CTR070044_Dustin__RubyHOWARD_Exp_CGL_SAM_3.5.25_PL_2.26.25.pdf

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

04/19/2024

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 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).

PRODUCER

Trust Risk Management Services, Inc.

1791 Paysphere Circle

Chicago, IL 60674

CONTACT

NAME: Trust Risk Management Services, Inc

PHONE

(A/C, No, Ext): 877.637.9700

FAX

(A/C, No): 877.251.5111

EMAIL

ADDRESS: info@trustrms.com

INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A: ACE American Insurance Company 22667

INSURED

Dr. Dustin Howard; Dr. Ruby Howard Desierto Psychological PLLC

1619 N Windsor Ct Mesa, AZ 85213

INSURER B:

INSURER C:

INSURER D:

INSURER E:

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

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.

INSR

LTR

TYPE OF INSURANCE

ADDL

INSR

SUBR

WVD

POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

LIMITS

A

X

COMMERCIAL GENERAL LIABILITY

Y

D42205631

03/05/2024

03/05/2025

EACH OCCURRENCE $1,000,000

CLAIMS MADE X OCCUR

DAMAGE TO RENTED

PREMISES (Ea occurrence)

$1,000,000

X Sexual Abuse & Molestation is included at full policy limits

MED EXP (Any one person)

$10,000

PERSONAL & ADV INJURY

$1,000,000

GEN’L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000

X

POLICY

PRO-

JECT LOC

PRODUCTS–COMP/OP AGG

$2,000,000

OTHER:

AUTOMOBILE LIABILITY

D42205631

03/05/2024

03/05/2025

COMBINED SINGLE LIMIT

(Ea accident)

$1,000,000

ANY AUTO

BODILY INJURY (Per Person) $

ALL OWNED

AUTOS

SCHEDULED

AUTOS BODILY INJURY (Per accident)

X

HIRED AUTOS X NON-OWNED

AUTOS

PROPERTY DAMAGE

(Per accident)

UMBRELLA LIAB OCCUR

EACH OCCURRENCE $

EXCESS LIAB CLAIMS-MADE AGGREGATE $

DED RETENTION $

WORKERS COMPENSATION

AND EMPLOYERS LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under

DESCRIPTION OF OPERATIONS below

Y / N

N / A

PER

STATUTE

OTH-

ER

E.L.EACH ACCIDENT $

E.L. DISEASE-EA EMPLOYEE $

E.L. DISEASE - POLICY LIMIT

Psychologist's Professional Liability Claims Made Retroactive Date: 02/26/2021

78G74138172

02/26/2024

02/26/2025

Each Incident Annual Aggregate

$2,000,000

$4,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required):

The State of Arizona, and its departments, agencies, boards, commissions, universities, and its officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor. This Policy contains a Waiver of Subrogation endorsement in favor of the State of Arizona, and its department, agencies, boards, commissions, universities, officers, agents, and employees for losses arising from work performed by or on behalf of the Contractor. Sexual Abuse and Molestation (SAM) Coverage is included and sub-limited to no less than $500,000, and Sexual Abuse and Molestation coverage is included under the Commercial General Liability. This insurance is Primary, Non-Contributory. The Certificate Holder below is also included as an Additional Insured. CONTRACT # CTR070044

CERTIFICATE HOLDER CANCELLATION

State of Arizona Department of Economic Security C/O: myCOI 1075 Broad Ripple Ave, Ste 313 Indianapolis, IN 46220

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED

BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED

IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

Insured Copy

ALL-24624 (01/08)

Policy Number

COMMON POLICY DECLARATIONS

Item 1. Named Insured and Mailing Address Agent Name and Address

Agent No.

Item 2. Policy Period From: To:

at 12:01 A.M., Standard Time at your mailing address shown above.

Item 3. Business Description:

Form of Business:

Item 4. 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.

This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment.

Coverage Part(s) Premium

Commercial Property Coverage Part

Commercial General Liability Coverage Part

Crime and Fidelity Coverage Part

Commercial Inland Marine Coverage Part

Commercial Auto (Business or Truckers) Coverage Part

Commercial Garage Coverage Part

Total Policy Premium

Item 5. Forms and Endorsements

Form(s) and Endorsement(s) made a part of this policy at time of issue:

See Schedule of Forms and Endorsements

BILL TYPE:

BILL PLAN:

Countersigned:

Date: By:

Authorized Representative

THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE NUMBERED POLICY.

OFRD42205631

03-05-2024 03-05-2025

OFR D42205631

LIMITED LIABILITY COMPANY

278988

ACE American Insurance Company 436 Walnut Street , Philadelphia, PA 19106

Renewal Of:

$ 706.00

Agent Billing

Annual

DUSTIN HOWARD

Desierto Psychological PLLC 1619 N. Windsor Circle Mesa AZ 85213

TRUST RISK MANAGEMENT SERVICES INC

DBA TRMS INSURA

111 ROCKVILLE PIKE

ROCKVILLE MD 20850

$ 420.00

$ 286.00

NOT COVERED

NOT COVERED

NOT COVERED

NOT COVERED

03/04/2024

CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

POLICY NUMBER: OFRD42205631 COMMERCIAL GENERAL LIABILITY

CG 20 26 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – DESIGNATED

PERSON OR ORGANIZATION

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s):

The State of Arizona, and its departments, agencies, boards, commissions, universities, and its officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor

The State of Arizona Department of Economic Security

C/O: myCOI

1075 Broad Ripple Ave, Ste 313

Indianapolis, IN 46220

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

A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf:

1. In the performance of your ongoing operations;

or

2. In connection with your premises owned by or rented to you.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable limits of insurance;

whichever is less.

This endorsement shall not increase the applicable limits of insurance.

This endorsement modifies insurance provided under the following:

CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 3

POLICY NUMBER: OFRD42205631 COMMERCIAL GENERAL LIABILITY

CG 24 04 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

ELECTRONIC DATA LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES

POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

RAILROAD PROTECTIVE LIABILITY COVERAGE PART

UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS

SCHEDULE

Name Of Person(s) Or Organization(s):

This Policy contains a Waiver of Subrogation endorsement in favor of the State of Arizona, and its department, agencies, boards, commissions, universities, officers, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

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

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

The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV – Conditions:

We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above.

Named Insured Endorsement Number

Policy Symbol Policy Number Policy Period to

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

OFR D42205631

LD-4R10a (6/87) Page 1 of 3

NON-OWNED AND RENTED AUTO LIABILITY

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE FORM

SCHEDULE

Insurance is provided only with respect to those coverages for which a specific premium charge is shown:

Coverage Limit of Insurance Premium

Non-Ownership Liability

Rented Auto Liability

(If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

COVERAGE

If a Limit of Insurance and premium is shown in the Schedule, we will pay all sums an insured legally must pay as damages because of "bodily injury" or "property damage" to which this insurance applies, caused by an "accident" which occurs during the policy period and results from: the maintenance or use of a "rented auto" by you or your employees in the course of your business; and/or the use of any "non-owned auto" in your business by any person other than you.

We have the right and duty to defend any "suit" asking for these damages. However, we have no duty to defend "suits" for "bodily injury" or "property damage" not covered by this endorsement. We may investigate and settle any claim or "suit" as we consider appropriate. Our duty to defend or settle ends when the Limit of Insurance shown in the Schedule or in the declarations as applicable to this endorsement has been exhausted by payment of judgements or settlements.

EXCLUSIONS

With respect to the insurance provided by this endorsement:

1. The COVERAGE A (Section 1.) exclusions a, b, d, and i and the Nuclear Liability Exclusion (Broad Form) apply to this endorsement. All other exclusions in Coverage A are deleted. The following additional exclusions apply to this endorsement only:

a. Bodily injury:

(1) To an employee of the insured arising out of and in the course of employment by the insured; or

(2) To the spouse, child, parent, brother or sister of that employee as a consequence of (1) above.

This exclusion applies:

(1) Whether the insured may be liable as an employer or in any other capacity; and

(2) To any obligation to share damages with or repay someone else who must pay damages because of injury.

$ 50 $ 1,000,000

LD-4R10a (6/87) Page 2 of 3

This exclusion does not apply to:

(1) Liability assumed by the insured under an "insured contract"; or

(2) "Bodily injury" arising out of and in the course of domestic employment by the insured unless benefits for such injury are, in whole or in part, either payable or required to be provided under any workers’ compensation law.

b. "Property damage" to:

(1) Property owned or being transported by, or rented or loaned to the insured; or

(2) Property in the care, custody or control of the insured.

c. "Bodily injury" or "property damage" arising out of the actual, alleged or threatened discharge, dispersal, release or escape of pollutants:

(1) That are, or that are contained in any property that is:

(a) Being transported or towed by, or handled for movement into, onto or from the covered "auto";

(b) Otherwise in the course of transit; or

(c) Being stored, disposed of, treated or processed in or upon the covered "auto";

(2) Before the pollutants or any property in which the pollutants are contained are moved from the place where they are accepted by the insured for movement into or onto the covered "auto"; or

(3) After the pollutants or any property in which the pollutants are contained are moved from the covered "auto" to the place where they are finally delivered, disposed of or abandoned by the insured.

Any loss, cost or expense arising out of any demand or request that you test for, monitor, clean up, remove, contain, treat, detoxify or neutralize any pollutants. This includes demands directives, complaints, "suits" or requests brought by any governmental entity or by any person or group of persons.

Pollutants means any solid, liquid, gaseous thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled, reconditioned or reclaimed.

Paragraph C.(1)(c) does not apply to fuels, lubricants, fluids, exhaust gases or other similar pollutants that are needed for or result from the normal electrical, hydraulic or mechanical functioning of the "auto" or its parts, if:

(1) The pollutants escape or are discharged, dispersed or released directly from an "auto" part designed by its manufacturer to hold, store, receive or dispose of such pollutants; and

(2) The "bodily injury" or "property damage" does not arise out of the operation of any "mobile equipment."

Paragraphs (2) and (3) of this exclusion do not apply if:

(1) the pollutants or any property in which the pollutants are contained are upset, overturned or damaged as a result of the maintenance or use of a covered "auto"; and

(2) the discharge, dispersal, release or escape of the pollutants is caused directly by such upset, overturn or damage.

2. WHO IS AN INSURED (SECTION II) is replaced by the following:

Each of the following is an insured under this insurance to the extent set forth below:

a. You;

b. Any other person using a "rented auto" with your permission;

c. With respect to a "non-owned auto," any partner or executive officer of yours, but only while such "non-owned auto" is being used in your business;

d. Any other person or organization, but only with respect to their liability because of acts or omissions of an insured under a., b., or c. above. None of the following is an insured:

LD-4R10a (6/87) Page 3 of 3

a. Any person engaged in the business of his or her employer with respect to "bodily injury" to any co-employee of such person injured in the course of employment;

b. Any partner or executive officer with respect to any "auto" owned by such partner or officer or a member of his or her household;

c. Any person while employed in or otherwise engaged in duties in connection with an "auto business," other than an "auto business" you operate;

d. The owner or lessee (of whom you are a sublessee) of a "rented auto" or the owner of a "non-owned auto" or any agent or employee of any such owner of lessee;

e. Any person or organization with respect to the conduct of any current or past partnership or joint venture that is not shown as an Insured in the Declarations.

3. LIMITS OF INSURANCE (Section III) is replaced by the following:

Regardless of the number of "autos," insureds, premiums paid, claims made or vehicles involved in the "accident," the most we will pay for all damages resulting from any one "accident" is the applicable Limit of Insurance shown in the Schedule.

All "bodily injury" and "property damage" resulting from continuous or repeated exposure to substantially the same conditions will be considered as resulting from one "accident."

4. Paragraph 4b of Section IV---COMMERCIAL GENERAL LIABILITY CONDITION is replaced by the following:

b. Excess Insurance

This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any other basis, that is covering the auto as an owned auto.

When this insurance is excess, we will have no duty under this endorsement to defend any claim or "suit" that any other insurer has a duty to defend. If no other insurer defends, we will undertake to do so, but we will be entitled to the insured’s rights against all those other insurers.

When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of:

(1) The total amount that all such other insurance would pay for the loss in the absence of this insurance;

and

(2) The total of all deductible and self-insured amounts under all that other insurance.

We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limit of Insurance shown in the Schedule.

5. The following additional definitions apply:

"Accident" includes continuous or repeated exposure to the same conditions resulting in "bodily injury" or "property damage."

"Auto business" means the business or occupation of selling, repairing, servicing, storing or parking "autos."

"Non-owned auto" means any "auto" you do not own, lease, hire or borrow which is used in connection with your business. However, if you are a partnership a "non-owned auto" does not include any auto owned by any partner.

"Rented auto" means any "auto" you lease, hire, or borrow. This does not include any "auto" you lease, hire, or borrow from any of your employees or members of their households, or from any partner or executive officer of yours.

Authorized Agent