ACORD~
DATE (MMIODIYYYY)
I
CERTIFICATE OF LIABILITY INSURANCE
~
01/04/2016
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 BElWEEN 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
MARK CLARK
NAME·
MARK CLARK
P.~~JA
PO BOX 631664
~6"&~ss: mclark@txfb-ins.com
"-"·
NACOGDOCHES, TX 75963
I f~
936-564-7374
936-564-3709
Nol:
INSURER(Sl AFFORDING COVERAGE
INSURED
ADMIRAL INSURANCE COMPANY-AMWINS
INSURER B :
PROGRESSIVE
SHELIA & JEFF CUPIT
INSURER c
OBA FREDONIA CONTRUCTION SERVICES
INSURER D :
5364 W STATE HWY 7
NAJC#
INSURER A :
: TEXAS MUTUAL
INSURER E :
TX 75964
NACOGDOCHES
INSURER F :
CERTIFICATE NUMBER:
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, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
A
j Auu~~uun
TYPE OF INSURANCE
-x
POLICY NUMBER
i 1.i<:n WVO
POLICY EFF
POLICY EXP
LIMITS
(MM/DDJYYYYl IMM/DD/YYYYl
COMMERCIAL GENERAL LlABIUTY
:=J
CLAIMS-MADE
[X] OCCUR
I
-
Y
N
CA000022617-01
10/1 5/2015 10/15/2016
GEN'L AGGREGATE LIMIT APPLIES PER:
~
POLICY
D JECT
PR~
O
I
I
Loc
EACH OCCURRENCE
$ 1,000,000
~~e~:S~J?E~~E~nce\
$
MEO EXP CArlv one person)
s 5,000
PERSONAL & ADV INJURY
$
1,000,000
GENERAL AGGREGATE
$
2,000,000
PRODUCTS· COMP/OP AGG
$
2,000,000
$
OTHER:
AUTOMOBILE LIABILITY
I
-
B
-x
x
ANY AUTO
ALL OWN ED
AUTOS
-
UMBRELLA LIAS
HIRED AUTOS
50,000
-
x
SCHEDULED
AUTOS
NON-OWN ED
AUTOS
y
x
02774858-0
BODILY INJURY (Per person )
11/11/2015 111/ 11/2016
I
H
EXCESS LIAS
I fOMB INED..SINGLE LIMIT
I •Ea accident •
$
BODILY INJURY (Per accident) S
PROPERTY DAMAGE
r(~IP=•r~aco~
·den
~t\_ _ _ _-t-: -1_,0_0_0_,0_0_0_ _--1
1
1
OCCUR
I EACH OCCURRENCE
$
CLAIMS.MADE
\ AGGREGATE
$
I I
OED
RETENTION$
WORKERS COMPENSATION
ANO E"1PLOYERS' LIABILITY
1,000,000
$
~t.K
I I OTHX I• STATUTE
ER
l-'---'-''-'='-"-',.___.._..,.__,,_~-1--------
YIN
C ~~~l~~R~1iW'~J~6~cifECUTIVE ~NIA X
20101202
12/02/2015
(Mandatory in NH)
12/0212016 ._E~.L~.=
EA~C~H_A~
CC~l~
DE~N~T_ _+'-$_5_o_o_
.o_o_o_ _- - t
E.L. DISEASE. EA EMPLOYEE $ 500,000
g~~~~~~~ O~PERATIONS below
E.L. DISEASE . POLICY LIMIT
I$
500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddWonal Remarl<$ Schedule, may be attached if more space Is required)
IT IS AGREED STEPHEN F AUSTIN STATE UNIVERSITY, ITS OFFICIALS , DIRECTORS, EMPLOYEES , REPRESENTATIVES AND VOLUNTEERS ARE
NAMED ADDITIONAL INSUREDS RESPECTS GENERAL LIABILITY WORKERS COMP BUSINESS AUTO.
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,
AUntORIZED REPRESENTATIVE
REPRESENTATIVES AND VOLUNTEERS
1936 NORTH ST, NACOGDOCHES .
TX 75962
I
~~0---1--
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ACORD 25 (2014/01)
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