Workers_Comp_11.14.2025.pdf

© 1988-2016 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

CERTIFICATE HOLDER

ACORD 25 (2016/03)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSD

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

OTHER:

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:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

E-MAIL

ADDRESS:

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED

IN ACCORDANCE WITH THE POLICY PROVISIONS.

Acct#: 2286179 11/14/2025

LOCKTON COMPANIES, LLC 888-828-8365

3657 Briarpark Dr., Suite 700 Houston, TX 77042

Indemnity Insurance Company of North America 43575

ABEL SCREENING, INC.

1151 HARBOR BAY PKWY STE 121

ALAMEDA, CA 94502-6568

NA X C73928709 10/01/2025 10/01/2026

X 1,000,000

1,000,000

1,000,000

WAIVER OF SUBROGATION IN FAVOR OF CERTIFICATE HOLDER WHERE REQUIRED BY WRITTEN CONTRACT.

All States Except ND OH WA WY

30 DAY NOTICE OF CANCELLATION APPLIES

insperitycerts@locktonaffinity.com

Arizona Department of Juvenile Corrections

100 N. 15th Avenue Suite 103 Phoenix AZ 85007

ATTN: Contracts/Procurement Dept.

WC 90 03 75 (05/18)

Workers' Compensation and Employers' Liability Policy

Named Insured Endorsement Number

Policy Number Symbol: Number:

Policy Period

TO

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

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

CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A.

of the Information Page.

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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us.

You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule.

Schedule

1. ( X ) Specific Waiver Name of person or organization:

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

2. Operations:

3. Premium:

The premium charge for this endorsement shall be INCLUDED percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described.

4. Minimum Premium: INCLUDED

Authorized Agent

10/01/2025 10/01/2026

C73928709

Arizona Department of Juvenile Corrections

100 N. 15th Avenue Suite 103 Phoenix, AZ 85007

WLR

ABEL SCREENING, INC.

ALAMEDA, CA 94502-6568

1151 HARBOR BAY PKWY STE 121

Indemnity Insurance Company of North America

11/14/2025

Workers' Compensation and Employers' Liability Policy Named Insured Endorsement Number

Policy Number Symbol: Number:

Policy Period

TO

Effective Date of Endorsement

Issued By (Name of Insurance Company)

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

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

NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES

A. If we cancel this Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below {the "Schedule"). You or your representative must provide us with both the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us on such Schedule.

B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy.

C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy.

D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement.

E. We may arrange with your representative to send such notice in the event of any such cancellation.

F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and physical address of the persons or organizations listed in the Schedule.

G. This endorsement does not apply in the event that you cancel the Policy.

SCHEDULE

Name of Certificate Holder E-Mail Address Physical Address

All other terms and conditions of this Policy remain unchanged.

This endorsement is not applicable in the states of AZ, FL, ID, ME, NC, NJ, NM, TX and WI.

Authorized Representative

WC 99 03 71 (01/11) Page 1 of 1

ABEL SCREENING, INC.

ALAMEDA, CA 94502-6568

1151 HARBOR BAY PKWY STE 121

10/01/2025 10/01/2026 11/14/2025

C73928709

Arizona Department of Juvenile Corrections 100 N. 15th Avenue Suite 103 Phoenix, AZ 85007

WLR

Indemnity Insurance Company of North America

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