CANCELLATION OF CERTIFICATE OF LIABILITY INSURANCE,.., CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
03/19/2013 02:35 PM
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 cerficate 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
Highpoint Risk Services LLC
5501 LBJ Freeway, Suite 1200
Dallas, TX 75240
CONTACT NAME:
PHONE AC, NO.EatI: (800) 728-0623 FAX (,,,c,No): (972) 404-0380
EMAIL ADDRESS:
INSURERS AFFORDING COVERAGE
NAIC #
INSURER A: Companion Property and Casualty Insurance company
12157
INSURED: PPS 1 /c /f:
ISLAND PAINTING AND WATERPROOFING, INC.
5608 NORTH CHURCH AVENUE
TAMPA, FL 33614
Phone: (727) 599 -7394 Fax: (909) 284 -1967
INSURER B:
❑
INSURER C:
°, 3
–
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f ,..
INSURER D:
EACH OCCURRENCE
INSURER E:
INSURER F:
$
COVERAGES
CERTIFICATE NUMBER: AC13- 40900050 - 1178043
REVISION NUMBER:
II-110 lb 1 U LtK I II- Y I HA I [Eft FULIL.ItO OF INJUKANGt LIS I tU BtLOW NAVE BEEN ItSUtU I U I NE INSUKEU NAME ABUVt FUN I lit PULILY YEKIUU INUILA I tU.
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 SI,>F�I 1r74'lF 9 E 1 , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS. '
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
DATE (MM /DD/YY)
POLICY EXP
DATE (MM /DD/YY)
LIMITS
GENERAL
LIABILITY
COMMERCIAL GENERAL
LIABILITY
❑ OCCUR
❑
❑
°, 3
–
°
f ,..
-.
'"
EACH OCCURRENCE
$
DAMAGE TO RENTED
PRFMISFS IFa occurrence/
$
CLAIMS MADE
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GEN AT:
GEN'L AGGR E LIMI LIES '
POLICY JPECT
PRO TS- COMP /O'
AUTOMOBI
—
—
_
BILI
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
❑
❑
COM D SINGLE LI
BODILY INJURY (Per person)
BODILY INURY (Per accident)
$
PROPERTY DAMAGE
Tar
$
RETENTION $
$
A
WORKERS COMPENSArIOWAND
EMPLOYERS' LIABILITY
ANY PROPERIETOR/EXECUTIVE
OFFICER.MEMBER EXCLUDED?
(Mandatory in NH)
K yes, describe under
SPECIAL PROVISION below
YIN
N/A
X
DPE00120440360
01/01/2013
01/01/2014
X I TORY LIMITS IX
''3*'U'Y- EIR-
E.L. EACH ACCIDENT
$ 1000000
N
E.L. DISEASE - EA EMPLOYEE
$ 1000000
E.L. DISEASE - POLICY LIMIT
$ 1000000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES (Attached ACORD101, Additional Remarks Schedule, if more space is required
1. This certificate remains in effect, provided the client's account is in good standing with PPS. Coverage is
not provided for any employee for which the client is not reporting wages to PPS. Applies to 100% of the
employees of PPS leased to ISLAND PAINTING AND WATERPROOFING, INC., effective 01/01/2013 2. Insured is
afforded Workers Compensation & Employers Liability as a co- employer under the policy for employees leased from
Professional Payroll Solutions dba Employee Professionals.
CERTIFICATE HOLDER
CANCELLATION
CITY OF CLEARWATER
P.O. BOX 4748
CLEARWATER, FL 33758
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
.f='
per,SAP*5
-x`"
ACORD 25 (2010/05)
1988-2010 ACORD CORPORATION. All right reserved