ACORD®
DATE (MM/DD/YYYY)
12/23/2015
I
CERTIFICATE OF LIABILITY INSURANCE
~
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
Sam J. Lamoreaux
WAUC •
Bent Tree Ins Agency, Inc
PHONE
(972)
466-0084
ff;~ Nft\•(000) 000-0000
t.a- "'" ·- • •,
PO Box 118394
E-MAIL
btiasam@verizon.net
TX 75011
Carrollton
INSURERIS\ AFFORDING COVERAGE
NAIC#
10328
1w~"RER A .Capitol Specialty Ins. Corp.
I
tA/f"
Ann.,~•• ·
INSURED
Arrow Services , Inc.
10202 Airline Dr. Ste. A
Houston
owc""ER e .Hallmark County Mutual
29408
1wc11"c" c .Texas Mutual Ins. Co.
22945
llJ~llDCD
TX
77037-0000
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INCll"C"
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IN~lll>CI>
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CERTIFICATE NUMBER:
COVERAGES
REVISION NUMBER·
THI S IS TO CERTIF Y 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 DOCUMEN T WITH RESPECT TO WHICH THIS
CERTIFI CATE MAY BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLIC IES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS ,
EXCLUSIONS AND CO NDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM S.
INSR
TYPE OF INSURANCE
I Tl>
GENERAL LIABILITY
A
-x
--x D
-
ADDL SUBR
"'"ft
. . . . . ft
COMMERCIAL GENERAL LIABILITY
"'" ICY NllUOC"
EV20150742-01
POLICYEFF
POLICY EXP
12/31/2 015 12/31 /2 016
$5000 deductible
0
OOC:Ul~J= _C::::.
CLAIMS-MADE
OCCUR
Asbestos/Lead/Pollut
GEN'L AGGREn
:xi POLICY
B
-
--x
c
~f,Q.;
-
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
x
UMBRELLA LIAB
EXCESS LIAB
1,000 ,000
50,000
5.000
PERSONAL & ADV INJURY
$
1,000 ,000
GENERAL AGGREGATE
s
2,000,000
$
2,000 ,000
$
12/31/2015 12/31 /2016
SCHEDULED
AUTOS
NON-OWNED
AUTOS
M
COMBINED
SINGLE LIMIT
I C.-. ,....,,..;,.,,.._.\
<
BODILYINJURY (Per person)
s
BODILY INJURY (Per accident)
PROPERTY DAMAGE
'°·- · ··'"··"
$
1,000,000
$
$
OCCUR
CLAIMS-MADE
10,000
mon X K" "N "•N <
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y/ N
ANYPROPRIETOR/PARTNER/EXECUTIVE ~ N/A
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe ~~er
holft..,
x
s
s
$
PRODUCTS - COMP/OPAGG
S PER:
LOC
A42507570-13
X
-
I C ...
MED EXP IAnv one oersonl
AUTOMOBILE LIABILITY
-
A
ELIMIT APn
LIMITS
EACH OCCURRENCE
DAMAGE TO RENTED
EVOOO 15154-01
12/31 /2015 12/31 /2016
Follow Form
I I
EACH OCCURRENCE
$
5,000 ,000
AGGREGATE
$
5,000 ,000
$
TSF0012881200-2015
12/31/2015 12/3 112016
x IT~-~T~Y.~~ I 1°JblE.L. EACH ACCIDENT
s
1,000,000
E.L. DISEASE - EA EMPLOYEE
$
1,000,000
E.L. DISEASE - POLICY LIMIT
$
1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLESJAttach ACORD 101 , Additional Remarks Schedule, If more si;ace ls required)
Policy form #CG 20100413 , CG20370413, EN 010361013 , CA9901T & WC420304B are attac ed . Please read carefully. A 30 day notice of cancellation
endorsement is added .
CANCELLATION
CERTIFICATE HOLDER
Stephen F. Austin State University,
its officials, directors , employees,
representatives & volunteers
purchase@sfasu.edu
1936 North Street
Nacogdoches
Al 001457
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF , NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
TX
75962-
© 1988-2010 ACORD CORPORATION . All rights reserved.
ACORD 25 (2010/05)
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER:
EV20150742-01
COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following :
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)
Any person or organization when you have agreed in
writing in a contract or agreement that such person or
organization be added as an Additional Insured .
Location(s) Of Covered Operations
As required by written contract that is executed on or
after the policy inception.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations .
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury"
caused , in whole or in part, by:
1. Your acts or omissions ; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above .
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured .
CG 20 10 04 13
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
Th is insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed ; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
© Insurance Services Office, Inc., 2012
Page 1 of 2
C. With respect to the insurance afforded to these
additional insureds , the following is added to
Section Ill - Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations .
1. Required by the contract or agreement; or
Page 2 of 2
© Insurance Services Office, Inc., 2012
CG 20 10 04 13
POLICYNUMBER:
EV20150742-01
COMMERCIAL GENERAL LIABILITY
CG 20 37 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)
Location And Description Of Completed Operations
Any person or organization when you have agreed in As required by written contract that is executed on or
writing in a contract or agreement that such person or after the policy inception.
organization be added as an Additional Insured for
Completed Operations Coverage .
Information required to complete this Schedule, if not shown above, will be shown in the Declarations .
A. Section II - Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury" or
"property damage" caused, in whole or in part, by
"your work" at the location designated and
described in the Schedule of this endorsement
performed for that additional insured and
included in the "products-completed operations
hazard".
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
B. With respect to the insurance afforded to these
additional insureds, the following is added to
Section Ill - Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits
Insurance shown in the Declarations;
of
whichever is less.
This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations .
2. If coverage provided to the additional insured
is required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured .
CG20370413
© Insurance Services Office , Inc., 2012
Page 1 of 1
Policy Number: EV20150742-01
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ENV 010361113
PRIMARY NON-CONTRIBUTORY INSURANCE ENDORSEMENT FOR SPECIFIED PROJECT
This Endorsement shall not serve to increase our limits of insurance, as described in the LIMITS OF
INSURANCE Section of the policy.
In consideration of the payment of premiums , it is hereby agreed as follows:
Solely with respect to the specified project listed below and subject to all terms, conditions and exclusions of the policy,
this insurance shall be considered primary to the Additional Insured listed below if other valid and collectible insurance is
available to the Additional Insured for a loss we cover for the Additiona l Insured . It is also agreed that any other insurance
maintained by the Additional Insured shall be non-contributory.
Additional lnsured(s)
Any person or organization with whom the Named
Insured enters into a written contract that requires them
to be named as an Additional Insured on a primary and
non contributory basis and the contract is executed prior
to the start of the project.
Specified Project
Where specified by written contra ct.
All other terms , conditions and exclusions under the policy are applicable to this Endorsement and remain unchanged.
ENV 01 036 11 13
Page 1 of 1
CA 99 on
(Ed. Effective 08/09)
ADDITIONAL INSURED
This endorsement modifies insurance provided unde·r the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
TRUCKERS COVERAGE FORM
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below:
Endorsement Effective
12-31-2015
Named Insured
Policy Number A42507570-13
Countersigned by
ARROW SERVICES, INC.
(Authorized Representative)
The provisions and exclusions that apply to LIABILITY COVERAGE also apply to this endorsement
Stephen F. Austin State University (Owner)
PO Box 13030; Nacogdoches, TX 75962
(Enter Name and Address of Additional Insured)
is an insured, but only with respect to legal responsibility for acts or omissions of a person for whom Liability
Coverage is afforded under this policy. The additional insured is not required to pay for any premiums stated in the
policy or earned from the policy. Any return premium and any dividend, if applicable, declared by us shall be paid to
you. You are authorized to act for the additional insured in all matters pertaining to this insurance. We will mail the
additional insured notice of any cancellation of this policy. If the cancellation is by us, we will give ten days notice to
the additional insured. The additional insured will retain any right of recovery as a claimant under this policy.
Additional Premium $ INCLUDED
this endorsement.
Endorsement:
will be reta ined by us regardless of any early termination of
1exasMuruaI®
WORKERS' COMPENSATION AND EMPLOYERS
LIABILITY INSURANCE POLICY
WC 42 03 04 B
Insurance Company
TEXAS WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement applies only to the insurance provided by the policy because Texas is shown in Item 3.A. of the
Information Page .
We have the right to recover our payments from anyone liable for an inju ry covered by this policy. We will not enforce our
right against the person or organization named in the Schedule , but this waiver applies only with respect to bodily injury
arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver
from us.
This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule .
The premium for this endorsement is shown in the Schedule .
Schedule
1. (
Specific Waiver
Name of person or organization
( X )
Blanket Waiver
Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver.
2. Operations:
ALL TEXAS OPERATIONS
3. Premium
2 , OO percent of the premium developed on payroll
The premium charge for this endorsement shall be
connection with work performed for the above person(s) or organization(s) arising out of the operations described .
4. Advance Premium
INCLUDED , SEE INFORMATION PAGE .
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
Pol icyN o. TSF-0012881200 20151231
Issued to
ARROW SERVICES
oftheTexasMutuallnsurance Company
I NC
Endorsement No.
Premium$
NCCI Carrier Code 29939
Authorized Representative
WC420304B (ED. 6--01-2014)
AGENT'S COPY
GUS ER
12-16-2015
in