CERTIFICATE OF LIABILITY INSURANCE

Transcription

1 CORE) CERTIFICTE OF LIBILITY INSURNCE DTE (MM/DDIYYYY) 3/19/2015 THIS CERTIFICTE IS ISSUED S MTTER OF INFORMTION ONLY ND CONFERS NO RIGHTS UPON THE CERTIFICTE HOLDER. THIS CERTIFICTE DOES NOT FFIRMTIVELY OR NEGTIVELY MEND, ETEND OR LTER THE COVERGE FFORDED BY THE POLICIES BELOW. THIS CERTIFICTE OF INSURNCE DOES NOT CONSTITUTE CONTRCT BETWEEN THE ISSUING INSURER(S), UTHORIZED REPRESENTTIVE OR PRODUCER, ND THE CERTIFICTE HOLDER. IMPORTNT: If the certificate holder is an DDITIONL INSURED, the policy(ies) must be endorsed. If SUBROGTION IS WIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HNI Risk Services PO Box INSURED New Berlin WI JMB Express Trucking, LLC 1933 E Kelly Lane CON JC I NME: F (/C No, Ext): (/C, No): E-MIL DDRESS: certshni.com INSURER(S) FFORDING COVERGE INSURER : Great West Casualty Company INSURER B : INSURER C : INSURER D : INSURER E : Cudahy WI INSURER F : COVERGES CERTIFICTE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THT THE POLICIES OF INSURNCE LISTED BELOW HVE BEEN ISSUED TO THE INSURED NMED BOVE FOR THE POLICY PERIOD INDICTED. NOTWITHSTNDING NY REQUIREMENT, TERM OR CONDITION OF NY CONTRCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICTE MY BE ISSUED OR MY PERTIN, THE INSURNCE FFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO LL THE TERMS, ECLUSIONS ND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MY HVE BEEN REDUCED BY PID CLIMS. INSR DDL SUER POLICY EFF POLICY EP LTR TYPE OF INSURNCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERL LIBILITY ECH OCCURRENCE 1,000,000 IJMUt 10 NtN i LU COMMERCIL GENERL LIBILITY MCP03527C 04/01/ /01/2016 PREMISES (Ea occurrence) CLIMS-MDE OCCUR MED EP (ny one person) GEN'L GGREGTE LIMIT PPLIES PER: PRO- POLICY n J ECT LOC UTOMOBILE LIBILITY NY UTO LL OWNED HIRED UMBRELL LIB ECESS LIB SCHEDULED NON-OWNED OCCUR CLIMS-MDE DED RETEgf ON WORKERS COMPENSTION ND EMPLOYERS' LIBILITY YIN NY PROPRIETOR/PRTNER/EECUTIVE OFFICE/MEMBER ECLUDED? (Mandatory in NH) If yes, describe under 11FSCRiPTiON OF OPFRTICINS hpinw N/ MCP03527C 04/01/201504/01/2016 WC25939C 02/01/201502/01/2016 PERSONL & DV INJURY 1 000,000 GENERL GGREGTE 2,000,000 PRODUCTS - COMP/OP GG 2.000,000 COMBINED SINGLE LIMIT jea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERIY DMGE (Per accident) ECH OCCURRENCE GGREGTE WC S1 i U- OTH- I TORY LIMITS I ER E.L. ECH CCIDENT 100,000 E.L. DISESE - E EMPLOYEE 100,000 E.L. DISESE - POLICY LIMIT 500,000 Motor Truck Cargo MCP03527C 04/01/201504/01/2016 Limit 100,000 Deductible 2,500 NIC ti DESCRIPTION OF OPERTIONS I LOCTIONS / VEHICLES (ttach CORD 101, dditional Remarks Schedule, if more space is required) Sample Certificate SHOULD NY OF THE BOVE DESCRIBED POLICIES BE CNCELLED BEFORE THE EPIRTION DTE THEREOF, NOTICE WILL BE DELIVERED IN CCORDNCE WITH THE POLICY PROVISIONS. UTHORIZED REPRESENTTIVE,-55Z -2S ;< I , a II..,..i....4 CORD 25 (2010/05) The CORD name and logo are registered marks of CORD

2 corti L CERTIFICTE OF LIBILITY INSURNCE DTE (MWDD/YYYY) 1/27/2015 THIS CERTIFICTE IS ISSUED S MTTER OF INFORMTION ONLY ND CONFERS NO RIGHTS UPON THE CERTIFICTE HOLDER. THIS CERTIFICTE DOES NOT FFIRMTIVELY OR NEGTIVELY MEND, ETEND OR LTER THE COVERGE FFORDED BY THE POLICIES BELOW. THIS CERTIFICTE OF INSURNCE DOES NOT CONSTITUTE CONTRCT BETWEEN THE ISSUING INSURER(S), UTHORIZED REPRESENTTIVE OR PRODUCER, ND THE CERTIFICTE HOLDER. IMPORTNT: If the certificate holder is an DDITIONL INSURED, the policy(ies) must be endorsed. If SUBROGTION IS WIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HNI Risk Services PO Box INSURED New Berlin WI JMB Express Trucking, LLC 1933 E Kelly Lane CON ICT NME: PHONE F (/C, No, Ext): (NC, No): E-MIL DDRESS: certsahni.com INSURER(S) FFORDING COVERGE NIC # INSURER : Great West Casualty Company INSURER B: INSURER C : INSURER D : INSURER E : Cudahy WI INSURER F : COVERGES CERTIFICTE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THT THE POLICIES OF INSURNCE LISTED BELOW HVE BEEN ISSUED TO THE INSURED NMED BOVE FOR THE POLICY PERIOD INDICTED. NOTWITHSTNDING NY REQUIREMENT, TERM OR CONDITION OF NY CONTRCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICTE MY BE ISSUED OR MY PERTIN, THE INSURNCE FFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO LL THE TERMS, ECLUSIONS ND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MY HVE BEEN REDUCED BY PID CLIMS. INSR DDL SUBR POLICY EFF POLICY EP LTR TYPE OF INSURNCE INSR VVVD POLICY NUMBER (MM/DDIYYYY) (MM/DDfYYYY) LIMITS GENERL LIBILITY COMMERCIL GENERL LIBILITY MCP03527B 04/01/ /01/2015 ECH OCCURRENCE 1,000,000 IF=NYEroccNiururence) CLIMS-MDE OCCUR MED EP (ny one person) 5,000 PERSONL & DV INJURY 1,000,000 GENERL GGREGTE 2,000,000 GEN'L GGREGTE LIMIT PPLIES PER: PRODUCTS - COMP/OP GG POLICY n 7E- p I LOC UTOMOBILE LIBILITY NY UTO LL OWNED HIRED SCHEDULED NON-OWNED MCP03527B 04/01/201404/01/2015 COMBINED SINGLE LIMIT (Ea accident) 1, BODILY INJURY (Per person) BODILY INJURY (Per accident) PR E i DM E (Per accident) UMBRELL LIB ECESS LIB OCCUR CLIMS-MDE DED RETENTION WORKERS COMPENSTION ND EMPLOYERS' LIBILITY YIN NY PROPRIETOR/PRTNER/EECUTIVE OFFICE/MEMBER ECLUDED? (Mandatory In NH) If yes, describe under DFSCRIPTIMI (if CIPFRTHINS hpinw NI WC25939C 02/01/201502/01/2016 ECH OCCURRENCE GGREGTE WC ST I U- TORY LIMITS I I OTH- ER E.L. ECH CCIDENT 100,000 E.L. DISESE - E EMPLOYEE 100,000 E.L. DISESE - POLICY LIMIT 500,000 Motor Truck Cargo MCP03527B 04/01/201404/01/2015 Limit 100,000 DESCRIPTION OF OPERTIONS / LOCTIONS / VEHICLES (ttach CORD 101, dditional Remarks Schedule, if more space is required) Deductible 2,500 Sample Certificate SHOULD NY OF THE BOVE DESCRIBED POLICIES BE CNCELLED BEFORE THE EPIRTION DTE THEREOF, NOTICE WILL BE DELIVERED IN CCORDNCE WITH THE POLICY PROVISIONS. UTHORIZED REPRESENTTIVE 2e < CORD 25 (2010/05) I The CORD name and logo are registered marks of CORD -..

