Ob
ACOR
DA TE (M M/DD/YYYY)
I
CERTIFICATE OF LIABILITY INSURANCE
01 /31 /2016
'-----"
THIS CERTIFICATE IS ISSUED AS A MATIER 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).
2i'~~ACT VICKI CARVER
PRODUCER
r..tJ8N~o Extl 630-833-0480
IFft:J'c Nol 630-833-0876
~-~o~~ss VCARVER@SHRIVERINSURANCE.COM
SHRVER-CAPACITY INSURANCE AGENCY, LLC
ONE OAK BROOK TERRACE SUITE 209
OAK BROOK TERRACE, IL 6018
INSURER(S) AFFORDING COVERAGE
INSURER A :
INSURED
NAIC#
UNITED STATES FIRE INS . CO.
21113
INSURER B:
ROADRUNNER CHARTERS , INC.
8972 TRINITY BLVD.
HARVEST, TX 76053
INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
102320
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 CONDITIONS OF SUCH POLICIES. LIMITS SHOWN SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS .
INSR
LTR
ADDL SUBR
INSR WVD
TYPE OF INSURANCE
POLICY NUMBER
,~shli~, ,~Src\g/M-Y,
GENERAL LIABILITY
A
-x
COMMERCIAL GENERAL LIABILITY
D
CLAIMS-MADE
0
5068839564
OCCUR
02/01/16
02/01 / 17
,____
,____
n
GENERALAGGREGATE
POLICY
n
PROJECT
n
AUTOS
HIRED AUTOS
UMBRELLA LIAB
-
PRODU CTS - COM P/OP AGG
LOC
;-_vM<!INED .:slN<..;LE LIMI I
(Ea accident)
AUTOMOBILE LIABILITY
,____
A ~ ANY AUTO
ALL OWNED
5068839564
SCHEDULED
AUTOS
NON-OWNED
AUTOS
02/01 /16
02/01/17
H
I I
BODILY INJURY (Per person)
CLAIMS-MADE
BODILY INJURY (Per accident)
$
s
s
s
s
s
AGGREGATE
s
D
PHYSICAL DAMAGE COV.
I T'n'R~, T.. ,¥<: 1
N/A
5068839564
02/0 1/16
02/01 /17
s
s
s
s
s
s
s
s
s
PROPERTY DAMAGE
{Per accident)
EACH OCCURRENCE
OCCUR
EXCESS LIAB
RETENTION
OED
WORKERS COMPENSATION
AND EMPLOYER S' LIABILITY
Y/ N
ANY PROPRIETOR/PARTN ER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes , describe under
DESCRIPTI ON OF OPERATIONS below
A
MED EXP (Any one person)
PERSONAL & ADV INJURY
GEN'L AGGREGATE LIMIT APP LI ES PER:
--
LIMITS
EACH OCCURRENCE
DAMAc;E Tu Rt:NTt:u
PREMISES (Ea occurrence)
5,000,000
250,000
5 000
5 000 000
5,000,000
5 000 000
5,000,000
l vdR'"
E.L. EACH ACCIDENT
s
E.L. DISEASE - EA EMPLOYEE
S
E.L. DISEASE - POLICY LIMIT
s
20,000 OED FOR SPECIFIED PERILS
AND COLLISON
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remar1<s Schedule, if more space is required)
STEPHEN F. AUSTIN STATE UNIVERSITY, ITS OFFICIALS , DIRECTORS , EMPLOYEES, REPRESENTATIVES AND VOLUNTEERS ARE
ADDED AS ADDITIONAL INSURED WITH RESPECTS OPERATIONS OF NAMED INSURED, BUT ONLY FOR CLAIMS OR SUITS ARISING
OUT OF THE SOLE NEGLIGENCE OF NAMED INSURED, ITS AGENTS OR EMPLOYEES .
CANCELLATION
CERTIFICATE HOLDER
STEPHEN F. AUSTIN STATE UNIVERSITY
1936 NORTH ST.
NACOGDOCHES, TX 75962
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
I
ACORD 25 (2010/05)
~:f?.'4 ·
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