: Federal Insurance Company

POLICY NUMBER: J06324733 EFF DATE: 07/01/2024 EXP DATE: 07/01/2025

TYPE OF INSURANCE: LIMIT DESCRIPTION LIMIT AMOUNT: Retention:

Directors & Officers Liability Each Incident $6,000,000 $100,000 Employment Practices Liability Each Incident $6,000,000 $150,000 Fiduciary Liability Each Incident $2,000,000 $0 Maximum Aggregate: Aggregate $6,000,000

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

WC 00 0313

(Ed. 4-84)

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

Specific Waiver

Person/Organization: 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 Contractor

Job Description: as per written agreement

Waiver Premium: 162.00

Class State

8864 AZ

Payroll Subject to Waiver

NA

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.)

Endorsement No.: Endorsement Effective: 03/01/2025 Policy No. WEWC621460 Insured:

Insurance Company: Berkshire Hathaway Homestate Ins Co

WC 00 0313

(Ed. 4-84)

© 1983 National Council on Compensation Insurance

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Countersigned by ______________ _