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From:Diana Amador FaxID 863-967-7592 Page 2 of 2 <br /> Date:10/17Q011 04.27 PM Page2 oi Z <br /> qC 0� OP ID: DA <br /> �--� . CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYYJ <br /> , o„ �i„ <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERIIFICATE DOES NOT AFFIRMATIVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIqES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONS7ITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S� AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADdT10NAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br /> the terms and conditions of the policy, oertain policies may require an endorsement A statemeM on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement s. <br /> PROOUCER 863-967-0454 CONTAC <br /> Mulling Insurance Agency, Inc. Ho� <br /> 863-967-7592 FAx <br /> P O Box 30B 208 E Park Street ac rro e�e : � � <br /> E*IAII <br /> Aubumdale, FL 33823-0308 ADDRESS. <br /> PROWCER GOLD-07 <br /> Brien Spann, AAI CUSTOMERID#. <br /> INSURER(S� AfFORDING COVERqGE Nq�� # <br /> INSURED �oe Goldsmith Const., �flC. INSURERA Southern Owners Insurance Co. 10190 <br /> Cindy Goldsmith INSURERB Owne Ins. Co. 32700 <br /> 3240 Galloway Rd. <br /> Lakeland, FL 33810 INSURERC. <br /> INSURER D <br /> INSURER E <br /> INSURER F . <br /> COVERAGES CERTIFICATE NUMBER: REt/ISION 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 CpVDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TNE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR <br /> �TR TYPE OF INSURANCE POLICY NUMBER MM1 MMAD� LIMfT& <br /> GENERAL LIABILITV <br /> EACH OCCURRENCE $ 1,000,00 <br /> A X COMMERCIAL GENEF;AL IIABIIRY 72709893 �&��� � ��3��2 pREMISES Ea occurrence $ 3��,�0 <br /> CLA�MSadP,DE �� OCCUR MED EXP (My one pprson) E �O,O <br /> PERSONAL & ADV IN.l1RY $ � �OOO,O <br /> x Hired 6 No O w n ed <br /> � GENERALAGGREGATE $ Y,OOO�O <br /> GEML AGGREGATE LIMIT aPPLIES PER <br /> POLICY <br /> PRO- LOC �ODUCTS-COMP/OPAGG b 2,000,0 <br /> AllrOMOBILE LIABILITV <br /> a <br /> COMBINED SYJGIE LIMIT $ � �OOO,O <br /> B ANY,4UT0 768580100 �/�f�� ��3a�2 (Eaacadent) <br /> ALLOVJNEOAUTOS 8 0DILYW,URY(Perperson} $ <br /> X SCHEDULED AUTOS BODILY IN,IURY (Per acadent} _ <br /> H IR ED AUTO S PROPERT Y DAMAGE <br /> (Peracatlent) $ <br /> NON-0'NNED AUTOS <br /> S <br /> S <br /> UMBRELLA UAB OCCUR <br /> EACH OCCURRENCE <br /> E%CESS UAB CLAIMS-MADE $ <br /> � AGGREGATE g <br /> DEOUCTBLE <br /> RETENTION $ <br /> $ <br /> VYOPotERS COMPENSATION $ <br /> APD EMPLOVERS' LIABILITV WC STATU- OTH- <br /> AM' PROPRIETORfPARTNERIEXECU77VE v � N TORY LIMITS ER <br /> OFFICERMIEMBER EXCLUDED� ❑ N/ A E.L EACH ACCIDENT S <br /> (Msndatory in NH) <br /> Ilyes, desaibe under EL DISEASE - EA EMPLOYEE $ <br /> DESCRIPTION OF OPERATIONS below <br /> E L DISEASE - POl ICY UMR $ <br /> DESCRIPTION OF OPERAl10NS / LOCATIONS ! VEHCLES (Altaeh ACORD 701, AdditionW R�marMs Schrdul�, it mon spae� is nquind) <br /> CERTIFICATE HOLDER CANCELLATION <br /> ZEPHBDE <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, N0710E WILL BE DELIVERED IN <br /> City of Zephyrhills ACCORDANCE YVfTH T}�E POUCY PROVISIONS. <br /> Building Department <br /> 5335 8th Street AUTHORIZED REPRESENTATIVE <br /> Zephyrhills, FL 33540 � <br /> O 1988-2009 ACORD CORPORATION. All righffi reserved. <br /> ACORD 25 (2009/08) The ACORD name and logo are registered marks oi ACORD <br />