DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
9/22/2015
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).
Cindy St a tho s,
PRODUCER
Marsh USA inc.
1166 Avenue of the Americas
New York, NY 10036
· ( 8 44)
Mi cha el Stastny
892- 00 92
or Terryn Castanon
Fffc No :
Pl e ase see b ott om o f
2 nd page
INSURER S AFFORDING COVERAGE
1----------------''----'"-'="""'~'"'--'-"''-"'-=-----IINSURED
SimplexGrinnell LP
1125 East Collins Blvd .
Richardson , TX 75081
United States
NAIC #
INSURER A: ACE American Insurance Company
INSURER B: ACE Fire Underwriters Insurance Company
INSURER C: indemnity Insurance Company of North America
22667
20702
43575
tyco.certs@marsh.com
CERTIFICATE NUMBER:
COVERAGES
1466965 -A
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. NOTWITHSTAN DING ANY REQUIREMENT, TERM OR CONDITION OF AN Y CONTRACT OR OTHER DOCUMENT W ITH 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 REDUC ED BY PAID CLAIMS .
ADDL SUBR
POLICY EFF
INSR
,.,.,n wvn
TYPE OF INSURANCE
LIMITS
POLICY NUMBER
LTR
CMM/DD/YYYYl ,~g~%Yv%i
COMMERCIAL
GENERAL
LIABILITY
$1 .000,000 .00
10/ 1/2016
EACH OCCURRENCE
$
10/ 1/20 15
HDO G27400358
A
L
D
>----
CLAIMS-MADE
x x
~ OCCUR
UAMA!3t: I U
OWNER'S & CONTRACTOR'S PROT
-
p=i
GEN'L AGGREGATE LIMIT APPLIES PER:
A
A
POLICY D
PROJECT
LOC
D
x x
>----
-x
AN Y AUTO
ALL OWNED
AUTOS
>---HIRED AUTOS
UMBRELLA LIAB
>----
EXCESS LtAB
-
10/1/201 5
10/ 1/20 15
ISA H08859905 (Excl ud es NH)
ISA H08859917 (NH)
10/ 1/2016
10/ 1/2016
SCHEDULED
AUTOS
NON-OWNED
AUTOS
-
x
-
c
H
OCCUR
CLAIMS-MADE
OED
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED?
(Mandatory In NH)
x
Y/N
EJ
N/A
WLR C48592284 (AZ, CA, MA)
SCF C48592296 {WI)
WLR C48592272 {All Other States )
10/ 1/2015
10/1/2015
10/1/20 15
10/ 1/2016
10/ 1/2016
10/ 1/2016
g~~~~~ir8~ OnFdgPERATIONS below
c
c
c
MED EXP (An y one person)
$
$10,000 .00
PERSONAL & ADV INJURY
$
$1 ,000 ,000 .00
GENERAL AGGREGATE
$
$2 ,000,000 .00
PRODUCTS - COMP/OP AGG
$
$2 ,000,000.00
COMBINED SINGLE LIMIT
IEa accident\
BODILY INJURY (Per person )
$
N10724429 001
N10724429 001
N10724429 001
Builder's Risk/insta llation/Contract Works
Rental EquipmenUContractor's Equipment
Blanket Transit
10/ 1/20 15
10/1/20 15
10/ 1/20 15
10/ 1/2016
10/ 1/2016
10/ 1/2016
EACH OCCURRENCE
$
AGGREGATE PRODUCTS -
$
NEW HAMPSHIRE (CSL)
$
X
I OTHI PER
STATUTE I
ER
$1 ,000,000 .00
$
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
$
CPer accident)
$
NEW HAMPSHIRE (CSU
I I
A
B
$1 ,000,000 .00
$
$
OTHER:
AUTOMOBILE LIABILITY
x
"c" 1 cu
PREMISES I Ea occurrence)
$250 ,000 .00
$
$2 ,000 ,000.00
E.L. DISEASE - EA EMPLOYEE $
$2,000 ,000 .00
E. L. DISEASE - POLICY LIMIT
$2,000 ,000.00
E.L. EACH ACCIDENT
$
USD $1 ,000 ,000.00 per jobsite
USD $1 ,000 ,000.00 per jobsite
USD $1 ,000 ,000.00 per conveyance
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached if more space Is required)
Pr oject :
S FA Backf l ow ,
Pl ease ref e r
Au s tin,
Rus k ,
FA Bl dg
t o attach ed ACORD 101 fo r
CERTIFICATE HOLDER
Stephen F Austin University
P 0 Box 6085
Nacogdoches, TX 75962
United States
fu r the r
r emar ks .
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED JN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZE D REPRESENTATIVE
,c¢-
I
MARSH USA INC, BY:
Matthew Ferrv. Casua1tv Proaram
1~r;v.~
Frankl in Hallock , Global Marine
Tran sit Pmnram
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
The ACORD name and logo are registe red marks of ACORD
AGENCY CUSTOMER ID:
LOC#:
ADDITIONAL REMARKS SCHEDULE
Page
..1.... of _2_
NAMED INSURED
AGENCY
Marsh USA Inc.
POLICY NUMBER
I
CARRIER
SimplexGrinnell LP
1125 East Collins Blvd .
Richardson , TX 75081
United States
NAIC
EFFECTIVE DATE :
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER:
25
FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE
REGARDING NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS :
This endorsement modifies the notice of cancellation of insurance prov ided hereunder :
Should any of the above described policies be cancelled, other than for non-payment of premium, before the
expiration date thereof , 30 days advice of cancellation will be delivered to certificate holders in
accordance with the policy endorsements.
All other terms and conditions of this policy remain unchanged .
REGARDING ADDITIONAL INSURED STATUS :
In accordance with the policy provisions, Stephen F Austin Un iversit y is included as an additional insured
under this policy, as a result of any contract or agreement entered i n t o by the named insured and Stephen F
Austin University .
In accordance with the policy prov is ions, coverage afforded to an add i tional insured will apply as primary
insurance where required by contract entered into by the named insured and the Stephen F Austin University .
Any other insurance issued to such additional i nsured shall apply as excess and noncontributory insurance .
Other Additional Insureds: its officials, directors, emp l oyees, representatives and vo l unteers
REGARDING WAIVER OF SUBROGATI ON:
In acc o rdance with the policy provisions, the Waiver of Subrogation applies per cont ra ct or agreement entered
into b y the named insured and Stephen F Austin University .
FOR QUESTIONS REGARDING THIS CERTIFICATE OF INSURANCE CONTACT:
Judi
Ing ram (Email : j u ingram@simplexgrinnell.com
Phone: 972-587-5264)
THIS CERTIFICATE OF INSURANCE WAS GENERATED AND DELIVERED BY EXIGIS RlskWorks® rm.Certificates®
Business Process Automation for Risk Management, Insurance, and Trade Fi nance
To learn what EXI GIS can do for your business visit exigis.com or ca ll 800.928.1963
ACORD 101 (2008/01)
© 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD