FY_26_DHS_HRPP_Contract_CTR074346_-_COI.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 8110 E. Union Avenue Suite 700 Denver CO 80237

(303) 414-6000

Aid to Adoption of Special Kids-AZ 2320 North 20th Street Phoenix, AZ 85006

Social Service Contractor's Indemnity Pool 0 CopperPoint General Insurance Company 13043

X X

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

X X

1,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X X 1,000,000 1,000,000

XXXXXXX

N

X

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

Professional Liab.

Claims Made Retro Date 7/6/88

Per Claim: $1,000,000

Aggregate: $3,000,000

A 6000167-8 7/6/2025 7/6/2026

A 6000167-8 7/6/2025 7/6/2026

A 6000167-8 7/6/2025 7/6/2026

A 6000168-8 7/6/2025 7/6/2026

B 1001754 7/6/2025 7/6/2026

7/6/2026

1413832

Y Y

Y Y

N N

Y

7/7/2025

N N

22106022

22106022 XXXXXXX

Arizona Department of Health Services 150 North 18th Avenue, Suite 260 Phoenix, AZ 85007

RE: Contract #CTR074346; High-Risk Perinatal Program (HRPP) Community Health Nursing Services. State of Arizona, its departments, agencies, boards, commissions, universities and its 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 and liability involving automobiles hired and/or non-owned by the Contractor. Sexual Abuse and Molestation coverage is not excluded. *See next page

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)

Waiver of Subrogation applies in favor of the State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees as respect to General Liability, Auto Liability and Workers' Compensation for losses arising from work performed by or on behalf of the Contractor. The Excess Liability policy referenced above affords limits in addition to the limits referenced for the following primary liability coverages: General Liability, Auto Liability, Professional Liability, Employers' Liability, and Sexual Abuse/Molestation.

Certificate Holder ID: 22106022

Sexual Abuse/Molestation

Carrier: Social Service Contractors Indemnity Pool

Policy#: 6000167-8

Policy Term: 7/6/2025 - 7/6/2026

Limits: $1,000,000 Each Act $3,000,000 Aggregate

Attachment Code: D607729 Master ID: 1413832, Certificate ID: 22106022