CERTIFICATE OF LIABILITY INSURANCE (129)Client#: 67108 SOTAGGRINDIN
DATE (MM/DD/YYYY)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE ,�2s�2o,2
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
certifcate holder in lieu of such endorsement(s).
PRODUCER coNTncr Heather Varnadoe
NAME:
J Smith Lanier 8 Co of Newnan a"c°NN ext : 7%0 683-1107 F'°X
P. O. Box 71429 E-MAIL ac, No : 770 683-1010
anoRess: hvarnadoe@jsmithlanier.com
Newnan, GA 30271-1429 INSURER(S) AFFORDING COVERAGE NAIC #
770 683-1000 ,NSURERA: Harleysville Mutual 14768
INSURED
TAG Grinding Services, Inc.
J W B Leasing Co., Inc.
1113 Horseshoe Bend Rd.
Dadeville, AL 36853
COVERAGES
CERTIFICATE NUMBER:
iNSUReR s: Navigators Specialty Insurance
iNSUReR c: American Safety Indemnity Compa
�NSUReR o: Travelers Casualty and Surety C
INSURER E :
INSURER F :
REVISION NUMBER:
19038
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 TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS
LTR INSR WVD POLICY NUMBER MM/DD MM/DD/YYYY
A GENERALLIABILITY X X MPA00000020785L �� � O7/27/201 EACHOCCURRENCE $�,OOO,OOO
X COMMERCIAL GENERAL LIABILITY PREMISES Ea oocu ence $1 OO OOO
CLAIMS-MADE � OCCUR MED EXP (My one person) $ rJ �0�
JUL3 0 2012 PERSONAL&ADVINJURY $�,OOO,OOO
GENER.4LAGGREGATE $Z�OOO�OOO
GEN'L AGGREGATE LIMIT APPLIES PER: �����er�tiL. Lia.l�D.7 `� PRODUCTS - COMP/OP AGG $ Z�OOO�OOO
PO�ICY jE� LOC i4 �S �� $
A AUTOMOBILE LIABILITY X X BA00000020784L 7/27/2012 07/27/201 COMBINED SINGLE LiM1T 2 OOO OOO
Ea accident � +
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
$
A �( UMBRELLA LIAB X OCCUR CMB00000020786L 7/27/2012 07/27/201 EACH OCCURRENCE $4 OOO OOO
EXCESS LIAB CLAIMS-MADE AGGREGATE $�i OOO OOO
DED X RETENTION $� O OOO $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY Y� N TO p R
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? � N / A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
�f yes, describe under
DESCRIPTION OF OPERATIONS below E.L. UISEASE - POLICY LIMIT $
B Leased/Rent Equip BINDER 7/27/2012 07/27/201 $250,000 (per item)
C Pollution Liab CPL0292951202 6/10/2012 06I10/201 $2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (AtWch ACORD 101, Additio�al Remarks Schedule, if more space is requlred)
Cit of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: City Clerk ACCORDANCE WITH THE POLICY PROVISIONS.
P O Box 4748
Clearwater, FL 33758-4748 AUTHORIZED REPRESENTATIVE
O 19 8- 010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S1623181/M1623142 HXS