ACORD®
CERTIFICATE OF LIABILITY INSURANCE
~
I
DATE (MM/DD/YYYY)
2/3/2016
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, su bject to
the terms and conditions of the policy, certain policies may require an endorsement. A stateme nt on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
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PRODUCER
Hibbs-Hallmark & Company
501 Shelley Drive
P.O. Box 8357
Tyler TX 75711 - 8357
Kim Bond
ACSR
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PRODUCER
CUSTOMER ID#: UNIVTIM-01
INSURER(S) AFFORDING COVERAGE
INSURED
Universal Time Equipment Company,
P .O . Box 727 9
Tyler TX 75711
Inc .
NAIC #
INSURER A :Everest Indemnitv Ins Co
1085 1
INSURER B : Texas Mutual
22945
Insurance Comoanv
INSURER c : Emo lovers Mut Cas Co
21415
INSURER D :
INSURER E :
INSURER F:
COVERAGES
CERTIFICATE NUMBER: 810377728
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED. NOTWITHSTANDING ANY REQU IREMENT, 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 ANO CONDITIONS OF SUCH POLICIES. LIM ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM S.
IADDL ISUBR
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INSR
TYPE OF INSURANCE
LTR
A
GENERAL LIABILITY
..__
x
..__
..__
..__
POLICY NUMBER
51GL0 07963 161
POLICY EFF
POLICY EXP
IMM/DDIYYYYl IMM/DD/YYYYl
1/ 1/ 2 016
1/ 1/ 20 17
COMMERCI AL GENERAL LIABILITY
D
~ OCCUR
CLAIMS-MADE
.__
n
GEN'L AGGREGATE LIMIT APPLIES PER :
A
lxl P,W-r
POLICY
AUTOMOBILE LIABILITY
n
x
s 1 . ooo , ooo
5100,000
MED EXP (Any one person)
55,000
PERSONAL & ADV INJURY
s1. oo o ,oo o
GENERAL AGGREGATE
52 , 000 ,000
PRODUCTS - COMP/OP AGG
52 , 000 ,000
COMBINED SINGLE LIMIT
(Ea accident)
$1,000, 000
BODILY INJURY (Per person)
s
s
Loc
51CAOOO S7116 1
1/ 1/ 20 16
1/ 1/ 20 17
~
..__
..__
..__
..__
LIMITS
EACH OCCURRENCE
DAMAGt: To HENTED
PREMISES IEa oca.Jrrence\
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY (Per accident) s
SCHEDULED AUTOS
PROPERTY DAMAGE
(Per accident)
HIRED AU TOS
$
s
NON-OWNED AUTOS
$
A
x
UMBRELLA LIAB
EXCESS LIAB
B
~ OCCUR
51CC00 30 08161
1/ 1/ 2016
1/ 1 /20 17
CLAIMS-MADE
S), 000 ,00 0
53 , 000 , 00 0
DEDUCTIBLE
5
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
N/A
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
D
s
TSF0010 14 6203
1 / 1/ 2016
1/ 1/ 2017
DESCRIPTION OF OPERATIONS below
Prope r t y Stored
I WCSTATU- I
TORY UMITS
E.L. EACH ACCIDENT
I OJ~$1, 000 ,000
E.L. DISEASE - EA EMPLOYEE $1, 000 ,0 00
If yes , describe under
c
EACH OCCURRENCE
AGGREGATE
SA4 l3 l3 l 7
1/ 1/ 20 17
1/ 1/ 2016
E.L. DISEASE - POLICY LIMIT $1, 000 , 000
Materials ®ins d Loe
201 , 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarl<s Schedule, if more space is required)
As Required by Written Contract, Certificate Holder is included as an addit ional insured with completed
per form ECG 20 599 ( 05 / 09) wi t h waiver of subrogation on the
operat ion s on the general l i a b i l i t y
pr imary and noncontributory basis per form ECG 24
general l i a b i l i t y per form ECG 24 522 (04/02) on a
See Attached ...
CANCELLATION
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
Stephen F Austin State Uni v ersity ,
off i cials, directors,employees,
representatives and volunteers
19 36 North St.
Nacogdoches TX 75962
I
its
AUTHORIZED REPRESENTATIVE
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© 1988-2009 ACORD
ACORD 25 (2009/09)
The ACORD name and logo are registered marks of ACORD
CORPORATION. All rights reserved.
AGENCY CUSTOMER ID : UN IVTI M- 01
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L0 C #:
~~~~~~~~
ADDITIONAL REMARKS SCHEDULE
A GENCY
NAMED INSURED
Un i versal Time Equipme nt Company, Inc.
P. O. Box 7279
Tyler TX 75 71 1
Hibbs -Hallmark & Compa ny
POLI CY NUMBER
CARRIER
Page 1_ _ of _1 _
I
NA IC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM ,
FORM NUMBER: 2 5
FORM TITLE : CERTIFICATE OF LIABI LITY INSURANCE
520
Additiona l Insured with waiver of subrogation on the automobile liab il ity policy per fo rm ECA 04
506 06 09 , waiver of subrogation on the wo rkers compe n sation policy p er fo rm WC 42 03 04B . Umbrel l a
liability is following form over automobile liability and general l iability policies .
ACORD 101 (2008/01)
© 2008 ACORD CORPORATION . All rights reserved.
The ACORD name and logo are registered marks of ACORD