3 Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Print or type See Specific Instructions on page 2. Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. JMB Express trucking LLC 2 Business name/disregarded entity name, if different from above JMB Express Trucking LLC Give Form to the requester. Do not send to the IRS. 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to II Individual/sole proprietor or. C Corporation El S Corporation III Partnership. Trust/estate certain entities, not individuals; see instructions on page 3): single-member LLC II Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) /J Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Exempt payee code (if any) Exemption from FTC reporting code (if any) Other (see instructions)w 5 ddress (number, street, and apt. or suite no.) 1933 E Kelly Lane 6 City, state, and ZIP code Cudahy,WI List account number(s) here (optional) (pplies to accounts Requester's name and address (optional) maintained outside the U S.) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Part II Certification Under penalties of perjury, I certify that: Social security number or Employer identification number The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FTC code(s) entered on this form (if any) indicating that I am exempt from FTC reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IR), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Here Signature of U.S. person Date 0/ 7 2v/ -c- 7 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at Purpose of Form n individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (TIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following: Form 1099-INT (interest earned or paid) Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FTC code(s) entered on this form (if any) indicating that you are exempt from the FTC reporting, is correct. See What is FTC reporting? on page 2 for further information. Cat. No Form W-9 (Rev )

4 0 U.S. Department of Transportation 1200 New Jersey ve., S.E. Federal Motor Carrier Safety dministration Washington, DC SERVICE DTE July 22, 2008 CERTIFICTE MC C JMB EPRESS TRUCKING LLC FRNKLIN, WI This Certificate is evidence of the carrier's authority to engage in transportation as a common carrier of property (except household goods) by motor vehicle in interstate or foreign commerce. This authority will be effective as long as the carrier maintains compliance with the requirements pertaining to insurance coverage for the protection of the public (49 CFR 387) and the designation of agents upon whom process may be served (49 CFR 366). The carrier shall also render reasonably continuous and adequate service to the public. Failure to maintain compliance will constitute sufficient grounds for revocation of this authority. Kathy Weiner, Chief Information Systems Division NOTE: Willful and persistent noncompliance with applicable safety fitness regulations as evidenced by a DOT safety fitness rating of "Unsatisfactory" or by other indicators, could result in a proceeding requiring the holder of this certificate or permit to show cause why this authority should not be suspended or revoked. CMO

5 JMB Express Trucking LLC MC#: January 16, 2014 Re: ssignment of ccounts Receivable To Whom It May Concern: We are excited to announce that we have recently qualified to fund our receivables with ecapital LLC. We are now assured of having the financial strength to serve you and meet the growing demand of our customers. To facilitate this new funding arrangement, this letter will confirm that JMB Express Trucking LLC has assigned its present and future accounts receivable to ecapital LLC, to whom any and all payments, including electronic payments of any kind, must be made. This letter constitutes "reasonable proof that the assignment has been made" as that term is used in Section of the Uniform Commercial Code. You are irrevocably authorized and requested to rely on a photocopy or fax copy of this letter. This letter supersedes any prior contrary communication that you may have received concerning the above, and may only be rescinded by ecapital LLC in writing. Sincerely, Signed: JMB Express Trucking LLC Director NOTICE OF SSIGNMENT This invoice has been assigned to and must be made payable to: ecapital LLC PO Box Las Vegas, NV ny claim or offset must be reported immediately to (800) Payment to any other party does not constitute payment.

6 JMB Express Trucking LLC MC#: January 16, 2014 Re: ssignment of ccounts Receivable To Whom It May Concern: We are excited to announce that we have recently qualified to fund our receivables with ecapital LLC. We are now assured of having the financial strength to serve you and meet the growing demand of our customers. To facilitate this new funding arrangement, this letter will confirm that JMB Express Trucking LLC has assigned its present and future accounts receivable to ecapital LLC, to whom any and all payments, including electronic payments of any kind, must be made. This letter constitutes "reasonable proof that the assignment has been made" as that term is used in Section of the Uniform Commercial Code. You are irrevocably authorized and requested to rely on a photocopy or fax copy of this letter. This letter supersedes any prior contrary communication that you may have received concerning the above, and may only be rescinded by ecapital LLC in writing. Sincerely, Signed: JMB Express Trucking LLC Director NOTICE OF SSIGNMENT This invoice has been assigned to and must be made payable to: ecapital LLC PO Box Las Vegas, NV ny claim or offset must be reported immediately to (800) Payment to any other party does not constitute payment.

7 National Motor Freight Traffic ssociation, Inc. pril 16, 2014 MIROSLV JOVIC JMB EPRESS TRUCKING LLC 1933 E KELLY LN CUDHY, WI CERTIFICTE OF STNDRD CRRIER LPH CODE (SCC) RENEWL The Standard Carrier lpha Code of JMBN has been renewed for: JMB EPRESS TRUCKING LLC 1933 E KELLY LN CUDHY, WI MC US DOT This lpha Code will apply only to the company name shown above through June 30, pproximately two months prior to expiration of this SCC, NMFT will provide a renewal notice which must be promptly returned together with payment to ensure its continued validity. Should the company name or address change, please notify the National Motor Freight ssociation, Inc. at the address below. lpha Codes ending with the letter "U" have been reserved for the identification of freight containers. If your lpha Code ends with the letter "U", it should be used only for this purpose. non-u ending lpha Code should be obtained to satisfy other requirements such as company identification for Customs, Electronic Data Interchange freight payments, etc. If you participate in the Bureau of Customs and Border Protection (BCBP) automated programs (CE, MS,CFES, FST, PPS), your SCC and related company information has been sent to BCBP electronically and is updated on a nightly basis. If you have encountered a problem using your SCC with BCBP, or a copy this letter has been requested by BCBP, only then should you forward the requested information ( preferred as a PDF or TIF attachment) to the following address: CBP SCC Processing Bureau of Customs and Border Protection 7681 Boston Blvd., Beauregard 1st Fl Wing Springfield, V [email protected] NOTICE: Renewal of the above listed SCC is unrelated to participation in the National Motor Freight Classification (NMFC). Further, it does not confer membership in the National Motor Freight Traffic ssociation, Inc. nor allow use of the NMFC inconnection with freight rates. For participation and membership information, please call (703) North Fairfax Street Suite 600 lexandria, V ph: fax: web: [email protected]

8 JMB Express Trucking LLC 1933 E Kelly Lane, Cudahy, WI phone (414) fax (414) [email protected] MC# US DOT# FEIN: Professional Freight Service t JMB Express Trucking we work with our Customers to rovide excellent service that you can count on.we have 11 years of experience in the industry as trucking company and we work hard to meet needs of our Customers. JMB Express Trucking LLC offers domestic trucking and delivery service troughout the 48 contiguous states, as well as full load and LTL load services.warehouseing at our location in Milwaukee Wisconsin area. JMB Express Trucking believes in building relationships with our Customers so that we can continue in our beliefs of complete satisfaction. We look forward to working with your company and bulding a great relationship that we can both be completely satisfied. REFERENCES: 1. Evans Transportation Jeffery M Coyote Logistics Mark R dvantage Jannine INSURNCE: HNI Risk Service fax [email protected] Comm. Gen. Liability /uto Liability / WC / Cargo TL LTL WREHOUSING CROSS DOCK DROP TRILER