CERTIFICATE OF INSURANCE (040)
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Certificate of Insurance 'c
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THISCERnFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT'FICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE
POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW.
This IS to Certify that
~TINDALL'S WATERPROOFING, I LmERTY .
INC. Name and MUTUAL e
12362 CAPRI CIRCLE +tI address of
lIUJY .... INIIIIRMC( COIIIWn' . LIHRTT....... fiRE INSUlWtCE COII'AI'r . IDSlOlI
NORTH TREASURE ISLAND, FL. 33706 Insured.
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is, at the date of this certificate, insured by the Company under the poIicy(ies) listed below. The insurance afforded by the listed policy(ies)
is subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other
document with respect to which this certificate may be issued.
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TYPE OF POLICY EXPIRATION DATE POLICY NUMBER LIMITS OF LIABILITY
COVERAGE AFFORDED UNDER W.e. LAW OF LIMIT OF lIABllITY-COV B
FOLLOWING STATES (Indicate Limit for each state)
WORKERS'
u u~_ - -
COMPENSATION 10-27-85 WCl-351-096621-014 FL 100,000
MARITIME COVERAGE. FOLLOWING STATES LIMIT OF LIABILITY MARITIME COVERA f.7E
o COMPREHENSIVE BODIL Y INJURY PROPERTY DAMAGE
FORM EACH EACH
o SCHEDULE FORM $ OCCURRENCE $ OCCURREN E
NOT APPLICABLE
....> o PRODUCTS COM- $ AGGREGATE $ AGGREGA E
PLETED OPERATIONS
<(.... 0
0:: -
w=
Zec INDEPENDENT CON- COMBINED SINGLE LIMIT
w<(
C>:::; o TRACTORS{CONTRAC' BODIL Y INJURY AND PROPERTY DAMAGE
TORS PRO ECTlVE
$ EACH OCCURRENCE
o CONTRACTUAL $
LIABILITY AGGREGATE
0
~ DOWNED $ EACH ACCIDENT-SINGLE LIMIT-B. I. AND P.D. COMBIN D
~~ D NON.OWNED NOT APPLICABLE $ EACH PERSON
<< D HIRED $ 6~C~c~5~I~l~~E $ EACH ACCIDEN
:::; OR OCCURREN E
-0::
w NONE
:I:
0
LOCATlON(S) OF OPERATIONS & JOB # (If Applicable) DESCRIPTION OF OPERATIONS:
MARSHALL STREET PLANT THIS CERTIFICATE VOIDS & SUPERSEDES THE CERTIFICATE ISSUEI
__NORTHEAST PLANT ON 12-17-84.
EAST PLANT BROAD FORM ALL STATES COVERAGE IS PROVIDED.
BECEIYED
..-NOTICE OF CANQLLATION: (NOT APPLICABLE UNLESS A NUMBER OF
. DAYS IS ENTERED BELOW). BEFORE THE STATED EXPIRATION DATE THE COMPANY
WILL NOT CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES
UNTIL AT LEAST~DAYS NOTICE OF SUCH CANCELLATION OR REDUCTION HAS BEEN
MAILED TO:
JAM 1 1r.tB[3
..
I CITY OF CLEARWATER
P. O. BOX 4748
CLEARWATER, FL. 33518
l
~n CLER~~ 1,
SEE ATTACHED 1710
AUTHORIZED REPRESENTATIVE
1-10-85 ds ATLANTA
OAT ISSUED OFFICE
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Thll certificate II executed by UBERTY MUTUAL INSURAN .COMPANY _ respects luch 1..._ _ Is affonIecI by That Company, It Is executecl byUBER1'Y MUTUAL FIRE INSURANC
COMPANY al ....pects luch Inlurance al.11 affardecl by That Compaay. ~ BS~34A R12~
COUNTERSIGNATURE OF RESIDENT AGENT
ientified below, of which this endorsement forms a part, is hereby countersigned with respect t<
lcated in the state in which the Resident Agent resides.
iler: WCl-351-096621-014
licyholder:
(/- \ B c.w...-
Couute"'.."! bY.....~..............:...m.................
[XI (Resident Agent of Liberty Mutual In:
[XI (Resident Agent of Liberty Mutual Fil
[XI (Resident Agent of Liberty Insurance
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( State)