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<br />e <br /> <br />A..) <br />'"\ \. <br />,V <br /> <br />e <br />LIBERn.~ <br />MUTUALtJI <br /> <br />(.:" <br /> <br />~. <br /> <br />LIBERTY ~1t,;TUAL l:\SURANCE COMPANY' LIBERTY ~IUTUAL FIRE I:\SVRA1'-;CE COMPA:-:Y <br />LIBERTY I:\SVRANCE CORPORATION - BOSTON, MA <br /> <br />Certificate of Insurance <br />THIS CERTIFiCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE <br />CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE <br />COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. <br /> <br />This is to Certify that <br />I <br /> <br />ROBERT DANIEL DBA <br />DANIEL'S DUMP TRUCK HAULING <br />P.O. BOX 832 <br />LA PORTE, TX 77571 <br /> <br />I <br /> <br />Name and <br />Address of <br />Insured <br /> <br />L <br /> <br />.J <br /> <br />is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. *The <br />insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and conditions and is <br />not altered by any requirement, term or condition of any contract or other document with respect to which <br />this certificate may be issued. <br /> <br />TYPE OF POLICY CERT .EXP. DATE POLICY NUMBER LIMITS OF LIABILITY <br /> COVERAGE AFFORDED COV.R <br /> U:-;DER W.C. LAW OF THE RODlLY INJURY RY <br /> FOLLOWI:-:G STATES: ACCIDENT <br />WORKERS' 04/21/90 WC2-391-075838-019 TX s 100,000 <br /> EACH ACCIDE:\'T <br /> BODILY I"JVRY RY <br /> DISEASE <br />COMPE:-;SATION s 100,000 <br /> EACH PERSON <br /> RODILY IXlURY BY <br /> DISEASE <br /> S 500,000 <br /> POLICY LIMIT <br />LOCATIO:'-:(S) OF OPERATIONS It JOB;: (IF APPLICABLE) DESCRIPTION OF OPERATlO:'-:S <br /> <br />NOTICE OF CANCELLATION: THE COMPANY WILL NOT TERMINATE OR REDUCE THE INSURANCE <br />AFFORDED UNDER THE ABOVE POLICIES UNLESS DAYS NOTICE OF SUCH TERMINATION OR <br />REDUCTION HAS BEEN MAILED TO: <br /> <br />~TY OF LA PORTE <br />POBOX 1115 <br />LA PORTE, 'IX 77571 <br /> <br />I <br /> <br />Producer's Name and Address <br />WESTBROOK INSURANCE AGENCY <br />904 PASADENA BLVD. <br />DEER PARK, TX 77536 <br /> <br /> <br />~ <br /> <br />CERTlACATE HOLDER <br /> <br />~pL <br /> <br /> <br />TYLER <br /> <br />OFFICE <br /> <br />This cenificate is e_UI8d by UBERTY MUTUAL INSURANCE COMPANY as respects such insurance as IS afforded by That Company, il is elleCuled by LIBERTY MUTUAL FIRE <br />INSURANCE COMPANY as respects such insurance as is afforded by ThaI Com~ny, il is OllscUl8d by UBERTY INSURANCE CORPORATION as respects such insurance as ,. <br />arrorded by That Company. <br /> <br />BS 7455 R1 <br />