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:1723417 <br />131BLUEGOO2 <br />ACORDT. CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM/DDIYYYY)12/16/2015 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />BB&T-J. Rolfe Davis Insurance <br />PO Box 4927 <br />Orlando, FL 32802-4927 <br />407 691-9600 <br />CONTACT <br />NAME: <br />PHONE 407 691-9600 FAx <br />(A/C, , Ext): (AIC, No): 888-635-4183 <br />Mai <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURER A National Trust Insurance Compan <br />20141 <br />INSURED <br />Blue Goose Construction LLC <br />P. O. Box 14709 <br />Fort Pierce, FL 34979-4709 <br />INSURER B FFVA Mutual Insurance Company <br />10385 <br />INSURER C FCCI Insurance Company <br />10178 <br />INSURER D <br />$1,000,000 <br />INSURER E <br />S 100,000 <br />INSURER F . <br />COVERAGES <br />CERTIFICATE NUMBER: <br />REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSLTR R <br />TYPE OF INSURANCE <br />DL <br />INSRL <br />SUBR <br />WVD <br />' <br />POLICY NUMBER <br />POLICY EFF <br />(MM/DD/YYYY) <br />POLICY EXP <br />(MM/DD/YYYY) <br />LIMITS <br />A <br />GENERAL <br />X <br />LIABILITY <br />COMMERCIAL GENERAL LIABILITY <br />X <br />GL0017683 <br />- <br />'03/01/2015 <br />03/01/2016 <br />EACH OCCURRENCE <br />$1,000,000 <br />PREMISES (Ea RENTED <br />S 100,000 <br />CLAIMS -MADE <br />X <br />OCCUR <br />MED EXP (Any one person) <br />S 5,000 <br />X <br />PD Ded: $5,000 <br />PERSONAL &ADV INJURY <br />51,000,000 <br />GENERAL AGGREGATE <br />52,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />nPOLICY n JE n LOC <br />PRODUCTS - COMP/OP AGG <br />$ 2,000,000 <br />S <br />C <br />AUTOMOBILE <br />X <br />X <br />LIABILITY <br />ANY AUTO <br />ALL OWNED <br />AUTOS <br />HIRED AUTOS <br />- <br />X <br />_AUTOS <br />SCHEDULED <br />AUTOS <br />NON -OWNED <br />X <br />CA0029256 <br />03/01/2015 <br />03/01/2016 <br />COMBIN <br />(EaacddEent) D SINGLE LIMIT <br />$1,000,000 <br />BODILY INJURY (Per person) <br />S <br />BODILY INJURY (Per acddent) <br />S <br />PROPERTY DAMAGE <br />(Per accident) <br />$ <br />S <br />A <br />X <br />UMBRELLA UAB <br />EXCESS LIAB <br />X <br />OCCUR <br />CLAIMS -MADE <br />UMB0020665 <br />03/01/2015 <br />03/01/2016 <br />EACH OCCURRENCE <br />$10,000,000 <br />AGGREGATE <br />510,000,000 <br />DED <br />X <br />RETENTION 510000 <br />S <br />B <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILRY <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />Y / N <br />N <br />N I A <br />WC84000311432015A <br />01/01/2015 <br />01/01/2016 <br />X <br />WcsTATU- <br />TORY LIMITS <br />OTH- <br />ER <br />E.L. EACH ACCIDENT <br />s500,000 <br />E.L. DISEASE - EA EMPLOYEE <br />$500,000 <br />E.L. DISEASE - POLICY LIMIT <br />s500,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />RE: IRC Project - 1st and 43rd Avenue Intersection Improvements. <br />Additional Insured status is granted as respects to General Liability if required by written contract or <br />agreement per endorsement "Additional Insured -Owners Lessees or Contractor - Automatic Status" form #CGL <br />084 (10/13) <br />Additional Insured status is granted as respects to Auto Liability if required by written contract or <br />(See Attached Descriptions) <br />CERTIFICATE HOLDER <br />CANCELLATION <br />Indian River County <br />1801 27th Street <br />Vero Beach, FL 32960-3388 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />'74-tit,Ait #444•44.4 <br />ACORD 25 (2010/05) 1 of 2 <br />#S15250146/M13802592 <br />© 1988-2010 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />EMTU <br />