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CERTIFICATE OF LIABILITY INSURANCE (302)Policy Number: 0830 -37643 Date Entered: 4/1/2014 ACO O CERTIFICATE OF LIABILITY INSURANCE 3/2(6/2014 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 WorkComp Partners 702 Tillman Place Plant City, FL 33566 CONTACT PHON: (A /C. "x .Extl: (813)747 -7490 (AC,No); (813)747 -7495 E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Bridgefield Employers Insurance Company LIABIUTY COMMERCIAL GENERAL LIABILITY INSURED Norris & Samon Pump Service, Inc. & Samon Group, Inc. Joel M. Samon 2620 20th Avenue North Saint Petersburg, FL 33713 INSURER B: y t a q ` P INSURER C: INSURERD: $ INSURER E: $ 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 POUCY NUMBER POUCY EFF (MM /DD/YYYYL(MM POUCY EXP /DD/YYYY) LIMITS GENERAL LIABIUTY COMMERCIAL GENERAL LIABILITY y t a q ` P .ti L EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ CLAIMS -MADE OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP /OP AGG $ GEN'L AGGREGATE 7 POLICY LIMIT APPLIES PER: PRO- IFF:T LOC $ AUTOMOBILE LIABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS .� Y • ,. Li. 1 y COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' UABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE Y /N OFFICER/MEMBER EXCLUDED? N I (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 0830 -37643 4/1/2014 4/1/2015 WC STATU- TORY LIMITS X / ` OTH- ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 II DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION City of Clearwater PO Box 4748 Clearwater, FL 34618 -4748 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 Robin R. Stenger ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Plus software. www.FormsBoss.com; Impressive Publishing 800 - 208 -1977