Workers_Comp_7-1-22.pdf

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

05/18/2022

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).

PRODUCER

Aon Risk Services, Inc of Florida 1001 Brickell Bay Drive, Suite #1100 Miami, FL 33131-4937

CONTACT

NAME: Aon Risk Services, Inc of Florida

PHONE

(A/C, No, Ext): 800-743-8130

FAX

(A/C, No): 800-522-7514

EMAIL

ADDRESS: ADP.COI.Center@Aon.com

INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : New Hampshire Ins Co 23841

INSURED

ADP TotalSource CO XXI, Inc.

5800 Windward Parkway Alpharetta, GA 30005

ALTERNATE EMPLOYER

ADVANCED HEALTHSTYLES FITNESS EQUIPMENT INC. DBA Advanced Exercise Equipment, Inc.

861 Southpark Dr 100 Littleton, CO 80120

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: 3888100 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.

INSR

LTR TYPE OF INSURANCE

ADDL

INSR

SUBR

WVD POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

COMMERCIAL GENERAL LIABILITY

EACH OCCURRENCE $

CLAIMS-MADE OCCUR

DAMAGE TO RENTED

PREMISES (Ea occurrence) $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

POLICY PROJECT LOC PRODUCTS - COMP/OP AGG $

OTHER $

AUTOMOBILE LIABILITY

COMBINED SINGLE LIMIT

(Ea accident) $

ANY AUTO BODILY INJURY (Per person) $

OWNED

AUTOS ONLY

SCHEDULED

AUTOS BODILY INJURY (Per accident) $

HIRED

AUTOS ONLY

NON-OWNED

AUTOS ONLY

PROPERTY DAMAGE

(Per accident) $

UMBRELLA LIAB OCCUR

EACH OCCURRENCE $

EXCESS LIAB CLAIMS-MADE AGGREGATE $

DEC RETENTION $

A

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

Y / N

N / A X

WC 038361529 CO

07/01/2021

07/01/2022

X

PER

STATUTE OTH-

ER

E.L. EACH ACCIDENT $ 2,000,000

E.L. DISEASE - EA EMPLOYEE $ 2,000,000

E.L. DISEASE - POLICY LIMIT $ 2,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) All worksite employees working for ADVANCED HEALTHSTYLES FITNESS EQUIPMENT INC. DBA ADVANCED EXERCISE EQUIPMENT, INC., paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. ADVANCED HEALTHSTYLES FITNESS EQUIPMENT INC. DBA ADVANCED EXERCISE EQUIPMENT, INC. is an alternate employer under this policy.

See attached Certificate Holder Cancellation Notice.

WAIVER OF SUBROGATION IN FAVOR OF ARIZONA DEPARTMENT OF PUBLIC SAFETY AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES. AS RESPECTS OF JOB PERFORMED BY ADVANCED HEALTHSTYLES FITNESS EQUIPMENT INC. DBA ADVANCED EXERCISE EQUIPMENT, INC. AS REQUIRED BY

WRITTEN CONTRACT.

RE: DPS Request No.: CTR060327, Reference GSA Contract No.: 47QSMA20D08Q1, DPS Training Center Fitness Equipment.

CERTIFICATE HOLDER CANCELLATION

Arizona Department of Public Safety 2102 W. Encanto Blvd.

Phoenix, AZ 85009

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

© 1988-2015 ACORD CORPORATION. All rights reserved.

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

Certificate Number: 3888100

WC 00 03 13

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below.

icy.)

This endorsement, effective on 05/18/2022 at 12:01 A.M. standard time, forms a part of Policy No. WC 038361529 of the New Hampshire Ins Co

Issued to:

ADP TotalSource CO XXI, Inc. (PEO Company) 5800 Windward Parkway Alpharetta, GA 30005 ADVANCED HEALTHSTYLES FITNESS EQUIPMENT INC. DBA Advanced Exercise Equipment, Inc. (Client of PEO Company) 861 Southpark Dr 100 Littleton, CO 80120

Premium (if any) $ Included Authorized Representative

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

In favor of:

ARIZONA DEPARTMENT OF PUBLIC SAFETY

AND ITS DEPARTMENTS, AGENCIES, BOARDS, COMMISSIONS, UNIVERSITIES, OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES.

2102 W. ENCANTO BLVD.

PHOENIX, AZ 85009

JOB DESCRIPTION:

RE: DPS REQUEST NO.: CTR060327, REFERENCE GSA CONTRACT NO.: 47QSMA20D08Q1, DPS TRAINING CENTER FITNESS

EQUIPMENT.

POLICY HOLDER NOTICE

CERTIFICATE HOLDER CANCELLATION NOTICE SCHEDULE

Should this policy be cancelled before the expiration date hereof, the producer will endeavor to mail 30 days written notice to the certificate holder named herein, but failure to do so shall impose no obligation or liability of any kind upon the insurer, the producer, or the respective agents or representatives of each.

SCHEDULE:

CERTIFICATE HOLDERS AS IDENTIFIED ON THE MOST RECENT QUARTERLY

SCHEDULE OF CERTIFICATE HOLDERS PROVIDED BY THE INSURED'S BROKER OF

RECORD TO THE INSURER.