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CERTIFICATE OF LIABILITY INSURANCE (15) DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/15/17 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 PRODUCER Aon Risk Services, Inc of Florida NAME: Aon Risk Services, Inc of Florida PHONEFAX 1001 Brickell Bay Drive, Suite #1100 800-743-8130800-522-7514 (A/C, No, Ext):(A/C, No): Miami, FL 33131-4937 EMAIL ADP.COI.Center@Aon.com ADDRESS: INSURER(S) AFFORDING COVERAGENAIC # INSURER A : Illinois National Insurance Co23817 INSURED INSURER B : ADP TotalSource CO XXI, Inc. 10200 Sunset Drive INSURER C : Miami, FL 33173 INSURER D : ALTERNATE EMPLOYER Boys & Girls Club Of the Suncoast Inc INSURER E : 4625 East Bay Drive #103 Clearwater, FL 33764 INSURER F : COVERAGESCERTIFICATE NUMBER: REVISION NUMBER: 1718400 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. LIMITS SHOWN ARE AS REQUESTED. INSR ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER LIMITS LTR INSR WVD (MM/DD/YYYY)(MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY $ EACH OCCURRENCE DAMAGE TO RENTED CLAIMS-MADE OCCUR $ PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: $ GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS - COMP/OP AGG $ OTHER COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ (Ea accident) $ ANY AUTO BODILY INJURY (Per person) OWNED SCHEDULED $ BODILY INJURY (Per accident) AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DEC RETENTION $ PER OTH- WORKERS COMPENSATION X STATUTE ER A WC 026160313 FL 07/01/17 07/01/18 AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE 2,000,000 $ E.L. EACH ACCIDENT N / A OFFICER/MEMBER EXCLUDED? 2,000,000 (Mandatory in NH) $ E.L. DISEASE - EA EMPLOYEE If yes, describe under 2,000,000 $ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) All worksite employees working for BOYS & GIRLS CLUB OF THE SUNCOAST INC, paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. BOYS & GIRLS CLUB OF THE SUNCOAST INC is an alternate employer under this policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Chuck Lane PO Box 4748 ACCORDANCE WITH THE POLICY PROVISIONS. Clearwater, FL 33758 AUTHORIZED REPRESENTATIVE © 1988-2015ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD