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, DATE (MM,DDiYYYY) <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 />PRODUCER CA <br />T "Oi' ;" 1' pd' C:•e�" __ OaCE c <br />PHONE _ FAX -. <br />... ;::n •. r.; , • . ,, iALG._N4.fiall a 19 ".8 3 fA/C, No} • e _ s ,. <br />E-MAIL <br />PRODUCER <br />INSURERJSj. AFFORDING COVERAGE _ Y NAIC / <br />INSURED - INSURERA; E--11 kDF-LPHJ-A-_-L=-- 1%S CG <br />. .:.: -: ':'.. INSURERS: <br />INSURER C <br />INSURER D : , <br />INSURER E <br />INSURER F <br />RFVISIAN NIIMRER- <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 />NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT <br />OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />INDICATED <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 <br />PAID CLAIMS. <br />-- -.._ -. 'ADDL SUSR-- �---'-1---- POLICY EFF <br />ILTR <br />POLICY <br />OMITS <br />TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY <br />MMIOOmYY <br />GENERAL LIABILITY <br />EACH OCCURRENCE S <br />S>SAMA6FTbTF--- <br />,'_�.MMr C� AL'.;E";-;zAL LIARIL;Tv <br />PREMISES ;Ea occuusr,ce} }.S.__. <br />" (,L Aia,IS-MACE OCCUR <br />I MED EKP IAnv one pe sort <br />-_ <br />PERSINAL 8 ADV INJURY I S <br />I GENERAL AGGREGATE S <br />.ENt A,, RL`,AT£ L MIT APPLIES PER i <br />1PRODUCTS -COMP OP AGOG$ <br />PRb- <br />- PCtICY LOC <br />AUTOMOBILE LIABILITY', <br />COMBINED SINGLE LIMIT S <br />(Eaacc,dent) <br />ANY S.UTC <br />BODILY INJURY (Per parse } $ <br />ALL AUTOS <br />i 1 BODILY INJURv IPer acEidenllj S <br />SL t :I ALIT! <br />PROPERTY DAMAGE S <br />(Per acGdenfi <br />S <br />AU*os <br />----- - -- -- <br />I S <br />3 UMBRELLA LIAR OCCJR <br />` EACH OCCURRENCE S <br />EXCESS LIAR CLAIMS MACE' t <br />( AGGREGATE $ <br />CED--! TIBtE <br />RE TENT!(,N $ <br />S <br />'. WORKERS COMPENSATION , j <br />WO 1 <br />! WC STATU- OTH <br />R <br />AND EMPLOYERS'LIABILITY N 1 <br />-' ' <br />i .TQHYLfit7TSI <br />r EL EACH AL,CI )cNT <br />ANVPRLPRIErORP R NE i'EkECU TIVE <br />. ___ <br />i r— _ .._.___ _ -..._ ___ _ -.. <br />OFFICERMEM6ER EKCLJuED"' �!NIAj <br />- <br />(Mandatory in NH) : !. <br />E L DISEASE EA EMPLOYEE; S <br />If ye,. les n • <br />DESCR PTV )N ,iE UPeRATVVNS oeiew 1 <br />E L DISEASE POLICY LIMITI S <br />2911 w-1... <br />fAyyrnga CE ;t � U'J'. <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Schedule, if more spats <br />is required) <br />..::,. .,. „ ... ..,. .. it t, -:71, o*c. ..5_ <br />LCKIIr•IVNIC r1VLVGR �`� <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 />IJ l9OO•LUV7 Oi{..VRV I.VRrV RH 11V1Y. Htl ngnts reserveu <br />ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD a,.)z z Jf <br />