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02/11/2p11 16 '2 FAX 407671252p FRSA SELF INSURERS fUND l�001/401 <br /> Issue Date� 2l11l2011 <br /> RORIDA fqOFING, SHEET METAL b AIR CpNqfflQNfNG CpNTHAC�'ORS AS$OCIATION, INC. <br /> � RSa - - r <br /> 1-800-767-3772 • FAX (40� 671-�520 <br /> CERTIFICATE OF INSURANCE <br /> ISSUED TO: COPY PROVIDED Tp: <br /> City of Zephyrhills Building DepaRment Dockside Roofing, Inc. <br /> 5335 eth 5treet 9916 Maislin Drive <br /> Zephyfiills, Fl 335a2 Tampa, FL 33637 <br /> AttenUon. <br /> Dodcside Roofing, Inc. <br /> This is to Ce►tify that: 8916 Maislin brive <br /> Tampa, FL 33837 <br /> being subjeCl co the provisions of the Flonda Workers' Compensation ACt, h85 SeCUred the paymCnt Of Cpmpensation <br /> by insuring their risk with the FLORIDA ROOFING, SHEET METAL � AIR CONDITIQNING CONTRACTQRS <br /> ASSOCIATION SELF INSURERS FUND, P.O. eox 4907, Wlnter Park, FL 32793. <br /> COVERAGE NUMBER� 870-0331 LIMITS <br /> Workers' Compensation� Statutory - State of Florida <br /> EFFECTIVE DATE� 1/7/201 <br /> Employers' Liability: $100,000.00 Each Accident <br /> EXPIRATION DATE: 1l1/20 $100,000.00 Disease, Each Employee <br /> �500,000.00 Disease, Policy Limit <br /> REMARKS Non-cancelable, without 30 days prior written notice, except for non-payment of premium which will be <br /> a 10 day wntten nOtiCe. <br /> No Exemptions. Robe�t Mattull as Qualifier, Li�ense #CCC1325525 <br /> This certificate is issued as a matter of information only, is not a policy and of itself dces not attord any insurance. <br /> Nothing contained in this certificate shall be constructed as extending coverage not afforded by the policy(ies) shown <br /> above o� as affording insurance to any insured not named above. This provides cover'�ge for Florida policyholders <br /> and Florida domiciled empbyees only. <br /> c <br /> BY= By: <br /> Brett Stiegel, Adrtanistrafor Debra Guidry, CPCU, Un erwri0ng Manager <br /> FRSA-S1F FRSA-S I F <br />