CTR076171_Family_First_Assisted_Living_Home_LLC_COI_7.15.2026.pdf

07/22/2025

AssuredPartners of Arizona, LLC 14805 N 73rd Street

Scottsdale AZ 85260

Celeste Brooks celeste.brooks@assuredpartners.com

Family First Assisted Living Home LLC 1500 N Yavapai St

Tucson AZ 85745

Social Service Contractors Indemnity Pool FirstComp Insurance Company 27626

25-26 GL and WC

A Prof Liab $1M/$3M Claims Made Y 6000788 07/15/2025 07/15/2026

1,000,000 1,000,000 10,000 1,000,000 3,000,000 3,000,000

HNOA 1,000,000

Y

A 6001469 07/15/2025 07/15/2026 1,000,000 1,000,000

XS of Prof Liab

B Y WC024280901 07/20/2025 07/20/2026

1,000,000 1,000,000 1,000,000

A Sexual Abuse/Molestation

6000788 07/15/2025 07/15/2026 Occurrence 1,000,000 Aggregate 3,000,000

RE: Contract No ADES - CTR076171. This policy contains an endorsement that includes the State of Arizona, and its departments, agencies, boards, commissions, universities, 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 departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

Waiver of subrogation as respects Worker's Compensation per order on file with carrier.

Cancellation: 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or 30 days before the effective date of cancellation if we cancel for any other reason.

The State of Arizona and Dept of Economic Security C/O: myCOI PO Box #501970 8710 Bash St Indianapolis IN 46256

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

Family First Assisted Living Home LLC

00066276

AssuredPartners of Arizona, LLC

25 Certificate of Liability Insurance

Workers Compensation Exclusions: Mary Juvera and Jim Juvera There are no job sites, only an operational location Sexual Abuse/Molestation is included.

No company owned autos.

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: