Page 4 - Introduction

PRUSCON-02 JAYME1JLB
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
06/07/2017
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 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).
CONTACT Jayme' Brown
PRODUCER NAME:
Keith E Tracy LLC PHONE FAX
100 Tower Drive (A/C, No, Ext): (630) 908-4227 (A/C, No):(630) 468-1709
STE 120 E-MAIL jbrown@ais-ins.com
ADDRESS:
Burr Ridge, IL 60527
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :Evanston Insurance Company
INSURED INSURER B :Pekin Insurance Company 24228
Prusak Construction & Roofing, Inc INSURER C :StarStone National Insurance Company 25496
8907 S. Odell INSURER D :Riverport Insurance Company 36684
Bridgeview, IL 60455
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 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 INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR 3C32018 05/31/2017 05/31/2018 DAMAGE TO RENTED $ 100,000
PREMISES (Ea occurrence)
5,000
MED EXP (Any one person) $
1,000,000
PERSONAL & ADV INJURY $
2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
X POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000
JECT
OTHER: $
B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
X ANY AUTO 00P619334 02/15/2017 02/15/2018 BODILY INJURY (Per person) $ 1,000,000
OWNED SCHEDULED 1,000,000
AUTOS ONLY AUTOS BODILY INJURY (Per accident) $
X HIRED X NON-OWNED PROPERTY DAMAGE 1,000,000
AUTOS ONLY AUTOS ONLY (Per accident) $
$
C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
X EXCESS LIAB CLAIMS-MADE Y71596170ALI 05/31/2017 05/31/2018 AGGREGATE $ 1,000,000
DED RETENTION $ $
D WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS' LIABILITY STATUTE ER
Y / N ILARP304832 05/05/2017 05/05/2018 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? Y N / A
(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 $

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The owners are excluded from the workers compensation policy.

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Sample Certificate of Insurance ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

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