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Agenda 12/10/2024 Item #16E 1 (Assign all rights, duties, benefits, and obligations to J&K Auto Parts, Inc., d/b/a Napa Auto Parts of Fort Myers, FL, concerning Collier County Agreement No. 19-7584 and Collier County Agreement No. 23-8110)12/10/2024 Item # 16.E.1 ID# 2024-1941 Executive Summary Recommendation to approve two Assumption Agreements assigning all rights, duties, benefits, and obligations to J & K Auto Parts, Inc., d/b/a Napa Auto Parts of Fort Myers, FL, concerning Collier County Agreement No. 19-7584, “OEM & Aftermarket Parts for Fleet” and Collier County Agreement No. 23-8110, “Filters for Fleet Vehicles & Equipment.” OBJECTIVE: To assign all rights, duties, benefits, and obligations concerning Agreement No. 19-7584, “OEM & Aftermarket Parts for Fleet” and Agreement No. 23-8110, “Filters for Fleet Vehicles & Equipment,” to J & K Auto Parts, Inc., d/b/a Napa Auto Parts of Fort Myers, FL (“J & K”). CONSIDERATIONS: On July 9, 2019 (Agenda Item No. 16.E.6), the County awarded Agreement No. 19-7584, “OEM & Aftermarket Parts for Fleet” and on November 14, 2023 (Agenda Item No. 16.E.1), the County awarded Agreement No. 23-8110, “Filters for Fleet Vehicles & Equipment” (the “Agreements”), to Sunbelt Automotive, Inc., (“Sunbelt”). On September 1, 2024, Sunbelt and J & K entered into an Asset Purchase Agreement whereby Sunbelt merged with and into J & K as presented in the Asset Purchase Agreement contained in Exhibit B of the attached Assumption Agreements. Accordingly, J & K wishes to formally assume all responsibilities, obligations, and duties under both Agreements. J & K, a Florida Foreign Profit Corporation, is registered to transact business in Florida and represents and warrants that it is now the successor in interest to the above Agreement entered into with the County. Staff obtained documentation of the merger, along with other necessary business documents from J & K, which have been reviewed and accepted by the County Attorney’s Office. Staff recommends approval of the attached Assumption Agreements assigning all rights, duties, benefits, and obligations under the Agreement, including any amendments thereto, to J & K. FISCAL IMPACT: There is no fiscal impact associated with this action. GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with this action. LEGAL CONSIDERATIONS: This item is approved as to form and legality and requires majority vote for Board approval. - CJS RECOMMENDATIONS: To approve an Assumption Agreement assigning all rights, duties, benefits, and obligations to J & K Auto Parts, Inc., d/b/a Napa Auto Parts of Fort Myers, FL concerning Agreement No. 19-7584 and Agreement No. 23-8110, and authorize the Chairman to sign the attached Assumption Agreements. PREPARED BY: Becca Zimmerman, Procurement Strategist, Procurement Services ATTACHMENTS: 1. 23-8110 Assumption_VS_ J&K 2. 23-8110_COI Packet 3. 19-7584 Assumption_VS_ J&K 4. 19-7584_COI Packet 5. COI_Assumption_J K._ Page 8206 of 10663 Page 8207 of 10663 Page 8208 of 10663 Page 8209 of 10663 Page 8210 of 10663 Page 8211 of 10663 Page 8212 of 10663 Page 8213 of 10663 Page 8214 of 10663 Page 8215 of 10663 Page 8216 of 10663 Page 8217 of 10663 Page 8218 of 10663 Page 8219 of 10663 Page 8220 of 10663 Page 8221 of 10663 Page 8222 of 10663 Page 8223 of 10663 Page 8224 of 10663 Page 8225 of 10663 Page 8226 of 10663 Page 8227 of 10663 Page 8228 of 10663 Page 8229 of 10663 Page 8230 of 10663 Page 8231 of 10663 Page 8232 of 10663 Page 8233 of 10663 Page 8234 of 10663 Page 8235 of 10663 Page 8236 of 10663 Page 8237 of 10663 Page 8238 of 10663 Page 8239 of 10663 Page 8240 of 10663 Page 8241 of 10663 Page 8242 of 10663 Page 8243 of 10663 Page 8244 of 10663 Page 8245 of 10663 Page 8246 of 10663 Page 8247 of 10663 Page 8248 of 10663 Page 8249 of 10663 Page 8250 of 10663 Page 8251 of 10663 Page 8252 of 10663 Page 8253 of 10663 Page 8254 of 10663 Page 8255 of 10663 Page 8256 of 10663 Page 8257 of 10663 Page 8258 of 10663 Page 8259 of 10663 Page 8260 of 10663 Page 8261 of 10663 INSURANCE REQUIREMENTS COVERSHEET Project Name Vendor Name Solicitation/Contract No. Attachments Risk Approved Insurance Requirements Risk Approved Insurance Certificate(s) Comments Attachments Approved by Risk Management Division Approval: Page 8262 of 10663 10/31/2024 Brown & Brown Insurance Services, Inc. 817 Beachland Blvd. Vero Beach FL 32963 Sheila Julian (772) 231-2828 Sheila.Julian@bbrown.com J&K Auto Parts, Inc. 1820 Boy Scout Drive Fort Myers FL 33907 Nutmeg Insurance Company 39608 Travelers Property Casualty Company of America 25674 Employers Assurance Company 25402 2024 LIAB A 21 UEC DR2110 10/01/2024 10/01/2025 1,000,000 B 10,000 CUP-9T58840A 10/01/2023 11/01/2024 5,000,000 5,000,000 C N EIG5329100-01 10/01/2024 10/01/2025 1,000,000 1,000,000 1,000,000 For any and all work performed on behalf of Collier County. 