CTR072924_COI_8-1-25.pdf

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Master Agreement AZ|CTR072924
Contract number
CTR072924
Issued by
Arizona

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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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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:

E-MAIL

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:

E-MAIL

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 .