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DocuSign Envelope ID: FF75FEC8-F41A-4602-AD91-CF4E1 D20FI 17 <br /> Client#: 39383 38EXCELLANCE1 <br /> DATE(MM/DD/YYYY) <br /> ACORD,. CERTIFICATE OF LIABILITY INSURANCE 01/10/2017 <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 /> CONTACT <br /> PRODUCER <br /> J Smith Lanier&Co-Huntsville <br /> A/C,NoONE 256 890-9000 256 890-9070 <br /> P.O.Box 6087 E-MAtL <br /> ADDRESS: <br /> Huntsville,AL 35813-0087 INSURER(B)AFFORDING COVERAGE NAIC# <br /> 256 890-9000 INSURER A:Alabama Self Insured WC Fund <br /> INSURED INSURERB:Midwest Employers Casualty <br /> Excellance,Inc. <br /> INSURER C <br /> 453 Lanier Road <br /> INSURER D: <br /> Madison,AL 35758 <br /> INSURER E: <br /> INSURER F <br /> COVERAGES 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 /> — — <br /> IµSFt ADI}L Ul3R POLICY EFF POLICY UP LIMITS <br /> LTR TYPE OF INSURANCE INSR NrYD POLICY NUMBER (MM/DDIYVYY]_(MMIDDIYYYY)_ <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE <br /> 1 A 411 O RENTED $ <br /> CLAIMS-MADE OCCUR PRI (Eaocciuren-ce1 <br /> MED EXP(Any one person) $ <br /> _PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ <br /> POLICY F�ECT f�LOC <br /> PRODUCTS-COMP/OP_AGG $ <br /> OTHER: _ _.. $ <br /> .. COMBINED SINGLE LIMIT <br /> AUTOMOBILE LIABILITY (Ea acddenl) - <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS AUTOS <br /> NON-OWNED PP.OPERTY DAMAGE $ <br /> HIRED AUTOS AUTOS ._(Per ai:cidanl <br /> $ <br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE $ - <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE _ _ $ J_ <br /> DED _ I RETENTION$ $AND <br /> EMPLOYERS' <br /> YERS'LIABILITY <br /> IST TUTS �� <br /> q WC10000998002017A 1/0112017 01/011201 X PEAR oT"- <br /> AND EMPLOYERS'LIABILITY <br /> ER <br /> B ANY PROFRIETOFVI=ARTNERIEXECUTIVE� PNAL129001 1101/2017 01/01/201 ,E.L.EACH ACCIDENT $1 000 000 <br /> OFFICERIMEMBER EXCLUDED? N N/A <br /> (Mandatary In NH) E.L.DISEASE-EA EMPLOYEE $1,000 000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $1.,000,000 -- <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> For Proof of Insurance Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> ©19 6. 014 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 ` <br />