MD_Merrett_-ACORD-Certificate_1006113workers_comp_10012021-10012022.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

AUTOS

NON-OWNED

SCHEDULED

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)

CERTIFICATE HOLDER

© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

AUTOS ONLY

OWNED

ANY AUTO

HIRED

AUTOS ONLY

10/07/2021

CopperPoint Insurance Companies 3030 N. 3rd Street

Phoenix AZ 85012-3068

CopperPoint Insurance Companies

602.631.2300 or 866.284.2694 602.631.2599

M D Merrett Inc

PO Box 3804

Carefree AZ 85377

COPPERPOINT INDEMNITY INSURANCE COMPANY 13928

A X 1006113 10/01/2021 10/01/2022 1,000,000 1,000,000 1,000,000

Job #: CRT055334 Location: Any and All Projects in Arizona

5213 - AZ - CONCRETE CONSTRUCTION-N.O.C.,5535 - AZ - SHEET METAL WORK - INSTALLATION,6003 - AZ - PILE DRIVING,6217 -

AZ - EXCAV-NOC-INC BORROW/FILL-BACK FILL,6306 - AZ - SEWER CONSTRUCTION-ALL OPERATIONS-,6319 - AZ - WATER MAIN OR

CONNEC CONST-INCL TUN

Arizona Game & Fish Department

5000 West Carefree Highway

Phoenix AZ 85086

EFFECTIVE DATE:

NAMED INSURED

POLICY NUMBER

NAIC CODECARRIER

AGENCY

LOC #:

AGENCY CUSTOMER ID:

ofPageADDITIONAL REMARKS SCHEDULE

ADDITIONAL REMARKS

FORM TITLE:FORM NUMBER:

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

© 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

ACORD 101 (2008/01)

2 2

1006113

COPPERPOINT INDEMNITY INSURANCE COMPANY 13928

M D Merrett Inc PO Box 3804 Carefree, AZ 85377

10/01/2021-10/01/2022

25 Certificate of Liability Insurance

This waiver of subrogation is effective only with respect to the Certificate Holder for the project described herein, and shall not benefit any other person or organization.

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. This waiver of Subrogation is as to the entities listed below. This Waiver does not waive or in any way limit our lien rights under ARS 23 - 1023.