CTR078198_COI_2025-10-01_GL__AL__WC.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD 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)

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

EACH OCCURRENCE $

DAMAGE TO RENTED

CLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-

POLICY LOC PRODUCTS - COMP/OP AGG $JECT

OTHER: $

COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED BODILY INJURY (Per accident) $

AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE $

AUTOS ONLY 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

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N

N / A (Mandatory in NH)

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 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)

CERTIFICATE OF LIABILITY INSURANCE

Lockton Companies, LLC

DBA Lockton Insurance Brokers, LLC in CA

CA license #0F15767

3280 Peachtree Rd. NE, Ste. 1000

Atlanta GA 30305

(404) 460-3600

Avesis, LLC 1295 W. Washington Street, Suite 212 Tempe AZ 85921

Hartford Accident and Indemnity Company 22357 Hartford Casualty Insurance Company 29424 Hartford Insurance Co of the Southeast 38261 Property and Casualty Ins Co of Hartford 34690

X X

1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000

X X

1,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X X

X 10,000

15,000,000 15,000,000

XXXXXXX

N

X

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

D 20UENEH6863 10/1/2024 10/1/2025

A 20UUNBE9CXH 10/1/2024 10/1/2025

B 20RHUBG8BF8 10/1/2024 10/1/2025

C 20WBAM9YCK 10/1/2024 10/1/2025

10/1/2025

1499451

Y Y

Y Y

N N

Y

8/19/2025

17931246

17931246 XXXXXXX

Arizona Department of Administration State Procurement Office 100 North 15th Ave Suite 103 Phoenix AZ 85007

THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED.

RE: Contract Number CTR078198. See attached.

X

See Attachment

CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Use only if more space is required)

ACORD 25 (2016/03)

State of Arizona is included as an additional insured with respects to General Liability and Auto Liability as per written contract, subject to terms, conditions and exclusions of policies. Additional insured applies on a blanket basis, where required by written contract with respects to General Liability and Automobile Liability. Insurance is primary with respects to General Liability. Waiver of Subrogation applies in favor of additional insured as required by written contract as respect to General Liability, Auto Liability and Workers Compensation Liability, subject to terms, conditions and exclusions where applicable by state law.

Certificate Holder ID: 17931246

Addendum

Named Insured List:

Avatar Holdings, LLC

Avesis, LLC

Avesis Third Party Administrators, LLC

Avatar Holdco 2, Inc

Avesis of New York, Inc.

Avesis Insurance Incorporated

Premier Access Insurance Company

Premier Group Inc.

Avesis Dental IPA, LLC

Avesis Eye Care IPA, LLC

Access Dental Plan

Access Dental Plan of Nevada, Inc.

Access Dental Plan of Utah, Inc.

Avesis of Florida, Inc.

Attachment Code: D598702 Master ID: 1499451, Certificate ID: 17931246