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HomeMy WebLinkAboutCertificate of Insurance -� ? A L CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 9/5/2012 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). CONTACT PRODUCER Jorge Arriola Farmers Insurance NAME: J orge Arriola 4413A S. Texas ( m.. PHONE . EXt): 979-260 -3708 Ira, No): 866- 900 -6434 Bryan, TX 77802 AD jarriolamayen@farmersagent.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Founders Insurance Company INSURED Hookah Station INSURER B : 106 College Main INSURER C : College Station, TX 77840 INSURER D : 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY �IJ INSR WVD EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY EPTX100068 07/25/2012 07/25/2013 PREM PREMISES occurrence) $ 50,000 I CLAIMS -MADE El OCCUR MED EXP (Any one person) $ 5,000 1 LIQUOR LIABILITY PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 1,000,000 D POLICY ❑ JE El LOC $ AUTOMOBILE LIABILITY I i I COMBINED SINGLE LIMIT 1� u (Ea accident) — ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR uu EACH OCCURRENCE $ EXCESS LIAB _ CLAIMS -MADE AGGREGATE $ , DED I 1 RETENTION $ $ WORKERS COMPENSATION u ( TOR LIMITS 1 IO ER TH AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE Y / N N / A E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DD El El IJ u 7 DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION City Of College Station 1101 Texas Ave SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN College Station, TX 77840 AC • - l'ANCE WITH THE POLICY PROVISIONS. UTHORI ED RE. ' NTATI / / © 10 ACORD ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and log v e registered marks of Produced using Forms Boss Web software. ..FormsBoss.com; © Impressive Publishing 800- 208 -1977 1 I o.�-k `\ , hereby agree to indemnify, hold harmless, and defend the City, its officers, agents, and employees from and against any and all claims, losses, damages, causes of action, suits, and liability of every kind, including all expenses of litigation, court costs, and attorney's fees, for injury to or death of any person or for damage to any property arising out of or in connection with the work done by the Applicant under this Permit. Such indemnity shall apply regardless of whether the claims, losses, damages, causes of action, suits, or liability arise in whole or in part from the negligence of the City or any third part . Sig - . ‘ A_c4 k 5w-d 1.4\ Name C H Title f otary 1 o1 PpYPU, GINASOUTHERLAND 1 1 / . Notary Public. State of Texas 1 s:. " ,: My Commission Expires 1 1 l 9lf 1 S SEPTEMBER4, 2013 1