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HomeMy WebLinkAboutLifecycle Renewables, Inc. - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Septage Pumping and Transporting Permit This is to certify that- RORY GAUNT/ROBERT GAUNT Doing business as: LIFECYCLE RENEWABLES, INC. P.O. BOX 1144 MARBLEHEAD MA 01945 Town of Mansfield 6 Park Row Mansfield, MA 02048 is hereby granted a SEPTA GE PUMPING AND TRANSPORTING PERMIT to engage in the pumping or transporting of the contents of privies, cesspools, septic tanks and other offensive substances. This permit is granted in conformity with the STATE ENVIRONMENTAL CODE: 310 CMR 15.02(2) and MGL chapter III section 31A and expires December 31, 2019 unless sooner suspended or revoked. LICENSE NUMBER 26 TRUCK REGISTRATION NUMBER(S): V14747 T61058 T52182 ALL MA REGISTRATIONS BOARD OF HEALTH Michae[HeaCey, Chairman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ntass.gov/dia Worlcers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: tt v k 4CLL/I "t l %� � ` Phone #: if3 � ��� / cc p / Are you an employer? Check the appropriate box: Business Type (required): L R I am a employer with ;:- employees (full and/ 5. ❑ Retail or part-time). * 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We 11.❑ Health Care are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.N Other RIM t pi l (yC m *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Addr( City/State/Zip: Policy # or Self -ins. Lie. # 1VG j &) jN Expiration Date: � Y 4 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif}nunder thepains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: C rporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ,.0 Town of Mansfield Town of Mansfield - Board of health 6 Park Row Mansfield, MA 02048 Septage pumpers Application BUSINESS NAME: 14,6#tp, ."C MAIL ADDRESS: F0 P{) TOWN: XJj6�L^ u'( NAME OF OWNER: I?,,- / lit-19 I STATE: BUSINESS TELEPHONE: E-mail: t��r�/ FED ID/SS NO: )6_ D3L 0-11 REGISTRATION NUMBER(S): Viq,jtj FEE PER TRUCK: �4 10() CELL: 0410 (717 -t S j _A0I FAX: Alt E-mail: d Uti 4) h�aC�t �� %FtG✓��G<.r (C�ri'7 NUMBER OF TRUCK(S): ,3 T61G,tif'> . S Its ` 1411 A1�� f �a lY r/Ic�S Please make appropriate changes. Sign, date, and enclose check payable to Town of Mansfield. Mail to: Board of Health, Town, of Mansfield, Six Park Row, Mansfield, MA 02048. / SIGNATURE: DATE: /� � �q TRUCKS INSPECTIONS: DATE: TIME: PLACE: AT THE TOWN HALL, ADJACENT TO SOUTH COMMON, PARK ROW, SO. MAIN STREET PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THESE DATES FOR HEALTH AGENT'S USE ONLY 310 CMR: State Environmental Code, Title 5; Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. 15.502 Transportation and Disposal of Privy, Cesspool, and Septic Tank Contents. 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. A. Mobile Tank: Securely mounted on truck _ Watertight _ Leak -proof cover Tight discharge tanks A = Acceptable NA = Not Acceptable B. Venting of Mobile Tanks: Vent permits escape of gas, but not liquid C. Hose: Suction or pressure hose in good repair D. Pumps: Maintained to prevent leaking of sewage Inspected by: Inspected on: LIFEREN-01 DKLILICK 4'% CERTIFICATE OF LIABILITY INSURANCE DpTE1Y) � 511412010Dl19 9 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 License # 1780862 HUB International New England 30D Ballardvale Street Wilmington, MA 01887 C TEACT PHONE FAX INC,, No, Ext : (978) 657.5100 A/c, No):(978) 988-0038 EODRE INSURERS AFFORDING COVERAGE NAIC N INSURER A: Selective of the Southeast 39926 INSURED INSURER 3:S0lective Insurance Company of South Carolina 19259 INSURER C Lifecycle Renewables Inc P O Box 1144 Marblehead, MA 01945 INSURER D: INSURER E : INSURER F : COVERAGES f:FRTi FIr:ATF NIIIIIIRFR- 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR NSR TYPE OF INSURANCE ADDL INSD SUBR D POLICY NUMBER POLICY EW POLICY EXXPP IMIDOMWI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENN�TEDPREMISEce $ MED E%P (Any one arson $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER POLICY ❑ JECT TOO GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGO EOMIJINEU51NGLELIMIT a accident)ANY S $ 1,000,000 A OTHER: AUTOMOBILE LIABILITY BODILY INJURY Perperson) S AUTO OSXAUTSULED AUTOS O X ATOONLY XUOLY N A 9106879 10/20/2018 10/20/2019 BODILY INJURY Per accident $ PERTY AMAGE PO�AUTTOS S S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE § EXCESS LIAB CLAIMS -MADE DED RETENTION§ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANVPROPRIETORIPARTNERIEXECUTIVE YIN (Mandatory in NH�E%CLUDEDP Dyes, de6Cnbe under We OFOPERATIONS below OTH- �( PER UTE ER $ B NIA C9080900 511I2019 5/1/2020 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE 11000,000 E. L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Comprehensive Deductible: $500Collision Deductible: $500 Pheasant Lane Realty Trust, Nashua, NH, its Managing Agent, Simon Property Group, Inc., and their respective officers, directors, shareholders, members, partners, parents, subsidiaries, related and affiliated entities, agents, servants, and employees are additional insured on Auto Liability per the policy provisions if required as such in a written contract with the Named Insured which has been executed prior to a loss/claim. Pheasant Lane Realty Trust Pheasant Lane Mall Management Office 310 Daniel Webster Highway Suite 280 Nashua, NH 03060 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE <' Icv.Rroul U 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A'CORCERTIFICATE OF LIABILITY INSURANCE °"06/10/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 term 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 endomement(s). PRODUCER Bean Insurance Agency LLC 151 Winnacunnet Road Hampton, NH 03842 CONTACT Robert B. Bean PHONE 603 926-3830 ac E . ( ) F ea: (603) 926-0283 EDR S: subob beaninrance.com ADDDRES INSURERS AFFORDING COVERAGE NAIC N INSURERA: Axis Surplus Insurance Co. 26620 INSURED Lifecycle Renewables Inc PO Box 1144 INSURER B: INSURERC: Marblehead, MA 01945-3450 INSURER D: INSURER E: INSURER F: CUiFRAGES GtK I IFIGA rE NUMBER- ccvrmnr.I Ulrssecn. 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 LTR TYPEOFINSURANCE ADDL D SUER D POLICY NUM3ER mmpCY EFF PmOyoCYIXP DMTS A COMMERCIAL GENERAL uABILnY EMP19000380-01 01/20/2019 1/20/2020 EACHOCCURENCE $ 1,000,000 CLAWWkDE P OCCUR PFEMSES Ea ccc,Trere $ 100,000 NED ExT, (Prry are person) $ 10,000 — PERSONALSADVIWURY $ 1,0i)9,696 GENLAGGREGATE UMTAPPLIES PER G-F_FERAL ACfilEGKTE $ 2,000,000 v PWCV ❑ JEMCT 1:1LOG PRODUCTS -COW/cP AGG $ 2,000,000 $ OTTER AUTOMDBILE LU1eIUTY COffitED SINGLE LIMIT Ee Scitle X $ ANY AUrO BCOILYIWLRY(Per person) $ D SCFEDAUTOS ED aCOILY IWUZY(Ps^accitlaY) $ AUTO HINDS QYV AUTOS HIRED NO`TowNED AUTOS OhLV N AUTOS ONLY PR(WERrY DAN14CE Per accitlent $ A UM3RELLALIAIS ✓ OCCUR EMX19000096-01 61/20/2019 01/20/2020 EACHOCCURENDE $ 2,000,000 E%CESS DAB AGGREGATE $ 2,000,000 CLAIhSMPDE DED RETENTION $ WORKERS COMPENSATION PER OTI-F :71STANIE AND EMPLOYPRMRJEERS' YIN ER EL EACHACCIDENT _ $ ARTWY ANYPR�PoMBER OCLUDEEXECUIIVE�FICE NH)E%CLLIDED4 Ll NIA E.LDISEASE-EAEMPLOYEE - $ (WndntoL In (Mantlalo n NH) ttyyes, tlescribe vxke _ E.L DISEASE -POLICY UMT __..... _..._ $ DESCPoPTON CE CPERATICfrS belv.v A Contractors Pollution Liability EMP19000380-01 01/20/2019 01/20/2020 Each CPL Condition $ 1'000,000 CPL Deductible $5,000 CPL Aggregate $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (ACORD 101, Atltlxional Remarks Sahetlule, maybe aHachetl R more spaw Is requiretl) Pheasant Lane Realty Trust 310 Daniel Webster Highway Suite 280 Nashua, NH 03060 ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOREED REPRESENTATIVE ©1988-2015 ACORD The ACORD. name and logo are registered marks of ACORD AC�RO6° CERTIFICATE OF LIABILITY INSURANCE D06i 0120D/ 9) 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 terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not conferrights to the certificate holder in lieu of such endorsement(s). PRODUCER Bean Insurance Agency LLC 151 Nfnnacunnel Road Hampton, NH 03842 CONTACT Robert B. Bean -N�' --- - PHCN o � . (603) 926-3830 ac No: (603) 926-0283 ADDRLESS: bob