Loading...
HomeMy WebLinkAbout131163 ADECCO INC & ITS SUBSIDIARIES - INSURANCE CERTIFICATE (7)1 0 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ,�2„20,5 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 Marsh USA, Inc. 1166 Avenue of the Americas CONTACT NAME: PHONE FAX ac No: E-MAIL ADDRESS: New York, NY 10036 Attn: Adecco.certs@Marsh.com Fax: 212-948-0018 INSURERS AFFORDING COVERAGE NAIC C INSURER A: AXA Insurance Company 33022 370044-ALL-ALL-16-17 NO INSURED Adecco Inc. 8 its subsidiaries 10151 Deerwood Park Blvd. INSURER B: National Union Fire Insurance Co Of Pittsburgh 19445 INSURER C : Insurance Company of the Stale of Pennsylvania 19429 INSURER D : Building 200 Jacksonville, FL 32256 INSURER E : INSURER F : COVFRAGFS CERTIFICATE NUMBER: NYC-007292558-08 REVISION NUMBER:1 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER Y (MMIDONMI IMMIDDfYYYYILIMITS A X COMMERCIAL GENERAL LIABILITY PCS002071(16) 01/01/2016 0110112017 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE r _X1 OCCUR PREM SESOEaEoccu ante $ 2,000,000 X MED EXP (Any one arson) $ 5,000 CONTRACTUAL LIABILITY PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY a PRO- JECT M LOC PRODUCTS - COMP/OP AGG $ 4,000,000 $ OTHER: B AUTOMOBILE LIABILITY 9734263 (MA) 01/01/2016 01/01/2017 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 X BODILY INJURY (Per person) $ B ANY AUTO 9734264 (FL) 01/01/2016 01/0112017 B ALL OWNED AUSCHETODULED AUTOS S 9734265 (NY) 01/0112016 01/0112017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIREDAUTOS AUTOS A X UMBRELLA LIAB X OCCUR XS002072(16) 01/01/2016 01/0112017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAR CLAIMS -MADE DED I X I RETENTION $10 000 $ C D C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE N (Mandatory in NH) EXCLUDED? NIA 066830117 (ADS) 066830118 CA ( ) 066830119 FL ( ) 01/01/2016 0110112016 01101/2016 0110112017 0110112017 0110112017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYEE $ 2.000,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 2,000,000 A E80I PROFESSIONAL LIABILITY PCS002073(16) 01/01/2016 01/01/2017 EA. CLAIMIAGG(SIR $500,000) $51W$5M (INCLUDING NETWORK SECURITY) PRIVACY EVENT EXPENSE EA. CLAIWAGG (SIR $250,000) $5W$5M DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Branch Location: Adecco Engineering 8 Technical, 300 E. Boardwalk, Fort Collins, CO 80525. I It City of Fort Collins Attn: Ed Bonnette 215 N. Mason St. Fort Collins, CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1 0 ACC 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 12/2112015 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 Attn: Adecco.certs@Marsh.com Fax: 212-948-0018 CONTACT NAME: PHONE FAX IA/C, No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC If INSURER A: 7XA Insurance Company 33022 370044-ALL-ALL-16-17 NO INSURED Adecco Inc. & its subsidiaries 10151 Deerwood Park Blvd. INSURER B : National Union Fire Insurance Co Of Pittsburgh 19445 INSURER C: Insurance Company of the State of Pennsylvania 19429 INSURER D : Building 200 Jacksonville, FL 32256 INSURER E : INSURER F : nnVFRAnFR CFRTIFICATF NtIMRER: NYC-007282597-08 REVISION NUMBER:I 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 LTR OF INSURANCE ADDLTYPE JNM SUER POLICY NUMBER LICY EFF MWDDIYYYY POLICY EXP MM /DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY PCS002071(16) 01/01/2016 01/01/2017 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE M OCCUR DAMAGE TO PREMISES EaENTED occurrence $ 2,000,000 X MED EXP (Any one person) $ 5,000 CONTRACTUAL LIABILITY PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY Ifl PRO- JECT a LOC PRODUCTS -COMP/OP AGG $ 4,000,000 $ OTHER: B AUTOMOBILE LIABILITY X 9734263 (MA) 01/01/2016 01/01/2017 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 BODILY INJURY (Per person) $ B X ANY AUTO 9734264 (FL) 0110112016 01101/2017 BODILY INJURY (Per accident) $ B ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS HAUTOS 9734265 (NY) 01101/2016 01/0112017 PROPERTYDAMAGE Per accident $ A X I UMBRELLA LIAR X OCCUR XS002072(16) 01/01/2016 01101/2017 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 EXCESS LIAR CLAIMS -MADE DIED X RETENTION $10000 $ C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? � (Mandatory in NH) NIA 066830117(ADS) 066830118 (CA) 066830119FL ( ) 0110112016 01/01/2016 01101/2016 01/01/2017 01101I2017 01101/2017 X PER OTH- STATUTE ER E.L EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 If yes, describe unde DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 2,01)0,000 A E80/ PROFESSIONAL LIABILITY PCS002073(16) 01/0112016 01/01/2017 EA. CLAIM/AGG(SIR $500,000) 10,000,000 (INCLUDING NETWORK SECURITY) PRIVACY EVENT EXPENSE EA. CLAIMIAGG (SIR $250,000) $5W$15M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space Is required) Branch Location: Adecco Engineering & Technical, 300 E. Boardwalk, Fort Collins, CO 80525. L" a31 IR RL•l la i Pl 011l;4 it City of Fort Collins Attn: Ed. Bonnette 215 N. Mason St. Fort Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ACORO0 CC> CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1212112015 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 Attn: Adecco.certs@Marsh.com Fax: 212-948-0018 CONTACT NAME: PHONE FAX A/c No): EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: AXA Insurance Company 33022 370044-ALL-ALL-16-17 NO INSURED AdeccINSURER 10151 0151 Inc. its subsidiaries Deelwood Park Blvd. B: National Union Fire Insurance Co Of Pittsburgh 19445 INSURER c :Insurance Company of the Stale of Pennsylvania 19429 INSURER D : Building 200 Jacksonville, FL 32256 INSURER E : INSURER F : rn111=13A^1=0 t%CDTInrTATG wrNraFn• NYC-007292557-08 RFVISION Ni1MRFRr1 - 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY PCS002071(16) 01/01/2016 01/01/2017 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE Ix I OCCUR DAMAGE TO RNTED PREMISES EaEoccu ence $ 2,000,000 X MED EXP (Any one person) $ 5,000 CONTRACTUAL LIABILITY PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 X POLICY E jE [K] LOG $ OTHER: B AUTOMOBILE LIABILITY 19734263 (MA) 01/01/2016 01/01/2017 COMBINED SINGLE LIMIT Ea accident It 2,000,000 BODILY INJURY (Per person) $ B X ANY AUTO 9734264 (FL) 01/01/2016 01/01/2017 BODILY INJURY (Per accident) $ B ALL OWNED SCHEDULED AUTOS Os NON -OWNED HIREDAUTOS AUTOS 9734265 (NY) 01/01/2016 01/01/2017 PeOPE TY DAMAGE $ A X UMBRELLA LIAB X OCCUR XS002072(16) 01/0112016 01101/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED I X I RETENTION $10 000 $ C C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBEREXCLUDED? � (Mandatory in NH) NIA 066830117 (ADS) 066830118 (CA) 066830119 FL ( ) 01/0112016 01/01/2016 01/01/2016 01/01/2017 01/01/2017 01101/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,000 E L DISEASE - EA EMPLOYEE $ 2,000,000 E.L. DISEASE - POLICY LIMIT $ 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below A E&O I PROFESSIONAL LIABILITY PCS002073(16) 0110112011 01/01/2017 EA. CLAIMIAGG(SIR $500,000) $5NV$5M (INCLUDING NETWORK SECURITY) PRIVACY EVENT EXPENSE EA. CLAIM/AGG (SIR $250,000) $5MI$5M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Branch Location: Adecm Staffing, 3711 JFK Parkway, Suite 305, Fort Collins, CO 80525, City of Fort Collins Attn: Ed Bonnette 215 N. Mason St. Fort Collins, CO 80524 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD ® ACORN CERTIFICATE OF LIABILITY INSURANCE _DATE(MM/DD/YYYY) 12/21/2015 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 Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 Attn: Adecco.certs@Marsh.com Fax: 212-948-0018 CONTACT NAME: PHONE FAX o : x A/c Not: E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC k INSURER A : AXA Insurance Company 33022 370044-ALL-ALL-16-17 NO INSURED Adecco Inc. 8 its subsidiaries 10151 Deerwood Park Blvd. INSURER B: National Union Fire Insurance Cc Of Pittsburgh 19445 INSURER C : Insurance Company of the State of Pennsylvania 19429 INSURER D : Building 200 Jacksonville, FL 32256 INSURER E : INSURER F: nAVFRAnFc cFRTIFICATF NIIMRFRr NYC-007292559-08 REVISION NUMBER:1 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. IN RI LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR CONTRACTUAL LIABILITY PCS002071(16) 01/01/2016 01/01/2017 EACH OCCURRENCE $ 2,000,000 DAMAGE TO PREMISES (Ea occurrence)$ 2,000,000 X MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JE� [XI LOC OTHER: GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 $ B B B AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AS NON-OWNED HIREDAUTOS AUTOSacci 9734263 (MA) 9734264 (FL) 9734265 (NY) 01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2017 01/01/2017 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Per PERTnDAMAGE $ A X I UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE XS002072(16) 01101/2016 01/01/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED X RETENTION$10000 $ C C C WORKERS COMPENSATION AND EMPLOYERS' UABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICERIMEMBEREXCLUDED? (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below N/A 066830117(ADS) 066830118 (CA) 066830119(FL) 01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2017 0110112017 OTH- X STATUTE ER E.L. EACH ACCIDENT $ 2,000.000 E.L. DISEASE - EA EMPLOYE $ 2.000,000 E.L. DISEASE - POLICY LIMIT $ 2,000,000 A E801 PROFESSIONAL LIABILITY (INCLUDING NETWORK SECURITY) PCS002073(16) PRIVACY EVENT EXPENSE 01/0112016 01/01/2017 EA. CLAIWAGG(SIR $500,000) $5M/$5M EA. CLAIWAGG (SIR $250,000) $5W$5M DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Branch Location: Adecco Engineering & Technical, 4025 Automation Way Ft, Fort Collins, CO 80525. City of Fort Collins Atfn: Ed Bonnette 215 N. Mason St. Fort Collins, CO 80522 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Jason Clarke (V 1VOU-ZU14 AGUKLI UUKYVKA I IUN. Au ngnis reservea. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 370044 LOC #: New Yc Aco o® ADDITIONAL REMARKS SCHEDULE L --' Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. Adecco Inc. & its subsidiaries 10151 Deerwood Park Blvd. Building 200 ' POLICY NUMBER Jacksonville, FL 32256 CARRIER NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance WORKERS COMP CONTINUED: POLICY NUMBER: 066830120 STATE:ME POLICY PERIOD: 01/01/2016 - 01/1/2017 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 066830122 STATE: MA, ND, WA, WI, WY POLICY PERIOD: 01 /01/2016 - 01/1/2017 PAPER: INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG POLICY NUMBER: 066830121 STATE: MN POLICY PERIOD: 01/01/2016 - 01/01/2017 PAPER: THE INSURANCE COMPANY OF THE STATE OF PA CARRIER: AIG EXCESS WORKERS COMP-OHIO ONLY: INSURER: NATIONAL INSURANCE COMPANY OF THE STATE OF PA POLICY NUMBER: XWC 2203536 POLICY PERIOD: 01/0112016- 01/01/2017 LIMITS: SIR: $3,000,000 EL EACH ACCIDENT: $1.000,000 EL DISEASE: $1,000,000 EL DISEASE - EACH EMPLOYEE: $1,000.000 CRIME: WITH THIRD PARTY COVERAGE POLICY NUMBER: CRM 1008374-00 CARRIER ZURICH AMERICAN INSURANCE COMPANY POLICY PERIOD: 05/01/2015 - 05/01/2016 LIMIT: $10,000,000 DEDUCTIBLE: $1,000,000 ACORD 101 (2008/01) U ZUUU AGUKU GUKF•UKA I IUN. All rlgnT,s reserves. The ACORD name and logo are registered marks of ACORD