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� ��""'� OP ID: DI ' CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDMlYY) 05/12/11 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. 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 727-447-6481 CONTACT Bouchard-Clearwater NAME: 107 Starcrest Drive 727-449-1267 A/C Ext : A!C No : P O BOX BO9O E-MAIL Clearwater, FL 33758-6090 ADORESS: Adam J. Bouchard PRODUCER gOLLE-1 CUSTOMER ID #: INSURER�S►AFFORDING COVERAGE NAIC # INSURED Bollenback Builders Inc INSURERA Amerisure Insurance Company 19488 160 Scarlet Blvd iNSUReRe.Westfield Insurance Company 24112 Oldsmar, FL 34677-3005 INSURER C : INSURER D 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 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 CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I LTR TYFE OF INSURANCE DD BR pOLICY NUMBER MM% I D/YYYY MMlDDmY LIMITS GENERAL LIABILITY EACHOCCURRENCE $ 'I�OOO�OO B X COMMERCIAL GENERAL LIABILITY TRA1954252 ��/��/� � 01/01l12 pREMISES Ea occurrence s 150 ��0 CLAIMS-MADE � OCCUR / MED EXP (Any one person) $ �� X XCU �/ PERSONAL & ADV INJURY $ 'I �OOO�OO X CONTRACTUAL LIAB GENERAL AGGREGATE $ Z�OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ Y�OOO�OO POLICY X P E � LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ �,��+�� B X ANY AUTO TRA1954252 01/01/11 01/01/12 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIREDAUTOS (Per accident) $ X NON-OWNED AUTOS $ $ UMBRELLA IIAB X OCCUR EACH OCCURRENCE $ S�OOO�OO EXCESS LIAB CLAIMS-MADE AGGREGATE $ $�OOO�OO B TRA1954252 0llot/11 07/07/12 DEDUCTIBLE g X RETENTION $ $ WORKERS COMPENSATION WC STATU- TH- AND EMPLOYERS' LIABILITY X TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N WC1315940-12 01/01/11 �'�� 2 E L EACH ACCIDENT $ ��0��0 OFFICERlMEMBER EXCLUDED? � N � A (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ �,��0,�� If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 'I,OOO,OO g Equipment Floater TRA1954252 01/01111 01l01/12 R/LEASE 75,00 E D 50 DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES ANach ACORD 101, Additional Remarks Schedule, if more space is required) FOR CONTRACTOR LICENSE REGISTRAT�ON CERTIFICATE HOLDER CANCELLATION CITYZEP SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF ZEPHYRHILLS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 5335 8TH STREET ZEPHYRHILLS, FL 33542 AUTHORIZED REPRESENTATIVE � O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD