The State of Arizona-ADOT COI 2023.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD 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)

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 RENTED

CLAIMS-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 AGG $JECT

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 LIMIT $DESCRIPTION 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.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE

Lockton Companies 444 W. 47th Street, Suite 900 Kansas City MO 64112-1906

(816) 960-9000 kcasu@lockton.com

RHYTHM ENGINEERING, LLC

14019 W 95TH ST

LENEXA KS 66215

The Travelers Indemnity Company of America 25666 Travelers Property Casualty Company of America 25674

X X

1,000,000 300,000 10,000 1,000,000 2,000,000 2,000,000

X 1,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X 1,000,000 1,000,000

XXXXXXX

N

X

1,000,000 1,000,000 1,000,000

CYBER/ERRORS &

OMISSIONS

$1M LIMIT

$25K RETENTION

A BA 3L220210 2/1/2023 2/1/2024

B ZLP-81M74098 2/1/2023 2/1/2024

B ZPL-61M73309 2/1/2023 2/1/2024

B CUP-9K895007 2/1/2023 2/1/2024

A UB-9J778435 2/1/2023 2/1/2024

2/1/2024

1450810

Y Y

Y Y

N N

Y

9/14/2023

N N

19894125

19894125 XXXXXXX

The State of Arizona 1324 N. 22nd Ave., Phoenix AZ 85009

The State of Arizona additional insured on general liability, auto liability, on a primary, non-contributory basis, if required by written contract. Waiver of subrogation in favor of the additional insured applies on general liability, auto liability and workers compensation, if required by written contract and where allowed by law. Coverage is subject to the terms and conditions of the policy.