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CERTIFICATE OF LIABILITY INSURANCE (431)ACORDw CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) 01/24/2014 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 POUCIES 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 FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 OWATONNA, MN 55060 CONTACT NAME: CLIENT CONTACT CENTER PHONE (A/C, No, Ext): 888 - 333 -4949 FAX No): 507 - 446 -4664 ADDRESS: CLIENTCONTACTCENTEReFEDINS.COM INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 058 -465 -6 J H WILLIAMS OIL CO INC P 0 BOX 439 TAMPA, FL 33601 INSURER B: 920618 C r, +'� JAN 2 INSURER C: 03/03/2015 INSURER D: $1,000,000 INSURER E: $100,000 INSURER F: COVERAGES CERTIFICATE NUMBER: 29 REVISION NUMBER: 0 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 (MMIDDIYYYYI POLICY EXP (MMIDD /YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY N N 920618 C r, +'� JAN 2 ,.,...,,,,, ,x'14 8 2 I4 03/03/2015 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 CLAIMS-MADE X OCCUR MED EXP (Any one person) EXCLUDED PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 — PRODUCTS - COMP /OP AGG $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY n JECT I I LOC A AUTOMOBILE X _ —AUTOS — LIABILITY ANY AUTO ALL OWNED HIRED AUTOS _AUTOS SCHEDULED NON -OWNED AUTOS N N ��1 RECORDS ��.q 92061Ji➢1 �°q �'' �A°(11 , 03/03/2015 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE N N 9001891 03/03/2014 03/03/2015 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 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 N 9336231 03/03/2014 03/03/2015 X WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) TOM BUTLER - LIC #ER0009464 J H WILLIAMS EMPLOYEE CERTIFICATE HOLDER CANCELLATION 058 -465 -6 29 0 CITY OF CLEARWATER PO BOX 4748 CLEARWATER, FL 33758 -4748 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE Qff/e47 ACORD 25 (2010/05) O 1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD FEDERATED INSURANCEr To Whom It May Concern, RE: J H WILLIAMS OIL CO INC Enclosed is a certificate of insurance that has been renewed for a new policy term. If a copy of an additional insured or policy endorsement was requested, the document will be sent in a separate envelope. If you have any questions regarding this please contact: the Federated Insurance Client Contact Center at: Phone: 1- 888 - 333 -4949 Fax: 507 - 446 -4664 E -mail: clientcontactcenter @fedins.com Thank you, Client Contact Center Federated Insurance Companies Enclosed: Certificate of Insurance MISC -0974 (04 -13)