DATE (MM/DDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE
9/30/2015
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).
PRODUCER
Bosworth
F..e~
& Associates, Inc.
No : (903) 5 8 1 - 5 369
1818 WSW Loop 323
INSURER S AFFORDING COVERAGE
TX
Tyler
INSURED
INSURER B
EAST TEXAS COPY SYSTEMS,
NAIC#
75701
INC .; ETCS LEASING,
I NC .
GREG WALKER ; RICK FEDELL
:Service
INSURER C :
INSURERD :
4545 OLD JACKSONVILLE HWY; SUITE 200
INSURER E :
TYLER
INSURERF :
TX
75703 -0527
CERTIFICATE NUMBER:CL1593004978
REVISION NUMBER:
COVERAGES
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, TE RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFO RDED BY THE POLICIES DESCRI BED HEREIN IS SUBJECT TO ALL TH E TERMS,
EXCLUSIONS AND CONDITION S OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAI MS.
INSR
LTR
ADDL SUBR
TYPE OF INSURANCE
x
f---
A
"'"" "nl"
COMMERCIAL GENERAL LIABILITY
D
Cl.AIMS -MADE
POLICY NUMBER
POLICY EXP
POLICY EFF
IMM/DD/YYYYI fMM/DDIYYYYl
w
OCCUR
ACP72 4578149 8
10/1/2015
10/1/2016
f---
f---
GEN'L AGGREGATE LIMI T APPLIES PER :
~
POLICY D
PROJECT
D
LIMITS
EACH OCCURRENCE
DAMAGE 1u l'<~NTED
PREMISES IEa occurrence\
$
1,000,000
$
300 , 000
MED EXP (Any one person)
s
5 , 000
PERS ONAL & ADV INJURY
$
1,000 , 000
GENERAL AGGREGATE
$
2 , 000,000
$
2,000,000
PRODUCTS - COMP/OP AGG
LOC
Additional Insured
OTHER:
fE~~~~~~t~INGLE
AUTOMOBILE LIABILITY
$
LIMI T
f---
A
x
f--f--f---
x
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
UMBRELLA LIAB
f---
A
B
EXCESS UAB
~
f--f---
SCHEDULED
AUTOS
NON-OWNED
AUTOS
ACP72 45781498
10/1/ 2015
10/1/20 16
H
s
BODILY INJUR Y (Per person)
$
BODILY INJUR Y (Per accident)
$
PROPERTY DAMAGE
I Per accident\
$
Schedule Mod Factor 1
$
1 , 000 , 000
OCCUR
EACH OCCURRENCE
$
5 000 000
CLAIMS-MADE
AGGREGATE
s
5 000 ,000
I I
OED
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTN ER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
tt yes, describe under
DESCRIPTION OF OPERATIONS below
ACP7245781498
10/1/20 15
10/1/20 16
x I ~f~TlJTE I
YIN
D
I OTHER
$
500 000
E.L. DISEASE - EA EMPLOYEE $
500 000
E.L. DISEASE - POLICY LIMIT
500 000
E.L. EACH ACCIDENT
N/A
SRZG23463-16
1 /1/201 6
1/1/2017
s
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached If more s pace Is required)
Certificate Holder is named as Additional Insured as respec ts all lines except Workers' Compensation.
Waiver of Subrogation applies in favor of Certificate Holder as respects to General Liability, Automobile
Liabil i ty , and Workers Compensation as required by written contract .
CANCELLATI ON
CERTIFICATE HOLDER
purchase @sfasu .edu
Stephen F Austin State University, its of
directors, employees, representatives and
volunteers
1936 North St .
75962
Nacogdoches, TX
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 REP RESENTATIVE
M Boswort h/BECKY
~ CJ' ~~
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ACORD 25 (2014/01)
INS025 1?01•011
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