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A'CO '® CERTIFICATE OF LIABILITY INSURANCE' <br />DATE (MMI°DIYYYY) <br />2/17/2017 <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(les) 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 />M3 Insurance Solutions, Inc. <br />828 John Nolen Drive <br />Madison WI 53713 <br />CONTCT <br />NAME: Trisha Stark <br />PHONE FX <br />PHM, t - - ac No: <br />EMAIL <br />ADDRESS: Trisha.Stark@m3ins.com <br />PRODUCER <br />CUSTOMER ID #: JOHNINC-01 <br />INSURERS AFFORDING COVERAGE NAIL # <br />INSURED <br />INSURER A:Amerisure Mutual Insurance <br />Johnson -Davis Incorporated <br />604 Hillbrath Drive <br />INSURERB: <br />Lantana FL 33462 <br />INSURERC: <br />INSURER D : <br />$ <br />INSURER E: <br />AUTOMOBILE <br />INSURER r: <br />f`n 1C13 r_oe !`COTICIC A TC IJI IMRR[?•1 Ao901 0111 RFVISIFIN NIIMI3tK' <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY <br />PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO <br />WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT <br />TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCEADDL <br />1 <br />POLICY NUMBER <br />POLICY EFF <br />MMIDDIYYYY <br />POLICY EXP <br />MMIDDIYYYY <br />LIMITS <br />GENERAL LIABILITY <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE D OCCUR <br />EACH OCCURRENCE $ <br />PREMISES Ea occurrence $ <br />MED EXP An one person)$ <br />PERSONAL&ADV INJURY E <br />GENERAL AGGREGATE $ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />RO LOC <br />POLICY PIECT <br />PRODUCTS-COMPIOP AGG S <br />$ <br />AUTOMOBILE <br />LIABILITY <br />ANY ALTO <br />ALL OWNED AUTOS <br />SCHEDULED AUTOS <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />COMBINED SINGLE LIMIT $ <br />(Ea accident) <br />BODILY INJURY (Per person) $ <br />BODILY INJURY (Per accident) S <br />PROPERTY DAMAGE <br />(Per accident) S <br />$ <br />E <br />EXCESS UMBRELLALIAB <br />LIAB <br />HCLAIMS-MADE <br />OCCUR <br />EACHOCCURRENCE $ <br />AGGREGATE $ <br />DEDUCTIBLE <br />RETENTION $ <br />$ <br />S <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERNLIABILITY <br />ANY PROPRIETORIPARTNERIEXECUTIVE Ya <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory In NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />N/A <br />WC210013500 <br />3/1/2017 <br />3/1/2018 <br />X WCSTATU- OTH <br />ER <br />E.L. EACH ACCIDENT $1,000,000 <br />E.L. DISEASE - EA EMPLOYE S7, 000, 000 <br />E.L. DISEASE -POLICY LIMIT 1 $S, 000, 000 <br />DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space la required) <br />i CERTIFICATE HOLDER <br />I. <br />Johnson -Davis, - <br />604 Hillbrath D <br />Lantana FL 3346 <br />ACORD 26 (2009109) <br />CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED <br />IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />©.1988-2009 ACORD CORPORATION... All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />