CTR075487_ACCEPTED_ANY_ALL_GL_AL_WC_10.01.24-10.01.25.pdf

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

E-MAIL

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)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

1/23/2025

Edgewood Partners Insurance Center (EPIC) License No: OB29370 4675 MacArthur Court, Suite 750 Newport Beach, CA 92660

949-417-9164 949-809-2364 www.epicbrokers.com Westchester Surplus Lines Insurance Co 10172

National Liability & Fire Insurance Co 20052

Berkshire Hathaway Homestate Ins Co 20044

Scottsdale Indemnity Company 15580

Lloyds of London

A 1,000,000G48781706 001 10/1/2024 10/1/2025

100,000 excluded

1,000,000

✓ $5,000 BI/PD Deductible

2,000,000

2,000,000✓

B 73APB009725 10/1/2024 10/1/2025 1,000,000

A G48781901 001 10/1/2024 10/1/2025 5,000,000✓

5,000,000✓

10,000

C ADWC557839 10/1/2024 10/1/2025 ✓

1,000,000 Y

1,000,000 1,000,000

C Business Personal Property BFS(25)56300891 10/1/2024 10/1/2025 $392,885 Limit, $2,500 deductible A Pollution Liability G73545249004 10/1/2024 10/1/2025 $1,000,000 Limit, $2,500 retention

10/1/2024 10/1/2025

BobbiJo DeNofa Broad

Tina Coleman tina.coleman@epicbrokers.com

Adopt A Highway Maintenance Corp.

3158 Redhill Avenue Costa Mesa CA 92626

83653948

The State of Arizona/ADOT is named additional insured with respects to General Liability, Auto Liability. Coverage is primary and non-contributory.

The State of Arizona/ADOT 206 S. 17th Avenue Phoenix AZ 85007

RE: Any and all work performed for or on behalf of the State of Arizona/ADOT

Waiver of Subrogation applies to General Liability, Auto Liability, Workers Compensation and Pollution.

83653948 | 24-25 AZ DOT only | Tina Coleman | 1/23/2025 8:59:28 AM (PST) | Page 1 of 11

Cindy Lewis Accepted

POLICY NUMBER: COMMERCIAL GENERAL LIABILITY

CG 20 10 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations

As required by a written contract AS required by a written contract

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:

1. Your acts or omissions; or

2. The acts or omissions of those acting on your behalf;

in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.

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 additional exclusions apply:

This insurance does not apply to "bodily injury" or "property damage" occurring after:

1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or

2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.

Adopt A Highway Maintenance Corp.

G48781706 001

83653948 | 24-25 AZ DOT only | Tina Coleman | 1/23/2025 8:59:28 AM (PST) | Page 5 of 11

Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13

C. 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 shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

83653948 | 24-25 AZ DOT only | Tina Coleman | 1/23/2025 8:59:28 AM (PST) | Page 6 of 11

COMMERCIAL GENERAL LIABILITY

CG 20 37 12 19

POLICY NUMBER:

© Insurance Services Office, Inc., 2018 Page 1 of 1CG 20 37 12 19

ADDITIONAL INSURED – OWNERS, LESSEES OR

CONTRACTORS – COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".

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.

Location And Description Of Completed Operations Where Required By Written Contract

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

Where Required By Written Contract

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

1/23/2025

83653948 | 24-25 AZ DOT only | Tina Coleman | 1/23/2025 8:59:28 AM (PST) | Page 7 of 11

CG 24 04 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

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

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):

Any person or organization to whom or to which you are obligated by virtue of a written contract to waive your right of recovery.

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.

83653948 | 24-25 AZ DOT only | Tina Coleman | 1/23/2025 8:59:28 AM (PST) | Page 8 of 11

CG 20 01 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

PRIMARY AND NONCONTRIBUTORY –

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

LIQUOR LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

The following is added to the Other Insurance Condition 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 writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured.

Insured Copy

1/23/2025 Adopt A Highway Maintenance Corp.

83653948 | 24-25 AZ DOT only | Tina Coleman | 1/23/2025 8:59:28 AM (PST) | Page 3 of 11

ADDITIONAL INSURED ENDORSEMENT

In consideration of payment of the additional premium listed below, LIABILITY COVERAGE is extended to include the additional insured named herein, provided that:

1) such insurance applies only to the ownership, maintenance or use of a covered auto; and

2) such insurance applies only to acts or omissions by you, your agents or your "employees" while such covered auto is being used in your business; and

3) such insurance does not apply to the acts or omissions of the additional insured or any of the additional insured's agents or "employees" other than you; and

4) such inclusion of additional insured shall not increase our limit of liability under this policy.

ADDITIONAL INSURED:

All other terms, conditions and agreements remain unchanged.

Company Name

Named Insured

Policy Number

Endorsement Effective

Countersigned by

(Authorized Representative)

(The Attaching Clause need be completed only when this endorsement is issued subsequent to preparation of the policy.)

M-3745a (06/2009)

M-3745a (06/2009)

Blanket as required by written contract

Adopt A Highway Maintenance Company

73APB009725

10/1/2024National Liability & Fire Insurance Co

WAIVER OF TRANSFER OF RIGHTS OF

RECOVERY AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

BUSINESS AUTO COVERAGE FORM

BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM

GARAGE COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

TRUCKERS COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Endorsement Effective: Countersigned By:

Named Insured:

(Authorized Representative)

SCHEDULE

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

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

The Transfer Of Rights Of Recovery Against others To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule. We will retain the additional premium shown above, regardless of any early termination of this endorsement or the policy.

Includes copyrighted material of Insurance Services Office, Inc. with its permission.

M-5144a (06/2007)

M-5144a (06/2007)

10/1/2024

Adopt A Highway Maintenance Corp.

Blanket as required by written contract

Policy# 73APB009725 Company: National Liability & Fire Insurance Company

Sepi.Esfahani Rectangle

Sepi.Esfahani Rectangle

Sepi.Esfahani Rectangle

Sepi.Esfahani Rectangle

Sepi.Esfahani Rectangle

Sepi.Esfahani Rectangle

Sepi.Esfahani Rectangle

Adopt A Highway Maintenance Corp.

ADWC55783910/1/2024

Scottsdale Indemnity Company

83653948 | 24-25 AZ DOT only | Tina Coleman | 1/23/2025 8:59:28 AM (PST) | Page 2 of 11

Auto AI and WOS Forms.pdf