CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/8/2016 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 Yates Insurance Agency PHONE FAX (A/C, No, Ext): 404-633-4321 (A/C, No): 404-633-1312 2800 Century Parkway NE E-MAIL Suite 300 ADDRESS: certs@yatesins.com Atlanta GA 30345- INSURER(S) AFFORDING COVERAGE INSURER A : Travelers Indemnity Company 25658 INSURED LINRROG-01 INSURER B : Charter Oak Fire Insurance Company 25615 Lin R. Rogers Electrical Contractors, Inc. INSURER C : National Union Fire Ins Co Pittsbur 19445 Rogers Electric Service Corporation INSURER D : Travelers Indemnity Company of Amer 25666 Rogers Electric Lighting Corporation 2050 Marconi Drive, Suite 100 INSURER E : Travelers Property Casualty Co of A 25674 Alpharetta GA 30005 INSURER F : COVERAGES CERTIFICATE NUMBER: 675841792 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY VTC2KCO5787B539 1/1/2016 1/1/2017 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $ 1,000,000 B C OTHER: AUTOMOBILE LIABILITY X X X X ANY AUTO ALL OWNED AUTOS HIRED AUTOS HA Phys Dmg UMBRELLA LIAB X SCHEDULED AUTOS NON-OWNED AUTOS OCCUR EXCESS LIAB CLAIMS-MADE DED X RETENTION $ 10,000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E Leased/Rented Equipment E Installation - Job Site X CONTACT NAME: MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 COMBINED SINGLE LIMIT CAP5787B540 1/1/2016 1/1/2017 (Ea accident) $ 1,000,000 BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) 15805728 1/1/2016 1/1/2017 EACH OCCURRENCE $ 15,000,000 VTC2JUB8571C373 1/1/2016 1/1/2017 X QT6600104L715 QT6600104L715 1/1/2016 1/1/2016 AGGREGATE $ 15,000,000 PER STATUTE E.L. EACH ACCIDENT GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY X JECT LOC OTH- ER E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1/1/2017 1/1/2017 (Stored - $1,000,000) $ $ $ $ $ $ $ 1,000,000 $ 1,000,000 $500,000 $4,000,000 NAIC # DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Subject to policy terms, conditions, forms, and exclusions, the insurance coverages afforded by the policies above include the following when required by written contract for the certificate holder and/or entities listed below: Blanket Additional Insured in regards to General Liability for ongoing and completed operations and Automobile Liability; Blanket Primary and Non-Contributory in regards to General Liability and Automobile Liability; Blanket Waiver of Subrogation in regards to General Liability, Automobile Liability and Workers Compensation; 30 day Notice of Cancellation; Blanket Loss Payee for Leased/Rented Equipment and Installation Floater; Per Project Aggregate applies to the General Liability. See Attached... CERTIFICATE HOLDER ABS Facility Maintenance 2415 North Illinois St Belleville IL 62226 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. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: LINRROG-01 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Yates Insurance Agency POLICY NUMBER CARRIER ADDITIONAL REMARKS NAIC CODE NAMED INSURED EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Lin R. Rogers Electrical Contractors, Inc. Rogers Electric Service Corporation Rogers Electric Lighting Corporation 2050 Marconi Drive, Suite 100 Alpharetta GA 30005 FORMS: CGT801 - Blanket Additional Insured (Contractors) CGD3161111 - Contractors XTEND Endorsement CGD2110104 - Designated Project(s) General Aggregate Limit CAT4740212 - Blanket Additional Insured - Primary and Non-Contributory with Other Insurance CAT3530310 - Business Auto Extension Endorsement WC000313(00)-01 - Waiver of Our Right to Recover From Others Endorsement CMT5600110 - Blanket Loss Payees ILT4050311 - Designated Entity - Notice of Cancellation Provided By Us (GL) ILT4050311 - Designated Entity - Notice of Cancellation Provided By Us (Auto) WC9906R3(00) - Notice of Cancellation to Designated Persons or Organizations 52138(7/95) - Georgia Amendatory Endorsement - Cancellation/NonRenewal ACORD 101 (2008/01) 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD