CTR069054_COI_Expires_7.01.2024.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

DATE (MM/DD/YYYY)

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 RENTED

CLAIMS-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 AGG $JECT

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 LIMIT $DESCRIPTION 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.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE

Lockton Companies 8110 E. Union Avenue Suite 700 Denver CO 80237

(303) 414-6000

Catholic Charities Community Services, Inc.

5151 N 19th Ave Phoenix, AZ 85015

Social Service Contractor's Indemnity Pool 0 CopperPoint American Insurance Company 13751

X X

1,000,000 1,000,000 10,000 1,000,000 3,000,000 3,000,000

X

X $500 comp X $500 coll

1,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X X X

5,000,000 5,000,000

XXXXXXX

N

X

1,000,000 1,000,000 1,000,000

See Attached See Attached

A 6000569 7/1/2023 7/1/2024

A 6000569 7/1/2023 7/1/2024

A 6000569 7/1/2023 7/1/2024

A 6000570 7/1/2023 7/1/2024

B 1019020 7/1/2023 7/1/2024

7/1/2024

1428315

Y Y

Y Y

N N

Y

10/25/2022

N N

19937461

19937461 XXXXXXX

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

Re: Division Name: ADES, Contract #CTR040852, CTR061944, CTR062399 & CTR066190 The State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees are included as Additional Insured with respect to liability arising out of the activities performed by or on behalf of the Named Insured as respect General Liability and Auto Liability, involving automobiles owned, hired and/or non-owned by the Contractor, where required by written contract. Waiver of Subrogation applies in favor of the State of Arizona and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees for

X

See Attachment

CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required)

ACORD 25 (2016/03)

losses arising from work performed by or on behalf of the Named Insured as respects General Liability, Auto Liability, and Workers’ Compensation where required by written contract as permitted by law. Sexual Abuse and Molestation coverage is included. The Excess Liability policy referenced above schedules General Liability, Automobile Liability, Employers' Liability (Occurrence) and Professional Liability (Claims Made, Retro Date 5/01/2013) as underlying insurance.

Certificate Holder ID: 19937461

Catholic Charities Community Services, Inc.

Policy: 6000569 Insurer: Social Services Contractor's Indemnity Pool Policy Term: 7/1/2023 – 7/1/2024

Other Coverages:

Professional Liability Claims Made Retro Date 5/1/2013

$3,000,000 Aggregate $1,000,000 Each Act

Sexual Abuse/Molestation Occurrence

$3,000,000 Aggregate $1,000,000 Each Act

Attachment Code: D593480 Master ID: 1428315, Certificate ID: 19937461

LOSS PAYEE

DATE (MM/DD/YYYY)

PRODUCER NAME, NAIC NO:PHONE COMPANY NAME AND ADDRESS

CONTACT PERSON AND ADDRESS (A/C, No, Ext):

IF MULTIPLE COMPANIES, COMPLETE SEPARATE FORM FOR EACHFAX E-MAIL

(A/C, No): ADDRESS:

POLICY TYPECODE: SUB CODE:

AGENCY

CUSTOMER ID #:

NAMED INSURED AND ADDRESS LOAN NUMBER POLICY NUMBER

EFFECTIVE DATE EXPIRATION DATE

ADDITIONAL NAMED INSURED(S) THIS REPLACES PRIOR EVIDENCE DATED:

LOCATION / DESCRIPTION

LENDER SERVICING AGENT NAME AND ADDRESS

NAME AND ADDRESS

AUTHORIZED REPRESENTATIVE

CONTINUED UNTIL

TERMINATED IF CHECKED

YES NO

YES NO

CONTRACT OF SALE LENDER'S LOSS PAYABLE

MORTGAGEE

YES NO N/A

PERILS INSURED BASIC BROAD SPECIAL

COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE: DED:

BUSINESS INCOME RENTAL VALUE If YES, LIMIT: Actual Loss Sustained; # of months:

BLANKET COVERAGE If YES, indicate value(s) reported on property identified above: $

TERRORISM COVERAGE Attach Disclosure Notice / DEC

IS THERE A TERRORISM-SPECIFIC EXCLUSION?

IS DOMESTIC TERRORISM EXCLUDED?

LIMITED FUNGUS COVERAGE If YES, LIMIT: DED:

FUNGUS EXCLUSION (If "YES", specify organization's form used)

REPLACEMENT COST

AGREED VALUE

COINSURANCE If YES, %

EQUIPMENT BREAKDOWN (If Applicable) If YES, LIMIT: DED:

ORDINANCE OR LAW - Coverage for loss to undamaged portion of bldg If YES, LIMIT: DED:

- Demolition Costs If YES, LIMIT: DED:

- Incr. Cost of Construction If YES, LIMIT: DED:

EARTH MOVEMENT (If Applicable) If YES, LIMIT: DED:

FLOOD (If Applicable) If YES, LIMIT: DED:

WIND / HAIL INCL Subject to Different Provisions: If YES, LIMIT: DED:

NAMED STORM INCL Subject to Different Provisions: If YES, LIMIT: DED:

PERMISSION TO WAIVE SUBROGATION IN FAVOR OF MORTGAGE

HOLDER PRIOR TO LOSS

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 EVIDENCE OF PROPERTY INSURANCE 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 EVIDENCE OF COMMERCIAL PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE ADDITIONAL INTEREST.

(ACORD 101 may be attached if more space is required)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE

DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

PROPERTY INFORMATION BUILDING OR BUSINESS PERSONAL PROPERTY

COVERAGE INFORMATION

CANCELLATION

ADDITIONAL INTEREST

© 2003-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 28 (2016/03)

EVIDENCE OF COMMERCIAL PROPERTY INSURANCE

Lockton Companies 8110 E. Union Avenue Suite 700 Denver CO 80237

(303) 414-6000

The ACORD name and logo are registered marks of ACORD

Property

Catholic Charities Community Services, Inc.

5151 N 19th Ave Phoenix, AZ 85015

Social Service Contractor's Indemnity Pool

60005691117987

7/1/2023 7/1/2024

25721

X X

X

38,861,044 $5,000

X X 300,000

X 38,861,044

X

X

X

X

X

X

X

X 100

X Included $5,000

X $500,000 $5,000

X $500,000 $5,000

X $500,000 $5,000

X

X X X Included $5,000 X X Included $5,000

X

11/27/2023

854092 Proof Coverage

Social Service Contractors Indemnity Pool

WHO IS AN INSURED - ADDITIONAL INSURED_SSCOMMAIAZ_08/21

SSCOMMAIAZ (08-21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WHO IS AN INSURED - ADDITIONAL INSURED

Policy Number: 6000569 Effective Date: 07/01/2022

This endorsement modifies insurance provided under the following:

SOCIAL SERVICE AGENCY PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION COVERAGE FORM

BUSINESS AUTO COVERAGE FORM (coverage applies to owned, leased, hired or borrowed vehicles) COMMERCIAL GENERAL LIABILITY COVERAGE FORM (including Products-Completed Operations Coverage)

Schedule:

Name Of Additional Insured Entities:

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The section entitled “Who is an Insured” in each of the coverage forms set forth above is amended to include as an insured the person or organization shown in the schedule, but only with respect to liability for injury or damage resulting from your operations performed for that insured and caused by your acts or omissions.

All other terms and conditions remain unchanged.

Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions,exclusions or limitations of the above-mentioned policy, except as expressly stated herein. This endorsement is part of such policy and incorporated therein.

Issuing Company: Travelers Casualty and Surety Company of America

Policy Number: 106728947

CRI-7019 Ed. 01-09 Printed in U.S.A.

©2009 The Travelers Companies, Inc. All Rights Reserved

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

JOINT LOSS PAYABLE ENDORSEMENT

This endorsement modifies the following coverage:

Crime

It is agreed that:

1. This endorsement modifies all Insuring Agreements forming part of this Crime Policy, unless specified below as indicated by the corresponding and then only to those so indicated:

A. FIDELITY

Employee Theft ERISA Fidelity Employee Theft of Client Property

B. FORGERY OR ALTERATION

C. ON PREMISES

D. IN TRANSIT

E. MONEY ORDERS AND COUNTERFEIT MONEY

F. COMPUTER CRIME

Computer Fraud Computer Program and Electronic Data Restoration Expense

G. FUNDS TRANSFER FRAUD

H. PERSONAL ACCOUNTS PROTECTION

I. CLAIM EXPENSE

2. The Insured agrees that any loss payable under the Insuring Agreement(s) indicated above and involving Money or Other Property in which the designated Loss Payee has an interest shall be paid jointly to the Named Insured and to the Loss Payee designated below:

Loss Payee Name Loss Payee Address

State of Arizona Department of Economic Security Division of Aging and Adult Services

1789 W. Jefferson Street, Mail Drop 6271, Phoenix, AZ 85007 and any such payment shall constitute payment to the Insured. The Company agrees to make all such payments to the Named Insured and to the Loss Payee, and the Company will not make any payment solely to the Named Insured unless the Company receives a request in writing from the Loss Payee to make such payment solely to the Insured.

3. The Company's liability under the Insuring Agreement(s) indicated above as extended by this endorsement are not cumulative.

4. No rights or benefits are bestowed on the Loss Payee other than payment of the loss as set forth herein.

Social Service Contractors Indemnity Pool

SSGLPRIMNONC (01/21) Includes wording © ISO Properties, Inc., used with permission Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRIMARY AND NONCONTRIBUTORY –

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

The following is added to the COMMERCIAL GENERAL LIABILITY CONDITIONS of SECTION IV, paragraph 4.

Other Insurance and supersedes any provision to the contrary:

Primary and Noncontributory Insurance

This insurance is primary to, and will not seek contribution from, any other insurance available to an additional insured under your policy provided that:

(1) The additional insured is a Named Insured under such other insurance; and

(2) You have agreed in a written contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured.

Please reference these credentials when accessing copperpoint.com

Policy Number:

Account Number:

1019020

5000024356

1 of 1P-799 | Doc Type: SFCOR 03 | 21

Phone: 602.631.2300 Toll Free: 1.800.231.1363

3030 N 3rd Street | Phoenix AZ 85012-3068 copperpoint.com

06/28/2023

Catholic Charities Community Services Inc 5151 N 19th Avenue Phoenix, AZ 85015

1019020Policy Number:

Dear Policyholder:

Thank you for renewing through CopperPoint Western Insurance Company. Enclosed please find your new Workers Compensation and Employers Liability Insurance Policy.

Total Premium Down Payment Installment Frequency or Payment Plan

$88,620.00 $9,006.00 Installment Plan - 10 Pay, 10% Down

As a reminder, helpful products and services are available on our website, copperpoint.com, where it is easy to create a registered account using your policy and account numbers located above.

Please visit the Customer Login page at ce.copperpoint.com to create your web account or call us at 1-800-231-1363 for assistance.

With your account, you’ll have 24/7 access to resources, such as:

• Fast claim filing

• Payroll reporting

• Account invoices and billing history

• Payment by electronic funds transfer (EFT)

• Exclusive safety videos

• Safety cards by industry and injury prevention

• Downloadable step-by-step safety plan template

• State-specific workplace compliance and safety posters

Again, we thank you for choosing CopperPoint Western Insurance Company, a premier provider of workers compensation and a leading advocate for workplace safety. “Put us to work for you.”

If you have any questions, please contact us at 602.631.2300 or 1.800.231.1363.

This document may have been uploaded to the CopperPoint Portal.

INFORMATION PAGE DOC TYPE: INFPG

Carrier Code 97046

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

ARIZONA

07/01/2023 - 07/01/2024

1 4747 N 7TH AVENUE, PHOENIX, AZ 85013

$110,467 0.040000 $44 8871 CLERICAL TELECOMMUTER EMPLOYEES

$1,661,409 0.880000 $14,620 8842 Group Homes-all Employees & Salespersons, Drivers

11,422,063 0.630000 $71,959 8864 SOCIAL SERVICES ORGANIZATION--ALL EMPLOYEES &

SALESPERSONS

$7,504,290 0.570000 $42,774 8869 CHILD DAY CAMP-ALL EMPLS INCL CLER/SLS

$2,282,093 0.070000 $1,597 8810 CLERICAL OFFICE EMPLOYEES-N.O.C.

