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INSRADD'LLTRINSRDDATE (MM/DD/YYYY)PRODUCERINSUREDPOLICY EFFECTIVEPOLICY EXPIRATIONPOLICY NUMBERLIMITSDATE (MM/DD/YY)DATE (MM/DD/YY)TYPE OF INSURANCEGENERAL LIABILITYAUTOMOBILE LIABILITYGARAGE LIABILITYEXCESS/UMBRELLA LIABILITYWORKERS COMPENSATION ANDEMPLOYERS' LIABILITYOTHERDESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONSSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIONDATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAILDAYS WRITTENNOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALLIMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS ORREPRESENTATIVES.AUTHORIZED REPRESENTATIVE
ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?INSURER A:INSURER B:INSURER C:INSURER D:INSURER E:EACH OCCURRENCE$DAMAGE TO RENTEDCOMMERCIAL GENERAL LIABILITY$PREMISES (Ea occurrence)CLAIMS MADEOCCURMED EXP (Any one person)$PERSONAL & ADV INJURY$GENERAL AGGREGATE$GEN'L AGGREGATE LIMIT APPLIES PER:PRODUCTS - COMP/OP AGG$PRO-POLICYLOCJECTCOMBINED SINGLE LIMIT$(Ea accident)ANY AUTOALL OWNED AUTOSBODILY INJURY$(Per person)SCHEDULED AUTOSHIRED AUTOSBODILY INJURY$(Per accident)NON-OWNED AUTOSPROPERTY DAMAGE$(Per accident)AUTO ONLY - EA ACCIDENT$ANY AUTOEA ACC$OTHER THANAUTO ONLY:AGG$EACH OCCURRENCE$OCCURCLAIMS MADEAGGREGATE$$DEDUCTIBLE$RETENTION$$WC STATU-OTH-TORY LIMITSERE.L. EACH ACCIDENT$E.L. DISEASE - EA EMPLOYEE$If yes, describe underE.L. DISEASE - POLICY LIMIT$SPECIAL PROVISIONS below
OTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED ORMAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCHPOLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.INSURERS AFFORDING COVERAGENAIC #COVERAGESCERTIFICATE HOLDERCANCELLATION SEE BELOW & PAGE 2ACORD 25 (2001/08)ACORD CORPORATION 1988
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CERTIFICATE OF LIABILITY INSURANCE
04/15/09Wortham Insurance & Risk Mgt1600 West Seventh StreetFort Worth, TX 76102-2505817 336-3030Jason Greene7202 Harvest Hill DrRowlett, TXColony Insurance Company39993AXXXPD Ded:250BINDER67109404/15/0904/15/102,000,0002,000,0001,000,0001,000,000100,0005,000Certificate Holder has been added as an Additional Insured in regard to General Liability as required bywritten contract.Gemini Stage Lighting andEquipment, Inc.10218 Miller RoadDallas, TX 752381of 2#S93292/M9329118JASONGREClient#: 8081618JDE
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