RISEWorkersCompCOI_FAS_FCSENSENPP_exp8.1.26.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

Alaska National Insurance Company

7/25/2025

MJ Insurance, Inc.

3900 E. Camelback Road, Suite 225 Phoenix, AZ 85018 602 772-3300

Kimberly Shedd 602-772-3304 3178057515 kimberly.shedd@themjcos.com

Rise Services, Inc.

4554 E. Inverness Ave.

Mesa, AZ 85206

38733

A

Y

X 25HWS12645

3A States Incl:

AZ, FL, ID, MO

OR, UT

08/01/2025 08/01/2026 X 1,000,000

1,000,000 1,000,000

** Supplemental Name ** First Supplemental Name applies to all policies - Rise Services, Inc.

Policy# 25HWS12645 - : Rise Inc.

Policy# 25HWS12645 - : Rise Early Intervention Services, LLC Policy# 25HWS12645 - : Opportunity Management Group, LLC (See Attached Descriptions)

Arizona Department of Child Safety (ADCS) Office of Contracts 3003 N Central Ave. Suite 2000, C010-20 Phoenix, AZ 85012

#S1737055/M1736838

RISESERClient#: 15660

KRS

#S1737055/M1736838

SAGITTA 25.3 (2016/03)

DESCRIPTIONS (Continued from Page 1) Policy# 25HWS12645 - : Rise Behavioral & Mental Health Services, LLC Policy# 25HWS12645 - : Therapy for Developmental Disabilities Policy# 25HWS12645 - : Arise, Inc. FN

Waiver of Subrogation applies to the Certificate Holder and others as defined in the written agreement per endorsement WC000313 subject to the terms, conditions and exclusions on the policy(ies) as permitted by law, when required by written contract.

Holder CONT: Office of Procurement and Contracts

Foster and Adoption Support (FAS) - CTR069602 Family Connections, Nurturing Parenting, and SENSE Services (FC/NPP/SENSE) - CTR071086

Policy shall contain a waiver of subrogation against the State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor

#S1737055/M1736838

WC 00 03 13 (04 84)

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 any one not named in the Schedule.

This endorsement changes the policy to which it is attached and, unless otherwise stated, is effective on the date issued at 12:01 A.M. standard time at your mailing address shown in the policy.

Endorsement Effective August 1, 2025 Policy No. 25H WS 12645

Insured Rise Services, Inc. Endorsement No. 6

Countersigned By Marc E. Schmittlein MJ Insurance/ Phoenix

All Docs Copy

State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and em-ployees for losses arising from work performed by or on be-half of the Contractor.

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