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<br />DATE (MM/DD/YYYY) <br />CERTIFICATE OF LIABILITY INSURANCE <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />CONTACT <br />PRODUCER <br />NAME: <br />FAX <br />PHONE <br />(A/C, No): <br />(A/C, No, Ext): <br />E-MAIL <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGENAIC # <br />INSURER A : <br />INSURED <br />INSURER B : <br />INSURER C : <br />INSURER D : <br />INSURER E : <br />INSURER F : <br />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />ADDLSUBR <br />INSRPOLICY EFFPOLICY EXP <br />TYPE OF INSURANCELIMITS <br />POLICY NUMBER <br />LTR(MM/DD/YYYY)(MM/DD/YYYY) <br />INSDWVD <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE$ <br />DAMAGE TO RENTED <br />CLAIMS-MADEOCCUR$ <br />PREMISES (Ea occurrence) <br />MED EXP (Any one person)$ <br />PERSONAL & ADV INJURY$ <br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ <br />PRO- <br />POLICYLOCPRODUCTS - COMP/OP AGG$ <br />JECT <br />$ <br />OTHER: <br />COMBINED SINGLE LIMIT <br />AUTOMOBILE LIABILITY$ <br />(Ea accident) <br />BODILY INJURY (Per person)$ <br />ANY AUTO <br />ALL OWNEDSCHEDULED <br />BODILY INJURY (Per accident)$ <br />AUTOSAUTOS <br />NON-OWNED <br />PROPERTY DAMAGE <br />$ <br />HIRED AUTOS <br />(Per accident) <br />AUTOS <br />$ <br />UMBRELLA LIAB <br />EACH OCCURRENCE$ <br />OCCUR <br />EXCESS LIAB <br />CLAIMS-MADEAGGREGATE$ <br />$ <br />DEDRETENTION$ <br />PEROTH- <br />WORKERS COMPENSATION <br />STATUTEER <br />AND EMPLOYERS' LIABILITY <br />Y / N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT$ <br />N / A <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />E.L. DISEASE - EA EMPLOYEE$ <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMIT$ <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Ejhjubmmz!tjhofe! <br />cz!Uv!Usbo! <br />Uv!Usbo! <br />Ohvzfo! <br />CzUvUsboOhvzfobu9;26bn-Bqs1:-3136 <br />Ebuf;!3136/15/1:! <br />Ohvzfo <br />19;39;23!.18(11( <br />CERTIFICATE HOLDERCANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />© 1988-2014 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014/01)The ACORD name and logo are registered marks of ACORD <br /> <br />