2 736 N. MAIN STREET, COTTONWOOD, AZ 86326

3 2220 S. COUNTRY CLUB DR, MESA, AZ 85210

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

4 1135 E. CHANDLER BLVD, CHANDLER, AZ 85224

5 2101 N. 4TH STREET, FLAGSTAFF, AZ 86004

6 434 W. GURLEY STREET, PRESCOTT, AZ 86301

7 5104 E. THOMAS RD., PHOENIX, AZ 85018

8 6738 N 45TH AVE, GLENDALE, AZ 85301

9 525 E. HARRISON DR., AVONDALE, AZ 85323

10 113 E. CENTRE DR., BUCKEYE, AZ 85326

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

11 405 S. 7TH ST., BUCKEYE, AZ 85326

12 4801 W. MARYLAND AVE., GLENDALE, AZ 85301

13 7910 W. MARYLAND AVE., GLENDALE, AZ 85303

14 12397 W. THUNDERBIRD RD., EL MIRAGE, AZ 85335

15 6625 N. 56TH AVE., GLENDALE, AZ 85301

16 6600 W. MISSOURI AVE., GLENDALE, AZ 85301

17 6331 W. LAMAR RD., GLENDALE, AZ 85301

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

18 220 E. LA CANADA BLVD., AVONDALE, AZ 85323

19 5535 N. 67TH AVE., GLENDALE, AZ 85301

20 45 S. 3RD AVE., AVONDALE, AZ 85323

21 6242 N. 59TH AVE., GLENDALE, AZ 85301

22 10700 S. PALO VERDE RD., PALO VERDE, AZ 85343

23 11708 N. 80TH AVE., PEORIA, AZ 85345

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

24 4933 W. ORANGEWOOD AVE., GLENDALE, AZ 85301

25 9302 W. BADEN ST., TOLLESON, AZ 85353

26 7400 W OLIVE AVE, PEORIA, AZ 85258

27 1895 E DON CARLOS, TEMPE, AZ 85281

28 460-466 W BELLVIEW, MESA, AZ 85204

29 2422 W HOLLY STREET, PHOENIX, AZ 85009

30 5151 N 19TH AVENUE, PHOENIX, AZ 85015

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

31 5104 N. 16TH AVENUE, PHOENIX, AZ 85013

32 9261 W VAN BUREN STREET, TOLLESON, AZ 85353

33 5119 N 19TH AVE, PHOENIX, AZ 85015

34 1594 N. OATMAN ROAD, BULLHEAD CITY, AZ 86442

35 3834 S. 91ST AVENUE, TOLLESON, AZ 85353

36 1825 W. NORTHERN AVENUE, PHOENIX, AZ 85021

37 1252 S. AVONDALE, AVONDALE, AZ 85323

CopperPoint Western Insurance Company 3030 N. 3rd Street | Phoenix, Arizona 85012-3039 Policy No: 1019020

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

Prior Policy No:

Type of Ownership: Non or not for profit corp.

Item 1 CATHOLIC CHARITIES COMMUNITY SERVICES INC

5151 N 19TH AVENUE

PHOENIX, AZ 85015

Tax Identification No: 86-0223999 Item 2 Policy Period, From: 07/01/2023 To: 07/01/2024

12:01 AM Standard Time at your mailing address.

Item 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: AZ

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limit

C. Other States Insurance: Part three of the policy per the Terms of the Limited Others States Insurance Endorsement

D. This policy includes these endorsements and schedules: See Extension of Information Pages

See Item 4, below, for other workplaces not shown above.

Item 4 Classification of Operations

Class Code

The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit.

PREMIUM BASIS

Estimated Total

Annual Remuneration

RATES

Rate per $100 of Payroll

ESTIMATED

ANNUAL

PREMIUM

If indicated, interim adjustments of premium shall be made:

Installment Plan - 10 Pay, 10% Down

Minimum Premium: $360

Down Payment Premium: $9,006.00

Total Estimated Annual Premium: $88,620

Endorsement Numbers: Refer to Endorsement WC 99 06 60

Rating Effective Date: 07/01/2023

Countersigned: June 28 20 23

President / Authorized Representative WC 00 00 01 D (Ed. 03/22) © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved

NCCI Risk ID: 021178160

Experience Modification Factor: 0.700000 07/01/2024Expires:

Rating Effective Date:

WCIRB Risk ID:

Experience Modification Factor:

Expires:

$130,994 Manual Premium

$0 0.020000 $100 0930 Waiver of Subrogation - Scheduled

$130,994 0.011000 $1,441 9812 Increased Limit Charge

$132,535 0.700000 ($39,761)9898 Experience modifier

22,980,322 0.007000 $1,609 9740 Terrorism

22,980,322 0.007000 $1,609 9741 Catastrophe (other than Certified Acts of Terrorism)

$92,774 0.081191 ($7,532)0063 Premium discount

$1 160 $160 0900 Expense constant

$88,620 ARIZONA Total Premium

Note:

This endorsement may be used to extend the information page by listing additional endorsements and schedules that are part of the policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 60

(Ed. 05/22)

WC 99 06 60

(Ed. 05/22)

© 1991 National Council on Compensation Insurance.

EXTENSION OF INFORMATION PAGE

Schedule of Forms

ITEM 3D

1019020POLICY NO:

Form Numbers Form Name Applicable States P-503 Independent Contractor Premium Advisory AZ

P-504.1 Out of State Coverage Advisory AZ

P-799 Policy Renewal Statement Letter AZ

WC 00 00 00 C Workers Compensation and Employers Liability Insurance Policy

AZ

WC 00 00 01 D Information Page Notes AZ

WC 99 04 19 Premium When Due Endorsement AZ

WC 99 06 17 Dividend Endorsement AZ

WC 99 06 18 Notification of Dividend AZ

P-531 Installment Plan Schedule AZ

WC 00 04 21 F Catastrophe (Other Than Certified Acts of Terrorism) Premium Endorsement

AZ

WC 00 04 22 C Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement

AZ

WC 02 06 03 Arizona Amendatory Endorsement AZ

WC 00 99 03 22 Limited Other States Insurance Endorsement AZ

WC 00 99 06 23 Membership Endorsement AZ

WC 00 99 06 25 Schedule of Fees AZ

WC 02 04 01 C Arizona Alcohol & Drug Free Workplace Premium Credit Endorsement

AZ

WC 99 06 60 Extension of Information Page Item 3D Endorsement

AZ

WC 00 03 13 Waiver of Our Right to Recover from Others Endorsement

AZ

WC 00 04 04 Pending Rate Change Endorsement AZ

WC 00 04 14 A 90-Day Reporting Requirement—Notification of Change in Ownership Endorsement

AZ

WC 00 04 25 Experience Rating Modification Factor Revision Endorsement

AZ

Note:

This endorsement may be used to extend the information page by listing additional endorsements and schedules that are part of the policy.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 60

(Ed. 05/22)

WC 99 06 60

(Ed. 05/22)

© 1991 National Council on Compensation Insurance.

Form Numbers Form Name Applicable States WC 02 06 01 C Arizona Cancellation and NonRenewal

Endorsement

AZ

WC 99 06 22 Extension of Information Page Schedule of Named Insured

AZ

WC 00 03 10 Sole Proprietors Partners Officers and Others Coverage Endorsement

AZ

CopperPoint Western Insurance Company

CARRIER CODE 97046

POLICY ENDORSEMENT

Please attach this endorsement to your policy

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

MO DAY YEAR

EFFECTIVE

12:01 AM 07/01/2023

MO DAY YEAR

06/28/2023

AUTHORIZED REPRESENTATIVE

Counter signed at Phoenix, Arizona

1019020

AMENDING POLICY NUMBER

Catholic Charities Community Services Inc 5151 N 19th Avenue Phoenix, AZ 85015

1 of 1WC 99 06 22 | Doc Type: POLEND 05 | 15

EXTENSION OF INFORMATION PAGE

Schedule of Named Insured Item 1

Named Insured FEIN

N/A N/A

Doing Business As

N/A

Agency

Lockton Companies, LLC (Phoenix) 602-602-6002 14850 N Scottsdale Rd Suite 225 Scottsdale, AZ 85254

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C

(Ed. 01-15)

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows:

GENERAL SECTION

A. The Policy

This policy includes at its effective date the Infor-mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor-mation Page) and us (the insurer named on the In-formation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this poli-cy.

B. Who is Insured

You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an em-ployer of the partnership’s employees.

C. Workers Compensation Law

Workers Compensation Law means the workers or workmen’s compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen’s compensation law, any fed-eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits.

D. State

State means any state of the United States of America, and the District of Columbia.

E. Locations

This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self-insured for such workplaces.

PART ONE

WORKERS COMPENSATION INSURANCE

A. How This Insurance Applies

This workers compensation insurance applies to bodily injury by accident or bodily injury by disease.

Bodily injury includes resulting death.

1. Bodily injury by accident must occur during the policy period.

2. Bodily injury by disease must be caused or ag-gravated by the conditions of your employment.

The employee’s last day of last exposure to the conditions causing or aggravating such bodily in-jury by disease must occur during the policy pe-riod.

B. We Will Pay

We will pay promptly when due the benefits required of you by the workers compensation law.

C. We Will Defend

We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in-vestigate and settle these claims, proceedings or suits.

We have no duty to defend a claim, proceeding or suit that is not covered by this insurance.

D. We Will Also Pay

We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend:

1. reasonable expenses incurred at our request, but not loss of earnings;

2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance;

3. litigation costs taxed against you;

4. interest on a judgment as required by law until we offer the amount due under this insurance;

and

5. expenses we incur.

E. Other Insurance

We will not pay more than our share of benefits and costs covered by this insurance and other

WC 00 00 00 C

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

insurance or self insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid.

F. Payments You Must Make

You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required be-cause:

1. of your serious and willful misconduct;

2. you knowingly employ an employee in violation of law;

3. you fail to comply with a health or safety law or regulation; or

4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law.

If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly.

G. Recovery From Others

We have your rights, and the rights of persons enti-tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them.

H. Statutory Provisions

These statements apply where they are required by law.

1. As between an injured worker and us, we have notice of the injury when you have notice.

2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du-ties under this insurance after an injury occurs.

3. We are directly and primarily liable to any per-son entitled to the benefits payable by this in-surance. Those persons may enforce our duties;

so may an agency authorized by law. Enforce-ment may be against us or against you and us.

4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law.

5. This insurance conforms to the parts of the workers compensation law that apply to:

a. benefits payable by this insurance;

b. special taxes, payments into security or oth-er special funds, and assessments payable by us under that law.

6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law.

Nothing in these paragraphs relieves you of your du-ties under this policy.

PART TWO

EMPLOYERS LIABILITY INSURANCE

A. How This Insurance Applies

This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death.

1. The bodily injury must arise out of and in the course of the injured employee’s employment by you.

2. The employment must be necessary or inci-dental to your work in a state or territory listed in Item 3.A. of the Information Page.

3. Bodily injury by accident must occur during the policy period.

4. Bodily injury by disease must be caused or ag-gravated by the conditions of your employment.

The employee’s last day of last exposure to the conditions causing or aggravating such bodily in-jury by disease must occur during the policy pe-riod.

5. If you are sued, the original suit and any related legal actions for damages for bodily injury by ac-cident or by disease must be brought in the United States of America, its territories or pos-sessions, or Canada.

B. We Will Pay

We will pay all sums that you legally must pay as damages because of bodily injury to your employ-ees, provided the bodily injury is covered by this Employers Liability Insurance.

The damages we will pay, where recovery is permit-ted by law, include damages:

1. For which you are liable to a third party by rea-son of a claim or suit against you by that third party to recover the damages claimed against

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

such third party as a result of injury to your em-ployee;

2. For care and loss of services; and

3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em-ployee; provided that these damages are the di-rect consequence of bodily injury that arises out of and in the course of the injured employee’s employment by you; and

4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer.

C. Exclusions

This insurance does not cover:

1. Liability assumed under a contract. This exclu-sion does not apply to a warranty that your work will be done in a workmanlike manner;

2. Punitive or exemplary damages because of bodily injury to an employee employed in viola-tion of law;

3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers;

4. Any obligation imposed by a workers compensa-tion, occupational disease, unemployment com-pensation, or disability benefits law, or any simi-lar law;

5. Bodily injury intentionally caused or aggravated by you;

6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries;

7. Damages arising out of coercion, criticism, de-motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina-tion against or termination of any employee, or any personnel practices, policies, acts or omis-sions;

8. Bodily injury to any person in work subject to the Longshore and Harbor Workers’ Compensation Act (33 U.S.C. Sections 901 et seq.), the Non-appropriated Fund Instrumentalities Act (5 U.S.C.

Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651–1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901– 944), any other federal workers or workmen’s compensation law or other federal occupational disease law, or any amendments to these laws;

9. Bodily injury to any person in work subject to the Federal Employers’ Liability Act (45 U.S.C.

Sections 51 et seq.), any other federal laws obligating an employer to pay damages to an employee due to bodily injury arising out of or in the course of employment, or any amendments to those laws;

10. Bodily injury to a master or member of the crew of any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law;

11. Fines or penalties imposed for violation of feder-al or state law; and

12. Damages payable under the Migrant and Seasonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for violation of those laws or regulations issued there under, and any amendments to those laws.

D. We Will Defend

We have the right and duty to defend, at our ex-pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed-ings and suits.

We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance.

E. We Will Also Pay

We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend:

1. Reasonable expenses incurred at our request, but not loss of earnings;

2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance;

3. Litigation costs taxed against you;

4. Interest on a judgment as required by law until we offer the amount due under this insurance; and

5. Expenses we incur.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY

© Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved.

F. Other Insurance

We will not pay more than our share of damages and costs covered by this insurance and other in-surance or self-insurance. Subject to any limits of li-ability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is ex-hausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid.

G. Limits of Liability

Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below.

1. Bodily Injury by Accident. The limit shown for “bodily injury by accident—each accident” is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident.

A disease is not bodily injury by accident unless it results directly from bodily injury by accident.

2. Bodily Injury by Disease. The limit shown for “bodily injury by disease—policy limit” is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis-ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for “bodily injury by disease—each em-ployee” is the most we will pay for all damages because of bodily injury by disease to any one employee.

Bodily injury by disease does not include dis-ease that results directly from a bodily injury by accident.

3. We will not pay any claims for damages after we have paid the applicable limit of our liability un-der this insurance.

H. Recovery From Others

We have your rights to recover our payment from anyone liable for an injury covered by this insurance.

You will do everything necessary to protect those rights for us and to help us enforce them.

I. Actions Against Us

There will be no right of action against us under this insurance unless:

1. You have complied with all the terms of this poli-cy; and

2. The amount you owe has been determined with our consent or by actual trial and final judgment.

This insurance does not give anyone the right to add us as a defendant in an action against you to deter-mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga-tions under this Part.

PART THREE

OTHER STATES INSURANCE

A. How This Insurance Applies

1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor-mation Page.

2. If you begin work in any one of those states after the effective date of this policy and are not in-sured or are not self-insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page.

3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them.

4. If you have work on the effective date of this pol-icy in any state not listed in Item 3.A. of the In-formation Page, coverage will not be afforded for that state unless we are notified within thirty days.

B. Notice

Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page.

PART FOUR

YOUR DUTIES IF INJURY OCCURS

Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here.

1. Provide for immediate medical and other ser-vices required by the workers compensation law.

2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need.

3. Promptly give us all notices, demands and legal

© Copyright 2013…