OP ID: DZ
PINEY-1
ACORD"
I
CERTIFICATE OF LIABILITY INSURANCE
~
DATE (MMIDD/YYYY)
12/29/2015
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).
CONTACT
NAME:
PHONE
IA/C No Extl :
E-MAIL
ADDRESS :
PRODUCER
Naught-Naught I Jefferson City
1441 Christy Drive
P 0 Box 1768
Jefferson City, MO 65102
Naught Naught/Jefferson City
I IA/C
FAX
Nol :
INSURER(Sl AFFORDING COVERAGE
NAIC#
INSURER A : Texa s Workers' Comp. #22945
Piney Woods Sanitation Inc
5002 Business 50 West
Jefferson City, MO 65109
INSURED
25224
INSURER B : Great Divide Insurance #25224
INSURER c : Evanston Insurance Company
INSURER D :
INSURER E :
INSURER F :
CERTIFICATE NUMBER:
COVERAGES
REVISION NUMBER:
THIS IS TO CERT IFY THAT THE POLIC IES OF INSURA NCE LISTED BELOW HAVE BEEN ISS U E D TO THE INSURED NAM ED A BOV E F O R THE PO LICY PER IOD
INDICA TED. NOTWITHSTAN DING ANY REQUIREMENT. T ERM OR CON DITION OF A NY C ONTRAC T OR OTH ER D O C UMENT W IT H R ESPECT TO WHICH THI S
CERTIFICATE MAY B E ISSUED OR MAY PER TAIN , TH E INSURAN CE A FFO RDED B Y THE PO LI CI ES D ESCRI B ED H ERE IN IS S UBJECT TO A LL THE T ERMS ,
E XC LUSIONS AND CO NDITI O NS O F SUC H POLIC IES. LIMITS SHOWN MAY HAVE B EE N R E DUC ED BY PAID C LAIMS .
ADDL SUBH
INSR
POLICY EFF (POLICY EXP
unon
TYPE OF INSURANCE
LIMITS
POLICY NUMBER
LTR
IMM/DD/YYYYl MMIDD/YYYYl
-- D
....,,,
GENERAL LIABILITY
B
x
x
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE
GLP0152065615
12/31/2015 12/31/2016
[!] OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
Xl
-
B
c
n
n
~r!?-r
x
x
-
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
-
x
UMBRELLA LIAB
EXCESS LIAB
x
BAP152065515
12/31/2015 12/31/2016
SCHEDULED
AUTOS
NON-OWNED
AUTOS
100,000
MED EXP (Any one person)
$
5,00C
PERSONAL & ADV INJU RY
$
1,000,000
GENERALAGGREGATE
$
2,000,000
PRODUCTS - COMP/OP AGG
$
2,000,000
$
1,000,000
$
1,000,000
SINGLE LI MIT
Ea accident!
BODILY INJURY (Per person}
UM/UIM
~OCCUR
XOMW340015
CLAIMS-MADE
OED
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y/ N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
Y
(Mandatory in NH)
[i]
$
BODI LY INJURY (Per accident} $
rPRE9fI~cifi~~~AGE
12/31/2015 12/31/2016
N/A
TSF0001106943
07/01 /2015 07/01/2016
BAP152065514
Great Divide
$
$
85,000
EAC H OCCURRENCE
$
1,000,000
AGGREGATE
$
1,000,000
$
0
x ITORY
WCSTATU- I x 10 TH1IMITS
ER
g~~~~r~.m~~ ~~~PERATIONS below
B
1,000,000
$
~OM BI N ED
I I
A
$
Emp Ben .
LOC
AUTOMOBILE LIABILITY
x
-
POLICY
EAC H OCCURRENCE
Ul\Ml\U C I u '""" I c u
PREMISES IEa occurrence!
$
1,000,000
E.L. DISEASE - EA EMPLOYEE $
1,000 ,00C
E.L. DISEASE - POLICY LIMIT
1,000,000
E.L. EACH ACCIDENT
12/31/2015 12/31/2016 Pollution
$
1,000,00C
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101 , Additional Remarks Schedule, if more space is required)
CANCELLATION
CERTIFICATE HOLDER
STEPHE5
Stephen F. Austin State Univ.
Procurement & Property Serv.
Jaimie Garrie
P.O. Box 13030, SFA Station
1Nacoadoches TX 75962
SHOU L D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E X PIRATION DATE THEREOF , NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS .
AUTHORIZED REPRESENTATIVE
~
- -p
-~
© 1988-2010 ACORD CORPORATION . All rights reserved.
ACORD 25 (2010/05)
The ACORD name and logo are registered marks of ACORD
NOTEPAD:
HOLDER CODE
INSURED'S NAME
STEPHE5
Piney Woods Sanitation Inc
PINEY-1
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Date
3
12/29/2015
Stephen F . Austin State University, its officials , directors , employees,
representatives and volunteers are named additional insureds as their
interest may appear with respects to the auto and general liability with a
30 day prior notice of cancellation except for cancellation for non
payment of premium.
NOTEPAD
1NsURED's NAME
Piney Woods Sanitation Inc
Owners/Officers are covered under MO WC policy .
PINEY-1
OP ID: DZ
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Date
2
12/29/2015