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HomeMy WebLinkAboutGLIACOR4M CERTIFI ATE OF LIABILITY INSUKANCE D1O/IMM 17IDD/YYYzolzY) to/17/ 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 Willis of Minnesota, Inc. 10707 Pacific Street, Ste 200 Omaha, NE 68114 Amanda Craig CONTACT NAME: Amanda Craig _ Pn"ICCON s E,d): .736.4327 ac N,;800.328.0522 E-MAIL ADDRESS: PRODUCER T MER D INSURER(S) AFFORDING COVERAGE NAIL# INSURED Kappa Sigma Fraternity P.O. BOX 5066 Charlottesville, VA 22905 INSURER A: Admiral Insuran_c_e Company 124856 INSURER B: INSURER C: INSURER D: INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 12 SE 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. IPOLIC LTR TYPE OF INSURANCE I SR WVD POLICY NUMBER MM/DDYEFF fMMfDDfYYYYI LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE T OCCUR X Host Liquor Liab CA0000053811 10/01/2012 10/01/2013 EACH OCCURRENCE $ 1,000,00 DAMAGE TORENTA� PREMISES Ea odo nence $ 1, OOO,DD MED EXP (Any one person) S Exclude PERSONAL & ADV INJURY S 1,000,00 GENERAL AGGREGATE S 2,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY PRO JECT LOC PRODUCTS - COMP/OP AGG $ 1,000,00 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CA00000538111 10/01/2012 10/01/2013 COMBINED SINGLE LIMB (Ea accident) $_ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY(Peraccidem) $ PROPERTY DAMAGE (Peraccident) $ X X $ UMBRELLA UAB EXCESS iJAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY yIN ANY PROPRIETORIPARTNERIEXECUTIVE❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES Attach ACORD 101, Additional Remarks Schedule, if more spaceis re aired) he certificate holder is an z iJitional insured with regard to the above listed policy his is for the chapter at Texas A&M's Wicked Woods to be held on the following dates: 10/18/2012- 0/20/2012, 10/25/2012 - 10/27/2012, and 10/30/2012 - 10/31/2012 only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of College Station AUTHORIZED REPRESENTATIVE P.O. Box 9960 1101 Texas Avenue College Station„ TX 77842 Edward (Ned) Kirklin/MANDY © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ACORD, AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page of AGENCY Willis of Minnesota, Inc. NAMED INSURED Kappa Sigma Fraternity Charlottesville, VA 22905 POLICY NUMBER CARRIER NAIL CODE EFFECTIVE DATE: ,DDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: ACORD Certificate of Liability Insurance Garage Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MMIDD/YY) DATE IMMIDDIYY) LIMITS AUTO ONLY -EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ Automobile Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE (MM/DD/YY) DATE (MMIDDM) A Excess/Umbrella Liability INSR POLICY EFFECTIVE ICY EXPIRATION PDATE(MMMOrM LTRINSR� POLICY NUMBER Other Liability POLICY POLICY LTR POLICY NUMBER (MMFDDTIYY) DATE(MMIDDNY) The ACORD name and logo are registered marks of ACORD LIMITS LIMITS All rights HwRu� CERTIFs*. ATE OF LIABILITY INSVN<ANCE 10/0MID3/2022D/YWY) 0/0 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 endorsements). PRODUCER Willis of Minnesota, Inc. 10707 Pacific Street, Ste 200 Omaha, NE 68114 Amanda Craig NAME: Amanda Craig PnHc°"N E�1;800.736_4327 aDNp.800.328.0522 E-MAIL ADDRESS: PRODUCER T M RID# INSURERIS) AFFORDING COVERAGE NAIC# INSURED Kappa Sigma Fraternity P.O. Box 5066 Charlottesville, VA 22905 INSURERA: Admiral Insurance Company 24856 INSURERS: INSURERC: INSURER D: INSURER E : INSURER F: COVFRAnFS rFRTIFIrATF NIIMRFR- 17 Al 1 RFC 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADDLSUBR INSR MD POLICY NUMBER POLICY EFF 00MOD/YTI"(1 POUT YEXP fMMIDDfYYYY1LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X Host Liquor Liab CA0000053812 10/01/2012 10/01/2013 EACH OCCURRENCE S 1,000,00 RENTED DAMAGE TO PREMISES $ 1,000,00 „Eaoccu MED EXP (Any me Person) S Excluded PERSONAL BADVINJURY S 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- ECT LOC PRODUCTS-COMP/OP AGG $ 1,000,00 S A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNEDAUTOS CA0000053811 10/01/2012 10/01/2013 COMBINED SINGLE LIMIT (Ea accident) $ ]„ODD, 00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X X $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ S $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE❑ OFFICERIMEMSER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA P/CSITMIT ER TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES Attach ACORD 101, Additional Remainsschedule, if more space is required) te he certificate holder is lisr as an insured as their interest may appear with regard to the above referenced liability policy. r FDTIFIr ATF Will nPIP rANrFI I ATInN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All recognized undergraduate chapters, AUTHORIZED REPRESENTATIVE colonies, house corporations and alumni ch pters of Kappa Sigma Fraternity Edward (Ned) Kirklin/MANDY V 798B-2UUU AUUKU UUKI'VK I IUIN. All rlgnus ru5urveu. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD