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CERTIFICATE OF INSURANCE - BITEC

CERTIFICATE OF INSURANCE . ISSUE DATE (MM/DD/YY). tion shall survive such termination and ditions shall override those contained in the parties agree that the provisions of any writings exchanged between the par- PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS. this contract though otherwise a nullity ties and it shall not be modified except NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, shall be conclusive evidence of such by mutually executed amendment. The EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manufacturers of Advanced Technology Waterproofing Membranes binding commitment.

statutory $ (each accident) $ (disease–policy limit) $ (disease–each employee) commercial general products-comp/opsliability claims citymade occur.

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Transcription of CERTIFICATE OF INSURANCE - BITEC

1 CERTIFICATE OF INSURANCE . ISSUE DATE (MM/DD/YY). tion shall survive such termination and ditions shall override those contained in the parties agree that the provisions of any writings exchanged between the par- PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS. this contract though otherwise a nullity ties and it shall not be modified except NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, shall be conclusive evidence of such by mutually executed amendment. The EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manufacturers of Advanced Technology Waterproofing Membranes binding commitment.

2 Failure of either party to assert any right or remedy provided herein, regardless of CONTRACTORS INSURING AGENT COMPANIES AFFORDING COVERAGE. 16. This agreement is highly personal in the incidence, shall not bar the assertion COMPANY. A. APPLICATION FOR. LETTER NAME OF INSURANCE COMPANY. nature and it shall not be assignable by of such right or remedy thereafter. In any CODE SUB-CODE. operation of law or otherwise. dispute arising under this Agreement, COMPANY. Arkansas law shall be controlling, not- INSURED. LETTER B. AUTHORIZED APPLICATOR STATUS. 17. This Agreement encompasses the com- withstanding any conflict of law stature or COMPANY.

3 LETTER C. plete understanding between parties decision to the contrary. in the subject matter hereof. There are CONTRACTOR OR COMPANY COMPANY. D. LETTER Representative/Distributor Approval _____. no understandings between the parties IN WITNESS WHEREOF, the parties have COMPANY BITEC Approval _____. other than as expressed herein and no caused this Agreement to be executed by LETTER E. evidence of contemporaneous verbal their duly authorized representatives to COVERAGES. understandings shall be admissible to become effective as of the day and year first THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD Business Name_____.

4 Establish its meaning. Its terms and con- above written. INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED. ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS. 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. Type of Business: Sole Proprietorship _____ Partnership _____ Corporation _____ CO POLICY EFFECTIVE POLICY EXPIRATION. TYPE OF INSURANCE POLICY NUMBER ALL LIMITS IN THOUSANDS. This Section for BITEC Approval Only This Section to be signed by Applicant LTR DATE (MM/DD/YY) DATE (MM/DD/YY).

5 Business Address:_____. GENERAL LIABILITY GENERAL AGGREGATE $ 500 _____. BITEC , INC. COMPANY_____ A COMMERCIAL GENERAL LIABILITY The amounts-$'s and PRODUCTS-COMP/OPS AGGREGATE $ 500. _____ CLAIMS MADE OCCUR. types shown are the PERSONAL & ADVERTISING INJURY $ 500 City State Zip by_____ By_ _____. OWNER'S & CONTRACTOR'S PROT. minimum acceptable. EACH OCCURRENCE $ 250. Title _____ Title_____ FIRE DAMAGE (Any one fire) $ 50 Business Phone: ( _____ ) _____ Fax No. ( _____ ) _____ Signature must be officer of company. Area Code Area Code E. MEDICAL EXPENSE (Any one person) $ AUTOMOBILE LIABILITY COMBINED. L. SINGLE $. ANY AUTO LIMIT Year Business Established _____ Yearly Sales Volume: $_ _____.

6 P. ALL OWNED AUTOS BODILY. INJURY $. SCHEDULED AUTOS (Per person). Executive Officers: M. Processing Instructions for Application HIRED AUTOS BODILY. INJURY $ Name _____ Position _____. A. NON-OWNED AUTOS (Per accident). (1) Form must be filled out completely, and properly signed by an officer of the GARAGE LIABILITY Brief Resume of Experience: _____. S. PROPERTY. DAMAGE $. company in the shaded areas on pages 2 and 5. _____. EXCESS LIABILITY EACH AGGREGATE. OCCURRENCE. (2) Final approval can only be granted upon receipt of this original form to $ $ _____. BITEC . Final approval will not be granted to faxed copies. OTHER THAN UMBRELLA FORM Name _____ Position _____.

7 STATUTORY. WORKER'S COMPENSATION Brief Resume of Experience: _____. (3) The applicant's original CERTIFICATE of INSURANCE must accompany the appli- AND. $ (EACH ACCIDENT). _____. cation, or be forwarded direct to BITEC , Inc. upon the instructions of the $ (DISEASE POLICY LIMIT). EMPLOYER'S LIABILITY. applicant. No photo copies or fax copies can be accepted for final approval. $ (DISEASE EACH EMPLOYEE) _____. OTHER. Name _____ Position _____. (4) Upon final approval, BITEC will furnish a CERTIFICATE bearing an assigned Brief Resume of Experience: _____. application number. _____. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIO NS/SPECIAL ITEMS.

8 _____. ROOFING CONTRACTOR. Number of Employees: Office _____ Sales _____Laborers _____Supervisors _____ TOTAL_____. CERTIFICATE HOLDER CANCELLATION General Vicinity Where Majority of Work Performed: _____. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE. _____. EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO. BITEC , INC. MAIL _____ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE. Box 497. Visit our web site at LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR Division of Jobs: New Roofing _____% Re-roofing_____% Other_____% #2 Industrial Park Drive Box 497 Morrilton, Arkansas 72110 Fax (501) 354-3019 Phone 1-800-535-8597 Morrilton, AR 72110 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.

9 Explain Other_____. authorized representative Manufacturers of Advanced Technology Waterproofing Membranes (continued). Revised May 2006 1. 5 ACORD 25-S (3/88) ACORD CORPORATION 1988. List Three Major Jobs: 9. The Contractor acknowledges that he is tem will not provide a satisfactory service Installation not a sales agent, employee representa- life in such application. BITEC will not be Name City & State Specifications Date tive or franchise of BITEC and agrees he bound to offer a warranty on any roofing _____ _____ _____ _____ will not in any manner hold himself out system, nor shall BITEC be responsible _____ _____ _____ _____ to be performing the business of install- for any expense the Contractor may incur _____ _____ _____ _____.

10 Ing roofing on commercial and industrial or make in anticipation of a roofing sys- buildings and structures, and that the sole tem warranty, unless and until, BITEC . relationship created by this Agreement approves in writing its roofing system for Experience with Torch Applied Roofing: Types Used: AGREEMENT BY AND BETWEEN is a grant of the right by BITEC to repre- the particular application. None _____ Minor _____ Regularly _____ Extensive _____ SBS _____ APP _____ BITEC , INC. and sent himself as authorized by BITEC to install the roofing System by virtue of such 13. The Contractor acknowledges that the AUTHORIZED ROOFING CONTRACTOR appointment.


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