Board Of Aldermen - Agenda - 5/25/2021 - P180
DATE (MM/DD/YYYY}
——~™S ®
ACORD VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE [| geisioo01
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.
This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage
provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose.
PRODUCER NAME.” _Dan Bantham
StateFarm Dan Bantham LUTCF, Agent (AG, No, Ext), 603-429-2008 [FRE oy: 603-429-1524
289 DW HWY GOiatss. _ dan@danbantham.com
° PRODUCER
CUSTOMER ID #:
Merrimack NH 03054 INSURER(S} AFFORDING COVERAGE NAIC #
INSURED INSURER A; State Farm Mutual Automobile Insurance Company 25178
Stephen Ondus INSURER B:
95 Belmont Dr. INSURER C :
INSURER D :
Merrimack NH 03054 INSURER E :
DESCRIPTION OF VEHICLE OR EQUIPMENT
YEAR MAKE / MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER
2017 Chevrolet K2500 Pickup 1GC 1KXEY6HF 242984
DESCRIPTION VEHICLE/EQUIPMENT VALUE , SERIAL NUMBER
$
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS tS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD{S) 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 POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO
ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES).
INSR] ADDL. POLICY EFFECTIVE | POLICY EXPIRATION
LTR |INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDIYYYY) | DATE (MMIDD/YYYY} UMITS
x VEHICLE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
BODILY INJURY (Per person) | §
AlY 064 6949-F05-29 12/05/2020 12/05/2021
BODILY INJURY (Par accident) | $
PROPERTY DAMAGE $s
GENERAL LIABILITY EACH OCCURENCE $
OCCURRENCE GENERAL AGGREGATE $
CLAIMS MADE $s
INSR| Loss POLICY EFFECTIVE | POLICY EXPIRATION
LTR |PAYEE| TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDIYYYY} | OATE {MM/DDIYYYY) LIMITS / DEDUCTIBLE
VEH COLLISION LOSS ACV AGREED AMT | $ LIMIT
A LX 064 6949-F05-29 42/05/2020 12/05/2021 @ O
oO CO STATED AMT | $ 500 DED
VEH COMP VEH OTC ACV AGREED AMT | $ LIMIT
A LX LJ 064 6949-F05-29 12/08/2020 12/05/2021 = O
O (STATED AMT | 8 100 bED
EQUIPMENT (2) acy) [7] AGREED AMT 5 unit
BASIC BROAD C) rc (7 STATED AMT $ DED
SPECIAL oO
REMARKS (INCLUDING SPECIAL CONDITIONS / OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
*** includes all owned, non-owned, and hired autos ***
ADDITIONAL INTEREST CANCELLATION
Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
The additional interest described below has been added to the policy(ies) listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
5% A request has been submitted to add the additional interest described below to the policy(ies) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
listed herein licy number(s). 5 4
VEHICLE / EQUIPMENT INTEREST: i LEASED { i FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST
NAME AND ADDRESS OF ADDITIONAL INTEREST oo SX } ADDITIONAL INSURED LOSS PAYEE
City of Nashua, NH LENDER'S LOSS PAYEE
229 Main St LOANS eyes n
Nashua NH 03060 “PY EPRESE| “AL br
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1997-2015 ACORDLORPORATION. All rights reserved.
ered’marks of ACORD
ACORD 23 (2016/03) The ACORD name and logo are regi
1004361 142987.4 04-24-2020
