CERTIFICATE OF INSURANCE (138)
THIS CERTIFICATE IS ISSUEi:~~!~~I~~~A~O~ !N~Y~~ ~O~F~~~IGHTS UPON THE CERTIFICATE HOLDER
THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. '
NAME AND ADDRESS OF AGENCY
COMPANIES AFFORDING COVERAGES
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........ . .......
.. .. ... . ...
....,....,:..;... ...
COMPANY A
LETTER " i" "
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COMPANY B
LETTER
COMPAN Y C
LETTER
COMPANY D
LETTER
COMPANY E
LETTER
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NAME AND ADDRESS OF INSURED
COMPANY
LETTER
TYPE OF INSURANCE
POLICY NUMBER
POllCV
EXPIRATION DATE
AGGREGAT
This is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time, Notwithstanding any requirement, term or con-
dition 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,
GENERAL LIABILITY
BODILY INJURY
$'
COMPREHENSIVE FORM
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PREMISES-OPERATIONS
EXPLOSION AND COLLAPSE
HAZARD
UNDERGROUND HAZARD
PRODUCTS/COMPLETED
OPERATIONS HAZARD
CONTRACTUAL INSURANCE
BROAD FORM PROPERTY
, , DAMAGE
;t., INDEPENDENT CONTRACTORS
7" PERSONAL INJURY
PROPERTY DAMAGE
~
BODIL Y INJURY AND
PROPERTY DAMAGE
COMBII;ED
~
~
PERSONAL INJURY
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AUTOMOBILE LIABILITY
COMPREHENSIVE FORM
no
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BODILY INJURY
lEACH PERSONI
BDDIL Y INJURY
lEACH OCCURRENCE)
0'
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" OWNEt'
" HIRED
PROPERTY DAMAGE
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NON.QWNED
BOOI L Y INJURy AND
PROPERTY DAMAGE
COMBINED
UMBRELLA FORM
OTHER THAN UMBRELLA
FORM
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.. _._ . no _. .." _._ ... ..,
BODll Y INJURY AND
PROPERTY DAMAGE
COMBINED
.
EXCESS LIABILITY
'0
WORKER'S COMPENSATION
and
EMPLOYER'S LIABILITY
OTHER
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STATUTORY
(EACH ACCID NT!
UCRIPTION OF OPERATIDNS/LOCATIONSIVEHICLES
Cancellation: Should any of the above descri~d policies be cancelled before the expiration date thereof, the issuing com-
pany will endeavor to mail "J..., days written notice to the below named certificate holder, but failure to
mail such notice shall impose no obligation or liability of any kind upon the company.
NAME AND ADDRESS OF CERTIFICATE HOLDER