CTR066209-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

3/4/2024

24319

WestCare Arizona I, Inc.

PO Box 94738 Las Vegas, NV 89193-4738

44768 20044

A 1,000,000

X X 5088087804 7/1/2023 7/1/2024 1,000,000 20,000

1,000,000 3,000,000 3,000,000

ABUSE AGGREGATE 2,000,000

1,000,000B

X X 5091019304 7/1/2023 7/1/2024

3,000,000A X X 5090022304 7/1/2023 7/1/2024

10,000 C

X WEWC519890 3/1/2024 3/1/2025 1,000,000

N 1,000,000

1,000,000 A Professional Liabili 5088087804 7/1/2023 Aggregate 3,000,000 A Professional Liabili 5088087804 7/1/2023 7/1/2024 Occurrence 1,000,000

Contract #CTR066209 - Domestic Violence -Statewide The State of Arizona and the Dept. of Economic Security, Officials, Agents and Employees are included as additional insureds for general liability & auto liability arising out of the activities performed by the Named Insured where required by written contract. Waiver of subrogation is in favor of The State of Arizona and the Dept. of Economic Security, Officials, Agents and Employees where required by written contract.

Workers compensation waiver in favor of The State of Arizona and the Dept. of Economic Security, Officials, Agents and Employees where required by written contract.

Umbrella extends over General, Professional, and Automobile Liability.

30 Days notice of cancellation; except 10 days for nonpayment.

State of Arizona, Dept of Economic Security Procurement Office- bernadettehill@azdes.gov 1789 W. Jefferson, Mail Drop 1541 Phoenix, AZ 85007

WESTFOU-01 SE72KMORALESALVARE

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

Kelly Morales Alvarez

Kelly.Moralesalvarez@assuredpartners.com

Allied World Surplus Lines Insurance Company Vantapro Specialty Insurance Company Berkshire Hathaway Homestate

7/1/2024

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

SEE P 1

WestCare Arizona I, Inc.

PO Box 94738 Las Vegas, NV 89193-4738

SEE PAGE 1

SE72KMORALESALVAREZ

Additional Coverages:

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

POLICY NUMBER: 5088-0878-04 EFF DATE: 07/01/2023 EXP DATE: 07/01/2024

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: 09/21/2023 EXP DATE: 07/01/2024

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: 09/21/2023 EXP DATE: 07/01/2024

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

POLICY NUMBER: 5091-0193-04 COMMERCIAL AUTO

CA04 441013

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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: Westcare Foundation Inc.

Endorsement Effective Date: 07/01/2023

SCHEDULE

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

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

Information reauired 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.

CA 04 441013 © Insurance Services Office, Inc., 2011 Page 1 of 1

VP-UM 00001 00 (04/18)

Endorsement No:

This Endorsement, effective: 7/1/2023

(at 12:01 A.M. standard time at the address of the Named Insured as shown in Item 1. B. of the Declarations) forms a part of Policy No: 5090-0223-04 Issued to: Westcare Foundation, Inc.

by: Allied World Surplus Lines Insurance Company

SCHEDULE OF UNDERLYING INSURANCE

SCHEDULE

Type of Coverage

Insurer Policy Number Policy Period

Limits of Insurance

Allied World Surplus Lines Insurance Company

$1,000,000 Each Occurrence Limit

5088-0878-04 $3,000,000 General Aggregate Limit 7/1/2023 - 7/1/2024 $3,000,000 Products-Completed Operations

Aggregate Limit

1. Commercial General Liability

Personal & Advertising Injury Limit

$1,000,000 Any One Person Or Organization

Defense costs:

Erode Do not erode

The Limits of Insurance listed in the policy above.

RETROACTIVE DATE: None

Vantapro Specialty Insurance Company

$1,000,000 Any One Accident Or Loss

5091-0193-04

2. Automobile Liability

7/1/2023 - 7/1/2024 Defense costs:

Erode Do not erode The Limits of Insurance listed in the policy above.

Allied World Surplus Lines Insurance Company

$1,000,000 Each Professional Incident Limit (Per “Claim”)

5088-0878-04 $3,000,000 Professional Liability Aggregate Limit

7/1/2023 - 7/1/2024 $ 25,000 Information Privacy Limit

3. Non-Profit and Social Services Professional Liability Coverage Form $ 5,000 Disciplinary Proceedings Limit

(Per “Proceeding”) Defense costs:

Erode Do not erode The Limits of Insurance listed in the policy above.

RETROACTIVE DATE: N/A

Allied World Surplus Lines Insurance Company

$1,000,000 Each Occurrence Limit

5088-0878-04 $2,000,000 Aggregate Limit

4. Abuse and Molestation

7/1/2023 - 7/1/2024

VP-UM 00001 00 (04/18)

Type of Coverage

Insurer Policy Number Policy Period

Limits of Insurance

Defense costs:

Erode Do not erode

The Limits of Insurance listed in the policy above.

RETROACTIVE DATE: N/A

Allied World Surplus Lines Insurance Company

$1,000,000 Each Employee Limit

5088-0878-04 $3,000,000 Aggregate Limit

5. Employee Benefits Liability

7/1/2023 - 7/1/2024 Defense costs:

Erode Do not erode The Limits of Insurance listed in the policy above.

RETROACTIVE DATE: 5/12/2007

Allied world Surplus Lines Insurance Company

$1,000,000 Each Accident

5088-0878-04 $1,000,000 Disease – Each Employee

6. Stop Gap Liability

7/1/2023 – 7/1/2024 $ Disease – Policy Limit Defense costs:

Erode Do not erode The Limits of Insurance listed in the policy above.

All other terms and conditions of this policy remain unchanged.

By:

Joseph Saraiva

Title: Chief Underwriting Officer

Date: 7/21/2023

1,000,000