COMMERCIAL GENERAL LIABILITY
:.... : Capitol Specialty Insurance Corporation
. P.O. Box 5900, Madison, WI 53705
COVERAGE PART DECLARATIONS
TRANSACTION lYPE: New Business
ENDORSEMENT#: 000
POLICY NUMBER
CS02554043-01
POLICY PERIOD
/
07/02/2015 - 07/02/2016 ~
AGENCYJPRODUCERCODE
04745
12:01 A.M. standard T7me at the
address of the Insured stated herein.
AGENCY/PRODUCER
TEXAS ALL RISK GENERAL AGENCY INC I All RISK
GENERALAGENCYINC
9696 Skillman St
Ste 170
Dallas TX 75243-8253
Form of Business: lndlvldual
Business Description: WINDOW CLEANING LESS THAN 3 STORIES
I
..
General Aggregate Limit (Other Than Products-Completed Operations)
$ 2,000,000
Products-Completed Operations Aggregate limit
$ 2,000,000
Personal And Advertising Injury Umlt
$1,000,000
Each Occurrence Limit
$1,000,000
Damag~
$ 100,000 Any One Fire
To Premises Rented To You Limit
$ 5,000 Any One Person
Medical Expense Limit
Location of all Premises You Own, Rent or Occupy: SEE ATTACHED LOCATION FORM SCHEDULE CICG 176
Classification
Code No.
Premium
Rate
Basis
Pr/Co
SEE ATTACHED COMMERCIAL GENERAL LIABILITY SCHEDULE CICL 043
Advance
Premium
PrfCo
Other
Balance To Meet Minimum
$ 92.00
. TOTAL ADVANCE PREMIUM
$ 500.00
THE LIABILITY PREMIUM BASIS OF THIS POLICY IS SUBJECT TO AN AUDIT.
ADDITIONAL PREMIUM MAY BE DUE.
FORMS AND ENDORSEMENTS:
SEE COMMERCIAL GENERAL LIABILITY COVERAGEtJART
FORM SCHEDULE CICL 044
~!}JI\ .. ~
COUNTERSIGNED 07/02/2015 By---~-,.--~l..{--~----­
Authonzed Representative
CICL 042 (05-15)
Page 1of1
Texas Liability Insurance Card
Named lnsured(s):
Shawn Dillon
Alison R Dillon
1525 County Road 833
Nacogdoches, TX 75964-4787
Vehicle:
2002 Chevrolet Truck Slvrdo 1500 Pu Ext Cab 4W
VIN : 2GCEK19T421124721
Registered Owner(s):
Shawn Dillon
*
~FARMERS
INSURANCE
Policy Number:45468698
Effective: 1/25/2016
Expiration : 7 /25/2016
NAIC Number: 24392
Your Agent: Bailey Mclain
406 E Hospital St
Nacogdoches, TX 75961-5210
Agent Phone: (936) 569-6200
Farmers Texas County Mutual Insurance Company (800) 225-0011
This policy provides at least the minimum amounts of liability insurance required by the Texas Motor Vehicle Safety Responsibil ity
Act for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by
the insurance policy.
TEXAS LIABILITY INSURANCE CARD
TARJETA DE SEGURO DE RESPONSABILIDAD DE TEXAS
Keep This Card
Guarde esta tarjeta.
IMPORTANT: This card or a copy of your insurance policy must be shown
when you apply for or renew your:
tMPORTANTE: Esta tarjeta o una copia de su poliza de seguro debe ser
mostrada cuando usted solicite o renueve su :
motor vehicle registration
• d river's license
• motor vehicle safety inspection sticker.
You also may be asked to show this card or your policy if you have an accident
or if a peace officer asks to see it.
NI drivers in Texas must carry liability insurance on their vehicles or otherwise
meet legal requirements for financial responsibility. Failure to do so cou ld
result in fines up to $1,000, suspension of your driver's license and motor
vehicle registration, and impoondment of your vehicle for up to 180 days (at a
costof$15 per day).
To report a daim (Including roadside assistance), please contact Farmers
Claim Department {day or night) at 1-800-435-7764.
registro de vehiculo de motor
licencia para conducir
etiqueta de inspeccion de seguridad para su vehiculo.
Puede que usted tenga tambien que mostrar esta tarjeta o su poliza de seguro
si tiene un accidente o si un oficial de la paz se la p ide.
Todos los conductores en Texas deben de tener seguro de responsabilidad
para sus vehiculos, ode otra manera llenar los requ isites legales de
responsabilidad civil. Fallo en llenar este requis ite pudiera resuttar en muttas
de hasta $1 ,000, suspension de su licencia para conducir y su registro de
vehiculo de motor, y ta retencion de su vehiculo par un periodo de hasta 180
dias (a un costo de $15 por d ia).
Visit www .farmers.com to learn more about claim self-service options. It's
quick, convenient and always open!
See policy for actual coverage language.
Para espa~olt la me at Hl77-732-5266.
25-9008
2-14
~
Evidence of lnsurance/Lienholder Interest
Policy Number:
Policy Edition:
Effective:
Expiration:
Expiro tion Time:
Insured:
4546-86-98
Underwritten By:
14th
1/25/2014 12:0 1 AM
Continuous until cancelled
12:01 AM
Shawn Dillon
1525 County Road 833
Nacogdoches, TX 75964-4787
Your Agent:
-
FARMERS
INSURANCE
Farmers Texas County Mutual Insurance
Company
15700 Long Vista Dr
Austin , TX 78728
Bailey Mclain
406 E Hospital St
Nacogdoches, TX 75961-5210
(936) 569 -6200
FAX: (936) 569-2762
bmclain@farmersagent.com
Vehicle Information
Year
Make
Model
VIN
2002
Chevrolet Truck
Slvrdo 1500 Pu Ext Cab 4W
2GCEK19T421124721
Coverages
Coverage Type
Bodily Injury Liability
Property Damage Liability
Medical Coverage
Uninsured/ Underinsured
Motorist Bodily Inj ury
Other Than Collision
Limit/Deductible
$500,000 each person
$500,000 each accident
$100,000 each accident
$2,500 each person
$500,000 each person
$500,000 each accident
Coverage Type
Collision
Uninsured/ Underinsured
Motorist Property Damage
Towing and Labor Cost
Other
Limit/Deductible
$500 Deductible
$100,000 each accident
$250 each deductible
$120 each accident
Covered
$100 Deductible
Lien holders and Additional Interests
Additional Interest
Stephen F Austin State University
1936 North St
Ncgdchs, TX 75965-3940
Loan Number
Not Applicable
This evidence is subject to all of the terms, conditions and limitations set forth in the policy and endorsements attached to it. It is
furn ished as a matter of information only and does not change, modify or extend the policy in any way. It supersedes all previously issued
certificates.
farmers.com
25·8976 9-13
Page 1of2
Evidence of lnsurance/Lienholder Interest (continued)
Loss payable provisions
(Applicable only if lien holder is named, and no other Automobile loss payable endorsement is attached to the policy)
It is agreed that any payment for loss or damage to the vehicle
described in this policy shall be made on the following basis:
1. At our option, loss or damage shall be paid as interest may
appear to the policyholder and the lien holder shown in the
Declarations. or by repair of the damaged vehicle.
2. Any act or neglect of the policyholder or a person acting on
his behalf shall not void the coverage afforded to the
lien holder.
3. Change in title or ownership of the vehicle, or error in its
description shall not void coverage afforded to the
lien holder.
The policy does not cover conversion , embezzlement or
secretion of the vehicle by the policyholder or anyone acting in
his behalf while in possession under a contract with the
lien holder.
A payment may be made to the lien holder which we would not
have been obligated to make except for these terms . In such
event. we are entitled to all the rights of the lien holder to the
extent of such payment.
The lien holder shall do whatever is necessary to secure such
rights. No su brogation shall impa ir the right of the lien holder to
recover the full amount of its claim .
We reserve the right to cancel this policy at any t ime as provided
by its terms. In case of cancellation or lapse we will notify the
lien holder at the address shown in the Declarations. We will give
the lien holder advance notice of not less than 10 days from the
effective date of such cancellation or lapse as respects his
interest. Mailing notice to the loss payee is sufficient to effect
cancellation .
The following applies as respects any loss adjusted with the
mortgagee interest only:
1. Any deductible applicable to Comprehensive Coverage shall
not exceed $250.
2.
Any deductible applicable to Collision Coverage shall not
exceed $250.
1/12/2016
Authorized Representative
Date
farmers.com
25-8976 9-13
Page 2 of 2