CTR066284_-_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

1/25/2024

(520) 467-6066

18058

Community Action Human Resources Agency 109 N. Sunshine Blvd Eloy, AZ 85131

A 1,000,000

X X PHPK2560490 6/1/2023 6/1/2024 100,000

5,000

1,000,000 2,000,000 2,000,000

1,000,000A

X X PHPK2560490 6/1/2023 6/1/2024

1,000,000A

X X PHUB866214 6/1/2023 6/1/2024 1,000,000

10,000

A E&O/Professional Lia PHPK2560490 6/1/2023 Retro Date: 10/20/08 1,000,000 A E&O/Professional Lia PHPK2560490 6/1/2023 6/1/2024 Limit 2,000,000

Abusive Conduct Liability is Included in the E&O/Professional Liability - Aggregate Limit: $2,000,000 Each Abusive Conduct Limit: $1,000,000 Deductible: $0

Division Name: ADES.

- Contract ID: CTR066284.

SEE ATTACHED ACORD 101

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

COMMACT-05 VALERIESPRONG

NFP Property & Casualty Services, Inc.

6992 East Broadway Boulevard Tucson, AZ 85710

Patricia Dressler

Patti.Dressler@protek-insurance.com

Philadelphia Indemnity Insurance Company

6/1/2024

X X

X

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.

NFP Property & Casualty Services, Inc.

COMMACT-05

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

Community Action Human Resources Agency 109 N. Sunshine Blvd Eloy, AZ 85131

SEE PAGE 1

VALERIESPRONG

Description of Operations/Locations/Vehicles:

- Additional Insured Names: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

- Waiver of Subrogation applies in favor of:State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees

"Abusive Conduct coverage is not excluded"

Philadelphia Indemnity Insurance Company

NFP Property & Casualty Services, Inc 6992 East Broadway Blvd.

TUCSON, AZ 85710

(520)571-1900

NAMED INSURED: Community Action Human Resources Agency

MAILING ADDRESS: 109 N Sunshine Blvd Eloy, AZ 85131-2159

POLICY PERIOD: FROM 06/01/2023 TO 06/01/2024

TIME AT YOUR MAILING ADDRESS SHOWN ABOVE

AT 12:01 A.M. STANDARD

PI-CXL-002 (05/19)

POLICY NUMBER: PHUB866214

PHILADELPHIA

INSURANCE COMPANIES

One Bala Plaza, Suite 100

Bala Cynwyd, Pennsylvania 19004

610.617.7900 Fax 610.617.7940

PHLY.com A Member of the Tokio Marine Group

COMMERCIAL UMBRELLA LIABILITY INSURANCE

POLICY DECLARATIONS

IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS

POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.

LIMITS OF INSURANCE

EACH OCCURRENCE LIMIT

(LIABILITY COVERAGE) 1,000,000

PERSONAL & ADVERTISING INJURY LIMIT $ 1,000,000 Any one person or organization

PRODUCTS COMPLETED OPERATIONS AGGREGATE LIMIT 1,000,000

GENERAL AGGREGATE LIMIT (LIABILITY COVERAGE) (except with respect to Auto Liability and Products Completed Operations) 1,000,000

RETAINED LIMIT

RETAINED LIMIT: 10,000

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

$ 3,437.00

Not Applicable

$ 3,437.00

PREMIUM SUBTOTAL

STATE TAXES, FEES, SURCHARGES (if applicable)

PREMIUM TOTAL (including Taxes, Fees, Surcharges)

QUARTERLY SEMI-ANNUALLY I NOT APPLICABLE AUDIT PERIOD: ANNUALLY MONTHLY

PREMIUM

DESCRIPTION OF BUSINESS

FORM OF BUSINESS: NON PROFIT ORGANIZATION

BUSINESS DESCRIPTION: Non-Profit Umbrella

ENDORSEMENTS ATTACHED TO THIS POLICY

SEE ATTACHED SCHEDULE

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: Philadelphia Indemnity Insurance Company Policy Number: PHPK2560490 Policy Period: 06/01/2023 06/01/2024 Retroactive Date: Not Applicable Minimum Applicable Limits:

General Aggregate $ 2,000,000

Products-Completed Operations Aggregate $ 2,000,000 Personal And Advertising Injury $ 1,000,000 Each Occurrence $ 1,000,000

Commercial Auto Liability

Policy Number: PHPK2560490 Policy Period: 06/01/2023 06/01/2024 Minimum Applicable Limits

Garage Aggregate Limit For Other Than Autos (if applicable) $ Not Applicable

Each Accident $ 1,000,000

Professional Liability • Occurrence Claims-Made

Company: Philadelphia Indemnity Insurance Company Policy Number: PHPK2560490 Policy Period: 06/01/2023 06/01/2024 Retroactive Date: 10/20/2008

Minimum Applicable Limits Each Professional Incident $ 1,000,000

Aggregate $ 2,000,000

Employee Benefits Liability • Occurrence vi Claims-Made

Company: Philadelphia Indemnity Insurance Company

Policy Number: PHPK2560490 Policy Period: 06/01/2023 06/01/2024 Retroactive Date: 10/20/2008

Minimum Applicable Limits Each Claim $ 1,000,000

Aggregate $ 1,000,000

Abusive Conduct Liability Occurrence Claims-Made

Policy Number: PHPK2560490 Policy Period: 06/01/2023 06/01/2024 Retroactive Date: Not Applicable

Minimum Applicable Limits Each Abusive Conduct $ 1,000,000

Aggregate $ 2,000,000

Directors & Officers Liability • Occurrence Claims-Made

Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits

Liquor Liability • Occurrence Claims-Made

Company:

Policy Number:

Policy Period:

Retroactive Date:

Minimum Applicable Limits