CTR076593_-_COI_10.01.2025.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

5/20/2025

Lovitt & Touche A Marsh & McLennan Agency LLC Co 4703 E Camp Lowell Drive, #101 Tucson AZ 85712

Julie Reed 520-722-3000 julie.reed@marshmma.com

Hudson Insurance Company 25054

TOHONOODHA9

Tohono O'odham Nursing Care Authority dba Archie Hendricks Sr. Skilled Nursing Facility HC 01 Box 9100 Sells AZ 85634

934345381

A X 5,000,000 X 300,000

Included

10,000,000 X

Y Y NACL0118806 10/1/2024 10/1/2025

7,000,000

A 5,000,000

X

Y Y NACL0118806 10/1/2024 10/1/2025

A

N

Y OBHPTH281684372 10/1/2024 10/1/2027 X *See Below 5,000,000

5,000,000

5,000,000 A **Claims Made Coverage

Medical Malpractice Liability Sexual Misconduct Liability

NACL0118806 10/1/2024 10/1/2025 Each Claim 5,000,000 5,000,000

Annual Aggregate 5,000,000 5,000,000

Re: CTR049266 and CTR076593 NOTE: All coverages (other than Workers' Compensation) provided under the policy as certified above are subject to General Provision E., FEDERAL TORT

CLAIMS ACT LIMITATION.

*Coverage 3.A. Part One Tribal Workers' Compensation statutory benefits subject to a maximum limit of $10,000,000 per employee, per accident.

**Medical Malpractice Liability retroactive date: August 25, 2003. Sexual Misconduct Liability retroactive date: August 25, 2003.

General Liability: State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees are additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor. Waiver of Subrogation applies to State of Arizona, and See Attached...

The State of Arizona and Dept of Economic Security c/o myCOI PO Box 501970 8710 Bash Street Indianapolis IN 46256

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:

TOHONOODHA9

1 1

Lovitt & Touche Tohono O'odham Nursing Care Authority dba Archie Hendricks Sr. Skilled Nursing Facility HC 01 Box 9100 Sells AZ 85634

25 CERTIFICATE OF LIABILITY INSURANCE

its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor. Coverage is primary and non-contributory. Sexual Abuse and Molestation coverage is included. 30 days notice of cancellation.

Business Automobile Liability: 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 involving automobiles owned, hired and/or non-owned by the Contractor. Waiver of Subrogation applies to 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. Coverage is primary and non-contributory. 30 days notice of cancellation.

Workers' Compensation: Waiver of Subrogation applies to 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.

INSURANCE POLICY

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

Policy No.: OBHPTH281684372 Assured:

From: 10/1/2024 To 10/1/2027

THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:

WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE

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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us.

This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

The premium for this endorsement is shown in the Schedule.

SCHEDULE

When required by written contract.

Name of person or organization:

The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

Operations: Skilled Nursing & Assisted Living Facilities

Premium Charge: $450

Political Subdivision

Railroad

Lessor

Loss Payee/Mortgagee

Property Owner

Golf Mobile User

Watercraft User

Real Estate Manager

Railroad

Assured Status Required by Designated Contract

X Other-Describe:

This additional "Assured" status only applies to coverage provided by:

1. Insuring Agreement A - General Liability including Contractual Liability, Products and Completed Operations Liability;

2. Insuring Agreement B - Liquor Liability;

3. Insuring Agreement F - "Automobile Liability".

ENDORSEMENT - DESIGNATED ADDITIONAL ASSURED

Additional Assured

Additional "Assured" status is granted to the following scheduled entity listed below. The entity is an additional "Assured" under this policy, but only for liability arising out of the premises and operations of the Named Assured while acting by or on behalf of the Named Assured.

Status as an Additional Assured Name and Address of Additional Assured

Effective date of this Endorsement is 12:01 a.m., October 1, 2024

Endorsement No.:

This Endorsement attaches to and forms part of Policy No.: NACL01188-06

In the name of: Tohono O'odham Nursing Care Authority dba Archie Hendricks Sr. Skilled

Nursing Facility (See Schedule of Named Assureds)

Page 1 of 3Endt Designated Addl Assd 08/09 Revision

Political Subdivision

Railroad

Lessor

Loss Payee/Mortgagee

Property Owner

Golf Mobile User

Watercraft User

Real Estate Manager

Railroad

Assured Status Required by Designated Contract

X Other-Describe: See Attached List

This additional "Assured" status only applies to coverage provided by:

1. Insuring Agreement A - General Liability including Contractual Liability, Products and Completed Operations Liability;

2. Insuring Agreement B - Liquor Liability;

3. Insuring Agreement F - "Automobile Liability".

ENDORSEMENT - DESIGNATED ADDITIONAL ASSURED

Additional "Assured" status is granted to the following scheduled entity listed below. The entity is an additional "Assured" under this policy, but only

Additional Assured

Status as an Additional Assured Name and Address of Additional Assured for liability arising out of the premises and operations of the Named Assured while acting by or on behalf of the Named Assured.

Effective date of this Endorsement is 12:01 a.m., October 1, 2024 Nursing Facility (See Schedule of Named Assureds)

Page 2 of 3Endt Designated Addl Assd 08/09 Revision

Endorsement No.:

This Endorsement attaches to and forms part of Policy No.: NACL01188-06 In the name of: Tohono O'odham Nursing Care Authority dba Archie Hendricks Sr. Skilled

TBD; Tohono O'odham Nursing Care Authority dba Archie Hendricks Sr. Skilled Nursing Facility (See Schedule of Named Assureds)

Arizona Department of Economic Security

Division of Development Disabilities

1789 West Jefferson Mail Drop 2HC3

Phoenix, AZ 85007

RE: State contract for Skilled Nursing & Assisted Living Facilities

Arizona Department of Economic Security

Division of Development Disabilities

1789 West Jefferson Mail Drop 2HC3

Phoenix, AZ 85007

RE: State contract for Skilled Nursing & Assisted Living Facilities

List of Additional Assureds

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

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

Page 3 of 3Endt Designated Addl Assd 08/09 Revision

Gen Chg Page 1 of 1

Endorsement No.:

This Endorsement attaches to and forms part of Policy No.: NACL0188-06 In the name of: Tohono O'odham Nursing Care Authority dba Archie Hendricks Sr.

Skilled Nursing Facility (See Schedule of Named Insured)

Policy Effective date: October 1, 2024

ENDORSEMENT

Conditions Applicable to Coverage Parts I and II – Item F. is changed as follows only with respects to the Additional Insureds named below:

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

CANCELLATION/NON-RENEWAL: In the event of non-payment of premium by the “Assured”, “Hudson” will give ten

(10) days’ notice of cancellation, in writing, sent certified mail to the “Assured” and all coverage afforded by this policy will terminate ten (10) days after the mailing of such notice.

Notwithstanding the aforementioned, “Hudson” may elect to cancel this policy at any time upon thirty (30) days’ written notice to the “Named Assured”, otherwise this policy automatically expires at the end of the “policy period”.

All other terms and conditions remain the same.

(Ed. 7/12) 9/27/2024

HUDSON INSURANCE COMPANY

SOVEREIGN NATION COMMERCIAL INSURANCE POLICY

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Named Assured: Policy Number: Effective date of change:

Endorsement #:

Tohono O’odham Nursing Care Authority dba Archie Hendricks Sr. Skilled Nursing Facility (See Schedule of Named Assureds) NACL01188-06 October 1, 2024

PRIMARY AND NON-CONTRIBUTORY

This endorsement modifies insurance provided under the following:

INSURING AGREEMENT – A. General Liability INSURING AGREEMENT – F. Auto Liability

Name of Person(s) or Organization(s):

Arizona Department of Economic Security, Division of Development Disabilities, 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

1789 West Jefferson Mail Drop 2HC3, Phoenix, AZ 85007

RE: State contract for Skilled Nursing & Assisted Living Facilities

It is understood and agreed that this insurance is Primary and any other insurance maintained by

See above shall be excess only and not contributing with this insurance.

Authorized Representative All other Terms and Conditions remain the same.

(Ed. 7/12) 9/27/2024

HUDSON INSURANCE COMPANY

SOVEREIGN NATION COMMERCIAL INSURANCE POLICY

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

Named Assured: Policy Number: Effective date of change:

Endorsement #:

Tohono O’odham Nursing Care Authority dba Archie Hendricks Sr. Skilled Nursing Facility (See Schedule of Named Assureds) NACL01188-06 October 1, 2024

PRIMARY AND NON-CONTRIBUTORY

INSURING AGREEMENT – A. General Liability

Name of Person(s) or Organization(s):

Arizona Department of Economic Security, Division of Development Disabilities, 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

1789 West Jefferson Mail Drop 2HC3, Phoenix, AZ 85007

It is understood and agreed that this insurance is Primary and any other insurance maintained by

See above shall be excess only and not contributing with this insurance.

Authorized Representative All other Terms and Conditions remain the same.

Endt Waiver of Subrogation.GL.8_09. Page 1 of 1

In the name of: Tohono O’odham Nursing Care Authority dba Archie Hendricks Sr.

Skilled Nursing Facility (See Schedule of Named Assureds)

Effective date of this Endorsement is 12:01 a.m., October 1, 2024

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US

INSURING AGREEMENT A. – GENERAL LIABILITY

INSURING AGREEMENT F. – AUTO LIABILITY

PRODUCTS/COMPLETED OPERATIONS LIABILITY

Name of Person or Organization:

Division of Development Disabilities

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 1789 West Jefferson Mail Drop 2HC3

Phoenix, AZ 85007

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or “your work” done under a contract with that person or organization and included in the “products-completed operations hazard”. This waiver applies only to the person or organization shown in the Schedule above.

Endt Waiver of Subrogation.GL.8_09. Page 1 of 1

In the name of: Tohono O’odham Nursing Care Authority dba Archie Hendricks Sr.

Skilled Nursing Facility (See Schedule of Named Assureds)

Effective date of this Endorsement is 12:01 a.m., October 1, 2024

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US

INSURING AGREEMENT A. – GENERAL LIABILITY

PRODUCTS/COMPLETED OPERATIONS LIABILITY

Name of Person or Organization:

Division of Development Disabilities

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 1789 West Jefferson Mail Drop 2HC3

Phoenix, AZ 85007

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or “your work” done under a contract with that person or organization and included in the “products-completed operations hazard”. This waiver applies only to the person or organization shown in the Schedule above.