2016-665-E HR - Selerix Systems, Inc. for ACA filing terms and conditions

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DocuSign Envelope ID:9786A36A-88C6-45C6-8299-B927DCBC8AFC AC�® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/7/2016 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, 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:CONTACT Rosemary Bruscino Arthur J. Gallagher Risk Management Services, Inc. PHONE 972.663 6122 FAX 972-991-4061 Two Lincoln Centre (AFC_N Eat) (A/C.No): 5420 LBJ Freeway, Suite 400 ADDRIESS: Dallas TX 75240 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Hartford Lloyd's Insurance Company 38253 INSURED SELESYS-01 INSURER B:Hartford Fire Insurance Company 19682 Selerix Systems, Inc. INSURER c:ACE American Insurance Company 22667 2851 Craig Drive, Suite 300 Mc Kinney TX 75070 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1619679359 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD, POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY 46SBAVF1705 12/15/2015 12/15/2016 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADVINJURY $2,000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 X POLICY PRO- JECT _LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ A UMBRELLA LIAR X OCCUR 46SBAVF1705 12/15/2015 12/15/2016 EACH OCCURRENCE $3,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED X RETENTION$10,000 $ B WORKERS COMPENSATION 46WBCNO3918 12/15/2015 12/15/2016 PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 C Cyber G24243618005 12/15/2015 12/15/2016 Aggregate 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Informational Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD