CERTIFICATE OF LIABILITY INSURANCE (978)Client#: 67108
50TAGGRINDIN
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
DATE
9/26/2019
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 Newnan
P. O. Box 71429
47 Postal Parkway
Newnan, GA 30271-1429
CONTACT
Crystal Adams
PHONE FAx
(ac, No, Ext): 770-683-1000 (A/C, No): 770-683-1010
ADDRESS: cadams@jsmithlanier.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : Everest National Insurance Company
10120
INSURED
TAG Grinding Services, Inc.
Jay Brooks, LLC
1750 Powder Springs Rd. #190-171
Marietta, GA 30064
INSURER B : Everest Denali Insurance Company
16044
INSURER C : Stonewood Insurance Company
31925
INSURER D
$1,000,000
INSURER E
INSURER F :
X
COVERAGES
CERTIFICATE 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.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
wVD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
X
X
X
X
CF3GL00194'634--,---- .�
v .
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OF -i ..:,j.
CF3CA004ii--` d ° : , ,
19/25/2019
-
,.' `
`
401252619
09/25/2020
09/25/2020
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE
X
OCCUR
PREMISES (Ea occu ence)
$100,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$1,000,000
GEN'L
AGGREGATE
POLICY
OTHER:
LIMIT APPLIES
ECOT
PER:
LOCPRODUCTS-
GENERAL AGGREGATE
$ 2,000,000
COMP/OP AGG
$2,000,000
EO BINEDtSINGLE LIMIT
$
$1,000,000
B
AUTOMOBILE
X
LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
AUTOS ONLY
xAUTOS
X
SCHEDULED
NONOS-OWNEONLY D
AUT
BODILY INJURY (Per person)
- -
$
BODILY INJURY (Per accident)
-
$
PROPERTY DAMAGE
(Per accident)
$
$
B
x
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
XC5EX00820191
09/25/2019
09/25/2020
EACH OCCURRENCE
$1,000,000
$1,000,000
AGGREGATE
DED
RETENT ON $
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / N
N
N / A
X
87029
09/11/2019
09/11/2020
X I PER I 1OTH-
STATUTE ER
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYEE
$1,000,000
E.L. DISEASE - POLICY LIMIT
$1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
(GL) Additional Insured applies per Form CG20330413.
(GL) Additional Insured in regards to Completed Operations applies per Form CG20370413.
(GL) Primary & Noncontributory applies per Form CG20010413.
(GL) Waiver of Subrogation applies per Form CG24040509.
(CAU) Additional Insured applies per Form CA20481013.
(See Attached Descriptions)
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Attn: City Clerk
P O Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2016/03) 1 of 2
#S4504901/M4504648
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
19 88- 015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SZT
r
DESCRIPTIONS (Continued from Page 1)
(CAU) Waiver of Subrogation applies per Form ECA245030214.
(WC) Waiver of Subrogation applies per Form WC000313.
SAGITTA 25.3 (2016/03) 2 of 2
#S4504901/M4504648