CERTIFICATE OF LIABILITY INSURANCE (254)FULLS -2
OP ID: KI
ALXRL'l" CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DDIYYYV)
10/04/2013
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 Phone: 727-447-6481
Bouchard - Clearwater Fax: 727449 -1267
101 Starcrest Drive
P 0 Box 6090
Clearwater, FL 33758 -6090
Bouchard Insurance
CONTACT
PHO No, E,rt): FAX No):
E -MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A :American States Insurance Co
19704
INSURED Full Service Electric Inc
Mr John Sims
1327 Michigan Ave
Palm Harbor, FL 34683 -4532
INSURERB:BusinesSfirst Insurance Co
11697
INSURER C :Auto-Owners Insurance Company
18988
INSURER D :
$ 1,000,000
INSURER E :
$ 200,000
INSURER F :
$ 10,000
CERTIFICATE NUMBER:
REVISION NUMBER:
vTHIS,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
SUER
WVD
POLICY NUMBER
(MM /DD //1 YYFY)
(MM /DD /YYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
01CH6201196
09/28/2013
09/28/2014
EACH OCCURRENCE
$ 1,000,000
PREM SES (Ea occu ence)
$ 200,000
MED EXP (Any one person)
$ 10,000
CLAIMS -MADE
X
OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP /OP AGG
$ 2,000,000
GEN'L AGGREGATE
7 POLICY
LIMIT APPLIES
JF 0
PER:
LOC
$
C
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
—
SCHEDULED
NON -OWNED
AUTOS
4147947900
09/28/2013
09/28/2014
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$ 50,000
BODILY INJURY (Per accident)
$ 100,000
PROPERTY DAMAGE
(Per accident)
$ 50,000
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
$
DED
RETENT ON $
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABIL TY
ANY PROPRIETOR/PARTNER /EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / N
N / A
052101181
09/28/2013
09/28/2014
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEE
$ 500,
E.L. DISEASE - POLICY LIMIT
$ 500 000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
c --- g2013
CANCELLATION
llCR t rr-WA 1= PIVLUGR
CITY OF CLEARWATER
PO Box 4748
Clearwater, FL 33756
1
CICLEAR
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
1
_ .___ __._
ACORD 25 (2010/05)
F . .
The ACORD name and logo are registered marks of ACORD