MARIPOSACOMMUNITYHEALTHCENTERINC-20230920-195248.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

9/20/2023

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

Julie Reed 520-722-7114 jreed@lovitt-touche.com

Philadelphia Indemnity Insurance Co. 18058 MARIPCOMMU Sequoia Insurance Company 22985

Mariposa Community Health Center Inc 825 N. Grand Ave., Suite 100 Nogales AZ 85621

1366085949

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

20,000

1,000,000

2,000,000 X

Y Y PHPK2501311 1/1/2023 1/1/2024

2,000,000

A 1,000,000

X

Y Y PHPK2501311 1/1/2023 1/1/2024

B X

N

Y QWC1259659 1/1/2023 1/1/2024

1,000,000

1,000,000

1,000,000

Sexual Abuse and Molestation coverage is included on the GL policy with separate limits of$1,000,000 Each Claim and $2,000,000 Aggregate.

Re: Contract No. CTR066198, Domestic Violence - Statewide General Liability and Automobile Liability - Additional Insured and Waiver of Subrogation apply to: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees. Coverage is Primary and Non-Contributory. 30 day Notice of Cancellation. Endorsements attached.

Workers' Compensation - Waiver of Subrogation endorsement attached.

The State of Arizona and Department of Economic Security c/o myCOI 1075 Broad Ripple Ave., Suite 313 Indianapolis IN 46220

MANUSCRIPT (06/11)

Revised 6/13/12 Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – STATE OF ARIZONA

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

HUMAN SERVICES ORGANIZATION PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION VICARIOUS LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

Policy No. PHPK2501311 Policy Term. 01/01/2023 to 01/01/204

SCHEDULE

Name of Person or Organization:

The 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.

The 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 involving automobiles owned, leased, hired or borrowed by the Contractor.

The following provisions are added to the policy:

1. WHO IS AN INSURED is amended to include as an insured the person or organization shown in the above SCHEDULE, but only with respect to their liability for activities performed by you or on your behalf relating to the conduct of your business;

2. The coverage provided by this endorsement includes the assumption of liability in a written or oral contract between the named insured and the person or organization shown in the above SCHEDULE for work performed by you or on your behalf relating to the conduct of your business;

3. The coverage provided by this endorsement only is primary and non-contributory; and

4. We agree to waive any right of subrogation against 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.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION NOTICE TO SCHEDULED ADDITIONAL INSURED OR

CERTIFICATE HOLDER

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PROFESSIONAL LIABILITY COVERAGE PART

COMMERCIAL CRIME COVERAGE PART

COMMERCIAL INLAND MARINE COVERAGE PART

COMMERCIAL PROPERTY COVERAGE PART

COMMERCIAL AUTOMOBILE COVERAGE PART

SCHEDULE OF ADDITIONAL INSUREDS OR CERTIFICATE HOLDERS

AI or CH Additional Insured or Certificate Holder Address

A. CANCELLATION

A.

SCHEDULE

CANCELLATION NOTICE TO ADDITIONAL INSURED

OR CERTIFICATE HOLDER

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 anyone not named in the Schedule.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 04-84)

Schedule 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 W. Jefferson Street Mail Drop 1541 Phoenix, AZ. 85007

As per written contract

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

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 1/1/2023 Policy No. QWC1259659 Endorsement No. 2 Insured Mariposa Community Health Center, Inc. Premium $ 35,479 Insurance Company Sequoia Insurance Company

Countersigned by

WC 00 03 13

(Ed. 04-84)