ACORD®
I
CERTIFICATE OF LIABILITY INSURANCE
~
DATE (MM/DD/YYYY)
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).
PRODUCER
~~~~~CT Dee Bartlett
Sanford & TatW!l Insurance Agency
;A~~>Nl_t
6303
Indiana Ave.
~~n~~cc . bartlettd@sanfordtatum . com
P.O.
Box
!=vt\·
64790
79464
TX
INSURERA :National
INSURED
INSURER B :FCCI
TYLER GLASS
PO BOX
Nol: (8 0 6) 792-9344
INSURERCSl AFFORDING COVERAGE
Lubbock
EASTEX GLASS
I /A/C
FAX
(806) 792-5564
& MIRROR
co . ,
INC.
NAIC#
120141
10178
Trust Insurance Co.
Insurance Co.
INSURER C :
& MIRROR
INSURER D :
631883
INSURER E :
NACOGDOCHES
75963
TX
COVERAGES
INSURER F :
CERTIFICATE NUMBER:l6/l 7
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM ED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF AN Y CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TH E POLICIES DESCRIBED HEREIN JS SUBJECT TO ALL THE TERMS ,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADDL SUBR
INSR
POLICY EFF
POLICY EXP
TYPE OF INSURANCE
O•OCD ~"'n
LIMITS
LTR
POLICY NUMBER
IMM/DD/YYYYl IMM/DD/YYYYI
GENERAL LIABILITY
1,000,000
$
EACH OCCURRENCE
DAMAGE TU RENTED
100,000
x COMMERCIAL GENERAL LIABILITY
$
PREMISES fEa occurrence\
I CLAIMS-MADE [i] OCCUR
A
1/1 / 2016
CPP0019696
1/1/2017
>---
GEN'L AGGREGATE LIMIT APPLIES PER:
n
lxl ~~?.,:
POLICY
AUTOMOBILE LIABILITY
A
--x
-x
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
>---
x
A
B
-
EXCESS LIAB
5 , 000
$
1,000,000
GENERAL AGGREGATE
$
2,000,000
PRODUCTS - COMP/OP AGG
$
2,000,000
$
COMBINED SINGLE LIMIT
IEa accidentl
BODILY INJURY (Per person)
f--
UMBRELLA LIAB
$
n LOC
~
x
MED EXP (Any one person)
PERSONAL & ADV INJURY
SCHEDULED
AUTOS
NON-OWNED
AUTOS
CA0028720
11/1/2016
11/1/2017
M
BODILY INJURY (Per accident)
PROPERTY DAMAGE
IPer accident\
$
1 000 000
$
$
$
$
OCCUR
CLAIMS-MADE
I I
10, 00 C
DED x RETENTION $
WORKERS COMPENSATION
AN D EM PLOYERS' LIABILITY
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
N/A
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
1/1/2016
UMB0020508
EACH OCCURRENCE
$
5,000,000
AGGREGATE
$
5,000,000
1/1/2017
x
[:!]
11/1/2016
WC00003002
1/1/2017
6~~~~f~irg~ ~~OPERATIONS below
ITORY
WC STATU- I
I IMITS
$
1 °l~-
E.L. EACH ACCIDENT
$
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 VEH ICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
THE GENERAL LIABILITY & AUTO POLICIES INCLUDE 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 . THE GENERAL LIABILITY,
AUTO & WORKERS COMP POLICIES INCLUDE A BLANKET AUTOMATIC WAIVER OF SUBROGATION ENDORSEMENT THAT PROVIDES
THIS FEATURE ONLY WHEN THERE IS A WRITTEN CONTRACT BETWEEN THE NAMED INSURED AND THE CERTIFICATE HOLDER
THAT REQUIRES IT .
THE GENERAL LIABILITY,
AUTO
& WORKERS
CANCELLATION TO CERTIFICATE HOLDERS ENDORSEMENT,
CERTIFICATE HOLDER
'
COMP POLICIES INCLUDE A BLANKET NOTICE OF
PROVIDING FOR 30 DAYS ADVANCE NOTICE IF THE POLICY IS
CANCELLATIO N
STEPHEN F AUSTIN STATE UNIVERSITY
ATTN:
PURCHASING DEPARTMENT
PO BOX 13030
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 REPRESENTATIVE
Douglas Sanford/DAB
A C O R D 25 (2010/05)
INS025 (201oos).01
~~~~~+:?
© 1988-2010 A CORD CORPORATION. A ll rights reserved.
The ACORD name and logo are registered marks of A C ORD
COMMENT~REMARKS
CANCELED BY THE COMPANY OTHER THAN FOR NONPAYMENT OF PREMIUM , 10 DAY ' S NOTICE AFTER THE
POLICY IS CANCELED FOR NONPAYMENT OF PREMIUM . NOTICE IS SENT TO CERTIFICATE HOLDERS WITH
MAILING ADDRESSES ON FILE WITH THE AGENT OR THE COMPANY . THE ENDORSEMENT DOES NOT PROVIDE
FOR NOTICE OF CANCELLATION IF THE NAMED INSURED REQUESTS CANCELLATION .
OFREMARK
COPYRIGHT 2000 , AMS SERVICES INC .