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<br />Ejhjubmmz!tjhofe! <br />DATE (MM/DD/YYYY) <br />CERTIFICATE OF LIABILITY INSURANCE <br />1402803134 <br />Bohjf! <br />cz!Bohjf!Bdfwfep! <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 />Ebuf;!3135/14/15! <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 />Bdfwfep <br />27;56;33!.19(11( <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />CONTACT <br />PRODUCER <br />Kpobuibo!!Tfwfstpo <br />NAME: <br />Cboojtufs!'!Bttpdjbuft!Jotvsbodf!Bhfodz <br />FAX <br />PHONE <br />)825*!647.7197)825*!647.5165 <br />(A/C, No): <br />(A/C, No, Ext): <br />DB!Mjdfotf!$17:2182 <br />E-MAIL <br />416!28ui!Tusffu <br />kpobuiboAcbj.jot/dpn <br />ADDRESS: <br />Ivoujohupo!Cfbdi!DB!:3759 <br />INSURER(S) AFFORDING COVERAGENAIC # <br />Tfoujofm!Jotvsbodf!Dpnqboz <br />INSURER A : <br />):5:*!326.664: <br />INSURED <br />Ibsugpse!Dbtvbmuz!Jotvsbodf!Dp <br />INSURER B : <br />Cbssjpt!boe!Bttpdjbuf-!MMD <br />Qijmbefqijb!Joefnojuz!Jot!Dp <br />INSURER C : <br />ecb!Dpnnvojdbujpot!Mbc <br />812!F!Dibqnbo!Bwfovf <br />Byjt!Jotvsbodf!Dpnqboz <br />INSURER D : <br />INSURER E : <br />Psbohf!DB!:3977 <br />INSURER F : <br />Dfsu!JE!23545 <br />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />ADDLSUBR <br />INSRPOLICY EFFPOLICY EXP <br />TYPE OF INSURANCELIMITS <br />POLICY NUMBER <br />LTR(MM/DD/YYYY)(MM/DD/YYYY) <br />INSDWVD <br />COMMERCIAL GENERAL LIABILITY <br />BY!!!2-111-111 <br />EACH OCCURRENCE$ <br />DAMAGE TO RENTED <br />Y <br />CLAIMS-MADEOCCUR$ <br />ZZ 83TCBCH165715012031341501203135!!!2-111-111 <br />PREMISES (Ea occurrence) <br />MED EXP (Any one person)$ <br />!!!!!!21-111 <br />PERSONAL & ADV INJURY$ <br />!!!2-111-111 <br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ <br />!!!3-111-111 <br />PRO- <br />Y <br />POLICYLOCPRODUCTS - COMP/OP AGG$ <br />!!!3-111-111 <br />JECT <br />$ <br />OTHER: <br />COMBINED SINGLE LIMIT <br />AUTOMOBILE LIABILITY$ <br />!!!2-111-111 <br />(Ea accident) <br />ANY AUTO <br />BODILY INJURY (Per person)$ <br />B 83TCBCH165715012031341501203135 <br />OWNEDSCHEDULED <br />BODILY INJURY (Per accident)$ <br />AUTOS ONLYAUTOS <br />NON-OWNED <br />HIREDPROPERTY DAMAGE <br />$ <br />YY <br />(Per accident) <br />AUTOS ONLYAUTOS ONLY <br />$ <br />UMBRELLA LIAB <br />BYY 83TCBCH165715012031341501203135 <br />EACH OCCURRENCE$ <br />!!!7-111-111 <br />OCCUR <br />EXCESS LIAB <br />CLAIMS-MADEAGGREGATE$ <br />!!!7-111-111 <br />$ <br />Sfufoujpo!!!!!!21-111 <br />DEDRETENTION$ <br />PEROTH- <br />WORKERS COMPENSATION <br />Y <br />STATUTEER <br />C 83XFDBX8FI715012031341501203135 <br />AND EMPLOYERS' LIABILITY <br />Y / N <br />ANYP ROPRIETOR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT$ <br />!!!2-111-111 <br />N / A <br />OFFICER/MEMBER EXCLUDED? <br />!!!2-111-111 <br />(Mandatory in NH) <br />E.L. DISEASE - EA EMPLOYEE$ <br />If yes, describe under <br />!!!2-111-111 <br />E.L. DISEASE - POLICY LIMIT$ <br />DESCRIPTION OF OPERATIONS below <br />DQspgfttjpobm!Mjbcjmjuz QITE288967215012031341501203135 Mjnju!)qfs <br />$ <br />!!!3-111-111 <br />dmbjn*; <br />Efevdujcmf;!%6-1110dmbjn Mjnju!)bhhsfhbuf*; <br />$!!!5-111-111 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Djuz!pg!Tboub!Bob!boe!Tboub!Bob!Qpmjdf!Efqbsunfou-!jut!pggjdfst-!pggjdjbmt-!fnqmpzfft-!boe <br />wpmvouffst!bsf!obnfe!bt!beejujpobm!jotvsfet!)pgg.tjuf!boe!pohpjoh!pqfsbujpot!pomz*!xjui!sftqfdut <br />hfofsbm!mjbcjmjuz!qpmjdz!mjnjut/!Qsjnbsz!boe!opo.dpousjcvupsz!xpsejoh!bqqmjft!xjui!sftqfdut!hfofsbm <br />mjbcjmjuz!qpmjdz!mjnjut/!Xbjwfs!pg!tvcsphbujpo!bqqmjft!xjui!sftqfdut!hfofsbm!mjbcjmjuz!qpmjdz <br />mjnjut/ <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 />Djuz!pg!Tboub!Bob <br />Sjtl!Nbobhfnfou!Ejwjtjpo <br />AUTHORIZED REPRESENTATIVE <br />31!Djwjd!Dfoufs!Qmb{b <br />Tboub!Bob!DB!:3813 <br />© 1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD <br />Qbhf!2!pg!3 <br /> <br />