SUPEWA1 OP ID: KIJ
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 09/21/2022
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).
PRODUCER 706-884-3339 CONTACT Allison Folds
NAME:
Mallory Agency PHONE 706-884-3339 FAX
P.O. Box 1209 (A/C, No, Ext): (A/C, No):
LaGrange, GA 30241 E-MAIL
ADDRESS:
allisonf@malloryagency.com
Matthew H. Mallory
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : State Auto Insurance Company 23353
INSURED INSURER B :
BenCon Enterprises, Inc.
dba Superior Water Services INSURER C :
834 Atlanta Rd. SE
Marietta, GA 30060 INSURER D :
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 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
1,000,000
CLAIMS-MADE X OCCUR 10134360CP 06/01/2022 06/01/2023 DAMAGE TO RENTED
PREMISES (Ea occurrence) $
100,000
MED EXP (Any one person) $
10,000
PERSONAL & ADV INJURY $
1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
2,000,000
POLICY X PRO-
JECT LOC PRODUCTS - COMP/OP AGG $
2,000,000
OTHER: $
A AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident) $
1,000,000
X ANY AUTO 10134369CA 06/01/2022 06/01/2023 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 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $
5,000,000
EXCESS LIAB CLAIMS-MADE 10134438CU 06/01/2022 06/01/2023 AGGREGATE $
5,000,000
DED RETENTION $ $
A WORKERS COMPENSATION X PER
STATUTE
OTH-
ER
AND EMPLOYERS' LIABILITY
Y/N 10134372WC 06/01/2022 06/01/2023 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N N/A
1,000,000
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
If yes, describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
A Contractor's E&O 10134360CP 06/01/2022 06/01/2023 Per Claim 100,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
DEKACO7
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
DeKalb County School District
1701 Mountain Industrial Blvd.
AUTHORIZED REPRESENTATIVE
Stone Mountain, GA 30083
Matthew H. Mallory
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