ACORD®
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
~-
I
11/10/2015
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).
PRODUCER
~2a~~CT Cindy Stathos, Michael Stastny or Terryn Castanon
Marsh USA Inc.
1166 Avenue of the Americas
New York, NY 10036
I FAX
P.~~lN.. c-"· ( 844) 892-0092
CA/C Nol:
E-MAIL
ADDRESS : Please see bo ttom of 2nd page~ ~
t
INSURER($) AFFORDING COVERAGE
NAIC#
INSURER A: ACE American Insurance Company
INSURER B: ACE Fire Underwriters Insurance Company
INSURER C: indemnity Insurance Company of North America
INSURED
SimplexGrinnell LP
1125 East Collins Blvd .
Richardson, TX 75081
United States
CERTIFICATE NUMBER:
COVERAGES
1520603 -A
A
K
22667
20702
43575
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 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS .
ADDL SUBR
POLICY EXP
POLICY EFF
INSR
,., ._.,,,n
LIMITS
TYPE OF INSURANCE
POLICY NUMBER
IMM/DD/YYYYl IMM/DD/YYYYl
LTR
COMMERCIAL GENERAL LIABILITY
$2,000 ,000 .00
EACH OCCURRENCE
$
10/1/20 16
10/1/2015
HOO G27400358
A
DAMAuc: l O Kt:.N 1 c:u
$1 ,000 ,000 .00
$
CLAIMS-MADE [ ] OCCUR
PREM ISES IEa occurrence\
....
x
x
I
OWNER'S & CONTRACTOR'S PROT
-
GEN'L AGGREGATE LIMIT APPLIES PER:
~
A
A
POLICY D
PROJECT
OTHER:
AUTOMOBILE LIABILITY
r-ANY AUTO
ALL OWNED
r - - AUTOS
r-HIRED AUTOS
-
x
-
UMBRELLA LIAB
A
B
c
LOC
x
EXCESS LIAB
x
10/1 /2 015
10/1 /20 15
ISA H08859905 (Excludes NH)
ISA H08859917 (NH)
10/1/2016
10/1/2016
SCHEDULED
AUTOS
NON-OWNED
AUTOS
$10 ,000 .00
$
$2 ,000,000 .00
GENERALAGGREGATE
$
$4 ,000,000 .00
PRODUCTS - COMP/OP AGG
$
$4,000,000 .00
M
OCCUR
CLAIMS-MADE
x
Y/N
EJ
10/1 /201 5
10/1 /2015
XSA H08859929 (NH)
XSL G2740036A
I I RETENTION $
OED
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
COMBINED SINGLE LIMIT
(Ea accident)
BOD ILY INJURY (Per person )
$
$7,500,000 .00
$
BODILY INJURY (Per accidenl) $
N/A
WLR C48592284 (AZ, CA, MA)
SCF C48592296 (WI)
WLR C48592272 (All Other States)
10/1/20 15
10/1/20 15
10/1 /201 5
10/1/2016
10/1/2016
10/1/2016
10/1/2016
10/ 1/2016
~~sC:~~tir~~ ~n~~PERATIONS below
c
c
c
$
$
x
x
A
A
D
MED EXP (Any one person)
PERSONAL & ADV INJURY
Builder's Risk/installation/Contract Works
Rental EquipmenVContractor's Equipment
Blanket Transit
N10724429 001
N10724429 001
N10724429 001
10/ 1/2 015
10/1 /2015
10/ 1/20 15
10/1/2016
10/1/2016
10/1/2016
PROPERTY DAMAGE
IPer accident\
$
NEW HAMPSHIRE (CSL)
$
$250 ,000.00
EACH OCCURRENCE
$
$5 ,500,000 .00
AGGREGATE PRODUCTS -
$
$11,000 ,000.00
NEW HAMPSHIRE (CSL)
$
$7 ,250,000.00
x
I PER
I I OTHSTATUTE
ER
$
$2,000,000 .00
E.L. DISEASE - EA EMPLOYEE $
$2,000 ,000 .00
EL DISEASE - POLICY LIMIT
$2,000 ,000 .00
EL EACH ACCIDENT
$
USO $1,000 ,000.00 per jobsite
USO $1,000 ,000.00 per jobsite
USO $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)
!Project:
SFA University
Please ref er to attached ACORD 101 for further r emarks .
CANCELLATION
CERTIFICATE HOLDER
Stephen F Austin State University, its officals,
directors, employees, representavies and volunteers.
1936 North St
Nacogdoches, TX 75962
United States
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
,4¢?7-
I
MARSH USA INC, BY:
Matthew Ferrv Ca sualtv Prnnram
f~!Jv.~
Franklin Hallock, Global Marine
Transi t Prooram
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01)
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC #:
ADDITIONAL REMARKS SCHEDULE
AGENCY
Page .1.._ of -1._
NAMED INSURED
Marsh USA Inc.
POLICY NUMBER
I
CARRIER
SimplexGrinnell LP
1125 East Collins Blvd .
Ri chardson, 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:
Thi s endorsement modifies the notice of cancellation of insurance provided hereunder :
Should any of the above described polic ies be can celled, other than for non - payment of premium, before the
expira tion date thereof , 30 days advice of cance llation wi ll be del ivered to certificate holders i n
accordance with the policy endorsements.
All other terms and conditions of this policy remain unc h a nged .
REGARDING ADDITIONAL INSURED STATUS:
In accordance with the policy provisions, Stephen F Austin State Universi ty, its officals,
is i ncluded as an
additional insured under this policy, as a result of any contract or agreement entered into by the named
i nsured and Stephen F Austin State University, its officals, .
**
FOR QUESTIONS REGARDING THIS CERTIFICATE OF INSURANCE CONTACT:
Charla Davison (Ema il: chdavis on@simplexgrinnell.com
Phone : 972- 587 - 5200)
----------------------------------------------------------------------------------------------------------------------------------------------THIS CERTIFICATE OF INSURANCE WAS GENERATED AND DELIVERED BY EXIGIS RlskWorks® rm .Certificates®
Business Process Automation for Risk Management, Insurance, and Trade Finance
To learn what EXIGIS ca n do for your business visit exigis.com or call 800 .928 .1963
ACORD 101 (2008/01)
© 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD