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�' �'� CERTIFICATE OF.LIABILITY INSURANCE DATE(MM/DOMlYY� �Z�Z2�2�11 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 AMEND, EXTEND OR ALTER THE COVERAGE AfFORDED BY THE POLICIES BELOW. TWIS 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 WANED, 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 ofsuch endorsement(s). PRODUCER , 1- 727-797-4190 CONTACT Arthur J. Gallagher Risk Managament Services, Inc. PHONE N E : FAX 4904 Eisenhower 81vd., Ste 250 E-Ma� AlC N �_ ------ ' ADDRESS: PRODUCER ---�-- -'�� - --�–�— Tampa, FL 33634 ' — INSURER S AFFORDING COVERAGE Nq�C � INSURED ' ' —" IInited Employee Sezvices, Inc. INSURERA. TECHNOLOGY INS CO INC ___ 42376 ' INSURER B . 2420 Enterpzise Road, SuitE 208 INSURERC. � Clednvater, FL 337b3 INSURERD. � INSURER E . INSURER F . COVERAGES CERTIFICATE NUMBER: 198495oe REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSUR,4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION 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 CCNDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCEU BY PAID CLAIMS. INSR � – ADDL SUBR LTR TYPE OF INSURANCE POLICY NUMBER MM/DD E � F MMl EXP IIMITS GENERAL LIABILRY L � EACH OCCURRENCE ' COMMERCIAL GENERAI LIABILITY I i � ; DAMAGE TO N ED y I i PREMISES E occurrence S I_� CLAIMS-MACE � OCCUR I I r I I I MED EXP (Any one person) $ --- j i r PERSONAL 8 A INJUR �$ �� I __ _ _ � � ---�------ � i GENERALAGGREGATE 'g GEN'L AGGREGATE LIMIT APPLIES PER: � � � POUCY PRa �pC � I � I PRODUCTS - COMP/OP AGG $ � $ I AUTOMOBILE LIABILITY I I � I � COMBINED SINGLE LIMIT $ ' I ANY AUTO I ' ' (Ea acciden[) I I i - ------ � ALL OWNED AUTGS I � BODILY INJl1RY (Per person) $ � SCHEDULED AUTOS I �' I ' � I BODIIY INJURY (Per accident) j$ I HIRED AUTOS I i PROPER7Y DAMAGE i � � (Per accident) NON-OWNED AUTOS I I I I $ UMBREILA LIAB I OCCUR � I I I � I EXCESS LIAB r� i ' I `� EACH OCCURRENCE $ .___ � � CLAIMS-MApE I � I AGGREGATE DEDUCTIBLE i , I -- —a--$------ i RETENTION $ I I I � $ __ _ _ _ _ p WORKERSCOMPENSATION i ' TWC3266546 �$ I ANOEMPLOYERS'LIA814TY I 12/O1/lq 12/O1/11� X WCVTATT- x,OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE � N � I '' I I I OFFICER/MEMBER EXCLUDED' � i N! A� � E.L. EACH ACCIDENT �$ 1, 000, 000 �(Mandatory in NH) I '' I I I If yes, desrnbe under I I � E.L. DISEASE - EA EMP�OYE $ 1, 000, 000 DESCRIPTIONOFOPERATIONSbelow i 1,000,000 I E�. DISEASE - POLICY LIMIT $ i � j I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additfonal Remarks Sehedule if more space i I required) Larry W. Gatgen, dba AMS WC, Znc. is an alternate employer. Coverage is provided to contracted employees of IInited �tployee Services, Inc. (FL) not subcontract labor. License#: CGC1515749 CERTIFICATE HOLDER CANCELLATION City of Zephyrhills Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 5335 8th Street AUTHORI2E0 RE�RESENTATIVE Zephyrhills, FL 33542 � USA G �� (` V suaphiha ACORD 25 (2009/09) The ACORD name and lo o are re istered marks of ACORD RD CORPORATION. All rights reserved. 19849506 9 g