CTR077908_GL_AL_WC_SAM_Exp._3_01_2026.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

AUTHORIZED REPRESENTATIVE

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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 any rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

Nationwide Mutual Insurance Company

CopperPoint Indemnity Insurance Company

Professional Solutions Ins Co

Nationwide Property & Casualty Ins Co

7/31/2025

USI Insurance Services LLC 2375 E. Camelback Rd, Suite 740 Phoenix, AZ 85016

Jacob Keltner 602-374-1336

Jacob.Keltner@usi.com

Lutheran Social Services of the Southwest 2502 E University Dr Suite 125 Phoenix, AZ 85034

23787 13928 11127 37877

A X X

X

X X ACP3059653847 03/01/2025 03/01/2026 1,000,000

1,000,000 20,000 1,000,000 3,000,000 3,000,000

D X

X X

X X ACP3059653847 03/01/2025 03/01/2026 1,000,000

A X X

X 10,000

ACP3059653847 03/01/2025 03/01/2026 5,000,000

5,000,000

B

N

X WC1011811 03/01/2025 03/01/2026 X

1,000,000

1,000,000 1,000,000

A A C

Hu Svcs Prof Liab Abuse/Molestation Crime

ACP3059653847

ACP3059653847

IK968DMLA252

03/01/2025 03/01/2025 03/01/2025

03/01/2026 03/01/2026 03/01/2026

*See Description *See Description $500,000/$15,000 Ded

*Human Services Professional Liability - Limits: $1,000,000 Occurrence/$5,000,000 Aggregate *Abuse/Molestation Liability - Limits: $1,000,000 Occurrence/$5,000,000 Aggregate The General Liability and Automobile Liability policies include an automatic Additional Insured endorsement that provides Additional Insured status to the Certificate Holder only when there is a written contract that requires such status, and only with regard to work performed on behalf of the named insured. The General (See Attached Descriptions)

The State of Arizona & Department of Economic Security c/o myCOI PO Box# 501970; 8710 Bash Street Indianapolis, IN 46220-0000

#S50326704/M48470750

LUTHESOC7Client#: 1486119

JZKJD

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) Liability policy contains a special endorsement with "Primary and Noncontributory" wording, when required by written contract. The General Liability, Auto Liability and Workers Compensation policies provides a Waiver of Subrogation when required by written contract.

RE: CTR077908, Division Name: ADES.

Additional Insured includes: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees.

#S50326704/M48470750

COMMERCIAL GENERAL LIABILITY

CG 20 05 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - CONTROLLING INTEREST

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

CG 20 05 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

SCHEDULE

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

THE STATE OF ARIZONA, ITS DEPARTMENTS, SEE NIL-7000

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 their liability arising out of:

1. Their financial control of you; or

2. Premises they own, maintain or control while you lease or occupy these premises.

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. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization.

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;

whichever is less.

This endorsement shall not increase the applicable limits of insurance.

jacob.keltner Typewritten text

ACP3059653847

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - DESIGNATED

PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1

SCHEDULE

COMMERCIAL GENERAL LIABILITY

CG 20 26 12 19

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

THE STATE OF ARIZONA, ITS DEPARTMENTS, SEE NIL-7000

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 your acts or omissions or the acts or omissions of those acting on your behalf:

1. In the performance of your ongoing operations; or

2. In connection with your premises owned by or rented to you.

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.

jacob.keltner

AC2041 NAME EXTENSION FOR THE STATE OF ARIZONA,

Policy Level Coverages

IN

S

U R

E D

C O

P Y

A Z

20927

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

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

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.

COMMERCIAL GENERAL LIABILITY

CG 24 04 12 19

SCHEDULE

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

THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, AND ITS OFFICERS, AGENTS, AND EMPLOYEES OF THE DEPARTMENT OF ECONOMIC SECURITY

FOR LOSSES ARISING OUT OF THE WORK PERFORMED BY OR ON BEHALF OF THE CONTRACTOR.

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

jacob.keltner

A. Who Is An Insured for COVERED AUTOS LIABILITY COVERAGE is amended to include as an “insured” for Covered Autos Liability Coverage:

Each person or organization shown in the Schedule, but only to the extent that person or organization qualifies as an “insured”. The “accident” must arise out of ongoing operations performed for the Named Insured.

B. Changes in CONDITIONS

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 the person or organization named in the Schedule under your policy provided that:

(1) The person or organization 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 them.

All terms and conditions of this policy apply unless modified by this endorsement.

SCHEDULE

NCA 04 49 01 18 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1

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

THE STATE OF ARIZONA, ITS DEPARTMENTS, SEE NIL-7000

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

jacob.keltner

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

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

COMMERCIAL AUTO

CA 04 44 10 13

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, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

All terms and conditions of this policy apply unless modified by this endorsement

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

SCHEDULE

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

THE STATE OF ARIZONA, ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, AND ITS OFFICERS, AGENTS, AND EMPLOYEES OF THE DEPARTMENT OF ECONOMIC SECURITY

FOR LOSSES ARISING OUT OF THE WORK PERFORMED BY OR ON BEHALF OF THE CONTRACTOR.

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

jacob.keltner

THE STATE OF ARIZONA, ITS DEPARTMENTS, 1075 BROAD RIPPLE AVE SUITE 313

AGENCIES, BOARDS COMMISSIONS, INDIANAPOLIS, IN 46220

UNIVERSITIES AND SEE BLANK FORM 28

ACP GLAO3039653847 LC8E 23261 INSURED COPY 46 0002402

COMMERCIAL GENERAL LIABILITY

CG 20 01 12 19

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.

Job 1: The State of Arizona & Department of Economic Security