Sample_Certificate_of_Liability.pdf
PDF 361 KB Posted
- Solicitation number
- BPM007009
- Issued by
- Arizona
About this file
This is a Sample Certificate of Liability Insurance form provided by the Arizona Department of Education for contractors and vendors seeking to work with the state's educational institutions. The certificate documents comprehensive insurance coverage for Windom Security Strategies Today, LLC, a vendor providing school resource and school safety officer services. The certificate reflects multiple insurance policies in effect from May 1, 2024, through May 1, 2025, across six different insurers, demonstrating the vendor's financial responsibility and risk management capacity for school safety operations.
The insurance coverage includes general liability with limits of $2,000,000 per occurrence and $2,000,000 aggregate, automobile liability coverage at $1,000,000, workers' compensation and employers' liability at $1,000,000, an umbrella liability policy with $5,000,000 coverage, and specialized policies addressing sexual abuse and molestation liability at $1,000,000 and professional liability with $2,000,000 aggregate limits. The policies are underwritten by reputable carriers including Indian Harbor Insurance Company, State Automobile Mutual Insurance Company, Axis Surplus Insurance Company, Service Lloyds Insurance Company, and Lloyds Syndicate 3623. The certificate holder is WINDSEC-01, and the producer of record is NFP Property & Casualty Services, Inc., located in Minneapolis, Minnesota. This comprehensive insurance portfolio reflects the stringent risk management requirements typically imposed by Arizona educational institutions when contracting for personnel who will have direct contact and responsibility for student safety.
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Text version
Sample Certificate of Liability Insurance Form
Arizona Department of Education 1535 W. Jefferson Street
Phoenix, AZ 85007
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
PRODUCER CONTACT
NAME:
FAXPHONE
(A/C, No):(A/C, No, Ext):
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER POLICY EFF POLICY EXPTYPE 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 RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
PRO-
PRODUCTS - COMP/OP AGGJECT
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 LIMITDESCRIPTION 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.ACORD 25 (2016/03)
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
The ACORD name and logo are registered marks of ACORD
6/13/2024
36940
Windom Security Strategies Today, LLC 25135 26620 43389
A 1,000,000
X X ESG006254201 5/1/2024 5/1/2025 100,000
1,000,000 2,000,000 2,000,000
X ASSAULT & BATTER AGGREGATE 2,000,000
1,000,000B
X X 10153171CA 9/21/2023 9/21/2024
5,000,000C X X P-001-001057966-02 5/1/2024 5/1/2025 5,000,000
D
X SLTIS0574600 5/1/2024 5/1/2025 1,000,000
1,000,000 1,000,000
E Special Risk W340E1240201 5/1/2024 Sexual Abuse/Molesta 1,000,000 A Professional Liab ESG006254201 5/1/2024 5/1/2025 Aggregrate 2,000,000
FOR YOUR REFERENCE ONLY
FOR YOUR REFERENCE ONLY
WINDSEC-01 CARLYFOLDENAUR
NFP Property & Casualty Services, Inc.
505 Highway 169 N Suite 1100 Minneapolis, MN 55441
Carly Foldenaur carly.foldenaur@nfp.com
Indian Harbor Insurance Company State Automobile Mutual Insurance Company Axis Surplus Insurance Company Service Lloyds Insurance Company, a Stock Company
Lloyds Syndicate 3623 (Beazley Furlonge Limited)
5/1/2025
X X
POLICY LOC
X
X X
X
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