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CERTIFICATE OF LIABILITY INSURANCE (324)Client#: 9695 COURNOYE ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 9/15/2014 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 Bouchard Insurance (CLW) 101 N Starcrest Dr. Clearwater, FL 33765 727 447 -6481 CONTACT NAME: PHONE FAX (A/C, No, Ext): 727 4476481 (A/c, No): 727 449 -1267 EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Bridgefield Employers Ins Co 10701 INSURED Cournoyer Construction Inc Louise Cournoyer 1476 Cleveland St Clearwater, FL 33755 INSURER B : RECEIVED SEP 16 2014 INSURER C : INSURER D : $ INSURER E : $ INSURER F : CERTIFICATE 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 (MMIDD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS GENERAL — LIABILITY COMMERCIAL GENERAL LIABILITY RECEIVED SEP 16 2014 EACH OCCURRENCE $ PREMISES (Ea occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE 7 POLICY LIMIT APPLIES PRO- — PER: LOC PRODUCTS - COMP /OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS AUTOS NON -OWNED AUTOS OFFICIAL RECORDS �� AND � 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 RETENT ON $ $ 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 y N / A 083032105 05/01/2014 05/01/2015 WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $1 00,000 E.L. DISEASE - EA EMPLOYEE $100,000 EL. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) ** Workers Comp Information ** Proprietors /Partners /Executive Officers /Members Excluded: Pierre Cournoyer, Pres Pierre Cournoyer, Pres (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION CITY OF CLEARWATER PO Box 4748 Clearwater, FL 33756 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) 1 of 2 #S15435/M15433 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ROBSW DESCRIPTIONS (Continued from Page 1) ** Supplemental Name** First Supplemental Name applies to all policies - c/o Louise Cournoyer NOTICE: Bouchard Insurance is required to comply with the licensing agreement we hold With ACORD. ACORD, in conjunction with the Department of Insurance, creates and enforces the rules and regulations pertaining to proper use of the Certificate of Liability Insurance form. We are required to mark a Y next to the line of business in which the Additional Insured or Waiver of Subrogation coverage applies. According to ACORD, the Description of Operations section must be limited to describing information necessary to identify the operations, locations and vehicles for which the certificate was issued. Please note the Description of Operations section of the Certificate cannot be used to add additional information except as just described. Marking a Y next to the line of business adequately documents coverage. Equally important, it satisfies the rules and regulations governing the proper use of the Certificate of Liability Insurance form. Certificate is a reflection of the current coverages provided for the insured. Limits and coverages are afforded to the certificate holder only if required by written contract. SAGITTA 25.3 (2010/05) 2 of 2 #S15435/M15433 COURN -1 OP ID: R8 '4`,°R& CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/3012014 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 101 Starcrest Drive Fax: 727-449 -1267 P 0 Box 6090 Clearwater, FL 33758 -6090 Bouchard Insurance CONTACT NAME: (TPA. Est): (A//C, No): E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Bridgefield Employers Ins Co 10701 INSURED Cournoyer Construction Inc Louise Cournoyer 1476 Cleveland St Clearwater, FL 33755 INSURER B : "' C-" INSURER C : INSURER D : $ INSURER E : $ INSURER F : $ • 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 yvvn POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MDD/YYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY "' C-" , EACH OCCURRENCE $ DAMAGE 10 RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ CLAIMS -MADE OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: 7 POLICY n IFRfOT fl LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED NON -OWNED AUTOS .. .. COMBINED SINGLE LIMIT (Ea accident) J $ BODILY INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 083032105 05/01/2014 05/01/2015 X TWC STAT- S ORY LIMIUT OTH- ER E.L. EACH ACCIDENT $ 100,000 E.L. 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) CELLATION CICLEAR CITY OF CLEARWATER PO Box 4748 Clearwater, FL 33756 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) @ 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD