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CERTIFICATE OF LIABILITY INSURANCE (666) Client#: 15483 COUNTRYS5 DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 1 7/23/2015 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 CONTACT NAME: Bouchard Insurance(CLW) PHONE 727 447-6481 FAX 727 449-1267 A/C,No,Ext: (A/C,No): 101 N Starcrest Dr. ADDRESS: cicerts @bouchardinsurance.com Clearwater, FL 33765 INSURER(S)AFFORDING COVERAGE NAIC# 727 447-6481 INSURERA:Westfield Insurance Company 24112 INSURED INSURER B: Bridgefield Employers Ins Co 10701 Countryside Glass &Mirror Inc INSURERC:Colony National Insurance Co 34118 2650 Gandy Blvd INSURER D Pinellas Park, FL 33702-5511 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 CONTRACTOR 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.ADDLSUBR LTR TYPE OF INSURANCE NSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY Y Y CMM4824170 07/02/2015 07/02/2016 EACHOCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISESRENT'E'D '.'c.) $150,000 CLAIMS-MADE Fx_]OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO LOC $ JECT A AUTOMOBILE LIABILITY Y Y CMM4824170 07/02/2015 07/02/201 Ee accciden SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ A X UMBRELLA LAB X d OCCUR Y Y CMM4824170 07/02/2015 07/02/2016 EACH OCCURRENCE s6,000,000 EXCESS LAB CLAIMS-MADE AGGREGATE s6,000,000 DED X RETENTION$O $ B WORKERS COMPENSATION Y 083026338 01/01/2015 01/01/201 X TvORY LIMITS EORH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 C Pollution Y CPL302431 07/11/2015 07/02/201 $2 Mill Agg/$1 Mill Oc Mold Included $10,000 Deductible DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Coverage is primary as respects to General Liability and non-contributory as subject to the terms, conditions and exclusions of your policy. Umbrella Liability Coverage is Follow Form. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION 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 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #S222941/M204237 C HAW I DESCRIPTIONS (Continued from Page 1) 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 #S222941/M204237