Ohio_Department_of_Rehabilitation___Correction.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT

NAME:

FAXPHONE

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

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

DAMAGE TO RENTED

CLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-

POLICY LOC PRODUCTS - COMP/OP AGG $JECT

OTHER: $

COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED BODILY INJURY (Per accident) $

AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE $

AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N

N / A (Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE

Lockton Companies 1185 Avenue of the Americas, Suite 2010 New York NY 10036 646-572-7300

Wilsonart LLC 13413 Galleria Circle #200 Austin TX 78738

Liberty Insurance Corporation 42404 Liberty Mutual Fire Insurance Company 23035

LM Insurance Corporation 33600

X X

$1,000,000 $1,000,000 $5,000 $1,000,000 $10,000,000 $2,000,000

X $5,000,000

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

X X $10,000,000 $10,000,000

XXXXXXX

N

X

$1,000,000 $1,000,000 $1,000,000

A AS2-631-510797-013 10/31/2023 10/31/2024

A TB2-631-510797-023 10/31/2023 10/31/2024

B TH7-631-510797-063 10/31/2023 10/31/2024

C WA5-63D-510797-033 (AOS) 10/31/2023 10/31/2024

C WC5-631-510797-053 (WI) 10/31/2023 10/31/2024

10/31/2024

1499686

N N

N N

N N

N

11/16/2023

20069458

20069458 XXXXXXX

Ohio Department of Rehabilitation & Correction 4545 Fisher Road, Columbus, OH 43228

Auto physical damage is self-insured.

X

See Attachment

Lockton Companies Three CityPlace Dr, Suite 900 / St. Louis, MO 63141-7088

314-432-0500 / FAX: 314-812-3299

lockton.com

Ohio Department of Rehabilitation & Correction 4545 Fisher Road, Columbus, OH 43228

Dear Wilsonart LLC certificate holder:

In an effort to meet demand for instant electronic delivery of certificates, Lockton Companies now provides paperless delivery of Certificates of Insurance. Thank you for your patience and willingness to help us lessen our environmental footprint.

To fulfill your certificate delivery, we need your email address. Please contact us via one of the methods below with your Holder ID number, email address, and phone number in the event we have any questions.

Your Holder ID number is 20069458.

Email: Wilsonartcertrequests@lockton.com Toll-free automated phone service: 866-218-4018

If this certificate is no longer needed or valid, please notify us.

Thank you, Lockton Companies

Attachment Code: D600268 Master ID: 1499686, Certificate ID: 20069458 mailto:Northeast-TSA@lockton.com