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Universal Engineering Sciences | 74 <br />H. Forms and Attachments <br />c. Firm’s Current Certificate(s) of Insurance; <br />INSR ADDL SUBRLTRINSRWVD <br />DATE (MM/DD/YYYY) <br />PRODUCER CONTACTNAME: <br />FAXPHONE(A/C, No):(A/C, No, Ext): <br />E-MAILADDRESS: <br />INSURER A : <br />INSURED INSURER B : <br />INSURER C : <br />INSURER D : <br />INSURER E : <br />INSURER F : <br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) <br />COMMERCIAL GENERAL LIABILITY <br />AUTOMOBILE LIABILITY <br />UMBRELLA LIAB <br />EXCESS LIAB <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />AUTHORIZED REPRESENTATIVE <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />Y / N <br />N / A <br />(Mandatory in NH) <br />ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? <br />EACH OCCURRENCE $ <br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR <br />MED EXP (Any one person)$ <br />PERSONAL & ADV INJURY $ <br />GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS - COMP/OP AGG $ <br />$ <br />PRO- <br />OTHER: <br />LOCJECT <br />COMBINED SINGLE LIMIT $(Ea accident) <br />BODILY INJURY (Per person)$ANY AUTO <br />OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS <br />AUTOS ONLYHIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident) <br />$ <br />OCCUR EACH OCCURRENCE $ <br />CLAIMS-MADE AGGREGATE $ <br />DED RETENTION $$ <br />PER OTH-STATUTE ER <br />E.L. EACH ACCIDENT $ <br />E.L. DISEASE - EA EMPLOYEE $If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below <br />POLICY <br />NON-OWNED <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). <br />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: <br />CERTIFICATE HOLDER CANCELLATION <br />© 1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) <br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE <br />Valley Forge Insurance Company <br />National Fire Insurance Co of Hartford <br />Various Carriers - See Description <br />2/11/2020 <br />McGriff Insurance Services <br />PO Box 4927 <br />Orlando, FL 32802-4927 <br />407 691-9600 <br />407 691-9600 888-635-4183 <br />Universal Engineering Sciences LLC <br />3532 Maggie Blvd. <br />Orlando, FL 32811 <br />20508 <br />20478 <br />20/21 Master BAI/BWS <br />A X <br />X <br />X Incl X,C,U <br />X <br />**6075841134 01/01/2020 01/01/2021 1,000,000 <br />100,000 <br />15,000 <br />1,000,000 <br />2,000,000 <br />2,000,000 <br />B <br />X <br />**6075841120 01/01/2020 01/01/2021 1,000,000 <br />C <br />X <br />X See Description <br />for Excess Liab <br />information <br />01/01/2020 01/01/2021 See Descripti <br />See Descripti <br />A <br />N <br />*6075841151 01/01/2020 01/01/2021 X <br />1,000,000 <br />1,000,000 <br />1,000,000 <br />*Additional Insured status is granted with respect to General Liability if required by written contract per <br />"Blanket Additional Insured-Owners, Lessees or Contractors-with Products-Completed Operations Coverage <br />Endorsement" Form #CNA75079XX 10/16. <br /> <br />Primary and Non-Contributory status is granted with respects to General Liability if required by written <br />(See Attached Descriptions) <br />Proof of Insurance for <br />Information Purposes Only <br /> <br />1 of 2#S25184452/M25113912 <br />131UNIVEENGClient#: 1405231 <br />PSBE1of 2#S25184452/M25113912