State of Arizona.pdf

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77777 77707

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66660 60006

06006 C er ti fi ca te N o

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

04/25/2023

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.

PRODUCER

Aon Risk Services Central, Inc.

Philadelphia PA Office 100 North 18th Street 15th Floor Philadelphia PA 19103 USA

PHONE

(A/C. No. Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

(866) 283-7122

INSURED 37273AXIS Insurance CompanyINSURER A:

35289The Continental Insurance CompanyINSURER B:

20443Continental Casualty CompanyINSURER C:

20427American Casualty Co. of Reading PAINSURER D:

20494Transportation Insurance Co.INSURER E:

INSURER F:

FAX

(A/C. No.): (800) 363-0105

CONTACT

NAME:

Fidelity National Information Serv. Inc.

and all subsidiaries 601 Riverside Ave Jacksonville FL 32204-2946 USA

COVERAGES CERTIFICATE NUMBER: 570099166369 REVISION NUMBER:

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. Limits shown are as requested

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

(MM/DD/YYYY)

SUBR

WVD

INSR

LTR

ADDL

INSD POLICY NUMBER TYPE OF INSURANCE LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY LOC

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

X

X

X

GEN'L AGGREGATE LIMIT APPLIES PER:

$2,000,000

$2,000,000

Excluded

$2,000,000

$4,000,000

$4,000,000

C 01/01/2023 01/01/2024GL7036257993

PRO-

JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

SCHEDULED

AUTOS

HIRED AUTOS

ONLY

NON-OWNED

AUTOS ONLY

BODILY INJURY ( Per person)

PROPERTY DAMAGE

(Per accident)

X BODILY INJURY (Per accident)

$2,000,000C 01/01/2023 01/01/2024 COMBINED SINGLE LIMIT

(Ea accident)

BUA7036257962

EXCESS LIAB

X OCCUR

CLAIMS-MADE AGGREGATE

EACH OCCURRENCE

DED

$10,000,000

$10,000,000

$10,000

01/01/2023UMBRELLA LIABB 01/01/20247018146359

RETENTIONX

X

E.L. DISEASE-EA EMPLOYEE

E.L. DISEASE-POLICY LIMIT

E.L. EACH ACCIDENT $1,000,000

X OTH-

ER

PER STATUTED 01/01/2023 01/01/2024

WC AOS

WC7036292615E 01/01/2023 01/01/2024

$1,000,000

Y / N

(Mandatory in NH)

ANY PROPRIETOR / PARTNER / EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / AN

WC WI

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

If yes, describe under DESCRIPTION OF OPERATIONS below

$1,000,000

WC7036257976

E&O/CyberP00100004790605 11/09/2022 11/09/2023 E&O/Cyber/Prof Liab

Cyber LiabilityA

SIR applies per policy terms & conditions

$15,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

Employers' Liability/Stop Gap coverage is included within the AOS Policy (WCUC66921232). RE: Contract reference:

CTR060124. The State of Arizona and the Arizona Department of Economic Security, subject to the terms, conditions & exclusions of the policies, the State of Arizona and Its departments, agencies, boards, commissions, universities, officials, agents and employees shall be Included as Additional Insureds with respect to General Liability policy arising out of the activities performed by or on behalf of the Contractor. The General Liability, Automobile Liability, Umbrella Liability and Workers' Compensation policies contain a Waiver of Subrogation in favor of 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

CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVEState of Arizona Department of Economic Security Attn: Jonelle Benally-Clytus 1789 West Jefferson Street Phoenix AZ 850057 USA

ACORD 25 (2016/03)

©1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

POLICY PROVISIONS.

AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE

LOC #:

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY

See Certificate Number:

See Certificate Number:

570099166369

570099166369

Aon Risk Services Central, Inc.

570000080055

ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits.

INSURER

INSURER

INSURER

INSURER

INSURER(S) AFFORDING COVERAGE

Page _ of _

NAIC #

Fidelity National Information Serv. Inc.

TYPE OF INSURANCE

POLICY NUMBER LIMITS

WORKERS COMPENSATION

E WCE7036298219 01/01/2023 01/01/2024

D WC7036292601 01/01/2023 01/01/2024

WC Ohio

WC CA,MA

N/A

N/A

ADDL

INSD

INSR

LTR

SUBR

WVD

POLICY

EFFECTIVE

DATE

(MM/DD/YYYY)

POLICY

EXPIRATION

DATE

(MM/DD/YYYY)

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD behalf of the Contractor.

FORM TITLE:FORM NUMBER:

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

ADDITIONAL REMARKS

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

Aon Risk Services Central, Inc.

NAMED INSUREDAGENCY

LOC #:

570000080055AGENCY CUSTOMER ID:

© 2008 ACORD CORPORATION. All rights reserved.

See Certificate Number:

See Certificate Number:

The ACORD name and logo are registered marks of ACORD

570099166369

570099166369

ACORD 25 Certificate of Liability Insurance Additional Description of Operations / Locations / Vehicles:

ACORD 101 (2008/01)

ADDITIONAL REMARKS SCHEDULE Page _ of _

Fidelity National Information Serv. Inc.