30-day notice to be given in case of cancellation or nonrenewal, and 10-day notice for non-payment of premium. Collier County Board of Commissioners 3295 Tamiami Trail East Naples FL 34112 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Page 8263 of 10663 Page 8264 of 10663 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY CLAUSE ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM It is agreed that the insurance provided by any additional insured endorsement is primary. We will not seek contribution from any other insurer when insurance on a non-contributing basis is required by contract. Includes copyrighted material of Insurance Services Office, Inc. with its permission. BP-F-119 (07-04)Policy Number: 1871667 Transaction Effective Date: 10/01/2024 Page 8265 of 10663 FEDERATED INSURANCE COMPANIES THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT This endorsement modifies the insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM SCHEDULE Name of Person or Organization: Collier County Board of County Commissioners 3295 Tamiami Trl E Naples, FL 34112-5758 Relationship to the Named Insured: Regarding delivery of parts performed by the Named Insured. A.The following is added to Paragraph C. Who is an Insured: 4.Any person or organization shown in the Schedule is also an insured, but only with respect to "bodily injury" or "property damage" liability arising out of your ongoing operations performed for that insured or premises owned by or rented to you. B.This insurance does not apply to "bodily injury" or "property damage" liability arising out of the sole negligence of the additional insured named above. C.The following exclusion is added to Paragraph B. Exclusions: This insurance does not apply to "bodily injury" or "property damage" occurring after: (1)All work including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2)That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Insured:Place of Issue: J & K Auto Parts, Inc. 1820 Boy Scout Dr Fort Myers, FL 33907-2113 Federated Mutual Insurance Company Home Office 121 East Park Square Owatonna, MN 55060 (507) 455-5200 Includes copyrighted material of Insurance Services Office, Inc. with its permission. BP-F-239 (09-08)Policy Number: 1871667 Transaction Effective Date: 10/01/2024 Page 8266 of 10663 Page 8267 of 10663 Page 8268 of 10663 Page 8269 of 10663 Page 8270 of 10663 Page 8271 of 10663 Page 8272 of 10663 Page 8273 of 10663 Page 8274 of 10663 Page 8275 of 10663 Page 8276 of 10663 Page 8277 of 10663 Page 8278 of 10663 Page 8279 of 10663 Page 8280 of 10663 Page 8281 of 10663 Page 8282 of 10663 Page 8283 of 10663 Page 8284 of 10663 Page 8285 of 10663 Page 8286 of 10663 Page 8287 of 10663 Page 8288 of 10663 Page 8289 of 10663 Page 8290 of 10663 Page 8291 of 10663 Page 8292 of 10663 Page 8293 of 10663 Page 8294 of 10663 Page 8295 of 10663 Page 8296 of 10663 Page 8297 of 10663 Page 8298 of 10663 Page 8299 of 10663 Page 8300 of 10663 Page 8301 of 10663 Page 8302 of 10663 Page 8303 of 10663 Page 8304 of 10663 Page 8305 of 10663 Page 8306 of 10663 Page 8307 of 10663 Page 8308 of 10663 Page 8309 of 10663 Page 8310 of 10663 Page 8311 of 10663 Page 8312 of 10663 Page 8313 of 10663 Page 8314 of 10663 Page 8315 of 10663 Page 8316 of 10663 Page 8317 of 10663 Page 8318 of 10663 Page 8319 of 10663 Page 8320 of 10663 Page 8321 of 10663 Page 8322 of 10663 Page 8323 of 10663 Page 8324 of 10663 Page 8325 of 10663 Page 8326 of 10663 Page 8327 of 10663 Page 8328 of 10663 Page 8329 of 10663 Page 8330 of 10663 Page 8331 of 10663 Page 8332 of 10663 Page 8333 of 10663 Page 8334 of 10663 Page 8335 of 10663 Page 8336 of 10663 Page 8337 of 10663 Page 8338 of 10663 Page 8339 of 10663 Page 8340 of 10663 Page 8341 of 10663 Page 8342 of 10663 Page 8343 of 10663 Page 8344 of 10663 Page 8345 of 10663 Page 8346 of 10663 Page 8347 of 10663 Page 8348 of 10663 Page 8349 of 10663 Page 8350 of 10663 Page 8351 of 10663 Page 8352 of 10663 Page 8353 of 10663 Page 8354 of 10663 Page 8355 of 10663 Page 8356 of 10663 