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From:Michelle Hall FaxID:86?-967-7592 Page 2 of 2 <br /> Date:05/02/11 10:52 AM Page2 oi 2 <br /> , �� <br /> ACORO" OP ID: MH <br /> �-- CERTIFICATE OF LIABILITY INSURANCE o^T�{MMroonm�� <br /> OS/02111 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAIIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIqES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSIITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S� AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certfficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, aubject to <br /> the tertns and conditions of the policy, certain policies may require an endorsemerrt. A statement on this certificate does not confer rigMs to the <br /> certificate holder in lieu of such endorsemertt s <br /> PRODUCER 863-967-0454 �«dTACT <br /> Mulling Insurance A enc , Inc. """" <br /> P O Box 308 208 E Park Street 863-967-7592 PHO^� F,ix <br /> !C No Ext : AJC No : <br /> E�AAIL <br /> Aubumdale, FL 33823-0308 noor�ss: <br /> Jim Mullin PROOUCER gROC-03 <br /> g CUSTOMER ID t: <br /> INSURED INSURER�S) AFFORDING COVERAGE NAIC i <br /> Brock Industrial Electric, LLC INSURERA Auto-Owners Insurance Co. �gygg <br /> Curt Brocklesby INSURERB Western Sure Com an <br /> 189 Lagoon Rd. 13188 <br /> Winter Haven, FL 33884-2564 INSURERC <br /> INSURER D <br /> INSURER E <br /> INSURER F . <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LiMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR <br /> LTR TYPE OF INSURANCE POLICY NUMBER MMAD MMAD� LIMRS <br /> GENERAL LIqBIIITY <br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO�OO <br /> 72685037 07/03/10 07/03/11 pREMISES Eaoccurrence s 300,00 <br /> CLAIMS�v1ADE C] OCCUR MED EXP (My one person) $ ���QQ <br /> x N&NOA:1000000 PERSONAL&ADVINJURY $ ��OOO�OO <br /> GENERALAGGREGATE $ Y�OOO�OO <br /> GEN'L AGGREGATE LIMIT APPLIES PER <br /> POLICY PR � LOC PRODUCTS-COMP/OPAGG $ Z,OOO�OO <br /> AUTOMOBILE LIABILITY $ <br /> COMBINEDSINGLELIMIT $ <br /> ANY AUTO (Ea acadenq <br /> ALL OWNEDAUTOS BODILY INJURY (Perperson) $ <br /> SCHEDULED AUTOS BODILY INJURY (Per acadent) $ <br /> H IR ED AUTO S PROPERTY DAMAGE <br /> (Peracade�t) $ <br /> NON-OWNED AUTOS <br /> $ <br /> UMBRELLA LUIB $ <br /> OCCUR <br /> ExCE3S LWB EACH OCCURRENCE $ <br /> CLAIMS-MADE <br /> AGGREGATE g <br /> DEDUCTIBLE <br /> RETENTION $ $ <br /> VMOPoCERS COMPENSATION $ <br /> APD EMPLOYERS' LIABILI7Y WC STATU- OTH- <br /> ANYPROPRIETORlPARTNERIEXf:CUTIVE Yf N TORYLIMITS ER <br /> OFFICERMIEMBER EXCLUDED� � N/ A E L EACH ACCIDENT $ <br /> (Mandatory In NH) <br /> If yes, desrnbe under E L DISEASE - EA EMPLOYEE $ <br /> DESCRIPTION OF OPERATIONS below <br /> B License & Permit 2484���4 E L DISEASE- POLICY LIMIT $ <br /> 10/28/10 10I28171 Bond 5,00 <br /> DESCRIPTION OF OPERATIONS 1 LOCATION3/4EHCLES (Attaoh ACORD 101, Additlonal Remarks 3chedule, i/moro spacs is rsqulrod) <br /> Electrical work - with-In bldgs. <br /> CERTIFICATE HOLDER CANCELLATION <br /> CITYOZE <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN <br /> City of Zephyrhills ACCORDANCE WITH iHE POLICY PROVISIONS. <br /> Building Department <br /> 5335 8th Street AUTHORIZED REPRESENTATIVE <br /> Zephyrhills, FL 33542 (►,�;,_ rn„a�-�.�, <br /> �'iL/rI/ AA�i��i�a.�, <br /> V <br /> O 1988-2009 ACORD CORPORATION. All rights reserved. <br /> ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD <br />