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CERTIFICATE OF LIABILITY INSURANCE (134) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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 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). CONTACT PRODUCER NAME: õÇÎÎïÍÅ×ÊÃððù FAX PHONE (A/C, No): (A/C, No, Ext): ìíúÍÄ E-MAIL ùÛÏÌôÓÐÐìû ADDRESS: PRODUCER CUSTOMER ID #: INSURER(S) AFFORDING COVERAGENAIC # INSURED øÓÉÙÍÆ×ÊìÊÍÌÈùÛÉÇÛÐÈÃ INSURER A : õÛÎÎ×ÈÈöÐ×ÏÓÎÕóÎÙ ÷Æ×Ê×ÉÈîÛÈÓÍÎÛÐóÎÉÇÊÛÎÙ×ùÍ INSURER B : ìíúÍÄ ôÛÊÊÓÉÚÇÊÕìû INSURER C : INSURER D : INSURER E : INSURER F : COVERAGESCERTIFICATE NUMBER: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. ADDLSUBR POLICY EFFPOLICY EXP INSR TYPE OF INSURANCELIMITS POLICY NUMBER (MM/DD/YYYY)(MM/DD/YYYY) LTR INSRWVD ûããø GENERAL LIABILITY EACH OCCURRENCE$ DAMAGE TO RENTED ä COMMERCIAL GENERAL LIABILITY$ PREMISES (Ea occurrence) ä CLAIMS-MADEOCCURMED EXP (Any one person)$ PERSONAL & ADV INJURY$ GENERAL AGGREGATE$ GEN'L AGGREGATE LIMIT APPLIES PER:PRODUCTS - COMP/OP AGG$ PRO- $ ä POLICYLOC JECT COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY ûããø û $ (Ea accident) ä ANY AUTO BODILY INJURY (Per person)$ ä ALL OWNED AUTOS BODILY INJURY (Per accident)$ ä SCHEDULED AUTOS PROPERTY DAMAGE $ ä (Per accident) HIRED AUTOS $ ä NON-OWNED AUTOS $ UMBRELLA LIAB úäããù EACH OCCURRENCE$ OCCUR ä EXCESS LIAB CLAIMS-MADEAGGREGATE$ $ DEDUCTIBLE ä $ RETENTION$ WC STATU-OTH- WORKERS COMPENSATION ã ûø ä TORY LIMITSER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT$ N / A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ If yes, describe under E.L. DISEASE - POLICY LIMIT$ DESCRIPTION OF OPERATIONS below ûÅÔ×ÎÊ×ËÇÓÊ×ØÚÃÉÓÕÎ×Øããø úÐÛÎÑ×ÈûØØÓÈÓÍÎÛÐóÎÉÇÊ×Ø ÙÍÎÈÊÛÙÈåÛÓÆ×ÊÍÖéÇÚÊÍûÌÌÐÓ×É ìÊÓÏÛÙÃûÌÌÐÓ×É DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) öÍÊÏ×ÊæÛÎÇÉÌÊÒ ùÓÈÃÍÖùÐ×ÛÊÅÛÈ×ÊÓÉÎÛÏ×ØÛØØÈÓÍÎÛÐÓÎÉÇÊ×ØÓÎÊ×ÉÌ×ÙÈÉÈÍ õ×Î×ÊÛÐðÓÛÚÓÐÓÈÃÛÎØûÇÈÍÛÉÈÔ×ÓÊÓÎÈ×Ê×ÉÈÉÏÛÃÛÌÌ×ÛÊ CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ùÓÈÃÍÖùÐ×ÛÊÅÛÈ×Ê ìíúÍÄ ùÐ×ÛÊÅÛÈ×Êöð AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09)The ACORD name and logo are registered marks of ACORD