CERTIFICATE OF LIABILITY INSURANCE (950)Client#: 67108
50TAGGRINDIN
ACORD„ CERTIFICATE OF LIABILITY INSURANCE
DATED/YYYY)
07/26/2018
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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
J Smith Lanier & Co of Newnan
Marsh & McLennan Agency, LLC
P. O. Box 71429
Newnan, GA 30271-1429
EACT Crystal Adams
NAME:
PHONE FAX
(A/C, No, Est): 770 683-1000 (A/C, No): 770 683-1010
E-MAILDSS: cadams@jsmithlanier.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : Hart ysvIlls Mutual
14168
INSURED
TAG Grinding Services, Inc.
Jay Brooks, LLC
1750 Powder Springs Rd. #190-171
Marietta, GA 30064
INSURER B : Federal Insurance
20281
INSURER C : Evanston Insurance Company
35378
INSURER D :
ppEACCAH��OEECTCUURRENCE
PREINISES (EaEooauErrence1
INSURER E
INSURER F :
MED EXP (Any one person)
CERTIFICATE NUMBER:
•
THIS IS TO LLL r IFY 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
INSR
X
SUER
MD
X
POLICY NUMBER
MPA00000020785L
RECEIVED
q
('.', j t )1
��
IAL RECORDS AND
POLICY EFF
(MM/DD/YYYY)
07/27/2018
POLICY EXP
(MM/DDIYYYY)
07/27/2019
LIMITS
$1,000,000
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE
X
OCCUR
ppEACCAH��OEECTCUURRENCE
PREINISES (EaEooauErrence1
$100,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$1,000,000
GEN
'L AGGREGATE
POLICY
OTHER:
LIMIT APPLIES
PRO-
JECT
PER:
LOC
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMP/OP AGG
$2,000,000
$
A
AUTOMOBFLE
X
X
X
LIABILITY
ANYAUTO
OWNED
AUTOS ONLY
AIT OS ONLY
Drive Oth Car
—
X
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
X
X
BAO I, 1 1 I
SRVCS Dliit7/2018
07/27/2019
OBINED S
(EaCMacGdent> INGLE LIMIT
_$1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
A
X
UMBRELLA LIAB
EXCESS UAB
X
OCCUR
CLAIMS -MADE
N I A
CMB00000020786L
07/27/2018
07/27/2019
EACH OCCURRENCE
$5,000,000
AGGREGATE
$5,000,000
WORKERS
AND
ANY
OFFICER/MEMBER
(Mandatory
tf yes,
DESCRIPTION
DED
EMPLOYERS'
PROPRIETOR/PARTNER/EXECUTIVE
describe
X
COMPENSATION
in NH)
under
OF
RETENT ON $10,000
LIABILITY
EXCLUDED?
OPERATIONS below
Y I N
PER
STATUTE
OTH-
ER
$
E.L. EACH ACCIDENT
$
EL DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
B
C
Rented/Leased Eqp
Pollution/Profess
6711154
MMAENV001090
07/27/2018
07/27/2018
07/27/2019
07/27/2019
$750,000 Lmt/$5,000 Ded
$1,000,000/$2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
CANCELLATION
City of Clearwater
Attn: City Clerk
P 0 Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2016/03) 1 of 1
#S3972050/M3972009
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
/0 122r—
8RD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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