DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
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 CONTACT
NAME:
PHONE FAX
(A/C, No, Ext): (A/C, No):
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
SAMPLE
INSURER A :
INSURED INSURER B :
INSURER C :
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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES (Ea occurrence) $
MED EXP (Any one person) $
Policy # Current Current PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
PRO-
POLICY X JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
X ANY AUTO BODILY INJURY (Per person) $ 500,000
OWNED SCHEDULED Policy # Current Current BODILY INJURY (Per accident) $ 500,000
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $ 500,000
AUTOS ONLY AUTOS ONLY (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000
X EXCESS LIAB CLAIMS-MADE Policy # Current Current AGGREGATE $ 1,000,000
DED RETENTION $ $
WORKERS COMPENSATION PER OTH- 1,000,000
AND EMPLOYERS' LIABILITY STATUTE ER
Y/N
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? N/A
Policy # Current Current
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Independence Realty Trust, Inc., IRT Management, LLC and the entities which have an ownership interest in the properties where work/service is performed,
together with their respective affiliates, are additional insured on the general liability policy as their interests appear
CERTIFICATE HOLDER CANCELLATION
IRT Management LLC, ISAOA, ATIMA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
C/O Conservice CONTROL THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO Box 4704 ACCORDANCE WITH THE POLICY PROVISIONS.
Logan, UT 84323
irtcontrol@conservice.com
AUTHORIZED REPRESENTATIVE
Fx# 435-713-2142
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ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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