CERTIFICATE OF LIABILITY INSURANCE (17) ,rt C DATE(MM/DD/YYYY)
Cid. CERTIFICATE OF LIABILITY INSURANCE 06/18/18
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 CONTACT
Aon Risk Services,Inc of Florida NAME: Aon Risk Services,Inc Of Florida
1001 Brickell Bay Drive,Suite#1100 PHONE FAX
Miami,FL 33131-4937 AIC No Ext):800-743-8130 A/C,
/C No):800-522-7514
EMAIL
ADDRESS: ADP.COI.Center@Aon.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: Illinois National Insurance Co 23817
INSURED INSURER B:
ADP TotalSource CO XXI,Inc.
10200 Sunset Drive INSURER C:
Miami,FL 33173
ALTERNATE EMPLOYER INSURER D:
Boys&Girls Club Of the Suncoast Inc INSURER E:
4625 East Bay Drive#103
Clearwater,FL 33764 INSURER F:
COVERAGES CERTIFICATE NUMBER: 2018041 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. LIMITS SHOWN ARE AS REQUESTED.
INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR WVD MM/DD/YYYY MMIDD
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE ❑ OCCUR PREM,
REM SESOEa oNTEcurrDence $
MED EXP(Any oneperson) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
]POLICY LIPROJECT EILOC PRODUCTS-COMP/OP AGG $
OTHER $
ACOMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY
Ea accident $
ANY AUTO BODILY INJURY Perperson) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY Per accident $
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEC I I RETENTION$
WORKERS COMPENSATION X PER OTH-
A AND EMPLOYERS'LIABILITY YIN WC 047014231 FL 07/01/18 07/01/19 STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ 2,000,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 2,000,000
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
City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn:Chuck Lane THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO Box 4748 ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater,FL 33758
AUTHORIZED REPRESENTATIVE ] �p
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