CERTIFICATE OF LIABILITY INSURANCE (979)Client#: 67108
50TAGGRINDIN
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
DATD/YYYY)
9/12/2019
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 Corporate
Marsh & McLennan Agency, LLC
P 0 Box 70
West Point, GA 31833
CONTACT
NAME: Adams
PHONE FAX
((E-MAILo, Ext): 770-683-1000 (A/C, No): 770-683-1010
ADDRESS: cadams@jsmithlanier.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : Harleysville Mutual
14168
INSURED
TAG Grinding Services, Inc.
Jay Brooks, LLC
1750 Powder Springs Rd. #190-171
Marietta, GA 30064
B :Federal Insurance
20281
INSURER c : Evanston Insurance Company
35378
INSURER D : Stonewood Insurance Company31925
$1,000,000
$100,000
INSURER E :
INSURER F
X
COVERAGES
CERTIFICATE NUMBER:
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.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
D/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMITS
A
COMMERCIAL GENERAL LIABILITY
X
X
X
X
MPA0000002R la� A
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SEP L(D ),•[I"j
O�,`F(��IyCCI!',I_ �,, ,l._ \'I/(
/84 LAfl s:NLS
BA000000 L
/2019
``
AND
.25 1; �,'
DEPT.
07/27/2019
09/25/2019
EACH
�ES (EOCCURRENCE
PREMISa occu ence)
$1,000,000
$100,000
CLAIMS -MADE
X
OCCUR
MED EXP (Any one person)
$ 5,000
PERSONAL&ADV INJURY
$1,000,000
GEN'L
AGGREGATE
POLICY
OTHER:
LIMIT APPLIES PER:
PR-
JECOT I I LOC
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMP/OPAGG
$2,000,000
09/25/2019Ea
COMaccidBINEDent)SILIMIT
(
$
$NGLE
1,000,000
A
AUTOMOBILE
X
X
X
LIABILITY
ANY AUTO
OWNED AUTOS ONLY
Al ONLY
Drive Oth Car
X
SCHEDULED
AUTOS
NON-OOS ONWNELY D
AUT
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
A
X
UMBRELLA LIAB
EXCESS LIAB
_
OCCUR
CLAIMS -MADE
CMB00000020786L
07/27/2019
09/25/2019 EACH OCCURRENCE
$5,000,000
AGGREGATE
$5,000,000
DED
X
RETENT ON $10,000
$
D
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 / A
87029
09/11/2019
09/11/2020 X
PER
STATUTE
OTH-
ER
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYEE
$1,000,000
E.L. DISEASE - POLICY LIMIT
$1,000,000
B
C
Rented/Leased Eqp
Pollution/Profess
6711154
MMAENV001090
07/27/2019
07/27/2019
09/25/2019 $750,000 Lmt/$5,000 Ded
09/25/2019 $1,000,000/$2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Attn: City Clerk
P 0 Box 4748
Clearwater, FL 33758-4748
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
ACORD 25 (2016/03) 1 of 1
#S4488626/M4487734
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