CTR069670 2025.10.01 COI.pdf
PDF 1 MB Posted
- Attached to
- Master Agreement AZ|CTR069670
- Contract number
- CTR069670
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance for Helena Agri-Enterprises, LLC, issued by multiple insurers including National Union Fire Insurance Company of Pittsburgh, PA, AIU Insurance Co, ACE Property & Casualty Insurance Company, and Evanston Insurance Company. The certificate is primarily for the benefit of the State of Arizona, its departments, agencies, boards, commissions, universities, and their officers, officials, agents, and employees. The insurance policies cover various liability types including commercial general liability, automobile liability, workers' compensation, and excess/umbrella liability.
The insurance policies are effective from 10/01/2024 to 10/01/2025, with coverage limits varying by type. Notable details include a $5,000,000 self-insured retention for Products and Completed Operations Liability, with an excess policy providing coverage beyond that threshold. The policies include additional insured provisions for the State of Arizona, with coverage extending to liability arising from the contractor's operations. Workers' compensation coverage is provided for multiple states, including California and Wisconsin. The policies also include waivers of subrogation and provisions for primary insurance status when required by contract, ensuring comprehensive protection for the insured and additional insured parties.
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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)
© 1988-2016 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
A 10/01/2024
10/01/2025
35192
X
AI
A
19445
1,000,000
WC 014111749 (CA)
19399
MKLV2ENV104344
3,000,000
10/01/2025
D
B
5,000,000
10/01/2025 X
Evanston Insurance Company
Excess Products
10/01/2024
CN102359568-HCC-#5-24-25
1,000,000
20699
10/01/2025
ATL-004542986-50
10/01/2024
X
EXCLUDED
11/05/2024
X
10/01/2025
Products and Completed Operations Liability coverage is self-insured for the first $5,000,000. The Excess Products Liability policy provides coverage excess of the first $5,000,000 self-insured.
10/01/2024
5,000,000
10/01/2025
Site Pollution Legal
1,000,000
X
SIR:
1,000,000 1,000,000
D
10/01/2025
10/01/2024
10/01/2024
X
35378
AL 4594415 (AOS)
Limit:
5,000
10/01/2024
WC 014111748 (AOS)
WC 014111750 (WI)
X
G47487894 001
1,000,000 and any other insurance policy such additional insured may have shall be deemed to be excess and not contributory.
The State of Arizona, its departments, agencies, boards, commissions, universities and it officers, officials, agents, and employees as required by written contract shall be named as additional insureds with respect General Liability, Automobile Liability and Umbrella Liability and arising out of the activities performed by or on behalf of the Contractor. Policies shall be primary insurance with respect to such additional insured, National Union Fire Ins Co. of Pittsburgh PA 225 Schilling Boulevard
Helena Agri-Enterprises, LLC
Collierville, TN 38017 Suite #300
1,000,000
AIU Insurance Co
X
6410 Poplar Avenue, Suite 540
MARSH USA LLC.
Attn: amber.roetker@marsh.com Memphis, TN 38119
D
GL1728981
ACE Property & Casualty Insurance Company
N
Phoenix, AZ 85009
The State of Arizona
1324 N. 22nd Ave.
10/01/2024
AL 4594416 (MA)
A
1,000,000
Contractual Liability
X
X
C
3,000,000
10/01/2025
G0171 Accepted
ACORD 101 (2008/01)
The ACORD name and logo are registered marks of ACORD
© 2008 ACORD CORPORATION. All rights reserved.
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: FORM TITLE:
ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY CUSTOMER ID:
LOC #:
AGENCY
CARRIER NAIC CODE
POLICY NUMBER
NAMED INSURED
EFFECTIVE DATE:
MARSH USA LLC.�
Completed Operations $5,000,000 each occurrence limit | Policy number 1728982 | Policy period 10/01/2024 - 10/01/2025 | Insurer National Union Fire Insruance Company of self-insured. �� respects losses arising from work performed by or on behalf of the Contractor.� Waiver of subrogation in favor of the State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees applies as
With respect to Workers Compensation - Deductible is BI by accident $1,000,000 / by disease $1,000,000�
Pittsburgh, PA.
Memphis
Certificate of Liability Insurance25
Products and Completed Operations Liability coverage is self-insured for the first $5,000,000. The Excess Products Liability policy provides coverage excess of the first $5,000,000
225 Schilling Boulevard� Helena Agri-Enterprises, LLC�
Suite #300�
CN102359568
Collierville, TN 38017
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