ACOffD~
DATE (MM/00/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
I
12/8/2015
~
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
NAME :
PRODUCER
Watkins Insurance Group-Austin
fA~gN:o
3834
Spicewood Springs Rd, St
Austin TX 78759
Tiffany Arvie
Eit•·
I ff.~
512-452-8877
>Jn• ·
512-452-0999
JDM0AJ~ss:~ a~i e@watkinsinsurancegrou p . com
INSURERISI AFFORDING COVERAGE
NAIC #
10677
INSURER A : Cinci nnati Insurance Company
INSURED
JELC0-1
INSURER B :
Jelco
..
INSURER C :
Jared Jellison
PO Box
IN SURER 0 :
151085
78715
INSURER E :
Austin TX
INSURER F :
CERTIFICATE NUMBER· 1647805823
COVERAGES
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. NOTVVITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT \l\llTH RESPECT TO VVHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS ,
EXCLUSIONS AND CONDITIO NS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS .
INSR
LTR
A
"UUL
TYPE OF INSU RANCE
x
r--
INSO
"UB"
wvo
D
CLAIMS-MADE
POLICY EFF
POLICY EXP
IMM/00/YYYYI IMM/00/YYYYI
POLICY NUMBER
EPP 0171044
COMMERCIAL GENERAL LIABILITY
w
12/5/2015
12/5/2016
OCCUR
r-r-GEN'L AGGREGATE LIMIT APPLIES PER:
Fl
A
POLICY 0
PROJECT
D
LOC
12/5/2015
EBA0171044
12/5/201 6
x
f--
r--
A
x
·-
ALL OVVN ED
AUTOS
~
t--
HIRED AUTOS
t--
UMBRELLA LIAB
EXCESS LIAB
SCHEDULED
AUTOS
NON-OVVNED
AUTOS
MED EXP (An y one person)
$10,000
PERSONAL & ADV INJURY
$1 ,000,000
GENERAL AGGREGATE
$2 ,000,000
PRODUCTS - COMP/OP AGG
$2,000,000
$
1,,vrvlBINt:U SINGLt: LIM\ 1
BODILY INJURY (Per person)
s1 ,ooo .ooo
$
BODILY INJURY (Per accident)
$
r"vrio':' I Y utvV1A<.;t:
(Per accid ent)
$
I Ea accident!
$
M
12/5/2015
EPP 0171044
OCCUR
12/5/2016
EACH OCCURRENCE
AGGREGATE
CLAIMS-MADE
Ix I
OED
RETENTION $10,000
WORKERS COMPENSATION
ANO EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
YI N
D
N/A
I PER
I I OTH
STATUTE
ER
Se.e ~~
o/~3/t 7
~m::~~~fi~ '01oPERATIONS below
A
A
$1 ,000,000
$300,000
OTHER:
AUTOMOBILE LIABILITY
r-ANY AUTO
,_
LIMITS
EACH OCCURRENCE
0AM1'1.>t: TO Kt:N I t:U
PREMIS ES IEa occurrence\
E.L. EACH ACCIDENT
Property
Equipment Fltr
12/5/2015
12/5/2015
12/5/2016
12/5/2016
$2 ,000,000
s
$
E.L. DISEASE · EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT
EPP 0171044
EPP 0171044
$2 ,000,000
BPP Limit
Limit
Equipment Ded
$
$127 ,000
$31,900
$500
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlonal Remarl<I Schedule, may be attached If more apace la required)
SUBJECT TO POLICY TERMS AND CONDITIONS .
CANCELLATION
CERTIFICATE HOLDER
Stephen
F. Austin
P .O . Box 13030
Nacogdoches TX
I
State University
75962
SHOULD ANY OF THE ABO VE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AU THORIZED REPRESENTATIVE
)ur. :l!rL
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
The ACORD name and logo are registered marks of ACORD
JELLINC-01
MJENKINS
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
2/18/2016
THIS CERTIFICATE IS ISSUED AS A MATIER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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
NAME:
PRODUCER
Cravens Warren Insurance Agency, Inc.
10011 W. Gulf Bank Rd.
Houston, TX 77040
E-MAIL
ADDRESS :
NAIC #
INSURER S AFFORDING COVERAGE
INSURER A : Texas
INSURED
:JeJCO
G&A Outsourcing, Inc. dba G&A Partners
INSURER B :
4801 Woodway Drive, Suite #210
Houston, TX 77056
INSURER D :
22945
Mutual Insurance Com pan
INSURERC :
INSURER E :
INSURER F :
COVERAGES
CERTIFICATE 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. NOTWITH STANDING ANY REQUIREMENT, TERM OR CONDITION OF AN Y CONTRACT OR OTHER DOCUMENT V\/ITH 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.
INSR
LTR
5UDM
INSD WVD
l "UUL
TYPE OF INSURANCE
-D
-
POLICY NUMBER
POLICY EFF
POLICY EXP
IMM/DD/YYYYI IMM/DD/YYYYI
COMMERCIAL GENERAL LIABILITY
I-
CLAIMS-MADE D
OCCUR
I-
Fl
GEN'L AGGREGATE LIMIT APPLIES PER:
POLI CY D
PRO JECT
Loc
O
LIMITS
EACH OCCURRENCE
DAMAGE TO REN 1 t: u
PREMISES !Ea occurrence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJ URY
$
GENERALAGGREGATE
$
PRODUCTS - COMP/O P AGG
$
$
OTHER:
-
YE~~~~~~tlSINGLE
AUTOMOBILE LIABILITY
I-
AN Y AUTO
ALL OWNED
AUTOS
HIRED AUTOS
UMBRELLA LIAB
EXCESS LIAB
LIMIT
BODILY INJURY (Per person)
~
I-
-
SCHEDU LED
AUTO S
NON-OWN ED
AUTOS
PROPERTY DAMAGE
! Per accident!
$
H
$
$
OCCUR
EACH OCCURRENC E
CLAIMS-MADE
AGGREGATE
RETENTION $
OED
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRI ETOR/PARTNER/EXECUTIVE
OFFICER/M EMBER EXCLUDED?
(Mandatory in NH )
$
BODILY INJURY (Per accident) $
I I
A
$
x I ~f~TUTE I I OTHER
Y/N
D
N/A
TSF0001076234
02/23/2016 02/23/2017
g~~~~rtfi8~ O~OPERATIONS below
$
$
$
$
1,000,000
E.L. DISEASE - EA EMPLOYEE $
1,000,000
E.L. DISEASE - POLICY LIMIT
1,000,000
E.L. EACH ACCIDENT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached If more space ls required)
Form WC 42 03 11 , Texas Professional Employer Organization (PEO) Endorsement, extends coverage to the covered employees of Jellison, Inc. dba Jelco,
the client of the Named Insured.
CANCELLATION
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Stephen F. Austin State University , its officials, directors,
employees, representatives and volunte
1936 North Street
1Nacoadoches TX 75962
AUTHORIZED REPRESENTATIVE
~!M~
© 1988-2014 ACORD CORPORATION. All rights reserved .
ACORD 25 (2014/01)
The ACORD name and logo are registered marks of ACORD
1exasMuruaI®
WORKERS COMPENSATION AND EMPLOYERS
LIABILITY INSU RANCE POLICY
Insurance Company
WC 42 03 11
TEXAS PROFESSIONAL EMPLOYER ORGANIZATION (PEO) ENDORSEMENT
This endorsement provides coverage for the covered employees of the client shown in the Schedule below.
This endorsement applies only if attached to a policy issued in your name as the primary insured , and only with respect to
your client's and your covered employees under a professional employer services agreement between you and your client
shown in the Schedule below.
Certain words and phrases in this endorsement are defined as follows :
Client means any person who enters into a professional employer services ag reement with a PEO.
Coemployment relationship means a contractual relationship between a client and a PEO that involves the
sharing of employment responsibilities with, or allocation of employment responsibilities to , covered employees in
accordance with the professional employer services agreement and Texas Labor Code , Chapter 91.
Professional Employer Organization (PEO) means a business entity that offers professional employer services.
Covered employee means an individual having a coemployment relationship with a PEO.
Direct employee means an individual who is employed by a PEO or a cl ient and does not have a coemployment
relationsh ip with a PEO .
Professional Employer Services Agreement means a contract between a PEO and a client that includes details of
the coemployment relationsh ip.
Part One (Workers Compensation Insurance) and Part Two (Employers Liability Insurance) apply to the covered
employees of the client shown in the Schedule below. Under Part One , we wi ll reimburse you for the benefits required by
the workers compensation law if we are not permitted to pay the benefits directly to the persons entitled to them .
Under Part Two , the limits of our liability apply jointly to you and the client. Our duty is to provide a single defense for you
and the client on a claim, proceeding , or suit for damages payable under this insurance .
The coverage afforded by this endorsement is not intended to satisfy the client's duty to secure its obligations under the
workers compensation law fo r its direct employees.
If th is policy is cancelled , we will send notice of such cancellation to you . You must notify each cl ient by certified mail
within three days of rece ipt of such notice .
Premium will be charged for covered employees of the client shown in the Schedule below. To satisfy your obligations
under Part Five (Premium) , C.2, you must maintain and furnish to us a complete payroll record by cl ient for these covered
employees.
Part Fou r (Your Duties If Injury Occurs) applies to you and to the client. The client will recognize our right to defend under
Parts One and Two and our right to inspect under Part Six (Conditions) .
WC420311 (ED . 7-15)
1 of 2
INSURED'S COPY
Schedule
Name of Client:
Address:
See attached Extension of Information Page, Locations - Client, for list of clients.
2 of 2
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below.
(The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement, effective on
at 12:01 A.M. standard time, forms a part of
Policy No. TSF-0001076234 20160223
ofthe Texas Mutual Insurance Company
Issued to G & A OUTSOURCING I NC
OBA: G & A PARTNERS
Endorsement No.
Premium$
NCCI Carrier Code 29939
Authorized Representative
WC420311 (ED. 7-15)
INSURED 'S COPY
BSBUHAY
2-16-2016