Soutwest_Siteworks_-_General-Auto-Umbrella-Workers__Exp_07.27.24_.pdf
PDF 111 KB Posted
- Attached to
- Master Agreement AZ|CTR062276
- Contract number
- CTR062276
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by Crest Insurance Group, LLC for Southwest Siteworks, LLC, with Acuity (NAIC #14184) as the primary insurer. The certificate is addressed to the State of Arizona Department of Emergency and Military Affairs, located in Phoenix, AZ, and is associated with a specific project identified as BPM004630/M22-0024.
The insurance coverage includes Commercial General Liability, Automobile Liability, Umbrella Liability, and Workers' Compensation, with policy periods from 7/27/2023 to 7/27/2024. Key coverage limits include $1,000,000 for each occurrence in multiple categories, with a general aggregate limit of $3,000,000. The certificate provides additional insured status to the certificate holder when required by written contract, includes primary and non-contributory coverage, and features a waiver of subrogation for General and Automobile Liability. The policy is issued under policy number ZN4991 and covers Southwest Siteworks, LLC, based in Tucson, AZ.
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Text version
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
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
7/19/2023
Crest Insurance Group, LLC 5285 E. Williams Circle Suite 4500 Tucson AZ 85711
Jynessa Shaffer 520-784-7617 520-618-3948 jshaffer@crestins.com
License#: 967026 Acuity 14184
SOUTSIT-01
Southwest Siteworks, LLC 6727 N. Silverbell Road Tucson AZ 85743
243317193
A X 1,000,000 X 300,000
10,000
1,000,000
3,000,000 X
Y Y ZN4991 7/27/2023 7/27/2024
3,000,000
A 1,000,000
X
X X
Y Y ZN4991 7/27/2023 7/27/2024
A X 1,000,000 X
Y ZN4991 7/27/2023Y 7/27/2024
1,000,000
A XY ZN4991 7/27/2023 7/27/2024
1,000,000
1,000,000
1,000,000
Certificate holder and others when required in a written contract or agreement are Additional Insured (General Liability & Automobile Liability) including Products Completed. Coverage is Primary & Non-Contributory (General Liability). Waiver of Subrogation (General Liability & Automobile Liability) applies. This form is subject to all policy forms, terms, endorsements, conditions definitions & exclusions.
Project: BPM004630/M22-0024
STATE OF ARIZONA
DEPARTMENT OF EMERGENCY AND MILTARY
AFFAIRS
5636 East McDowell Road, Bldg M5800 Phoenix AZ 85008-3495
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