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<br />ACOBl1. CERTIFICATE OF LIABILITY INSURANCE 1 ~ CERTlFICATE 110./ DATE <br />1tJ::.Oi-16000S02-S6S821 <br />8/23/2001 1:49:S0PM <br />,RODUCER TtftS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />Rigbpoint Risk S.n'iCl88 LI.C ONLY AND CONfERS NO RIGHTS UPON THE CERTIFICATE <br />14160 ~1.. V&rkw.y 1500 ~ER. THIS CERTIFICATE DOES N9tr~pram OR <br />Del.],.., B 7525& R THE BY IES BELOW. <br />(800) 632-5096 (972) 715-0959 INSURERS AFFOItDING COVERAGE <br />....: 1Sl72\ &0&-&&50 <br />"lURED: MIS l/c/f: INSURER '" Companion Property and Casualty Insurance Comp <br />TLC ROOFING, LLC INSURER 8: <br />14138 18TH CT <br />DADE CITY, FL 33525 INSURER c: <br />(352) 521-0423 Fax: INSURERD: <br /> INSURER E: <br /> <br /> <br />THE POUC;IIS OF IN8URANCE U8lED -..ow MAVE BEEII..-D TO 1H& INSURED NAMED AlllCNE fOR THE POUCV PPlOD IIOCATED. N01WITM8TANDlNG <br />ANY REQUIRE_NT, ~RII OR CONDl11ONOF ANY CONTRACT OR OTHER DOCUllENTWlTHRE8PECTTOWHlCHTHIS CERT1f1CA~ MAY _ISSUED OR <br />MAY PERTAIN, THE IM8URANCE AFPORDED '" THIi POLICIU DESCRIBED HEMIN IS 8UUCT TO ALl. THE ~RIIS. EXCLUSIONS AND CONDmoNS Of' SUCH <br />POLICIES. AGQREGA.~ LIMRW SHOWN MAY HAW BEEN MOUCID '" PAID CLAIMS. <br /> <br />TYPE 01' IIil8UfWlIGE l'OLICY IIUIIIIEIt <br /> <br />GENEIW. UAIM.1l'Y <br /> <br />COIiMiRCW.. GENERAL L.IAIIILlTY <br /> <br />aAlMSMACEOOCCUR <br /> <br />~~.h~.;.1f.~ It:t \-;'J.~~..W..:t <br /> <br />EACH OCCURRENCE <br />FIRE DAMAGE Wrt Ono Fh) <br />IlIED ElCP Wrt __I <br />PeRSONAL &NN INJURY <br />GENEftAlAGGlll!Gi'TE <br />PRODlICTS -lXlIolPIG' AGG <br /> <br />UMITIS <br />$ <br />S <br />$ <br />S <br />S <br />S <br /> <br />C()MBINEDSlNGlELNIT <br />{EII--.q <br /> <br />$ <br /> <br />IlOIlIL Y INJURY <br />(PWper-'l <br /> <br />s <br /> <br />8ODIl. Y INURY <br />(Per -.Q <br /> <br />$ <br /> <br />PROPERTY DAMAGE <br />(PW--.q <br /> <br />AlJTO ONLy - EA ACClo&NT S <br /> <br />OTHER lHAN EA N:.C S <br />AUTO OIIL Y: AGO S <br /> <br />EACH OCCURRENCE S <br />AGGREGATE $ <br />$ <br />S <br /> <br />OCCUR <br /> <br />IlEDUCT1BLE <br />RETENTlON $ <br />WORKERS COIIPENIATlON AND <br />EIIPLOYERI' LIABUTY <br /> <br />WC77179990401 <br /> <br />08/27/2007 04/01/2008 <br /> <br />E.L. EACH ACCICENT <br />E.L. DI&EASE. EA EMPI..OYEE <br />E,L, DISEA8E - POlJCY LMT <br /> <br /> <br />A <br /> <br />OTHeR <br /> <br />UMIT8 <br />UMITS <br /> <br />S <br />S <br /> <br />DESCR~ OF ClPMATIONSIl.OCA~ IIDCED...EMIORIEIIEIITII PRIMIIONS <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 TLC ROOFING, LLC, effective 08/27/2007. 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 /> <br />CERTIFICATE <br /> <br />IlOOlTIONAL INIUMD; ..... LET18t <br /> <br />SttCXa.O _ OF TItI! MOVE ~ POUCIEI BE CMC!LLE'D IIEI'ClIE TItI! ~TION <br /> <br />DAn! nEIlEOF. TItI! --..0 INIUAER WILL ENDEAVOR TO IIAII. 30 DAYS WRITTIII <br /> <br />tlOT1C& TO lite c:ERTFlCA11! HOLJIER, NAIED TO THE LEFT. BUT F/IlIlDlE TO DO ~ IIW.L <br />~ NO Cl8l.lGATIONOR...-uTY OFNrf KIM) UPON THI!"-. ITIIlG1!NT11OR <br /> <br />CITY OF ZEPHYRHILLS BUILDING DEPARTMENT <br />ATTN: KAREN HILLER <br />5355 8TH STREET <br />ZEPHYRHILLS, FL 33542 <br /> <br />Al/THORIZEII_A'INE <br /> <br />ACORD 25-S (7197) <br />