CERTIFICATE OF LIABILITY INSURANCE (640)SO17913
A� �® CERTIFICATE OF LIABILITY INSURANCE
DATE IYYW)
2/24/2015 M/DD/T
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
Commercial Lines
Wells Fargo Insurance Services USA, Inc.
6100 Fairview Road
Charlotte, NC 28210
CONTACT
NAME:
PHONE FAX
JA/C. Ext. 888 572 -2412 (A /C No):
ADDRESS: certs @trinet.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A: Indemnity Insurance Company of North America
43575
INSURED
Strategic Outsourcing, Inc
F/W /L Heath Consultants Incorporated
PO Box 241448
Charlotte, NC 28224
INSURER B
INSURER C :
INSURER D :
$
INSURER E
INSURER F :
COVERAGES
CERTIFICATE NUMBER: 8776672
REVISION NUMBER: See below
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
INSD
SUBR
W VD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
CLAIMS -MADE
OCCUR
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GE
'L AGGREGATE
POLICY
OTHER:
LIMIT APPLIES
PRO-
JECT
PER:
LOC
GENERAL AGGREGATE
$
PRODUCTS - COMP /OP AGG
$
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
_
SCHEDULED
AUTOS
NON -OWNED
AUTOS
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
RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR /PARTNER /EXECUTIVE
OFFICER/MEMBER EXCLUDED? N
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
X
WLRC48567885
03/01/2015
03/01/2016
X
STATUTE
TA
EERH
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 I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Workers' Compensation coverage is limited to employees leased to Heath Consultants, Inc by Strategic Outsourcing, Inc. A Waiver of Subrogation applies
in favor of City of Clearwater Gas Department as required by written contract. A 30 day notice of cancellation is endorsed to the policy for City of Clearwater
Gas Department (Except for 10 days for non - payment of premium).
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Attn.: Clearwater Gas Systems
y
P.O. Box 4748
Clearwater FL 33758 -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
9 «li
The ACORD name and logo are registered marks of ACORD
ACORD 25 (2014/01)
@ 1988 -2014 ACORD CORPORATION. All rights reserved.
Workers' Compensation and Employers' Liability Policy
Named Insured
STRATEGIC OUTSOURCING, INC.
3023 HSBC WAY, SUITE 100
FORT MILL SC 29707
Endorsement Number
Policy Number
Symbol: WLR Number: C48561226
Policy Period
03 -01 -2015 TO 03-01 -2016
Effective Date of Endorsement
03 -01 -2015
Issued By (Name of Insurance Company)
INDEMNITY INS. CO. OF NORTH AMERICA
Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule.
Schedule
ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR
RIGHT OF RECOVERY IN A WRITTEN CONTRACT PROVIDED SUCH CONTRACT WAS
EXECUTED PRIOR TO THE DATE OF LOSS.
For the states of CA, UT, TX, refer to state specific endorsements.
This endorsement is not applicable in KY, NH, and NJ.
Authorized Agent
WC 00 03 13 (11/05) Ptd. U.S.A. Copyright 1982 -83, National Council on Compensation