HomeMy WebLinkAboutCERTIFICATE OF INSURANCE ,aco Q� CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYYY)
(....-- 10/26/2016
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(les)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 ,NAME..,,. Paula Washnock
Diversified Insurance Group --
1602 E.8th St. PHONE (812)283-3500 FAx 812 282-1374
Jeffersonville,IN 47130 MAIL —__ lac Nor ( )
ADDRESS: psula@diginsure.net
INSURE 5 AFFORDING COVERAGE MAIC#
INSURERA: PEKIN INSURANCE
INSURED David Ka ie INSURER B:
113 Ciearview Drive —_..........._......__..._.
Jeffersonville,IN 47130 INSURER C:
INSURER 0:
INSURER g_-,_
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 REOUIREMENT, 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 ADEFL Rr-- __........—
TR TYPE OF INSURANCE POLICY EFF POLICY EXP .--..._.._._._________._..._......_._.._..._. _.
POLICY NUMBER M. LIMITS
A COMMERCIAL GENERAL LIABILITY I CLO180352 11/25/2016 111125/2017 EACH DccuRRENCE $ 1,000,000
DAMAGE TO RENTD
__ CLAIMS-MADE OCCUR PREMI Ea ocpurrenca) $ 100,000
i
MED EXP(Any one person) s 5,000
_. —_....._...._.._............_............._...
PERSONAL 8 ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: i
POLICY GENERAL AGGREGATE 1, 00
n C $ 000,0
_. _000,0...._..
u JET LOC PRODUCTS-COMPIOP AGG $ 1,000 000
OTHER-
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
! BODILY INJURY(Per person) $ --
OWNED SCHEDULED ~BODILY INJURY(Per accident $
AUTOS ONLY AUTOS }
HIRED NON-OWNED ._.._.._.........._...............__..._ .,_—_--
i PROPERTY DAMA��
AUTOS ONLY AUTOS ONLY i P de $
is
UMBRELLA UAB OCCUR ( EACH OCCURRENCE $
EXCESS UAB _ I CLAIMS-MADE AGGREGATE $
DED I RETENTION$
is
WORKERS COMPENSATION 0TH_AND EMPLOYERS'LIABILITY Y/N STAT TE i ER__ _
i ANY PROPRIETOR/PARTNERIEXECUTIVE $
OFFICEREMBER EXCLUDED? ❑
IMN 1 A E.LEACH ACCIDENT m _ _ _.. __......,
(Mandata }_____ry in NH) E.L DISEASE-EA EMPLOYEE $
I If as,tlescribe under
!DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS i LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more apace Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Jeffersonville ACCORDANCE WITH THE POLICY PROVISIONS.
500 QuarterMaster
Jeffersonville,IN 47130 AUTHORIZED REPRESENTATIVE
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