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.4co� CERTIFICATE OF LIABILITY INSURANCE °"�`""�°°""Y",
<br /> `,r,i 08l28/2013
<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 NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br /> BEL�IV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEENTHE ISSUING INSURER(S),AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certiflcate holder is an ADDITIONAL INSURED,the policy(fes)must be endorsed. If SUBROGATION IS WANED,subject to
<br /> the terms and conditions of the pollry,certaln policies may require an endorsement. A statement on this certiHcate does not confer rights to the
<br /> certificate holder in lieu of such endoraement(s).
<br /> PRODUCER �E; Melanie Allen
<br /> MCGRIFF,SEIBELS&WILLIAMS,INC. PHONE 800„4��y22�� FAX
<br /> P.O.Bou 10265 p!C No:
<br /> Birmingham,AL 35202 E-MAI� maU m rdf com
<br /> ADDRE88: � � •
<br /> INSURE S AFFORDINO COVERA6E NAIC/!
<br /> INSURER A:RLI Insurence Com an 13056
<br /> INSURED iNSURER e:James River Insurance Com an 12203
<br /> S.Vitale Pyrotechnic Industrfes.Inc.dba Pyrotecnico
<br /> P.O.Box 149 INSURER C:Catlin S ecia lnsurance Com n 15989
<br /> New CasUe,PA 16103
<br /> INSURER D:See BelOw
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER:7QNXBZT8 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 /> INDICATEO. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT 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 /> IN8R POLICY EFF OLIC EXP
<br /> LTR TYPE OF INSURANCE POUCY NUMBER MWD MIDD LIM�TS
<br /> B ceNEw►�unsi�m 00292605 0111412013 01l14/2014 1,000,000
<br /> enctt occuaRer�cE s
<br /> X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocarrence S 100,000
<br /> CIAIAAS�AADE �OCCUR MED EXP(My one person� $
<br /> PERSONAL 8 ADV IN.IURY $ 1,000,000
<br /> GENERAI AGGREGATE S 2,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG 5 2�000,000
<br /> POLICY X PR�' LOC POIi re ete: S 5,000,000
<br /> A nuroMOei�unsluTr LFT0012741 01/14/2013 a1H4/2014 SINGLE LIMIT
<br /> Ee acdden� S 1,000,000
<br /> X ppry pUTp BODILY INJURY(Per pereonj S
<br /> ALL OWNED SCHEDULED BODILY INJURY(Par accident) S
<br /> AUTOS AUTOS
<br /> X HIRED AUTOS X NON-OWNED PROPERTY OAMAGE a
<br /> Trlr InlerChg �TOS Per accldent
<br /> X Stmil Comp.52500 deductible Coll.$2500 deductible
<br /> B UMBRELLA LIAB X pCCUR �292625 01114/2013 01/14/2014 EACH OCCURRENCE S 4,000,000
<br /> X EXCESSLIAe C�q�M&MADE AGGREGATE $ 4�000.000
<br /> DED RETENTION S t
<br /> D woRKERE CoNPENSATION 738720960102-CalHornia lns.Co p8/p7/y013 08/07f2016 X wC STA7U- OTH-
<br /> IANO EMPL.OYERS'LIABWTY y�N 38720960101-Contlnental Indmnity R
<br /> ANV PROPRIETORIP11ftINERIEXECUTNE �• E.L.EACH ACCIDENT j 1.000,000
<br /> OFFICERIMEMBER EXCLUDED9 � N�A (Blanket Waiver of Subrogation Incid)
<br /> (MandaWry In NH) E.L.DtSEASE-EA EMPLOYEE S �•����
<br /> Ifyaa desaibs under
<br /> DESCRIPTION OF OPERATION3 below E.L.DISEASE-POLICY UAAIT 5 �•��•�
<br /> C EXCESS UMBRELLA OVERAGE SA2002600114 01H4l2073 01H4/2014 XS Underlying 4,Mil 5,000,000
<br /> S
<br /> S
<br /> 1
<br /> S
<br /> DESCRIPTION OF OPERATIONS/LOCATION8 f VEHICLES (Atheh ACORD 101,AddHlonal Rsmark�Sch�dula,H more spsu is roquhed)
<br /> Fireworks Display Date: December 8,2013
<br /> Location Florida Hospital Zephyrhllls,south parking lot,7050 Gall Blvd.,Zephyrhiils
<br /> City of Zephyrhllls,FL
<br /> The above listed are Additionai Insured respects to Generel Liabflity policy as required by written contrect subjed to policy terms,conditions and exclusions.
<br /> The Cert�cate Holder is Additlonal insured with respect to General Liability as required by written contrect.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELtVERED IN
<br /> ACCORDANCE WITHTHE POLICY PROVISIONS.
<br /> Florida Hospital Zephyrhills AUTHORIZED REPRESENTATIVE �--""•�
<br /> 7050 Gali B1vd.
<br /> Zephyrhills,FL 33541 \,�'p��y�1.,u,�s,.��
<br /> �
<br /> Page 1 of 1 p 1988-2010 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
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