beaninsurance.com ADDRESS, INSURERIS)AFFORDING COVERAGE NAIL# INSURERA: AXIS Surplus Insurance Co. 26620 INSURED Lifecycle Renewables Inc INSURERS: PO Box 1144 Marblehead, MA 01945-3450 INSURERC: 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 LTR TYPEOFINSURANCE ADDL SUBR POUCYNUNBER POLICYEPF WDq POLICY EXP NNMD LIMITS A coNNERcwL GENERAL LWBILI 1 E M P19000380-01 01/20/2019 1/20/2020 EACHOCCUTRENCE g 1,000,000 CLAIMS -MADE � OCCI.R PREM ES Ea c—DAMAGE TO u,. $ 100,000 MED EXP(My we Perron) _._... $ 10,000 PERSCNALb ADVINJUiY $ I,000,000 GENERAL AGGREGATE $ 2,000,000 GENLA�GATEUMITAPPUESPER 2,000,000 y POLICY LOG PRCOLCISCCMPICP ACG $ OTHER $ AUTOMDBILE LIABILITY , INED SINGLE UNIT ,MINED $_ BCCILYINIUW Pe P+mn) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AL/TC6 BOULY IWURY IPeraaitlentl $ PROPERTY DAMAGE Per accitlenl $ HIRED N OWNED AMCO ONLY AUTC6 ONLY $ A UMBRELLA LWB � '.EMX19000096-01 01/20/2019 0112012020_E_ncHcCcurnEWE $ 2,000,000 EXCESS HAS CLNMSMADE ! AGGREGATE $ 2,000,000 DED RETEMICN $ $ WORKERS CONDENSATION I PER OR+ AND ENPLOYERS' LIABILITY Y/ N STATUTE ER EL EACH ACCIDENT $ ANY PROPRIETOWPARTNEWEXECUUVE OFFICER/MEMBER EXCLUDED? ❑ N/A - --- -- (Maneat,n,inNH) E.L. DISEASEEAEMPLOYEE $ If Ye; tlemnbe DESCRPTION CF �ERAlIIXJ56elgv EL DISEASE -POLICY LIMIT $ A Contractors Pollution Liability EMP19000380-01 01 /20/2019 01/20/2020 Each CPL Condition $ 1,000,000 CPL Deductible $5,000 CPL Aggregate $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (ACOR0101, AddRienai Rem s Sc Wule, m y be aaacbetl R enre space is renuirea) Pheasant Lane Realty Trost 310 Daniel Webster Highway Suite 280 Nashua, NH 03060 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD <t- LIFEREN-01 OK ULICK CERTIFICATE OF LIABILITY INSURANCE DATE 1 5114/2019 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 License # 17BO862 CO ICT HUB International New England 300 Ballardvale Street Wilmington, MA 01887 PHONE FAX atc, Ne, Eat: (976) 657.5100 AIC. No:(978) 988.0038 E-MAIL ADDINSURER(SI AFFORDING COVERAGE NAIC M INSURER A: Selective of the Southeast 39926 INSURED INSURERB:Selective Insurance Company Of South Carolina 19259 INSURER C: Lifecycle Renewables Inc INSURER °: - P0Box 1144 - Marblehead, MA 01945 INSURER E : INSURER F : COVERAGES CFRTIFICATF NI IMRFR- DFVIQInM MI IMRCD• 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 LTR TYPE OF INSURANCE ADDLSUBR IN50 WVD POLICY NUMBER POLICY EFF I y1, POLICY EXP (MMIDDAYVYYI LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACHOCCURRENCE $ DAEAGETORENTD yc $ MED EXP (Any person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER'. POLICY ❑ JECT LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OPAGG $ OTHER: A AUTOMOBILE LIABILITY CEOM�BIINdEED SINGLE LIMIT $ 1,000,000 BODILY INJURY Per person)$ ANY AUTO A 9106879 10/20/2018 10/20/2019 Ix OWNED X SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Par accident $ PROPERTYDAMAGE A�T OS ONLY X NON-OWAUTOS NED $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CIAIMS-MADE DED I I RETENTION$ $ B WORKERS COMPENSATION x PERTUTE OTH- ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ ,Mandatory In NH) It yes, descdbe under DESCRIPTION OF OPERATIONS below N/A C9080900 6/1/2019 6/1/2020 E.L. EACH ACCIDENT $ 1,000,000 E. L. DISEASEEAEMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) Comprehensive Deductible: $500Collision Deductible: $500 Pheasant Lane Realty Trust, Nashua, NH, its Managing Agent, Simon Property Group, Inc., and their respective officers, directors, shareholders, members, partners, parents, subsidiaries, related and affiliated entities, agents, servants, and employees are additional insured on Auto Liability per the policy provisions if required as such in a written contract with the Named Insured which has been executed prior to a loss/claim. Pheasant Lane Realty Trust Pheasant Lane Mall Management Office 310 Daniel Webster Highway Suite 280 Nashua, NH 03060 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ALJVKU ZO (ZUIb/UJ) U 19BU-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD