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CERTIFICATE OF LIABILITY INSURANCE (420) DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/15/2016 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). CONTACT BRENDA M CORDER Town & Country Insurance Agency PRODUCER NAME: 1525 Herbert St. Ste 106 FAX PHONE 386 767 0147386 767 5075 (A/C, No): (A/C, No, Ext): Port Orange FL 32129 E-MAIL BRENDA@TOWNCO1.COM ADDRESS: INSURER(S) AFFORDING COVERAGENAIC # Phone: 386-767-0147 Fax: 386-767-5075 FOREMOST INS CO11185 INSURER A : 10700 RETAILFIRST INSURANCE COMPANY Williamson Dacar Associates Inc INSURED INSURER B : 24856 ADMIRAL INSURANCE COMPANY P.O. Box 2008 INSURER C : New Smyrna Beach FL 32170 INSURER D : INSURER E : INSURER F : COVERAGESCERTIFICATE 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 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. ADDLSUBRPOLICY EFFPOLICY EXP INSR TYPE OF INSURANCELIMITS POLICY NUMBER (MM/DD/YYYY)(MM/DD/YYYY) LTR INSDWVD X 2,000,000 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE$ X DAMAGE TO RENTED 1,000,000 CLAIMS-MADEOCCUR$ PREMISES (Ea occurrence) 10,000 MED EXP (Any one person)$ A 1,000,000 XPAS 03221571 09/24/2017 09/24/2016 PERSONAL & ADV INJURY$ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ 4,000,000 PRO- POLICYLOCPRODUCTS - COMP/OP AGG$ JECT $ OTHER: COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY $ (Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNEDSCHEDULED A BODILY INJURY (Per accident)$ AUTOS ONLYAUTOS PAS 03221571 09/24/201609/24/2017 X NON-OWNED HIREDPROPERTY DAMAGE X $ (Per accident) AUTOS ONLYAUTOS ONLY $ X 2,000,000 UMBRELLA LIAB EACH OCCURRENCE$ OCCUR A PAS 03221571 2,000,000 09/24/201609/24/2017 EXCESS LIAB CLAIMS-MADEAGGREGATE$ $ DEDRETENTION$ PEROTH- X WORKERS COMPENSATION STATUTEER AND EMPLOYERS' LIABILITY Y / N 500,000 B ANYP ROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT$ 0520-19270-0 N / A OFFICER/MEMBER EXCLUDED? 01/01/201601/01/2017 500,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ If yes, describe under 500,000 E.L. DISEASE - POLICY LIMIT$ DESCRIPTION OF OPERATIONS below PROFESSIONAL LIABILITY 2,000,000 AGGREGATE $5,000 DED EO000030428-02 09/14/2016 09/14/2017 claims made retro date 9/14/1996 1,000,000 OCCURRENCE C DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSURED'SLOCATION:15500LIGHTWAVEDRSUITE106,CLEARWATER,FL33760 CERTIFICATEHOLDERISNAMEDASADDITIONALINSUREDWITHAWAIVEROFSUBROGATIONINTHEFAVOR OFCITYOFCLEARWATERWITHRESPECTSTOPROFESSIONALSERVICESCONTRACTFORMISC.CITY FACILITIESIMPROVEMENTPROJECTS 30DAYSNOTICEOFCANCELLATION10DAYSNOTICEFORNONPAYMENTOFPREMUM CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITYOFCLEARWATER ACCORDANCE WITH THE POLICY PROVISIONS. C/OENGINEERINGDEPARTMENT POBOX4748 AUTHORIZED REPRESENTATIVE CLEARWATER,FL33758-4748 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD