CODECON-02
JJACKSON2
ACORD®
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
1/19/2022
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
PRODUCER
NAME:
Energy Insurance Agency, Inc.
P o Box 55268
(A/C, PHONE No, Ext): (859) 273-1549
(A/C, FAX No): (859) 272-0075
Lexington, KY 40555
ADDRESS: E-MAIL eia@energyinsagency.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : National Trust Insurance Company
20141
INSURED
INSURER B : FCCI Insurance Company
10178
Codell Construction Company
INSURER C : Kentucky Employers Mutual Ins.
10320
4475 Rockwell Road
INSURER D : Arch Specialty Insurance Co.
21199
Winchester, KY 40392
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
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
1,000,000
CLAIMS-MADE
OCCUR
CPP100030538-03
10/1/2021
10/1/2022
DAMAGE TO RENTED
$
300,000
PREMISES Ea occurrence)
MED EXP (Any one person)
$
5,000
PERSONAL & ADV INJURY
$
1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$
2,000,000
POLICY
PRO-
JECT
LOC
PRODUCTS - COMP/OP AGG
$
2,000,000
OTHER:
$
B
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY
$
1,000,000
(Ea accident)
ANY AUTO
CA100030539-03
10/1/2021
10/1/2022
BODILY INJURY (Per person)
$
OWNED
SCHEDULED
AUTOS ONLY
AUTOS
BODILY INJURY (Per accident)
$
HIRED
NON-OWNED
PROPERTY DAMAGE
AUTOS ONLY
AUTOS ONLY
(Per accident)
$
$
A
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
10,000,000
EXCESS LIAB
CLAIMS-MADE
UMB100030540-03
10/1/2021
10/1/2022
AGGREGATE
$
10,000,000
DED
RETENTION $
10,000
$
c
WORKERS COMPENSATION
PER
OTH-
AND EMPLOYERS' LIABILITY
STATUTE
ER
Y/N
383944
1/1/2022
1/1/2023
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$
1,000,000
OFFICER/MEMBER EXCLUDED?
N/A
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
1,000,000
D
Professional Lia
PDCPP0012905
4/3/2021
4/3/2022
Professional
1,000,000
A
Equipment Floater
CPP100030538-03
10/1/2021
10/1/2022
Leased & Rented
300,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
HICKMAN COUNTY SCHOOLS
CENTERVILLE, TN 37033
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Hickman County Schools
ACCORDANCE WITH THE POLICY PROVISIONS.
114 North Central Avenue Ste 203
Centerville, TN 37033
AUTHORIZED REPRESENTATIVE
700m
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: CPP100030538-03
COMMERCIAL GENERAL LIABILITY
CGL 084 (10 13)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -
AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION
AGREEMENT WITH YOU - ONGOING OPERATIONS AND
PRODUCTS-COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE (OPTIONAL)
Name of Additional Insured Persons or Organizations
(As required by written contract or agreement per Paragraph A. below.)
Locations of Covered Operations
(As per the written contract or agreement, provided the location is within the "coverage territory".)
(Information required to complete this Schedule, if not shown above, will be shown in the Declarations.)
A. Section II - Who Is An Insured is amended to include as an additional insured:
1. Any person or organization for whom you are performing operations when you and such person or
organization have agreed in writing in a contract or agreement in effect during the term of this policy that
such person or organization be added as an additional insured on your policy; and
2. Any other person or organization you are required to add as an additional insured under the contract or
agreement described in Paragraph 1. above; and
CGL 084 (10 13) Includes copyrighted material of the Insurance Services Offices, Inc. with its permission.
Page 1 of 3
Copyright 2013 FCCI Insurance Group.
Insured Copy
3. The particular person or organization, if any, scheduled above.
Such person(s) or organization(s) is an additional insured only with respect to liability for "bodily injury",
"property damage" or "personal and advertising injury" occurring after the execution of the contract or
agreement described in Paragraph 1. above and caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf in the performance of your ongoing operations for
the additional insured; or
3. "Your work" performed for the additional insured and included in the "products-completed operations
hazard" if such coverage is specifically required in the written contract or agreement.
However, the insurance afforded to such additional insured(s) described above:
1. Only applies to the extent permitted by law;
2. Will not be broader than that which you are required by the contract or agreement to provide for such
additional insured;
3. Will not be broader than that which is afforded to you under this policy; and
4. Nothing herein shall extend the term of this policy.
B. The insurance provided to the additional insured does not apply to "bodily injury", "property damage" or
"personal and advertising injury" arising out of the rendering of, or the failure to render, any professional
architectural, engineering or surveying services, including:
1. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports,
surveys, field orders, change orders or drawings and specifications; or
2. Supervisory, inspection, architectural or engineering activities.
C. This insurance is excess over any other valid and collectible insurance available to the additional insured
whether on a primary, excess, contingent or any other basis; unless the written contract or agreement
requires that this insurance be primary and non-contributory, in which case this insurance will be primary and
non-contributory relative to insurance on which the additional insured is a Named Insured.
D. With respect to the insurance afforded to these additional insureds, the following is added to Section III -
Limits of Insurance:
The most we will pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement described in Paragraph A.1.; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
E. Section IV - Commercial General Liability Conditions is amended as follows:
The Duties In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the following
additional conditions applicable to the additional insured:
An additional insured under this endorsement must as soon as practicable:
CGL 084 (10 13) Includes copyrighted material of the Insurance Services Offices, Inc. with its permission.
Page 2 of 3
Copyright 2013 FCCI Insurance Group.
Insured Copy
1. Give us written notice of an "occurrence" or an offense which may result in a claim or "suit" under this
insurance, and of any claim or "suit" that does result;
2. Send us copies of all legal papers received in connection with the claim or "suit", cooperate with us in the
investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy
conditions; and
3. Tender the defense and indemnity of any claim or "suit" to any provider of other insurance which would
cover the additional insured for a loss we cover under this endorsement and agree to make available all
such other insurance. However, this condition does not affect Paragraph C. above.
We have no duty to defend or indemnify an additional insured under this endorsement until we receive from
the additional insured written notice of a claim or "suit".
F. This endorsement does not apply to any additional insured or project that is specifically identified in any other
additional insured endorsement attached to the Commercial General Liability Coverage Form.
CGL 084 (10 13) Includes copyrighted material of the Insurance Services Offices, Inc. with its permission.
Page 3 of 3
Copyright 2013 FCCI Insurance Group.
Insured Copy

## Table 1

|  | INSURER(S) AFFORDING COVERAGE | NAIC # |
| --- | --- | --- |
| INSURER A : | National Trust Insurance Company | 20141 |
| INSURER B : | FCCI Insurance Company | 10178 |
| INSURER C : | Kentucky Employers Mutual Ins. | 10320 |
| INSURER D : | Arch Specialty Insurance Co. | 21199 |
| INSURER E: |  |  |
| INSURER F : |  |  |

## Table 2

|  | THIS IS TO CERTIFY THAT THE POLICIES INDICATED. NOTWITHSTANDING ANY CERTIFICATE MAY BE ISSUED OR MAY EXCLUSIONS AND CONDITIONS OF SUCH | OF POLICIES. | REQUIREMENT, PERTAIN, | INSURANCE LISTED BELOW HAVE TERM OR CONDITION OF THE INSURANCE AFFORDED BY LIMITS SHOWN MAY HAVE BEEN | BEEN ISSUED ANY CONTRACT THE POLICIES REDUCED BY | TO THE INSURED OR OTHER DESCRIBED PAID CLAIMS. | NAMED ABOVE FOR DOCUMENT WITH RESPECT HEREIN IS SUBJECT | THE POLICY PERIOD TO WHICH THIS TO ALL THE TERMS, |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| INSR LTR | TYPE OF INSURANCE | ADDL INSD | SUBR WVD | POLICY NUMBER | POLICY EFF (MM/DD/YYYY) | POLICY EXP (MM/DD/YYYY) | LIMITS |  |
| A | [X] COMMERCIAL GENERAL LIABILITY |  |  |  |  |  | EACH OCCURRENCE | $ 1,000,000 |
|  | [X] CLAIMS-MADE OCCUR |  |  | CPP100030538-03 | 10/1/2021 | 10/1/2022 | DAMAGE TO RENTED PREMISES Ea occurrence) | $ 300,000 |
|  |  |  |  |  |  |  | MED EXP (Any one person) | $ 5,000 |
|  |  |  |  |  |  |  | PERSONAL & ADV INJURY | $ 1,000,000 |
|  | GEN'L AGGREGATE LIMIT APPLIES PER: |  |  |  |  |  | GENERAL AGGREGATE | $ 2,000,000 |
|  | [X] [X] PRO- POLICY JECT LOC |  |  |  |  |  | PRODUCTS - COMP/OP AGG | $ 2,000,000 |
|  | OTHER: |  |  |  |  |  |  | $ |
| B | AUTOMOBILE LIABILITY |  |  |  |  |  | COMBINED SINGLE LIMIT (Ea accident) | $ 1,000,000 |
|  | [X] ANY AUTO |  |  | CA100030539-03 | 10/1/2021 | 10/1/2022 | BODILY INJURY (Per person) | $ |
|  | OWNED SCHEDULED AUTOS ONLY AUTOS |  |  |  |  |  | BODILY INJURY (Per accident) | $ |
|  | HIRED NON-OWNED AUTOS ONLY AUTOS ONLY |  |  |  |  |  | PROPERTY DAMAGE (Per accident) | $ |
|  |  |  |  |  |  |  |  | $ |
| A | [X] [X] UMBRELLA LIAB OCCUR |  |  |  |  |  | EACH OCCURRENCE | $ 10,000,000 |
|  | EXCESS LIAB CLAIMS-MADE |  |  | UMB100030540-03 | 10/1/2021 | 10/1/2022 | AGGREGATE | $ 10,000,000 |
|  | [X] DED RETENTION $ 10,000 |  |  |  |  |  |  | $ |
| c | WORKERS COMPENSATION AND EMPLOYERS' LIABILITY |  |  |  |  |  | [X] PER OTH- STATUTE ER |  |
|  | Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE |  |  | 383944 | 1/1/2022 | 1/1/2023 | E.L. EACH ACCIDENT | $ 1,000,000 |
|  | OFFICER/MEMBER EXCLUDED? (Mandatory in NH) | N/A |  |  |  |  | E.L. DISEASE - EA EMPLOYEE | $ 1,000,000 |
|  | If yes, describe under DESCRIPTION OF OPERATIONS below |  |  |  |  |  | E.L. DISEASE - POLICY LIMIT | $ 1,000,000 |
| D A | Professional Lia Equipment Floater |  |  | PDCPP0012905 CPP100030538-03 | 4/3/2021 10/1/2021 | 4/3/2022 10/1/2022 | Professional Leased & Rented | 1,000,000 300,000 |