CERTIFICATE OF LIABILITY INSURANCE (933) A �> ?®� CERTIFICATE OF LIABILITY INSU RANCE DATE(MWDDNYYY)
No=
IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
2018TE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
TATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
T: If the certificate holder is an ADDITIONAL INSURED„the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
ATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
ate does not confer rights to the certificate holder in lieu of such endorsement(s).
' PRODUCER SUtNZ Insurance Solutions, LLC. ID: Vensure HR CONTACT
2600 W Geronimo Place rtAME_ Tiffany Meye
r
PHONE �'" .
Suite 100 Ari-nIa y rs: 800 40)8958 � FAX
Chandler, AZ 85224 1 SAIL �AFG Noy
ADDRESS; tiff8ny,me�yensUre.COm _
I
___"N URERS�FORDINGCOVERAGE MAIC
� INSURED � -
.. INSURER A- United Wisconsin Insurance Company 29157
National Employer Services, LLC INSURERB.
2425 Commerce Ave INSURER C:
Suite 300
Duluth GA 30096 INSUR Ro:
INSURER E:
�.Q����Ey, INSURER F
' CERTIFICATE NUMBER: 45366110 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.
LTR TYPE OF INSURANCE ADDLSUBR j POLICY EFF POLICY EXP POLICY NUMBER (MMIDDNYYY) MM/DDtYY LIMITS
t COMMERCIALOENERALLIABILITY - -
''.EACH OCCURRENCE
CLAIMS-MADE $ ..
OCCUR DAMAGE TO RENTEi3
PREMISES(Ea occurrenr�eb $
f MED EXP(I y one person) $
INJURY. � ..
' GE INI'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV $- �.�...,_.
I
POLICY PERO CT U LOC GENERAL AGGREGATE
OTHER:
PRODUCTS-COMPIOP AGG $
..
AUTOMOBILE LIABILITY $
COMBINED SINGLE LIMIT $ -
ANY AUTO Ea accident)
r�OWNED SCHEDULED BODILY INJURY(Per person) $ �.�.�..
AUTOS ONLY I AUTOS
HIRED NON-OWNED BODILY INJURY(per accident) $
..-`
AUTOS ONLY _ AUTOS ONLY PROPERTY DAMAGE M
Per accident $
UMBRELLA.LIAB {OCCUR 4 $
.. EXCESS LIAB EACH OCCURRENCE $
DED RETENTION$... CLAIMS-MADE � - -_..- .......�.
AGGREGATE '$
A AND KERSEMPLOYERS'
LIABTIONILITY
WC516-00001-118-SZ 12/112018 12/1/2019 PER OTH- $
AND EMPLOYERS'LIABILITY YIN ✓ STATUTE ER -
ANYPROPRIETOR/PARTNERIEXECUTIVE WC516-00001-018 2119/2018 12/112018
OFFICERJMEMBEREXCLUDED? NIA E.LEACH ACCIDENT �.... $1OI)I3,t}I70
(Mandatory in NH) ,
If yes,describe under E.L.D€SEASE-EA EMPLOYE $1.Cj00^
DESCRIPTION OF OPERATIONS below Q00 _.
E.L.DISEASE-POLICY LIMIT $1 000000
I
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached if more space is required)
Coverage provided for all leased employees but not subcontractors of:JW Harris Contractors Inc
Client Effective:712/2018
CERTIFICATE HOLDER
11641 CANCELLATION
City Of Clearwater Administrative SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Office and South Area Service Center THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
400 North fillyyrtle Ave ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater FL 33756
a1JTHORIZEp R£PF2ESENTATIYE Y�+�+r��
Glen J Distefano
(D 1988-2015
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORDORD CORPORATION. All rights reserved.
45366116 f National EmPIQYer Services Pett 516 MASTER CERT I Shawna Calcatera 117,/13/2028 3:47:24 PM (EST) I Page 1 c,f a