COI_Exp_12.04.24.pdf

H o ld e r

Id e n ti fi e r

C e rt if ic a te

N o

CERTIFICATE OF LIABILITY INSURANCE

DATE(MM/DD/YYYY)

12/06/2023

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.

PRODUCER

PHONE

(A/C. No. Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

INSURED INSURER A:

INSURER B:

INSURER C:

INSURER D:

INSURER E:

INSURER F:

FAX

(A/C. No.):

CONTACT

NAME:

COVERAGES CERTIFICATE NUMBER: 570102965534 REVISION NUMBER:

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. Limits shown are as requested

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

(MM/DD/YYYY)

SUBR

WVD

INSR

LTR

ADDL

INSD POLICY NUMBER TYPE OF INSURANCE LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

POLICY LOC

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

X

X

X

GEN'L AGGREGATE LIMIT APPLIES PER:

B

PRO-

JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

SCHEDULED

AUTOS

HIRED AUTOS

ONLY

NON-OWNED

AUTOS ONLY

BODILY INJURY ( Per person)

PROPERTY DAMAGE

(Per accident)

X

BODILY INJURY (Per accident)

B COMBINED SINGLE LIMIT

(Ea accident)

Comp./Coll. Deductible

EXCESS LIAB

X OCCUR

CLAIMS-MADE AGGREGATE

EACH OCCURRENCE

DED

UMBRELLA LIABC

RETENTIONX

X

E.L. DISEASE-EA EMPLOYEE

E.L. DISEASE-POLICY LIMIT

E.L. EACH ACCIDENT

X OTH-

ER

PER STATUTEA

Y / N

(Mandatory in NH)

ANY PROPRIETOR / PARTNER / EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / AN

WORKERS COMPENSATION AND

EMPLOYERS' LIABILITY

If yes, describe under DESCRIPTION OF OPERATIONS below

E

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

CANCELLATIONCERTIFICATE HOLDER

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

©1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

POLICY PROVISIONS.

AGENCY CUSTOMER ID:

ADDITIONAL REMARKS SCHEDULE

LOC #:

ADDITIONAL REMARKS

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

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

EFFECTIVE DATE:

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSUREDAGENCY

ADDITIONAL POLICIES

If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits.

INSURER

INSURER

INSURER

INSURER

INSURER(S) AFFORDING COVERAGE NAIC #

TYPE OF INSURANCE

POLICY NUMBER LIMITSADDL

INSD

INSR

LTR

SUBR

WVD

POLICY

EFFECTIVE

DATE

(MM/DD/YYYY)

POLICY

EXPIRATION

DATE

(MM/DD/YYYY)

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

The ACORD name and logo are registered marks of ACORD