HomeMy WebLinkAbout47255 TXR000081205 000 02-18-2020 CORR AOO CERTIFICATE OF INSURANCE 1
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ACOR& CERTIFICATE OF LIABILITY INSURANCE �1oi22//20 9n
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 poll y(lea)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 endoreememl. A statement on
this Certificate does not Confer rights to the Carl holder In lieu of such endomemant s).
PRODUCER NAME:
Xi11i0 of Na....h...tt0, Inc. PNONE 1-BT1-9t5-'J3'IB FPY Xo I-888-66y-2378
a/o 26 Oa..ry S1W Ed1pIL
O.O. eo[ 305191 ADDR [e[tifioawaSWillia.eem
Na.hvilla, W 372305191 USA INSURNISRAFFORESSIGMERMHE NAICe
INSURER A: ACE ,aea[Scan Inauranee Cwpany 22.67
INSURED INSURER.: ADS -[ -ty E Ceaeaits Immfanas COMpNy 20690
..Y.W uwn 6yatua xno, xntlwnit IneVcance Campersdf NecN IMwd 63575
ane its aLLillatY IXMIRERC: Y
42 bn tta[ D[LYs INSURERO:
nnll, M 02061 UM HSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:N13135832 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 CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBL ECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
IXSR PWCYEFF PWY EIP Lane OF INSURANCE PoLoymaaFA M MMTC
X WMMERCMLOENEMLMMUW EACHOCCURRENCE f 2,000,000
CUIMSMDE O OCCUR PREMISE enro $ 500100D
A X %ROD, MEDEXP l t S,000
X Cmtcaetual MM71453364 11/01/2019 11/01/2020 PERSONALeAWINJURY f 2,000,000
GEN'LAGGREGATE UMpn.APPLIES PER: GENERALAGGREQATE f 4,000,000
POLOY•O2M LOC PRCDLOTS COMPgPMJG f 4,000,000
t
OTHER: X
AU TOMOlff
BE£MMUw EB ectlbI t S,000,000
X ANYAMG BODILY INJURY(PW mmn) i
A X OWNED SCHEALOCSWLED ISANMIL1TS 11/O1/201911/01/2020 pDILYINJURYIPWBWAM) f
X MINED gYLY % NONiWAJED Per PE..^fl DAMAGE f
X AyT%ORLY vfros CMLY
f
X UMBRELLA Me % OCCUR EACH OCCURRENCE $ 30,000,000
lyCE88 MB cue,,,,,,,a CA602586A 003 11/01/2011 11/OS/2020 AG3REGPTE t 10,000,000
DED I X I RETENTION 0 t
WORKERS COMPENSATION X AT E
ANOEMPLOYERB'MBIIJTY YIN
N ROPRIETORrvARTNERIE%ECUUYE E.L.EACH A DENT f 2,000,000
C A
OFFICERMEMSEREXCLUCED9 a NIA NLRCS5893939 (ADS) ll/O1/2019 11/01/2020
(MmOnaryln Nin E.L.DISEASE-EA EMPLOYEE f 2,000,000
MY 00unCu r i E.L DISEASE-POLICY LIMn $ 2,000,000
DESCRIPTION OF OPERATIONS Ww
A Mertes Cmpnntim TPLR C65893976 1., MI 11/01/201; 21/01/2020 S.L. SAC. Acc... $2,000r000
L Evploye[s Liability a.L. DISG3S - M 82,000,000
Is. Statues E.L. DISEASE-PoL IHT $2,000,000
DESCRIPTONOFOPERATOMILOCAUOXSIVEHMLEB IACOROI(r,A6dMMnaI MrIVM aCM6uN,ImyMMMPRM XmOn aq[B IP rFeulnd)
anvi[o Vast. Oil Recewry LLC is now a y..t Of Safety-.lean 8yetwe, ins.
SEE ATYACRED
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTIO`RMEEEDDRREPRESENTATWE
avidenw of Inau .— r/
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Ia 1.: 18709410 B cR: 1422032
AGENCY CUSTOMER ID:
LOC s:
AGOR® ADDITIONAL REMARKS SCHEDULE Page a Of 2
AGENCY oA—IH SXREO
r.rWillis of Massachusetts. Inc. or. i' Rem ....eu Zna.
ma w affu iao.
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CARRIER XAIC CODE
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ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM 13 A SCHEDULE TO ACORD FORM,
FORM NUMBER: IS FORM TITLE: certificsu of Llab111ty xnsucanw
RE: 219 sputa 6 MahoPao NY 10581
Evidence of insurance only
INSORER AFFORDING COVERAGE: ACE Amaricen Insurances Company NAICS: 22667
POLICY NUMBER: COO G27416603 005 EFF DATE: 11/01/2019 ESP DATE: 11/01/2020
TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:
Professional Liability Each Claim $10,000,000
all Claims $10,000,000
SIR $250,000
INSURER AFFORDING COVERAGE: ACE Saari can Insurance COm,eny NAICS: 22667
POLICY WONDER: COO G27426603 005 a" RATE: 11/01/2019 ESP RATE: 11/01/2020
TYPE OF INSURANCE: LIMIT DESCRIPTION: LI6IIT AMOUNT:
Contractor's Pollution Liability Each Claim $10,000,000
All Claims $10,000,000
SIR $250,000
ACORD 101 (2008101) ®2008 ACORD CORPORATION. All rights reserved.
The ACORD name and Ingo ere registered marks of ACORD
SR SO: 18709410 BATCH: 2422032 CENT: NY 3435832