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CERTIFICATE OF LIABILITY INSURANCE (788)------1 ® ACORO CERTIFICATE OF LIABILITY INSURANCE L.----- DATE (MM /DD/YYYY) 8/22/2016 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 have ADDITIONAL INSURED provisions or 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 Wells Fargo Insurance g Liberty Mutual Insurance PO Box 188065 Fairfield, OH 45018 CONTACT NAME: PHONE FAX ac. No. Ext): 800- 962 -7132 (A/C. No): 800- 845 -3666 E-MAIL ADDRESS: BusinessService ©LibertyMutual.com INSURER(S) AFFORDING COVERAGE NAIC 0 INSURERA: First National Insurance Co of America 24724 INSURED Cynthia Williams DBA Uniquely Organic PO Box 309 Brandon FL 33509 INSURER B : 25CC36441240 INSURER C: 10/2/2017 INSURER D : $ 1,000,000 INSURERE: $ 1,000,000 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 INCn SUBR WVD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS A / COMMERCIAL GENERAL LIABILITY 1/ 25CC36441240 10/2/2016 10/2/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMISES (Ea RENTE ence) $ 1,000,000 CLAIMS -MADE ✓ OCCUR MED EXP (Any one person) $ 10,000 PERSONAL &ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE ✓ 'L AGGREGATE POLICY OTHER: LIMIT APPLIES JET PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY 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 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PEATUTE 0TH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) a Y The City of Clearwater is Additional Insured if required in a written contract, agreement, permit or schedule. AUG 2 2il if'. r-V EGAL RECORDS AND CERTIFICATE HOLDER CANCELLATION The City of Clearwater P.O. Box 4748 Clearwater FL 33758 k 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 Kelly Poulsen ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 31426928 1 2642059723 1 16 -17 Master Certificate 1 Kelly Poulsen 1 8/22/2016 8:57:45 AM (PDT) 1 Page 1 of 1 Wells Fargo Insurance Liberty Mutual Insurance PO Box 188065 Fairfield, OH 45018 The City of Clearwater P.O. Box 4748 Clearwater FL 33758 Mutual INSURANCE Kelly Poulsen 800 - 962 -7132 Cert No. 31426928 - Cynthia Williams - Certificate of Liability - 25CC36441240 8/22/2016 Hello, Attached please find the 16 -17 Certificate of Liability for our insured, Cynthia Williams DBA Uniquely Organic for holder The City of Clearwater. A copy of this certificate was mailed US Mail to the holder and emailed to the insured. Thank you on behalf of Wells Fargo Insurance and Liberty Mutual Insurance. Attached is a Certificate of Insurance for the above - mentioned insured. Please note that any changes to the proof of insurance, other than basic changes to the Certificate Holder name and /or address, must be requested by the Named Insured or Agent of Record directly. If you have any questions or need any amendments, please contact us via email: BusinessService @LibertyMutual.com or call: 800 - 962 -7132. Thank you! Kelly Poulsen Associate Service Representative Liberty Mutual Insurance Toll Free: (800)- 962 -7132 Fax: (800) -845 -3666 BusinessService @LibertyMutual.com This information and any attachments are intended only for the use of the addressee(s) named herein and may contain legally privileged and /or confidential information. If you are not the intended recipient of this information, you are hereby notified that any dissemination, distribution or copying of this information, and any attachments thereto, is strict[y prohibited. If you have received this information in error, please notify, me via return e-mail and via telephone at 800 - 962 -7132, and please permanently delete the original- and any copy of any information and any printout thereof. RECEIVED AU( 2; 201b OFFICIAL RECORDS AND LEGISLATIVE SRVCS DEFT THIS MESSAGE IS INTENDED FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. IF THE READER OF THE MESSAGE IS NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE OR AGENT RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY US IMEDIATELY BYTELEPHONE, AND RETURN THE ORIGINAL MESSAGE TO US AT THE ABOVE ADDRESS VIA REGULAR POSTAL SERVICE. Certificate of Insurance Delivered by ecertsonlineTM Insurance Visions, Inc. All rights reserved.