Certificate of Liability Insurance: SVG/LLGC Is Additional Insured

Download as pdf or txt
Download as pdf or txt
You are on page 1of 1

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE 1/24/2019


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 have ADDITIONAL INSURED provisions or 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 CONTACT
NAME: Jerry Brewton
PHONE FAX
Brewton Insurance Agency Inc (A/C, No, Ext): 5748758506 (A/C, No):
E-MAIL
21797 Omega Court ADDRESS: jerrybrewtoninsurance@gmail.com
INSURER(S) AFFORDING COVERAGE NAIC #
Goshen IN 46528 INSURER A : INDIANA FARMERS MUT INS CO 22624
INSURED INSURER B :
Snappy Construction Service Llc INSURER C :
2040 S Lynhurst Dr Ste F INSURER D :

INSURER E :
Indianapolis IN 46241 INSURER F :

COVERAGES CERTIFICATE NUMBER: 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.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1000000
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ 100000
SPC MED EXP (Any one person) $ 5000
A Y CPP1014615 02/04/2019 02/04/2020 PERSONAL & ADV INJURY $ 1000000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000
PRO-
POLICY JECT LOC PRODUCTS - COMP/OP AGG $ 2000000
OTHER: $

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $


(Ea accident) 1000000
ANY AUTO BODILY INJURY (Per person) $
OWNED SCHEDULED BODILY INJURY (Per accident) $
A AUTOS ONLY AUTOS CAP1007725 03/25/2018 03/25/2019
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per accident)
$

UMBRELLA LIAB OCCUR EACH OCCURRENCE $


EXCESS LIAB CLAIMS-MADE AGGREGATE $

DED RETENTION $ $
WORKERS COMPENSATION PER OTH-
STATUTE ER
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1000000
A OFFICER/MEMBER EXCLUDED? N/A WCP1006541 04/05/2018 04/05/2019
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1000000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1000000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

SVG/LLGC IS ADDITIONAL INSURED

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE


THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SFV/LLGC ACCORDANCE WITH THE POLICY PROVISIONS.

ATTN: ACCOUNTING AUTHORIZED REPRESENTATIVE

25550 GRAND RIVER


REDFORD, MI 48240
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

You might also like