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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
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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