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DocuSign Envelope ID: 890AB1BA- 173D- 46A1- B569- D7AE7E5CA4F3 <br />Client #: 39383 38EXCELLANCE1 <br />DATE (MM /DD/YYYY) <br />ACORD,. CERTIFICATE OF LIABILITY INSURANCE 1 01/1012017 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER CONTACT <br />NAME: <br />J Smith Lanier & Co- Huntsville <br />PHONE 25 VAX 256 890 -9070 <br />{A!C Nv, ✓=t x 16 890 -9000 {Alf:, Nat: <br />P. O. Box 6087 E -MAIL <br />ADDRESS: <br />Huntsville, AL 35813 -0087 IKSURER(S AFFORDING COVERAGE NAIC# <br />256 890 -9000 Alabama Self Insured WC Fund <br />INSURED <br />Excellance, Inc. <br />453 Lanier Road <br />Madison, AL 35758 <br />INSURER A: <br />INSURER B: Midwest Employers Casualty <br />INSURER C : <br />INSURER D: <br />INSURER E.' <br />INSURER F: <br />rnVFRAnFS CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />tNSR J1DOL U POLICY EFF POLICY EXP LIMITS <br />LTR TYPE OF INSURANCE IN_SR ICtAID POLICY NUMBER _ (MM/DD /YYYY)_ (MMIDDIYYY_Y) _ __ _ <br />COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br />CLAIMS -MADE I OCCUR DAME j0 RENTED <br />PR 1 ES (Ea occurrence). $ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRO- <br />. POLICY F_] JECT LOC <br />OTHER: <br />AUTOMOBILE LIABILITY <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />UMBRELLA LIAR OCCUR <br />EXCESS LIAB CLAIMS_ -MADE <br />DED I I RETENTION $ <br />A WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />Y / N <br />B ANY PROPRIETORIPART N£RIEXECUTIVE <br />OFFICERIMEMBER EXCLUDED? � N/A <br />(Mandatory In NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />MED EXP (Any one person) $ <br />PERSONAL & ADV INJURY $ <br />GENERAL AGGREGATE $ <br />PRODUCTS - COMP/OP AGG $ <br />BODILY INJURY (Per person) $ <br />BODILY INJURY (Per accident) $ <br />PROPERTY DAMAGE $ <br />IFer accident <br />EACH OCCURRENCE <br />AGGREGATE <br />WC10000998002017A 1/01/2017 01/01/201 X PER OTH- <br />PNAL129001 !13111011/20117 01/01/201 E.L. EACH ACCIDENT $1 <br />E.L. DISEASE - EA EMPLOYEE $1 <br />E.L. DISEASE -POLICY LIMIT $1 <br />DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) <br />CERTIFICATE HOLDER k ANUt:LLR I IVN <br />For Proof of Insurance Only <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />019$`8 -fU14 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD <br />#S3312929/M3312927 PZR ` u <br />