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CERTIFICATE OF LIABILITY INSURANCE (1128)
71/25/2024 E(MM/DDYYY) A�" CERTIFICATE OF LIABILITY INSURANCE /Y 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 NAME: Aon Risk Services, Inc.of Florida Aon Risk Services, Inc.of Florida PHONE FAX 7650 W.Courtney Campbell Causeway, Suite 1000 (A/C,N ,Ext: A/C No: Tampa, FL 33607 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# www.praxiomriskmanagement.com INSURERA: State National Insurance Company, Inc. 12831 INSURED INSURER B: Congruity HR, LLC 100 North Cherry Street INSURERC: Suite 520 INSURER D7 Winston Salem NC 27101 INSURER E7 INSURER F: COVERAGES CERTIFICATE NUMBER: 78384655 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 1:1PREMISES OCCUR DAMAGE TOEa RENTED occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AMX-426-0001-003 11/15/2023 11/15/2024 �/ SPER TATUTE OERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVEF—] E.L.EACH ACCIDENT $1,000,000 OFFICE R/M EMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Project/Job#: Project/Job: - PEO Client: Clearwater For Youth Inc PEO ClientlD#:2J1042 Main Location: 1501 N Belcher Rd., Suite 711 Clearwater, FL 33765 Workers Compensation coverage is provided for only those employee leased to, but not subcontractors of Clearwater For Youth Inc CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Clearwater For Youth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1501 N Belcher Rd, Ste 711 ACCORDANCE WITH THE POLICY PROVISIONS. Clearwater FL 33765 AUTHORIZED REPRESENTATIVE David E.Carothers ✓� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 78384655 1 PEO 12023-24 Clearwater for Youth (251042) I Taylor Gray 11/25/2024 3:28:40 PM (EST) I Page 1 of 1 This certificate cancels and supersedes ALL previously issued certificates.