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<br /> ^ November 1,Z000 � . CERTIFICATE O� INSITIZANCE FORIVI 4
<br /> PRODUCER THIS CERTIF'ICATE IS ISSUED AS A NIATTER OF INFORMATION
<br /> ONLY AND CONF'ERS NO RIGHTS UPON THE CERTIFICATE
<br /> Your Agent HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
<br /> � � ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
<br /> �
<br /> (:UMYANIL�'J'Ar'r'U1Cll1N(i t;UVr:KAIiL�'
<br /> ' I
<br /> COMPANY A —ABC Company
<br /> INSURED ' ; ' COMPANY B — 123 Company �
<br /> (Your Company) ; �
<br /> (Address) ,� , COMPANY C —
<br /> (City, State, Zip) � ; COMPANY D —
<br /> � , COVERAGES
<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 OA CONDITION�OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS I
<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 />, CO � TYPE OF INSURANCE POLICY EFFECTIVE LIMITS
<br /> LTR NUMBER EXPIRATION
<br /> (mm/ddlyy)
<br /> I� A GENERAL LIABILITY XXXXX (mm/dd/yy) GENERAL AGGREGATE $2,000,000
<br /> :COMMERCIAL GENERAL LIABILITY ;
<br /> ; i PRODUCTS-C.O. AGGREGATE $2,000,000 `
<br /> CLAIMS MADE
<br /> : OCCURRENCE � ; 1 PERSONAL&ADVERTISING INJURY $1,000,000
<br /> � � ! EACH OCCURRENCE
<br /> $1,000,000
<br /> �� i
<br /> i . � FIRE DAMAGE(Any one fire) $50,000
<br /> � , i
<br /> � ' Medical Expense(Any one person) $
<br /> A AUTOMOBILE LIABILITY XXXXX (mm/dd/yy) COMBINED SINGLE LIMIT $1,000,000
<br /> ANY AUTO � ! BODILY INJURY (Per Person) $
<br /> :ALL OWNED AUTOS
<br /> SCHEDULED AUTOS � BODILY INJURY (Per Accident) $
<br /> .HIRED AUTOS �
<br /> ' NON-OWNED AUTOS � PROPERTY DAMAGE $
<br /> i
<br /> PROPERTY � BUSINESS PERSONAL PROPERTY $
<br /> ' DEDUCTIBLE $
<br /> B WORKERS COMPENSATION AND XXXXX (mm/dd/yy) STATUTORY LIMITS
<br /> EMPLOYERS=LIABILITY
<br />, j EACH ACCIDENT $100,000
<br /> � DISEASE-POLICY LIMIT $500,000
<br /> — � DISEASE-EACH EMPLOYEE $100,000
<br /> A EXCESS/UMBRELLA LIABILITY XXXXX (mm/dd/yy) GENERAL AGGREGATE $2,000,000
<br />' � , ; EACH OCCURRENCE $2,000,000
<br /> oEs�R'°T'°"°F°PER^T'°"S"°`^T'°"�"E""�E�SPE°'""TE""S_East Pasco Medical Center Diagnostics Addition Project. Adventist Health System/Sunbelt,
<br /> East Pasco Medical Center, and Poole Construction Co., Inc., their directors, agents, and employees are included as AAdditional
<br /> Insureds=_. Waiver of Subrogation is included in favor of Adventist Health System/Sunbelt, East Pasco Medical Center, and Poole
<br /> Construction Co., Inc.'! ' i
<br /> " � CERTIFICATE HOLDER CANCELLATION
<br /> �
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<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED
<br /> ' ' ! BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPA[YY
<br />� National Insurance Advisors, IriC. Telephone: (407)46'4-0814 WILL ENDEAVOR TO MAIL 30 DAYS WRIT"I'EN NOTICE TO THE
<br /> CERTIFICATE HOLDER NAMED TO THE LEFC,BUT FAILURE TO MAIL
<br /> P.O. B ox 162266 ; i Facsimile: (407)464-3631 SUCH NOTICE SHALL IMPOSE NO OBLIGAT[ON OR LIAB[L1TY OF AIYY
<br /> Altam'onte Springs;Florida 32716-2266 � �ND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
<br /> AttII. DeUVle HUr$t� ' AUTHORIZEDREPRESENTATIVE
<br /> �� � � ,
<br /> i ' (Your Agent)
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