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HomeMy WebLinkAboutCertificates of Insurance 79/3/2025 E(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 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). PRODUCER CONTACT NAME: WS Certificates Woodruff-Sawyer&Co. PHONE FAX 50 California Street, Floor 12 A/C No Ext: 844-972-6326 A/C,No): E-MSan Francisco CA 94111 ADDRESS: Certificates@woodruffsawyer.com INSURER(S)AFFORDING COVERAGE NAIC# License#:0329598 INSURERA: Hartford Casualty Insurance Company 29424 INSURED ROLLTEC-01 INSURERB: Fortegra Specialty Insurance Company 16823 RollKall Technologies, LLC INSURERC:Westchester Surplus Lines Insurance Company 10172 909 Lake Carolyn Pkwy, Suite 1500 Irving TX 75039 INSURERD: Lexington Insurance Company 19437 INSURERE: Endurance American Specialty Insurance Company 41718 INSURER F: Lloyds of London COVERAGES CERTIFICATE NUMBER:1483021741 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MM/DD C X COMMERCIAL GENERAL LIABILITY Y Y G48795535001 8/14/2025 8/14/2026 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $100,000 MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY❑ PRO- JECT ❑ LOC PRODUCTS-COMP/OP AGG $2,000,000 X OTHER: Deductible $25,000 AUTOMOBILE LIABILITY as try T COMBINED SINGLE LIMIT $ Ea accident ANY AUTO '* 9.4"'$ BODILY INJURY(Per person) $ OWNED SCHEDULED WANIF WAXY"—, BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident D X UMBRELLA LIAB X OCCUR 020744147 8/14/2025 8/14/2026 EACH OCCURRENCE $5,000,000 EXCESS LAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$ $ A WORKERS COMPENSATION Y 57WECBS5Z9Y 6/13/2025 6/13/2026 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICE R/M EMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B E&O/Cyber Liability C4LRH090216CYBER2025 7/12/2025 7/12/2026 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) E&O/Cyber Liability Retention:$ Type Of Insurance: Crime Insurer Affording Coverage:Amwins Global Risks Limited Policy Number: EKI3579791; EFF Date:6/25/2025; EXP Date:7/12/2026 Limit of Liability:$1,000,000 See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Monroe County BOCC 1100 Simonton Street AUTHORIZED REPRESENTATIVE Key West, FL 33040 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: ROLLTEC-01 LOC#: ACOOR 0 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Woodruff-Sawyer&Co. RollKall Technologies, LLC 909 Lake Carolyn Pkwy, Suite 1500 POLICY NUMBER Irving TX 75039 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Monroe County BOCC is included as Additional Insured as respects General Liability on a Primary and Non-contributory basis with a waiver of subrogation to the extent provided in the attached form. ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: G48795535001 COMMERCIAL GENERAL LIABILITY CG20101219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Any person or organization where required Any premises where required by written contract by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodilyinjury" or damage" or "personal and advertising injury" property damage occurring after: pp y caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable limits of additional insureds, the following is added to insurance; Section III— Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable limits of insurance. will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 20 10 12 19 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG24531219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) - AUTOMATIC This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery against any person or organization, because of any payment we make under this Coverage Part, to whom the insured has waived its right of recovery in a written contract or agreement. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person or organization prior to loss. CG 24 53 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1 Auto-Chlor System of Washington, Inc. rut THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Policy Number: 57 WEC BS5Z9Y Endorsement Number: Effective Date: 06/13/25 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: RollKall Technologies 909 LAKE CAROLYN PKWY IRVING TX 75039 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE Any person or organization for whom you are required by contract or agreement to obtain this waiver from us. Endorsement is not applicable in KY, NH, NJ or for any MO construction risk Countersigned by Authorized Representative Form WC 00 03 13 Printed in U.S.A. Process Date: 06/16/25 Policy Expiration Date: 06/13/26 DATE(MMIDD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 0/10/2022 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). PRODUCER CONTACT Nikki McKelvey NAME: Threlkeld&Company Insurance HCNN. Ext: (903)581-0077 a/c,No): (903)306-0652 515 WSW Loop 323 E-MAIL nmckelvey@threlkeld.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Tyler TX 75701 INSURERA: Allied World Surplus Lines Ins.Co. 24319 INSURED INSURER B: Mercury County Mutual Insurance Company 29394 RollKall Technologies,LLC. INSURER C: Texas Mututal Insurance Company 600 Las Colinas Blvd INSURER D: Trisura Specialty Insurance Company Ste 900 INSURER E: Berkley Insurance Company Irving TX 75039 INSURER F: Argonaut Ins.Co. COVERAGES CERTIFICATE NUMBER: 22/23 Auto w/WC 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 TYPE OF INSURANCEAUULbUBK POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX OCCUR PREM SDAMAGES Ea oNcurDreme $ 100'000 MED EXP(Any one person) $ 10,000 A 5200-4107-00 09/01/2022 09/01/2023 PERSONAL&ADV INJURY $ 1,000,000 MOTHER LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 3'000'000 JECT: Errors&Omissions $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ B OWNED rx SCHEDULED BA420000020741 09/23/2022 09/23/2023 BODILY INJURY(Peraccident) $ AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LAB HCLAIMS-MADE 5201-1783-00 09/01/2022 09/01/2023 AGGREGATE $ 10,000,000 DED I I RETENTION $ $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABI LI TY Y/N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ C OFFICER/MEMBER EXCLUDED? N/A 0002079181 06/13/2022 06/13/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Cyber Liability D ATB-6612495-02 09/01/2022 09/01/2023 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The general liability,automobile and umbrella policies include a blanket automatic additional insured endorsement provision that provides additional insured status to the certificate holder only when there is a written contract between the insured and the certificate holder that requires such status. The general liability,automobile,workers compensation and umbrella policies include a blanket automatic waiver of subrogation endorsement that provides this feature only when there is a written contract between the named insured and the certificate holder that requires it. CERTIFICATE HOLDER CANCELLATION APPROVED BY RISK MANAGEMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BY THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Monroe County BOCC DATE 101111/2..022 w ACCORDANCE WITH THE POLICY PROVISIONS. 1100 Simonton Street WAIVER N/A YES AUTHORIZED REPRESENTATIVE Key West FL 33040 .—.ae @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Additional Named Insureds Other Named Insureds Athos Group, LLC Limited Liability Company, Additional Named Insured OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Threlkeld&Company Insurance RollKall Technologies,LLC. POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes Crime Coverage Carrier(E):Berkley Insurance Company Policy#:BCCR-45004935-20 Effective Date:9/1/2022 to 9/1/2023 Employee Theft:$1,000,000 Forgery or Alteration:$1,000,000 Computer&Funds Transfer Fraud:$1,000,000 Money Orders and Counterfeit Money:$50,000 Corporation Deception Fraud:$50,000 Deductible:$10,000 Other States Workers'Compensation Carrier(F):Argonaut Ins.Co. Policy#WC 928878776574 Effective Date:06/13/2022 to 06/13/2023 E.L.Each Accident:$1,000,000 E.L.Disease-EA Employ:$1,000,000 E.L.Disease-Policy Limit:$1,000,000 ACORD 101 (2008/01) © 2008ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD