WA0301-CN050705JUL-~-2005 lq:q2 F~OH:FOXCO ~7272~6007 T0:97~0~S70 R.~
B?YBS/B~ 11:55:13 817-Zgg-3Bg0-)gTZ7236BB7 Pag~ BB1
Clle fllb~: 3707 FOXCON1
ACORD. CERTIFICATE OF LIABILITY INSURANCE I
__
p~ODUCER THIS C~RTIFI~TE IS ISSUED AS A MA~ER OF INFOR~TION
Cadenh~d Shinier Insuran~ ONLY AND CONERS NO RIGHTS UPON THE C~TIRCATE
HO~ER. THIS CERTIFICATE DOES NOT ~END, E~END OR
8701 ~o~ Euless R~., ~ ALTER THE COVE~GE ~FORDED BY THE POUCIES BELOW.
Hur~, TX 76053
817 58~00 INSURERS ~FO~ING CO~RAGE N~C ·
~ t,SU~= ~u~ ~ Amerisum Mutual Ins Co 233~
PO Box 951
Mid~thian, TX 7606~0951
COVERAGES
A (~NERXL L L&glLI'r¢ :PP2029081 05110/05 05110106 I ;xc~ r~cum~ENCE si,Q00,000
~ *Blkt A]~O~30
~ ~ J~r ~ L~ wri~en contact
~ ~um j~,~ ~1,000,000
~,~,000
~0001000
A w~mc~*,~= WC20~084 05110105 0~10106 X Im~Hu~*~ I ~
LOch ~ne ~ter Line
Ci~ of Cop~l Is included ~ Addi~onal Insur~ on Genii Liability and
CERTIFICATe, HOLDER CANCELLATION
P.O. Box 9478
Coppell, TX 75019
ACORO 25 {2001108) I of 2 #M32925
CHR e ACORD CORPORATION t988
IMPORTANT
If U~e certificate tmlder ~ an ADDITIONAL INSURED, the policy(les)must be endorsed. A sbatwment
on this certificate does not confer ~ighl~ to ttle cer~icale holder In lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms enO conditionsofthe policy, certain policies may
require an endo~'sement. A statement on d~is c~tiflcete does not confer rights to the certificate
holder in lieu of such endorsement(s)
DISCLAIMER
The Certificate of Insurance on the reveme side of th~ form does nd canstituire a contract between
the issuing Insurer(s), authorized repreca~tative or producer, and the cartlflcate holder, nor dOes it
affirmatively or negatively amend, extend or ~ter the cover-age afforded by tl~e policies listed thereon.
ACORD 25~ (~0'1;08) 2 of 2 #M3~9~5