CERTIFICATE OF LIABILITY INSURANCE (841) DATE(MMfDDIYYYY)
AC R" CERTIFICATE OF LIABILITY INSURANCE 2/12/2017
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 15 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{s1,
PRODUCER CONTACT
Commercial Lines-[305)443-4886 NAME:
P�I4�E 886-672-24'12 _ Fwc NO);
AIC.Nv.Ett):
Wells Fargo Insurance Services USA,Inc. E-MAIL
ADDRESS.
2609 South Bayshore Drive,Suite 1600 �INSURER(S I AFFORDING COVERAGE NAIC9
Coconut Grove,FL 33133 INSURFRA; Indemnity Insurance Company-of.-North America 43575
INSURED INSURER B
Strategic Outsourcing,Inc ---�.. —._. T..__.....
INSURER G
F1W1L Heath Consultants Incorporated INSURER D:
PO Box 241448 INSURER F:
Charlotte,NC 28224 INSURER F
COVERAGES CERTIFICATE NUMBER. 11422225 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 � AUbL SESeRPbL3CY EFF POLICY E7CP
f,7R TYPE OF INSURANCE IN POLICY NUMBER MMIAfNYYYY MMIDOIYYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s
DAMAGE TO RE NTE
CLAIMS-MADE F—I OCCUR PREMiSES�Ea occurrence 5
ME EXP(Any one person) s
1E t"AL&ADV INJURY 5
GEN'L AGGREGATE LIMITAPPLIES PER. GENERAL AGGREGATE_ s
^ POLICY F—I PRC7 O- 1-1 LOC PRODUCTS-COMPIOP AGG S T
JF
OTHER 5
AUTOMP6[LEL.IABILITY COMBINED SINGLE LIMIT S
Fa orCidenl
ANY AUTO BODILY INJURY(Per person) 5
OWNED SCHEDULED BODILY INJURY(Per accident) 5
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE s
AUTOS ONLY AUTOS ONLY Per a�denl
UMBRFLLALIAS I OCCUR EACHOCCURRENCE 5
EXCESS LLAB CLAIMS-MADE AGGREGATE Is
DIED RETENTION s Is
WORKERS COMPENSATION 1)311}112017 03/01/2018 X S�ATUTE ER
A AND EMPLOYERS'LIABILITY YIN WLRC64309535
ANYPROPRlrzTORIPARTNER IExECUT1VE E.L.EACH ACCIDENT Is 5,000,000
OFFICERIMEMBEREXCLUDED9 N NIA
(Mandatory In NH) L.DISEASE-EA EMPLOYEE 5 1,000.000
If ycs.describe undor 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101,Additional Remarks Schedule,may be attached it more space Is required)
Re:ITB#15-16 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).
RECEIVED
CERTIFICATE HOLDER MAP 2 0 2017 CANCELLATION
City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE
`
Attn.:Clearwater Gas Systems AS ADMYN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Y ACCORDANCE WITH THE POLICY PROVISIONS.
P.O.Box 4748
Clearwater FL 33758-4748 AUTHORIZED REPRESENTATIVE
9e�""'i` "'�
The ACORD name and logo are registered marks of ACORD @ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103)
Workers'Compensation and Employers' Liability Policy
Named Insured Endorsement Number
STRATEGIC OUTSOURCING,INC.
3023 HSBC WAY,SUITE 200 Policy Number
FORT MILL SC 29707 Symbol: WL.R Number:064309535
Policy Period Effective Date of Endorsement
03-01-2017 TO 03-01-2015 03-01-2017
Issued By(Name of Insurance Company)
INDEMNITY INS.CO.OF NORTH AMERICA
Insert tha po[ic number.The remainder of the information is to be cam pleted on]y when[his endorsement is issued sobse q uent to the p re aration of the 20 leic .
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.
The endorsement does not apply to policies in Missouri where the employer is in the construction group of code
classifications.According to Section 287.150(6) of the Missouri statutes, a contractual provision purporting to waive
subrogation rights against public policy and void where one party to the contract is an employer in the construction
group of code classifications.
For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A..
16-1801 through 16-1867 and any amendments thereto) and the Kansas Fairness in Public Construction Contract
Act(K.S.A 16-1901 through 16-1908 and any amendments thereto). According to the Acts a provision in a contract
for private or public construction purporting to waive subrogation rights for losses or claims covered or paid by
liability or workers compensation insurance shall be against public policy and shall be void and unenforceable
except that, subject to the Acts, a contract may require waiver of subrogation for losses or claims paid by a
consolidated or wrap-up insurance program.
MAR 2 0 2017
Authorized Representative
:GAS ADM-IN
WC 00 03 13 X11/05)Ptd. U.S.A. Copyright 1982-83,National Council on Compensation
CHUBPRO
LIAR 2 0 2017
GAS A.DI` IN
NOTICE TO OTHERS -SPECIFIC PARTIES
A. if we cancel this Policy prior to its expiration date by notice to you or the first Named insured for any reason
other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation,
via such electronic or other form of notification as we determine, to the persons or organizations listed in the
schedule set out below (the "Schedule"). You or your representative must provide us with both the physical and
e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that
you or your representative provided to us on such Schedule.
B. We will endeavor to semi or deliver such notice to the e-mail address or physical address corresponding to each
person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the
Policy.
C. The notice of cancellation is intended only to be a courtesy notification to the person(s) or organization(s) named
in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to
any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s)
or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents
or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy.
D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for
any incorrect information that you or your representative provide to us. If you or your representative does not
provide us with the information necessary to complete the Schedule, we have no responsibility for taking any
action. In addition, if neither you nor your representative provides us with e-mail and physical address
information with respect to a particular person or organization, then we shall have no responsibility for taking
action with regard to such person or entity.
E. We may arrange with your representative to send such notice in the event of any such cancellation.
F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and
physical address of the persons or organizations listed in the Schedule.
G. The provisions of this notice do not apply in the event that you cancel the Policy.
SCHEDULE
Name of Certificate Holder E-Mail Address Physical Address
CITY OF CLEARWATER TTN: CLEARWATER GAS SYSTEMS,
PO BOX 4748, CLEARWATER, FL 337
58-4748
RE: HEATH CONSULTANTS, CLIENT I
17: 7913
WC 99 03 86(10/11) Page 1 of 1