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CERTIFICATE HOLDER

© 1988-2014 ACORD CORPORATION. All rights reserved.ACORD 25 (2014/01)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE

LOCJECTPRO-POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

PREMISES (Ea occurrence) $DAMAGE TO RENTEDEACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

$

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

INSRLTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF(MM/DD/YYYY)

POLICY EXP(MM/DD/YYYY) LIMITS

PERSTATUTE

OTH-ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

$

$

$

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe underDESCRIPTION OF OPERATIONS below

(Mandatory in NH)OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTOALL OWNED SCHEDULED

HIRED AUTOSNON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)PROPERTY DAMAGE $

$

$

$

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSDADDL

WVDSUBR

N / A

$

$

(Ea accident)

(Per accident)

OTHER:

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE(A/C, No, Ext):

PRODUCER

ADDRESS:E-MAIL

FAX(A/C, No):

CONTACTNAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.

INS025 (201401)

8/25/2015

Frank H. Furman, Inc.1314 East Atlantic Blvd.P. O. Box 1927Pompano Beach FL 33061

Griselidys Acosta(954)943-5050 (954)942-6310

gris@furmaninsurance.com

Kelly Roofing, LLC465 Production Blvd

Naples FL 34104

AmTrust Int'l Underwriters LtdNationwide Ins Co of America 25453

15-16

A

X

X

X

PAL125583500 9/1/2015 9/1/2016

1,000,000

100,000

5,000

1,000,000

2,000,000

2,000,000

B XACP7145212174 9/1/2015 9/1/2016

1,000,000

Uninsured motorist BI split limit 100,000

GL: Blanket additional insured applies to the General Liability as per written contract per form CG2010 04 13. Blanket additional insured which includes products and completed operations as per written contract applies per frm CG2037 04 13 . Blanket waiver of subrogation applies per form CG2404 0509. Primary and non-contributory wording applies per form CG2001 04 13. Designated Construction Project General Aggregate limit applies per form CG2503 0509. Auto: Blanket additional insured applies to the Auto Liability.

Dirk DeJong/GA

"For Bidding Purposes Only"

Quick Tips to understand the Certificate of Insurance

What is a Certificate of Insurance?

A Certificate of Insurance is simply PROOF that the Roofing Contractor has insurance coverage.

Certificate of the insurance are usually one page and show coverage and limits. It is veryimportant to make sure the certificate you received is current (check the policy effectivedates and expiration dates). Most of certificates expires within 12 months.

1. Producer: is the insurance broker that wrote the insurance policy(ies) for the insured. 2. Insured: is the person or entity for whom the insurance policy is written. 3. Name of the Insurance Company providing Commercial General Liability insurance coverage to the insured. 4. Name of Insurance Company providing Automobile Insurance. 5. Name of Insurance Company providing Workers’ compensation and employers’ liability insurance. 6. Name of Insurance Company proving Inland Marine Insurance 7. Commercial General Liability: Here you can find information about the policy number, the effective date, expiration date, limits in the policy. Also there are boxes marked indicate the type of the general liability coverage and whether coverage is extended on a “claims made” or “occurrence”. All the time you can find on an occurrence basis. 8. Automobile Liability: you can find information about the policy number, effective date of the policy, expiration date and limits. In this case you can see in the form that the property damage and bodily injury are combined per accident. 9. Worker’s Compensation: information about the policy number, effective date of the policy, expiration date and limits. 10. Inland Marine Insurance. This insurance coverage the equipment and installation floater that Kelly Roofing has. Also you can see the policy number, effective, expiration date, and limits. 11. A certificate Holder is simply the person or company to whom the Certificate of Insurance is being mailed. 12. The cancellation clause outlines the terms for proving notice about cancellation of the policy. In this case it is a 10 days’ written notice of policy cancellation.

Example