2023-09-06 WC.pdf

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

CONTACTPRODUCER

NAME:

PHONE FAX

(A/C, No, Ext): (A/C, No):

EMAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSR

LTR TYPE OF INSURANCE ADDL

INSR

SUBR

WVD POLICY NUMBER POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

AUTHORIZED REPRESENTATIVE

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

SCHEDULED

AUTOS

HIRED

AUTOS ONLY

NON-OWNED

AUTOS ONLY

UMBRELLA LIAB

EXCESS LIAB

OCCUR

CLAIMS-MADE

DED RETENTION $

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

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident)

EACH OCCURRENCE

AGGREGATE

PER

STATUTE

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

CERTIFICATE HOLDER CANCELLATION

ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

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).

Fleming Trailers Inc 5600 99th Ave Ste A Kenosha, WI 53144

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.

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

09/27/2022

Sentry Customer Service

800-473-6879 800-514-7191 businessproducts_direct@sentry.com

Sentry Select Insurance Company 21180

2668775

A A0144250002 09/06/2022 09/06/2023

X

1,000,000

1,000,000

1,000,000

X

Sentry Insurance 1800 North Point Drive Stevens Point, WI 54481

COMMERCIAL GENERAL LIABILITY

The State of Arizona 1324 N 22nd Ave Phoenix, AZ 85009-3715

09/27/2022A0144250

Sentry Select Insurance Company 00001 0000000000 22270 0 N1 a4798fad-8cbb-4a7e-aa75-b774bdb7a0e6a4798fad-8cbb-4a7e-aa75-b774bdb7a0e6 a8812 WC Only

AGENCY CUSTOMER ID:

LOC #:

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY

POLICY NUMBER

CARRIER NAIC CODE

ADDITIONAL REMARKS

NAMED INSURED

EFFECTIVE DATE:

Fleming Trailers Inc

XXXXXX0059

2 2

Kyle Zdroik

A0144250002

Sentry Select Insurance Company 21180 09/06/2022

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:ACORD 25 Certificate of Liability Insurance

ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD 09/27/2022A0144250

Sentry Select Insurance Company

(Ed. 4-84)

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

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

Name: The State of Arizona

Address: 1324 N 22nd Ave Phoenix, AZ 85009-3715

Description of Waiver: WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

JobID:

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No.

Insured Premium

Insurance Company Countersigned by

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

© 1983 National Council on Compensation Insurance.

WC 00 03 13

(Ed. 4-84)

Change effective 09/26/2022

09/27/2022A0144250002

Sentry Select Insurance Company 00001 0000000000 22270 0 N1 29ec00a8-64b7-42df-81f7-aba465a20d8729ec00a8-64b7-42df-81f7-aba465a20d87