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OCT- 17 - 2005 MON 02 , 44 PM WM , DAY , INC , FAX NO, 772 546 5772 P . 04 <br /> Florida Retail Federation t3oarrl of Truxrees <br /> Self Insurers <br /> W. " Gill " Kundrat, Jr., C'hpilrurrut <br /> 4F C ;eUrgL' Sandcrer, Vier Cin.1 i6Urrnr <br /> John U. 1 Linselm ;m <br /> Nis Nksur <br /> ArlmbriaiercvlAy3r,r,ru11 N111cc 1979 Thorwm S - NICOfr <br /> 13,p. 13ax 988 • L7kchnd , 1. 1, 33802 .,0988 urrresumrnitlt �IdingY• Coll' ('harles R . VVillU, <br /> Tcicphnnc ( 903 ) 66 :5. 6060 or 1 -800-282-7648 • ras (863) 666- 1958 <br /> C� 1-t�ificate of InSW ranee <br /> RE : 0520 - 25864 <br /> ISSUED T0 : Indian River County Board or County Commissioners <br /> 1840 25th St <br /> Vero Beach , FL 32960 - 3365 <br /> This is to certify that boys girls G.11�b of IndLrl _Rjver_�ounty , In R., �,� c�306 $ �(ero Beach ,�l.3296 } , being subject to <br /> the provisions of the Florida Workers ' Compensation Law, has secured the payment of any workers ' compensation benefits <br /> due by insuring their risk with the Florida Retail Federation Self Insurers Fund . <br /> POLICY NUMBER : 052_0_2 664 Statutory Limits - -State of Florida <br /> Employers liability <br /> EFFECTIVE DATE ; $ept€.nber-I3.-?S05 $ 500 , 000 ( Each Accident) <br /> $ 500 , 000 (Disease - - Each Employee) <br /> EXPIRA'T'ION DATE : Septernber 13 , 7ti006 $ 500, 000 ( Disease - - Policy', Limit) <br /> This certificate is not a policy and of itself does not afford any insurance . Nothing contained in thlsj certificate shall <br />be <br /> construed as amending , extending , or altering coverage not afforded by the policy shown above or affording Insurance to any <br /> Insured not named above . period indicated . Notwithstanding <br /> The policy of insurance listed above has been issued to the named insured for the policy p <br /> any requirement , term or condition of any contract or other document to which this certificate may pertain , the Insurance <br /> made available by the described policy in this certificate is subject to only the terms , exclusions and Conditions of such <br /> policy . <br /> Paid claims may have reduced the shown limits , <br /> re the expiration date indicated , the issuing company will attempt to mail 30 <br /> If the policy described above is cancelled befo <br /> days ' written notice to the certificate holder named above, although if cancellation is for nonpayment of premium , then the <br /> Issuing company will attempt to mail 10 days ' written notice to the certificate holder . In any event, the issuing company <br />, its <br /> agents , and representatives accept no obligation or liability of any kind for failure to mail such notice . <br /> Date 10/ 17/ 2005 <br /> 1l <br /> Summit, ndministraior <br /> Florida Retail ku'doration Self Insurers F "I' d <br />