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Jun, 21. 2Q11 9:31AM No, 9595 P, 1/1 <br /> �� ;� <br /> '`�`°R � CERTIFICATE OF LIABILITY INSURANCE ;i,2`�'` o i'"" <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOROED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CON371TUTE A CONTRACT BET4VEEN THE ISSUING INSURER(S�, AUTHORI2ED <br /> REPRESENTATIVE OR PRODUCER, AND THE CERTIFlCATE HOLDER. <br /> IMPORTANT: If the certificata holder is an ADDITIONAL INSURED, ths policy(iss) must be sndorssd. If SUBROGATION IS WAIVED, subject to <br /> the terms and conditions of the policy, cartain policias may raquire an endorsemeM. A statement on this certificate does not corder rights to the <br /> cartificate holder in lisu a�f such endorsamer�t(s). <br /> PROW(Bt <br /> NAME: <br /> Adcock & Adcock Insurance Agency P�� E: 813.933.6691 F � � <br /> 315 W. Fletcher Ave. E <br /> n�or�s: <br /> cusroMe� i r. <br /> T a FL 336123414 iNSU� 3 AFFORpINGCOyg7AGE ruic� <br /> ��� INSURH2A:OWIIET3 Insurance Co. <br /> INSUR62B�11t0—�WI1PS3 Insurance CO. <br /> Michael John Ent Inc. iNSUqetc• lo ers Preferred Insurance <br /> P.O. Box 1156 INSUR62D. <br /> IN3UR62 E . <br /> Brandon FL 335091156 INSURB2F. <br /> COVERAGES CER�IFICATE NUMBER:11/12 wC 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 REQUIREMBJT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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 7YPEOFINSURANCE POV ��� POU ffF POLJCYIXP <br /> GBJ62AL LIABILITY LIMITS <br /> 0536272 8/17/2010 8/17/2011 ��OCCURRENCE $ 500,000 <br /> X COMMERCIAL GENERAL LIABILITY PREMISES Ea octurrence $ $O , OOO <br /> A CLNMSMADE � OCCUR Mm EXP (Ary one person) $ 5� OOO <br /> PERSONAL & ADV INJURY $ 5OO � OOO <br /> GENERAL AGGREGATE $ 5OO � OOO <br /> GEN'LAGGREGATEIIMITAPPLIESPER PF20WCTS-COMPlOPAGG $ 500�000 <br /> POLIGY PR � LOC $ <br /> AUTOMOBILELW&LT' 571790400 8/17/2010 8/17/2011 COM&NEDSINGLELIMIT $ 500,000 <br /> X ANY AUTO (Ea ecaderrt) <br /> B ALL OWNED AUTOS <br /> BODILY INJURY (Pet person) $ <br /> SCHEDULFD AUTOS <br /> BOOILY INJURY (Per ecadent) $ <br /> X PROPERTY DAMAGE <br /> HIRED AUTOS (Per accident) $ <br /> x NON-OWNm AUTOS $ <br /> $ <br /> X�e���� p�p�R 346461700 8/17/2010 8/17/2011 <br /> EACH OCCURRENCE $ 1� OOO � OOO <br /> IX �s ��'� CLAIMSMADE AGGREGATE $ 1� O00 � OOO <br /> DEDUCTIBLE $ <br /> B X RET�nON $ 10 000 $ <br /> C WOIil�RSCOMPENSATION 076437 1/O1/2011 1/Ol/2012 WCSTATU- OTH- <br /> APD EMPLOYERS' LIABILT' Y 1 N Y <br /> ANY PROPRIETORfPARTNERrEXECUTIVE E.L EACH ACCIDENT $ <br /> OFFICERIMEMBER IXCLUDED7 ❑ NIA ZOO OOO <br /> (MandrtarylnNFq ELOISEASE-EAEMPLOYE $ lO0 OOO <br /> If yes, tlescribe under <br /> oESCRIPTION OF OPERATIONSbelow E.L DISEASE- POUCY LIMIT $ SOO OOO <br /> DESCPoPTION OF OPERATIONS I LOCATIONS! VEFICLES (Att�ch ACORD 1Q1, AddtlorW Rsmarks SehsdJe, N moro apaa is nqulro� <br /> License Holder: Michael Heyer �CCCO52492 License Holder: Michael Heyer $ CBCO57573 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SN01LD ANY OF TNE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE <br /> TFIE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City Of Zephyrhills ACCORDANCE WITH TME POLICY PR0IASIONS. <br /> 5335 8th 3tTeet <br /> Zephyrhills, FL 33540 a�TH°���'�sEMArv� <br /> Jaaues Randall , I I I , �_�' " ��� L�� —'��+�� -- + ' T` <br /> ACORD 25 (2009l09) � 1988-2009 ACORD CORPORATION. All rights reserved. <br /> INS025 czoosos� The ACORD name and logo are registered marks of ACORD <br />