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<br />06/27/2007 14:38 FAX 3527976028 <br /> <br />PAYROLL <br /> <br />~ 0011002 <br /> <br /> AC!JBD. CERTIFICATE OF LIABILITY INSURANCE 1 CEItTW'ICATI! NO.1 DATE <br /> ACO 1-14700095-5524 94 <br /> 6/27/2007 2: 22:51PH <br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOAMAnON <br />Highpoint Risk Services LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />14160 Dallas Parkway '500 HOLDER. THIS CERnFICATE DOES NOT AMEND, EXTEND OR <br />Dallas, '1'X 75254 ALTER VERAGE AFFORDED BY THE POLICIES BELOW. <br />(800) 632-5096 (972) 715-0959 INSURERS AFFORDING COVERAGE <br />Pax: 1972\ 404-4450 <br />INSURED: AMS l/c/f: INSURER A: Companion Property and Casualty Insurance Comp <br />CHELADYN ENTERPRISES INC. INSURER B; <br />17041 BODOWSKI RD. <br />BROOKSVILLE, FL 34614 INSURER c: <br />(352) 428-7222 Fax: (352) 754-9184 INSURER D; <br /> INSURER E: <br />C <br /> THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING <br /> ANY REQUIREMENT, TERM OR CONDmoN OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICAT2 MAY BE ISSUED OR <br /> MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDmONS OF SUCH <br /> POLICIES. AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED 8YPAlD C~~ <br />1'\.\" TYPE OF INSURANCE fOOUCY NUM.ER ...ITS <br /> ~NERAJ. LlA8lLlTY EACH OCCURRENCE I <br /> ::J~ERCIAL GENERAL LIABILITY FIRE ~E (An, one FIN' I <br /> f-- CLAIMS MADe 0 OCCUR <br /> - MED EXP IAn\' _ pe_l I <br /> PERSONAl. & ADV INJURY I <br /> - GENERAL AGGREGATE I <br /> ~N'LAGGREn LIMIT APn PER; PRODUCTS. COMfJIOP AGG I <br /> POLICY ~~,g" LOC <br /> AUTOMOIILE UABlLITY COMBINED SINGLE LNIT <br /> - (Ea accident) I <br /> - ANY AUTO <br /> ALL OWNED AUTOS BODILY INJURY <br /> - I <br /> SCHEDULED AUTOS ("-r pel'lOft) <br /> ~ <br /> ~ HIRED AUTOS 80DlL Y INURY <br /> NON-OWNED AUTOS (Per ea:idenQ . <br /> ... <br /> ... PROPERTY DAMAGE I <br /> ("-r aa:idenl) <br /> GARAOE LIA8IUTY AUTO ONLY. EA ACCIDENT I <br /> ==I ANY AUTO OTHER THAN EAACC I <br /> AlITO ONLY; AGG I <br /> EXCesS LIABILITY EACH OCCURRENCE I <br /> - o CLAIMS MADE <br /> OCCUR AGGREGATE I <br /> - <br /> ~ I <br /> ... DeDUCTIBLE I <br /> RETENTION I I <br /> WORKERS COMPENSATION AND WC7777 9990401 04/01/2007 04/01/2008 X I w""'TAnL I IOJ.t'- <br /> EMPLOYERS' LIABILITY 1000000 <br /> E.L. EACH ACCIDENT I <br />A 1000000 <br /> E.L. DlSEASI: - EA EMPLOYEE I <br /> E.L. DISEAse. POLICY LIMIT I 1000000 <br /> OTHER <br /> ~ LIMITS I <br /> LIMITS I <br />DESCRPTION OF DPEMTICINSlLOCATIONSIVEHlCLUlEXCLUSIONI ADDeD BY ENDORSEIlENTISPlCIAL PROVISIONS <br />1. This certificate remains in effect, provided the client's account is in good standing with AMS. Coverage <br />is not provided for any employee for which the client is not reporting wages to AMS. Applies to 100% of the <br />employees of AMS leased to CHELADYN ENTERPRISES INC., effective 04/01/2007. 2. Insured is afforded Workers <br />Compensation' Employers liability as a co-employer under the policy for employees leased from AMS Staff <br />Leasing, Inc. <br />***PLEASE SEE ATTACHED EMPLOYEE ROSTER.*** <br />CERTIFICATE HOLDER I I ADDITIONAL INSURED; JNSU~ LETTEIt: CANCELLATION <br /> SHOULD AllY Of THi AIIOVE DESCRIBED POLICES BE CANCElLED 1I~0lIE THE EXPIRATION <br /> DATE TH&IlI!OF, THE ISSUING INSURER WILL ENDEAVOR TO MAl. 30 DAYS WlVTT!N <br /> CITY OF ZEPHYRHILLS BUILDING DEPARTMENT NOTICE TO THE CERTFICATI! NOLDER NAIlED TO TIlE LEFT, BUT FAILURE TO DO SO SHALL <br /> ATTN: KAREN MILLER <br /> 5355 8TH STREET IMPOII NO OSLIGATION OR LIAIIlLITY OF AllY KIND UPON THE ~ ITS AGIiNTS OR <br /> ZEPHYRHILLS, FL 33542 REPIWS <br /> AUTMORIZED REPREIINTATIVE I ~ ~. <br /> <br />ACORD ~S (7/97) <br /> <br />~ACORD CORPORATION 1988 <br />