CERTIFICATE OF LIABILITY INSURANCE (14) DATE(MMIDDrt-M)
� � CERTIFICATE OF LIABILITY INSURANCE 10/03/2017
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(les)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).
CONPRODUCER "It
PIAT LLC
PHONE (708)679 3128X,Na:FAX (888)333-1234
Paczolt Insurance Alliance WC No Ext
E-MAIL certfcates@paczolt,com
2215 Enterprise Drive ADDRESS
Suite 1510 INSURERISI AFFORDING COVERAGE NAIL#
Westchester IL 60154 INSURERA: Mesa Underwriters Specialty ins Co 36838
INSURED Jerry Bic el INSURER 8:
Bits N Pieces Puppet Theatre INSURER C:
12904 Tom Gallagher Rd INSURER D:
Dover,FL 33527 INSURERE:
INSURER F
COVERAGES CERTIFICATE NUMBER: MASTER CERTIFICATE 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 CONTRACTOR 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
ILTR P LI Y EFF POLICY EXP LIMITS
TYPE OF ADDLSUBR INSURANCE _9NS0 WVD POLICY NUMBER MMIDDNYYY MMIDDIYYYY
1
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S ,000,000
DAMAGE I ETA 100.000
CLAIMS-MADE FX OCCUR PREMISES Eaoccurrenee
MED EXP(Any one person) 5 6'000
A MPOO12009000580 10/06/2017 10/06/2018 PERSONAL 8 ADV INJURY s 1 000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER.
PRODUCTS-COMPIOP AGG $
1,000,0
00
X POLICY ❑JECOT- El LOC 5
OTHER
COMBINED
SINGLE LIMIT 5
AUTOMOBILE LIABILITY (Ea awdent
BODILY INJURY(Perperson) S
ANY AUTO
OWNED SCHEDULED BODILY INJURY(Peraccadent) S
AUTOS ONLY AUTOS PROPERTY DAMAGE
HIRED NON-OWNED Per accident 9
AUTOS ONLY AUTOS ONLY
$_
__
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $,
5
PED I I RETENTION 5 PER OTH-
WORKERS COMPENSATION STATUTE ER
AND EMPLOYERS'LIABILITY Y i N
ANY PROPRIETORIPARTNERIEXECUTIVE E L EACH ACCIDENT S
OFPICERIMEMBER EXCLUDED? N I A
(Mandatory in NH) E L DISEASE-EA EMPLOYEE 5
if yes describe under E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certificate shows Evidence of Coverage
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Certificate Shaws Evidence of Coverage ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988-2015 ACORD CORPORATION. All rights reserved.
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