DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
2/16/2016
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).
PRODUCER
Tracy Darrin
FAX
Electric Insurance Company
A/C No :
75 Sam Fonzo Drive
Beverly, MA 01915-1000
INSURER S AFFORDING COVERAGE
NAIC#
21261
INSURER A : Electric Insurance Com an •
INSURED
INSURER B : • A.M . Best: "A" FSC X as of 8/1 2/1 4
GE Healthcare Bio-Sciences Corp .
100 Results Way
Marlborough , MA 01752
United States
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES
CERTIFICATE NUMBER: 176838
REVISION NUMBER:
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 REQUIRE MENT, 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 CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDU CED BY PAID CLAIMS.
ADDL SUBR
POLICY EFF
POLICY EXP
INSR
TYPE OF INSURANCE
LIMITS
1 1.,~n wvn
POLICY NUMBER
IMM/DDIYYYYI IMM/DDIYYYYI
LTR
EACH OCCURRENCE
x COMMERCIAL GENERAL LIABILITY
$ $2 500 000
DAMl\l.>t: TO REN I t:U
~ CLAIMS-MADE
OCCUR
$ $50,000
PREMISES IEa occurrence\
MED EXP (Any one person)
$ $10,000
~
Ii]
-
A
x
~
fl
x
GL 16-1
1/1/2016
1/1/2017
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY D
PROJECT
D
LOC
OTHER:
AUTOMOBILE LIABILITY
A
-
A
x
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
UMBRELLA LIAB
EXCESS LIAB
$
$2 500 000
$5,000,000
PRODUCTS - COMP/OP AGG
$
Included in Gen Agg .
COMBINED SINGLE LIMIT
!Ea accidenll
BODILY INJURY (Per person)
-
SCHEDULED
AUTOS
NON-OWNED
AUTOS
F-4
x
x
ML 16-2
1/1/2016
1/1/2017
BODILY INJURY (Per accidenl)
PROPERTY DAMAGE
!Per accident)
$
$2 ,500,000
$
$
$
s
OCCUR
CLAIMS-MADE
x
x
XS 16-1
1/1/2016
1/1/2017
I I
A
$
GENERAL AGGREGATE
$
~
x
-
PERSONAL & ADV INJURY
RETENTION $
OED
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETORIPARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
EACH OCCURRENCE
$
$2,500 ,000
AGGREGATE
$
$5 000 000
x I ~f:TUTE I
YIN
[El NIA x
WC 16-1
1/1/2016
1/1/2017
~~~~~;;;.fr~~ ~nFdOPERATIONS below
I OTHER
E.L. EACH ACCIDENT
$
$
$2 500 000
E.L. DISEASE - EA EMPLOYEE $ $2 500 000
E.L. DISEASE · POLICY LIMIT $ $5 000 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarl<s Schedule, may be attached If more space Is required)
Should any of the above referenced policies be cancelled befo re the expiration date thereof, the issuing insurer will endeavor to mail 30 days prior written
notice to the certificate hold er, however failure to do so shall not impose any obligation or liability of any kind upon the Insurer affording coverage , or its
agents or representatives.
Subject to the insurance policy terms and conditions , the above referenced insurances shall contain a waiver of subrogation , but only to the extent required by
the underlying written contract with the Named Insured that is in place prior to an "occurrence" giving rise to a loss .
CERTIFICATE HOLDER
Stephen F. Austin State University
P.O. Box 13030, SFA Station
Nacogdoches , TX 75962
United States
CANCELLATI ON
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
© 1988-2014 ACORD CORPORATION. All rights reserved .
ACORD 25 (2014/01)
The ACORD name and logo are registe red marks of ACORD
ADDITIONAL REMARKS SCH EDULE
NAMED INSURED
AGENCY
GE Healthcare Bio-Sciences Corp.
100 Results Way
Marlborough , MA 01752
United States
Electric Insurance Company
75 Sam Fonzo Drive
Beverly, MA 01915-1000
EFFECTIVE DATE:
1/1/2016
ADDITIONAL REM ARKS
TH IS ADDITIO NAL REMARKS FORM IS A SCHEDULE TO ACORD FORM ,
FORM NUMBER:
25
FORM TITLE:
Certificate of Liability Insurance
GL Coverages:
a. Premises-Operations
b. Products/Completed Operations
c.
xcu
d. Blanket Contractual Liability
e. Personal and Advertising Injury Limit
f. Independent Contractors
g. Separation of Insureds I Cross Liabi lity
h. Sudden and Accidental Pollution Liab ility
Auto Coverages:
a. Symbol 1 - All Vehicles
Excess Liability:
a. Following Form
WC Coverages:
a. USL&H
b. Jones Act I Maritime Liability
c. Outer Continental Shelf Lands Act
d. The Workers Compensation policy provides coverage in all states where the insured has operations, except for monopolistic states (ND, WY, PR, USVI)
and states where the insured qualifies for self-insured status (OH, WA)
ACORD 101 (2008/01)
© 2008 ACORD CORPORATION. All right s reserved .
The ACORD name and logo are registered marks of ACORD