CERTIFICATE OF LIABILITY INSURANCE (1104) 0. page 2 of 41
Client#:115 79EOUIPCON
DATE(MMMONYYY)
T
ACORD,. CERTIFICATE OF LI ABILITY INSURANCE r71E2'6f2022
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
IW(5F1tA'Nt':If the c'e-r-t-411-ca-te ho-I d-a r-is an_AD'DITT 0N_WE,INSURE,_„the---p-o-l-i-cy—(,ie—s,)"m-u"s"t"hav e- 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 GA Certificate Team
.NAME:
McGrIff Insurance Services PHONE ------- FAX
N EX :770 471-7100 jNqlp�q), -1559
o,_I) _8.77 11 6 5.7
741 W.Lanier Ave.,Slufte 100 E-MAIL
,A, DDRESS, certifIcatesgaQMCGrIff.com___
Fayetteville,GA 30214-GA
INSUREFI(S)AFFORDING COVERAGE _.N_--
AIC#
I
770 471-7100 tim
INSURER A:Phoenix Insurance Company 3
.......... . .................. ............
INSURED INSURER B!Travelers Property Casualty Co of Amer X25674
Equipment-Controls Company
INSURER C:Charter Oak Fire Insurance Company
PO Box 728,
INSURER D Travelers Indemnity Co of CT (25662
Norcross,GA 30091
INSURER E:
............ I...".-,................... ............................................................................
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT -rHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERK)D
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT 70 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 FIEDUCEDBY PAID CLAIMS.
................................................................. ...............Pocfei?_
AshWE SL EW P-0.LIcy_9153
LTF1 TYPE OF INSURANCE rINSR. POLICY NUMBER LIMITS
(MWDDNyyy)_�Mh�rqDyyyyj I
A COMMERCIAL GENERAL LIABILITY Y6301 R474048PHX22 D7/3Ot2O22 07/30/2023EACH
OCCUR RAMAOE TO RENTED
CI_AIMG,MADE
MED EXP Al
iyorieperson)
��PERSONIAL&ADV INX RY S i,000,WO
GEN'L AGGREGATE LIMIT APPUES PER: GE!IERAL AGGREGATE s3,000,OOD
PRO- JOC
JECT P ROD UCTS,-C OM P�O P AGG S 000,0'00
OTHER: S
--cohe IN ED SiNGLE LN IT
D AUTOMOME LIABILITY 8101 R4742462214G D7/30=22107/3=023�,j a(',cidqn
1,000X0
_"X ANYAUTO SCHEDULED BODILYINJURY(Petperson) IS
AUTNOESPONLY AUTOS BODILY INJURY,Per acmdent)_ 6 ---
......................
x HIRED NON-OWNED PROPERTY DAMAGE S
AUTOS ONLY AUTOE ONIJ.Y JReracade �).
_]qx -
X UMEIRELLALIAS X OCCUR
CUP1 R4746752214 07/3D/2022 2311L EACH OCCURRENCE
IT. Exc ESS UA 8
CLAIMS.MADE AGGREGATE $5 000 ow
IR __7
JIDED Lx-- TE..
..............................I................... ..............
WORKERS COMPENSATION
C I �UB1 R4747,672214G 07/3(Y2022 071,W2023 X. TUTE OTII_
AND EMPLOYERS'LIABILITY TA F;
L'Y--1 N
AN Y P RO P RIIETOFV PA R7N E$q,?FX ECU TIV E E-L,EACH ACCIDENT
OFFICERiMEMSER EXCLUDED) Y]INIA� ....................... A 1000
(Mandatory In NHI
ASE-_E.A.EMPLOYEE S1,900,000
If�m describe un def
0_S.CHIPT1$ON..10P CIPERATION§Poyy' I EL�DISEASE-POLICY LIMIT S`1,00010W
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES JACORD 101,Additional Remarks Schedule,maybe allached 11mora space Is required)
Workers Compensation Officer Excluded. James E Bell Jr.
**See Attached Forms"
CGD246 041'9 Blanket Additional Insured(Includes Products-Completed Operations If Requited By Contract)
CG0458 0219 XTEND Endorsement for Manufacturers And Wholesalers
(See Attached Descriptions)
TI
CERFICATE HOLDER CANCELLATION
. . .......... —-----
RECEIVED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Clearwater Gas Systems THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
777 Maple Street ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater,FL 33755
AUTHORIZED REPRESENTATIVE
GAS ADM II llw I
0 1 988-201 5 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD
5581 #S'30478844/M30472157 DF1
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CGT100.0219 Commercial General Liability Coverage.Form
CAT353 0215 Business Auto Extension Endorsement
CAT474 0216 Blanket Additional.Insured-Primary and Non-Contributory.With Other Insurance
WC000313(00)Waiver of Out Right To Recover From Others Endorsement.
SAGITTA:25.3(201.610.3) 2 of 2.
#530478844/M3n472157
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