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CERTIFICATE OF LIABILITY INSURANCE (247)PETER -1 OP ID: JW '4`c.. - RO. CERTIFICATE OF LIABILITY INSURANCE DATE 10 /18D/YYYY) 10/18/13 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 863- 294 -4241 GIS /Green Insurance Services 1500 6th Street NW 863- 2944243 Winter Haven, FL 33881 NAME: CT Wanda "Jean "Willis, AAI X 102 (q/2,NN . Ext): 863 - 294 -4241 FAX No): 863 - 294-4243 E-MAIL SS: jean @greeninsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:F C B & I Fund (FUBA) LIABILITY COMMERCIAL GENERAL LIABILITY INSURED Big Daddy's Mobile Home Set Up Service, LLC Jackie Peterson P O Box 2281 Eagle Lake, FL 33839 INSURER B: Southern Owners Insurance 10190 INSURER C 10/18/14 INSURER D : $ 1,000,000 INSURER E : $ 300,000 INSURER F : 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS B GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY 72107834 E 10/18/13 E� 10/18/14 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATELIMIT POLICY APPLIES JECT PER: LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS AUTOS SCHEDULED AUTOS NON-OWNED AU OCT 2 3 r IC ALECOgiDS r 2013 ANT DE j COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE iMSRVS EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A 10645771 09/03/13 09/03/14 X C STATU- TWORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 100,000 E . DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space Is required) Jackie Peterson Installer License #IH01025291 Aggregate limits shown may have been reduced by paid claims in reference to General Liability CERTIFICATE HOLDER CANCELLATION CLEAR -1 City of Clearwater tY 100 S Myrtle Avenue Clearwater, FL 34616 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