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01/08/2010 FRI 17:16 FAX 0)001 /001 Policy Number: Date Entered: 1/8/2010 A W CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYWY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AM END, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT WorkComp Solutions, Inc. NAME: 5115 South Lakeland Drive INC. No.Est1: (863) 646 -4642 FAX NC No) (863) 646 -3521 EMAIL Ste. 3 ADDRESS: PRODUCER Lakeland, FL 33813 CUSTOMER ID 0: INSURER(S) AFFORDING COVERAGE NAIC 0 INSURED INSURER A : Bridgefield Employers Insurance Company Fuqua Electric, Inc. INSURER B : INSURER C : 2411 Cypress Gardens Blvd. Winter Haven, FL 33884 INSURER INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVVDI STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SLERI POLICY EFF POLICY EXP 1NSR POLICY NUMBER (M1011DYYYV moenortrtvi LIMITS GENERAL LIABILITY ■I EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurrence) $ _ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE _ $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 7 POLICY n PRO - IF LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON -OWNED AUTOS $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE _ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- �( OTH- AI' D EMPLOYERS' LIABILITY Y TORY LIMITS I/� FR ANY PROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBER EXCLUDED? N N /A E.L. EACH ACCIDENT $500,000 (Mandatory in NH) 0830-25228 7/18/2009 7/18/2010 E.L. DISEASE- EA EMPLOYEE $500,000 If yes. describe ES CR under IPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION DESCRIPTION OF OPERATIONS !LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Michael Fuqua- EC13001238 CERTIFICATE HOLDER CANCELLATION City of Zypherhills Bldg. Department SHOULD ANY OF 714E ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE 5335 8th Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Zypherhills, FL 33542 AUTHORIZED REPRESENTATIVE Mills 1 DARRELL J. MILLS ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Pius software. vwwu.FormsBoss.corn, Impressive Publishing 800 -208 -1977