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-........ r Certificate of Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. ~- Name and address of Insured. LI BE RlY lit. MUTUALiPJ I I I I I I This is to Certify that I Staff Leasing, L.P., Staff Leasing II, L.P., Staff , Leasing III, L.P., Staff Leasing, IV, L.P., Staff Leasing V, L.P. tj 600 301 Blvd., West, Suite 202 I Bradenton, FL 34205 ~ Is at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their teims, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be ~iSSUedp~' 180 EXP. DATE I CONTINUOUS TYPE OF POLICY 0 EXTENDED i w:;O:L1CY NUMBER ___ I [SCI POLICY TERM --r-- COVERAGE AFFORDED UNDER we: 'I I 1-1-97 W A 1-650-004110-296 LAW OF THE FOllOWING STATES: WORKERS AL, AR, AZ, CA, CO, CT, COMPENSATION I i I LIMIT OF LIABILITY GENERAL LIABILITY D CLAIMS MADE IRETRO_DATE __I D OCCURRENCE DE, FL, GA, IL, IN, KY, LA, , , Accident MO, MI, MN, MS, MO, NC, Bodily Injury By Disease NE, NH, NM, OK, PA, SC, $1,000,000 Policy , ; limit TN,TX,UT,VA Bodily Injury By Disease $1,000,000 Each Person General Aggregate - Other than Products/Completed Operations Products/Completed Operations Aggregate _._~-- , Bodily Injury and Property Damage Uability Per I Occurrence Personal Injury Per Person! Organization Other rer__ , , EMPLOYERS LIABILITY Bodily Injury By Accident $1 000 000 Each AUTOMOBILE LIABILITY I I HIRED k~--- - - OTHER EMPLOYEES lEASED TO: I l-= . Each ACCident - Single Limit B.1. and P,D. Combined -~- Each Person --~-------_. - - Each Accident or Occurrence --- -----~_._---"-_.._- I Each Accident or Occurrence - -----~--__t----__+ ------------- I I I I I . ~--- !-.l_ EFFECTIVE DATE: OWNED NON-OWNED L i :.r F.,:!'. (c.:r'-l:::; I f-:{..!i__ .J ()I\~ U! 1':, ()t:.\/ll_Cl~)I\'!Lr'~'f i T l\;i~.,. " The above referenced Workers' Compensation policy provides statutory benefits only to employees of the Named Insured(s) on the policy, not to employees of any other employer. . If the certificate expiration date is continuous or extended term, you will be notified if coverage is terminated or reduced before the certificate expiration date. However you will not be notified annually of the continuation of coverage. ' ~~Ef~~b~~~~~.g~l~iLE~NX ~ElJ~0~0~~2N~~H ~~li~~ b~ g~~~~~Pv~~T~~~~ENN~ ~~^Ju7Ms Jtf~~U~~1~8lF~~e~~ AGAINST AN INSURER, SUBMITS Liberty M u tu al G rou p NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST 30 DAYS NOTICE OF A T A f-H Yf~H J L ~~ ~-----~ cmrmrr t<<Jrn:R f:;. ~:~ ~j :::; [T r.; I"." J' 1--1 OJ" ~<: t.~, E Linda Mielke AUTHORIZED REPRESENTATIVE Orlando/508 (407) 862-8111 (:: ~,:~",/ 1. < .- ";, t'. .Z f~'.}:) 1-1 \/ F.' r-; J L, C r~' L_ . ~< -_~ ::; 4 () OFFICE PHONE DATE ISSUED This certificate is executed by LIBERTY MUTUAL GROUP as respects such insurance as is afforded by Those Companies BS 7721. (FL)