|
INSR ADDL SUBR
<br />LTR INSR WVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACT
<br />NAME:
<br />FAXPHONE
<br />(A/C, No):(A/C, No, Ext):
<br />E-MAIL
<br />ADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER
<br />POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY)
<br />COMMERCIAL GENERAL LIABILITY
<br />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />AUTHORIZED REPRESENTATIVE
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR
<br />MED EXP (Any one person)$
<br />PERSONAL & ADV INJURY $
<br />GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT
<br />$(Ea accident)
<br />BODILY INJURY (Per person)$ANY AUTO
<br />OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS
<br />AUTOS ONLY
<br />HIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $$
<br />PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />POLICY
<br />NON-OWNED
<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 />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 CONTRACT OR 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 />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 have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE
<br />Sentinel Insurance Company Ltd.
<br />Hartford - WC Multiple Issuing Cos
<br />Swiss Re Corp Solutions America Ins Co
<br />Twin City Fire Insurance Company
<br />4/19/2024
<br />USI Insurance Services, LLC
<br />2375 E. Camelback Road, Suite 250
<br />Phoenix, AZ 85016
<br />877 468-6516
<br />Christine Torrance
<br />602 666-4830 610 537-2283
<br />christine.torrance@usi.com
<br />Matrix Consulting Group, Ltd
<br />1650 S Amphlett Blvd, Ste 213
<br />San Mateo, CA 94402
<br />11000
<br />00914
<br />29874
<br />29459
<br />A X
<br />X
<br />X
<br />X X 59SBARO0849 08/08/2023 08/08/2024 2,000,000
<br />1,000,000
<br />10,000
<br />2,000,000
<br />4,000,000
<br />4,000,000
<br />A
<br />X X
<br />X X 59SBARO0849 08/08/2023 08/08/2024 2,000,000
<br />A X X
<br />X 10,000
<br />59SBARO0849 08/08/2023 08/08/2024 3,000,000
<br />3,000,000
<br />B
<br />Y
<br />X 59WECAB6S04 08/08/2023 08/08/2024 X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />C
<br />D
<br />Cyber Liability
<br />Professional Liab
<br />C4LTK141409CYBER20
<br />59PG029737223
<br />10/04/2023
<br />08/08/2023
<br />10/04/2024
<br />08/08/2024
<br />$2,000,000/$5,000 ret
<br />$2,000,000/$3,000,000
<br />$10,000 ded/ea claim
<br />General Liability, including completed operations, and Hired & Non-Owned Auto Liability include an
<br />automatic Additional Insured endorsement that provides Additional Insured status to the Certificate Holder,
<br />only when there is a written contract or written agreement between the named insured and the certificate
<br />holder and with regard to work performed by or on behalf of the named insured. General Liability, Hired &
<br />Non-Owned Auto Liability and Workers Compensation provide a blanket Waiver of Subrogation in favor of the
<br />(See Attached Descriptions)
<br />Orange County
<br />300 W. Tryon St.
<br />PO Box 8181
<br />Hillsborough, NC 27278
<br />1 of 2
<br />#S44490415/M42201670
<br />MATRICON2Client#: 1635640
<br />RYEZP
<br />1 of 2
<br />#S44490415/M42201670
<br />DocuSign Envelope ID: 37D73797-B014-4FA8-81C5-C7EB90A72742
|