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<br />DATE (MM/DD/YYYY) <br />CERTIFICATE OF LIABILITY INSURANCE <br />1303803137 <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 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 />DBTJF!M!DSPDLFS <br />NAME: <br />SJTL!NBOBHFNFOU!TFSWJDFT-!JOD/ <br />FAX <br />PHONE <br />)713*!951.4345 <br />(A/C, No): <br />(A/C, No, Ext): <br />Q/P/!CPY!61421 <br />E-MAIL <br />DBTJF/DSPDLFSAUIFSJTLQFPQMF/DPN <br />ADDRESS: <br />QIPFOJY!B\[!96187 <br />INSURER(S) AFFORDING COVERAGENAIC # <br />JOEJBO!IBSCPS!JOT!DP47:51 <br />INSURER A : <br />INSURED <br />OBUJPOBM!DBTVBMUZ!DP22::2 <br />INSURER B : <br />FOFSHZ!FYQFSUT!JOUFSOBUJPOBM <br />IEJ!HMPCBM!TQFDJBMUZ!TF <br />INSURER C : <br />666!UXJO!EPMQIJO!ES-!TUF!261 <br />UXJO!DJUZ!GJSF!JOT!DP3:5:6 <br />INSURER D : <br />INSURER E : <br />SFEXPPE!DJUZ!DB!:5176 <br />)761*!6:4.5372 <br />INSURER F : <br />DDDFSU!JE!45595)224* <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 VT11267338MJ36B19012031361901203137!!!!!411-111 <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 />BZZ VT11267338MJ36B19012031361901203137 <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 />BYZZ VT11267339MJ36B19012031361901203137 <br />EACH OCCURRENCE$ <br />!!!5-111-111 <br />OCCUR <br />EXCESS LIAB <br />Y <br />CLAIMS-MADEAGGREGATE$ <br />!!!5-111-111 <br />$ <br />DEDRETENTION$ <br />PEROTH- <br />WORKERS COMPENSATION <br />Y <br />STATUTEER <br />CZ XDD451322B19012031361901203137 <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 />O <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 />DQSPG!MJBC.DMBJNT!NBEF GST.I.Q.QM.11123367.1315024031361502403137 BH0DM <br />$ <br />!!!6-111-111 <br />EDZCFS 6:NC1855841.3714012031371401203138 PDD0BHH!EFE <br />$!!!6-111-111 <br />%211-111 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />DPOTVMUBOUT/!DJUZ!PG!TBOUB!BOB-!JUT!PGGJDFST-!PGGJDJBMT-!FNQMPZFFT-!BHFOUT!BOE!WPMVOUFFST!BSF!OBNFE <br />BT!BEEM!JOTVSFE!XJUI!SFTQFDUT!UP!UIF!HM!'!BVUP!QFS!XSJUUFO!DPOUSBDU/!DPWFSBHF!JT!QSJNBSZ!OPO. <br />DPOUSJCVUPSZ/!XBJWFS!PG!TVCSPHBUJPO!BQQMJFT!XJUI!SFTQFDTU!UP!UIF!HM-!BVUP!'!XD/!41.EBZ!OPUJDF!PG <br />DBODFMMBUJPO!BQQMJFT/!JOTVSFE!EPFT!OPU!PXO!BOZ!BVUPT/ <br />CzUvUsboOhvzfobu:;55bn-Nbs22-3137 <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 />326!DFOUFS!TUSFFU!N.96 <br />TBOUB!BOB!DB!:3814 <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!2 <br /> <br />