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HomeMy WebLinkAboutRiver Road.pdfCERTIFICATE HOLDER © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) JECT LOC POLICY PRO- GEN'L AGGREGATE LIMIT APPLIES PER: CLAIMS-MADE OCCUR COMMERCIAL GENERAL LIABILITY GENERAL LIABILITY PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DED RETENTION $ CLAIMS-MADE OCCUR $ AGGREGATE $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNED AUTOS AUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) ENDORSEMENT NO. ATTACHED TO AND FORMING A PART OF POLICY NUMBER ENDORSEMENT EFFECTIVE DATE (12:01 A.M. STANDARD TIME) NAMED INSURED AGENT NO. Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 GLS-326s (8-11) Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED—OPERATORS OF NON-OWNED FIREWORK STANDS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Section II—Who Is An Insured is amended to include as an additional insured any person or organization that holds a certificate of insurance for the “non-owned fire- work stands” through an agreement with you, but only with respect to “bodily injury,” “property damage” or “per- sonal and advertising injury,” subject to the following addi- tional exclusions: 1. The insurance afforded the additional insured does not apply to: a. Any express warranty unauthorized by you; b. Any physical or chemical change in the prod- uct made intentionally by the additional in- sured, including the ignition of “fireworks”; c. Repackaging, except when unpacked solely for the purpose of sale or inspection; d. “Bodily injury” or “property damage” arising out of “fireworks” that are not purchased from the Named Insured; e. Any failure to make such inspections, adjust- ments or servicing as the additional insured has agreed to make or normally undertakes to make in the usual course of business, in con- nection with the distribution or sale of the products; or e. Demonstration or product testing operations. 2. This insurance does not apply to any insured per- son or organization, from which you have ac- quired such products, or any ingredient, part or container, entering into, accompanying or contain- ing such products. 3. Coverage provided is limited to those certificate holders who obtain a certificate of insurance prior to an “occurrence” and whose certificate of insur- ance is on file with us. 4. Coverage provided by this endorsement is limited to the certificate holder of the “non-owned fire- work stands” and to the time period specified in the certificate of insurance. For purposes of this endorsement, the following defini- tions apply: “Non-owned firework stands” means any premises, site or location which is owned, or occupied by, or rented or loaned to a certificate of insurance holder, including any temporary structures, used for the retail sale of the Named Insured’s “fireworks.” “Fireworks” means an explosive or burning device or pyro- technic material, product or device. AUTHORIZED REPRESENTATIVE DATE PROPERTY DAMAGE $ $ $ $ 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 WVD SUBR N / A $ $ (Ea accident) (Per accident) 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). The ACORD name and logo are registered marks of ACORD COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ryder Rosacker McCue & Huston (MGD by Hull & Company) 509 W Koenig St Grand Island NE 68801 Kristy Wolfe 308-382-2330 308-382-7109 Kwolfe@ryderinsurance.com SCOTTSDALE INS CO 41297 LIT Fireworks LLC 653 Florence Dr Greenfield IN 46140 2089012223 A X 1,000,000 250,000 X 1,000,000 2,000,000 2,000,000 CPS4020649 8/25/2022 8/25/2023 X 5,000 4/26/2023 Non-Owned Stand Coverage provided per attached form GLS-326s. Blanket Additional Insured applies to the entities listed below per attached form GLS-150s when required by written agreement. For premise liability – this certificate reflects coverage for the dates and location noted below. For product liability – this certificate reflects coverage for products purchased from the above Named Insured only. KLC Realty LLC & Jay's Fireworks 14650 River Road, Suite 150, Carmel, IN 46033 KLC Realty LLC 14650 River Road, Suite 150 Carmel IN 46033 United States