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INTERIM CERTIFICATE OF INSURANCE <br /> When countersigned by an authorized representative of the Company, this certificate supersedes any previously issued certificates and ceri.if,es <br /> that the fallowing policy(ies) have been issued to the insured for the coverage indicated.This certificate is subject to all of the terms, con- <br /> 4itions aid limitations set forth in the described pohcy(ies) and endorsements thereto. It is furnished as a matter of information only and does <br /> not change, modify or extend the policyjies) in any way. <br /> 1 <br /> Aiamed <br /> Insured . f/>�ji. /� L/,1=�.G��C!• ���i `�o' <br /> Address / L `'/ � �)� �� Policy No.—Workmen's <br /> [..' f� � _SCompensohon <br /> 70_ <br /> ! I Agent Policy No.—Other Cov. <br /> UNLESS REPLACED BY THE COMPANY'S STANDARD CERTIFICATE OR UNLESS NC LLED, THI TE M RTIFICATE <br /> SHALL BE EFFECTIVE FOR A PERIOD OF THIRTY DAYS COMMENCING M 19 <br /> ' Agent: Check here if a permanent certificate is to be issued by the Policyv)r Itir_Office. <br /> �1 COVERAGE LIMITS OF LIABILITY <br /> COVERED NOT <br /> COVERED AUTO LIABILITY <br /> H <br /> Owned Bodily Injury $ 000 each person <br /> Hired $ 000 each occurrence <br /> Non-Owned Property Damage $ 000 each occurrence <br /> L1 M. <br /> Employers Non-Ownership <br /> ' Contingent Liability <br /> GENERAL LIABILITY <br /> M&C-OLT Bodily Injury $ 000 each person** <br /> Owners&Contractors $ 000 each occurrence <br /> Contractual * $ 000 aggregate products <br /> ❑ ❑ Elevators Property Damage $ ,000 each occurrence <br />% Products $ 000 aggregate products <br /> owners $ contractors protective*** <br /> 4 —contractual***—completedoperations <br /> *** <br /> Single Limit liability for Coverages checked above $ ,000 aggregate products <br /> $ ,000 each occurrence <br /> CARGO $ 000 each vehicle <br /> $ 000 each occurrence <br /> Less$ Deductible <br /> WORKMEN'S <br /> COMPENSATION Statutory <br /> nclu es Goods or Products Warranty, Written Lease of Premises, Easement Agreement, Municipal Or- <br /> mance Agreement, Sidetrack Agreement, Elevator or Escalator. Maintenance Agreement only, unless ac- <br /> companied by specific endorsement providing additional Contractual Coverage. <br /> Described 0 1:1Deiption <br /> below woscrivad <br /> OWNED YEAR, MAKE,TYPE OF BODY, LOAD CAPACITY IDENTIFICATION NUMBER <br /> AUTO- <br /> MOBILES, <br /> IF LAST 3 <br /> COVERED DIGITS <br /> SHOWN <br /> (ALL STATES EXCEPT OKLAHOMA) (OKLAHOMA CERTIFICATE) <br /> It is hereby agreed that upon cancellation or termination In the event of any material chaneffortge in or cancellation of said policies, <br /> of this policy or polities from any cause the Company the Company will make everryy to notify the poity to whom this <br /> will mail _ //�-days notice in certlficate is issued of such 7ange or cancellation,but the Company <br /> undertakes no responsibility by reason of any failure so to do. <br /> writing thereof to the otter Interest shown below. <br /> Other �J TRUCK INSURANCE EXCHANGE <br /> Interests ��.��/ '� t s � Truc Underwriters Association, Atty- in fact ; <br /> T/ <br /> R `SV13 ^rc7 m <br /> ` P ide <br /> 0 4 i <br /> Countersigned t �z1 <br /> « . Not Applicable in Texas. —r aiif 174 94 <br /> Applicable in Texas only, a��.9 Qrhie 91 <br /> W S1 8�89�2�7 <br /> 58-051 o 10-76 1371 PRINTED IN us.�. d � <br /> l I <br /> I I <br />