ACCEPTED ANY_ALL GL,AL,WC 07.30.23-07.30.24.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

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

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

2/23/2024

Crystal IBC LLC Alliant Services 2000 West Loop S, Suite 2150 Houston TX 77027

Shari Rose

(713) 913-3385 (713) 621-5425

Shari.Rose@alliant.com

License#: BR-800584 Admiral Insurance Company 24856 SIGNGR1 Trumbull Insurance Company 27120

ORIUX

5825 N. Sam Houston Pkwy W Ste 220 Houston TX 77086

Navigators Specialty Insurance 36056 Hartford Insurance Group 914

2134614295

A X 1,000,000 X 300,000

10,000

1,000,000

2,000,000 X

CA000037116-05 7/30/2023 7/30/2024

2,000,000

Employee Benefits Li 2,000,000 B 1,000,000

X

X X

61UENHH1247 7/30/2023 7/30/2024

C X 5,000,000 X

HO23EXCZ028MJIC 7/30/2023 7/30/2024

5,000,000 X 0

D X61WEAS9920 7/30/2023 7/30/2024

1,000,000

1,000,000

1,000,000

RE: "For Any and All Work Performed on or Behalf of ADOT and the State of Arizona"

GENERAL LIABILITY: Additional Insured when required by written contract including completed operations. Waiver of Subrogation when required by written contract; Primary/Non-Contributory wording when required by written contract.

AUTOMOBILE: Additional Insured when required by written contract; Waiver of Subrogation when required by written contract; Primary/Non-Contributory wording when required by written contract.

See Attached...

State of Arizona and/or ADOT Attn: Amir Sakhi - Procurement Officer 1739 West Jackson Street, Ste. A, MD 100P Phoenix AZ 85007-3276

F0950 Accepted

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

SIGNGR1

1 1

Crystal IBC LLC ORIUX 5825 N. Sam Houston Pkwy W Ste 220 Houston TX 77086

25 CERTIFICATE OF LIABILITY INSURANCE

WORKERS COMPENSATION: Waiver of Subrogation when required by written contract.

UMBRELLA LIABILITY: Follow form underlying including Additional Insured when required by written contract, Waiver of Subrogation when required by written contract

(Policy Provisions: WC000000C)

INFORMATION PAGE

WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY

Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 06/27/23 Policy Expiration Date: 07/30/24

INSURER: SEE ATTACHED ENDORSEMENT

NCCI Company Number: 14397 Company Code: 9

Suffix

LARS RENEWAL

POLICY NUMBER: 61 WE AS9920 6

Previous Policy Number: 61 WE AS9920

1. Named Insured and Mailing Address:

(No., Street, Town, State, Zip Code)

SIGNAL GROUP INC

5825 N SAM HOUSTON PKWY W STE 220

HOUSTON TX 77086

FEIN Number: 75-3269022 State Identification Number(s): Refer to the EXTENSION OF THE INFORMATION PAGE – WC990365.

The Named Insured is: Corporation Business of Named Insured: Audio and Video Equipment Manufacturing Other workplaces not shown above: See Endorsement - WC990366

2. Policy Period: From 07/30/23 To 07/30/24 ANNUAL 12:01 a.m., Standard time at the insured's mailing address.

Producer’s Name: ALLIANT INSURANCE SERVICES INC

2000 W LOOP S STE 2150

HOUSTON TX 77027

Producer’s Code: 61611778 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER

3600 WISEMAN BLVD

SAN ANTONIO TX 78251

(866) 487-1744

Total Estimated Annual Premium: $13,628 Deposit Premium:

Policy Minimum Premium: $628 FL (Includes Increased Limit Min. Prem.)

Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%) The policy is not binding unless countersigned by our authorized representative.

Countersigned by 06/27/23 Authorized Representative Date

INFORMATION PAGE (Continued) Policy Number: 61 WE AS9920

Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 06/27/23 Policy Expiration Date: 07/30/24

3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: FL SEE ENDORSEMENT - WC 99 03 67

B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.

The limits of our liability under Part Two are:

Bodily injury by Accident $1,000,000 each accident Bodily injury by Disease $1,000,000 policy limit Bodily injury by Disease $1,000,000 each employee

C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here:

ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES

DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.

D. This policy includes these endorsements and schedule:

SEE ENDORSEMENT-WC 99 03 68

4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit.

Classifications Code Number and Description

Premium Basis Total Estimated Annual Remuneration

Rates Per $100 of Remuneration

Estimated Annual Premium

Total Standard Premium $13,162 Premium Discount -$195 Expense Constant $260 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement $343 Catastrophe (Other Than Certified Acts Of Terrorism) $0 Estimated Annual Premium (before Surcharges) $13,570 Total Estimated Surcharges $58

*See the attached Schedule(s) of Operations for Location and State Level Premium Information

Total Estimated Annual Premium: $13,628 Deposit Premium:

Policy Minimum Premium: $628 FL (Includes Increased Limit Min. Prem.)

Interstate/Intrastate Identification Number: Refer to Schedule of Operations

NAICS: 334310

Labor Contractors Policy Number: SIC: 3651

Form WC 99 03 65 Printed in U.S.A.

Process Date: 06/27/23 Policy Expiration Date: 07/30/24

EXTENSION OF THE INFORMATION PAGE - ITEM 1 - NAMED INSURED

Policy Number: 61 WE AS9920 Endorsement Number:

Effective Date: 07/30/23 Effective hour is the same as stated on the Information Page of the policy.

Named Insured and Address: SIGNAL GROUP INC

5825 N SAM HOUSTON PKWY W STE 220

HOUSTON TX 77086

Item 1 of the Information Page is completed to include as named insured:

Named Insured : PAC-TEC INC State ID : Not Applicable

FEIN : 31-1117404

DBA Name Not Applicable

Named Insured : SIGNAL GROUP INC State ID : Not Applicable

FEIN : 75-3269022

DBA Name Not Applicable

Named Insured : PEEK TRAFFIC CORPORATION State ID : Not Applicable

FEIN : 20-0348594

DBA Name Not Applicable

Named Insured : TEKNOTRAFFIC INC State ID : Not Applicable

FEIN : 36-4100882

DBA Name Not Applicable