CTR066290_OCCAC_CGL_Auto_SAM_exp_11.12.25.pdf
PDF 37 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 Company as the primary insurer. The certificate is for a contract with the State of Arizona, specifically the Department of Economic Security, under contract number CTR066290. The insurance covers commercial general liability, automobile liability, and umbrella liability policies, with the State of Arizona listed as an additional insured party.
The insurance policies are valid from 11/12/2024 to 11/12/2025, with various coverage limits including $1,000,000 for each occurrence and $2,000,000 aggregate for general liability. The auto insurance only covers hired and non-owned vehicles, as the insured owns no vehicles. The policy includes a waiver of subrogation and additional insured endorsements for auto and general liability. Notably, the policy includes abuse and molestation coverage with $1,000,000 occurrence and aggregate limits, though sexual abuse and molestation are excluded under the umbrella policy. The work comp coverage is not written by this agent.
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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
12/17/2024
Broadbent Insurance, LLC
PO Box 459
St. Johns AZ 85936
Eric Broadbent
928-245-0800 928-244-2444 eric@broadbentinsurance.com
OLD CONCHO COMMUNITY ASSISTANCE CENTER
PO Box 50
Concho AZ 85924
Berkshire Hathaway Specialty Insurance Company
A Y Y 47-SPK-265007-01 11/12/2024 11/12/2025
1,000,000
100,000
5,000
1,000,000
2,000,000
2,000,000
A Y Y 47-RWS-261285-03 11/12/2024 11/12/2025
A
10,000
47-SUM-313058-05 11/12/2024 11/12/2025
1,000,000
1,000,000
This agent doesn't write the Work Comp Coverage
The State of Arizona, its departments, agencies, boards, commissions, universities, officers, officials, agents and employees for losses arising from work performed by or on behalf of the Contractor. For ADES Contract #CTR066290. Waiver of Subrogation and Additional Insured endorsements are attached for Auto and General Liability policies. Sexual abuse and Molestation are excluded under the Umbrella Policy. Abuse and Molestion are included by endorsement on the GL policy with a $1,000,000 occurrence and $1,000,000 aggregrate limit.
Auto insurance only includes Hired and Non-owned because insured owns no autos whatsoever. Only autos used are Non-Owned used by employees.
State of Arizona and Department of Economic Security
C/O myCOI
1075 Broad Ripple Ave, Suite 313
Indianapolis IN 46220
File details come from the government source that posted it. Updated .