CERTIFICATE OF INSURANCE (257)
I-
ACORDTM
Client#: 4800
SMITIND
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
03/10/05
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER
Lanier Upshaw, Inc.
1115 US Hwy 98 South
P.O. Box 468
Lakeland, FL 33802
Smithbilt Industries Inc
1061 Hwy 92 West
Auburndale, FL 33823
INSURERS AFFORDING COVERAGE
INSURER A: Zurich-American
INSURER B: North River Insurance Company
INSURERC: Brldgefield Employers Insurance Comp
INSURER D: Pennsylvania Lumbermen's
INSURER E:
NAIC#
10335
14974
INSURED
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR NSR TYPE OF INSURANCE POLICY NUMBER P.g-~1~:68~E Pg~fl,~~~tMN LIMITS
A ~NERAL LIABILITY CP0278033701 03/09/05 03/09/06 EACH OCCURRENCE $1 000.000
X COMMERCIAL GENERAL LIABILITY" DAMAGE TO RENTED $500,000
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $10000
PERSONAL & ADV INJURY $1.000.000
GENERAL AGGREGATE $2 000 000
~'L AGGREnE ;~~ APnS PER: PRODUCTS - COMP/OP AGG $2.000.000
POLICY JECT LOC
A ~TOMOBILE LIABILITY CP0278033701 03/09/05 03/09/06 COMBINED SINGLE LIMIT
1L ANY AUTO (Ea accident) $1,000,000
- ALL ,OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
-
1L HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
RRAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B OOESS/UMBRELLA LIABILITY 5530871169 03/09/05 03/09/06 EACH OCCURRENCE $3 000.000
X OCCUR D CLAIMS MADE AGGREGATE $6 000 000
$
~ DEDUCTIBLE $
X RETENTION $0 $
C WORKERS COMPENSATION AND 83003985 MfQ1105_ ~~~ 04/01106 ". -" X I wc STA~~;" I 10J~-
F-- ~'(j;RS"L1ASIL:IIV".--- ~--- - -':--" ..--;--.-- - I' -- "~
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500,000
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $500,000
If yes, describe under E.L. DISEASE - POLICY LIMIT $500,000
SPECIAL PROVISIONS below
D OTHER Leased/Rente 8241 03/09/05 03/09/06 $35,000 limit/$1000 ded
Equipment
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
** Supplemental Name **
Smithbilt Industries Inc
D.J.G. Partnership
D & J Enterprises of Polk County Inc
CERTIFICATE HOLDER
CANCELLATION
City Of Clearwater
Attn: Jack Comm Bldg Permits
310 Counts Street
Clearwater, FL 34616-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -1.0.... DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPR ENTATlVE
G.-
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ACORD 25 (2001/08) 1 of 2
#M90928
BHS
€l ACORD CORPORATION 1988