CERTIFICATE OF LIABILITY INSURANCE (1077)/
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
A� " CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
INSR
LTR
08/12/2021
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 Amanda Yoder -Carr
NAME:
CGB Insurance, LLC
(813) 749-7948 FA (813) 200-2120
SCC
JCExt): No):
E-MAIL amanda@cgbinsurance.com
2531 Green Forest Lane
CLAIMS -MADE FX OCCUR
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
#101
INSURERA: Main Street America Protection Ins Co 13026
Lutz FL 33558
INSURED
INSURER B: Old Dominion Insurance Company 01573
INSURER C :
Florida Gas & Plumbing, Inc
INSURER D:
5680 66th St N
INSURER E:
INSURER F:
St Petersburg FL 33709
COVERAGES CERTIFICATE NUMBER: 2021-2022 Master 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 INSURANCEADDLSUBR
INSD
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
CLAIMS -MADE FX OCCUR
PREM SES Ea oNcE ence $ 500,000
MED EXP (Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
A
Y
MPP3887X
09/08/2021
09/08/2022
LAGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $2,000,000
POLICY❑PRO ❑ LOC
JECT:
MOTHER
PRODUCTS-COMP/OPAGG $ 2,000,000
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
BODILY INJURY (Per person) $
X
ANYAUTO
B
OWNED SCHEDULED
AUTOS ONLY AUTOS
Y
B1 P3888X
09/08/2021
09/08/2022
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $ 1,000,000
AGGREGATE $ 1,000,000
B
X
EXCESS LAB
CLAIMS -MADE
CUP3887X
09/08/2021
09/08/2022
DED I X1 RETENTION $ 10,000
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
PEROTH-
STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
OFFICER/MEMBER EXCLUDED?
NIA
E.L. EACH ACCIDENT $
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
This policy includes an automatic additional insured endorsement that provides coverage to entities as an Additional Insured when there is a written contract
in place that requires this.
CERTIFICATE HOLDER CANCELLATION
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Clearwater Gas
ACCORDANCE WITH THE POLICY PROVISIONS.
400 N Myrtle Ave
AUTHORIZED REPRESENTATIVE
Clearwater FL 33755
it
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD