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CERTIFICATE OF LIABILITY INSURANCE (114)TAGGR -1 OP ID: TT A� ---- CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) 07 /26 07/26/11 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 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 888 -822 -1173 Hawkins & Rawlinson, Inc. 334 - 821 -5801 P.O. Box 3493 2515 East Glenn Ave, Ste 101 Auburn, AL 36831 -3493 Chuck Hawkins NAmE: T a/c NN , Ext): (A/X (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC INSURER A: Companion Property & Casualty 12157 INSURED TAG Grinding Services, Inc. JWB Leasing Co,. Inc PO Box 25 Daviston, AL 36256 INSURER B: OCCUR INSURER C: INSURER D : INSURER E : EACH OCCURRENCE DAMAGE To RENTED PREMISES (Ea occurrence) INSURER F : MED EXP (Any one person) COVERAGES CERTIFICATEE UMB�17: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N POL- ICY-.P OD _ 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 LTR TYPE OF INSURANCE ADDL INSg SUBR WVD POUCY NUMBER POLICY EFF LMM /DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS GENERAL COMMERCIAL w LIABILITY GENERAL CLAIMS -MADE LIABILITY OCCUR RECEIVED EACH OCCURRENCE DAMAGE To RENTED PREMISES (Ea occurrence) $ $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GE 'L AGGREGATE POLICY LIMIT APPLIES PRO- JECT PER: LOC PRODUCTS PRODUCTS - COMP /OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON-OWNED UT OWNED AUTOS JUL 0: y Y06A` L RECORDS Y6. 2 q 2011 ANC ANC SIS CS DEPT COMEINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE LEGMAN?: EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A -- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? Y/ N N / A CWC 3070514 08 04 .. ... 07/27/11 07/27/12 X TORY L MITS 10TH- E.L. EACH ACCIDENT $ 1,000,000 E.L. vrst.ASE-z-E-R-EMPCOYEE`$ _— .:-" eOfr 41Bandeler .. If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule If more space Is required) Grinding / Covered states are Georgia, Alabama, Texas and Florida CERTIFICATE HOLDER CANCELLATION CITCL01 City of Clearwater City Clerk P 0 Box 4748 Clearwater, FL 33758 i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Client#: 67108 50TAGGRINDIN ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE M ATE (MIDD/ YYY1� _ 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 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 J Smith Lanier & Co of Newnan P. O. Box 71429 Newnan, GA 30271 -1429 770 683 -1000 CONTACT NAME: (MMIDDY/YYYY). 07/27/2011 PHONE 770 683 -1000 F 7706831010 : IIAlC, No): -,IA/G0NciExt E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Harleysville Insurance Company 23582 INSURED TAG Grinding Services, Inc. J W B Leasing Co., Inc. 1113 Horseshoe Bend Rd. Dadeville, AL 36853 INSURER B : Indian Harbor Ins. Co. 36940 American Safety Indemnity Comp INSURER C: Y Y p 33103 INSURER D : $100,000 INSURER E INSURER F : X 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. INS TYPE OF INSURANCE ADDL INSR SUER WVD -- ^POLICY NU•._.._._ NUMBER (MMIDDY/YYYY). 07/27/2011 LNM/DD //YYYY) 07/27/2012 LIMITS A GENERAL LIABILITY MPA00000020785L EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY ��MACE TO RENTED EMI E3 (Ea occuvence) $100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY PRO- JECT LOC $ A AUTOMOBILE LIABILITY BA00000020784L 07/27/2011 07/27/201z OaBcciID S S INGLE LIMIT X -- X ANY AUTO BODILY INJURY (Per person) _$1,000,000 $ ALL OWNED AUTOS HIRED AUTOS X SCHEDULED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CMB00000020786L 07/27/2011 07/27/2012 EACH OCCURRENCE AGGREGATE $4,900 000 $4,.. 00 .__., 000 0 " -- $ DED X RETENT ON $10,000 . -- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC�STATU- TIC TORY LIMITS OTH- ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? .ielaie.r.. 1.I W l _ - Y / N N / A E.L. EACH ACCIDENT $ E,L. DI CFtA5E F4- EMP If yes, descdbe under DESCRIPTION OF OPERATIONS below . E.L. DISEASE - POLICY LIMIT ------ — _- $ B B C Equipment Floater Leased /Rent Equip Pollution Liab UM00000165MA11A UM00000165MA11A CPL0292951101 07/27/2011 i a I': r1 I 07/27/2012 17/ 2012 I : s . ;• 2 Limit Per Policy $100,000/$5,000 ded. $2,000,000/$25,000 ded. DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101. Additional Remarks Schedule. If more space is required JUL 2 9 2011 t..x fci & RECORDS AN LEGISLk yp S WCS DEPT CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn: City Clerk P O Box 4748 Clearwater, FL 33758 -4748 ACORD 25 (2010/05) 1 of 1 #S1268828/M1266819 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 194- © 0 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD HXS