2012-101A - Laserfiche WebLink

Home Browse Search

From : Tani Jacobson FaxID : STUiNS- FAX01 Page 2 of 2 Date 5252012 01 : 07 PM Page 2 of 2 CERTIFICATE OF LIABILITY INS OP ID : Ti INSURANCE N C E DATE (MMIDDIYYYY) 05/0 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOL E5R . 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 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 endorsements . PRODUCER 772 -2861334 CON ACT Stuart Insurance , Inc . NAME : 3070 S W Mapp 772 -286.9389 PHONE -_ — Fa - - — Palm City, FL 34990 A1C No Ext x_ A X No : Rick Halcomb , CIC , ARM ADMDRESS : — CUSTOMER ID If TIMOR - 1 INSURERS) AFFORDING COVERAGE T INSURED Timothy Rose — — Nalc If Contracting , Inc . INSURERA Westfield Insurance _ 24112 1360 Old Dixie Hwy SW INSURER B Vero Beach , FL 32962 INSURER C : --- INSURER D INSURER E _ t COVERAGES INSURER F : L _ — 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 . LTR TYPE OF INSURANCE POLICY NUMBER0 --- GENERAL LIABILITY MMIDDIYYYY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY X CMM6079889 EACH OCCURRENCE , $ 1000, 00 06/06/11 06106/12 CLAIMS- MADE Fx ] OCCUR PREMISES Ea occurrence I $ 100100 X Contractual Liab MED EXP ( Anyone Person ) 1E 5100 X Incl XCU PERSONAL a ADV INJURY $ 11000, 00 $ GEN 'L AGGREGATE LIMIT APPLIES PERGENERAL AGGREGATE 21000, 00. POLICY X PRT LOC PRODUCTS - COMP/OP AGC $ 2, 000, 00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A $X ANY AUTO CMM6079889 06/ 06/11 06/06/12 ( Ea accident) 11000 , 00 ALL OWNED AUTOS BODILY INJURY (Per person ) SCHEDULED AUTOS BODILY INJURY ( Per accident ) $ X HIRED AUTOS PROPERTY DAMAGE $ X NON- OWNEDAUTOS ( Per accident ) --- —__ _ UMBRELLA LIAR i $ X OCCUR EXCESS LIAR EACH OCCURRENCE 31000, 00 A CLAIMS -MADE AGGREGATE $ 3, 000, 00 DEDUCTIBLE CMM6079889 06/06 /11 06/06/12 RETENTION $ -- WORKERSCOMPENSAT1oN AND EMPLOYERS ' LIABILITY WC STATU- 0TH - ANY PROPRIETORIPARTNERIEXECUTIVE YIN TORY LIMITS ER OFRCERIMEMBER EXCLUDED? N I A E L EACH ACCIDENT $ (Mandatory in NH) If yes , describe under E L DISEASE - EA EMPLOYEE ] $ DESCRIPTION OF OPERATIONS below A ontractors Equip CMM6079889E L DISEASE - FOL CY LJN1 T , $ 06/06/11 06/06/12 Rented 50 , 00 Equipment DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101 , Additional Remarks Schedule, if more space is required) S1000 de Grading of Land/ Site Prep - State of Florida RE : Oslo Roadway Improvments Indian River County is additional insued for general liability CERTIFICATE HOLDER CANCELLATION IRCOUB - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Indian River County ACCORDANCE WITH THE POLICY PROVISIONS, 1800 27th St Vero Beach , FL 32960 AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION . All rights reserved . ACORD 25 ( 2009/09 ) The ACORD name and logo are registered marks of ACORD