CERTIFICATE OF LIABILITY INSURANCE (341)STATE -4
OP ID: AJ
AFRO CERTIFICATE OF LIABILITY INSURANCE
DATE 04 /18 /2014Y)
04/18/2014
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 Phone: 386- 252 -9601
Brown & Brown of Florida, Inc. Fax: 386 - 239 -5729
Daytona Beach Office
P.O. Box 2412
Daytona Beach, FL 32115 -2412
Richard Fulton
NAME: CT APRIL D. JONES, CPSR
PHONE 386- 239 -7298 FAX Not: 386 - 238 -8919
(A/c, No, E :t):
E-MAIL AJONES @BBDAYTONA.COM
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : Auto Owners Insurance Co.
18988
INSURED STATEWIDE CONSTRUCTION
RICK PATTERSON, INC. DBA
5458 HOFFNER AVENUE SUITE 308
ORLANDO, FL 32812
INSURER a :Association Insurance Company
11240
INSURER C : First Mercury Insurance
10657
INSURER D :
$ 1,000,000
INSURER E :
$ 50,000
INSURER F :
$ EXCLUDED
CERTIFICATE NUMBER•
N 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
C
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
NJCGL000000068403
10/29/2013
10/29/2014
EACH OCCURRENCE
$ 1,000,000
pREM SES Ea occTur ence)
$ 50,000
MED EXP (Any one person)
$ EXCLUDED
CLAIMS -MADE
X
OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
X
PER PROJECT AGG
PRODUCTS - COMP /OP AGG
$ 2,000,000
GE
'L AGGREGATE
POLICY
LIMIT APPLIES PER
JEFt T 1 LOC
Emp Ben.
$ 1,000,000
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
X
X
SCHEDULED
AUTOS
NON -OWNED
AUTOS
4632286000
04/18/2014
04/18/2015
Ea accdeDtj SINGLE LIMIT
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
C
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
NJEX000000101603
10/29/2013
10/29/2014
EACH OCCURRENCE
$ 2,000,000
AGGREGATE
$ 2,000,000
$
DED
X
RETENTION $ 0
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
AND
ANY PROPRIETOR /PARTNER /EXECUTIVE
OFFICER /MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / N
N / A
WCV050074906
04/16/2014
04/16/2015
X
WC STATU-
TORY LIMITS
-
0TH -
°N
E.L. EACH ACCIDENT
$ 1,000,000
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space Is required) E'i { -`
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IiCK I Iru.m 1 C r1VLL'CR
CITYCI0
CITY OF CLEARWATER
100 S MYRTLE AVE
CLEARWATER, FL 33756
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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
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ACORD 25 (2010/05)
- . •
The ACORD name and logo are registered marks of ACORD