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<br />Gold Seal RooTing <br /> <br />8136203191 <br /> <br />p.5 <br /> <br /> <br />ISSUED TO: <br /> <br />CERTIFICATE OF INSURANCE <br /> <br />COPY PROVIDED TO: <br /> <br />City of Zephyrhills <br />5335 8th St. <br />Zephyrhills FL 33542 <br /> <br />Gold Seal Roofing & <br />Construction, Inc. <br />5400 East Diana Street <br />Tampa FL 33610 <br /> <br />ATTN: To whom it may concern <br /> <br />Date: 12/12/2006 <br /> <br />This is to certify that Gold Seal Roofing & Construction, Inc. <br />5400 East Diana Street <br />Tampa FL 33610 <br /> <br />being subject to the provisions of the Florida Workers' Compensation Act, has secured the payment of <br />compensation by insuring their risk with the FLORIDA ROOFING, SHEET METAL 8. AIR CONDITIONING <br />CONTRACTORS ASSOCIATION SELF INSURERS FUND. <br /> <br />COVERAGE NUMBER: 870 - 033324 <br /> <br />EFFECTIVE DATE: <br /> <br />01/01/2007 <br /> <br />LIMITS <br />Workers' Compensation Statutory - State of Florida <br /> <br />EXPIRATION DATE: <br /> <br />01/01/2008 <br /> <br />Employers' Liability <br /> <br />$100,000 - Each Accident <br />$100,000 - Disease, Each Employee <br />$500,000 - Disease, Policy Umit <br />REMARKS: Non-cancelable without 30 days prior written notice, except for non-payment of premium which will <br />be a , 0 day written notice. <br />Employers Liability Limits amended to: <br />1,000,000/1,000,000/1,000,000. <br /> <br />By: <br /> <br />This certificate is not a policy and of itseH does not afford any insurance. Nothing contained in this certificate <br />shall be constructed as extending coverage not afforded by the policy(ies) shown above or as affording <br />insurance to any insured not named above. This provides coverage for Florida poliCyholders and Florida <br />domicile employees only. <br /> <br />.&.;;r ~ <br /> <br />Bren Stieget. Admlnletra <br />FRSA-SIF <br /> <br />BY:~.~11 ~L\. <br />Oebbie Kemmerer. Underwriting Manlllger <br />FRSA-SIF <br /> <br />'--./ <br />