®
ACCORD
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
6/16/2017
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
Burgin, Platner, Hurley Insurance Agency, LLC
14 Franklin St.
as Janet Sweeney, CIC, CPCU
PHONE exp, (617) 691-2628
es No); (617) 472-7248
EMAL 5. JS2@bphins.com
INSURER(S) AFFORDING COVERAGE NAIC #
Quincy MA 02169 INSURER A:Great Divide Insurance Company
INSURED INSURERB:Excelsior Insurance Company 11045
Waldron Engineering & Construction, Inc.
iNsURERC:‘Nautilus Insurance Company
37 Industrial Drive INSURER D :
Suite G- 1 INSURER E :
Exeter NH 03833 INSURER F :
COVERAGES CERTIFICATE NUMBER:2017-2018 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 IN D POLICY NUMBER (MMI/DD/YYYY) | (MM/DD/YYYY) LIMITS
GENERAL LIABILITY GLP2012054-13 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
X | COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $ 100,000
c CLAIMS-MADE [x] OCCUR Y|Y 6/25/2017 6/25/2018 | wep EXP (Any one person) | $ 5,000
|_| PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 3,000,000
POLICY x | FRO: | LOC $
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000
B ANY AUTO BODILY INJURY (Per person) | $
Autos iio. YIN 6/25/2017 |6/25/2018 | BobILy INJURY (Per accident)| $
x | NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
Underinsured motorist $
UMBRELLA LIAB | X | occur Y | Y jrx2012059-14 EACH OCCURRENCE $ 5,000,000
Cc EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
DED | | RETENTION $ Follow Form Excess Liab. |6/25/2017 (6/25/2018 $
A. | WORKERS COMPENSATION Y $yca2012053-13 WC STATU- OTH-
AND EMPLOYERS ' LIABILITY YIN X | TORY Limits ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? NIA 6/25/2017 16/25/2018 : £000,000
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 1,000,000
C | Professional $50,000 ded CCP2012057-14 6/25/2017 \6/25/2018 | Each Claim/Shared Aggregate $5,000,000
C | Pollution $10,000 Ded. ¥ | Y cp2012057-14 6/25/2017 \6/25/2018 | Ea Poll COndition/Shared Agg $5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER
CANCELLATION
For Proposal Only
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
~ ro , Fae lt ol
K Besse, CIC CISR CPI > * Ee a:
ACORD 25 (2010/05)
INS025 rominon 91
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