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ACCORD
ee
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
10/27/2017
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
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
certificate holder in lieu of such endorsement(s).
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
PRODUCER
Cross Insurance
CONTACT
NAME: Matt D'Arcy
PHONE (603) 742-2552
FAX
(AIC, No, Ext): {Ale, No): (603) 742-4509
475C High Street poreeae. mdarcy@crossagency.com
INSURER(S) AFFORDING COVERAGE NAIC #
Somersworth _NH_ 03878 INSURERA:Ohio Security Ins Co 24082
INSURED INSURER B:‘Ohio Casualty Insurance Company 24074
Forcier Contracting & Building Services Ince INSURERC :Peerless Ins Co 24198
51 Lake St # 13 INSURER D:
INSURER E :
Nashua NH 03060 INSURER F :
COVERAGES CERTIFICATE NUMBER:CL175808 938 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.
endorsements and special provisions.
INSR ADDL |SUBR| POLICY EFF | POLICY EXP
LTR TYPE OF INSURANCE INSD | wvD POLICY NUMBER (MMIDDIYYYY) | (MMIDD/YYYY) LIMITS
X | COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
A CLAIMS-MADE OCCUR PREMISES (Ea occurrence} $ 300,000
x BKS56130313 5/12/2017 | 5/12/2018 | MED EXP (Any one person) $ 15,000
PERSONAL & ADV INJURY | $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY [ x | SECT [| LOC PRODUCTS - COMP/OP AGG | $ 2,000,000
OTHER: Schedule Mod Factor 1 $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO BODILY INJURY (Per person) | $
ALL OWNED SCHEDULED :
AUTOS AUTOS BODILY INJURY (Per accident) $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident}
$
X | UMBRELLA LIAB x | occUR EACH OCCURRENCE $ 2,000,000
B EXCESS LIAB CLAIMS-MADE USO56130313 5/12/2017 | 5/12/2018 | AGGREGATE $ 2,000,000
DED | x RETENTION $ 10,000 $
WORKERS COMPENSATION x | PER OTH-
AND EMPLOYERS’ LIABILITY YIN STATUTE | ER
ANY PROPRIETOR/PARTNER/EXECUTIVE WC3409243 3a: NH & MA 5/12/2017 | 5/12/2018 | E.L. EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? NIA ; ;
C |(Mandatory in NH) John & Michael Forcier are jexcluded E.L. DISEASE - EA EMPLOYEE $ 500,000
¥ yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of Nashua is additional insured under the General Liability as required by written contract.
John Forcier & Michael Forcier are excluded from Workers Compensation. Refer to policy for exclusionary
CERTIFICATE HOLDER
CANCELLATION
City of Nashua
9 Riverside Street
Nashua, NH 03060
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
Angela Mita/AM4 Omeae de PAL ta
ACORD 25 (2014/01)
§INSO25 1901401)
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