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CERTIFICATE OF INSURANCE ISSUE DATE ACORD 10/12/2010 PRODUCER This certificate is issued as a matter of information only and confers no rights MCGRIFF, SEIBELS & WILLIAMS, INC. upon the Certificate Holder. This Certificate does not amend, extend or alter the P.O. Box 10265 coverage afforded by the policies below. Birmingham, AL 35202 PHONE: 800 - 476 -2211 COMPANIES AFFORDING COVERAGE Company United States Fire Insurance INSURED company James River Insurance Company Pyrotecnico of Florida, LLC P.O. Box 310 New Castle, PA 16103 Company Westchester Surplus Lines Ins Company See Attachment Company E This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding any requirement, term or condition of 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, conditions and exclusions of such policies. Limits shown may have been reduced by paid claims. CO TYPE OF INSURANCE POLICY NUMBER EFFECTIVE LIMITS OF LIABILITY LT EXPIRATION B GENERAL LIABILITY 000292602 01/14/2010 EACH OCCURRENCE $ 1,000,000 ® Commercial General Liability 01/14/2011 FIRE DAMAGE $ 100,000 ❑ Claims Made ® Occurrence ❑ Owners' and Contractors' Protection MEDICAL EXPENSE $ EXCLUDED ® Per Project Cap $2,000,000 Gen Agg PERS. AND ADVERTISING INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 5,000,000 General Aggregate Limit applies per: PRODUCTS AND COMP. OPER. AGG. $ 2,000,000 ® Policy ❑ Project ❑Location A AUTOMOBILE LIABILITY 1337289354 01/14/2010 COMBINED SINGLE LIMIT $ 1,000,000 ® Any Automobile 01/14/2011 BODILY INJURY (Per person) $ ❑ All Owned Automobiles 12 Scheduled Automobiles BODILY INJURY (Per accident) ❑ Hired Automobiles PROPERTY DAMAGE (Per accident) $ ❑ Non -owned Automobiles COMPREHENSIVE $1000 deductible ❑ COLLISION $1000 deductible D WORKERS' COMPENSATION 6FR13U80668N01409 06/22/2009 WC Statutory Limit I X1 Other 1 AND EMPLOYERS' LIABILITY 06/22/2010 EL EACH ACCIDENT $ EL DISEASE fEach employee) $ EL DISEASE (Policy Limit) $ B EXCESS LIABILITY 000296262 01/14/2010 EACH OCCURRENCE $ 4,000,000 ® Occurrence El Claims Made 01/14/2011 AGGREGATE $ 4,000,000 C EXCESS UMBRELLA COVERAGE G22054752003 01/14/2010 Excess of Underlying $4, Million $ 5,000,000 01/14/2011 $ Fireworks Display Date: December 5, 2010 Location: Florida Hospital Zephyrhills City of Zephyrhills, FL The above listed are Additional Insured respects to General Liability policy as required by written contract subject to policy terms, conditions and exclusions. The Certificate Holder is named as Additional Insured with respect to General Liability as required by written contract subject to policy terms, conditions, and exclusions. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Authorized Representative Florida Hospital Zephyrhills 7050 Gall Boulevard Zephyrhills, FL 33541 Page 1 of 2 Certificate 10 # 3MV4D538