.. 3 ACORD , CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) 6/26/2015 ~ 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 POLICI ES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AN D THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 endorsementlsl. CONTACT PRODUCER Ruth T roast NAME' William Gammon Insurance ~.~~N,_t t -•" 512-477-6745 1 I fM ..n•· 512-469-0443 Higginbotham Insurance Agency, Inc. ~~~~~u . gen mai l @gamm on in su ran ce . com 1615 Guadalupe Austin TX 78701 NAIC# INSURERISI AFFORDING COVERAGE 22306 INSURER A ,Massachusetts Bav Insurance Co INSURED 4 1840 DAVID197 1NsuRER B :Allmerica Financial Benefit Ins . D avidson Document Solutions Inc., dba Texas INSURERC : Document Solutions, Arizona Document Solutions INSURER D: Ran dall E. Davidson INSURERE : 2600 Longhorn Blvd #1 02 Austin TX 78758 INSURER F : REVISION NUMBER: COVERAGES CERTIFICATE NUMBER· 726173056 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. INSR POLICY EFF POLICYEXP LIMITS lYPE OF INSURANCE LTR POLICYNUMBER IMM/DDIYYYYI IMM/DDIYYYYI INSD WVD A x COMMERCIAL GENERAL LIABILilY ODDA04275402 7/1/2015 7/1/2016 $1 ,000,000 EACH OCCURRENCE - ,..___ :=J CLAIMS-MADE ~ OCCUR PREMit:~~ 'i'E~~encel -GEN'L AGGREGATELIMIT APPLIES PER: =i D 0 POLICY ~r& OTHER: B AUTOMOBILE UABILilY x AmAUTO - AL~8'MIED AU S LOC - x A x $500.000 MED EXP IArlv one person) HIRED AUTOS UMBRELLA LIAB EXCESSLIAB AWDA04274502 7/1/2015 7/1/2016 ODDA04275402 7/1/2015 7/1/2016 EACH OCCURRENCE AGGREGATE WDDA04273902 7/1/2015 7/1/2016 ODDA04275402 7/1/2015 7/1/2016 x I l;f~TL!T~ I I OTH· ER $1,000,000 E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1 .000.000 1,599,837 Business Persl Prop 1,000 Deductible ~CHO~LED X ~-O'MIED AUTOS - $5.000 $1 ,000,000 PERSONAL & ADV INJURY $2,000,000 GENERAL AGGREGATE PRODUCTS · COMP/OP AGG $2,000,000 $ IEa acciden~l~IN\;iLt LIMI s1 .ooo.ooo BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ $ iPIM"a~~tr'Ml\\>C: $ OCCUR CLAIMS-MADE OED IX I RETENTION$0 A WORKERS COMPENSATION AND EMPLOYERS' UABILilY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICERIMEMBER EXCLUDED? (Mandatory In NH) M D :!l~4'~~ '&*"OPERATIONS below A Property Special Form Replacement Cost Loe: 2600 Longhorn, Austin, TX $5,000,000 $5,000,000 $ DESCRIPTION OF OPERATIONSI LOCATIONSI VEHICLES (ACORD 101, Additio""I Rt111111<1Schedule, may be tttached If mor9 1pact l1 r9quired) General Liability policy provides a blanket automatic additional insured primary basis endorsement to the certificate holder only w hen there is a written contract between the insured and certificate holder that requires such status per form # 391-1331 06 09 General Liability policy includes a blanket automatic waiver of subrogation endorsement that provides this feature only w hen there is a written contract between the insured and certificate holder that requires it per form # BP0497 07 02 See Attached ... CERTIFICATE HOLDER CANCELLATION Stephen F. Austin State University Procurement & Property Services P.O. Box 13030 Nacogdoches TX 75962-0000 I ACORD 25 (2014/01 ) 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 ~-~ © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: DAVID197 ------------------~ LOC#: -------- ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED William Gammon Insurance POLICY NUMBER CARRIER Page ~ of j__ I NAICCOOE Davidson Document Solutions Inc., dba Texas Document Solutions, Arizona Document Solutions Randall E. Davidson 2600 Longhorn Blvd #102 Austin TX 78758 EFFECTIVE DA TE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Auto policy includes a blanket automatic additional insured endorsement that provides additional insured status to the certificate holder only when there is a written contract between the insured and certificate holder that requires such status Automobile policy includes a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the insured and certificate holder that requires it Worker's Compensation policy includes a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the insured and certificate holder that requires it per form #WC420304A Stephen F. Austin State University, its officials, directors, employees, representatives and volunteers are included in the blanket additional insured for general liability as required by written contract but limited to the operations of the Insured under said contract, and always subject to the policy terms, conditions and exclusions. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All r ights reserved. The ACORD name and logo are registered marks of ACORD