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9/16/2009 9:14 AM FROM: Fax AMS Staff Leasing TO: 18137800021 PAGE: 001 OF 002 ACORD CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE NO. /DATE AC09 -1600 DS D2- 822966 09/16/2009 09:13 WI PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Highpoint Risk Services LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 14160 Dallas Parkway #500 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Dallas, TX 75254 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (800) 632 -5096 Fax: (972) 404 -4450 INSURERS AFFORDING COVERAGE INSURED: AMS 1 /C /t: INSURER A: Companion Property and Casualty Insurance Comp TLC ROOFING, LLC INSURER B: Companion Property and Casualty Insurance Comp PO BOX 1745 DADE CITY, FL 33526 WSURERC (352) 437 -4073 Fax: () - INSURERD INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDMON 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. AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMBS LTR DATE IMVVDD /YYI DATE IMBVDD /YYI GENERAL LIABILITY EACH OCCURRENCE $ 1000000 X COMMERCIALGENERALUABIUTV FLG2081595 08/22/2009 08/22/2010 RRE DAMAGE (Any One Fire) S 100000 I CLAIMS MADE © OCCUR MEDEXP (Any one person) $ 5000 A PERSONALBADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GENL AGGREGATE LIMIT APPLIES PER'. PRODUCTS - COMP /OPAGG $ 2000000 X I POLICY f PEa F LOC AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ ANY AUTO (Ea acciaent) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY INURV $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per Decider() GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR IT' CLANS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ - WORKERS COMPENSATION AND WL LIMIT S UIN- E WC77779990901 X TORVUMIT ER MlLOYERS' LIABILITY 04/01/2009 09/01/2010 E.L. EACH ACCIDENT $ 1000000 E.L. DISEASE - EA EMPLOYEE $ 1000000 E.L. DISEASE - POUCYUMIT $ 1000000 OTHER UMITS $ - UMITS E DESCRIPTION OF OPERATONS/ LOCATIONSNEHICLES IEXCLUSONSADDED BY ENDORSEME NT/SPE OAL PROVISIONS 1. This certificate remains in effect, provided the client's account is in good standing with AMS. Coverage is not provided for any employee for which the client is not reporting wages to AMS. Applies to 100% of the employees of AMS leased to TLC ROOFING, LLC, effective 04/01/2009 2. Insured is afforded Workers Compensation & Employers liability as a co- employer under the policy for employees leased from AMS Staff Leasing, Inc. CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRM ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER IMLL ENDEAVOR TO MAL 30 DAYS WRITTEN CITY OF ZEPHYRHILLS BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL ATTN: KAREN MILLER IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 5355 8TH STREET ZEPHYRHILLS, FL 33542 RFPRFSFNTATIVF S. AUTHORIZED REPRESENTATIVE ACORD 25 -S (7/97) © ACORD CORPORATION 1988