supplement_insurance.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

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 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-POLICY LOC 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

5/12/2023

(480) 385-7375 (480) 946-3512

10851

Atlas Fire Company, LLC 7615 N 75th St #101-102 Glendale, AZ 85303

A 1,000,000

X X 51GL016579-231 5/15/2023 5/15/2024 100,000

5,000

1,000,000 2,000,000 2,000,000

5,000,000A

X X 51CC006494-231 5/15/2023 5/15/2024 5,000,000

10,000

A Prof Liability 51GL016579-231 5/15/2023 Per Claim 1,000,000 A Professional Liab 51GL016579-231 5/15/2023 5/15/2024 Aggregate 1,000,000

SEE ATTACHED ACORD 101

CSLB

PO Box 26000 Sacramento, CA 95826

ATLAFIR-01 JMIRACLE

HUB International Insurance Services (SOW) 4835 E Cactus Road Suite 246 Scottsdale, AZ 85254

Jennifer Miracle jenny.miracle@hubinternational.com

Everest Indemnity Insurance Company

5/15/2024

X X

X

X

X

X

FORM NUMBER:

EFFECTIVE DATE:

The ACORD name and logo are registered marks of ACORD

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE

FORM TITLE:

Page of

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

ACORD 101 (2008/01)

AGENCY CUSTOMER ID:

LOC #:

AGENCY NAMED INSURED

POLICY NUMBER

CARRIER NAIC CODE

© 2008 ACORD CORPORATION. All rights reserved.

HUB International Insurance Services (SOW)

ATLAFIR-01

SEE PAGE 1

SEE PAGE 1

ACORD 25 Certificate of Liability Insurance

SEE P 1

Atlas Fire Company, LLC 7615 N 75th St #101-102 Glendale, AZ 85303

SEE PAGE 1

JMIRACLE

Description of Operations/Locations/Vehicles:

Certificate Holder, Owner and all others as required by written contract are Additional Insured(s) on a Primary Non-Contributory basis including Waiver of Subrogation with respects to General Liability. Per Project Aggregate applies per attached endorsement.

Commercial Auto Liability Additional Insured including Waiver of Subrogation applies per attached endorsements. Waiver of Subrogation applies to Workers Compensation per attached endorsement. Umbrella Liability is Following Form over General Liability, Professional Liability, Auto Liability, and Workers Compensation. APPLICABLE FORMS ATTACHED: ECG 20 597 05 09, ECG 20 612 04 15, ECG 24 520 08 05, ECG 24 522 04 02, ECG 25 529 01 10, CAE 0131 1508, WC 00 03 13 04 84.

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 4-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

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.

Schedule

This endorsement changes the policy to which it is attached effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective 05/15/2023 Policy No.

20-WC-003364808-1 Endorsement No. 000

Insured Atlas Fire Company LLC Premium $ Insurance Company Countersigned by

SECURA Insurance Company

WC 00 03 13

(Ed. 4-84)

1983 National Council on Compensation Insurance.

State Entity Name Contract or Project Number Description of Work

Waiver Premium Waiver Type

AZ Blanket Waiver of Subrogation

Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.

BLANKET