INSR ADDL SUBR
LTR
INSR WVD
DATE (MM/DD/YYYY)
PRODUCER
CONTACT
NAME:
FAX
PHONE
(A/C, No):
(A/C, No, Ext):
E-MAIL
ADDRESS:
INSURER A :
INSURED
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER
POLICY EFF POLICY EXP
TYPE OF INSURANCE LIMITS
(MM/DD/YYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
INSURER(S) AFFORDING COVERAGE NAIC #
Y / N
N / A
(Mandatory in NH)
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
EACH OCCURRENCE $
DAMAGE TO RENTED
$
PREMISES (Ea occurrence)
CLAIMS-MADE OCCUR
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
$
PRO-
OTHER:
LOCJECT
COMBINED SINGLE LIMIT
$(Ea accident)
BODILY INJURY (Per person) $
ANY AUTO
OWNED SCHEDULED
BODILY INJURY (Per accident) $
AUTOS ONLY
AUTOS
AUTOS ONLY
HIRED
PROPERTY DAMAGE
$
AUTOS ONLY
(Per accident)
$
OCCUR
EACH OCCURRENCE $
CLAIMS-MADE AGGREGATE $
DED RETENTION $
$
PER OTH-
STATUTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
POLICY
NON-OWNED
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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 any rights to the certificate holder in lieu of such endorsement(s).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
ACORDTM
CERTIFICATE OF LIABILITY INSURANCE
Lexington Insurance Company
Key Risk Insurance Company
Arch Insurance Company
Selective Insurance Co of America
National Union Fire Ins Co of Pitt. PA
5/22/2023
McGriff Insurance Services LLC
1150 Julian Drive 2nd Floor
Suite 200
Watkinsville, GA 30677
678 726-0540 770 725-5282
Mount Vernon Towers Condominium
Association, Inc.
300 Johnson Ferry Rd NE (Admin)
Sandy Springs, GA 30328-4157
19437
10885
11150
12572
19445
A X
X
X BI/PD Ded: 10,000
X SLG4NP000525601 05/08/2023 05/08/2024 1,000,000
1,000,000
50,000
1,000,000
3,000,000
3,000,000
E
X
X X
X X SLNUHA001377203 05/08/2023 05/08/2024 1,000,000
A
X
X SLG4NP000525601 05/08/2023 05/08/2024 1,000,000
1,000,000
PROD/CO AGG 1,000,000
B
N
KEY0136026 01/01/2023 01/01/2024 X
500,000
500,000
500,000
C
D
Property
Crime
PMM100082600
B6013092
05/08/2023
05/08/2023
05/08/2024
05/08/2024
$69,917,590
$850,000/$8,500 ded.
300 Unit Condominium Association. 300 Johnson Ferry Road NE, Atlanta GA 30328
Property:
Arch Insurance Company - Policy #PMM100082600 - Eff Date: 05/08/2023 Exp Date: 05/08/2024
Special Perils / Replacement Cost Coverage. Original Specifications - Cost to repair or replace. Equipment
(See Attached Descriptions)
Mount Vernon Towers Condominium
Association, Inc.
300 Johnson Ferry Rd NE (Admin)
Sandy Springs, GA 30328
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#S32177823/M32177446
594MOUNTVERClient#: 2107376
PCRAN
1 of 2
#S32177823/M32177446
SAGITTA 25.3 (2016/03)
DESCRIPTIONS (Continued from Page 1)
Breakdown Coverage is included
Property Deductible = $15,000. Wind/Hail Deductible = $25,000. Water Damage Deductible = $50,000
$ 1,000,000 - Flood Coverage - $50,000 Deductible.
$67,100,000 - Demolition and Increased Cost of Construction for Undamaged Buildings
$ 250,000 - Demolition and Increased Cost of Construction for Increased Cost of Construction
$ 250,000 - Demolition and Increased Cost of Construction for Increased Cost to Replace Equipment
$ 1,000,000 - Demolition and Increased Cost of Construction for Law and Ordinance Amendment
Crime:
Selective Insurance Co of America - Policy #B6013092 - Eff Date: 05/08/2023 Exp Date: 05/08/2024
$ 850,000 - Blanket Employee Dishonesty - $8,500 Deductible.
2 of 2
#S32177823/M32177446
