BAILBAR-01
ACORD
CERTIFICATE OF LIABILITY INSURANCE
~
AMA
DATE (MMIDDIYYYY)
I
3/1/2016
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:
Dwight W. Andrus Insurance, Inc.
rlJgN~o Extl: (337) 981-7300
r~ Nol: (337) 984-2166
P.O . Box 60970
E-MAIL
· ~@;an d rus .com
Lafayette, LA 70596-0970
ADDREss:
c us t omerserv1ce
I
INSURER(S) AFFORDING COVERAGE
INSURED
Bailey Bark Materials Inc
3366 FM 2259
Nacogdoches, TX 75961
NAIC #
INSURER A : State National Ins. Co.
12831
INSURER B : Travelers Property Casualty Co of America
25674
INSURER c : LUBA Casualty Insurance Co.
12472
INSURER D :
INSURER E :
INSURER F :
REVISION NUMBER·
CERTIFICATE NUMBER·
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURAN CE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOT\tVITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH 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 CON DITIONS OF SUCH POLICI ES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LIMITS
TYPE OF INSURANCE
:~us"~ ~;
POLICY NUMBER
(~2~J%Yv~Vv, (~2}-~%~Vv,
LTR
A
X COMMERCIAL GENERAL LIABILITY
1 ,000,000
EACH OCCURRENCE
$
I CLAIMS-MADE
0
XNDP-01338-01
OCCUR
01/21/2016 01/21/2017
c--
~=rPOLICY
AGGREa
~~~~
E
APEr PER
JECT
LOG
I--
ANY AUTO
I-- ALL OWNED
AUTOS
7
I--
HIRED AUTOS
UMBRELLA LIAB
8
')(
EXCESS LIAB
XNDA-01338-01
01/21/2016 01/21/2017
' ) ( SCHEDULED
AUTOS
NON-OWNED
I-- AUTOS
$
PERSONAL & ADV IN JURY
$
1,000,000
GENERAL AGGREGATE
$
2 ,000,000
PRODUCTS • COMP/OP AGG
$
2,000,000
100,000
fE~~:~~~I)SINGLE LIMIT
$
BODILY INJURY (Per person)
$
1 ,000,000
BODILY INJURY (Per accident) $
7
rp~~~.i~d~t~AMAGE
M
$
$
OCCUR
CLAIMS-MADE
ZUP-31 M49875-16-NF
01/21/2016 01/21/2017
I l
c
$
$
OTHER:
AUTOMOBILE LIABILITY
A
~~~:S~~ YE~~~ence)
MED EXP (Any one person)
10,000
OED X RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
N/A
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
0
EACH OCCURRENCE
$
2 ,000,000
AGGREGATE
$
2 ,000,000
X I ~i~uTE
028000020000115
10/21/2015 10/21/2016
g~St~~tir~ o~'6PERATIONS below
I I OTH·
ER
$
$
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 is required)
ADDENDUM TO CERTIFICATE:
NOTE: Any information contained in the Certificate of Insurance or this
Addendum is general and descriptive only. The Certificate of Insurance
and this Addendum may not contain descriptions of any or all operations,
locations, vehicles or exclusions. Please see policy forms and
endorsements for specific coverages and exclusions.
SEE ATTACHED ACORD 101
CANCELLATION
CERTIFICATE HOLDER
Stephen F. Austin State University , its officials,
directors, employees, representatives and volunteers
1936 North St.
Nacogdoches, TX 75962
I
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
_(Z__~~
© 1988-2014 ACORD
ACORD 25 (2014/01)
The ACORD name and logo are registered marks of ACORD
CORPORATION. All nghts reserved.
AMA
AGENCY CUSTOMER ID: BAILBAR-01
--------------------------------------LOC # : 1
----------------
-~
ACORD"
ADDITIONAL REMARKS SCHEDULE
~
AGENCY
1
of
1
NAMED INSURED
Bailey Bark Materials Inc
3366 FM 2259
Nacogdoches, TX 75961
Dwight W. Andrus Insurance, Inc.
POLICY NUMBER
~EE
Page
PAGE 1
I~ NAIC CODE
CARRIER
SEE PAGE 1
SEEP 1
EFFECTIVE DATE:
SEE PAGE 1
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER:
ACORD 25
FORM TITLE:
Certificate of Liability Insurance
Description of Operations/LocationsNehicles:
General Liability: includes a blanket automatic additional insured endorsement that provides additional insured status to the
certificate holder only when there is a written contract between the named insured and the certificate holder that requires such
status ; includes a blanket automatic wavier of subrogation endorsement that provides this feature only when there is a written
contract between the named insured and the certificate holder; contains a s pecial endorsement with "Primary and Noncontributory"
wording; includes contractual liability; includes cross-liability
Commercial Auto : includes a blanket automatic additional insured endorsement that provides additional insured status to the
certificate holder only when there is a written contract between the named insured and the certificate holder that requires such
status ; includes a blanket automatic wavier of subrogation endorsement that provides this feature only when there is a written
contract between the named insured and the certificate holder.
Worker's Compensation: includes a blanket automatic wavier of subrogation endorsement that provides this feature only when there
is a written contract between the named insured and the certificate holder; includes an alternate employer endorsement that
provides alternate employer status to the certificate holder only when there is a written contract between the named insured and the
certificate holder that requires such status.
ACORD 101 (2008/01)
© 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD