ANY PROPRIETOR/ PARTNER/ EXECUTIVE
OFFICER/ MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
DATE ( MM/DD/YYYY)
PRODUCER CONTACT
NAME:
FAXPHONE
A/C, No, Ext): A/C, No):(
E-MAIL
ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER EXPTYPEPOLICY EFF POLICY
OF INSURANCE MM/DD/YYYY)( MM/DD/YYYY) LIMITS(
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ( ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS- MADE OCCUR $ PREMISES ( Ea occurrence)
MED EXP ( Any one person)$
PERSONAL & ADV INJURY $
GEN' L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PROPOLICY LOC PRODUCTS - COMP/ OP AGG $ JECT
OTHER:$
COMBINED SINGLE LIMIT $(
Ea accident)
ANY AUTO BODILY INJURY ( Per person)$
OWNED SCHEDULED BODILY INJURY ( Per accident)$
AUTOS ONLY AUTOS
HIRED NON- OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY ( Per accident)
OCCUR EACH OCCURRENCE $
CLAIMS- MADE AGGREGATE $
DED RETENTION $$
PER OTHSTATUTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ INSURER( S) AFFORDING COVERAGE NAIC #
COMMERCIAL GENERAL LIABILITY
Y / N
N / A
Mandatory in NH)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
1988-2015 ACORD CORPORATION. All rights reserved.
ACORDACORD 25 (2016/03) The ACORD name and logo are registered marks of
CERTIFICATE OF LIABILITY INSURANCE
Lockton Companies, LLC
DBA Lockton Insurance Brokers, LLC in CA
CA license # 0F15767
8110 E Union Ave., Ste. 100
Denver CO 80237
denver- certs@lockton. com
JustFOIA, Inc.
3717 Apalachee Parkway
Tallahassee FL 32311
Scottsdale Insurance Company 41297
Berkley National Insurance Company 38911
At-Bay Specialty Insurance Company 19607
X
X
1,000, 000
1,000, 000
15, 000
1,000, 000
2,000, 000
2,000, 000
X
X
X Comp. Ded. $ 100
1,000, 000
XXXXXXX
XXXXXXX
XXXXXXX
Coll. Ded. 1,000
X X 5,000, 000
5,000, 000
XXXXXXX
N
X
1,000, 000
1,000, 000
1,000, 000
Tech E& O/Cyber Liability
XS Tech E& O/ Cyber
Limit: $5,000, 000
SIR: $ 50, 000
Limit: $ 5,000, 000 xs $ 5,000, 000
A TCP 7030322- 12 12/1/2025 12/ 1/2026
A TCP 7030322- 12 12/ 1/2025 12/ 1/ 2026
B AB-6712027- 01 12/1/2025 12/ 1/2026
C EKS3600167 12/ 1/2025 12/ 1/ 2026
A TCP 7030322- 12 12/ 1/2025 12/ 1/ 2026
A TWC 7030323- 11 12/ 1/2025 12/ 1/ 2026
12/1/2026
1456427
N N
N N
N N
N
12/ 1/2025
N N
17681908
17681908 XXXXXXX
Evidence of Coverage
X
See Attachment
Evidence of Coverage
To whom it may concern:
In our continuing effort to provide timely certificate delivery, Lockton Companies is transitioning to paperless delivery of Certificates of Insurance, thus this is your final hard-copy delivery.
To ensure electronic delivery for future renewals of this certificate, we need your email address.
Please contact us via one of the methods below, referencing Certificate ID 17681908.
Email: [email protected]
Phone: 303-728-8060
If you received this certificate through an internet link where the current certificate is viewable, we have your email and no further action is needed.
In the event your mailing address has changed, will change in the future, or you no longer require this certificate, please let us know using one of the methods above.
The above inbox and phone number is for automating electronic delivery of certificates only.
Please do NOT send future certificate requests to this inbox or contact the phone number below with email updates.
Thank you for your cooperation and willingness in reducing our environmental footprint.
Lockton Companies
Lockton Companies
8110 E. Union Avenue, Suite 100
Denver, CO 80237
Attachment Code: D644713 Master ID: 1456427, Certificate ID: 17681908