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DocuSign Envelope ID:4E36FD70-9689-46BE-A761-56385A3E3120 SAMPLE INSURANCE CERTIFICATE 0 ACCOR" CERTIFICATE OF LIABILITY INSURANCE FDATE(IdP.VDD/YYYY) `-� XX/XX/20XX 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 CONTACT NAME: Insurance Agency Name PHONE (XXX)XXX-XXXX FAX (xxx)xxx-xracx A/C No): Address E-MAIL ADD ESS: INSURERS AFFORDING COVERAGE NAIC Y City St Zip Code INSURER A A- Or Better by A.M. Best INSURED INSURERBA- or Better by A.M. Best Subcontractor Name INSURERCA- or Better by A.M. Best Address INSURERDA- or Better by A.M. Best I INSURER E: i City St Zip CodeI INSURERF: COVERAGES CERTIFICATE NUMBER CL1572100627 REVISION 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 TYPE OF INSURANCE ADDLiSUBR POLICY EFF POLICY EXP LTfl IN SD WVD I POLICY NUMBER MMIDD/YYv MM/DD/YYY LIMITS A X I COMMERCIAL GENERAL LIABILITY I POLICY NUMBER FM/DD/YY FM/DD/YY 1 EACH OCCURRENCE S 1,000,000 r-- AM11A ' O RENTED I CLAIMS-MADE UOCCUR PR OCCUR n."ce S 50,000 X 1 Contractual Liability X i Y XCU is not Excluded j MED FRCP(Any one person) S 5,000 I per GL Form i i I PERSONAL&ADV INJURY S 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 I POLICY I X I�E T I I LOC I I PRODUCTS-COMP/OP AGG S 2,000,000 i OTHER: COMBINED I I S B AUTOMOBILE LIABILITY { POLICY NUMBER Ea acccident5tNGLE LIMIT UM 5 1,000,000 X 1 ANY ADO II BODILY INJURY(Per person) S ALL OWNED SCHEDULED I f BODILY INJURY(Per accident) S AUTOS AUTOS I X I S X NON-OWNED I I PROPERTY DAMAGE HIRED AUTO S AUTOS I Per aceident I I s C X I UMBRELLA LIAR 1 X I OCCUR POLICY NUMBER i EACH OCCURRENCE $ 1,000,000 I EXCESS LIAR j f CLAIMS-MADE Excess over GL, Auto, WC j ;AGGREGATE S 1,000,000 I DED I I RETENTIONS I ( S D WORKERS COMPENSATION 1 Y POLICY NUMBER I I X I STATUTE I 1 ERI{ AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE IA-'N/AI j E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? �N� (Mandatory In NH) I I E.L.DISEASE-EA EMPLOYE $ 500,000 I 0 yes.describe under 1 DESCRIPTION OF OPERATIONS beau I i E.L.DISEASE-POLICY LIMIT S 500,000 I i I + DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Project Name from-Subcontract Agreement J. Raymond Construction Corp. and Owner are granted Additional Insured status by the General Liability for claims arising out of'its work for both ongoing and completed operations of the named insured. (Attach endt CG 20 10- 11 85 or equivalent) . A Waiver of Subrogation is provided in favor of J. Raymond Construction Corp and the Owner for the General Liability and Workers Compensation. The Umbrella Liabilityfollows form. The insurance of the Subcontractor shall be primary and non-contributory to the insurance maintained by J. Raymond Construction Corp. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE J. Raymond Construction Corp. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 465 West Warren Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Longwood, FL 32750 AUTHORIZED REPRESENTATIVE tiU L.11V11Z.CU ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)XX