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OCT-18-2011 12:17 From:FJ VELTEN 7277536104 To:8137800021 Pa9e:1�1 <br /> �idgefield Casualty <br /> Tnsurance Companym <br /> Member of I.iberty Mun�af Group <br /> �tated A(Excellen� by A,M. Best Company <br /> surnmithaldin,qs.cum <br /> CERTIFICATE OF iNSURANCE <br /> RE : 0796-16175 Producer : Phillip Wood <br /> ISSU�p �'a ; City of Zephyrhiils Company : F.J. Velten & Sons <br /> insurance qgency, lnc. <br /> 5338 8th Street Address : 5701 Main ST <br /> ZeAhyrhills, FL 33542 New Port Richey, FL 34652 <br /> Phone : (727) 753-0050 <br /> Attn: Jackie <br /> This is to cerdfy that Keene Services, Inc., 97841 Us Highwa 41 S rin Hill, FL 34610-7440, being <br /> subject to the provisipns r� o ers mpensa on w, r e o any <br /> workers compensation benefits due by insuring their risk witll tlte Bridgefreld Casualty Insurance <br /> Company. <br /> POLICY NUMBER: 0196-16175 Statutory Limits — State of Fiprida <br /> — <br /> EmplQyers Liabiliiy <br /> EFFECTIVE DATE: September 01, 2011 1,000,000 (Each Accident) <br /> 1,000,000 (Disease--Each Employee) <br /> EXPIRATION DATE: September 01, 2012 1,000,000 (Disease--Policy Limit) <br /> This ce�tificate is not a policy and of itself daes not aiford any insurance. Nothing contained in this <br /> certificate shali be construed as �mending, extendir�g, or altering oaverage not affor+ded by the policy <br /> shown above or affording insuranoe ta any insured nut named above. <br /> The policy of insurance tisted above has been issued to the named 'tnsured for the poliCy period <br /> indicated. Ndtwithstanding any requirement, tertn or condition of any contract or other document to which <br /> this cewficate may pertain, the insurance made avaifable by the described policy in this ce�tificate is <br /> subject to only the terms, exdusions and conditions af such policy, Paid daims may have reduced the <br /> shown limits. <br /> If the polfcy described above is cancelled befone the expiration date indicated, the issuing companX <br /> will endeavor to mail 30 days' written notice to the certfiCate holder named above, although if CanCella#i4n <br /> is for nonpayment of premium, then the issuing company will endeavor to mail 30 days' written notice to <br /> the certiflcate holder. In any event, the issuing company, its agents, and repr�sentatives �cc�pt no <br /> obligation or liability of �ny kind for failure to mail suCh notice. <br /> � - • Date: October 17, 2011 <br /> A�uthonzed S�gn�shuc � ---.'�'—" <br /> Sooth,rrst Reg�on C°rporate Of6oe � � <br /> AI4bmMa. ArRanja,f, j.p�q�arm, M+it+spiP� Flwl/a (`ipprKe. K<�tkv. Nxfb Corofma S�1ACarotra4 Tinn�ssar <br /> P.O. Boz 80439 • Batop Rpuge,l,A 70898-0439 �O. �aot 988 • I,aktlAnd, FL 33802.0988 P.O. 800t 60p • Gainesville, GA, 30503-0600 <br /> (2.Z5) 9z6 • I (863) 665 • 1 (d78) 450 • 1 <br /> �vuc(225)926-a102 Fax (863)666-1958 Fxxf770)531-13a9 <br /> B►idge�i'dd Casuol�y tnsvmrroc Can�y u an affili.fe of imd is nranq�qed by Su�mrt. <br /> wc 97-0s6 fRw �oe� 5ummit rndYda Sunann Consu I�. ar+d ita ar�baidmrres. <br /> u� ca xse�s2.� �2 �o n"�R <br />