2019-714-E AMS - Xybix Systems Inc. ES furniture

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DocuSign Envelope ID:95ED4E50-2135-4421-9D73-64AF3CA1B6D8 ERGOSYS-02 KDERRILL '4�aRo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/11/2019 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 License#0757776 CONTACT Jennifer Wilke NAME: HUB International Insurance Services(COL) PHONE FAX, 720 207-2367 FAX 866 243-0727 2000 S.Colorado Blvd., ) ( (A/C,No):( ) Tower 2,Suite 150 E-MAIL SS:jennifer.wilke@hubinternational.com Denver,CO 80222 INSURERS AFFORDING COVERAGE NAIC# INSURER A:The Travelers Indemnity Company of America 25666 INSURED Ergoflex Systems,Inc. INSURER B:Travelers Casualty Insurance Company of Americ 19046 dba Xybix Systems,Inc. INSURERC:The Phoenix Insurance Company 25623 CQCR LLC INSURER D: 8207 Southpark Circle Littleton,CO 80120 INSURER E 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR IN SD WVD MM DD MM DD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 680009A16819518 10/1/2018 10/1/2019 DAMAGE TO RENTED 300,000 X X PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ X ANY AUTO X X BA9A17253A18 10/1/2018 10/1/2019 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PerOaccitlenDAMAGE $ AUTOS ONLY AUTOS ONLY A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE CUP9A18097118 10/1/2018 10/1/2019 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER UB5J67568818 10/1/2018 10/1/2019 1,000,000 OFFICERO/MEMBER EXCLUDEDXECUTIVE ❑ N/A X E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Purchase Workstation Consoles Orange County is included as additional insured under General Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange Count THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g y ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 9181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE w ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD