Workers Compensation Representative
Resume:
Form_SCTNID_CTGRY.XX****ACORD**_ACORD
<docindex><index>ACORD</index></docindex>
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) PRODUCER CONTACT
NAME:
PHONE
(A/C, No, Ext):
FAX
(A/C, No):
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INSR
LTR
ADDL
INSD
SUBR
TYPE OF INSURANCE WVD
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY
OTHER:
PRO-
JECT LOC
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON-OWNED
AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y/N
N / A
POLICY NUMBER
POLICY EFF POLICY EXP
(MM/DD/YYYY) (MM/DD/YYYY) LIMITS
$
$
$
$
$
$
$
EACH OCCURRENCE
DAMAGE TO RENTED
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
PREMISES (Ea occurrence)
$
$
$
$
$
COMBINED SINGLE LIMIT
PROPERTY DAMAGE
BODILY INJURY (Per person)
(Ea accident)
BODILY INJURY (Per accident)
$
$
$
AGGREGATE
EACH OCCURRENCE
E.L. EACH ACCIDENT
INSURED
$
$
E.L. DISEASE - POLICY LIMIT $
E.L. DISEASE - EA EMPLOYEE
PER
STATUTE
OTH-
ER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
© 1988-2015 ACORD CORPORATION. All rights reserved.
(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 have ADDITIONAL INSURED provisions or 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). 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. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
*********************@*****.***********.***
12/02/2022
DAVID BOWMAN ENTEREPRISE LLC
14707 GLADEBROOK DR
HOUSTON, TX 77068
MAX LOGISTICS LLC
1801 N. GREENVILLE AVENUE
SUITE 3127
RICHARDSON, TX 75081
Progressive Commercial Lines Customer and Agent Servicing 911465454004682144D120222T190805
INSURANCEHUB LEAVITT
1720 LAKE PKWY, LAWRENCEVILLE, GA 30043
Progressive County Mutual Insurance Company 29203
A X N N 963******-**/01/2022 12/01/2023
1,000,000
A N N 963******-**/01/2022 12/01/2023
Motor Truck Cargo $100,000 w/$1,000 Ded
Form_SCTNID_CTGRY.XX0108ACORD101_ACORD
<docindex><index>ACORD</index></docindex>
INSURANCEHUB LEAVITT
963873874
Progressive County Mutual Insurance Company 29203
DAVID BOWMAN ENTEREPRISE LLC
14707 GLADEBROOK DR
HOUSTON, TX 77068
12/01/2022
AGENCY CUSTOMER ID:
LOC #:
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY
POLICY NUMBER
CARRIER NAIC CODE
NAMED INSURED
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance 1 1
Description of Location/Vehicles/Special Items
Scheduled autos only
2021 FORD TRANSIT 1FDBF6P87MKA81543
Comprehensive $1,000 Ded
Collision $1,000 Ded
Liability coverage may not apply to all scheduled vehicles. ACORD 101 (2008/01)
The ACORD name and logo are registered marks of ACORD
© 2008 ACORD CORPORATION. All rights reserved.
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