CTR066290_-_COI.pdf
PDF 36 KB Posted
- Attached to
- Master Agreement AZ|CTR066290
- Contract number
- CTR066290
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by Broadbent Insurance, LLC for Old Concho Community Assistance Center, with Berkshire Hathaway Specialty Insurance as the coverage provider. The certificate is for the State of Arizona, specifically the Department of Economic Security, and covers multiple insurance policies including Commercial General Liability, Automobile Liability, and Umbrella Liability. The insurance is associated with ADES Contract #CTR066290 and provides coverage for the insured and additional parties such as the State of Arizona, its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees.
The insurance policies are effective from 11/12/2023 to 11/12/2024, with various coverage limits including $1,000,000 for each occurrence in General Liability and Automobile Liability, and a $2,000,000 aggregate limit. Notable provisions include additional insured status for the State of Arizona and a waiver of subrogation. The policy includes Products/Completed Operations coverage and has specific endorsements for Abuse and Molestation, with a $1,000,000 occurrence and aggregate limit. Sexual Abuse and Molestation are excluded under the Umbrella Policy but covered by endorsement on the General Liability 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
ACORD 0025 2016-03 Acroform
05/14/2024
Broadbent Insurance, LLC
PO Box 459
St. Johns AZ 85936
928-245-0800 928-244-2444 eric@broadbentinsurance.com
OLD CONCHO COMMUNITY ASSISTANCE CENTER
PO Box 50
Concho AZ 85924
Berkshire Hathaway Specialty Insurance
A
Products/Completed Operations
Y Y 47-SPK-313057-04 11/12/2023 11/12/2024
1,000,000
1,000,000
20,000
1,000,000
2,000,000
2,000,000
A Y Y 47-RWS-261282-03 11/12/2023 11/12/2024
1,000,000
A Y Y 47-SUM-313058-04 11/12/2023 11/12/2024
1,000,000
1,000,000
Additional Insured Names: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees. Waiver of Subrogation applies to: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees. Additional Insured endorsement for GL and Auto Liablility attached. Waiver of Subrogation for GL attached. For ADES Contract #CTR066290. Sexual Abuse and Molestation are excluded under the Umbrella Policy. Abuse and Molestation are included by endorsement on the GL policy with a $1,000,000 occurrence and $1,000,000 aggregrate limit.
State of Arizona and Department of Economic Security
C/O: myCOI
1075 Broad Ripple Ave, Suite 313
Indianapolis, IN 46220
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