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OP ID: TJ ACC, I?' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/15/2015 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 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 Phone: 772-286-4334 Insurance, Inc. 3070 S W Mapp Fax: 772-286-9389 Palm City, FL 34990 Rick Halcomb, CIC, ARM CONTACT Tani JacobsonStuart NAME: r No. Ext): 772-286-4334 FAX No): 772-286-9389 ADDREss. tjacobson@stuartinsurance.net PRODUCER CUSTOMER ID #: TIMOR -1 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Timothy Rose Contracting, Inc. 1360 Old Dixie Hwy SW, Ste 106 Vero Beach, FL 32962 INSURERA Westfield Insurance 24112 INSURER B . INSURER C . 06/06/2015 INSURER D . EACH OCCURRENCE INSURER E . 1,000,000 INSURER F . DAMAGE TO REN IED PREMISES (Ea occurrence) COVERAGES CERTIFICATE NUMBER: EVISION 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 ADOLSUBR INSR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR X CMM6079889 06/06/2015 06/06/2016 EACH OCCURRENCE 5 1,000,000 X DAMAGE TO REN IED PREMISES (Ea occurrence) S 500,000 CLAIMS -MADE X MED EXP (Any one person) 5 5,000 X Contractual Liab PERSONAL &ADV INJURY $ 1,000,000 X Ind XCU GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE��LIMIT APPLIES PER: POLICY I ^Imi flLOC PRODUCTS - COMP/OP AGG 5 2,000,000 7 5 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CMM6079889 06/06/2015 06/06/2016 COMBINED SINGLE LIMIT (Ea accident) 5 1,000,000 X BODILY INJURY (Per person) 5 BODILY INJURY (Per accident) 5 PROPERTY DAMAGE (Per accident) 5 X X 5 A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CMM6079889 06/06/2015 06/06/2016 EACH OCCURRENCE 5 3,000,000 AGGREGATE 5 3,000,000 DEDUCTIBLE RETENTION 5 S S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A TWC STATU- ORY LIMITS I O ER E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE S below E.L. DISEASE - POLICY LIMIT 5 A Contractors Equip CMM6079889 06/06/2015 06/06/2016 Rented Equipment 50,000 $1000 ded DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: Old Dixie Hwy Resurfacing from 71st Street to CR 510. Indian River County Project #1138. -Indian River County is additional insured with respect to general liability insurance for ongoing and completed operations. CERTIFICATE HOLDER CANCELLATION IRCPW-1 Indian River County Public Works Department 1801 27th Street Vero Beach, FL 32960 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 ga!V etin4.4_4_____ ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION All rights reserved. The ACORD name and logo are registered marks of ACORD