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��� � DATE(MM/DDlYYYY) <br /> �,,.,,.,-� CERTIFICATE OF LIABILITY INSURANCE <br /> 07113/11 <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 AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br /> IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. N SUBROGATION IS WAIVED, subject to <br /> the terms and conditions of the policy, eertain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s�. <br /> PRODUCER CONTACT <br /> Statewide Insurance LLC PHONE <br /> (352) 523-0800 ac No : (352) 521-5936 <br /> 12214 US 301 E-MAIL Statewidelns�earihlink.net <br /> Dade City FL 33SZ5 � INSURER S AFFORDING COVERAOE <br /> NAIC # <br /> Phone (352) 523-0800 Fax (352) 521-5936 INSURERA. United SpeciaNylnsurance <br /> INSURED <br /> INSURER B . <br /> Widner Roofing INSURER C . <br /> 37506 Moore Dr INSURER D. <br /> Dade City, FL 335255635 (352) 567-1465 INSURER E: <br /> INSURER F . <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERT�FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TF1E INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED NOTWITHSTANDING ANY REQUIREMENT, 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 ADD UBR <br /> LTR TYPE OF INSURANCE PO�ICY NUMBER MMroD/YYYY MM%DWYYYY LIMITS <br /> GENERAL LIABILITY <br /> EACH OCCURRENCE $ 'I,OOO,OOO.00 <br /> � COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ���� <br /> ' PREMISES Ea occunence S <br /> ❑❑ CLAIMS-MADE � OCCUR NS1 Z1009 �` � MED EXP (Any one person) $$,�.0� <br /> A ❑ 07/07/2011 07/07/2012 � <br /> ❑ PERSONAL & ADV INJURY S 'I.�OO,OOO.00 <br /> GENERAL AGGREGATE S Z,OOO,OOO.00 <br /> GEN'L AGGREGATE LIMR APPLIES PER. <br /> PRODUCTS - COMP/OP AGG 3 Z,OOO,OOO.00 <br /> POLICY ❑ PR �� ❑ LOC <br /> S <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> Ea accident y <br /> � ANY AUTO BODILV INJURY (Per person) S <br /> ALL OWNED SCHEDULED <br /> ❑ AUTOS ❑ q�7ps BODILY INJURY (Par accident) $ <br /> ❑ HIRED AUTOS NON-OWNED <br /> ❑ AUTOS PROPERN DAMAGE $ <br /> � ❑ Per accident <br /> S <br /> a UMBRELLA LIAB Q �LAIMS-MADE <br /> EXCESS LIAB <br /> EACH OCCURRENCE S <br /> AGGREGATE y <br /> ❑ DED ❑ RETENTION $ <br /> WORKERS CAMPENSATION 3 <br /> AND EMP�OYERS' LIABILITY � WC STATU- � ORH- <br /> Y/N I T <br /> ANY PROPRIE70R/PARTNER/EXECUTIVE <br /> OFFICER/MEMBER EXCLUDED? ❑ N/ A E.L. EACH ACCIDENT g <br /> (Mandatory in NH) <br /> If yes, describe under E.L. DISEASE - EA EMPLOYE S <br /> DESCRIPiION OF OPERATIONS below <br /> E.L. DISEASE - POLICY LIMIT S <br /> DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, if more space Is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> City of Zephyrhills THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE PO�ICY PROVISIONS. <br /> � <br /> AU7HORI2ED REPRESENTATIVE <br /> Mark Capes <br /> ACORD 25 (2010/05) QF O 1988-2010 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />