CTR077216_ADL_Solutions_Inc_WC_exp10.1.26__1_.pdf

© 1988-2016 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

ACORD 25 (2016/03)

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 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).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

E-MAIL

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.

Acct#: 3041846 09/18/2025

Lockton Companies, LLC 214-771-4411 2100 Ross Ave, Suite 1400 Dallas, TX 75201

Indemnity Insurance Company of North America 43575

ADL Solutions 221 E Willis Rd Suite 6 Chandler, AZ 85286

NA X C74282027 10/01/2025 10/01/2026

X 1000000

1000000

1000000

Division ADES Contract ID CTR077216 WAIVER OF SUBROGATION IN FAVOR OF CERTIFICATE HOLDER WHERE REQUIRED BY WRITTEN CONTRACT.

Waiver of Subrogation applies in favor of State of Arizona and its departments agencies boards commissions universities officers officials agents and employees where required by written contractAlternate Employer applies in favor of State of Arizona and its departments agencies boards commissions universities officers officials agents and employees where required by written contract

REI.Certs@onedigital.com

The State of Arizona and Dept of Economic Security C/O: myCOI

Indianapolis IN 46256 P.O Box 501970, 8710 Bash Street

Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number

Policy Number Symbol: Number:

Policy Period

TO

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

ALTERNATE EMPLOYER ENDORSEMENT

This endorsement applies only with respect to bodily injury to your employees while in the course of special or temporary employment by the alternate employer in the state named in Item 2 of the Schedule. Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) will apply as though the alternate employer is insured. If an entry is shown in Item 3 of the Schedule the insurance af forded by this endorsement applies only to work you perform under the contract or at the project named in the Schedule.

Under Part One (Workers Compensation Insurance) we will reimburse the alternate employer for the benef its required by the workers compensation law if we are not permitted to pay the benef its directly to the persons entitled to them.

The insurance af forded by this endorsement is not intended to satisfy the alternate employer's duty to secure its obligations under the workers compensation law. We will not f ile evidence of this insurance on behalf of the alternate employer with any government agency.

We will not ask any other insurer of the alternate employer to share with us a loss covered by this endorsement.

Premium will be charged for your employees while in the course of special or temporary employment by the alternate employer.

The policy may be canceled according to its terms without sending notice to the alternate employer.

Part Four (Your Duties If Injury Occurs) applies to you and the alternate employer. The alternate employer will recognize our right to defend under Parts One and Two and our right to inspect under Part Six.

Schedule

1. Alternate Employer Address

2. State of Special or Temporary Employment

3. Contract or Project

This endorsement is not applicable in the states of AK, HI, Ml, OK and TX

. Authorized Representative

WC 00 03 01A (Ed. 2-89) © Copyright 1984, 1988 National Council on Compensation Insurance, Inc. All Rights Reserved.

C74282027

10/01/2025 10/01/2026

Indemnity Insurance Company of North America

The State of Arizona and Dept of Economic Security C/O: myCOI P.O Box 501970, 8710 Bash Street

Indianapolis, IN 46256

WLR

ADL Solutions

Suite 6 221 E Willis Rd

Chandler, AZ 85286

10/01/2025

WC 00 03 13 (11/05) © Copyright 1983-2017 National Council on Compensation Insurance, Inc. All Rights Reserved.

Workers' Compensation and Employers' Liability Policy

Named Insured Endorsement Number

Policy Number Symbol: Number:

Policy Period

TO

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

Authorized Agent

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 any one not named in the Schedule.

Schedule

For the states of CA, UT, TX, refer to state specific endorsements.

This endorsement is not applicable in KY, NH, and NJ.

The endorsement does not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive subrogation rights against public policy and void where one party to the contract is an employer in the construction group of code classifications.

For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A..

16-1801 through 16-1807 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by liability or workers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a consolidated or wrap-up insurance program.

C74282027

10/01/2025 10/01/2026

The State of Arizona and Dept of Economic Security C/O: myCOI

P.O Box 501970, 8710 Bash Street

Indianapolis, IN 46256

WLR

ADL Solutions

Suite 6 221 E Willis Rd

Chandler, AZ 85286

Indemnity Insurance Company of North America

Division ADES Contract ID CTR077216

Waiver of Subrogation applies in favor of State of Arizona and its departments agencies boards commissions universities officers officials agents and employees where required by written contractAlternate Employer applies in favor of State of Arizona and its departments agencies boards commissions universities officers officials agents and employees where required by written contract

10/01/2025