CTR072924_COI_8-1-25.pdf
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- Attached to
- Master Agreement AZ|CTR072924
- Contract number
- CTR072924
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by Bubolz Insurance for Agate Software, Inc., providing comprehensive insurance coverage for the State of Arizona, including its departments, agencies, boards, commissions, universities, and other governmental entities. The insurance is underwritten by Continental Casualty Co and American Casualty Co of Reading PA, with multiple policy types including commercial general liability, automobile liability, umbrella liability, workers' compensation, and technology errors & omissions coverage.
The insurance policies are effective from August 1, 2024 to August 1, 2025, with various coverage limits including $1,000,000 for general liability, $5,000,000 umbrella liability, and $3,000,000 for technology errors & omissions and information risk coverage. The policy includes additional insured endorsements for the State of Arizona, with specific provisions for waiver of subrogation and primary non-contributory status. Notable features include employee dishonesty coverage of $75,000, employment practices liability insurance with a $2,500 deductible, and network security/cyber risk coverage with a $1,000 deductible.
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Other files
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| IntelliGrants_IGX_License_Agreement.pdf | ||
| CTR072927_Amendment_Extension_9-16-26.doc | DOC document | |
| Price_Sheet.pdf |
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Text version
8/2/2024
Bubolz Insurance 1159 Trowbridge Rd.
East Lansing MI 48823
Ivy Cook (517)332-8671 (517)332-8423 ivy@bubolz.com
Agate Software, Inc.
2214 University Park Drive
Okemos MI 48864
Continental Casualty Co American Casualty Co of Reading PA
24/25
A X Employee Dishonesty $75,000
X
X Employment Prac Liab Ins
X B 6045380516 8/1/2024 8/1/2025
1,000,000
1,000,000
10,000
1,000,000
2,000,000
2,000,000
EPLI 2500 deductible 500,000
X X B 6045380516 08/01/2024 08/01/2025
1,000,000
1,000,000
A
X X
X 10,000
B 6045380564 08/01/2024 08/01/2025
Umbrella is NOT excess over
E&O or Infomation Risk Covg 8/1/2024 8/1/2025
5,000,000
5,000,000
B WC679167268 8/1/2024 8/1/2025
X
1,000,000
1,000,000
1,000,000
A Tech E&O--Claims-Made & Info B 6045380564 08/01/2024 08/01/2025 $15,000 deductible claims made $3,000,000
Risk (Network Security-Cyber) Tech E&O $3,000,000 per agg Info Risk--$1,000 deductible $1,000,000
State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are an additional insured on the general liability. Additional insured endorsement SB300113D and blanket additional insured apply. Waiver of subrogation form SB30022C on the GL and form WC000313 on the work comp. Primary & Noncontributory CNA80103XX apply on the GL.
ADOT
1324 N. 22nd Ave.
Phoenix, AZ 85009
G Bubolz III/IVYCK
The ACORD name and logo are registered marks of ACORD
CERTIFICATE HOLDER
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
AUTHORIZED REPRESENTATIVE
CANCELLATION
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE
LOCJECT
PRO-
POLICY
GEN'L AGGREGATE LIMIT APPLIES PER:
OCCURCLAIMS-MADE
COMMERCIAL GENERAL LIABILITY
PREMISES (Ea occurrence) $
DAMAGE TO RENTED
EACH OCCURRENCE $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$RETENTIONDED
CLAIMS-MADE
OCCUR
AGGREGATE $
EACH OCCURRENCE $UMBRELLA LIAB
EXCESS LIAB
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
INSR
LTR TYPE OF INSURANCE POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
PER
STATUTE
OTH-
ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
ANY PROPRIETOR/PARTNER/EXECUTIVE
If yes, describe under DESCRIPTION OF OPERATIONS below
(Mandatory in NH)
OFFICER/MEMBER EXCLUDED?
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
HIRED AUTOS
NON-OWNED
AUTOS AUTOS
AUTOS
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE $
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.
INSD
ADDL
WVD
SUBR
N / A
(Ea accident)
(Per accident)
OTHER:
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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INSURED
PHONE
(A/C, No, Ext):
PRODUCER
ADDRESS:
FAX
(A/C, No):
CONTACT
NAME:
NAIC #
INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
INSURER(S) AFFORDING COVERAGE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
INS025 (201401)
8/2/2024
Bubolz Insurance 1159 Trowbridge Rd.
East Lansing MI 48823
Ivy Cook (517)332-8671 (517)332-8423 ivy@bubolz.com
Agate Software, Inc.
2214 University Park Drive
Okemos MI 48864
Continental Casualty Co American Casualty Co of Reading PA
24/25
A X Employee Dishonesty $75,000
X
X Employment Prac Liab Ins
X B 6045380516 8/1/2024 8/1/2025
1,000,000
1,000,000
10,000
1,000,000
2,000,000
2,000,000
EPLI 2500 deductible 500,000
X X B 6045380516 08/01/2024 08/01/2025
1,000,000
1,000,000
A
X X
X 10,000
B 6045380564 08/01/2024 08/01/2025
Umbrella is NOT excess over
E&O or Infomation Risk Covg 8/1/2024 8/1/2025
5,000,000
5,000,000
B WC679167268 8/1/2024 8/1/2025
X
1,000,000
1,000,000
1,000,000
A Tech E&O--Claims-Made & Info B 6045380564 08/01/2024 08/01/2025 $15,000 deductible claims made $3,000,000
Risk (Network Security-Cyber) Tech E&O $3,000,000 per agg Info Risk--$1,000 deductible $1,000,000
The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees is an additional insured on the general liability for any and all work performed for or on behalf of the State of Arizona/ADOT. Waiver of subrogation applies on the general liability and worker's compensation policies. The 30 day cancellation notice does not apply to non-payment or fraud which are 10 days. The umbrella policy is excess over General Liability and Worker's Compensation.
The State of Arizona/ADOT 206 S. 17th Ave.
Phoenix, AZ 85007
G Bubolz III/IVYCK
The ACORD name and logo are registered marks of ACORD
CERTIFICATE HOLDER
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
AUTHORIZED REPRESENTATIVE
CANCELLATION
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE
LOCJECT
PRO-
POLICY
GEN'L AGGREGATE LIMIT APPLIES PER:
OCCURCLAIMS-MADE
COMMERCIAL GENERAL LIABILITY
PREMISES (Ea occurrence) $
DAMAGE TO RENTED
EACH OCCURRENCE $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$RETENTIONDED
CLAIMS-MADE
OCCUR
AGGREGATE $
EACH OCCURRENCE $UMBRELLA LIAB
EXCESS LIAB
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
INSR
LTR TYPE OF INSURANCE POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
PER
STATUTE
OTH-
ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
ANY PROPRIETOR/PARTNER/EXECUTIVE
If yes, describe under DESCRIPTION OF OPERATIONS below
(Mandatory in NH)
OFFICER/MEMBER EXCLUDED?
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
HIRED AUTOS
NON-OWNED
AUTOS AUTOS
AUTOS
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE $
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.
INSD
ADDL
WVD
SUBR
N / A
(Ea accident)
(Per accident)
OTHER:
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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INSURED
PHONE
(A/C, No, Ext):
PRODUCER
ADDRESS:
FAX
(A/C, No):
CONTACT
NAME:
NAIC #
INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
INSURER(S) AFFORDING COVERAGE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
INS025 (201401)
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Workers Compensation And Employers Liability Insurance
Policy Endorsement
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
ARIZONIA DEPARTMENT OF TRANSPORTATION
The premium charge for the endorsement is reflected in the Schedule of Operations.
All other terms and conditions of the policy remain unchanged.
This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below.
WC 6 79167268
Endorsement No: 4; Page: 1 of 1 Policy Page: 94 of 123 Underwriting Company: American Casualty Company of Reading, Pennsylvania, 151 N Franklin St, Chicago, IL 60606
Form No: WC 00 03 13 (04-1984) Endorsement Effective Date:
Policy No:
Policy Effective Date: 08/01/2024Endorsement Expiration Date:
Copyright 1983 National Council on Compensation Insurance.
| Agate Cert and Addtl Pages for State of Arizona |
| Cert for State of Arizona |
| Agate State of Arizona Additional Pages from Pkg |
| Agate State of Arizona Additional Pages from Pkg 2 |
Agate State of AZ WC Waiver of Sub Page
File details come from the government source that posted it. Updated .