Page 8357 of 10663 Page 8358 of 10663 Page 8359 of 10663 Page 8360 of 10663 Page 8361 of 10663 Page 8362 of 10663 Page 8363 of 10663 Page 8364 of 10663 Page 8365 of 10663 Page 8366 of 10663 Page 8367 of 10663 Page 8368 of 10663 Page 8369 of 10663 Page 8370 of 10663 Page 8371 of 10663 Page 8372 of 10663 Page 8373 of 10663 Page 8374 of 10663 Page 8375 of 10663 Page 8376 of 10663 Page 8377 of 10663 Page 8378 of 10663 Page 8379 of 10663 Page 8380 of 10663 Page 8381 of 10663 INSURANCE REQUIREMENTS COVERSHEET Project Name Vendor Name Solicitation/Contract No. Attachments Risk Approved Insurance Requirements Risk Approved Insurance Certificate(s) Comments Attachments Approved by Risk Management Division Approval: Page 8382 of 10663 10/31/2024 Brown & Brown Insurance Services, Inc. 817 Beachland Blvd. Vero Beach FL 32963 Sheila Julian (772) 231-2828 Sheila.Julian@bbrown.com J&K Auto Parts, Inc. 1820 Boy Scout Drive Fort Myers FL 33907 Nutmeg Insurance Company 39608 Travelers Property Casualty Company of America 25674 Employers Assurance Company 25402 2024 LIAB A 21 UEC DR2110 10/01/2024 10/01/2025 1,000,000 B 10,000 CUP-9T58840A 10/01/2023 11/01/2024 5,000,000 5,000,000 C N EIG5329100-01 10/01/2024 10/01/2025 1,000,000 1,000,000 1,000,000 For any and all work performed on behalf of Collier County. 30-day notice to be given in case of cancellation or nonrenewal, and 10-day notice for non-payment of premium. Collier County Board of Commissioners 3295 Tamiami Trail East Naples FL 34112 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Page 8383 of 10663 Page 8384 of 10663 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTORY CLAUSE ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM It is agreed that the insurance provided by any additional insured endorsement is primary. We will not seek contribution from any other insurer when insurance on a non-contributing basis is required by contract. Includes copyrighted material of Insurance Services Office, Inc. with its permission. BP-F-119 (07-04)Policy Number: 1871667 Transaction Effective Date: 10/01/2024 Page 8385 of 10663 FEDERATED INSURANCE COMPANIES THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT This endorsement modifies the insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM SCHEDULE Name of Person or Organization: Collier County Board of County Commissioners 3295 Tamiami Trl E Naples, FL 34112-5758 Relationship to the Named Insured: Regarding delivery of parts performed by the Named Insured. A.The following is added to Paragraph C. Who is an Insured: 4.Any person or organization shown in the Schedule is also an insured, but only with respect to "bodily injury" or "property damage" liability arising out of your ongoing operations performed for that insured or premises owned by or rented to you. B.This insurance does not apply to "bodily injury" or "property damage" liability arising out of the sole negligence of the additional insured named above. C.The following exclusion is added to Paragraph B. Exclusions: This insurance does not apply to "bodily injury" or "property damage" occurring after: (1)All work including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2)That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Insured:Place of Issue: J & K Auto Parts, Inc. 1820 Boy Scout Dr Fort Myers, FL 33907-2113 Federated Mutual Insurance Company Home Office 121 East Park Square Owatonna, MN 55060 (507) 455-5200 Includes copyrighted material of Insurance Services Office, Inc. with its permission. BP-F-239 (09-08)Policy Number: 1871667 Transaction Effective Date: 10/01/2024 Page 8386 of 10663 10/31/2024 Brown & Brown Insurance Services, Inc. 817 Beachland Blvd. Vero Beach FL 32963 Sheila Julian (772) 231-2828 Sheila.Julian@bbrown.com J&K Auto Parts, Inc. 1820 Boy Scout Drive Fort Myers FL 33907 Nutmeg Insurance Company 39608 Travelers Property Casualty Company of America 25674 Employers Assurance Company 25402 2024 LIAB A 21 UEC DR2110 10/01/2024 10/01/2025 1,000,000 B 10,000 CUP-9T58840A 11/01/2024 10/01/2025 5,000,000 5,000,000 C N EIG5329100-01 10/01/2024 10/01/2025 1,000,000 1,000,000 1,000,000 For any and all work performed on behalf of Collier County. 30-day notice to be given in case of cancellation or nonrenewal, and 10-day notice for non-payment of premium. Collier County Board of Commissioners 3295 Tamiami Trail East Naples FL 34112 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY Page 8387 of 10663